BACKGROUND AND OBJECTIVES: 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). METHODS: 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 highrisk infants as balancing measures. RESULTS: 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 lowrisk 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. CONCLUSIONS: 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.
Introduction:
Timely administration of corticosteroids improves asthma care in the pediatric emergency department (ED). Using the Model for Improvement, we aimed to decrease time to delivery of corticosteroids in patients presenting to the ED with an acute asthma exacerbation.
Methods:
This is a single-center, prospective, multidisciplinary quality improvement (QI) project targeting ED patients 1−18 years of age with an acute asthma exacerbation. We collected 5 months of baseline data from the arrival time of an ED patient with an asthma exacerbation with a Modified Pulmonary Index Score ≥5 to the time of administration of corticosteroids. A quality improvement project was launched in October 2017 involving multiple Plan-Do-Study-Act ramps. Improvement interventions continued for 9 months through June 2018, including reeducation of residents and nurses in the ED asthma order set and nursing treatment protocols, respectively, and changes to the electronic health record. Data were tacked for 15 additional months until September 2019. To promote the use of the nursing treatment protocol, we utilized real-time improvement feedback and continuing nursing education.
Results:
The mean percentage of patients receiving steroids within 60 minutes of arrival improved from 59.3% to 84.3% over the first 5 months. The mean time to the administration of steroids within 60 minutes of arrival improved from 71.4 to 48.1 minutes. There was no increase in ED return rates.
Conclusions:
Our project improved the percentage of patients with acute asthma exacerbations receiving steroids within 60 minutes of ED arrival and mean time to administration of steroids. We sustained improvement for 18 months after the implementation of our QI interventions.
Simple educational initiatives can improve the use of topical anesthetics. By using educational tools as part of a quality improvement initiative, we were able to significantly improve the rates of LET gel application for facial lacerations in children and decrease the time to administration.
Controversies persist about the diagnosis and management of Lyme disease. Recently published guidelines and primary research can aid clinicians in diagnosing Lyme properly.
Pediatric patients with dilated cardiomyopathy can initially be present for medical attention with non-specific and misleading signs and symptoms. We present the case of a 7-year-old girl with vague complaints of fever, vomiting, and abdominal pain and cardiac murmur on physical exam who progressed to congestive heart failure before her dilated cardiomyopathy was diagnosed. Clinicians should maintain a high index of suspicion for dilated cardiomyopathy in any patient with cardiac murmur and systematic symptoms.
Information shared by parents on written forms designed to capture needs and expectations provides potential value to a patient-centered ED system. The high level of informational value is consistent across patient type and acuity level.
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