Charlotte Woods-Hill

Association of a Clinical Practice Guideline With Blood Culture Use in Critically Ill Children

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.

Work System Assessment to Facilitate the Dissemination of a Quality Improvement Program for Optimizing Blood Culture Use: A Case Study Using a Human Factors Engineering Approach

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 Childrens 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 patients 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.

Dissemination of a Novel Framework to Improve Blood Culture Use in Pediatric Critical Care

Introduction: Single center work demonstrated a safe reduction in unnecessary blood culture use in critically ill children. Our objective was to develop and implement a customizable quality improvement framework to reduce unnecessary blood culture testing in critically ill children across diverse clinical settings and various institutions. Methods: Three pediatric intensive care units (14 bed medical/cardiac; 28 bed medical; 22 bed cardiac) in 2 institutions adapted and implemented a 5-part Blood Culture Improvement Framework, supported by a coordinating multidisciplinary team. Blood culture rates were compared for 24 months preimplementation to 24 months postimplementation. Results: Blood culture rates decreased from 13.3, 13.5, and 11.5 cultures per 100 patient-days preimplementation to 6.4, 9.1, and 8.3 cultures per 100 patient-days postimplementation for Unit A, B, and C, respectively; a decrease of 32% (95% confidence interval, 25–43%; P < 0.001) for the 3 units combined. Postimplementation, the proportion of total blood cultures drawn from central venous catheters decreased by 51% for the 3 units combined (95% confidence interval, 29–66%; P < 0.001). Notable difference between units included the identity and involvement of the project champion, adaptions of the clinical tools, and staff monitoring and communication of project progress. Qualitative data also revealed a core set of barriers and facilitators to behavior change around pediatric intensive care unit blood culture practices. Conclusions: Three pediatric intensive units adapted a novel 5-part improvement framework and successfully reduced blood culture use in critically ill children, demonstrating that different providers and practice environments can adapt diagnostic stewardship programs.

379: PEDIATRIC CCM FELLOWSHIP BEDSIDE ULTRASOUND CURRICULUM DEVELOPMENT.

Learning Objectives: There is increased interest in non-procedural bedside ultrasound (BUS) in pediatric critical care medicine (PCCM) practice. However, BUS curriculum has not been standardized in PCCM fellowship training and competency is not well defined. We created a BUS curriculum integrated into our PCCM fellowship to develop non-procedural image acquisition and image interpretation skills, including a 2-week clinical ultrasound rotation and departmentsponsored enrollment in a 2-day course. We sought to evaluate PCCM fellow BUS knowledge acquisition and number of non-procedural BUS clinical studies over the course of training, and the potential effect of BUS clinical study experience on knowledge acquisition. Methods: PCCM fellows from 2013-present were assessed. All fellows completed a 50-question test (normalized 0-100 score). Non-procedural BUS clinical studies were quantified from a QA database. Test scores (mean±SD) were compared among fellowship classes by one-way ANOVA. Number of studies was assessed by chi squared test for trend. Relationship of BUS studies and test scores was assessed by correlation coefficient. Results: Twentythree PCCM fellows (pre-fellowship=0y, n=6; end of 1st year=1y, n=5, end of 2nd year=2y, n=5, end of 3rd year=3y, n=7) took the test with mean score 59+/-16. Test scores were significantly different among fellow classes (0y:39+/-7, 1y:64+/-11, 2y:66+/-12, 3y:66+/-16; p=0.003). The number of non-procedural clinical BUS studies was associated with duration of PCCM fellowship (0y: median 0, IQR 0-0, 1y: median 2, IQR 0-3, 2y:median 15 IQR 12-15, 3y:median 14: IQR 9-22; p<0.001). The number of BUS clinical studies correlated with test scores (r=0.54, p=0.008). Conclusions: A PCCM BUS integrated fellowship training curriculum resulted in BUS knowledge acquisition. Quantity of BUS clinical studies was associated with test scores. In addition to knowledge acquisition, we are evaluating other domains of learning within BUS image acquisition and interpretation skill development to create a method of competence assessment.

94: PHASE OF CARE MORTALITY ANALYSIS FOR A PEDIATRIC CARDIOTHORACIC SURGICAL POPULATION

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) HAS-BLED score was 3. Gastrointestinal and intracranial bleeds occurred in 63% and 27% of patients, respectively. Rivaroxaban doses were excessive based on renal function in 35% of patients. Concurrent antiplatelet medications were prescribed in 70% of patients, with 10% receiving dual antiplatelet therapy. Two patients had a periprocedural/medication reconciliation error prior to the bleeding event, 10% had an invasive procedure within 7 days of the bleed, and 5% of patients were given rivaroxaban with concerns of bleeding. Nearly 50% of patients spent time in the ICU post-bleed. Bleed management consisted of a procedure/surgery in 18%, PRBC in 73%, FFP in 20%, and hemostatic agent use in 35% of patients. Anticoagulation was held at discharge in 76% of patients. Ten percent of patients were made hospice or palliative care. In-hospital mortality was 10%. Conclusions: Patients experiencing a rivaroxaban major bleed in practice were elderly and often on antiplatelet therapy. More than 25% of all major bleeds were intracranial. Hemostatic agents were administered to over one-third of patients. In-hospital mortality was 10%. Anticoagulation therapy remained held at discharge in the majority of patients.

778: ICU CAPACITY STRAIN AS A RISK FACTOR FOR INCREASED BEDSIDE EMERGENCY EVENTS IN A PICU

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