O1016: Decreasing emergency department revisits for febrile infants with positive blood cultures with likely contaminant organisms

Purpose/Objectives: The American Academy of Pediatrics (AAP) recommends obtaining blood cultures as part of the emergency department (ED) evaluation for febrile young infants (FYI) and allows for older, well-appearing FYI (>28 days) with normal urinalysis and inflammatory markers to be discharged home. Positive blood cultures after discharge require ED revisit for evaluation leading to potential unnecessary invasive testing, antibiotics, and hospitalization. Rapid molecular testing (Verigene/ePlex) of positive blood cultures can identify common gram-positive organisms (pathogens and contaminants) in 2-3 hours. We aimed to reduce ED revisits and hospitalizations for discharged well-appearing FYI 29-56 days old with a positive blood culture and Gram stain with gram positive cocci (GPC) in clusters or pairs and clusters from 100% to 50% over 12 months.

Design/Methods: This quality improvement initiative was conducted in a quaternary care children’s hospital system with urban and suburban campuses. We included healthy, well-appearing FYI 29-56 days old discharged from the ED and subsequently had a positive blood culture with GPC in clusters or pairs and clusters on Gram stain, suggesting likely contaminant organism. Our multidisciplinary team reviewed local epidemiology, Verigene/ePlex testing targets and updated the ED blood culture follow-up protocol, integrating rapid molecular testing results into the ED revisit criteria for positive blood cultures (Figure 1). Our PDSA cycles included revising and implementing a new ED policy for delayed positive blood cultures, creating a smartform for electronic health record documentation and providing clinical decision support for the new policy, and divisional education sessions. Statistical process control methodology was used to monitor improvement from baseline (January 1, 2018 – October 31, 2023) through the intervention period (November 1, 2023 – March 31, 2025). Primary outcome measures were percentage of ED revisits and hospital admissions. Secondary outcomes included percentage of infants with invasive testing (blood culture, urine culture, lumbar puncture) and antibiotic administration during ED revisit. Balancing measures included percentage of infants with delay in care for true pathogen on blood culture and percentage of discordance between Gram stain, Verigene/ePlex result, and final blood culture result.

Results: ED revisits decreased from 100% to 35.7% (p < 0.001) and days between ED revisits increased consistent with special cause variation (Figure 2). Hospital admissions decreased from 42.9% to 14.3% (p=0.068). There was a significant reduction in infants undergoing blood testing (82.1% to 33.3%, p=0.002) and antibiotic administration (28.6% to 0%, p=0.028). Lumbar puncture rates decreased (14.3% to 0%, p=0.14). Urine testing remained relatively unchanged (7.2% and 11% p=0.68). There were no infants with delayed care for true pathogens and no discordance between Gram stain, Verigene/ePlex result and pathogen speciation.

Conclusion/Discussion: This quality improvement initiative safely reduced ED revisits, hospitalizations, invasive testing, and unnecessary antibiotic administration in FYI with positive blood cultures due to contaminant organisms after ED discharge.