Embed Size (px)
Citation preview
Reducing Unnecessary Imaging for Patients With Constipation in the Pediatric Emergency DepartmentCatherine Craun Ferguson, MD, a Matthew P. Gray, MD, a Melissa Diaz, BS, a Kevin P. Boyd, DOb
aDepartment of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and bChildren’s Hospital of Wisconsin, Milwaukee, Wisconsin
Dr Ferguson conceptualized and designed the study, drafted the initial manuscript, and revised the manuscript; Dr Gray informed the design of the study, reviewed and revised the manuscript, and assisted with data analysis and chart creation; Ms Diaz aided in data collection and helped to draft the initial manuscript; Dr Boyd informed the design of the study and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
DOI: https:// doi. org/ 10. 1542/ peds. 2016- 2290
Accepted for publication Mar 9, 2017
Address correspondence to Catherine Craun Ferguson, MD, Department of Pediatrics, The Medical College of Wisconsin, 999 N 92nd St, Suite C550, Milwaukee, WI 53226. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2017 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
The overall use of diagnostic imaging for pediatric patients presenting to the emergency department (ED) is increasing.1, 2 This increased use is despite the pervasive concern that nonessential imaging increases the cost of medical care and exposes pediatric patients to unnecessary radiation. Although the use of computed tomography accounts for much of this increase and exposure, the overutilization of plain radiographs for the diagnosis of
commonly seen problems, such as constipation, bronchiolitis, and ankle sprains, is also detrimental to both the patient and to the health care system at large.3 As overuse in medical care becomes more widely recognized as a significant issue in the United States, there are calls for quality improvement (QI) efforts aimed at reducing the inappropriate use of diagnostic tests and treatments.3, 4
abstractOBJECTIVES: 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.METHODS: 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.RESULTS: 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.CONCLUSIONS: 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.
QUALITY REPORTPEDIATRICS Volume 140, number 1, July 2017:e20162290
To cite: Ferguson CC, Gray MP, Diaz M, et al. Re-ducing Unnecessary Imaging for Patients With Constipation in the Pediatric Emergency Depart-ment. Pediatrics. 2017;140(1):e20162290
by guest on July 20, 2020www.aappublications.org/newsDownloaded from
FERGUSON et al
As part of a broader aim to improve the effectiveness of care provided in our pediatric ED by decreasing unnecessary imaging tests for common diagnoses, we looked at our utilization rate of abdominal radiographs (AXRs) for patients diagnosed with constipation. Constipation is a leading cause of acute abdominal pain in childhood and has a significant impact on ED utilization and the cost of health care.5 – 7
In a 2014 clinical guideline, the North American and European Societies of Pediatric Gastroenterology, Hepatology, and Nutrition found that the evidence supports not performing an AXR to diagnose functional constipation.8 Similarly, a National Institute for Health and Clinical Excellence workgroup determined that AXRs should not be used to diagnose constipation.9 Both groups instead advocate the use of a careful history and physical examination to diagnose functional constipation. These recommendations were based, in part, on studies that revealed that the inter- and intraobserver agreement on the existence of constipation on AXR varies between the radiographic scoring system used10 and that AXRs have limited value in the evaluation of children with suspected constipation.11, 12 Recent studies showed that AXRs performed in the ED for constipation resulted in increased return visits to the ED for the same problem.13 Perhaps more troubling, the sole use of AXRs may lead to significant misdiagnoses in pediatric patients discharged with the diagnosis of constipation, in part because plain radiographs are often normal in patients with major abdominal diagnoses.14, 15
The few studies that describe the ED management of children with constipation highlight the variability in approaches to the diagnosis and treatment of this common problem and reveal that between 50% and
70% of children seen in the ED for constipation undergo an AXR as part of their workup despite the lack of support for their utility.16, 17 To our knowledge, there is no published literature on applying QI methodology to the management of constipation in the pediatric ED setting.
Consistent with these studies, we found that during a 7-month preintervention period, 800 low-acuity patients (Emergency Severity Index [ESI] levels 4 and 5) were diagnosed with constipation and 63% of these patients received an AXR during their visit to our pediatric ED. On the basis of the guidelines and existing literature outlined above, we determined that our performance was not in line with best practice. The rationale for our project was that if providers in our ED understood that constipation can be safely diagnosed clinically without an AXR and were aware of how many patients currently undergo AXRs for this purpose that our overall utilization of AXRs for this patient population would significantly decrease. The specific aim of this project was to decrease the percentage of low-acuity patients (ESI levels 4 and 5) between 6 months and 18 years of age diagnosed with constipation who have an AXR in the pediatric ED from 62% to 20% over a period of 12 months.
METhODS
Context
The Children’s Hospital of Wisconsin is a 296-bed tertiary care children’s hospital located in Milwaukee, Wisconsin, and is affiliated with the Medical College of Wisconsin. The 36-bed ED receives >64 000 annual visits. There are 2 geographically separate sections of the ED. The “Green” section of the ED houses 22 beds and is staffed by pediatric emergency medicine (PEM) physicians, PEM fellows, and
advanced practice providers (APPs) 24 hours per day. Trainees include pediatric, emergency medicine, and family practice residents; medical students; nurse practitioner students; and physician assistant students. Trainees perform histories and physical examinations for the majority of patients presenting to the Green ED before staffing with an attending or fellow. Decisions about whether to obtain imaging studies are ultimately made by the staffing PEM attending or fellow. APPs staff emergent patients (ESI levels 1–3) with faculty or fellows and care for urgent patients (ESI levels 4–5) on their own. Between 1000 and 0030 every day of the week, lower-acuity patients may be seen in the 14-bed “Gold” section of the ED, which is staffed primarily by general pediatricians and APPs who make the decision about whether to obtain imaging studies.
Interventions
To decrease the number of patients diagnosed with constipation who receive an AXR during their ED visit, we assembled a multidisciplinary team including 3 PEM physicians, 1 general pediatrician, a pediatric gastroenterologist, a pediatric radiologist, and a medical student. In addition to a current-state assessment, the team obtained background information between June and October 2013 through a review of the literature, 1-on-1 interviews, and a series of meetings and e-mails with section faculty members. This information was used to map the process of caring for patients with constipation in the ED and create a cause-and-effect diagram to identify barriers at the system and individual provider level. The team then created a key driver diagram and initially prioritized a large-scale educational intervention and metrics reporting.
Project implementation began in January 2014 with a section-wide
e2 by guest on July 20, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 140, number 1, July 2017
Grand Rounds educational presentation led by a PEM attending (C.C.F.), a hospital-based pediatric gastrointestinal subspecialist, and a hospital-based pediatric radiologist (K.P.B.). On the basis of our key drivers, the primary objectives of this educational intervention were as follows: (1) to inform providers of the indications for an AXR and the pitfalls of obtaining an AXR for the diagnosis of constipation, (2) to review the use of a focused physical examination for the diagnosis of constipation, and (3) to generate a group discussion around how to talk with patients and their caregivers about the risks and benefits of imaging for abdominal pain when constipation is the leading diagnosis. The providers in attendance were tracked, and annotated PowerPoint (Microsoft Corporation, Redmond, WA) slides from the Grand Rounds presentation were distributed via e-mail to all ED providers after the presentation.
Next, we shared the project dashboard that displayed our outcome measure on statistical process control (SPC) charts with ED providers via e-mail, including PEM faculty, fellows, general pediatricians, and APPs. Individual metrics were also available to those providers who requested them.
Measures
The primary outcome measure was the percentage of low-acuity patients with constipation who had an AXR in the ED. The analysis included all patients between 6 months and 18 years of age with ESI levels 4 or 5 who presented with a chief complaint of constipation or who were discharged from the ED with constipation as 1 of the diagnoses (International Classification of Diseases, Ninth Revision code 564.xx). This level of severity was selected in an attempt to exclude patients with concerns of an acute abdomen or other pathology that may have
required an AXR. The providers in attendance at PEM Grand Rounds were recorded as a process measure.
Although it was not an intervention that we implemented for this project, it should be noted that the number of shifts in the Gold ED assigned to PEM faculty and fellows increased beginning in June 2013. Our team theorized that this change would increase the interaction between the PEM faculty and fellows and the general pediatricians and potentially affect our outcome measure positively. Therefore, the number of shifts in the Gold ED completed by PEM providers (PEM faculty and fellows) every month was tracked as a process measure.
As a balancing measure, we collected the number of “bounce backs, ” defined as patients diagnosed with constipation in the ED who returned to the ED within 48 hours during the pre- and postintervention time periods for any reason. These charts were reviewed by the team leader (C.C.F.) on a monthly basis.
“Gold providers” were defined as providers (general pediatricians and APPs) who work exclusively in the Gold ED. “Green providers” included PEM faculty and fellows as well as APPs who work the majority of their shifts in the Green ED.
Analysis
The proportion of patients who had an AXR stratified by individual provider was abstracted monthly from the electronic medical record. We used P charts with funnel limits to identify individual providers with higher utilization before implementation and subsequently to track individual physician performance metrics. We used run charts and SPC charts to identify variations along the project timeline with implemented improvements and revised our center line and limits when special cause became evident. On the basis of our baseline data
and our hypothesis that there would be differences in the utilization of AXRs between the general pediatricians and the PEM faculty, we disaggregated the data by provider type (Green versus Gold providers) by using rational subgrouping from November 2012 through September 2014 to effectively target our interventions to each provider group as the project developed. For analysis, the preintervention period was November 2012 through May 2013, the intervention period was December 2013 through May 2014, and the postintervention period was June 2014 through September 2014. We continue to follow the outcome measure monthly for surveillance purposes.
The Pearson χ2 test was used to compare the use of other imaging modalities in the pre- and postintervention time periods and the rate of 48-hour return visits in patients who had an AXR and those that did not. Analysis was conducted with SAS Enterprise Guide 7.1 (SAS Institute, Cary, NC). This project was reviewed by The Children’s Hospital of Wisconsin Institutional Review Board and determined to be a local QI project and was classified as nonhuman subjects research.
RESULTS
On average, 104 (SD: ±13) children were diagnosed with constipation each month in our ED during the 23-month study period. As reflected in the upper and lower control limits shown in Fig 1, this number was stable throughout the project timeline. In the preintervention period, the utilization of AXRs was high among both groups of providers, but a funnel plot indicated that the highest individual utilizers were in the Gold provider group (Fig 2).
Figure 3 shows the main outcome measure stratified by provider type (Green versus Gold providers). After the planning period and before any
e3 by guest on July 20, 2020www.aappublications.org/newsDownloaded from
FERGUSON et al
planned interventions, there was a decrease in the number of AXRs ordered by Green providers for patients diagnosed with constipation from 54% to 37% (P < .01). There was an additional decrease in the Green provider group after the Grand Rounds presentation. There
were no such decreases in the Gold provider group during this same time period. The project team noted that, whereas 68% of PEM faculty and fellows and 55% of APPs attended the Grand Rounds presentation, none of the Gold providers did so. This observation informed the
subsequent plan-do-study-act cycles, which centered on the electronic distribution of educational materials and the use of academic detailing (ie, peer-to-peer educational outreach aimed at improving clinical practice in a targeted area).18 The academic detailer chosen for this project is a
e4
FIGURE 1Annotated P chart displaying the AXR rate by month during preintervention, intervention, and postintervention periods (November 2012–January 2016). The percentages of children (ESI levels 4 or 5) diagnosed with constipation in the pediatric ED who received an AXR (all providers) are shown.
FIGURE 2P chart with funnel limits displaying the average AXR rate of individual providers over 3 months during the preintervention period (April 2013–June 2013). The percentages of patients with constipation who received an AXR (by individual provider) are shown.
by guest on July 20, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 140, number 1, July 2017
general pediatrician with a lower AXR utilization rate and a member of the project team. She provided insight into how Gold providers learned new information most effectively and spoke informally with other providers in the Gold ED during her shifts. After these interventions, the mean subsequently decreased in both groups and the overall mean has remained at 24% through October 2016.
There was no special cause variation noted in the number of bounce backs between November 1, 2012, and September 30, 2014. Including our surveillance data collected through October 2016, 48 of 1624 (3.0%) of those patients who had an AXR in the ED returned within 48 hours, whereas 80 of 3198 (2.5%) of those patients who did not have an AXR in the ED returned within 48 hours (P = .394).
Although not tracked as a balancing measure, we found that the decrease in AXRs did not result in an increase in other imaging studies for this group of patients. Before our interventions, 17 of 672 (2.5%) included patients had computed tomography or ultrasound of the abdomen and/or pelvis in addition
to or instead of an AXR, compared with 93 of 4150 (2.2%) during the postintervention and surveillance periods (P = .675).
DISCUSSION
The preintervention utilization rate of AXRs for the diagnosis of constipation in low-acuity patients presenting to our pediatric ED was >60%, a rate that seemed unacceptable given that (1) expert consensus suggests constipation should be diagnosed clinically, (2) there is no reliable radiologic scoring system for constipation, and (3) AXRs in children with abdominal pain may lead to missed diagnoses of more-emergent abdominal pathology. Through the implementation of feasible and cost-effective interventions over a 12-month period, we observed a significant and sustained decrease from mean rate of 62% to a mean rate of 24% in the utilization of AXRs for this group of patients.
What our work also shows is that, even within a single unit or
department, different types of providers have varying practice patterns and may benefit from interventions aimed at improvement that are tailored to their specific needs and training background. The use of rational subgrouping and stratification on SPC charts to analyze these provider groups was essential to studying and reacting to these differences and shows the importance of using these methods to inform the planning and implementation of QI projects aimed at changing practice patterns in the pediatric ED.
It is interesting to note that the Green providers, a group made up predominantly of PEM physicians and fellows, significantly changed their clinical practice after the announcement of the project aim and before the implementation of any planned intervention. This finding may represent the presence of a Hawthorne effect, the social phenomenon driven by a desire to please and meet the expectations of the researcher, or in this case the improvement team leader, 19 but we postulate that the rapid change in provider behavior may be due to
e5
FIGURE 3Side-by-side P charts displaying the AXR rate by month stratified by provider type from November 2012 through September 2014. The percentages of children (ESI levels 4 or 5) diagnosed with constipation are shown.
by guest on July 20, 2020www.aappublications.org/newsDownloaded from
FERGUSON et al
other factors. First, there is a general sentiment within our provider group of the merits of decreasing unnecessary interventions in our vulnerable patient population, a sentiment that seems to be shared by PEM providers as a group.20, 21 Second, this change in practice did not place additional demands on the providers’ time or workload. Third, providers seemed sensitive to the knowledge that their performance was being monitored in an ongoing manner even though few providers asked for their individual metrics. Finally, within the time frame of this project there was an overall shift toward a culture of improvement; our capacity for QI was increasing and became an academic focus for several of our providers during this time.
Change in ordering practices of the Gold provider group, made up of general pediatricians and APPs, did not happen as quickly as in the Green provider group. The inclusion of Grand Rounds attendance as a process measure pushed us to develop alternative means of distributing educational materials that were more effective for this group of providers, a lesson that has been carried over to other QI initiatives in the ED. Academic detailing also seemed to drive change in this group; however, because these 2 interventions occurred within the same month, it is difficult to say with any certainty which had the greatest impact. For this project, our academic detailer served as a role model and provided support to other Gold providers to improve their performance during shared shifts.
A formal cost analysis was beyond the scope of this work. However, under increasingly common prospective payment models, any reduction in resource use would be expected to yield a cost savings to the hospital. We used the 2016 global Medicaid payment for an abdominal series radiograph (including both the technical component and
interpretation) as a proxy for cost. If sustained, our change in practice for this limited group of patients would yield an estimated annual savings for the hospital of ∼$17 500.
There are limitations to our findings. We did not include all children with abdominal pain or all those who underwent an AXR. It is possible that some children diagnosed with constipation in our ED may have subsequently received care in another ED or clinic. Although we are confident in our analysis of the SPC charts, there was no control group, so it is possible that improvement occurred because of a secular trend toward decreased imaging rather than as a result of our interventions.
Our findings are important for PEM physicians and any physician involved in the care of pediatric patients who desires to decrease patient exposure to radiation and reduce health care waste. The percentage of children who should undergo an AXR in the ED when constipation is being considered is not known and there is currently no published benchmark around AXRs for the diagnosis of constipation. This study is supportive of reevaluating not only our use of diagnostic imaging resources in the ED but the whole of pediatric quality measures to provide safer and more effective health care overall. Our work also shows that, even within a single unit or department, different groups of providers may have different practice patterns and may benefit from interventions aimed at QI that are tailored to their specific needs. The use of rational subgrouping and stratification on SPC charts was essential to identifying these differences and examining how our interventions affected each group.
CONCLUSIONS
We significantly decreased the use of AXRs in the diagnosis of constipation for patients presenting to a pediatric
ED by using simple, cost-efficient interventions that included provider education, metrics reporting, and academic detailing. Formal QI tools and methods, particularly rational subgrouping and stratification with SPC charts, were instrumental in ensuring that the interventions were appropriately designed to achieve a rapid and sustained improvement in our outcome measure. Our next steps include working with hospital-affiliated community pediatricians to inform their AXR-ordering practices for patients with constipation, and we plan to reach out to other community urgent care centers and EDs in the future.
ACkNOwLEDGMENTS
C.C.F. thanks every one of her colleagues in the ED at the Children’s Hospital of Wisconsin for their willingness to improve.
AbbREvIATIONS
APP: advanced practice providerAXR: abdominal radiographED: emergency departmentESI: Emergency Severity IndexPEM: pediatric emergency
medicineQI: quality improvementSPC: statistical process control
REFERENCES
1. Broder J, Fordham LA, Warshauer DM. Increasing utilization of computed tomography in the pediatric emergency department, 2000-2006. Emerg Radiol. 2007;14(4):227–232
2. Bhargavan M, Sunshine JH. Utilization of radiology services in the United States: levels and trends in modalities, regions, and populations. Radiology. 2005;234(3):824–832
3. Reed MH. Imaging utilization commentary: a radiology perspective. Pediatr Radiol. 2008;38(suppl 4):S660–S663
e6 by guest on July 20, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 140, number 1, July 2017
4. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513–1516
5. Loening-Baucke V, Swidsinski A. Constipation as cause of acute abdominal pain in children. J Pediatr. 2007;151(6):666–669
6. Reynolds SL, Jaffe DM. Diagnosing abdominal pain in a pediatric emergency department. Pediatr Emerg Care. 1992;8(3):126–128
7. Liem O, Harman J, Benninga M, Kelleher K, Mousa H, Di Lorenzo C. Health utilization and cost impact of childhood constipation in the United States. J Pediatr. 2009;154(2):258–262
8. Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43(3):e1–e13
9. National Institute for Health and Clinical Excellence. Constipation in Children and Young People: Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care. NICE Guideline (CG99). London, United Kingdom: RCOG Press; 2010
10. Reuchlin-Vroklage LM, Bierma-Zeinstra S, Benninga MA, Berger MY. Diagnostic
value of abdominal radiography in constipated children: a systematic review. Arch Pediatr Adolesc Med. 2005;159(7):671–678
11. Pensabene L, Buonomo C, Fishman L, Chitkara D, Nurko S. Lack of utility of abdominal x-rays in the evaluation of children with constipation: comparison of different scoring methods. J Pediatr Gastroenterol Nutr. 2010;51(2):155–159
12. Jackson CR, Lee RE, Wylie AB, Adams C, Jaffray B. Diagnostic accuracy of the Barr and Blethyn radiological scoring systems for childhood constipation assessed using colonic transit time as the gold standard. Pediatr Radiol. 2009;39(7):664–667
13. Freedman SB, Thull-Freedman J, Rumantir M, Eltorki M, Schuh S. Pediatric constipation in the emergency department: evaluation, treatment, and outcomes. J Pediatr Gastroenterol Nutr. 2014;59(3):327–333
14. Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr. 2014;164(1):83–88.e2
15. Rothrock SG, Green SM, Harding M, et al. Plain abdominal radiography in the detection of acute medical and surgical disease in children: a retrospective analysis. Pediatr Emerg Care. 1991;7(5):281–285
16. Miller MK, Dowd MD, Fraker M. Emergency department management
and short-term outcome of children with constipation. Pediatr Emerg Care. 2007;23(1):1–4
17. Patel H, Law A, Gouin S. Predictive factors for short-term symptom persistence in children after emergency department evaluation for constipation. Arch Pediatr Adolesc Med. 2000;154(12):1204–1208
18. Agency for Healthcare Research and Quality. Module 10. Academic Detailing as a Quality Improvement Tool. Rockville, MD: Agency for Healthcare Research and Quality. Available at: www. ahrq. gov/ professionals/ prevention- chronic- care/ improve/ system/ pfhandbook/ mod10. htm. Accessed May 2013
19. Haessler S. The Hawthorne effect in measurements of hand hygiene compliance: a definite problem, but also an opportunity. BMJ Qual Saf. 2014;23(12):965–967
20. Weiner SG, Ruffing RP, Barnewolt BA. A comparison of resource utilization between emergency physicians and pediatric emergency physicians. Pediatr Emerg Care. 2012;28(9):869–872
21. Johnson DW, Adair C, Brant R, Holmwood J, Mitchell I. Differences in admission rates of children with bronchiolitis by pediatric and general emergency departments. Pediatrics. 2002;110(4). Available at: www. pediatrics. org/ cgi/ content/ full/ 110/ 4/ e49
e7 by guest on July 20, 2020www.aappublications.org/newsDownloaded from
DOI: 10.1542/peds.2016-2290 originally published online June 14, 2017; 2017;140;Pediatrics
Catherine Craun Ferguson, Matthew P. Gray, Melissa Diaz and Kevin P. BoydEmergency Department
Reducing Unnecessary Imaging for Patients With Constipation in the Pediatric
ServicesUpdated Information &
http://pediatrics.aappublications.org/content/140/1/e20162290including high resolution figures, can be found at:
Referenceshttp://pediatrics.aappublications.org/content/140/1/e20162290#BIBLThis article cites 19 articles, 2 of which you can access for free at:
Subspecialty Collections
subhttp://www.aappublications.org/cgi/collection/quality_improvement_Quality Improvement_management_subhttp://www.aappublications.org/cgi/collection/administration:practiceAdministration/Practice Managementsubhttp://www.aappublications.org/cgi/collection/emergency_medicine_Emergency Medicinefollowing collection(s): This article, along with others on similar topics, appears in the
Permissions & Licensing
http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or
Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:
by guest on July 20, 2020www.aappublications.org/newsDownloaded from
DOI: 10.1542/peds.2016-2290 originally published online June 14, 2017; 2017;140;Pediatrics
Catherine Craun Ferguson, Matthew P. Gray, Melissa Diaz and Kevin P. BoydEmergency Department
Reducing Unnecessary Imaging for Patients With Constipation in the Pediatric
http://pediatrics.aappublications.org/content/140/1/e20162290located on the World Wide Web at:
The online version of this article, along with updated information and services, is
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
by guest on July 20, 2020www.aappublications.org/newsDownloaded from
