NR 451 Week 3 Blood Culture Contamination Review Example

Reducing Blood Culture Contamination in the Emergency Department: A Review of the Literature

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College of Nursing, Chamberlain University

NR 451: RN Capstone Course

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Month Day, Year

Reducing Blood Culture Contamination in the Emergency Department: A Review of the Literature

Introduction

The approved problem for this capstone is blood culture contamination in the emergency department of a composite 280-bed community hospital, where 4.1 of every 100 blood culture sets drawn over the past year grew organisms that the laboratory classified as contaminants, above the 3 per 100 benchmark the laboratory uses. The proposed change is to require an initial specimen diversion device for every peripheral blood culture drawn by emergency department nurses. This review sets out what the literature says about four questions that decide whether that change is justified: what contamination costs patients and the hospital, what collection practices affect it, whether diversion devices reduce it beyond what technique alone achieves, and what the evidence leaves open. The review draws on sources located through CINAHL and PubMed from 1991 to 2019, including one systematic review and meta-analysis, a laboratory practice guideline, several before-and-after studies and a controlled trial of a diversion device.

Contamination Is Not a Laboratory Nuisance

The literature agrees that a contaminated culture harms patients through the treatment that follows it. When a skin organism grows in a blood culture, clinicians cannot always tell it from true bacteremia, so many patients receive antibiotics, repeat cultures and longer stays while the result is sorted out. An early study at a large teaching hospital found that patients with contaminated cultures had higher charges and more antibiotic use than similar patients with negative cultures (Bates et al., 1991), and later reviews reached the same conclusion with more recent data, adding that contaminated cultures prompt vancomycin exposure, further laboratory testing and, in some patients, removal of central lines that were never infected (Hall & Lyman, 2006). A comprehensive update for clinical laboratories repeated these findings and argued that the long-accepted benchmark of 3 per 100 is too permissive, proposing 1 per 100 as an achievable goal (Doern et al., 2019).

The agreement here is broad, but the studies measuring cost differ in era and setting, and the size of the harm varies with local antibiotic practice. What the sources establish together is direction, not a precise figure for this hospital. For the capstone, the point that matters is that each contaminated set on this unit likely carries a real cost in antibiotic days and length of stay, which justifies spending on prevention.

Technique and Who Draws the Sample

The second theme concerns how and by whom the blood is drawn. A systematic review and meta-analysis prepared for the Laboratory Medicine Best Practices initiative found that dedicated phlebotomy teams achieved lower contamination rates than other staff, and that drawing by venipuncture rather than through an existing intravenous catheter was also associated with lower rates (Snyder et al., 2012). Doern et al. (2019) add skin antisepsis with an agent allowed to dry fully, disinfection of the bottle tops, and adequate blood volume as practices with supporting evidence. In a multicenter study in community hospital emergency departments, introducing sterile collection kits and training was followed by lower contamination (Self et al., 2014).

These findings complicate the proposed change in a useful way. If most contamination comes from drawing through catheters and incomplete antisepsis, a diversion device might add little on a unit that fixes technique first. The review therefore cannot treat the device as a substitute for technique, and the capstone plan should keep the technique elements in place. Emergency departments rarely have dedicated phlebotomy teams around the clock, which is why the device question matters here: nurses will continue to draw most cultures.

Initial Specimen Diversion Devices

The third theme is the device itself. An initial specimen diversion device diverts the first one to two milliliters of blood, which are the most likely to carry skin fragments and organisms from the needle path, into a separate chamber before the culture bottles fill. In a controlled trial in an academic emergency department, Rupp et al. (2017) found that cultures drawn with a diversion device had a contamination rate of 0.22 per 100 compared with 1.78 per 100 for cultures drawn by the same staff with standard technique, with no increase in false negatives. An emergency nursing study reported a similar fall after a diversion system was introduced (Bell et al., 2018).

The evidence is consistent in direction but narrow in design. The trial was conducted at one center, and staff could not be blinded to which method they used, so part of the effect could reflect extra care taken with the new device. The nursing study used a before-and-after design, which cannot exclude other changes introduced at the same time. Both studies were in emergency departments, which makes them directly relevant here, and neither found harm.

Where the Evidence Disagrees and What It Leaves Open

The main disagreement in the literature is about whether devices are needed where technique is already good. Rupp et al. (2017) started from a baseline below 2 per 100, which suggests the device helps even in a department with careful technique, while the laboratory guidance places devices alongside, not above, phlebotomy teams and antisepsis (Doern et al., 2019). A plausible reading is that the two work on different sources of contamination: technique reduces organisms on the skin surface, and diversion reduces those carried into the needle from deeper skin layers, which antisepsis cannot reach.

Three gaps remain. No study located compared a diversion device with a technique bundle head to head in a community hospital. No study reported how often nurses use the device correctly once the novelty wears off. And cost analyses, where reported, relied on assumptions about antibiotic use that may not hold in every hospital. These gaps are the strongest reason for this capstone to measure both contamination and correct device use rather than assuming the published effect will transfer.

Synthesis

Taken together, the evidence supports the proposed change with conditions. Contamination harms patients and costs the hospital; technique and the source of the draw strongly affect it; and diversion devices appear to reduce contamination further in emergency departments, though the strongest evidence comes from one center. For this capstone, that means the device should be introduced together with the existing technique elements rather than instead of them, that nurses should be trained to use it every time a peripheral culture is drawn, and that the evaluation should report both the contamination rate against the 4.1 per 100 baseline and the percentage of culture sets drawn with the device. If contamination falls without high device use, the improvement would belong to something else, and the plan would need to say so.

References

Bates, D. W., Goldman, L., & Lee, T. H. (1991). Contaminant blood cultures and resource utilization: The true consequences of false-positive results. JAMA, 265(3), 365-369. https://doi.org/10.1001/jama.1991.03460030071031

Bell, M., Bogar, C., Plante, J., Rasmussen, K., & Winters, S. (2018). Effectiveness of a novel specimen collection system in reducing blood culture contamination rates. Journal of Emergency Nursing, 44(6), 570-575. https://doi.org/10.1016/j.jen.2018.03.007

Doern, G. V., Carroll, K. C., Diekema, D. J., Garey, K. W., Rupp, M. E., Weinstein, M. P., & Sexton, D. J. (2019). Practical guidance for clinical microbiology laboratories: A comprehensive update on the problem of blood culture contamination and a discussion of methods for addressing the problem. Clinical Microbiology Reviews, 33(1), Article e00009-19. https://doi.org/10.1128/CMR.00009-19

Hall, K. K., & Lyman, J. A. (2006). Updated review of blood culture contamination. Clinical Microbiology Reviews, 19(4), 788-802. https://doi.org/10.1128/CMR.00062-05

Rupp, M. E., Cavalieri, R. J., Marolf, C., & Lyden, E. (2017). Reduction in blood culture contamination through use of initial specimen diversion device. Clinical Infectious Diseases, 65(2), 201-205. https://doi.org/10.1093/cid/cix304

Self, W. H., Speroff, T., Grijalva, C. G., McNaughton, C. D., Ashburn, J., Liu, D., Arbogast, P. G., Russ, S., Storrow, A. B., & Talbot, T. R. (2014). Reducing blood culture contamination in community hospital emergency departments: A multicenter evaluation of a quality improvement intervention. Academic Emergency Medicine, 21(3), 274-282. https://doi.org/10.1111/acem.12337

Snyder, S. R., Favoretto, A. M., Baetz, R. A., Derzon, J. H., Madison, B. M., Mass, D., Shaw, C. S., Layfield, C. D., Christenson, R. H., & Liebow, E. B. (2012). Effectiveness of practices to reduce blood culture contamination: A Laboratory Medicine Best Practices systematic review and meta-analysis. Clinical Biochemistry, 45(13-14), 999-1011. https://doi.org/10.1016/j.clinbiochem.2012.06.007