Poster - #2022UCDH-18 - Keywords: Blood Culture Contamination Emergency Department Projects Quality Improvement Antimicrobial Stewardship Microbiology

Reducing Blood Culture Contamination Rate in the Emergency Department

Charlotte Marcelino, MAN, RN, CEN, CPHQ and Jan Shepard, MSN, RN, CCRN-K, CSSGB
UC Davis Health

ABSTRACT:
Blood Culture Contamination in the Emergency Department Charlotte Marcelino, RN, MAN, CEN, CPHQ and Jan Shepard, MSN, RN, CCRN-K, CSSGB March 2022 Background: Contaminated blood culture may have detrimental effects to the patient (as it may result to unnecessary or delayed treatment), the organization and to antimicrobial stewardship efforts (Hughes et al. 2018). The Emergency Department (ED)’s blood culture contamination rate was noted to be above the target rate of 2.5%, ranging from 2.79% to 7.28% from 2018 to 2020. Reducing blood culture contamination aligns with ED’s strategic quality and financial stewardship goals. The department worked robustly to improve this metric using evidence-supported practice changes. In some studies (Self et al. 2014 and Doern et al. 2020), the use of blood culture collection kits and standardized procedures have been associated with a significant decrease in blood culture contamination. Surveillance and feedback systems have also shown to result in improved blood culture contamination rates, particularly when contamination rates are reported in a timely manner and directed individually to those who collected the sample (Hopkins et al. 2013; Lin et al. 2012). Purpose: It is the intention of this document to share the initiatives the department has taken to address blood culture contamination. This initiative aims to improve the department’s blood culture contamination rate through practice change and control measures and will eventually benefit the department and organization, from a financial standpoint; and ultimately, for the patients who will receive timely and proper antimicrobial therapy. Methods: A multidisciplinary team (consisted of ED Leadership, Clinical Nurse Leaders, Clinical Resource Nurses, Clinical Nurses, Infection Prevention, Quality and Safety, Laboratory) started to work collaboratively to improve this metric since 2018. Interventions were implemented by phases and continued throughout the project period. (1) Identified causes of increased contamination rates; (2) Increased staff awareness and reinforced education; (3) Validated reports; (4) Looked into “diversional device” or a passive device that sidelines skin contaminants (i.e. Kurin device) – intervention not selected due to cost; (5) Explored utilizing dedicated phlebotomist – not successful due to staffing challenges; (6) Added Best Practice Alert to draw Blood Culture samples for Sepsis Analytic Model (SAM) score > 8; (7) Improved skin antisepsis process and sample collection kit creation; (8) Developed standardized procedures or KATA card; (9) Optimized data available (determining contamination rate for each sample collector); (10) Solicited feedback to individuals with contaminated samples; (11) Created an Instruction Video for reference; (12) Incorporated content to Orientation Program; (13) Focused on Central Line source; and (14) BEST Rewards Recognition and Escalation of non-compliance for leadership intervention (implemented repeat check-off requirement and incorporated element in performance appraisal). Contamination rate before and after feedback intervention and contamination rate difference based on source were analyzed using Test of Significance via Chi Squared. Results: The first phase (2018) described by contamination cause identification, summarizing standardized procedures in KATA Card, together with teaching and coaching, did not show improvement in contamination rate. The second phase (2019) started to show less variation though the average remained at the same rate. The third phase (2020) denotes fluctuation and increased practice variation (indicated by widening control limits). The fourth and fifth phases (January 2021 to February 2022) indicate notable decrease in average rate and progressive narrowing of practice variation. Blood culture contamination rate was also compared six months before (March to August 2021) and six months during (September 2021 to February 2022) feedback intervention and showed significant decrease (3.52% pre-intervention and 2.95% post-intervention; p<0.45). From March 2021 to February 2022, blood culture contamination rate significantly differed based on source of blood culture draw (7.64% via line, 3.05% via peripheral and 4.53% via other; p<0.01). Conclusion: In this four-year period, ED only reached the target rate on four occurrences. Though keeping the rate ≤ 2.5% has been a challenge with remarkable staff transition, volume / variety and acuity of patients; the department is making progress in gradually reducing the contamination rate and narrowing practice variation. Future direction is headed to sustaining progress, reinforced coaching and feedback and more focus on other sources (i.e., central line, PICC, etc.) Acknowledgement: UC Davis Health Emergency Department Leadership, Unit-Based Practice Council, Clinical Resource Nurses (CN IIIs) and Sarina Fazio, PhD, RN References: 1. Hughes, J.A., Cabilan, C.J., Williams, J., Ray, M., & Cpyer, F. (2018). The effectiveness of interventions to reduce peripheral blood culture contamination in acute care: a systematic review protocol. Systematic Reviews, 7 (216), 1-6. 2. 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. 3. Doern, G.V., Carroll, K.C., Diekema, D.J., Garey, K.W., Rupp, M.E., Weinstein, M. P., & Sexton, D.J. (2020). A Comprehensive Update on the Problem of Blood Culture Contamination and a Discussion of Methods for Addressing the Problem. Clinical Microbiology Review, 3(1), 1-21. 4. Hopkins, K., Huynh, S., McNary, C., Walker, A., Nixon, R., & Craighead, J. (2013). Reducing blood culture contamination rates: A systematic approach to improving quality of care. American Journal of Infection Control, 41, 1272-1274. 5. Lin, C.M., Lee, W.S., Lin, F.Y., Yu, F.L., Ou, T.Y., & Teng, S.O. (2012). Reducing Blood Culture Contamination Rates by Educational Intervention and one-on-one Feedback in the Emergency Department. Journal of Experimental and Clinical Medicine, 4(3), 154-156.