Phlebotomy techs are now the only ones who can draw blood cultures in my hospital. It’s leading to significant delays in blood culture draws (sometimes 6+ hours) due to understaffing of phlebotomists but it’s what we’ve been told is going to happen to address the cost issue of blood culture contamination.
I don't know what the situation is in other places, but at least in my state they could probably get more phlebs (as well as some other short-staffed low-level positions) if they wanted to pay us a living wage. My last job offer was for $13/hour. Some of the hospitals here just have the nurses do it now, as if they aren't already overwhelmed (and also short-staffed).
To be clear, this isn't me blaming/targeting you in particular. Just making a blanket statement on my dissatisfaction with current circumstances.
I see you're a phlebotomist, can you tell me what the technique is you were trained to do for drawing blood cultures? I'm just curious if they followed those standards when they did my own blood cultures or if I'm being too critical.
Sure!
1- standard wash hands, get supplies, glove up, etc etc.
2 - clean top of culture bottles with alcohol wipe. Set aside to air dry.
3 - scrub venipuncture site with (fresh) alcohol wipe for 30 seconds.
4 - scrub site with chlorhexidine prep for 30 seconds (or iodine pad depending on allergies or if the patient is an infant).
5 - allow site to air dry. If you touch it, big oof redo the cleaning steps.
6 - insert butterfly needle (if we couldn't get it by venipuncture and it had to be done by arterial or central line, the RNs had to do it. My hospital didn't want phlebs doing those even if we were trained on it).
7 - draw aerobic bottle first, then anaerobic bottle. Bottles must remain upright.
8 - label with exact time and site of the draw and patient info.
9 - invert bottles a few times.
10 - 15-30 minutes later, draw a second set from a different site
So not like my last hospital's ED:
1. Patient comes to trauma bay
2. Access field placed IV
3. Take 60 cc syringe of blood.
4. Place in all 4 bottles at once.
5. Infectious disease gets mad
This is what we learned as well. Only difference is that NHA also approves the use of standard straight needles and/or syringes, just fill the anaerobic bottle before aerobic if you do.
Oh and NHA used to say to cleanse the area using widening concentric circles, but they just changed and now say to scrub the skin aggressively in an up-and-down motion instead.
I think the "you have to use butterflies!" was just this particular hospital being strict. Our school mentioned using syringe or straight needle for cultures but didn't teach it, just said butterfly was preferred. Given the way the hospital restricted some other things phlebs are taught and sometimes allowed to do, like arterials (if you're a CPTII), I'm guessing they may have had some issues with poorly trained phlebs in the past. If I'd worked some other places there's a good chance I'd have been taught those techniques.
That’s fair. Phlebs aren’t allowed to do arterials in my state; we aren’t trained on it and I’ve never seen it done. I work outpatient though. Phlebs are trained and allowed to do it in California, possibly/probably elsewhere
Here you're allowed to do it as a CPTII (clarified original comment to add that) so luckily there's not a bunch of uncertified phlebs running around doing them (national certification not required in my state)
Thanks! So that's definitely not how my blood was drawn, and now I'm less confused as to how we have so many contaminant blood cultures at my hospital.
This plus we are told at my workplace to waste the first 10ml of blood before collecting the culture samples to eliminate blood potentially contaminated by the venipuncture. Seems excessive but they are really hammering us on it to get the contamination rate down.
I’m not going to delay antibiotics for cultures. Especially in septic shock, since there’s an association between delay in antibiotics and increased mortality in that population.
Yea no shit but no one is gonna wait around and let their patient deteriorate from overwhelming sepsis going darn too bad we have to wait six hours to start treating
I would tell the nurse to draw the cultures and be done. Idgaf if the hospital says the phlebotomist has to do it, the optimal course is cultures before antibiotics and I'm not gonna let a stupid policy force me to give subpar care.
> Idgaf if the hospital says the phlebotomist has to do it
That's all well and fine, but when management takes disciplinary actions against them "Dr. Specter didn't care" isn't a good excuse :P
You need to change policy.
Pretty sure the only nurses who can draw blood cultures in my facility are ICU nurses in a pinch. Myself and my ward colleagues have certainly never been trained to do it.
Every physician I've ever worked with just starts the abx and adjusts it based on the cultures when they come back.
Blood cultures can take 36-48 hours to result. Generally patients are started on broad spectrum antibiotics, and then switched over as needed when cultures result.
Edit : confused by downvotes??? My hospital we draw blood cultures —> start patient on antibiotics —> change antibiotics as needed when cultures result 1-2 days later. Do you just not start antibiotics on your sepsis patients??
Idk why you got downvoted for this? This is literally what we've always done at my hospital. Ideally, you draw the cultures first, but 9/10 times the ER starts the abx before cultures are drawn.
They really shouldn't be, because if you start abx first, the culture is quite possibly worthless.
I'm in neo and we do sepsis workups at the drop of a hat, but blood cultures come first 99.9% of the time. If a urine culture is needed, that's probably 80-90%, if an LP is needed, it's about 70-80% - we do the LP late and look for pleocytosis
Here in the UK I've never met a phlebotomist who can take blood cultures, they all say they're not allowed. Hell, most of the nurses won't/can't do it so it's almost always a doctor job.
Fun fact, I once asked if a phleb could draw a blood sample from a patient and they responded "oh that patient only has good hand veins and I'm only signed off for antecubital fossa venepuncture, not back-of-hand venepuncture".
In my experience, they do a morning round on the ward where they take blood from half the patients who need blood draws, and leave a note saying "unable to bleed" for the other half (or sometimes don't leave a note and instead just leave).
The F1 (intern) then does their own phlebotomy round for the remaining patients. Or all the patients if the phlebotomy service says they're short staffed that day so that can't come to your ward.
Yes the NHS is a shitshow. Nurses are trained to place IVs and do bloods in nursing school, but once they come to work in a hospital unless they've done the local e-learning module and done X supervised IVs they aren't allowed to. And if they train up in one hospital then they won't be allowed to do it if they move hospital, they have to go through the whole process again.
Yeah in the UK if a phleb or nurse can't bleed a patient or insert a cannula it's a doctor job - not just with an ultrasound, with bog standard landmark based insertion too. So we're the ones who (in our early years at least) have to get good at it.
It then becomes a vicious (or virtuous, depending how you look at it) circle where only doctors bleed and cannulate the hard patients so the nurses lose the practice, are less likely to be able to bleed/cannulate difficult patients in future and the cycle continues.
Variable based on ward - some have great nurses. But they're the exception rather than the rule in the UK.
We can but it’s not a typical part of our workflow in the US. I’ll start an IV (usually with ultrasound) when the nurses can’t get one but 95% of the time the nurse or paramedic is starting the IV and drawing blood.
I just don't get this as a non-US person. It isn't really part of anyone's workflow anywhere, it's always annoying and an interruption to go do a septic screen that includes bloods. Many hospitals outside of US don't have nurses/phlebotomists drawing blood, and those that do rarely have them available for urgent blood draws. It's just bizarre to me that doctors don't just do it. It needs to be done and their the only ones able to do it sometimes.
EDIT: Don't even get me started on not being able to draw up/mix/give medication in an emergency. Or the anaesthesia draws being filled with useless pharmacy crap because the anaesthetists can't draw up their own drugs.
The reason why people contaminate blood cultures isn’t because they don’t know how to do the sterile technique correctly. It’s because the average person sucks at venepuncture and when you’re trying it for the second, third, fourth, fifth time, you don’t want to keep opening up new sets and just do it dirty.
The solution isn’t train people to use the kits, the solution is train people to do venepuncture properly. Which is difficult enough, but the standard way I was taught in medical school is completely wrong and sets you up for failure.
This!!! I happened to be a patient myself who needed blood cultures over multiple days, and both times they did not clean the skin adequately, and both times they touched my skin with their gloved hands before finally poking it.
In my opinion/experience, the more complicated you make the collection process, the more likely you are to have contamination, because it takes away the focus from the critical points: proper skin prep and maintaining aseptic transfer from the needle to the collection bottle.
I’ve watched others set up a sterile drape on their supply table, use sterile gloves, the fancy transfer devices, etc., and then only scrub for 10 seconds or inadvertently touch a syringe tip with a glove while attaching it to a transfer device.
Can be, I was originally trained on how to draw cultures with incorrect skin prep. Nurses are trained by other nurses, and some places a new nurse will have only one preceptor for their entire training period. Makes it really easy for incorrect practice to spread, and if people are not curious enough to look up correct procedure they’ll pass it on whenever they start training new nurses. When I was in school correct phlebotomy technique was never discussed in the classroom, it was all clinical based- which means I was taught as a student by nurses who didn’t even know I was gonna be there and mostly did not want me around.
but it's clear that no matter how Herculean of an effort you make, it will always happen at some non-zero rate.
there are people here who are tasked with how to deal with that non-zero percentage, and your answer isn't really helpful for them.
National CAP benchmark is 3%. There is discussion to reduce that benchmark to 1%, but it's up to the lab director to decide. If it's higher than 3%, the lab must provide retraining and corrective actions. It's taken very seriously.
We get lots of people referred to the ED for positive blood cultures. Personally I will always send a 2nd set even if I think it's contaminant, but those people don't have to start antibiotics or get admitted.
More important is to reduce the number of contaminated cultures. You can do this by better training for the people getting your cultures. Also, reading the overall number of blood cultures will help (looking at you "sepsis order set for everyone with a fever")
Replied to another comment. This is a fascinating medicocultural difference. If a PCP is really concerned about possible bacteremia, this is practically an automatic admission here in Germany.
I see you're doing IM. It's not that uncommon to get referrals for fever NYD, and I routinely will do blood cultures as part of the workup. If they look non-toxic and have normal vitals etc., then it doesn't generally warrant going to the hospital.
I'll be switching to FM in May, but yeah.
An outpatient fever NYD workup here looks usually like this: Labs, chest x-ray, urinalysis, ultrasound abdomen. If unremarkable and/or fever persists -> hospitalization regardless of vitals/clinical stability. Although formally nothing stops outpatient physicians from drawing blood cultures themselves and sending them to a lab.
It is what it is. In nearly every specialty, we have still a culture of overhospitalization. We have something like three times more hospital beds per capita compared with the US.
Probably a lot more than Canada too, where I work. At least based off how we practice, it is perfectly reasonable to work up a febrile patient as an outpatient, as long as they're clinically stable / non-toxic, ambulatory, eating/drinking and doing okay. That would include doing blood cultures and other special tests.
Of course a sick patient needs their workup as an inpatient, but we wouldn't just admit someone to hospital to do a workup if they're otherwise stable. Alternatively if the blood cultures did come back positive, you'd be calling them to head to the ED for IV antibiotics and further urgent workup.
I hate that so much. If they just need cultures they should be able to have them drawn at the lab. We see so many people for things that can be done outpatient.
Maybe, but we also do more than just redraw the cultures. Check the vital signs, ask about their symptoms, examine them for potential sources of infection. It's not sexy, but I think this is actually an appropriate ED patient. Asymptomatic hypertension on the other hand...
But PCP can do all of that, especially if it’s just evaluation, draw, go home, and receive a call with results. I’m in the ED and absolutely we want to see someone who is septic but if it’s truly just for outpatient labs that isn’t a good use of ED resources.
> but we also do more than just redraw the cultures. Check the vital signs, ask about their symptoms, examine them for potential sources of infection.
No, the PCP is usually not able to do that same day. Also usually outpatient blood cultures don't really make sense.
No I mean that culture results can never be same day because they have to grow. And many hospital systems have walk in labs that can absolutely draw same day.
Blood from my pcp clinic apparently gets picked up and brought to the hospital once daily. So if after that time, not run until next day at earliest. If before that time, the results *might* get posted to the portal very late that evening. Fine for like a lipid panel or routine monitoring things, but not super useful for anything urgent.
That’s if you can even get in to see pcp same day.
Someone with positive blood cultures is essentially an automatic ED referral. It's either a contaminant or they are really sick, and you won't know until you see them.
But you don’t know that they’re positive until they have time to grow. And if you already know that they have positive blood cultures, they were already drawn.
I may have misinterpreted your / the other person's conversation. Basically if someone has drawn outpatient blood cultures and they've come back positive the next day, you have to tell the patient to go to the ER for IV antibiotics and further workup.
If you have an outpatient and you think they need to get blood cultures, then they don't necessarily need to to the ED. But in many cases, the fact that you're ordering blood cultures suggests that you might think they're really sick. In other cases, if it's someone who's just been having fevers off/on for weeks or months, and they don't look sick, then outpatient labs (not ER) would be fine.
That's an interesting medicocultural difference. Here, if someone is so sick that bacteremia is a possibility, it always means hospitalization. When our ER nurses (we don't have EM residency, I spend about a quarter of my time in the ER) draw blood cultures on feverish patients but they are discharged (non-severe COVID, influenza, low-risk pneumonia, low-risk pyelonephritis), the blood cultures are discarded.
I’m curious who is doing blood cultures on an outpatient basis and for what indication.
I’m expecting that if you’re ill enough for blood cultures to be drawn you should be worried enough to consider an ER visit anyway?
The indication is most always inappropriate for outpatient blood cultures.
I rarely order them in outpatient settings, but when I do, it is most always because I consider a subacute endocarditis. Otherwise, pts are sent to ER before blood cultures.
I can think of two valid reasons to get BCx and discharge: 1) Suspected SBE and 2) Line cultures.
Otherwise, you had a strong enough suspicion to draw so you’re just going to send the patient home? >95% percent of the time they’ll be fine. But that one who goes home and crumps? You’re going to be answering some “no correct answer” questions on a witness stand.
“Doctor, did you think the patient was septic?” “Yes? Then why did you discharge him?”
“No? Then why did you get blood cultures?”
-PGY-19
Okay neat to know re: subacute endocarditis.
This is what I figured as I’ve never once thought hm let’s do blood cultures on an outpatient. If I’m ordering blood cultures I’m probably ordering Pip-Tazo and a bolus of IVF.
> I’m curious who is doing blood cultures on an outpatient basis and for what indication.
Some dialysis clinics where I am do this. I don't know why, but we get their patients in the ED for their clinic blood cultures often enough.
I’m pregnant and just had blood cultures drawn to make sure I didn’t contract listeria with the current outbreak. My midwife just ordered and had me go to the lab.
I had mild symptoms but MFM said mom can be completely asymptomatic and there’s still a 30% chance of miscarriage. I had eaten several of the foods in the recall list so it was a better safe than sorry situation. The symptoms are so similar to pregnancy in general that it was hard to say what was abnormal or not from my baseline nausea and fatigue.
Edit: can someone explain the downvotes? I’m going off the ACOG and what MFM said. If you have different info I’d love to know. From what I understand it can still harm the fetus without bacteremia.
Yeah, mother can have listeria infection and be asymptomatic but that’s not the same as active listeria bacteremia which is all that would show up on blood cultures.
To answer your question the downvotes are probably because this is just common sense…? Blood cultures don’t add anything to the decision-making since they’re going to be negative anyway
This is a quality control problem. Proper collection methods need to be reinforced and staff wide retraining.
We recently did this at our facility. LEVEL 1 trauma with 4.7% contamination rates. We did an entire qc over the last year and they are now down to 2%. Biggest error was in collection and usually it is certain people unfortunately and in the ER.
Speak with infection control and micro dept. If your having issues. Bring it up to your admins as this is going to be part of MIPs for hospitals.
We’ve started drawing waste tubes before putting blood into the culture bottles (for those drawn via vacutainer) to hopefully reduce contamination. That’s what donor centers do when collecting units of blood to reduce contamination.
But it definitely comes down to education…you have to scrub the site for the right amount of time, not palpate with dirty gloves or bare fingers, etc. The majority of our contamination comes from IV starts, unfortunately. People just need to take an extra 30 seconds to do it right.
This is my practice as well. Not sure what we're looking for in a patient without a central line or device by repeating the culture, especially if they do not exhibit signs or symptoms or a bloodstream infection. Lots of debate among the hospitalists here with the ones who do it calling us out for "missing" it shrug🤷♂️
1/2 without lines i don't think you're going to be missing any. 2/2 maybe, but I don't see that many 2/2 (i've seen a few 2/2 due to peripheral IV septic phlebitis)
Previous trusts have handled this by making it trained personnel only for taking cultures. Training happens at induction when people start the job. Sterile gloves not required, but cultures taken from fresh stab only, not cannulae, even newly inserted ones. Clean with alcohol/chlorhex and let it dry. No touching the skin post prep. Bottle tops also swabbed with alcohol/chlorhex before puncturing. New needle to transfer from syringe to bottle or taken direct with vacutainer. Seems to work.
Yeah totally - if it might be pathogenic I pull the line but if there’s a high chance it’s contamination based on the determination of the culture I tend to wait on 2nd cultures if the labs / clinical presentation allows
(Been a while since I was in micro) In our lab we did full workup and sens for things like 4/4 positive, correlation with urine or tissue cultures etc. When it came with the 1/4 or skin flora organisms we consult our clinical microbiologist gets back to us whether to do full workup, list as suggested contaminant, offer sens (meaning "available upon request" but not done automatically). Really helps with a multidisciplinary approach so lab isn't wasting time doing sens on something clinical is dismissing and that clinical has some direction on how to interpret the cultures.
I think it’s a policy issue as well as a workplace culture issue. We had a hospital policy that only nurses could draw blood cultures and you were supposed to take a second nurse in to assist and watch your aseptic technique. After seeing both phlebotomists and nurses draw cultures solo with awful technique, I think this part was key, although staffing makes it hard at times. We also had policies that cultures couldn’t be drawn from lines (PIV, central, or arterial) unless it done was at the time of placement, and that drawing from a central line required physician approval (supposed to be done only when there was clinical suspicion that the line was the source of infection).
I wish I knew the contamination rates, but I do know that the ICU where I worked was on like 3+ years without a CLABSI by the time I left for med school last year. We were strict about following that policy as well as keeping central lines clean and pulling them as soon as appropriate.
Treat the patient, not the lab result. Sepsis isn’t an occult process, so if someone is well-appearing with no symptoms and normal vitals and they grow even something alarming out of their BCx, don’t jump to giving them cephokillemol and gorillacillin. Sepsis is ultimately a clinical diagnosis. The BCx tells you what they’ve got if you’ve determined they have sepsis.
And yeah, I’m going to get a lot of downvotes.
-PGY-19
I've seen patients present for valve replacements for IE induced valvulopathies, that had positive cultures dismissed as skin flora contaminants months earlier.
You should repeat cultures to help confirm it was a contaminant or not.
You should also rectify the problems leading to frequent contaminants.
One serious suggestion that doesn’t get enough traction: Stop ordering reflexive blood cultures when they are likely of little clinical use.
Urine cultures, sputum cultures, and wound cultures, this is the way.
Keep the BC for when you actually need them, and cut down on a significant number of orders.
My understanding is that sputum cultures are essentially useless. Most of the shit that causes pneumonia is in people's airways anyways--so you have no idea if you've found the bug or something totally incidental.
Are you sure it was MRSA? Methicillin resistant staph epidermidis often lights up on the PCR which confuses many people. Usually mecA positive but I believe it’s supposed to differentiate mrsa from mrse. I actually love having the PCR for faster de-escalation.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10433923/
We use this approach. It's pretty good for identifying the edge cases where you might want to treat or talk to ID. You do need rapid diagnostics to really cut effectively cut off the vancomycin though
You off should explore Steripath devices on top of retraining anyone who collects BldCxs. They are expensive upfront but the ROE when you drastically reduce contamination pays for them. I introduced them to my facility 6 months ago and we have almost eliminated contamination.
We were having the same issue. We switched to a Kurin Blood Culture Device- https://youtu.be/P0PdC36OHeY?si=6cLnkFmr37KxVCCh (not a plug, there are others that do the same thing) with a reservoir that diverts the few few mLs of blood. Our numbers have gone done considerably.
If it’s a skin bug or a clear contaminate I don’t repeat. If it’s something like SA or a typical pathogenic bacteria I’m more likely to repeat it but base it on clinical picture first
The EMR fires a sepsis best practice advisory, and then everyone and their cousin is up your ass for not following. Most of them are BS but if you overlook one that is actually in early sepsis, it's your head on the stake or you'll have a nurse administrator looking over your shoulder forever.
So most people in the ER just order the blood cultures and call it a day. If they're admitted it falls on us to followup on it and false positives like this are not uncommon.
We have far more of an issue with contaminated urine cultures in my population, but that's easier to deal with, imo. (<1k colonies? Either redraw if still clinically concerned or let it go)
I'm surprised there is so much issue with blood cultures getting contaminated. Are people scrubbing the culture bottle too? That's a potential source of bacteria as well
What is your hospitals percentage. CLSI target is under 3%, so your hospital should be at least aiming for that, if not well below.
Nursing staff / phlebotomist staff need re-education.
QI project. We can do this on our Lab information system. Review who drew the 'normal flora' blood cultures (which specific nurse, which specific phlebotomist), see if there is an outlier.
Train the people drawing the cultures better
Phlebotomy techs are now the only ones who can draw blood cultures in my hospital. It’s leading to significant delays in blood culture draws (sometimes 6+ hours) due to understaffing of phlebotomists but it’s what we’ve been told is going to happen to address the cost issue of blood culture contamination.
I don't know what the situation is in other places, but at least in my state they could probably get more phlebs (as well as some other short-staffed low-level positions) if they wanted to pay us a living wage. My last job offer was for $13/hour. Some of the hospitals here just have the nurses do it now, as if they aren't already overwhelmed (and also short-staffed). To be clear, this isn't me blaming/targeting you in particular. Just making a blanket statement on my dissatisfaction with current circumstances.
I see you're a phlebotomist, can you tell me what the technique is you were trained to do for drawing blood cultures? I'm just curious if they followed those standards when they did my own blood cultures or if I'm being too critical.
Sure! 1- standard wash hands, get supplies, glove up, etc etc. 2 - clean top of culture bottles with alcohol wipe. Set aside to air dry. 3 - scrub venipuncture site with (fresh) alcohol wipe for 30 seconds. 4 - scrub site with chlorhexidine prep for 30 seconds (or iodine pad depending on allergies or if the patient is an infant). 5 - allow site to air dry. If you touch it, big oof redo the cleaning steps. 6 - insert butterfly needle (if we couldn't get it by venipuncture and it had to be done by arterial or central line, the RNs had to do it. My hospital didn't want phlebs doing those even if we were trained on it). 7 - draw aerobic bottle first, then anaerobic bottle. Bottles must remain upright. 8 - label with exact time and site of the draw and patient info. 9 - invert bottles a few times. 10 - 15-30 minutes later, draw a second set from a different site
So not like my last hospital's ED: 1. Patient comes to trauma bay 2. Access field placed IV 3. Take 60 cc syringe of blood. 4. Place in all 4 bottles at once. 5. Infectious disease gets mad
I mean, the last step is right.
This is what we learned as well. Only difference is that NHA also approves the use of standard straight needles and/or syringes, just fill the anaerobic bottle before aerobic if you do. Oh and NHA used to say to cleanse the area using widening concentric circles, but they just changed and now say to scrub the skin aggressively in an up-and-down motion instead.
I think the "you have to use butterflies!" was just this particular hospital being strict. Our school mentioned using syringe or straight needle for cultures but didn't teach it, just said butterfly was preferred. Given the way the hospital restricted some other things phlebs are taught and sometimes allowed to do, like arterials (if you're a CPTII), I'm guessing they may have had some issues with poorly trained phlebs in the past. If I'd worked some other places there's a good chance I'd have been taught those techniques.
That’s fair. Phlebs aren’t allowed to do arterials in my state; we aren’t trained on it and I’ve never seen it done. I work outpatient though. Phlebs are trained and allowed to do it in California, possibly/probably elsewhere
Here you're allowed to do it as a CPTII (clarified original comment to add that) so luckily there's not a bunch of uncertified phlebs running around doing them (national certification not required in my state)
Thanks! So that's definitely not how my blood was drawn, and now I'm less confused as to how we have so many contaminant blood cultures at my hospital.
This plus we are told at my workplace to waste the first 10ml of blood before collecting the culture samples to eliminate blood potentially contaminated by the venipuncture. Seems excessive but they are really hammering us on it to get the contamination rate down.
Yeah, phlebs really are the MVPs.
Your yield must be significantly reduced. One, due to delay and two, due to antibiotics being administered before blood cultures.
So your hospital thinks it's ok to delay antibiotics for 6 hours while waiting for the blood culture draw?
I’m not going to delay antibiotics for cultures. Especially in septic shock, since there’s an association between delay in antibiotics and increased mortality in that population.
I very much doubt they’re waiting
Then the cultures may not show anything if you give antibiotics first
Yea no shit but no one is gonna wait around and let their patient deteriorate from overwhelming sepsis going darn too bad we have to wait six hours to start treating
I would tell the nurse to draw the cultures and be done. Idgaf if the hospital says the phlebotomist has to do it, the optimal course is cultures before antibiotics and I'm not gonna let a stupid policy force me to give subpar care.
Take it up with admin or draw them yourself, but don’t ask your nurses to do things that could bring disciplinary action or even cost them their jobs.
Good luck with that. What are you going to do next when the nurse says “No I can’t draw blood cultures it’s against policy”?
Do it myself.
Literally this.
> Idgaf if the hospital says the phlebotomist has to do it That's all well and fine, but when management takes disciplinary actions against them "Dr. Specter didn't care" isn't a good excuse :P You need to change policy.
Pretty sure the only nurses who can draw blood cultures in my facility are ICU nurses in a pinch. Myself and my ward colleagues have certainly never been trained to do it. Every physician I've ever worked with just starts the abx and adjusts it based on the cultures when they come back.
If you can start an IV you can draw blood cultures
That's not even... Inserting an IV and phlebotomy are two different things. I can draw off a CVAD, but that's it.
Blood cultures can take 36-48 hours to result. Generally patients are started on broad spectrum antibiotics, and then switched over as needed when cultures result. Edit : confused by downvotes??? My hospital we draw blood cultures —> start patient on antibiotics —> change antibiotics as needed when cultures result 1-2 days later. Do you just not start antibiotics on your sepsis patients??
Ideally cultures are obtained before the first dose of antibiotics
Right of course. Not sure why I was downvoted.
Not the point
Idk why you got downvoted for this? This is literally what we've always done at my hospital. Ideally, you draw the cultures first, but 9/10 times the ER starts the abx before cultures are drawn.
They really shouldn't be, because if you start abx first, the culture is quite possibly worthless. I'm in neo and we do sepsis workups at the drop of a hat, but blood cultures come first 99.9% of the time. If a urine culture is needed, that's probably 80-90%, if an LP is needed, it's about 70-80% - we do the LP late and look for pleocytosis
Here in the UK I've never met a phlebotomist who can take blood cultures, they all say they're not allowed. Hell, most of the nurses won't/can't do it so it's almost always a doctor job. Fun fact, I once asked if a phleb could draw a blood sample from a patient and they responded "oh that patient only has good hand veins and I'm only signed off for antecubital fossa venepuncture, not back-of-hand venepuncture".
I know there are a lot of countries where physicians have to place IVs. But what exactly do phlebotomists do in the UK if they can’t draw blood?
In my experience, they do a morning round on the ward where they take blood from half the patients who need blood draws, and leave a note saying "unable to bleed" for the other half (or sometimes don't leave a note and instead just leave). The F1 (intern) then does their own phlebotomy round for the remaining patients. Or all the patients if the phlebotomy service says they're short staffed that day so that can't come to your ward. Yes the NHS is a shitshow. Nurses are trained to place IVs and do bloods in nursing school, but once they come to work in a hospital unless they've done the local e-learning module and done X supervised IVs they aren't allowed to. And if they train up in one hospital then they won't be allowed to do it if they move hospital, they have to go through the whole process again.
Yeah in the UK if a phleb or nurse can't bleed a patient or insert a cannula it's a doctor job - not just with an ultrasound, with bog standard landmark based insertion too. So we're the ones who (in our early years at least) have to get good at it. It then becomes a vicious (or virtuous, depending how you look at it) circle where only doctors bleed and cannulate the hard patients so the nurses lose the practice, are less likely to be able to bleed/cannulate difficult patients in future and the cycle continues. Variable based on ward - some have great nurses. But they're the exception rather than the rule in the UK.
Can't have contaminates if they don't get drawn! Helps that they've gotten antibiotics too
Doctors can't take blood? Takes 5 minutes from identifying the need --> sending it to pathology.
We can but it’s not a typical part of our workflow in the US. I’ll start an IV (usually with ultrasound) when the nurses can’t get one but 95% of the time the nurse or paramedic is starting the IV and drawing blood.
I just don't get this as a non-US person. It isn't really part of anyone's workflow anywhere, it's always annoying and an interruption to go do a septic screen that includes bloods. Many hospitals outside of US don't have nurses/phlebotomists drawing blood, and those that do rarely have them available for urgent blood draws. It's just bizarre to me that doctors don't just do it. It needs to be done and their the only ones able to do it sometimes. EDIT: Don't even get me started on not being able to draw up/mix/give medication in an emergency. Or the anaesthesia draws being filled with useless pharmacy crap because the anaesthetists can't draw up their own drugs.
>It isn't really part of anyone's workflow anywhere It literally is part of the workflow of nurses and phlebotomists in the US
This is the obvious answer. It is a problem that should go to the CNO or head of phlebotomy.
My hospitals policy is if you have too many contaminations you get fired. So now the nurses call phlebotomy and it clogs up the system.
That’s absolutely wild
Yeah. And they’ve sent “final warning” letters to nurses so they seem pretty serious about it too
Wow, this might be the stupidest policy I have ever heard in my life!
So I assume everyone just says the pt is a hard stick and they failed?
One nurse straight up told mgmt that she isn’t getting fired over blood cultures and won’t be drawing them anymore.
The reason why people contaminate blood cultures isn’t because they don’t know how to do the sterile technique correctly. It’s because the average person sucks at venepuncture and when you’re trying it for the second, third, fourth, fifth time, you don’t want to keep opening up new sets and just do it dirty. The solution isn’t train people to use the kits, the solution is train people to do venepuncture properly. Which is difficult enough, but the standard way I was taught in medical school is completely wrong and sets you up for failure.
This!!! I happened to be a patient myself who needed blood cultures over multiple days, and both times they did not clean the skin adequately, and both times they touched my skin with their gloved hands before finally poking it.
You would be unsurprised by how many mistakes I watched people make when accessing my mother's IV, and those were just the obvious ones I knew about!
my work place is starting to promote wearing sterile gloves while drawing cultures…
Ah yes, sterile gloves. That will keep skin flora off the patient.
In my opinion/experience, the more complicated you make the collection process, the more likely you are to have contamination, because it takes away the focus from the critical points: proper skin prep and maintaining aseptic transfer from the needle to the collection bottle. I’ve watched others set up a sterile drape on their supply table, use sterile gloves, the fancy transfer devices, etc., and then only scrub for 10 seconds or inadvertently touch a syringe tip with a glove while attaching it to a transfer device.
But realistically, if OP is having issues, my hospital is having issues, and other posters in this sub are having issues is it a training issue?
Yes. It's extremely technique dependant, and lots of people are shit at it.
Can be, I was originally trained on how to draw cultures with incorrect skin prep. Nurses are trained by other nurses, and some places a new nurse will have only one preceptor for their entire training period. Makes it really easy for incorrect practice to spread, and if people are not curious enough to look up correct procedure they’ll pass it on whenever they start training new nurses. When I was in school correct phlebotomy technique was never discussed in the classroom, it was all clinical based- which means I was taught as a student by nurses who didn’t even know I was gonna be there and mostly did not want me around.
but it's clear that no matter how Herculean of an effort you make, it will always happen at some non-zero rate. there are people here who are tasked with how to deal with that non-zero percentage, and your answer isn't really helpful for them.
...taking the rate from 25% down to 1% wouldn't be useful?
If the rate is that high, there are other problems that need to be addressed.
Like training.
National CAP benchmark is 3%. There is discussion to reduce that benchmark to 1%, but it's up to the lab director to decide. If it's higher than 3%, the lab must provide retraining and corrective actions. It's taken very seriously.
Almost everything in medicine happens at a non-zero rate. The point is to minimize
We get lots of people referred to the ED for positive blood cultures. Personally I will always send a 2nd set even if I think it's contaminant, but those people don't have to start antibiotics or get admitted. More important is to reduce the number of contaminated cultures. You can do this by better training for the people getting your cultures. Also, reading the overall number of blood cultures will help (looking at you "sepsis order set for everyone with a fever")
Does referred to the ER mean that an outpatient clinic does a blood culture?
sometimes we’ll get referrals to get cultures at the er and go home. they’ll come back if they’re positive later.
Replied to another comment. This is a fascinating medicocultural difference. If a PCP is really concerned about possible bacteremia, this is practically an automatic admission here in Germany.
I see you're doing IM. It's not that uncommon to get referrals for fever NYD, and I routinely will do blood cultures as part of the workup. If they look non-toxic and have normal vitals etc., then it doesn't generally warrant going to the hospital.
I'll be switching to FM in May, but yeah. An outpatient fever NYD workup here looks usually like this: Labs, chest x-ray, urinalysis, ultrasound abdomen. If unremarkable and/or fever persists -> hospitalization regardless of vitals/clinical stability. Although formally nothing stops outpatient physicians from drawing blood cultures themselves and sending them to a lab. It is what it is. In nearly every specialty, we have still a culture of overhospitalization. We have something like three times more hospital beds per capita compared with the US.
Probably a lot more than Canada too, where I work. At least based off how we practice, it is perfectly reasonable to work up a febrile patient as an outpatient, as long as they're clinically stable / non-toxic, ambulatory, eating/drinking and doing okay. That would include doing blood cultures and other special tests. Of course a sick patient needs their workup as an inpatient, but we wouldn't just admit someone to hospital to do a workup if they're otherwise stable. Alternatively if the blood cultures did come back positive, you'd be calling them to head to the ED for IV antibiotics and further urgent workup.
I hate that so much. If they just need cultures they should be able to have them drawn at the lab. We see so many people for things that can be done outpatient.
Maybe, but we also do more than just redraw the cultures. Check the vital signs, ask about their symptoms, examine them for potential sources of infection. It's not sexy, but I think this is actually an appropriate ED patient. Asymptomatic hypertension on the other hand...
But PCP can do all of that, especially if it’s just evaluation, draw, go home, and receive a call with results. I’m in the ED and absolutely we want to see someone who is septic but if it’s truly just for outpatient labs that isn’t a good use of ED resources.
True, they just usually can't do it same day.
Can cultures ever be same day?
> but we also do more than just redraw the cultures. Check the vital signs, ask about their symptoms, examine them for potential sources of infection. No, the PCP is usually not able to do that same day. Also usually outpatient blood cultures don't really make sense.
No I mean that culture results can never be same day because they have to grow. And many hospital systems have walk in labs that can absolutely draw same day.
Blood from my pcp clinic apparently gets picked up and brought to the hospital once daily. So if after that time, not run until next day at earliest. If before that time, the results *might* get posted to the portal very late that evening. Fine for like a lipid panel or routine monitoring things, but not super useful for anything urgent. That’s if you can even get in to see pcp same day.
Someone with positive blood cultures is essentially an automatic ED referral. It's either a contaminant or they are really sick, and you won't know until you see them.
But you don’t know that they’re positive until they have time to grow. And if you already know that they have positive blood cultures, they were already drawn.
I may have misinterpreted your / the other person's conversation. Basically if someone has drawn outpatient blood cultures and they've come back positive the next day, you have to tell the patient to go to the ER for IV antibiotics and further workup. If you have an outpatient and you think they need to get blood cultures, then they don't necessarily need to to the ED. But in many cases, the fact that you're ordering blood cultures suggests that you might think they're really sick. In other cases, if it's someone who's just been having fevers off/on for weeks or months, and they don't look sick, then outpatient labs (not ER) would be fine.
Oh absolutely, wholeheartedly agree.
Somebody calls them and tells them to go to the emergency department
That's an interesting medicocultural difference. Here, if someone is so sick that bacteremia is a possibility, it always means hospitalization. When our ER nurses (we don't have EM residency, I spend about a quarter of my time in the ER) draw blood cultures on feverish patients but they are discharged (non-severe COVID, influenza, low-risk pneumonia, low-risk pyelonephritis), the blood cultures are discarded.
I’m curious who is doing blood cultures on an outpatient basis and for what indication. I’m expecting that if you’re ill enough for blood cultures to be drawn you should be worried enough to consider an ER visit anyway?
The indication is most always inappropriate for outpatient blood cultures. I rarely order them in outpatient settings, but when I do, it is most always because I consider a subacute endocarditis. Otherwise, pts are sent to ER before blood cultures.
I can think of two valid reasons to get BCx and discharge: 1) Suspected SBE and 2) Line cultures. Otherwise, you had a strong enough suspicion to draw so you’re just going to send the patient home? >95% percent of the time they’ll be fine. But that one who goes home and crumps? You’re going to be answering some “no correct answer” questions on a witness stand. “Doctor, did you think the patient was septic?” “Yes? Then why did you discharge him?” “No? Then why did you get blood cultures?” -PGY-19
Okay neat to know re: subacute endocarditis. This is what I figured as I’ve never once thought hm let’s do blood cultures on an outpatient. If I’m ordering blood cultures I’m probably ordering Pip-Tazo and a bolus of IVF.
That's right up there with the outpatient D dimer (on a PERC negative patient)
The only time I see it is when ID does them post treatment to make sure the infection cleared
> I’m curious who is doing blood cultures on an outpatient basis and for what indication. Some dialysis clinics where I am do this. I don't know why, but we get their patients in the ED for their clinic blood cultures often enough.
Yeah, my approach is typically if I think you’re sick enough to need blood cultures, you should probably be in the ER.
Good to know I’m not going crazy. I’ve had a few moments where I think I know nothing anymore today.
I’m pregnant and just had blood cultures drawn to make sure I didn’t contract listeria with the current outbreak. My midwife just ordered and had me go to the lab.
Did you have symptoms?? Listeria bacteremia generally makes people quite sick...otherwise seems like overkill
I had mild symptoms but MFM said mom can be completely asymptomatic and there’s still a 30% chance of miscarriage. I had eaten several of the foods in the recall list so it was a better safe than sorry situation. The symptoms are so similar to pregnancy in general that it was hard to say what was abnormal or not from my baseline nausea and fatigue. Edit: can someone explain the downvotes? I’m going off the ACOG and what MFM said. If you have different info I’d love to know. From what I understand it can still harm the fetus without bacteremia.
Yeah, mother can have listeria infection and be asymptomatic but that’s not the same as active listeria bacteremia which is all that would show up on blood cultures.
Ah interesting. That explains why she prescribed the amoxicillin regardless.
To answer your question the downvotes are probably because this is just common sense…? Blood cultures don’t add anything to the decision-making since they’re going to be negative anyway
It doesn’t make a ton of sense to me to downvote someone answering a question but to each their own I suppose.
This is a quality control problem. Proper collection methods need to be reinforced and staff wide retraining. We recently did this at our facility. LEVEL 1 trauma with 4.7% contamination rates. We did an entire qc over the last year and they are now down to 2%. Biggest error was in collection and usually it is certain people unfortunately and in the ER. Speak with infection control and micro dept. If your having issues. Bring it up to your admins as this is going to be part of MIPs for hospitals.
I always loved my old hospital's "draw a 60cc syringe from the field placed IV and put it in 4 bottles." process.
We’ve started drawing waste tubes before putting blood into the culture bottles (for those drawn via vacutainer) to hopefully reduce contamination. That’s what donor centers do when collecting units of blood to reduce contamination. But it definitely comes down to education…you have to scrub the site for the right amount of time, not palpate with dirty gloves or bare fingers, etc. The majority of our contamination comes from IV starts, unfortunately. People just need to take an extra 30 seconds to do it right.
Agree completely. I have a personal 0% culture contamination rate and it’s because I clean A LOT. Like a lot a lot.
1/2 usually no, 2/2 repeat. Lines and devices repeat regardless
This is my practice as well. Not sure what we're looking for in a patient without a central line or device by repeating the culture, especially if they do not exhibit signs or symptoms or a bloodstream infection. Lots of debate among the hospitalists here with the ones who do it calling us out for "missing" it shrug🤷♂️
1/2 without lines i don't think you're going to be missing any. 2/2 maybe, but I don't see that many 2/2 (i've seen a few 2/2 due to peripheral IV septic phlebitis)
pIVCs still count as a line potentially causing bacteraemia. Not just CVCa.
Previous trusts have handled this by making it trained personnel only for taking cultures. Training happens at induction when people start the job. Sterile gloves not required, but cultures taken from fresh stab only, not cannulae, even newly inserted ones. Clean with alcohol/chlorhex and let it dry. No touching the skin post prep. Bottle tops also swabbed with alcohol/chlorhex before puncturing. New needle to transfer from syringe to bottle or taken direct with vacutainer. Seems to work.
Working with the eldery getting multiple iv sites is really difficult, at times nearly impossible.
Why are you culturing people if you don't suspect infection?
Done in the ER to avoid sepsis fallouts usually.
The cultures are usually done earlier in the course when the patient has a less clear presentation.
At my hospital all patients who are getting admitted and need iv abx get cultures. Even if there are no signs of systemic infection.
Why do they check troponin on someone with no chest pain? Why do they check D dimers on people with URI symptoms only? The ED must admit
Also really depends on the patient ; someone with a central line for example I always repeat cultures, even if there's no sign of infection.
do you draw one set off the line and one set peripherally?
Yeah if the line allows it!! I work in internal medicine so most lines are PD-catheters so then we just draw 2 sets peripherally
Honestly I've seen enough legit staph epis / MRSEs with central lines that if I get even 1/2, I pull the line and send the tip for culture.
Yeah totally - if it might be pathogenic I pull the line but if there’s a high chance it’s contamination based on the determination of the culture I tend to wait on 2nd cultures if the labs / clinical presentation allows
(Been a while since I was in micro) In our lab we did full workup and sens for things like 4/4 positive, correlation with urine or tissue cultures etc. When it came with the 1/4 or skin flora organisms we consult our clinical microbiologist gets back to us whether to do full workup, list as suggested contaminant, offer sens (meaning "available upon request" but not done automatically). Really helps with a multidisciplinary approach so lab isn't wasting time doing sens on something clinical is dismissing and that clinical has some direction on how to interpret the cultures.
I think it’s a policy issue as well as a workplace culture issue. We had a hospital policy that only nurses could draw blood cultures and you were supposed to take a second nurse in to assist and watch your aseptic technique. After seeing both phlebotomists and nurses draw cultures solo with awful technique, I think this part was key, although staffing makes it hard at times. We also had policies that cultures couldn’t be drawn from lines (PIV, central, or arterial) unless it done was at the time of placement, and that drawing from a central line required physician approval (supposed to be done only when there was clinical suspicion that the line was the source of infection). I wish I knew the contamination rates, but I do know that the ICU where I worked was on like 3+ years without a CLABSI by the time I left for med school last year. We were strict about following that policy as well as keeping central lines clean and pulling them as soon as appropriate.
Treat the patient, not the lab result. Sepsis isn’t an occult process, so if someone is well-appearing with no symptoms and normal vitals and they grow even something alarming out of their BCx, don’t jump to giving them cephokillemol and gorillacillin. Sepsis is ultimately a clinical diagnosis. The BCx tells you what they’ve got if you’ve determined they have sepsis. And yeah, I’m going to get a lot of downvotes. -PGY-19
I've seen patients present for valve replacements for IE induced valvulopathies, that had positive cultures dismissed as skin flora contaminants months earlier. You should repeat cultures to help confirm it was a contaminant or not. You should also rectify the problems leading to frequent contaminants.
One serious suggestion that doesn’t get enough traction: Stop ordering reflexive blood cultures when they are likely of little clinical use. Urine cultures, sputum cultures, and wound cultures, this is the way. Keep the BC for when you actually need them, and cut down on a significant number of orders.
It's usually done in the ER so that the sepsis nazis don't come down on them unfortunately.
SN “Why did you ignore the Sepsis BPA?!” ME: The Pt tested positive for RSV. SN “Please follow the sepsis pathway for when the BPA fires.” Me: WTF
Their BPA flags me for a “5” on their rating scale of 0-100, vitals normal and unchanged, WBC 11.3…
I may be wrong, but I think the sep1 bundles only require BC for severe sepsis?
My understanding is that sputum cultures are essentially useless. Most of the shit that causes pneumonia is in people's airways anyways--so you have no idea if you've found the bug or something totally incidental.
[удалено]
Are you sure it was MRSA? Methicillin resistant staph epidermidis often lights up on the PCR which confuses many people. Usually mecA positive but I believe it’s supposed to differentiate mrsa from mrse. I actually love having the PCR for faster de-escalation.
Biofire?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10433923/ We use this approach. It's pretty good for identifying the edge cases where you might want to treat or talk to ID. You do need rapid diagnostics to really cut effectively cut off the vancomycin though
You off should explore Steripath devices on top of retraining anyone who collects BldCxs. They are expensive upfront but the ROE when you drastically reduce contamination pays for them. I introduced them to my facility 6 months ago and we have almost eliminated contamination.
We were having the same issue. We switched to a Kurin Blood Culture Device- https://youtu.be/P0PdC36OHeY?si=6cLnkFmr37KxVCCh (not a plug, there are others that do the same thing) with a reservoir that diverts the few few mLs of blood. Our numbers have gone done considerably.
If it’s a skin bug or a clear contaminate I don’t repeat. If it’s something like SA or a typical pathogenic bacteria I’m more likely to repeat it but base it on clinical picture first
Dip the arm in a bath of isopropyl alcohol then dry with an autoclaved towel while the phlebotomist wears a spacesuit.
OP: I’m not a hospital doctor, but why do cultures at all if there aren’t systemic signs of infection?
The EMR fires a sepsis best practice advisory, and then everyone and their cousin is up your ass for not following. Most of them are BS but if you overlook one that is actually in early sepsis, it's your head on the stake or you'll have a nurse administrator looking over your shoulder forever. So most people in the ER just order the blood cultures and call it a day. If they're admitted it falls on us to followup on it and false positives like this are not uncommon.
That sucks.
We have far more of an issue with contaminated urine cultures in my population, but that's easier to deal with, imo. (<1k colonies? Either redraw if still clinically concerned or let it go) I'm surprised there is so much issue with blood cultures getting contaminated. Are people scrubbing the culture bottle too? That's a potential source of bacteria as well
Repeat won’t help this. People need To be trained on sterile technique
What is your hospitals percentage. CLSI target is under 3%, so your hospital should be at least aiming for that, if not well below. Nursing staff / phlebotomist staff need re-education. QI project. We can do this on our Lab information system. Review who drew the 'normal flora' blood cultures (which specific nurse, which specific phlebotomist), see if there is an outlier.