P2B061: Reduction of Urine Cultures for Febrile Neonates by Implementation of Recent Clinical Practice Guidelines and Institutional Pathway

Purpose/Objectives: In the 2021 the American Academy of Pediatrics (AAP) updated their Clinical Practice Guidelines (CPG) for the well appearing febrile infant. In particular, the routine collection of urine cultures in febrile neonates with a negative urinalysis is no longer recommended. The objective of our study was to determine if the creation of an institutional pathway and order set, based on the 2021 CPG, would improve adherence to this recommendation.

Design/Methods: A clinical pathway utilizing the 2021 AAP CPG was designed by a multidisciplinary team and implemented June 2022, as part of a wider national AAP research project REVISE II: Reducing Excess Variability in Infant Sepsis Evaluation. Prior to the launch of the pathway, institutional approval was obtained and staff was educated on the CPG in the form of presentations and emails as part of an educational initiative for the clinical pathway. With the clinical pathway, we instituted an order set designed to follow the clinical pathway and CPG.
Inclusion and exclusion criteria were based on the REVISE II project standards. Only healthy, well-appearing neonates age 8-60 days old were included. A urinalysis was defined as positive if there was any leukocyte esterase, >5 white blood cells per high-powered field on centrifuged sample. Our data collection spanned October 2020-October 2022. Data was obtained for 10 months prior to the introduction of the AAP CPG (August 2021) and for 14 months after the introduction. Our clinical pathway was initiated in June 2022 therefore, patient encounters were assigned into 1 of 3 groups based on the time they presented: pre-guideline release, post-guideline but pre-pathway, and post-pathway. We were able to compare effect of CPG publishment and pathway implementation. Plan-do-study-act cycles were performed regularly, staff feedback was reviewed and reeducation provided. These interventions are seen in the control chart.

Results: There were 599 charts reviewed during the study period. Of the 285 who met inclusion criteria, 276 had UA obtained and 197 were negative. 207 total cultures were sent. The percent of patients who had a culture sent after a negative UA was 87% during the pre-guideline period, 83% during the post-guideline to pre pathway period and 38% in the post pathway period. This is displayed in Chart 1. Special cause was achieved only after pathway implementation, see control chart.

Conclusion/Discussion: While the CPG decreased the utilization of urine cultures, there was a far greater effect seen with implementation of an institutional clinical pathway and corresponding electronic medical record order set. It is quite complicated to assess harm caused by a change in practice like sending fewer urine cultures, but by one measure we can say it likely did not cause harm— lack of any positive urine cultures with negative UA in our study population.