Shore Health. Attachment SE1EOe, Blood Culture Collection Educational Program

Transcription

1 Shore Health Attachment SE1EOe, Blood Culture Collection Educational Program 1

2 Why Culture Blood? Micro-organisms present in a patient s blood are a threat to every organ in the body and can cause serious illness and/or death if not treated promptly with the right antibiotics. Blood cultures are performed to : find micro-organisms rule out the presence of microorganisms in the patient s blood. Attachment SE1EOe, Blood Culture Collection Educational Program 2

3 Skin Because skin has its own normal flora, bacteria present on the patient s skin can contaminate the tip of the needle and enter the blood flowing into the blood culture bottles causing the blood culture to become falsely positive if the venipuncture site is not adequately cleansed. Bacteria from the collector s fingers or hands and exposure of the sterile collection supplies to environmental surfaces like the bed or bed-side table can also be a source of blood culture contamination. Improper technique leads to blood culture contamination Proper site preparation and aseptic technique are paramount to a successful blood culture collection. Blood Culture Contamination Consequences The patient may be treated for an organism that is not present in the bloodstream. The contaminant may overgrow the pathogen so it will never be recovered. The patient may go untreated for a life-threatening infection. 3

4 Contamination Consequences Cost and Increased Length Of Stay Length of stay increased by 4.5 days Cost increase of $5,000 - $8,800. (1,2) Contributes To Bacterial Resistance Needless antibiotic treatment leads to creation of drug resistant bacteria Confusion- when and when NOT to treat Physician must make a decision over treatment on unreliable results May cause an unnecessary delay in patient care 4

5 Timing and Draw Sites Attachment SE1EOe, Blood Culture Collection Educational Program Blood Culture Collection Pre-Analytical Variables Routine blood cultures: should be drawn 15 minutes apart and from different sites unless otherwise specified by the physician When it is necessary to draw 2 sets of blood cultures at the same time, they should be drawn from 2 different sites. You may perform 2 separate cleansings/ venipuncture events on the same extremity if drawing from 2 different extremities is impossible. 5

6 Skin Preparation (patients > 2 mos. old) 1. Locate the vein to be used. 2. If skin is visibly dirty, wash with soap and water. Dry. 3. Wipe area with alcohol prep pad. 4. Prep the ChloraPrep FREPP sponge. Squeeze wings to release solution. Press the sponge against the skin surface to be cleansed, saturating it. 5. Vigorously scrub the area for 30 seconds using a back and forth motion. This removes loose skin cells and sterilizes the area The scrubbing should continue for a full 30 seconds, allowing the chlorhexidene solution to reach into the cracks and fissures of the skin surface surface 6. Allow area to air dry for about 30 seconds. Avoid touching the prepared venipuncture site!! Poor skin preparation in the #1 cause of BC contamination!!! 6

7 Skin Preparation (Patients < 2 months old) (11) Locate the vein to be used. Using a Betadine preparation, scrub the area thoroughly. Allow the Betadine to dry. Perform the venipuncture. After blood has been collected, remove the Betadine from the infant s skin with a sterile saline prep. 7

8 Bottle Choice One pair of Aerobic and Anaerobic bottles. Use of paired Aerobic and Anaerobic bottles for each set drawn recovers more pathogens compared to use of aerobic bottles only. (4,5,6) Pediatric - Peds Plus bottles are used for pediatric blood cultures. One bottle per blood culture order/ set. Resin - The Plus Aerobic bottle is used only when the physician has ordered use of Antimicrobial Removal Resins Bottles for Blood Cultures. Substitute for Standard Aerobic Bottle. Fungal - Myco/F Lytic use upon physician order for fungal blood cultures. Obtain 2 bottles from Lab for each order. 8

9 Successful recovery of bacteria from a blood culture is highly dependent on collection of an adequate volume of blood without overfilling the BD BACTEC bottles. Under-filling the bottles: may cause bacteremia to go undetected Overfilling the bottles : causes false positive readings on the Bactec blood culture instrument. Specimen Volume Goal: Draw the maximum optimum blood volume The yield of pathogens detected in a blood culture increases in direct proportion to the volume of blood that is cultured. (3) Attachment SE1EOe, Blood Culture Collection Educational Program Bottle Type Standard Aerobic Blue lid Anaerobic Purple lid Plus Aerobic Gray lid Mycolytic (fungal)whit e lid Pediatric Pink lid Fill Volume 8-10 ml 8-10 ml 8-10 ml 8-10 ml 1-3 ml 9

10 Order of Draw Always draw Blood cultures first! When combining blood cultures with other lab test specimens draw blood cultures first. Be sure the adapter or transfer device needle does not touch the top of a tube that has not been cleaned. Use Aseptic technique. Fill the Aerobic bottle first Any air in the tubing should go into the aerobic bottle, not the anaerobic bottle When less that recommended volume of blood is obtained, inoculate the aerobic bottle first. Most bacteria recover better in this environment. 10

11 Aseptic Technique Strict aseptic technique must be followed throughout the collection. Gather proper equipment and stage area. Do not open and place sterile equipment on a non-sterile surface. Keep the equipment in the opened wrappers until ready to use. Use proper PPE If drawing blood culture and other lab test specimens together- Blood culture bottles must ALWAYS be drawn and filled prior to drawing the other lab test tubes so that the adapter or transfer device needle does not touch the top of a tube that has not been cleaned It is best practice to draw blood cultures by venipuncture. Drawing blood from an IV catheter can significantly increase blood culture contamination with skin organisms, even if the IV catheter is newly inserted. (7,8,9,10) Blood cultures should NOT be collected through an IV catheter, whether it is a newly inserted IV catheter or an established IV, unless investigating a possible established IV line catheter-caused bloodstream infection by drawing simultaneous catheter and venous specimens. 11

12 Equipment Scenario 1 (Direct Draw) Scenario 2 (Syringe and Transfer Device) Sterile Alcohol Pads Tourniquet ChloraPrep FREPP sponge Sterile Safety-Lok Blood Collection Set (butterfly) with pre-attached holder Blood Culture Bottles Sterile Alcohol Pads Tourniquet ChloraPrep FREPP sponge Winged Blood Collection Set (butterfly) Sterile 3-20cc syringe Blood Transfer Device Blood Culture Bottles 12

13 BLOOD VOLUME Attachment SE1EOe, Blood Culture Collection Educational Program On rare occasions, it may be impossible to collect the desired amount of blood. In that case, there is flexibility: Blood Volume ml 3-9 ml <3 ml Instruction Using equal volume, inoculate the Aerobic and Anaerobic bottles Inoculate Aerobic bottle only Inoculate Pediatric bottle 0.5ml minimum 13

14 Common Pitfalls Failure to wash hands prior to donning gloves Inadequate skin preparation Not allowing the venipuncture site to dry prior to specimen collection Failure to scrub the tops of the BC bottles with alcohol prior to inoculation. Not allowing the tops of the BC bottles to dry prior to inoculation Touching the venipuncture site with your fingers after skin prep Allowing the tourniquet to touch the venipuncture site Exposure of sterile equipment to non-sterile surfaces prior to use. Touching the hubs of transfer device or syringe with fingers When using a syringe, pull back on plunger before use to break the seal. But DO NOT TOUCH the part of the plunger that goes back into the syringe. DO NOT TOUCH the hub of the syringe or luer adaptor that connects to transfer devices. Overfilling the bottles can cause false positive readings 14

15 Blood Culture Collection Instructions Step 1: Skin Preparation If skin visibly dirty, wash with soap and water, and dry. Cleanse the skin with a sterile alcohol pad and allow to dry. Using a ChloraPrep One Step Frepp ** Press sponge against skin surface to be cleansed once or twice to saturate the skin. ** Do not use the ChloraPrep One Step Frepp on patients less than 2 months old. Instead, use Betadine to clean the site. After the venipuncture has been completed, remove the Betadine from the skin with a sterile saline prep. (11) Attachment SE1EOe, Blood Culture Collection Educational Program Cleanse area thoroughly, scrubbing vigorously using a back- and- forth friction scrub ensuring the solution reaches into the cracks and fissures of the skin for a full 30 seconds. Adequate skin decontamination at the site of the venipuncture is the single most important factor in avoiding skin-organism contaminated blood cultures. Allow area to dry for approximately 30 seconds. Note: Avoid touching the site of venipuncture. All site locating should be done prior to cleansing the site. If it is absolutely necessary to touch the site after it has been cleansed, then your fingers (gloved) need to be cleansed thoroughly with ANOTHER Frepp and allowed to dry before touching the site. 15

16 Blood Culture Collection Instructions Step 2: Prepare the Bactec Bottles Note the media fluid level of the un-inoculated Bactec Culture bottles being used and mark the bottles at the maximum fill level Remove the flip caps from the Bactec culture bottles Scrub the tops of the bottles with sterile alcohol pads and allow to dry 16

17 Blood Culture Collection Instructions Step 3: Blood Collection Two Options: Direct Draw Preferred method because of reduced opportunities for contamination. or Syringe and Transfer Device Use syringe if patient s veins are delicate and likely to collapse and when using Peds Plus bottle. 17

18 Direct Draw Attachment SE1EOe, Blood Culture Collection Educational Program Remove sheath covering needle at wings and perform venipuncture Fill the aerobic bottle first. Be sure to hold bottle upright. Push and hold the holder over the top of the bottle to puncture bottle septum. Carefully monitor the blood volume collected in the bottle and collect blood to desired fill level. When desired fill level is achieved in aerobic bottle, remove holder from bottle and immediately push and hold holder on anaerobic bottle. 18

19 Direct Draw (continued) If unable to obtain of patient's blood, a minimum of 10 cc may be divided equally (5cc to each bottle) between the Standard 10 Aerobic/F and the Lytic/10 Anaerobic/F bottles. If only 3-9cc of patient's blood can be obtained, place the entire amount in the Standard 10 Aerobic/F (Blue) Bottle When final bottle is filled, withdraw the needle by grasping the wings (not the yellow safety device) and gently pull. Cover the venipuncture site with sterile gauze and apply pressure. Label bottles with patient name, location, date and time of draw and initials of phlebotomist, being careful not to obscure the bar code labels on the media bottles. The appropriately labeled bottles should then be left at room temperature and forwarded to Microbiology as soon as possible Attachment SE1EOe, Blood Culture Collection Educational Program 19

20 Aerobic & Anaerobic 20

21 Venipuncture Option 2 Syringe and Transfer Device Peel apart transfer device, syringe, and butterfly packaging while maintaining sterility of equipment. Maintaining sterility of butterfly-syringe connection, remove multisample luer adapter from butterfly. Attach butterfly to syringe Draw blood into a syringe and inoculate the Bacter bottles using a Blood Transfer safety device Fill the aerobic bottle first 21

22 Venipuncture Option 2 (Cont.) Blood Volume collected Attachment SE1EOe, Blood Culture Collection Educational Program Instruction ml Using equal volume, inoculate the Aerobic and Anaerobic bottles 3-9 ml Inoculate Aerobic bottle only <3 ml (0.5 ml minimum) Inoculate Pediatric bottle Label bottles with patient name, location, date and time of draw and initials of phlebotomist, being careful not to obscure the bar code labels on the media bottles. Forward bottles to the lab promptly. 22

23 References: Attachment SE1EOe, Blood Culture Collection Educational Program 1. Ernst, Dennis. Controlling Blood Culture Contamination Rates. MLO 3/ Gander, Rita,et al. Impact of Cultures Drawn by Phlebotomy on Contamination Rates and Health Care Costs in a Hospital Emergency Department. JCM4/2009.p Reller, L.B., P.R. Murray, and J.D. McLowry Cumitech 1A, Blood Culture II. Coordinating ed., J.A. Washington II. American Society for Microbiology, Washington, D.C. 4. Murray, Patrick etal. Manual of Clinical Microbiology th ed. P Hall,Keri. Updated Review of Blood Culture Contamination. Clin. Micro. Reviews. Oct p Mahon,Connie. Etal. Textbook of Diagnostic Microbiology rd ed. p

24 References (cont.): 7. Weinstein,Melvin P. Blood Culture Contamination: Persisting Problems and Partial Progress. J. Clin. Micro. June p Everts, Richard J. etal. Contamination of Catheter-Drawn Blood Cultures.J. Clin Micro. Sept v39. p Principles and Procedures for Blood Cultures: Approved Guideline. M-47-A Vol. 27NO.17.CLSI.Wayne, Pa Norberg, A., Christopher, NC et al.contamination Rates of Blood Cultures Obtained by Dedicated Phlebotomy vs Intravenous Catheter.JAMA Feb. 12;289 (6) p Personal Communication Vonnie Rosemary,RN- SHS-MHE Birthing Unit. January 19,