P0284 - Chest X-ray Utilization in Febrile Infants 60 Days or Less in the Emergency Department

BACKGROUND/PURPOSE
Of febrile infants aged 60 days or less who present to the Emergency Department (ED), it is reported that 1-10% have a serious bacterial infection. Prior studies have determined that a chest x-ray (CXR) is not indicated for febrile infants in this age range who do not have respiratory symptoms. This is a quantitative study to evaluate if a clinical pathway would decrease the CXR utilization rate at our institution.
 
METHODS
This study is a retrospective chart review study that included all patients between the age of 0 to 60 days who presented to the ED of a tertiary care hospital for fever. Baseline data from September 2015 to August 2016 consisted of 44 patients; 25 with non-respiratory symptoms and 19 with respiratory symptoms. The baseline CXR utilization rate was 56.82% (n=25/44). In 2016, a clinical pathway was implemented to standardize the work up of febrile infants less than 60 days. Patient charts from September 2016 to June 2019 were reviewed. Infants with a documented fever of 38 degrees Celsius or more were included. Furthermore, it was noted whether the patient had respiratory symptoms. We defined respiratory symptoms as a respiratory rate (RR) greater than or equal to 60 breaths per minute, hypoxia with a pulse oximetry reading of 91% or less in room air (RA), cough, increased work of breathing, and/or focal lung findings on the physical exam. In addition, it was noted whether patients who had fever with non-respiratory symptoms received a CXR.
 
RESULTS
144 patients were included in this study. Of these 144 patients, 42 received a CXR with non-respiratory symptoms, and 102 received a CXR with respiratory symptoms. The calculated CXR utilization rate was 29.17% (n=42/144). Of the 102 patients with respiratory symptoms, many presented with more than one symptom, with a total of 142 total respiratory symptoms. Cough was the most common respiratory symptom 60.56% (n=86/142), followed by RR of 60 19.01% (n=27/142), focal lung findings on physical exam 9.15% (n=13/142), increased work of breathing 6.34% (n=9/142), and hypoxia of 91% or less in RA 4.93% (n=7/142). Application of the clinical pathway demonstrated a statistically significant decrease in the CXR utilization rate in febrile infants with no respiratory symptoms (rate of 56.82% vs. 29.17%, P < 0.05).

CONCLUSION
Previous literature has quoted that evaluation of febrile infants between the age of 0 to 60 days can vary greatly. The results of this study showed that implementation of a clinical pathway can decrease the CXR utilization rate in febrile infants without respiratory symptoms. Standardizing care by implementing a clinical pathway can help risk stratify patients and result in less practice variation in the utilization of chest x-rays in the workup of a febrile infant.