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. 2022 Mar 30;7(2):e545.
doi: 10.1097/pq9.0000000000000545. eCollection 2022 Mar-Apr.

Trainee-led Engagement of the Care Team Improves Application of an Institutional Blood Culture Clinical Decision Algorithm to Pediatric Oncology Inpatients: A Single-institution Quality Improvement Project

Kathryn M Lemberg  1 , Danielle W Koontz  2 , David J Young  1 , P Galen DiDomizio  2 , Anne King  2 , Allen R Chen  1 , Christopher J Gamper  1 , Elizabeth Colantuoni  3 , Aaron M Milstone  2 , Stacy L Cooper  1
Affiliations

Trainee-led Engagement of the Care Team Improves Application of an Institutional Blood Culture Clinical Decision Algorithm to Pediatric Oncology Inpatients: A Single-institution Quality Improvement Project

Kathryn M Lemberg et al. Pediatr Qual Saf. .

Abstract

Meaningful engagement in quality improvement (QI) projects by trainees is often challenging. A fellow-led QI project aimed to improve adherence to a blood culture clinical decision algorithm and reduce unnecessary cultures in pediatric oncology inpatients.

Methods: We visualized preintervention rates of blood cultures drawn on pediatric oncology inpatients using a control chart. Following the introduction of the algorithm to our division, an Ishikawa fishbone diagram of cause-and-effect identified two areas for improvement: prescriber education on the algorithm and targeted feedback on its use. We developed two interventions to support algorithm awareness and use: (1) bundled educational interventions and (2) targeted chart review and feedback. Fellows reviewed >750 blood culture episodes and adjudicated each as "adherent" or "nonadherent" to the algorithm. In addition, fellows provided direct feedback to prescribers regarding nonadherent episodes and discussed strategies for algorithm adherence.

Results: Blood culture rates in preintervention, intervention, and follow-up periods were 33.35, 25.24, and 22.67 cultures/100 patient-days, respectively. The proportion of nonadherent culture episodes decreased from 47.14% to 11.11%. The use of the algorithm did not prolong the time to cultures drawn on patients with new fever. Seventy-five percent of fellows provided feedback to inpatient teams on algorithm use. Following this project, trainees reported feeling more qualified to apply QI principles to patient care.

Conclusions: Implementation of a clinical decision algorithm reduced the rate of cultures drawn on pediatric oncology inpatients. Fellow-led education of the care team decreased the proportion of nonadherent culture episodes and provided active engagement in QI.

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Figures

Fig. 1.
Fig. 1.
Hospital-wide blood culture decision algorithm as of September 2016.
Fig. 2.
Fig. 2.
Ishikawa cause-and-effect diagram to analyze potential causes of unnecessary blood culture draws. Circled areas represent targets for the QI project.
Fig. 3.
Fig. 3.
Control chart for the number of blood cultures per 100 patient-days displaying cultures from January 2015 to December 2018. Three time periods are preintervention (January 2015–October 2016), intervention (November 2016–July 2018), and follow-up (July–December 2018). Interventions are highlighted in the figure (^ = algorithm introduction, ^^ = educational intervention, ^^^ = feedback intervention).
Fig. 4.
Fig. 4.
Results of trainee led chart review on blood cultures during QI project. A, Proportion nonadherent culture episodes identified from sampled cultures grouped by year. B, Time from new fever detected to blood cultures drawn on pediatric oncology inpatients comparing August–November 2016 and August–November 2017 time periods.
See this image and copyright information in PMC

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