Checklist cuts blood tests for kids in the hospital

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A checklist appears to halve the number of potentially unnecessary blood cultures in critically ill children, preventing false positives that can lead to unneeded treatment and longer hospital stays.

Using the checklist to decide when not to draw blood didn’t undermine doctors’ ability to find and treat life-threatening blood infections, a two-year study found.

The researchers, who report their findings in JAMA Pediatrics, says that many doctors in pediatric intensive care units routinely order blood cultures for children who run a fever. They think of the test as harmless insurance against sepsis, a potentially life-threatening infection complication, the researchers say.

“Our work focuses on the prevention of infections, in this case blood infections, in hospitalized patients,” says coauthor Aaron Milstone, associate professor of pediatrics at Johns Hopkins University and associate epidemiologist at Johns Hopkins Hospital. “We have found that blood cultures are a really challenging test to go after, because the perceived risks are pretty low, which leads to overuse.”

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In general, 5 to 15 percent of blood cultures ordered because of a patient’s fever test positive, but as many as half of those are false positives. Beyond the stress and pain that sometimes daily blood draws cause young ICU patients, false positives lead to treatment that triggers longer hospitals stays. That creates added potential for hospital-contracted infections and increases risk for disease resistance due to overuse of antibiotics.

“…clinicians are uneasy when asked to do less, especially when facing an acute condition like sepsis.”

“It is common for children in the ICU to have a fever and get a blood culture. Sometimes, the culture is positive, but before the clinician can order treatment, the child clears the fever on his or her own,” says Charlotte Woods-Hill, attending physician at the Children’s Hospital of Philadelphia. “The clinicians are left with the decision of what to do with that information, so to be safe, they treat them. We have had a number of kids who are ready to go home and the next thing you know, they are spending two more weeks in the hospital getting IV antibiotics because a blood culture was positive.”

Sepsis is only one item on a long list of conditions that can cause a fever in a hospitalized child. Withdrawal from narcotics, adverse reactions to medications, or being too physically hot for too long can all cause a fever.

Drawing on clinical experience and data, a team of nurses, vascular access specialists, and physicians developed a checklist protocol and a decision-making flow chart for the study. Factors such as unexplained tachycardia and immune deficiency were among conditions that could warrant a blood culture. If a patient is being weaned from painkillers or has had recent negative blood cultures, drawing blood may not be necessary.

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The researchers compared patient length of stay, mortality, readmission, and episodes of suspected septic shock at the Johns Hopkins Children’s Center ICU before and after the checklist was introduced. In the year before, there were 2,204 patient visits to the ICU and 1,807 blood cultures drawn. After, that number decreased to 984 blood cultures drawn for 2,356 patient visits.

There was no statistical difference in occurrence of septic shock, mortality, or readmission, which, according to Milstone, means that patients experienced no increased risk of a missed sepsis diagnosis.

Assessing other potential causes of each patient’s fever using the tools, clinicians were able to appropriately treat patients based on their individual risk, Milstone says.

“While our study was promising, there are limitations,” says James Fackler, associate professor of anesthesiology and critical care medicine at Johns Hopkins. “Primarily, clinicians are uneasy when asked to do less, especially when facing an acute condition like sepsis. We hope that the tools developed by our team will ease these concerns by offering guidelines for a clear and effective path to diagnosis.”

The checklist is now being tried at Johns Hopkins All Children’s Hospital in Florida and in the pediatric ICU at the University of Virginia.

The MITRE Corp. contributed partial funding to the work.

Source: Johns Hopkins University