From the 2024 HVPA National Conference
Urmi Kumar MPH (The Johns Hopkins University School of Medicine), Abigail Arthur MD, MPH, Charlotte Woods-Hill MD, MSHP, Daniel Kelly MD, Danielle Koontz MAA, Anping Xie Ph.D., Jill Marsteller PhD, MPP, Aaron Milstone MD, MHS, Anna Sick-Samuels MD, MPH
Background
There is a wide variability in respiratory culture practices in pediatric intensive care units (PICU) and unnecessarily collected respiratory cultures. 14 hospitals participated in BrighT STAR Respiratory, a multi-center quality improvement (QI) collaborative, and implemented clinical decision-making support tools to improve respiratory culture practices at their sites. The collaborative monitored the impact of the QI project on site culture rates for 18 months.
Objective
The objective of the study is to identify the implementation facilitators and barriers related to successfully reducing respiratory culture overuse practices.
Methods
We developed an electronic survey to assess the perceptions of implementation facilitators and barriers by QI site leads using primarily Likert-scale questions. The survey format mirrored the framework of the Clinical Sustainability Assessment Tool, which was provided to sites to develop their QI programs. The survey content was based on qualitative data from focus groups we previously conducted with site leads.
The first section of the survey asked site leads to what extent 66 implementation factors (45 facilitators and 21 barriers) were true to execute the project. The second section asked site leads to categorize 23 implementation strategies into low or high effort required to execute and low or high perceived importance to facilitate the adoption of recommendations.
Survey responses were analyzed as mean responses within each site and then across the 14 sites. We compared responses between high and low-performing sites that achieved ≥ or < 20% respiratory cultures rate reduction.
Results
Of the 44 requested surveys, 40 respondents completed the survey (91%) among all 14 participating hospitals (100%). 19 implementation factors significantly differed between high and low-performing sites. Distinguishing facilitators included (1) participation in prior BrighT STAR collaboration enabling leadership buy-in, clinician buy-in to adopt the recommendations, and data collection; (2) unit leaders promoting the project; and (3) the project fit into the existing unit culture. Significant barriers included (1) attending physicians being reluctant to change; (2) having high pre-existing baseline respiratory culture collection rates; and (3) clinicians having concerns regarding insufficient evidence that respiratory cultures can be reduced safely for application in medically complex patients and for missing ventilator-associated infections.
The implementation strategies of highest importance to reducing culture rates and requiring least effort to execute included: (1) engaging the QI team champions, leads, and team members; (2) engaging RTs, APPs, and fellow physicians; (3) routinely reminding unit clinicians about the project; and (4) routinely reporting respiratory culture data to the unit clinicians. Strategies of least importance were: (1) engaging hospital leadership and engaging resident physicians; (2) having annual project education for current unit clinicians; and (3) routinely reporting safety data to the unit clinicians.
Conclusions
This survey provides insight into organizational readiness factors and implementation strategies that may be most important to successfully implementing a clinical decision-making support tool, such as prior participation in the BrighT STAR collaborative or fitting the project into the unit’s existing culture. The survey also highlights important barriers, especially clinician reluctance to change practices and clinical concerns, that are important to address for the adoption of recommendations. Additionally, these findings may help inform strategies to consider prioritizing based on importance to success and expected effort to execute them when implementing respiratory culture diagnostic stewardship in the PICU setting.