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Kim TW, Lee SU, Park B, Jeon K, Park S, Suh GY, Oh DK, Lee SY, Park MH, Lee H, Lim CM, Ko RE. Clinical effects of bacteremia in sepsis patients with community-acquired pneumonia. BMC Infect Dis 2023; 23:887. [PMID: 38114902 PMCID: PMC10729397 DOI: 10.1186/s12879-023-08887-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 12/09/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Data regarding the clinical effects of bacteremia on severe community-acquired pneumonia (CAP) are limited. Thus, we investigated clinical characteristics and outcomes of severe CAP patients with bacteremia compared with those of subjects without bacteremia. In addition, we evaluated clinical factors associated with bacteremia at the time of sepsis awareness. METHODS We enrolled sepsis patients diagnosed with CAP at emergency departments (EDs) from an ongoing nationwide multicenter observational registry, the Korean Sepsis Alliance, between September 2019 and December 2020. For evaluation of clinical factors associated with bacteremia, we divided eligible patients into bacteremia and non-bacteremia groups, and logistic regression analysis was performed using the clinical characteristics at the time of sepsis awareness. RESULT During the study period, 1,510 (47.9%) sepsis patients were caused by CAP, and bacteremia was identified in 212 (14.0%) patients. Septic shock occurred more frequently in the bacteremia group than in the non-bacteremia group (27.4% vs. 14.8%; p < 0.001). In multivariable analysis, hematologic malignancies and septic shock were associated with an increased risk of bacteremia. However, chronic lung disease was associated with a decreased risk of bacteremia. Hospital mortality was significantly higher in the bacteremia group than in the non-bacteremia group (27.3% vs. 40.6%, p < 0.001). The most prevalent pathogen in blood culture was Klebsiella pneumoniae followed by Escherichia coli in gram-negative pathogens. CONCLUSION The incidence of bacteremia in severe CAP was low at 14.0%, but the occurrence of bacteremia was associated with increased hospital mortality. In severe CAP, hematologic malignancies and septic shock were associated with an increased risk of bacteremia.
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Affiliation(s)
- Tae Wan Kim
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea
| | - Se-Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Boram Park
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Kyeongman Jeon
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dong Kyu Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Soo Yeon Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Mi Hyeon Park
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Haein Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea.
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Hjelmgren H, Heintz E, Ygge BM, Andersson N, Nordlund B. Direct costs of blood drawings with pre-analytical errors in tertiary paediatric hospital care. PLoS One 2023; 18:e0290636. [PMID: 37624763 PMCID: PMC10456202 DOI: 10.1371/journal.pone.0290636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 08/02/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Blood drawings is a common hospital procedure involving laboratory and clinical disciplines that is important for the diagnosis and management of illnesses in children. Blood drawings with pre-analytical error (PAE) can lead to increased costs for hospitals and healthcare organisations. The direct cost of blood drawings after a PAE is not fully understood in paediatric hospital care. AIM The aim of this study was to estimate the average direct cost of PAE per year and per 10,000 blood drawings in tertiary paediatric care. METHODS A cost analysis using a bottom-up approach was conducted on the basis of combined information from the hospital's laboratory register for the period 2013-2014 and clinical in-ward observations at a tertiary children's referral hospital in Sweden, the Astrid Lindgren Children's Hospital. For the analysis, we hypothesised the re-collection of all blood drawings with PAE and included the average costs of the sampling materials, the time of the healthcare personnel, the laboratory analyses, and in-ward premises based on the time spent on the blood sampling procedure. RESULTS The annual cost of PAE was estimated to be 74,267 euros per 54,040 blood drawings, which corresponds to 13,756 euros per 10,000 blood drawings or 1.5 euros per draw. The personnel cost represented 60.1% (45,261 euros per year) of the cost due to PAE, followed by costs for hospitalisation (25.2%), laboratory analyses (8.1%), and materials (5.7%). CONCLUSION PAEs lead to substantial increases in the costs in tertiary paediatric hospital care. If these PAEs can be avoided, costs related to the re-collection of blood drawings with PAE may be re-allocated to other health-promoting activities for children visiting hospital institutions.
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Affiliation(s)
- Henrik Hjelmgren
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
| | - Emelie Heintz
- Department of Learning, Informatics, Management and Ethics, Karolinska Institute, Stockholm, Sweden
| | - Britt-Marie Ygge
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
| | - Nina Andersson
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
| | - Björn Nordlund
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
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Butala N, Berkwitt A, Osborn R. Contamination Frustration: Considering Value-Based Approaches to Manage Contaminated Cultures. Hosp Pediatr 2022; 12:e414-e417. [PMID: 36305208 DOI: 10.1542/hpeds.2022-006819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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Povroznik MD. Initial Specimen Diversion Device Utilization Mitigates Blood Culture Contamination Across Regional Community Hospital and Acute Care Facility. Am J Med Qual 2022; 37:405-412. [PMID: 35353719 PMCID: PMC9426727 DOI: 10.1097/jmq.0000000000000055] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A West Virginia regional community hospital incorporated an initial specimen diversion device (ISDD) into conventional blood culture protocol with the objective to bring the hospital-wide blood culture contamination (BCC) rate from a 3.06% preintervention rate to a target performance level below 1%. Emergency department staff, laboratory phlebotomists, and nursing staff on acute-critical care floors were trained on ISDD (Steripath Gen2, Magnolia Medical Technologies, Inc., Seattle, WA) operating procedure and utilized the device for blood culture sample collection with adult patients from September 2020 through April 2021. Of 5642 blood culture sets collected hospital-wide, 4631 were collected with the ISDD, whereas the remaining sets were collected via the conventional method. The ISDD BCC rate of 0.78% differed from the conventional method BCC rate of 4.06% observed during the intervention period (chi-squared test P < 0.00001). The ISDD group attained a sub-1% BCC rate to satisfy the intervention objective.
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Affiliation(s)
- Mark D. Povroznik
- Department of Quality, WVU Medicine: United Hospital Center, Bridgeport, WV
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Minami K, Yamada T, Yoshioka K, Kawanishi F, Ogawa T, Ukimura A. Effect of the introduction of a management bundle for blood culture collection. Am J Infect Control 2022; 50:772-776. [PMID: 34863897 DOI: 10.1016/j.ajic.2021.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Inappropriate blood collection subjected to blood culture (BC) causes BC contamination and may complicate the diagnose is of infectious diseases. Therefore, we developed a bundle based on the guideline recommendations for appropriate blood collection and examined the effects of bundle introduction. METHODS We performed a retrospective analysis of BC samples to determine the contamination rates before and after introducing the BC bundle. We also analyzed the correlation between the compliance rate of the bundle and contamination rate, and between each bundle element and contamination. RESULTS After the introduction of the bundle, the contamination rate was significantly reduced from 5.4% ± 0.9% to 1.7± 0.7% (P < .01). The compliance rate of the bundle was significantly associated with a lower contamination rate (P < .01). Multivariable logistic regression showed that collection from superficial veins of the cubital fossa (odds ratio [OR], 0.25; 95% confidence interval [CI], 0.13-0.51, P < .01) and disinfection of the skin at the blood collection site with 1% chlorhexidine alcohol swab (OR, 0.41; 95% CI, 0.25-0.68, P < .01) were significantly associated with lower contamination. CONCLUSIONS This study suggests that the introduction of the BC bundle significantly reduced the contamination rate, and bundle compliance was associated with a lower contamination rate.
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Affiliation(s)
- Kenta Minami
- Infection Control Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan; Department of Central Clinical Laboratory, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan.
| | - Tomoyuki Yamada
- Infection Control Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan; Department of Pharmacy, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
| | - Kyouhei Yoshioka
- Infection Control Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
| | - Fumiko Kawanishi
- Infection Control Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
| | - Taku Ogawa
- Infection Control Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan; Department of Microbiology and Infection Control, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Akira Ukimura
- Infection Control Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan; Department of Central Clinical Laboratory, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
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6
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Sacchetti B, Travis J, Steed LL, Webb G. Identification of the main contributors to blood culture contamination at a tertiary care academic medical center. Infect Prev Pract 2022; 4:100219. [PMID: 35692894 PMCID: PMC9184864 DOI: 10.1016/j.infpip.2022.100219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022] Open
Abstract
Background Blood culture contamination poses an issue to all hospital systems worldwide because of the associated costs of extended length of stays, unnecessary antibiotic therapy, and additional laboratory testing that are preventable with proper handling and collection techniques. Methods In our study, multiple units, staff, and collection methods were compared to determine the primary culprits of contamination from a tertiary care academic medical center, which includes a pediatric hospital and both adult and pediatric emergency departments. Results Over 33 months, 2,083 out of 88,322 total blood cultures collected were contaminated, with an overall contamination rate of 2.4%. A moderate positive correlation was found between the monthly total number of cultures and monthly contamination rate (r = 0.411 P < .01). The most notable factors associated with contamination were found to be phlebotomy teams (2.7%) (P < .01), peripheral draws (2.3%) (P <.01), adult emergency departments (2.6%) (P < .01), and pediatric intensive care units (2.7%) (P < .01). A positive correlation was present between the number of hospital beds per unit and unit contamination rates (r = 0.429 P < .01). Conclusion Our results were used to make recommendations for decreasing the rate of blood culture contamination in this institution, which includes acknowledgement of an overwhelmed staff and mandatory periodic training on acceptable aseptic technique and contamination awareness. Understanding the factors contributing to blood culture contamination can aid efforts to reduce contamination rates.
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Blood Culture Contamination: A Single General Hospital Experience of 2-Year Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19053009. [PMID: 35270715 PMCID: PMC8910491 DOI: 10.3390/ijerph19053009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 01/25/2023]
Abstract
In the event of blood culture contamination (BCC), blood culture (BC) needs to be repeated. This may delay appropriate treatment, prolong hospitalization and, consequently, increase its costs. The aim of the study was to assess the frequency of BCC and associated factors in a general hospital in Poland based on reports of BC in samples submitted for laboratory testing in 2019−2020. BCC is recognized when bacteria (especially those belonging to natural human microbiota) are isolated from a single sample and no clinical signs indicated infection. True positive BC is confirmed by the growth of bacteria in more than one set of blood samples with the corresponding clinical signs present. The structure of BC sets, microorganisms, and laboratory costs of BCC were analyzed. Out of 2274 total BC cases, 11.5% were true positive BC and 9.5% were BCC. Of all the BCC identified in the entire hospital, 72% was from Internal Medicine (IM) and Intensive Care Unit (ICU) combined. When single sets for BC were used in IM in 2020, the use increased to 85% compared with 2019 (p < 0.05). The predominant isolates were coagulase-negative staphylococci (84%). The estimated extra laboratory costs of BCC exceeded EUR 268,000. The BCC was a more serious problem than expected, including non-recommended using of single BC sets. Compliance with the BC collection procedure should be increased in order to reduce BCC and thus extra hospital costs.
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Sastry A, Shaji R, Madigubba H, Priyadarshi K, Anandh P, Nathan B, Vivekanandan M. Effectiveness of multimodal intervention to improve blood culture collection in the emergency department. J Glob Infect Dis 2022; 14:10-16. [PMID: 35418732 PMCID: PMC8996457 DOI: 10.4103/jgid.jgid_138_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/20/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction: The blood culture (BC) contamination was a significant problem in our hospital, especially in the emergency department (ED). The study, therefore, was undertaken to improve the BC collection in the ED. Methods: The study was conducted for 1 year divided into two phases of 6 months each: Preintervention phase and intervention phase (regular and phlebotomist groups). The interventions comprised implementing standard protocol for BC collection and conducting educational sessions. In preintervention and regular groups, the BCs were collected by interns and technicians, while dedicated phlebotomist did so in the phlebotomist group. Data were analyzed and interpreted for the contamination rate as well as compliance in adequate filling of the requisition form. Statistical Package for the Social Sciences (SPSS) version 22. A value of P < 0.005 was considered statistically significant, and P < 0.01 was considered statistically significant. Results: In the preintervention group, 13.7% of specimens were reported as contaminated which was reduced to 4.2% and 3.2% in the regular and phlebotomist group, respectively, after intervention. Compliance of health-care workers to various elements of BC collection protocol was also found to be significantly improved in the intervention phase compared to the preintervention phase (P < 0.001). Conclusions: Implementation of this multimodal intervention resulted in a drastic reduction in BC contamination and improvement in compliance to BC collection protocol and filling of various parameters in the BC requisition form, thus improving the overall effectiveness of BC testing. It was also noted that the contamination rate was further reduced by implementing dedicated phlebotomist.
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Impact of sterile gloves on blood-culture contamination rates: A randomized clinical trial. Am J Infect Control 2022; 50:49-53. [PMID: 34492326 DOI: 10.1016/j.ajic.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Reducing the blood-culture contamination rate is a constant challenge for health services. This study aimed to analyze whether blood-culture (BC) collection using sterile gloves reduces the contamination rate when compared to the non-sterile gloves, and to compare baseline and intervention periods. METHODS A randomized clinical trial, performed in an intensive care unit in Brazil and paired in two groups: sterile (BCs obtained with modified sterile technique: only sterile gloves; no fenestrated drape or dedicated sterile collection kit) and clean (clean technique: usual care with non-sterile gloves). Two paired blood samples were obtained from each patient by trained and calibrated nurses. BCs were processed by conventional microbiological methods and the results were issued by blinded microbiologists. RESULTS There was no difference (P = 1.00) in the contamination rate of BC between the sterile (1%) and clean (1%) groups. However, there was a significant difference (P = 0.05; relative risk: 0.17; 95% confidence interval: 0.04-0.70) in the contamination rate between baseline (6.1%; 20/330) and intervention (1%; 2/200). CONCLUSIONS This study suggests that the aseptic care provided in obtaining samples is more important than the sterile technique itself, and highlights the value of standardizing the practices, qualification and calibration of phlebotomists.
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Regression discontinuity of blood culture contamination rate after changing of disinfectants: retrospective observational study. Sci Rep 2021; 11:21235. [PMID: 34707137 PMCID: PMC8551281 DOI: 10.1038/s41598-021-00498-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/05/2021] [Indexed: 11/13/2022] Open
Abstract
Blood cultures are indispensable for detecting life-threatening bacteremia. Little is known about associations between contamination rates and topical disinfectants for blood collection in adults. We sought to determine whether a change in topical disinfectants was associated with the rates of contaminated blood cultures in the emergency department of a single institution. This single-center, retrospective observational study of consecutive patients aged 20 years or older was conducted in the emergency department (ED) of a university hospital in Japan between August 1, 2018 and September 30, 2020. Pairs of blood samples were collected for aerobic and anaerobic culture from the patients in the ED. Physicians selected topical disinfectants according to their personal preference before September 1, 2019; alcohol/chlorhexidine gluconate (ACHX) was mandatory thereafter, unless the patient was allergic to alcohol. Regression discontinuity analysis was used to detect the effect of the mandatory usage of ACHX on rates of contaminated blood cultures. We collected 2141 blood culture samples from 1097 patients and found 164 (7.7%) potentially contaminated blood cultures. Among these, 445 (20.8%) were true bacteremia and 1532 (71.6%) were true negatives. Puncture site disinfection was performed with ACHX for 1345 (62.8%) cases and with povidone-iodine (PVI) for 767 (35.8%) cases. The regression discontinuity analysis showed that mandatory ACHX usage was significantly associated with lower rates of contaminated blood cultures by 9.6% (95% confidence interval (CI): 5.0%–14.2%, P < 0.001). Rates of contaminated blood cultures were significantly lower when ACHX was used as the topical disinfectant.
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Clinical Nurse Specialist Practice: Impact on Emergency Department Blood Culture Contamination. CLIN NURSE SPEC 2021; 35:314-317. [PMID: 34606211 DOI: 10.1097/nur.0000000000000634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE/OBJECTIVES Blood culture collection is 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. A team of nurses and technicians undertook a quality improvement project to decrease blood culture contamination rates in a suburban emergency department. DESCRIPTION OF THE PROJECT 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. OUTCOME Through this work, blood culture contamination rates decreased from greater than 3.0% to less than 1.5% consistently for nearly 24 months. CONCLUSIONS Providing feedback and continued monitoring has made this quality improvement initiative a success for the department and the organization and has resulted in cost savings of nearly 2 million dollars.
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Opperman CJ, Baloyi B, Dlamini S, Samodien N. Blood culture contamination rates at different level healthcare institutions in the Western Cape, South Africa. S Afr J Infect Dis 2021; 35:222. [PMID: 34485484 PMCID: PMC8378204 DOI: 10.4102/sajid.v35i1.222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 10/22/2020] [Indexed: 11/02/2022] Open
Abstract
Sterile blood culture (BC) collection procedures are important to prevent the consequences of contamination, namely, prolonged patient hospitalisation, unnecessary antimicrobial exposure and an increase in hospital costs. Blood culture contamination rates were determined at different hospitals in the Cape Metropole over a 3-year period. Study findings showed that contaminated BCs have a financial impact on the healthcare system and contamination rates remain above accepted international standards, except in the presence of a phlebotomist team. High BC contamination rates might be reduced by the implementation of cost-effective educational intervention programmes, which reminds healthcare workers to collect BC samples aseptically.
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Affiliation(s)
- Christoffel J Opperman
- Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, National Health Laboratory Service, University of Cape Town, Cape Town, South Africa
| | - Banyana Baloyi
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sipho Dlamini
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nazlee Samodien
- Division of Medical Microbiology, National Health Laboratory Service, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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A Quality Improvement Initiative to Reduce Blood Culture Contamination in the Neonatal Unit. Pediatr Qual Saf 2021; 6:e413. [PMID: 34046542 PMCID: PMC8143735 DOI: 10.1097/pq9.0000000000000413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 12/07/2020] [Indexed: 11/25/2022] Open
Abstract
Peripheral blood culture contamination (BCC) can lead to an initiation of unnecessary antimicrobial treatment, further laboratory tests, increased length of stay, and increased costs. This study describes a 12-month quality improvement (QI) program to reduce the BCC rate in a neonatal unit by 50%. Methods The QI team focused on standardizing processes to align with best practices using process mapping and cause and effect diagrams. Plan-Do-Study-Act (PDSA) 1: inoculation of blood culture bottles with the introduction of transfer device; PDSA 2: preparation of the skin for peripheral intravenous cannula insertion; PDSA 3: aseptic technique education package; and PDSA 4: optimizing blood volume of blood collected for culture. The team used statistical process control methodology to detect special cause variation. Results Compliance with the standard processes as part of PSDA 1 improved from a mean level of 50% to 100% and for PDSA 2 improved from a mean level of 50% to 95%. After implementation of PDSA 3, scores on a relevant knowledge test increased from a mean of 39% (pretraining test; n = 10) to 92% (posttraining test; n = 10) (P < 0.001). Postimplementation of the processes for PDSA 4, a minimum of 1 mL was collected in 94% of blood culture collection events (n = 450) (mean 1.1 mL; range 0.5-3.5 mL). Special cause variation occurred after the implementation of the PDSA cycles. During the baseline period, the BCC rate was 2.0% and decreased to 1.0% postinterventions implementation. Conclusions Interventions focused on standardizing practices around collection of blood cultures in neonates were associated with fewer contaminants.This study is reported according to the SQUIRE 2.0 guidelines.
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Risk factors and clinical outcomes associated with blood culture contamination. Infect Control Hosp Epidemiol 2021; 43:291-297. [PMID: 33896442 DOI: 10.1017/ice.2021.111] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine patient-specific risk factors and clinical outcomes associated with contaminated blood cultures. DESIGN A single-center, retrospective case-control risk factor and clinical outcome analysis performed on inpatients with blood cultures collected in the emergency department, 2014-2018. Patients with contaminated blood cultures (cases) were compared to patients with negative blood cultures (controls). SETTING A 509-bed tertiary-care university hospital. METHODS Risk factors independently associated with blood-culture contamination were determined using multivariable logistic regression. The impacts of contamination on clinical outcomes were assessed using linear regression, logistic regression, and generalized linear model with γ log link. RESULTS Of 13,782 blood cultures, 1,504 (10.9%) true positives were excluded, leaving 1,012 (7.3%) cases and 11,266 (81.7%) controls. The following factors were independently associated with blood-culture contamination: increasing age (adjusted odds ratio [aOR], 1.01; 95% confidence interval [CI], 1.01-1.01), black race (aOR, 1.32; 95% CI, 1.15-1.51), increased body mass index (BMI; aOR, 1.01; 95% CI, 1.00-1.02), chronic obstructive pulmonary disease (aOR, 1.16; 95% CI, 1.02-1.33), paralysis (aOR 1.64; 95% CI, 1.26-2.14) and sepsis plus shock (aOR, 1.26; 95% CI, 1.07-1.49). After controlling for age, race, BMI, and sepsis, blood-culture contamination increased length of stay (LOS; β = 1.24 ± 0.24; P < .0001), length of antibiotic treatment (LOT; β = 1.01 ± 0.20; P < .001), hospital charges (β = 0.22 ± 0.03; P < .0001), acute kidney injury (AKI; aOR, 1.60; 95% CI, 1.40-1.83), echocardiogram orders (aOR, 1.51; 95% CI, 1.30-1.75) and in-hospital mortality (aOR, 1.69; 95% CI, 1.31-2.16). CONCLUSIONS These unique risk factors identify high-risk individuals for blood-culture contamination. After controlling for confounders, contamination significantly increased LOS, LOT, hospital charges, AKI, echocardiograms, and in-hospital mortality.
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Ota K, Oba K, Fukui K, Ito Y, Hamada E, Mori N, Oka M, Ota K, Shibata Y, Takasu A. Sites of blood collection and topical antiseptics associated with contaminated cultures: prospective observational study. Sci Rep 2021; 11:6211. [PMID: 33737624 PMCID: PMC7973780 DOI: 10.1038/s41598-021-85614-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/26/2021] [Indexed: 11/14/2022] Open
Abstract
We aimed to determine whether puncture sites for blood sampling and topical disinfectants are associated with rates of contaminated blood cultures in the emergency department (ED) of a single institution. This single-center, prospective observational study of 249 consecutive patients aged ≥ 20 years proceeded in the ED of a university hospital in Japan during 6 months. Pairs of blood samples were collected for aerobic and anaerobic culture from all patients in the ED. Physicians selected puncture sites and topical disinfectants according to their personal preference. We found 50 (20.1%) patients with potentially contaminated blood cultures. Fifty-six (22.5%) patients were true bacteremia and 143 (57.4%) patients were true negatives. Multivariate analysis associated more frequent contamination when puncture sites were disinfected with povidone-iodine than with alcohol/chlorhexidine (adjusted risk difference, 12.9%; 95% confidence interval [CI] 8.8–16.9; P < 0.001). Sites of blood collection were also associated with contamination. Femoral and central venous with other sites were associated with contamination more frequently than venous sites (adjusted risk difference), 13.1% (95% CI 8.2–17.9; P < 0.001]) vs. 17.3% (95% CI 3.6–31.0; P = 0.013). Rates of contaminated blood cultures were significantly higher when blood was collected from femoral sites and when povidone-iodine was the topical antiseptic.
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Affiliation(s)
- Koshi Ota
- Department of Emergency Medicine, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki City, Osaka, 596-8686, Japan.
| | - Koji Oba
- Department of Biostatistics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keisuke Fukui
- Research and Development Center, Osaka Medical College, Osaka, Japan
| | - Yuri Ito
- Research and Development Center, Osaka Medical College, Osaka, Japan
| | - Emi Hamada
- Department of Nursing, Osaka Medical College Hospital, Osaka, Japan
| | - Naomi Mori
- Department of Nursing, Osaka Medical College Hospital, Osaka, Japan
| | - Masahiro Oka
- Department of Emergency Medicine, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki City, Osaka, 596-8686, Japan
| | - Kanna Ota
- Department of Emergency Medicine, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki City, Osaka, 596-8686, Japan
| | - Yuriko Shibata
- Department of Clinical Laboratory, Osaka Medical College Hospital, Osaka, Japan
| | - Akira Takasu
- Department of Emergency Medicine, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki City, Osaka, 596-8686, Japan
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Farrell M, Bram S, Gu H, Mathew S, Messer E, Hayes E, Srinivasan M. Impact of Contaminated Blood Cultures on Children, Families, and the Health Care System. Hosp Pediatr 2020; 10:836-843. [PMID: 32878937 DOI: 10.1542/hpeds.2020-0146] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Contaminated blood cultures pose a significant burden. We sought to determine the impact of contaminated peripheral blood cultures on patients, families, and the health care system. METHODS In this retrospective case-control study from January 1, 2014, to December 31, 2017, we compared the hospital course, return visits and/or admissions, charges, and length of stay of patients with contaminated peripheral blood cultures (case patients) with those of patients with negative cultures (controls). Patients were categorized into those evaluated and discharged from the emergency department (ED) (ED patients) and those who were hospitalized (inpatients). RESULTS A total of 104 ED case patients were matched with 208 ED control patients. A total of 343 case inpatients were matched with 686 inpatient controls. There was no significant difference between case and control patient demographics, ED, or hospital course at presentation. Fifty-five percent of discharged ED patients returned to the hospital for evaluation and/or admission versus 4% of controls. There was a significant (P < .0001) increase in repeat blood cultures (43% vs 1%), consultations obtained (21% vs 2%), cerebrospinal fluid studies (10% vs 0%), and antibiotic administration (27% vs 1%) in ED patients compared with controls. Each ED patient requiring revisit to the hospital incurred, on average, $4660 in additional charges. There was a significant (P < .04) increase in repeat blood cultures (57% vs 7%), consultations obtained (35% vs 28%), broadening of antibiotic coverage (18% vs 11%), median length of stay (75 vs 64 hours), and median laboratory charges ($3723 vs $3296) in case inpatients compared with controls. CONCLUSIONS Contaminated blood cultures result in increased readmissions, testing and/or procedures, length of stay, and hospital charges in children.
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Affiliation(s)
- Megan Farrell
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Sarah Bram
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | - Shakila Mathew
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Elizabeth Messer
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Ericka Hayes
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Mythili Srinivasan
- Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
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Improving adherence to facility protocol and reducing blood culture contamination in an intensive care unit: A quality improvement project. Aust Crit Care 2020; 33:546-552. [PMID: 32417183 DOI: 10.1016/j.aucc.2020.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 01/14/2020] [Accepted: 03/01/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Blood culture contamination (BCC) is a safety and quality indicator for intensive care units (ICUs). BCC rates in our ICU ranged from 2.90% to 6.70% in 2017. OBJECTIVE This quality improvement project aimed to reduce the contamination rate from a mean of 4.52% to <3.0% in 1 year by improving the adherence of nurses to the facility protocol during blood collection. METHODS This project used a before-after design. It was conducted by a leadership team in a 32-bed ICU where approximately 4000 cultures are drawn annually. We observed the performance of ICU nurses during blood collection, interviewed them regarding the difficulties they encountered with protocol adherence, and conducted a cause-and-effect analysis to identify the main problems. Based on a literature review, we developed and implemented a countermeasure protocol, including a standardised medical order, an online learning program, a weekly departmental report and individual feedback routine, and phlebotomy training to address these problems in 2 months. RESULTS The interview results indicated that blood contamination resulted from the environment, difficult phlebotomy, and the inadequate knowledge and skill of the nurses. The countermeasure protocol reduced the average BCC rate from 4.52% to 2.59% during the intervention period and to 0.59% during the 10-month postintervention period. Nursing adherence to the standard protocol for blood culture collection also improved. CONCLUSIONS BCC in ICUs is multifactorial. By optimising the work environment, offering skill training, and reinforcing education and individualised feedback, we successfully reduced BCC in our unit to a sustainable low rate.
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Actual Clinical Practice Related to Contaminated Blood Cultures May Limit the Cost Savings Associated with Interventions To Reduce Contamination Rates. J Clin Microbiol 2020; 58:JCM.01796-19. [PMID: 31996447 DOI: 10.1128/jcm.01796-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Doern GV, Carroll KC, Diekema DJ, Garey KW, Rupp ME, Weinstein MP, Sexton DJ. Practical Guidance for Clinical Microbiology Laboratories: A Comprehensive Update on the Problem of Blood Culture Contamination and a Discussion of Methods for Addressing the Problem. Clin Microbiol Rev 2019; 33:e00009-19. [PMID: 31666280 PMCID: PMC6822992 DOI: 10.1128/cmr.00009-19] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
In this review, we present a comprehensive discussion of matters related to the problem of blood culture contamination. Issues addressed include the scope and magnitude of the problem, the bacteria most often recognized as contaminants, the impact of blood culture contamination on clinical microbiology laboratory function, the economic and clinical ramifications of contamination, and, perhaps most importantly, a systematic discussion of solutions to the problem. We conclude by providing a series of unanswered questions that pertain to this important issue.
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Affiliation(s)
- Gary V Doern
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Karen C Carroll
- Division of Medical Microbiology, Department of Pathology, John Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel J Diekema
- Division of Infectious Diseases, Department of Medicine and Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Mark E Rupp
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Melvin P Weinstein
- Department of Pathology and Laboratory Medicine, Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Daniel J Sexton
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Al-Hamad AM. Successful Reduction of Blood Culture Contamination in an Emergency Department by Monitoring and Feedback. Open Microbiol J 2019. [DOI: 10.2174/1874285801913010279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:Blood Culture (BC) contamination is a common problem in the Emergency Department (ED) and is associated with prolonged length of patient stay and excess costs.Objective:The study aimed to investigate the impact of monthly monitoring and feedback of BC results on contamination rates.Methods:Data from a previous study showed that the contamination rate in the ED consistently exceeded the recommended level. This triggered an ad hoc Quality Improvement team to develop and implement a corrective action plan. In 2017, BC contamination rates were reported to the ED on a monthly basis. In response to this, ED staff conducted intensified educational workshops, followed by private counselling and competency assessment of nurses who collected contaminated BCs.Results:A total of 12 educational workshops were conducted in February and March, 2017. The intervention resulted in >60% reduction in the contamination rate, from 8.6% baseline level to less than 3%. Of the 2660 BC sets drawn in 2017 from 1318 patients, 128 (4.8%) were contaminated, accounting for 39.5% of the total number of positive cultures. Sixty percent of the contaminated BCs grew Coagulase-negativeStaphylococcusspecies; other contaminants includedCorynebacteriumspp.,Micrococcusspp.,Propionibacteriumspp.,viridansStreptococcus, andNeisseriaspp.Conclusion:Continuous monitoring and feedback of contamination rates reduced BC contamination.
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Lalezari A, Cohen MJ, Svinik O, Tel-Zur O, Sinvani S, Al-Dayem YA, Block C, Moses AE, Oster Y, Salameh S, Strahilevitz J. A simplified blood culture sampling protocol for reducing contamination and costs: a randomized controlled trial. Clin Microbiol Infect 2019; 26:470-474. [PMID: 31539635 DOI: 10.1016/j.cmi.2019.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Blood culture contamination carries risks for patients, such as unnecessary antimicrobial therapy and other additional hazards and costs. One method shown to be effective in reducing contamination is initial blood specimen diversion during collection. We hypothesized that initial blood specimen diversion without a designated device or procedure would suffice for reduction in blood culture contamination rate. METHODS From 1 September 2017 through to 6 September 2018, we conducted a randomized controlled trial to assess the effect of an initial-specimen diversion technique (ISDT) on the rate of blood-culture contamination by changing the order of sampling using regular vacuum specimen tubes instead of commercially available sterile diversion devices. We included adults from whom the treating physician planned to take blood cultures and additional blood chemistry tests. Additionally, we evaluated the potential economic benefits of an ISDT. This was a researcher-initiated trial, Clinicaltrials.gov NCT03088865. RESULTS In all, 756 patients were enrolled. This method, compared with the standard procedure in use at our medical centre, reduced contamination by 66% (95% CI 17%-86%), from 20/400 (5%) with the standard method to 6/356 (1.6%) with the ISDT, without compromising detection of true bloodstream infection and at no additional cost. Hospital-wide implementation of ISDT was associated with a 1.1% saving in hospitalization days. CONCLUSIONS We offer this novel approach as a simple, cost-effective measure to reduce risks to patient safety from contaminated blood cultures, without the need for using costly devices.
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Affiliation(s)
- A Lalezari
- Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - M J Cohen
- Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - O Svinik
- Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - O Tel-Zur
- Department of Emergency Medicine, Hadassah Medical Centre, Jerusalem, Israel
| | - S Sinvani
- Department of Emergency Medicine, Hadassah Medical Centre, Jerusalem, Israel
| | - Y Abed Al-Dayem
- Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, The Hebrew University, Jerusalem, Israel
| | - C Block
- Hadassah-Hebrew University School of Medicine, Jerusalem, Israel; Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, The Hebrew University, Jerusalem, Israel
| | - A E Moses
- Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, The Hebrew University, Jerusalem, Israel
| | - Y Oster
- Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, The Hebrew University, Jerusalem, Israel
| | - S Salameh
- Department of Emergency Medicine, Hadassah Medical Centre, Jerusalem, Israel
| | - J Strahilevitz
- Hadassah-Hebrew University School of Medicine, Jerusalem, Israel; Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, The Hebrew University, Jerusalem, Israel.
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22
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Corboy JB, Attridge M. Impact of Blood Culture Contamination on Patients and Health Care Systems: A Review of QI Strategies Within the ED. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2019. [DOI: 10.1016/j.cpem.2019.100718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Dempsey C, Skoglund E, Muldrew KL, Garey KW. Economic health care costs of blood culture contamination: A systematic review. Am J Infect Control 2019; 47:963-967. [PMID: 30795840 DOI: 10.1016/j.ajic.2018.12.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/12/2018] [Accepted: 12/12/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Blood culture contamination with gram-positive organisms is a common occurrence in patients suspected of bloodstream infections, especially in emergency departments. Although numerous research studies have investigated the cost implications of blood culture contamination, a contemporary systematic review of the literature has not been performed. The aim of this project was to perform a systematic review of the published literature on the economic costs of blood culture contamination. METHODS PubMed was searched (January 1, 1978, to July 15, 2018) using the search terms "blood culture contamination" or "false-positive blood cultures." Articles were title searched and abstracts were reviewed for eligible articles that reported immediate or downstream economic costs of blood culture contamination. RESULTS AND DISCUSSION The PubMed search identified 151 relevant articles by title search, with 49 articles included after abstract review. From the studies included, overall blood culture contamination rates ranged from 0.9%-41%. Up to 59% of patients received unnecessary treatment with parenteral vancomycin as a result of blood culture contamination, resulting in increased pharmacy charges between $210 and $12,611 per patient. Increases in total laboratory charges between $2,397 and $11,152 per patient were reported. Attributable hospital length of stay increases due to blood culture contamination ranged from 1-22 days. CONCLUSIONS This systematic review of the literature identified several areas of health care expenditure associated with blood culture contamination. Interventions to reduce the risk of blood culture contamination would avoid downstream economic costs.
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Affiliation(s)
- Casey Dempsey
- University of Houston College of Pharmacy, Department of Pharmacy Practice and Translational Research, Houston, TX
| | - Erik Skoglund
- University of Houston College of Pharmacy, Department of Pharmacy Practice and Translational Research, Houston, TX; Baylor St. Luke's Medical Center, Departments of Pharmacy and Microbiology, Houston, TX
| | - Kenneth L Muldrew
- Baylor St. Luke's Medical Center, Departments of Pharmacy and Microbiology, Houston, TX; Baylor College of Medicine, Department of Pathology & Immunology and Internal Medicine, Houston, TX; University of Texas MD Anderson Cancer Center, Department of Microbiology, Houston, TX
| | - Kevin W Garey
- University of Houston College of Pharmacy, Department of Pharmacy Practice and Translational Research, Houston, TX; Baylor St. Luke's Medical Center, Departments of Pharmacy and Microbiology, Houston, TX.
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Stowell JR, Pugsley P, Jordan H, Akhter M. Impact of Emergency Department Phlebotomists on Left-Before-Treatment-Completion Rates. West J Emerg Med 2019; 20:681-687. [PMID: 31316710 PMCID: PMC6625689 DOI: 10.5811/westjem.2019.5.41736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/11/2019] [Accepted: 05/11/2019] [Indexed: 11/15/2022] Open
Abstract
Introduction The emergency department (ED) serves as the primary access point to the healthcare system. ED throughput efficiency is critical. The percentage of patients who leave before treatment completion (LBTC) is an important marker of department efficiency. Our study aimed to assess the impact of an ED phlebotomist, dedicated to obtaining blood specimen collection on waiting patients, on LBTC rates. Methods This study was conducted as a retrospective observational analysis over approximately 18 months (October 5, 2015–March 31, 2017) for patients evaluated by a triage provider with a door-to-room (DtR) time of > 20 minutes (min). LBTC rates were compared in 10-min DtR increments for when the ED phlebotomist collected the patient’s specimen vs not. Results Of 71,942 patient encounters occurring during the study period, 17,349 (24.1%) met study inclusion criteria. Of these, 1842 (10.6%) had blood specimen collection performed by ED phlebotomy. The overall LBTC rate for encounters included in the analysis was 5.26% (95% confidence interval [CI], 4.94%–5.60%). Weighting the LBTC rates for each 10-min DtR interval using the fixed effects model led to an overall LBTC rate of 2.74% (95% CI, 2.09%–3.59%) for patient encounters with ED phlebotomist collection vs 5.31% (95% CI, 4.97%–5.67%) in those which did not, yielding a relative reduction of 48% (95% CI, 34%–63%). The effect of the phlebotomist on LBTC rates increased as DtR times increased. The difference in the rate of the rise of LBTC percentages, per 10-min interval, was 0.50% (95% CI, 0.19%–0.81%) higher for non-ED phlebotomist encounters vs phlebotomist encounters. Conclusion ED phlebotomy demonstrated a significant reduction in ED LBTC rates. Further, as DtR times increased, the impact of ED phlebotomy became increasingly significant. Adult EDs with increased rates of LBTC patient encounters may want to consider the implementation of ED phlebotomy.
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Affiliation(s)
- Jeffrey R Stowell
- University of Arizona College of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, Arizona.,Maricopa Integrated Health System, Department of Emergency Medicine, Phoenix, Arizona.,Creighton University School of Medicine, Department of Emergency Medicine, Omaha, Nebraska
| | - Paul Pugsley
- Maricopa Integrated Health System, Department of Emergency Medicine, Phoenix, Arizona
| | - Heather Jordan
- Maricopa Integrated Health System, Department of Emergency Medicine, Phoenix, Arizona
| | - Murtaza Akhter
- University of Arizona College of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, Arizona.,Maricopa Integrated Health System, Department of Emergency Medicine, Phoenix, Arizona.,Creighton University School of Medicine, Department of Emergency Medicine, Omaha, Nebraska
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Model to evaluate the impact of hospital-based interventions targeting false-positive blood cultures on economic and clinical outcomes. J Hosp Infect 2019; 102:438-444. [PMID: 30928573 DOI: 10.1016/j.jhin.2019.03.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 03/21/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Blood culture contamination (BCC) increases length of stay (LOS) and leads to unnecessary antimicrobial therapy and/or hospital-acquired conditions (HACs). AIM To quantify the magnitude of additional LOS, costs to hospitals and society, and harm to patients attributable to BCC. METHODS A retrospective matched survival analysis was performed involving hospitalized patients with septicaemia-compatible symptoms. BCC costs, HACs and potential savings were calculated based on the primary LOS data, a modified Delphi process and published sources. The cost analysis compared standard care with interventions for reducing BCC, and estimated annual economic and clinical consequences for a typical hospital and for the USA as a whole. FINDINGS Patients with BCC experienced a mean increase in LOS of 2.35 days (P=0.0076). Avoiding BCC would decrease costs by $6463 [$4818 from inpatient care (53% of which was from reduced LOS) and 26% from reduced antibiotic use]. Annually, in a typical 250- to 400-bed hospital, employing phlebotomists would save $1.3 million and prevent 24 HACs (including two cases of Clostridium difficile infection); based on clinical efficacy evidence, use of the studied initial specimen diversion device (ISDD) would save $1.9 million and prevent 34 HACs (including three cases of C. difficile infection). In the USA, the respective strategies would prevent 69,300 and 102,900 HACs (including 6000 and 8900 cases of C. difficile infection) and save $5 and $7.5 billion. CONCLUSION Costs and clinical burdens associated with false-positive cultures are substantial and can be reduced by available interventions, including phlebotomists and use of ISDD.
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Skoglund E, Dempsey CJ, Chen H, Garey KW. Estimated Clinical and Economic Impact through Use of a Novel Blood Collection Device To Reduce Blood Culture Contamination in the Emergency Department: a Cost-Benefit Analysis. J Clin Microbiol 2019; 57:e01015-18. [PMID: 30355758 PMCID: PMC6322461 DOI: 10.1128/jcm.01015-18] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/01/2018] [Indexed: 11/30/2022] Open
Abstract
Blood culture contamination results in increased hospital costs and exposure to antimicrobials. We evaluated the potential clinical and economic benefits of an initial specimen diversion device (ISDD) when routinely utilized for blood culture collection in the emergency department (ED) of a quaternary care medical center. A decision analysis model was created to identify the cost benefit of the use of the ISDD device in the ED. Probabilistic costs were determined from the published literature and the direct observation of pharmacy/microbiology staff. The primary outcome was the expected per-patient cost savings (microbiology, pharmacy, and indirect hospital costs) with the routine use of an ISDD from a hospital perspective. The indirect costs included those related to an increased hospital length of stay, additional procedures, adverse drug reactions, and hospital-acquired infections. Models were created to represent hospitals that routinely or do not routinely use rapid diagnostic tests (RDT) on positive blood cultures. The routine implementation of ISDD for blood culture collection in the ED was cost beneficial compared to conventional blood culture collection methods. When implemented in a hospital utilizing RDT with a baseline contamination rate of 6%, ISDD use was associated with a cost savings of $272 (3%) per blood culture in terms of overall hospital costs and $28 (5.4%) in direct-only costs. The main drivers of cost were baseline contamination rates and the duration of antibiotics given to patients with negative blood cultures. These findings support the routine use of ISDD during blood culture collection in the ED as a cost-beneficial strategy to reduce the clinical and economic impact of blood culture contamination in terms of microbiology, pharmacy, and wider indirect hospital impacts.
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Affiliation(s)
- Erik Skoglund
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Casey J Dempsey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
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Bae M, In Kim H, Park JH, Ryu BH, Chang J, Sung H, Jung J, Kim MJ, Kim SH, Lee SO, Choi SH, Kim YS, Woo JH, Kim MN, Chong YP. Improvement of blood culture contamination rate, blood volume, and true positive rate after introducing a dedicated phlebotomy team. Eur J Clin Microbiol Infect Dis 2018; 38:325-330. [PMID: 30536210 DOI: 10.1007/s10096-018-3430-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/11/2018] [Indexed: 11/28/2022]
Abstract
The introduction of dedicated phlebotomy teams certified for blood collection has been reported to be highly cost-effective by reducing contamination rates. However, data on their effects on blood volume and true positive rate are limited. Therefore, we investigated the effect of replacing interns with a phlebotomy team on blood culture results. We performed a 24-month retrospective, quasi-experimental study before and after the introduction of a phlebotomy team dedicated to collecting blood cultures in a 2700-bed tertiary-care hospital. The microbiology laboratory database was used to identify adult patients with positive blood culture results. During the study period, there were no changes in blood collection method, blood culture tubes, and the application of antiseptic measures. Blood volume was measured by the BACTEC™ FX system based on red blood cell metabolism. A total of 162,207 blood cultures from 23,563 patients were analyzed, comprising 78,673 blood cultures during the intern period and 83,534 during the phlebotomy team period. Blood volume increased from a mean of 2.1 ml in the intern period to a mean of 5.6 ml in the phlebotomy team period (p < 0.001). Introduction of the phlebotomy team also reduced contamination rate (0.27% vs. 0.45%, p < 0.001) and led to a higher true positive rate (5.87% vs. 5.01%, p < 0.05). The increased true positive rate associated with the phlebotomy team involved both gram-positive and gram-negative bacteria. The introduction of a dedicated phlebotomy team can increase blood volumes, reduce blood culture contamination rate, and increase true positive rate.
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Affiliation(s)
- Moonsuk Bae
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Hae In Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Joung Ha Park
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Byung-Han Ryu
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang, South Korea
| | - Jeonghyun Chang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.
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El Feghaly RE, Chatterjee J, Dowdy K, Stempak LM, Morgan S, Needham W, Prystupa K, Kennedy M. A Quality Improvement Initiative: Reducing Blood Culture Contamination in a Children's Hospital. Pediatrics 2018; 142:peds.2018-0244. [PMID: 30217808 DOI: 10.1542/peds.2018-0244] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Blood culture contamination is a safety and quality concern in children's hospitals; it leads to increased unnecessary testing, admissions, antibiotic exposure, and cost. The standard benchmark for blood culture contamination is 3%. Our aim with the quality improvement project was to reduce the contamination rate at our children's hospital from a mean of 2.85% to <1.5% in 2 years. METHODS After initial unit-specific efforts, we formed a multidisciplinary team, created a process map and a cause-and-effect analysis, sent out surveys to nurses, and created observation sheets used to identify problem areas and record the most common deviations during the collection process. We also standardized the blood culture collection protocol and reemphasized nurse education in person and with online modules. During our project, we noted that nurses were collecting 1 to 3 mL of blood on all children regardless of weight. We developed optimal weight-based blood volumes and, after educating ordering providers, we updated our electronic medical record to reflect appropriate volumes in the order. RESULTS Despite a steady increase in the number of blood cultures collected at our children's hospital, we were able to decrease the average contamination rate from 2.85% to 1.54%, saving the hospital an estimated average of $49 998 per month. CONCLUSIONS By standardizing blood culture collection methods, optimizing blood volume, creating checklists, and reinforcing nurse education, we were able to develop a best practice for pediatric blood culture collection and reduce blood culture contamination to a sustainable low rate at our children's hospital.
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Affiliation(s)
| | | | | | | | - Stephanie Morgan
- Children's of Mississippi Laboratory, University of Mississippi Medical Center, Jackson, Mississippi
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Dargère S, Cormier H, Verdon R. Contaminants in blood cultures: importance, implications, interpretation and prevention. Clin Microbiol Infect 2018; 24:964-969. [DOI: 10.1016/j.cmi.2018.03.030] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 03/17/2018] [Accepted: 03/20/2018] [Indexed: 11/24/2022]
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Adverse Economic Impact Associated With Blood Culture Contamination in a Pediatric Emergency Department. Pediatr Infect Dis J 2018; 37:755-758. [PMID: 29846358 DOI: 10.1097/inf.0000000000001898] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Blood culture contamination (BCC) leads to unnecessary interventions including hospitalization, antibiotic administration and additional laboratory tests. Previous studies in adults revealed that BCC was associated with unnecessary financial expenditures. However, information pertaining to the pediatric population is limited. Therefore, we investigated the details of the adverse economic impact associated with BCC in a pediatric emergency department (ED) in Japan. METHODS This study was a retrospective, observational study. We collected data on blood cultures performed in patients 18 years of age in a pediatric ED. Medical records of patients with positive blood cultures were reviewed, and the information regarding adverse events related to BCC was extracted. Medical costs related to BCC were estimated from the data. RESULTS In total, 13,139 sets of blood cultures were performed from April 2013 to June 2016, and 141 cases (1.1%) of BCC were identified. Among these, 106 patients (75%) experienced at least 1 adverse event associated with BCC. The total medical cost due to BCC was 4,076,713 Japanese yen. Multifaceted approaches targeting ED physicians including lectures on optimal blood collection methods and monthly feedback on BCC rates were effective in reducing the BCC rate and its related costs. CONCLUSIONS Interventions associated with BCC were common and accounted for significant adverse economic impact on pediatric patients. Regular education and monitoring were effective in reducing BCC and its related costs.
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Posillico SE, Golob JF, Zosa BM, Sajankila N, Kreiner LA, Claridge JA. Consequences of Implementing a "Better" Blood Culture System. Surg Infect (Larchmt) 2018; 19:582-586. [PMID: 29812994 DOI: 10.1089/sur.2017.239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
BACKGROUND Blood cultures (BCx) are the gold standard for diagnosing blood stream infections. However, contamination remains a challenge and can increase cost, hospital days, and unnecessary antibiotic use. National goals are to keep overall BCx contamination rates to ≤3%. Our healthcare system recently moved to a BCx system with better organism recovery, especially for gram-negative, fastidious, and anaerobic bacteria. The study objectives were to determine the benefits/consequences of implementing a more sensitive blood culture system, specifically on contamination rates. METHODS The electronic health record was queried for all BCx obtained within our tertiary-care health system from April 2015 to October 2016. Cultures were divided into those obtained 12 months before and six months after the new system was introduced. A positive BCx was defined as one with any growth. Contaminated BCx were defined as those showing coagulase-negative Staphylococcus, Corynebacterium, Bacillus, Micrococcus, or Propionibacterium acnes. Cultures with Staphylococcus aureus, Klebsiella pneumoniae, or Escherichia coli were said to contain a true pathogen. Results based on hospital location of blood drawing also were determined. RESULTS A total of 20,978 blood cultures were included, 13,292 before and 7,686 after the new system was introduced. With the new system, positive BCx rates increased from 7.5% to 15.7% (p < 0.001). Contaminants increased from 2.3% to 5.4% (p < 0.001), and pathogens increased from 2.5% to 5.8% (p < 0.001). Contaminated BCx increased significantly in the surgical/trauma intensive care unit (STICU), emergency department (ED), and medical ICU (MICU), while pathogen BCx increased on the surgical floor, ED, and MICU. CONCLUSIONS A new blood culture system resulted in significant increases in the rates of positive, contaminated, and pathogen BCx. After the new system, multiple hospital units had contamination rates >3%. These data suggest that a "better" BCx system may not be superior regarding overall infection rates. More research is needed to determine the impact of identifying more contaminants and pathogens with the new system.
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Affiliation(s)
- Sarah E Posillico
- 1 Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Joseph F Golob
- 1 Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Brenda M Zosa
- 1 Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Nitin Sajankila
- 2 Department of Surgery, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Laura A Kreiner
- 1 Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
| | - Jeffrey A Claridge
- 1 Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine , Cleveland, Ohio
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Elmer J, Yamane D, Hou PC, Wilcox SR, Bajwa EK, Hess DR, Camargo CA, Greenberg SM, Rosand J, Pallin DJ, Goldstein JN, Takhar SS. Cost and Utility of Microbiological Cultures Early After Intensive Care Unit Admission for Intracerebral Hemorrhage. Neurocrit Care 2017; 26:58-63. [PMID: 27605253 DOI: 10.1007/s12028-016-0285-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Fever is common among intensive care unit (ICU) patients. Clinicians may use microbiological cultures to differentiate infectious and aseptic fever. However, their utility depends on the prevalence of infection; and false-positive results might adversely affect patient care. We sought to quantify the cost and utility of microbiological cultures in a cohort of ICU patients with spontaneous intracerebral hemorrhage (ICH). METHODS We performed a secondary analysis of a cohort with spontaneous ICH requiring mechanical ventilation. We collected baseline data, measures of systemic inflammation, microbiological culture results for the first 48 h, and daily antibiotic usage. Two physicians adjudicated true-positive and false-positive culture results using standard criteria. We calculated the cost per true-positive result and used logistic regression to test the association between false-positive results with subsequent antibiotic exposure. RESULTS Overall, 697 subjects were included. A total of 233 subjects had 432 blood cultures obtained, with one true-positive (diagnostic yield 0.1 %, $22,200 per true-positive) and 11 false-positives. True-positive urine cultures (5 %) and sputum cultures (13 %) were more common but so were false-positives (6 and 17 %, respectively). In adjusted analysis, false-positive blood and sputum results were associated with increased antibiotic exposure. CONCLUSIONS The yield of blood cultures early after spontaneous ICH was very low. False-positive results significantly increased the odds of antibiotic exposure. Our results support limiting the use of blood cultures in the first two days after ICU admission for spontaneous ICH.
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Affiliation(s)
- Jonathan Elmer
- Departments of Emergency Medicine and Critical Care Medicine, University of Pittsburgh, Iroquois Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA, 15213, USA.
| | - David Yamane
- Department of Anesthesiology and Critical Care Medicine, George Washington University Hospital, Washington, DC, USA
| | - Peter C Hou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Surgical Intensive Care Unit, Brigham and Women's Hospital, Boston, MA, USA
| | - Susan R Wilcox
- Divisions of Emergency Medicine and Pulmonary, Critical Care and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ednan K Bajwa
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Dean R Hess
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA, USA
- Department of Respiratory Care, Massachusetts General Hospital, Boston, MA, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Sukhjit S Takhar
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
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Kim B, Choi J, Kim K, Jang S, Shin TG, Kim WY, Kim JY, Park YS, Kim SH, Lee HJ, Shin J, You JS, Kim KS, Chung SP. Bacteremia Prediction Model for Community-acquired Pneumonia: External Validation in a Multicenter Retrospective Cohort. Acad Emerg Med 2017; 24:1226-1234. [PMID: 28714287 DOI: 10.1111/acem.13255] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/10/2017] [Accepted: 07/12/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Many studies have described constructing a prediction model for bacteremia in community-acquired pneumonia (CAP), but these studies were not validated in external heterogeneous groups. The objective of this study was to test the generalizability of a previous bacteremia prediction model for CAP by external validation. METHODS This multicenter retrospective cohort analysis was performed in eight tertiary urban hospital emergency departments (EDs). We reviewed adult patients who were hospitalized after presentation to the ED with CAP. We categorized the enrolled patients into three groups according to the bacteremia prediction model score and calculated the number of patients with or without a blood culture-positive result. We performed a multivariable analysis to identify significant predictors for bacteremia. RESULTS Among the enrolled 2,001 patients, 1,592 (79.6%), 371 (18.5%), and 38 (1.9%) were stratified to a low-, moderate-, and high-risk group, respectively, and this proportion was similar with previous study. Each group had a bacteremia-positive rate as follows: 1.2% for the low-risk group, 7.2% for the moderate-risk group, and 31.5% for the high-risk group. The area under the receiver operating characteristic curve for the bacteremia model in the external validation cohort was 0.81, and there was no significant difference with that of the previous internal validation cohort (p = 0.246). Assuming that blood cultures were not performed in the low-risk patients, the sensitivity and specificity of this model were 0.68 and 0.81, respectively. Additionally, the positive predictive value and negative predictive value were 9.54 and 98.87%, respectively. A platelet count less than 130 × 109 cells/L, albumin less than 3.3 mg/dL, and C-reactive protein greater than 17 mg/dL were identified as significant predictors with a sensitivity and specificity of 0.70 and 0.83, respectively. CONCLUSION The bacteremia prediction model was well validated in the general population and could help physicians make the decision to reduce the number of blood cultures in patients with CAP.
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Affiliation(s)
- Byunghyun Kim
- Department of Emergency Medicine; Seoul National University Bundang Hospital; Gyeonggi-do Korea
| | - Jungho Choi
- Department of Emergency Medicine; Mediplex Sejong Hospital; Incheon Korea
| | - Kyuseok Kim
- Department of Emergency Medicine; Seoul National University Bundang Hospital; Gyeonggi-do Korea
| | - Sujin Jang
- Department of Emergency Medicine; Seoul National University Bundang Hospital; Gyeonggi-do Korea
| | - Tae Gun Shin
- Department of Emergency Medicine; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Won Young Kim
- Department of Emergency Medicine; University of Ulsan College of Medicine; Asan Medical Center; Seoul Korea
| | - Jung-Youn Kim
- Department of Emergency Medicine; Korea University College of Medicine; Guro Hospital; Seoul Korea
| | - Yoo Seok Park
- Department of Emergency Medicine; Yonsei University College of Medicine; Seoul Korea
| | - Soo Hyun Kim
- Department of Emergency Medicine; College of Medicine; The Catholic University of Korea; Seoul Korea
| | - Hui Jai Lee
- Department of Emergency Medicine; Seoul National University Boramae Medical Center; Seoul Korea
| | - Jonghwan Shin
- Department of Emergency Medicine; Seoul National University Boramae Medical Center; Seoul Korea
| | - Je Sung You
- Department of Emergency Medicine; Yonsei University College of Medicine; Seoul Korea
| | - Kyung Su Kim
- Department of Emergency Medicine; Seoul National University Hospital; Seoul Korea
| | - Sung Phil Chung
- Department of Emergency Medicine; Yonsei University College of Medicine; Seoul Korea
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El-Naggari MA, Al-Mulaabed SW, Al-Muharrmi Z, Mani R, Abdelrahim R, Abdwani R. Blood Culture Contaminants in a Paediatric Population Retrospective study from a tertiary hospital in Oman. Sultan Qaboos Univ Med J 2017; 17:e202-e208. [PMID: 28690893 DOI: 10.18295/squmj.2016.17.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/29/2016] [Accepted: 01/26/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Most children presenting with febrile illness require a blood culture to determine the causative organism as well as its sensitivity to antibiotics. However, false-positive results lead to unnecessary hospitalisations, prescriptions and tests. This study aimed to evaluate the impact of false-positive blood cultures among a paediatric population at a tertiary hospital in Oman. METHODS This retrospective study included all 225 children <13 years old with positive blood cultures who presented to the Sultan Qaboos University Hospital, Muscat, Oman, between July 2011 and December 2013. Blood cultures were reviewed to determine whether they were true-positive or contaminated. RESULTS A total of 344 positive blood cultures were recorded during the study period, of which 185 (53.8%) were true-positive and 159 (46.2%) were contaminated. Most true-positive isolates (26.5%) were coagulase-negative Staphylococcus spp. (CONS) followed by Escherichia coli (9.7%), while the majority of contaminated isolates were CONS (67.9%) followed by Streptococcus spp. (6.9%). Children with contaminated cultures were significantly younger (P <0.001) while those with true-positive cultures required significantly more frequent hospital admissions, longer hospital stays and more frequent antibiotic prescriptions (P <0.001 each). Chronic illness and mortality was significantly more frequent among those with true-positive cultures (P <0.001 and 0.04, respectively). While white blood cell and absolute neutrophil counts were significantly higher in true-positive cultures (P <0.001 each), there was no significant difference in C-reactive protein (CRP) level (P = 0.791). CONCLUSION In this population, CRP level was not an adequate marker to differentiate between true- and false-positive cultures. A dedicated well-trained phlebotomy team for paediatric patients is essential.
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Affiliation(s)
| | - Sharef W Al-Mulaabed
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman.,Department of Pediatrics, Brookdale University Hospital and Medical Center, Brooklyn, New York, USA
| | | | - Renjith Mani
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
| | - Rana Abdelrahim
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
| | - Reem Abdwani
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
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Foggiato GF, Tuon FF, Becker G, Dos Santos AH, Pereira BR, de Souza GL, Limberger LM. Reduction of blood culture contamination rates after implementation of a phlebotomist team. Am J Infect Control 2017; 45:698-699. [PMID: 28359613 DOI: 10.1016/j.ajic.2017.02.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 02/21/2017] [Indexed: 11/28/2022]
Affiliation(s)
| | - Felipe F Tuon
- School of Medicine, Pontifícia Universidade Católica do Paraná, Brazil; Division of Infectious Diseases, Hospital de Clínicas da UFPR, Curitiba, Brazil.
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Bowen CM, Coleman T, Cunningham D. Reducing Blood Culture Contaminations in the Emergency Department: It Takes a Team. J Emerg Nurs 2016; 42:306-11. [DOI: 10.1016/j.jen.2015.10.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 10/17/2015] [Accepted: 10/22/2015] [Indexed: 11/29/2022]
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Rate of blood culture contamination in a teaching hospital: A single center study. J Taibah Univ Med Sci 2015. [DOI: 10.1016/j.jtumed.2015.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Garcia RA, Spitzer ED, Beaudry J, Beck C, Diblasi R, Gilleeny-Blabac M, Haugaard C, Heuschneider S, Kranz BP, McLean K, Morales KL, Owens S, Paciella ME, Torregrosa E. 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. Am J Infect Control 2015; 43:1222-37. [PMID: 26298636 DOI: 10.1016/j.ajic.2015.06.030] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/23/2015] [Accepted: 06/29/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND A literature search was conducted using keywords for articles published in English from January 1990 to March 2015. Using criteria related to blood culture collection and handling, the search yielded 101 articles. References used also included Microbiology Laboratory standards, guidelines, and textbook information. RESULTS The literature identified diverse and complex issues surrounding blood culture practices, including the impact of false-positive results, laboratory definition of contamination, effect on central line-associated bloodstream infection (CLABSI) reporting, indications for collecting blood cultures, drawing from venipuncture sites versus intravascular catheters, selection of antiseptics, use of needleless connectors, inoculation of blood culture bottles, and optimizing program management in emergency departments, education, and implementation of bundled practice initiatives. CONCLUSION Hospitals should optimize best practice in the collection, handling, and management of blood culture specimens, an often overlooked but essential component in providing optimal care of patients in all settings and populations, reducing financial burdens, and increasing the accuracy of reportable CLABSI. Although universal concepts exist in blood culture practices, some issues require further research to determine benefit. Institutions undertaking a review of their blood culture programs are encouraged to use a checklist that addresses elements that encompass the research contained in this review.
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Park W, Myung S, Oh MD, Lee J, Kim NJ, Kim EC, Park J. Educational intervention as an effective step for reducing blood culture contamination: a prospective cohort study. J Hosp Infect 2015; 91:111-6. [DOI: 10.1016/j.jhin.2015.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 04/28/2015] [Indexed: 10/23/2022]
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Ramirez P, Gordón M, Cortes C, Villarreal E, Perez-Belles C, Robles C, de Hevia L, Marti JV, Botella J, Bonastre J. Blood culture contamination rate in an intensive care setting: Effectiveness of an education-based intervention. Am J Infect Control 2015; 43:844-7. [PMID: 26026825 DOI: 10.1016/j.ajic.2015.04.183] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 04/09/2015] [Accepted: 04/09/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Blood culture (BC) contamination rate is an indicator of quality of care scarcely explored in intensive care units (ICUs). We analyzed the BC contamination rate in our ICU to assess the effectiveness of an education-based intervention. METHODS We conducted an interventional study with concurrent controls. Consecutive BCs drawn during a 6-month period were included. An education-based intervention was presented to case nurses (optimal technique). The remaining nurses comprised the control group (standard technique). Two independent observers assessed clinical significance of saprophytic skin bacteria isolated in BCs. RESULTS Six hundred fifty-six BCs were obtained: 308 (47%) via optimal technique and 348 (53%) via standard technique (47%). One hundred eighty-seven BCs were positive for saprophytic microorganisms; 127 (89%) were considered unrelated to infection. Coagulase-negative staphylococci isolation was lower in the optimal technique group (14% vs 26%; P < .001), as well as contamination due to coagulase-negative staphylococci (12% vs 21%; P = .002) or Acinetobacter baumannii (0.3% vs 2%; P = .013). BC contamination rate was 13% in the optimal technique group versus 23% in the standard group (P < .005). In the optimal technique group, BC contamination rate was higher in BCs drawn through the catheter (17% vs 7%; P = .028). CONCLUSIONS An education-based intervention significantly reduced the BC contamination rate in our ICU. It seems necessary to design a tool to extract BCs through the catheter to minimize the risk of contamination.
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Affiliation(s)
- Paula Ramirez
- Critical Care Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain; CIBERES (Research Center for Respiratory Pathologies) Instituto de Salud Carlos III, Madrid, Spain.
| | - Mónica Gordón
- Critical Care Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Concepción Cortes
- Critical Care Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Esther Villarreal
- Critical Care Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Carmen Perez-Belles
- Microbiology Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Cristobal Robles
- Critical Care Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Luis de Hevia
- Critical Care Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Jose Vicente Marti
- Critical Care Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Javier Botella
- Critical Care Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Juan Bonastre
- Critical Care Department, Hospital Universitario y Politécnico la Fe, Valencia, Spain
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Culshaw N, Glover G, Whiteley C, Rowland K, Wyncoll D, Jones A, Shankar-Hari M. Healthcare-associated bloodstream infections in critically ill patients: descriptive cross-sectional database study evaluating concordance with clinical site isolates. Ann Intensive Care 2014; 4:34. [PMID: 25593750 PMCID: PMC4273689 DOI: 10.1186/s13613-014-0034-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 10/29/2014] [Indexed: 12/21/2022] Open
Abstract
Background Healthcare-associated bloodstream infections are related to both increased antibiotic use and risk of adverse outcomes. An in-depth understanding of their epidemiology is essential to reduce occurrence and to improve outcomes by targeted prevention strategies. The objectives of the study were to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates. Methods We conducted a descriptive cross-sectional study in critically ill adults admitted to a tertiary semi-closed intensive care unit in England to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates. All nosocomial positive blood cultures over a 4-year study period were identified. Pathogens detected and concordances with clinical site are reported as proportions. Results Contaminant pathogens accounted for half of the isolates. The most common non-contaminant pathogens cultured were Pseudomonas spp. (8.0%), Enterococcus spp. (7.3%) and Escherichia coli (5.6%). Central venous catheter-linked bloodstream infections represent only 6.0% of the positive blood cultures. Excluding contaminants and central venous line infections, in only 39.5% of the bloodstream infections could a concordant clinical site source be identified, the respiratory and urinary tracts being the most common. Conclusions Clinical practice should focus on a) improving blood culture techniques to reduce detection of contaminant pathogens and b) ensuring paired clinical site cultures are performed alongside all blood cultures to better understand the epidemiology and potential implications of primary and secondary discordant health-care associated bloodstream infections.
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Affiliation(s)
- Nick Culshaw
- Department of Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK
| | - Guy Glover
- Department of Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK
| | - Craig Whiteley
- Department of Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK
| | - Katie Rowland
- Department of Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK
| | - Duncan Wyncoll
- Department of Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK
| | - Andrew Jones
- Department of Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK
| | - Manu Shankar-Hari
- Department of Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust, 1st Floor, East Wing, St Thomas' Hospital, London, SE1 7EH, UK ; Division of Asthma, Allergy and Lung Biology, King's College London, London, SE1 9RT, UK
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