Clinical Practice Guideline:
Chamberlain College of Nursing
NR505 Advanced Research Methods: Evidence-based PracticeAdva
Clinical Practice Guideline: Prevention of Blood Culture Contamination
Clinical practice guidelines (CPGs) are documents that are evidence based and have been developed to guide daily practices in healthcare. They are based on critical analysis and systematic reviews of clinical questions or procedures (Peterson et al., 2014). When evaluating or rating the evidence there are different levels used to do so. The purpose of this is to critique evaluate to ensure that the evidence is credible and suited for using in practice (Peterson et. al., 2014).
Since blood cultures are considered to be the “gold standard” in diagnosis and treatment of bacteremia, however, this is limited by the rates of contamination or false positives (Proehl et al., 2012, p. 1). It has been well documented that blood culture contamination can contribute to an increase in patient morbidity and increased healthcare costs. Unfortunately, it is a common problem in the emergency department (ER/ED) due to a variety of problems such as high staff turnover rates, attempting to collect cultures from critically ill patients in an emergent manner secondary to time pressures to collect prior to the first dose of antibiotics (Self et al., 2013, p. 90). The purpose of this guideline is to provide education to all staff regarding proper specimen collection and handling in an effort to prevent blood culture contamination that can lead to increased healthcare costs to the patient as well as preventing them from unnecessary procedures and treatments and to reduce the contamination rate to less than three percent as recommended by the Clinical and Laboratory Standards Institute (Self et al., 2013, p. 90)
Scope and Purpose of the Clinical Practice Guideline
The objective of this guideline is to evaluate which variables related to peripheral venous specimen collection and transportation decrease contamination of blood cultures based on the (“Clinical Practice Guideline,” 2012).
Profession that are most involved with this guideline in all areas include:
– Advance Practice Nurses
– Allied Health Personnel
– Clinical Laboratory Personnel
– Physicians Assistants
Clinical Specialty areas include:
The guideline was created by members of the Emergency Nurses Association (ENA) to provide nurses in the emergency department resources evidenced-based information to utilize and implement nursing care of patients and families within the emergency department (Proehl et al., 2012, p. 1). The target population is all patients presenting to the emergency department with suspected bacteremia.
Rigor of Development
A critical review and analysis of the literature was performed utilizing the ENA’s Guidelines for the Development of Clinical Practice Guidelines with articles specifically relevant to the topic being identified by performing a literature search. Databases used for the search were: PubMed, Google Scholar, CINAHL, eTBlast, Ovid, Cochrane Library, Agency for Healthcare Research and Quality (AHRQ; www.AHRQ.gov), Specimen Care (www.specimencare.com) and the National Guideline Clearinghouse with the searches performed using combinations of key words of blood culture contamination, blood culture collection, hand preparation, phlebotomy technique and blood samples with the initial searches being limited to English language articles ranging from January 2002 to October 2012. However due to limitations the search was widened to begin in January 1990 (Proehl et al., 2012).
The articles meeting the criteria were selected to help develop the CPG and consisted of research studies, meta-analyses, systematic reviews, and current guidelines considered to have relevance to the topic of blood culture contamination. If separate articles were included in the systematic reviews or meta-analysis they were not considered as an independent resource unless there were issues not already covered in the meta-analysis/systematic review (Proehl et al., 2012, p. 1).
After reviewing the literature, it was determined that quality of blood culture results a dependent on the quality throughout the three phases of laboratory testing. It was determined that the most errors occurred in the pre-analysis phase (prior to laboratory analysis), which would include specimen collection, handling and patient variables. It was not specified how many articles were reviewed, however it was determined that inadequate skin preparation was a very common cause of contamination as normal flora on the skin can contaminate the specimens if the site is not prepared properly or if the site was cleaned and not allowed to dry for the recommended amount of time (Proehl et al., 2012).
The majority of the studies reviewed evaluated the use of chlorhexidine and alcohol as opposed to other products such as povidine-iodine. It was interesting to learn that in a separate systematic review included in one of the meta-analyses indicated that alcohol might be sufficient by itself as learned through the conduction of a non-randomized trial and was also determined to be more time and cost efficient as compared to the combination of isopropyl alcohol and povidine-iodine (Proehl et al., 2012).
It is reported that the type of skin antiseptic used could be equally important as the cleaning technique used as another study reported that cleaning in concentric circles was not as effective as actual scrubbing as the concentric circle technique is used for water based products which take additional time to dry. It was learned that the use of sterile glove lowered the odds of specimen contamination but was insignificant in already low contamination rates and interestingly it was learned that the cleaning of the blood culture bottle tops prior to introducing the specimen had no impact on contamination rates (Proehl et al., 2012).
The method used to formulate the recommendations was expert consensus and internal peer review along with conference calls to committee members and staff as needed for progress updates including members of the sub-committee and each subcommittee was responsible for preparing topic descriptions, definition, background, significance and evidence table (“Clinical Practice Guideline,” 2012). The guideline was released in 2012 and this is the current
The method used to formulate the recommendations was expert consensus and a standard reference table was used to gather the information and formulate the tables of evidence. Each article was ranked by level and quality of evidence, relevance and applicability to practice and findings and recommendations were made by the ENA 2012 Emergency Nursing Resources Development Committee (“Clinical Practice Guideline,” 2012).
Key recommendations included cleansing the skin using products containing alcohol prior to collecting the blood cultures including the use of alcohol chlorhexidine in patients over 2 months of age and allowing the skin to air dry prior to venipuncture when drawing blood cultures. These recommendations are supported by Level A evidence, indicating a large degree of clinical certainty based on availability of high quality level I, II or III evidence presented according to the grading system of Melnyk and Fineout-Overholt (2015).
The guideline was validated through an internal peer review and no cost analysis was performed. A potential barrier to the use of chlorhexidine is the Food and Drug Administrations warning concerning the use of chlorhexidine in infants and children under 2 months of age as it could cause excessive skin irritation and chemical burns (“Clinical Practice Guideline,” 2012). Practices considered included use of skin preparations, sterile gloving, cleaning culture bottle caps, and the use of preassembled blood culture collection packs to name just a few.
The potential to prevent contamination of blood cultures in the pre-analytic phase will aid in accurate and timely identification of causative organisms and reduce the number of false positive cultures therefore reducing the overall cost and length of hospital stays, decrease the use of unnecessary antibiotics and laboratory testing, therefore reducing overall costs and increasing patient survival rates (“Clinical Practice Guideline,” 2012).
There were no conflicts of interest identified in the CPG nor were there any financial disclosures. The guideline is available through the ENA website and 38 total documents were include din the evidence tables.
This CPG addresses how the contamination of blood cultures can not only increase healthcare costs and hospital lengths of stay while decreasing patient mortality by utilizing the best evidence and procedures in the guideline to reduce the contamination of blood culture specimens within the emergency department. While this guideline is geared toward specimen collection in the ER, its recommendations can also be used throughout the healthcare and laboratory areas to reduce the overall rate of culture contamination. Nurses are at the frontline in man hospitals and often responsible for blood draws in the ER as well as collecting specimens for culture.
Clinical practice guideline: Prevention of blood culture contamination. (2012). Retrieved from https://guideline.gov/summaries/summary/47353/clinical-practice-guideline-prevention-of-blood-culture-contamination
Melnyk, B., & Fineout-Overholt, E. (2015). Evidenced-based practice in nursing and healthcare (3rd ed.). Philadelphia: Wolters Kluwer.
Peterson, M. H., Barnason, S., Donnelly, B., Hill, K., Riggs, L., & Whiteman, K. (2014). Choosing the best evidence to guide clinical practice: Application of AACN levels of evidence. Critical Care Nurse, 34(2), 58-68. http://dx.doi.org/10.4037/ccn2014411
Proehl, J. A., Leviner, S., Bradford, J. Y., Storer, A., Barnason, S., Brim, C., … Williams, J. (2012). Clinical practice guideline: Prevention of blood culture contamination. Retrieved from https://www.ena.org/practice-research/research/CPG/Documents/BCCSynopsis.pdf
Self, W. H., Sperhoff, T., Grijalva, C. G., McNaughton, C. D., Ashburn, J., Liu, D., … Talbot, T. R. (2013, January). Reducing blood culture contamination in the emergency department: An interrupted time series quality improvement study. Academic Emergency Medicine_: Official Journal of the Society for Academic Emergency Medicine, 20(1), 89-97. http://dx.doi.org/10.1111/acem.12057
Link to Guideline
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Clinical Practice Guidelines .docx