Return Visits for Febrile Infants Aged 60 Days or Younger

The American Academy of Pediatrics (AAP) febrile infant clinical practice guideline (CPG) provides recommendations for the management of febrile infants, including shared decision-making (SDM) opportunities for discharge from the emergency department (ED).1 Since the CPG’s implementation, the frequency and characteristics of return visits after discharge from the ED is unknown. This information would aid SDM discussions regarding disposition on initial visit in the context of risks and benefits of hospitalization.2 We aimed to determine the frequency and characteristics of return visits among febrile infants discharged from the ED.We conducted a secondary analysis of the Reducing Excessive Variability in Infant Sepsis Evaluation II (REVISE II) quality improvement initiative, which included infants aged 8 to 60 days with temperatures of 38 °C or higher evaluated from 2020 to 2022 at 106 sites. For inclusion in this secondary analysis, infants had to be in the postintervention period (2021–2022) and discharged from the ED at the initial visit. Exclusion criteria aligned with the AAP CPG.1,3We calculated the proportion of infants discharged from the ED who had a 7-day return visit, return visit with admission, and return visit with diagnosis of invasive bacterial infection (IBI), stratified by hospital type and patient-level factors. Data on laboratory results were recorded as positive or negative per the AAP CPG. Inflammatory markers (IMs) were considered negative if all obtained were negative or positive if at least 1 was positive. IBI was defined as growth of an a priori defined pathogen in blood or cerebrospinal fluid or, if initial cultures had no growth but a participant indicated diagnosis of IBI at a return visit. Initial culture results with contaminants were not classified as IBI. Statistical analysis was performed using Stata version 18.0 (StataCorp, Inc). The study was exempt by the AAP institutional review board.Among 6333 infants discharged from the ED, 737 (11.6%) had a return visit within 7 days, including 255 (4.0%) who were hospitalized and 35 (0.6%) diagnosed with IBI (Table 1). The frequency of return visits did not differ based on demographics. Infants with positive IMs were more often admitted and diagnosed with IBI at a return visit. A higher proportion of infants with positive urinalysis had a return visit and were admitted.Characteristics of infants diagnosed with IBIs at return visits are shown in Table 2. The most common IBI was bacteremia (74.3%). Four of these infants had meningitis based on a participant indicating the diagnosis at a return visit; all were 29 to 60 days and had temperatures higher than 38.5 °C (Supplemental Table 1).Among febrile infants aged 8 to 60 days discharged from the ED, 1 in 10 had a return visit and 1 in 25 required hospitalization. Given that the AAP guideline recommends SDM regarding disposition for certain populations of febrile infants (eg, aged 29–60 days with positive IMs), this data can help inform the discussion about risks.1Reassuringly, diagnoses of IBIs are uncommon at return visits at an overall frequency of 1 in 200 infants. Because the risk is nonzero, however, our data emphasize the importance of close outpatient follow-up. Future investigation is needed to explore outcomes of infants discharged from the ED and strategies for reducing unnecessary return visits. Limitations of our study include retrospective data collection and unknown reasons for return visits such as parental concern or symptomatology. Additionally, our definition of IBI included infants with participants indicated delayed diagnoses of IBIs without documented culture results.The nonnegligible frequency of return visits provides baseline data for further quality improvement initiatives. This information can be used when counseling families at discharge and performing SDM regarding admission for observation or discharge.The authors acknowledge all the sites and site team members that collected data for this study as part of the AAP REVISE II QI Collaborative.