Fear, Reflexive Habits Prompt the Ordering of Blood Cultures

Fear and reflexive habits are common drivers for ordering blood cultures for patients in pediatric intensive care units (PICUs), according to an AHRQ-funded study published in Pediatric Critical Care Medicine. Researchers explored practice variation and clinician beliefs and attitudes about blood culture testing in critically ill children in 15 hospital PICUs participating in the Bright Star collaborative, a nationwide quality improvement project led by Johns Hopkins University School of Medicine. Among the study findings: 86 percent of survey respondents reported that blood cultures are ordered reflexively; 71 percent did not examine patients before ordering cultures; and 90 percent obtained cultures for PICU patients with a new fever. Eighty percent of clinicians noted the fear of missing sepsis as a barrier to not reducing unnecessary cultures. Researchers concluded these habits may contribute to overtesting for bacteremia, and that further investigation is needed on how to optimize blood culture use. Access the study abstract.

2019 Nov 6. doi: 10.1097/PCC.0000000000002176. [Epub ahead of print]

Practices, Perceptions, and Attitudes in the Evaluation of Critically Ill Children for Bacteremia: A National Survey.

Woods-Hill CZ1,2, Koontz DW3, King AF3, Voskertchian A3, Colantuoni EA4, Miller MR5,6,7, Fackler JC8, Bonafide CP9, Milstone AM3, Xie A8,10; Bright StarAuthorship group.

Collaborators (34)

Author information

1: Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
2: The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
3: Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.
4: Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
5: Rainbow Babies and Children's Hospital, Cleveland, OH.
6: Case Western Reserve University School of Medicine, Cleveland, OH.
7: Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
8: Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
9: Pediatric Hospital Medicine, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
10: Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD.

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.