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Reducing Invasive Care for Low-risk Febrile Infants Through Implementation of a Clinical Pathway
Kathryn E Kasmire1,2,3, Eric C Hoppa4,5, Pooja P Patel2
1Connecticut Children's Medical Center, Hartford, Connecticut; kkasmire@pennstatehealth.psu.edu.
Insights
A new clinical pathway significantly reduced invasive interventions for febrile infants, decreasing lumbar punctures and antibiotic use. This quality improvement initiative safely identified low-risk infants for outpatient management without missing serious bacterial infections (SBIs).
Area of Science:
- Pediatrics
- Clinical Quality Improvement
- Evidence-Based Medicine
Background:
- Management of febrile infants (29-60 days) shows significant variation.
- Risk stratification can identify low-risk infants for outpatient management, avoiding lumbar puncture (LP) and antibiotics.
- Serious bacterial infections (SBIs) require timely and appropriate intervention.
Purpose of the Study:
- To reduce invasive interventions for low-risk febrile infants (29-60 days) with potential for serious bacterial infection (SBI).
- To implement an evidence-based clinical pathway supported by quality improvement (QI) methods.
- To maintain appropriate care for high-risk infants while reducing interventions in low-risk infants.
Main Methods:
- Developed and implemented an evidence-based clinical pathway for febrile infants.
- Utilized continuous-process quality improvement (QI) to sustain pathway use.
- Compared invasive interventions (LP, antibiotics, admission) and SBI rates pre- and post-implementation in low-risk infants.
Main Results:
- Invasive interventions decreased significantly post-implementation: LPs from 32% to 0%, antibiotics from 30% to 1%, admissions from 17% to 2%.
- No serious bacterial infections (SBIs) were missed in low-risk infants post-implementation (0% vs. 29.2% in high-risk infants).
- Improvements were sustained for 12 months via QI interventions like order sets and reminders.
Conclusions:
- Clinical pathway implementation using QI methods successfully reduced invasive interventions for low-risk febrile infants.
- This approach achieved sustained reductions without compromising the detection of serious bacterial infections (SBIs).
- Clinical pathways and QI are effective strategies for delivering evidence-based care to febrile infants.
Background And Objectives:
Significant variation in management of febrile infants exists both nationally and within our institution. Risk stratification can be used to identify low-risk infants who can be managed as outpatients without lumbar puncture (LP) or antibiotics. Our objective was to reduce invasive interventions for febrile infants aged 29 to 60 days at low risk for serious bacterial infection (SBI) through implementation of a clinical pathway supported by quality improvement (QI).
Methods:
The evidence-based clinical pathway was developed and implemented by a multidisciplinary team with continuous-process QI to sustain use. Low-risk infants who underwent LP, received antibiotics, and were admitted to the hospital were compared pre- and postpathway implementation with SBI in low-risk infants and appropriate care for high-risk infants as balancing measures.
Results:
Of 350 included patients, 220 were pre- and 130 were postpathway implementation. With pathway implementation in July 2016, invasive interventions decreased significantly in low-risk infants, with LPs decreasing from 32% to 0%, antibiotic administration from 30% to 1%, and hospital admission from 17% to 2%. Postimplementation, there were 0 SBIs in low-risk infants versus 29.2% in high-risk infants. The percentage of high-risk patients receiving care per pathway remained unchanged. Improvement was sustained for 12 months through QI interventions, including order-set development and e-mail reminders.
Conclusions:
Implementation of a clinical pathway by using QI methods resulted in sustained reduction in invasive interventions for low-risk febrile infants without missed SBIs. Clinical pathways and QI can be key strategies in the delivery of evidence-based care for febrile infants.
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