Evaluating culture practices used to identify infection in patients with brain injury

The neurosurgical intensive care unit staff at Harborview Medical Center, Seattle, Washington, had a strong desire to implement strategies to lower temperatures in their patients with brain injury because the patients with elevated temperatures often have lower Glasgow Coma Scores. In addition, neurologic improvement was demonstrated when high temperatures were lowered. Hospital policy dictated that temperatures be allowed to climb to more than 38.5°C before treatment because this temperature was used as the trigger for culture collection every 24 hours. The expressed rationale was that temperature management would obscure the trigger and infections would be missed. Thus, the investigators wanted to determine whether temperature elevation was a reliable indicator of infection. A quality improvement tool was developed, and the patient populations to be evaluated were those admitted with the diagnosis of subarachnoid hemorrhage, arteriovenous malformation, or traumatic brain injury. The number of times each patient was cultured and whether he or she was cultured because of temperature, a white blood cell count elevation, or clinical indicators were tracked. Findings showed that the use of temperature as a screening indicator for infection produced few positive cultures and that the practice of daily cultures yielded few positive results generally. Conclusions made from the data were that temperature is not an accurate indicator of infection in these patients with brain injury and fever management would not adversely impact infection identification. Policy within the Neuroscience intensive care unit was changed to reflect these findings.