BrighT STAR Collaborative

The BrighT STAR (Testing STewardship to reduce Antibiotic Resistance) Collaborative includes children’s hospitals across the United States with a common mission of reducing overtesting in critically ill children.


Formed in 2018, the BrighT STAR Collaborative is a prospective multicenter quality improvement (QI) collaborative that includes children’s hospitals in 17 states across the U.S. Participating hospitals share the common goal of implementing diagnostic stewardship interventions — appropriate use of laboratory testing — to reduce bacterial culture overuse.


Diagnostic stewardship is an essential component of our health care system’s advancement to a high- value care model and provides a novel strategy to reduce overuse. Diagnostic stewardship involves altering how providers order, perform and report diagnostic tests. The goal of this multicenter collaborative is to implement diagnostic stewardship strategies on a large scale and determine if this can reduce unnecessary antibiotic treatment. The long-term goal is to safely avoid unnecessary testing and treatment to improve patient care, decrease antibiotic resistance and provide high-value care.

Blood Cultures

In January 2014, pediatricians at Johns Hopkins Children’s Center developed and implemented a clinical practice strategy to guide clinicians in the use of blood cultures when evaluating patients with signs and symptoms of sepsis (1). Between 2016 and 2018, the program was first extended to Johns Hopkins All Children’s Hospital and University of Virginia Children’s Hospital and then expanded to 15 BrighT STAR collaborative hospitals. Each BrighT STAR hospital developed and implemented a local QI program to improve blood culture use within their ICU. Implementation was guided by a modifiable five-part approach, incorporating principles of the Comprehensive Unit-based Safety Program. Thus far, there has been a 31% overall reduction in blood culture use across the collaborative. This collaborative also contributed to development of consensus recommendations for blood culture use in pediatric intensive care unit (PICU) patients — which will be released in the coming months.

Respiratory Cultures

In 2018, pediatricians at Johns Hopkins Children’s Center developed and implemented a clinical practice strategy to guide clinicians in the use of respiratory cultures when evaluating mechanically ventilated patients for respiratory infections (9). In 2021, this respiratory culture project will expand across the BrighT STAR collaborative, using a similar multicenter QI framework. Guided by a Translating Evidence into Practice model, each collaborative site will develop and implement QI initiatives to improve respiratory culture practices. The BrighT STAR team will support the collaborative, as well as collect aggregate data on respiratory culture rates and clinical outcomes. This collaborative work will be the foundation to develop evidence-based toolkits other hospitals can use to improve respiratory culture practices in the future.


Multidisciplinary quality improvement teams at each site work closely with the BrighT STAR coordinating team. Sites in the collaborative develop and implement tools for clinicians to use when deciding whether or not a patient should have a blood or respiratory culture. These tools help the medical team decide if a culture should be obtained, how frequently, and how to collect the sample. The BrighT STAR team tracks culture rates and patient outcomes to monitor project results.

New Blood Draw Protocol Could Minimize Risk for Critically Ill Children

Researchers at Johns Hopkins Children's Center and Children's Hospital of Philadelphia have found that fostering cross-departmental collaboration and offering guidelines to clinicians helped reduce the number of unnecessary blood draws on some of the smallest and most vulnerable patients.

Collaborative Partner Organizations*

*Evolving as of April 13, 2021.

  • Johns Hopkins Children’s Center
  • Johns Hopkins All Children’s Hospital
  • University of Virginia Children’s Hospital
  • Boston Children’s Hospital
  • The Children's Hospital of Philadelphia
  • Children’s Healthcare of Atlanta
  • Cleveland Clinic Children’s
  • Dell Children’s Medical Center
  • Doernbecher Children's Hospital
  • Le Bonheur Children’s Hospital
  •  Ann & Robert H. Lurie Children’s Hospital of Chicago

  • Intermountain Primary Children’s Medical Center
  • UH Rainbow Babies and Children's Hospital
  • Lucile Packard Children’s Hospital
  • Seattle Children's Hospital
  • St. Jude Children's Research Hospital
  • St. Louis Children’s Hospital
  • Children’s Hospital Association
  • Children’s Minnesota
  • Vanderbilt Children’s Hospital
  • Children’s Hospital and Medical Center Omaha


  • Woods-Hill CZ, Koontz DW, Voskertchian A, Xie A, Shea J, Miller MR, Fackler JC, Milstone AM; BrighT STAR Consensus Authorship Group. Consensus Recommendations for Blood Culture Use in Critically Ill Children Using a Modified Delphi Approach. Pediatr Crit Care Med. 2021 Apr 23. Epub ahead of print. PMID: 33899804.
  • Woods-Hill CZ, Fackler J, Nelson McMillan K, Ascenzi J, Martinez DA, Toerper MF, Voskertchian A, Colantuoni E, Klaus SA, Levin S, Milstone AM. Association of a Clinical Practice Guideline with Blood Culture Use in Critically Ill Children. JAMA Pediatr. 2017 Feb 1;171(2):157-164. doi: 10.1001/jamapediatrics.2016.3153. PubMed ID: 27942705.
  • Xie A, Woods-Hill CZ, King AF, Enos-Graves H, Ascenzi J, Gurses AP, Klaus SA, Fackler JC, Milstone AM. Work System Assessment to Facilitate the Dissemination of a Quality Improvement Program for Optimizing Blood Culture Use: A Case Study Using a Human Factors Engineering Approach. J Pediatric Infect Dis Soc. 2017 Nov 20. doi: 10.1093/jpids/pix097. PubMed ID: 29165616.
  • Woods-Hill CZ, Lee L, Xie A, King AF, Voskertchian A, Klaus SA, Smith MM, Miller MR, Colantuoni EA, Fackler JC, Milstone AM. Dissemination of a Novel Framework to Improve Blood Culture Use in Pediatric Critical Care. Pediatr Qual Saf. 2018 Oct 16;3(5):e112. doi: 10.1097/pq9.0000000000000112. PMID: 30584639; PMCID: PMC6221585.
  • Sick-Samuels AC, Woods-Hill CZ, Fackler JC, Tamma PD, Klaus SA, Colantuoni EE, Milstone AM. Association of a blood culture utilization intervention on antibiotic use in a pediatric intensive care unit. Infect Control Hosp Epidemiol. 2019 Apr;40(4):482-48 doi: 10.1017/ice.2019.10. Epub 2019 Feb 15. PMID: 30767809; PMCID: PMC6459704.

  • Woods-Hill CZ, Koontz DW, King AF, Voskertchian A, Colantuoni EA, Miller MR, Fackler JC, Bonafide CP, Milstone AM, Xie A; BrighT STAR Authorship group. Practices, Perceptions, and Attitudes in the Evaluation of Critically Ill Children for Bacteremia: A National Survey. Pediatr Crit Care Med. 2020 Jan;21(1):e23-e29. doi: 10.1097/PCC.0000000000002176. PMID: 31702704; PMCID: PMC6942229.
  • Sick-Samuels AC, Fackler JC, Berenholtz SM, Milstone AM. Understanding reasons clinicians obtained endotracheal aspirate cultures and impact on patient management to inform diagnostic stewardship initiatives. Infect Control Hosp Epidemiol. 2020 Feb;41(2):240-242. doi: 10.1017/ice.2019.347. PMID: 31813405; PMCID: PMC7041429.
  • Xie A, Koontz DW, Voskertchian A, Fackler JC, Milstone AM, Woods-Hill CZ. Survey-based Work System Assessment to Facilitate Large-scale Dissemination of Healthcare Quality Improvement Programs. Pediatr Qual Saf. 2020 Apr 9;5(2):e288. doi: 10.1097/pq9.0000000000000288. PMID: 32426645; PMCID: PMC7190253.
  • Ormsby J, Conrad P, Blumenthal J, Carpenter J, Jones S, Sandora TJ, Vaughan A, Vincuilla J, McAdam AJ, Fogg LF, Flett K, Kelly DP. Practice Improvement for Standardized Evaluation and Management of Acute Tracheitis in Mechanically Ventilated Children. Pediatr Qual Saf. 2020 Dec 28;6(1):e36 doi: 10.1097/pq9.0000000000000368. PMID: 33403314; PMCID: PMC7775031.
  • Sick-Samuels AC, Linz M, Bergmann J, Fackler JC, Berenholtz SM, Ralston SL, Hoops K, Dwyer J, Colantuoni E, Milstone AM. Diagnostic Stewardship of Endotracheal Aspirate Cultures in a PICU. Pediatrics 2021 Apr 7:e20201634. doi: 10.1542/peds.2020-1634. Epub ahead of print. PMID: 33827937.