Physicians’ and Nurses’ Perspectives on the Decision to Perform Lumbar Punctures on Febrile Infants ≤8 Weeks Old

Age of the Infant

Nearly all physicians stated that they routinely obtain an LP on febrile infants ≤4 weeks old. A common reason cited for this age cutoff was the perception that there is consensus among physicians nationwide that performing an LP in this age group is always done (Table 2, 1a) and that the “rules” dictate this practice. For low-risk infants 4 to 8 weeks old, most physicians did not routinely perform an LP, although some did until infants were either 6 or 8 weeks old. Some found that the decision was more difficult in infants 4 to 6 weeks old because of the lack of consensus among physicians (Table 2, 1b).

Physicians’ Clinical Experience

Physicians’ years of clinical experience influenced their reported practice of performing an LP on low-risk infants 4 to 8 weeks old. Some younger physicians reported that they were more risk averse (Table 2, 2a). Although 1 physician with more experience still worried about missing meningitis, he said that over time he was willing to forgo the LP as long as the decision-making process involved the parents (Table 2, 2b). Attending physicians with >10 years of experience varied in how experience affected their stated practice. Some of these experienced physicians said that their practice had evolved recently to not routinely perform the LP. However, 1 physician with >20 years of experience stated that his practice of always obtaining the LP had not changed because he had cared for many infants with bacterial meningitis and therefore had seen its consequences (Table 2, 2c). One general EM physician said that the infrequency of managing febrile infants resulted in some discomfort about the decision of whether to perform an LP (Table 2, 2d). Some younger physicians, including a senior fellow, identified that the dominant practice patterns during their training influenced their current decisions about LP (Table 2, 2e).

Physicians’ Use of Research Findings

For febrile infants ≤4 weeks old, physicians’ practices of routinely obtaining an LP were informed by long-standing results of research in which both the higher risk of bacterial meningitis and the lack of reliability of clinical appearance had been documented as indicators of IBI in this age group. For infants 4 to 8 weeks old, many physicians had stopped routinely obtaining an LP because of newer management algorithms such as the Step-by-Step (or “stepwise”) approach that allows infants in this age group to be classified as low risk without routine use of LP (Table 2, 3a). However, some physicians felt that there were insufficient data regarding the risk of meningitis in this older age group, which made the decision about LP difficult. The 2 general EM physicians felt it was challenging to stay informed about the algorithms used for managing febrile infants (Table 2, 3b).

Physicians’ Values

Risk aversion was an important value for physicians in the decision about whether to perform an LP. For infants ≤4 weeks old, physicians felt the risk of meningitis was too high for them to not perform an LP. For physicians who routinely obtain an LP on infants 4 to 8 weeks old, risk aversion remained an important value (Table 2, 4a). Other physicians, however, valued the sense of being ethical in providing parents with the option of not performing an LP given the lack of consensus among physicians about infants in this age group (Table 2, quotation 4b).

Role of the Primary Care Pediatrician

For infants ≤4 weeks old, EM physicians reported that primary care pediatricians played an important role in setting expectations of parents, before the ED visit, about the need for an LP. In the ED, EM physicians reported that they sometimes collaborated with the primary care pediatrician to help parents feel comfortable with the decision to perform an LP. For infants 4 to 8 weeks old, EM physicians reported that, on occasion, their recommendation about the need for an LP differed from that of the primary care pediatrician, which sometimes led to a discussion about the need for LP (Table 2, 5a). In deciding not to perform an LP on these infants, EM physicians stated that the ability to arrange close follow-up with the primary care pediatrician was very important (Table 2, 5b).

Barriers

Barriers included factors related to parents, providers, and time constraints (Table 3). Among factors related to parents, perceived understanding of information was identified as an important barrier. Factors identified as influencing parents’ understanding included language barriers and parents’ cognitive abilities (Table 3, 1a). Physicians and nurses also commonly identified parents’ emotions (such as stress and feeling overwhelmed) as barriers to effective communication and to shared decision-making. Providers felt that parents often feared LP, which inhibited their ability to clearly think through the risks of not performing the LP and could result in medicolegal risks for the physician if the parents decided against LP and the infant was later diagnosed with meningitis (Table 3, 1b). Disagreements in decision-making between family members were also identified as barriers (Table 3, 1c). Parents’ receipt of contradictory messages, from different health care providers, from other family members, or from the Internet, was cited as a barrier to shared decision-making given the multiple and often conflicting sources of information (Table 3, 1d).

If physicians believed there was only 1 reasonable management pathway, shared decision-making was not considered to be an option. For example, physicians uniformly stated that LP was the only option for infants ≤4 weeks old (Table 3, 2a). Some physicians and nurses also felt a sense of paternalism in making the decision to perform an LP, given physicians’ level of knowledge about risks compared with that of parents (Table 3, 2b).

Time constraints that inhibit the ability of providers to effectively communicate and to engage parents in shared decision-making were also identified as barriers. Specific time barriers were related to the volume of patients in the ED that prohibited the physician from adequately communicating with the parents (Table 3, 3a). Nurses identified protocols that dictated the need for timely evaluation and prompt administration of antibiotics for febrile infants as a barrier to effective communication (Table 3, 3b).

Facilitators

Facilitators of shared decision-making similarly included factors related to both parents and providers as well as to the primary care pediatrician (Table 3). Although parents’ abilities to understand risks was cited as a barrier, it was also identified as a facilitator by both physicians and nurses if providers were able to effectively communicate risks in a manner that parents understood (Table 3, 4a). Similarly, parents’ acceptance of risk was felt to be a facilitator because parents would need to accept a small amount of risk whether an LP was performed or not (Table 3, 4b).

The physician’s sense of clinical equipoise in deciding whether to perform an LP for an infant was viewed as a facilitator. In situations in which the physician felt there were 2 reasonable options, shared decision-making was viewed as a viable process to use with parents (Table 3, 5a). Some physicians also felt that recent research that found that LP is not always necessary in infants 4 to 8 weeks old enabled them to incorporate shared decision-making into the decision about whether to perform an LP (Table 3, 5b).

Providers also felt that shared decision-making was facilitated if the pediatrician set expectations with parents that matched those of the EM physician (Table 3, 6a) as opposed to contradictory messages, which were a barrier. Additionally, the availability of follow-up with the primary care pediatrician was an important facilitator because it allowed EM physicians to feel comfortable with not performing an LP if the parents preferred that option (Table 3, 6b).