Especially for busy hospital emergency departments, avoiding blood culture contamination is a constant challenge for those tasked with collecting blood culture specimens
Better, faster diagnosis and treatment of sepsis continues to be a major
goal at hospitals, health networks, and other medical facilities throughout the
United States. Yet microbiologists
and clinical
laboratory managers continue to be frustrated with how frequently
contaminated blood culture specimens show up in the laboratory.
A recent poll of more than 200 healthcare professionals who
attended a
sponsored webinar hosted by Dark Daily, showed that nearly 10% of
those who responded reported an overall blood culture contamination rate in
their hospitals at above 4%.
However, the arrival of new technology may provide hospital
staff with a way to reduce contamination rates in blood culture specimens, in
ways that improve patient outcomes.
The effectiveness of a new tool, the Steripath Initial Specimen Diversion
Device (ISDD), is being demonstrated in a growing number of prominent
hospitals in different regions of the United States. What will be particularly
intriguing to clinical laboratory professionals is that the ISDD is capable of
collecting blood while minimizing the problems caused by human factors, micro-organisms,
and skin plugs or fragments. This device was developed by Magnolia Medical Technologies
of Seattle, Wash.
The ISDD isolates the initial 1.5
to 2.0 mL aliquot of the blood culture sample, which is most likely to be
contaminated with microscopic skin fragments colonized with bacteria. The device diverts this initial aliquot into a sequestration
chamber, mechanically isolating it from the rest of the sample, and then
automatically opens an independent sterile pathway into blood culture collection
bottles.
Such technology may be welcomed by medical laboratory
professionals based in hospitals and other healthcare facilities. That’s
because it is the lab staff that typically identifies a contaminated blood
culture specimen and must go back to the nurses, staffers, and physicians on
the wards to have them redraw an acceptable specimen that will produce an
accurate, reliable result. Patients under these circumstances generally
continue on unnecessary broad-spectrum antibiotics, and their length of stays
have been reported to increase by two days on average.
Problem of Decentralized Phlebotomy
One problem contributing to high blood culture rates is
that, in many hospitals and health networks, phlebotomy has been decentralized
and is no longer managed by the clinical laboratory.
“I’ve seen the havoc decentralized phlebotomy wreaks on contamination rates of blood culture rates,” stated Dennis Ernst, Director of the Center for Phlebotomy Education based in Mio, Mich. “That staffing model, which swept through the hospital industry in the late 1990s, may have looked good on paper, but I can count the number of facilities that have successfully decentralized on the fingers of one hand. And I don’t know of any decentralized setting that has an acceptable blood culture contamination rate.”
Dennis Ernst, MT(ASCP), NCPT(NCCT) (above), Director of the Center for Phlebotomy Education, shared his expertise during a recent webinar hosted by Dark Daily. Ernst considers blood culture contamination to be among the “low-hanging fruit” in every medical laboratory that can be easily and permanently corrected with the proper approach. (Photo copyright: Dennis Ernst.)
Ernst, a medical
technologist and educator, has seen the
difficulty in lowering contamination rates in a decentralized,
multidisciplinary workforce. He has worked for more than 20 years advocating
for best practices in the diagnostic blood collection industry and has helped clinical
laboratory facilities achieve a 90% reduction in their contamination rates. Ernst considers blood
culture contamination to be among the “low-hanging fruit” in every laboratory
that can be easily and permanently corrected with the proper approach.
“One statistic we’ve heard over and over again is that the American Society of Microbiology established the ‘threshold’ for blood culture contamination to be 3%,” Ernst said. “I believe strongly that a 1% contamination rate or less is what should be required and that it’s not only achievable, but sustainable.”
Regardless of
staffing mix, blood culture contamination is a common problem in the emergency
department, Ernst explained during his presentation, “Evidence-Based
Technology to Reduce Blood Culture Contamination, Improve Patient Care, and
Reduce Costs in Your Clinical Lab or Hospital,” which is available
free for streaming.
Improving Patient Care and Reducing Avoidable Costs
With unnecessary
antibiotic use, increased length of stay, and the cost of unnecessary
laboratory testing at issue, hospitals are tracking blood culture collection
results and exploring ways to reduce episodes of blood culture contamination. On these and other healthcare quality
improvement aims, providers are publishing study results on contamination
reduction and potential direct and indirect hospital cost savings. For example:
At the University of Nebraska, a
prospective, controlled, matched-pair clinical study showed an 88% reduction in
blood culture contamination with a 12-month sustained rate of 0.2% when
Steripath was used by phlebotomists in the ED. The author estimated the institution
would save approximately $1.8 million if the technology was adopted
hospitalwide, reported an article in Clinical
Infectious Diseases in July 2017.
Florida-based Lee
Health system’s microbiology laboratory reported an 83% reduction in
contamination rates comparing their standard method to ISDD for a seven-month
trial period. Their systemwide potential cost avoidance estimates ranged from
$4.35 million to nearly $11 million, reported an article in the Journal of Emergency
Nursing in November 2018.
Researchers from Massachusetts General reported that
ISDD is the single most effective intervention so far explored for reducing
costs related to false-positive blood cultures, potentially saving the typical
250- to 400-bed hospital $1.9 million or $186 per blood culture and preventing
34 hospital-acquired conditions (including three C.
difficile cases). The recent article “Model to Evaluate the Impact of
Hospital-based Interventions Targeting False-Positive Blood Cultures on
Economic and Clinical Outcomes” in the Journal
of Hospital Infection explains more.
Blood Facilities Should be Tracking Their Contamination
Rate
One of the biggest challenges faced during blood sample
collection is making sure an organism is not inadvertently introduced into the
blood. Therefore, importance has been placed on clinical laboratories and other healthcare providers
developing policies and procedures to limit the introduction of likely
contaminants.
“I believe most places monitor blood culture contamination,
but they are not doing much that is effective to reduce it,” Ernst said.
“That’s a real problem.”
To assist healthcare providers in blood culture quality
improvement, the free webinar, “Evidence-Based Technology to Reduce Blood
Culture Contamination, Improve Patient Care, and Reduce Costs in Your Clinical
Lab or Hospital,” available on-demand through Dark Daily, can be
downloaded by clicking here,
or by pasting the URL “https://darkintelligenceprogramsondemand.uscreen.io/programs/evidence-based-technology-to-reduce-blood-culture-contamination-improve-patient-care-and-reduce-costs-in-your-clinical-lab-or-hospital”
into a web browser.
This program, which polled more than 200 healthcare
professionals, explores the clinical and economic significance of blood culture
contamination, the downstream impact of false-positive blood cultures, and case-study
evidence of sustained reductions in contamination.
AUSTIN, Texas (July 18, 2019) – As a result of contamination of blood specimens at the time of collection, 35% to 50% of positive blood culture results indicating sepsis are actually false positive. These false positive results confound clinical decisions regarding antibiotic therapy, including selection and de-escalation of broad-spectrum antibiotic treatment. The result is that patients are often treated with unnecessary antibiotics, with attendant risks of secondary infection such as C. difficile, MDROs, and other antibiotic-associated complications.
This significant issue impacts every clinical laboratory, adding unnecessary lab workflow burden and incurring millions of dollars of avoidable costs each year. Typical interventions such as ongoing training and education cannot effectively address blood culture contamination issues, and have shown only modest and unsustainable reduction in contamination rates. But now, there is evidence of an intervention that can address this challenge, with five peer-reviewed studies along with eight clinical abstracts presented at major national medical society conferences that support the positive clinical and economic impact of the Steripath® Initial Specimen Diversion Device®. These studies have shown a reduction in false positive blood cultures up to 92%, sustained blood culture contamination rates as low as 0.2%, positive predictive value as high as 97%, and reduction in vancomycin days of therapy as much as 37%.
Some clinicians continue to believe that the 3% national benchmark for blood culture contamination is sufficient for patients and their care providers. To demonstrate why this is not the case, and to provide laboratory leaders with a superior understanding of the scale of the blood culture contamination problem and the profound impact it has on patient care and lab costs—as well as present best practices and evidence-based solutions to efficiently and effectively impact this serious issue—Dark Daily is hosting an informative FREE webinar sponsored by Magnolia Medical Technologies entitled “Evidence-Based Technology to Reduce Blood Culture Contamination, Improve Patient Care and Reduce Costs in Your Clinical Lab or Hospital,” taking place Tuesday, July 23, 2019, at 1 pm EDT.
The expert presenter of this webinar is Dennis J. Ernst, MT(ASCP), NCPT (NCCT), Director of The Center for Phlebotomy Education in Mio, MI. “We are excited to be partnering with Magnolia Medical to address one of the biggest problems plaguing our healthcare system today,” stated Ernst, Founding Director of the Center. “Steripath Gen2 is an evidence-based technology solution to a problem many thought could never be solved. This training and educational program effectively demonstrates the clinically proven combination of technique and technology to empower laboratory staff to seize control of blood culture contamination rates and improve the lives of over a million people each year, all while saving the healthcare system billions of dollars.”
During the 60-minute session, webinar participants will learn:
The downstream impact of false-positive blood cultures, with a focus on antimicrobial stewardship in this era of antibiotic resistance
Why traditional intervention methods that have been attempted have had only limited effectiveness
Best practices to dramatically reduce blood culture contamination
Case study evidence of sustained reductions in blood culture contamination, and the resulting direct and indirect clinical and economic significance
For more information about “Evidence-Based Technology to Reduce Blood Culture Contamination, Improve Patient Care and Reduce Costs in Your Clinical Lab or Hospital,” click here. You may also contact Chris Garcia at 512-264-7103.
About MAGNOLIA MEDICAL TECHNOLOGIES
Magnolia Medical Technologies is a medical device company that develops, manufactures and markets innovative blood and bodily fluid collection devices to facilitate significant improvements in the accuracy, consistency, and predictability of critical laboratory tests.
Decades of research show that false positive and false negative test results routinely lead to inappropriate and unnecessary treatments. Often times, these misdiagnoses increase the use of powerful antibiotics which are associated with complications and extended patient length of stay as well as risk for hospital-acquired-infections and conditions.
Through groundbreaking device design, Magnolia Medical Technologies has become a provider ally and patient advocate. Our products address the human errors that cause preventable inaccurate test results, improving patient safety and hospital care.
We are unrelenting in our pursuit to improve current ‘standards of care’- constantly researching, testing and reinventing conventional processes in order to make the world of healthcare a better place.
Thorough hand-washing protocols aren’t just for healthcare professionals anymore. Patients also need to be educated to prevent hospital-acquired infections
Microbiologists and clinical laboratory managers will be particularly interested to learn that patients are bringing deadly organisms into hospitals on their hands. That’s the conclusion of a University of Michigan (UM) study which found that as patients enter and move throughout hospitals, they deposit and spread multi-drug resistant organisms, or MDROs on clinical surfaces. When those surfaces are not properly decontaminated, the bacterial contamination spreads on contact.
This finding has implications for the nosocomial infection teams in hospitals that include microbiologists and clinical laboratories. After all, every day there is a large flow of walk-in patients and visitors who come in contact with dozens of surfaces. The potential for contamination with multi-drug resistant organisms is high.
Antibiotic-resistant bacteria have been the root cause of a marked increase in hospital-acquired infections (HAIs), which Dark Daily has covered extensively. That’s why healthcare professionals practice proper hand-washing protocols to help reduce the transmission of pathogens and curtail possible infections.
The UM study, however, suggests that patients also should be
educated on proper hand hygiene to diminish the potential spread of bacteria,
especially before making trips to the emergency room.
Between February and July of 2017, UM researchers at two
hospitals in Southeast Michigan tested 399 general medicine hospital patients
for the presence of MDROs, also known as superbugs. They swabbed the palms,
fingers, and around the nails of the patients’ dominant hands and the interior
of both nostrils.
The researchers found that 14% of the patients tested
positive for MDROs. In addition, nearly one third of high-touch objects and
surfaces in the hospital rooms tested positive for superbugs as well.
The hospital room surfaces that were swabbed for the
presence of MDROs were:
Due to the overuse of antibiotics, these types of bacteria
are often resistant to the drugs that were once used to kill them.
“Hand hygiene narrative has largely focused on physicians, nurses, and other frontline staff, and all the policies and performance measurements have centered on them, and rightfully so,” said Lona Mody, MD (above) in a press release. Mody is Professor of Internal Medicine at UM and one of the lead researchers for the study. “But our findings make an argument for addressing transmission of MDROs in a way that involves patients, too.”
Anatomy of a Hospital-Acquired Infection
The scientists tested patients and surfaces at different
stages of their hospital stays. The samples were taken on the day of admission,
days three and seven of the stays, and weekly thereafter until the patients
were discharged.
The team found that 6% of the patients who did not have
MDROs present at the beginning of their hospital stays tested positive for
superbugs at later stages of their stays. Additionally, 20% of the tested
objects and surfaces in the patients’ rooms had superbugs on them at later test
stages that were not present earlier in the hospital stays.
“This study highlights the importance of hand washing and environmental cleaning, especially within a healthcare setting where patients’ immune systems are compromised,” noted Katherine Reyes, MD, Department of Infectious Diseases, Henry Ford Hospital, in the press release. “This step is crucial not only for healthcare providers, but also for patients and their families. Germs are on our hands; you do not need to see to believe it. And they travel. When these germs are not washed off, they pass easily from person to person and objects to person and make people sick.”
Patients included in the study had to be new admissions, on
general medicine floors, and at least 18 years of age. Criteria that excluded
individuals from participation in the research included:
Being in observation status, typically after a
medical procedure;
Transfers from other hospitals;
Transfers from intensive care units;
Having cystic fibrosis (these patients have a
higher likelihood of MDRO colonization);
Receiving end-of-life care; and
Non-English speaking.
Patients who were transferred to a room on a
nonparticipating floor within the hospitals were immediately discharged from
the study.
Patients Travel Throughout Hospitals Spreading Germs
The presence of superbugs on patients or surfaces does not
automatically translate to a patient getting sick with antibiotic-resistant
bacteria. Only six of the patients in this study developed MRSA. However, all
six of those individuals tested positive for the superbug either on their hands
or on surfaces within their room.
The researchers noted that hospital patients typically do
not stay in their rooms. They are encouraged to walk throughout the hospital to
speed up the recovery process, and often are transported to other areas of
hospitals for medical tests and procedures. Patients also may be picking up
superbugs from other patients and staff members, other hospital areas, and
commonly-touched surfaces.
The UM researchers concluded in their study that “while the
burden of preventing infections has largely been borne by [healthcare
personnel], our study shows that patient hands are an important reservoir and
play a crucial role in the transmission of pathogens in acute care hospitals.
Thus, patient hand hygiene protocols should be implemented and tested for their
ability to reduce environmental contamination, pathogen transmission, and
healthcare-associated infections, as well as to increase meaningful patient
engagement in infection prevention.”
“Infection prevention is everybody’s business,” stated Mody
in the press release. “We are all in this together. No matter where you are, in
a healthcare environment or not, this study is a good reminder to clean your
hands often, using good techniques—especially before and after preparing food,
before eating food, after using a toilet, and before and after caring for
someone who is sick—to protect yourself and others.”
These
research findings should prove to be valuable for infection control teams and
microbiology laboratories in the nation’s hospitals and health systems, as well
as independent clinical laboratories, urgent care centers, and retail
healthcare clinics.
Learning
more about the transmission of infectious agents from patient to patient and
from surfaces to patients could aid in the development of new techniques and
strategies to prevent superbugs from manifesting in medical environments.
OIG suggests better use of analytics by CMS could prevent gaming of the system by providers; clinical laboratories can help through test utilization management technology
In 2015, CMS implemented the Hospital-Acquired Condition Reduction Program (HACRP) as part of the Patient Protection and Affordable Care Act (ACA). The HACRP program incentivizes hospitals to lower their HAI rates by adjusting reimbursements according to the inpatient quality reporting (hospital IQR) data provided by the healthcare providers. Hospital IQR data is the basis on which CMS validates a hospital’s HAI rate (among other things CMS is tracking) to determine the hospital’s reimbursement rate for that year.
CMS, in 2016, met its regulatory requirement to validate inpatient quality reporting data;
It reviewed data of 400 randomly selected hospitals as well as 49 hospitals targeted for failing to report half their HAIs, or for low scores in the prior year’s validation process;
However, OIG also reported that CMS did not include hospitals that displayed abnormal data patterns in its targeted sample. Targeting those hospitals, according to the OIG, could identify inaccurate reporting.
CMS staff had identified 96 hospitals with aberrant data patterns, but did not target them for validation—even though the agency can select up to 200 targeted hospitals for review, Becker’s Hospital Review pointed out.
Dollars More Important than Deaths
According to the OIG report, Medicare excluded in its investigation dozens of hospitals with suspected HAI reporting. This is odd since the CMS and the Centers for Disease Control (CDC) apparently are aware that some healthcare providers have manipulated data to improve their quality measure scores and thus increase their reimbursement rates.
“Collecting and analyzing quality data is increasingly central to Medicare programs that link payments to quality and value. Therefore, it is important for CMS to ensure that hospitals are not gaming [manipulating data to improve scores] their reporting of quality data,” the OIG report noted.
“There are greater requirements for what a company says about a washing machine’s performance than there is for a hospital on quality of care. And this needs to change,” stated Peter Pronovost, MD, PhD, in the Kaiser Health News article. “We require auditing of financial data, but we don’t require auditing of healthcare quality data, and that implies that dollars are more important than deaths.” Pronovost is Senior Vice President for Patient Safety and Quality at Johns Hopkins University School of Medicine.
Peter Pronovost, MD, PhD (above) testifying on preventable deaths before the Senate Subcommittee on Primary Health and Aging in 2014. He is Senior Vice President for Patient Safety and Quality at Johns Hopkins University School of Medicine in Baltimore. Pronovost told Kaiser Health News that there are no uniform standards for reviewing data that hospitals report to Medicare. (Photo copyright: US Senate Committee on Health, Education, Labor and Pensions.)
Medicare Missed Hospitals with Suspected HAI Data
CMS should have done an in-depth review of many hospitals that submitted “aberrant data patterns” in 2013 and 2014, the OIG stated in its report. According to a Kaiser HealthNews article, such patterns could include:
A rapid change in results;
Improbably low infection rates; and
Assertions that infections nearly always struck before patients arrived at the hospital.
“There’s a certain amount of blind faith that hospitals are going to tell the truth. It’s a bit much to expect that if they had a bad record they are going to fess up to it,” noted Lisa McGiffert, Director of the Safe Patient Project at Consumers Union, in the Kaiser Health News article.
CMS Needs Better Data Analytics
So, what does the OIG advise CMS to do? The agency called for “better use of analytics to ensure the integrity of hospital-reported quality data.” Specifically, OIG suggested CMS:
Identify hospitals with abnormal percentages of patients who had infections on admission;
Apply risk scores to identify hospitals with high propensity to manipulate reporting;
Use experiences to create and improve models that identify hospitals most likely to game their reporting.
CMS’ Administrator Seema Verma reportedly responded, “We will continue to evaluate the use of better analytics as feasible, based on Medicare’s operational capabilities.”
Medical Laboratory Diagnostic Testing Part of Gaming the System
A 2015 CMS/CDC joint statement noted “three ways that hospitals may be deviating from CDC’s definitions for reportable HAIs,” and two involve diagnostic test ordering. According to the OIG report, they include:
Overculturing: Diagnostic tests may be overutilized by providers in absence of clinical symptoms. Hospitals may use positive results to game their data by claiming infections that appeared days later were present on admission and thus not reportable.
Underculturing: Hospitals underculture when they do not order diagnostic tests in the presence of clinical symptoms. By not ordering the test, the hospital does not learn whether the patient truly has an infection and, therefore, the hospital does not have to report it.
Adjudication: Hospital administrative staff may inappropriately overrule those who report infections. HAIs are, therefore, not shared.
Clinical Laboratories Can Help
One in 25 people each day receives an HAI, CDC estimates. The OIG findings should be a reminder to medical laboratories and pathology groups that quality measures and patient outcomes are often transparent to media, patients, and the public.
One way medical laboratories in hospitals and health systems can help is by investing in utilization management technology and protocols that ensure appropriate lab test utilization. Informing doctors on the availability of appropriate diagnostic tests based on patients’ existing conditions, unique physiologies, or medical histories, could help prevent hospitals from inadvertently or deliberately game the system.
Clearly, transparency in healthcare is increasing. That means there will be more news stories revealing federal agencies’ failures to respond to healthcare data in ways that could have protected patients and the public. Clinical laboratories don’t want to be included in negative reporting.
Latest research provides new opportunities for clinical laboratories to demonstrate how testing can help curb hospital-acquired infections
Pathologists, microbiologists, and other healthcare providers have long been aware that hospital patients taking antibiotics are at higher risk of contracting the potentially deadly Clostridium difficile infection (C. diff). But new research adds an interesting twist to this issue.
Recent research indicates that being a “second user” of a bed may be another risk factor for acquiring the disease. This will give clinical laboratory professionals, microbiologists, and others on the front lines of hospital infection control programs another factor to consider when working to halt the spread of hospital-acquired infections (HAIs).
The recent study was published online in JAMA Internal Medicine. It shows that patients put in a hospital bed previously occupied by someone given antibiotics are 22% more likely to develop the C. difficile infection, even if they do not themselves receive antibiotics. (more…)
