Internal medicine residents’ evaluation of fevers overnight

Abstract

Background Scant data exists to guide the work-up for fever in hospitalized patients, and little is known about what diagnostic tests medicine residents order for such patients. We sought to analyze how cross-covering medicine residents address fever and how sign-out systems affect their response. Methods We conducted a prospective cohort study to evaluate febrile episodes that residents responded to overnight. Primary outcomes included diagnostic tests ordered, if an in-person evaluation occurred, and the effect of sign-out instructions that advised a “full fever work-up” (FFWU). Results Investigators reviewed 253 fevers in 155 patients; sign-out instructions were available for 204 fevers. Residents evaluated the patient in person in 29 (11%) episodes. The most common tests ordered were: blood cultures (48%), urinalysis (UA) with reflex culture (34%), and chest X-ray (30%). If the sign-out advised an FFWU, residents were more likely to order blood cultures [odds ratio (OR) 14.75, 95% confidence interval (CI) 7.52–28.90], UA with reflex culture (OR 12.07, 95% CI 5.56–23.23), chest X-ray (OR 16.55, 95% CI 7.03–39.94), lactate (OR 3.33, 95% CI 1.47–7.55), and complete blood count (CBC) (OR 3.16, 95% CI 1.17–8.51). In a multivariable regression, predictors of the number of tests ordered included hospital location, resident training level, timing of previous blood culture, in-person evaluation, escalation to a higher level of care, and sign-out instructions. Conclusions Sign-out instructions and a few patient factors significantly impacted cross-cover resident diagnostic test ordering for overnight fevers. This practice can be targeted in resident education to improve diagnostic reasoning and stewardship.

Blood culture utilization practices among febrile and/or hypothermic inpatients

“…[ 12 ] This practice of reflexive blood culture ordering was found to be more prevalent among cross-covering residents at night shift. [ 23 , 24 ] Potential explanation for this observation in the survey include fewer staffing and supervision, and less familiarity with the patients during night shifts and on the weekends. [ 25 ] Our study expands on previous studies [ 12 , 13 ] by providing a better understanding on how variation in shift work and day of the week may influence the clinical decision making around blood culture.…”

Relationship Between the Use of Preprinted Physician Orders for Hospital-Acquired Fever and Time to Blood Culture Collection: A Single-Center Retrospective Cross-Sectional Study

“…There is no standardized approach, and little is known about how physicians respond to fever and the diagnostic tests that are commonly used. 1 In a systematic review by Kaul et al, the incidence of hospital-acquired fever ranged from 2% to 17%, with infections accounting for 37–74% of the cases. 2 Invasive procedures are considered a risk factor for hospital-acquired infections, and the most common infections are pneumonia, urinary tract infections, and bloodstream infections.…”

“…3 Therefore, these infections are the likely cause of hospital-acquired fever. However, the effects of early intervention in such cases have not been studied, 1 and the actual response likely depends on the clinical situation. For example, some studies have shown no significant difference in the timing of antimicrobial administration within 24 h in patients with febrile neutropenia; 4 however, for bacteremia caused by Staphylococcus aureus , even a delay of 1 day in the treatment increases the risk of death.…”