Purpose or Case Report: Screening for developmental hip dysplasia by ultrasound (US) is most accurate after 6 weeks corrected gestational age (CGA). Scanning earlier increases false-positive rates, leading to repeat exams, stress for families, higher healthcare costs, and exposure of unvaccinated infants to sick patients. We noted that many premature infants were scheduled for hip US before 6 weeks CGA. Working with a multidisciplinary Quality Improvement (QI) team, we aimed to reduce the incorrectly scheduled exam rate from 50% to below 25% within 6 months.
Methods & Materials: The QI team, including pediatric radiologists, orthopedists, US technologists, IT staff, and scheduling leadership, used the Model for Improvement methodology to assess scheduling processes, identify key error drivers, and ensure hip dysplasia screenings were scheduled after 6 weeks CGA. In the first Plan-Do-Study-Act (PDSA) cycle, the Orthopedics Department agreed to adopt the 6-week CGA guideline. To help them, we added a new EHR question that prompted providers to specify if the US was for physical exam findings or screening. It also provided scheduling guidance and displayed CGA when available. The team manually audited hip US orders and CGA data to calculate error rates. The second PDSA cycle introduced a dedicated work queue for pediatric hip US scheduling which was assigned to specialized schedulers.
Results: Before the interventions, the mean error rate for incorrectly scheduled exams was 50%. Following provider education and manual rescheduling (intervention #1), the error rate decreased to 29%. After introducing the EHR screening question with embedded scheduling guidance (intervention #2), the error rate was further reduced to 27%. Additional analysis revealed that many hip ultrasound orders came through fax, requiring schedulers to determine the indication based on the provided history. Furthermore, CGA was often unavailable in the EHR, necessitating phone calls to parents for accurate scheduling. In response, the QI team tried a special work queue managed by trained schedulers (intervention #3). This final intervention reduced the scheduling error rate to 6-7%.
Conclusions: Through a combination of IT-based and process-driven interventions, we lowered the error rate in hip ultrasound scheduling from 50% to 6%. These measures resulted in less stress for parents, decreased costs, and protection of unvaccinated infants from sick patients.