Implementation of decision support for the evaluation of new fever in the pediatric intensive care unit

From the 2022 HVPA National Conference

Anna Sick-Samuels MD, MPH (Johns Hopkins University School of Medicine), Lauren Booth MSN, Aaron Milstone MD, MHS, Christina Schumacher PhD, Jules Bergmann MD, Lindsey Gnazzo RN, David Stockwell MD, MBA

Background

There is variability in diagnostic testing practices among pediatric intensive care unit (PICU) patients. Clinical decision support tools can standardize testing practices. Previously, our PICU implemented blood culture and endotracheal culture guidelines. We developed a comprehensive infectious disease testing algorithm for critically ill children with new fever, incorporating guidance for blood, endotracheal, and urine cultures with additional considerations.

Objective

The objective of this study was to describe the algorithm development, implementation process and impact on testing practices.

Methods

This was a quality improvement project using mixed-methods to evaluate the impact of a new “PICU fever algorithm” at a single center quaternary children’s hospital. The algorithm was implemented in July 2020. We monitored the impact on monthly blood culture, endotracheal culture, and urine culture rates and urinalysis testing per 1,000 ICU patient-days using statistical process control charts (U-charts). We conducted surveys assessing safety concerns of attending and fellow physicians for 12 months post-implementation. Survey responses were analyzed using descriptive statistics and comments were grouped thematically.

Results

Introduction of a PICU fever algorithm was associated with reductions in blood cultures by 14% (IRR 0.86, 95%CI 0.81-0.91), endotracheal cultures by 26% (IRR 0.74, 95%CI 0.63-0.86), and urine cultures by 31% (IRR 0.69, 95%CI 0.60-0.78). There was an anticipate rise in urinalysis testing by 19% (IRR 1.19, 95%CI 1.11-1.28). Forty-six of 108 invited physicians replied to the surveys (43%). Thirty-nine (85%) had used the algorithm during the prior week, none reported a patient safety concern, 2 (4%) provided feedback leading to revisions, and 28 (61%) felt the algorithm improved patient care.

Conclusion

A comprehensive PICU fever algorithm maintained prior reductions in avoidable blood and endotracheal cultures and reduced avoidable urine cultures without detection of patient harm by physician report. Further study on clinical outcomes, impact on costs, equity of adherence, as well implementation in different patient settings is warranted.

Clinical Implications

This study suggests that we may be able to promote judicious testing – both avoiding testing over-use and broadening diagnostic differentials – to improve patient management in critically ill children.

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