Choosing Wisely Overnight? Residents’ Approach to Fever

Howard‐Anderson, Jessica; Schwab, Kristin; Quinn, Roswell; Graber, Christopher J.

doi:10.1093/ofid/ofx080

Cited by 4 publications

(4 citation statements)

References 9 publications

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“…19,20 Such practice is even more pronounced in academic centers most cultures are ordered by trainees. 21 A prospective survey of internal medicine residents showed that trainees practice panculturing as a reflexive response to fever knowing that it is not evidence based or cost-effective. 21 Re-evaluation of the role of fever as a prompt for culturing, especially without consideration of focused, site-specific signs or symptoms, is needed to decrease overdiagnosis of infections such VAP.…”

Section: Discussionmentioning

confidence: 99%

Understanding healthcare provider preferences for ordering respiratory cultures to diagnose ventilator associated pneumonia: A discrete choice experiment

Kenaa

O’Hara

et al. 2022

ASHE

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Objective: Ventilator-associated pneumonia (VAP) can be overdiagnosed on the basis of positive respiratory cultures in the absence of clinical findings of pneumonia. We determined the perceived diagnostic importance of 6 clinical attributes in ordering a respiratory culture to identify opportunities for diagnostic stewardship. Design: A discrete choice experiment presented participants with a vignette consisting of the same “stem” plus variations in 6 clinical attributes associated with VAP: chest imaging, oxygenation, sputum, temperature, white blood cell count, and blood pressure. Each attribute had 3–4 levels, resulting in 32 total scenarios. Participants indicated whether they would order a respiratory culture, and if yes, whether they preferred the bronchoalveolar lavage or endotracheal aspirate sample-collection method. We calculated diagnostic utility of attribute levels and relative importance of each attribute. Setting and participants: The survey was administered electronically to critical-care clinicians via a Qualtrics survey at a tertiary-care academic center in the United States. Results: In total, 59 respondents completed the survey. New radiograph opacity (utility, 1.15; 95% confidence interval [CI], 0.99–1.3), hypotension (utility, 0.88; 95% CI, 0.74–1.03), fever (utility, 0.76; 95% CI, 0.62–0.91) and copious sputum (utility, 0.75; 95% CI, 0.60–0.90) had the greatest perceived diagnostic value that favored ordering a respiratory culture. Radiograph changes (23%) and temperature (20%) had the highest relative importance. New opacity (utility, 0.35; 95% CI, 0.17–0.52) and persistent opacity on radiograph (utility, 0.32; 95% CI, 0.05–0.59) had the greatest value favoring bronchoalveolar lavage over endotracheal aspirate. Conclusion: Perceived high diagnostic value of fever and hypotension suggest that sepsis vigilance may drive respiratory culturing and play a role in VAP overdiagnosis.

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Section: Discussionmentioning

confidence: 99%

Understanding healthcare provider preferences for ordering respiratory cultures to diagnose ventilator associated pneumonia: A discrete choice experiment

Kenaa

O’Hara

et al. 2022

ASHE

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“…[ 12 ] This practice of reflexive blood culture ordering was found to be more prevalent among cross-covering residents at night shift. [ 23 , 24 ] Potential explanation for this observation in the survey include fewer staffing and supervision, and less familiarity with the patients during night shifts and on the weekends. [ 25 ] Our study expands on previous studies [ 12 , 13 ] by providing a better understanding on how variation in shift work and day of the week may influence the clinical decision making around blood culture.…”

Section: Discussionmentioning

confidence: 99%

Blood culture utilization practices among febrile and/or hypothermic inpatients

et al. 2022

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Background Predictors associated with the decision of blood culture ordering among hospitalized patients with abnormal body temperature are still underexplored, particularly non-clinical factors. In this study, we evaluated the factors affecting blood culture ordering in febrile and hypothermic inpatients. Methods We performed a retrospective study of 15,788 adult inpatients with fever (≥ 38.3℃) or hypothermia (< 36.0℃) from January 2016 to December 2017. We evaluated the proportion of febrile and hypothermic episodes with an associated blood culture performed within 24h. Generalized Estimating Equations were used to determine independent predictors associated with blood culture ordering among febrile and hypothermic inpatients. Results We identified 21,383 abnormal body temperature episodes among 15,788 inpatients (13,093 febrile and 8,290 hypothermic episodes). Blood cultures were performed in 36.7% (7,850/ 21,383) of these episodes. Predictors for blood culture ordering among inpatients with abnormal body temperature included fever ≥ 39℃ (adjusted odd ratio [aOR] 4.17, 95% confident interval [CI] 3.91–4.46), fever (aOR 3.48, 95% CI 3.27–3.69), presence of a central venous catheter (aOR 1.36, 95% CI 1.30–1.43), systemic inflammatory response (SIRS) plus hypotension (aOR 1.33, 95% CI 1.26–1.40), SIRS (aOR 1.26, 95% CI 1.20–1.31), admission to stem cell transplant / medical oncology services (aOR 1.09, 95% CI 1.04–1.14), and detection of abnormal body temperature during night shift (aOR 1.06, 95% CI 1.03–1.09) or on the weekend (aOR 1.05, 95% CI 1.01–1.08). Conclusion Blood culture ordering for hospitalized patients with fever or hypothermia is multifactorial; both clinical and non-clinical factors. These wide variations and gaps in practices suggest opportunities to improve utilization patterns.

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“…We designed the chart abstraction instrument based on our prior survey [12]. We collected data on patient demographics and comorbidities, history of bacteremia, vital signs at the time of fever, tests ordered, documentation performed, documentation of bedside evaluation, cause of fever in progress notes, complications after fever, blood culture results, and 30-day mortality.…”

Section: Chart Abstractionmentioning

confidence: 99%

“…At the study institution, the sign-out provides guidance regarding performing a "full fever work-up" (FFWU), although its definition is not standardized. In a recent survey of residents, we found that almost all residents included blood cultures, urine studies, and a chest X-ray in the FFWU, but over half included at least one additional test [12]. In this study, we aimed to delineate what diagnostic tests overnight residents order in response to fevers and what sign-out, patient, and clinical factors influence ordering practices.…”

Section: Introductionmentioning

confidence: 99%

Internal medicine residents’ evaluation of fevers overnight

et al. 2019

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Background Scant data exists to guide the work-up for fever in hospitalized patients, and little is known about what diagnostic tests medicine residents order for such patients. We sought to analyze how cross-covering medicine residents address fever and how sign-out systems affect their response. Methods We conducted a prospective cohort study to evaluate febrile episodes that residents responded to overnight. Primary outcomes included diagnostic tests ordered, if an in-person evaluation occurred, and the effect of sign-out instructions that advised a “full fever work-up” (FFWU). Results Investigators reviewed 253 fevers in 155 patients; sign-out instructions were available for 204 fevers. Residents evaluated the patient in person in 29 (11%) episodes. The most common tests ordered were: blood cultures (48%), urinalysis (UA) with reflex culture (34%), and chest X-ray (30%). If the sign-out advised an FFWU, residents were more likely to order blood cultures [odds ratio (OR) 14.75, 95% confidence interval (CI) 7.52–28.90], UA with reflex culture (OR 12.07, 95% CI 5.56–23.23), chest X-ray (OR 16.55, 95% CI 7.03–39.94), lactate (OR 3.33, 95% CI 1.47–7.55), and complete blood count (CBC) (OR 3.16, 95% CI 1.17–8.51). In a multivariable regression, predictors of the number of tests ordered included hospital location, resident training level, timing of previous blood culture, in-person evaluation, escalation to a higher level of care, and sign-out instructions. Conclusions Sign-out instructions and a few patient factors significantly impacted cross-cover resident diagnostic test ordering for overnight fevers. This practice can be targeted in resident education to improve diagnostic reasoning and stewardship.

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Choosing Wisely Overnight? Residents’ Approach to Fever

Cited by 4 publications

References 9 publications

Understanding healthcare provider preferences for ordering respiratory cultures to diagnose ventilator associated pneumonia: A discrete choice experiment

Understanding healthcare provider preferences for ordering respiratory cultures to diagnose ventilator associated pneumonia: A discrete choice experiment

Blood culture utilization practices among febrile and/or hypothermic inpatients

Internal medicine residents’ evaluation of fevers overnight

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