Rapid Implementation of Evidence-Based Guidelines for Imaging After First Urinary Tract Infection
Rapid Implementation of Evidence-Based Guidelines for Imaging After First Urinary Tract Infection
复制标题
DOI：
10.1542/peds.2013-0720
复制
发表时间：
2013-09-01
期刊：
影响因子：
8
通讯作者：
Brinkman, William B.
中科院分区：
文献类型：
--
作者：
Jerardi, E.;Elkeeb, Dena;Brinkman, William B.
背景和目的：美国儿科学会于2011年9月发布了新的2至24月龄儿童首次尿路感染（UTI）治疗指南。影像学评估由之前的指南更改为仅对肾脏和膀胱超声（RBUS）异常的患者推荐排尿性膀胱尿道造影（VCUG）。目的是将符合指南条件且 RBUS 正常的儿童接受 VCUG 的比例从住院患者的中位数 92% 和急诊科治疗的患者的 100% 降低到两种情况下的 5%。 方法：这是在大型学术医疗中心进行的一项质量改进实施研究。关键驱动因素包括：适当的指南知识、及时识别符合指南的患者以及与社区初级保健提供者的有效沟通。多学科团队开发并测试了干预措施。使用带注释的运行图评估影响。采用chi(2)分析和Fisher精确检验进行统计比较。结果：在住院患者中，首次UTI且RBUS正常的儿童接受VCUG的比例在开始该项目后1个月内从中位数92%下降到0%，在急诊科诊断的儿童中从100%在4个月内下降到40%。利率已分别维持 12 个月和 8 个月。使用电子病历和订购系统的干预措施最有影响力。结论：在多种环境中快速采用基于证据的 UTI 护理是可以实现的。与门诊相比，住院患者的实践变化发生得更快、幅度更大。
BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics published a new guideline for management of first urinary tract infection (UTI) in children aged 2 to 24 months in September 2011. The imaging evaluation changed from the previous guideline to recommend voiding cystourethrogram (VCUG) only for patients with an abnormal renal and bladder ultrasound (RBUS). The objective was to decrease the proportion of guideline-eligible children with a normal RBUS who underwent VCUG from median of 92% for patients treated as inpatients and 100% for patients treated in the emergency department to 5% in both settings.METHODS: This was a quality improvement implementation study in a large academic medical center. Key drivers included: appropriate guideline knowledge, timely identification of guideline eligible patients, and effective communication with the community-based primary care provider. A multidisciplinary team developed and tested interventions. Impact was assessed with annotated run charts. Statistical comparisons were made with chi(2) analysis and Fisher's exact test.RESULTS: The proportion of children with first UTI and normal RBUS who underwent VCUG decreased from a median of 92% to 0% within 1 month of initiating the project among those hospitalized and from 100% to 40% within 4 months among those diagnosed in the emergency department. Rates have been sustained for 12 months and 8 months, respectively. Interventions using the electronic medical record and ordering system were most impactful.CONCLUSIONS: Rapid adoption of evidence-based UTI care across multiple settings is achievable. Practice change occurred faster and to a greater magnitude in the inpatient setting compared with the outpatient setting.