A Survey of PICU Clinician Practices and Perceptions regarding Respiratory Cultures in the Evaluation of Ventilator-Associated Infections in the BrighT STAR Collaborative

Abstract

Objectives: To characterize respiratory culture practices for mechanically ventilated patients, and to identify drivers of culture use and potential barriers to changing practices across PICUs. Design: Cross-sectional survey conducted May 2021–January 2022. Setting: Sixteen academic pediatric hospitals across the United States participating in the BrighT STAR Collaborative. Subjects: Pediatric critical care medicine physicians, advanced practice providers, respiratory therapists, and nurses. Interventions: None. Measurements and Main Results: We summarized the proportion of positive responses for each question within a hospital and calculated the median proportion and IQR across hospitals. We correlated responses with culture rates and compared responses by role. Sixteen invited institutions participated (100%). Five hundred sixty-eight of 1,301 (44%) e-mailed individuals completed the survey (median hospital response rate 60%). Saline lavage was common, but no PICUs had a standardized approach. There was the highest variability in perceived likelihood (median, IQR) to obtain cultures for isolated fever (49%, 38–61%), isolated laboratory changes (49%, 38–57%), fever and laboratory changes without respiratory symptoms (68%, 54–79%), isolated change in secretion characteristics (67%, 54–78%), and isolated increased secretions (55%, 40–65%). Respiratory cultures were likely to be obtained as a “pan culture” (75%, 70–86%). There was a significant correlation between higher culture rates and likelihood to obtain cultures for isolated fever, persistent fever, isolated hypotension, fever, and laboratory changes without respiratory symptoms, and “pan cultures.” Respondents across hospitals would find clinical decision support (CDS) helpful (79%) and thought that CDS would help align ICU and/or consulting teams (82%). Anticipated barriers to change included reluctance to change (70%), opinion of consultants (64%), and concern for missing a diagnosis of ventilator-associated infections (62%). Conclusions: Respiratory culture collection and ordering practices were inconsistent, revealing opportunities for diagnostic stewardship. CDS would be generally well received; however, anticipated conceptual and psychologic barriers to change must be considered.

Breaking Boundaries in Pneumonia Diagnostics: Transitioning from Tradition to Molecular Frontiers with Multiplex PCR

“…Diagnostic decision-making and associated clinical behavior (e.g., antibiotic prescribing) are deeply rooted in behavioral determinants [57]. The decision to order a test is associated with the clinician's baseline understanding of the pre-test probability of the disease of interest, and increasingly, with severe diseases such as VAP, the fear of missing something important [58][59][60][61].…”