Evaluation of a Comprehensive Algorithm for PICU Patients With New Fever or Instability: Association of Clinical Decision Support With Testing Practices.

IF 4 2区 医学 Q1 CRITICAL CARE MEDICINE
Pediatric Critical Care Medicine Pub Date : 2024-11-01 Epub Date: 2024-07-19 DOI:10.1097/PCC.0000000000003582
Matthew S Linz, Lauren D Booth, Aaron M Milstone, David C Stockwell, Anna C Sick-Samuels
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引用次数: 0

Abstract

Objectives: Previously, we implemented a comprehensive decision support tool, a "New Fever Algorithm," to support the evaluation of PICU patients with new fever or instability. This tool was associated with a decline in culture rates without safety concerns. We assessed the impact of the algorithm on testing practices by identifying the proportion of cultures pre- vs. post-implementation that were discordant with algorithm guidance and may have been avoidable.

Design: Retrospective evaluation 12 months pre- vs. post-quality improvement intervention.

Setting: Single-center academic PICU and pediatric cardiac ICU.

Subjects: All admitted patients.

Interventions: Implementing the "New Fever Algorithm" in July 2020.

Measurements and main results: Patient medical records were reviewed to categorize indications for all blood, respiratory, and urine cultures. Among cultures obtained for new fever or new clinical instability, we assessed specific testing patterns that were discordant from the algorithm's guidance such as blood cultures obtained without documented concern for sepsis without initiation of antibiotics, respiratory cultures without respiratory symptoms, urine cultures without a urinalysis or pyuria, and pan-cultures (concurrent blood, respiratory, and urine cultures). Among 2827 cultures, 1950 (69%) were obtained for new fever or instability. The proportion of peripheral blood cultures obtained without clinical concern for sepsis declined from 18.6% to 10.4% ( p < 0.0007). Respiratory cultures without respiratory symptoms declined from 41.5% to 27.4% ( p = 0.01). Urine cultures without a urinalysis did not decline (from 27.6% to 25.1%). Urine cultures without pyuria declined from 83.0% to 73.7% ( p = 0.04). Pan-cultures declined from 22.4% to 10.6% ( p < 0.0001). Overall, algorithm-discordant testing declined from 39% to 30% ( p < 0.0001).

Conclusions: The majority of cultures obtained were for new fever or instability and introduction of the "New Fever Algorithm" was associated with reductions in algorithm-discordant testing practices and pan-cultures. There remain opportunities for improvement and additional strategies are warranted to optimize testing practices for in this complex patient population.

评估针对新发热或病情不稳定的 PICU 患者的综合算法:临床决策支持与测试实践的关联。
目的:此前,我们采用了一种综合决策支持工具--"新发热算法",以支持对新发热或病情不稳定的重症监护病房患者进行评估。该工具降低了培养率,但不存在安全问题。我们评估了该算法对检测实践的影响,确定了实施前与实施后与算法指导不一致且可能可以避免的培养比例:设计:质量改进干预前后 12 个月的回顾性评估:研究对象: 所有入院患者:干预措施干预措施:2020 年 7 月实施 "新发热算法":回顾患者病历,对所有血液、呼吸道和尿液培养的适应症进行分类。在因新发热或新的临床不稳定性而进行的培养中,我们评估了与算法指导不一致的特定检测模式,如在无脓毒症记录的情况下进行血液培养,且未开始使用抗生素;在无呼吸道症状的情况下进行呼吸道培养;在无尿检或脓尿的情况下进行尿培养;以及泛培养(同时进行血液、呼吸道和尿液培养)。在 2827 份培养中,1950 份(69%)是因新发热或病情不稳定而获得的。无败血症临床症状的外周血培养比例从 18.6% 降至 10.4%(p < 0.0007)。无呼吸道症状的呼吸道培养从 41.5% 降至 27.4%(p = 0.01)。未进行尿检的尿培养率没有下降(从 27.6% 降至 25.1%)。无脓尿的尿培养率从 83.0% 降至 73.7%(p = 0.04)。泛培养从 22.4% 降至 10.6%(p < 0.0001)。总体而言,算法不一致的检测从 39% 降至 30%(p < 0.0001):大多数培养都是针对新发热或不稳定的情况,而 "新发热算法 "的引入与算法不一致的检测实践和泛培养的减少有关。但仍有改进的余地,需要采取更多策略来优化这一复杂患者群体的检测方法。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Pediatric Critical Care Medicine
Pediatric Critical Care Medicine 医学-危重病医学
CiteScore
7.40
自引率
14.60%
发文量
991
审稿时长
3-8 weeks
期刊介绍: Pediatric Critical Care Medicine is written for the entire critical care team: pediatricians, neonatologists, respiratory therapists, nurses, and others who deal with pediatric patients who are critically ill or injured. International in scope, with editorial board members and contributors from around the world, the Journal includes a full range of scientific content, including clinical articles, scientific investigations, solicited reviews, and abstracts from pediatric critical care meetings. Additionally, the Journal includes abstracts of selected articles published in Chinese, French, Italian, Japanese, Portuguese, and Spanish translations - making news of advances in the field available to pediatric and neonatal intensive care practitioners worldwide.
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