I need some EBP. Do you discard the waste,(first syringe of blood withdrawn) or do you waste the blood then draw the blood culture. I would appreciate feed back. we are in the process of reviewing the policy. Thanks
NO WASTE--The first 10ml go into the culture bottle--BUT I do scrub the hub with CHG and put on a new end cap (CLC) before withdrawing the sample--The same prep Iwould use to draw a peripheral Blood Culture
First of all allow me to make a disclaimer that I am not an infection control expert as it pertains to a speciality or dedicated position within a facility. If I convey information that is not correct please inform me, constructive criticism is essential, whether providing or accepting.
We (PICC Team) are easily frustrated that at almost any change in patient status e.g. fever, WBC elevation, etc... the PICC is the first thing ordered to be replaced. Hence, our central vascular catheter tip culture policy requests blood cultures within 24 hours. A recent policy change mandates all blood cultures be drawn peripherally unless the physician orders one set from the central vascular catheter. To be proactive and do what is best for the patient we obtain orders for just that. To answer the topic question, the specimen from the the catheter is obtained aseptically hub to hub and without any waste. This I believe is important if the facility is utilizing time to sensitivity or time to positivity resulting technology. This method and depending on the results can determine Catheter Associated BSI versus Catheter Related BSI.
Please, any experts in this field, comments (and clarification of anything I posted) are welcome and vitally important especially since recent CMS changes have spotlighted CRBSI's.
Short version: do not waste/discard any from the central catheter.
Timothy L. Creamer, RN
PICC Team Leader, Regional Medical Center Bayonet Point
draw a sample from each lumen - label cultures from each lumen and time drawn (hub to hub) would be best and change cap, don't forget to flush after with 20 ml if manufactuer recommends it.
Draw a peripheral culture as well
No discard/waste - you want the first sample draw as it is the most potent
Than it depends on if you are doing semi-quatitative or semi-qualitative testing as to how the samples are treated
I also need references to support not wasting first draw from CVC. I've read it in the latest INS 2010 infusion therapy book. However, I have to present more evidence to support this practice. Any other articles?
M Wilson, M. Mitchell, A. Morris, P. Murray LR, L. Reller, M. Towns, M. Weinstein, S. Wellstood, W. Dunne, R. Jerris, D. Welch. Principles and Procedures for Blood Cultures; Approved Guideline. Clinical and Laboratory Standards Institute. 2007;27(17).
Our ID team does NOT recommend blood cx from Venous catheters, only from direct needle sticks, using Chloraprep to cleanse the skin.
When there is no visible peripheral veins, we get called and use U/S to get the blood cultures.
Our ID team developed a Guideline for all physicians on how to deal with Suspected Infection and a great Algorithm for work up of fever in a patient with venous central access.
I find that we, as professional venous experts, forget that when it comes to hospitalized patients especially in large medical centers, there are so many different people who access those catheters, some are more knowlegable then others, some are Radiology techs, some are physicians in different levels of their trainings, some are visitors, RN, LVN, not to mention the patients themselves, the different drains on their bed in close proximity to the catheters, the food that falls from the tray on to the bed right next to the catheter hub, and so on and so forth. Sometime I consider it a miracle when the patient gets better! So to ask other professionals with different levels of understanding and different levels of practice knowledge to access catheter for blood culture, you are taking a chance that you are actually culturing the blood, and not the hub.
Bacteremia/fungemia in a patient with an intravascular catheter with at least one positive blood culture obtained from a peripheral vein, clinical manifestations of infections (i.e., fever, chills, and/or hypotension), and no apparent source for the BSI except the catheter. One of the following should be present: a positive semiquantitative (>15 CFU/catheter segment) or quantitative (>103 CFU/catheter segment catheter) culture whereby the same organism (species and antibiogram) is isolated from the catheter segment and peripheral blood; simultaneous quantitative blood cultures with a >5:1 ratio CVC versus peripheral; differential period of CVC culture versus peripheral blood culture positivity of >2 hours.
We are not suggesting not to perform peripheral venipunctures for blood cultures, but if performing CVC vs peripheral as stated above from Appendix A on the CDC website then do not discard or waste any blood from the line draw.
Timothy L. Creamer, RN
PICC Team Leader, Regional Medical Center Bayonet Point
Again, a disclaimer I am not an infection control nurse or recognized expert. Very informative article regarding study conducted at M.D. Anderson Cancer Center. They chose one method for obtaining blood sampling specimens from a CVC and for their patient diagnosis population it was highly appropriate. Their method of choice as stated in the article "to avoid contamination with previously administered agents that could have antimicrobial activity." Our team has been obtaining specimens without discarding any blood for some time, this year we implented some changes and our CRBSI rate decreased from over 3%/1000 days to 0%/1000 days (1st quarter to 3rd quarter).
Thanks again for article link.
Timothy L. Creamer, RN
PICC Team Leader, Regional Medical Center Bayonet Point
For those who do not discard a waste sample when drawing blood cultures from a CVAD, do you follow this practice regardless of whether an infusion is running through the line (i.e., an antimicrobial agent)?
Thanks,
Daphne Broadhurst RN Desjardins Pharmacy Ottawa ON
Are you asking about a single lumen catheter in need for blood cultures to confirm a CRBSI and there is a continuous infusion of an antimicrobial agent? This would be the only situation where there would be a problem. I am not aware of too many antimicrobial agents that require continuous infusion, although I am certain that many can be infused this way. If you are infusing intermittently, there should be no issue. Flush and lock the catheter according to your policy. When the need for a sample for culture presents, draw the initial sample for culture. Doses of antimicrobial agents given by the IV route are not in a concentration great enough to penetrate the biofilm. The culture is trying to collect organisms from the biofilm for culture. Lynn
If you're referring to CVCs, our policy is 5 mL discard volume and then draw the samples.
Angelo M. Aguila, MSN, RN, VA-BC
Vascular Access Nurse
[email protected]
Robbin George RN VA-BC
First of all allow me to make a disclaimer that I am not an infection control expert as it pertains to a speciality or dedicated position within a facility. If I convey information that is not correct please inform me, constructive criticism is essential, whether providing or accepting.
We (PICC Team) are easily frustrated that at almost any change in patient status e.g. fever, WBC elevation, etc... the PICC is the first thing ordered to be replaced. Hence, our central vascular catheter tip culture policy requests blood cultures within 24 hours. A recent policy change mandates all blood cultures be drawn peripherally unless the physician orders one set from the central vascular catheter. To be proactive and do what is best for the patient we obtain orders for just that. To answer the topic question, the specimen from the the catheter is obtained aseptically hub to hub and without any waste. This I believe is important if the facility is utilizing time to sensitivity or time to positivity resulting technology. This method and depending on the results can determine Catheter Associated BSI versus Catheter Related BSI.
Please, any experts in this field, comments (and clarification of anything I posted) are welcome and vitally important especially since recent CMS changes have spotlighted CRBSI's.
Short version: do not waste/discard any from the central catheter.
Timothy L. Creamer, RN
PICC Team Leader, Regional Medical Center Bayonet Point
Clinical Educator, Bard Access Systems
Timothy L. Creamer, RN
Clinical Specialist, Bard Access Systems
Kathy Kokotis
Bard Access Systems
draw a sample from each lumen - label cultures from each lumen and time drawn (hub to hub) would be best and change cap, don't forget to flush after with 20 ml if manufactuer recommends it.
Draw a peripheral culture as well
No discard/waste - you want the first sample draw as it is the most potent
Than it depends on if you are doing semi-quatitative or semi-qualitative testing as to how the samples are treated
kathy
Kathy
Kathy Kokotis
Bard Access Systems
I need a reference to support this practice. I totally agree with this method. Can you help?
PBarney RN CRNI OCN
I also need references to support not wasting first draw from CVC. I've read it in the latest INS 2010 infusion therapy book. However, I have to present more evidence to support this practice. Any other articles?
Thanks,
Dawn
M Wilson, M. Mitchell, A. Morris, P. Murray LR, L. Reller, M. Towns, M. Weinstein, S. Wellstood, W. Dunne, R. Jerris, D. Welch. Principles and Procedures for Blood Cultures; Approved Guideline. Clinical and Laboratory Standards Institute. 2007;27(17).
Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Our ID team does NOT recommend blood cx from Venous catheters, only from direct needle sticks, using Chloraprep to cleanse the skin.
When there is no visible peripheral veins, we get called and use U/S to get the blood cultures.
Our ID team developed a Guideline for all physicians on how to deal with Suspected Infection and a great Algorithm for work up of fever in a patient with venous central access.
I find that we, as professional venous experts, forget that when it comes to hospitalized patients especially in large medical centers, there are so many different people who access those catheters, some are more knowlegable then others, some are Radiology techs, some are physicians in different levels of their trainings, some are visitors, RN, LVN, not to mention the patients themselves, the different drains on their bed in close proximity to the catheters, the food that falls from the tray on to the bed right next to the catheter hub, and so on and so forth. Sometime I consider it a miracle when the patient gets better! So to ask other professionals with different levels of understanding and different levels of practice knowledge to access catheter for blood culture, you are taking a chance that you are actually culturing the blood, and not the hub.
Catheter-Related BSI
Bacteremia/fungemia in a patient with an intravascular catheter with at least one positive blood culture obtained from a peripheral vein, clinical manifestations of infections (i.e., fever, chills, and/or hypotension), and no apparent source for the BSI except the catheter. One of the following should be present: a positive semiquantitative (>15 CFU/catheter segment) or quantitative (>103 CFU/catheter segment catheter) culture whereby the same organism (species and antibiogram) is isolated from the catheter segment and peripheral blood; simultaneous quantitative blood cultures with a >5:1 ratio CVC versus peripheral; differential period of CVC culture versus peripheral blood culture positivity of >2 hours.
We are not suggesting not to perform peripheral venipunctures for blood cultures, but if performing CVC vs peripheral as stated above from Appendix A on the CDC website then do not discard or waste any blood from the line draw.
Timothy L. Creamer, RN
PICC Team Leader, Regional Medical Center Bayonet Point
Clinical Educator, Bard Access Systems
Timothy L. Creamer, RN
Clinical Specialist, Bard Access Systems
To rivka livni-San Francisco General Hospital-
Can you share your ID Guidelines on dealing with suspected infections/algorithm?
[email protected] Thanks.
Cindy Hunchusky, BSN, RN, CRNI
Please look at the literature attached to see how the blood samples were obtained from the CVC.
Angelo M. Aguila, MSN, RN, VA-BC
Vascular Access Nurse
[email protected]
Again, a disclaimer I am not an infection control nurse or recognized expert. Very informative article regarding study conducted at M.D. Anderson Cancer Center. They chose one method for obtaining blood sampling specimens from a CVC and for their patient diagnosis population it was highly appropriate. Their method of choice as stated in the article "to avoid contamination with previously administered agents that could have antimicrobial activity." Our team has been obtaining specimens without discarding any blood for some time, this year we implented some changes and our CRBSI rate decreased from over 3%/1000 days to 0%/1000 days (1st quarter to 3rd quarter).
Thanks again for article link.
Timothy L. Creamer, RN
PICC Team Leader, Regional Medical Center Bayonet Point
Clinical Educator, Bard Access Systems
Timothy L. Creamer, RN
Clinical Specialist, Bard Access Systems
For those who do not discard a waste sample when drawing blood cultures from a CVAD, do you follow this practice regardless of whether an infusion is running through the line (i.e., an antimicrobial agent)?
Thanks,
Daphne Broadhurst RN
Desjardins Pharmacy
Ottawa ON
Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada
Are you asking about a single lumen catheter in need for blood cultures to confirm a CRBSI and there is a continuous infusion of an antimicrobial agent? This would be the only situation where there would be a problem. I am not aware of too many antimicrobial agents that require continuous infusion, although I am certain that many can be infused this way. If you are infusing intermittently, there should be no issue. Flush and lock the catheter according to your policy. When the need for a sample for culture presents, draw the initial sample for culture. Doses of antimicrobial agents given by the IV route are not in a concentration great enough to penetrate the biofilm. The culture is trying to collect organisms from the biofilm for culture. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
To the nurse who posted about having an algorythm from there hospital would you share or post for us. Rinka linvi sp?????
Also, Tim Creamer, you make mention of an article . Which one is it.? Is it the below article that Lynn refernces?
Thanks, Gina
Gina Ward R.N., VA-BC