Reducing Unnecessary Pediatric Tracheal Aspirate Cultures Using a Quality Improvement Approach

BACKGROUND Pediatric patients managed on mechanical ventilation via artificial airway are at risk for respiratory infections (Wilson et al., 2014). Although there is a gap in the literature regarding the diagnostic benefit of frequent repeat respiratory cultures, routine infection prevention (IP) surveillance shows this is a common practice in the Medical Intensive Care Unit (MICU). This quality improvement (QI) initiative describes the impact of implementing a standardized process for using tracheal aspirate culture for detection of respiratory infections. METHODS Utilizing Plan-Do-Study-Act (PDSA) cycles, MICU patients requiring mechanical ventilation via an artificial airway (endotracheal or tracheostomy tube) from 11/1/17 to 10/31/18 were included. Tracheal aspirate sampling was standardized and a guideline was created in collaboration with IP, Antimicrobial Stewardship, and the Infectious Diseases Diagnostic Laboratory. The primary outcome measures were tracheal aspirate culture rate per 100 ventilator days and the number of repeat tracheal aspirate cultures within 3?days. The process measure was compliance with the indications for obtaining a culture. RESULTS During the study period, 251 tracheal aspirate cultures?were collected; 78% were obtained via tracheostomy tube. Within 3 months, a 20% reduction in the tracheal aspirate culture rate was achieved and maintained. The culture rate ranged from 3.8 to 13.3 per 100 ventilator days (mean 7.4). The tracheostomy culture rate had a larger decrease over time compared to the ETT culture rate. Repeat cultures within 3?days decreased to from 4.4 to 0.7 per 100 ventilator days. Compliance with the guideline increased from 27% to 73% over the study period. Ninety-one percent of the positive cultures were obtained from tracheostomies. CONCLUSIONS Implementing a guideline to standardize collection of?tracheal aspirate cultures in ventilated patients with an artificial?airway reduces the culture rate and repeat sampling, especially in patients with tracheostomy. A multidisciplinary approach applied over several PDSA cycles is required to change practice.