Clinical question: What is the impact of an evidence-based care process model (EB-CPM) on outcomes and costs in febrile infants?
Background: The care of febrile infants <90 days of age is common, and national guidelines have been in existence for nearly 20 years. However, variation in practice has been noted surrounding management of these infants, and there are limited reports of outcomes and costs related to implementation of local guidelines and quality-improvement (QI) projects.
Study design: Retrospective review of QI project.
Setting: Intermountain Healthcare System in Utah.
Synopsis: Over a period of five years, 8,044 infants with 8,431 febrile episodes were evaluated within the Intermountain Healthcare System, an integrated healthcare network that provides care for about 85% of the children in Utah. The EB-CPM was implemented in the middle of this five-year span and applied modified Rochester criteria to risk-stratify infants. Low-risk infants were eligible for discharge to home; high-risk infants were admitted and received viral testing. Infants with negative bacterial cultures and positive viral studies were eligible for discharge at 24 hours. For the remainder of admitted infants, discharge was recommended after 36 hours of negative bacterial cultures.
The review showed no statistically significant differences in readmissions or admission rates for serious bacterial infection before and after the implementation. There were significant reductions in mean hospital length of stay (60 to 44 hours, P<0.001) and cost per admitted infant ($7,178 to $5,979, P<0.001) after the EB-CPM was released. Cost savings were estimated at $1.9 million during the five-year study period.
Several limitations of this study are relevant. First, this QI project occurred within the confines of an integrated healthcare delivery system, a context that is uncommon in most of the country. Compliance with recommendations was not universal, which suggests that there is potential for improvement upon these results, or that clinical judgment played a significant role in decision-making.
Nonetheless, this report demonstrates that there is significant potential for cost savings with focused recommendations for discharge of febrile infants.
Bottom line: Standardized recommendations for discharge in febrile infants could result in substantial cost savings.
Citation: Byington CL, Reynolds CC, Korgenski K, et al. Cost and infant outcomes after implementation of a care process model for febrile infants. Pediatrics. 2012;130:e16-e24.
Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.