Sponsor: Reviewer(s): Dr Roberta Parnaby (Consultant Microbiologist) Dr Alicja Baczynska (F2 Microbiology) Dr Chris Gordon (Medical Director) Dr Roberta Parnaby Dr Matthew Dryden (Consultant Microbiologists) Type: Scope: Major Trust Reference CP110 Number: Status: Published Approval body: Infection Control Committee Effective Date: 28 September 2009 Review Date: September 2012 Disposal Date: January 2034 Document Authorisation Control Prepared By: Dr Roberta Parnaby (Consultant Microbiologist) Dr Alicja Baczynska (F2 Microbiology) Signature: Authorised Officer Martin Wakeley Chief Executive Signature: Page 1 of 12
DOCUMENT CONTROL Document Amendments No. Details By Whom Date 1 Original document Dr R Parnaby 05/01/2009 Consultant Microbiologist Dr A Baczynska F2 Microbiology 2 Amended K Davis-Blues 24/09/2009 Infection Control Nurse 3 Amended document format to meet both the NHSLA (Acute) Standards and OP001 - on Management of Controlled Documents S Jennings Divisional Governance Head 01/06/2009 Review Timetable Date Reason By Whom Date Completed 2012 3 year review Infection Control team Distribution List No Title 1 All holders of infection control manual 2 All medical staff 3 All training packs for new medical staff 4 Medical assistants 5 Winchester and Eastleigh Healthcare NHS Trust Intranet & Internet RELATED TRUST POLICIES: CP073 : Hand Hygiene CP076 : Standard Precautions and PPE CP055 : MRSA CP072 : Training for Employees of WEHCT in Infection Control CP021 : Surveillance CP022 : Isolation and Infectious Diseases OP039 : Management of Needlestick/Sharps Injuries and Exposure to Body Fluids Page 2 of 12
Contents Section Title Page 1. Purpose 4 2. Scope 4 3. Roles and Responsibilities 4 4. Introduction 5 5. Procedure 5 6. Training Implications 7 7. Monitoring Compliance and Effectiveness 7 8. Definitions 8 9. References 8 Appendix 1 Summary of best practice 9 Appendix 2 Process for undertaking a root cause analysis 10 Appendix 3 Equality Impact Assessment Tool 11 Appendix 3 Communications Log 12 Page 3 of 12
1 PURPOSE 1.1 This document adopts the 2007 Department of Health Saving Lives guidance for collection of blood cultures at Winchester & Eastleigh Healthcare NHS Trust as a Trust policy to ensure best practice and minimise the blood culture contamination rate. The DH advises that a level of 5% is achievable but the American guidance recommends <3%, which WEHCT is going to aim for. 2 SCOPE 2.1 This policy applies to all Winchester & Eastleigh Healthcare NHS Trust staff who takes blood cultures from patients e.g.: doctors, nurses, phlebotomists and medical assistants. 3 ROLES AND RESPONSIBILITIES 3.1 Line managers are responsible for ensuring that all relevant staff have accessed, read and understood the content of the policy. 3.2 All staff that collect blood cultures are responsible for reading and complying with this policy. 3.3 The Chief Executive (CEO) has overall responsibility for ensuring the Trust has appropriate strategies, policies and procedures in place to ensure the Trust continues to work to best practice and complies with all relevant legislation. The CEO has responsibility to ensure there is a safe environment for staff and patients. 3.4 The CEO is accountable for establishing and maintaining an adequately resourced Infection Control Team (ICT) and infection prevention and control arrangements throughout the Trust. 3.5 The Director of Infection Prevention and Control (DIPC) is the lead Executive within the Trust whilst the daily management of infection prevention and control is the remit of the ICT, supported by the DIPC. 3.6 Line managers are responsible for ensuring that all Infection Control (IC) policies and procedures are accessible for all their staff and that they have read them. Also ensuring that any changes in practice are implemented. Ensure systems exist to identify staff training needs and the implementation of new and updated IC policies. Matrons, Managers and consultants should ensure that all healthcare workers comply with this policy and attend mandatory infection control induction and updates, or complete the relevant e- learning modules. 3.7 All staff have a duty of care to adhere to all Trust policies and protocols applicable to infection control and ensure their practice follows the current IC policies in use, as per CP072 Training for employees of WEHCT in Page 4 of 12
Infection Control. Information regarding the failure to comply with the policy e.g. lack of training or inadequate equipment, must be reported to the line manager and the incident reporting system used where appropriate. If patients or staff safety is compromised as a result of the revised policy, staff must inform their line manager, the ICT and Health and Safety Adviser/Patient Safety Manger as appropriate. A risk assessment is completed and revisions made if appropriate to the policy. 3.8 All Trust staff have a duty to ensure that visitors, locums and agency staff to the hospital are made aware of the Trust Infection Control Policies, if appropriate by producing those sections relevant to their visit or area of work. 4 INTRODUCTION 4.1 A 2008 audit revealed that the practice of blood culture collection needs to be improved significantly. According to microbiology department data the contamination rate for blood cultures was 6.8% in the first half of 2008. 4.2 Contaminated blood cultures may compromise patient care by prolonging their hospital stay and exposing them to unnecessary antibiotic therapy. It also leads to a needless engagement of clinicians, laboratory and microbiologist s working time and unnecessary repeated cultures. 4.3 For the above reasons it is important that all staff collecting blood cultures closely follow the summary of best practice from the Department of Health (available via link 283198BC_blood_cultures.pdf) and review the posters available on the wards which contain 10 main points to consider before taking a blood cultures (see Appendix 1.) 5 PROCEDURE (see Appendix 1) 5.1 Blood culture should only be taken if there is a clinical suspicion of bacteraemia/sepsis e.g.: high temperature, hypotension, tachycardia, chills or rigors, new onset confusion, focal signs of infection before the administration of antibiotics or in case of the patient being already treated before the next dose of antibiotic. 5.2 Blood cultures must only be collected by competent trained hospital staff (doctors, nurses, phlebotomists, medical assistants). 5.3 Ideally, 2 sets of blood cultures (10 mls each) from separate fresh stabs should be taken. In certain circumstances a central line may be also used. 5.4 Members of staff must wash their hands with soap and water as per CP073 Hand Hygiene and wear n sterile gloves as per CP076 Standard Precautions and PPE. Patient s skin should be disinfected with skin antiseptic; preferably a 2% chlorhexidine/70% alcohol preparation (exceptionally a 0.5% chlorhexidine in 70% alcohol may be used for example if Page 5 of 12
the 2% chlorhexidine preparation is t available) and the vein should t be palpated again. (DOH 2007). Bottle Preparation 5.5 Bottle tops are n sterile, so they must be wiped/disinfected with a fresh 70% alcohol or alcoholic chlorhexidine gluconate swab. Allow to dry. Preparation described above, before iculation. Venepuncture and Bottle Iculation 5.6 The Trust would advocate the use of method one. However in the absence of the equipment or practitioner skills required method 2 may be used. Method 1: Direct Draw with blood collection set: Use the BacT/ALERT Vacutainer & insert 1. Connect the Vacutainer to the leur connector of the blood collection set. 2. Perform venepuncture using a n-touch technique, only the sterile needle tip should come into contact with the prepared venepuncture site. When the needle in the vein, hold in place. 3. Place the vacutainer on the aerobic culture bottle septum and press down to penetrate and obtain blood flow. Hold the vacutainer down over the bottle. 4. Using the fill indicator lines on the label, obtain the specified amount of blood. Move the vacutainer from the aerobic bottle to the anaerobic bottle and continue the collection. 5. After the blood collection is complete, remove the vacutainer from the culture bottle and then remove the needle from the patient s vein. 6. Place needle and collection system in the sharps bin. Method 2: Needle and syringe 1. Perform venepuncture using a n-touch technique, only the sterile needle tip should come into contact with the prepared venepuncture site. A 20ml portion of the blood per set for cultures is recommended per adult patient. 2. Directly iculate the blood culture bottle using the same needle used to perform the venepuncture, i.e. do t change the needle to avoid the risk of accidental injury as per OP039 Management of Needlestick/Sharps Injuries and Exposure to Body Fluids. 3. Dispose of the needle and syringe in the appropriate sharps bin. RESHEATHING THE NEEDLE IS NOT ALLOWED UNDER ANY CIRCUMSTANCE Page 6 of 12
5.7 Labelling Remove gloves, dispose of in clinical waste bag, and decontaminate hands. All bottles must be correctly labelled with patient s details. The barcode labels must never be removed from the bottles. 5.8 The procedure must be recorded in patient s tes specifying the indication for blood culturing, the time and site of venepuncture and any complications. 6 TRAINING IMPLICATIONS 6.1 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 IV cannulation team or senior phlebotomist to provide it. 6.2 Information on how to take blood cultures correctly will be provided at Trust Induction for medical staff. 6.3 Medical assistants will have specific training initially, complete competence assessments and annual competence assessments. 6.4 Nursing 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. 7 MONITORING COMPLIANCE AND EFFECTIVENESS 7.1 Audits will be undertaken, annually or more frequently if indicated, to check staff s awareness of the guidance and assess competence as per CP021 Surveillance and show any changes to the contamination rate. 7.2 The cause of any blood culture contaminated by Meticillin-Resistant Staphylococcus Aureus (MRSA) will be identified by root cause analysis (RCA) as per CP055 MRSA. An RCA will be undertaken within five working days 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. (See Appendix 2.) Page 7 of 12
8 DEFINITIONS Term Contaminated blood culture Definition A 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 t indicated. Recovery of the patient will occur without specific therapy for the blood culture findings. 9 REFERENCES Department of Health, (2007) Saving Lives - Taking blood Cultures: A summary of best practice Page 8 of 12
Appendix 1 Summary of best practice in taking blood cultures Page 9 of 12
Appendix 2 PROCESS FOR UNDERTAKING ROOT CAUSE ANALYSIS MRSA Bacteraemia/Clostridium difficile death DAY 1 Microbiologist Infection Control Nurse Infection Control Divisional Leads: Clinician Senior Nurse Ward nurse Divisional risk facilitator 10 minute meeting. (to be triggered by Infection Control Team) DAY 5 (triggered by Division) Infection Control Divisional Leads: Clinician Senior Nurse Ward nurse Infection Control Nurse Meeting: RCA process using NPSA adapted tool Defined learning Action plans DAY 6 Feedback by RCA Team to: DIPC CEO Agenda Item Divisional Risk Management Forum Patient Safety Committee Infection Control Committee PS/lam04 November 2009 Page 10 of 12
Appendix 3 - Equality Impact Assessment Tool To be completed and attached to any controlled document when submitted to the appropriate committee for consideration and approval. Yes/No Comments 1. Does the policy/guidance affect one group less or more favourably than ather on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A If you have identified a potential discriminatory impact of this procedural document, please refer it to the Company Secretary, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Company Secretary (Tel No: 01962 825903). Page 11 of 12
Appendix 4 Communications Log Ref Date of Issue To Whom Signed as read and Understood Page 12 of 12