Febrile Infant Clinical Pathways Standardize Care in the ED Setting

The implementation of an emergency department (ED)-specific clinical pathway for febrile infants enhanced the timeliness of initial patient workup and therapy initiating while simultaneously reducing treatment variability, according to research published in Pediatric Emergency Medicine Practice
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Infants frequently present in the ED with febrile illnesses, and treatment delays or variability could result in serious injury or death due to bacterial infections. Clinical pathways that standardize initial assessment and treatment strategies may improve overall outcomes and prevent lasting medical damage due to improper treatment.

Ashlee Lynn Murray, MD, attending physician in the department of emergency medicine at Children’s Hospital of Philadelphia (Philadelphia, PA), and colleagues developed an ED pathway for infants aged 56 days or younger presenting with a rectal temperature at or above 38°C. The diagnostic pathway mandates that all infants receive a complete blood count with blood cultures and bedside glucose as needed, as well as catheterization to collect urine cultures for enhanced urinalysis. 

The pathway recommends that all infants aged 0 to 28 days and all ill infants aged 29 to 56 days receive a lumbar puncture and antimicrobial treatment, and be admitted to the hospital. Treatment selection for infants aged 29-56 days, with or without bronchiolitis, treatment strategies are based on risk category (low-risk, high-risk, and required admission for bronchiolitis).

Pathway implementation occurred in 2009. Dr Murray and colleagues conducted a retrospective observational study to determine the pathway’s impact by comparing presentation and treatment initiation in periods before (September 2007 through August 2008) and after (September 2009 through August 2010).

The study included data from 520 patients treated at the Children’s Hospital of Pennsylvania ED. Following pathway implementation, the researchers observed a mean time to urine collection of 23 minutes, as well as a mean time to first antibiotic initiation of 36 minutes. Infants treated on pathway experienced improved treatment with regard to age-appropriate antibiotic therapy (odds ratio [OR] = 7.2; 95% CI, 4.4-11.9); particularly, more infants appropriately received acyclovir on pathway (OR = 8.8; 95% CI, 2.9-30).

“The ED-based febrile young infant clinical pathway has improved the timeliness of initiation of workup, as measured by urine collection, and of therapy by an earlier administration of the first antibiotic,” Dr Murray and colleagues wrote. “It has also decreased the variability of care.” – Cameron Kelsall