Source: Jain S, Cheng J, Alpern ER, et al. Management of febrile neonates in US pediatric emergency departments. Pediatrics. 2014; 133(2): 187– 195; doi: 10.1542/peds.2013-1820Investigators from multiple institutions across the United States sought to identify variation in the management of febrile infants <28 days old presenting to pediatric emergency departments (PEDs) and determine the prevalence of serious infection (SI) in this population. Data were obtained using de-identified records from 36 of the 44 children’s hospitals in the United States that participated in the Pediatric Health Information System database for the year 2010, and were analyzed for adherence to recommended clinical guidelines. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses were used to identify infants with fever and serious infection, which was broadly identified as a focal or systemic bacterial infection or invasive viral infection (eg, meningitis). Records were reviewed for compliance with recommended testing (all 3 of blood, urine, and cerebrospinal fluid cultures); treatment (parenteral antibiotic therapy with ampicillin and either gentamicin or a third-generation cephalosporin); and management (recommended laboratory evaluation, treatment, and hospital admission).From a total of 41,890 neonates evaluated in participating hospital PEDs in 2010, 2,253 carried a diagnosis of fever. Of these neonates, 369 (16.4%) were seen in the PED and discharged, contrary to recommendations for admission. The proportion of febrile neonates who received the recommended testing was 73% (range 39%–90%); recommended treatment was provided to 79% of febrile neonates (range 39%–100%); and recommended management was provided to 66% of neonates (range 39%–88%). Multiple combinations of incomplete testing, treatment, and management were identified. Of the 2,253 febrile infants, 64 (2.8%) were discharged from the PED without receiving any recommended testing or treatment whatsoever. Approximately 12% (n = 269) of the infants in the cohort were diagnosed with SI, including 3 who were discharged contrary to recommendations. Of the 269 who developed SI, 223 (82.9%) were managed in accordance with all recommendations.The investigators note that previous studies have shown variation between PED and office-based practitioners’ management of febrile neonates.1,2 They conclude that the high rate of SIs in admitted patients (12%) underscores the importance of vigilance in this age group; the low rate of SIs in those discharged contrary to recommendations and subsequently readmitted (0.08%) begs for additional investigation into both the source of the wide variation and the ensuing implications for all stakeholders.Dr Springer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Febrile neonates represent a unique and challenging group of patients. For many years, clinicians and researchers alike have been trying to balance “aggressive” evaluation and empiric treatment with the more conservative “watchful waiting.” Baraff et al,3 in 1993, published clinical guidelines for the evaluation and management of febrile infants without a source. Since that time, innumerable guidelines and recommendations have been published by various entities worldwide, all with the goal of finding the ideally balanced approach that optimizes outcomes for this vulnerable group of patients. And it is remarkable that, despite the wealth of differing recommendations, a preponderance of experts consistently advocate for the approach assessed in the current study. It is gratifying to learn that about 80% of the participating PEDs followed guideline recommendations for treatment. It is equally disturbing that 16% of infants were discharged to home contrary to recommendations, and 3% of those without undergoing any of the recommended management. One wonders what an analysis of nonpediatric EDs would reveal. The researchers do acknowledge that at least some of the detected variation in practice across PEDs may be explained by information that was not included in the database records. It is possible that some infants presented for evaluation for concerns of fever without a documented temperature of >100.4° (rectally) at home or in the PED.As the emphasis continues to shift in favor of evidence-based practice, hospitals and providers will experience increasing pressure to adhere to published guidelines and best practices. A 2005 report by the Institute of Medicine noted that achieving quality in health care includes measuring, reporting, and improving.4 The Continuous Quality Improvement loop is then closed by re-measuring and re-reporting. The authors of this study have started this important process with their insightful report. It’s up to the rest of us to continue the process.
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Feb 3, 2023
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