Sami Arnaout, Shannon Stock, Julia M Clifford, Thomas C Greenough, Azalea Wedig, Michael J Mitchell, and Richard T Ellison. UMass Memorial Medical Center

Background
Blood culture contaminants can lead to inappropriate antibiotic use, prolonged length of stay, and additional hospital costs. Several devices have been developed to reduce the risk of blood culture contamination by diverting a portion of the initial blood sample from the blood culture bottle. We assessed the effectiveness of 1 blood diversion device (BDD) in a prospective trial performed at the 2 separate emergency departments (EDs) of an academic medical center.

Methods
A multiphase prospective crossover trial was performed with the BDD in use at 1 ED and standard equipment at the other ED for 10 weeks, and a second 10-week study phase was conducted with the use of the BDD and standard equipment in the EDs reversed. Contaminants were identified both by standard clinical microbiology lab criteria and by independent retrospective review by 3 infectious disease (ID) physicians. The primary analysis was performed based on intention-to-use data using the physician review of positive blood cultures.

Results
A total of 5637 blood samples were obtained, with 5625 samples analyzed after 12 blood culture results were deemed inconclusive by the ID physician review. The University ED had a higher blood culture contamination rate of 2.9% compared with the Memorial ED at 1.4%. In an intention-to-use analysis, the overall contamination rates were 2.0% and 2.9% in the BDD and standard equipment periods, respectively (P =.03), and in an actual-use analysis the contamination rates were 1.2% and 3.0% for the BDD and standard equipment, respectively (P < .001).

Conclusion
The BDD was associated with significantly lower blood culture contamination rates at the institution’s 2 EDs, with a stronger effect noted at the campus caring for higher acuity patients.

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.

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.

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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.”