Reducing Variability in the Infant Sepsis Evaluation (REVISE): A National Quality Initiative

Abstract

BACKGROUND: Substantial variability exists in the care of febrile, well-appearing infants. We aimed to assess the impact of a national quality initiative on appropriate hospitalization and length of stay (LOS) in this population. METHODS: The initiative, entitled Reducing Variability in the Infant Sepsis Evaluation (REVISE), was designed to standardize care for well-appearing infants ages 7 to 60 days evaluated for fever without an obvious source. Twelve months of baseline and 12 months of implementation data were collected from emergency departments and inpatient units. Ill-appearing infants and those with comorbid conditions were excluded. Participating sites received change tools, run charts, a mobile application, live webinars, coaching, and a LISTSERV. Analyses were performed via statistical process control charts and interrupted time series regression. The 2 outcome measures were the percentage of hospitalized infants who were evaluated and hospitalized appropriately and the percentage of hospitalized infants who were discharged with an appropriate LOS. RESULTS: In total, 124 hospitals from 38 states provided data on 20 570 infants. The median site improvement in percentages of infants who were evaluated and hospitalized appropriately and in those with appropriate LOS was 5.3% (interquartile range = 22.5% to 13.7%) and 15.5% (interquartile range = 2.9 to 31.3), respectively. Special cause variation toward the target was identified for both measures. There was no change in delayed treatment or missed bacterial infections (slope difference 0.1; 95% confidence interval, 28.3 to 9.1). CONCLUSIONS: Reducing Variability in the Infant Sepsis Evaluation noted improvement in key aspects of febrile infant management. Similar projects may be used to improve care in other clinical conditions.

United States’ Emergency Department Visits for Fever by Young Children 2007-2017

“…Quality-based measures, such as the recently reported Reducing Excessive Variability in the Infant Sepsis Evaluation, which includes clinical algorithms, order sets, education, and a mobile phone application for the management of febrile infants, can reduce variability with respect to hospital admission and lengths of stay. 27 Bacteremia is relatively uncommon among infants >90 days of age. In one multicenter review of 57,000 blood cultures from children 3-36 months of age, rates of bacteremia were <0.5%.…”

Learning from Each Other: A Multisite Collaborative to Reduce Electrolyte Testing

“…Similar variability in improvement has been previously described in other large-scale QI collaborative projects. 30 – 32 In our collaborative, sites varied in several factors highlighted in Table 1 . Local operational and demographic factors can significantly affect intervention success.…”

Testing for Meningitis in Febrile Well-Appearing Young Infants With a Positive Urinalysis

“…15,16 The goal of REVISE was to increase the rate of appropriate evaluation, hospitalization, and length of stay (LOS) for well-appearing febrile infants aged 7 to 60 days presenting to the emergency department (ED) or inpatient setting. 17 Of note, there were no specific recommendations on when to obtain CSF testing included as part of the intervention package for this project. A total of 124 universityaffiliated and community hospitals participated, and deidentified data were collected retrospectively on eligible patients evaluated from September 2015 to November 2017.…”