Blood Culture Collection (excluding neonates)€¦ · Web viewbacteraemia, candidaemia, and infective endocarditis. Back to Table of Contents Section 1 – Peripheral blood culture

CHS19/074

Canberra Health ServicesClinical ProcedureBlood Culture Collection (excluding neonates) Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 3

Section 1 – Peripheral blood culture collection........................................................................4

Section 2 – Collection from a Central Venous Catheter (CVC) or Peripherally Inserted Central Catheter (PICC)..........................................................................................................................7

Section 3 – Collection from an Implanted Venous Access Devices (e.g. PortacathTM).............9

Implementation........................................................................................................................ 9

Related Policies, Procedures, Guidelines and Legislation.......................................................10

References.............................................................................................................................. 10

Definition of Terms................................................................................................................. 11

Search Terms.......................................................................................................................... 13

Attachment A..........................................................................................................................14

Doc Number Version Issued Review Date Area Responsible PageCHS19/074 1 24/04/2019 01/04/2022 NMPSS 1 of 14

Do not refer to a paper based copy of this policy document. The most current version can be found on the CHS Policy Register

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Purpose

To provide information to Canberra Health Services staff on the correct, safe and appropriate collection of blood cultures to confirm and identify the possible causative micro-organism in bacteraemia/septicaemia.

Scope

Alerts

1. Blood culture collection is a standard aseptic non touch technique (ANTT). 2. Adult patients – For each septic episode two complete separately drawn sets of blood

cultures are required (four bottles in total). One set of adult blood culture bottles consists of two separate bottles (one aerobic and one anaerobic – see Figure 1).

Figure 1 Adult Set

3. Paediatric patients - A single bottle system is used for paediatric patients as bacteraemia caused by anaerobic pathogens are less common than aerobic pathogens (see Figure 2). One set (one pink coloured paediatric bottle) is required unless the patient is considered to be immunocompromised, in which case two sets (2 x each bottle of adult aerobic and anaerobic bottles) are to be collected.

Figure 2 Paediatric Set

4. Paediatric bottles can be used for adult patients when only a small blood volume is able to be collected.

5. Skin preparation is with 2% Chlorhexidine and 70% alcohol applied in an up/down and across technique and allowed to dry for at least 30 seconds for skin disinfection to be



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effective. If the patient has a Chlorhexidine allergy use a 70% alcohol swab only for bottle disinfection and skin preparation.

6. A vacuum container set with a safety lock scalp vein needle is to be used to minimise the risk of occupational exposure and to facilitate appropriate specimen collection.

7. Patients with a centrally inserted vascular access device (CVAD) require one set of blood cultures collected via venepuncture from a peripheral site and two sets from two separate lumens of the CVAD (three sets in total). This is to assist in diagnosis of systemic infection versus CVAD related infection.

8. When a micro-organism is identified and the patient is receiving the appropriate antibiotics, it is unnecessary to collect any further blood cultures unless:a. the patient is still febrile after 48 hours of treatment of the appropriate agentb. the patient becomes febrile after a period of being afebrilec. the patient has staphylococcus aureus bacteraemia, candidaemia or infective

endocarditis. These cases require serial collection until they are culture negative.

Paediatrics If you are inserting an IV cannula into a neonate, infant or child and a blood culture collection is indicated, the blood culture can be taken from the cannula at the time of insertion, providing the cannula has been inserted under strict standard aseptic non touch technique (ANTT). Specimens collected in this manner have a high risk of contamination.

Back to Table of Contents

Scope

This document pertains to all patients (excluding neonates) that require collection of blood cultures within Canberra Health Services.

This document applies to: medical officers nurses and midwives who are working within their scope of practice phlebotomists (venepuncture only, not intravascular device access).

Indications for collection of blood culture include: clinical conditions suggestive of microorganisms in blood e.g. fever, chills, rigors,

tachycardia, tachypnoea fever and hypotension not explained by non-infectious causes fever in the presence of neutropenia and when IV devices are present in the absence of fever:

o patient with focal infection e.g. pneumonia, meningitis, osteomyelitiso infants with unexplained hypothermiao children or elderly with sudden failure to thriveo elderly with deterioration from baseline status e.g. confusion, sudden altered

mentation or frequent fallso patient with renal insufficiency and unexplained leucocytosis altered mentation or

unexplained tachycardia



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o unexplained pulmonary, renal, or hepatic dysfunction in an immuno-compromised or critically ill patient

o unexplained haemodynamic instability ongoing monitoring of Staphylococcus aureus bacteraemia, candidaemia, and infective

endocarditis.Back to Table of Contents

Section 1 – Peripheral blood culture collection

Equipment * (refer to Attachment A) Pathology collection form or e-order pathology Patient pathology identification labels x 2 (if required) Dressing trolley Alcohol based hand rub (ABHR) 2% chlorhexidine and 70% alcohol swabs x 4 (for bottle cleaning) 2% chlorhexidine and 70% alcohol (e.g. Chloraprep 3ml) (for patient) Detergent impregnated wipes (e.g. Tuffie wipes) IV starter kit Figure 3: luer lock or luer slip

Vacuum container system o Blood transfer device (see Figure 3)o Safety lock - scalp vein set 21G

Pressure dot/band aid® Sterile gloves Blood culture bottles

o Adults Aerobic blood culture bottle (blue colour) Anaerobic blood culture bottle (purple colour)

o Paediatric Paeds Plus/F Plus bottle

Protective glasses or goggles Biohazard sharps container Clinical waste receptacle Under pad* This is the equipment necessary for collection of 1 set of blood cultures.

Procedure 1. Ensure that the relevant history and tests are stated on the pathology blood culture

request form as this may affect incubation requirements. 2. Collect all equipment required (including personal protection equipment) and place on

bottom of trolley that has been cleaned from top to bottom with detergent‐based wipes. Bring trolley to the patient zone.

3. Check expiry date for each bottle and mark 10ml above the broth for fill level for adult patients (collect 8 - 10mls) and 3ml above the broth for paediatric patients (collect 1-3ml).

4. Perform hand hygiene (Moment 1) and perform positive patient identification checks.



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5. Perform hand hygiene (Moment 4), open dressing pack and place blood collection equipment and skin preparation onto sterile field.

6. Prepare winged infusion set, blood transfer device, and other equipment. 7. Remove the cap of each blood culture bottle and scrub the vial stoppers and neck of

bottle well using a 2% chlorhexidine and 70% alcohol swab. Allow to dry completely for at least 30 seconds. Place to side or on back corner of sterile field.

8. Perform hand hygiene (Moment 1). 9. Position patient appropriately, apply tourniquet to palpate and identify appropriate

vein.10. Perform hand hygiene (Moment 4 after positioning patient and Moment 2 before the

procedure). 11. Put on sterile gloves. 12. Skin preparation is with 2% Chlorhexidine and 70% alcohol in an up/down and across

technique which must be allowed to dry for at least 30 seconds for skin disinfection to be effective.

13. It is preferable that the venepuncture site is not re-palpated after skin preparation however if necessary, re-palpate the venepuncture site to check vein position with sterile gloves that have not been contaminated.

14. Perform venepuncture using winged infusion set and syringe or blood transfer device. Release tourniquet during procedure where appropriate. This will contaminate the gloved hand and using a sterile towel or the non dominant hand is advised, unless there‐ is an assistant available that can perform this function.

15. Inoculate the blood culture bottles aerobic bottle (blue) first followed by anaerobic (purple) bottle.

16. Place 8 - 10ml blood per bottle (16 - 20ml/set), keeping blood culture bottle upright and at/below the level of the venepuncture.

17. If blood is collected via a syringe, use a blood transfer device to transfer 8 to 10mls of blood into each bottle – aerobic followed by anaerobic

18. If collecting additional blood pathology tubes always collect/inoculate the blood culture bottles FIRST.

19. Remove winged infusion set, apply gauze and pressure to site (where possible obtain patient assistance to hold and apply pressure).

20. Discard sharps, collect all rubbish/dirty items and dispose of appropriately. 21. Immediately after specimen collection, at the patient bedside, collector must personally

label each bottle with patient name, medical record number (MRN), date/time for collection of blood and location of site used. If using pre-printed patient pathology identification labels do not cover any bar codes or the bottom of the bottle.

22. Place bottles into biohazard bag and arrange to send to the lab with request form. Transport bottles at room temperature within 2 hours. Do not send more than two blood culture bottles at a time in the pathology pneumatic rapid transport tube system, due to the potential for breakage.

23. Remove gloves and perform hand hygiene (Moment 3) after the procedure.

Note: Repeat entire procedure for second set of blood cultures collected from a different



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peripheral site, using new dressing pack and general aseptic field and maintaining standard aseptic technique. Ideally if time permits collect second set 30 minutes later. If patient is acutely unwell and requires empirical antibiotics collect second set as soon as possible. If original specimen has been collected by phlebotomist, a second set should ideally be collected by a different collector if available.

Note:Blood is normally sterile; the purpose of collecting blood cultures is to identify any bacteria or fungi growing in the blood that may cause sepsis. If there are pathogens growing in the blood they take time (usually up to 48 hours) to grow and to be identified in the laboratory.

Explain to the patient that results may not be available for 48 hours or more. Once two sets of cultures have been collected, do not delay administering antibiotics if they have been ordered and do not wait for culture results as any delay in antibiotic administration may be detrimental to the patient.

DocumentationPlace small peel off barcode label from blood culture bottles in clinical notes and document: (a) number of sets of blood cultures taken(b) site/s of collection (c) reason for site choice if this differs from a peripheral site. Additional Samples1. Additional sample may be requested by the medical officer.2. A peripheral vein (upper limb) access is preferable, however if the patient’s venous

access is poor, one set may be taken from a central line, and clearly marked as such on bottles.

3. At least one set of blood cultures should be obtained peripherally.4. There is usually no need for more than three sets of blood cultures to be collected during

any single febrile event.5. Repeat blood cultures should also be collected routinely in Staphylococcus aureus

bacteraemia and candidaemia, to determine when cultures become negative on appropriate antibiotics.

6. Patients with suspected or confirmed infective endocarditis should have further regular cultures to determine when cultures become negative.

7. Specific blood culture bottles are required for mycobacterial species. These also are enhanced to support the growth of fungi in patients at high risk for fungaemia. Contact ACT Pathology to organise mycobacterial bottles.

8. In an extremely ill patient, additional blood cultures may be taken sequentially from two separate sites prior to commencing antibiotic treatment.


Section 2 – Collection from a Central Venous Catheter (CVC) or Peripherally Inserted Central Catheter (PICC)



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Patients with a Central Venous Access device (CVAD) also need to have one set of blood cultures collected peripherally by venepuncture, to assist in determining diagnosis of systemic infection or CVAD related infection.

Ongoing blood culture specimens can be collected from CVAD only.

Equipment * Pathology collection form or e-order pathology Patient pathology identification labels x 2 (if required) Dressing trolley Alcohol based hand rub (ABHR) 2% chlorhexidine and 70% alcohol swabs x 4 (for bottle cleaning) 2% chlorhexidine and 70% alcohol (e.g. Chloraprep 3ml) (for patient) Detergent impregnated wipes (e.g. Tuffie wipes) IV starter kit Syringe 20ml for blood collection Syringe 10ml for Saline flush OR 10ml premixed saline flush for post draw CVAD flush 10ml normal saline for flush if not using premixed saline flush Vacuette blood transfer device Replacement Needleless injection caps or positive pressure valves Sterile gloves Blood culture bottles

o Adults Aerobic blood culture bottle Anaerobic blood culture bottle

o Paediatric Paeds Plus/F Plus bottle

Protective glasses or goggles Biohazard sharps container Clinical waste receptacle Under pad* This is the equipment necessary for collection of 1 set of blood cultures.

Procedure 1. Ensure that the relevant history and tests are stated on the blood culture request form

as this may affect incubation requirements. 2. Collect all equipment required (including personal protection equipment) and place on a

trolley cleaned with detergent‐based wipes and bring to the patient zone. 3. Request assistance from another staff member.4. Check expiry date for each bottle and mark 10ml above the broth for fill level for adult

patients and 3ml above the broth for paediatric patients (1-3ml).5. Perform Hand Hygiene (Moment 1). Check patient identification and inform patient of

the procedure and its purpose. 6. Perform hand hygiene (Moment 4). Open dressing pack and place blood collection

equipment and skin preparation onto sterile field.



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7. Remove the cap of each blood culture bottle and scrub the vial stoppers and neck of bottle well using a 2% chlorhexidine and 70% alcohol swab, and allow to dry completely for at least 30 seconds. Place to side or on back corner of sterile field.

8. Perform hand hygiene (Moment 1). 9. Position patient appropriately for ease of access to CVAD.10. Perform hand hygiene (Moment 4 after positioning patient and Moment 2 before the

procedure). 11. Don sterile gloves. 12. Prepare syringe, blood transfer device, and other equipment.13. Ask assistant to attend hand hygiene, don non sterile gloves and lift CVAD lumens. 14. Place sterile drape under CVAD lumens. 15. Check needleless injection cap for visible contamination and if present change

needleless injection cap prior to collecting blood cultures. 16. Swab the needleless injection cap thoroughly with 2% chlorhexidine and 70% alcohol

swab for 30 seconds. Allow to dry for 30 seconds.

17. Choose collection methodSyringe draw

Attach syringe to injection site and withdraw 16 - 20mls of blood into syringe and disconnect syringe from CVAD.

Attach blood transfer device to syringe and inoculate the blood culture bottles aerobic bottle first followed by anaerobic bottle.

ORBlood transfer device collection

Attach luer lock access device (blue top) device to CVAD injection site. Connect the blood cultures bottles to the transfer device and inoculate the blood

culture bottles aerobic bottle (blue) first followed by anaerobic bottle. Place 8-10ml blood per bottle (16-20ml/set), keeping blood culture bottle upright

and at/below the level of the CVAD.

18. If collecting additional blood pathology tubes always collect/inoculate the blood culture bottles FIRST.

19. Flush CVAD lumen with 10mls 0.9% sodium chloride for injection using a pulsatile action.20. Replace needleless injection cap as per Central Venous Access Device (CVAD)

Management – Children, Adolescents and Adults (NOT Neonates) procedure if there is residual blood visible within device.

21. Discard sharps, collect all rubbish/dirty items and dispose of appropriately. 22. At the patient bedside label each bottle with patient name, MRN, date/time for

collection of blood and location of site used for each set (eg. Blue lumen PICC). Do not cover any bar codes or the bottom of the bottle.



Note:When collecting blood cultures from a CVAD DO NOT discard blood or fluid as per routine practice for CVAD blood draws. Pathogens may be residing within the lumen and collecting the initial blood draw will lead to greater accuracy.

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23. Place bottles into biohazard bag and arrange to send to the lab with request form. Transport bottles at room temperature to pathology lab within two hours.

24. Remove gloves and perform hand hygiene (Moment 3) after the procedure.

Note: Repeat entire procedure for 2nd set of blood cultures from a different lumen, using new dressing pack / sterile field and maintaining standard aseptic technique. If original specimen has been collected by phlebotomist, second set should ideally be collected by a different collector if available.


Section 3 – Collection from an Implanted Venous Access Devices (e.g. PortacathTM)

Patients with an Implanted Venous access device also need to have one set of blood cultures collected by venepuncture to assist in determining diagnosis of systemic infection or device related infection.

For ongoing testing only Implanted Venous Port specimens are required.

Procedure1. The implanted venous device should be accessed as per the Central Venous Access

Device (CVAD) Management – Children, Adolescents and Adults (NOT Neonates) procedure

2. For blood culture collection from implanted device follow steps in section 2 above


Implementation

This procedure will be communicated to relevant staff via: organisation wide notification of updated procedure discussion at clinical / ward based meetings incorporation into existing education and training programs blood culture collection posters available in clinical areas.


Related Policies, Procedures, Guidelines and Legislation

PoliciesCHS Clinical Policy – Patient Identification and Procedure Matching



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Procedures CHS Clinical Procedure – Central Venous Access Device (CVAD) Management – Children, Adolescents and Adults (NOT Neonates)CHS Clinical Procedure – Venepuncture Blood Specimen CollectionCHS Clinical Procedure – Aseptic TechniqueACT Health Procedure – Patient Identification: Pathology Specimen LabellingCHS Clinical Procedure – Healthcare Associated Infections

Guidelines NSW Health Clinical Excellence Commission (CEC), Sepsis Kills – Blood Culture collection Guideline http://www.cec.health.nsw.gov.au/programs/sepsis


References

BACTEC Blood Collection Instructions, Becton Dickinson Pty Ltd, NSW Australia. https://www.bd.com/ds/technicalCenter/charts/ch_3_2340.pdf

Burton, G & Engelkirk P. G., (2000) Microbiology for the Health Sciences 6th Edition, Lippincott Williams & Wilkins, p285- 286.

Clinical Excellence Commission (2016). Sepsis kills: Paediatric blood culture guideline. Accessed 11/02/2019 http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0003/259419/paediatric-blood-culture-guideline.pdf

Doem, G. (2018). Blood cultures for the detection of bacteraemia. Accessed 11/02/2019 https://www.uptodate.com/contents/blood-cultures-for-the-detection-of-bacteremia#PATIENT_INFORMATION

Garcia, R.A., Spitzer, E.D., Beaudry, J., Beck, C., Diblasi, R., Gilleeny-Blabac, M., . . . Torregrosa, E. (2015) Multidisciplinary team review of the best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremias, reducing contamination, and eliminating false-positive central line-associated bloodstream infections. American Journal of Infection Control, 43(11), 1222 – 1237. doi:10.1016/j.ajic.2015.06.030

Lamy, B., Dargère, S., Arendrup, M. C., Parienti, J. J., & Tattevin, P. (2016). How to Optimize the Use of Blood Cultures for the Diagnosis of Bloodstream Infections? A State-of-the Art. Frontiers in Microbiology, 7, 697. doi:10.3389/fmicb.2016.00697

Mandell, Douglas and Bennett’s principles and practices of infectious diseases – 7th Edition (2010). Edited by Gerald Mandell, John E Bennett & Raphael Dolin, Churchill Livingstone Inc. pp235 -236



https://doi.org/10.1016/j.ajic.2015.06.030

https://www.uptodate.com/contents/blood-cultures-for-the-detection-of-bacteremia#PATIENT_INFORMATION

https://www.uptodate.com/contents/blood-cultures-for-the-detection-of-bacteremia#PATIENT_INFORMATION

http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0003/259419/paediatric-blood-culture-guideline.pdf

http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0003/259419/paediatric-blood-culture-guideline.pdf

https://www.bd.com/ds/technicalCenter/charts/ch_3_2340.pdf

http://www.cec.health.nsw.gov.au/programs/sepsis

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Mylotte JM., Tayara A., (2000) Blood Cultures: Clinical Aspects and Controversies. European Journal of Clinical Microbiology and Infectious Diseases 19: p157 – 163.

NSW Health Clinical Excellence Commission (CEC) (2016), Sepsis Kills Program: Adult blood culture sampling guideline. Accessed 20/12/2018 http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/sepsis-kills/sepsis-tools

Wenzel, R., (1997) Prevention and Control of Nosocomial Infections 3rd edition. Williams and Wilkins A, Waverly Company.

World Health Organization (2010), WHO guidelines on drawing blood: best practices in phlebotomy, accessed 13/02/2019 http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf


Definition of Terms

Aerobic: Occurring in the presence of oxygen or requiring oxygen to live.

Alcohol Based Hand Rub (ABHR): Alcohol containing preparation designed for application to the hands in order to reduce the number of viable micro-organisms with maximum efficacy and speed.

Anaerobic: Occurring in the absence of oxygen or not requiring oxygen to live. Anaerobic bacteria grow without the presence of oxygen.

Aseptic Non Touch Technique (ANTT): ANTT is a technique used to prevent contamination of key parts and key sites by microorganisms that could cause infection. In ANTT, asepsis is ensured by identifying and then protecting key parts and key sites by hand hygiene, non-touch technique, using new sterilised equipment and/or cleaning existing key parts to a standard that renders them aseptic prior to use

Candidaemia: A bloodstream infection caused by yeast (a type of fungus) called Candida. These infections often result in long hospital stays, high medical costs, and poor outcomes

Central Venous Catheter (CVC): Central Venous Catheter is an intravascular device placed into a large vein in the neck (internal jugular vein), chest (subclavian vein) or groin (femoral vein) with the tip terminating in the superior vena cava or right atrium. CVC’s can be non tunnelled (percutaneous) or tunnelled; inserted with a tunnel under the skin creating distance between skin insertion site and vascular insertion site (HickmanTM, VascathTM).

Contamination / False positive: A false positive is defined as growth of bacteria in the blood culture bottle that were not present in the patient’s bloodstream and were introduced during sample collection. Contamination can come from a number of sources: the patient’s



http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf

http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/sepsis-kills/sepsis-tools

http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/sepsis-kills/sepsis-tools

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skin, the equipment used to take the sample and transfer it to the culture bottle, the hands of the person taking the blood sample, or the general environment.

Fungaemia: A bloodstream infection caused by fungi.

Hand Hygiene (HH): A process that reduces the number of micro-organisms on hands. Hand hygiene is a general term applying to the use of soap solution (non-anti-microbial or antimicrobial) and water or water-less antimicrobial agent to the surface of the hands (e.g. alcohol based hand rub).

Implanted Venous Access Device / Port (Port, PortacathTM, PasportTM): An implantable medical device consisting of a fluid reservoir connected to a central venous catheter. The device is completely underneath the skin and the catheter tip generally terminates in the superior vena cava. Access is made through the skin into the reservoir using a non-coring needle device (Gripper™)

Peripherally inserted Central Catheter (PICC): A PICC is an intravascular catheter inserted in a peripheral vein in the arm, such as the cephalic vein, basilic vein or brachial vein, and then advanced proximally toward the heart until the tip rests in the distal superior vena cava or cavoatrial junction.




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Search Terms

Blood culture, Bacteraemia, Bloodstream Infection, Central Venous Catheter, CVC, Fungaemia, Infection, Peripherally inserted Central Catheter, PICC, Sepsis, venepuncture


Disclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 26/08/2019 Pg 5 and 8 reference to

“Invert bottles gently several times to prevent clotting” removed

Jacqui Taylor, ED Medicine

CHS Policy Team

This document supersedes the following: Document Number Document NameCHHS16/004 Blood Culture Collection Clinical Procedure



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Attachment A



Documents

Blood Culture Collection (excluding neonates)€¦ · Web viewbacteraemia, candidaemia, and infective endocarditis. Back to Table of Contents Section 1 – Peripheral blood culture