88 - Clinical Pathway Decreases Lumbar Puncture Rates in Febrile Infants 22-28 Days Old: An Emergency Department Quality Improvement Project

Poster Number: 88
Publication Number: 88.1553

Background: Lumbar puncture (LP) was routinely recommended in febrile infants less than one month old to evaluate for bacterial meningitis (BM). The American Academy of Pediatrics (AAP) published a Clinical Practice Guideline (CPG) in 2021 recommending LP for well-appearing febrile infants 22-28 days old based on abnormal inflammatory markers (IMs).

Objective: Our objective was to decrease LP rates in febrile infants 22-28 days of age in the emergency department (ED) within one year of a quality improvement initiative regardless of race, ethnicity, and preferred language from a baseline of 85%.

Design/Methods: We conducted a quality improvement project of infants 22-28 days old undergoing ED evaluation for fever from March 2022-July 2023 at a tertiary care children’s hospital with urban and suburban campuses. A multidisciplinary team collaborated to review the AAP CPG and local epidemiology and to identify key drivers. Interventions included updating our clinical pathway, integrating age-based non-interruptive clinical decision support (CDS), and iterative education updates presented at division meetings and disseminated via e-mail. Our primary outcome measure was LP rates in febrile infants 22-28 days old. Process measures included percentage of infants with resulted ANC or procalcitonin. Balancing measures included missed BM (defined as inpatient or return visit LP with growth of pathogenic bacteria in infants who were not empirically treated for BM in the ED) and ED length of stay (LOS). Statistical process control methodology was used to assess the effect of these interventions.

Results: There were 249 infants included (Table 1). LP rates decreased from 85% to 45% (Figure 1), and similar trends in decreased LP rates were seen regardless of race, ethnicity, or preferred language. ANC rates maintained from 100% to 97% and procalcitonin rates increased from 5% to 96%. There was no special cause variation in ED LOS (Figure 2), and in this small cohort, there were no infants with missed BM.

Conclusion(s): Implementation of clinical pathway with CDS and education safely reduced LP rates in infants 22-28 days old without impacting LOS. Future projects should focus on opportunities to decrease unnecessary care in febrile infants including reducing empiric antibiotics and hospitalizations in select infants.