Improving the care of infants with fever

Children’s Hospital of Georgia Joins National Collaborative to Improve the Care of Infants with Fever

Over the past year, through the dedicated work of Drs. Kate Mahoney and Nirupma Sharma, the Children’s Hospital of Georgia hospitalists and emergency medicine physicians participated in a national quality initiative. We want to share what we learned from this project. There is presumed variability nationwide in the management of febrile infants. Despite the variability, the existing data do suggest a “best practices” approach. In 2016 and 2017, the Children’s Hospital of Georgia participated in Project Revise, a national quality improvement effort sponsored by the American Academy of Pediatrics. The project was led by Dr. Eric Biondi, a pediatric hospitalist at Johns Hopkins Hospital. Nationwide, 126 academic and general community hospitals contributed data. The project designers’ primary aims included the following: 1. Decrease admissions for infants ages 7-60 days presenting to EDs with fever who are at low risk of bacterial infection 2. Decrease variation in care of febrile infants presenting to the ED and/or hospital, 3. Decrease length of stay for infants admitted to the hospital with fever, and 4. Decrease unnecessary chest X-rays in the care of febrile infants. Baseline data collected from the 126 participating hospitals showed the following:

The study has shown that there is fair consensus across the country on how to approach a febrile infant. Improvements can be made in expediting discharge from the hospital of low-risk infants. For the other measures studied, a strong majority managed febrile infants as recommended by Project Revise. Project Revise did not mandate blood cultures, nor did they mandate lumbar punctures, although they are generally included in a “full sepsis workup”. We at Children‘s support and are compliant with the goals of the Revise Project. We have adopted the REVISE algorithms of care with minor adjustments relevant to our institution. Areas noted to have improved through the use of a shared algorithm at Children’s included improved length of stay, more appropriately admitted patients and improved urinalysis evaluation. In practice, we advocate cultures of blood, CSF, and urine as part of the sepsis workup in children under 28 days. There is variability between Pediatric ED attendings in the management of older infants, especially regarding the performance of a lumbar puncture. Most if not all febrile infants under 28 days of age are admitted to the hospital. Most febrile infants over that age are sent home if all low-risk criteria are met. It should be noted that Project Revise did not study toxic infants. All toxic appearing infants should have a full sepsis workup, be admitted to the hospital, and be started on broad-spectrum antibiotics. Participating in this collaborative was a learning experience as well as a means of bringing the hospitalists and emergency medicine physicians together in a worthy project. It also afforded us an opportunity to earn MOC credits. Knowing how we approach children with fever hopefully will help our community come together consistently to provide excellent care. There is an APP (application) created by Children’s Mercy Hospital in Kansas that incorporates the elements of the fever algorithms. It is entitled CMPeDS and can be downloaded.