PC1245: Coming in Hot!: A Multi-modal Intervention to Improve the Management of Well-appearing Febrile Young Infants at Tripler Army Medical Center

Purpose/Objectives: Healthy infants, 0-90 days old, presenting to the Emergency Department (ED) with fever can be challenging to manage since this population is at increased risk of bacterial infection, but may not exhibit other supporting signs. Until recently, there were limited nationally adopted guidelines to direct the care of febrile neonates, resulting in wide inconsistency in management. At our institution, provider variability impeded timely transition from presentation to disposition of such infants. Our objectives were to (1) increase pediatric provider awareness of the institutional Febrile Infant Management Guideline (FIMG) from 86% to 100% within 6-8 months of implementation, and (2) reduce the length of time from ED presentation to disposition by 40% within 8-10 months of implementation.

Design/Methods: We utilized the QI model Find-Organize-Clarify-Understand-Select-Plan-Do-Study-Act (FOCUS-PDCA) to systematically meet our objectives. Key stakeholders from six hospital departments convened and identified the existence of multiple, outdated, and inefficient pathways in use. This inconsistency directly affected the variability of workup performed and time to disposition. Together, this multidisciplinary team designed and implemented the following interventions: a) created an institutional-specific FIMG highlighting specific laboratory and antibiotic guidance; b) expunged all prior algorithms from pediatric clinical areas; c) provided electronic and printed accessibility to the FIMG; d) provided FIMG education; and e) elicited feedback from providers regarding FIMG ease of use. The primary outcome measure was the percentage of providers aware of the FIMG within 6-8 months of implementation, evaluated using Fisher’s Exact test. The secondary outcome measure was the median time from ED presentation to disposition after 8-10 months of implementation, evaluated using Kruskal-Wallis test.

Results: Among pediatric providers anonymously surveyed between August and October 2021, 100%, (24 of 24) reported FIMG awareness, versus 86% (37 of 43) of providers surveyed during the pre-intervention period, (p=0.08). The median time from presentation to disposition from July-September 2021 decreased by 30.7% to 135 minutes, versus 195 minutes in July-September 2019, (p=0.885) (figure 1).

Conclusion/Discussion: Our first PDCA cycle from January-October 2021 resulted in notable improvements in provider awareness of the institutional FIMG and time from presentation to disposition. Although all surveyed providers reported FIMG awareness, we did not reach statistical significance, likely as a result of meager survey response in the year 2021 versus 2020. During our next PDCA cycle we expect to achieve a significant reduction in time to disposition, since the volume of febrile neonates presenting to the ED in July-September 2021 was reduced by 50%, likely attributable to the global pandemic and implementation of a new electronic medical record. Overall, the FIMG intervention demonstrated strong promise to be a lasting solution.