Emergency Medicine: All Areas
Emergency Medicine 3
Nirupama Kannikeswaran, MBBS (she/her/hers)
professor of pediatrics and emergency medicine
Childrens Hospital ofMichigan
Detroit, Michigan, United States
Evidence based guidelines recommend that febrile infants at low-risk for invasive bacterial infection (IBI) are discharged from the Emergency Department (ED) without lumbar puncture or antibiotics and with primary care physician (PCP) follow up within 24-48 hours. There is little evidence that such follow up changes clinical outcomes in these infants. Further, it may serve as a barrier to discharge of such infants from ED.
Objective:
To assess the association between having an identified PCP in the electronic health record (EHR) and the management and disposition of low-risk febrile infants.
Design/Methods:
This was a secondary analysis of a multicenter, cross-sectional study of low-risk febrile infants 29-60 days who were evaluated in 34 Pediatric EDs in 2018-2019. Infants were classified as low-risk by institutional or standardized guidelines. Trained investigators abstracted data through chart review. Investigators identified if the infant had an identified PCP documented in the EHR and reviewed provider notes to determine if there was documentation of barriers to discharge from the ED. We performed bivariate and multivariable logistic regression, controlling for a priori identified potential confounders and hospital-level clustering.
Results:
Of 4,212 infants, 411 (9.8%) had no documented PCP. Table 1 shows the demographics of infants with and without a documented PCP. There was no difference in lumbar puncture (15.8% vs. 17.1%, p =0.56), antibiotic (15.1% vs. 14.1%, p= 0.64) or hospitalization rates (15.3% vs. 17.3%, p =0.34) between infants without and with a documented PCP (Table 1). The rates of return ED visit within 72-hours and of IBI were similar among patients without and with a documented PCP (Table 1). All discharged infants with IBI returned to the ED and were subsequently admitted. In multivariable regression analysis, there was no association between documented PCP and additional interventions (lumbar puncture, antibiotic administration, hospitalization) (Table 2). Barriers to discharge were documented for 61 infants (1.5%), of which 9 noted lack of PCP.
Conclusion(s):
Having EHR documentation of a PCP was not associated with ED evaluation or disposition for low-risk febrile infants. IBI was diagnosed infrequently and no discharged infants with IBI were lost to follow-up. Though hospital admission was frequent, barriers to discharge were rarely documented. There is a need for additional work to understand costs and benefits of close PCP follow-up as a requirement for ED discharge of low-risk febrile infants..png)
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