Reducing Invasive Care for Low-risk Febrile Infants Through Implementation of a Clinical Pathway
Reducing Invasive Care for Low-risk Febrile Infants Through Implementation of a Clinical Pathway
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DOI：
10.1542/peds.2018-1610
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发表时间：
2019-03-01
期刊：
影响因子：
8
通讯作者：
Waynik, Ilana Y.
中科院分区：
文献类型：
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作者：
Kasmire, Kathryn E.;Hoppa, Eric C.;Waynik, Ilana Y.
背景和目的：发烧婴儿的管理在全国和我们机构内都存在显著差异。风险分层可以用来识别低风险婴儿，这些婴儿可以作为门诊患者进行管理，而不需要腰椎穿刺术(LP)或抗生素。我们的目标是通过实施由质量改进(QI)支持的临床路径，减少对29~60天发热儿严重细菌感染(SBI)风险较低的侵入性干预。方法：循证临床路径由多学科团队开发和实施，具有持续过程的QI，以持续使用。将接受LP、接受抗生素和住院的低风险婴儿与低风险婴儿实施前和后途径实施进行比较，并对高危婴儿进行适当护理作为平衡措施。结果：在纳入的350例患者中，220人实施了途径前，130人实施了途径后。随着2016年7月路径的实施，低风险婴儿的侵入性干预显著减少，LP从32%下降到0%，抗生素使用从30%下降到1%，住院人数从17%下降到2%。实施后，低危儿SBI发生率为0，高危儿为29.2%。每条路径接受护理的高危患者的百分比保持不变。通过QI干预，包括制定订单和电子邮件提醒，持续12个月的改善。结论：通过使用QI方法实施临床路径，可以持续减少对低风险发热婴儿的侵入性干预，而不会遗漏SBI。临床路径和QI可以是为发热婴儿提供循证护理的关键策略。
BACKGROUND AND OBJECTIVES: Significant variation in management of febrile infants exists both nationally and within our institution. Risk stratification can be used to identify low-risk infants who can be managed as outpatients without lumbar puncture (LP) or antibiotics. Our objective was to reduce invasive interventions for febrile infants aged 29 to 60 days at low risk for serious bacterial infection (SBI) through implementation of a clinical pathway supported by quality improvement (QI).METHODS: The evidence-based clinical pathway was developed and implemented by a multidisciplinary team with continuous-process QI to sustain use. Low-risk infants who underwent LP, received antibiotics, and were admitted to the hospital were compared pre- and postpathway implementation with SBI in low-risk infants and appropriate care for high-risk infants as balancing measures.RESULTS: Of 350 included patients, 220 were pre- and 130 were postpathway implementation. With pathway implementation in July 2016, invasive interventions decreased significantly in low-risk infants, with LPs decreasing from 32% to 0%, antibiotic administration from 30% to 1%, and hospital admission from 17% to 2%. Postimplementation, there were 0 SBIs in low-risk infants versus 29.2% in high-risk infants. The percentage of high-risk patients receiving care per pathway remained unchanged. Improvement was sustained for 12 months through QI interventions, including order-set development and e-mail reminders.CONCLUSIONS: Implementation of a clinical pathway by using QI methods resulted in sustained reduction in invasive interventions for low-risk febrile infants without missed SBIs. Clinical pathways and QI can be key strategies in the delivery of evidence-based care for febrile infants.