Gupta Joel, Zipursky Amy R, Pirie Jonathan, Freire Gabrielle, Karin Amir, Bohn Mary Kathryn, Adeli Khosrow, Ostrow Olivia
Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada.
Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada.
Paediatr Child Health. 2023 Nov 20;29(3):135-143. doi: 10.1093/pch/pxad070. eCollection 2024 Jun.
Significant practice variation exists in managing young infants with fever. Quality improvement strategies can aid in risk stratification and standardization of best care practices, along with a reduction of unnecessary interventions. The aim of this initiative was to safely reduce unnecessary admissions, antibiotics, and lumbar punctures (LPs) by 10% in low-risk, febrile infants aged 29 to 90 days presenting to the emergency department (ED) over a 12-month period.
Using the Model for Improvement, a multidisciplinary team developed a multipronged intervention: an updated clinical decision tool (CDT), procalcitonin (PCT) adoption, education, a feedback tool, and best practice advisory (BPA) banner. Outcome measures included the proportion of low-risk infants that were admitted, received antibiotics, and had LPs. Process measures were adherence to the CDT and percentage of PCT ordered. Missed bacterial infections and return visits were balancing measures. The analysis was completed using descriptive statistics and statistical process control methods.
Five hundred and sixteen patients less than 90 days of age were included in the study, with 403 patients in the 29- to 90-day old subset of primary interest. In the low-risk group, a reduction in hospital admissions from a mean of 24.1% to 12.0% and a reduction in antibiotics from a mean of 15.2% to 1.3% was achieved. The mean proportion of LPs performed decreased in the intervention period from 7.5% to 1.8%, but special cause variation was not detected. Adherence to the CDT increased from 70.4% to 90.9% and PCT was ordered in 92.3% of cases. The proportion of missed bacterial infections was 0.3% at baseline and 0.5% in the intervention period while return visits were 6.7% at baseline and 5.0% in the intervention period.
The implementation of a quality improvement strategy, including an updated evidence-based CDT for young infant fever incorporating PCT, safely reduced unnecessary care in low-risk, febrile infants aged 29 to 90 days in the ED.
To develop and implement a multipronged improvement strategy including an evidence-based CDT utilizing PCT to maximize value of care delivered to well-appearing, febrile infants presenting to EDs.
在管理发热的小婴儿方面存在显著的实践差异。质量改进策略有助于进行风险分层和规范最佳护理实践，同时减少不必要的干预措施。该倡议的目的是在12个月内，使前往急诊科（ED）就诊的29至90日龄低风险发热婴儿的不必要住院、抗生素使用和腰椎穿刺（LP）减少10%。
多学科团队采用改进模型制定了多管齐下的干预措施：更新临床决策工具（CDT）、采用降钙素原（PCT）、开展教育、使用反馈工具以及设置最佳实践建议（BPA）横幅。结果指标包括低风险婴儿的住院比例、接受抗生素治疗的比例以及进行LP的比例。过程指标为对CDT的依从性和PCT检测医嘱的百分比。漏诊细菌感染和复诊情况为平衡指标。分析采用描述性统计和统计过程控制方法完成。
516名年龄小于90日龄的患者纳入研究，其中403名患者属于主要关注的29至90日龄亚组。在低风险组中，住院率从平均24.1%降至12.0%，抗生素使用率从平均15.2%降至1.3%。干预期间进行LP的平均比例从7.5%降至1.8%，但未检测到特殊原因变异。对CDT的依从性从70.4%提高到90.9%，92.3%的病例开具了PCT检测医嘱。基线时漏诊细菌感染的比例为0.3%，干预期间为0.5%；基线时复诊率为6.7%，干预期间为5.0%。
实施包括更新后的基于证据的小婴儿发热CDT（纳入PCT）在内的质量改进策略，安全地减少了29至90日龄前往ED就诊的低风险发热婴儿的不必要护理。
制定并实施多管齐下的改进策略，包括利用PCT的基于证据的CDT，以最大化向外观良好的发热婴儿提供的护理价值，这些婴儿前往ED就诊。
