You Have To Bleed a Little To Reach the Big Time

ISSUE: Contaminated blood cultures result in an increased use of antibiotics leading to potential antibiotic resistance, unnecessary treatment, increased length of stay, and an increase in the cost of care. The College of American Pathologists (CAP) has established an acceptable contamination rate at ≤3%. At our institution an average of 2500 blood cultures are collected monthly. Initial review of our data revealed a blood culture contamination rate of 7.3% (>CAP 90th percentile). PROJECT: A multidisciplinary team representing nursing, microbiology laboratory, Epidemiology, Materials Management, and Nursing Education and Professional Development was assembled to address this issue. Microbiology staff provided the contamination data. Materials Management provided information on the products available for use. Nursing staff was queried on practice, policy, and products used to perform collection. Epidemiology developed a web-based education program and with the support of hospital administration the education was mandated for all staff who drew blood cultures. Unit-based nurse educators were made accountable for completion of the education program by their staff. Trainees were evaluated via a posttest and a hands-on demonstration of competency. Product changes included replacement of povidone-iodine with chlorhexidine/alcohol for skin preparation, and a kit was developed that included all products needed to perform the procedure as well as an instruction sheet and bottle labels for designation of the culture site (central line or peripheral vein). A monthly report was generated and distributed, which included a contamination rate for each nursing unit in the inpatient, outpatient, and emergency department (ED) settings. Nurse clinicians reviewed the report and followed each contaminated culture down to the person who performed the culture collection. RESULTS: We achieved 98% compliance with mandatory education. The hospital-wide blood culture contamination rate decreased from 7.3% to 3.8%. Stratified by hospital area, the contamination rates fell to 3.2% for inpatient units and 2.3% for outpatient clinics. The ED is responsible for an average of 500 blood cultures/month; their rate decreased from a high of 11% to 5.4%. LESSONS LEARNED: The 3% rate continues to be our “Big Time” or long-range goal but we consider our progress to date to be highly significant. Monitoring continues, products continue to evolve, and education for new staff has been implemented. The ED and administration continue to review the collection process to achieve complete success. The additional success of educating hundreds of clinical staff via a web-based tutorial has opened the door to many possibilities when considering future educational programs for our 4000 clinical providers.