title: Association of clinical practice guidelines with emergency department management of febrile infants ≤56 days of age.
abstract: BACKGROUND
  Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increased healthcare costs.
  
  
  OBJECTIVE
  Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants.
  
  
  METHODS
  Retrospective cross-sectional study in 2013.
  
  
  METHODS
  Thirty-three hospitals in the Pediatric Health Information System.
  
  
  METHODS
  Infants aged ≤56 days with a diagnosis of fever.
  
  
  METHODS
  The presence and content of ED-based febrile infant CPGs assessed by electronic survey.
  
  
  METHODS
  Using generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in 2 age groups: ≤28 days and 29 to 56 days. We also assessed CPG impact on healthcare costs.
  
  
  RESULTS
  We included 9377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29 to 56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (adjusted odds ratio: 0.5, 95% confidence interval: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29 to 56 days old at hospitals with CPGs.
  
  
  CONCLUSIONS
  CPG recommendations for febrile infants 29 to 56 days old vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs.
authors: Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.
authors: Paul L
authors: PL
authors: Aronson
authors: Children's Hospital Association, Overland Park, Kansas.
authors: Cary
authors: C
authors: Thurm
authors: Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors: Derek J
authors: DJ
authors: Williams
authors: Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
authors: Lise E
authors: LE
authors: Nigrovic
authors: Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors: Elizabeth R
authors: ER
authors: Alpern
authors: Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington.
authors: Joel S
authors: JS
authors: Tieder
authors: Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.|Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
authors: Samir S
authors: SS
authors: Shah
authors: Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
authors: Russell J
authors: RJ
authors: McCulloh
authors: The Center for Pediatric Clinical Effectiveness and Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
authors: Fran
authors: F
authors: Balamuth
authors: Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
authors: Amanda C
authors: AC
authors: Schondelmeyer
authors: James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
authors: Evaline A
authors: EA
authors: Alessandrini
authors: Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee.
authors: Whitney L
authors: WL
authors: Browning
authors: Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
authors: Angela L
authors: AL
authors: Myers
authors: Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
authors: Mark I
authors: MI
authors: Neuman
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000191:economics / Q000592:standards; D001774:Blood Chemical Analysis; D002443:Ceftriaxone / Q000008:administration & dosage* / Q000191:economics / Q000592:standards; D002555:Cerebrospinal Fluid / Q000737:chemistry; D003363:Cost Control; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data*; D005334:Fever / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics; D019983:Guideline Adherence / Q000191:economics / Q000706:statistics & numerical data; D019538:Health Care Surveys; D063005:Health Information Systems / Q000706:statistics & numerical data; D006776:Hospitals, Pediatric / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D014481:United States; D016482:Urinalysis
chemical_list: D000900:Anti-Bacterial Agents; D002443:Ceftriaxone