Blood Culture Contamination
10/15/2009
Educating for Quality Improvement & Patient Safety
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• 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
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• Mentor Luci Leykum MD, MBA, MSc
• Wayne Fischer, Ph.D.
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.
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
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%.
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 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.
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Mean blood culture contamination rate on 8th floor
from 6/2008 to 4/2009 was 4.38%
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


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%.
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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.
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10
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






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.
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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.
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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.
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Contaminated Blood Cultures on 8th Floor of UH
16.0%
Preintervention
14.0%
Postintervention
% of Blood Cultures Contaminated
UCL
12.0%
10.0%
9.4%
8.1%
8.0%
7.1%
0.063
6.6%
6.0%
5.9%
5.8%
5.3%
4.0%
4.0%
3.2%
2.0%
5.2%
5.1%
4.7%
CL
3.2%
3.0%
3.5%
3.6%
3.3%
2.3%
1.7%
1.1%
0.0%
2.8%
1.8%
3.0%
2.6%
1.6%
0.021
1.4%
0.0%
Two week intervals
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• 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?
Ju
lA
0
Ju 8
lB
A 08
ug
A
A 08
ug
B
A 08
ug
C
S 08
ep
A
S 08
ep
B
O 08
ct
A
O 08
ct
B
N 08
ov
A
N 08
ov
B
D 08
ec
A
D 08
ec
B
Ja 0 8
nA
Ja 0 9
nB
Ja 0 9
nC
Fe 09
bA
Fe 09
bB
M 09
ar
A
M 09
ar
B
A 09
pr
A
A 09
pr
B
M 09
ay
A
M 09
ay
B
Ju 09
nA
Ju 0 9
nB
0
Ju 9
lA
0
Ju 9
lB
A 09
ug
A
A 09
ug
B
A 09
ug
C
S 09
ep
A
S 09
ep
B
09
% of Blood Cultures Contaminated
Contaminated Blood Cultures on 8th Floor of UH
0.160
Pre-intervention
0.060
5.3%
CL
3.2%
0.020
3.2%
Post-intervention
0.140
UCL
0.120
0.100
0.102
9.4%
0.080
8.1%
7.1%
6.6%
5.8%
4.7%
5.1%
3.0%
5.2%
0.040
3.5%
3.3%
1.7%
1.1%
Two Week Intervals
3.6%
2.8%
2.3%
1.8%
3.0%
2.6%
1.6%
2.9%
2.0%
0.019
1.4%
1.1%
0.000
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.
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

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.
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



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.
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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 CoagulaseNegative 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-
Thank you!
Educating for Quality Improvement & Patient Safety
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