Enhancing Care of Young Febrile Infants in Hawaii: A Quality Improvement Initiative to Reduce Unnecessary Hospitalizations and Procedures

Young infants under the age of 60 days are at high risk of invasive bacterial infection. Historically, several different criteria were developed to risk stratify this population and guide management yet since then epidemiology of invasive bacterial infection has changed. In 2021, the American Academy of Pediatrics released a clinical practice guideline on the evaluation and management of well-appearing infants aged 8 to 60 days with fever, with subcategories 8-21 days, 22-28 days, and 29-60 days. At the only pediatric hospital in the state of Hawai'i, practices for evaluation and management of infants 22-60 days differed from the published clinical practice guidelines. In 2022, a local quality improvement initiative was implemented in connection to a larger national quality improvement initiative to align the institution's practice with the guidelines, thereby decreasing unnecessary hospitalizations, procedures, and medications. After implementation, the admission rate for infants 22 to 60 days decreased significantly from 19% to 2% (P=.010). Lumbar puncture rates decreased for infants 22 to 60 days from 39 out of 47 (83%) to 12 out of 59 (20%) (P<.0001). There was a significant decrease in the number of infants 29 to 60 days with normal inflammatory markers and normal urinalysis who received antibiotics 74% to 20% (P<.0001). There was no increase in delayed diagnosis of invasive bacterial infection (P=NS). Within one year of implementation, there was significant change in clinical practice with adherence to the clinical practice guideline, resulting in fewer unnecessary hospitalizations, antibiotic administration, and lumbar punctures.