Ferguson Catherine Craun, Gray Matthew P, Diaz Melissa, Boyd Kevin P
Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and
Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and.
Pediatrics. 2017 Jul;140(1). doi: 10.1542/peds.2016-2290. Epub 2017 Jun 14.
Constipation is a common diagnosis in the pediatric emergency department (ED). Children diagnosed with constipation may undergo an abdominal radiograph (AXR) as part of their diagnostic workup despite studies that suggest that an AXR in a patient suspected of being constipated is unnecessary and potentially misleading. We aimed to decrease the percentage of low-acuity patients aged between 6 months and 18 years diagnosed with constipation who undergo an AXR in our pediatric ED from 60% to 20% over 12 months.
We conducted an interventional improvement project at a large, urban pediatric ED by using the Institute for Healthcare Improvement's Model for Improvement. The primary outcome was the proportion of patients ultimately diagnosed with constipation who had an AXR during their ED visit. Analysis was performed by using rational subgrouping and stratification on statistical process control (SPC) charts.
Process analysis was performed by using a cause-and-effect diagram. Four plan-do-study-act cycles were completed over 9 months. Interventions included holding Grand Rounds on constipation, sharing best practices, metrics reporting, and academic detailing. Rational subgrouping and stratification on SPC charts were used to target the interventions to different ED provider groups. Over 12 months, we observed a significant and sustained decrease from a mean rate of 62% to a mean rate of 24% in the utilization of AXRs in the ED for patients with constipation.
The use of rational subgrouping and stratification on SPC charts to study different ED provider groups resulted in a substantial and sustained reduction in the rate of AXRs for constipation.
便秘是儿科急诊科常见的诊断。尽管有研究表明，对疑似便秘的患者进行腹部X光检查（AXR）既无必要，还可能产生误导，但被诊断为便秘的儿童在诊断检查中仍可能接受腹部X光检查。我们的目标是在12个月内，将我院儿科急诊科6个月至18岁被诊断为便秘的低急症患者接受腹部X光检查的比例从60%降至20%。
我们在一家大型城市儿科急诊科开展了一项干预性改进项目，采用了医疗改进研究所的改进模型。主要结果是在急诊科就诊期间接受腹部X光检查且最终被诊断为便秘的患者比例。使用统计过程控制（SPC）图上的合理子群划分和分层进行分析。
通过因果图进行过程分析。在9个月内完成了四个计划-实施-研究-改进循环。干预措施包括举办关于便秘的全院大查房、分享最佳实践、指标报告和学术详述。利用SPC图上的合理子群划分和分层，将干预措施针对不同的急诊科医疗服务提供者群体。在12个月的时间里，我们观察到，急诊科中便秘患者接受腹部X光检查的平均比例从62%显著且持续下降至24%。
利用SPC图上的合理子群划分和分层来研究不同的急诊科医疗服务提供者群体，使得便秘患者接受腹部X光检查的比例大幅且持续下降。
