TABLE 2.

Local Drivers, Supporting Literature, and Workgroup Consensus That Informed Development and Implementation of an Algorithm to Reduce EAC Use

Primary Drivers	Secondary Drivers	Literature, Data, or Workgroup Consensus	Action Taken
Reflexive testing for clinical changes in ventilated patient	Absence of guidance when to obtain EAC	Common triggers for EACs were fever, ventilator changes, secretions, WBCs, and CRP.16The workgroup consensus was that infections would be associated with abnormal temperatures and WBC but did not specify cutoff values consistent with recent evidence.35	Addressed common triggers in the algorithm
	Misconception of EACs’ ability to distinguish colonization from infection	Airways are nonsterile and become colonized with bacteria. EAC with bacterial growth is not specific to infection.5–7	Paired algorithm implementation with education
	Ordering clinicians are unaware of previous EAC results	A review of EAC results from 2017 revealed 75% of EACs repeated within 3 d did not have new bacterial species (unpublished observations). Microbiology laboratory does not repeat antibiotic susceptibilities if repeated within 3 d.	Incorporated step necessitating review of existence of previous EACs and avoiding cultures repeated within 3 d
	Competing demands reducing time to consider utility of EAC		Ensured algorithm is brief and easily accessible by print or online
	Variable experience of members of care team with complex communication pattern of clinical information		Involved input from all groups of health care workers in guideline development and ensured the algorithm was accessible to everyone
Significance attributed to a reported change in respiratory secretions	Variability in interpretation between providers of secretion description	Increased secretion quantity supported as a common feature of patients with respiratory infections.36Sputum color and purulence has not correlated with bacterial respiratory infections.37–41	Algorithm included quantity of secretions instead of sputum color or thickness descriptions
	EACs ordered from patients without sufficient secretions, and RTs used saline lavage to obtain cultures.	Saline lavage is not a recommended practice.25	Discouraged saline lavage and empowered RT to inform ordering clinician if insufficient quantity of secretions to send for culture

CRP, C-reactive protein; ETA, endotracheal aspirate; RT, respiratory therapist; WBC, white blood cell.