blood culture utilization metrics

dcasip.medicine.duke.edu

Blood Culture Utilization MetricsRebekah Moehring, MD, MPHBobby Warren, MPS

http://dason.medicine.duke.edu/

Current practice: Question 1 Does your hospital routinely review or track Blood culture utilization

data?

Metrics of volume Who uses and reviews the data? Automated or manual tracking?

2

Current practice: Question 2 Does your hospital routinely review or track Blood culture

contamination data?

Metrics of skin contaminant pathogens Who uses and reviews the data? Automated or manual tracking?

3

What metrics and Best Practice standards are there? “I’m not aware of benchmarking recommendations for blood culture utilization /

denominator and imagine it would be hard to recommend or apply given the wide variation in bacteremia risk between clinical syndrome, populations, units, and institutions.”

CLSI M47 (5/2007, update pending) <3% BCx contamination rate – CAP Survey and IDSA GL for the Micro Lab Cumulative Techniques and Procedures in Clinical Microbiology (Cumitech)

from ASM (2005) Purpose: “to provide consensus recommendations regarding the judicious use of clinical

microbiology and immunology laboratories and their role in patient care.”

Others?

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CLSI M47-A “Example QA Indicators” 10.1.1 Patient Evaluation “…every organization [should develop] guidelines to identify appropriate patients

for blood culture…” 10.1.2 Test Selection and Ordering Example QA Indicator 1: Proportion of patients with Blood Cultures who have the

recommended number of blood culture sets submitted. Collection of 2 or 3 blood culture sets is recommended per episode.

Example QA Indicator 2: Proportion of patients with more than the recommended number of blood cultures submitted. Collection of 2 or 3 blood culture sets is recommended per episode for the initial patient

evaluation. Collection of another 2 or 3 blood culture sets may be indicated after 48-72h if the initial

cultures were noninformative. “Surveillance” cultures are not recommended.

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CLSI M47-A. May 2007

CLSI M47-A “Example QA Indicators” 10.1.3 Sample Collection Example QA Indicator 1: Blood culture contamination rate.

Goal is less than 3% whether analyzed overall or stratified by location, phlebotomist, etc.

Example QA Indicator 2: Proportion of blood culture bottles inoculated with more or less than the recommended volume of blood. Adults = 10mL recommended.

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IDSA Guidelines on Use of the Microbiology Lab: BSI and Cardiovascular system Volume of blood collected, not timing, is most critical. Disinfect the venipuncture site with chlorhexidine or 2% iodine tincture in adults and

children >2 months old (chlorhexidine NOT recommended for children <2 months old), using povidone-iodine and alcohol).

Draw blood for culture before initiating antimicrobial therapy. Catheter-drawn blood cultures have a higher risk of contamination (false positives). Do not submit catheter tips for culture without an accompanying blood culture

obtained by venipuncture. Never refrigerate blood prior to incubation. Use a 2- to 3-bottle blood culture set for adults, at least 1 aerobic and 1 anaerobic;

use 1–2 aerobic bottles for children and consider aerobic and anaerobic when clinically relevant.

Streptococcus pneumoniae and other gram-positive organisms and facultatively anaerobic organisms may grow best in the anaerobic bottle (faster time to detection).

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Miller et al. CID 2018:67

Cumitech: Blood Cx Quality Assurance

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Baron, E. J., M. P. Weinstein, W. M. Dunne, Jr., P. Yagupsky, D. F. Welch, and D. M. Wilson.2005. Cumitech 1C, Blood Cultures IV. Coordinating ed., E. J. Baron. ASM Press, Washington, D.C.

Contamination is “a single culture positive for coagulase-negative staphylococci or coryneform gram-positive rods or Micrococcus or Propionibacterium, or a single bottle with Bacillus species, not anthracis.” Nat’l standard: 2-3%

Single BCx: ~3.4% for “top performing” hospitals

Cumitech: Blood Cx Quality Assurance

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Percent positive: 7.7-8.2% (sample of 650 labs). Range cutoffs suggested for investigation of

BCx appropriateness: 5% and 15%.

BCx/1000ptd: hospital-level sample (1999) ranged between 103-188. “A number between these two extremes is

recommended.”

Baron, E. J., M. P. Weinstein, W. M. Dunne, Jr., P. Yagupsky, D. F. Welch, and D. M. Wilson.2005. Cumitech 1C, Blood Cultures IV. Coordinating ed., E. J. Baron. ASM Press, Washington, D.C.

Presenter

Presentation Notes

So… measurement alone doesn’t change anything. What do you do if you think you have a problem?

Pediatric ICU: BCx guideline

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Woods-Hill. JAMA Pediatrics 2017;171(2):157-164.

Hopkins PICU Before/After Study

Goals: Reduce BCx Use and Reduce BCx draws off of catheters

Intervention: 1. Fever/sepsis screening

checklist.2. BCx decision algorithm

Result: 16.1 vs 8.8 cultures per 100 ptd(46% reduction)

Diagnostic Stewardship: We need clinical guidance…

<5% (Very Low) <10% (Low) 10% - 20% (Low-Mod) 20% - 50% (Moderate) >50% (High)

Fever ≤48hrs of surgery

Uncomplicated cellulitis

Cellulitis in pts w severe comorbidities

CholangitisPyogenic liver

abscess

Discitis / VOEpidural abscess

Isolated fever on non-ICU ward Lower UTI VAP Acute pyelo Acute native septic

joints

CAP / HCAP Severe CAP Meningitis

Non-vascular shunt infections VP shunt infections

Severe sepsis Septic shock

Rigors in a febrile patient Catheter related BSI

Fabre V, et al. Clin Inf Dis. 2020;71(5):1339-7

Pretest probability of Bacteremia in Common Clinical Scenarios

Presenter

Presentation Notes

Possible poll Q opportunity

Diagnostic Stewardship: We need clinical guidance…

Fabre V, et al. Clin Inf Dis. 2020;71(5):1339-7

Presenter

Presentation Notes

Figure 1. Algorithm for bacterial blood cultures recommendations in nonneutropenic patients. The algorithm is not a substitute for clinical judgment. *Blood culture (BCx) required by US Centers for Medicare and Medicaid Services severe sepsis criteria of the Severe Sepsis and Septic Shock Early Management Bundle. †BCx positive for Candida species require routine follow-up blood culture (FUBCx). ‡Septic thrombophlebitis, infected endovascular thrombi, implantable cardioverter defibrillator (ICD)/pacemaker lead infections, intravascular catheter infections, and vascular graft infections. §Consider > 2 sets for suspected endocarditis. ||Patients at risk of endovascular infection: ICD/pacemaker, vascular graft, prosthetic valves and prosthetic material used for cardiac valve repair, history of infective endocarditis, valvulopathy in heart transplant recipient, unrepaired congenital heart disease, repaired congenital heart disease with residual shunt or valvular regurgitation, or within the first 6 months postrepair. ¶Before ordering BCx, assess the patient’s clinical history and perform a physical examination to identify infectious and noninfectious sources for the isolated fever episode and review the potential benefit added by BCx. £Prosthesis: joint or intravascular prosthesis. **Routine additional FUBCx for a single BCx with skin flora (eg, coagulase-negative staphylococci) in an immunocompetent patient are not necessary unless bacteremia is suspected or a prosthesis is present. ††Cellulitis in patients with comorbidities: immunocompromised hosts or those at risk of poor outcomes from sequelae from missed Staphylococcus aureus bacteremia. Abbreviations: BCx, blood culture; CAP, community-acquired pneumonia; HCAP, healthcare-associated pneumonia; PSI, Pneumonia Severity Index; S. aureus, Staphylococcus aureus; S. lugdunensis, Staphylococcus lugdunensis; UTI, urinary tract infection; VAP, ventilator-associated pneumonia; VO, vertebral osteomyelitis.

Diagnostic Stewardship: We need clinical guidance… DISTRIBUTE study: Reduced BCx rates decreased from 27.7 to 22.8 BCx / 100 pt days in MICU Reduced 10.9 to 7.7 BCx / 100 pt days in the 5 medicine units No change in inappropriate BCx BCx positivity went up from 8 to 11%, P<0.001 in MICU Solitary BCx decreased by 21% Compliance with BCx component of the SEP-1 measure was similar on the

med units and actually improved in the MICU (not significant)

Fabre V, et al. J Clin Micro. Oct 2020

Conclusion: These results suggest that we can optimize the use of blood cultures with education and practice guidance without affecting

sepsis quality metrics

dcasip.medicine.duke.edu

Example Data: Blood Culture Utilization at Six Southeastern United States Hospitals

Presenter

Presentation Notes

Hey everyone, I’m Bobby Warren, the lab director for the center and I’m going to walk us through some recent study data from a project titled Blood Culture Utilization at Six Southeastern United States Hospitals.

http://dason.medicine.duke.edu/

Overview Population: Six southeastern United States hospitals 1 academic (Hospital A) and 5 community hospitals (B-F) May 2019 to April 2020 Inpatient and ED blood cultures

Primary Outcome: Hospital-level blood culture utilization rate* Secondary Outcomes (based on observations from DETOURS

Trial): Day of the week – targeted AS opportunities? Seasonality – links with influenza season? Other available patient- or practice-level factors (e.g. age, unit)

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Presenter

Presentation Notes

This study analyzed blood culture data from May 2019 to April 2020 at 6 southeastern US hospitals, 1 major academic center, hospital A, and 5 community hospitals which are B through F. Blood culture data included data from inpatient stays and the ED. Our primary outcome was hospital level blood culture utilization rate, which we will discuss shortly. Other outcomes included day of the week and seasonality analyses.

Definitions Patient days – A count of the number of days for all patients in an

inpatient care location during the study time period. Inpatient location – Locations defined as inpatient by the CDC in

the instructions for mapping patient care locations excluding procedural, operating and perioperative, behavioral, rehabilitation, psychiatric units. Inpatient Admission – A distinct visit in a study hospital of at least

one calendar day on an inpatient unit.

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Presenter

Presentation Notes

Quickly, we defined patient days as A count of the number of days for all patients in an inpatient care location during the study time period. Inpatient locations by the CDC in the instructions for mapping patient care locations excluding cardiac catherterization, cesarean section, operating, interventional radiology, behavioral, rehabilitation, psychiatric, recovery, and ventilator-dependent rooms/units. Inpatient admissions were distinct inpatient visits in a study hospital of at least one calendarday. If admission began in the ED, patient must subsequently have been admitted to an inpatient unit.

Definitions cont. Blood Culture – Unique blood culture set defined by a distinct

laboratory accession number. Paired culture – Blood culture sets taken within 1-hour of another

blood culture set, based on date/time of collection. Single culture – Blood culture set taken without another blood

culture set within 12 hours, based on date/time of collection

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Presenter

Presentation Notes

Blood cultures were defined by a distinct laboratory accession number. Paired cultures were blood cultures taken within 1-hour of each other. Positive blood cultures were sets processed positive for an organism considered to be a pathogen or positive for a common skin commensal, as defined by the NHSN, in 1 of 1 (or more) blood cultures collected on separate occasions. Blood culture contamination event occurred when one of two (or more) blood cultures collected in the same calendar day were positive for a common skin commensal organism, as defined by the NHSN, and is not identified from a second or more blood culture on a separate occasion.

Definitions cont. Positive blood culture – Blood culture sets processed positive for an

organism considered to be a pathogen or positive for a common skin commensal*, in 1 of 1 (or more) blood cultures collected on separate date/time occasions. Blood culture contamination event – One of two, three, or more, blood

cultures collected in the same calendar day positive for a common skin commensal*, and not identified from a second or more blood culture on separate date/time occasion.

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*Centers for Disease Control and Prevention, NHSN Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-central Line Associated Bloodstream Infection). Common Commensal List. January 2021. https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

Presenter

Presentation Notes

Blood cultures were defined by a distinct laboratory accession number. Paired cultures were blood cultures taken within 1-hour of each other. Positive blood cultures were sets processed positive for an organism considered to be a pathogen or positive for a common skin commensal, as defined by the NHSN, in 1 of 1 (or more) blood cultures collected on separate occasions. Blood culture contamination event occurred when one of two (or more) blood cultures collected in the same calendar day were positive for a common skin commensal organism, as defined by the NHSN, and is not identified from a second or more blood culture on a separate occasion.

https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

Blood Culture Utilization Rate (BCUR) Original metric: Blood cultures per 1,000 patient days Inflated when more paired cultures were taken -- practice that should be

encouraged! Sensitivity analysis: Minimal difference in clinical value within 12-hour

window

New metric: Blood culture events per 1,000 patient days Blood culture event: An initial blood culture and all subsequent drawn within

12 hours within an inpatient encounter

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Presenter

Presentation Notes

Previous studies have measured BCUR as the total number of blood cultures per 1,000 patient days, however, this definition causes inflation of the BCUR when more paired cultures are taken. *Need a statement about why paired cultures are better clinically*. Also, there is minimal difference in clinical value within 12-hour of a culture being taken. We modified the definition to blood culture events over 1,000 patient days and defined a blood culture event as an initial blood culture and all subsequent drawn within 12 hours within a hospital encounter.

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Age and Single Cultures

Pediatrics have different culturing practice than Adults.Only 1 hospital had peds.So…We excluded pediatrics from hospital-level comparisons.

IDSA Guidelines for Micro Lab Use CID 2018

Presenter

Presentation Notes

Originally, our analysis include pediatrics and neonatal units, however, we noticed the majority of these cultures were not paired unlike adult cultures as can be seen here with Single cultures in red and paired cultures in blue with a line between the two groups. As a result, we removed all patients 17 or younger from our analyses which included 11% of total blood culture events ranging from 0-19% from each study hospital

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Overall BCUR

NOTE: BCUR included cultures collected in the emergency department (ED) and inpatient areas divided by inpatient days.

Excluding pediatricsPooled Rate

Blood Culture Events Per 1,000 Patient Days 92.4

Blood Cultures Per 1,000 Patient Days 196.0

Presenter

Presentation Notes

Overall, the BCUR with the older definition was 196 blood cultures per 1,000 patient days and the BCUR with our definition was 92.4 blood culture events per 1,000 patient days, a bit less than half.

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Overall Overalln (%)

N=52550Median Blood Culture Events Per Admission (Range) 1 (1-31)BCE with only a single culture 3594 (7)BCE that began in ED 28985 (55)BCE in first 3 HD 40400 (77)BCE after first 3 HD 11585 (22)

Overalln (%)

N=111520

Percent Positive Blood Cultures 8583 (7.7)Percent Contaminated Blood Cultures 2297 (2.1)Number of Initial Blood Cultures Collected after Initiation of Antibiotics 6596 (5.9)Number of Follow up Blood Cultures Collected after Initiation of Antibiotics 33628 (30.2)

Overall Blood Culture Event Data

Overall Blood Culture Data

Presenter

Presentation Notes

The median number of blood culture events was 1, 7% of events were a single culture, 55% of events began in the ED and 77% began in the first 3 hospital days. 7.7% of raw blood cultures were likely positive, 2.1% were likely contaminated, and 5.9% of cultures were order after the initiation of antibiotics. Comparison of % contaminant to national “standard” of 2-3% -- not too bad. Comparison of % positive to Cumitech estimate of ~8% -- pretty close. Fabre study “improved” the % positive from 8 to 11%. BCE with single culture – compared to “top performing hospitals” per Cumitech of 3.4% -- as a group we were higher, but not as bad as Cumitech’s lower performing sites (up to 40% whoo.)

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Proportion of Blood Culture Events per Hospital Day

Skewed distribution mirrors LOS.

Presenter

Presentation Notes

The proportion of blood culture events per hospital day was front loaded, as discussed on the previous slide, with the majority of events occurring on day 1 with a sharp drop on day 2.

Hospital-Level Blood Culture Utilization Rate

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Hospital A B C D E F Overall

Blood Cultures Per 1,000 Patient Days 168.3 206.3 533.3 261.6 126.5 248.5 196.0

Blood Culture Events Per 1,000 Patient Days 84.9 97.7 154.8 123.5 63.5 124.2 92.4

0

100

200

300

400

500

600

A B C D E F Overall

BCU

R

Hospital

BCUR by Hospital and Numerator

Cultures Per 1,000 Patient Days Events Per 1,000 Patient Days

Presenter

Presentation Notes

At the hospital level, BCUR with cultures varied between hospitals with the lowest being 126.5 and the highest at 533.3. Similar, yet less extreme, variation was seen with our definition of events with the lowest being 63.5, the same hospital as before, and the highest at 154.8, which is also the same as before.

Hospital-Level Blood Culture Event Data

HospitalA

n (%)N=20883

Bn (%)

N=3592

Cn (%)

N=3954

Dn (%)

N=6307

En (%)

N=8606

Fn (%)

N=9208

Overalln (%)

N=52550

Median Blood Culture Events Per Admission (Range) 1 (1-31) 1 (1-5) 1 (1-5) 1 (1-6) 1 (1-11) 1 (1-6) 1 (1-31)

Events with ≥ 1 Paired Culture 16162 (78) 2887 (80) 3887 (98) 5924 (94) 7974 (93) 7848 (85) 44682 (85)Events with only a Single culture 2489 (12) 220 (6) 61 (2) 231 (4) 275 (3) 318 (3) 3594 (7)Events that Began in ED 7952 (38) 2637 (73) 2434 (62) 4702 (75) 4056 (47) 7204 (78) 28985 (55)BCE in First 3 HD 12950 (62) 3344 (93) 3647 (92) 5622 (89) 6401 (74) 8436 (82) 40400 (77)BCE after First 3 HD 7563 (36) 241 (7) 290 (7) 649 (10) 2099 (24) 753 (8) 11585 (22)

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Presenter

Presentation Notes

The median BC events per admission was similar between hospitals, however, the upper end of the range was higher at hospital A, the large academic center, at 31 with the next highest at 11. However, the amount of single and paired cultures varied greatly. Notably, 98 percent of all BC events included a paired culture at hospital C potentially contributing to their high BCUR with cultures as the numerator. Other hospitals ranged between 78 and 94% paired. The amount of events with a single culture also differed among hospitals. Hospital A had the highest of 12% with the next highest being 6%. The majority of blood culture events began in the ED in all but hospitals A and E. The majority of BC events occurred in the first 3 hospital days at all hospitals.

Hospital-Level Blood Culture Data

HospitalA

n (%)N=41365

Bn (%)

N=7585

Cn (%)

N=13625

Dn (%)

N=13356

En (%)

N=17162

Fn (%)

N=18427

Overalln (%)

N=111520

Percent Positive Blood Cultures 3481 (8.4) 343 (4.5) 954 (7.0) 1203 (9.0) 1537 (9.0) 1065 (5.8) 8583 (7.7)Percent Contaminated Blood Cultures 626 (1.5) 145 (1.9) 418 (3.1) 425 (3.2) 216 (1.3) 467 (2.5) 2297 (2.1)Number of Initial Blood Cultures Collected after Initiation of Antibiotics 2476 (5.9) 403 (5.3) 480 (3.5) 756 (5.7) 1454 (8.5) 1027 (5.6) 6596 (5.9)Number of Follow up Blood Cultures Collected after Initiation of Antibiotics 16931 (40.7) 1347 (17.8) 3103 (22.8) 2361 (17.7) 5541 (32.3) 4345 (23.6) 33628 (30.2)

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Presenter

Presentation Notes

At the culture level, positivity rates ranged from 4.5 to 9.0%, contaminated cultures ranged from 1.3 to 3.2%. The proportion of cultures ordered after the initiation of antibiotics was similar between hospitals except for a higher value at hospital E of 8.5%. Follow-up blood cultures varied greatly from 17.8 to 40.7%.

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Notable Trend?

Higher BCx Contamination rate in hospitals with higher BCURHigher BCx Contamination rate in hospitals with higher % drawn in ED

Target = ED?

Hospital A B C D E F Overall

Blood Cultures Per 1,000 Patient Days 168.3 206.3 533.3 261.6 126.5 248.5 196.0

Blood Culture Events Per 1,000 Patient Days 84.9 97.7 154.8 123.5 63.5 124.2 92.4

An (%)

N=20883

Bn (%)

N=3592

Cn (%)

N=3954

Dn (%)

N=6307

En (%)

N=8606

Fn (%)

N=9208

Overalln (%)

N=52550

ED Blood Culture Events 7952 (38) 2637 (73) 2434 (62) 4702 (75) 4056 (47) 7204 (78) 28985 (55)

An (%)

N=41365

Bn (%)

N=7585

Cn (%)

N=13625

Dn (%)

N=13356

En (%)

N=17162

Fn (%)

N=18427

Overalln (%)

N=111520

Percent Positive Blood Cultures 3481 (8.4) 343 (4.5) 954 (7.0) 1203 (9.0) 1537 (9.0) 1065 (5.8) 8583 (7.7)Percent Contaminated Blood Cultures 626 (1.5) 145 (1.9) 418 (3.1) 425 (3.2) 216 (1.3) 467 (2.5) 2297 (2.1)

Presenter

Presentation Notes

With the previous 3 tables in mind, we noticed that hospitals with higher contamination rates also had higher BCUR with both methods and higher proportions of cultures drawn in the ED.

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Condensed Unit-level BCUR

HospitalA B C D E F Overall

Intensive Care 113.4 45.3 NA 50.9 69.1 80.8 95.6

ONC/Transplant 80.4 30.5 NA NA 57 NA 69.2

Medical/Surgical 35 22.4 58.7 32.2 30.7 27.8 33.2

Mixed Acuity NA 21.1 34.1 24.4 19.9 11.4 21.8

Labor and Delivery 5.7 14.2 69 4.3 1.4 3.2 7.3

0

20

40

60

80

100

120

Intensive Care ONC/Transplant Medical/Surgical Mixed Acuity Labor and Delivery

BCU

R (E

vent

s)

NHSN Unit Type

BCUR by NHSN Unit Type and Hospital

A B C D E F Overall

Presenter

Presentation Notes

Compare to fabre study estimates (have to multiple x 10 to get per 1000 ptd and compare with ours) Reduced from 27.7 to 22.8 BCx / 100 pt days in MICU Reduced from 10.9 to 7.7 BCx / 100 pt days in medicine wards

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Contamination Rate by Condensed Unit Type

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

Medical/Surgical Labor and Delivery Intensive Care ONC/Transplant Mixed Acuity ED

Percent Contaminated Blood Cultures by Condensed Unit

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Proportion of Contaminated Cultures by Condensed Unit

Medical/Surgical10%

Labor and Delivery0%

Intensive Care9%

ONC/Transplant3%

Mixed Acuity1%

ED77%

Proportion of Contaminated Cultures by Condensed Unit

Medical/Surgical Labor and Delivery Intensive Care ONC/Transplant Mixed Acuity ED

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Single Culture Events by Inpatient UnitExcludes Pediatrics

Single culture events highest in Heme/ONC units

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Adult Mixed Acuity U

nit

Adult Step Dow

n Unit (post-critical care)

Emergency D

epartment

Labor and Delivery W

ard

Labor, Delivery, R

ecovery, Postpartum Suite (LD

RP)

Medical C

ardiac Critical C

are

Medical C

ritical Care

Medical W

ard

Medical/Surgical C

ritical Care

Medical/Surgical W

ard

Mixed Age M

ixed Acuity Unit

Neurologic C

ritical Care

Neurology W

ard

Neurosurgical W

ard

ON

C G

eneral Hem

atology/Oncology W

ard

ON

C H

ematopoietic Stem

Cell Transplant W

ard

Orthopedic W

ard

Postpartum W

ard

Pulmonary W

ard

Solid Organ Transplant SC

A

Surgical Cardiothoracic C

ritical Care

Surgical Critical C

are

Surgical Ward

Telemetry W

ardProportion of Single Culture-Blood Culture

Events by Unit

Presenter

Presentation Notes

At the unit level, single cultures were in higher proportion in oncology units.

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Seasonality

No noticeable seasonal trends

0.0

50.0

100.0

150.0

200.0

250.0

May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20

Bloo

d C

ultu

re E

vent

s pe

r 1,0

00 P

atie

nt D

ays

Average Hospital A Hospital B Hospital C Hospital D Hospital E Hospital F

Presenter

Presentation Notes

We plotted monthly BCUR at the event level to assess for seasonality and did not uncover any noticeable trends at the hospital level, or overall as can be seen here.

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Day of the Week

Relatively high number of events on Mondays

Lower on weekends

However…

93.2

102.8

97.396.7

93.5

96.5

92.4

86.0

88.0

90.0

92.0

94.0

96.0

98.0

100.0

102.0

104.0

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Bloo

d C

ultu

re E

vent

s pe

r 1,0

00 P

atie

nt D

ays

Presenter

Presentation Notes

We have experience in the DETOURS trial of anecdotally high number of cultures on Mondays and less on the weekends so we decided to look at overall BCUR per day of the week in order to understand if there was a workflow implication for stewardship. We did find a higher number events occurring on Monday and the lowest on the weekends…however,

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Day of the Week

Monday/Weekend pattern driven by ED

Presenter

Presentation Notes

We then broke it down into ED blood culture events and non-ED events and uncovered that this pattern was being driven by the ED culture volume, which mimics the previous slide, where other inpatient units are relatively stable peaking on Wednesdays. So, it may be that EDs are just busier on Mondays and that’s what led to our observation of increased BCx to review on Mondays.

Conclusions Few studies have evaluated hospital-level BCx utilization. Used metric of “blood culture events” based on 12h time window Avoid “punishing” hospitals that use paired cultures more consistently

Pediatrics have very different BCx practice than adults BCUR varied by hospital, unit-type, and day of the week and was

heavily influenced by ED culture volumes Observed higher BCx contamination rates among hospitals with

higher BCUR and ED cultures Single BCx events occurred in oncology units

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Presenter

Presentation Notes

So in conclusion, we note that BCUR with both numerators varied by hospital, unit, and day of the week We observed higher contamination rates among hospitals with higher BCUR, with both numerators, and ED cultures No seasonality was discovered And the Monday spike in blood culture events was driven by ED cultures

Discussion Question 1 What metric(s) “spoke” to you the most in reviewing hospital-level data?

What do you find to be meaningful?

Overall Blood cultures/ 1,000 patient days Blood culture events/ 1,000 patient days % ED % drawn from catheters Antibiotics prior to blood culture Single blood culture events Unit-level stratified utilization rates or Single BCx events

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Discussion Question 2 Do hospital comparisons help? What if there is minimal adjustment for patient mix?

Factors that can influence BCx utilization: Age Unit-type Diagnosis Acuity Others?

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Discussion Questions 3 What group would you want to take blood culture utilization and/or

contamination data back to for discussion and planning? What if your hospital is ALREADY at the national goal <3%? Do you think the ED should be separated from the hospital in

comparative analyses?

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Discussion Question 4 What data feedback strategies have you used for BCx utilization or

contamination data at your hospital?

More details to come in the “Success Stories” Session

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Contaminated Blood Cultures

Presenter

Presentation Notes

Example of facility wide feedback

Contaminated Blood Cultures

Presenter

Presentation Notes

Example of feedback given by group or type of collector

Contaminated Blood Cultures – by collector

blood culture utilization metrics

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