BrighT STAR: Blood 

In January 2014, a multidisciplinary team at Johns Hopkins Children’s Center developed and implemented a clinical practice strategy to guide clinicians in the use of blood cultures when evaluating patients with signs and symptoms of sepsis (https://pubmed.ncbi.nlm.nih.gov/27942705/). Between 2016 and 2018, the program was first extended to Johns Hopkins All Children’s Hospital and University of Virginia Children’s Hospital and then expanded to 14 BrighT STAR collaborative hospitals with funding from the Agency for Healthcare Research and Quality.

Each BrighT STAR hospital developed and implemented a local QI program to improve blood culture use within their ICU. Site Implementation, guided by the BrighT STAR coordinating center, was tailored to each site’s individual needs and readiness. Findings from this program demonstrated 33% overall reduction in blood culture use across the collaborative. In addition, there was an 13% reduction in broad spectrum antibiotic use and a 36% reduction in central line-associated bloodstream infection (CLABSI) rates.

These findings suggest that multidisciplinary efforts to standardize blood culture collection and avoid unnecessary testing in the PICU can be done successfully and safely in diverse settings, and that reducing blood culture use can, in turn, reduce broad-spectrum antibiotic use.

Consensus Recommendations

A multi-disciplinary, multi-institutional expert panel came together on October 25, 2019 for the first BrighT STAR Consensus Meeting. The panel of 29 subject matter experts worked to establish consensus recommendations for safe blood culture reduction in PICU patients. (https://pubmed.ncbi.nlm.nih.gov/33899804/)

BrighT STAR: Respiratory

In 2018, a multidisciplinary team at Johns Hopkins Children’s Center developed and implemented a clinical practice strategy to guide clinicians in the use of respiratory cultures when evaluating mechanically ventilated patients for respiratory infections.

In 2021 with additional funding from the Agency for Healthcare Research and Quality, this respiratory culture project expanded across the BrighT STAR collaborative, using a similar multicenter QI framework. Guided by a Translating Evidence into Practice model, each collaborative site developed and implemented QI initiatives to improve respiratory culture practices. Participating sites collected aggregate data on respiratory culture rates and clinical outcomes.

This collaborative work will be the foundation to develop evidence-based toolkits other hospitals can use to improve respiratory culture practices in the future. Analysis is under way to determine the association of this multicenter QI program on rates of respiratory culture use, antibiotic use, and safety among BrighT STAR sites.

Consensus Recommendations

On November 9, 2023 a second BrighT STAR Consensus Meeting was held to establish consensus recommendations for safe respiratory culture reduction in PICU patients. The expert panel of 37 multi-disciplinary, multi-institutional panel met for 2 days.  An algorithm was developed and 44 consensus statements were supported; a manuscript detailing the statements is in process with an expected publication coming in 2024.

Fever

Building off the success of the prior blood and respiratory BrighT STAR initiatives, a multidisciplinary team at Johns Hopkins Children’s Center looked to further reduce avoidable testing, decrease practice variability, and promote expanded consideration for etiology of fevers in critically ill children.

Leaning on direct feedback from the clinical staff, the JHCC team worked toward a single streamlined resource addressing the primary clinical scenarios that triggered blood, endotracheal and urine culture testing, leading to the development of a fever algorithm. The fever algorithm was implemented on July 1, 2020. The algorithm was associated with 17% decline in blood culture, 26% decline in endotracheal cultures, and 36% decline in urine cultures. There was no patient harm and physicians reported improved patient care. (https://pubmed.ncbi.nlm.nih.gov/37125808/)

BrighT STAR: LIBRA

Expected to launch in 2024, BrighT STAR: LIBRA is a study led by BrighT STAR steering committee member Dr. Charlotte Woods-Hill and funded by NHLBI. BrighT STAR: LIBRA is a randomized, single-blind interventional hybrid pilot study exploring the impact of different strategies for blood culture reduction in 8 new PICUs. The study uses implementation and behavioral science to study and improve blood culture practices and will use mixed methods to evaluate both clinical and implementation outcomes over 12-months.

The sites were enrolled in 2023 and are anticipated to kick off their projects in early 2024. LIBRA will provide critical data on how to most effectively change blood culture practices in the pediatric critical care environment, leveraging insights about clinician decision making and exploring how to target drivers of overuse.