Effect of Combined Clinical Practice Guideline and Electronic Order Set Implementation on Febrile Infant Evaluation and Management

Abstract

Objective Management of febrile infants 60 days and younger for suspected serious infection varies widely. Clinical practice guidelines (CPGs) are intended to improve clinician adherence to evidence-based practices. In 2011, a CPG for managing febrile infants was implemented in an urban children's hospital with simultaneous release of an electronic order set and algorithm to guide clinician decisions for managing infants for suspected serious bacterial infection. The objective of the present study was to determine the association of CPG implementation with order set use, clinical practices, and clinical outcomes. Methods Records of febrile infants 60 days and younger from February 1, 2009, to January 31, 2013, were retrospectively reviewed. Clinical documentation, order set use, clinical management practices, and outcomes were compared pre-CPG and post-CPG release. Results In total, 1037 infants pre-CPG and 930 infants post-CPG implementation were identified. After CPG release, more infants 29 to 60 days old underwent lumbar puncture (56% vs 62%, P = 0.02). Overall antibiotic use and duration of antibiotic use decreased for infants 29 to 60 days (57% vs 51%, P = 0.02). Blood culture and urine culture obtainment remained unchanged for older infants. Diagnosed infections, hospital readmissions, and length of stay were unchanged. Electronic order sets were used in 80% of patient encounters. Conclusions Antibiotic use and lumbar puncture performance modestly changed in accordance with CPG recommendations provided in the electronic order set and algorithm, suggesting that the presence of embedded prompts may affect clinician decision-making. Our results highlight the potential usefulness of these decision aids to improve adherence to CPG recommendations.

Decreasing Hospital Observation Time for Febrile Infants

“…Similar to previous studies aimed at improving diagnosis and management among febrile infants, [13][14][15][16] generation and structured dissemination of an institutional evidence-based guideline was crucial to safely shortening COT in our population. These prior studies established a goal COT of 36 to 42 hours for hospitalized febrile infants.…”

A cluster randomized stepped-wedge trial to de-implement unnecessary post-operative antibiotics in children: the optimizing perioperative antibiotic in children (OPerAtiC) trial

“…Two strategies, order set review and modification, and order set review and modification plus enhanced facilitation, will be compared. These strategies have been successful in previous healthcare implementation efforts but have not been directly compared [19,[43][44][45][46]. As each hospital receives their facilitation training, we hypothesize that participants' beliefs in this process will improve.…”

Piloting a Mobile Clinical Decision Support Application for Pediatric Clinical Guidelines

“…1 One method to promote more uniform and streamlined care is the implementation of clinical guidelines which have been shown to improve numerous outcome metrics such as appropriate resource use, hospital length-of-stay, and cost. [2][3][4][5][6][7] Despite promotion of clinical guidelines, however, clinician uptake and adoption vary due to persistent barriers involving guideline access at point of care, usability concerns, guideline updating, and incorporation with workflow cognitive demands. [4][5][6][7][8][9][10] Clinical Decision Support Systems (CDSSs) are a heterogeneous collection of information systems that may improve guideline adherence by encoding guideline content into the CDSS itself.…”