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An Emergency Department Quality Improvement Project to Decrease Lumbar Puncture Rates in Febrile Infants 22 to 28
Jessica M Kelly1, Brandon C Ku1, Payal Gala1
1From the Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pa.
Insights
This study reduced lumbar puncture (LP) rates in febrile infants aged 22-28 days from 87% to 44% using quality improvement methods. These changes were safely implemented without increasing missed bacterial meningitis cases.
Area of Science:
- Pediatrics
- Quality Improvement Science
- Infectious Disease Management
Background:
- Historically, universal lumbar puncture (LP) was standard for well-appearing, febrile infants aged 22-28 days.
- The American Academy of Pediatrics updated guidelines in 2021, recommending LPs only when inflammatory markers are abnormal for this age group.
- A quality improvement project was initiated to decrease LP rates in emergency departments for febrile infants aged 22-28 days.
Purpose of the Study:
- To reduce lumbar puncture (LP) rates in febrile infants aged 22-28 days in the emergency department.
- To achieve a significant decrease from a baseline rate of 87% within one year.
- To ensure reductions were equitable across all racial and ethnic groups.
Main Methods:
- Implementation of a quality improvement framework utilizing Plan-Do-Study-Act cycles.
- Multidisciplinary team review of literature, local epidemiology, and key drivers for LP performance.
- Departmental education, clinical pathway updates, and integration of clinical decision support tools.
Main Results:
- Lumbar puncture (LP) rates decreased from a baseline of 87% to 44% during the intervention period.
- No significant disparities in LP rates were observed across different racial/ethnic groups.
- Procalcitonin testing rates increased, and no adverse events related to missed bacterial meningitis were detected.
Conclusions:
- Quality improvement initiatives effectively and safely reduced lumbar puncture (LP) rates in febrile infants aged 22-28 days.
- The interventions included education, updated clinical pathways, and decision support.
- The project demonstrated a successful reduction in invasive procedures while maintaining patient safety.
Introduction:
Most providers have routinely performed universal lumbar puncture (LP) on well-appearing, febrile infants 22 to 28 days old. In 2021, the American Academy of Pediatrics recommended clinicians should perform an LP in this age group if inflammatory markers are abnormal. This quality improvement project aimed to decrease LP rates in febrile infants 22 to 28 days old in the emergency department (ED) within 1 year, regardless of race/ethnicity, from a baseline of 87%.
Methods:
We used our institution's quality improvement framework to perform multiple Plan-Do-Study-Act cycles. A multidisciplinary team reviewed the febrile infant literature, local epidemiology, and identified key drivers. We provided departmental education, updated our clinical pathway, and used clinical decision support. We analyzed baseline (January 2017-March 2022) and intervention data (April 2022-March 2024) and tracked data using statistical process control charts. Our primary outcome measure was rates of LP in the ED for this cohort. Process measures included rates of infants with procalcitonin results. ED length of stay, rates of first LP attempt after hospitalization, and missed bacterial meningitis were balancing measures.
Results:
The baseline LP rate of 87% decreased to 44% during the intervention period, resulting in a downward centerline shift. There were no significant differences when LP rates were analyzed by race/ethnicity. There was an upward centerline shift in the process measure of infants with procalcitonin results. There was no observed special cause variation in our balancing measures.
Conclusion:
Quality improvement efforts, including education, clinical pathway updates, and clinical decision support, safely reduced rates of LPs in febrile infants 22 to 28 days old.
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