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 Program Discussion Facility Intro by Champion Ready Access to Tools Staff Meetings Building EB 17 Publications QI Test of Change Six PCMC Comparative Data Monitoring

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 HS , 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. Facility System Region 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 LeversIntervention ElementsEmergent Themes Shared ValueBoard goal Visibility & leadership involvement: A corporate wide effort, supported by a Board goal helps---knowing that everyone is doing it. StrategyBuilding 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. StructureClinical integration/programs Resources: We have the clinical program infrastructure to determine priorities, identify solutions, and make decisions about focused efforts for change. SystemsCPM; decision support tools; informatics Tools: Providing documentation and support materials that are easily/readily accessible and that support or improve normal work flow. StyleFeedback reports; monitoring Feedback (to involved staff); and monitoring with valid measures; tracking costs. StaffAdmin/managers, MDs, nurses, lab staff People: Involvement of nursing to make it happen! Physician buy-in. MOC SkillsDx, process, lab tests Staff training (with refresher), alignment with laboratory