Eliminating Lumbar Puncture for Low-Risk Febrile Infants: A Quality Improvement Initiative

An Emergency Department Quality Improvement Project to Decrease Lumbar Puncture Rates in Febrile Infants 22 to 28 Days Old

Introduction

Most providers have routinely performed universal lumbar puncture (LP) on well-appearing, febrile infants 22 to 28 days old. In 2021, the American Academy of Pediatrics recommended clinicians should perform an LP in this age group if inflammatory markers are abnormal. This quality improvement project aimed to decrease LP rates in febrile infants 22 to 28 days old in the emergency department (ED) within 1 year, regardless of race/ethnicity, from a baseline of 87%.

Methods

We used our institution's quality improvement framework to perform multiple Plan-Do-Study-Act cycles. A multidisciplinary team reviewed the febrile infant literature, local epidemiology, and identified key drivers. We provided departmental education, updated our clinical pathway, and used clinical decision support. We analyzed baseline (January 2017-March 2022) and intervention data (April 2022-March 2024) and tracked data using statistical process control charts. Our primary outcome measure was rates of LP in the ED for this cohort. Process measures included rates of infants with procalcitonin results. ED length of stay, rates of first LP attempt after hospitalization, and missed bacterial meningitis were balancing measures.

Results

The baseline LP rate of 87% decreased to 44% during the intervention period, resulting in a downward centerline shift. There were no significant differences when LP rates were analyzed by race/ethnicity. There was an upward centerline shift in the process measure of infants with procalcitonin results. There was no observed special cause variation in our balancing measures.

Conclusion

Quality improvement efforts, including education, clinical pathway updates, and clinical decision support, safely reduced rates of LPs in febrile infants 22 to 28 days old.

Equity in Receipt of a Lumbar Puncture for Febrile Infants at an Academic Center

BACKGROUND

The evaluation of febrile infants ≤60 days of age is often guided by established protocols. However, structural racism and physicians' implicit bias may affect how such clinical guidelines are applied.

OBJECTIVE

To determine the association between self-identified race, insurance type, ZIP code-based median household income (MHI) and receiving a guideline-concordant lumbar puncture (GCLP) in febrile infants.

METHODS

This was a 3-year retrospective cross-sectional study of all febrile infants ≤60 days old presenting to a children's hospital from 2015 to 2017. GCLP was defined as obtaining or appropriately not obtaining a lumbar puncture as defined by the hospital's clinical practice guideline, which recommended performing a lumbar puncture for all febrile infants ≤60 days of age unless an infant was >28 days of age and had respiratory syncytial virus-positive bronchiolitis. Univariate analyses were used to identify variables associated with receiving a GCLP. Variables with a P < .1 were included in a multivariate logistic regression with race, MHI, and insurance type.

RESULTS

We included 965 infants. Age (adjusted odds ratio, 0.95; 95% confidence interval, 0.94-0.97) and temperature on arrival (adjusted odds ratio, 1.36; 95% confidence interval, 1.04-1.78) were significantly associated with receipt of a GCLP. Self-identified race, insurance type, and MHI were not associated with receiving a GCLP.

CONCLUSION

Receipt of a GCLP was not associated with race, MHI, or insurance type. As recent national guidelines change to increase shared decision-making, physician awareness and ongoing assessment of the role of factors such as race and socioeconomic status in the clinical evaluation and outcomes of febrile infants will be critical.