Reducing Inpatient Length Of Stay For Febrile Young Infants

Background and Objectives: Fever is a common cause of hospitalization in infants under 8-weeks of age. Traditionally these patients have been admitted on empiric intravenous antibiotics for 48-72 hours pending culture results. Recent evidence suggests that it is safe to adopt a shorter period of antibiotic therapy of 24-36 hours. Aim: Reduce inpatient length of stay (LOS) of febrile infants less than 8 weeks of age by 12 hours within 2 years. Methods: This Quality Improvement (QI) project was implemented at two community hospitals affiliated with a children's hospital in a suburban, mid Atlantic community health system. We used a QI framework to identify barriers to reducing LOS for this cohort and prioritize solutions. Barriers included the lack of a rapid-resulting Herpes Simplex Virus (HSV) CSF PCR and a practice bias towards monitoring these patients for 48 hours. In cycle 1, we liaised with our laboratory and procured an in-house, rapid turn-around HSV CSF PCR. In cycle 2, we joined 126 other hospitals participating in Project REVISE (Reducing Excessive Variability in Infant Sepsis Evaluation), a QI collaborative of the AAP Value in Inpatient Pediatrics Network, to improve care of febrile neonates. As a part of this initiative, we adopted the discharge criteria recommended by our affiliated children's hospital Pathway for Treatment of the Febrile Young Infant. Results: The project included 118 patients, 28 pre-intervention (June 2015 - Feb 2016), and 90 post-intervention; 33 in cycle 1 (March 2016 - Dec 2016) and 57 in cycle 2 (Dec 2016 - Dec 2017). The median LOS decreased by approximately 14 hours, from 50.3 hours at baseline to 35.7 hours in cycle 2. There were no positive cultures (excluding contaminants) resulted after discharge and no re-admission for any serious bacterial infection including UTI, bacteremia, or meningitis within 7 days. Conclusions: LOS was successfully reduced in well appearing young febrile infants by using in-house HSV PCR and implementing an evidence-based clinical pathway. This initiative demonstrates high value care that safely reduces exposure to antimicrobials and allows patients and families to return home faster.