Reducing routine chest X-ray in patients with bronchiolitis
Bronchiolitis is a viral chest infection that affects infants under the age of one-year-old. It is the most common reason for infants to be admitted to hospital, particularly in winter. For bronchiolitis, there are no tests which can confirm or exclude the diagnosis and no treatments available, other than supportive care such as breathing support and fluids.
Why is it low-value care?
Chest X-rays in bronchiolitis rarely affect clinical treatments and outcomes. They are difficult to reliably reproduce in infants, and poorly distinguish between viral and bacterial infection. In addition, they expose infants to radiation early in their lifetime cumulative dosage, increase the chance of being prescribed antibiotics 10-fold and lead to increased demand on hospital resources.
All local and international guidelines recommend against routinely performing a chest X-ray in bronchiolitis. The best reported rate internationally is 4 per cent in the UK. Our recommendation is that chest X-rays are not used to look for consolidation or collapse.
What were we doing?
Baseline data collected from April 2016 to June 2018, demonstrated rates of 12 per cent. Through the Choosing Wisely project, we aimed to reduce this to an ambitious rate of less than 5 per cent.
What interventions did we introduce?
The Choosing Wisely campaign introduced a regular audit and feedback tool to frontline clinicians in the Emergency Department and general medical wards. Regular education sessions for staff were also held.
How effective were we?
As at March 2020, our rates of chest X-ray in patients with bronchiolitis have been reduced to 6.4 per cent. Once we achieve our target, we will convert to a sustainability model to regularly monitor rates and ensure they are maintained.
References and further reading (collapsible)
Cao AY, Choy JP, Mohanakrishnan L, Bain RF, van Driel M. Chest radiographs for acute lower respiratory tract infections. Cochrane Database of Systematic Reviews. 2013; 12: CD009119.
Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. Journal of Pediatrics. 2007; 150(4):429-33.
Yong JH, Schuh S, Rashidi R et al. A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis. Pediatric Pulmonology. 2009; 44(2):122-7.
Friedman J N, Davis T, Somaskanthan A, Ma A. Avoid doing chest x rays in infants with typical bronchiolitis BMJ 2021; 375 :e064132
Lawrence JG, Andrew L, Bracken J, Voskoboynik A, Oakley E, South M, Middleton K, Scanlan B, Marshall T, Hiscock H. Bronchiolitis at a specialist paediatric centre: The electronic medical record helps to evaluate low-value care. J Paediatr Child Health. 2020 Feb;56(2):304-308