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Published on: October 15, 2014
Determinants of Blood Culture Use in Critically Ill Children: A Multicenter Qualitative Study
Charlotte Z Woods-Hill1,2, Maria N Nelson3, Whitney Eriksen4
1Division of Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa.
Insights
Understanding factors influencing blood culture use in pediatric intensive care units (PICUs) is key. Clinician beliefs, unit practices, and behavioral biases like outcome bias affect decisions, guiding strategies to optimize blood culture use.
Area of Science:
- Pediatric Intensive Care
- Infectious Disease Diagnostics
- Healthcare Quality Improvement
Background:
- Blood cultures are crucial for sepsis diagnosis in pediatric intensive care units (PICUs).
- Current practices for blood culture utilization vary significantly, leading to potential overuse and associated risks like false positives and unnecessary antibiotic administration.
- Factors influencing these clinical decisions remain largely uncharacterized.
Purpose of the Study:
- To identify the perceived determinants influencing the use and overuse of blood cultures in the PICU setting.
- To explore clinician perspectives on factors affecting blood culture ordering decisions.
Main Methods:
- Conducted semistructured interviews with clinicians (physicians, nurses, advanced practitioners) across six PICUs.
- Utilized a combined approach integrating the Consolidated Framework for Implementation Research (CFIR) and behavioral economics principles for interview question development.
- Employed open-coding and modified content analysis to identify key themes from interview transcripts.
Main Results:
- Thematic saturation was achieved with 24 interviews, revealing seven core themes across CFIR domains: individual characteristics (e.g., personal belief in test importance), inner setting (e.g., adherence to usual practices, unit culture), and outer setting (e.g., patient risk factors, guidelines).
- Behavioral economics concepts, including outcome bias, default bias, and loss aversion, were identified as significant influences.
- Specific factors included clinician beliefs, site-specific practices, influence of non-PICU clinicians, patient risk, and sepsis guidelines.
Conclusions:
- Blood culture utilization decisions are shaped by a complex interplay of individual clinician factors, the PICU's internal environment, external influences, and cognitive biases.
- Understanding these determinants, such as default bias and outcome bias, is essential for developing targeted strategies.
- These findings will inform the creation of interventions aimed at optimizing blood culture practices in PICUs.
Abstract:
Blood cultures are fundamental in diagnosing and treating sepsis in the pediatric intensive care unit (PICU), but practices vary widely. Overuse can lead to false positive results and unnecessary antibiotics. Specific factors underlying decisions about blood culture use and overuse are unknown. Therefore, we aimed to identify perceived determinants of blood culture use in the PICU.
Methods:
We conducted semistructured interviews of clinicians (M.D., D.O., R.N., N.P., P.A.) from 6 PICUs who had participated in a quality improvement collaborative about blood culture practices. We developed interview questions by combining elements of the Consolidated Framework for Implementation Research and behavioral economics. We conducted telephone interviews, open-coded the transcripts, and used modified content analysis to determine key themes and mapped themes to elements of Consolidated Framework for Implementation Research and behavioral economics.
Results:
We reached thematic saturation in 24 interviews. Seven core themes emerged across 3 Consolidated Framework for Implementation Research domains: individual characteristics [personal belief in the importance of blood cultures, the perception that blood cultures are a low-risk test]; inner setting [adherence to site-specific usual practices, site-specific overall approach to PICU care (collaborative versus hierarchical), influence of non-PICU clinicians on blood culture decisions]; and outer setting [patient-specific risk factors, sepsis guidelines]. In addition, outcome bias, default bias, and loss aversion emerged as salient behavioral economics concepts.
Conclusions:
Determinants of blood culture use include individual clinician characteristics, inner setting, and outer setting, as well as default bias, outcome bias, and loss aversion. These determinants will now inform the development of candidate strategies to optimize culture practices.
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