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How to Really Change Physician Behavior – Reducing CXRs for Bronchiolitis

September 2, 2021

Written by Clay Smith

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A redesigned workflow was better than educational campaigns to change physician behavior when it came to ordering CXRs for bronchiolitis.

Why does this matter?
Children with bronchiolitis usually don’t need a CXR, and once one is obtained and shows abnormalities, antibiotic use increases. The AAP guidelines recommend against routine CXR in these patients. But how can we change physician ordering behavior?

What really changes physician behavior?

  • The authors performed a QI initiative from 2012 to 2020 to reduce CXR ordering in pediatric patients with bronchiolitis.

  • They succeeded in reducing ordering from a baseline average of 42% of cases to 19%. There was no adverse impact on repeat ED visits. They found that educational interventions were not helpful long term. However, changing the electronic order set to not default to ordering a CXR and giving best practice alerts and individual feedback on ordering practices was more effective and led to sustained decreases in CXR utilization.

  • This is, of course, important for bronchiolitis, but it is also likely generalizable in changing other physician/clinician behaviors. If you want something to happen in the ED, it has to be incorporated into the workflow.

  • There could have been other factors at play, such as greater diffusion and uptake of AAP guidelines over time, but the abrupt, sustained reductions in CXR ordering directly correlated with the timing of the workflow interventions.

Reducing Chest Radiographs in Bronchiolitis Through High-Reliability Interventions. Pediatrics. 2021 Aug 3;e2020014597. doi: 10.1542/peds.2020-014597. Online ahead of print.

What are your thoughts?