Do I Need Proof of the Culprit? Decreasing Respiratory Viral Testing in Critically Ill Patients

Abstract

A 2-year-old, previously healthy boy with an upper respiratory infection presents to the emergency department with acute-onset stridor and respiratory distress. He quickly improves with intramuscular dexamethasone and initiation of heliox via high-flow nasal cannula. He is admitted to the PICU for respiratory insufficiency, requiring heliox, and high risk of respiratory failure. Before calling the PICU team for admission, the emergency department resident sends a respiratory viral polymerase chain reaction (PCR) panel. When her attending questions its necessity, she answers, "They [PICU admitting team] will ask for it. They always want to know which bug it is." Historically, at our institution, respiratory viral PCR panels were commonly ordered for patients with more severe disease requiring PICU admission to find the culprit virus. Local practice had evolved to sending respiratory viral PCR tests for the majority of PICU patients with respiratory complaints, even before admission.Since its introduction, respiratory viral PCR panel-testing proponents have advocated its use to reduce unnecessary health care resource use. [1][2][3] However, studies in which authors evaluate the clinical impact of respiratory viral PCR panel testing have varied in their results and lacked consistent evidence to support changes in management or outcomes, including antibiotic administration, chest radiographic imaging, hospital admission, and hospital length of stay. [3][4][5][6][7] In addition, commonly held beliefs include the need to test for isolation and cohort practices or to identify treatable viruses. The Choosing Wisely guidelines of the American Society for Clinical Pathology recommend against routine, broad respiratory viral PCR panels on the basis of the evidence and, in place, recommend specific rapid molecular tests that impact management, such as respiratory syncytial virus (RSV) or influenza A and B testing. 8,9 In critically ill pediatric patients, current evidence does not support routine testing for common diagnoses, such as status asthmaticus or bronchiolitis. 8,10 We aim to "bend the value curve" 11 through a pediatric critical care fellow-led quality improvement project addressing overuse of respiratory viral PCR testing. The primary specific aim was to reduce respiratory viral PCR panel testing per PICU patient day in a 35-bed, medical-surgical PICU at Cincinnati Children' s Hospital Medical Center by 30% within 1 year and demonstrate sustainability. We selected a 30% overall reduction because of the necessity for extended respiratory viral PCR panel testing in specific PICU populations for prognostication and treatment. The secondary specific aim was to reduce patient charges for viral respiratory testing within the PICU, defined as patient charges per patient day. The balancing metrics were rate of rapid molecular testing (RSV, influenza A and B, pertussis and/or parapertussis), rate of total overall respiratory viral testing (respiratory viral PCR panel and rapid