Division of Critical Care Medicine and Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
Infect Control Hosp Epidemiol. 2023 Feb;44(2):191-199. doi: 10.1017/ice.2022.299. Epub 2023 Jan 3.
To conduct a process evaluation of a respiratory culture diagnostic stewardship intervention.
Mixed-methods study.
Tertiary-care pediatric intensive care unit (PICU).
Critical care, infectious diseases, and pulmonary attending physicians and fellows; PICU nurse practitioners and hospitalist physicians; pediatric residents; and PICU nurses and respiratory therapists.
This mixed-methods study was conducted concurrently with a diagnostic stewardship intervention to reduce the inappropriate collection of respiratory cultures in mechanically ventilated children. We quantified baseline respiratory culture utilization and indications for ordering using quantitative methods. Semistructured interviews informed by these data and the Consolidated Framework for Implementation Research (CFIR) were then performed, recorded, transcribed, and coded to identify salient themes. Finally, themes identified in these interviews were used to create a cross-sectional survey.
The number of cultures collected per day of service varied between attending physicians (range, 2.2-27 cultures per 100 days). In total, 14 interviews were performed, and 87 clinicians completed the survey (response rate, 47%) and 77 nurses or respiratory therapists completed the survey (response rate, 17%). Clinicians varied in their stated practices regarding culture ordering, and these differences both clustered by specialty and were associated with perceived utility of the respiratory culture. Furthermore, group "default" practices, fear, and hierarchy were drivers of culture orders. Barriers to standardization included fear of a missed diagnosis and tension between practice standardization and individual decision making.
We identified significant variation in utilization and perceptions of respiratory cultures as well as several key barriers to implementation of this diagnostic test stewardship intervention.
对一项呼吸培养物诊断管理干预措施进行过程评估。
混合方法研究。
三级儿童重症监护病房（PICU）。
重症监护、传染病和肺病主治医生和研究员；PICU 护士从业者和医院医师；儿科住院医师；以及 PICU 护士和呼吸治疗师。
本混合方法研究与诊断管理干预措施同时进行，以减少机械通气儿童中不适当的呼吸培养物采集。我们使用定量方法量化了基线呼吸培养物利用情况和下订单的指征。然后，根据这些数据和实施研究综合框架（CFIR）进行半结构化访谈，记录、转录和编码以确定突出主题。最后，使用这些访谈中确定的主题创建了一项横断面调查。
每位主治医生每天采集的培养物数量有所不同（范围为每 100 天 2.2-27 个培养物）。共进行了 14 次访谈，87 名临床医生完成了调查（应答率为 47%），77 名护士或呼吸治疗师完成了调查（应答率为 17%）。临床医生在培养物订购方面的做法存在差异，这些差异不仅按专业聚类，而且与对呼吸培养物的感知效用相关。此外，群体“默认”实践、恐惧和等级制度是培养物订购的驱动因素。标准化的障碍包括担心漏诊和实践标准化与个人决策之间的紧张关系。
我们发现，在呼吸培养物的利用和认知方面存在显著差异，并且在实施该诊断性测试管理干预措施方面存在几个关键障碍。
