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

The Febrile Infant-Who Has SBI?

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 > 38°C 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

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 ½ of the • Utah’s population of

about 2.8 million

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.

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

Intermountain Clinical Programs

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

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

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.

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

Implementation Process: Key Steps

Clinical ProgramDiscussion

Facility Intro byChampion

Ready Access toTools

StaffMeetings

Building EB17 Publications

QI Test of ChangeSix Sigma @ PCMC

ComparativeData Monitoring

200605 200610 200703 200708 200801 200806

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Sum mary

Data Source: Casemix, and General Lab (Extracted: 09-03-2008)

Percent of Admitted Febrile Infants receiving a Urinanlysis from January 2006 to July 2008: MK, PC, UV, and DX

Phase: Before CPM CPM

89 56 40 47 60 68 55 62 65 65 65 61 86 73 74 69 60 74 96 84 68 69 66 65 103 106 77 57 64 49 64N

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-CPMEffect of offering the EB-CPM for Pediatric MOC

AHRQ 1 R18 HS018034-01, 7/1/09-6/30/11

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

The 7S Framework of McKinsey

Facility Context

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

FacilitySystemRegion

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

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