607 - Improving Adherence to the 2021 AAP Well-Appearing Febrile Infant Clinical Practice Guideline within a Rural Health System

Publication Number: 2592.607

Emma Freeman, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, United States; Leah Mallory, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, United States; Leah Marie Seften, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, CT, United States; Anya Cutler, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, United States; Tara Palnitkar, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, United States; Jillian Gregory, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, United States; Meredith Jackson, The Barbara Bush Children's Hospital at Maine Medical Center, Scarborough, ME, United States

Background: There has been variability in the evaluation of febrile infants across the United States. The American Academy of Pediatrics (AAP) published their first Clinical Practice Guideline (CPG) on the management of well-appearing febrile infants aged 8-60 days old in 2021. We published an institution-specific CPG in May 2023.Baseline variation existed in CPG adherence across the three locations of our tertiary care center. Reducing care variation is essential in addressing resource utilization and outcomes.

Objective: This QI project aims to increase adherence to our CPG. By December 2026, we aim to increase adherence to our CPG by 25%, as measured by an increase in the number of consecutive fully adherent encounters between nonadherence events on a G-chart.

Design/Methods: This was deemed not research. Infants aged 22-60 days who met criteria for use of the CPG and were seen at the three tertiary care center locations from January 2024-September 2025 were included. Due to the low number of eligible patients and frequent months with zero cases, we used a G-chart to track the number of consecutive opportunities with full adherence between instances of non-adherence. Participants were assessed as having a complete (defined as absolute neutrophil count, urine culture, blood culture and either procalcitonin or c-reactive protein) or incomplete initial evaluation (representing an "event"). We have implemented PDSA cycles informed by baseline data and stakeholder engagement including [1] educational conference for pediatric senior residents, [2] email to pediatric hospitalist providers, [3] EMR order set publication, [4] multisite QI team data review, and [5] didactics for pediatrics and emergency department faculty. Our outcome measure is the number of infants managed as per the CPG between each incomplete initial evaluation. Use of the order set was tracked as a process measure.

Results: Our study included 94 infants eligible during the study period. Following multiple PDSA cycles after a baseline period, a centerline shift was observed, indicating a significant improvement in adherence to our CPG (Figure 1A). The use of the order set for eligible patients was tracked after its publication in August 2024 as a process measure (Figure 1B).

Conclusion(s): These data show significantly improved adherence to CPG for the management of well-appearing febrile infants. Future PDSA cycles will target increased use of the order set. There remains opportunity for continued improvement and decreased number of incomplete initial evaluations. We plan to expand this work throughout our rural health system.

Complete Work-Up Obtained in Eligible Patients Ages 22-60 days, G-Chart
Figure 1A - SPC G-chart graphing the date of an "event" (an infant who met inclusion criteria but did not receive a complete initial evaluation) on the x-axis and the number of febrile infants who were seen between each case with a complete workup. The centerline shift goes from 1.0 infants prior to start of interventions to 3.0 with different color arrows marking corresponding PDSA cycles.

Use of EMR Order Set for Eligible Patients 22-60 Days Old, G-Chart
Figure 1B - SPC G-chart graphing the use of the EMR order set on eligible patients after publication in August 2024 (our process measure). Future PDSA cycles will target increased use of the order set.