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Background: Respiratory cultures are commonly obtained from patients with suspicion for ventilator-associated infections (VAIs). In the absence of specimen ordering and collection guidelines, management practices may differ. We characterized current respiratory culture collection practices and perceptions and identified potential barriers to changing practices among a national collaborative of pediatric intensive care units (PICUs). Methods: We conducted an electronic survey of PICU physicians, advanced practice providers (APPs), respiratory therapists (RTs), and nurses at 16 US academic pediatric hospitals across the United States. Positive Likert-scale responses (eg, “agree” and “strongly agree”) were grouped. To account for varying hospital representation, we analyzed the results as the median proportion of participants with that response across the hospitals. Results: After excluding incomplete responses, 568 (44%) of 1,301 invited participants responded (range, 16–107 per site); the median hospital response rate was 60% (range, 17%–83%). Roles included physicians (35%), APPs (10%), RTs (24%), and nurses (31%). Moreover, 44% of the participating units cared for cardiac surgery patients. Across hospitals, specimens are often collected by RTs, followed by nurses, typically via inline endotracheal aspirate for either endotracheal tubes or tracheostomies. Saline lavage is a common practice, but only 4% reported a standardized approach. Examining the likeliness to obtain cultures for different clinical symptoms, the widest variation in responses were for fever and inflammatory markers without respiratory symptoms (median proportion, 68%; IQR, 54%–79%), isolated change in secretion characteristics (67%; IQR, 54%–78%), isolated increased secretions (55%; IQR, 40%–65%), isolated inflammatory markers (49%; IQR, 38%–57%) or isolated fever (49%; IQR, 38%–61%). Overall, 75% (IQR, 70%–86%) of reported respiratory cultures were likely to be obtained as a “pan culture.” Most respondents (median proportion, 69%) felt confident about the indications to obtain cultures, but 60% felt that clinicians had a low threshold, and 84% reported clinical practice variation. Barriers to change included reluctance to change (70%), opinion of consultants (64%), and fear of missing a diagnosis of VAI (62%). Respondents agreed that they would find clinical decision support (CDS) tools helpful (79%). In addition, 83% expected that they would follow CDS, and 82% thought that CDS would help align ICU and/or consulting teams. Conclusions: Among 16 participating hospitals, we detected a lack of standardized respiratory-culture specimen collection and ordering practices. Most respondents agreed that CDS tools would be helpful. Diagnostic stewardship of respiratory cultures using CDS must account for potential reluctance to change and needs to address stakeholder perspectives, including fear of missing infections.
Background: Environmental cleaning is critical in preventing pathogen transmission and potential consecutive healthcare-acquired infections. In operating rooms (ORs), multiple invasive procedures increase the infectious risk for patients, making proper cleaning and disinfection of environmental surfaces of paramount importance. A human-factors engineering (HFE) approach emphasizing the impact of the entire work system on care processes and outcomes has been proposed to improve environmental cleaning. Using the lens of this HFE approach, we conducted a systematic review to synthesize existing evidence and identify gaps in the literature on OR cleaning. Methods: The systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and limited to English-written, peer-reviewed journal articles reporting empirical studies on OR cleaning. Figure 1 shows the flowchart of study search and screening. The following data were extracted from each included article: (1) general information of the article (eg, first author, title, journal, year of publication) and (2) characteristics of the study (eg, country, objectives, design, outcome measures and measuring techniques, findings, funding source). In addition, work-system elements (eg, people, tasks, tools and technologies, physical environment, organizational conditions) and cleaning processes (eg, turnover cleaning, terminal cleaning) addressed in each included studywere coded based on the Systems Engineering Initiative for Patient Safety (SEIPS) model. The methodological quality of included studies using a (non)randomized controlled design was assessed using the version 2 of the Cochrane risk-of-bias tool for randomized trials. Results: In total, 35 studies were included in this review, among which 10 examined the effectiveness of OR cleaning in reducing environmental contamination (Fig. 2), 1 examined the compliance of OR cleaning practices (Fig. 3), and 24 examined interventions for improving OR cleaning effectiveness and/or compliance (Fig. 4). Figure 5 summarizes the characteristics of the included studies. Conclusions: In this review, OR cleaning was inconsistently performed in practice, and mixed findings were reported regarding the effectiveness of OR cleaning in reducing environmental contamination. No study has systematically examined work-system factors influencing OR cleaning. Efforts to improve OR cleaning focused on cleaning tools and technologies (eg, ultraviolet light) and staff monitoring and training. Interventions targeting the broader work system influencing the cleaning processes are lacking. The scientific rigor of the included studies was modest. Most studies were either commercially funded or did not reveal their funding sources, which might introduce a desirability bias.
Financial support: This study was funded by the Centers for Disease Control and Prevention.
Background: Blood cultures are fundamental in the diagnosis and treatment of sepsis. Culture practices vary widely, and overuse can lead to false-positive results and unnecessary antibiotics. Our objective was to describe the implementation of a multisite quality improvement collaborative to reduce unnecessary blood cultures in pediatric intensive care unit (PICU) patients, and its 18-month impact on blood culture rates and safety metrics. 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 critically ill children. Guided by a centralized multidisciplinary study team, sites first reviewed existing evidence for safe reduction of unnecessary blood cultures and assessed local practices and barriers to change. Subsequently, local champions developed and implemented clinical decision-support tools informed by local patient needs to guide new blood-culture practices. The coordinating study team facilitated regular evaluations and discussions of project progress through monthly phone calls, site visits if requested by sites or the study team, and collaborative-wide teleconferences. The study team collected monthly blood culture rates and monitored for possible delays in obtaining blood cultures using a standardized review process as a safety balancing metric. We compared 24 months of baseline data to 18 months of postimplementation using a Poisson regression model accounting for the site-specific patient days and correlation of culture use within a site over time. Results: Across the 14 sites, before implementation, 41,768 blood cultures were collected over 259,701 PICU patient days. The mean preimplementation site-specific blood culture rate was 15.7 cultures per 100 patient days (rate range, 9.6–48.2 cultures per 100 patient days). After implementation, 22,397 blood cultures were collected over 208,171 PICU patient days. The mean postimplementation rate was 10.4 cultures per 100 patient days (rate range, 4.7–28.3 cultures per 100 patient days), which was 33.6% lower than the preimplementation (relative rate 0.66; 95% CI, 0.65–0.68 p <0.01). In 18 months post-implementation, sites reviewed 793 positive blood cultures, and identified only one suspected delay in culture collection possibly attributable to the site’s blood culture reduction program. Conclusions: Multidisciplinary quality improvement teams safely facilitated a 33.6% average reduction in blood culture use in critically ill children at 14 hospitals. Future collaborative work will determine the impact of blood culture diagnostic stewardship on antibiotic use and other important patient safety outcomes.
ABSTRACT IMPACT: Optimizing the use of endotracheal aspirate cultures (EACs) has the potential to improve the care of complex mechanically ventilated children by improving testing practices and avoiding unnecessary antibiotic treatment for false-positive results. OBJECTIVES/GOALS: An electronic survey has previously been employed to characterize the practices and attitudes around blood cultures among critically ill children. The objective of this work was to develop and pilot a new survey as a tool to understand practices and attitudes that could inform quality improvement initiatives to optimize EAC practices. METHODS/STUDY POPULATION: Informed by prior experience of diagnostic stewardship of EAC in other settings and using a similar structure to the blood culture practice survey, we developed an electronic self-administered survey sent to respiratory therapists, advanced practice providers, and physicians at the Johns Hopkins All Children’s pediatric intensive care unit. RESULTS/ANTICIPATED RESULTS: A total of 27 of 87 clinicians (37%) responded to the survey (22 respiratory therapists, 9 attending physicians and 1 advanced practice provider). Responses indicated samples are typically collected by respiratory therapists via in-line (endotracheal) or open suctioning (tracheostomy). Most respondents did not feel EACs could lead to unintended negative consequences (71%), agreed practices vary between people (89%), and felt an algorithm would help align the clinical team (79%). Most respondents agreed some clinicians may be reluctant to change practice (82%) and may not change practice due to concern for missing diagnosis of ventilator-associated pneumonia or tracheitis (78%). Surveillance cultures were not used in this unit and there were no prior EAC diagnostic stewardship efforts. DISCUSSION/SIGNIFICANCE OF FINDINGS: This survey captured practices, perceptions and barriers to changes that will inform the implementation of quality improvement initiatives to optimize EAC use in this unit. Future studies can consider utilizing an electronic survey to describe practice variation, clinician believes and attitudes about EAC testing in ventilated patients.
We compared the fluorescent gel removal rate using fewer high-touch surfaces (HTSs) and rooms and determined the optimum number of HTSs and rooms needed to ensure accuracy using 2,942 HTSs in 228 rooms on 13 units. Randomly selecting 3 HTS in 2 rooms predicted the optimal removal rate.
To systematically assess enhanced personal protective equipment (PPE) doffing safety risks.
We employed a 3-part approach to this study: (1) hierarchical task analysis (HTA) of the PPE doffing process; (2) human factors-informed failure modes and effects analysis (FMEA); and (3) focus group sessions with a convenience sample of infection prevention (IP) subject matter experts.
A large academic US hospital with a regional Special Pathogens Treatment Center and enhanced PPE doffing protocol experience.
Eight IP experts.
The HTA was conducted jointly by 2 human-factors experts based on the Centers for Disease Control and Prevention PPE guidelines. The findings were used as a guide in 7 focus group sessions with IP experts to assess PPE doffing safety risks. For each HTA task step, IP experts identified failure mode(s), assigned priority risk scores, identified contributing factors and potential consequences, and identified potential risk mitigation strategies. Data were recorded in a tabular format during the sessions.
Of 103 identified failure modes, the highest priority scores were associated with team members moving between clean and contaminated areas, glove removal, apron removal, and self-inspection while preparing to doff. Contributing factors related to the individual (eg, technical/ teamwork competency), task (eg, undetected PPE contamination), tools/technology (eg, PPE design characteristics), environment (eg, inadequate space), and organizational aspects (eg, training) were identified. Participants identified 86 types of risk mitigation strategies targeting the failure modes.
Despite detailed guidelines, our study revealed 103 enhanced PPE doffing failure modes. Analysis of the failure modes suggests potential mitigation strategies to decrease self-contamination risk during enhanced PPE doffing.
In this systematic evaluation of fluorescent gel markers (FGM) applied to high-touch surfaces with a metered applicator (MA) made for the purpose versus a generic cotton swab (CS), removal rates were 60.5% (476 of 787) for the MA and 64.3% (506 of 787) for the CS. MA-FGM removal interpretation was more consistent, 83% versus 50% not removed, possibly due to less varied application and more adhesive gel.