A Novel Comprehensive Algorithm for Evaluation of PICU Patients With New Fever or Instability*

Abstract

OBJECTIVES: There is variation in microbiology testing among PICU patients with fever offering opportunities to reduce avoidable testing and treatment. Our objective is to describe the development and assess the impact of a novel comprehensive testing algorithm to support judicious testing practices and expanded diagnostic differentials for PICU patients with new fever or instability. DESIGN: A mixed-methods quality improvement study. SETTING: Single-center academic PICU and pediatric cardiac ICU. SUBJECTS: Admitted PICU patients and physicians. INTERVENTIONS: A multidisciplinary team developed a clinical decision-support algorithm. MEASUREMENTS AND MAIN RESULTS: We evaluated blood, endotracheal, and urine cultures, urinalyses, and broad-spectrum antibiotic use per 1,000 ICU patient-days using statistical process control charts and incident rate ratios (IRRs) and assessed clinical outcomes 24 months pre- and 18 months postimplementation. We surveyed physicians weekly for 12 months postimplementation. Blood cultures declined by 17% (IRR, 0.83; 95% CI, 0.77–0.89), endotracheal cultures by 26% (IRR, 0.74; 95% CI, 0.63–0.86), and urine cultures by 36% (IRR, 0.64; 95% CI, 0.56–0.73). There was an anticipated rise in urinalysis testing by 23% (IRR, 1.23; 95% CI, 1.14–1.33). Despite higher acuity and fewer brief hospitalizations, mortality, hospital, and PICU readmissions were stable, and PICU length of stay declined. Of the 108 physician surveys, 46 replied (43%), and 39 (85%) recently used the algorithm; 0 reported patient safety concerns, two (4%) provided constructive feedback, and 28 (61%) reported the algorithm improved patient care. CONCLUSIONS: A comprehensive fever algorithm was associated with reductions in blood, endotracheal, and urine cultures and anticipated increase in urinalyses. We detected no patient harm, and physicians reported improved patient care.