Strategy raises adherence to guideline-recommended pediatric blood cultures

By Will Boggs MD

NEW YORK (Reuters Health) - A strategy focused on three key drivers significantly improved one hospital's adherence to guideline-recommended blood cultures in children hospitalized with pneumonia.

The Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) guideline "recommends blood cultures for children with moderate to severe pneumonia, but this recommendation has been controversial," Dr. Eileen Murtagh Kurowski, from Cincinnati Children's Hospital Medical Center, Ohio, told Reuters Health by email.

She continued, "In a setting with a low rate of false-positive blood cultures it is possible to universally obtain blood cultures in all children admitted with pneumonia without prolonging length of stay."

Dr. Murtagh Kurowski's team aimed to increase ordering of blood cultures for children hospitalized with community-acquired pneumonia (CAP) from 53% to 90% over six months while monitoring the effect of obtaining blood cultures on length of stay.

They first used a failure mode and effects analysis to identify three key drivers to achieve their aim: shared knowledge of the guideline across all providers; efficient, reliable, and accurate ordering of diagnostic tests; and provider knowledge of group and individual performance.

By employing education, identification and mitigation/education, and changes in the electronic medical records system, the group was able to improve the percentage of patients who had blood cultures from 53% at baseline to 100% about five months later. This level of adherence was sustained for 12 months.

The length of stay did not differ significantly between patients who did and did not have a blood culture performed, according to the March 16th Pediatrics online report.

Of the 239 blood cultures performed during the study, six (2.5%) were positive, including three true-positives and three that were considered false-positives.

One true-positive blood culture that yielded methicillin-resistant Staphylococcus aureus (MRSA) resulted in a change in antibiotic coverage.

"Our false-positive rate in this cohort was far lower than that seen in prior studies of pediatric pneumonia," Dr. Murtagh Kurowski said. "The benefit of identifying the true-positives is in the ability to identify children who have resistant organisms or are more likely to develop complications of pneumonia before they clinically deteriorate."

"While the false-positive rate was the same as the true-positive rate in our study, none of the patients with false-positive blood cultures had prolonged length of stay or received broad spectrum antibiotics," she said. "Thus, we think the benefits of identifying the true-positives outweigh any negative effect of false-positive blood cultures."

Dr. Alan R. Schroeder, from Santa Clara Valley Medical Center, San Jose, California, recently questioned the need to perform blood cultures in various settings. He told Reuters Health, "I do not believe that this report gives us any more information about the necessity of blood cultures in children hospitalized with CAP, and I believe that the evidence is fairly convincing that they are unnecessary."

"It is clear that process improved (more blood cultures were obtained), but there's no evidence of enhanced value," Dr. Schroeder said. "Costs certainly increased. The length of stay outcome was likely analyzed as a balancing measure, but where's the actual evidence that 'quality' really improved?"

"I am surprised that so much manpower and expenses were invested on such a big project when the value of the intervention itself is still very much in question," Dr. Schroeder concluded. "I suspect that there are bigger fish to fry."

Dr. Russell McCulloh from Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, Missouri, who recently published a report evaluating the use of blood cultures in children like these, told Reuters Health by email, "The debate regarding blood culture obtainment in children hospitalized with CAP will continue. The strength of this article lies in the description of the comprehensive, systematic, and innovative approach the authors took to increase adherence to evidence-based guidelines."

"Their report provides other institutions with an array of interventions that could be used for improving adherence to a variety of guidelines," Dr. McCulloh said. "Electronic medical records-based tools can play a major role in increasing clinician adherence to evidence-based guidelines."

A National Research Service Award and the National Institute of Allergy and Infectious Diseases partially supported this research. The authors declared no conflicts of interest.

SOURCE: http://bit.ly/1bcub10

Pediatrics 2015.

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