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.

2022

690-698

05/2022

2168-6211

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.

10.1001/jamapediatrics.2022.1024

JAMA Pediatr

35499841

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.

2022

690-698

12/2022

2168-6211

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.

10.1001/jamapediatrics.2022.1024

JAMA Pediatr

35499841

Numbers and narratives: how qualitative methods can strengthen the science of paediatric antimicrobial stewardship.

2022

dlab195

2022 Mar

2632-1823

<p>Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents' perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.</p>

10.1093/jacamr/dlab195

JAC Antimicrob Resist

35098126

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

2021

2021 Apr 23

1529-7535

<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>

10.1097/PCC.0000000000002749

Pediatr Crit Care Med

33899804

Harnessing implementation science to optimize harm prevention in critically ill children: a pilot study of bedside nurse CLABSI bundle performance in the pediatric intensive care unit.

2020

2020 Aug 17

1527-3296

<p><strong>OBJECTIVES: </strong>Central-line associated bloodstream infection (CLABSI) is associated with increased mortality, morbidity, and cost in hospitalized children. An evidence-based bundle of care can decrease CLABSI, but bundle compliance is imperfect. We explored factors impacting bundle performance in the pediatric intensive care unit (PICU) by bedside nurses.</p>

<p><strong>METHODS: </strong>Single-center cross sectional electronic survey of PICU bedside nurses in an academic tertiary care center; using the COM-B (capability, opportunity, motivation) and TDF (theoretical domains framework) behavioral models to explore CLABSI bundle performance and identify barriers to compliance.</p>

<p><strong>RESULTS: </strong>We analyzed 160 completed surveys from 226 nurses (71% response rate). CLABSI knowledge was strong (capability). However, challenges related to opportunity were identified: 71% reported that patient care requirements impact bundle completion; 32% described the bundle as stressful; and CLABSI was viewed as the most difficult of all bundles. 75% reported being highly impacted by physician attitude toward the CLABSI bundle (motivation).</p>

<p><strong>CONCLUSIONS: </strong>PICU nurses are knowledgeable and motivated to prevent CLABSI, but face challenges from competing clinical tasks, limited resources, and complex family interactions. Physician engagement was specifically noted to impact nurse motivation to complete the bundle. Interventions that address these challenges may improve bundle performance and prevent CLABSI in critically ill children.</p>

10.1016/j.ajic.2020.08.019

Am J Infect Control

32818579

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

2020

e288

2020 Mar-Apr

2472-0054

<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>

10.1097/pq9.0000000000000288

Pediatr Qual Saf

32426645

Development and Implementation of a Bedside Peripherally Inserted Central Catheter Service in a PICU.

2019

71-78

2019 01

1529-7535

<p><strong>OBJECTIVES: </strong>To create a bedside peripherally inserted central catheter service to increase placement of bedside peripherally inserted central catheter in PICU patients.</p>

<p><strong>DESIGN: </strong>Two-phase observational, pre-post design.</p>

<p><strong>SETTING: </strong>Single-center quaternary noncardiac PICU.</p>

<p><strong>PATIENTS: </strong>All patients admitted to the PICU.</p>

<p><strong>INTERVENTIONS: </strong>From June 1, 2015, to May 31, 2017, a bedside peripherally inserted central catheter service team was created (phase I) and expanded (phase II) as part of a quality improvement initiative. A multidisciplinary team developed a PICU peripherally inserted central catheter evaluation tool to identify amenable patients and to suggest location and provider for procedure performance. Outcome, process, and balancing metrics were evaluated.</p>

<p><strong>MEASUREMENTS AND MAIN RESULTS: </strong>Bedside peripherally inserted central catheter service placed 130 of 493 peripherally inserted central catheter (26%) resulting in 2,447 hospital central catheter days. A shift in bedside peripherally inserted central catheter centerline proportion occurred during both phases. Median time from order to catheter placement was reduced for peripherally inserted central catheters placed by bedside peripherally inserted central catheter service compared with placement in interventional radiology (6 hr [interquartile range, 2-23 hr] vs 34 hr [interquartile range, 19-61 hr]; p &lt; 0.001). Successful access was achieved by bedside peripherally inserted central catheter service providers in 96% of patients with central tip position in 97%. Bedside peripherally inserted central catheter service central line-associated bloodstream infection and venous thromboembolism rates were similar to rates for peripherally inserted central catheters placed in interventional radiology (all central line-associated bloodstream infection, 1.23 vs 2.18; p = 0.37 and venous thromboembolism, 1.63 vs 1.57; p = 0.91). Peripherally inserted central catheters in PICU patients had reduced in-hospital venous thromboembolism rate compared with PICU temporary catheter in PICU rate (1.59 vs 5.36; p &lt; 0.001).</p>

<p><strong>CONCLUSIONS: </strong>Bedside peripherally inserted central catheter service implementation increased bedside peripherally inserted central catheter placement and employed a patient-centered and timely process. Balancing metrics including central line-associated bloodstream infection and venous thromboembolism rates were not significantly different between peripherally inserted central catheters placed by bedside peripherally inserted central catheter service and those placed in interventional radiology.</p>

10.1097/PCC.0000000000001739

Pediatr Crit Care Med

30234675

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

2019

482-484

2019 04

1559-6834

<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>

10.1017/ice.2019.10

Infect Control Hosp Epidemiol

30767809

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

2019

117-118

2019 Apr/Jun

1550-5154

<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>

10.1097/QMH.0000000000000211

Qual Manag Health Care

30921286

Novel risk factors for central-line associated bloodstream infections in critically ill children.

2019

1-6

2019 Nov 05

1559-6834

<p><strong>OBJECTIVE: </strong>Central-line-associated bloodstream infections (CLABSI) cause morbidity and mortality in critically ill children. We examined novel and/or modifiable risk factors for CLABSI to identify new potential targets for infection prevention strategies.</p>

<p><strong>METHODS: </strong>This single-center retrospective matched case-control study of pediatric intensive care unit (PICU) patients was conducted in a 60-bed PICU from April 1, 2013, to December 31, 2017. Case patients were in the PICU, had a central venous catheter (CVC), and developed a CLABSI. Control patients were in the PICU for ≥2 days, had a CVC for ≥3 days, and did not develop a CLABSI. Cases and controls were matched 1:4 on age, number of complex chronic conditions, and hospital length of stay.</p>

<p><strong>RESULTS: </strong>Overall, 72 CLABSIs were matched to 281 controls. Univariate analysis revealed 14 risk factors, and 4 remained significant in multivariable analysis: total number of central line accesses in the 3 days preceding CLABSI (80+ accesses: OR, 4.8; P = .01), acute behavioral health needs (OR, 3.2; P = .02), CVC duration &gt;7 days (8-14 days: OR, 4.2; P = .01; 15-29 days: OR, 9.8; P &lt; .01; 30-59 days: OR, 17.3; P &lt; .01; 60-89 days: OR, 39.8; P &lt; .01; 90+ days: OR, 4.9; P = .01), and hematologic/immunologic disease (OR, 1.5; P = .05).</p>

<p><strong>CONCLUSIONS: </strong>Novel risk factors for CLABSI in PICU patients include acute behavioral health needs and &gt;80 CVC accesses in the 3 days before CLABSI. Interventions focused on these factors may reduce CLABSIs in this high-risk population.</p>

10.1017/ice.2019.302

Infect Control Hosp Epidemiol

31685049