Reducing Blood Culture Contamination Rates: Introduction of a Combined Education and Skin Antisepsis Intervention
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Background. Blood culture contamination (BCC) is an important quality concern in clinical microbiology as it can lead to unnecessary antimicrobial therapy in patients and increased workload for laboratory scientists. The Clinical Laboratory and Standards Institute recommend BCC rates to be <3 % and recently updated guidelines have set a new goal of 1 %. The aim of this project was to design and implement interventions to reduce BCC rates at our institution.
Methods. We introduced a combined education and skin antisepsis intervention in a large Model 4 academic teaching hospital in the South of Ireland. BD ChloraPrep skin antisepsis applicators (2 % chlorhexidine gluconate/70 % isopropyl alcohol), licensed for use for blood culture specimen collection, were introduced, replacing Clinell (2 % chlorhexidine gluconate/70 % isopropyl alcohol) wipes. In addition, a multimodal education programme was designed and delivered. This consisted of a video demonstrating the recommended blood culture specimen collection technique using the new applicators as well as simulation training for all interns. The video was uploaded to the intranet as an educational resource available to all staff.
Results. The interventions were implemented in July 2022 and BCC rates pre- and post-intervention were calculated. The average BCC rate for the 12 months preceding the intervention (July 2021 to July 2022) was 2.56 % with highest rates in the Emergency Department. This compared to an average rate of 2.2 % in the 12 months post-intervention (July 2022 to July 2023). In comparing the two rates the reduction in BCC rates between the two periods was not statistically significant ( P =0.30).
Conclusion. Overall BCC rates reduced but the difference between the two periods did not reach statistical significance. The resource-intensive nature of providing regular and timely feedback of contamination rates and the larger impact of in-person education and training over virtual modalities may explain the modest reduction. Further investments in these areas, particularly in the Emergency Department, will be necessary to further reduce rates in line with new recommendations.
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Thank you for addressing the points raised by the reviewers.
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The manuscript is well-written, describing an interesting study. The reviewers raise some points that should be addressed. I do not think additional analysis is required, but please pay consideration to the requests for clarification in the Methods and Discussion.
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Comments to Author
The document entitled " Reducing Blood Culture Contamination Rates: Introduction of a Combined Education and Skin Antisepsis Intervention" sheds light on the persistent problem of blood culture contamination within healthcare environments. The manuscript outlines the authors' intervention, which includes educational sessions such as video module for healthcare professionals responsible for specimen collection and replacing antiseptic wipes with applicators also contributed to a decrease in contamination. However, these approaches did not yield a statistically significant difference in the contamination rate before and after the intervention. This manuscript addresses a crucial issue and emphasizes the importance of implementing comprehensive strategies to combat contamination effectively. Major It …
Comments to Author
The document entitled " Reducing Blood Culture Contamination Rates: Introduction of a Combined Education and Skin Antisepsis Intervention" sheds light on the persistent problem of blood culture contamination within healthcare environments. The manuscript outlines the authors' intervention, which includes educational sessions such as video module for healthcare professionals responsible for specimen collection and replacing antiseptic wipes with applicators also contributed to a decrease in contamination. However, these approaches did not yield a statistically significant difference in the contamination rate before and after the intervention. This manuscript addresses a crucial issue and emphasizes the importance of implementing comprehensive strategies to combat contamination effectively. Major It would be more appropriate to perform an analysis of the data derived from the months in which the contamination rate is 2.0% or higher. It would be beneficial to ascertain whether the new healthcare workforce entrants are contributing, given their lack of experience, or poor understanding of the ramifications of contamination on a broader scale. This information will facilitate the identification of potential variables that could alleviate contamination levels. This data will help as the data per month varies as some months display contamination rates below 2.0%. It will be worth exploring the details embedded there. In the discussion authors can mention since there was a modest change in contamination, one way to improve is to make the training session bi-annually and then assess if there was improvement in the contamination rate. The authors have indicated in the introduction line 67 …… sample collection or processing and therefore is not causing infection. It is important to address the role of laboratory personnel or microbiologists in contributing to contamination and provide a more detailed explanation. For instance, how contamination occurs even when using sterile tubes for specimen plating. This point should be further elaborated upon or omitted. The mention of "processing" needs further clarification in the discussion or the introduction. And if the training modules were made available to the lab personnel in addition to phlebotomist/NP should be discussed.
Please rate the manuscript for methodological rigour
Very good
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
Introduction Line 79-80: "The most important causes of BCC are improper technique when collecting the blood sample and inadequate disinfection of the skin." Rewrite the statement, I suggest replacing "most important" with a more appropriate qualifier of "cause'. Line 94: "The literature has shown that BCC rates frequently..." Delete "The". The statement should read, "Literature has shown that BCC rates frequently..." Methodology Line 121: "Prior to blood culture collection". Does the statement seek to indicate prior to the collection of blood for culture? If so, please revise the statement. The phrase "blood culture collection technique" highlights the process of collecting blood specifically to conduct a blood culture, which involves inoculating the blood sample into a culture medium to detect the …
Comments to Author
Introduction Line 79-80: "The most important causes of BCC are improper technique when collecting the blood sample and inadequate disinfection of the skin." Rewrite the statement, I suggest replacing "most important" with a more appropriate qualifier of "cause'. Line 94: "The literature has shown that BCC rates frequently..." Delete "The". The statement should read, "Literature has shown that BCC rates frequently..." Methodology Line 121: "Prior to blood culture collection". Does the statement seek to indicate prior to the collection of blood for culture? If so, please revise the statement. The phrase "blood culture collection technique" highlights the process of collecting blood specifically to conduct a blood culture, which involves inoculating the blood sample into a culture medium to detect the presence of microorganisms. However, the phrase "blood collection technique for culture" emphasizes the purpose of the blood collection, which is for subsequent culturing to detect microorganisms. It specifies that the blood is collected to be used for culture. Which of the above does the authors want to put across in this manuscript? The choice should inform the phrase to be used. The authors failed to mention how the data analysis was performed. Which statistical tools and techniques were used to analyse the data obtained from the data collection process. The authors should provide details of the intervention and a link to the educational material posted online. Results Figures and Tables should appear immediately after their respective description Present each BCC rate with a 95% confidence interval Present the BCC rates of all clinical areas in a single table and show if there is any statistical significance between pre- and post-intervention BCC rates The results needs to revised to clearly inform the readers of impact of the intervention. The structure and presentation of the results need a lot of work. Please refer to other publications for the presentation of results Discussion Line 206: "There was excellent attendance at simulation training sessions as these were incorporated into the hospital induction training programme for new interns." How do the authors quantify/determine "excellent attendance"? Generally, the authors should carefully revise the manuscript and correct all grammatical errors, taking into consideration punctuations and the appropriate use of articles
Please rate the manuscript for methodological rigour
Satisfactory
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
-
Comments to Author
Many thanks to the authors for their contribution. They propose the introduction of a combined education and skin antisepsis intervention to reduce blood culture contamination (BCC) rates. Overall, I think the manuscript is excellent. Very well presented, the methods are sound and allows for reproducibility, and even though their outcomes do not reach statistical significance, reasonable explanations for this were put forward. The implications of BCC were well described, and relevant studies referenced. Limitations were acknowledged and areas for future work presented. All in all, a very insightful manuscript which would be of interest to clinicians who may consider similar approaches to reduce BCC at their institutions.
Please rate the manuscript for methodological rigour
Very good
Comments to Author
Many thanks to the authors for their contribution. They propose the introduction of a combined education and skin antisepsis intervention to reduce blood culture contamination (BCC) rates. Overall, I think the manuscript is excellent. Very well presented, the methods are sound and allows for reproducibility, and even though their outcomes do not reach statistical significance, reasonable explanations for this were put forward. The implications of BCC were well described, and relevant studies referenced. Limitations were acknowledged and areas for future work presented. All in all, a very insightful manuscript which would be of interest to clinicians who may consider similar approaches to reduce BCC at their institutions.
Please rate the manuscript for methodological rigour
Very good
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
-