Clinical Safety & Effectiveness Session # 11 Blood Culture Contamination 10/15/2009 Educating for Quality Improvement & Patient Safety

The Team Nancy Ray RN, MA. Chief Nursing Officer/Associate Administrator. CS&E Participant Greg Bowling MD. Hospitalist/Assistant Professor. CS&E Participant Joyce Ornelas RN, Roselle Cabagay RN, Wen Pao RN, Rosette Atienza RN, Leticia Wilson RN, Katherine Cox RN, Esther Hazelwood RN, Carol Monk RN, Jennifer Mapa RN, Deanne Richter RN, Lorisa Gray RN, Liza Paulma RN, Shiji Paulson RN, Cecile Ferrer RN, Renimol Kochumon RN, James Jorgensen PhD, Rosemary Paxson MT(ASCP), Charles Reed RN, 8th floor nursing staff Facilitator Amruta Parekh MD, MPH

Special Thanks To: Mentor Luci Leykum MD, MBA, MSc Wayne Fischer, Ph.D.

What We Are Trying to Accomplish? OUR AIM STATEMENT The aim of our project was to reduce the blood culture contamination rate to less than 2% by August, 2009, on the 8th floor of the University Hospital. We implemented our interventions in May 2009.

Background Blood Culture contaminants lead to: Increased length of stay Delays in procedures Increased costs of patient care Unnecessary use of antibiotics (with resultant adverse effects) Recommended Benchmark for contamination rates is in the range of 2-3%. Examples of increased LOS: I am ready to discharge a patient who has GPC in clusters grow from culture the day of anticipated discharge – pt kept for 1-2 more days awaiting identification of organism. Pt who was to get surgery on hand on a Fri, was found to be “bacteremic” and surgery was delayed over the weekend, during which time it was determined the bacteremia was actually just a contaminant. Unnecessary use of antibiotics in turn leads to drug resistant organisms, adverse drug reactions The recommended industry standard is that blood culture contaminants should not exceed 2-3%

Background In five different patient care areas of our hospital, the average rate of contaminated blood cultures was 6.2% during the time period from 11/2007 to 11/2008. 6 6

Background Data Mean blood culture contamination rate on 8th floor from 6/2008 to 4/2009 was 4.38%

How Will We Know That a Change is an Improvement? Types of measures: Number of contaminated blood cultures expressed as a rate. How we will measure: Data reported from the lab in 2 week intervals. Specific targets for change: Contamination rate less than 2%.

Selected Process Analysis Tools Fishbone – This helped organize brainstorming sessions to analyze what areas could be improved to decrease the contamination rates of blood cultures. Flowchart – This helped to break down the process to isolate individual points in the process that needed improvement. See “The Quality Toolbox,” Second Edition, Nancy R. Tague, Pages 4 – 12 for a complete list of quality improvement tools

What Changes Can We Make That Will Result in an Improvement? Standardize sterilization of skin with chlorhexidine. Avoid contamination of sterilized site prior to blood draw. Prep Blood Culture bottle tops with alcohol swabs. Sterilize claves with chlorhexidine, switch claves on central lines. Avoid use of peripheral IV lines for blood culture draws. Use standardized kits that have all supplies ready for the nurses along with the instruction sheet. Feedback to nurses regarding their contaminated blood cultures. Outline the changes that will be tried by your team. These are based on findings from your process analysis tools, decision-making tools and relevant organizational factors.

Intervention Plan We worked with nurses on the 8th floor of the University Hospital to establish sterile technique and to standardize the process. We held brainstorm sessions with nursing to develop a viable process using equipment and a model arm.

Implementing the Change Do Nursing champions carried out training sessions with a check-list using an arm and a sample kit. They started this in May ‘09. This involved the education of 55 nurses on both day and night shifts. Nursing developed a kit that stream-lined their process so all of the supplies were readily available. How you implemented the change, including date, documentation, implementation issues and lessons learned.

So… What happened between the beginning of August until now? Is this sustainable or just an example of the Hawthorne effect? Is it wise to look at more data before presenting at a big conference?

Expansion of Our Implementation Act We are working to roll out the intervention to other patient care areas. We need the kits to be produced on a larger scale to facilitate this effort. We are working at expanding availability of the PICC team to 24/7 coverage. We are working with IT to streamline the work of obtaining data to monitor for sustained improvement. IT will also work to provide individual feedback to nurses regarding contamination rates. Explain how your change will be implemented elsewhere (spread or expanded) or if will it be abandoned because it did not result in an improvement.

Return on Investment Decreasing our rate of blood culture contaminants in five patient care areas from 6.2% to 2% could lead to savings of as much as $535,000 to $2.3 million, and save from 535 to 2400 days of unnecessary length of stay. The estimated increased cost to provide the kits for all blood cultures drawn in these 5 areas would be approximately $50,000. 852 incidents of contaminated blood cultures/13841 total blood cultures drawn in these 5 patient care areas. Represents weighted average between 5 patient care areas of 6.2%. A decrease to a rate of 2% would represent a 68% decrease in the rate of contaminants. This would mean a decrease of 580 incidents over a 13 month period (11/07-11/08), or a decrease of 535 incidents annually ([580/13] x 12). Given data suggesting blood culture contaminants lead to increased patient care costs of 1000 to 4385 per incident, and increase of up to 4.5 days of length of stay, this decrease in blood culture contamination rate could lead to: savings of $535,000 to $2.3 million annually; decrease of unnecessary length of stay of up to 2400 days. Cost of kits for these 5 areas is based on presumed 12776 blood cultures drawn annually (13841/13 x 12). 12776 x 3.5 = $44716. Cost of $3.50 increase per kit is based on 0.71 + 0.10 + 0.78 + 0.36 + 1.55.

Conclusion/What’s Next We have successfully decreased the blood culture contamination rate on 8th floor of UH to an average of 1.9% from the prior average rate of 4.38%. We will need to follow the data over time to ensure that this impact is sustained. The process improvement will be implemented in other patient care areas of University Hospital. The impact of this change can significantly improve the quality and safety of our patient care as well as lead to significant economic savings for our healthcare system. Highlight your final conclusions, knowledge gained from the project, and any next steps that the team is considering. You may also address future benefits that you anticipate for patients, clinicians or the organization and/or barriers that may affect your ability to sustain your project results.

References Bates, D. W., L. Goldman, and T.H. Lee. 1991. Contaminant blood cultures and resource utilization: the true consequences of false positive results.  JAMA 265: 365-369. Souvenir, D., et al. 1998. Blood cultures positive for coagulase-negative staphylococci: antisepsis, pseudobacteremia, and therapy of patients.  J. Clin. Microbiol. 36: 1923-1926. Weinbaum, F.I. et al. 1997. Doing it right the first time: quality improvement and the contaminant blood culture.  J. Clin. Microbiol. 35: 563-565. Weinstein, M.P. 2003. Blood Culture Contamination: Persisting problems and partial progress.  J. Clin. Microbiol. 41:2275-2278 Hall and Lyman, Updated Review of Blood culture contamination.  Clin Microbiol Rev.  Vol 19, 2006, pgs 795-797. Everts et al. Contamination of Catheter-Drawn Blood Cultures.  Journal of Clinical Miccrobiology, Vol 39, No 9, Sep 2001, p 3393-3394 Beekman and Diekema.  Determining The Clinical Significance of Coagulase- Negative Staphylococci Isolated From Blood Cultures.  Infection Control and Hospital Epidemiology. Vol 26, No 6.  June 2005.  pg 559-566 Richter, Beekmann, Diekema, et al.  Minimizing the Workup of Blood Culture Contaminants: Implementation and Evaluation of a Laboratory-based Algorithm.  Journal of Clinical Microbiology.  July 2002 Vol 40 No 7 pg 2437- 2444

Educating for Quality Improvement & Patient Safety Thank you! Educating for Quality Improvement & Patient Safety