Woods-Hill Charlotte Z, Nelson Maria N, Eriksen Whitney, Rendle Katharine A, Beidas Rinad S, Bonafide Christopher P, Brajcich Michelle R, Milstone Aaron M, Shea Judy A
Division of Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa.
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia Pa.
Pediatr Qual Saf. 2023 Apr 10;8(2):e647. doi: 10.1097/pq9.0000000000000647. eCollection 2023 Mar-Apr.
Blood cultures are fundamental in diagnosing and treating sepsis in the pediatric intensive care unit (PICU), but practices vary widely. Overuse can lead to false positive results and unnecessary antibiotics. Specific factors underlying decisions about blood culture use and overuse are unknown. Therefore, we aimed to identify perceived determinants of blood culture use in the PICU.
We conducted semistructured interviews of clinicians (M.D., D.O., R.N., N.P., P.A.) from 6 PICUs who had participated in a quality improvement collaborative about blood culture practices. We developed interview questions by combining elements of the Consolidated Framework for Implementation Research and behavioral economics. We conducted telephone interviews, open-coded the transcripts, and used modified content analysis to determine key themes and mapped themes to elements of Consolidated Framework for Implementation Research and behavioral economics.
We reached thematic saturation in 24 interviews. Seven core themes emerged across 3 Consolidated Framework for Implementation Research domains: individual characteristics [personal belief in the importance of blood cultures, the perception that blood cultures are a low-risk test]; inner setting [adherence to site-specific usual practices, site-specific overall approach to PICU care (collaborative versus hierarchical), influence of non-PICU clinicians on blood culture decisions]; and outer setting [patient-specific risk factors, sepsis guidelines]. In addition, outcome bias, default bias, and loss aversion emerged as salient behavioral economics concepts.
Determinants of blood culture use include individual clinician characteristics, inner setting, and outer setting, as well as default bias, outcome bias, and loss aversion. These determinants will now inform the development of candidate strategies to optimize culture practices.
血培养在儿科重症监护病房（PICU）中对脓毒症的诊断和治疗至关重要，但操作方法差异很大。过度使用会导致假阳性结果和不必要的抗生素使用。关于血培养使用和过度使用决策的具体因素尚不清楚。因此，我们旨在确定PICU中血培养使用的感知决定因素。
我们对来自6个PICU的临床医生（医学博士、医学博士、注册护士、执业护士、医师助理）进行了半结构化访谈，这些医生参与了一项关于血培养操作的质量改进合作项目。我们通过结合实施研究综合框架和行为经济学的要素来制定访谈问题。我们进行了电话访谈，对访谈记录进行开放编码，并使用改进的内容分析来确定关键主题，并将主题映射到实施研究综合框架和行为经济学的要素上。
我们在24次访谈中达到了主题饱和。在实施研究综合框架的3个领域中出现了7个核心主题：个体特征[对血培养重要性的个人信念，认为血培养是低风险检查的观念]；内部环境[遵守特定地点的常规做法，特定地点的PICU护理总体方法（协作与分层），非PICU临床医生对血培养决策的影响]；以及外部环境[患者特定的风险因素，脓毒症指南]。此外，结果偏差、默认偏差和损失厌恶作为突出的行为经济学概念出现。
血培养使用的决定因素包括个体临床医生特征、内部环境和外部环境，以及默认偏差、结果偏差和损失厌恶。这些决定因素现在将为优化培养操作的候选策略的制定提供信息。
