RESEARCH ARTICLE

Evaluating the Impact of Implementing a ClinicalPractice Guideline for Febrile InfantsWith PositiveRespiratory Syncytial Virus or Enterovirus TestingAdrienne DePorre, MD,a David D. Williams, MPH,b Jennifer Schuster, MD,a Jason Newland, MD,a Jacqueline Bartlett, PhD, RN,c Rangaraj Selvarangan, PhD,d

Keith Mann, MD,a,c Russell McCulloh, MDa

A B S T R A C T OBJECTIVES: To evaluate clinical practice patterns and patient outcomes among febrile low-risk infants withrespiratory syncytial virus (RSV) infection or enterovirus (EV) meningitis after implementing a clinical practiceguideline (CPG) that provides recommendations for managing febrile infants with RSV infection and EV meningitis.

METHODS: Our institution implemented a CPG for febrile infants, which gives explicit recommendations formanaging both RSV-positive and EV-positive infants in 2011. We retrospectively analyzed medical records offebrile infants #60 days old from June 2008 to January 2013. Among 134 low-risk RSV-positive infants, wecompared the proportion of infants who underwent lumbar puncture (LP), the proportion of infants who receivedantibiotics, antibiotic hours of therapy (HOT), and length of stay (LOS) pre- and post-CPG implementation.Among 274 low-risk infants with EV meningitis, we compared HOT and LOS pre- and post-CPG implementation.

RESULTS: Among low-risk RSV-positive patients, the proportion of infants undergoing LP, the proportion ofinfants receiving antibiotics, HOT, and LOS were unchanged post-CPG. Among low-risk infants with EVmeningitis, HOT (79 hours pre-CPG implementation versus 46 hours post-CPG implementation, P , .001)and LOS (47 hours pre-CPG implementation versus 43 hours post-CPG implementation, P 5 .01) bothdecreased post-CPG.

CONCLUSIONS: CPG implementation is associated with decreased antibiotic exposure and hospital LOSamong low-risk infants with EV meningitis; however, there were no associated changes in the proportion ofinfants undergoing LP, antibiotic exposure, or LOS among low-risk infants with RSV. Further studies areneeded to determine specific barriers and facilitators to effectively incorporate diagnostic viral testing intomedical decision-making for these infants.

aDepartment of Pediatrics,Children’s Mercy Kansas

City, University of Missouri-Kansas City School ofMedicine, Kansas City,

Missouri; and Departmentsof bHealth Services and

Outcomes Research,dPathology and

Laboratory Medicine, andcCenter for Clinical

Effectiveness, Children’sMercy Kansas City,

Kansas City, Missouri

www.hospitalpediatrics.orgDOI:https://doi.org/10.1542/hpeds.2016-0217Copyright © 2017 by the American Academy of Pediatrics

Address correspondence to Adrienne DePorre, MD, Division of Hospital Medicine, Department of Pediatrics, Children’s Mercy Hospital,2401 Gillham Rd, Kansas City, MO 64108. E-mail: adeporre@cmh.edu

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Dr Newland’s current affiliation is Department of Pediatrics, Washington University School of Medicine, St Louis, MO.

Drs DePorre and McCulloh contributed to the concept and design of the study, performed data collection, drafted the initial manuscript,and coordinated all edits of the manuscript; Mr Williams contributed to the concept and design of the study, performed the statisticalanalyses for the study, and edited the manuscript; Dr Schuster contributed to study design and data analysis, helped draft the initialmanuscript, and edited the manuscript; Drs Newland, Bartlett, Selvarangan, and Mann contributed to the concept and design of thestudy, crafted the clinical practice guideline, performed data collection, and edited the manuscript; and all authors approved the finalversion of the manuscript as submitted.

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Medical decision-making for febrile infants#60 days of age can be challengingbecause it is often difficult to differentiateinfants with a benign self-limiting illnessfrom those with a more serious illness thatcould progress to sepsis, permanentdisability, or death if left untreated. Inaddition, the lack of standardized nationalguidelines for the testing and empiricaltreatment of febrile infants can lead tovariability and uncertainty in themanagement of febrile infants, especiallyamong those with positive viral test results.1

Infants with respiratory syncytial virus(RSV) infection and infants with enterovirus(EV) meningitis both have a relatively lowrate of concomitant bacterial infection,2–10

and recommendations for RSV and EVtesting have been incorporated into localand regional practice guidelines for febrileinfant management.11 In previous work,Byington et al11 described patient outcomesand cost after implementation of a carepractice model that provided explicitguidelines regarding the care of bothRSV-positive and EV-positive infants. Theimplementation of their care practice modelwas associated with overall increased ratesof EV testing, decreased hospital length ofstay (LOS), and decreased duration ofantibiotics among all febrile infants.11

However, clinical practice patterns andhealth outcomes specifically amongRSV-positive and EV-positive febrile infants,2 populations likely highly impactedby clinical practice guideline (CPG)implementation, are unknown. Ourobjectives in this study were to determinethe impact of implementing a febrile infantCPG that gives explicit managementrecommendations for infants with RSV orEV has on the following outcomes: (1)proportion of lumbar punctures (LPs)performed, antibiotic exposure, and hospitalLOS among low-risk RSV-positive infants,and (2) antibiotic exposure and LOS amonglow-risk infants with EV meningitis.

METHODSCPG Creation

On February 1, 2011, at our institution, weimplemented a CPG for febrile infants#60 days of age that recommended RSVtesting of infants with clinical signs of

bronchiolitis and EV testing of cerebrospinalfluid (CSF) from infants evaluated formeningitis. Among low-risk RSV-positiveinfants, avoidance of both LPs andantibiotics was recommended (Fig 1). Forlow-risk RSV-positive infants #28 days old,hospital admission for observation (withoutantibiotics) was recommended; for low-riskRSV-positive infants .29 days old,discharge from the hospital with closefollow-up was recommended. Amonglow-risk infants with EV meningitis,discontinuation of antibiotics andconsideration of discharge wasrecommended (Fig 2). This was ourinstitution’s first febrile infant CPG, andno revisions were made to the CPGafter initial implementation.

This CPG was developed to addressvariability in the care of febrile infants,and it was created and implemented by ateam consisting of physician and nurserepresentatives from the clinical areas mostimpacted by the guideline, physician andnurse informatics experts, experts inliterature review, and a family memberasked to represent the voice of the family.The quality of evidence was assessed byusing the Grading of RecommendationsAssessment, Development and Educationapproach.12 The febrile infant CPG wascompleted in January 2011 andimplemented in the Children’s MercyHospital emergency departments (EDs),urgent care centers, and hospital inFebruary 2011. An electronic order setguiding practice was developed for febrileinfants #28 days old and for febrile infants29 to 60 days old (Supplemental Figures1 and 2, respectively). The guideline in bothwritten and algorithmic format was placedon the Children’s Mercy Hospital Evidence-Based Practice Web site. In addition, asupporting “app” with decision support wasdeveloped. Academic detailing with the ED,urgent care, hospital medicine, and generalpediatric groups was completed.

Study Design, Setting, and Population

A retrospective study was performed atChildren’s Mercy Kansas City (CMKC), apediatric health system that includesa tertiary-care freestanding children’shospital, a community-based suburban

freestanding children’s hospital (with itsown ED), and 3 urgent care centers. Infants#60 days of life who presented to ourhealth care system with caregiver report offever or documented temperature $38.0°C($100.4°F) between June 25, 2008 andJanuary 31, 2013 were identified frommedical records for inclusion by using boththe International Classification of Diseases,Ninth Revision discharge diagnosis codes of780.60 (fever, unspecified) and 780.61 (feverpresenting with conditions classifiedelsewhere), and through query of ourelectronic health record (EHR). EHR querywas done by using Business Objectssoftware (Web Intelligence version 3.3; SAPBusiness Objects, San Jose, CA), whichidentified any of the following in medicalprovider notes: reason for visit being fever,documented temperature $38°C, ordischarge diagnosis of fever. Qualifyingcharts were manually reviewed to ensurethe presence of a fever.

Febrile infants found to be RSV-positive orto have EV meningitis were divided into2 separate low-risk cohorts. A subsetof infants #28 days old were analyzedseparately in each low-risk cohort.RSV-positive infants were included in thelow-risk RSV cohort if they met our CPG’scriteria for infants at low risk for seriousbacterial infection on the basis of riskfactors for herpes simplex virus, urinalysis,and/or clinical examination (Fig 1). Forpurposes of the study, ill-appearing infantsincluded any infant described in the EHR bya health care provider as “irritable,” “ill-appearing,” “lethargic,” in “moderate-severerespiratory distress,” or in any distress notspecified as respiratory. Of note, infant agewas not a factor in determining whichinfants met low-risk criteria for RSV-positiveinfants.

Infants diagnosed with EV meningitis werecategorized as low-risk by our CPG if theywere afebrile, well-appearing, .7 days ofage, and had negative bacterial cultureresults at 24 hours of incubation (Fig 2).Infants #7 days old were considered to beat higher risk because of the risk ofdisseminated EV among young infants.Because of limitations in manual chartreview, neither time to fever resolution nor

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culture results at 24 hours of incubationcould be captured; thus, only infants#7 dayswere excluded from the low-risk EV cohort.

Data Collected

Data were collected on patientdemographics, initial clinical presentation,diagnostic tests and results, medicationsadministered, and the following patientoutcomes: hospital admission, hospital LOS,subsequent ED visit, and subsequenthospital readmission. Positive bacterialcultures were independently reviewed by2 authors (A.D. and R.M.) to assess growth

of a true pathogen versus a contaminantbased on bacteria isolated and urine colonycounts.

Definitions

A positive urinalysis was defined by ourfebrile infant CPG as having .5 white bloodcells per high-power field or positivenitrites. Urinary tract infection was definedby $10 000 colony-forming units of a singlespecies of bacterium isolated from aurinary catheter–obtained specimen.Bacteremia and bacterial meningitis weredefined by isolation of pathogenic bacteria

in the blood or CSF. Presence of coagulase-negative Staphylococcus in the blood or CSFwas determined to be a contaminant andwas not considered a true infection unlessmultiple blood cultures grew isolates ofcoagulase-negative Staphylococcus withidentical speciation and antimicrobialsusceptibility.

Hours of therapy (HOT) was defined as theaggregate number of hours of antibioticexposure. The HOT for a patient on multipleantibiotics is the sum of the hours eachantibiotic was administered to the patient.

FIGURE 1 RSV test interpretation algorithm. CBC, complete blood cell count; CBC-D, CBC with differential; Cx, culture; HPF, high-power field; UA,urinalysis; UAM, urinalysis with microscopic examination; WBC, white blood cell.

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For example, the HOT for an infant whoreceived 24 hours of ampicillin and24 hours of cefotaxime is 48 hours. HOT isderived from antibiotic days of therapy, awell-described method to measureantibiotic exposure and stewardship.13–15

Our data set provided sufficient detail todetermine antibiotic exposure at the level ofHOT based on the date and time antibioticswere administered. We defined asubsequent visit and readmission aspresenting or being admitted to our healthcare system because of a febrile illnesswithin 14 days of discharge.

Hospital LOS was defined as the hoursbetween the infant’s admission time anddate and the infant’s discharge time anddate as recorded in our health system’sEMR. Time spent outside of an inpatient unit,including time spent in the ED or urgentcare among those infants discharged fromthe hospital from EDs or urgent cares, wasnot included in LOS calculations.

Virology Testing

RSV testing during the study period wasperformed either as part of a multiplexpolymerase chain reaction (PCR) panel(Biofire FilmArray or Luminex xTAG RVP) orby rapid antigen testing (BD Veritor System,BD Directigen EZ RSV, or Binax NOW RSV).Turn-around time for RSV testing rangedfrom ∼1 to 15 hours depending on whichtesting modality was used and from whichCMKC location the sample was collected.

EV testing during the study period wasperformed via real-time reversetranscription PCR, by an CepheidEnterovirus analyte-specific reagent assay(Cepheid, Sunnyvale, CA), an EnterovirusR-gene (bio-Mérieux, Marcy-l’Étoile, France),or via an in-house assay as describedpreviously,16 with the exception that duringthe nonpeak EV incidence months of2008 to 2010, EV testing was performed at areference laboratory. Reference laboratoryEV testing time to results ranged from∼24 to 48 hours. In-house EV testing timeto results ranged from ∼8 to 43 hoursdepending at which CMKC location thespecimen was collected and on the timeof year.

Data Analysis

Primary outcomes among low-risk RSV-positive infants included the proportionof infants undergoing LPs, the proportionof infants who received antibiotics, andHOT and LOS pre- versus post-CPGimplementation. Primary outcomes amonglow-risk infants with EV meningitis includedHOT and LOS pre- versus post-CPGimplementation. A subanalysis of low-riskinfants with EV meningitis that excludedthose who had testing performed at areference laboratory, which had a longerturn-around-time of 24 to 48 hours, wasconducted to assess whether observeddifferences in LOS and HOTwere attributableto this subset of infants. Secondary

outcomes among both cohorts included theproportion of subsequent ED visits andhospital readmissions pre- versus post-CPGimplementation. We also determined therates of positive blood, urine, and CSFbacterial cultures among both cohorts.

Fisher’s exact or x2 tests were used forcategorical variables and 2-sample Wilcoxonrank (Mann–Whitney U test) tests wereperformed for continuous variables, asappropriate. Statistical significance wasregarded at P , .05 (2-sided). Statisticalanalyses were performed by using Stata13.0 (StataCorp, College Station, TX). Thehospital’s institutional review boardapproved the study.

RESULTS

Demographic and clinical outcome datacollected from a total of 2036 febrile infantsare presented in Table 1. A flow diagramdepicting the included 134 low-riskRSV-positive infants, of whom 131 werediagnosed with RSV through rapid antigentesting, and the 274 low-risk infants withEV meningitis is presented in Fig 3.

Primary Outcomes

In the low-risk RSV cohort, the proportion ofLPs performed, the proportion of infantsreceiving antibiotics, HOT, and LOS wereunchanged post-CPG implementation(Table 2). In the low-risk EV cohort, HOT(median 79 hours pre-CPG versus median46 hours post-CPG, P , .001) and LOS

FIGURE 2 EV test interpretation algorithm. a infants ,1 week of age with EV are at risk for significant multisystem disease. An infectious diseaseconsult is recommended.

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(median 47 hours pre-CPG versus median43 hours post-CPG, P 5 .01) both decreased

post-CPG implementation (Table 2). Among

infants #28 days old included in the

low-risk EV cohort, HOT decreased (median

90 hours pre-CPG versus median 75 hours

post-CPG, P 5 .03) and LOS was unchanged(Table 2).

A subanalysis of infants with EV meningitisthat excluded 27 infants whose EV testingwas performed at a reference laboratoryshowed a similarly significant decrease

in both LOS and HOT post-CPGimplementation.

Secondary Outcomes

There were no differences in subsequent EDvisits or hospitalizations post-CPGimplementation in either cohort. In thelow-risk RSV cohort, 8.2% of pre-CPG versus12.3% of post-CPG (P 5 .57) infants hadsubsequent ED visits, and 4.9% of pre-CPGversus 9.6% of post-CPG (P 5 .35) infantshad subsequent hospital readmissions. Allrevisits or readmissions were because ofsymptoms related to bronchiolitis, andthere were no positive results for blood,urine, or CSF bacterial cultures noted onsubsequent ED visits or readmissions. In thelow-risk EV cohort, 2.9% of pre-CPG versus0% of post-CPG (P 5 .34) infants hadsubsequent ED visits and 1% of pre-CPGversus 1.5% of post-CPG (P 5 .56) infantshad subsequent hospital readmission. Allrevisits or readmissions were because ofrecurrence of fever, and there were nopositive results for blood, urine, or CSFbacterial cultures noted on subsequentED visits or readmissions.

No cases of bacterial meningitis orbacteremia were diagnosed in either low-risk RSV-positive infants or in low-risk infantwith EV meningitis. Urine culture resultswere positive in 0% of low-risk RSV-positiveinfants and in 1.2% of low-risk infants withEV meningitis. As mentioned above, infantswere excluded from our low-risk RSV cohortif they had a urinalysis that containednitrites or .5 white blood cells per high-power field.

We noted significant differences in patientoutcomes when comparing low-risk RSV-positive infants and low-risk infants with EVmeningitis evaluated pre-CPG to all otherfebrile infants evaluated pre-CPG.Specifically, compared with all other febrileinfants evaluated pre-CPG, low-risk RSV-positive infants evaluated pre-CPG wereobserved to have a decreased proportion ofboth LP obtainment (29% of RSV-positiveinfants versus 70% of all other febrileinfants, P , .001), and antibioticadministration (31% of RSV-positive infantsversus 70% of all other febrile infants,P , .001). Compared with all other febrileinfants evaluated pre-CPG, low-risk infants

TABLE 2 Patient Management and Outcomes Pre- Versus Post-CPG Implementation

Pre-CPG Post-CPG P

Low-risk RSV-positive infants N 5 61 N 5 73 —

LP performed, n (%) 17 (28) 19 (26) .81

Infants #28 d old, LP performed, frequency (%) 7/11 (64) 8/12 (67) .999

Received antibiotics, n (%) 18 (30) 15 (21) .23

Infants #28 d old, received antibiotics,frequency (%)

7/11 (64) 7/12 (58) .999

LOS in h, median (IQR) 41 (10–68) 36 (4–86) .79

Infants #28d old, LOS in h, median (IQR) 46 (38–201) 56.5 (42–148.5) .78

HOT, median (IQR) 89 (54–94) 74 (16–106) .59

Infants #28 d old, HOT, median (IQR) 92 (62–94) 98 (80–110) .06

Subsequent ED visits, n (%) 5 (8.2) 9 (12.3) .57

Subsequent readmission, n (%) 3 (4.9) 7 (9.6) .35

Low-risk EV-positive infants N 5 208 N 5 66 —

HOT, median (IQR) 79 (48–96) 46 (27–74) ,.0001

Infants #28 d old, HOT, median (IQR) 90 (75–103) 75 (53–95) .03

LOS in h, median (IQR) 47 (38–56.5) 42.5 (25–51) .01

Infants #28 d old, LOS in h, median (IQR) 49 (41–60.5) 48 (42–63) .76

Subsequent ED visits, n (%) 6 (2.9) 0 (0) .34

Subsequent readmission, n (%) 2 (1.0) 1 (1.5) .56

—, not applicable.

TABLE 1 Febrile Infant Patient Demographics and Microbiology Results

Low-riskRSV-positive(n 5 134)

Low-riskEV-positiveMeningitis(n 5 274)

AdmittedFebrile Infants(n 5 1554)

All FebrileInfants

(N 5 2036)

Female, n (%) 58 (43) 135 (49) 734 (47) 929 (46)

Public insurance, n (%) 81 (60) 154 (56) 937 (60) 1235 (61) (n 5 2035)

Age #28 d old, n (%) 23 (17) 120 (44) 564 (36) 595 (29)

Admitted to hospital, n (%) 100 (75) 267 (97) 1554 (100) 1554 (76)

Temperature (°C) on arrival,mean 6 SD

38.3 6 0.6 38.4 6 0.8 38.3 6 0.7 38.2 6 0.7

Positive urinalysis results,a

frequency (%)0/102 (0) 8/255 (3.1) 165/1408 (11.7) 177/1724 (10.3)

Positive urine culture results,a

frequency (%)0/102 (0) 3/261 (1.2) 143/1428 (9.9) 151/1757 (8.6)

Positive blood culture results,b

frequency (%)0/86 (0) 0/266 (0) 32/1444 (2.2) 33/1739 (1.9)

Positive CSF culture results,frequency (%)

0/36 (0) 0/270 (0) 3/1288 (0.2) 3/1395 (0.2)

a Infants with a positive urinalysis were excluded from the low-risk RSV-positive cohort.b With or without positive urine culture.

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with EV meningitis evaluated pre-CPG haddecreased HOT (79 hours [interquartilerange (IQR) 48–96] versus 90 hours [IQR52.5–105], P 5 .001) and LOS (47 hours[IQR 38–56.5] versus 48 hours [IQR 41–63],P 5 .03).

DISCUSSION

We found that implementing a febrile infantCPG that gives explicit managementrecommendations based on RSV and EV testresults was associated with no changes inthe proportion of infants undergoing LP,antibiotic exposure, or LOS among low-riskRSV-positive infants but that HOT and LOSdecreased among low-risk infants with EVmeningitis. We also found a low rate ofconcomitant bacterial infections in bothcohorts. CPG implementation was notassociated with adverse patient outcomes,suggesting that adjusting clinicalmanagement of a well-defined low-risksubset of febrile infants based on RSV andEV test results is reasonably safe.

The lack of observed changes among low-risk RSV infants is likely multifactorial, but itcould be attributed to preexisting clinicianknowledge and skill in incorporating RSVtesting into febrile infant management.

Compared with all other febrile infantsevaluated pre-CPG at our institution, low-risk RSV-positive infants evaluated pre-CPGwere observed to have a decreasedproportion of both LP obtainment andantibiotic administration. Thus, on the basisof these observations, we speculate thatCPG recommendations did not reflect anovel way of managing these patients in ourhealth system, and that clinicians may havealready been incorporating RSV testing andinterpretation into their managementpractices. LOS was unchanged among low-risk RSV-positive infants. This in our view isnot surprising, given that RSV-positiveinfants likely had many confounding factorscontributing to LOS, particularly symptomsof bronchiolitis. Additionally, although ourCPG provided explicit discharge criteria forpatients with EV, no similar criteria fordischarge for RSV-positive infants wereprovided. No changes in management oroutcomes were observed among low-riskRSV-positive infants #28 days of life, apopulation expected to be moreconservatively managed pre-guidelines. Thislack of change may be because of smallsample size in this subset of infants, orhealth care providers may still have had

uncertainty regarding optimal managementof these young infants even after CPGimplementation.

Our study highlights the positive role thatEV testing, when combined with explicitmanagement recommendations for infantswith EV meningitis, can play in medicaldecision-making. We build on previousresearch performed at both our institutionand elsewhere that describes an associatedreduction in hospital LOS and antibioticsreceived among febrile infants with positiveEV testing.17,18 Although EV testing had beenavailable at our institution for more than adecade and had been associated withsubstantial reductions in antibioticexposure and LOS,17 we observed evenfurther decreases in both post-CPGimplementation. Specifically, compared withall other febrile infants evaluated pre-CPG,low-risk infants with EV meningitis haddecreased HOT and LOS. Post-CPGimplementation, we observed even furtherdecreases in HOT and LOS for low-riskinfants with EV meningitis (Table 2). Thus,we propose that guidelines that give explicitmanagement recommendations based ontest results are likely needed to optimize

FIGURE 3 Flow diagram of included low-risk RSV and low-risk EV infants. ALT, alanine aminotransferase; AST, aspartate aminotransferase; UA,urinalysis. a 1 RSV-positive infant was described as both seizing and ill appearing.

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changes in practice patterns. We donote the discrepancy in the number oflow-risk infants with EV meningitisevaluated pre-CPG versus post-CPGimplementation. Because testing patternswere unchanged pre-CPG versus post-CPG(Fig 3), we attribute this discrepancy tonatural temporal fluctuations that occurwith EV.19

Our study has several limitations. Thisreview was performed at a single pediatrichealth system and was not a multicenterreview, decreasing its generalizability.Febrile infant encounters may havebeen misclassified by using our caseidentification strategy; however, this riskwas reduced through manual confirmationof patient encounter eligibility. Because HOTis based on the aggregate number ofantibiotics given, the use of HOT as a markerof antibiotic exposure could confoundresults if infants presenting post-CPGreceived a different number of antibioticsthan infants evaluated pre-CPG. We find thisunlikely to affect our results because therewere no significant differences in thenumber of antibiotics given to either low-risk RSV-positive infants or low-risk infantswith EV meningitis pre-CPG versus post-CPG.A subanalysis of infants within each low-riskcohort broken down by age #28 or.29 days similarly revealed no significantchange in number of antibiotics givenpre-CPG versus post- CPG. We cannot fullyassess the impact that variations in testturnaround time could have had on clinicalcourse or patient outcomes. Because of theretrospective nature of this study, changesseen in clinical practice patterns andpatient outcomes cannot be attributed toCPG implementation with certainty. However,clinicians did use an electronic order set,which was linked to and based on the CPGin 80% of febrile infant encounters,suggesting that elements of the CPG were atleast reviewed in most clinical encounters.Finally, patient and provider characteristicsthat may have driven viral testing were notanalyzed. There may be a selection biasamong infants who underwent viral testing,which we were unable to account for in aretrospective study. Specifically, althoughthe proportion of infants tested for EV wasunchanged, it is unknown if inherent clinical

differences among infants tested for EVpre- versus post-CPG affected our results.

CONCLUSIONS

Integrating testing and clinical managementrecommendations for RSV and EV into CPGsfor febrile infants may enhance medicaldecision-making and poses a minimalrisk of missing concomitant bacterialinfections. However, merely includingrecommendations regarding testinterpretation into a CPG may beinsufficient. Further studies are needed todetermine specific barriers and facilitatorsto effectively incorporate diagnostic viraltesting into medical decision-making forthese infants.

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DOI: 10.1542/hpeds.2016-0217 originally published online September 21, 2017; 2017;7;587Hospital Pediatrics 

Bartlett, Rangaraj Selvarangan, Keith Mann and Russell McCullohAdrienne DePorre, David D. Williams, Jennifer Schuster, Jason Newland, Jacqueline

Infants With Positive Respiratory Syncytial Virus or Enterovirus TestingEvaluating the Impact of Implementing a Clinical Practice Guideline for Febrile

ServicesUpdated Information &

http://hosppeds.aappublications.org/content/7/10/587including high resolution figures, can be found at:

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DOI: 10.1542/hpeds.2016-0217 originally published online September 21, 2017; 2017;7;587Hospital Pediatrics 

Bartlett, Rangaraj Selvarangan, Keith Mann and Russell McCullohAdrienne DePorre, David D. Williams, Jennifer Schuster, Jason Newland, Jacqueline

Infants With Positive Respiratory Syncytial Virus or Enterovirus TestingEvaluating the Impact of Implementing a Clinical Practice Guideline for Febrile

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