Enhancing Care of Young Febrile Infants in Hawai'i: A Quality Improvement Initiative to Reduce Unnecessary
Jannet Lee-Jayaram1, Benetta Chin2, Robert Pantell3
1John A Burns School of Medicine SimTiki Simulation Center, University of Hawai'i at Mānoa.
Insights
A quality improvement initiative successfully aligned clinical practice with American Academy of Pediatrics guidelines for febrile infants, significantly reducing hospitalizations and unnecessary procedures like lumbar punctures.
Area of Science:
- Pediatrics
- Infectious Disease
- Quality Improvement
Background:
- Young infants (<60 days) are vulnerable to invasive bacterial infections.
- Evolving epidemiology necessitates updated risk stratification and management guidelines.
- The American Academy of Pediatrics (AAP) issued guidelines in 2021 for febrile infants (8-60 days).
Purpose of the Study:
- To implement and evaluate a quality improvement initiative aligning clinical practice with 2021 AAP guidelines for infants 22-60 days with fever.
- To reduce unnecessary hospitalizations, lumbar punctures, and antibiotic use in this population.
Main Methods:
- A quality improvement initiative was implemented at a pediatric hospital in Hawai'i.
- Practices were aligned with the 2021 AAP clinical practice guidelines for evaluating and managing febrile infants aged 22-60 days.
- Data on admission rates, lumbar puncture rates, and antibiotic use were collected before and after implementation.
Main Results:
- Infant admission rates for ages 22-60 days decreased from 19% to 2% (P=.010).
- Lumbar puncture rates for infants 22-60 days decreased significantly from 83% to 20% (P<.0001).
- Antibiotic use in infants 29-60 days with normal inflammatory markers and urinalysis decreased from 74% to 20% (P<.0001), with no increase in delayed diagnoses.
Conclusions:
- Implementation of the quality improvement initiative successfully aligned institutional practice with AAP guidelines.
- Adherence to guidelines led to a significant reduction in hospitalizations, lumbar punctures, and antibiotic administration.
- The initiative demonstrated effective clinical practice change without compromising patient safety regarding invasive bacterial infections.
Abstract:
Young infants under the age of 60 days are at high risk of invasive bacterial infection. Historically, several different criteria were developed to risk stratify this population and guide management yet since then epidemiology of invasive bacterial infection has changed. In 2021, the American Academy of Pediatrics released a clinical practice guideline on the evaluation and management of well-appearing infants aged 8 to 60 days with fever, with subcategories 8-21 days, 22-28 days, and 29-60 days. At the only pediatric hospital in the state of Hawai'i, practices for evaluation and management of infants 22-60 days differed from the published clinical practice guidelines. In 2022, a local quality improvement initiative was implemented in connection to a larger national quality improvement initiative to align the institution's practice with the guidelines, thereby decreasing unnecessary hospitalizations, procedures, and medications. After implementation, the admission rate for infants 22 to 60 days decreased significantly from 19% to 2% (P=.010). Lumbar puncture rates decreased for infants 22 to 60 days from 39 out of 47 (83%) to 12 out of 59 (20%) (P<.0001). There was a significant decrease in the number of infants 29 to 60 days with normal inflammatory markers and normal urinalysis who received antibiotics 74% to 20% (P<.0001). There was no increase in delayed diagnosis of invasive bacterial infection (P=NS). Within one year of implementation, there was significant change in clinical practice with adherence to the clinical practice guideline, resulting in fewer unnecessary hospitalizations, antibiotic administration, and lumbar punctures.
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