Decreasing Ordering and Obtaining of Lowvalue Blood Cultures in a Large Community Children's Hospital

ABSTRACT

Blood cultures are often an important part of evaluation of febrile illnesses in children. There exists a plethora of evidence suggesting routinely obtaining blood cultures in certain clinical situations, namely uncomplicated pneumonia (CAP), urinary tract infection (UTI), skin and soft tissue infection (SSTI), and viral illnesses (URI), is low-value and adds little to the management plan, while increasing risk of repeat visits, prolonged hospital stay, prolonged antibiotic course, and other unnecessary testing due to false-positive results.We sought to implement a guideline for obtaining blood cultures in the pediatric emergency department and pediatric hospital medicine floor with the goal of decreasing the obtainment of low-value blood cultures by at least 50% over a 6-month period. Baseline data was collected from July 2019 to June 2020, which included the number of blood cultures obtained in the pediatric ED and floor, result of blood cultures with organism identification (if positive), and associated visit diagnoses, particularly CAP, UTI, SSTI, and URI. An evidencebased guideline identifying patients/diagnoses with indications for obtaining a blood culture in addition to those in which it is considered low-value was created and distributed to the pediatric ED and PHM providers. Data was reviewed in the postimplementation period from July 2020 to December 2020 on a monthly basis. Results were shared with provider groups monthly and individual providers as needed. Balancing measures of re-visit/-admission and admission to a higher level of care was also tracked. A total of 830 blood cultures were obtained during the baseline period, with 230 (27.4%) of those deemed low-value. Following implementation of the guideline, a total of 320 blood cultures were obtained, with 29 (9.1%) of these deemed low-value, a percentage decrease of 67% from the baseline state. Observed balancing measures were unchanged Implementation of a guideline identifying clinical diagnoses in which routine obtainment of blood cultures is low-value led to a sustained decrease in this practice, which may positively impact other clinical variables outlined above. Interpretation of changes in individual diagnosis groups was limited by seasonality as well as COVID-19 pandemic-related decreases in patient volumes from the baseline period. Further work involving targeted order sets for these diagnoses to aid sustainability of change and increased standardization of this and other aspects of care is ongoing.