Dr. Michael Smith (Host): So, our topic today is Project REVISE: Reducing Excessive Variability in the Infant Sepsis Evaluation. My guest is Dr. Russell McCulloh. He is an internal medicine doctor but also a pediatric specialist working in infectious disease at Children’s Mercy Kansas City. Dr. McCulloh, welcome to the show.

Dr. Russell McCulloh, MD (Guest): Thanks for having me.

Dr. Smith: So, let's just talk a little bit first about what exactly is Project REVISE?

Dr. McCulloh: Project REVISE is a national practice improvement and standardization project that is sponsored by the American Academy of Pediatrics, specifically the quality improvement and innovations network. Some of the providers listening may know that network as sponsoring the Value in Inpatient Pediatrics Network as well as the Pediatric Improvement Network which both conduct multi-site national quality improvement projects in part for MOC credit.

Dr. Smith: And so how many people came together to develop Project REVISE?

Dr. McCulloh: There was a national committee that consisted of about a dozen individuals and the focus was on interdisciplinary participation, specifically having experts in infectious diseases, in hospital medicine, emergency medicine, and in general pediatrics who really put together the collaborative and helped develop the metrics for success and the intervention package. A lot of times for these sort of networks and network projects, they want to work from a national clinical practice guideline which is still in process for being developed for the febrile infant or infant sepsis evaluation and so for this project we had experts who were recognized in the field in that area and who were also some of whom were working on that draft guideline which is still in process.

Dr. Smith: So, in terms of infant sepsis evaluation, tell us a little bit about why we had to have Project REVISE? What’s the challenges there and what's really then the goal of this project?

Dr. McCulloh: Well, I think any general pediatrician or family medicine doctor who sees infants regularly has faced it at least once – the conundrum of a parent calling about their young infant with a fever, and for young infant we're talking about infants generally under 60 days of age, although some go all the way up to under 90 days of age depending on who you’re talking to. And the reasons that infants at this age are a concern is that fever can sometimes be the only symptom that precedes a child suffering a very severe infection. And, when we talk about a severe bacterial infection in these infants, we usually are talking about meningitis or bacteremia although traditionally urinary tract infections are also included in that group.

Dr. Smith: Yeah and so, you know, so when you look at the project and the recommendations that are coming out of it – kind of run through some of that with us. What are some of the changes that are being recommended and how does that affect, you know, the community physician?

Dr. McCulloh: Ummm hmmm. So, like I said, those serious bacterial infections are a large concern for infants in this younger age group because of the uncertainty of the presentation, but when we get down to the actual numbers of infants who will experience particularly for bacteremia or meningitis, we're really talking about less than 2% of infants overall -- maybe about 2% in infants in the first month of life, and less than 2% in the second month of life, and so what that means is that the evaluation on a lot of these infants is going to turn out to be that they have some unconcerning infection, either viral infections or certainly not a bacterial infection. And, when you think about the evaluation for these infants – a complete evaluation, particularly for meningitis – requires that a child undergo several uncomfortable procedures including blood draws, blood cultures, and even a spinal tap or spinal fluid analysis, and if 98 out of 100 infants with a fever aren’t going to have this most concerning type of infection, it's important to – as best one can – identify those kids who really don’t require that more invasive testing. There's been a lot of different risk stratification tools that have been put together over the last three or four decades, and they're pretty good at identifying infants that are low-risk for bacterial infections, and who could safely avoid some of these more invasive tests, but the risk prediction tools that are in existence they are three to four decades old. So, they’re changes in what bacteria are responsible for those infections, and they also differ in specific aspects of the evaluation that they recommend to help determine whether a child is low-risk, and so that discrepancy across risk prediction tools ends up causing some uncertainty which results in a lot of variation and how those infants may be evaluated at different medical facilities across the country, so you literally could have an infant who would undergo a spinal tap, blood cultures, antibiotics, hospital admission, stay in the hospital for a couple of days at one hospital whereas in another they may undergo a very limited evaluation and go straight home….

Dr. Smith: Ummm, yeah.

Dr. McCulloh: ...and that sort of variation is, you know, often excessive.

Dr. Smith: Yeah, and so that’s where Project REVISE comes in, right where you're trying to bring all this together to have a better guideline or a better standardization of how we approach infants with fever – that’s kind of like the big goal, right?

Dr. McCulloh: Absolutely. When you think about it from quality improvement, we may not exactly know where the bullseye is for every specific patient, but if we're all throwing generally in the same place on the dartboard, it gives us a better idea of what's going to work best for any individual patient, and what we're trying to do is get everybody pretty much aiming at the same place on the dartboard.

Dr. Smith: So, you touched on this a little bit – what about, you know, viral testing in a respiratory viral testing, herpes simplex virus testing, is that a part of the project or not?

Dr. McCulloh: There is some discussion of it in the supporting documents that we have – we focused, as part of this national collaborative, on low hanging fruit – which was really trying to get people to test for the most common bacterial causes for fever, which, like I said earlier was urinary tract infection – so getting people to do urine testing to avoid doing chest X rays in folks who are not having respiratory symptoms because although number one pneumonia is a concern it is a very uncommon concern in a child who is not suffering from a cough or respiratory distress. And for viral testing, the mention is regarding how could potentially help improve decision making after the initial evaluation. So, would this be a child who could be safely observed at home or if they are hospitalized, to have a shorter hospital observation stay, and viral testing was really not incorporated into the original risk prediction tools, and so our expert group that helped develop the revised change package and metrics used more contemporary data that has outlined a couple infection scenarios where if you’ve got this sort of infection you pretty much don’t have a bacterial infection, or you're associated with a urinary tract infection, but definitely not meningitis, those…

Dr. Smith: Mmm.

Dr. McCulloh: …sort of associations.

Dr. Smith: Right. So it seems that, you know, Project REVISE might be a good, you know, blueprint for many other types of diagnostic workups that pose these kind of challenges. I mean, do you see more Project REVISEs – you know, similar programs for other types of diagnoses?

Dr. McCulloh: Oh, absolutely. The nice thing about the Value in Inpatient Pediatrics Network is they’ve got a long track record with other common pediatric infection scenarios or syndromes that are encountered by both community providers as well as folks at major tertiary medical centers, so focus on bronchiolitis, there's been two projects over the last 10 years that have focused on that, community-acquired pneumonia, urinary tract infections. Absolutely, there's a lot of room for really focusing on doing those procedures and diagnostic tests that are most likely to yield beneficial results and avoiding in patients the more invasive testing and unnecessary treatments when they are clearly at low risk for the infection of concern.

Dr. Smith: Right, and so practicing physicians, nurse practitioners out in the community if they want to learn more about this what should they do?

Dr. McCulloh: Well, one of the things they can do is they can go to the American Academy of Pediatrics Quality Improvement and Innovation Network’s website. We also have at Children’s Mercy our evidence-based practice, our clinical practice models, and clinical practice guidelines which are freely available on the Children’s Mercy website. That includes algorithms. There’s also -- we developed as part of this collaborative a freely available app that can be downloaded on iOS or Android devices called CMPeDS, Pediatric Decision Support, and it provides some step-wise guidance to help people think through the evaluation and management of a young infant with fever.

Dr. Smith: Great, Dr. McCulloh, thank you for the work that you’re doing at Children’s Mercy and also thank you for coming on the show today. You’re listening to Transformational Pediatrics. For more information, you can go to childrensmercy.org. That’s childrensmercy.org. I’m Dr. Mike Smith. Thanks for listening.