Supporting Nurse-Driven Diagnostic Stewardship: Nurse Perceptions of Blood Culture Utilization in a Pediatric Intensive Care Unit

Abstract Corresponding Author: Tiffany Mullen MSN, RN, ACCNS-P, CCRN, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, (816) 983-6879, [email protected] No conflicts of interest. Background The Bright STAR collaborative has been a leader in increasing the appropriate use of blood cultures in critically ill children by standardizing practices and safely reducing unnecessary cultures. Their interdisciplinary work aligns with recommendations from The Centers for Disease Control and Prevention Core Elements of Antimicrobial Stewardship Programs which specifically call for the engagement of nurses in diagnostic stewardship efforts. We have previously shown that nurses feel a high degree of confidence obtaining cultures and that specimen collection is a critical function to their role. We recognized an opportunity to improve blood culture practices at our institution and sought to gather the perspectives of nurses prior to beginning additional improvement work. Our objective was to survey direct care pediatric and cardiac intensive care nurses’ perspectives on blood culturing practices, expose barriers, and prioritize improvements to recommended practices. Methods Our Pediatric Intensive Care Unit (PICU) modified the Bright STAR work system assessment (following permission) to deploy a survey to direct care nurses. A clinical nurse specialist, a nurse quality improvement project coordinator, a nurse researcher with stewardship expertise, and an intensivist recruited five direct care PICU nurses to select pertinent questions and refine survey wording. The survey was comprised of 32 questions (6 general blood culture practice, 10 indication for blood culture, 6 barriers to blood culture reduction, 8 barriers to peripheral collection, and 2 preferred intervention tools) scored on a 3-point Likert scale (1 = agreement or likelihood, 2= neither or sometimes, 3 = disagree or unlikely), 1 question ranking frequency of collection, 4 demographic questions, and 3 free text options. We used descriptive statistics to compare survey responses between PICU, cardiac intensive care unit (CICU), and nurses who “flexed” (practiced in both the PICU and CICU). The survey was open for 1 month (February – March 2023) with a single email reminder. Results Forty-six nurses from the PICU, CICU, and those who flexed participated with a response rate of 20%, with variation by unit (n=29; n=12; n=5) respectively. A majority of respondents had been in practice > 8 years (41%) and work primarily days (56%). Most respondents disagreed that providers routinely perform a patient physical assessment immediately prior to ordering blood cultures and agreed that blood culturing practices vary between providers (Table 1). Respondents cited the most common barrier in reducing blood cultures was the concern for missing sepsis. Patients with difficult venous access was the most common barrier for obtaining peripheral blood cultures. Clinical decision tools such as an algorithm to guide selection of blood culture source or a checklist of clinical information for review prior to ordering were identified as potentially useful. Eleven comments were provided discussing blood culture reduction (n=5), challenges with peripheral sticks (n=2), and implementation of interventions (n=4). Conclusion Nurses can and should make significant contributions to diagnostic stewardship, however, there is a paucity of literature detailing approaches that amplify nursing’s voice in improving culturing practices. Our survey results indicate direct care nurses are highly engaged and motivated to participate in the implementation of interventions to refine blood culture practices in the ICU. Based on challenges with peripheral access, input from direct care nurses led to improvement work to increase the availability of ultrasound-trained nurses enhancing timely access to peripheral venipuncture. This nurse-driven initiative will inform future drivers for improvement efforts where opportunities include addressing practice variations and barriers to blood culture standardization through clinical decision tools. Table 1