Reducing Invasive Care for Low-risk Febrile Infants Through Implementation of a Clinical Pathway

Abstract

BACKGROUND AND OBJECTIVES: Significant variation in management of febrile infants exists both nationally and within our institution. Risk stratification can be used to identify low-risk infants who can be managed as outpatients without lumbar puncture (LP) or antibiotics. Our objective was to reduce invasive interventions for febrile infants aged 29 to 60 days at low risk for serious bacterial infection (SBI) through implementation of a clinical pathway supported by quality improvement (QI). METHODS: The evidence-based clinical pathway was developed and implemented by a multidisciplinary team with continuous-process QI to sustain use. Low-risk infants who underwent LP, received antibiotics, and were admitted to the hospital were compared pre-and postpathway implementation with SBI in low-risk infants and appropriate care for highrisk infants as balancing measures. RESULTS: Of 350 included patients, 220 were pre-and 130 were postpathway implementation. With pathway implementation in July 2016, invasive interventions decreased significantly in low-risk infants, with LPs decreasing from 32% to 0%, antibiotic administration from 30% to 1%, and hospital admission from 17% to 2%. Postimplementation, there were 0 SBIs in lowrisk infants versus 29.2% in high-risk infants. The percentage of high-risk patients receiving care per pathway remained unchanged. Improvement was sustained for 12 months through QI interventions, including order-set development and e-mail reminders. CONCLUSIONS: Implementation of a clinical pathway by using QI methods resulted in sustained reduction in invasive interventions for low-risk febrile infants without missed SBIs. Clinical pathways and QI can be key strategies in the delivery of evidence-based care for febrile infants.

Parenteral Antibiotic Use Among Ambulatory Children in United States Children’s Hospital Emergency Departments

“…The evaluation of the febrile infant <2 months of age includes assessment for invasive bacterial infection (bacteremia, UTI, and/or meningitis) and often includes hospital admission and empiric antibiotic administration. However, recent efforts have focused on identifying lower-risk infants who may be managed with fewer invasive interventions with or without oral or parenteral antibiotics in the ambulatory setting [ 23 ]. Febrile neonate evaluation is among the most common conditions managed in pediatric EDs [ 24 ], and these lower-risk infants managed in the ambulatory setting may have contributed to the parenteral antibiotic use we observed in this age group.…”

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“…departmental coordination, equipment deployment, and rules on leave). The variations can be divided into positive and negative categories based on their nature [26].…”

Disparities and implicit bias in the management of low-risk febrile infants: a mixed methods study protocol

“…[1][2][3][4] Clinical guidelines that seek to standardise care and decrease medical overuse recommend against routinely pursuing additional interventions for febrile infants aged 29-60 days with normal blood and urine screening tests. [4][5][6][7] The use of clinical guidelines has been associated with fewer potentially unnecessary additional interventions. [5][6][7][8][9] Yet, there…”