Evidence Based Practice for The Baccalaureate Prepared Nurse
Proper collection of blood cultures are necessary and the most direct method of determining whether or not a patient is septic. The purpose of obtaining blood cultures is to identify and isolate the bacteria that are causing an illness and then determine the best course of treatment based on the sensitivity of the bacteria to particular antibiotics. One of the most frustrating problems plaguing hospitals is the increased rate at which blood culture results are being returned as contaminated specimens. These results can lead to a significant increase in cost to the hospital and patient as well as an increased length in hospital stay and the administration of unnecessary antibiotics. The Center for Medicare Services (CMS) has recently implemented a core measure for Community Acquired Pneumonia (CAP). This new guideline states that blood cultures are to be obtained prior to the administration of antibiotics for all patients suspected of or diagnosed with CAP. Furthermore, this requirement states that the first antibiotic is to be administered to the patient within six hours of arrival to the hospital. This means in order to meet this requirement more and more blood cultures are being obtained in the emergency department by emergency room personnel, thus leading to the PICOT question; In patients presenting to the emergency room, how does contamination of blood cultures obtained by nurses compared to proper collection of blood cultures obtained by nurses, affect administration of unnecessary antibiotics and increased length of stay. Although it is impossible to completely eliminate the contamination of blood cultures a review of the literature and studies will show that the rate of contamination can be greatly reduced by implementing a training and education program to all staff that obtain blood cultures.
Review of the Literature
In order to implement any change in the clinical or practice setting a review of the literature must be completed to ensure that the best practices are being maintained. In a study completed at Parkland Memorial Hospital, a large 968-bed teaching hospital located in Dallas, TX, contamination rates of blood cultures were compared between phlebotomists and non phlebotomists (Gander, Byrd, DeCrescenso, Hirany, Bowen, & Baughman, 2009) The purpose of this study was to determine whether or not or the addition of a phlebotomist in the ED would lower blood culture contamination rates. This prospective study analyzed the contamination rates of blood cultures when phlebotomists versus clinical nurses in the ED obtained three months for a total of thirteen months. “In addition to contamination rates, the financial impact of false-positive blood cultures was reviewed by looking at incremental charge differences and length of stay between patients with false-positive, negative, and true-positive blood cultures” (Gander et al., 2009,). Blood culture data was reviewed for 2,642 patients seen in the ED from December 1, 2006 – December 31, 2007. This review leads to the PICOT question; In patients presenting to the emergency room, how does contamination of blood cultures obtained by nurses compared to proper collection of blood cultures obtained by nurses, affect administration of unnecessary antibiotics and increased length of stay. For the purpose of this study, a bacterial blood culture is defined as a set of bottles into which a single blood specimen is inoculated, regardless of the number of bottles (Gander et al., 2009). This data was placed into two groups, blood taken from patients located in the Western wing of the ED (ED west) and blood taken from those patients from the nonwestern wing of the ED (non west). A full-time phlebotomist was employed in ED west and collected 2,012 (55%) of the blood cultures. The remaining 1,650 (45%) were collected by nursing and ancillary...