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Evaluation of Hemoculture Extraction Technique in an Emergency Department: Nursing Staff Self-Perception and Reality
RESEARCH
EVALUATION OF HEMOCULTURE EXTRACTION TECHNIQUE IN AN EMERGENCY DEPARTMENT: NURSING STAFF SELF-PERCEPTION AND REALITY Authors: Roberto Velasco, MD, Jose Luis Fernández, MD, Maria Natali Campo, MD, and Sara Puente, MD, Valladolid, Spain
Earn Up to 9.0 CE Hours. See page 108. Introduction: Between 2009 and 2010, the rate of contamination of hemocultures drawn in our emergency department was much higher than the quality standards recommended, so we decided to check the extraction procedure of the samples to detect possible faults. We also wanted to study the perception of the nursing staff about the quality of their practice. Methods: This is a prospective study developed in 2 phases. In the first phase, medical staff observed the extraction of hemocultures. In the second phase, an anonymous test was sent to the nursing staff of the emergency department.
lood cultures are the gold standard for the diagnosis of bacteremia. The main problem faced with this test is the increase in nonpathogenic flora, which is regarded as contamination flora. At our hospital’s pediatric emergency department, which does not provide any specific nursing staff, the rate of contaminated blood cultures was 12.56% between 2009 and 2010. For this reason, to detect possible faults in the technique for extraction of blood cultures in the pediatric emergency department, we decided to check the extraction procedure for samples by checking the degree of agreement between the perception
B
Roberto Velasco is Staff Pediatrician, Pediatric Emergency Department, Rio Hortega Hospital, Valladolid, Spain. Jose Luis Fernández is Staff Pediatrician, Pediatric Emergency Department, Rio Hortega Hospital, Valladolid, Spain. Maria Natali Campo is Staff Pediatrician, Pediatric Emergency Department, Rio Hortega Hospital, Valladolid, Spain. Sara Puente is Staff Pediatrician, Pediatric Emergency Department, Rio Hortega Hospital, Valladolid, Spain. For correspondence, write: Roberto Velasco Zúñiga, C/ Pisuerga, 7, 3° B, 47140-Laguna de Duero, Valladolid, Spain; E-mail: [email protected]. J Emerg Nurs 2014;40:36-8. Available online 5 November 2012. 0099-1767/$36.00 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.07.024
36
JOURNAL OF EMERGENCY NURSING
Results: We observed major faults in the extraction procedure. Of the 10 items checked, only 2 had a compliance rate greater than 50%. There were significant differences between test answers and data recovered from observation in 7 items. Discussion: Several technical deficiencies were observed in the procedure for extraction of blood cultures. This fact partly explains the high rate of contamination found in our emergency department. Key words: Contamination; Extraction; Hemoculture
of the work done by nursing staff and the real practice carried out by them. Methods
This is a prospective study developed in 2 phases. The study was performed at Rio Hortega Hospital’s Pediatric Emergency Department. The Pediatric Emergency Department attends to over 25,000 patients a year, and it has nursing staff that is shared with the general emergency department. So, pediatric emergency nurses are specialized emergency nurses but are not pediatric specialized nurses. In the first phase of the study, between August and September 2010, doctors and residents of the Pediatric Emergency Department observed the extraction of blood cultures and verified compliance with several indicators of the extraction technique carried out. In the second phase, an anonymous test was sent to the pediatric emergency department nursing staff; the test was made up of some questions related to the perception of compliance for each of the indicators stated in the first phase. Responses were then compared with what we had observed in practice. Results
Eighty-eight blood cultures were collected during the first phase of the study. We only recovered extraction data from 40 of those 88 blood cultures (45.45%). In the second phase of the study, 28 nurses answered the test questions
VOLUME 40 • ISSUE 1
January 2014
Velasco et al/RESEARCH
TABLE
Nursing staff responses about their perception of compliance with items and real compliance observed by medical staff Item
Affirmative responses (n = 28)
Do you sterilize puncture zone? Do you wait 1 minute before puncturing? Do you use sterile gloves? If you do not use gloves, do you sterilize the finger you touch the vein with? Do you sterilize the hemoculture bottle tap? If you canalize a vein, do you extract blood through the catheter? Do you speak during extraction? When you take out the needle, do you touch it with the cotton piece? Do you change the needle before you introduce blood in the hemoculture bottle? Do you introduce blood in the hemoculture bottle in the first place?
100% 89% 11% 60.7% 32.17% 75%
Real compliance (n = 40)
85% 11.75% 0% 5% 0% 100%
P value
.03 .0001 NS .0001 .0001 .032
53.5% 42.9%
77.5% 75%
NS .011
89.2%
15%
.0001
89.2%
70%
NS
NS, Not significant.
(46.66% of staff). The Table shows the comparison of the results of the test and what we have observed in practice. Discussion
Upon review, we found there to be a growth rate of germs (considered as contaminants germs) of some 12.56% in the blood cultures collected in our pediatric emergency department. Several clinical guidelines consider acceptable rates below 3%.1,2 The result was initially attributed to an inadequate sample extraction technique; that is why we decided to review the technique. In the first phase, one medical staff member (pediatrician or resident) stayed in the room during the blood culture extraction and supervised and checked the extraction. Records indicate if the technique was in compliance with several of the indicators taken from corresponding articles.1–7 To avoid the Hawthorne effect, the observation was not reported to the nursing staff. Later, the nursing staff members were tested to find out their compliance rate with the indicators based on their perception. We have observed weak compliance of most of the indicators with the data obtained in the first phase. The only 2 indicators with more than 50% compliance were (1) “sterilizing the area to puncture” and (2) “introduction of blood in the blood culture bottle in the first place.” However, regarding the first item, it was striking that in 15% of the cases observed, we found that the area had not been previously
January 2014
VOLUME 40 • ISSUE 1
sterilized before being punctured. It should be pointed out that if the area was sterilized first but the area was touched with a nonsterile object later, the area was considered a nonsterile area. Similarly, if the person who was going to extract the blood culture washed his or her hands and applied antiseptic solution beforehand but then touched a nonsterile surface, the area was considered a nonsterile area. This also explains the small percentage of compliance with this first indicator. Although the second indicator mentioned had more than 50% compliance, there still was a 30% rate of noncompliance. One possible explanation for this may be the fact that the extraction of samples from patients with few indications, such as acute appendicitis, is made from the blood left over after filling the laboratory test tubes. This poor patient selection has been corrected after our study. Also remarkable is the fact the bottle cap was not sterilized at any time. This behavior may be because of a previous protocol distributed by our hospital Microbiology Department, in which it advised against this measure. Although it was later recommended to sterilize the cap based on scientific evidence, the protocol mentioned has not been reviewed since, which is why the measure is not routinely carried out. Clinical guidelines advise against talking during the extraction; however, it is understandable that we speak to children while they are being punctured. Pediatric patients are usually scared because of the pending pain caused by the puncture, and it is an important practice for nurses
WWW.JENONLINE.ORG
37
RESEARCH/Velasco et al
to calm them. Currently, our nursing staff wear masks when puncturing. After a venipuncture is performed, a very common practice is to apply pressure to the punctured area with a piece of cotton after removal of the needle to avoid the appearance of a bruise. A frequent mistake is to touch the needle with the cotton piece, which is rarely sterile. One solution we have adopted in our department was to perform this task with sterile gauze instead of cotton. We found the discrepancy between the perception of nursing staff practice and the real practice performed by them very alarming, finding substantial differences in 7 of the 10 indicators studied.
Conclusions
Limitations
3. Marlowe L, Mistry RD, Coffin S, et al. Blood culture contamination rates after skin antisepsis with chlorhexidine gluconate versus povidone-iodine in a pediatric emergency department. Infect Control Hosp Epidemiol. 2010;31(2):171-6. 4. Ramsook C, Childers K, Cron SG, Nirken M. Comparison of blood‐culture contamination rates in a pediatric emergency room: newly inserted intravenous catheters versus venipuncture. Infect Control Hosp Epidemiol. 2000;21(10):649-51. 5. Norberg A, Christopher NC, Ramundo ML, Bower JR, Berman SA. Contamination rates of blood cultures obtained by dedicated phlebotomy vs intravenous catheter. JAMA. 2003;289(6):726-9.
Our study has important limitations. The number of patients treated in the emergency department decreases during the months of August and September. This makes the number of blood cultures lower, although the low compliance rates make us believe that this lack of compliance reflects a real problem. On the other hand, the fact that our tests have been carried out during such a short period implies that some nursing staff have not been observed. Given the high level of contamination, instead of waiting to have a greater sample size, we decided to accept this limitation and perform an intervention that might improve the quality of the extraction method immediately.
38
JOURNAL OF EMERGENCY NURSING
Despite our small-sample test, several technical deficiencies were observed in the blood culture extractions, which partly explain the high contamination rate in our emergency department. For this reason, to reduce the contamination rate, a consistent extraction protocol was developed based on current scientific evidence. REFERENCES 1. Pavlovsky M, Press J, Peled N, Yagupsky P. Blood culture contamination in pediatric patients. young children and young doctors. Pediatr Infect Dis J. 2006;25(7):611-4. 2. Gonsalves WI, Cornish N, Moore M, Chen A, Varman M. Effects of volume and site of blood draw on blood culture results. J Clin Microbiol. 2009;47(11):3482-5.
6. Buttery JP. Blood cultures in newborns and children optimising an everyday test. Arch Dis Child Fetal Neonatal Ed. 2002;87(1):F25-8. 7. Isaacman DJ, Karasic RB. Lack of effect of changing needles on contamination of blood cultures. Pediatr Infect Dis J. 1990;9(4):274-8.
VOLUME 40 • ISSUE 1
January 2014
EVALUATION OF HEMOCULTURE EXTRACTION TECHNIQUE IN AN EMERGENCY DEPARTMENT: NURSING STAFF SELF-PERCEPTION AND REALITY Authors: Roberto Velasco, MD, Jose Luis Fernández, MD, Maria Natali Campo, MD, and Sara Puente, MD, Valladolid, Spain
Earn Up to 9.0 CE Hours. See page 108. Introduction: Between 2009 and 2010, the rate of contamination of hemocultures drawn in our emergency department was much higher than the quality standards recommended, so we decided to check the extraction procedure of the samples to detect possible faults. We also wanted to study the perception of the nursing staff about the quality of their practice. Methods: This is a prospective study developed in 2 phases. In the first phase, medical staff observed the extraction of hemocultures. In the second phase, an anonymous test was sent to the nursing staff of the emergency department.
lood cultures are the gold standard for the diagnosis of bacteremia. The main problem faced with this test is the increase in nonpathogenic flora, which is regarded as contamination flora. At our hospital’s pediatric emergency department, which does not provide any specific nursing staff, the rate of contaminated blood cultures was 12.56% between 2009 and 2010. For this reason, to detect possible faults in the technique for extraction of blood cultures in the pediatric emergency department, we decided to check the extraction procedure for samples by checking the degree of agreement between the perception
B
Roberto Velasco is Staff Pediatrician, Pediatric Emergency Department, Rio Hortega Hospital, Valladolid, Spain. Jose Luis Fernández is Staff Pediatrician, Pediatric Emergency Department, Rio Hortega Hospital, Valladolid, Spain. Maria Natali Campo is Staff Pediatrician, Pediatric Emergency Department, Rio Hortega Hospital, Valladolid, Spain. Sara Puente is Staff Pediatrician, Pediatric Emergency Department, Rio Hortega Hospital, Valladolid, Spain. For correspondence, write: Roberto Velasco Zúñiga, C/ Pisuerga, 7, 3° B, 47140-Laguna de Duero, Valladolid, Spain; E-mail: [email protected]. J Emerg Nurs 2014;40:36-8. Available online 5 November 2012. 0099-1767/$36.00 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.07.024
36
JOURNAL OF EMERGENCY NURSING
Results: We observed major faults in the extraction procedure. Of the 10 items checked, only 2 had a compliance rate greater than 50%. There were significant differences between test answers and data recovered from observation in 7 items. Discussion: Several technical deficiencies were observed in the procedure for extraction of blood cultures. This fact partly explains the high rate of contamination found in our emergency department. Key words: Contamination; Extraction; Hemoculture
of the work done by nursing staff and the real practice carried out by them. Methods
This is a prospective study developed in 2 phases. The study was performed at Rio Hortega Hospital’s Pediatric Emergency Department. The Pediatric Emergency Department attends to over 25,000 patients a year, and it has nursing staff that is shared with the general emergency department. So, pediatric emergency nurses are specialized emergency nurses but are not pediatric specialized nurses. In the first phase of the study, between August and September 2010, doctors and residents of the Pediatric Emergency Department observed the extraction of blood cultures and verified compliance with several indicators of the extraction technique carried out. In the second phase, an anonymous test was sent to the pediatric emergency department nursing staff; the test was made up of some questions related to the perception of compliance for each of the indicators stated in the first phase. Responses were then compared with what we had observed in practice. Results
Eighty-eight blood cultures were collected during the first phase of the study. We only recovered extraction data from 40 of those 88 blood cultures (45.45%). In the second phase of the study, 28 nurses answered the test questions
VOLUME 40 • ISSUE 1
January 2014
Velasco et al/RESEARCH
TABLE
Nursing staff responses about their perception of compliance with items and real compliance observed by medical staff Item
Affirmative responses (n = 28)
Do you sterilize puncture zone? Do you wait 1 minute before puncturing? Do you use sterile gloves? If you do not use gloves, do you sterilize the finger you touch the vein with? Do you sterilize the hemoculture bottle tap? If you canalize a vein, do you extract blood through the catheter? Do you speak during extraction? When you take out the needle, do you touch it with the cotton piece? Do you change the needle before you introduce blood in the hemoculture bottle? Do you introduce blood in the hemoculture bottle in the first place?
100% 89% 11% 60.7% 32.17% 75%
Real compliance (n = 40)
85% 11.75% 0% 5% 0% 100%
P value
.03 .0001 NS .0001 .0001 .032
53.5% 42.9%
77.5% 75%
NS .011
89.2%
15%
.0001
89.2%
70%
NS
NS, Not significant.
(46.66% of staff). The Table shows the comparison of the results of the test and what we have observed in practice. Discussion
Upon review, we found there to be a growth rate of germs (considered as contaminants germs) of some 12.56% in the blood cultures collected in our pediatric emergency department. Several clinical guidelines consider acceptable rates below 3%.1,2 The result was initially attributed to an inadequate sample extraction technique; that is why we decided to review the technique. In the first phase, one medical staff member (pediatrician or resident) stayed in the room during the blood culture extraction and supervised and checked the extraction. Records indicate if the technique was in compliance with several of the indicators taken from corresponding articles.1–7 To avoid the Hawthorne effect, the observation was not reported to the nursing staff. Later, the nursing staff members were tested to find out their compliance rate with the indicators based on their perception. We have observed weak compliance of most of the indicators with the data obtained in the first phase. The only 2 indicators with more than 50% compliance were (1) “sterilizing the area to puncture” and (2) “introduction of blood in the blood culture bottle in the first place.” However, regarding the first item, it was striking that in 15% of the cases observed, we found that the area had not been previously
January 2014
VOLUME 40 • ISSUE 1
sterilized before being punctured. It should be pointed out that if the area was sterilized first but the area was touched with a nonsterile object later, the area was considered a nonsterile area. Similarly, if the person who was going to extract the blood culture washed his or her hands and applied antiseptic solution beforehand but then touched a nonsterile surface, the area was considered a nonsterile area. This also explains the small percentage of compliance with this first indicator. Although the second indicator mentioned had more than 50% compliance, there still was a 30% rate of noncompliance. One possible explanation for this may be the fact that the extraction of samples from patients with few indications, such as acute appendicitis, is made from the blood left over after filling the laboratory test tubes. This poor patient selection has been corrected after our study. Also remarkable is the fact the bottle cap was not sterilized at any time. This behavior may be because of a previous protocol distributed by our hospital Microbiology Department, in which it advised against this measure. Although it was later recommended to sterilize the cap based on scientific evidence, the protocol mentioned has not been reviewed since, which is why the measure is not routinely carried out. Clinical guidelines advise against talking during the extraction; however, it is understandable that we speak to children while they are being punctured. Pediatric patients are usually scared because of the pending pain caused by the puncture, and it is an important practice for nurses
WWW.JENONLINE.ORG
37
RESEARCH/Velasco et al
to calm them. Currently, our nursing staff wear masks when puncturing. After a venipuncture is performed, a very common practice is to apply pressure to the punctured area with a piece of cotton after removal of the needle to avoid the appearance of a bruise. A frequent mistake is to touch the needle with the cotton piece, which is rarely sterile. One solution we have adopted in our department was to perform this task with sterile gauze instead of cotton. We found the discrepancy between the perception of nursing staff practice and the real practice performed by them very alarming, finding substantial differences in 7 of the 10 indicators studied.
Conclusions
Limitations
3. Marlowe L, Mistry RD, Coffin S, et al. Blood culture contamination rates after skin antisepsis with chlorhexidine gluconate versus povidone-iodine in a pediatric emergency department. Infect Control Hosp Epidemiol. 2010;31(2):171-6. 4. Ramsook C, Childers K, Cron SG, Nirken M. Comparison of blood‐culture contamination rates in a pediatric emergency room: newly inserted intravenous catheters versus venipuncture. Infect Control Hosp Epidemiol. 2000;21(10):649-51. 5. Norberg A, Christopher NC, Ramundo ML, Bower JR, Berman SA. Contamination rates of blood cultures obtained by dedicated phlebotomy vs intravenous catheter. JAMA. 2003;289(6):726-9.
Our study has important limitations. The number of patients treated in the emergency department decreases during the months of August and September. This makes the number of blood cultures lower, although the low compliance rates make us believe that this lack of compliance reflects a real problem. On the other hand, the fact that our tests have been carried out during such a short period implies that some nursing staff have not been observed. Given the high level of contamination, instead of waiting to have a greater sample size, we decided to accept this limitation and perform an intervention that might improve the quality of the extraction method immediately.
38
JOURNAL OF EMERGENCY NURSING
Despite our small-sample test, several technical deficiencies were observed in the blood culture extractions, which partly explain the high contamination rate in our emergency department. For this reason, to reduce the contamination rate, a consistent extraction protocol was developed based on current scientific evidence. REFERENCES 1. Pavlovsky M, Press J, Peled N, Yagupsky P. Blood culture contamination in pediatric patients. young children and young doctors. Pediatr Infect Dis J. 2006;25(7):611-4. 2. Gonsalves WI, Cornish N, Moore M, Chen A, Varman M. Effects of volume and site of blood draw on blood culture results. J Clin Microbiol. 2009;47(11):3482-5.
6. Buttery JP. Blood cultures in newborns and children optimising an everyday test. Arch Dis Child Fetal Neonatal Ed. 2002;87(1):F25-8. 7. Isaacman DJ, Karasic RB. Lack of effect of changing needles on contamination of blood cultures. Pediatr Infect Dis J. 1990;9(4):274-8.
VOLUME 40 • ISSUE 1
January 2014