Resident UCSF Benioff Children's Hospital Oakland San Francisco, California, United States
Background: In 2022, the AAP published the CPG for well-appearing febrile infants recommending discharge within 36 hours for infants hospitalized with negative cultures. Little is known about barriers to accomplishing this target. Studies have proposed timing of culture reporting as a barrier without quantified data. Objective: As part of the VIP Network’s Reducing Variability in Sepsis Evaluation II (REVISE II) collaborative, we implemented clinical pathways for care of well-appearing febrile infants ages 8-60 days of age at our single-center, free-standing, academically affiliated, children’s hospital. We sought to further characterize barriers to discharge for these infants within our institution. Design/Methods: Our sample included febrile infants ages 8-60 days with negative cultures hospitalized over 24 months. We conducted a chart review of orders, results, and notes across disciplines to identify reasons for delay of discharge. We calculated non-mutually exclusive percentages of these reasons. Results: Of 91 febrile infants included in the cohort, 34% (31/91) were hospitalized and had negative cultures. Of those, 80.6% (25/31) were discharged beyond 36 hours. Of the 25 cases with prolonged hospitalizations, barriers to discharge included no viral source (60%), culture collection time (32%), social factors (32%), coinciding condition (28%), contaminant/incomplete work-up (24%), and prolonged fevers (12%). A small minority of cases (8%) had no identified cause. Most cases (76%) had more than one cause. The same criteria were assessed in the 6 appropriately discharged patients. Potential barriers, although circumvented, included no viral source (50%), culture collection time (50%), social factors (33.3%), and contaminant/incomplete work-up (16.7%). No case had a coinciding condition or prolonged fever.
Conclusion(s): The majority of cases had barriers resulting in delayed discharge with the most common being no viral source, culture collection time, and social factors. Education regarding viral testing in discharge decision making may be worthwhile given the overall prevalence. Additionally, assessing and addressing social drivers of health may be important to overcoming discharge obstacles, as this was noted in one third of cases. Coinciding condition and prolonged fevers were not observed in the appropriately discharged group warranting further study into the impact of these barriers. Though this is a limited single-center analysis, we determined discrete barriers to discharge. We suggest standardized collection of data using these categories in national QI collaboratives to further quantify this burden.
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