Improving the Care of the Febrile Infant: Lessons Learned from AHRQ's Implementation Science Awards (Text Version)
On September 28, 2010, Carrie L. Byington made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (6.39 MB).
AHRQ 2010 Annual Meeting
Improving the Care of the Febrile Infant: Lessons Learned from AHRQ's Implementation Science Awards
Carrie L. Byington, MD
HA and Edna Benning Presidential Professor of Pediatrics
University of Utah
Lucy Savitz, PhD
Director of Research and Education
The Febrile Infant-Who Has SBI?
Images of 11 babies are displayed on the slide.
- Fever in infants 1-90 days of age is one of the most common reasons for medical encounters
- 20% of all medical encounters in first 90 days
- 58% of all ED visits at PCMC
- Fever of ≥ 38C is associated with serious bacterial infection (SBI)
- ~ 10% will have bacteremia, meningitis, or UTI
- Significant variation in care
- Low compliance with guidelines
- Recognized as a research priority by AAP, ABP, IOM, PROS
What are we Doing About the Febrile Infant at Intermountain Healthcare?
- Not-for-profit hospitals, physician group, and health plan
- 24 Hospitals
- 144 Clinics
- 736 employed & 2,000+ affiliated physicians
- Serves about of the 1/2 Utah's population of about 2.8 million
Image of a map of Utah is on the whole slide.
Intermountain's Clinical Integration Structure
- Clinical excellence is our core business.
- Implementation of evidence-based medicine as an institutional responsibility, rather than responsibility of individual physicians.
- Process identification & priority setting.
- Process and outcomes improvement through clinical programs structure.
- Care organized by clinical services across the system (shared work processes rather than traditional departments)
- Led by practicing clinicians (physicians, nurses)
- Supported by operational and administrative staff and other clinicians from allied specialties
Intermountain Clinical Programs
- Behavioral Health
- Cardiovascular Medicine and Surgery
- General Surgery
- Intensive Medicine
- Patient Safety
- Pediatric Specialties
- Primary Care
- Women and Newborn
Challenge: Moving Evidence into Practice
Reducing variation in compliance with evidence-based guidelines.
- Care Process Models (CPMs) are narrative documents that aim at representing state-of-the-art medical knowledge.
- Clinical Decision Support Tools can include all ways in which health care knowledge is represented in health information systems.
- Advantages of computerized EB-CPM:
- Provide readily accessible references and allow access to knowledge in guidelines that have been selected for use in a specific clinical context
- Often improve the clarity of a guideline
- Can be tailored to a patient's clinical state
- Propose timely decision support that is specific for the patient
Key components of our strategy.
- Identify problem
- Establish evidence base
- Develop, test, & implement using quality improvement tools (e.g., Six Sigma-define, measure, analyze, improve, control)
The University of Utah/Intermountain Febrile Infant EB-CPM was developed using an evidence base derived from prospective research at our institutions & others together with a Six Sigma process.
Key Quality Measures Included in the EB-CPM (The Intervention)
- Core Laboratory Testing (CBC and UA)
- Admit Patients High Risk for SBI
- Viral Testing (EV and Respiratory Viruses)
- Appropriate Antibiotics
- Stop Antibiotics within 36 hours for Infants with Negative Bacterial Cultures
- LOS 42 hours or less
Implementation Process: Key Steps
QI Test of Change Six Sigma @ PCMC
Facility Intro by Champion
Ready Access to Tools
Comparative Data Monitoring
A screen shot of Intermountain Physician.org is shown.
An image of a page titled "Inpatient Management of Febrile Infants 1—90 days old" and a flowchart of "Algoritum: Inpatient Care of Febrile Infants 1—90 days old." is shown.
An image of two forms are shown.
Image of a graph titled "Percent of Admitted Febrile Infants receiving a Urinalysis from January 2006 to July 2006: MK, PC, UV, and DX" is shown.
Median LOS for Febrile Infant Admissions with Negative Cultures by Admission Year
|Median LOS (hours) MEDIAN(LOS_HRS)|
|Admit Year||McKay-Dee||Primary Children's||Utah Valley||Dixie|
Evaluation of an Evidence-Based Care Process Model for Febrile Infants
Mixed Methods Study Aims
Semi-structured interviews to identify themes and unique aspects related to the implementation process, generating data to inform the spread
- Hypothesis: the successful implementation of the EB-CPM at each facility required multiple and different factors as well as crosscutting themes.
Cost effectiveness of implementing the EB-CPM
Effect of offering the EB-CPM for Pediatric MOC
AHRQ 1 R18 HS018034-01, 7/1/09-6/30/11
Aim 1 Qualitative Analysis of Factors Related to Implementation of the EB-CPM
The 7S Framework of McKinsey
|Facility||SystemRegion||2009 ER Visits|
|PCMC(271 beds)||Urban Central||46,331|
|Utah Valley(367 beds)||Urban South||45,547|
|McKay Dee(311 beds)||Urban North||65,193|
|Dixie Regional(245 beds)||Southwest||40,430|
All facilities are tertiary care, regional referral centers. Staffed beds noted.
|7S Model Levers||Intervention Elements||Emergent Themes|
|Shared Value||Board goal||Visibility & leadership involvement: A corporate wide effort, supported by a Board goal helps---knowing that everyone is doing it.|
|Strategy||Building evidence base; phased implementation; clinical champion visit||MD champion: Having a credible physician meeting in person with staff at their facilities to describe the evidence, rationale for CPM, and answer questions was important.|
|Structure||Clinical integration/programs||Resources: We have the clinical program infrastructure to determine priorities, identify solutions, and make decisions about focused efforts for change.|
|Systems||CPM; decision support tools; informatics||Tools: Providing documentation and support materials that are easily/readily accessible and that support or improve normal work flow.|
|Style||Feedback reports; monitoring||Feedback (to involved staff); and monitoring with valid measures; tracking costs.|
|Staff||Admin/managers, MDs, nurses, lab staff||People: Involvement of nursing to make it happen! Physician buy-in. MOC|
|Skills||Dx, process, lab tests||Staff training (with refresher), alignment with laboratory|