Optimizing Diagnostic Stewardship of Bacteremia in Critically Ill Children

From the 2021 HVPAA National Conference

Danielle Maholtz (Cincinnati Children’s Hospital Medical Center), Maya Dewan, James Odum, Garret Williams, Maria Frazier, Charles Spear

Background

Severe sepsis has a prevalence of 8.2% in hospitalized children with a morality rate of 25% [1, 2]. Bacteremia is a major cause of sepsis. The current gold standard to diagnose bacteremia is blood culture, with a yield of only 5-15% and false positive rates up to 50% [3-5]. Cultures drawn from central venous catheters (CVC) have an even higher false positive rate than peripherally drawn samples. These diagnostic errors lead to unnecessary antibiotic administration. This puts children at risk for harmful side effects from medication exposure and increases hospital length of stay and cost. Common indicators, such as fever and leukocytosis, have low correlation with positive blood cultures (5-10%) [6]. Preliminary work has shown that reduction in unnecessary blood cultures in PICU patients is feasible and safe [7]. The Bright STAR QI collaborative convened a multidisciplinary team to review this work and provide consensus recommendations to standardize blood culture practices in critically ill children [8]. We sought to adapt these guidelines to our key stakeholders and patient population to reduce avoidable blood culture collection.

Objective

We seek to adapt and implement an algorithm to reduce avoidable blood culture collection rates in critically ill children at CCHMC.

Methods

We applied improvement science to develop and evaluate a blood culture algorithm and, employing staff feedback to inform frequent assessment and process changes. Our algorithm was developed with guidance from previously published pathways. Our course was guided by the experience of a multidisciplinary team including Infectious Disease (ID) and Immunocompromised ID physicians. This approach allowed for the collaborative development of a process to identify patients most at risk for bacteremia. We included all patients admitted to our PICU. Our main interventions focused on staff education on the algorithm and building our workflow into Epic and our daily rounding process to automate our unit approach collecting blood cultures.

Results

We saw a decrease from 17 to 15 in our primary outcome measure of blood culture rate per 100 patient days. During this time period, our PICU CLABSI rate decreased by 38% and 100% of the positive samples collected were compliant with our algorithm. Through our sepsis collaborative we found no increase in delayed sepsis recognition with application of our algorithm.

Conclusions

A systematic approach can safely reduce blood culture collection rates in critically ill children. Our limiting factors included rapid staff turnover requiring frequent education and the impact of COVID on our patient population. We addressed staff turnover by building our workflow into Epic and daily patient rounds. During COVID, we had increased admissions of high risk immunocompromised patients and were restricted by consultants who frequently recommended blood cultures not indicated by our algorithm. We also saw decreased low-risk surgical and viral respiratory illness patients who have previously most benefitted from application of similar algorithms. Future improvements may be made with increased engagement and education of consulting clinicians.

Clinical Implications

General application of the blood culture collection consensus recommendations would allow for universal standardization of blood culture collection practices. The potential reduction in blood culture collection rates could greatly improve patient outcomes and reduce hospital costs.

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