Effect of Combined Clinical Practice Guideline and Electronic Order Set Implementation on Febrile Infant Evaluation and Management

Decreasing Hospital Observation Time for Febrile Infants

BACKGROUND

Febrile infants aged 0 to 60 days are often hospitalized for a 36-to-48 hour observation period to rule out invasive bacterial infections (IBI). Evidence suggests that monitoring blood and cerebrospinal fluid (CSF) cultures for 24 hours may be appropriate for most infants. We aimed to decrease the average culture observation time (COT) from 38 to 30 hours among hospitalized infants 0 to 60 days old over 12 months.

METHODS

This quality improvement initiative occurred at a large children's hospital, in conjunction with development of a multidisciplinary evidence-based guideline for the management of febrile infants. We included infants aged 0 to 60 days admitted with fever without a clear infectious source. We excluded infants who had positive blood, urine, or CSF cultures within 24 hours of incubation and infants who were hospitalized for other indications (eg, bronchiolitis). Interventions included guideline dissemination, education regarding laboratory monitoring practices, standardized order sets, and near-time identification of failures. Our primary outcome was COT, defined as time between initiation of culture incubation and hospital discharge in hours. Interventions were tracked on an annotated statistical process control chart. Our balancing measure was identification of IBI after hospital discharge.

RESULTS

In our cohort of 184 infants aged 0 to 60 days, average COT decreased from 38 hours to 32 hours after structured guideline dissemination and order-set standardization; this decrease was sustained over 17 months. IBI was not identified in any patients after discharge.

CONCLUSIONS

Implementation of an evidence-based guideline through education, transparency of laboratory procedures, creation of standardized order sets, and near-time feedback was associated with shorter COT for febrile infants aged 0 to 60 days.

A cluster randomized stepped-wedge trial to de-implement unnecessary post-operative antibiotics in children: the optimizing perioperative antibiotic in children (OPerAtiC) trial

BACKGROUND

Antibiotic-resistant infections have become a public health crisis that is driven by the inappropriate use of antibiotics. In the USA, antibiotic stewardship programs (ASP) have been established and are required by regulatory agencies to help combat the problem of antibiotic resistance. Post-operative antibiotic use in surgical cases deemed low-risk for infection is an area with significant overuse of antibiotics in children. Consensus among leading public health organizations has led to guidelines eliminating post-operative antibiotics in low-risk surgeries. However, the best strategies to de-implement these inappropriate antibiotics in this setting are unknown.

METHODS/DESIGN

A 3-year stepped wedge cluster randomized trial will be conducted at nine US Children's Hospitals to assess the impact of two de-implementation strategies, order set change and facilitation training, on inappropriate post-operative antibiotic prescribing in low risk (i.e., clean and clean-contaminated) surgical cases. The facilitation training will amplify order set changes and will involve a 2-day workshop with antibiotic stewardship teams. This training will be led by an implementation scientist expert (VRM) and a pediatric infectious diseases physician with antibiotic stewardship expertise (JGN). The primary clinical outcome will be the percentage of surgical cases receiving unnecessary post-operative antibiotics. Secondary clinical outcomes will include the rate of surgical site infections and the rate of Clostridioides difficile infections, a common negative consequence of antibiotic use. Monthly semi-structured interviews at each hospital will assess the implementation process of the two strategies. The primary implementation outcome is penetration, which will be defined as the number of order sets changed or developed by each hospital during the study. Additional implementation outcomes will include the ASP team members' assessment of the acceptability, appropriateness, and feasibility of each strategy while they are being implemented.

DISCUSSION

This study will provide important information on the impact of two potential strategies to de-implement unnecessary post-operative antibiotic use in children while assessing important clinical outcomes. As more unnecessary medical practices are identified, de-implementation strategies, including facilitation, need to be rigorously evaluated. Along with this study, other rigorously designed studies evaluating additional strategies are needed to further advance the burgeoning field of de-implementation.

TRIAL REGISTRATION

NCT04366440. Registered April 28, 2020, https://clinicaltrials.gov/ct2/show/NCT04366440 .