<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>

<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>

<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>