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Pediatr Qual Saf. 2019 May 23;4(3):e177. doi: 10.1097/pq9.0000000000000177. eCollection 2019 May-Jun.

A Multifaceted Quality Improvement Intervention to Improve Watchful Waiting in Acute Otitis Media Management.

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Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, Calif.
Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Los Angeles, Calif.
Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, Calif.



Despite the American Academy of Pediatrics (AAP) guidelines for acute otitis media (AOM) describing a watchful waiting (WW) approach in qualifying patients, immediate antibiotics are consistently overutilized. The study team developed a multifaceted quality improvement intervention that educated providers and families about WW and included a behavioral component to modify physician prescribing patterns.


We used data from a prior study of 250 patients 18 years old and younger with AOM in a tertiary care children's hospital emergency department (ED) to characterize baseline AOM management before interventions. In this study, interventions took place from September to December 2016. Following the interventions, 65 patients were randomly selected, which would allow for the detection of a 20% increase in adherence to AAP guidelines for management of AOM.


In the preintervention cohort of 250 patients, 247 had documented AOM. Two hundred thirty-one (93.5%) received immediate antibiotics, 7 (2.8%) underwent WW, and 9 (3.6%) were sent home without antibiotics. Overall management agreed with AAP guidelines at a rate of 44.1%. In the postintervention cohort of 65 patients, 63 met age and diagnostic criteria for AOM; 56 (88.9%) patients received immediate antibiotics; and 7 (11.1%) underwent WW. Postintervention, which the ED management of AOM agreed with AAP guidelines 60.3% of the time, was significantly increased from preintervention adherence (P = 0.02).


A multipronged quality improvement intervention for AOM management in a single pediatric ED significantly improved adherence to AAP guidelines by increasing WW and reducing immediate antibiotic prescriptions.

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