2019 Research Forum

Blood Culture Contamination Rates Reduced With the Introduction of Steripath Device in the Emergency Department

Boone, L., RN; Conner, B., RN; Fabbri, G., RN; Grisham, H., RN; Hernandez, B., RN; Mora, D., RN; Moretti, J., RN; Tien, E., RN; Wayts, H., RN

Upon approval of the EBBP, staff education began August, 9, 2018. Nurses were trained on the use of the Steripath device by Magnolia, through a 3-day, unit-wide in-service via both educational and hands-on methods. A total of nine (9) “Super-Users” were selected to train the remaining unit staff unable to attend the in-services. Competency was achieved by a 15 minute demonstration, and a total of three (3) observed blood culture draws using the Steripath device. The device was implemented in the ED starting August 21, 2018, until supplies exhausted (November 31, 2018). Devices used for this study consisted of both a Luer-lock version (for fresh IV start), and a 23g butterfly for blood draws. Upon collection, the specimen was sent to lab following hospital policy, and an “SP” was written in the patient label to differentiate the control (non-Steripath) versus those samples drawn with the Steripath device. Data was collected through records kept by the Microbiology department in the Kern Medical laboratory. Materials and Methods Results

Conclusions 1. In the beginning before we started this project, our blood contamination rate for ER in January 2018 was 3.85%. 2. Before using Steripath, the average contamination rate for ER was 2.1%. 3. Upon the implementation of the device, a goal of a 50% reduction was targeted. 4. After the three month trials of using Steripath and compliance of use from staff, the average contamination rate for ER was 0.175%. 5. Hospital wide for Kern Medical the blood contamination rate for January 2018 was 3.06%. 6. Following the trial, blood culture contaminations were reduced in the Emergency 7. Following the implementation of the SteriPath device, the Kern Medical Emergency Department has been able to show a significant decrease in contaminated blood cultures 8. Department by 277.77%. 9. As a result of using Steripath device, there has been a dramatic decrease in contamination rates for the Emergency Department, which directly helps the physician determine potentially life-threatening blood infection such as sepsis. 10. This improves the length of stay for the patient as well as improving patient outcomes. 11. With this dramatic decrease in our contamination rates, ER is now implementing continued use of the Steripath device indefinitely. 12. In a year, Kern Medical plans on campus-wide implementation, pending a year’s worth of data collection following antibiotic use, length of stays, and sepsis outcomes. References 1. BellM., Bogar C., Plante J., Rasmussen K., Winters S. (2018). Effectivenessof a Novel Specimen CollectionSystem inReducingBloodCultureContamination Rates. Journal of Emergency Nursing,44 (6) , pp. 570-575.

Introduction

In the emergency department setting, time is of the essence when caring for critically-ill patients. Any delay in imperative diagnosis or treatment could potentially create further harm to the patient. Blood culture results play a vital role in detecting bacteremia in a suspected patient population. False positive results not only cause harm to the patient, but also cause unnecessary health- care related costs. “Blood culture contamination may interfere with clinical judgment and has negative impacts on the initial proper patient care for serious infections. Moreover, blood culture contamination results in unnecessary financial costs, poor patient-care quality, and additional use of unnecessary antibiotics.” Chang CJ, Wu CJ, Hsu HC, Wu CH, Shih FY, et al. (2015) contamination rates have been a clinical problem in the ED. Adherence to proper hand hygiene, site preparation and technique become overwhelming for the primary nurse when pressure to initiate antimicrobial therapy in a timely manner becomes a top priority. A study to introduce Steripath an initial specimen diversion device into clinical practice in the ED will help bring forth the overall goal of providing non-maleficence to the patient population and decrease the financial burden to the patient and healthcare facility, that is acquired from false positive results. “In addition to being cost effective and improving patient safety, the ISDD device is easy to implement in busy clinical settings such as the emergency department.” Bell M., Bogar C., Plante J., Rasmussen K., Winters S. (2018). To improve patient outcomes and provide due diligence, a plan to decrease blood culture contamination was set forth. In the past, blood culture Starting this project we wanted to help decrease the contamination rates of our blood cultures in the ED by 50%. A 50% decrease in contamination rates will ultimately prevent the following: ● Unnecessary and inappropriate use of potent antibiotics ● Improper diagnosis ● Repeat tests and invasive procedures ● Needless hospitalization and extended length of stay ● Reduce costs Improving patient safety and care through specimen integrity and accurate results can impact patient care by the following: • Eliminating false positives • Decreasing fatal anaphylaxis due to an antibiotic • Death due to Clostridium Difficile from a dose of prophylaxis antibiotic and hospital acquired infections from unnecessary extended hospital stays. For our patient safety and best care practice, Kern Medical needs hospital wide implementation of SP for a more reliable, practical, and sustainable solution to blood culture contamination. Objectives

Fig.2: BloodCulturescollectionbottles

2. Bentley, J., Thakore, S., Muir, L., Baird, A., & Lee, J. (2016). A changeof culture: reducingblood culturecontamination rates inan EmergencyDepartment. BMJquality improvement reports, 5 (1), u206760.w2754.doi:10.1136/bmjquality.u206760.w2754

Fig.4:Total bloodculturescollectedby month compared to their contamination rates

Fig.3:2018 ED contamination rate by month

3. Chang CJ, Wu CJ, Hsu HC, Wu CH, Shih FY, et al. (2015) Factors AssociatedwithBloodCulture Contamination in the EmergencyDepartment: Critical Illness,End-Stage Renal Disease,and OldAge. PLOS ONE 10(10): e0137653. https://doi.org/10.1371/journal.pone.0137653

4. Mark E. Rupp,R. JenniferCavalieri,ColeMarolf,Elizabeth Lyden; Reduction in BloodCulture Contamination Through Use of Initial SpecimenDiversionDevice,Clinical InfectiousDiseases, Volume65, Issue2, 15 July 2017, Pages 201–205, https://doi.org/10.1093/cid/cix304

5. Self,W. H., Talbot, T. R., Paul, B. R., Collins,S. P., & Ward, M. J. (2014). Cost analysis of strategies to reduce bloodculture contamination in the emergencydepartment: sterilecollectionkits and phlebotomy teams. Infectioncontroland hospital epidemiology, 35 (8), 1021-8.

PROPRIETARY User-ControlledDiversion enablesnecessaryadjustments for “hard stick” patients with lowvenouspressure through negative pressure

PROPRIETARY Initial SpecimenDiversionMechanism diverts and sequesters the initial (potentiallycontaminated) specimen into the isolation chamber

PROPRIETARY Independent2nd SterileBlood Flow Path allowsonlypurevenousblood, without skincontaminants, to flow into culturebottles

Fig.5:Steripath devicecompliance in the ED

Fig.6:Data Inclusion

PROPRIETARY Specimen IsolationChamber ensures sequesteredcontaminants are isolated from the bloodculture specimen

ComesPreassembled& Sterile to eliminate touch-point contamination

Fig.9:Steripath collectiondevice

Skin Plugs Skin plugs, when present, will always enter the culture specimen bottle and commonly will contain microorganisms

Skin Flora You can disinfect but not sterilize the skin; up to 20% of skin flora remains viable in the keratin layer of the skin even after skin prep

Human Factors Risk of contamination during assembly and preparation of supplies, and skin prep

Acknowledgments Ricco Reynolds, RN- Emergency Department Clinical Facilitator Anna Palacio, RN- Emergency Department Clinical Facilitator Michelle Peterson, RN, MSN- Emergency Department Clinical Director Suzie Marderosian, RN- Emergency Department Clinical Supervisor

Danna Mejia, CLS- Director of Microbiology Pamela Gavin, RN- NRP Program Coordinator Tammy Johnson, RN- Steripath Representative Lee Swomley- Steripath Representative

Fig.1: Contributing factors to bloodculturecontaminations.

Fig.7: Number of Blood cultures collected with/without device during trial

Fig.8:Contamination rates trends(Steripath VS control)

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