Divisions of Hospital Medicine.
Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
Pediatrics. 2019 Aug;144(2). doi: 10.1542/peds.2018-0262.
Neonatal herpes simplex virus (HSV) infections are associated with high mortality and long-term morbidity. However, incidence is low and acyclovir, the treatment of choice, carries risk of toxicity. We aimed to increase the percentage of patients 0 to 60 days of age who are tested and treated for HSV in accordance with local guideline recommendations from 40% to 80%.
This quality improvement project took place at 1 freestanding children's hospital. Multiple plan-do-study-act cycles were focused on interventions aimed at key drivers including provider buy-in, guideline availability, and accurate identification of high-risk patients. A run chart was used to track the effect of interventions on the percentage managed per guideline recommendations over time by using established rules for determining special cause. Pre- and postimplementation acyclovir use was compared by using a χ test. In HSV-positive cases, delayed acyclovir initiation, defined as >1 day from presentation, was tracked as a balancing measure.
The median percentage of patients managed according to guideline recommendations increased from 40% to 80% within 8 months. Acyclovir use decreased from 26% to 7.9% ( < .001) in non-high-risk patients but did not change significantly in high-risk patients (73%-83%; = .15). There were no cases of delayed acyclovir initiation in HSV-positive cases.
Point-of-care availability of an evidence-based guideline and interventions targeted at provider engagement improved adherence to a new guideline for neonatal HSV management and decreased acyclovir use in non-high-risk infants. Further study is necessary to confirm the safety of these recommendations in other settings.
新生儿单纯疱疹病毒（HSV）感染与高死亡率和长期发病有关。然而，发病率较低，而阿昔洛韦是首选治疗药物，但具有毒性风险。我们的目的是将符合当地指南推荐的 0 至 60 天龄的 HSV 检测和治疗患者比例从 40%提高到 80%。
本质量改进项目在一家独立的儿童医院进行。多个计划-执行-研究-行动循环侧重于针对关键驱动因素的干预措施，包括提供者认同、指南可用性以及准确识别高危患者。使用确定特殊原因的既定规则，通过运行图来跟踪干预措施对符合指南推荐的患者管理百分比随时间的变化效果。通过 χ 检验比较实施前后阿昔洛韦的使用情况。在 HSV 阳性病例中，将延迟开始阿昔洛韦治疗（定义为从就诊到开始治疗的时间超过 1 天）作为平衡措施进行跟踪。
在 8 个月内，根据指南建议管理的患者比例中位数从 40%提高到 80%。非高危患者的阿昔洛韦使用率从 26%降至 7.9%（<0.001），但高危患者的阿昔洛韦使用率没有明显变化（73%-83%；=0.15）。在 HSV 阳性病例中，没有发现延迟开始阿昔洛韦治疗的情况。
基于证据的指南的即时可用性和针对提供者参与的干预措施改善了对新生儿 HSV 管理新指南的遵循，并减少了非高危婴儿中阿昔洛韦的使用。需要进一步研究以确认这些建议在其他环境中的安全性。
