Connecticut Children's Medical Center, Hartford, Connecticut;
School of Medicine, University of Connecticut, Farmington, Connecticut; and.
Pediatrics. 2019 Mar;143(3). doi: 10.1542/peds.2018-1610. Epub 2019 Feb 6.
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).
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 high-risk infants as balancing measures.
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 low-risk 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.
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.
在全国范围内和我们的机构内，发热婴儿的治疗存在显著差异。风险分层可用于识别低危婴儿，这些婴儿可以在门诊接受治疗，无需腰椎穿刺（LP）或抗生素。我们的目标是通过实施临床路径并辅以质量改进（QI），减少低危、年龄在 29 至 60 天、有严重细菌感染（SBI）风险的发热婴儿的侵入性干预。
由多学科团队制定并实施循证临床路径，并通过持续的过程 QI 来维持其使用。将接受 LP、使用抗生素和住院的低危婴儿与实施路径前后的低危婴儿的 SBI 和高危婴儿的适当治疗进行比较，作为平衡措施。
在 350 名纳入的患者中，220 名是实施前，130 名是实施后。2016 年 7 月实施路径后，低危婴儿的侵入性干预显著减少，LP 从 32%降至 0%，抗生素使用从 30%降至 1%，住院率从 17%降至 2%。实施后，低危婴儿中无 SBI，高危婴儿中为 29.2%。按照路径接受治疗的高危患者比例保持不变。通过 QI 干预，包括医嘱集开发和电子邮件提醒，持续改善了 12 个月。
通过使用 QI 方法实施临床路径，持续减少了低危发热婴儿的侵入性干预，而未遗漏 SBI。临床路径和 QI 可以成为发热婴儿提供循证护理的关键策略。
