Improving the Evidence-based Care of Febrile Neonates: A Quality Improvement Initiative

Our emergency department updated our care algorithm to provide evidence-based, standardized care to 0- to 60-day-old febrile neonates. Specifically, we wanted to increase the proportion of visits for which algorithm-adherent care was provided from 90% to 95% for infants 0-28 days, and from 67% to 95% for infants 29-60 days, by June 30, 2020.

Our emergency medicine team outlined our theory for improvement and used multiple plan-do-study-act cycles to test interventions aimed at key drivers. Interventions included constructing an updated care algorithm, clinician, and nurse education, integrating an updated opt-out order set, and streamlined discharge instructions. Our primary outcome was the proportion of patient encounters in which clinicians ordered algorithm-adherent care. In addition, our quality improvement team manually reviewed all failures to determine the reasons for failure and inform further interventions.

We evaluated 2,248 visits between January 2018 and October 2021. Algorithm-adherent care for 29- to 60-day-old infants improved from 67% to 92%. Algorithm-adherent care for 0- to 28-day infants improved from 90% to 96%. We sustained these improvements for 22 months. Failure to adhere to the algorithm in the 29- to 60-day-old infant group was primarily due to clinicians not ordering procalcitonin.

Using quality improvement methods, we successfully increased algorithm-adherent evaluation of febrile neonates 0-60 days old in our pediatric emergency departments. Education and opt-out order sets were keys to implementing our new algorithm.