Rapid Implementation of Evidence-Based Guidelines for Imaging After First Urinary Tract Infection

Abstract

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics published a new guideline for management of first urinary tract infection (UTI) in children aged 2 to 24 months in September 2011. The imaging evaluation changed from the previous guideline to recommend voiding cystourethrogram (VCUG) only for patients with an abnormal renal and bladder ultrasound (RBUS). The objective was to decrease the proportion of guideline-eligible children with a normal RBUS who underwent VCUG from median of 92% for patients treated as inpatients and 100% for patients treated in the emergency department to 5% in both settings. METHODS:This was a quality improvement implementation study in a large academic medical center. Key drivers included: appropriate guideline knowledge, timely identification of guideline eligible patients, and effective communication with the community-based primary care provider. A multidisciplinary team developed and tested interventions. Impact was assessed with annotated run charts. Statistical comparisons were made with x 2 analysis and Fisher' s exact test. RESULTS:The proportion of children with first UTI and normal RBUS who underwent VCUG decreased from a median of 92% to 0% within 1 month of initiating the project among those hospitalized and from 100% to 40% within 4 months among those diagnosed in the emergency department. Rates have been sustained for 12 months and 8 months, respectively. Interventions using the electronic medical record and ordering system were most impactful.CONCLUSIONS: Rapid adoption of evidence-based UTI care across multiple settings is achievable. Practice change occurred faster and to a greater magnitude in the inpatient setting compared with the outpatient setting. Pediatrics 2013;132:e749-e755

Current primary care management of children aged 1–36 months with urinary tract infections in Europe: large scale survey of paediatric practice

“…In this regard, a recent paper described a quality improvement implementation study aimed at achieving acceptance of AAP recommendations on when to perform a voiding cystourethrogram (VCUG) across multiple settings. The authors were able to achieve substantial adherence to the new recommendations in a short period of time (4 months) 24. A further study showed a reduction in MCU requests and in prescriptions for antibiotic prophylaxis during the 2 years following publication of the NICE guidelines 25.…”

Impact of a Bronchiolitis Guideline on ED Resource Use and Cost: A Segmented Time-Series Analysis

“…Previous studies have shown that guideline adoption is usually slower and more challenging in outpatient compared with inpatient settings. 31,32 We believe the speed of adoption of the guideline recommendations after implementation and the sustainability of improvements in our ED are probably indicative of the robustness of our implementation strategy. Despite similar ED volumes during both periods, ED LOS also decreased by 41 minutes.…”

Pediatric Urology

“…Surgery in combination with systemic therapy is the treatment of choice [ 61 ]. Surgery in combination with systemic therapy is the treatment of choice [ 61 ].…”

“…Moreover, sodium entry into the collecting duct principal cell is via the epithelial sodium channel (ENaC). This is refl ected by an increase in the expression of EnaC as the infant matures [ 61 ]. Part of the reason for the excess excretion of sodium seems to be resistance to the effect of aldosterone on sodium transport in the tubule [ 58 ].…”