Choosing an evidence-based evaluation and management strategy for febrile young infants, making appropriate antibiotic selection for bacterial infections, and de-escalating respiratory support for children with bronchiolitis are commonly encountered scenarios for pediatricians in the outpatient, emergency department, and inpatient settings.
This month’s issue of Pediatrics includes the results of three multicenter, large-scale quality improvement (QI) initiatives conducted through the American Academy of Pediatrics (AAP) Value in Inpatient Pediatrics (VIP) network that demonstrated improvement in each of these scenarios.
Dr. Corrie McDaniel from the University of Washington and colleagues (10.1542/peds.2023-063339) (disclosure: I am an author) used a multifaceted implementation bundle across 103 hospitals to improve adherence to several recommendations from the 2021 AAP clinical practice guideline for febrile infants. Dr. Russell McCulloh at the University of Nebraska and colleagues (10.1542/peds.2023-062246) used several interventions at 118 hospitals to increase the appropriate use of empiric (i.e., before culture results) antibiotic therapy, use of definitive (i.e., after culture results) antibiotic therapy, and duration of antibiotics for several common pediatric infections. Dr. Courtney Byrd from Emory University and colleagues (10.1542/peds.2023-063509) reduced the initiation and duration of high flow nasal cannula for bronchiolitis at 71 hospitals without increasing length of stay.
Each of the three initiatives also had a catchy acronym:
- Reducing Excessive Variability in Infant Sepsis Evaluation II (REVISE II)
- Better Antibiotic Selection In Children (BASiC)
- High Flow Interventions to Facilitate Less Overuse (HIFLO).
All of these QI projects engaged large groups of hospitals in the US and Canada that were diverse geographically and in structure, with hospitals ranging from large, academic, freestanding children’s hospitals to smaller, non-academic general hospitals. Multidisciplinary teams participated at each hospital to implement the QI interventions and enact local change. By centralizing each QI collaborative through an AAP VIP project leadership team, shared resources and a central data collection system, sites were able to compare individual site performance to the larger collaborative.
REVISE II, BASiC, and HIFLO all demonstrated positive changes in their project measures during the intervention period: improvement in guideline-concordant care for febrile infants, increase in appropriate antibiotic initiation and duration, and reduction in unnecessary high flow nasal cannula therapy for bronchiolitis.
These three QI initiatives demonstrate the power of large-scale collaboratives that engage diverse groups of hospitals and stakeholders.
A particular strength of the AAP VIP network is the inclusion of non-academic hospitals, including those who primarily serve adults, that are often excluded from pediatric research. This inclusion doesn’t just increase the generalizability of the findings, but more importantly provides necessary resources and facilitates improvement in pediatric care at hospitals that might not otherwise be able to participate in this type of work.
Of note, all of these projects were conducted during the COVID-19 pandemic and associated respiratory viral surges. All the participants in these initiatives, from the project leadership team to the local teams at each site, should be commended for their collaboration and QI success during what was a busy and challenging time at all the hospitals.
Please also read the excellent commentary, entitled “We Need it All in Quality Improvement: Local Change, Collaboration, and an Equity Lens,” from Margaret Ridge, MD, and Angela Statile, MD, from the University of Cincinnati (10.1542/peds.2024-065653) that contextualizes these three projects and makes a call to include an equity lens to these QI initiatives, including strategies to ensure equitable implementation and positive change.
