Case Studies in Process Improvement Reducing Blood Culture Contamination Rates and Sustaining Success Dana Sorenson Operations Supervisor- Phlebotomy Mayo Clinic Health System- Franciscan Healthcare La Crosse, Wisconsin 2015 MFMER slide-1
Disclosures Relevant Financial Relationship(s): List or Nothing to Disclose Off Label Usage: List or Nothing to Disclose 2015 MFMER slide-2
Learner Objectives Define Blood Culture Contamination per CAP guidelines Recognize the importance of awareness of the impact of blood culture contamination on patient care Discuss interventions to aid in keeping awareness at heightened level 2015 MFMER slide-3
CAP Definition of Contamination A blood culture is considered to be contaminated if 1 or more of the following organisms are identified in only 1 of a series of blood culture specimens in a 24hr period: coagulase-negative Staphylococcus species Propionibacterium acnes Micrococcus species viridans -group streptococci Corynebacterium species Bacillus species 2015 MFMER slide-4
Background CAP has set a contamination rate threshold of 3.0% for corrective action We want to do better than that Our goal is <2.0% Improper site preparation is leading cause of contamination 2015 MFMER slide-5
Lean Tool A3: Background October 2014 contamination rate was 2.9% Previously 4 of 8 months had contamination rates above 2% Background 2015 MFMER slide-6
Lean Tool A3: Current State Current State 2015 MFMER slide-7
Fishbone Diagram: Root Causes Lack of awareness of patient impact Lack of standard method of following SOP Outside pressures from other members of the care team Training Not performed by subject matter experts Too soon based on skill set 2015 MFMER slide-8
Target State Standard method of following SOP in place Heightened awareness of contamination effects on patients Appropriate and Adequate Training 2015 MFMER slide-9
Best Practice Determination Observed phlebotomists with no contamination Phlebotomist #1 Completed the arm prep per SOP Phlebotomist #2 Followed SOP as written Both explained the process to the patient Both restarted the site preparation required 2015 MFMER slide-10
Awareness Identifying the Cost of Quality (COQ) According journals contaminated culture results on average Increase in laboratory charges 20% Increase in antibiotic treatment 39% (~$1000) Increase in hospitalization by 3.3 days A total cost of quality per patient for 1 contaminated blood culture approximately $2889 - $8720 2015 MFMER slide-11
Awareness Applied October 2014 2.9% Contamination rate 15 Contaminated cultures Cost of Quality $43,335 - $130,800 49.5 additional days of hospitalization 2015 MFMER slide-12
Awareness Phlebotomy Feedback Post project implementation feedback provided Phlebotomy Supervisor ~ within 24 hours of resulted contamination by email Response is required to help identify possible improvements Use of the Safety Cross Daily visual management of how we are doing as a team 2015 MFMER slide-13
Safety Cross 2015 MFMER slide-14
Standard Method Blood Collection Card Provides the steps for the arm preparation on the card to ensure no step is missed Provides space for all necessary collection information to be recorded Provides the instructions for inoculation on the back Provides an area for comments to note an issues in collection useful for follow up if contamination occurs 2015 MFMER slide-15
Blood Collection Card 2015 MFMER slide-16
Training Beginning in 2015 Training was done by selected subject matter experts >2 years experience Low contamination rates Training for blood culture collection was delayed until 3-6 months after hire based on Previous experience Venipuncture skills 2015 MFMER slide-17
Achieving and Maintaining Success Pace of change November 2014-January 2015 Project analysis, raising awareness February 2015 - March 2015 Training changes, Collection Cards March Present Continued use of safety cross and feedback model 2015 MFMER slide-18
Recognizing Resistance and Guilty Feelings Training guideline changes Established Staff felt burdened Newly Hired felt guilty that they were not helping Blood culture cards Time constraints 2015 MFMER slide-19
Overcoming Resistance The Needs of the Patient Come First Consistent and persistent education on the cost of quality and impacts of contaminated blood cultures Celebrating success 2015 MFMER slide-20
Outcomes 2015 MFMER slide-21
Next Steps Share Best Practices Move project countermeasures to operational standards throughout MCHS- SWWI region 2015 MFMER slide-22
Next Steps continued Monitor and identify additional causes of contamination July 8 contaminated cultures 3 IV starts (performed by nursing) 2 Line access (performed by nursing) 3 venipuncture (performed by phlebotomist) July has shown the need to bring nursing staff on board 2015 MFMER slide-23
Team Members and References Entire MCHS-FH La Crosse Campus Phlebotomy team Heidi Miksanek, Senior Systems Engineer- Department of Lab Medicine and Pathology Kristin Hagen, Operations Supervisor - Microbiology http://www.captodayonline.com/archives/0412/0412c_contaminated.html http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1592696/ http://www.ncbi.nlm.nih.gov/pubmed/19171686 2015 MFMER slide-24