The Art and Science of Infusion Nursing Theresa Murphy, BS, RN, CRN, VA-BC, CRNI® Deborah Maile, RN, AAS, CIC, CRCST Tara Barsch, BS, MT, ASCP Florence Jerdan, PhD, RN, ANP, CNE

Investigating the Impact of Blood Culture Bundles on the Incidence of Blood Culture Contamination Rates ABSTRACT Blood cultures are integral diagnostic procedures for identifying serious infections and selecting antimicrobials. Positive blood cultures are the initial step in attaining a conclusive diagnosis of sepsis. Relative risk is blood culture contamination, falsepositive blood culture results, diagnostic error delays, treatment errors, excessive lab testing, and increased length of stay. A complicating issue is the increased use of central venous access devices (CVADs). The purpose of this descriptive, comparative study is to evaluate the effectiveness of blood culture bundles on blood cultures drawn through a CVAD and contamination rates. The study revealed a decrease in blood culture contamination rates by 61%. Key words: American Microbiology Association, blood culture bundle, central venous access device, contamination, descriptive comparative design study

BACKGROUND Blood cultures are an integral part of diagnostic measures used for the identification of serious infections and in the selection of appropriate antimicrobial therapy. Positive blood cultures can be the initial step in attaining a critical diagnosis in patients with sepsis. Confirmed results for pathogenic bacteria can potentially decrease exposure to inadequate antibiotics or inappropriate antibiotic use with consequences of multidrug-resistant organisms such as C. difficile, decreased hospital length of stay, and decreased costs. However, a relative risk of obtaining blood cultures is the occurrence of blood culture contamination, which can result in false-positive cultures. Blood culture contamination occurs when organisms that are not present in the blood sample are grown in the culture. It may contribute to diagnosis and treatment errors or delays, excessive laboratory testing, increased length of stay, and increased hospital costs.1,2 Complicating this issue further is the increasing use of central venous access devices (CVADs).

Author Affiliation: John T. Mather Memorial Hospital, Port Jefferson, New York (Mss Murphy, Maile, Barsch, and Jerdan). Theresa Murphy, BS, RN, CRN, VA-BC, CRNI®, is an infusion therapy coordinator responsible for decreasing complications related to peripheral and central venous accesses. She is a national INS and AVA podium and poster presenter and has had her work published in Images, E-Van, and HANYS Quality Initiative. Deborah Maile, RN, AAS, CIC, CRCST, received an associate’s degree in nursing from Suffolk Community College, New York, and is currently pursuing a bachelor’s degree at Delhi State University in New York. She is certified in infection prevention and central sterile. Her focus is on establishing scientifically based infection prevention practices. Tara Barsch, BS, MT, ASCP, holds bachelor degrees in biology and clinical laboratory science from the University of North Carolina at Wilmington and the State University of New York at Stony Brook. She is currently the laboratory quality systems coordinator and research coordinator for the John T. Mather Memorial Hospital’s Department of Clinical Trials. Florence Jerdan, PhD, RN, ANP, CNE, is the nursing research coordinator at John T. Mather Memorial Hospital and an associate professor and coordinator of the graduate nursing program at St. Joseph’s College in New York. The authors of this article have no conflicts of interest to disclose. Corresponding Author: Theresa Murphy, BS, RN, CRN, VA-BC, CRNI®, 75 North Country Road, Port Jefferson, NY 11777 (TMurphy@ matherhospital.org.) DOI: 10.1097/NAN.0000000000000032

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Contamination results from a variety of factors. Two of the major reasons for blood culture contamination include poor collection technique and knowledge deficit. The increasing incidence of contamination rates in blood cultures drawn through CVADs varies from hospital to hospital. Potential methods for addressing high contamination rates have included educational programs, various types of disinfectant, methods of draw, and dedicated phlebotomy teams.3 Although these methods have been somewhat successful, investigations continue into other processes that might be developed to decrease the risk of contamination of blood cultures. One procedure investigated in this study is the use of blood culture bundles. Bundles identify a set of key interventions from evidence-based guidelines that improve patient outcomes when they are implemented.4 For example, sepsis bundles have been shown to be important in the management of patients with septic infections.5 Care bundles for the management of ventilator-associated pneumonia have been used to improve the care processes of patients.6 Insertion and maintenance central-line bundles have been used with success to decrease the rates of catheter-related bloodstream infections.7 The bundles usually consist of elements that must be accomplished during a particular time frame and are based on best evidence.8 The purpose of care bundles is to identify a group or series of interventions or elements that, if implemented in patients with a common disease at specified points in time, will provide consistency in patient care and improve outcomes.9 Few studies have examined blood culture bundles and their impact on contamination rates. In 2 studies, the introduction of a blood culture collection kit significantly lowered the contamination rate. However, the blood cultures were obtained peripherally, not through CVADs.10,11 The blood culture collection kits included blood culture bottles, a safety blood collection set, adapter caps, chlorhexidine wipes, and leaflets with instructions. There have not been any studies on reducing contamination rates in blood cultures drawn through CVADs. At the authors’ institution, the investigation of contamination rates from blood cultures drawn from CVADs revealed a contamination rate above the American Society of Microbiology’s (ASM) benchmark of 3%.12

PURPOSE The purpose of this study was to evaluate the use of blood culture bundles on contamination rates of blood cultures drawn through CVADs.

METHODS A descriptive, comparative design study was conducted at a 248-bed community hospital in New York. The

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study explored the differences in blood culture contamination rates between a group not using the blood culture bundles and a group using the blood culture bundles. All inpatients that met the criteria for a blood culture drawn through a CVAD from October 2010 through May 2011 (before blood culture bundle implementation) and June 2011 through September 2011 (after blood culture bundle implementation) were included in the study. Two additional remonitoring periods were included— November 2011 through December 2011 and December 2011 through January 2012. In addition, blood culture bottles needed appropriate documentation of critical information, which is provided by the legible initials of the registered nurse who took the sample. The concept of a blood culture bundle was developed and implemented to assist registered nurses in obtaining blood cultures from CVADs. The bundle included hand hygiene; a revised policy and procedure for procurement of the blood sample; procedures for adequate labeling and accession of specimens; instructions for the use of the blood culture kit; and staff education, including catheter patency and risk associated with false-positive results; as well as surveillance to monitor contamination of samples and staff reeducation as needed. The contents in the blood culture kit were selected to help ensure that the standard of care to obtain a sample using aseptic technique with sterile equipment was met. The blood culture bundle was designed as a kit within a kit. The outer kit contains instructions for use and 3 prefilled syringes intended to establish catheter patency before opening the inner bundle. The inner sterile kit contains a hand sanitizer wipe, 1 package of three 70% alcohol swab sticks, a 10-mL syringe, a needleless access device, a Vacutainer device (BD), and a mask and gloves. The aerobic and anaerobic culture bottles, specimen labels, and a biohazard bag are distributed to the patient care area by laboratory personnel.

PROTOCOL In May 2010, in collaboration with the Microbiology and Infection Prevention and Control departments, the infusion therapy coordinator explored the concept of creating a blood culture bundle to decrease contamination rates when a nurse obtains a blood culture from a CVAD. A blood culture kit was piloted on the oncology unit to create an optimum blood culture kit and guide the hospital-wide educational plan. The initial step was to determine contamination rates when a blood culture was obtained by a registered nurse before educating the nursing staff. Partnering with the laboratory quality systems coordinator and the infection prevention and control nurse, the rate of contamination was calculated each month from October 2010 to December 2010. The second step of the study

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was the analysis of the posteducation contamination rate, which was calculated from January 2011 to May 2012. The next step of the study was the hospital-wide implementation of the blood culture bundle. The contamination rates were calculated from June 2011 through September 2011 and during 2 remonitoring periods—November 21, 2011, to December 17, 2011; and December 20, 2011, to January 16, 2012. Throughout the third step of the study, registered nurses who obtained blood cultures from CVADs were informed of the results: whether the sample was contaminated, positive for a pathogen, or negative. In instances when the sample was contaminated, the registered nurse who obtained the blood culture was reeducated.

RESULTS A total of 286 blood cultures that met the study’s criteria were included: 97 before the implementation of the bundles, 140 after the implementation of the bundles, and an additional 49 drawn during the remonitoring periods. In Step 1, the rate of contamination for blood cultures obtained from a CVAD was retrospectively analyzed from data for the months of October 2010 through December 2010. A total of 50 blood cultures were analyzed during this 3-month period. Of these, 4 (8.0%) were found to grow contaminants. During Step 2, January 2011 through May 2011, 47 blood cultures were obtained from a

CVAD. Of these, 6 (12.77%) were found to grow contaminants (Figure 1). These results revealed contamination rates well above the ASM benchmark of 3%. Following the implementation of the blood culture bundle, contamination rates were calculated between the months of June 2011 through September 2011. During this period, 140 blood cultures were obtained from a CVAD. Of these, 6 (4.29%) were found to grow nonpathogenic bacteria. To remonitor the effectiveness of the blood culture bundle, data were collected during 2 additional periods. During the first period, 26 blood cultures were obtained from a CVAD, and 1 (3.85%) was found to grow nonpathogenic bacteria. During the second period, 23 blood cultures were obtained from a CVAD; 1 (4.35%) was found to grow nonpathogenic bacteria. Of the 189 blood cultures collected from a CVAD after education and implementation of the blood culture bundles, 8 (4.23%) were found to grow nonpathogenic bacteria. This indicated a 61% decrease in the overall contamination rates of blood cultures drawn from CVADs after implementation of the blood culture bundles (Figure 2). Contamination rates when drawing blood cultures through a CVAD using the blood culture bundle were significantly different from contamination rates in blood cultures not drawn using the blood culture bundle. In this study, a 2-sample, 2-tailed z test to compare proportions was used. The z score was 2.0033 with P = .045, indicating a statistically significant

Figure 1 Time line for rates of contamination for inpatient blood cultures obtained from a central venous access device.

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Figure 2 Blood culture bundle. (Courtesy of Centurion Medical Products, Williamston, MI.)

difference between the 2 groups at the significance level of P = .05.13 This difference can be said to be the result of the implementation of the blood culture bundles. One hundred eight registered nurses completed a survey with the following results: (1) Were the directions easy to follow? One hundred six nurses indicated yes, and 2 indicated no. (2) Did using the blood culture bundle save time? Ninety-three nurses indicated yes, and 13 indicated no. (3) Were you able to find the blood culture bundle on the central supply cart? Ninety-six nurses indicated yes, and 10 indicated no. Two questionnaires were incomplete. In response to the survey findings, the standard supply level on the central supply cart was increased, and the outer package label was changed to yellow for enhanced visibility.

LIMITATIONS Although the work plan to investigate the impact of blood culture bundles on the incidence of blood culture contamination rates was carefully considered, there were unavoidable limitations in this clinical nursing research

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project. The policy at the authors’ facility requires that blood cultures obtained from CVADs be labeled “line draws” and include legible initials of the person obtaining the specimen. If any of this critical information was not included, the blood culture was excluded from the study. Maintaining an adequate and visible supply of blood culture bundles on the nursing units was a challenge at times. In spite of “flags” pointing directly to the location of the blood culture bundles, the nursing staff indicated they were unable to find blood culture bundles. When this occurred, they resorted to previous methods of gathering necessary supplies. The limitations of this research must be kept in the forefront. Nevertheless, a 61% decrease was observed in the contamination rate when blood culture samples were obtained from CVADs using blood culture bundles (Figure 3).

DISCUSSION The ASM recommends a standard blood culture contamination rate equal to or less than 3%.13 The

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Figure 3 Bar graph for comparison of blood culture contamination rates from a central venous access device.

incidence of contamination rates varies from hospital to hospital. Although the cost of a repeat blood culture is easily determined, not all costs can be calculated. A contaminated specimen may increase the length of stay, hospital costs, expenses for the family, administration of unnecessary antibiotics, and the risk of the patient acquiring a central line-associated bloodstream infection as a result of repeated blood sampling. It may also have a financial impact on the patient and family as a result of lost wages and visiting expenses. At the authors’ facility, a retrospective analysis of data suggested an average contamination rate of 12.77% (N = 97) when a blood culture was obtained from a CVAD by a registered nurse. Although studies have been conducted to examine blood culture bundles and contamination rates, they were conducted when the blood culture was obtained peripherally. This descriptive, comparative design study examined blood cultures obtained from a CVAD by a registered nurse before and after the implementation of a blood culture bundle. To ensure that the standard of care is met, a blood culture bundle was created to obtain a sample from a CVAD using aseptic technique with sterile equipment. The oncology nursing unit was selected to pilot the blood culture bundle. Information from registered nurses facilitated revising the policy and procedure, clarifying the blood culture bundle instructions for use, improving the bundle design, and identifying the need for readily available resources. During the pilot, knowledge deficits were identified, and a teaching plan was

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developed to educate the nursing staff throughout the hospital regarding the standard of care for obtaining a blood culture sample from a CVAD. Following the implementation of the blood culture bundle, the registered nursing staff was informed of the results, whether the sample was contaminated or positive for a pathogen or negative. At the same time, a survey was conducted to assess nurse satisfaction and improve the process as indicated; in the event that nonpathogenic bacteria were detected, the procedure was reviewed with the nurse. The buy-in from staff was phenomenal. They would contact the lead investigator and let her know they had collected a blood culture and wanted to know the results. In addition, when nurses were asked what had been done to help them do their job, they responded “the blood culture bundle.” Following implementation of the blood culture bundle, the calculated contamination rate plummeted to 4.23%. Despite being an impressive achievement, our goal is to exceed or at the very least maintain the ASM benchmark. During the past 1½ years, it has been rare that a blood culture has been contaminated. However, the authors will continue to audit blood cultures obtained by registered nurses from CVADs. There will be followup on contaminated cultures to determine the potential cause of contamination. Education regarding the critical nature of obtaining a blood culture is conducted when a nurse is hired and each year thereafter, as well as on the spot as it relates to a specific patient and nurse.

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In summary, this project resulted in a 61% reduction in the contamination rate when blood cultures were obtained from CVADs using a blood culture bundle. The use of the blood culture bundle was clearly endorsed when an infectious disease physician commented that the blood culture bundle gave him 1 day of knowledge he did not have before, and a nurse noted that the bundle made her “do the right thing.” ACKNOWLEDGMENTS The authors acknowledge the assistance of Richard A. Wymbs, MS, MT (ASCP), microbiology supervisor at John T. Mather Memorial Hospital, and Raymond P. Luttinger, MSN, ANP, CIC, the hospital’s infection prevention and control coordinator. REFERENCES 1. Alahmade YM, Aldeyab MA, EcElnay JC, et al. Clinical and economic impact of contaminated blood cultures within the hospital setting. J Hosp Infect. 2011;77(3):233-236. 2. Waltzman M, Harper M. Financial and clinical impact of falsepositive blood culture results. Clin Infect Dis. 2001;33(3): 296-299. 3. Hall K, Lyman JA. Updated review of blood culture contamination. Clin Microbiol Rev. 2006;19(4):788-802. 4. Fulbrook P, Mooney S. Care bundles in critical care: a practical approach to evidence-based practice. Nurs Crit Care. 2003;8(6): 249-255.

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5. Khan P, Divatia JV. Severe sepsis bundles. Indian J Crit Care Med. 2010;14(1):8-13. 6. Rello J, Chastre J, Cornaglia G, Masterton R. A European care bundle for management of ventilator-associated pneumonia. Intensive Care Med. 2010;36(5):793-780. 7. Kim J, Holtom P, Vigen C. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: epidemiologic and economic consequences. Am J Infect Control. 2011;39(8):296-299. 8. Institute for Healthcare Improvement. Bundle up for safety. http:// www.ihi.org/resources/Pages/ImprovementStories/BundleUpforSafety .apsx. 9. Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2012. 10. Thomas S, Cheesbrough J, Plumb S, et al. Impact of blood culture collection kit on the quality of blood culture sampling: fear and the law of unintended consequences. J Hosp Infect. 2011;78(4): 256-259. 11. Bamber AI, Cunniffe JG, Nayar D, Ganguly R, Falconer E. Effectiveness of introducing blood culture collection packs to reduce contamination rates. Brit J Biomed Sci. 2009;66(1):6-9. 12. Clinical and Laboratory Standards Institute. Principles and Procedures for Blood Cultures: Approved Guidelines. CLSI document M47-A. Wayne, PA: Clinical and Laboratory Standards Institute; 2007. 13. Centers for Disease Control and Prevention. Compare Two Proportions. http://sdn7.cdc.gov/nhsn/ratecalculator.do?method =showpagessubstractiojn=twoproportions&navreset=true7currentmenu =menu_anal_gen&nhsnsessionID=995/.

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Investigating the impact of blood culture bundles on the incidence of blood culture contamination rates.

Blood cultures are integral diagnostic procedures for identifying serious infections and selecting antimicrobials. Positive blood cultures are the ini...
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