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Loscalzo SM, White LJ, Rosenblatt S, Woods-Hill CZ, Teran F, Wolfe H, Himebauch AS, Glau C, Nishisaki A, Conlon TW. Ultrasound in Cardiopulmonary Arrest and Resuscitation: Constructing Comprehensive Implementation Frameworks in High-Risk Settings. Pediatr Emerg Care 2024:00006565-990000000-00444. [PMID: 38713851 DOI: 10.1097/pec.0000000000003165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
OBJECTIVES Information obtained from point-of-care ultrasound during cardiopulmonary arrest and resuscitation (POCUS-CA) can be used to identify underlying pathophysiology and provide life-sustaining interventions. However, integration of POCUS-CA into resuscitation care is inconsistent. We used expert consensus building methodology to help identify discrete barriers to clinical integration. We subsequently applied implementation science frameworks to generate generalizable strategies to overcome these barriers. MEASURES AND MAIN RESULTS Two multidisciplinary expert working groups used KJ Reverse-Merlin consensus building method to identify and characterize barriers contributing to failed POCUS-CA utilization in a hypothetical future state. Identified barriers were organized into affinity groups. The Center for Implementation Research (CFIR) framework and Expert Recommendations for Implementing Change (CFIR-ERIC) tool were used to identify strategies to guide POCUS-US implementation. RESULTS Sixteen multidisciplinary resuscitation content experts participated in the working groups and identified individual barriers, consolidated into 19 unique affinity groups that mapped 12 separate CFIR constructs, representing all 5 CFIR domains. The CFIR-ERIC tool identified the following strategies as most impactful to address barriers described in the affinity groups: identify and prepare champions, conduct local needs assessment, conduct local consensus discussions, and conduct educational meetings. CONCLUSIONS KJ Reverse-Merlin consensus building identified multiple barriers to implementing POCUS-CA. Implementation science methodologies identified and prioritized strategies to overcome barriers and guide POCUS-CA implementation across diverse clinical settings.
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Affiliation(s)
| | - Lauren J White
- Department of Pediatrics, Critical Care Medicine, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT
| | - Samuel Rosenblatt
- From the Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia
| | | | - Felipe Teran
- Department of Emergency Medicine, Weill Cornell Medical College, New York, NY
| | | | - Adam S Himebauch
- From the Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia
| | - Christie Glau
- From the Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia
| | - Akira Nishisaki
- From the Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia
| | - Thomas W Conlon
- From the Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia
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Sick-Samuels AC, Koontz DW, Xie A, Kelly D, Woods-Hill CZ, Aneja A, Xiao S, Colantuoni EA, Marsteller J, Milstone AM. A Survey of PICU Clinician Practices and Perceptions regarding Respiratory Cultures in the Evaluation of Ventilator-Associated Infections in the BrighT STAR Collaborative. Pediatr Crit Care Med 2024; 25:e20-e30. [PMID: 37812030 PMCID: PMC10756695 DOI: 10.1097/pcc.0000000000003379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
OBJECTIVES To characterize respiratory culture practices for mechanically ventilated patients, and to identify drivers of culture use and potential barriers to changing practices across PICUs. DESIGN Cross-sectional survey conducted May 2021-January 2022. SETTING Sixteen academic pediatric hospitals across the United States participating in the BrighT STAR Collaborative. SUBJECTS Pediatric critical care medicine physicians, advanced practice providers, respiratory therapists, and nurses. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We summarized the proportion of positive responses for each question within a hospital and calculated the median proportion and IQR across hospitals. We correlated responses with culture rates and compared responses by role. Sixteen invited institutions participated (100%). Five hundred sixty-eight of 1,301 (44%) e-mailed individuals completed the survey (median hospital response rate 60%). Saline lavage was common, but no PICUs had a standardized approach. There was the highest variability in perceived likelihood (median, IQR) to obtain cultures for isolated fever (49%, 38-61%), isolated laboratory changes (49%, 38-57%), fever and laboratory changes without respiratory symptoms (68%, 54-79%), isolated change in secretion characteristics (67%, 54-78%), and isolated increased secretions (55%, 40-65%). Respiratory cultures were likely to be obtained as a "pan culture" (75%, 70-86%). There was a significant correlation between higher culture rates and likelihood to obtain cultures for isolated fever, persistent fever, isolated hypotension, fever, and laboratory changes without respiratory symptoms, and "pan cultures." Respondents across hospitals would find clinical decision support (CDS) helpful (79%) and thought that CDS would help align ICU and/or consulting teams (82%). Anticipated barriers to change included reluctance to change (70%), opinion of consultants (64%), and concern for missing a diagnosis of ventilator-associated infections (62%). CONCLUSIONS Respiratory culture collection and ordering practices were inconsistent, revealing opportunities for diagnostic stewardship. CDS would be generally well received; however, anticipated conceptual and psychologic barriers to change must be considered.
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Affiliation(s)
- Anna C Sick-Samuels
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD
| | - Danielle W Koontz
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel Kelly
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Anushree Aneja
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Shaoming Xiao
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elizabeth A Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Jill Marsteller
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD
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Woods-Hill CZ, Koontz DW, Colantuoni EA, Xiao S, Xie A, Miller MR, Milstone AM. Sustainability of the Bright STAR Diagnostic Stewardship Program to Reduce Blood Culture Rates Among Critically Ill Children. JAMA Pediatr 2023; 177:1234-1237. [PMID: 37695609 PMCID: PMC10495921 DOI: 10.1001/jamapediatrics.2023.3229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/09/2023] [Indexed: 09/12/2023]
Abstract
This quality improvement study evaluates whether pediatric intensive care units sustained reduced blood culture rates after participation in the Bright STAR collaborative from 2017 to 2020.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Danielle W. Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth A. Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Shaoming Xiao
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marlene R. Miller
- Rainbow Babies and Children’s Hospital, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Woods-Hill CZ, Wolfe H, Malone S, Steffen KM, Agulnik A, Flaherty BF, Barbaro RP, Dewan M, Kudchadkar S. Implementation Science Research in Pediatric Critical Care Medicine. Pediatr Crit Care Med 2023; 24:943-951. [PMID: 37916878 PMCID: PMC10624111 DOI: 10.1097/pcc.0000000000003335] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Delay or failure to consistently adopt evidence-based or consensus-based best practices into routine clinical care is common, including for patients in the PICU. PICU patients can fail to receive potentially beneficial diagnostic or therapeutic interventions, worsening the burden of illness and injury during critical illness. Implementation science (IS) has emerged to systematically address this problem, but its use of in the PICU has been limited to date. We therefore present a conceptual and methodologic overview of IS for the pediatric intensivist. DESIGN The members of Excellence in Pediatric Implementation Science (ECLIPSE; part of the Pediatric Acute Lung Injury and Sepsis Investigators Network) represent multi-institutional expertise in the use of IS in the PICU. This narrative review reflects the collective knowledge and perspective of the ECLIPSE group about why IS can benefit PICU patients, how to distinguish IS from quality improvement (QI), and how to evaluate an IS article. RESULTS IS requires a shift in one's thinking, away from questions and outcomes that define traditional clinical or translational research, including QI. Instead, in the IS rather than the QI literature, the terminology, definitions, and language differs by specifically focusing on relative importance of generalizable knowledge, as well as aspects of study design, scale, and timeframe over which the investigations occur. CONCLUSIONS Research in pediatric critical care practice must acknowledge the limitations and potential for patient harm that may result from a failure to implement evidence-based or professionals' consensus-based practices. IS represents an innovative, pragmatic, and increasingly popular approach that our field must readily embrace in order to improve our ability to care for critically ill children.
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Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Heather Wolfe
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Sara Malone
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine
| | - Katherine M Steffen
- Stanford University Department of Pediatrics, Division of Pediatric Critical Care Medicine
| | - Asya Agulnik
- Department of Global Pediatric Medicine, Division of Critical Care, St Jude Children’s Research Hospital
| | - Brian F Flaherty
- University of Utah, Department of Pediatrics, Division of Critical Care
| | - Ryan P Barbaro
- Division of Pediatric Critical Care, University of Michigan Medical School, Ann Arbor, MI; Susan B. Miester Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine; Cincinnati, OH; Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center; Cincinnati, OH; Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center; Cincinnati, OH
| | - Sapna Kudchadkar
- Department of Anesthesiology and Critical Care Medicine; Department of Pediatrics; Department of Physical Medicine & Rehabilitation. Johns Hopkins University School of Medicine, Baltimore, Maryland
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Xie A, Koontz DW, Colantuoni EA, Voskertchian A, Miller MR, Fackler JC, Milstone AM, Woods-Hill CZ. Application of Participatory Ergonomics to the Dissemination of a Quality Improvement Program for Optimizing Blood Culture Use. Jt Comm J Qual Patient Saf 2023; 49:529-538. [PMID: 37429759 PMCID: PMC10688017 DOI: 10.1016/j.jcjq.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Blood cultures are overused in pediatric ICUs (PICUs), which may lead to unnecessary antibiotic use and antibiotic resistance. Using a participatory ergonomics (PE) approach, the authors disseminated a quality improvement (QI) program for optimizing blood culture use in PICUs to a national 14-hospital collaborative. The objective of this study was to evaluate the dissemination process and its impact on blood culture reduction. METHODS The PE approach emphasized three key principles (stakeholder participation, application of human factors and ergonomics knowledge and tools, and cross-site collaboration) with a six-step dissemination process. Data on interactions between sites and the coordinating team and site experiences with the dissemination process were collected using site diaries and semiannual surveys with local QI teams, respectively, and correlated with the site-specific change in blood culture rates. RESULTS Overall, participating sites were able to successfully implement the program and reduced their blood culture rates from 149.4 blood cultures per 1,000 patient-days/month before implementation to 100.5 blood cultures per 1,000 patient-days/month after implementation, corresponding to a 32.7% relative reduction (p < 0.001). Variations in the dissemination process, as well as in local interventions and implementation strategies, were observed across sites. Site-specific changes in blood culture rates were weakly negatively correlated with the number of preintervention interactions with the coordinating team (p = 0.057) but not correlated with their experiences with the six domains of the dissemination process or their interventions. CONCLUSIONS The authors applied a PE approach to disseminate a QI program for optimizing PICU blood culture use to a multisite collaborative. Working with local stakeholders, participating sites tailored their interventions and implementation processes and achieved the goal of reducing blood culture use.
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Affiliation(s)
- Anping Xie
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Danielle W. Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth A. Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Marlene R. Miller
- Rainbow Babies and Children’s Hospital, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - James C. Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron M. Milstone
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Xiao S, Woods-Hill CZ, Koontz D, Thurm C, Richardson T, Milstone AM, Colantuoni E. Comparison of Administrative Database-Derived and Hospital-Derived Data for Monitoring Blood Culture Use in the Pediatric Intensive Care Unit. J Pediatric Infect Dis Soc 2023; 12:436-442. [PMID: 37417679 PMCID: PMC10895403 DOI: 10.1093/jpids/piad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 07/07/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Optimizing blood culture practices requires monitoring of culture use. Collecting culture data from electronic medical records can be resource intensive. Our objective was to determine whether administrative data could serve as a data source to measure blood culture use in pediatric intensive care units (PICUs). METHODS Using data from a national diagnostic stewardship collaborative to reduce blood culture use in PICUs, we compared the monthly number of blood cultures and patient-days collected from sites (site-derived) and the Pediatric Health Information System (PHIS, administrative-derived), an administrative data warehouse, for 11 participating sites. The collaborative's reduction in blood culture use was compared using administrative-derived and site-derived data. RESULTS Across all sites and months, the median of the monthly relative blood culture rate (ratio of administrative- to site-derived data) was 0.96 (Q1: 0.77, Q3: 1.24). The administrative-derived data produced an estimate of blood culture reduction over time that was attenuated toward the null compared with site-derived data. CONCLUSIONS Administrative data on blood culture use from the PHIS database correlates unpredictably with hospital-derived PICU data. The limitations of administrative billing data should be carefully considered before use for ICU-specific data.
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Affiliation(s)
- Shaoming Xiao
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Danielle Koontz
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kansas, USA
| | | | - Aaron M Milstone
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Woods-Hill CZ, Nelson MN, Eriksen W, Rendle KA, Beidas RS, Bonafide CP, Brajcich MR, Milstone AM, Shea JA. Determinants of Blood Culture Use in Critically Ill Children: A Multicenter Qualitative Study. Pediatr Qual Saf 2023; 8:e647. [PMID: 37051407 PMCID: PMC10085482 DOI: 10.1097/pq9.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/11/2023] [Indexed: 04/14/2023] Open
Abstract
Blood cultures are fundamental in diagnosing and treating sepsis in the pediatric intensive care unit (PICU), but practices vary widely. Overuse can lead to false positive results and unnecessary antibiotics. Specific factors underlying decisions about blood culture use and overuse are unknown. Therefore, we aimed to identify perceived determinants of blood culture use in the PICU. Methods We conducted semistructured interviews of clinicians (M.D., D.O., R.N., N.P., P.A.) from 6 PICUs who had participated in a quality improvement collaborative about blood culture practices. We developed interview questions by combining elements of the Consolidated Framework for Implementation Research and behavioral economics. We conducted telephone interviews, open-coded the transcripts, and used modified content analysis to determine key themes and mapped themes to elements of Consolidated Framework for Implementation Research and behavioral economics. Results We reached thematic saturation in 24 interviews. Seven core themes emerged across 3 Consolidated Framework for Implementation Research domains: individual characteristics [personal belief in the importance of blood cultures, the perception that blood cultures are a low-risk test]; inner setting [adherence to site-specific usual practices, site-specific overall approach to PICU care (collaborative versus hierarchical), influence of non-PICU clinicians on blood culture decisions]; and outer setting [patient-specific risk factors, sepsis guidelines]. In addition, outcome bias, default bias, and loss aversion emerged as salient behavioral economics concepts. Conclusions Determinants of blood culture use include individual clinician characteristics, inner setting, and outer setting, as well as default bias, outcome bias, and loss aversion. These determinants will now inform the development of candidate strategies to optimize culture practices.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia Pa
| | - Maria N. Nelson
- University of Pennsylvania Mixed Methods Research Laboratory
| | | | | | | | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle R. Brajcich
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Judy A. Shea
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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Patel B, Yver H, Woods-Hill CZ, Harhay MO, Yehya N. Elements of Statistical Power in Pediatric Critical Care Trials. Ann Am Thorac Soc 2023; 20:152-155. [PMID: 36044710 PMCID: PMC9819260 DOI: 10.1513/annalsats.202202-154rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Bhavesh Patel
- Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
| | - Hugues Yver
- Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
| | - Charlotte Z. Woods-Hill
- Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
- University of PennsylvaniaPhiladelphia, Pennsylvania
| | | | - Nadir Yehya
- Children’s Hospital of PhiladelphiaPhiladelphia, Pennsylvania
- University of PennsylvaniaPhiladelphia, Pennsylvania
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Fitzgerald JC, Reddy AR, Woods-Hill CZ. Let's get loud: Amplifying female voices in sepsis research. EBioMedicine 2022; 86:104370. [PMID: 36470833 PMCID: PMC9783136 DOI: 10.1016/j.ebiom.2022.104370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/03/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Julie C Fitzgerald
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Anireddy R Reddy
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Charlotte Z Woods-Hill
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Woods-Hill CZ, Colantuoni EA, Milstone AM. The Implementation of Diagnostic Stewardship for Blood Cultures in Critically Ill Children-Reply. JAMA Pediatr 2022; 176:1151-1152. [PMID: 36066880 PMCID: PMC10659024 DOI: 10.1001/jamapediatrics.2022.3166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Elizabeth A Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Aaron M Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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11
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Woods-Hill CZ, Colantuoni EA, Koontz DW, Voskertchian A, Xie A, Thurm C, Miller MR, Fackler JC, Milstone AM. Association of Diagnostic Stewardship for Blood Cultures in Critically Ill Children With Culture Rates, Antibiotic Use, and Patient Outcomes: Results of the Bright STAR Collaborative. JAMA Pediatr 2022; 176:690-698. [PMID: 35499841 PMCID: PMC9062771 DOI: 10.1001/jamapediatrics.2022.1024] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/15/2022] [Indexed: 12/15/2022]
Abstract
Importance Blood culture overuse in the pediatric intensive care unit (PICU) can lead to unnecessary antibiotic use and contribute to antibiotic resistance. Optimizing blood culture practices through diagnostic stewardship may reduce unnecessary blood cultures and antibiotics. Objective To evaluate the association of a 14-site multidisciplinary PICU blood culture collaborative with culture rates, antibiotic use, and patient outcomes. Design, Setting, and Participants This prospective quality improvement (QI) collaborative involved 14 PICUs across the United States from 2017 to 2020 for the Bright STAR (Testing Stewardship for Antibiotic Reduction) collaborative. Data were collected from each participating PICU and from the Children's Hospital Association Pediatric Health Information System for prespecified primary and secondary outcomes. Exposures A local QI program focusing on blood culture practices in the PICU (facilitated by a larger QI collaborative). Main Outcomes and Measures The primary outcome was blood culture rates (per 1000 patient-days/mo). Secondary outcomes included broad-spectrum antibiotic use (total days of therapy and new initiations of broad-spectrum antibiotics ≥3 days after PICU admission) and PICU rates of central line-associated bloodstream infection (CLABSI), Clostridioides difficile infection, mortality, readmission, length of stay, sepsis, and severe sepsis/septic shock. Results Across the 14 PICUs, the blood culture rate was 149.4 per 1000 patient-days/mo preimplementation and 100.5 per 1000 patient-days/mo postimplementation, for a 33% relative reduction (95% CI, 26%-39%). Comparing the periods before and after implementation, the rate of broad-spectrum antibiotic use decreased from 506 days to 440 days per 1000 patient-days/mo, respectively, a 13% relative reduction (95% CI, 7%-19%). The broad-spectrum antibiotic initiation rate decreased from 58.1 to 53.6 initiations/1000 patient-days/mo, an 8% relative reduction (95% CI, 4%-11%). Rates of CLABSI decreased from 1.8 to 1.1 per 1000 central venous line days/mo, a 36% relative reduction (95% CI, 20%-49%). Mortality, length of stay, readmission, sepsis, and severe sepsis/septic shock were similar before and after implementation. Conclusions and Relevance Multidisciplinary diagnostic stewardship interventions can reduce blood culture and antibiotic use in the PICU. Future work will determine optimal strategies for wider-scale dissemination of diagnostic stewardship in this setting while monitoring patient safety and balancing measures.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Elizabeth A. Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Danielle W. Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Annie Voskertchian
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cary Thurm
- Children’s Hospital Association, Lenexa, Kansas
| | - Marlene R. Miller
- Rainbow Babies and Children’s Hospital, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - James C. Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
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Abstract
Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents’ perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Corresponding author. E-mail:
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 E Pratt St., Baltimore, MD 21202, USA
| | - John Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Heather A. Wolfe
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Alex S. Plattner
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Sara Malone
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Kathleen Chiotos
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Julia E. Szymczak
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
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Woods-Hill CZ, Koontz DW, Voskertchian A, Xie A, Shea J, Miller MR, Fackler JC, Milstone AM. Consensus Recommendations for Blood Culture Use in Critically Ill Children Using a Modified Delphi Approach. Pediatr Crit Care Med 2021; 22:774-784. [PMID: 33899804 PMCID: PMC8416691 DOI: 10.1097/pcc.0000000000002749] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Blood cultures are fundamental in evaluating for sepsis, but excessive cultures can lead to false-positive results and unnecessary antibiotics. Our objective was to create consensus recommendations focusing on when to safely avoid blood cultures in PICU patients. DESIGN A panel of 29 multidisciplinary experts engaged in a two-part modified Delphi process. Round 1 consisted of a literature summary and an electronic survey sent to invited participants. In the survey, participants rated a series of recommendations about when to avoid blood cultures on five-point Likert scale. Consensus was achieved for the recommendation(s) if 75% of respondents chose a score of 4 or 5, and these were included in the final recommendations. Any recommendations that did not meet these a priori criteria for consensus were discussed during the in-person expert panel review (Round 2). Round 2 was facilitated by an independent expert in consensus methodology. After a review of the survey results, comments from round 1, and group discussion, the panelists voted on these recommendations in real-time. SETTING Experts' institutions; in-person discussion in Baltimore, MD. SUBJECTS Experts in pediatric critical care, infectious diseases, nephrology, oncology, and laboratory medicine. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 27 original recommendations, 18 met criteria for achieving consensus in Round 1; some were modified for clarity or condensed from multiple into single recommendations during Round 2. The remaining nine recommendations were discussed and modified until consensus was achieved during Round 2, which had 26 real-time voting participants. The final document contains 19 recommendations. CONCLUSIONS Using a modified Delphi process, we created consensus recommendations on when to avoid blood cultures and prevent overuse in the PICU. These recommendations are a critical step in disseminating diagnostic stewardship on a wider scale in critically ill children.
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Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Danielle W Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Annie Voskertchian
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Judy Shea
- Division of General Internal Medicine, Department of Medicine and Leonard Davis Institute of Health Economics
| | - Marlene R Miller
- Rainbow Babies and Children’s Hospital
- Case Western Reserve University School of Medicine
- Johns Hopkins Bloomberg School of Public Health
| | - James C Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron M Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Woods-Hill CZ, Papili K, Nelson E, Lipinski K, Shea J, Beidas R, Lane-Fall M. Harnessing implementation science to optimize harm prevention in critically ill children: A pilot study of bedside nurse CLABSI bundle performance in the pediatric intensive care unit. Am J Infect Control 2021; 49:345-351. [PMID: 32818579 DOI: 10.1016/j.ajic.2020.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Central-line associated bloodstream infection (CLABSI) is associated with increased mortality, morbidity, and cost in hospitalized children. An evidence-based bundle of care can decrease CLABSI, but bundle compliance is imperfect. We explored factors impacting bundle performance in the pediatric intensive care unit (PICU) by bedside nurses. METHODS Single-center cross-sectional electronic survey of PICU bedside nurses in an academic tertiary care center; using the COM-B (capability, opportunity, motivation) and TDF (theoretical domains framework) behavioral models to explore CLABSI bundle performance and identify barriers to compliance. RESULTS We analyzed 160 completed surveys from 226 nurses (71% response rate). CLABSI knowledge was strong (capability). However, challenges related to opportunity were identified: 71% reported that patient care requirements impact bundle completion; 32% described the bundle as stressful; and CLABSI was viewed as the most difficult of all bundles. Seventy-five percent reported being highly impacted by physician attitude toward the CLABSI bundle (motivation). CONCLUSIONS PICU nurses are knowledgeable and motivated to prevent CLABSI, but face challenges from competing clinical tasks, limited resources, and complex family interactions. Physician engagement was specifically noted to impact nurse motivation to complete the bundle. Interventions that address these challenges may improve bundle performance and prevent CLABSI in critically ill children.
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Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Kelly Papili
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Eileen Nelson
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kathryn Lipinski
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Judy Shea
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rinad Beidas
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), Philadelphia, PA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Meghan Lane-Fall
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Woods-Hill CZ, Koontz DW, MPH AV, PhD AX, Miller MR, MD JCF, PhD EAC, Milstone A, Milstone A. 1350. Optimizing Blood Culture Use in Critically Ill Children: Year One of a Multi-Center Diagnostic Stewardship Collaborative. Open Forum Infect Dis 2020. [PMCID: PMC7776673 DOI: 10.1093/ofid/ofaa439.1532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Overuse of blood cultures can lead to false positives and unnecessary antibiotics. Our objective was to describe the implementation and 12-month impact of a multi-site quality improvement collaborative to reduce unnecessary blood cultures in pediatric intensive care unit (PICU) patients.
Methods
In 2018, 14 PICUs joined the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children (Bright STAR) Collaborative, designed to understand and improve blood culture practices in PICUs. Guided by a multidisciplinary study team, sites 1) reviewed existing evidence for safe blood culture reduction, 2) assessed local practices and barriers to change, and 3) developed and implemented new blood culture practices informed by local context. We facilitated and monitored project progress through phone calls, site visits, and collaborative-wide teleconferences. We collected monthly blood culture rates and monitored for delays in culture collection as a safety balancing metric. We compared 24 months of baseline data to post-implementation data (2-14 months) using a Poisson regression model accounting for the site-specific patient days and correlation of culture use within a site over time.
Results
Across 14 sites, there were 41,986 pre-implementation blood cultures collected over 238,182 PICU patient days. The mean pre-implementation site-specific blood culture rate was 19.42 cultures/100 patient days (range 9.59 to 48.18 cultures/100 patient days). Post-implementation, there were 12,909 blood cultures collected over 118,600 PICU patient days. The mean post-implementation rate was 14.02 cultures/100 patient days (range 5.40 to 37.57 cultures/100 patient days), a 23% decrease (relative rate 0.77, 95% CI: 0.60, 0.99, p = 0.04). In 12 months post-implementation, sites reviewed 463 positive blood cultures, and identified only one suspected delay in culture collection possibly attributable to the site’s culture reduction program.
Bright STAR Collaborative Site Blood Culture Rate 100 Patient Days
Conclusion
Multidisciplinary teams facilitated a 23% average reduction in blood culture use in 14 PICUs. Future work will determine the impact of blood culture diagnostic stewardship on antibiotic use and other important patient safety outcomes.
Disclosures
James C. Fackler MD, MD, Rubicon Health LLC (Other Financial or Material Support, Founder)
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Affiliation(s)
- Charlotte Z Woods-Hill
- Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Xie A, Koontz DW, Voskertchian A, Fackler JC, Milstone AM, Woods-Hill CZ. Survey-based Work System Assessment to Facilitate Large-scale Dissemination of Healthcare Quality Improvement Programs. Pediatr Qual Saf 2020; 5:e288. [PMID: 32426645 PMCID: PMC7190253 DOI: 10.1097/pq9.0000000000000288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 03/20/2020] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: The dissemination of quality improvement (QI) interventions to a broader range of healthcare settings requires a proactive assessment of local work systems and processes. The objective of this study was to examine the feasibility of using a survey-based work system assessment (WSA) tool to facilitate the dissemination of a program for optimizing blood culture (BC) use. Methods: Informed by findings from an onsite, interview-based WSA at 2 hospitals, a 50-item WSA survey was devised and administrated to 15 hospitals participating in a QI collaborative. WSA survey data were summarized, shared, and discussed with individual hospitals to inform the adaptation and implementation of the BC program. Physician champions leading the local QI team assessed the use of the WSA survey by completing an 8-item survey. Results: A total of 347 clinicians completed the WSA survey, and physician champions at 12 hospitals evaluated the use of the WSA survey. Both the WSA survey data and the evaluation of the WSA survey showed that the survey-based WSA tool could help participating hospitals understand their current BC ordering practices and identify potential barriers to implementing the program from the perspectives of different clinicians. Conclusions: We demonstrated how a survey-based tool could be used to facilitate WSA in the dissemination of a program for improving BC use to a multisite collaborative. A survey-based WSA tool can be used to facilitate future large-scale intervention dissemination efforts.
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Affiliation(s)
- Anping Xie
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Md.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Danielle W Koontz
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Annie Voskertchian
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Md
| | - James C Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Aaron M Milstone
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Md.,Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Md.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Charlotte Z Woods-Hill
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pa
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Woods-Hill CZ, Koontz DW, King AF, Voskertchian A, Colantuoni EA, Miller MR, Fackler JC, Bonafide CP, Milstone AM, Xie A. Practices, Perceptions, and Attitudes in the Evaluation of Critically Ill Children for Bacteremia: A National Survey. Pediatr Crit Care Med 2020; 21:e23-e29. [PMID: 31702704 PMCID: PMC6942229 DOI: 10.1097/pcc.0000000000002176] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Sending blood cultures in children at low risk of bacteremia can contribute to a cascade of unnecessary antibiotic exposure, adverse effects, and increased costs. We aimed to describe practice variation, clinician beliefs, and attitudes about blood culture testing in critically ill children. DESIGN Cross-sectional electronic survey. SETTING Fifteen PICUs enrolled in the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children collaborative, an investigation of blood culture use in critically ill children in the United States. SUBJECTS PICU clinicians (bedside nurses, resident physicians, fellow physicians, nurse practitioners, physician assistants, and attending physicians). INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Survey items explored typical blood culture practices, attitudes and beliefs about cultures, and potential barriers to changing culture use in a PICU setting. Fifteen of 15 sites participated, with 347 total responses, 15-45 responses per site, and an overall median response rate of 57%. We summarized median proportions and interquartile ranges of respondents who reported certain practices or beliefs: 86% (73-91%) report that cultures are ordered reflexively; 71% (61-77%) do not examine patients before ordering cultures; 90% (86-94%) obtain cultures for any new fever in PICU patients; 33% (19-61%) do not obtain peripheral cultures when an indwelling catheter is in place; and 64% (36-81%) sample multiple (vs single) lumens of central venous catheters for new fever. When asked about barriers to reducing unnecessary cultures, 80% (73-90%) noted fear of missing sepsis. Certain practices (culture source and indication) varied by clinician type. Obtaining surveillance cultures and routinely culturing all possible sources (each lumen of indwelling catheters and peripheral specimens) are positively correlated with baseline blood culture rates. CONCLUSIONS There is variation in blood culture practices in the PICU. Fear and reflexive habits are common drivers of cultures. These practices may contribute to over-testing for bacteremia. Further investigation of how to optimize blood culture use is warranted.
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Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Danielle W Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anne F King
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Annie Voskertchian
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth A Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Marlene R Miller
- Rainbow Babies and Children’s Hospital
- Case Western Reserve University School of Medicine
- Johns Hopkins Bloomberg School of Public Health
| | - James C Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher P Bonafide
- Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Aaron M Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
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18
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Xie A, Woods-Hill CZ, King AF, Enos-Graves H, Ascenzi J, Gurses AP, Klaus SA, Fackler JC, Milstone AM. 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. J Pediatric Infect Dis Soc 2019; 8:39-45. [PMID: 29165616 DOI: 10.1093/jpids/pix097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 10/27/2017] [Indexed: 11/14/2022]
Abstract
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 Children's 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 patient's 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.
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Affiliation(s)
- Anping Xie
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland.,Department of Anesthesiology and Critical Care Medicine
| | - Charlotte Z Woods-Hill
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Pennsylvania
| | - Anne F King
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Heather Enos-Graves
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland
| | - Judy Ascenzi
- Department of Pediatrics, Johns Hopkins Nursing, Baltimore, Maryland
| | - Ayse P Gurses
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland.,Department of Anesthesiology and Critical Care Medicine
| | | | | | - Aaron M Milstone
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland.,Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Woods-Hill CZ, Biedron LM, Rigby VA, Kaminski S, Papili KE, Fitzgerald JC, Weiss SL. Electronically-augmented Huddle Improved Antibiotic Delivery for Sepsis in the Pediatric Intensive Care Unit. Pediatr Qual Saf 2018. [PMCID: PMC6132748 DOI: 10.1097/pq9.0000000000000059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Fowler JC, Woods-Hill CZ, Meaney PA. Don't wait for the weight. Resuscitation 2017; 117:A3-A4. [PMID: 28610964 DOI: 10.1016/j.resuscitation.2017.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 05/18/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Jessica C Fowler
- Perelman School of Medicine at the University of Pennsylvania, United States
| | | | - Peter A Meaney
- Perelman School of Medicine at the University of Pennsylvania, United States.
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Woods-Hill CZ, Fackler J, Nelson McMillan K, Ascenzi J, Martinez DA, Toerper MF, Voskertchian A, Colantuoni E, Klaus SA, Levin S, Milstone AM. Association of a Clinical Practice Guideline With Blood Culture Use in Critically Ill Children. JAMA Pediatr 2017; 171:157-164. [PMID: 27942705 DOI: 10.1001/jamapediatrics.2016.3153] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Charlotte Z Woods-Hill
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland2Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - James Fackler
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Kristen Nelson McMillan
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Judith Ascenzi
- Department of Pediatrics, Johns Hopkins Nursing, Baltimore, Maryland
| | - Diego A Martinez
- Department of Emergency Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Matthew F Toerper
- Department of Emergency Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Annie Voskertchian
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sybil Ann Klaus
- MITRE Corporation, Mclean, Virginia8Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Scott Levin
- Department of Emergency Medicine, The Johns Hopkins University, Baltimore, Maryland9Department of Civil Engineering, The Johns Hopkins University, Baltimore, Maryland
| | - Aaron M Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland10Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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