Reducing contamination of peripheral blood cultures in a pediatric emergency department.

OBJECTIVE: Blood culture contamination rates (CRs) in emergency departments (EDs) vary from 1% to 9% in previous studies. High CRs cause unnecessary admissions, antibiotics, and costs. Different measures have been tried to improve CR. This study sought to determine the ED CR at Arkansas Children's Hospital (ACH) and evaluate an educational intervention. DESIGN: A slide presentation of the ACH's blood culture collection procedure was made. The ED nursing staff viewed this individually and demonstrated the procedure on a mock extremity. Data before (from June 1 to November 30, 2007; PRE) and after (from February 1 to July 31, 2008; POST) intervention regarding blood cultures positive for organism submitted to the ED and any descriptive data were collected retrospectively. Descriptive statistics described the CR, positivity rate (PSR), and pathogen rate (PR). Frequent collectors were identified as those submitting more than 72 blood cultures during PRE and during POST. Contamination rate in frequent collectors was independently assessed for improvement. This study was approved by the institutional review board of the University of Arkansas for Medical Sciences. RESULTS: Positivity rate during PRE was 6.8% (n = 15; 95% confidence interval [CI], 2.9-10.7); 114 were contaminants (CR, 5.0%; 95% CI, 1.04-8.98) and 40 were pathogens (PR, 1.8%; 95% CI, ± 4.28). Positivity rate during POST was 6.3% (n = 157; 95% CI, 2.6-10.0); 124 were contaminants (CR, 4.9%; 95% CI, 1.14-8.66) and 33 were pathogens (PR, 1.4%; 95% CI, ± 4.22). For both PRE and POST, contaminants represented 74% or greater of all the positives and more than 75% of contaminants occurred in patients 0 to 36 months old.Contamination rates of individual practitioners ranged from 0% to 17% (PRE) and from 0% to 21% (POST). The CR was lower in POST for samples submitted from frequent collectors (practitioners submitting >72 blood cultures per study period, n = 6), was evaluated separately, and found to improve in POST (from 4.1% to 2.7%). A t test for matched samples for these samplers revealed a significant decrease in the POST period, P = 0.03. CONCLUSIONS: The CR in the ACH ED for peripherally drawn blood cultures is approximately 5% monthly with less than 2% PR. For each culture positive for organism, the chance of contamination is 75% or higher. An intervention emphasizing the appropriate technique, monitored training, and improved CR of a group of frequent collectors is warranted.

Summary of NIH Medical-Surgical Emergency Research Roundtable held on April 30 to May 1, 2009.

STUDY OBJECTIVE: In 2003, the Institute of Medicine Committee on the Future of Emergency Care in the United States Health System convened and identified a crisis in emergency care in the United States, including a need to enhance the research base for emergency care. As a result, the National Institutes of Health (NIH) formed an NIH Task Force on Research in Emergency Medicine to enhance NIH support for emergency care research. Members of the NIH Task Force and academic leaders in emergency care participated in 3 roundtable discussions to prioritize current opportunities for enhancing and conducting emergency care research. The objectives of these discussions were to identify key research questions essential to advancing the scientific underpinnings of emergency care and to discuss the barriers and best means to advance research by exploring the role of research networks and collaboration between the NIH and the emergency care community. METHODS: The Medical-Surgical Research Roundtable was convened on April 30 to May 1, 2009. Before the roundtable, the emergency care domains to be discussed were selected and experts in each of the fields were invited to participate in the roundtable. Domain experts were asked to identify research priorities and challenges and separate them into mechanistic, translational, and clinical categories. After the conference, the lists were circulated among the participants and revised to reach a consensus. RESULTS: Emergency care research is characterized by focus on the timing, sequence, and time sensitivity of disease processes and treatment effects. Rapidly identifying the phenotype and genotype of patients manifesting a specific disease process and the mechanistic reasons for heterogeneity in outcome are important challenges in emergency care research. Other research priorities include the need to elucidate the timing, sequence, and duration of causal molecular and cellular events involved in time-critical illnesses and injuries, and the development of treatments capable of halting or reversing them; the need for novel animal models; and the need to understand why there are regional differences in outcome for the same disease processes. Important barriers to emergency care research include a limited number of trained investigators and experienced mentors, limited research infrastructure and support, and regulatory hurdles. The science of emergency care may be advanced by facilitating the following: (1) training emergency care investigators with research training programs; (2) developing emergency care clinical research networks; (3) integrating emergency care research into Clinical and Translational Science Awards; (4) developing emergency care-specific initiatives within the existing structure of NIH institutes and centers; (5) involving emergency specialists in grant review and research advisory processes; (6) supporting learn-phase or small, clinical trials; and (7) performing research to address ethical and regulatory issues. CONCLUSION: Enhancing the research base supporting the care of medical and surgical emergencies will require progress in specific mechanistic, translational, and clinical domains; effective collaboration of academic investigators across traditional clinical and scientific boundaries; federal support of research in high-priority areas; and overcoming limitations in available infrastructure, research training, and access to patient populations.