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.

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.

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.”

Sami Arnaout 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.

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.