The early detection and aggressive management of sepsis is vital in reducing morbidity and mortality, and the gold standard in detecting bacteraemia in our patients is the blood culture.

Contamination of blood culture specimens or poor technique may lead to delay in optimum clinical decisions and management with inappropriate or unnecessary antibiotics. Not to mention wasted expenses.

Blood culture bottles contain a soup of nutrients that feed a wide range of bacteria/fungi. Some bottles (including the BD BACTEC Plus media) also contain a resin to neutralise any antibiotics present in the patient’s blood in order to promote organism growth.

When taking blood cultures aseptic non-touch technique should be followed.
Emphasis should be placed on following your hospital blood culture collection policy without taking shortcuts.

Decontamination:

The most common cause of false positive results occurs due to contamination from the patient’s own skin at the collection site.

Solutions that can be used for site decontamination include:

• greater than 0.5% alcohol chlorhexidine (drying time 60 seconds)
• 70% isopropyl alcohol (drying time 0 seconds)
• providone iodine (drying time 2 minutes)

Always allow enough time for antiseptic solution to dry before taking cultures. It is also important to thoroughly clean the tops and necks of culture bottles prior to collection.

There are also commercially available one-step applicators containing combinations such as chlorhexidine gluconate and isopropyl alcohol.

Studies have found alcohol based products show statistically significant improvement in reducing false positives from skin contamination (Dawson 2013).

Technique:

One randomized, study involving 64 interns in an ICU/medical wards found that the routine use of sterile gloves resulted in lower contamination rates.
Sterile or not, it is important to resist the urge to re-palpate the vein after cleaning the site as this increases contamination risk.

Blood specimens obtained after an antibiotic has been administered may contain enough quantities of antibiotic to kill any bacteria collected in the bottle (Halm 2011).
Therefore specimens should be collected prior to antibiotics…. with the important caveat that blood collection must not significantly delay time to antibiotic administration.
If antibiotics have been administered the cultures should be taken just prior to the next dose for this same reason (Dawson 2013)

Volume:

It is very important to obtain the correct volume of blood. The preferred volume for each blood culture bottle is 10mls (However, you should refer to your individual manufacturers recommendation).
So that means a 20mls collection from a single site divided into each bottle.
Under filling may result in an insufficient ‘yield’ of microorganisms.
Overfilling may result in false positive results.

Each blood culture collection should comprise a paired set, each set taken from a different location.
In patients with limited peripheral access both sets can be taken from the same site. However the second specimen should be obtained as if from a separate site with new equipment and re-cleaning of the area etc.

If an infected central line is suspected (eg cellulitis or discharge from the insertion site or extended use of the line), the second set of cultures may be taken from this site. Blood should be drawn from the distal lumen after decontamination as above.

Order of draw:

Which bottle should you fill first?
Actually it depends on the technique used.
The idea is to prevent air being introduced into the ANAEROBIC bottle and altering its environment.

• If a butterfly needle and needle-safety connector device is used the AEROBIC bottle should be filled first as there will likely be air in the tubing.
• If a needle and syringe is used the ANAEROBIC bottle should be filled first as any air is likely to be at the top of the syringe and thus introduced into the second bottle.
• If blood is being collected for other tests at the same time the culture bottles should be filled first to prevent cross contamination from other blood tubes.

Collection of separate samples can be done “back to back”. The common practice of separating collection samples by 15 to 30 minutes does not enhance the yield of bacteria and may increase the time to antibiotic administration. (Halm 2011)

The labelling of the specimen bottles is important.
As well as patient details information should be included describing:

• Source of sample (eg central line, anatomical location).
• Time sample was obtained

—————————————————–
References:

Dawson S. Blood cultures. British Journal Of Hospital Medicine (17508460) April 2012;73(4):C53–5. Accessed March 18, 2013.

Jennifer Denno, Mary Gannon, Practical Steps to Lower Blood Culture Contamination Rates in the Emergency Department, Journal of Emergency Nursing, 10.1016/j.jen.2012.03.006.
(http://www.sciencedirect.com/science/article/pii/S0099176712001109)

Flayhart D. Blood cultures and detection of sepsis… …Tips from the clinical experts. MLO: Medical Laboratory Observer. March 2012;44(3):34 Accessed March 18, 2013.

Halm M, Hickson T, Stein D, Tanner M, VandeGraaf S. BLOOD CULTURES AND CENTRAL CATHETERS: IS THE “EASIEST WAY” BEST PRACTICE?. American Journal Of Critical Care. July 2011;20(4):335–338. Accessed March 18, 2013.

Kim N, Kim M, Oh M, et al. Effect of routine sterile gloving on contamination rates in blood culture: a cluster randomized trial. Annals Of Internal Medicine February 2011;154(3):145–151. Accessed March 18, 2013.

One of the most frustrating and time consuming activities that befalls a nurse working in the paediatric area of the emergency department is obtaining a midstream urine collection from a baby.

Some units may opt for using sterile stick-on collection bags. But my own experience has been that this method is less than effective often resulting in a contaminated specimen that is not really mid-stream anyways.
And collection of a spontaneous pee (often delegated to the parents) although hilarious to watch, is also sub-optimal.

A recent paper from Madrid proposes a method to produce a flow of urine on demand in infants. And I can report that our own unit has found it to be quite effective for both neonates, infants and some older babies.

Procedure:

It takes a minimum of two people to perform this procedure. However, it is better with three, one dedicated to making the catch.

1. Encourage oral fluid intake.
2. 25 minutes following this feed, the baby/infants genitals are cleaned thoroughly with warm soapy water and dried with sterile gauze.
3. Sterile container is prepared to collect specimen.
4. Baby is held under the armpits (just above the bed) with legs dangling (the parents can easily assist with this).
5. The nurse then starts bladder stimulation which consists of gentle tapping in the suprapubic area at a rate of 100 taps per minute for 30 seconds.
6. Next, the lumbar paravertebral zone (think the small of the lower back) is massaged in a light circular motion for 30 seconds.
7. Step 5 and six are repeated until urine is released.
   Stand clear & catch the mid-stream.

The paper goes on to discuss the theory behind this manoeuvre which aims to stimulate the detrusor muscle:

The detrusor muscle is innervated by the parasympathetic pelvic nerves (S2–S4). The spinal micturition reflex is a simple arch reflex. Distended bladder walls stimulate efferent fibres going to the medulla, the arch reflex is produced in S2–S4, and afferent fibres stimulate the detrusor muscle which contracts to pass urine. This reflex is voluntarily inhibited and controlled in continent individuals by the cortex, but not in newborns. In neonates, it can be triggered, as we propose.
A new technique for fast and safe collection of urine in newborns¹

As I mentioned, our own nurses are reporting a pretty good pee-on-demand success rate using this method.

So. A relatively easy non-invasive intervention that you can try out for yourself.
Impress parents and colleagues with your skills!

Let us know how effective you find it.

1. Herreros Fernandez ML, Gonzalez Merino N, Tagarro Garcia A, et al. Arch Dis Child 2013, 98, 27–29 [↩]

I have written about this before but I still see it a lot. Perhaps you have too.

A doctor orders for a fluid bag (or a set bolus of fluid) to be delivered STAT

The nurse diligently loads the bag into an infusion pump (or perhaps it was already running via a pump) and maxes up the delivery rate.
On many pumps (for example the Imed) this will be 999mls/hr. Our new Bbraun Space pumps max out at 1200mls/hr. Other pumps might allow faster delivery rates 2000 perhaps? Or 3000?
Indeed these are big numbers. But they are not STAT.

We need to be up around 11,000–12,000 mls/hr here…..conditions permitting.

The word stat comes from the Latin statim which means immediately. Right now, at once, instantly.
Unfortunately, even at full throttle an Imed pump dialled up to 999 is going to take an hour to deliver a 1L bag of fluid….which is a long way from instantly.

So here are some quick tips for delivering a fluid bolus Stat:

• Remove the drip set from the pump and open the roller clamp fully. We can then raise the IV pole as high as it will go to increase the flow.
  If your rusted pre-Civil War IV pole (held at half mast with tape) wont go any higher….drop the bed height.
• Look at the drip chamber. Ideally, you do not want to see drips. What you want to see is a solid ‘tube’ of fluid flowing across the chamber.
• Consider using a separate blood/fluid pump giving set to deliver the bolus. These sets have a small reservoir container built into the giving set, that allows you to hand pump in the fluids at a much greater rate. Every nurse should be familiar with how to prime and use these sorts of pump sets.
• Consider increasing the flow by using a pressure bag over the IV flask ( um…..unless of course its a glass one right?)
• If the patient is going to need rapid fluid resuscitation it is important to look at the size and state of the patients cannula. A small diameter cannula will offer greater resistance to fluid flow. And a cannula sited in some tortuously winding vein in the back of the patients thumb just wont cut it. Consider inserting a large bore cannula into a large vein (eg anti-cubital fossa), or seeing if central access is required.
• If we are delivering a set bolus of fluid (say 500mls from a 1L bag), keep a close eye on the infusion so you can throttle back once the desired volume has been administered.

So the take home message is: You cannot deliver a Stat fluid bolus via an electronic pump that has a maximum delivery rate in the vicinity of 999 mls/hr.

Amanda Stock, Amber Hill and Franz E Babl (a hospital play therapist and two ED physicians) have published a paper in Emergency Medicine Australasia describing some age-appropriate non-threatening and positive language statements for use by clinicians when describing  procedures to children.

The table of descriptors has been developed for use in an emergency department setting where resources such as play therapists may be limited or unavailable and where clinicians may have only a few minutes to develop a rapport with both the child and family, and provide clear explanation of what is about to happen.

In stressful environments it is easy for details about the child’s care to be misunderstood by the family. The medical jargon that healthcare providers use can frighten and intimidate families leading to communication failures. Using simple language appropriate to the child’s developmental level is vital as children have a more concrete way of understanding the world. The commonly used phrases, such as ‘going to theatre’, ‘doing a dressing change’ and ‘flushing the iv’, can be very confusing as these phrases can be interpreted as having alternative meanings. This makes it fundamental for healthcare staff to pay close attention to the language used with children and their families.

There is some very useful stuff here. Have a think about the language you use to give important information to the children you are caring for (and the adults too for that matter). Is the message you are delivering encoded in medico speak? Or do you make on-the-fly adjustments for age, education, development and context.

The full article is well worth seeking out. It goes on to give communication tips for the parents/ family as well.

You may have your own tried and true explanations for various procedures or pieces of equipment that you could share with us.

Equipment:

• Topical anaesthetic cream: The cream on your skin helps to make your skin feel numb. Numb means that you can’t feel that part as much or not at all.
• Bandage For a wound or fracture – this helps to keep your sore (name body part) nice and safe.
  For an intravenous catheter – this helps keep the straw in your hand.
• Blood pressure cuff: This goes around your arm and gets tight. It doesn’t stay tight for long. It helps to know how strong your heart is pumping.
• Cardiac monitor leads: These are the buttons on your tummy and chest – the long strings go to the monitor and help check how your heart is beating.
• Monitor: Your body is drawing lines on the screen – this helps us look after you.
• Electrocardiogram (ECG): These stickers on your chest, arms and legs connect to the ECG machine and give a picture of how your heart is beating. It is important to keep still while we are taking the picture.
• Intravenous catheter (IVC): A small straw or tube that goes into your vein to give your body a drink of medicine.
• Plaster of Paris: Protects your broken bone until it gets better.
• Stethoscope: Helps to hear the sounds the inside of your body makes – how your heart is beating, how you are breathing.
• Syringe: A tube with numbers on it – describe its purpose.
  E.g. a helper to give medicine in your mouth.
• Tape: Special hospital sticky tape to make sure the straw (IVC) stays in the your hand.
  Tegaderm Like big clear sticky tape.
• Tourniquet: Looks like a belt that goes around your arm. It may feel tight – its job is to find the best veins.

Procedures:

• Anaesthetic Medicine: we give you through the straw in your hand or with a mask that makes you go to sleep so the doctor can (name procedure). You will not feel anything and when it is finished you will wake up.

• Blood test: A needle that goes under the skin to take a very small amount of blood. Explain reason for blood test. Tells the doctor information about how to make you better.
• Fasting: You cannot eat or drink anything. Explain reason why in developmentally appropriate terms.
• Flush intravenous catheter (IVC): Water goes into the straw with the syringe to make sure it is working.
• Fracture: Broken bone.
• Fracture reduction: Putting the broken bone back in the right spot so that it can get better.
• Infusion:  Medicine that takes a bit of time to go through the straw and into your body.
• Injection: Medicine that we put into your body with a small needle.
• Lumbar puncture: A needle that goes into your back to take a small amount of fluid.
  Describe positioning during lumbar puncture.
  Explanation of cerebrospinal fluid and purpose of test depends on age of child.
• Magnetic resonance imaging (MRI)/computed tomography scan (CT): Takes a picture of the inside of you. Describe what the child will see, sounds they will hear, how equipment will move, what the child’s role is.
• Nitrous oxide: Special medicine air that comes out through the mask. You can’t see it. It helps make the pain go away.
  Some children say it makes them have funny dreams.
  It is sometimes called laughing gas because it makes some people laugh a lot.
• Observations ‘obs’: The nurses do ‘obs’ to see how your body is working. ‘Obs’ mean they find out how fast your heart is going and how quickly you are breathing.

• Oxygen saturation (sats): This machine is like a peg that sits on your finger. It tells us how your lungs are working.
• Ondansetron wafer: A medicine that helps to make your tummy better and stops the vomiting.
  It is small and goes on your tongue.
  You don’t need to swallow it.
• Procedure/treatment room: A different room to go to for your ‘name of procedure’. It has everything the doctors and nurses need. Mum and/or dad (caregiver) can come with you when you go there.

• Sedation Medicine that helps you to feel more relaxed. Explain sensations further depending on sedation agent.

• Stool collection: Use familiar term, e.g. poo
• Suture: Like a band aid made out of strings to hold your skin together so it can heal the best (explain steps of procedure if developmentally appropriate).
• Going to theatre: Explain reasoning for operation on a developmentally appropriate level. Only use details relevant to child, what they will experience awake, pre- and postoperative care.
• Urine collection/checking urine: Checking to see how healthy your wee/pee is.

Abstract: Practical communication guide for paediatric procedures.

I received an email today from Matt:

I have just received a copy of our new ‘6 rights of medication’ poster that will apparently be distributed to our appropriate health service sites. To say that it is uninspiring and forgettable is a dramatic understatement.

I was hoping with your experience you might have seen something that I
may be able to present to our administration for use or inspiration?

Now, I had a bit of a poke around and couldn’t find anything very interesting……but as Matt is a cool dude, and gives me a regular fix of comment crack, the very least I can do is whip something up for him.
And, I have even thrown in an extra 2 ‘rights’ at no extra charge.

I have tried to keep it simple, crisp and clean. A small A4 size that is easily printed out and stuck on medication cupboards etc.
Let me know what you think.

You can download the 8 rights of medication administration as a pdf file in two versions.

1. Version one: with no fluff, no guff, and no duff.
   
2. Version two: with some explanatory notes.

Stick them where you think they may be of use!