best practices in blood cultures: effective qa
DESCRIPTION
Best Practices in Blood Cultures: Effective QA. Michael Mitchell, MD, F(CAP) Department of Hospital Laboratories, UMass Memorial Medical Center Worcester, MA. Introduction and Overview. Review issues related to bacteremia and fungemia Review general principles of QA monitors - PowerPoint PPT PresentationTRANSCRIPT
Michael Mitchell, MD, F(CAP)Department of Hospital
Laboratories,UMass Memorial Medical Center
Worcester, MA
Best Practices in Blood Cultures: Effective QA
Introduction and OverviewReview issues related to
bacteremia and fungemiaReview general principles of QA
monitorsQA monitors for routine blood
culturesData analysisResponses and interventions
Bacteremia and Fungemia
Significant Bacteremia
Bugs in > Bugs outEndovascular vs. extra-vascular infection
Bacteremia may be continuous or intermittent
“Organism load” (cfu/mL) is low
Clinical Implications
Bacteremic infections are increasing
Bacteremic infection result in high morbidity and mortality
Isolates are more likely to be resistant
Bacteremic infection may cause metastatic, localized complications
Risk Factors
Pathogen virulence factorsHost underlying medical conditionsNosocomial factors
Impact of True Positive CulturesProvides therapeutic and
prognostic insight
Informs a general approach to careAntimicrobialsCritical care interventionsInvestigation of sources
Impact of True Positive CulturesProvides a pathogen for further
testingAnother indicator of prognosisSusceptibility testingTesting for specific virulence factor
Stocked organisms
Impact of Contaminated Cultures
Costs to PatientAdditional testingUnneeded antimicrobial therapyAdditional LOSComplications of the above!
Impact of Contaminated Cultures
Costs to the Institution$10 to $40 thousand dollars per episode of care!
Patient safety and satisfactionPublic Reporting
Quality assurance: general issues
Quality Monitors
PROCESSAnalyticalPre-analyticalPost-analytical
DATA → INFORMATION
What is Monitored and Reported
Will Improve…
Effective QA Programs
Harmonize Lab’s and Institution’s QA activities
Choose Indicators that reflect quality
Choose Indicators for a assessment of all aspects of analytical process
Engage stakeholders
Effective QA Monitor Data
Measurable, reliable and objectiveCollection must be achievableInterpretable and informativeAllow for relevant stratificationActionable
Developing Effective Monitors
Define critical elements in processDetermine informative dataDetermine how data will be analyzedDetermine potential “interventions”Collectable over time; analyze effects of
interventionsDetermine “Life Cycle”?
Microbiologists and Hospital QAAccess to patient-specific and
cumulative dataComfortable with computer
databases and analytical toolsInsight into pre-, post- and
analytical aspects of qualityExperience working in multi-
disciplinary teamsUse of Standards is standard
Choose indicators wisely
Objective dataEasily capturedInformative analysis (insight into problems)Subject to intervention
Don’t choose too many!
Specific QA monitors for blood cultures
Resources
CLSI document M-47A: Principles and Procedures for Blood Cultures; Approved Guideline
Cumitech 1C Blood Cultures IVVarious publications (See
Reference pages below)
Local process analysis—Ishikawa diagram
M-47A Quality ComponentsPre-Analytical
Patient EvaluationTest Selection and OrderingSample Collection and Inoculation
Sample TransportSample Receipt and Initial Processing
M-47A Quality ComponentsAnalytical
Platforms and procedures for detection
Identification of IsolatesSusceptibility testing protocolsVerification of resultsInterpretation of results
M-47A Quality ComponentsPost-Analytical
ReportingRecord ManagementConsultation
UMMMC Quality Monitors
True Positive and Contamination Rates
Single Bottle CulturesSingle Culture EvaluationsClinically Uninformative Cultures
Stratification by Location Harmonize with CR-BSI Activities
UMMMC Blood Culture QA InitiativeLaboratory
Microbiology, Information Services, Phlebotomy, Quality Management
Critical Care OperationsInfection ControlPatient Safety/Quality
Management
NPR Report
Lab#MR#Patient nameDate and time of collectionLocation of collectionRequesting MDCulture results
Activities Related to Blood Culture Quality
Review External BenchmarksProvide Educational ResourcesOn-site visits to UnitsStress critical aspects for QualityQuarterly monitoring and reporting
Specificity
Avoid collection through lines.Sterilize of each “barrier” crossedCollection of multiple independent
cultures; Avoid excessive culturesRecognize of probable
contaminants
Skin Decontamination
M47 discusses several methods for effective skin decontamination:
Tincture of iodine or chlorhexidine gluconate
30 second abrasive scrub
Specificity: Number of Cultures per Evaluation
The risk of a patient having a contaminated blood culture increases arithmetically with the number of cultures obtained.
The Cost of Contaminated Blood Culture is High
Increased LOSIncreased antibiotic treatmentIncreased numbers of laboratory
testsComplications of above
Sensitivity: Volume of blood inoculatedYou have to get bugs in the broth
to get a positive blood culture!
Typical bacteremia 1 cfu/mL + log10.
Linear increased detection as inoculum increases.
Sensitivity
How do we get volume?Volume of blood per bottleNumber of bottles per cultureNumber of cultures per evaluation
Culture Timing
Back-to-back cultures may be collected.
Wait 48 to 72 hours before repeating evaluation with additional blood cultures.
Consider other sources of infection or diagnostic techniques.
Prior Probability of Bacteremia or Fungemia
CLSI Recommendation: For patients with low prior probability of bacteremia or fungemia, surveillance cultures or extensive test of cure assessments are not recommended.
Evaluation RecommendationEach blood culture:
Collect 20 mL by venipuncture for each culture
Inoculate 10mL of blood each into an aerobic and an anaerobic bottle
Immediately collect a second, independent blood culture
If you think about doing a blood culture,
DO TWO
Inoculum Volume for Adults
Data analysis
Paper is sooo Last MileniumReports
Relevant FieldsUnformated text fileImportable into data
management program
Blood Culture QA Data
Lab #Patient NamePatient MR#Patient AgeCollection DateCollection TimeCollection
Location
Submitting MDAerobic Bottle
ResultAnaerobic
Bottle ResultInterpretation
(TP, FP)
Interpretation of Positive Cultures
Species isolatedOther co-isolated organismsIsolation of the organism from
other independent blood cultures or infected sites
Blood Culture Pairs
Label bottles so that those from a single collection can be accurately paired
Never submit bottles from different collections as a single culture
Questionable Positive
SPEC# DATE TIME BOTTLE RESULT SIG
1 11/21/2005 1706 RESIN NO GROWTH Q
1 11/21/2005 1706 ANAEROBIC STAPH. SPECIES, (NOT AUREUS) Q
2 11/21/2005 1706 ANAEROBIC NO GROWTH Q
2 11/21/2005 1706 RESIN STAPH. SPECIES, (NOT AUREUS) Q
COLLECTED
SUBMITTED
1-1 2-2
1-2 2-1
STERILE CONTAM
CONTAMCONTAM
How Have We Done?
Performance Over Time
2006 2010# PTS 378 553
Pts w/ >10 Cultures 33 10Pts w/ >20 Cultures 8 1
# EVALS 886 993# SINGLE EVALS 255 286% SINGLE EVALS 28.8% 28.8%
Performance Over Time
2006 2010# CULTS 1565 1740
# TP 91 63% TP CULTS 5.8% 3.6%
# FP 66 34% FP CULTS 4.2% 1.9%
# PTS W/ ANY FP 60 30% PTS W/ ANY FP 15.9% 5.4%# PTS W/ ANY TP 41 33% PTS W/ ANY TP 10.8% 6.0%
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Pe
r C
en
t o
f T
ota
l Blo
od
Cu
ltu
res
Month (2006)
Classification of Positive ICU Blood Cultures
%FP
%TP
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2010
% T
ota
l Blo
od
Cu
ltu
res
ALL ICU LOCATIONS
% TP
% FP
ICU A
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
2010 2011
% TP
% FP
ICU B
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
2010 2011
% TP
% FP
Responses and interventions
Assess/Seal Cracks
If a monitor exceeds threshold:Is it real?Is it sustained?Does it stratify by location or time?Change in patient population?Change in any aspect of process?
Interventions
Assess for “breaks” in processRe-education, general or site-
focusedStress: “Take time to do it right!”Establish phlebotomy teamsCreate barriers against poor
quality practices
Summary
QA activities related to blood cultures are critical for patient outcome and cost-effective care
Objective, actionable monitors are part of the laboratory’s QA activities
A committed multi-disciplinary team is involved
Significant improvements have been achieved, but challenges continue
Thank You!
Contact InformationMichael J. Mitchell, MD, FCAP
Director, Microbiology ServicesDepartment of Hospital LaboratoriesUMass Memorial Medical Center365 Plantation Street, Room 279Worcester, MA 01605Phone: [email protected]
References Baron EJ, et al. Cumitech 1C: Blood Cultures IV. 2005. Cockerill FR, et al. Optimal Testing Parameters for Blood
Cultures. 2004. Clin Infect Dis 38: 1724-30. Connell TG, et al. How Reliable Is a Negative Blood
Culture Result? Volume of Blood Submitted for Culture in Routine Practice in a Children’s Hospital. 2007. Pediatrics 119: 891-6.
Dwivedi S, et al. Discarding the Initial Aliquot of Blood Does Not Reduce Contamination Rates in Intravenous-Catheter-Drawn Blood Cultures. 2009. JCM 47: 2950-1.
Everts RJ, et al. Contamination of Catheter-Drawn Blood Cultures. 2001. JCM 39: 3393-94.
References 2 Gander RM, et al. Impact of Blood Cultures Drawn by
Phlebotomy on Contamination Rates and Health Care Costs in a Hospital Emergency Department. 2009. JCM 47: 1021-24.
Hall KK and JA Lyman. Updated Review of Blood Culture Contamination. 2006. Clin Microbiol Rev 19: 788-802.
Ilstrup DM and JA Washington 2d. The importance of volume of blood cultured in the detection of bacteremia and fungemia. 1983. Diagn Microbiol Infect Dis. 1: 107-10.
Levin PD, et al. Routine Surveillance Blood Cultures: Their Place in the Management of Critically Ill Patients. 1997. J Infect 35: 125-8.
References 3 Mermel LA and DG Maki. Detection of Bacteremia in
Adults: Consequences of Culturing an Inadequate Volume of Blood. 1993. Ann Intern Med 119: 270-272.
Mirrett S, et al. Relevance of the Number of Positive Bottles in Determining Clinical Significance of Coagulase-Negative Staphylococci in Blood Cultures. 2001. JCM 39: 3279-81.
Nielsen J, et al. Poor Value of Surveillance Cultures of Prediction of Septicaemia Caused by Coagulase-negative Staphylococci in Patients Undergoing Haemodialysis with Central Venous Catheters. 1998. Scand J Infect Dis 30: 569-72.
Patel R, et al. Optimized Pathogen Detection with 30- Compared to 20-Milliliter Blood Culture Draws. 2011. JCM 49: 4047-4051.
References 4 Seifert H. The Clinical Importance of Microbiological
Findings in the Diagnosis and Management of Bloodstream Infections. 2009. Clin Infect Dis 48: S238-45.
Weinbaum FI, et al. Doing It Right the First Time: Quality Improvement and the Contaminant Blood Culture. 1997. JCM 35: 563-65.
Weinstein MP, et al. The Clinical Significance of Positive Blood Cultures in the 1990s… 1997. Clin Infect Dis 24: 584-602.
Wilson ML, et al. CLSI document M47-A Principles and Procedures for Blood Cultures; Approved Guideline. 2007.
References 5 Yokoe DS, et al. Simplified Surveillance for Nosocomial
Bloodstream Infections. 1998. Infect Control Hosp Epidem 19: 657-60.
Zwang O and RK Albert. Analysis of Strategies to Improve Cost Effectiveness of Blood Cultures. 2006. J Hosp Med 1: 272-6.