Collection of Blood Cultures Policy HH(1)/IC/758/17 Previous document(s) being replaced Location Policy No Policy Name N/A

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1 Collection of Blood Cultures Policy HH(1)/IC/758/17 Previous document(s) being replaced Location Policy No Policy Name N/A Document Summary This document adopts the 2011 Department of Health (DH) Saving Lives guidance for collection of blood cultures to ensure best practice and minimise the blood culture contamination rate. The DH advises that a contamination rate of 5% is achievable but the American guidance recommends <3%. This policy is intended to ensure that blood cultures are only taken in appropriate circumstances using the standard accepted technique advocated by the DH best practice guidelines. Ownership Author Helen O Horan Job Title Vascular Access Nurse Document Type Level Level 1 (trust wide) Related Documents Document Details HHFT Adult Sepsis guidelines Standard Precautions (Incorporating Personal Protective Equipment) policy Hand Hygiene policy Consent to Examination or Treatment policy Aseptic Technique policy Waste Management policy Needlestick / Sharps injuries and exposure to Body fluids Prevention and management policy Surveillance policy Learning and Development policy Relevant Standards CQC Outcome Level 1 (trust wide) Equality Analysis Completed by Lorraine Amos Date Completed 12 April 2017 Final Document Committee Policy Approval Group Approval Date Approved 24 April 2017 Final Document Committee Executive Committee Ratification Date Ratified 27 April 2017 Authorisation Authoriser Alex Whitfield Job Title Chief Executive Signature Date Authorised 8 May 2017 Dissemination Target Audience All staff Dissemination and Implementation Plan Action Owner Due by Publicise detail of new document via Intranet and Midweek message Communications Team Within 1 week of publication Page 1 of 24

2 Communication to all Senior Managers to advise HHFT Healthcare Library publication of policy The policy will be available on the intranet and web HHFT Healthcare Library and site Communications Team Publicise detail of new document via Intranet and Communications Team Midweek message Review Expiry date 24 April 2020 Review date 24 January 2020 On publication Within 1 week of authorisation Within 1 week of publication Document Control Document Amendments Version No. Details Key amendments to note By whom Date 1. New policy Helen O Horan January 2017 Page 2 of 24

3 Contents 1. Introduction Purpose Scope Explanation of Terms Duties Consent Sepsis Recognising Sepsis Rationale for blood cultures Timing of blood culture Number of blood culture sets Volume of blood to be drawn Preparation and inoculation of blood culture bottles Labelling blood culture bottles Taking blood cultures Collection of blood cultures from a central vascular access device Contamination of blood cultures Documentation Transport of blood cultures to the laboratory Positive blood culture results Repeat blood culture(s) Stakeholders Engaged During Consultation Training Monitoring Compliance with the Document References Legislation Associated Documentation Contributors Appendix A Equality Analysis Form Appendix B Peripheral Blood Culture collection Appendix C Central line Blood Culture Collection Appendix D Adult Blood Culture Collection Staff competency Assessment Page 3 of 24

4 1. Introduction Blood culture is the key investigation for diagnosis of sepsis, and is essential for the microbiological diagnosis of bacteraemia, fungaemia, infective endocarditis and conditions associated with a clinical presentation of pyrexia of unknown origin and if used appropriately, blood cultures can help reduce morbidity and mortality. Blood culture is also important for the diagnosis of prosthetic device infections (e.g. joints and vascular grafts) and intravascular line associated sepsis and is considered the gold standard (PHE 2014). Prompt accurate detection of bacteraemia and fungaemia is important for improving patient care and clinical outcomes. Positive blood culture either establishes or confirms infectious aetiology of sepsis. Collection of Blood cultures forms part of the Sepsis Six bundle (Daniels et al. 2011) and should be collected within one hour of diagnosis/ suspicion of sepsis. A positive blood culture provides the etiologic agent for antimicrobial susceptibility testing for optimisation of antibiotic therapy. Antibiotic resistance amongst pathogens (particularly Gram negative bacteria) is the most frequent cause of ineffective empirical treatment in bloodstream infection. Early identification and antibiotic susceptibility results for blood culture isolates provide valuable diagnostic information on which appropriate antimicrobial therapy can be based, so helping to reduce morbidity and mortality, improve patient care and reduce healthcare costs. However, contaminated blood cultures or false positives can have direct and indirect effect on patient care (Weinbren et al 2015), cause confusion and lead to unnecessary tests and may compromise patient care by prolonging their hospital stay and thus exposing them to unnecessary antimicrobial therapies. This can in fact harm the patient as well as having financial implications, both in terms of direct costs, clinicians and lab time and use of equipment, and through adversely affecting the Trusts ability to comply with national surveillance targets i.e. MRSA bacteraemia trajectory and skews monthly surveillance data used to demonstrate the Trust s contribution towards reducing healthcare associated infections. The Department of Health s Saving Lives: reducing infection, delivering clean and safe care (2007) document estimates that blood culture contamination rates could be as high as 10%. Health Protection Scotland (2014) has identified 5 key areas to consider when preventing contamination of blood cultures: Decontamination of Blood culture bottle tops Hand hygiene Single use skin cleanser containing 2% Chlorhexidine in 70% isopropyl alcohol Aseptic technique Blood culture bottles inoculated first (if taking blood for other samples) This policy must be read in conjunction with the HHFT Sepsis guidelines, Standard Precautions (Incorporating Personal Protective Equipment) policy, Hand Hygiene policy, Page 4 of 24

5 Consent to Examination or Treatment policy, Aseptic Technique policy and the Waste Management policy. 2. Purpose This document adopts the 2011 Department of Health (2007) (DH) Saving Lives: reducing infection, delivering clean and safe care guidance for collection of blood cultures at HHFT as a Trust policy to ensure best practice and minimise the blood culture contamination rate. The DH advises that a contamination rate of 5% is achievable but the American guidance recommends <3%. This policy is intended to ensure that blood cultures are only taken in appropriate circumstances using the standard accepted technique advocated by the DH best practice guidelines. 3. Scope This policy applies to all Hampshire Hospitals NHS Foundation trust staff who take blood cultures from patients including but not exclusively, doctors, nurses, phlebotomists and medical assistants. Blood cultures must only be collected by competent trained hospital staff, who have received appropriate training. See Appendix D for assessment guidelines. This policy and procedure will be applied fairly and consistently to all employees and service users regardless of their protected characteristics as defined by the Equality Act 2010 namely, age, disability, gender reassignment, race, religion or belief, gender, sexual orientation, marriage or civil partnership, pregnancy and maternity. For employees this policy also applies irrespective of length of service, whether full or part time or employed under a permanent or a fixed term contract, irrespective of job role or seniority within the organisation. Where an employee or service user has difficulty in communicating, whether verbally or in writing, arrangements will be put in place as necessary to ensure that the processes to be followed are understood and that the individual is not disadvantaged during the application of this policy. The application of this policy is completely clinically based and ensuring prompt testing/treatment would be the priority, however the Trust would endeavour to continue to meet patients individual needs as far as is practicable. In line with the Equality Act 2010, the Trust will make reasonable adjustments to the processes to be followed where not doing so would disadvantage an individual with a disability during the application of this policy. This policy complements professional and ethical guidelines and The Code Professional standards of practice and behaviour for nurses and midwives (NMC 2015). Page 5 of 24

6 4. Explanation of Terms Contaminated blood culture positive result when the organisms found are unlikely to be pathogenic in the clinical scenario in question or the patient is clinically well and treatment of the organisms is not indicated. Recovery of the patient will occur without specific therapy for the blood culture findings. False positive a false positive is defined as growth of bacteria in the blood culture bottle that were not present in the patients blood stream but were introduced during sample collection. Contamination can come from a number of sources: the patients skin, the equipment used to take the sample and transfer it to the culture bottle, the hands of the person taking the sample, the general environment or a contaminated intravenous cannula inserted for IV administration. 5. Duties 5.1 Post holders with duties Chief Executive (CE) has overall responsibility for the strategic and operational management of the Trust ensuring there are appropriate strategies and policies in place to ensure the Trust continues to work to best practice and complies with all relevant legislation in regard to the collection of blood samples for culture. The Director of Infection Prevention and Control (DIPC) is the Trust Director responsible to the board for the delivery of Infection Prevention and Control (IPC) standards. The Director of Nursing will ensure that the Divisional Directors take clinical ownership of the policy. The Divisional Operational Directors will ensure that all health care workers comply with this policy and that all health care workers attend mandatory infection prevention and control training and training specific to this policy. They are responsible for ensuring adequate facilities and resources are available to adhere to this policy. The Clinical Matrons/Service Managers/Leads will ensure that the current version of this policy is available in all of their areas. They will ensure that all health care workers comply with this policy and that all health care workers attend mandatory infection prevention and control training. Medical Staff who collect blood for culture should be competent to do so. This should be assessed by their Educational Supervisor. Additional training can be offered by the Vascular Access Nurse. All Trust employees will comply with this policy and inform the Infection Prevention and Control Team about any issues or concerns relating to the policy. All staff will attend mandatory Infection Prevention and Control training annually. Infection control is the responsibility of ALL staff associated with patient care. A high standard of infection control is required on ALL wards and units, although the level of risk may vary. It is an important part of total patient care. Page 6 of 24

7 5.2 Groups and Committees with duties The Infection Prevention and Control Team (IPCT) will act as a resource for information and support. They will provide education in relation to this policy which includes mandatory training. They will monitor the implementation of this policy via audit within clinical areas and be responsible for regularly reviewing and updating it. The Health4Work department will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and health care workers regarding the use of personal protective equipment. The Health and Safety Advisors will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and health care workers regarding the use of personal protective equipment. 6. Consent See Consent to Examination or Treatment Policy. Consent must be obtained from all patients who have capacity prior to any blood sampling procedure. Consent may be given verbally or non verbally and may be the act of the patient holding out their arm for the practitioner to carry out a procedure, providing the patient has received appropriate information prior to this. 7. Sepsis Sepsis is defined as infection plus a systemic response to, or manifestation of, infection. Around 20% of sepsis cases are associated with bacteraemia, the rest are secondary to infection at other sites in the body. The incidence of sepsis continues to rise with a reported associated mortality rate of 35 65%. Early and appropriate empirical antibiotic treatment is associated with decreased mortality rates and improved clinical outcomes. In severe sepsis each hour of delay in antibiotic treatment results in increased mortality. Septic shock is defined as the persistence of sepsis induced hypotension despite adequate fluid resuscitation (PHE 2014). The clinical symptoms are usually attributed to toxic bacterial products and/or the host response to these. Shock is more commonly seen with Gram negative septicaemia, but shock may also be associated with Gram positive organisms, particularly with fulminant pneumococcal, Lancefield Group A streptococcal and staphylococcal bacteraemia. Intravenous antibiotic therapy within the first hour of recognition of sepsis or septic shock is recommended as oral antimicrobial agents are of little help in combating the acute effects of shock (PHE 2014). 8. Recognising Sepsis See Adult Sepsis guidelines Page 7 of 24

8 neonatal sepsis guidelines see NICE at 9. Rationale for blood cultures Blood cultures should be taken when there is suspicion of infection, i.e. symptoms of Sepsis as above and/or Unexplained hypotension (Systolic BP <90mmHg) Chills or rigors Unexplained deterioration in the patient s condition. Focal signs of infection. Or, but not exclusively limited to the following: To confirm infection, or specific diagnosis e.g., Typhoid or Paratyphoid fever, brucellosis. To isolate and identify pathogen(s) and perform antimicrobial drug susceptibilities to guide therapy To establish diagnosis of endovascular infections e.g. infective endocarditis (IE) To de escalate (empirical) antibiotic to targeted pathogen specific therapy or step down therapy to a suitable narrow spectrum antimicrobial agent, and/or IV to Oral switch therapy based on antimicrobial susceptibility profile of isolated pathogen(s). To establish primary diagnosis, or to exclude infection in High Risk patient populations i.e. Suspected Neutropenic sepsis New onset of confusion in elderly Febrile child and floppy baby Immunosuppressed host Fever in an intravenous drug user (IVDU) Liver Disease/Chronic kidney disease or end stage renal failure Febrile hospitalised patients Patients with suspected deep seated or severe infections such as: o o o o o o o o o o o Catheter associated blood stream infection Hospital acquired/ventilator associated pneumonia Surgical site infection (SSI) Ascertainment or confirmation of microbial aetiology of focal infection. Osteomyelitis Septic arthritis / discitis Meningitis Cellulitis Pneumonia/empyema Catheter associated urinary tract infection (CA UTI) Complicated urinary tract infection (UTI) i.e. UTI in men, children and elderly, pyelonephritis, and UTI in patients with underlying urological abnormalities/urological interventions and those with CA UTI Page 8 of 24

9 10. Timing of blood culture Blood cultures should be taken within the first hour of recognition of sepsis, prior to commencing antimicrobials wherever possible, provided this does not significantly delay antibiotic administration, do not delay treatment. Collection of blood culture in a hypothermic patient is as important as in a patient who has pyrexia, cultures should be taken within few minutes of noticing a spike in temperature however, clinical judgement needs to be exercised and it should be remembered that early signs of infection may be absent or minimal in the young, the elderly and those on immunosuppressant therapy. A blood culture should only be taken if the result will affect patient management. A blood culture should not be taken if there is no intention to treat (e.g. terminally ill). When already receiving antibiotics blood cultures should be collected just before the next dose is due, when the concentration of antibiotic in the blood is at its lowest point. 11. Number of blood culture sets A single culture set equates to; one anaerobic and one aerobic bottle filled with blood taken from a single venepuncture site. A Paired set (i.e., a central and a peripheral set ) equates to; one anaerobic and one aerobic bottle filled with blood taken from a central vascular access device (CVC, PICC, Hickman, Portacath etc) plus a peripheral venepuncture sample. Blood cultures should be collected from indwelling vascular access devices to aid diagnosis of catheter related blood stream infection (CRBSI). Blood culture bottles must be clearly labelled with the site of venepuncture / lumen and time of collection prior to sending for analysis to indicate the venepuncture site / specimen collection site. Multi lumen intravascular catheters such as skin tunnelled catheters / Peripherally Inserted Central Venous Catheter (PICC) must be separately cultured from each lumen. Short term intravascular catheters such as internal jugular (IJ) CVP lines in ICU, only one lumen need be cultured. Central line bloods must be taken prior to peripheral bloods. A separate peripheral set; collected almost simultaneously (with in 20mins 1hour) should also be drawn. Bloods must not be taken from a vein in which an intravenous infusion is running In a patient with suspected infective endocarditis 3 sets of blood cultures should be collected over 24 hours. To achieve the greatest chance of detecting a bacteraemia it is recommended that TWO sets of blood cultures are taken an hour apart from separate sites, A second or third set taken from a different site not only increases yield but also allows recognition of contamination Page 9 of 24

10 In patients with sepsis or septic shock at the time of presentation, TWO sets of blood cultures should be taken at different times in the hour prior to commencing empirical antibiotics, providing this does not delay antimicrobial treatment. In most conditions other than endocarditis, bacteraemia is intermittent, given it is related to the fevers and rigors which occur minutes after the entry of organisms into the bloodstream. Samples should be taken as soon as possible after a spike of fever. 12. Volume of blood to be drawn Blood culture volume is the most significant factor affecting the detection of organisms in bloodstream infection. There is a direct relationship between blood volume and yield, with approximately a 3% increase in yield per ml of blood cultured. Ideally for adult patients 20mls of blood should be inoculated into one paired set i.e. 10mls into each bottle; failure to obtain 20mls of blood may result in false negative cultures and inappropriate or delayed patient treatment, because the number of organisms present in adult bacteraemia is frequently low (PHE 2014). For infants and younger children, the volume of blood drawn should be no more than 1% of the patient s total blood volume. Recommended volume per set (ml) Neonates 1 year 0.1 1ml (inoculate aerobic [yellow] bottle only) Children 1 6 Years 1 ml per year of age Adults & older children 20mls (10ml per bottle) 13. Preparation and inoculation of blood culture bottles Central line bloods must always be taken prior to peripheral blood cultures: Inspect the blood culture bottles for damage Ensure blood culture bottles are within use by date. Observe bottom of bottles to ensure they are not yellow. If they are yellow, do not use the bottle as this indicates contamination. The bottle tops are not sterile, therefor prior to use, remove caps from blood culture bottles and decontaminate septum with 70% v/v Isopropyl alcohol in 2% w/v chlorhexidine impregnated wipe. Scrub for 30 seconds on septum (one wipe per bottle), leave to dry for 30 seconds. When drawing blood, hold each bottle vertically to observe when 10mls of blood has infused into the culture bottle. Holding culture bottles inverted has resulted in culture medium being infused into patients. Fill indicator lines run down the side of blood culture bottles. A biro mark may be made on this line to indicate when 10mls of blood has been inoculated into each bottle. Do not overfill bottles as this can result in false positive results. Blood cultures must not be refrigerated, store at room temperature. Page 10 of 24

11 14. Labelling blood culture bottles Do not label blood culture bottles with patient details until the blood sample has been successfully collected. Label samples at the patient s bedside, to avoid incorrect labelling. ICE labels should be used, but must not inhibit inspection of the bottle bar code or lot numbers. If hand written, a minimum of four patient identifiers must be evident on the bottle to reflect the pathology request. If any of the four identifiers are not evident, the sample may be rejected by the laboratory. Ensure the route of culture e.g. peripheral/central venous catheter (PICC, Portacath, Hickman etc.) is clearly documented on ICE, and each blood culture bottle. For central venous catheters include which port has been sampled on both bottle and ICE request form. Ensure the date and time of collection is documented. Each culture bottle has a removable bar code. This must be left on the bottle to aid laboratory analysis. 15. Taking blood cultures Collection of blood from the patient should be carried out following Department of Health guidance (2011), and should always be taken from FRESH venepuncture sites ideally either in the anterior cubital fossa or the back of the hand using a sharp safe winged butterfly blood collection set. A needle and syringe should not be used. Other sites (especially femoral stabs) should only be used as a last resort due to high likelihood of contamination. Blood cultures should not be taken from peripheral cannulae as it is not possible to accurately judge the sample volume; there may be the potential for backflow of blood culture media to patient veins and there is an increased risk of contaminating the sample if taken via this means. Note: If blood for other tests such as ESR is to be taken at the same venepuncture, the blood culture bottles should be collected first to avoid contamination. Skin must be disinfected with 2% chlorhexidine in 70% isopropyl alcohol, in the form of a pre loaded cleansing device i.e. chloraprep, for 30 seconds and allowed to air dry for 30 seconds (Loveday et al 2014). The vein must not be re palpated prior to blood draw due to contamination, if re palpation is necessary to relocate the vein then the site must be re cleansed (Thompson 2009). See Appendix B for procedure. 16. Collection of blood cultures from a central vascular access device Confirming that a central venous catheter is the source of an infection can be difficult, there is often no evidence of infection at the catheter insertion site, and the organisms involved are frequently part of the normal skin flora and are common contaminants of blood cultures. Blood culture contaminants can create diagnostic uncertainty and lead to the unnecessary removal of lines. Therefore, it is essential that line cultures are only taken by appropriately trained staff using the strictest aseptic technique. If patients have Page 11 of 24

12 central line devices (i.e. CVCs, PICCS etc) for >48 hours they must have paired line and peripheral cultures taken at the same time, preferably before antimicrobial therapy to aid interpretation of cultures. If this isn t possible the reason should be documented in the patients notes. See Appendix C for procedure. 17. Contamination of blood cultures Contamination complicates interpretation and can lead to unnecessary antimicrobial therapy and increased costs. In general, contamination target rates are set at less than 3% (DOH 2011). Several criteria are used to differentiate between contamination and true bacteraemia and to determine the clinical significance of a positive result. These include the identity of the organism, the number of positive sets, the number of positive bottles within a set, quantity of growth, and clinical and laboratory data (including source of culture). Prevention of contamination can be achieved through appropriate skin and bottle preparation, obtaining cultures from peripheral venepuncture instead of vascular catheters, and through training and intervention measures 18. Documentation After blood cultures have been taken, the procedure should be clearly documented in the patient s medical notes to aid subsequent interpretation of positive results. The date, time and site(s) of venepuncture along with the indication for the blood culture being taken should be recorded as well as a record of who has taken the culture. Blood cultures should be requested via ICE. If this is not possible, conventional specimen request forms can be used. The date, time and site of collection along with pertinent clinical details, antibiotic exposure and details of the clinical team responsible for taking the culture and the patients care should all be included on the request form. 19. Transport of blood cultures to the laboratory Inoculated bottles should be incubated as soon as possible, ideally within four hours. Blood cultures are processed in the Microbiology laboratory at HHFT. Once taken, samples should be sent to the Pathology Reception at either the BNHH or RHCH from where they will be sent to the Microbiology laboratory to be processed. Out of hours there is no need to contact the Microbiology BMS on call. 20. Positive blood culture results Blood cultures are routinely incubated for 5 days. Positive results will be communicated directly between the Microbiologists and the clinical team responsible for the patient as soon as the result becomes available. Once the culture flags positive a Gram stain result will be available +/ a provisional identity. Formal identity and sensitivities will usually be available 24 hours later but in some instances this may take longer. Negative culture results will be placed on the ICE results system. Page 12 of 24

13 The results of blood cultures MUST be pro actively followed up by medical staff through discussion with the Consultant Medical Microbiologist. Empirical antimicrobial therapy MUST BE rationalised in light of blood culture results 21. Repeat blood culture(s) Once bacteraemia is identified (i.e., Positive blood culture) repeating blood culture with every spike of temperature is unnecessary, except: When there is clinical deterioration, and effective antimicrobial therapy has been given for at least 24 hours before change of antimicrobial therapy In critically ill patients in HDU/ITU In a neonate with suspected endovascular source In a febrile patient without a focus of infection, if previous blood culture(s) have been negative Whilst receiving appropriate antimicrobial therapy in a febrile patient to identify breakthrough Bacteraemia In patients with Staphyloccus aureus (MSSA/MRSA) bacteraemia 72 hours after therapy and Candida spp. fungaemia (14h after therapy) to check clearance and detect any metastatic seeding or complications such as infective endocarditis, septic thrombophlebitis etc. 22. Stakeholders Engaged During Consultation Stakeholder Date of Consultation Infection Prevention and Control (Lead Infection Prevention & Control 16/03/2017 Nurse) Health and Safety (Health and Safety Advisor) 16/03/2017 Safeguarding (Trust Safeguarding Lead) 16/03/2017 Information Governance (Information Governance Manager) 16/03/2017 Risk and Compliance Manager (Risk and Compliance) 16/03/2017 Operational (Divisional Operations Directors) 16/03/2017 Head of Health4Work 16/03/2017 Infection Prevention and Control Committee 16/03/2017 Consultant Microbiologists 16/03/2017 Clinical Matrons/Service Managers/Leads 16/03/2017 Page 13 of 24

14 23. Training In order to mitigate the risk of contamination of blood culture specimens, blood cultures MUST only be collected by staff assessed as competent to do so by a designated assessor, i.e Clinical Matron. It is a prerequisite that clinical staff are trained when and how to collect blood cultures correctly (including number of sets, for example where line sepsis is suspected taking a peripheral set and a culture through the line) minimising the risk of contamination. Training on blood culture taking will be provided to all staff involved in blood culture collection. Those who are identified as needing additional support will be offered it. It is the responsibility also of individuals and their line managers or team Consultants to identify when additional training is needed and to provide it or to ask the Vascular Access Nurse to provide it. Nursing staff and unregistered clinical staff, who take on the extended role of phlebotomy, will have specific training initially, complete competence assessments and be competence assessed on an annual basis. See Appendix D. Nursing staff who have joined HHFT from another organisation who have evidence of previously achieving the competency will be assessed initially in their department by a designated assessor, i.e. Clinical Matron, and then on an annual basis. See Appendix D Individuals in the Trust should also receive annual Infection Prevention and Control Training to ensure they are aware of their responsibilities Prior to undertaking any blood collection procedure, all staff must be able to demonstrate clinical competence and a clear understanding of the underlying principles of practice. This will be achieved by: Nursing and other health care staff complete the Trust venous Venepuncture and blood collection e learning attend a Venepuncture assessment session complete a period of supervised clinical practice Staff who have been trained and practised in a previous post may be allowed to demonstrate an equivalent level of competence through a period of supervised practice only. Medical staff All doctors new to the trust, Including Foundation, Core and Speciality trainees, will require training on local policy and principles of practice. Staff identified as requiring additional training will be required to: complete the Trust Venepuncture e learning package attend a venepuncture study session complete a period of supervised clinical practice Page 14 of 24

15 24. Monitoring Compliance with the Document Audits will be undertaken, annually or more frequently if indicated, to check staff awareness of the guidance and assess competence as per Surveillance Policy and show any changes to the contamination rate. The cause of any blood culture contaminated by Methicillin Resistant Staphylococcus Aureus (MRSA) will be identified by root cause analysis (RCA) as per Surveillance Policy. The RCA will be undertaken on all MRSA blood culture positive findings with feedback provided to staff involved and organisationally through the Patient Safety and Infection Control Committees. It is important that feedback is constructive and supportive to enhance learning and competence in taking blood cultures. Contamination rates will be reported to the board on a six monthly basis. Minimum requirements A. Effectiveness of policy B. Clinical Supervision Requirement Reviewed by Infection Prevention and Control Team Supervisors Method of Monitoring Quality control audits to ensure continued standards and adherence of Policy during Blood culture collection Clinical practice Frequency of Review Ongoing Ongoing Monitoring Committee Infection Prevention and Control Committee/Divisional Governance Boards N/A 25. References Daniels R. Nutbeam T. McNamara G. Galvin C. (2011) The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J (2011) vol. 28 (6) pp Department of Health, (2007) Saving Lives Taking blood Cultures: A summary of best practice Department of Health. Taking blood cultures Available from 03/Document_Blood_culture_FINAL_ pdf Equality Act London: HMSO Health protection Scotland (2014) Targeted literature review: what are the key infection prevention and control recommendations to inform a prevention of blood culture contamination tool? NHS Scotland. Loveday H.P, Wilson J.A. et al (2014) epic3: National evidence based guidelines for preventing Healthcare associated Infections in NHS Hospitals in England. Journal of Page 15 of 24

16 Hospital infection 86 (Supplement 1) S1 S70 Nursing and Midwifery Council (2015) The Code Professional standards of practice and behaviour for nurses and midwives. London : NMC Public Health England. (2014). Investigation of Blood Cultures (for Organisms other than Mycobacterium species). UK Standards for Microbiology Investigations. B 37 Issue 8. Accessed 18 th December 2015 at: standards for microbiology investigations smi quality andconsistency in clinical laboratories Thompson F. Madeo M. (2009) Blood culture: towards zero false positives. Journal of infection Prevention Sept 2009, Vol 10 supp 1 Weinbren M. Tilley R. Daniels R. Nutbeam t. (2015) Clinical Toolkit 8: Laboratory handling and reporting of blood cultures. The UK. Sepsis trust 26. Legislation HSE (2013) Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 Guidance for employers and employees 27. Associated Documentation HHFT Adult Sepsis guidelines Aseptic Technique Policy Consent to Examination or Treatment Policy Hand Hygiene Policy Needlestick / Sharps injuries and exposure to Body fluids Prevention and management Policy Standard Precautions (incorporating Personal Protective Equipment) Policy Surveillance policy Waste Management policy Learning and Development policy 28. Contributors Contributor Job Title Vascular Access Nurse Contributor Name Helen O Horan Page 16 of 24

17 Appendix A Equality Analysis Form To be completed by the Policy Author at the development stage of the policy and before consultation. Part 1 should be forwarded to an Equality Analysis Lead (list available on the Document Control Trust Intranet page) for sign off and any comments from them considered and addressed before seeking final approval of the policy. Document Title: Collection of Blood Cultures Policy PART 1 Policy Author to complete and forward on to an EA Lead for sign off 1. Could the application of this document have a detrimental equality impact on individuals with any of the following protected characteristics? (See Note 1) a Age No b Disability No c Gender reassignment No d Race No e Religion or belief No f Sex No g Sexual orientation No h Marriage & civil partnership No i Pregnancy and maternity No 2. If Yes to question 1, do you consider the detrimental impact to be valid, justifiable and lawful? If so, please explain your reasoning. Yes/No/ NA Summarise the equality and diversity related elements within the policy 3. Specify with which, if any, individuals and groups you have consulted in reaching your decision. PART 2 Equality Analysis Lead to complete and forward back to the Policy Author Provide a brief summary of the potential impact of the policy and whether sufficient consideration has been given to the Equality Duty. The policy describes the importance of blood cultures as a diagnostic tool and gives guidance on the appropriate collection to avoid contamination. Special consideration is given to children and individuals with disabilities. 1. Is this document recommended for publication? Y Page 17 of 24

18 Document Title: Collection of Blood Cultures Policy If yes go to question 3 if No complete number 2 below. 2. This document is not recommended for publication because: A Amendments are suggested as follows: B A more detailed equality analysis should be undertaken as follows: C Other (please specify) 3. Specify with which, if any, individuals and groups you have consulted in reaching your decision. Name: Lorraine Amos Job Title: Pathology Business Manager Date: 12/04/17 PART 3 Policy Author to complete on receipt of part 2 and before forwarding for final policy approval 1. I have reviewed the Part 2 assessment and have made the necessary amendments to the policy. If you have answered no, please explain why not Name: Helen O Horan Job Title: Vascular Access Nurse Date: 12/04/17 Note 1 Under the terms of the Equality Act 2010 s public sector Equality Duty, the Trust has a legal responsibility to think about the following three aims of the Equality Duty as part of our decision making and policy development. Eliminate unlawful discrimination, harassment and victimisation; Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and Foster good relations between people who share a protected characteristic and people who do not share it. Page 18 of 24

19 Appendix B Peripheral Blood Culture collection ADULT BLOOD CULTURE COLLECTION INDICATIONS & SITES FOR TAKING BLOOD CULTURES Do s DO take Blood cultures when there is a clinical reason to suspect a septicaemia. DO take Blood cultures from a suitable, fresh venepuncture site. DO take Blood cultures as soon as possible from all patients who attend the ED with signs of sepsis. DO take Blood cultures from a central venous catheter (CVC) in combination with a separate peripheral site when investigating potential CVC related bacteraemia. If the CVC removal is because of localised site infection alone; a CVC site swab and the CVC tip only should be sent for Microbiology culture. DO decontaminate hands and wear STERILE gloves to take Blood cultures Don ts DO NOT take Blood cultures for routine assessment or the investigation of localised infection. DO NOT take Blood cultures from a peripheral venous access device. DO NOT take Blood cultures from veins which are immediately proximal to existing venous cannulae. DO NOT use a needle and syringe to take Blood cultures DO NOT take Blood cultures from the femoral vein as it is difficult to disinfect the skin adequately, so there is a high risk of contamination. If there is no other venous access e.g. IVDU and a femoral stab is the only option for taking the blood culture, this information must be clearly documented in the site section of the documentation in the patients notes. Hints and Tips Optimally, 20ml of blood should be drawn from Adults (10ml/bottle), the recommended blood to broth ration is 1:5 to 1:10. As the volume of blood drawn is increased, the yield of positive cultures increases. For best volume control, mark the fill level on the side of the bottle prior to collection. Do not overfill the bottles, as this may cause false positive readings. When labelling bottles, do not cover the peel off section of the barcode labels or lot numbers To avoid contamination of the blood culture sample, inoculate blood culture bottles first. Then fill additional blood collection bottles. When taking Blood culture from a CVC use a vacutainer luer adapter (Blue cover). Page 19 of 24

20 ADULT BLOOD CULTURE COLLECTION PROCEDURE Blood cultures should only be collected by members of staff who have been specifically trained in the collection procedure and whose competence in blood culture collection has been assessed. 1. Confirm Patient details verbally with patient where possible, confirm details with wristband, and Gain consent. 2. Wash hands with soap and water 3. Ensure you have the relevant blood culture collection equipment 4. Ensure the blood culture bottle to be used is in date and not already positive (the bottom of the bottle should be grey prior to inoculation). 5. Remove the plastic flip cap of the blood culture bottles and disinfect the septum for 30 seconds using a new 2% Chlorhexidine Gluconate (CHG) / 70% Alcohol wipe for each bottle. Allow bottle tops to dry 6. Prepare venepuncture site and palpate vein if needed 7. Cleanse venepuncture site with Chloraprep for 30 seconds and allow to air dry for 30 seconds (When taking cultures from CVC, disinfect the port with 2% Chlorhexidine Gluconate(CHG)/70% Alcohol for 30 secs and allow to dry for 30 seconds) 8. Open all remaining components onto sterile field 9. Fasten disposable tourniquet 10. Wash hands again or apply alcohol hand rub and don sterile gloves 11. Attach a winged blood collection set to a collection adapter cap. DO NOT repalpate vein before inserting needle (DO NOT use a needle and syringe) 12. Insert needle into patient s vein and ensure there has been a flash back 13. To collect the blood insert the aerobic (BLUE) bottle first, followed by the anaerobic ( PURPLE) bottle into the collection adapter cap (Optimally 10mls/bottle), loosen tourniquet as blood flows into first bottle 14. Invert the bottles three times to ensure the blood and medium are mixed well 15. Discard the winged collection set into a sharps container at the point of care 16. Remove gloves and aprons and decontaminate hands 17. Fill in the patients name and details on the bottle at the patients bed side, document the procedure in the patients notes Page 20 of 24

21 Appendix C Central line Blood Culture Collection Collecting Blood cultures from a Central vascular access device Preparation Establish if blood cultures need to be taken via the line and if so whether a paired peripheral sample is required. All equipment for taking line cultures should be sterile. Ensure the blood culture bottle to be used is in date and not already positive (the bottom of the bottle should be grey prior to inoculation). Explain the procedure to the patient and obtain consent. Equipment Ice request labels Cleaned dressing trolley Sterile pack containing Gloves, apron and sterile field Sharps container Several PDI/ Clinell wipes(70% v/v Isopropyl alcohol in 2% w/v chlorhexidine) one for each bottle and one for each lumen of CVC Blue vacutainer adaptor used for accessing ports one for each lumen to be accessed Blood culture vacutainer holder one for each lumen to be accessed Blood culture set(s) one set for each lumen (mark 10ml line on each bottle to aid filling) 10mls normal saline flush one for each lumen accessed Process for undertaking CVC blood cultures Clean your hands and then clean a trolley with a sanitising detergent wipe. Decontaminate hands thoroughly using liquid soap and water and dry. Expose CVC to aid access, prepare patient and bed space. Decontaminate hands with hand gel. Prepare clinical area as per asepsis policy to maintain sterile field. Open sterile pack onto dressing trolley Open all other equipment on to sterile field, keeping any non sterile items to the side, The blood culture bottles should be placed within easy reach but not in the sterile field Remove the cover from the top of the blood culture bottle and clean the rubber top of the bottle with a 2%CHG/70%Alcohol wipe, and allow to dry Attached blue luer vacutainer adaptors to holders maintaining sterility of luer tip. Decontaminate hands Don sterile apron and gloves Lift the terminal part of the line up with one hand and clean the distal terminal part of the line / connector (bung) Using ANTT process, scrub catheter hub with 70% v/v Page 21 of 24

22 Isopropyl alcohol in 2% w/v chlorhexidine impregnated wipe for 30 seconds and allow to air dry Connect safety vacutainer collection set (blunt luer connection) into the hub of the catheter, protecting key parts. Insert aerobic [blue] bottle into the holder, draw off 10mls of blood, then repeat process with anaerobic [purple] bottle, draw off another 10mls. Gently invert contents of each bottle to mix broth with blood when required sample is obtained. Take further venous samples in correct order of draw according to Trust policy if required Remove vacutainer collection set, flush port with 10mls sodium chloride 0.9% using push pause technique. Dispose of equipment in appropriate waste receptacle or Sharps bin. Remove gloves and apron, decontaminate hands with liquid soap and water, dry. Clean dressing trolley Complete documentation, ensuring that each bottle is clear labelled with the correct lumen Once the CVC bloods have been taken complement with corresponding peripheral blood culture set. Documentation in medical notes and on request forms Page 22 of 24

23 Appendix D Adult Blood Culture Collection Staff competency Assessment Surname: Dept & Ward / Unit: Forename(s): Job title / designation: The staff member must be able to demonstrate Initial Assessment Date: Final Assessment Date: Explaining the procedure and rationale to the patient and obtain a valid consent Maintaining a patient s privacy and dignity throughout the procedure Gather the required equipment: Blood Culture Bottles Sterile pack and Sterile gloves Disposable Tourniquet Plastic tray Chloraprep 2% chlorhexadine/70% alcohol i.e. PDI wipes Safety Butterfly collection set and Vacutainer holder Sterile gauze and Tape Sharps Bin Hands decontaminated and correct use of Personal Protective Equipment Yes/No Yes/No Open sterile pack and equipment, maintaining asepsis Yes/No Yes/No Prepare Culture Bottles. Mark 10ml line on each bottle Remove flip off caps from blood culture bottles and clean bottle tops with 2%CHG/70% alcohol wipe. Leave to dry for 30 seconds Apply disposable tourniquet Identify and palpate vein Decontaminate hands, don apron & sterile gloves Disinfect skin using 2% chlorhexidine gluconate and 70% isopropyl alcohol applicator using vertical and horizontal motion for thirty seconds and allow to dry for 30 seconds (DO NOT palpate the site again after cleaning) Remove safety sheath from needle (butterfly). Perform venepuncture If necessary secure butterfly to patients arm with micropore Place adaptor cap over Blue bottle(aerobic) collection bottle first, Hold bottle upright and fill to 10ml mark Place adaptor cap over then purple bottle (anaerobic)hold bottle upright and fill to 10ml mark Loosen tourniquet as second bottle is filling Invert bottles to mix specimens (If blood is to be collected for other tests always collect culture first) Page 23 of 24

24 To remove adaptor: Place sterile gauze over puncture site and needle Safely remove the adaptor and needle using the sharp safe activation mechanism As needle retracts apply pressure to puncture site to stop bleeding. Apply appropriate dressing Dispose of Sharps and waste as per trust policy Remove PPE, decontaminate hands, dressing trolley/sharps receptacle Label blood culture bottles immediately at the patient s bedside Do not cover or remove bottle bar codes. Place in specimen bag and send to laboratory immediately. Request must have clear indications for why blood cultures being taken Correct disposal of equipment adhering to Trust policies and procedures Completion of all relevant documentation i.e Nursing/Medical notes STATEMENT OF ASSESSMENT I certify that I have assessed the above individual and that they meet the standards laid out in Trust policy at the time of assessment. Further training required: Name Signed Date (Assessor to be competent in Venepuncture and blood culture collection with at least 1 years experience and to have completed an assessors or mentorship course) Keep this form in your personal portfolio or training record. Page 24 of 24