SCCM Resource Library-Diagnostic Stewardship in the Pediatric Intensive Care Unit: Results of the Bright STAR Collaborative

Video Transcription

Hello, my name is Charlie Woodsell. I'm a pediatric intensivist from the Children's Hospital of Philadelphia, and I am very happy to be here to share with you this work,  Diagnostic Stewardship in the Pediatric Intensive Care Unit, the results of a project we call the Bright Star Collaborative.  This is my current funding, and I have no conflicts of interest to disclose.  I have three objectives for this brief talk. One, we'll talk a little bit about the concept of medical overuse in the context of sepsis in the Pediatric Intensive Care Unit.  I'll highlight blood cultures as a particular example of harmful overuse in PICU patients,  and then focus on the Bright Star Collaborative and what we did to harness diagnostic stewardship  to reduce medical overuse and hopefully reduce patient harm. So I'm going to frame this  discussion really around the idea of medical overuse. Now, this is a complex and very important  topic, and to define it very simply, it is medical care, whether that's tests or treatments or both,  in which the net benefits do not exceed the net harms for the patient.  About a third of United States healthcare spending represents medical overuse,  and has been linked in multiple care settings to excess cost, worse patient outcomes, and even death.  An important strategy that is emerging to fight medical overuse is diagnostic stewardship, and this is simply optimizing the use of diagnostic tests in order to improve  the downstream treatment decisions. Getting more specific to this work, so blood cultures,  as we know, are the gold standard for diagnosing sepsis due to bacteremia in PICU patients,  and they are probably thought of by most of us as essentially a zero harm test, right? If a child  has a fever and you're concerned that they might be infected, seems like a very reasonable and not  harmful thing to do to collect a blood culture. But the problem is that when we collect blood  cultures in patients in which there is really a low pretest probability or low suspicion for sepsis, we are potentially subjecting those patients to unnecessary empiric antibiotics.  We might get false positive results on those blood cultures, and then we begin kind of a  downstream cascade of unnecessary and potentially harmful care. And so this work, the Bright Star  Project, is really focusing on reducing unnecessary blood cultures in PICU patients. And when you do that in patients for whom there is low clinical suspicion for sepsis,  we believe this could be feasible and safe. And we wanted to know, can you do this consistently  across multiple types of PICU settings? And is there actually an impact on the downstream  initiation of antibiotics? So this work really began as simple, single center quality improvement  in the Johns Hopkins PICU several years ago at this point. We created a checklist for our  providers and a decision algorithm that we wanted them to simply consult before deciding to get a  blood culture in patients in our PICU. We found a 46% reduction in blood cultures from that work, and importantly, no increase in sepsis or septic shock and no increase  in the use of antibiotics without a preceding blood culture.  We followed that up by doing a similar program in three additional PICUs and found, again, about a 32% decrease in blood culture rates after implementation of a similar program.  And we really spent some time with those centers beginning to think about how to build a framework for larger scale dissemination of blood culture improvement work.  So that preliminary work really laid the groundwork for what is now the Bright Star Collaborative. And this is an exploration of the potential for diagnostic stewardship to reduce  iatrogenic harm and overuse focused on blood cultures in PICU patients, standing for Testing Stewardship to Reduce Antibiotic Use and Resistance.  So this is the Bright Star team. The PI is Dr. Aaron Millstone, a pediatric ID doc at Johns Hopkins.  But we've got experts here in pediatric intensive care, pediatric quality improvement, human factors engineering, and several wonderful study coordinators, study managers,  and a statistician, all of whom I have to thank for incredible work over the last four years on  this project. So we enrolled 14 sites in Bright Star, and they're listed here for you. And you  can see that they're a mix of large and freestanding and academic centers, smaller centers that are  affiliated with adult institutions. These places are really the heart and soul of the project,  and we were blessed with just the most incredibly engaged, thoughtful collaborators from beginning  to end. And I thank each and every one of these sites for incredible participation over the last  several years. So this is a 50,000-foot view of what we actually did with each of our Bright Star  sites during the project period. So we held an introductory webinar in early 2018. We asked each  site to form a core project team, a combination of a pediatric intensivist and a pediatric ID doc.  We asked each of our site leads to identify and meet with key stakeholders in their institutions  who were going to have sort of a vested interest in a project that changed blood culture practices.  We obtained baseline data for each of our outcome metrics. We did a work system assessment,  which was a human factors engineering-based assessment, essentially, of pre-project typical  practices around blood cultures. We asked each site to create a clinical tool that was focused  then on optimizing blood culture practices in their particular setting. Now, this is important.  So we did not hand these 14 sites exactly what the clinical tool or the clinical guidance about  blood cultures was going to be. We did want each site to develop a clinical tool reflecting the  needs of their own patient population and the important input of their own stakeholders. So everybody's clinical approach actually looked a little bit different,  although each of the sites was tasked with optimizing blood culture practices in ways that was going to reduce unnecessary cultures in a way that was safe. So not for patients in  which there was clinical suspicion for sepsis, but you're thinking really more stable patients  with, for example, perhaps persistent fever that had already had a set or two of negative blood  cultures. Perhaps we didn't need blood cultures on day three or day four of fever in patients  who were clinically unchanged. But again, it's important to recognize that the clinical tool  in each of the sites was a little bit different. We asked them and worked with each of the sites  to come up with a variety of implementation strategies. So how are you actually going to get your clinicians to change practices, set a launch date, and then implement the program.  We collected monthly data from that point from each site in terms of blood cultures and our  other outcomes, and we maintained close contact with all of our site leads. We did monthly individual site calls, we did quarterly collaborative wide calls, and we also  continued to survey each of our sites, focusing more on kind of the implementation process itself  with a semi-annual implementation survey. The primary outcome for BrightStar was blood culture rates, and we compared 24 months of pre-BrightStar baseline data to 18 months  post-implementation and found a 33% relative reduction in blood culture rate.  We also analyzed a variety of safety and balancing metrics throughout the BrightStar project period in recognition of the fact that the most important part of a program designed  to reduce the use of a diagnostic test is that you don't see the unintended consequence of something  like poor recognition or delayed recognition of sepsis and an increase potentially in mortality  as a result of this program. This is showing results of the 11 of the 14 sites that were CHA-FIS participating hospitals where we were able to pull this data from, and you can see  across those 11 sites there's no statistically significant change in any of these balancing  metrics. Now, while there were no statistically significant increases in mortality or sepsis or septic shock in the post-BrightStar time period, we also looked at these metrics on  an individual site level, and actually you can see that there were outlier sites for mortality and for sepsis and actually for some of the other outcomes as well that sort of skewed  the results, but there was no systemic signal that across all of our sites in the post-project  time period that any of these balancing metrics were increased, which we found quite reassuring.  One last note about the safety of the work. So, our site leads also examined in detail 793 episodes of positive blood cultures for any evidence of delay in obtaining those cultures  as an additional sort of layer of safety, and happily we found that in 99 percent of those episodes, so 792 out of 793, there was no evidence of a delay in obtaining a culture  that was ultimately positive during the BrightStar time period. So, in addition to wanting to understand if we could meaningfully reduce blood culture use across 14 diverse sites,  we also wanted to know is there a downstream impact on broad-spectrum antibiotic use, and we actually found a 13 percent relative reduction in broad-spectrum antibiotic use  for PICU days three and later in the post-project time period.  We also found an 8 percent relative reduction in new initiations of broad-spectrum antibiotics  in the post-project time period. So, from our results, we were pretty thrilled to conclude  that BrightStar is the first multidisciplinary quality improvement collaborative to demonstrate  a significant reduction in blood culture use and broad-spectrum antibiotic use while safety and balancing measures remain stable. So, multidisciplinary diagnostic stewardship  to optimize blood culture practices in patients with low suspicion for sepsis can safely decrease blood cultures and antibiotics in critically ill children.  Next, we plan the creation and large-scale implementation of a toolkit for blood culture practice change based both on the BrightStar process that I've outlined here, as well as  some BrightStar consensus guidelines that we developed as a separate component to this work.  Also, we have BrightStar Respiratory, a separate collaborative that is now underway doing similar  work for endotracheal aspartic cultures. I would like to thank the Society of Critical  Care Medicine for the opportunity to share this work with you. I'd like to thank Aaron Milstone,  who's the BrightStar PI and my primary mentor. Every member of the BrightStar project team,  our incredible BrightStar sites, Carrie Thurm and CHA for their help with data and data analysis, and then my division chief and my division of critical care medicine  at CHOP. Thank you all very much. I'd be happy to take questions.

Video Summary

In this video transcript, Charlie Woodsell, a pediatric intensivist, discusses the concept of medical overuse in the context of sepsis in the pediatric intensive care unit (PICU). He highlights the overuse of blood cultures as an example of harmful overuse and introduces the Bright Star Collaborative project, which aims to reduce medical overuse and patient harm in the PICU through diagnostic stewardship. The project involved implementing clinical tools and strategies across multiple PICUs to optimize blood culture practices and reduce unnecessary cultures. The results showed a significant reduction in blood culture and broad-spectrum antibiotic use without compromising patient safety. The success of the project paves the way for the creation of a toolkit for blood culture practice change and the expansion of the collaborative to tackle other diagnostic areas.

Asset Subtitle

Pharmacology, Quality and Patient Safety, Pediatrics, 2022

Asset Caption

INTRODUCTION/HYPOTHESIS: 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 evaluate the impact of a multi-site quality improvement collaborative focused on blood culture practices in pediatric intensive care units (PICUs) on blood culture rates, antibiotic use, and balancing measures. We hypothesized that decreased blood cultures would be associated with decreased antibiotic use. METHODS: In 2018, 14 PICUs joined the Bright STAR (Testing STewardship to reduce Antibiotic Use and Resistance) Collaborative. Sites assessed local practices, developed and implemented clinical decision support tools to guide new blood culture practices, and audited post-implementation cultures for compliance and safety. We compared 24 months of baseline data to 18 months of post-implementation data using a Poisson regression model accounting for the site-specific patient days and correlation within a site over time. RESULTS: Across the 14 sites, there were 41,731 pre-implementation blood cultures and 22,408 post-implementation blood cultures. Per 1000 patient days/month, there were an estimated 156.9 blood cultures pre-implementation and 104.1 blood cultures post-implementation, a 34% reduction in the relative rate and an absolute reduction of 52.78 blood cultures (p < .001). Per 1000 patient days/month, there were 505.99 total days of broad-spectrum antibiotic use pre-implementation and 440.34 days of broad-spectrum antibiotic use post-implementation, a 13% relative reduction in antibiotic use, and an absolute reduction of 65.65 days of antibiotic therapy (p < .001). Balancing metrics of PICU mortality rates, length of stay, readmission, and sepsis/septic shock were unchanged. In addition, 793 episodes of post-implementation bacteremia were reviewed in detail, and in 99.9%, no concern for delay in obtaining blood cultures was identified. CONCLUSIONS: Multidisciplinary diagnostic stewardship work can reduce blood culture and antibiotic use in critically ill children. Future work will determine optimal strategies for wider-scale dissemination of blood culture diagnostic stewardship in the PICU setting, while monitoring for patient safety and unintended consequences.

Meta Tag

Content Type Presentation

Knowledge Area Pharmacology

Knowledge Area Quality and Patient Safety

Knowledge Area Pediatrics

Knowledge Level Advanced

Membership Level Select

Tag Antibiotics

Tag Evidence Based Medicine

Tag Pediatrics

Tag Guidelines

Year 2022

Keywords

medical overuse

sepsis

pediatric intensive care unit

Bright Star Collaborative

diagnostic stewardship

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