Right Care Rounds: Debunking the 48-hour rule

June 18th, 2018

Each year, the Lown Institute chooses chief residents from across the country to participate in the Right Care Educator Program. The RCEP provides chief residents with training and support to implement Right Care Rounds, case presentations that explore the drivers of medical overuse, at their home institutions.

Dr. Olivia Widger is finishing up her year as pediatric chief resident at Johns Hopkins Hospital in Baltimore and recently gave a

Dr. Olivia Widger

Right Care Rounds presentation at her hospital. We spoke with Dr. Widger about her experience in the RCEP and the case she presented.

Lown Institute: How did you first get interested in the Right Care Educator Program?

Dr. Olivia Widger: I had already been interested in high value care and had volunteered to sit on the newly formed Pediatric High Value Committee at the Johns Hopkins Children’s Center. My program director told me about the Right Care Educators Program, and it sounded like a great opportunity. At Johns Hopkins we have the usual morning report and M&M (morbidity and mortality) conferences, but no real education around overuse. So I’ve been working to institute Right Care Rounds to fill that gap.

Tell me about the case you presented.

I based the presentation off of a “Things We Do for No Reason” article co-authored by my colleague, Dr. Carrie Herzke, recently published in the Journal of Hospital Medicine. The article is about a common problem in pediatrics, deciding how long to keep infants with fever in the hospital to rule out an infection.

When young infants have a fever it’s considered an emergency. We admit them to the hospital and test and treat them as though they have a serious infection. Historically, the standard has been to keep these infants in the hospital for 48 hours. But if you look at the recent literature, the traditional “48 hour rule-out” may not be necessary for well-appearing infants.

How did the 48-hour standard get started?

Part of the reason for the two-day standard is because cultures were processed more slowly in the past. Current technology allows labs to continuously monitor blood cultures, so as soon as bacteria starts to grow, the lab and medical team are alerted. Recent studies have shown that most positive cultures are identified well before the 48 hour mark.

It turns out that most of our residents did not know how a blood culture is processed in the lab. This is really critical to understanding why the 48 hour rule-out is being challenged.

How did your presentation go?

It went really well! I tried to make it as interactive as possible. The residents commented that there is wide variation in practice; some babies stay in the hospital for 24 hours and some babies are kept for 48 hours. We split into two groups and brainstormed the risks and benefits of keeping these infants in the hospital for a full 48 hours.

Some providers might choose to keep an infant in the hospital for a full 48 hours because they believe that it is safer, but there are also risks. For example, the longer you stay in the hospital, the greater your risk of acquiring other infections. There are also potential harms from giving a newborn more antibiotics, increased costs, and you’re disrupting families’ lives.

Are there any other cases on pediatric overuse you presented this year?

I also presented a case of a 7-year-old boy who presented with fever and had a blood culture taken as part of his workup in the ER. He was discharged home but needed to return to the ER and be admitted because the blood culture turned positive. It turns out that he didn’t really have an infection; the blood culture had been contaminated. But because of this, he required additional tests and antibiotics that were ultimately unnecessary.

We discussed the indications for and risks and benefits of blood cultures, and also the risk of contamination. In pediatrics, it’s tricky because you don’t want to do unnecessary tests that could lead to overtreatment, but you also don’t want to have to go back and stick the patient again. One solution could be to draw the blood when you do the first tests, but wait to send it to the lab until you think it’s absolutely necessary.

It’s highly unlikely that a child with a fever has a bloodstream infection. But also I work in the ER so I know how challenging it is to identify the one patient with a bloodstream infection out of all the patients that come in with a fever. There was not a straightforward answer in this case, but it was a good discussion about blood cultures.

How is the conversation about overuse different in pediatrics?

High-value care is discussed a lot less in pediatrics than in other specialties. I was the only pediatrician in the RCE program this year; it would be great if there were more pediatricians involved.

In pediatrics, it’s more difficult to do tests, so we already try to be thoughtful about testing. It’s possible that overuse isn’t discussed as much because we believe we’re not overtesting, or because we’re more concerned with preventive care and access than overuse. But there are a lot of areas we can improve upon.