Responses to Fever Overnight: Do Residents Choose Wisely?

Abstract

BackgroundResidents at our institution rely heavily on the terminology “Full Fever Work Up” (FFWU) as a cognitive tool for cross-covering patients with a fever. Prior survey data revealed that residents vary considerably in how they respond to fevers and what FFWU means. We sought to determine what tests are included in the FFWU, how often the term is adhered to, and if it significantly changes clinical outcomes.MethodsFor 3 months, study investigators collected FFWU instructions for patients who experienced a fever at night. For each febrile episode, investigators reviewed chart data on patient factors, circumstances surrounding the fever, tests ordered, etiologies of the fever, and outcomes (immediately and 30-days after the fever). The UCLA Institutional Review Board approved this study.ResultsWe reviewed 253 fever episodes. For 204 episodes, written sign-out by the primary team was available. 59% of the fevers were in male patients and the mean age was 59 years. 12% had an organ transplant and 45% qualified as highly immunocompromised. 79% met SIRS criteria, whereas only 3% met qSOFA criteria and 2% required escalation of care.The cross-covering physician wrote a note in 4% of the cases and evaluated the patient in-person in 12% of the cases per chart review. Residents most often ordered bacterial blood cultures (48%), followed by urinary tests (34%) and chest X-rays (30%). These tests, as well as fungal blood cultures, lactate and CBC, were significantly more likely to be ordered by the cross-covering resident if the sign-out instructed to perform a FFWU. The mean number of diagnostic tests ordered was 2 and residents started or changed antibiotics in 14% of cases. 88% of the time patients were alive 30 days after their fever. 11% had an antibiotic-related complication and 8% of blood cultures drawn were positive.ConclusionOrdering practices overnight were significantly influenced by the FFWU sign-out instructions, yet evaluating the patient in-person was rare. We hypothesize that the FFWU standardization has replaced a more individualized evaluation overnight. Fortunately, poor outcomes including death, bacteremia, escalation of care, or antibiotic-related complications were low in this population.Disclosures All authors: No reported disclosures.