Safely Avoiding Lumbar Puncture in the Evaluation of Infants with Fever

CHOP News

By identifying babies at low risk of serious bacterial infection, a quality improvement team at CHOP safely reduced the use of lumbar puncture in infants being evaluated for fever.

Fevers in newborn babies are considered emergencies. That’s because young infants who have immature immune systems are at a higher risk of serious bacterial infections, including meningitis.

In the past, nearly all babies younger than 56 days old who arrived at The Children’s Hospital of Philadelphia (CHOP) with a fever higher than 100.4° F (38°C) had a “complete sepsis workup” to check for bacterial infection. That workup included a screening for meningitis, which requires an invasive and usually painful lumbar puncture (also known as a spinal tap).

During this procedure, a hollow needle is inserted into the spine to withdraw spinal fluid that is then tested for signs of inflammation and bacteria. Following this procedure, patients were admitted to the hospital to await results. 

Physicians in CHOP’s Emergency Department wondered whether there was a way to reduce the need for lumbar punctures in infants with fever, without increasing the risk of missing a serious infection.

Looking at the numbers

A quality improvement team from CHOP’s Office of Clinical Quality Improvement (OCQI) analyzed seven years of data from more than 1,000 febrile infants from CHOP’s electronic health record. The data indicated that babies between 29 and 56 days old who met specific low-risk criteria (for example, full term and no prior NICU stay) were highly unlikely to have meningitis. In fact, over the course of 7 years, there weren’t any low-risk infants who had bacterial meningitis. The team determined that these babies could be safely discharged from the Emergency Department without a lumbar puncture.

The OCQI team then worked with ED physicians to make changes to the clinical pathway for the treatment of infants with fever. The pathway was updated to clarify the low-risk criteria and help physicians determine which patients could be eligible for discharge without a lumbar puncture.

The information about the pathway change was distributed to all Emergency Department physicians and incoming data was reviewed daily to ensure the safety of the new protocol.

The results

Since the introduction of the new pathway in June of 2014, the percentage of febrile infants between 29 and 56 days old who are discharged without a spinal tap has dramatically increased. Before the pathway was changed, 21 percent were discharged without a lumbar puncture. Now, about 55 percent of infants are sent home without the procedure, and no infants with meningitis were missed.

In all, more than 240 babies were spared a painful lumbar puncture procedure in the first year after the pathway changes were implemented.

“The implementation of this pathway change has allowed for the safe evaluation of febrile young babies while reducing the need for invasive testing and hospitalization,” says Richard Scarfone, MD, one of the Emergency Department physicians who led the charge for this quality improvement project.