Active Monitoring and Feedback to Improve Blood Culture Fill Volumes and Positivity across a Large Integrated Health System.
BACKGROUND:The sensitivity of blood cultures increases with the volume of blood collected. However, hospitals face challenges in collecting adequate fill volume and under-filled blood bottles are ubiquitous. METHODS:Blood bottle fill volumes were measured using an automated monitoring system across multiples sites (10 hospitals, 3 laboratories) within a large suburban/urban health system. Baseline fill volumes were measured for 4 months. A quality improvement program was then implemented over 36 months. Strategies to improve fill volume included education, standardized data collection, novel and unblinded information cascades, targeted communication, and bottle markings for blood collectors. RESULTS:A total of 516,201 blood cultures were evaluated over 40 months. In the pre-implementation period no hospitals collected the recommended 8-10 ml/bottle, and the average system fill volume was 2.3 ml. At the end of the post-implementation period, 7 of 10 hospitals achieved ≥8 ml/bottle and the system-average increased to 8.6 ml (p<0.0001). The positivity rate increased 20%, from 7.39% to 8.85% (p <0.01). Compared to the pre-implementation period, the proportion of positive cultures with potential contaminants (such as coagulase negative staphylococci) decreased, while the proportion of potential pathogens (such as Gram negative rods) increased (p < 0.05). CONCLUSIONS:Here we show that under-filled blood cultures are extremely common but that certain operational and educational strategies can result in sustained improvements across a large and complex network of hospitals and laboratories. This leads to increased detection of pathogens which can have tremendous impact on the management of bloodstream infections and sepsis.