- Describe your topic.
- As a clinician I have frequently looked to the guidance that AHRQ provides for evidence based practices. As a clinician concerned about the development of MDROs, Clostridium difficile infection and antibiotic stewardship, I am reaching out to you to provide information and evidence or harm from contaminated blood cultures and the reduction of such with a new technology. One of the peer reviewed articles is attached to validate evidence based practices. The P values are very strong. Over 1 million Americans are impacted by a contaminated blood culture every year. Currently over $4 Billion dollars is spent on an unnecessary extended length of stay and potentially harmful broad spectrum antibiotic treatment of these contaminated cultures. This may lead to a host of downstream complications increasing morbidity and mortality. The benchmark of 3% is truly not a 3% when we consider that 8% of blood cultures come back as positive (either true or false positive). This means that a 3% is really a 3/8 which is almost 40% diagnostic inaccuracy. Even if the hospital has PCR or rapid diagnostic molecular testing and the organism comes back as CoNS (coagulase negative staph), this organism is responsible for true bacteremia anywhere from 15%-38% of the time per peer reviewed articles. This then puts the treating physician in a conundrum and historically we then treat a majority of the time even though this could be a contaminant, we cannot take the chance that this represents a true bacteremia and not treat. Accurate blood cultures are needed and to date training and education have not been able to sustain outcomes. This technology reduced contamination of blood cultures to 0.2% at the University of Nebraska ED and kept these rates for 12 months until the product was taken away and the rates jumped to 2.8% at the end of the study. While that does not seem high, it ends up impacting hundreds of patients/year in just one facility ED. When we start extrapolating these numbers out across hospitals in America, it is clear that we are harming many hundreds of thousands of patients unnecessarily even when rates are "acceptably" low.
- Describe why this topic is important.
- A very significant decrease in blood culture contamination using an Initial Specimen Diversion Device prevents the untoward downstream consequences from the unnecessary utilization of antibiotics. Some of the most problematic ones being development of Clostridium difficile infection, false CLABSI reporting and treatment and an unnecessary extended length of stay. This clinically and statistically significant reduction that has been demonstrated in the attached peer reviewed literature, also greatly enhances antibiotic stewardship. This has been proven to reduce Vancomycin DOT hospital wide by 37% when this technology was used in the Emergency Department alone. This is outlined in a poster presented at SHEA. This work was done by San Antonio Military Medical Center, the largest DoD hospital in the United States. This evidence based practice greatly enhances patient safety, quality and prevention of harm. Some of the untoward consequences from contaminated blood cultures are outlined below. A link for the University of Nebraska; Dr. Mark Rupp video is below. • https://vimeo.com/217573223/77dd887424
- Tell us why you are suggesting this topic.
- Peer reviewed articles on false CLABSIs due to contaminated blood cultures are available. Currently there are three of these peer reviewed articles identifying this costly additional problem as a result of contaminated blood cultures. Below is a synopsis of how this technology helps the patient and the hospital. Improves Patient Safety, Care and Experience • Reduces unnecessary and inappropriate use of antibiotics due to false positive culture results and associated patient risks of developing antibiotic-resistant infections (MRSA, VRE, etc.) and other complications including Clostridium difficile infection (C. diff). • Reduces patient exposure to hospital-acquired infections/conditions (HAIs/HACs) associated with extended length of stay due to false positive results. Facilitates Mandated Antimicrobial Stewardship Compliance • Aids hospital compliance with The Joint Commission, CMS and Federally mandated 2017 requirements to implement an effective antimicrobial stewardship program to reduce unnecessary and inappropriate use of antibiotics. Meeting NPSG 7.03.01 can be aided by using this technology due to reduction of antibiotic utilization, helping prevent the formation of MDROs. • National Quality Forum (NQF) National Quality Partner Playbook: Antibiotic Stewardship in Acute Care states that avoiding inappropriate treatment of culture contaminants, is a method to improve antibiotic use. • Administration of non-essential broad spectrum antibiotics is a contributor to Clostridium difficile infection affirming a need to adopt aggressive antimicrobial stewardship practices. "Appropriate antimicrobial stewardship therefore is, and will likely remain, central to the control of C.difficile infections (1)”. o 1Effects of control interventions on Clostridium difficile infection in England: an observational study, Lancet Infect Dis 2017; 17: 411-21 o Hospitals across the US increased their Vancomycin usage (DOT) by 32% from 2006-2012. (JAMA). San Antonio Military Medical Center decreased their dosing (DOT) hospital wide by 37% with the use of this technology. The SAMMC poster is attached. Reduces Hospital-and System-wide Costs • Avoidable costs associated with blood culture contamination and false positive cultures include: o Additional testing and lab costs. o Increased use of antibiotics. o Treatment of complications due to antibiotic-resistant infections and other complications including C diff. Unnecessary extended length of stay. o Preventable HACs/HAIs due to extended length of stay. It would be an honor and privilege to work with you on this significant problem in order to enhance antimicrobial stewardship and make our healthcare delivery safer, of higher quality and one that prevents harm.
- Target Date.
- Describe what you are doing currently and what you are hoping will change because of a new evidence report.
- Multiple hospitals and systems that have adopted this initial specimen diversion device have all seen tremendous outcomes for patient safety, quality and prevention of harm. If we can prevent blood culture contamination and have an accurate diagnosis for sepsis and not treat unnecessarily with broad spectrum antibiotics we will see vast improvements. $4Billion dollars of healthcare dollars that are currently spent doing harm from unnecessary antibiotics will then be able to used to do good for our patient population. This in turn helps prevent the formation of MDROs and CDI. This has been evidenced by the SHEA poster presented by SAMMC on Vancomycin reduction of 37% DOT hospital wide by what was done in the ED. Secondarily we will see fewer readmission since we know from the ICAAC study and presentation that when a robust antibiotic stewardship program is in place and fewer antibiotics are given, readmissions are reduced. Thirdly we will have fewer patients with an extended length of stay that is unnecessary and this lessens their exposure to acquiring an HAI or HAC.
- How will you or your group use the information from a new evidence report?
- The new evidence report would help to serve clinical knowledge where there is currently a knowledge gap. This in turn would help develop a new standard of care for patient safety, quality and prevention of harm to be integrated into medical practice. Hospitals that have integrated this technology have put a new practice and policy in place. However there is still a very significant knowledge gap and paucity of best practice across the United States. Thousands of patients are still being misdiagnosed due to a contaminated blood culture and receiving unnecessary and potentially harmful antibiotic dosing and an unnecessary extended length of stay.
- How would you or your group plan to disseminate information from the report? Who would you plan to disseminate it to?
- This report would be disseminated to acute care hospitals for knowledge of a new evidence based practice.
- Do you know of organizations that could use an evidence report to change clinical practice? Are you a part of, or have you been in contact with, any organizations that might implement the research findings of an evidence report?
- Acute care hospitals, The Joint Commission, IHI, NPSF, The Armstrong Institute Center for Diagnostic Excellence, APIC, SHEA, IDSA, NQF, CDC, ENA, Robert Wood Johnson Foundation, ISMP, Coalition to Improve Diagnosis, ASM, ECRI etc.
- Information About You: (optional)
-
- Provide a description of your role or perspective.
- RN Clinician; National Clinical Operations
- If you are you making a suggestion on behalf of an organization, please state the name of the organization.
- Magnolia Medical Technologies
- Please tell us how you heard about the Effective Health Care Program.
- I use AHRQ to reference and discover evidence based practices
