Improving the Care of the Febrile Infant: Lessons Learned from AHRQ's Implementation Science Awards

Slide presentation from the AHRQ 2010 conference.

On September 28, 2010, Carrie L. Byington made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (6.39 MB). Free PowerPoint® Viewer (Plugin Software Help).

Slide 1

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

Intermountain Healthcare

Slide 2

The Febrile Infant-Who Has SBI?

The Febrile Infant-Who Has SBI?

Images of 11 babies are displayed on the slide.

Slide 3

Background

Background

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

Slide 4

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

Slide 5

Intermountain's Clinical Integration Structure

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.

Slide 6

Clinical Programs

Clinical Programs

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

Slide 7

Intermountain Clinical Programs

Intermountain Clinical Programs

Behavioral Health
Cardiovascular Medicine and Surgery
General Surgery
Intensive Medicine
Oncology
Patient Safety
Pediatric Specialties
Primary Care
Women and Newborn

Slide 8

Challenge: Moving Evidence into Practice

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

Slide 9

Key components of our strategy . . .

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.

Slide 10

Key Quality Measures Included in the EB-CPM (The Intervention)

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

Slide 11

Implementation Process: Key Steps

Implementation Process: Key Steps

Building EB
17 Publications

↓

Clinical Program
Discussion

↓

QI Test of Change Six Sigma @ PCMC

↓

Facility Intro by Champion

↓

Staff Meetings

↓

Ready Access to Tools

↓

Comparative Data Monitoring

Slide 12

A screen shot of Intermountain Physician.org is shown.

Slide 13

An image of a page titled Inpatient Managemnt of Febrile Infants 1-90 days old

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.

Slide 14

An image of two forms are shown.

Slide 15

An image titled

An image titled "Percent of Admitted Febrile Infants receiving a Urinalysis from January 2006 to July 2006: MK, PC, UV, and DX" is shown.

Slide 16

Median LOS for Febrile Infant Admissions with Negative Cultures by Admission Year

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
2002	58.5	53	94.5	72
2003	58	48	114	64
2004	61	47	95	60
2005	63	43	72	53
2006	52	47	68	54
2007	50.5	46	53	70
2008	46	43	46	48
2009	42	42	42	42

Slide 17

Evaluation of an Evidence-Based Care Process Model for Febrile Infants: Mixed Methods Study Aims

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

Slide 18

Aim 1 Qualitative Analysis of Factors Related to Implementation of the EB-CPM

Aim 1 Qualitative Analysis of Factors Related to Implementation of the EB-CPM

The 7S Framework of McKinsey

Slide 19

Facility Context

Facility Context

All facilities are tertiary care, regional referral centers. Staffed beds noted.

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

Slide 20

Graph

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

Current as of December 2010

Internet Citation: Improving the Care of the Febrile Infant: Lessons Learned from AHRQ's Implementation Science Awards. December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2010/byington/index.html