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How to Reduce Strep Tests for Kids Under 3

October 29, 2019

Written by Thomas Davis

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Rapid streptococcal testing (RST) among children under age 3 was reduced by 52% following a quality improvement initiative.

Why does this matter?
IDSA guidelines recommend against routine testing for GAS pharyngitis among children < 3 years of age. Why? First, there is a low prevalence of GAS pharyngitis within this age group. Second, young children rarely develop acute rheumatic fever. It is thought that repeated exposures to GAS are required to prime the immune system before an immune response can cause ARF. Therefore, the IDSA only recommends testing for GAS when a child < 3 years old is both symptomatic and is exposed to a close-contact with documented GAS pharyngitis.

Don’t strep on the guidelines.
A single, urban, tertiary pediatric ED sought to decrease its rate of RST using a variety of quality improvement interventions. Prior to intervention, an average of 20.1 RSTs were ordered monthly in children under 3 years of age. NPs who staffed the fast track area ordered the most RSTs (69%) followed by residents (13%) and attendings (10%). Interventions began with education of clinicians, nurses, and families. It was then followed by a daily management system and computerized order alerts that prompted reconsideration of the need to order RST. In the 10-month intervention period, RST dropped 52%. This improvement was sustained throughout an 8-month monitoring period. This led to a $2,200/mo reduction in hospital costs for RST and culture supplies and presumably decreased unnecessary antibiotic exposure. There was one formal complaint from family for not performing RST and no identified complications.

Reducing Streptococcal Testing in Patients <3 Years Old in an Emergency Department. Pediatrics. 2019 Sep 11. pii: e20190174. doi: 10.1542/peds.2019-0174. [Epub ahead of print]

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