Carrie Sona, BSN, CCNS, CCRN, MSN
Clinical Nurse Specialist
Barnes Jewish Hospital
Saint Louis, MO
Disclosure information not submitted.
Danny vanValkinburgh, MD
MD
St. Louis University, United States
Disclosure information not submitted.
Lynn Pauls, MD
MD
Washington University in Saint Louis School of Medicine, United States
Disclosure information not submitted.
John Mazuski, MD, PhD, MCCM
Professor of Surgery
Washington University in Saint Louis SOM, United States
Disclosure information not submitted.
Title: Choosing Wisely: The Use of Clinical Criteria to Guide Blood Culturing Practices
Introduction: Fever is a common problem in ICU patients. Despite clinical research and guideline recommendations indicating that clinical criteria and not fever alone should be used to order blood cultures (BC), these cultures are frequently obtained as part of a "fever workup" without careful review of the patient's clinical status. Unnecessary BC increase clinical workload and can lead to inappropriate treatments if the culture is contaminated. The purpose of this quality improvement (QI) initiative was to develop clinical criteria that providers were to review when ordering BC, with a goal to reduce the numbers of inappropriate BC.
Methods: This QI project was completed in a 36-bed surgery/trauma/burn ICU. After reviewing pertinent studies and guidelines, clinical criteria for obtaining blood cultures were developed by a subcommittee and approved by the ICU QI committee. These criteria included a core temperature of 38.3°C on at least two separate readings, evidence of sepsis with worsening physiologic parameters in at least one organ system, no apparent non-infectious cause of fever, at least 48 hours after non-emergency surgery, no BC obtained in the past 36 hours unless positive, and no plans for end of life or comfort care. The protocol was implemented in February, 2021. Numbers of BC were tracked for 5 months after implementation, and compared for the same 5-month periods for 2019 and 2020, to capture trends both before and during the COVID pandemic.
Results: The average number of BC/month prior to implementation of clinical criteria were 218 in 2019 and 209 in 2020 (CI 212-225). After implementation of clinical criteria, the number was 184 (CI 139-221) in 2021. This represented a 14% decrease in the number of BC, although this decrease did not achieve statistical significance.<
Conclusions: The implementation of clinical criteria for when to obtain BC resulted in a reduced cultures. Further investigation is needed to determine if this decrease is sustainable and will reach statistical significance, if the criteria can be further modified to further decrease inappropriate BC, and to ensure that decreasing the number of BC does not result in delayed recognition of bacteremia or other infections. Following clinical criteria to avoid unnecessary BC could be a helpful tool to help clinicians to choose wisely.