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Cohen R, Tannous E, Natan OB, Vaknin A, Ganayem M, Reisfeld S, Lipman-Arens S, Mahamid L, Ishay L, Karisi E, Melnik N, Leibel M, Ashkar J, Freimann S. An emergency department intervention to improve earlier detection of community-onset bloodstream infection among hospitalized patients. Am J Infect Control 2024; 52:664-669. [PMID: 38232901 DOI: 10.1016/j.ajic.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND Blood cultures (BCs) are essential microbiologic tests, but blood culturing diagnostic stewardship is frequently poor. We aimed to study the process-related failures and to evaluate the effect of an emergency department (ED) intervention on BCs collection practices and yield. METHODS We implemented an ED-quality improvement intervention including educational sessions, phlebotomists addition, promoting single-site strategy for BC-collection and preanalytical data feedback. BC-bottles collected, positive BCs, blood volumes and documentation of collection times were measured, before (December 2021-August 2022) and after (September 2022-July 2023) intervention. Results were corrected to hospitalizations admissions or days. We used interrupted-time series analyses for comparisons. RESULTS A total of 64,295 BC bottles were evaluated, 26,261 before and 38,034 postintervention. The median ED-BCs collected per week increased from 88 to 105 BCs (P < .0001), resulting from increased early sampling (P = .0001). Solitary BCs decreased (95%-28%), documented times increased (2.8%-25%), and average blood volume increased (3 mL to 4.5 mL) postintervention. Community-onset Bloodstream infections (BSIs) increased (39.6-52 bottles/1,000 admissions, P = .0001), while Health care-associated BSIs decreased (39-27 bottles/10,000 days, P = .0042). Contamination rates did not change. CONCLUSIONS An ED-focused intervention based on the education sessions and single-site strategy improved culturing stewardship and facilitated the early identification of BSI without an increase in contamination.
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Affiliation(s)
- Regev Cohen
- Infection Control and Infectious Diseases Units, Hillel Yaffe Medical Centre, Hadera, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - Elias Tannous
- Pharmacy Department, Hillel Yaffe Medical Centre, Hadera, Israel; Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Orna Ben Natan
- Infection Control and Infectious Diseases Units, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Aliza Vaknin
- Infection Control and Infectious Diseases Units, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Mohammed Ganayem
- Infection Control and Infectious Diseases Units, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Sharon Reisfeld
- Infection Control and Infectious Diseases Units, Hillel Yaffe Medical Centre, Hadera, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Shelly Lipman-Arens
- Infection Control and Infectious Diseases Units, Hillel Yaffe Medical Centre, Hadera, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Lamis Mahamid
- Infection Control and Infectious Diseases Units, Hillel Yaffe Medical Centre, Hadera, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Linor Ishay
- Infection Control and Infectious Diseases Units, Hillel Yaffe Medical Centre, Hadera, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Erez Karisi
- Information Technology Department, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Noa Melnik
- Information Technology Department, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Mira Leibel
- Emergency Department, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Jalal Ashkar
- Emergency Department, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Sarit Freimann
- Department of Laboratories, Clinical Microbiology Laboratory, Hillel Yaffe Medical Centre, Hadera, Israel
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A Diagnostic Stewardship Intervention To Improve Blood Culture Use among Adult Nonneutropenic Inpatients: the DISTRIBUTE Study. J Clin Microbiol 2020; 58:JCM.01053-20. [PMID: 32759354 DOI: 10.1128/jcm.01053-20] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/25/2020] [Indexed: 12/18/2022] Open
Abstract
Interventions to optimize blood culture (BCx) practices in adult inpatients are limited. We conducted a before-after study evaluating the impact of a diagnostic stewardship program that aimed to optimize BCx use in a medical intensive care unit (MICU) and five medicine units at a large academic center. The program included implementation of an evidence-based algorithm detailing indications for BCx use and education and feedback to providers about BCx rates and indication inappropriateness. Neutropenic patients were excluded. BCx rates from contemporary control units were obtained for comparison. The primary outcome was the change in BCxs ordered with the intervention. Secondary outcomes included proportion of inappropriate BCx, solitary BCx, and positive BCx. Balancing metrics included compliance with the Centers for Medicare and Medicaid Services (CMS) SEP-1 BCx component, 30-day readmission, and all-cause in-hospital and 30-day mortality. After the intervention, BCx rates decreased from 27.7 to 22.8 BCx/100 patient-days (PDs) in the MICU (P = 0.001) and from 10.9 to 7.7 BCx/100 PD for the 5 medicine units combined (P < 0.001). BCx rates in the control units did not decrease significantly (surgical intensive care unit [ICU], P = 0.06; surgical units, P = 0.15). The proportion of inappropriate BCxs did not significantly change with the intervention (30% in the MICU and 50% in medicine units). BCx positivity increased in the MICU (from 8% to 11%, P < 0.001). Solitary BCxs decreased by 21% in the medicine units (P < 0.001). Balancing metrics were similar before and after the intervention. BCx use can be optimized with clinician education and practice guidance without affecting sepsis quality metrics or mortality.
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Choi J, Ensafi S, Chartier LB, Van Praet O. A Quality Improvement Initiative to Decrease the Rate of Solitary Blood Cultures in the Emergency Department. Acad Emerg Med 2017; 24:1080-1087. [PMID: 28109033 DOI: 10.1111/acem.13161] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 01/05/2017] [Accepted: 01/07/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Best practice guidelines recommend that at least two sets of blood cultures (BCs) be sent when blood cultures are required. However, high rates of solitary BCs are still common in the emergency department (ED). The aim of this study was to evaluate the efficacy of different quality improvement initiatives aimed at reducing the rate of solitary blood cultures being sent to the laboratory on patients ultimately discharged from our ED. METHODS This was a multicenter, multiphase, prospective study evaluating a comprehensive education-based intervention and a second intervention that combined a computerized forcing function (FF) along with a brief education-based intervention. The results were analyzed using segmented regression analysis, as well as statistical process control charts. RESULTS The baseline rate of solitary sets of BCs was 41.1%. The education intervention reduced this rate to 30.3%. The introduction of a FF with a brief educational intervention further reduced the rate to 11.6%. This represents an absolute reduction of 29.5% from baseline (relative reduction of 71.8%). According to segmental regression analyses, the education intervention alone did not produce a statistically significant change when factoring possible background time-related trends (p = 0.071). However, the FF produced a statistically significant improvement (p < 0.0005), which was maintained for 6 months. CONCLUSION The combination of a brief education-based intervention and a computerized FF was more effective than education alone in reducing solitary BC collection in our ED in this time series study. FFs can be a powerful tool in modifying behaviors and processes in the clinical setting.
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Affiliation(s)
- Joseph Choi
- Department of Emergency Medicine; University Health Network; University of Toronto; Toronto, Ontario Canada
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto, Ontario Canada
| | - Sahand Ensafi
- Department of Emergency Medicine; University Health Network; University of Toronto; Toronto, Ontario Canada
| | - Lucas Brien Chartier
- Department of Emergency Medicine; University Health Network; University of Toronto; Toronto, Ontario Canada
- Division of Emergency Medicine; Department of Medicine; University of Toronto; Toronto, Ontario Canada
| | - Oliver Van Praet
- Department of Emergency Medicine; University Health Network; University of Toronto; Toronto, Ontario Canada
- Department of Family and Community Medicine; University of Toronto; Toronto, Ontario Canada
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Clinical Significance of Molecular Diagnostic Tools for Bacterial Bloodstream Infections: A Systematic Review. Interdiscip Perspect Infect Dis 2016; 2016:6412085. [PMID: 27974890 PMCID: PMC5128711 DOI: 10.1155/2016/6412085] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/27/2016] [Indexed: 12/15/2022] Open
Abstract
Bacterial bloodstream infection (bBSI) represents any form of invasiveness of the blood circulatory system caused by bacteria and can lead to death among critically ill patients. Thus, there is a need for rapid and accurate diagnosis and treatment of patients with septicemia. So far, different molecular diagnostic tools have been developed. The majority of these tools focus on amplification based techniques such as polymerase chain reaction (PCR) which allows the detection of nucleic acids (both DNA and small RNAs) that are specific to bacterial species and sequencing or nucleic acid hybridization that allows the detection of bacteria in order to reduce delay of appropriate antibiotic therapy. However, there is still a need to improve sensitivity of most molecular techniques to enhance their accuracy and allow exact and on time antibiotic therapy treatment. In this regard, we conducted a systematic review of the existing studies conducted in molecular diagnosis of bBSIs, with the main aim of reporting on clinical significance and benefits of molecular diagnosis to patients. We searched both Google Scholar and PubMed. In total, eighteen reviewed papers indicate that shift from conventional diagnostic methods to molecular tools is needed and would lead to accurate diagnosis and treatment of bBSI.
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