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Clinical pathway reduces invasive care for febrile infants
Researchers used continuous-process quality improvement to implement a clinical pathway that reduced lumbar punctures, antibiotic use and hospital admission in febrile infants at low risk for serious bacterial infection, according to study results published in Pediatrics.
“Fever is a common reason for [ED] visits in infants,” the researchers wrote. “Fever in infants can be a presenting sign of a serious bacterial infection (SBI), which must be identified and treated promptly to prevent morbidity and mortality.”
According to the researchers, numerous strategies have been studied and proposed for risk stratification of febrile infants, and the criteria vary in regard to use of lumbar puncture (LP), empirical antibiotic administration and hospital admission. Common criteria known as the Rochester criteria do not recommend LP or antibiotics for low-risk infants. The researchers developed an evidence-based clinical pathway that involved risk stratification for SBI based on modified Rochester criteria.
They conducted the study at an urban, tertiary children’s hospital with an annual ED volume of 61,000 patients. They sought to reduce invasive interventions in infants aged 29 to 60 days with a fever who were at low risk for SBI by implementing the clinical pathway supported by quality improvement (QI).
The study included 350 infants who underwent LP, received antibiotics and were admitted to the hospital. The patients were compared “pre- and postpathway implementation with SBI in low-risk infants and appropriate care for high-risk infants as balancing measures.”
During the 3-year study period, 220 infants were included before pathway implementation, and 130 after, the researchers explained. With the pathway implemented, the researchers recorded significant decreases in low-risk infants with LPs (32% to 0%), antibiotic administration (30% to 1%) and hospital admission (17% to 2%).
According to the study findings, no SBIs in low-risk infants were recorded postimplementation vs. 29.2% in high-risk infants. There was no change in the percentage of high-risk patients who received care through the clinical pathway.
“Improvement was sustained for 12 months through QI interventions, including order-set development and email reminders,” the researchers wrote.
“By using continuous-process QI to support the implementation of an evidence-based clinical pathway, we successfully achieved our goal of reducing LPs, antibiotic use, and hospital admission for febrile infants who are at low risk for SBI on the basis of modified Rochester criteria,” they wrote. “This was achieved without detriment to the identification of SBIs or care for the high-risk infants.” – by Bruce Thiel
Disclosures: The researchers report no relevant financial disclosures.
