title: Rapid implementation of evidence-based guidelines for imaging after first urinary tract infection.
abstract: OBJECTIVE
  The American Academy of Pediatrics published a new guideline for management of first urinary tract infection (UTI) in children aged 2 to 24 months in September 2011. The imaging evaluation changed from the previous guideline to recommend voiding cystourethrogram (VCUG) only for patients with an abnormal renal and bladder ultrasound (RBUS). The objective was to decrease the proportion of guideline-eligible children with a normal RBUS who underwent VCUG from median of 92% for patients treated as inpatients and 100% for patients treated in the emergency department to 5% in both settings.
  
  
  METHODS
  This was a quality improvement implementation study in a large academic medical center. Key drivers included: appropriate guideline knowledge, timely identification of guideline eligible patients, and effective communication with the community-based primary care provider. A multidisciplinary team developed and tested interventions. Impact was assessed with annotated run charts. Statistical comparisons were made with χ(2) analysis and Fisher's exact test.
  
  
  RESULTS
  The proportion of children with first UTI and normal RBUS who underwent VCUG decreased from a median of 92% to 0% within 1 month of initiating the project among those hospitalized and from 100% to 40% within 4 months among those diagnosed in the emergency department. Rates have been sustained for 12 months and 8 months, respectively. Interventions using the electronic medical record and ordering system were most impactful.
  
  
  CONCLUSIONS
  Rapid adoption of evidence-based UTI care across multiple settings is achievable. Practice change occurred faster and to a greater magnitude in the inpatient setting compared with the outpatient setting.
authors: Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA. karen.jerardi@cchmc.org
authors: Karen E
authors: KE
authors: Jerardi
authors: Dena
authors: D
authors: Elkeeb
authors: Jason
authors: J
authors: Weiser
authors: William B
authors: WB
authors: Brinkman
mesh_terms: D000046:Academic Medical Centers; D004636:Emergency Service, Hospital; D019317:Evidence-Based Medicine; D005260:Female; D019983:Guideline Adherence; D006284:Health Plan Implementation; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007318:Inservice Training; D008297:Male; D009820:Ohio; D058996:Quality Improvement / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014463:Ultrasonography / Q000706:statistics & numerical data*; D014551:Urinary Tract / Q000002:abnormalities; D014552:Urinary Tract Infections / Q000175:diagnosis*; D014567:Urography / Q000706:statistics & numerical data*; D014600:Utilization Review
keywords: VCUG; evidence-based medicine; quality improvement; urinary tract infection
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