Table 2.

Representative Quotes: CFIR-guided Determinants of Blood Culture Overuse

CFIR Domain	Theme	Representative Quote	Participant Type and Site
Individual characteristics	Personal belief in the overall importance of blood cultures	“[Without a culture] you may delay providing appropriate antibiotic coverage if needed.”“…I think there’s a sense of urgency to figure out what is going on with the patient and I think there’s a heightened awareness for the possibility of sepsis. So, I think understanding that sepsis can go south pretty quickly if it’s not under control…and that we don’t take it lightly.”	Fellow, low performing site (2)Nurse, high performing site (4)
Individual characteristics	Perception that blood cultures are a low-risk test	“I think there’s almost no risk of getting it besides worsening the amount of anemia that the patient can get in the ICU, but all those things are in theory reversible, right. So, I think it’s a minimal risk to get it and more benefit.”“I think that my, having been at this at this institution now, it’s made me realize that many of the blood cultures that I may have obtained in the past were unnecessary. And not only may not have provided any benefit, but may also have led to some degree of inappropriate harm, or, harm I used almost as a loose term, but inappropriate antibiotic usage certainly. And I think it’s also important that having these institutional recommendations helps remove some of that uncertainty and variability.”	Fellow, low performing site (2)Attending physician, high performing site (3)
Inner setting	Adherence to site-specific usual practices	“I would say my personal approach is pretty similar to the way the group practices.”“I would say that our physicians are pretty standard across the board. We are very standardized and policy driven.”	Attending physician, low performing site (2)Nurse and clinical staff leader, low performing site (5)
Inner setting	Site-specific overall approach to PICU care (team-based and collaborative versus hierarchical)	“So, in our unit it’s the ICU team that makes the decisions…it’s a team approach…it’s the whole team that meets and makes the decision.”“The more experienced clinicians tend to follow [the algorithm], and the less experienced ones will defer to nursing preference, so I guess that would be the way that they deviate away from it, like, ‘Oh, what do you think? Do you think that they’re meeting [the threshold for testing]? Or what do we usually do?’ Rather than actually looking at the policy. That’s usually what we’ll look at that, we have a decision tree.”	Nurse, low performing site (1)Nurse, low performing site (1)
Inner setting	Influence of non-PICU clinicians on blood culture decisions	“If our PICU team wants cultures or doesn’t want cultures and let’s say the heme-onc team wants cultures, I would say usually the heme-onc team wins in that perspective.”	Nurse, high performing site (4)
Outer setting	Patient-specific risk factors	“I think about the patient’s underlying process that’s going on to their underlying diagnosis and reason for being in the PICU in relation to the fever. That’s probably the first priority in thinking about how to or whether to order a blood culture.”“In immune compromised patients, I would be much more likely to get a blood culture in general, regardless of the other factors that are not in an immune compromised patient.”“More than a diagnosis, any patient who has a central line in place, either a tunneled line or a PICU line. It’s probably one of the biggest things” [to prompt getting a culture].	Attending physician, high performing site (4)Attending physician, high performing site (4)Fellow, low performing site (2)
Outer setting	Institution-wide or national sepsis guidelines	[Discussing a 1-hour time goal for antibiotics]“The time goal puts you on the crunch to be like, okay, immediately get the culture and get the antibiotics in as soon as possible. So, I think it defaults us to sometimes get more cultures.”“Yeah obviously, an hour can go by very quickly….[] …So, I think there is definitely a sense of urgency and when there’s a sense of urgency, I think there’s always a possibility that obviously, you’re thinking quicker. So, you don’t have as much time to fully think through every possibility…”	Attending physician, high performing site (6)Resident, high performing site (6)