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Impact on Emergency Department Interventions After Implementing a Guideline Based on the Pediatric Emergency Care
Gargi Mukherjee1, Evan Orenstein, Shabnam Jain
1From the Department of Pediatrics, Emory University/Children's Healthcare of Atlanta, Atlanta, GA.
Insights
Implementing a clinical guideline based on the Pediatric Emergency Care Applied Research Network (PECARN) prediction rule reduced lumbar punctures and antibiotic use in low-risk febrile infants. Overall lumbar puncture rates decreased, with no change in serious bacterial infections or admissions.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Practice Guidelines
- Infectious Disease
Background:
- The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule aids in identifying febrile infants at low risk for serious bacterial infection (SBI).
- The impact of this rule on reducing unnecessary interventions in emergency departments was previously unknown.
Purpose of the Study:
- To evaluate the effect of a clinical practice guideline, based on the PECARN prediction rule, on lumbar puncture (LP) rates, empiric antibiotic use, and hospital admissions.
- The study focused on infants aged 29 to 60 days presenting with fever in a pediatric emergency department.
Main Methods:
- A pre-post intervention study design was employed, comparing data from November 2018 to November 2021.
- A clinical practice guideline utilizing the PECARN prediction rule was implemented in December 2019.
- Lumbar puncture attempts, antibiotic administration, and admissions were analyzed pre- and post-guideline implementation, stratified by risk groups.
Main Results:
- Overall lumbar puncture rates significantly decreased post-guideline implementation (30.6% to 22.6%).
- Low-risk infants showed significant reductions in LPs (17.2% to 4.4%) and antibiotic use (14.5% to 4.1%).
- No significant changes were observed in overall antibiotic use, admissions, or missed serious bacterial infections, including meningitis.
Conclusions:
- Implementation of a guideline based on the PECARN prediction rule successfully reduced lumbar punctures and antibiotic use in low-risk febrile infants.
- The guideline led to an overall decrease in LPs without compromising the detection of serious bacterial infections or altering admission rates.
Background:
The Pediatric Emergency Care Applied Research Network (PECARN) prediction rule identifies febrile infants at low risk for serious bacterial infection (SBI). However, its impact on avoidable interventions in the emergency department remains unknown.
Objective:
To study the impact on lumbar puncture (LP) performance, empiric antibiotic use, and admissions after implementing a febrile infant clinical practice guideline for infants aged 29 to 60 days based on the PECARN prediction rule in the pediatric emergency department.
Methods:
This single center preintervention to postintervention study included infants 29 to 60 days old who presented with a chief complaint of fever from November 2018 to November 2021 and were assessed for SBI via blood culture and either urinalysis or urine culture. A new clinical practice guideline based on the PECARN prediction rule was implemented on December 2019. Lumbar puncture attempts, antibiotic administration, and admissions were compared preimplementation and postimplementation and in subgroups of low- and high-risk patients.
Results:
Of 1597 (PRE: 785, POST: 812) infants presenting with fever, 1032 (PRE: 500, POST: 532) met inclusion criteria. Adoption of guideline recommendations (measured as procalcitonin order rate) was 89.7% in eligible infants postimplementation. Overall, there was a significant decrease in LPs (PRE: 30.6%, POST: 22.6%, P < 0.05) and no significant change in antibiotics or admissions. Among low-risk infants, there was a significant reduction in LPs (PRE: 17.2%, POST: 4.4%, P < 0.05) and antibiotics (PRE: 14.5%, POST: 4.1%; P < 0.05). There was no change in missed SBI (PRE: 3, POST: 2, P = 0.65). No cases of missed meningitis preimplementation or postimplementation were observed.
Conclusions:
After implementation of a guideline based on the PECARN prediction rule, we observed a reduction of LPs and antibiotics in low-risk infants. Overall, a decrease in LPs was observed, whereas antibiotic use and admissions remained unchanged.
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