First name
Aaron
Middle name
M
Last name
Milstone

Title

Association of Diagnostic Stewardship for Blood Cultures in Critically Ill Children With Culture Rates, Antibiotic Use, and Patient Outcomes: Results of the Bright STAR Collaborative.

Year of Publication

2022

Number of Pages

690-698

Date Published

05/2022

ISSN Number

2168-6211

Abstract

Importance: Blood culture overuse in the pediatric intensive care unit (PICU) can lead to unnecessary antibiotic use and contribute to antibiotic resistance. Optimizing blood culture practices through diagnostic stewardship may reduce unnecessary blood cultures and antibiotics.

Objective: To evaluate the association of a 14-site multidisciplinary PICU blood culture collaborative with culture rates, antibiotic use, and patient outcomes.

Design, Setting, and Participants: This prospective quality improvement (QI) collaborative involved 14 PICUs across the United States from 2017 to 2020 for the Bright STAR (Testing Stewardship for Antibiotic Reduction) collaborative. Data were collected from each participating PICU and from the Children's Hospital Association Pediatric Health Information System for prespecified primary and secondary outcomes.

Exposures: A local QI program focusing on blood culture practices in the PICU (facilitated by a larger QI collaborative).

Main Outcomes and Measures: The primary outcome was blood culture rates (per 1000 patient-days/mo). Secondary outcomes included broad-spectrum antibiotic use (total days of therapy and new initiations of broad-spectrum antibiotics ≥3 days after PICU admission) and PICU rates of central line-associated bloodstream infection (CLABSI), Clostridioides difficile infection, mortality, readmission, length of stay, sepsis, and severe sepsis/septic shock.

Results: Across the 14 PICUs, the blood culture rate was 149.4 per 1000 patient-days/mo preimplementation and 100.5 per 1000 patient-days/mo postimplementation, for a 33% relative reduction (95% CI, 26%-39%). Comparing the periods before and after implementation, the rate of broad-spectrum antibiotic use decreased from 506 days to 440 days per 1000 patient-days/mo, respectively, a 13% relative reduction (95% CI, 7%-19%). The broad-spectrum antibiotic initiation rate decreased from 58.1 to 53.6 initiations/1000 patient-days/mo, an 8% relative reduction (95% CI, 4%-11%). Rates of CLABSI decreased from 1.8 to 1.1 per 1000 central venous line days/mo, a 36% relative reduction (95% CI, 20%-49%). Mortality, length of stay, readmission, sepsis, and severe sepsis/septic shock were similar before and after implementation.

Conclusions and Relevance: Multidisciplinary diagnostic stewardship interventions can reduce blood culture and antibiotic use in the PICU. Future work will determine optimal strategies for wider-scale dissemination of diagnostic stewardship in this setting while monitoring patient safety and balancing measures.

DOI

10.1001/jamapediatrics.2022.1024

Alternate Title

JAMA Pediatr

PMID

35499841

Title

Association of Diagnostic Stewardship for Blood Cultures in Critically Ill Children With Culture Rates, Antibiotic Use, and Patient Outcomes: Results of the Bright STAR Collaborative.

Year of Publication

2022

Number of Pages

690-698

Date Published

12/2022

ISSN Number

2168-6211

Abstract

Importance: Blood culture overuse in the pediatric intensive care unit (PICU) can lead to unnecessary antibiotic use and contribute to antibiotic resistance. Optimizing blood culture practices through diagnostic stewardship may reduce unnecessary blood cultures and antibiotics.

Objective: To evaluate the association of a 14-site multidisciplinary PICU blood culture collaborative with culture rates, antibiotic use, and patient outcomes.

Design, Setting, and Participants: This prospective quality improvement (QI) collaborative involved 14 PICUs across the United States from 2017 to 2020 for the Bright STAR (Testing Stewardship for Antibiotic Reduction) collaborative. Data were collected from each participating PICU and from the Children's Hospital Association Pediatric Health Information System for prespecified primary and secondary outcomes.

Exposures: A local QI program focusing on blood culture practices in the PICU (facilitated by a larger QI collaborative).

Main Outcomes and Measures: The primary outcome was blood culture rates (per 1000 patient-days/mo). Secondary outcomes included broad-spectrum antibiotic use (total days of therapy and new initiations of broad-spectrum antibiotics ≥3 days after PICU admission) and PICU rates of central line-associated bloodstream infection (CLABSI), Clostridioides difficile infection, mortality, readmission, length of stay, sepsis, and severe sepsis/septic shock.

Results: Across the 14 PICUs, the blood culture rate was 149.4 per 1000 patient-days/mo preimplementation and 100.5 per 1000 patient-days/mo postimplementation, for a 33% relative reduction (95% CI, 26%-39%). Comparing the periods before and after implementation, the rate of broad-spectrum antibiotic use decreased from 506 days to 440 days per 1000 patient-days/mo, respectively, a 13% relative reduction (95% CI, 7%-19%). The broad-spectrum antibiotic initiation rate decreased from 58.1 to 53.6 initiations/1000 patient-days/mo, an 8% relative reduction (95% CI, 4%-11%). Rates of CLABSI decreased from 1.8 to 1.1 per 1000 central venous line days/mo, a 36% relative reduction (95% CI, 20%-49%). Mortality, length of stay, readmission, sepsis, and severe sepsis/septic shock were similar before and after implementation.

Conclusions and Relevance: Multidisciplinary diagnostic stewardship interventions can reduce blood culture and antibiotic use in the PICU. Future work will determine optimal strategies for wider-scale dissemination of diagnostic stewardship in this setting while monitoring patient safety and balancing measures.

DOI

10.1001/jamapediatrics.2022.1024

Alternate Title

JAMA Pediatr

PMID

35499841

Title

Implementation of the Comprehensive Unit-Based Safety Program to Improve Infection Prevention and Control Practices in Four Neonatal Intensive Care Units in Pune, India.

Year of Publication

2021

Number of Pages

794637

Date Published

2021

ISSN Number

2296-2360

Abstract

<p>To implement the Comprehensive Unit-based Safety Program (CUSP) in four neonatal intensive care units (NICUs) in Pune, India, to improve infection prevention and control (IPC) practices. In this quasi-experimental study, we implemented CUSP in four NICUs in Pune, India, to improve IPC practices in three focus areas: hand hygiene, aseptic technique for invasive procedures, and medication and intravenous fluid preparation and administration. Sites received training in CUSP methodology, formed multidisciplinary teams, and selected interventions for each focus area. Process measures included fidelity to CUSP, hand hygiene compliance, and central line insertion checklist completion. Outcome measures included the rate of healthcare-associated bloodstream infection (HA-BSI), all-cause mortality, patient safety culture, and workload. A total of 144 healthcare workers and administrators completed CUSP training. All sites conducted at least 75% of monthly meetings. Hand hygiene compliance odds increased 6% per month [odds ratio (OR) 1.06 (95% CI 1.03-1.10)]. Providers completed insertion checklists for 68% of neonates with a central line; 83% of checklists were fully completed. All-cause mortality and HA-BSI rate did not change significantly after CUSP implementation. Patient safety culture domains with greatest improvement were management support for patient safety (+7.6%), teamwork within units (+5.3%), and organizational learning-continuous improvement (+4.7%). Overall workload increased from a mean score of 46.28 ± 16.97 at baseline to 65.07 ± 19.05 at follow-up ( &lt; 0.0001). CUSP implementation increased hand hygiene compliance, successful implementation of a central line insertion checklist, and improvements in safety culture in four Indian NICUs. This multimodal strategy is a promising framework for low- and middle-income country healthcare facilities to reduce HAI risk in neonates.</p>

DOI

10.3389/fped.2021.794637

Alternate Title

Front Pediatr

PMID

35071137

Title

Consensus Recommendations for Blood Culture Use in Critically Ill Children Using a Modified Delphi Approach.

Year of Publication

2021

Date Published

2021 Apr 23

ISSN Number

1529-7535

Abstract

<p><strong>OBJECTIVES: </strong>Blood cultures are fundamental in evaluating for sepsis, but excessive cultures can lead to false-positive results and unnecessary antibiotics. Our objective was to create consensus recommendations focusing on when to safely avoid blood cultures in PICU patients.</p>

<p><strong>DESIGN: </strong>A panel of 29 multidisciplinary experts engaged in a two-part modified Delphi process. Round 1 consisted of a literature summary and an electronic survey sent to invited participants. In the survey, participants rated a series of recommendations about when to avoid blood cultures on five-point Likert scale. Consensus was achieved for the recommendation(s) if 75% of respondents chose a score of 4 or 5, and these were included in the final recommendations. Any recommendations that did not meet these a priori criteria for consensus were discussed during the in-person expert panel review (Round 2). Round 2 was facilitated by an independent expert in consensus methodology. After a review of the survey results, comments from round 1, and group discussion, the panelists voted on these recommendations in real-time.</p>

<p><strong>SETTING: </strong>Experts' institutions; in-person discussion in Baltimore, MD.</p>

<p><strong>SUBJECTS: </strong>Experts in pediatric critical care, infectious diseases, nephrology, oncology, and laboratory medicine.</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>Of the 27 original recommendations, 18 met criteria for achieving consensus in Round 1; some were modified for clarity or condensed from multiple into single recommendations during Round 2. The remaining nine recommendations were discussed and modified until consensus was achieved during Round 2, which had 26 real-time voting participants. The final document contains 19 recommendations.</p>

<p><strong>CONCLUSIONS: </strong>Using a modified Delphi process, we created consensus recommendations on when to avoid blood cultures and prevent overuse in the PICU. These recommendations are a critical step in disseminating diagnostic stewardship on a wider scale in critically ill children.</p>

DOI

10.1097/PCC.0000000000002749

Alternate Title

Pediatr Crit Care Med

PMID

33899804

Title

Chlorhexidine gluconate bathing in children with cancer or those undergoing hematopoietic stem cell transplantation: A double-blinded randomized controlled trial from the Children's Oncology Group.

Year of Publication

2020

Date Published

2020 Oct 20

ISSN Number

1097-0142

Abstract

<p><strong>BACKGROUND: </strong>To the authors' knowledge, information regarding whether daily bathing with chlorhexidine gluconate (CHG) reduces central line-associated bloodstream infection (CLABSI) in pediatric oncology patients and those undergoing hematopoietic stem cell transplantation (HCT) is limited.</p>

<p><strong>METHODS: </strong>In the current multicenter, randomized, double-blind, placebo-controlled trial, patients aged ≥2 months and &lt;22 years with cancer or those undergoing allogeneic HCT were randomized 1:1 to once-daily bathing with 2% CHG-impregnated cloths or control cloths for 90 days. The primary outcome was CLABSI. Secondary endpoints included total positive blood cultures, acquisition of resistant organisms, and acquisition of cutaneous staphylococcal isolates with an elevated CHG mean inhibitory concentration.</p>

<p><strong>RESULTS: </strong>The study was stopped early because of poor accrual. Among the 177 enrolled patients, 174 were considered as evaluable (88 were randomized to the CHG group and 86 were randomized to the control group). The rate of CLABSI per 1000 central line days in the CHG group was 5.44 versus 3.10 in the control group (risk difference, 2.37; 95% confidence interval, 0.05-4.69 [P = .049]). Post hoc conditional power analysis demonstrated a 0.2% chance that the results would have favored CHG had the study fully enrolled. The rate of total positive blood cultures did not differ between groups (risk difference, 2.37; 95% confidence interval, -0.41 to 5.14 [P = .078]). The number of patients demonstrating the new acquisition of resistant organisms did not differ between groups (P = .54). Patients in the CHG group were found to be more likely to acquire cutaneous staphylococcal isolates with an elevated CHG mean inhibitory concentration (P = .032).</p>

<p><strong>CONCLUSIONS: </strong>The data from the current study do not support the use of routine CHG bathing in children with cancer or those undergoing allogeneic HCT.</p>

DOI

10.1002/cncr.33271

Alternate Title

Cancer

PMID

33079403

Title

Survey-based Work System Assessment to Facilitate Large-scale Dissemination of Healthcare Quality Improvement Programs.

Year of Publication

2020

Number of Pages

e288

Date Published

2020 Mar-Apr

ISSN Number

2472-0054

Abstract

<p><strong>Introduction: </strong>The dissemination of quality improvement (QI) interventions to a broader range of healthcare settings requires a proactive assessment of local work systems and processes. The objective of this study was to examine the feasibility of using a survey-based work system assessment (WSA) tool to facilitate the dissemination of a program for optimizing blood culture (BC) use.</p>

<p><strong>Methods: </strong>Informed by findings from an onsite, interview-based WSA at 2 hospitals, a 50-item WSA survey was devised and administrated to 15 hospitals participating in a QI collaborative. WSA survey data were summarized, shared, and discussed with individual hospitals to inform the adaptation and implementation of the BC program. Physician champions leading the local QI team assessed the use of the WSA survey by completing an 8-item survey.</p>

<p><strong>Results: </strong>A total of 347 clinicians completed the WSA survey, and physician champions at 12 hospitals evaluated the use of the WSA survey. Both the WSA survey data and the evaluation of the WSA survey showed that the survey-based WSA tool could help participating hospitals understand their current BC ordering practices and identify potential barriers to implementing the program from the perspectives of different clinicians.</p>

<p><strong>Conclusions: </strong>We demonstrated how a survey-based tool could be used to facilitate WSA in the dissemination of a program for improving BC use to a multisite collaborative. A survey-based WSA tool can be used to facilitate future large-scale intervention dissemination efforts.</p>

DOI

10.1097/pq9.0000000000000288

Alternate Title

Pediatr Qual Saf

PMID

32426645

Title

Association of a blood culture utilization intervention on antibiotic use in a pediatric intensive care unit.

Year of Publication

2019

Number of Pages

482-484

Date Published

2019 04

ISSN Number

1559-6834

Abstract

<p>Blood cultures are essential for the evaluation of sepsis. However, they may sometimes be obtained inappropriately, leading to high false-positive rates, largely due to contamination.1 As a quality improvement project, clinician decision-support tools for evaluating patients with fever or signs and symptoms of sepsis were implemented in April 2014 in our pediatric intensive care unit (PICU). This initiative resulted in a 46% decrease in blood culture obtainment2 and has been replicated in other institutions.3 It is important to evaluate antibiotic use as a balancing measure because a reduction in blood cultures could lead to an increase in antibiotic treatment days if clinicians continued empiric treatment in scenarios when blood culture results were not available. The objective of this study was to evaluate whether antibiotic use in the PICU changed in association with a reduction in blood culture utilization.</p>

DOI

10.1017/ice.2019.10

Alternate Title

Infect Control Hosp Epidemiol

PMID

30767809

Title

Use of Human Factors and Ergonomics to Disseminate Health Care Quality Improvement Programs.

Year of Publication

2019

Number of Pages

117-118

Date Published

2019 Apr/Jun

ISSN Number

1550-5154

Abstract

<p>Human factors and ergonomics (HFE) is recognized as a key systems engineering approach to improve health care quality and safety. HFE is a scientific discipline that studies the interactions among people and other elements of a system and applies theory, principles, data, and methods to design in order to optimize the well-being of people and the overall system performance. An HFE approach to health care quality and safety emphasizes the deployment of HFE tools, knowledge, and professionals and the participation of local stakeholders in the design or redesign of health care work systems and processes to improve patient, employee, and organizational outcomes.</p>

DOI

10.1097/QMH.0000000000000211

Alternate Title

Qual Manag Health Care

PMID

30921286

Title

Practices, Perceptions, and Attitudes in the Evaluation of Critically Ill Children for Bacteremia: A National Survey.

Year of Publication

2019

Date Published

2019 Nov 06

ISSN Number

1529-7535

Abstract

<p><strong>OBJECTIVES: </strong>Sending blood cultures in children at low risk of bacteremia can contribute to a cascade of unnecessary antibiotic exposure, adverse effects, and increased costs. We aimed to describe practice variation, clinician beliefs, and attitudes about blood culture testing in critically ill children.</p>

<p><strong>DESIGN: </strong>Cross-sectional electronic survey.</p>

<p><strong>SETTING: </strong>Fifteen PICUs enrolled in the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children collaborative, an investigation of blood culture use in critically ill children in the United States.</p>

<p><strong>SUBJECTS: </strong>PICU clinicians (bedside nurses, resident physicians, fellow physicians, nurse practitioners, physician assistants, and attending physicians).</p>

<p><strong>INTERVENTIONS: </strong>None.</p>

<p><strong>MEASUREMENT AND MAIN RESULTS: </strong>Survey items explored typical blood culture practices, attitudes and beliefs about cultures, and potential barriers to changing culture use in a PICU setting. Fifteen of 15 sites participated, with 347 total responses, 15-45 responses per site, and an overall median response rate of 57%. We summarized median proportions and interquartile ranges of respondents who reported certain practices or beliefs: 86% (73-91%) report that cultures are ordered reflexively; 71% (61-77%) do not examine patients before ordering cultures; 90% (86-94%) obtain cultures for any new fever in PICU patients; 33% (19-61%) do not obtain peripheral cultures when an indwelling catheter is in place; and 64% (36-81%) sample multiple (vs single) lumens of central venous catheters for new fever. When asked about barriers to reducing unnecessary cultures, 80% (73-90%) noted fear of missing sepsis. Certain practices (culture source and indication) varied by clinician type. Obtaining surveillance cultures and routinely culturing all possible sources (each lumen of indwelling catheters and peripheral specimens) are positively correlated with baseline blood culture rates.</p>

<p><strong>CONCLUSIONS: </strong>There is variation in blood culture practices in the PICU. Fear and reflexive habits are common drivers of cultures. These practices may contribute to over-testing for bacteremia. Further investigation of how to optimize blood culture use is warranted.</p>

DOI

10.1097/PCC.0000000000002176

Alternate Title

Pediatr Crit Care Med

PMID

31702704

Title

Current infection prevention and antibiotic stewardship program practices: A survey of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN).

Year of Publication

2019

Number of Pages

1-4

Date Published

2019 Jul 17

ISSN Number

1559-6834

Abstract

<p>We used a survey to characterize contemporary infection prevention and antibiotic stewardship program practices across 64 healthcare facilities, and we compared these findings to those of a similar 2013 survey. Notable findings include decreased frequency of active surveillance for methicillin-resistant Staphylococcus aureus, frequent active surveillance for carbapenem-resistant Enterobacteriaceae, and increased support for antibiotic stewardship programs.</p>

DOI

10.1017/ice.2019.172

Alternate Title

Infect Control Hosp Epidemiol

PMID

31311610

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