BLOOD CULTURE COLLECTIONS POLICY

Page 1 of 16 IPC: Blood culture collection policy Version No 4.0

BLOOD CULTURE COLLECTIONS POLICY

Policy Type Clinical Infection Prevention and Control

Directorate

Corporate Nursing

Policy Owner

Chief Nurse including Midwifery and Allied Health Professionals

Policy Author

IPC Doctor

Next Author Review Date

1st November 2022

Approving Body

Policy Management Sub-Committee 23rd April 2019

Version No.

4.0

Policy Valid from date

1st April 2019

Policy Valid to date:

30th April 2023

‘During the COVID19 crisis, please read the policies in conjunction with any updates

provided by National Guidance, which we are actively seeking to incorporate into policies through the Clinical Ethics Advisory Group and where necessary other

relevant Oversight Groups’


DOCUMENT HISTORY (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time – the initial draft will be version 0.1)

Date of Issue

Version No.

Date Approved

Director Responsible for Change

Nature of Change Ratification / Approval

03 Nov 11 1.3 03 Nov 11 Consultant Medical Microbiologist

Revised Endorsed at Quality and Patient Safety Committee

20 Dec 11 1.4 20 Dec 11 Revised Endorsed at Service Delivery Executive Board

3 Sep 12 2 3 Sep 12 Revised Executive Board

Oct 15 2.1 IPC Doctor Revised IPCC

4 Dec 15 2.1 Executive Director of Nursing

For ratification Clinical Standards Group

15 Dec 15 3 15 Dec 15 Executive Director of Nursing

For approval Policy Management Group

Mar 19 3.1 Director of Nursing Revised to new format

29/03/2019 3.1 Director of Nursing Endorsed at Clinical Standards Group

23 April 2019

4.0 23 April 19 Director of Nursing Approved at Policy Management Sub-Committee

29 Jan 2021

4.0 23 April 19 Chief Nurse including Midwifery and Allied Health Professionals

12 month blanket policy extension due to covid 19 applied with author review date set 6 months prior to Valid to Date.

Quality & Performance Committee

12th May 2021

4.0 23 April 2019

Chief Nurse including Midwifery and Allied Health Professionals

Extended policy uploaded and linked back

Corporate Governance

18/02/2022 4.0 18/02/2022 Director of Nursing Policy updated reflecting new MCA guidance

Corporate Governance

NB This policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust


Contents Page

1. Executive Summary…………………………………………...... 4

2. Introduction……………………………………………………….. 4

3. Definitions………………………………………………………… 4

4. Scope……………………………………………………………… 4

5. Purpose…………………………………………………………… 4

6. Roles & Responsibilities………………………………………… 4

7. Policy Detail / Course of Action………………………………… 5 7.1 Indications for taking blood cultures 5 7.2 Timing of blood cultures 5 7.3 Blood Culture Collection 6 7.4 Procedure for peripheral blood culture collection 6 7.5 Suspected line associated infection 7 7.6 Procedure for central line blood culture collection 7

(Only for use in diagnosis of central line infection)

8. Consultation……………………………………………………… 9

9. Training…………………………………………………………... 9

10. Monitoring Compliance and Effectiveness…………………… 9

11. Links to other Organisational Documents…………………… 9

12. References……………………………………………………… 9

13. Appendices 10 Appendix A – ANTT Blood Culture Collection 11 Appendix B – Financial and Resourcing Impact 12

Assessment on Policy Implementation Appendix C – Equality Impact Assessment (EIA) 14

Screening Tool


1 Executive Summary Blood cultures are used to diagnose serious infections in patients admitted to hospital. This policy outlines why and when blood cultures should be taken, who they should be taken by and how they should be taken.

2 Introduction Taking blood cultures to detect bacteraemia (blood stream infection) is a very important clinical investigation. Blood cultures are essential for diagnosis of serious infections and to help selection of appropriate antibiotic treatment as well as surveillance of these infections. However, if not taken correctly, blood cultures can be contaminated with skin flora leading to so called ‘false positive’ results. This policy is based on guidance from the Dept. of Health on ‘Taking Blood Cultures – a summary of best practice’. http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/files/2011/03/Document_Blood_culture_FINAL_100826.pdf

It aims to ensure that blood cultures are taken for the correct indication, at the correct time and using the correct technique to prevent contamination and minimise risk. Mental Capacity Act 2007:

In applying this policy you must also comply with the principles of the Mental Capacity Act 2007: 1. Always assume a person has capacity unless you have established that they lack

capacity.

2. Do everything you can to help the person make a decision for themselves.

3. An unwise decision does not prove that the person lack capacity.

4. Anything you do or any decision made for or to the person must be in their best interest.

5. Always consider whether the outcome can be achieved in a way that interferes less with

the person’s wishes.

Whenever there is a doubt about the person’s capacity you must assess their capacity and if they do lack capacity you must act in their best interests. Further guidance can be found in the Trusts’ MCA Policy and in the MCA Code of Practice.

3 Definitions Bacteraemia – blood stream infection ANTT - aseptic non-touch technique

4 Scope This policy applies to all staff who collect blood culture samples and in all healthcare settings within the Trust.

http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/files/2011/03/Document_Blood_culture_FINAL_100826.pdf



5 Purpose This guidance and blood culture collection procedure is to provide a clear standard for blood culture collection. The overall purpose is to improve the quality of blood culture investigations, to reduce blood sample contamination which results in complications for patient safety, quality and associated cost of care.

6 Roles and Responsibilities 6.1 Director of Infection Prevention and Control (DIPC)

The DIPC oversees this policy and its implementation. 6.2 Infection Prevention and Control (IPC) Doctor

The IPC Doctor is responsible for maintaining this policy and providing advice related to this topic.

6.3 Staff undertaking Blood Culture Collection

• Staff who undertakes blood culture collection must ensure they are trained and competent to do so, including carrying out aseptic non-touch technique (ANTT); they should undertake further training if they produce repeat contaminated blood cultures. Details of the requirements for maintaining competence are set out in the Infection Prevention & Control Aseptic Non Touch Technique (ANTT) Policy

6.4 Modern Matrons / Ward Managers / Clinical Supervisors

Modern Matrons , Ward Managers and Clinical Supervisors have a key responsibility to ensure that blood culture collection in their area of responsibility is undertaken only by staff who are trained and competent to do so, including carrying out aseptic non-touch technique (ANTT).

6.5 Clinical educators

The clinical education department is responsible for providing training in ANTT. 6.6 Consultant Medical Microbiologists

Consultant medical Microbiologists are responsible for liaising with clinicians and departments regarding positive blood culture samples and monitoring/feedback of contamination rates.

7 Policy detail/Course of Action

7.1 Indications for taking blood cultures

• Take blood cultures whenever there is clinical indication to suspect bacteraemia or sepsis.

Only take blood for culture when there is clinical need to do so and not as routine

There are many signs and symptoms in a patient which may suggest bacteraemia. The following symptoms may suggest bacteraemia:

• Core temperature out of normal range

• Focal signs of infection

• Tachycardia, low BP, or increased respiratory rate


• Chills or rigors

• Raised or very low white cell count

• New or unexplained confusion

7.1.2 This list is not exhaustive or exclusive and clinical judgement is required. Signs of sepsis may be minimal or absent in the very young and elderly. A medically qualified doctor should normally make the decision to request blood culture. Other healthcare staff may perform collection of blood cultures provided they are trained and competent in performing the procedure in line with this policy.

7.2 Timing of blood cultures 7.2.1 Take blood cultures as soon as bacteraemia suspected and before giving antibiotic

therapy and in line with Sepsis Six recommendations.

7.2.2 If the patient is already on antibiotics, blood cultures should ideally be taken immediately before the next dose is given.

7.2.3 For investigation of infective endocarditis, multiple blood culture sets are necessary. 7.2.4 In suspected sub-acute endocarditis where there are no signs of fulminant infection,

and antibiotic therapy can be delayed for investigation, 3 blood culture sets should be performed at least 30 minutes apart.

7.2.5 In acute endocarditis, where there are signs of fulminant infection and a need to start

antibiotics urgently, 3 blood culture sets should be performed within 30 minutes before commencing empirical antibiotics.

7.3 Blood culture collection - General Recommendations

• To minimise needle-stick injury, safe sharps systems/devices should be used routinely where provided in the Trust. Blood cultures should be collected using the butterfly vacutainer system wherever possible (to minimise the risk of needle stick injury and blood culture contamination).

• If a department/clinician identifies a need to use a non-safe sharp when a safe system is provided, a full detailed risk assessment must be completed and shared with the Associate Director for Health and Safety (As per Safe Handling & Disposal of Sharps Policy)

• Blood culture collection should only be undertaken by staff who have been trained in the collection procedures, including ANTT and whose competence on blood culture collection has been assessed.

• Blood cultures should always be collected using a new venepuncture site.

• Avoid femoral vein puncture because of the difficulty in adequate skin cleansing and disinfection (high contamination risk).

• For adult blood culture collection, the optimal volume of blood is 10mls for each bottle (aerobic and anaerobic); obtaining less will reduce the sensitivity of the culture but do not overfill.


• Blood cultures should not be collected through pre-existing peripheral or central vascular access devices (PVADs and CVADs) or from sites immediately above peripheral line, due to the risk of infecting the device. The only exception would be where a central line is thought to be associated with infection when paired central and peripheral cultures should be taken (see next section below).

• Documentation in the patient’s notes should be made when blood cultures are performed, including date and time of collection and indication. (Bottle stickers are used in the laboratory so should not be removed before sending).

• Send the bottles and request form (in plastic bag) to laboratory in the normal way for incubation and processing (they must not be refrigerated)

• The on-call Biomedical Scientist does NOT need to be informed when blood cultures are taken out of hours; significant positive results will be notified to the clinician by the Consultant Microbiologist.

7.4 Procedure for Peripheral blood culture collection

- See also illustrated guide available at: Appendix A and http://intranet.iow.nhs.uk/Portals/0/Assets/Development_Training/Clinical%20Education/ANTT%20Charts/Blood%20Culture%20Guideline%202017%20v1.1.pdf

• Preparation: Consent patient, confirm patient identification (ask patient name and date of birth, check against the patient’s wristband and request form) , assess veins visually and ensure arm visibly clean

• Clean your hands

• Prepare clean tray for procedure

• Gather equipment: Blood culture collection kit, disposable tourniquet, sterile gauze for dressing, Sharps bin


• Prepare equipment with non-touch technique (connect vacutainer adapter cap with butterfly blood collection set)


• Prepare blood culture bottles – flip off cap and clean with Sanicloth or alcohol steret (allow to dry)

• Position arm, apply disposable tourniquet and palpate suitable vein before relaxing tourniquet


• Retighten tourniquet

• Put on non-sterile gloves

• Clean skin gently but firmly with ChloraPrep applicator for 30 seconds (use side-to-side and up-and-down pattern of application)and allow to dry – do not re-palpate vein again

• Insert the needle without re-palpating the injection site or touching the needle

• Inoculate blood culture bottles by placing the adapter cap over the blood culture bottle, press down to pierce the septum, hold bottle upright whilst filling (monitor the draw process closely at all times during collection to assure proper flow is obtained and to prevent flow of bottle contents into the adaptor tubing)

• When using the adult 2 bottle blood culture set, inoculate first the aerobic culture bottle (blue cap/label) and then the anaerobic bottle (purple cap/label) so that any oxygen trapped in the tubing will not be transferred to the anaerobic bottle.

http://intranet.iow.nhs.uk/Portals/0/Assets/Development_Training/Clinical%20Education/ANTT%20Charts/Blood%20Culture%20Guideline%202017%20v1.1.pdf

http://intranet.iow.nhs.uk/Portals/0/Assets/Development_Training/Clinical%20Education/ANTT%20Charts/Blood%20Culture%20Guideline%202017%20v1.1.pdf


• 10 mls of blood per bottle is optimal for adult blood culture sets (smaller amounts appropriate for children but ideally need at least 1ml)

• If venepuncture fails: clean new site after palpation as previously and use a new butterfly needle for each attempt

• Release tourniquet before removing needle and applying sterile dressing.

• Dispose of sharps in Sharps bin at bedside

• Clean tray with detergent wipe

• Dispose of gloves in clinical waste bin


• Ensure the bottles are correctly labelled with the patient’s details. Complete the request form and provide relevant clinical information.

• Record the procedure in the patient’s notes including indication, date time, site of venepuncture and any complications.

7.5 Suspected line associated infection If the patient has a central line and where line associated infection is suspected, blood may be taken from the central vascular access device (VAD) for culture by staff who are trained and competent in access of the central line. Strict ANTT principles must be followed for accessing the central line (see ANTT policy). A set of blood cultures should also be taken at the same time by venepuncture from a separate peripheral site.

7.6 Procedure for Central line Blood Culture Collection (Only for use in

diagnosis of central line infection)

• Consent patient


• Prepare clean tray for procedure

• Gather equipment: Blood culture collection kit, 1x20ml syringes, Multiple Sample Luer Adapter (use wherever available, otherwise will need to use second syringe with needle), Sanicloth for port cleaning, Sharps bin


• Prepare blood culture bottles – flip off cap and clean with Sanicloth or alcohol steret (allow to dry)

• Put on non-sterile gloves

• Clean the port of the needle free access device using new Sanicloth wipe

• Use non-touch technique to insert sterile syringe into needle free access device, draw back 5mls blood for discard (syringe should also be discarded)

• Connect Multiple Sample Luer adapter with large vacutainer holder and insert into needle free access device, protecting key parts from contamination by using no-touch technique

• Inoculate blood culture bottles by placing the adapter cap over the blood culture bottle, press down to pierce the septum, hold bottle upright whilst filling

• Only if the Multiple Sample Luer adapter is not available, use a second 20ml sterile syringe to obtain the blood for culture, then transfer to the blood culture bottles using a sterile needle (with caution to avoid needlestick injury – for this reason the Multiple Sample Luer adapter or equivalent with the vacutainer holder should be used wherever possible). Do not forcibly inject blood into the culture bottle, allow gentle entry.


• When using the adult 2 bottle blood culture set, inoculate first the aerobic culture bottle (blue cap/label) and then the anaerobic bottle (purple cap/label) so that any oxygen trapped in the tubing will not be transferred to the anaerobic bottle.

• 10 mls of blood per bottle is optimal for adult blood culture sets (smaller amounts appropriate for children but ideally need at least 1ml)

• Dispose of sharps in Sharps bin at bedside (if a needle and syringe is used discard the needle and syringe as one piece.

• Clean tray with detergent wipe

• Dispose of gloves in clinical waste bin


• Ensure the bottles are correctly labelled with the patient’s details. Complete the request form and provide relevant clinical information.

• Record the procedure in the patient’s notes including indication, date time, site of venepuncture and any complications.

8 Consultation 8.1 Revision October 2015 sent to members of IPCC, clinical educators and Emergency

Department/MAAU/ICU consultants, OHPIT lead nurse. Reviewed by IPC team in October 2018, minor changes in ANTT picture link not sent out for further consultation as no major changes made.

9 Training

9.1 This Blood culture collection policy does not have a mandatory training requirement but the following non mandatory training is recommended: Watch the following video: https://www.youtube.com/watch?v=iAH0yEOqBaE

9.2 Blood culture specimen collection must only be undertaken by staff who are specifically trained and competent in the procedure (including in aseptic non touch technique). http://intranet.iow.nhs.uk/Portals/0/Assets/Development_Training/ANTT/Blood%20Culture%20Guideline%202017%20v1.1.docx

9.3 Skills training and competency assessment should be provided by clinical educators or

trained peer group members.

10 Monitoring Compliance and Effectiveness

10.1 Blood culture contamination rates will be monitored monthly; (based on laboratory reports) by the Consultant Microbiologist.

10.2 Results will be fed back to the Emergency Department

10.3 Results will be fed back to wards with contamination rates above 3%. 10.4 Blood culture contamination rates will be reported by Department to the Infection

Prevention and Control Committee.

11 Links to other Organisational Documents

• Infection Prevention & Control Hand Hygiene Policy

https://www.youtube.com/watch?v=iAH0yEOqBaE

http://intranet.iow.nhs.uk/Portals/0/Assets/Development_Training/ANTT/Blood%20Culture%20Guideline%202017%20v1.1.docx

http://intranet.iow.nhs.uk/Portals/0/Assets/Development_Training/ANTT/Blood%20Culture%20Guideline%202017%20v1.1.docx


• Infection Prevention & Control Aseptic Non Touch Technique (ANTT) Policy

• Infection Prevention & Control Use of Personal Protective Equipment policy

• Infection Prevention & Control Safe handling & disposal of sharps policy

12 References • High Impact Intervention – Taking Blood Cultures, a summary of good practice.

Department of Health. http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/files/2011/03/Document_Blood_culture_FINAL_100826.pdf

• The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections (revised 2015) Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122604

13 Appendices



http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122604

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122604


Appendix A


Appendix B

Financial and Resourcing Impact Assessment on Policy Implementation

NB this form must be completed where the introduction of this policy will have either a positive or negative impact on resources. Therefore this form should not be completed where the resources are already deployed and the introduction of this policy will have no further resourcing impact.

Document title

Blood culture collection Policy

Totals WTE Recurring £

Non Recurring £

Manpower Costs Nil new

Training Staff Nil new

Equipment & Provision of resources Nil new

Summary of Impact: There will be a manpower impact of this policy; however this is necessary in order to safely deliver the services of the Trust. The Trust employs a number of staff who within their primary role have responsibility for maintenance of an effective risk management system. In addition staff across the Trust will have specific responsibilities; however this will fluctuate depending on the number and nature of risks. Risk Management Issues: This policy is document is designed to support effective risk

management across the Trust.

Benefits / Savings to the organisation: Effective risk management will support the Trust to deliver its service efficiently, effectively with due regard to the financial envelope and quality agenda. Equality Impact Assessment ▪ Has this been appropriately carried out? YES/NO ▪ Are there any reported equality issues? YES/NO If “YES” please specify:

Use additional sheets if necessary. Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered.

Manpower WTE Recurring £ Non-Recurring £


Operational running costs Nil new

Totals:

Staff Training Impact Recurring £ Non-Recurring £

Nil new

Totals:

Equipment and Provision of Resources Recurring £ * Non-Recurring £ *

Accommodation / facilities needed

Building alterations (extensions/new)

IT Hardware / software / licences

Medical equipment

Stationery / publicity

Travel costs

Utilities e.g. telephones

Process change

Rolling replacement of equipment

Equipment maintenance

Marketing – booklets/posters/handouts, etc

Totals: Nil new

• Capital implications £5,000 with life expectancy of more than one year.

Funding /costs checked & agreed by finance:

Signature & date of financial accountant:

Funding / costs have been agreed and are in place:

Signature of appropriate Executive or Associate Director:


Appendix C

Equality Impact Assessment (EIA) Screening Tool

1. To be completed and attached to all procedural/policy documents created within individual services.

2. Does the document have, or have the potential to deliver differential outcomes or affect in an adverse way any of the groups listed below? Policy does not discriminate against any of the groups below. If no confirm underneath in relevant section the data and/or research which provides evidence e.g. JSNA, Workforce Profile, Quality Improvement Framework, Commissioning Intentions, etc. If yes please detail underneath in relevant section and provide priority rating and determine if full EIA is required.

Gender

Positive Impact Negative Impact Reasons

Men

Women

Race

Asian or Asian British People

Black or Black British People

Chinese people

People of Mixed Race

Document Title: Blood culture collection Policy

Purpose of document

This guidance and blood culture collection procedure is to provide a clear standard for blood culture collection. The overall purpose is to improve the quality of blood culture investigations, to reduce blood sample contamination which results in complications for patient safety, quality and associated cost of care.

Target Audience Staff collecting Blood cultures

Person or Committee undertaken the Equality Impact Assessment

E Macnaughton


White people (including Irish people)

People with Physical Disabilities, Learning Disabilities or Mental Health Issues

Sexual Orientation

Transgender

Lesbian, Gay men and bisexual

Age

Children

Older People (60+)

Younger People (17 to 25 yrs)

Faith Group

Pregnancy & Maternity

Equal Opportunities and/or improved relations

Notes: Faith groups cover a wide range of groupings, the most common of which are Buddhist, Christian, Hindus, Jews, Muslims and Sikhs. Consider faith categories individually and collectively when considering positive and negative impacts. The categories used in the race section refer to those used in the 2001 Census. Consideration should be given to the specific communities within the broad categories such as Bangladeshi people and the needs of other communities that do not appear as separate categories in the Census, for example, Polish. 3. Level of Impact If you have indicated that there is a negative impact, is that impact:

YES NO

Legal (it is not discriminatory under anti-discriminatory law)

Intended

If the negative impact is possibly discriminatory and not intended and/or of high impact then please complete a thorough assessment after completing the rest of this form. 3.1 Could you minimise or remove any negative impact that is of low significance? Explain how below:


3.2 Could you improve the strategy, function or policy positive impact? Explain how below:

3.3 If there is no evidence that this strategy, function or policy promotes equality of opportunity or improves relations – could it be adapted so it does? How? If not why not?

Scheduled for Full Impact Assessment Date:

Name of persons/group completing the full assessment.

Date Initial Screening completed 9/11/15