Asynchronous Testing of 2 Specimen-Diversion Devices to Reduce Blood Culture Contamination: A Single-site Product Supply Quality Improvement Project

Monica Arenas, Gracia M Boseman, John D Coppin, Janell Lukey, Chetan Jinadatha, Dhammika H Navarathna from Central Texas Veterans Health Care System

Objective
Blood culture contamination above the national threshold has been a consistent clinical issue in the ED setting. Two commercially available devices were examined that divert an initial small volume of the specimen before the collection of blood culture to reduce skin contamination.

Methods
Prospectively, 2 different blood culture-diversion devices were made available in the unit supplies to ED clinicians at a single site during 2 different periods of time as a follow-up strategy to an ongoing quality improvement project. Blood samples were collected in the emergency department over a period of 16 months. A retrospective record review study was conducted comparing the use of the 2 specimen-diversion devices with no device (control group) for blood culture contamination rates. The main outcome of monthly blood culture contamination per device was tested using a Bayesian Poisson multilevel regression model.

Results
A total of 4030 blood samples were collected and analyzed from November 2017 to February 2019. The model estimated that the mean incidence of contaminated blood draws in the device A group was 0.29 (0.14-0.55) times the incidence of contaminated draws in the control group. The mean incidence of contaminated blood draws in the device B group was 0.23 (0.13-0.37) times the incidence of contaminated draws in the control group, suggesting that initial-diversion methods reduced blood culture contamination.

Conclusion
Initial specimen-diversion devices supplement present standard phlebotomy protocols to bring down the blood culture contamination rate.

Reducing False-Positive Blood Cultures: Using a Blood Diversion Device

David M. O’Sullivan and Lee Steere, Hartford Hospital, Hartford, CT.

Background
Determining if and when a patient receives antibiotic therapy can be a life saving decision. If a person has an infection, starting antibiotics early is important;  however if a person does not need the antibiotics, starting them has significant financial and health-related consequences.

Objective
To evaluate if a minimal-risk blood diversion device could be used successfully to reduce the rate of false-positive blood cultures.

Methods
The false-positive blood culture rate (FPR) was compared for three months using a blood diversion device and three months not using a blood diversion device.

Results
There was a significantly lower rate of FPR during use of the blood diversion device (0.44%), compared with an average of 1.71% for the three months not used, an average reduction of 74.1%.

Read the study: ctmed.csms.org

Reduction of False Positive Blood Culture Rates using a Passive Blood Diversion Device in an Urban Academic Pediatric Emergency Department

Christina Ostwald and Kelly Whitsell, John R. Oishei Children’s Hospital, Buffalo, NY

Identification of Problem
Blood culture contamination rates in emergency departments (ED) across the United States are as high as 11%, with a range of 1.7%13 to 11%.9

Bacteria found on the skin, also known as common commensals or skin flora, are the culprit of false positive blood cultures (FPBC). FPBC results lead to increased financial costs and unnecessary distress to patients and families. The literature gives a range of values to attribute cost to a FPBC from $100015 to $10,078.6

Hospital cost is related to avoidable admissions, increased lengths of stay, unnecessary antibiotic treatment, and further laboratory investigation to rule out suspected bacteremia. Antibiotic overuse leads to multi-drug resistant organisms that are harder to treat and lead to poor outcomes.

Background
Pediatric patient that present to the emergency department with signs and symptoms of infection may require diagnostic tests that rule out bacteremia and sepsis including a blood culture.

In pediatric patient, it can be challenging even for the most experienced nurse to obtain blood specimens due to patient related factors11 such as: developmental level, ethnicity, size, illness, dehydration, sepsis, and trauma. Mental and emotional status can also be barriers to proper technique.10

Blood cultures are obtained by trained Registered Nurses in the ED. It is imperative for nurses to follow aseptic technique in the process of blood culture collection using the age-appropriate skin decontamination methods, together with allowance for dwell time of the skin preparation. Even with proper aseptic technique, there is the potential for a false positive results due to skin flora.

The microbiology lab provides a list of FPBC every month. The ED Nurse Educator provides targeted 1:1 education for aseptic technique, but this has only led to temporary improvement in the FPBC rate. Retrospective review of FPBC rates in this ED prior to the intervention ranged between 0.45 and 5.63.

PICO
In a Pediatric Emergency Department will the implementation of a novel passive blood diversion device (PBDD) in addition to staff education decrease blood culture contamination rates compared to staff education only?

Review of the Literature
A literature search was conducted using the terms: reduce false-positive blood cultures; contaminated blood cultures; best practice for collection of blood cultures; blood specimen diversion device. This search yielded 702 articles which were then narrowed to include the previous 10 years, peer review only, and the Boolean phrase AND pediatrics and Emergency Department. This advanced search provided 106 articles that were reviewed for inclusion criteria pertinent to the PICO question. Upon completion, 17 articles were included in the literature review including (5) Levell II, (3) Level III and (9) Level V according to the Johns Hopkins Nursing Evidence Level and Quality Guide appendix D.12 Due to a majority scoring greater than a level II and zero level 1 articles, this body of evidence suggested that proceeding cautiously with a pilot study and thorough analysis was recommended.

From the sources of evidence found by searching the databases for relevant literature, several reoccurring themes emerged including: false positive blood cultures lead to: unnecessary antibiotic use contributing  to antibiotic resistance, increased length of stay, increased diagnostic testing, decreased patient satisfaction, increased overall medical cost.

While there are many published quality improvement studies implementing best practices to reduce false positive blood cultures (FPBC) in adults, literature is lacking on efforts in children. Furthermore, fewer studies address the use of passive blood diversion devices – instruments designed to remove and divert a small volume of blood most likely to contain skin flora and contamination.

Implementation Plan
In the Spring of 2018, a vendor claimed to have a passive blood diversion device (PBDD) product to decrease FPBC rates. The Infection Preventionist (IP) was aware that ED was struggling with a high rate of FPBC rate. Despite diligent educational efforts by the ED to reduce FBPCs, historical data showed the results were not sustained. Current practice involved didactic and hand on education regarding technique to properly prep the skin with age-appropriate disinfection agents, never touching the insertion site after disinfection or tearing the finger off a glove when performing venipuncture. Additional initiatives involved targeted feedback for the individuals involved in the blood draws determined to be FPBCs.

A team was assembled to design a plan to pilot the PBDD in the ED. This involved Infection Prevention, the Emergency Department, and the Value Analysis Team (VAT). The team investigated historical data including costs analysis choosing two months in the summer of 2017, and then implemented the intervention for two months in the summer of 2018, followed by comparison of the data from the intervention.

Infection Prevention reviewed all results for true FPBC based on the Center for Disease Control National Healthcare Safety Network definitions, and used data-mining software for all blood cultures drawn in the ED historically and in the study periods.

Process in the ED for blood specimen collection for pediatric patients is specimen collection from new intravenous (IV) insertion instead of peripheral venipuncture. The vendor provided 400 IV PBDD and the team decided to bundle all the components of the blood draw into readily available kits.

Education for the nurses involved direct 1:1, hands on exposure to the device, review of the blood draw policy, and a vendor created video that was added learning management system. Other components of education included the process for documentation on an exception log when unable to use the device so that follow-up from the nurse manager, educator, and Infection Preventionist could occur. In addition to education, strategies for nurse engagement included creating a sense of excitement around the roll-out with snacks and balloons.

The Finance Department determined the hospital’s actual cost incurred due to a FPBC from 2017 data analysis. Infection Prevention then did a cost analysis of PBDD device implementation vs cost of FPBC. All data was presented to VAT at the hospital and corporate levels.

Conclusions
Feedback on the PBDD was collected on a five question nurse satisfaction survey. The survey provided options to make comments. Overall the nurses found the PBDD to be easy to use (45%) and made sense (85%). Themes identified from the survey included length of tubing was “clumsy, too long, and bulky” with the pediatric patient and “wasting too much blood.” The results were share with the vendor and they modified their product for pediatric patients with shorter tubing which was then implemented in the second study period.

The average cost of FPBCs is both quantifiable and non-quantifiable. After itemizing the hospital related costs, Finance was sought to identify the quantifiable cost of calling a patient back in and/or admission due to the FPBC. Our results ranged from $232 to $6850 which were outliers. Most cases fell between $1500 and $2300 with an average of $1907. Non-quantifiable costs itemized and not considered in our analysis  included lost time for the patient and their parents to come back to the hospital, patient satisfaction, staff time for call-backs, physician time/cost, and length of stay in the ED. A cost savings of $71,422 annually was estimated if the PBDD was fully implemented for use with all blood culture draws. It is important to do a cost analysis for each area prior to implementation and the PBDD may prove more cost effective in a high blood culture volume area.

Data collection continued following the intervention period when the device was not available and working its way through the value analysis process. Approval for the device took eight months. Once it was approved, the team repeated the exact study in 2019 for three months using the pediatric modified PBDD with improved nurse satisfaction, decreased return visits and costs, and decreased unnecessary antibiotic use.

Results

In the first study period, a total of 341 blood cultures were drawn, with an overall FPBC rate of 1.5%. The rate of FPBC when the device not used was 10.5% (4 of 38). No FPBCs were seen in 303 instances when the device was employed (significantly different by Fisher’s exact test, p = 0.0001).

In the second study period, a total of 905 blood cultures were drawn, with an overall FPBC rate of 0.22%. The rate of FPBC when the device not used was 6.06% (2 of 33). No FPBCs were seen in 874 instances when the device was employed (significantly different by Fisher’s exact test, p = 0.0001).

The Fisher exact test statistic value is < 0.0001 ~ The result is significant at p < .01.

This significant reduction in FPBC suggests that employing a passive blood diversion device in addition to education on best practices may decrease FPBCs; return visits in the pediatric ED setting, antibiotics overuse, and overall costs.

Contacts
Christina Ostwald MS RN CIC costwald@kaleidahealth.org

Kelly A. Whitsell MS RN CPEN kwhitsell@kaleidahealth.org

Acknowledgements
Special thanks to Jeremy Killson MD, Betty Beyer MS RN, Karl Yu MD, Brian Wrotniak PhD, Pam Trevino PhD RN, & the John R. Oishei ED Nurses.

Download a PDF of this study.

REFERENCES:
1 Bell, M., Bogar, C., Plante, J., Rasmussen, K., & Winters, S. (2018). Effectiveness of a novel specimen collection system in reducing blood culture contamination rates. Journal of Emergency Nursing Online. https://doi.org/10.1016/j.jen.2018.03.007
2 Bentley, J., Thakore, S., Muir, L., Baird, A., & Lee, J. (2016). A change of culture: reducing blood culture contamination rates in an Emergency Department. BMJ Open Quality, 5(1), 1-7. u206760-w2754.doi10.1136/bmjquality.u206760.w2754
3 Centers for Disease Control and Prevention National Healthcare Safety Network. NHSN Organisms List Validation 2018. CDC.gov, Retrieved 7/1/2018.
4 Doern, G. V. (2013). Blood cultures for the detection of bacteremia: U: UpToDate, Calderwood SB ur. UpToDate [Internet]. Waltham, MA: UpToDate, .Retrieved 07/01/2018 from https://www.uptodate.com/contents/blood-cultures-for-the-detection-of-bacteremi
5 Gander, R. M., Byrd, L., DeCrescenzo, M., Hirany, S., Bowen, M., & Baughman, J. (2009). Impact of blood cultures drawn by phlebotomy on contamination rates and health care costs in a hospital emergency department. Journal of Clinical Microbiology, 47(4), 1021-1024.
6 Garcia, R. A., Spitzer, E. D., Beaudry, J., Beck, C., Diblasi, R., Gilleeny-Blabac, M., Haugaard, C., Heuschneider, S., Kranz, B.,McLean, K., Morales, K. L., Owens, S., Paciella, M., Torregrosa, E. (2015). Multidisciplinary team review of best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremia, reducing contamination, and eliminating false-positive central line–associated bloodstream infections. American Journal of Infection Control, 43(11), 1222-1237.
7 Garcia, R. A., Spitzer, E. D., Kranz, B., & Barnes, S. (2018). A national survey of interventions and practices in the prevention of blood culture contamination and associated adverse health care events. American Journal of Infection Control, 46(5), 571-576.
8 Gorski LA, Hadaway L, Hagle ME, et al. Infusion therapy standards of practice. Journal of Infusion Nursing (2021); 44 (suppl 1):S1-S224. doi:10.1097/NAN.0000000000000396
9 Hall, R. T., Domenico, H. J., Self, W. H., & Hain, P. D. (2013). Reducing the blood culture contamination rate in a pediatric emergency department and subsequent cost savings. Pediatrics, 131(1), e292-e297.
10 Hall, K. K., & Lyman, J. A. (2006). Updated review of blood culture contamination. Clinical Microbiology Reviews, 19(4), 788-802. Retrieved 7/1/2018 from https://cmr.asm.org/content/cmr/19/4/788.full.pdf
11 Kuensting, L.L., DeBoer, S., Holleran, R., Shultz, B., Steinmann, R., Venella, J. (2009) Difficult venous access in children: Taking control. Journal of Emergency Nursing 35(5). 419-424.
13 Marlowe, L., Mistry, R. D., Coffin, S., Leckerman, K. H., McGowan, K. L., Dai, D., Bell, L., & Zaoutis, T. (2010). Blood culture contamination rates after skin antisepsis with chlorhexidine gluconate versus povidone-iodine in a pediatric emergency department. Infection Control & Hospital Epidemiology, 31(2), 171-176.
14 McAdam, A. J. (2017). Reducing contamination of blood cultures: Consider costs and clinical benefits. Journal of Emergency Nursing 43(2).126-132
15 Moeller, D. (2017). Eliminating blood culture false positives: Harnessing the power of nursing shared governance. Journal of Emergency Nursing, 43(2), 126-132.
16 Nair, A., Elliott, S., & Mohajer, M. (2017). Knowledge, attitude, and practice of blood culture contamination: A multicenter study. American Journal of Infection Control 45. 547-548.
17 Rupp, M. E., Cavalieri, R. J., Marolf, C., & Lyden, E. (2017). Reduction in blood culture contamination through use of initial specimen diversion device. Clinical Infectious Diseases, 65(2), 201-205
18 Self, W. H., Mickanin, J., Grijalva, C. G., Grant, F. H., Henderson, M. C., Corley, G., … & Paul, B. R. (2014). Reducing blood culture contamination in community hospital emergency departments: A multicenter evaluation of a quality improvement intervention. Academic Emergency Medicine, 21(3), 274-282.
19 Snyder, S. R., Favoretto, A. M., Baetz, R. A., Derzon, J. H., Madison, B. M., Mass, D., Shaw, C., Layfield, C., Vhristenson, R., & Liebow, E. B. (2012). Effectiveness of practices to reduce blood culture contamination: A laboratory medicine best practices systematic review and metaanalysis. Clinical biochemistry, 45(13-14), 999-1011.
20 Weddle, G., Jackson, M.A., & Selvarangen, R., (2011). Reducing blood culture contamination in a pediatric emergency department. Pediatric Emergency Care. 27(3), 179-181.

Decreasing Blood Culture Contamination Rates When Using an Initial Peripheral IV: Implementing the 5 P’s and Using a Closed System Device

Denise Rhew and Wendy Childress, Cone Health, Greensboro, NC

Abstract
Blood culture remains the gold standard for the diagnosis and treatment of bacteraemia and is the first-line tool or detecting bloodstream infections1. Research shows that the emergency department (ED) is an essential component of the health care system and subject to workflow challenges, which may hinder ED personnel adherence to guideline-based infection prevention practices.2 This impact has wide-reaching effects. Moreover, a fast-paced ED presents a host of challenges with competing priorities. In addition, EDs are perceived as 24/7 portals where rapid and efficient diagnosis, urgent attention, primary care, and inpatient admission is provided for stabilizing seriously ill and wounded patients.3 Blood culture contaminants are common, and they have a significant impact on patients and staff, contributing to unnecessary or inappropriate antibiotic treatment, increased length of stay, and costly economic burden.4 The aim of this study was to evaluate the use of an automated blood culture collection system when drawing blood cultures from a peripheral IV and to evaluate the effectiveness of implementing evidence-based policies, procedures, practice, products, and patient care to reduce blood culture contamination rates.

Read the full articlehttps://scivisionpub.com/pdfs/decreasing-blood-culture-contamination-rates-when-using-an-initial-peripheral-iv-implementing-the-5-ps-and-using-a-closed-system-d-1718.pdf

REFERENCES:
1 Clinical Practice Guideline: Prevention of Blood Culture Contamination. Journal of Emergency Nursing. 2018; 44: 285: e1-285.e24.
2 Health and Medicine New Infection Control Findings from Columbia University Outlined Common Infection Control Practices in the Emergency Department A Literature Review. Health & Medicine Week. 2014; 3009.
3 Ortíz-Barrios, Miguel A, Juan-José Alfaro-Saíz. Methodological Approaches to Support Process Improvement in Emergency Departments A Systematic Review. International Journal of Environmental Research and Public Health. 2020; 17: 2664.
4 Cardoso T, Carneiro AH, Ribeiro O, et al. Reducing mortality in severe sepsis with the implementation of a core 6-hour bundle results from the Portuguese community-acquired sepsis study SACiUCI study. Crit Care. 2010; 14: R83.

Impact on Emergency Department Blood Culture Contamination

Jeannie Burnie, MS, APRN, AGCNS-BC, CEN, FAEN, FCNS and Samantha Vining, MSN, RN, FNP-C
TriHealth and Bethesda North Hospital, Cincinnati, Ohio.

Clinicians at TriHealth Bethesda North Hospital published new clinical findings related to blood culture collection, a common procedure performed in emergency departments. Rate of blood culture contamination is a metric that is tracked by organizations to ensure appropriate treatment for patients suspected of having bacteremia and ensure appropriate use of hospital resources. The co-authors, Jeannie Burnie and Samantha Vining noted that, “The College of American Pathologist guideline recommends blood culture contamination (BCC) rates of less than 3%.” However, their suburban ED located in a midwestern city was not consistently meeting this recommendation. Therefore, a team of nurses and technicians undertook a quality improvement project to decrease blood culture contamination rates in a suburban emergency department.

According to the authors, the project included use of standardized blood culture collection kits, creation of a dedicated collection team, and implementation of a new blood culture collection device (Kurin, Inc., San Diego, California) “designed to sideline potential skin contaminants with a passive, low-volume (0.15 mL) initial specimen discard.” In order to cost justify the new device, the ED clinical nurse specialist worked with the organization’s value analysis coordinator to determine the associated costs to the organization per BCC incident revealing “an increased length of stay of 2.65 days and an increase in cost of admission of $5863 per BCC.”

TriHealth’s results showed immediate, significant and sustained improvement. According to the authors, “In 2018, the average BCC rate was 2.92%. In 2019, after the implementation of the Kurin diversion device intervention, the average BCC rate dropped to 1.42%, a 51% decrease.” The team continued to monitor BCC rates and estimated cost savings of “nearly 2 million dollars.” The authors noted that during the study, “nearly 250 patients have benefited from the introduction of the Kurin diversion device.” Blood culture contamination rates remained below 1.5% consistently for a 2-year period.

Upon achieving these results, the improvement project was initiated in a second TriHealth ED. Evaluation data from the first 6 months of Kurin use at the second ED “have been impressive and have shown marked improvement in BCC rates, from a pre-implementation rate of 4.96% to a postintervention rate of 1.6%,” representing a decrease of over 70%.

The TriHealth team employed a variety of change processes yet the authors specify that “the use of the Kurin device and focused individual feedback have been the key to sustaining BCC rates consistently lower than the accepted contamination rates.”

Reducing False-Positive Blood Cultures in Adult A&E using a Initial Specimen Diversion Device

Jane Hodson, James Stebbing, Catherine Graham and Siobhan O’ Donnell
Guy’s and Thomas’ NHS Foundation Trust, London, England

Introduction
Blood cultures are the gold standard for obtaining important diagnostic information to enable detection of the presence of a bacteraemia. The Clinical and Laboratory Standards Institute recommend that hospitals achieve a contamination rate of   <3%1 though rates are estimated to range from 2% to over 10%. Economically false positive blood culture results are estimated to cost between £2,000 – £4,200 and have a significant negative impact on patients1. These costs include delays in diagnosis, unnecessary administration of intravenous antibiotics, increased risk of complications related to unnecessary intravenous cannulation, unplanned removal of central venous access devices, additional laboratory testing, and delayed discharge by 2 days2 resulting in an overall increase in the cost of hospitalisation. Additionally, there are time and costs pressures associated with the manpower required to investigate each false positive blood culture. In our trust the contamination rate of blood cultures has consistently averaged 6% for many years despite prior quality improvement projects that included the introduction of blood culture collection packs and refresher training on how to take a blood culture at every new doctor induction. The highest number of contaminated specimens are associated with A & E. The use of a cannula for blood culture sampling is associated with increased risk of contamination contamination1 and against our Trust intravenous access guideline. Despite this, we are aware, through bacteraemia investigations, that in A & E, blood cultures are taken from cannulae. Our project was to determine if the introduction of an initial specimen diversionary device (ISDD) that automatically side-line’s the first flash of blood during the routine process of drawing a blood culture will reduce the number of false positives in this department.

Methods

  • The diversionary device was introduced into our central London A & E that sees 400 -450 patients / day.
  • Introduction and training on the use of the device was provided at weekly early morning educational sessions by the company
  • The ISDD diverts the first 0.15 ml of blood that may contain skin contaminants and “locks” it into a small chamber is available in two versions: a traditional style butterfly needle and an extension set that attaches to an intravenous cannula (Images 1 and 2)
  • The ISDD was the only change in practice implemented for the duration of the study
  • The PDN and 2 research nurses provided ongoing support and promotion of the project
  • All A & E staff members were involved in the study
  • The current phlebotomy equipment was removed from the cannulation trolleys located across the adult A & E
  • Bags containing all the equipment required for blood culture collection were prepared by the department research nurses and centrally located at the staff desk in Majors
  • Data collection was totally anonymised with the only question asked, on a form included in the bag, was if the blood culture was taken from a cannula or using a butterfly
  • Staff members collected a bag prior to taking a blood culture then returned the completed form to a box co – located with the equipment
  • The completed forms were collected weekly and the data reviewed to determine the number of contaminated samples
  • The project is reaching its conclusion and the final results will be reviewed by a Trust microbiologist, an A & E research consultant and the Lead IV Practitioner representing Infection Prevention and Control

Results

  • The project has run over 5 months, May -Sept 2021
  • Data has been collected on approximately 500 specimens using the ISDD
  • The initial calculation demonstrates that the current contamination rate is <2%
  • An overall reduction of 66%
  • There was no difference in the rate of false positive results between the cultures taken from a cannula and those done from a direct stab using a butterfly.

Discussion
The project has demonstrated a significant reduction in the number of false – positive blood cultures using the ISDD.  The staff in A & E embraced the project. They found the ISDD very simple to use as it required no change in their current practice. The results of the weekly data collection was fed back to the A & E research nurses to share with the department. The project made clear despite a cannula being used regularly for blood culture collection, use of the ISSD mitigated the increased risk of contamination. The decrease in false positives encouraged A & E staff to continue to use the ISDD.  All current stock has been used and they are eager to continue using the product.  A report on the project will be presented at the next Trust Infection Control Committee with a view to endorse adoption of the ISDD Trust – wide.  Initial plans for roll out are in the early stages.  Following on from A & E the adult intensive care unit will be the next department to adopt use of the device.  Further roll out to specialist areas will then follow.  Currently the ISDD is not available in a blood culture pack which is our current practice.  Plans are in place to include it in a pack as our usage increases. The ISDD as a stand alone item is expensive so the project was slow to start. Based on the estimated costs of a false – positive blood culture, savings are estimated to be £28 – 72K for this initial sample.  This has been an exciting project for all of those involved.  The reduction in contamination rates were evident from the beginning.  The ISDD has the potential to not only reduce false – positive blood culture contamination rates and thus generate savings for the Trust but also to have a positive impact for our patients in their hospital journey.

REFERENCES:
1 Dempsey C, Skoglund E, Muldrew KL, Garey KW Economic health care costs of blood culture contamination: A systematic review. American Journal of Infection Control 47 (2019) 963 -967
2 Geisler BP, Jilg N, Patton RG, Pietzsch JB Model to evaluate the impact of hospital hospital-based interventions targeting false false-positive blood cultures on economic and clinical outcomes. Journal of Hospital Infection 102 (2019) 438 -444

Prospective Trial of Passive Diversion Device to Reduce Blood Culture Contamination

Sami Aranout MD1, Richard T Ellison III, MD FIDSA, FSHEA1, Thomas C Greenough MD1, Azalea Wedig BS, CIC1, Michael J Mitchell, MD1, Lauren St. John, B.Math2, and Shannon Stock Ph.D.2
1UMass Chan Medical School, Worcester, MA; 2College of the Holy Cross. Worcester, MA.

Researchers with the University of Massachusetts Chan Medical School documented a clinical study of Kurin blood culture collection sets at UMass Memorial Medical Center. The study summarized the trial data in two ways: when the product was intended to be used and when it was actually used, thereby estimating the role of clinician compliance in the device’s efficacy.

UMass Memorial Medical Center is a three-campus facility with two separate Emergency Departments (ED) based at the two campuses with inpatient units. One campus has a higher level of patient acuity and therefore historically has had much higher rates of blood culture contamination. Both ED sites were involved in the trial, with one ED using Kurin for ten weeks, while the other used their standard collection technique. After a wash out period, the two EDs switched roles.

Approximately 5600 cultures were collected during the trial and about half of those were drawn using a Kurin set. The “observed” contamination rate was reduced from 3% to 1.1% when Kurin was used, representing a 63% decrease. As would be expected, there was no change in true positive rates.

The researchers applied an estimated cost of $7,000 per contaminated culture, yielding a cost savings calculation of $1.8M attributable to the drop in the “observed” rate. Likewise, they reported an increased length of stay of 1.3 days per contaminated culture, which translated to 343 avoided hospital days per year.

Passive Engineering Controls Result in Sustained 66% Reduction in Blood Culture Contamination

Monica Baxter, Carolyn Cook and Angie James from St. Mary’s Regional Medical Center, Russellville, AR.

Background
Blood culture testing is an important diagnostic tool in identifying the presence of microbes in the bloodstream. Tests are frequently contaminated, leading to false-positive results. Blood culture contamination can result in unnecessary antibiotic treatment, extended hospital length of stay, and patient exposure to hospital-acquired conditions.

Methods
St. Mary’s Regional Medical Center (SMRMC) in Russellville, Arkansas, struggled with blood-culture contamination rates, with an average of 6.8% from 2014 to 2018. Ongoing staff education yielded a reduction to an average of 5%. In an effort to reduce the contamination rates, our facility elected to try a novel specimen diversion device. Laboratory and emergency department (ED) staff were educated on the diversion device prior to the initiation of the trial period. Compliance with the diversion device averaged 70%–75% during the trial period. Monitoring of contaminations was added to our daily safety huddle to provide a quick turnaround time for false-positive education to specific clinical staff.

Results
The results were significant, with a decrease in contamination rates from 4.93% to 1.66%—a 66% reduction. Improved blood culture testing has several advantages: best practice for patient care is first and foremost, along with other financial benefits for the facility. Several articles have estimated the cost of a contaminated culture to be $3,000–$10,000 per event; SMRMC has adopting an estimated cost of $4,000. The number of cultures at our hospital averages ~4,400 per year, and these results suggest a savings of >$500,000 per year (as contaminations on an annual basis fell from 217 to 73). With this intervention, 144 patients were spared from receiving unnecessary antibiotics as a result of a false-positive blood culture testing.

Conclusions
We conducted a brief analysis to determine whether there was any obvious change in length of stay for patients with a false-positive blood culture compared to those with true negative results. In analyzing data for 3 different months, patients with contaminated cultures spent an average of 3.97 additional days in the facility. In conclusion, the implementation of this specimen diversion device significantly lowered our contamination rates, was integrated into practice, and has provided clinical and financial benefits.

Download a PDF of this abstract

Preventing Blood Culture Contamination using a Novel Engineered Passive Blood Diversion Device

Jared Sutton, MPH, CIC; Paula Fritsch, MPH, MT, CIC; Marybeth Moody, MT(ASCP), SM; Kesha Dinaro, MSN, RN, CEN; Clinton Holder, MD. Bayfront Health St. Petersburg, St. Petersburg, FL

Introduction
Blood culture contaminants lead to increased empirical antibiotics usage, contributing to antibiotic associated colitis, multi-drug resistant bacteria, and increased risks for drug interactions. Quality improvement programs have led to complex costly blood culture collection bundles, including sterile kits, blood diversion tubes, and advanced skin preps, all with the goal of reducing blood culture contaminants. Despite current interventions contamination continues to occur because bacteria reside deep in the dermis where antiseptics cannot penetrate. This study investigates the efficacy of an engineered passive blood diversion device in preventing blood culture contaminates.

Methods
This quasi-experimental study focused on blood cultures collected by phlebotomy and the emergency department between January and September 2017 (Pre: Jan – April, Post: May – September). The ratio of contamination was evaluated using a chi-square test at a 0.05 alpha level. The intervention was only indicated for vacutainer draws during the study period, but stratifying the pre-intervention data for vacutainer collections was not possible. For this reason, this study focuses on total blood culture contaminants, and not just vacutainer collections. Without stratification, the mentioned results are what a user could expect to reproduce in a “real world” scenario.

Results
Results from 4220 blood cultures were analyzed. The pre- intervention period included 1953 cultures with a contamination rate of 0.025, 95% CI [0.019, 0.033]. The post-intervention period included 2267 cultures and a contamination rate of 0.012, 95% CI [0.008, 0.017]. A chi-square statistic was calculated to examine if the intervention reduced blood culture contamination. The test was found to be statistically significant, X2(1, N = 2852) = 10.979, p < 0.05.

Intervention Design Variations

Blood Culture Contaminant Control Chart

Intervention Cost Analysis

Conclusion
The results suggest that there is a relationship between the proportion of a blood culture contaminants and the type of device used. This may be more apparent given that the intervention was not indicated for all types of blood draws during the study period. It appears that this product can potentially reduce blood culture contaminants, but more research is required.

Study Limitations

  • The studied intervention is not indicated for use for all types of blood draws.
  • Intervention was utilized in 50% of blood draws during the post intervention period.
  • During the first 3 months of post Intervention period, the trial device was not indicated for use in 8 out of 9 contaminated cultures.
  • In the post study period, the device was redesigned to allow for different types of blood cultures (ex. draws from a freshly placed IV).

Download a PDF of this study.

References:
Bekeris, Leonas G., et al. “Trends in blood culture contamination: A College of American Pathologists Q-Tracks study of 356 institutions.” Archives of Pathology and Laboratory Medicine 129.10 (2005): 1222-1225.

Garcia, Robert A., et al. “Multidisciplinary team review of best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremias, reducing contamination, and eliminating false-positive central line–associated bloodstream infections.” American journal of infection control 43.11 (2015): 1222-1237.

Hall, Keri K., and Jason A. Lyman. “Updated review of blood culture contamination.” Clinical microbiology reviews 19.4 (2006): 788-802.

Self, Wesley H., et al. “Cost analysis of strategies to reduce blood culture contamination in the emergency department: sterile collection kits and phlebotomy teams.” Infection Control & Hospital Epidemiology 35.8 (2014): 1021-1028.

Not Your “Average” ED: A CNS-Led Project That Reduced Blood Culture Contaminations in One Emergency Department to Below Expected Levels

Michael Allain, MS, RN, ACNS-BC, CCRN, Crouse Hospital

At the 2018 National Association of Clinical Nurse Specialists Conference, Michael Allain, MS, RN, ACNS-BC, CCRN, emergency services clinical nurse specialist at Crouse Hospital in Syracuse, New York, presented results related to the use of a novel FDA-cleared blood culture collection device that diverts the initial aliquot of blood to help hospitals in their efforts to reduce contaminated blood cultures (CBCs)

According to Allain, contamination makes interpreting results difficult and can cost millions of dollars. To address the issue at Crouse, Allain, in conjunction with the hospital’s phlebotomy manager, implemented strategies to reduce contamination in 2012. They provided department-wide education, limited who drew blood cultures, and closely monitored compliance on monthly basis. The overall contamination rate from 2013-2016 ranged from 2.1% to 1.6%.

In January 2017, the CNS for the emergency department re-evaluated the current state of blood culture collection at the hospital and revised its evidence-based protocol. At the same time, Crouse began using Kurin®, a blood culture collection set with an automated specimen diversion device that diverts skin microbes. Allain reported significant reductions in contaminated blood culture rates and associated costs post intervention. Accounting for the cost of the Kurin device, Allain calculated that the hospital would save more than $185,000 per year.

Allain concluded the abstract acknowledging that even a hospital operating at the acceptable CBC benchmark rate, can further lower their CBC rate with this process improvement inclusive of education, compliance monitoring, and the use of Kurin blood collection device with automated specimen diversion.

In 2018, the National Association of Clinical Nurse Specialists (NACNS) received 267 abstracts for consideration. Every abstract underwent blind peer review by 3 reviewers and their scores were averaged. This abstract was among the highest scoring abstracts submitted to the conference.1

Download a PDF of this study.

1 Horner SD. Top Scoring Abstracts From the 2018 National Association of Clinical Nurse Specialists Annual Conference. Clinical Nurse Specialist. May/June 2018