Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children

The Bright STAR Collaborative (BSC), or Blood Culture Improvement Guidelines and Diagnostic
Stewardship for Antibiotic Reduction in Critically Ill Children Collaborative, is a
multicenter quality improvement program to reduce blood culture use within pediatric
intensive care units. Investigators will use data collected by participating sites to
determine whether reliable implementation of clinical practice guidelines for evaluation of
patients with signs and symptoms of sepsis can decrease antibiotic use in pediatric intensive
care units. Investigators will perform a quasi-experimental study to compare outcome data in
pre- and post- periods.

Greater than or equal to 10 institutions will participate in this collaborative.
Participating institutions will develop and implement an evidenced-based clinical
decision-making tool as part of their quality improvement (QI) program in their pediatric
intensive care unit (PICU).

Aim 1: To determine if reliable implementation of clinical practice guidelines for evaluation
of patients with signs and symptoms of sepsis can decrease blood culture use in pediatric
intensive care units.

Aim 2: To determine if reliable implementation of clinical practice guidelines for evaluation
of patients with signs and symptoms of sepsis can decrease central line-associated
bloodstream infections in pediatric intensive care units.

Aim 3. To determine if reliable implementation of clinical practice guidelines for evaluation
of patients with signs and symptoms of sepsis can reduce antibiotic use and Clostridium
difficile infection.

Aim 4. To determine whether a clinical practice guideline for evaluation of patients with
signs and symptoms of sepsis in the PICU has an unintended consequence of patient harm.

Aim 5. To evaluate the implementation of a multi-institutional quality improvement initiative
and identify strategies for successful scale-up and adoption of similar practice guidelines
in other clinical settings.

Variables: blood cultures and central line-associated blood stream infections (CLABSIs),
antibiotic use, , episodes of Clostridium difficile infection mortality, length of stay, ICU
readmission, hospital readmission, episodes of sepsis, and episodes of septic shock.

Analyses: The analytic approach equates to estimating and comparing the blood culture
incidence during the "baseline/pre-implementation" and "post-implementation" periods, using a
generalized linear mixed model (GLMM) assuming a Poisson distribution for the monthly number
of blood cultures with the monthly number of patient days as an offset. Similar analyses will
be conducted to evaluate the incidence of blood cultures drawn from central lines and
CLABSIs. Due to the expected low incidence of CLABSIs, investigators will define time in
quarters, not months, for that outcome. Similar analyses will be performed for secondary
outcomes.

Inclusion Criteria:

- Institutions that plan to develop and implement a quality improvement program to
reduce blood culture use in their ICUs

Exclusion Criteria:

- No exclusion criteria