Following a 2014 examination of bacterial bloodstream infections occurring in patients at the Johns Hopkins Children’s Center pediatric ICU, a multidisciplinary team determined that two practices were in need of thoughtful review: blood culture order rates and the source (peripheral venipuncture or central venous catheter) of those cultures. For a study published in JAMA Pediatrics, Charlotte Z. Woods-Hill, MD, and colleagues examined the impact of a quality improvement initiative meant to reduce unnecessary blood cultures in PICU patients.

“We had two key questions,” says Dr. Woods-Hill. “Was a unique type of diagnostic stewardship approach to blood cultures possible in a PICU (could it significantly and sustainably change clinicians’ behaviors around screening for bacterial bloodstream infection), and was it safe?

The intervention was a two-part clinical guideline, developed by a multidisciplinary team, for consulting when considering blood culture necessity that included information on bacteremia risk factors and non-infectious causes of fever. The guideline became the standard approach to blood cultures in the PICU. The research team examined blood culture rates in the 12 months before and after guideline implementation.

During the year prior to implementation, the blood culture incidence rate was 16.1 per 100 patient-days, compared with a rate of 8.8 in the year after. Blood culture collection rates decreased 46.0% with the intervention. Significantly fewer cultures were collected from central venous catheters following implementation when compared with prior to implementation (39.5% vs 73.1%). In-hospital mortality and hospital readmission rates were unchanged with the intervention. “A simple, two-part guideline brought sustained practice change in short order for something as critical as the question of bacterial sepsis,” says Dr. Woods-Hill.