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Background: Blood cultures are overused in pediatric ICUs (PICUs), which may lead to unnecessary antibiotic use and antibiotic resistance. Using a participatory ergonomics (PE) approach, the authors disseminated a quality improvement (QI) program for optimizing blood culture use in PICUs to a national 14-hospital collaborative. The objective of this study was to evaluate the dissemination process and its impact on blood culture reduction., Methods: The PE approach emphasized three key principles (stakeholder participation, application of human factors and ergonomics knowledge and tools, and cross-site collaboration) with a six-step dissemination process. Data on interactions between sites and the coordinating team and site experiences with the dissemination process were collected using site diaries and semiannual surveys with local QI teams, respectively, and correlated with the site-specific change in blood culture rates., Results: Overall, participating sites were able to successfully implement the program and reduced their blood culture rates from 149.4 blood cultures per 1,000 patient-days/month before implementation to 100.5 blood cultures per 1,000 patient-days/month after implementation, corresponding to a 32.7% relative reduction (p < 0.001). Variations in the dissemination process, as well as in local interventions and implementation strategies, were observed across sites. Site-specific changes in blood culture rates were weakly negatively correlated with the number of preintervention interactions with the coordinating team (p = 0.057) but not correlated with their experiences with the six domains of the dissemination process or their interventions., Conclusions: The authors applied a PE approach to disseminate a QI program for optimizing PICU blood culture use to a multisite collaborative. Working with local stakeholders, participating sites tailored their interventions and implementation processes and achieved the goal of reducing blood culture use., (Copyright © 2023 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Optimizing blood culture practices requires monitoring of culture use. Collecting culture data from electronic medical records can be resource intensive. Our objective was to determine whether administrative data could serve as a data source to measure blood culture use in pediatric intensive care units (PICUs)., Methods: Using data from a national diagnostic stewardship collaborative to reduce blood culture use in PICUs, we compared the monthly number of blood cultures and patient-days collected from sites (site-derived) and the Pediatric Health Information System (PHIS, administrative-derived), an administrative data warehouse, for 11 participating sites. The collaborative's reduction in blood culture use was compared using administrative-derived and site-derived data., Results: Across all sites and months, the median of the monthly relative blood culture rate (ratio of administrative- to site-derived data) was 0.96 (Q1: 0.77, Q3: 1.24). The administrative-derived data produced an estimate of blood culture reduction over time that was attenuated toward the null compared with site-derived data., Conclusions: Administrative data on blood culture use from the PHIS database correlates unpredictably with hospital-derived PICU data. The limitations of administrative billing data should be carefully considered before use for ICU-specific data., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: 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., Design: 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., Setting: Experts' institutions; in-person discussion in Baltimore, MD., Subjects: Experts in pediatric critical care, infectious diseases, nephrology, oncology, and laboratory medicine., Interventions: None., Measurements and Main Results: 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., Conclusions: 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., Competing Interests: Drs. Woods-Hill’s, Koontz’s, Voskertchian’s, Xie’s, and Milstone’s institutions received funding from the Agency for Healthcare Research and Quality (AHRQ). Dr. Woods-Hill’s institution received funding from the National Institutes of Health (NIH). Drs. Woods-Hill and Xie received support for article research from the NIH. Drs. Woods-Hill and Milstone received support for article research from the AHRQ. Dr. Milstone’s institution received funding from Merck. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: 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., Design: Cross-sectional electronic survey., Setting: 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., Subjects: PICU clinicians (bedside nurses, resident physicians, fellow physicians, nurse practitioners, physician assistants, and attending physicians)., Interventions: None., Measurement and Main Results: 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., Conclusions: 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.

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.

Background: Work system assessments can facilitate successful implementation of quality improvement programs. Using a human factors engineering approach, we conducted a work system assessment to facilitate the dissemination of a quality improvement program for optimizing blood culture use in pediatric intensive care units at 2 hospitals., Methods: Semistructured face-to-face interviews were conducted with clinicians from Johns Hopkins All Children's Hospital and University of Virginia Medical Center. Interview data were analyzed using qualitative content analysis., Results: Blood culture-ordering practices are influenced by various work system factors, including people, tasks, tools and technologies, the physical environment, organizational conditions, and the external environment. A clinical decision-support tool could facilitate implementation by (1) standardizing blood culture-ordering practices, (2) ensuring that prescribing clinicians review the patient's condition before ordering a blood culture, (3) facilitating critical thinking, and (4) empowering nurses to communicate with physicians and advocate for adherence to blood culture-ordering guidelines., Conclusion: The success of interventions for optimizing blood culture use relies heavily on the local context. A work system analysis using a human factors engineering approach can identify key areas to be addressed for the successful dissemination of quality improvement interventions., (© The Author(s) 2017. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: Sepsis and septic shock are common and, at times, fatal in pediatrics. Blood cultures are often obtained when clinicians suspect sepsis, yet are low-yield with a false-positive rate up to 50%., Objectives: To determine whether a novel, 2-part, clinical practice guideline could decrease the rates of total blood cultures and cultures collected from central venous catheters in critically ill children and to examine the effect of the guideline on patient outcomes., Design, Setting, and Participants: A retrospective cohort study was performed to determine the effect of a new clinical practice guideline on blood culture practices in a 36-bed, combined medical/surgical pediatric intensive care unit of an urban, academic, tertiary care center from April 1, 2013, to March 31, 2015. All patients admitted to the pediatric intensive care unit with length of stay of 4 hours or more were evaluated (4560 patient visits: 2204 preintervention, 2356 postintervention visits)., Interventions: Two documents were developed: (1) fever/sepsis screening checklist and (2) blood culture decision algorithm. Clinicians consulted these documents when considering ordering blood cultures and for guidance about the culture source., Main Outcomes and Measures: Primary outcome was the total number of blood cultures collected per 100 patient-days., Results: Of the 2204 children evaluated before the intervention, 1215 were male (55.1%); median (interquartile range) age was 5 (1-13) years. Postintervention analysis included 2356 children; 1262 were male (53.6%) and median (interquartile range) age was 6 (1-13) years. A total of 1807 blood cultures were drawn before the intervention during 11 196 patient-days; 984 cultures were drawn after the intervention during 11 204 patient-days (incidence rate, 16.1 vs 8.8 cultures per 100 patient-days). There was a 46.0% reduction after the intervention in the blood culture collection rate (incidence rate ratio, 0.54; 95% CI, 0.50-0.59). After the intervention, there was an immediate 25.0% reduction in the rate of cultures per 100 patient-days (95% CI, 4.2%-39.7%; P = .02) and a sustained 6.6% (95% CI, 4.7%-8.4%; P < .001) monthly decrease in the rate of cultures per 100 patient-days. Significantly fewer cultures were collected from central venous catheters after vs before the intervention (389 [39.5%] vs 1321 [73.1%]; P < .001). Rates of episodes defined as suspected infection and suspected septic shock decreased significantly after the intervention, but patients meeting these criteria underwent cultures at unchanged frequencies before vs after the intervention (52.1% vs 47.0%, P = .09, compared with 56.7% vs 55.0%, P = .75). In-hospital mortality (45 [2.0] vs 37 [1.6]; P = .23) and hospital readmissions (107 [4.9] vs 103 [4.4]; P = .42) were unchanged after the intervention., Conclusions and Relevance: A systematic approach to blood cultures decreased the total number of cultures and central venous catheter cultures, without an increase in rates of mortality, readmission, or episodes of suspected infection and suspected septic shock.