From the 2024 HVPA National Conference
Matthew Linz BS (Rutgers New Jersey Medical School), Lauren Booth MSN, CRNP, PNP-AC (The Johns Hopkins University School of Medicine), Aaron Milstone MD, MHS, David Stockwell MD, MBA, Anna Sick-Samuels MD MPH
Background:
Previously we implemented a comprehensive decision support tool, a “New Fever Algorithm”, to assist with the evaluation of PICU patients with new fever or instability. This tool was associated with declines in culture rates without safety concerns. We assessed the impact of the algorithm on testing practices by identifying the proportion of cultures pre and post-implementation that were discordant with algorithm guidance and may be avoidable.
Objective:
The objective was to determine if cultures collected in the PICU were obtained for new fever versus other clinical indications, if a “New Fever Algorithm” led to reductions in algorithm-discordant testing practices, and if there were areas to further improve culture practices.
Methods:
This was a single-center retrospective study at an academic PICU and pediatric cardiac ICU evaluating outcomes 12 months pre- and post-implementation of a quality improvement intervention. Patient medical records were reviewed to categorize indications for all blood, respiratory and urine cultures. Among cultures obtained for new fever or new clinical instability, we assessed specific testing patterns that were discordant from the algorithm’s guidance such as blood cultures obtained without documented concern for sepsis without initiation of antibiotics, respiratory cultures without respiratory symptoms, urine cultures without a urinalysis or pyuria, and pan-cultures (concurrent blood, respiratory and urine cultures).
Results:
Among 2,827 cultures, 1,950 (69%) were obtained for new fever or instability. Peripheral blood cultures obtained without concern for sepsis declined from 18.6% to 10.4% (P<0.001). Respiratory cultures without respiratory symptoms declined from 41.5% to 27.4% (P=0.01). Urine cultures without a urinalysis did not significantly decline (27.6%, 25.1%), but urine cultures without pyuria declined from 83.0% to 73.7% (P=0.04). Pan-cultures declined from 22.4% to 10.6% (P<0.001). Overall algorithm-discordant testing declined from 39% to 30% (P<0.001).
Conclusion:
The majority of cultures obtained were for new fever or instability and introduction of the “New Fever Algorithm” was associated with reduction in cultures discordant with algorithm guidance. Despite reductions in algorithm-discordant testing, this review suggests 80% of obtained urine cultures may still be avoidable.
Clinical implications:
A comprehensive decision support tool to assist with evaluation of PICU patients with new fever was associated with safe reductions in bacterial testing rates and more deliberate testing practices. There remain opportunities for improvement and additional strategies are warranted to optimize testing practices for this complex and vulnerable patient population.