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AHRQ 2010 Annual Meeting Improving the Care of the Febrile Infant: Lessons Learned from AHRQ’s Implementation Science

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

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AHRQ 2010 Annual Meeting Improving the Care of the Febrile Infant: Lessons Learned from AHRQ’s Implementation Science

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  1. AHRQ 2010 Annual MeetingImproving 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

  2. The Febrile Infant-Who Has SBI?

  3. 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 seriousbacterial 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

  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 ½ of the • Utah’s population of about 2.8 million

  5. 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.

  6. 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

  7. Intermountain Clinical Programs • Behavioral Health • Cardiovascular Medicine and Surgery • General Surgery • Intensive Medicine • Oncology • Patient Safety • Pediatric Specialties • Primary Care • Women and Newborn

  8. 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

  9. 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.

  10. 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

  11. Implementation Process: Key Steps Clinical Program Discussion Building EB 17 Publications Facility Intro by Champion QI Test of Change Six Sigma @ PCMC Staff Meetings Ready Access to Tools Comparative Data Monitoring

  12. Evaluation of an Evidence-Based Care Process Model for Febrile InfantsMixed 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

  13. Aim 1 Qualitative Analysis of Factors Related to Implementation of the EB-CPM The 7S Framework of McKinsey

  14. Facility ContextAll facilities are tertiary care, regional referral centers. Staffed beds noted.

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