A fever is a positive sign that the body is fighting against infection. But, for parents and loved ones of a newborn, a fever signals concern and oftentimes leads to an emergency department (ED) trip.
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While rarely related to serious illness, determining the source of the infant’s fever is imperative.
“Fortunately, most neonates with fever are not critically ill, and we can help reassure families after the appropriate workup and treatment in the ED,” says Bryan Baskin, DO, a Cleveland Clinic emergency medicine physician and the Emergency Services Institute’s (ESI) quality improvement officer. “However, when we see them in the ED, it is critical we get the care right.”
Historically, treatment for fever in patients less than 60 days old was very aggressive with extensive testing, including lumbar punctures. The availability and varying use of national scoring tools, differing recommendations, and guideline discrepancies add to the complexity.
“Because clinician training and experience varies, we wanted to tighten practice patterns and/or any knowledge gaps with a standard evidence-based workup and treatment approach for these tiny patients across all Cleveland Clinic locations.” Dr. Baskin adds, “By removing variability and providing real-time resources, we’re ensuring the best course of action regardless of where the patient is seen.”
Developing a standard practice entailed ongoing discussions.
As Molly Gourash, ESI’s project manager, describes: “This was an iterative, collaborative initiative with multidisciplinary input and considerations to define the process maps required to safely care for these patients.”
Through a collective partnership among Cleveland Clinic emergency medicine physicians, pediatricians, and infectious disease experts, the team identified the critical steps for patients with fevers under the age of 60 days.
Cleveland Clinic physician Purva Grover, MD, Director of Cleveland Clinic’s Pediatric Emergency Medicine, is credited with providing significant direction in developing the infant fever care paths.
Cleveland Clinic care paths are evidence-based process tools developed by clinical and operational teams that consistently guide clinical workflows. These tools are then integrated into the electronic health record (EHR) to support clinical decision-making.
“Defining the decision points for clinicians to consider throughout the patient workup was pivotal.” Dr. Baskin adds, “Dr. Grover led our expert panel in creating a seamless workflow from the onset of the visit, the necessary testing and the next steps based on those findings.”
Dr. Baskin continues, “There have been significant advancements in using inflammatory markers to determine the necessity of lumbar punctures. Although these improvements didn’t impact recommendations for patients ages 0-28 days, the guidelines shifted for babies ages 29 – 60 days. Regardless of the patient’s age, we’re doing everything possible to limit unnecessary testing and admissions.”
Linking clinical guidance with digital tools
Cleveland Clinic emergency medicine physician Jeffrey Ruwe, MD, led the next phase.
“Integrating the care path into our EHR was an intricate process due to the distinct age groups. While treatment for ages 0-29 remains the same, for infants ages 29 – 60 days, there are potentially four pathways depending on the lab findings,” says Dr. Ruwe, who also serves as the ESI’s director of clinical informatics and operations.
Dr. Ruwe worked with Cleveland Clinic clinical systems analyst Erica Uhlich, RN, to build the care path workflows and decision-making pathways into an easy-to-use format.
Uhlich, who previously worked as an ER nurse, strives to incorporate her clinical background into her technical designs.
“Having worked in the ER, I know the challenges of trying to remember all the recommendations for all sorts of patients of different ages,” says Uhlich. “With that understanding, my goal is to build digital tools that make documentation faster and more efficient while prompting caregivers throughout their clinical decision-making process.”
Prior to the build, Uhlich frequently met with the team to thoroughly review each step of the algorithm.
Uhlich explains, “This build is more than adding a flowchart to the EHR. This process involved multiple reviews to ensure the tool was functioning as intended. My focus is on making error-proof tools, so I continued to modify the build until it worked as expected.”
This isn’t cookbook medicine
The embedded care path launches once a fever is documented in the patient’s chart. The tool is dynamic and continuously aggregates resulted lab data.
“There’s a fine line with this type of medicine.” Dr. Ruwe continues, “This isn’t the computer telling you what to do. There are checkpoints throughout the evaluation where the clinician has to review and interpret the data. The care path is designed to highlight the lab values and guide the work, but at any point, the clinician can adjust the treatment.”
Cascading options are dependent on the clinician’s input, which allows for individual interpretation throughout the evaluation.
“The tool is an interactive, step-by-step algorithm that only displays pertinent information specific for that patient.” Uhlich adds, “This real-time support keeps current recommendations at the forefront, while still allowing for personal clinical judgment.”
Deviating from the care path is always an option.
Dr. Ruwe explains, “Sometimes there are valid reasons to veer from what’s being recommended — and that’s OK. Clinicians simply document the contributing factors that justify their decision.”
Reducing high variability among standard practice
At Cleveland Clinic, there are more than 500 clinicians who care for pediatric patients.
“The intricacies of patient care are ever-changing. The infant fever care path was a clear opportunity to push toward standardization using the best, most current evidence-based practice,” says Dr. Baskin.
Dr. Ruwe adds, “No matter the clinical setting or background, there’s mindful attention to always look for what’s best for our patients. Standardization supports our clinicians with their decision-making and ensures the consistent delivery of safe, high-quality care.”
Uhlich agrees, “Safety remains our priority. Using this tool encompasses our unwavering commitment to always do our best for every patient, every day.”