Objective: Blood culture is an important laboratory test to determine bacteremia in Fungemia in patient's blood. Frequent blood culture contamination (BCC) leads to unnecessary treatment, waste of laboratory resources, and false-positive blood culture. The College of American Pathologist Accreditation states that monitoring of BCC rate should be within average 2%–3%. Based on May 2015 to May 2016 data at King Khalid University Hospital, it showed that we had experienced a consistent increase in BCC rate with an average of 4.6%. Emergency department (ED) had the highest contamination rate (5.7%). The aim of this study was to reduce the rate of contamination to <2%. Methods: A multidisciplinary quality team has been formed, (IHI) the institute for healthcare improvement model, used for improvement and other relevant quality tools for testing and implementing the choice of solution. Several plan-do-study-act (PDSA) cycles have been conducted to test the proposed solutions. All PDSA cycle data on the project measures were extracted from the lab information system to be analyzed and presented on run and control charts. Results: Over a 6-month period, a reduction in the BCC rate at the emergency department (ED) of the University Hospital reached 1.5% compared with the baseline at 4.0%. There was a significant reduction in BCC in the adult ED, which reached zero rates. However, BCC in the pediatrics ED was reduced to 1.5%, resulting from changes that were proposed, tested, and implemented during the running period. Essentially, the results of this initiative both met and exceeded the benchmark by 2%–3%. Conclusion: Standardizing work processes based on updated policy and procedures, conducting regular audits, and sending feedback are practical evidence-based strategies that lead to reducing BCC in the ED.
Monitoring blood culture contamination (BCC) is an important quality assurance indicator of the laboratory's performance. According to the College of American Pathologists' (CAP) accreditation standards, the expected BCC should not exceed 3% of all collected and analyzed blood samples as a laboratory quality performance benchmark. However, a recent analysis at King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia, experienced a high rate of contaminated blood cultures across all hospital units. Based on the data which were retrospectively collected, the overall average contamination rate was shown to be 4.6% over the last 6 months [Figure 1]. Further analysis was done on each hospital unit, and the results of the analysis revealed that the emergency department (ED) has a higher contamination rate than that of the Intensive Care Unit [Figure 2].
The project setting was at the ED at KKUH affiliated with King Saud University Medical City (KSUMC) in Riyadh, Kingdom of Saudi Arabia, which is an 850-bed facility with a total of 125 new admissions per day. Thus, our primary improvement aim was to reduce the rate of contamination to <3%, meeting at least the CAP standards and standardizing the existing practice of blood culture specimen collection based on the updated Administrative Policies and Procedures (APPs).
The process of collecting blood samples affects the quality of the specimen. Thus, emphasis should be placed on honing the necessary skills needed for this practice. Moreover, standard process and procedures need to be observed to prevent laboratory error, patient injury, and even death. For example, a nurse who fails to observe proper hygiene would increase the chances of contamination by merely touching the patient to verify the location of a vein before insertion of the needle to collect the specimen. This can cause false blood culture results, which would require prolonged hospitalization of the patient, delayed diagnosis, and waste of valuable laboratory resources, and may lead to a poor treatment plan and the unnecessary use of antibiotics. Clerical errors in completing the relevant forms and identifying patients are both common and costly, although such errors are preventable. Other forms of error include bruising at the site of puncture, fainting, nerve damage, and hematomas. Hence, it has been recognized that BCC is a significant quality problem in our laboratory and within the hospital as well. Thus, action should be implemented immediately to improve our laboratory performance to meet international best practices, recommendations, and benchmarks.
BCC is a significant quality and safety issue leading to false-positive blood culture, resulting in an increase in the length of stay, unnecessary treatment, waste of resources, and added cost to the patient. A study of Alahmadi et al. indicated that 254 patients with false-positive blood cultures added 1372 extra hospital days and increased hospital costs of £1,270,381 ($1,905,572) per year. The rate of BCC should be continuously monitored to keep it within both the recommended international and CAPs' accreditation standards of <3%.[4,5] Previous studies that have outlined several interventions to reduce peripheral BCC rates have stated the importance of developing an interdisciplinary method with the fundamental aim of reducing the contamination rate to <3%.[6–9]
Recent studies have suggested that intervention can be divided into three types of best practice. First, intervention which involves changing the technique of blood culture specimen collection from the traditional clean procedure to a new sterile procedure, with the use of standardized sterile gloves and a new material kit containing a 2% chlorhexidine skin antiseptic device, a sterile fenestrated should be implemented.[8,9] Second, the next best practice recommendation is a strong reinforcement of education and training of all phlebotomists and nursing staff who are responsible for blood culture collection. These include private conversations and disciplinary counseling with individual staff members in relation to areas identified with higher or significant numbers of contaminated draws. Dialog with head nurses and service managers in their respective service areas, giving them monthly feedback. Lastly, decreases in BCC have been observed with the implementation of an observational retrospective study to evaluate the effects of routine labeling of blood culture bottles with the initials of the health-care worker who drew them, followed by individualized feedback on BCC rates.
Figure 1 shows a consistent increase in the rate of BCC at KKUH. As a result of this finding, further analysis was done per hospital unit to determine which area has the highest contamination rate. Figure 2 shows that the ED has a higher contamination rate followed by the Surgical Intensive Care Unit. As part of the assessment, 120 nurses were randomly selected as respondents to participate in the competency-based examination and survey questionnaires to assess knowledge of nurses in different areas of hospital in education and training programs. The training stressed the importance of the strict compliance of nurses to the best practices of blood collection or phlebotomy, which include maintaining hand hygiene, using a recommended disinfectant solution, and observing a certain time period of skin disinfection. The training program also recommended using personal protective equipment and an appropriate technique of blood collection. Posttraining assessment results revealed that 100% of nurses do their hand washing before and after collection, but only 87.5% used chlorhexidine with 70% isopropyl as recommended. Incidentally, 38% of nurses allowed the disinfectant solution to dry completely for 30 s. The results revealed that nurses are aware of the necessary steps and criteria in collecting blood samples, but they lack the knowledge of the prescribed time period of disinfecting the skin and drying the skin after application of the solution.
Choice Of Solution
Review and update all blood culture collection APPs and transition the content into visible reminder posters, and review and update the supervisor performance checklist and external quality auditing and feedback tool pertaining to the whole BCC during three different blood collection procedures. Such procedures typically involve the central venous catheter, pediatric umbilical artery catheter, and peripheral venipuncture intravenous cannulation.
Conduct awareness campaign among hospital staff regarding the processes involved in BCC and appropriate blood culture collection methods by providing lectures and training to all nurse educators in order to facilitate and translate all information of the updated APP to all nurses in their units.
Conduct supervisory performance assessment using a supervisor checklist that constitutes the best practices based on the updated APP of collecting blood culture specimens to ensure that all staff strictly adhere to the updated APP contents.
Schedule weekly meetings with service managers and head nurses from the ED to discuss the results of measures put into place and to define any BCC results in order to inform the quality team for remedial action using plan-do-study-act (PDSA) cycle approach.
Sending monthly feedback from the Microbiology Department to the relevant hospital departments informing them about the improvement in BCC rates.
Conduct just-in-time in-service training and education for staff nurses if needed.
Several PDSA cycles have been conducted to test the choice of solution and the improvement ideas as follows.
Formed a core team to take the lead reviewing and updating the existing policy and procedures on BCC to become part of standard hospital policy and practice. The core quality team members reviewed and approved the content of the updated policy and then submitted to the quality department to finalize the process. The quality team produced the updated policy and procedures with clear, simple explanations regarding collecting blood for culture purposes, compliance with standard aseptic techniques in all four procedures (venipuncture, peripheral, central venous catheter, and pediatric umbilical artery catheter), and clear regulations were set relating to the adherence of the new policy by all staff members. Then, the updated content of the best practices in updated APP was transformed into visible posters and placed in the designated areas for blood collection in the ED to keep staff nurses reminded of the correct and appropriate technique for blood collection.
Regular meetings were held to spread awareness of blood sample contamination rates among service managers, head nurses, and nurse educators in the ED. Key leaders were selected in each service area to be trained in order to provide expert guidelines on what is considered the best practice in BCC. In addition to the above, several seminars and a workshop entitled, “Train the Trainers in Infusion Therapy and Phlebotomy” were conducted at KSUMC. Strict compliance with universal standard aseptic techniques during blood collection were requested by all staff across the units.
This step includes developing and implementing the checklist of best practices that served as a quality assurance measure to all nurses and phlebotomists, summarizing the necessary steps during blood collection to increase compliance with aseptic technique procedures.
This includes conducting weekly auditing by quality coordinators using a standardized audit checklist created by the project team based on the updated policy and procedures. Anyone who was found to be noncompliant with the new policy was reported to head nurses, pending for further investigation.
Monthly feedback was required to be sent by microbiology laboratory department regarding the rate of BCC to highlight those areas with the highest and lowest BCC rates.
As shown clearly in the control chart [Figure 1], the changes that were implemented as a result of the project led to a noticeable reduction in the contamination rate of blood cultures. After implementation of the first choice solution, there was a significant reduction in the contamination rate of blood cultures from 4.6% to 3.9% in the hospital overall and from 3.6% to 2.1% in the ED. Then, after introducing the supervisory checklist, the contamination rate of blood cultures dropped and reached 3.1% at hospital level and 2.3% at ED level. The continuity of the improvement efforts led to a hugely successful outcome in the adult ED, where a contamination rate reached 0 and decreased to 1.7% at the hospital level [Figure 5].
Lessons Learned and Limitations
This is a large-scale project focused on reducing the rate of BCC in KSUMC Hospital, which resulted in a significant improvement in BCC. Several lessons have been learned as a result of this initiative. Initially, frontline staff members were critical to the success of the project. However, implementing an evidence-based policy and promoting best practices guided by clinical guidelines, along with a supervisory checklist, regular auditing, and feedback prompted change in BCC rates. The key aspect of this project was that the provision of frequent feedback to ED staff had a profound effect on their valuable contribution to discussions regarding the main causes of BCC. Sharing proposed solutions and getting feedback from staff on a regular basis about the impact of changes and ideas using the appropriate visual aids, such as run and control charts, were paramount in completing the project and achieving the desired outcomes. Although this project has been conducted in one of the leading largest teaching hospitals, we are not sure about the generalizability of the findings to other teaching hospitals in Saudi Arabia and beyond.
Testing and implementing policies and best practices using the quality improvement methods and tools through simple and rapid PDSA cycles in the ED resulted in a significant reduction in contamination rates of blood culture samples. Implementing quality improvement projects about blood contamination rates in the ED achieved noticeable reduction in the rate of BCC, reaching 1.5% compared with a baseline of 4.0% over a 6-month time period in which changes were implemented. Moreover, at a hospital-wide level, the figure reached 1.7% as a result of implementing the project's recommendations. Most encouragingly, this result exceeded the CAP benchmark of 2%–3%.
Financial support and sponsorship
The authors disclosed no funding for this article.
Conflicts of interest
The authors disclosed no conflicts of interest.
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