Association of clinical practice guidelines with emergency department management of febrile infants ≤56 days of age

Abstract

Background Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increase healthcare costs. Objective Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants. Design Retrospective cross-sectional study in 2013. Setting Thirty-three hospitals in the Pediatric Health Information System. Patients Infants ≤ 56 days with a diagnosis of fever. Exposures The presence and content of ED-based febrile infant CPGs assessed by electronic survey. Measurements Using generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in two age groups: ≤ 28 days and 29-56 days. We also assessed CPG impact on healthcare costs. Results We included 9,377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤ 28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29-56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (aOR 0.5, 95% CI: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29-56 days at hospitals with CPGs. Conclusions CPG recommendations for febrile infants 29-56 days vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs.

Interpretation of Cerebrospinal Fluid White Blood Cell Counts in Young Infants With a Traumatic Lumbar Puncture

“…29 Similar to previous work, we observed a significantly higher admission rate for older infants with a traumatic LP compared to those without. 2 Our CSF WBC count correction factor would allow almost 600 additional infants age 29–60 days without bacterial meningitis to be appropriately classified as not having CSF pleocytosis for every misclassified case of bacterial meningitis.…”

Impact of Enteroviral Polymerase Chain Reaction Testing on Length of Stay for Infants 60 Days Old or Younger

“…First, prior investigations each were conducted at a single center, where clinical care could have been more determined by protocol. 23 Our study demonstrates the impact of a positive EV PCR test result across clinical settings, which increases the generalizability of our findings. Second, our substantially larger sample size allowed stratification of results by patient age (infants 0 to 28 days vs 29 to 60 days) as well as by the presence of CSF pleocytosis.…”

Development and implementation of a mobile device-based pediatric electronic decision support tool as part of a national practice standardization project

“…(2015) found that use of antibiotics, invasive diagnostic tests, and hospitalization for febrile infants varied significantly 9 . Implementation of institutional clinical practice guidelines (CPGs) is associated with substantially decreased variation in care, but the specific content of these CPGs remains unstandardized 10 . Therefore, developing and disseminating standardized CPGs across a broad range of institutions could have a profound impact on the management of febrile infants nationally.…”