Increasing the Reliability of Fully Automated Surveillance for Central Line–Associated Bloodstream Infections

OBJECTIVETo increase reliability of the algorithm used in our fully automated electronic surveillance system by adding rules to better identify bloodstream infections secondary to other hospital-acquired infections.METHODSIntensive care unit (ICU) patients with positive blood cultures were reviewed. Central line–associated bloodstream infection (CLABSI) determinations were based on 2 sources: routine surveillance by infection preventionists, and fully automated surveillance. Discrepancies between the 2 sources were evaluated to determine root causes. Secondary infection sites were identified in most discrepant cases. New rules to identify secondary sites were added to the algorithm and applied to this ICU population and a non-ICU population. Sensitivity, specificity, predictive values, and kappa were calculated for the new models.RESULTSOf 643 positive ICU blood cultures reviewed, 68 (10.6%) were identified as central line–associated bloodstream infections by fully automated electronic surveillance, whereas 38 (5.9%) were confirmed by routine surveillance. New rules were tested to identify organisms as central line–associated bloodstream infections if they did not meet one, or a combination of, the following: (I) matching organisms (by genus and species) cultured from any other site; (II) any organisms cultured from sterile site; (III) any organisms cultured from skin/wound; (IV) any organisms cultured from respiratory tract. The best-fit model included new rules I and II when applied to positive blood cultures in an ICU population. However, they didn’t improve performance of the algorithm when applied to positive blood cultures in a non-ICU population.CONCLUSIONElectronic surveillance system algorithms may need adjustment for specific populations.Infect. Control Hosp. Epidemiol. 2015;36(12):1396–1400

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Electronic Surveillance for Healthcare-Associated Central Line—Associated Bloodstream Infections Outside the Intensive Care Unit

Infection Control and Hospital Epidemiology ◽

10.1086/662181 ◽

2011 ◽

Vol 32 (11) ◽

pp. 1086-1090 ◽

Cited By ~ 35

Author(s):

Keith F. Woeltje ◽

Kathleen M. McMullen ◽

Anne M. Butler ◽

Ashleigh J. Goris ◽

Joshua A. Doherty

Keyword(s):

Intensive Care ◽

Blood Culture ◽

Predictive Value ◽

Chart Review ◽

Positive Culture ◽

Bloodstream Infections ◽

Central Line ◽

Electronic Surveillance ◽

Predictive Values ◽

Best Fit

Background.Manual surveillance for central line-associated bloodstream infections (CLABSIs) by infection prevention practitioners is time-consuming and often limited to intensive care units (ICUs). An automated surveillance system using existing databases with patient-level variables and microbiology data was investigated.Methods.Patients with a positive blood culture in 4 non-ICU wards at Barnes-Jewish Hospital between July 1, 2005, and December 31, 2006, were evaluated. CLABSI determination for these patients was made via 2 sources; a manual chart review and an automated review from electronically available data. Agreement between these 2 sources was used to develop the best-fit electronic algorithm that used a set of rules to identify a CLABSI. Sensitivity, specificity, predictive values, and Pearson's correlation were calculated for the various rule sets, using manual chart review as the reference standard.Results.During the study period, 391 positive blood cultures from 331 patients were evaluated. Eighty-five (22%) of these were confirmed to be CLABSI by manual chart review. The best-fit model included presence of a catheter, blood culture positive for known pathogen or blood culture with a common skin contaminant confirmed by a second positive culture and the presence of fever, and no positive cultures with the same organism from another sterile site. The best-performing rule set had an overall sensitivity of 95.2%, specificity of 97.5%, positive predictive value of 90%, and negative predictive value of 99.2% compared with intensive manual surveillance.Conclusions.Although CLABSIs were slightly overpredicted by electronic surveillance compared with manual chart review, the method offers the possibility of performing acceptably good surveillance in areas where resources do not allow for traditional manual surveillance.

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Secondary Analysis of an Electronic Surveillance System Combined with Multi-focal Interventions for Early Detection of Sepsis

Applied Clinical Informatics ◽

10.4338/aci-2016-07-ra-0112 ◽

2017 ◽

Vol 26 (01) ◽

pp. 47-66 ◽

Cited By ~ 7

Author(s):

Bonnie Westra ◽

Sean Landman ◽

Pranjul Yadav ◽

Michael Steinbach

Keyword(s):

Early Detection ◽

Surveillance System ◽

Point Of Care ◽

Management Strategies ◽

Secondary Analysis ◽

Length Of Hospital Stay ◽

Separate Analysis ◽

Electronic Surveillance ◽

Predictive Values ◽

Sensitivity Specificity

SummarySummary: To conduct an independent secondary analysis of a multi-focal intervention for early detection of sepsis that included implementation of change management strategies, electronic surveil-lance for sepsis, and evidence based point of care alerting using the POC AdvisorTM application. Methods: Propensity score matching was used to select subsets of the cohorts with balanced covariates. Bootstrapping was performed to build distributions of the measured difference in rates/ means. The effect of the sepsis intervention was evaluated for all patients, and High and Low Risk subgroups for illness severity. A separate analysis was performed patients on the intervention and non-intervention units (without the electronic surveillance). Sensitivity, specificity, and the positive predictive values were calculated to evaluate the accuracy of the alerting system for detecting sepsis or severe sepsis/ septic shock.Results: There was positive effect on the intervention units with sepsis electronic surveillance with an adjusted mortality rate of –6.6%. Mortality rates for non-intervention units also improved, but at a lower rate of –2.9%. Additional outcomes improved for patients on both intervention and non-intervention units for home discharge (7.5% vs 1.1%), total length of hospital stay (-0.9% vs –0.3%), and 30 day readmissions (-6.6% vs –1.6%). Patients on the intervention units showed better outcomes compared with non-intervention unit patients, and even more so for High Risk patients. The sensitivity was 95.2%, specificity of 82.0% and PPV of 50.6% for the electronic surveillance alerts. Conclusion: There was improvement over time across the hospital for patients on the intervention and non-intervention units with more improvement for sicker patients. Patients on intervention units with electronic surveillance have better outcomes; however, due to differences in exclusion criteria and types of units, further study is needed to draw a direct relationship between the electronic surveillance system and outcomes.

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2143. Attempting to Add Clarity to “Indeterminates” on a Deployed Rapid Diagnostic with Antimicrobial Stewardship Program (ASP) Intervention

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1823 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S726-S726

Author(s):

Heather L Cox ◽

April E Attai ◽

Allison M Stilwell ◽

Kasi B Vegesana ◽

Frankie Brewster ◽

...

Keyword(s):

Pasteurella Multocida ◽

Diagnostic Testing ◽

Bloodstream Infections ◽

Empiric Therapy ◽

Central Line ◽

Blood Cultures ◽

University Hospital ◽

Salmonella Spp ◽

Gram Negative ◽

Stewardship Program

Abstract Background Rapid diagnostic testing paired with ASP intervention optimizes therapy and improves outcomes but few data guide ASP response in the absence of organism identification (ID). We describe the microbiology for organisms unidentified by Accelerate Pheno™ Gram-negative platform (AXDX) in order to inform ASP-provider team communication (PTC). Methods Consecutive, non-duplicate inpatient blood cultures with Gram-negative bacilli (GNB) following AXDX implementation at a single university hospital between April 2018 and March 2019 were included. Standard of care (SOC) ID and susceptibility followed AXDX. Clinical Microbiology emailed AXDX results to the ASP in real time; results were released into the EMR paired with telephone PTC or withheld after ASP review. Bloodstream Infections (BSIs) and patient outcomes for organisms labeled no/indeterminate ID by the AXDX were characterized. Results AXDX was performed on 351 blood cultures. Among 52 (15%) labeled no/indeterminate ID, SOC methods revealed: Enterobacteriaceae (40%; 9 monomicrobial with AXDX targets), anaerobes (21%), non-lactose fermenters (NLFs) other than Pseudomonas aeruginosa (21%), and fastidious GNB (10%). Frequent organisms without AXDX targets included: Raoultella planticola (4); Bacteroides fragilis, Cupriavidus spp., Haemophilus spp., Prevotella spp., Providencia spp., non-aeruginosa Pseudomonas spp., Salmonella spp. (3 each); Pasteurella multocida, Stenotrophomonas maltophilia (2 each). BSI sources were most commonly intra-abdominal (21%), central line-associated (17%), or unknown (17%). CLABSIs were associated with immune suppression and/or substance abuse in all but 1 case. BSIs without active empiric therapy included: NDM-producing Providencia stuartii SSSI; OXA-48-producing R. planticola intraabdominal infection (IAI); Pandoraea spp. CLABSI after liver transplant; enteric fever; B. fragilis, Leptotrichia wadei, and S. maltophilia, each of unknown source. In-hospital mortality occurred in 4 of these cases. Conclusion When AXDX yields no/indeterminate ID, ASP chart review for possible anaerobic/IAI, unique environmental exposures, and travel history may assist in guiding empiric therapy. GNB with AXDX targets are not excluded. Disclosures All authors: No reported disclosures.

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The Efficacy of Blood Culture in Postoperative Patients

The American Surgeon ◽

10.1177/000313481007601035 ◽

2010 ◽

Vol 76 (10) ◽

pp. 1172-1175 ◽

Cited By ~ 1

Author(s):

Jenny J. Lee ◽

David R. Martin

Keyword(s):

National Research Council ◽

Bloodstream Infections ◽

Central Line ◽

Blood Cultures ◽

Blood Cell Count ◽

Blood Draw ◽

Suspected Sepsis ◽

Wound Classification ◽

Preoperative Antibiotics ◽

Rule Out

Blood cultures are often obtained in postoperative patients to rule out bloodstream infections. Our study objectives were to determine the efficacy of blood cultures in postoperative patients with suspected sepsis and to determine variables predisposing patients to positive cultures. This was a retrospective study including patients with blood cultures drawn from January to March 2009 at our institution. We recorded demographics, presence of fever (temperature 101.5°F or higher), elevated white blood cell count (12,000/μL or greater), central line, diabetes, intensive care unit admission, postoperative day of blood draw, National Research Council surgical wound classification, and pre- or postoperative antibiotics. Blood cultures were drawn from 150 patients undergoing surgery within 30 days prior. Sixteen had positive cultures and nine were true-positives (6.3%). There was no statistical difference ( P > 0.05) between patients with positive and negative cultures except that those with negative cultures were more likely to have received preoperative antibiotics ( P = 0.0186). Blood cultures are invasive, expensive tests with low yield. We recommend that blood cultures be drawn in patients not receiving preoperative antibiotics who have undergone surgery more than 4 days before culture.

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Development and Evaluation of a Fully Automated Surveillance System for Influenza-Associated Hospitalization at a Multihospital Health System in Northeast Ohio

Applied Clinical Informatics ◽

10.1055/s-0040-1715651 ◽

2020 ◽

Vol 11 (04) ◽

pp. 564-569

Author(s):

Patrick C. Burke ◽

Rachel Benish Shirley ◽

Jacob Raciniewski ◽

James F. Simon ◽

Robert Wyllie ◽

...

Keyword(s):

Health System ◽

Surveillance System ◽

Cost Savings ◽

Automated System ◽

Surveillance Systems ◽

Predictive Values ◽

Visualization Software ◽

Independent Information ◽

Influenza Activity ◽

Automated Surveillance

Abstract Background Performing high-quality surveillance for influenza-associated hospitalization (IAH) is challenging, time-consuming, and essential. Objectives Our objectives were to develop a fully automated surveillance system for laboratory-confirmed IAH at our multihospital health system, to evaluate the performance of the automated system during the 2018 to 2019 influenza season at eight hospitals by comparing its sensitivity and positive predictive value to that of manual surveillance, and to estimate the time and cost savings associated with reliance on the automated surveillance system. Methods Infection preventionists (IPs) perform manual surveillance for IAH by reviewing laboratory records and making a determination about each result. For automated surveillance, we programmed a query against our Enterprise Data Vault (EDV) for cases of IAH. The EDV query was established as a dynamic data source to feed our data visualization software, automatically updating every 24 hours.To establish a gold standard of cases of IAH against which to evaluate the performance of manual and automated surveillance systems, we generated a master list of possible IAH by querying four independent information systems. We reviewed medical records and adjudicated whether each possible case represented a true case of IAH. Results We found 844 true cases of IAH, 577 (68.4%) of which were detected by the manual system and 774 (91.7%) of which were detected by the automated system. The positive predictive values of the manual and automated systems were 89.3 and 88.3%, respectively.Relying on the automated surveillance system for IAH resulted in an average recoup of 82 minutes per day for each IP and an estimated system-wide payroll redirection of $32,880 over the four heaviest weeks of influenza activity. Conclusion Surveillance for IAH can be entirely automated at multihospital health systems, saving time, and money while improving case detection.

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81. Reducing Unnecessary Blood Cultures Through Diagnostic Stewardship

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.283 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S157-S157

Author(s):

Sujeet Govindan ◽

Luke Strnad

Keyword(s):

Blood Culture ◽

Positive Blood Culture ◽

Cost Savings ◽

Bloodstream Infections ◽

Central Line ◽

Blood Cultures ◽

Coagulase Negative Staphylococci ◽

Candida Sp ◽

Daily Frequency ◽

Oregon Health

Abstract Background At our institution, we learned the frequency of blood cultures was sometimes being changed from “Once” to “Daily” without a defined number of days. We hypothesized this led to unnecessary blood cultures being performed. Methods Over a 3 month period from 12/6/2019-3/6/2020, we retrospectively evaluated the charts of patients who had a blood culture frequency changed to “Daily”. We evaluated if there was an initial positive blood culture within 48 hours of the “Daily” order being placed and the number of positive, negative, or “contaminant” sets of cultures drawn with the order. Contaminant blood cultures were defined as a contaminant species, present only once in the repeat cultures, and not present in initial positive cultures. Results 95 unique orders were placed with 406 sets of cultures drawn from 89 adults. ~20% of the time (17 orders) the order was placed without an initial positive blood culture. This led to 62 sets of cultures being drawn, only 1 of which came back positive. 78/95 orders had an initial positive blood culture. The most common initial organisms were Staphylococcus aureus (SA) (38), Candida sp (10), Enterobacterales sp (10), and coagulase negative staphylococci (7). 43/78 (55%) orders with an initial positive set had positive repeat cultures. SA (26) and Candida sp (8) were most common to have positive repeats. Central line associated bloodstream infections (CLABSI) were found in 5 of the orders and contaminant species were found in 4 of the orders. 54% of the patients who had a “Daily” order placed did not have positive repeat cultures. The majority of the cultures were drawn from Surgical (40 orders) and Medical (35 orders) services. Assuming that SA and Candida sp require 48 hours of negative blood cultures to document clearance and other species require 24 hours, it was estimated that 51% of the cultures drawn using the "Daily" frequency were unnecessary. Cost savings over a year of removing the "Daily" frequency would be ~&14,000. Data from "Daily" blood culture orders drawn at Oregon Health & Science University from 12/6/2019-3/6/2020 Conclusion Unnecessary blood cultures are drawn when the frequency of blood cultures is changed to "Daily". Repeat blood cultures had the greatest utility in bloodstream infections due to SA or Candida sp, and with CLABSI where the line is still in place. These results led to a stewardship intervention to change blood culture ordering at our institution. Disclosures All Authors: No reported disclosures

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Central Line–Associated Bloodstream Infections in Adult Hematology Patients with Febrile Neutropenia An Evaluation of Surveillance Definitions Using Differential Time to Blood Culture Positivity

Infection Control and Hospital Epidemiology ◽

10.1086/668431 ◽

2013 ◽

Vol 34 (1) ◽

pp. 89-92 ◽

Cited By ~ 27

Author(s):

Joshua T. Freeman ◽

Anna Elinder-Camburn ◽

Catherine McClymont ◽

Deverick J. Anderson ◽

Mary Bilkey ◽

...

Keyword(s):

Blood Culture ◽

Febrile Neutropenia ◽

Positive Predictive Value ◽

Bloodstream Infections ◽

Central Line ◽

Blood Cultures ◽

National Healthcare ◽

Culture Positivity ◽

National Healthcare Safety Network ◽

Blood Culture Positivity

We used differential time to positivity between central and peripheral blood cultures to evaluate the positive predictive value (PPV) of the National Healthcare Safety Network central line–associated bloodstream infection (CLABSI) surveillance definition among hematology patients with febrile neutropenia. The PPV was 27.7%, which suggests that, when the definition is applied to this population, CLABSI rates will be substantially overestimated.

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