COVINGTON, KY. – Peripheral blood culture contamination can be reduced by more than half with little to no cost and without a dreaded second venipuncture for the patient, new research shows.
The contamination rate at in the pediatric emergency department at Vanderbilt University Medical Center in Nashville, Tenn., fell 60% from 4% to 1.6% after an intervention that focused on establishing a sterile bedside field, staff education and using a single-site intravenous insertion, Dr. Paul Hain said at Pediatric Hospital Medicine 2012.
Patrice Wendling/IMNG Medical Media
Dr. Paul Hain
The American Society of Microbiology currently recommends that contamination rates should not exceed 3% for the hospital setting.
Akron (Ohio) Children’s Hospital and Kansas City (Mo.) Children’s Hospital have both reported reducing false-positive blood culture rates from 9% to 2.8% and from 6.7% to 2.3%, respectively, but they did so by drawing culture specimens from a site separate from the inserted IV catheters, he explained.
The tipping point at Vanderbilt centered on a 7-week-old admitted with a diagnosis of apparent life-threatening event who, as a result of blood culture contamination, underwent an unnecessary lumbar puncture, received 2 days of unneeded antibiotics and antiviral therapy, spent 2 extra days in the hospital because of concerns for a serious bacterial infection and, ultimately, needed a plastic surgeon consult for an infiltration wound, he said.
A preintervention analysis revealed several opportunities during the process that could contribute to contamination. They were:
• The top of the culture bottle, clearly labeled as being nonsterile, was not sterilized with alcohol or chlorhexidine.
• Chlorhexidine solution was not allowed to completely dry on the skin prior to catheter insertion.
• The catheter site was palpated with a gloveless, nonsterile finger prior to insertion, but after cleansing.
• The blood sample was injected into a nonsterile container before injection into a sterile blood culture bottle or was placed on a nonsterile surface, bed, or sheets.
• The blood culture was drawn from peripheral intravenous catheter placed at the transferring hospital.
Dr. Randon T. Hall
Based on these observations, lead author Dr. Randon T. Hall created a kit that included an IV catheter, transfer device, syringe, T-connector, clave, sterile tape and gloves, and an IV needle to help set up a sterile field.
A webinar was created to educate day and night shift nurses and the blood draw procedure was standardized, explained Dr. Hain, who recently became vice president and medical director for population health and network development at Children’s Medical Center, Dallas.
The procedure requires cleaning the top of the blood culture bottle with alcohol or chlorhexidine, placing extra tape on the side of the stand for later use in securing the IV, and having a holder ready the patient and position the sterile field kit for easy access.
The nurse dons sterile gloves, attaches the syringe to the T-connector and leaves it on the sterile field before cleansing the IV site thoroughly with a chlorhexidine swab, and creating a generous sterile area above and below the injection site, he said.
A tourniquet is then applied, the IV catheter placed, the blood drawn, and the sample put directly into a blood culture bottle. If working alone, the syringe has to be placed on the sterile glove field before securing the catheter, Dr. Hain said.
"It seems like this should have been the old procedure, I realize that, but it wasn’t," he added. "The old procedure was: If you learned how to draw blood in nursing school, good."
Contamination rates began falling within a month of the intervention began in July 2009, and hit a low of about 0.5% in early 2011 before reaching an average of 1.6% at the time of the analysis in December 2011.
From July 2009 to June 2010, there were 149 contaminations, costing the hospital $416,243, Dr. Hain said. That’s not counting the additional 53 calls made to families for repeat cultures, two needle sticks, one IV infiltrate and, on two occasions, police being sent to the home to retrieve a child when parents could not be reached by phone.
A 60% reduction in $417,000 yearly costs is $250,000 in approximate savings or $2,800/contamination. If one calculates the true cost, which current dogma places at approximately 50% of costs, then the true cost savings per year in the pediatric ED is $125,000, Dr. Hain said.
"This costs nothing to do, except Dr. Hall’s time," he said. "And the interesting part is that the [pediatric ED] collects only about 30% of our blood cultures, so we think there is the opportunity to double or triple our return on investment of zero dollars, if we can get this to spread to the rest of the hospital."