The pivotal role of nurses in the ongoing detection of bloodstream infections

This article was fully funded and initiated by BD, global medical technology leader and partner to the NHS; and developed in collaboration with Nursing Times. This article has no promotional intent.

The burden of disease caused by bacterial infections continues to grow. In the UK, 40% of emergency hospital admissions are due to bacterial infections, with a third of inpatients on antibiotics at any one time (NHS England, 2023). These statistics highlight the threat and rising risk of antimicrobial resistance (AMR) to our population and impact on our healthcare system.

Leanne Pratico says: “Blood culture analysis remains the primary diagnostic test available to detect bacterial bloodstream infections, identify the causative organism and inform the most appropriate antimicrobial treatment. We are actively committed to supporting a greater adherence to best practice across the blood culture pathway through a series of educational collaborations with healthcare professionals and the patients they care for.”

‘Saving Time Changes Lives’ event acknowledges adherence

Leanne Pratico: “We recently hosted an educational event series Saving Time Changes Lives (STCL) which looked at a more holistic view of the blood culture pathway. Among the attendees were healthcare professionals including phlebotomists, pathology specialists, sepsis nurses and government bodies sharing their knowledge from sample collections, audits, analysis and discussing experiences from a patient’s perspective. The feedback was hugely positive and provided the opportunity to learn about the challenges that may have previously been thought of as unique within their own roles.”

Bloodstream infections and sepsis

An average of 130,000 bloodstream infections are detected every year in the UK alone (NHS England, 2023).

The key to improving patient outcomes is early identification (NHS England, 2015). To put this into context, six hours after the onset of hypotension each hour that treatment is delayed can result in a survival rate reduction of approximately 8% (Kumar et al, 2006). A staggering 80% of sepsis deaths can be prevented with rapid diagnosis and treatment (Kumar et al, 2006). However, every year contaminated blood cultures flag false-positive results leading to complex, unintended patient consequences. These include (Doern et al, 2019):

• Unnecessary and prolonged antibiotic exposure;
• Increased repeated diagnostic testing;
• Prolonged hospital stays.

Beyond the initial identification of symptoms, nurses are responsible for initiating the blood culture pathway to allow for the administration of treatment (Chua et al, 2023).

The role of the nurse in accident and emergency (A&E)

Claire Burnett: “A&E nurses play a vital role at the beginning of the blood collection pathway, yet they can be overlooked. This is an important factor when we consider the patient challenges they might face such as needle phobia or difficult vascular access. There might be other ongoing patient complexities too, such as comorbidities and psychological safety, so it is vital we acknowledge them, and that the collaboration starts there.”

Claire Burnett: “Diagnosing cause of infection is often seen as a lab-based task from a nurses perspective yet there are huge benefits across the patient pathway and sharing the key role nurses play right from the start. If we relay this message throughout all stages of the patient pathway, it can lead to great adoption, adherence, and improvement.”

Evidence-based guidelines improve adherence

Blood culture contamination can not only compromise quality of care, but it can also lead to unnecessary antibiotic exposure and prolonged length of hospitalisation resulting in secondary risks for the patient (Palavecino, 2023).

NHS England and NHS Improvement are leading the way to improving pre-analytical aspects of the blood culture pathway with the aim to standardise best practice by the end of 2024-25.

NHS England’s recommendations (NHS England, 2023), published in 2023, include:

• Building upon existing guidance and best practice through comprehension and training;
• Implementing local audits to identify areas for improvement ensuring AMR is a key focus of the clinical leadership.

Leanne Pratico: “At BD, we continue to support these recommendations through training, resources, and by facilitating opportunities to gather healthcare professionals and peers together to discuss how to build and implement improvements effectively in their organisation.”

Skin antisepsis is key

Effective skin antisepsis is an important actionable practice that can improve blood collection contamination. The Aseptic Non-Touch Technique (ANTT®) is used in over 30 countries internationally including the UK (Clare and Rowley, 2021).

In 2022, a roundtable of expert vascular access, IV, healthcare-associated infection and intensive care unit clinicians concluded that the ANTT®, should be adhered using an MHRA-licensed applicator containing 2% chlorhexidine gluconate in 70% isopropyl alcohol solution using the following guidelines (Clare and Rowley, 2021):

• Bidirectional (back and forth) strokes for up to 30 seconds;
• Leaving the skin to fully air dry for 30 seconds.

In 2020, studies from the Royal College of Nursing explored clinicians’ views to guide the practice of aseptic technique. As part of the study, data was collected from clinical groups, including interviews with smaller groups of healthcare participants to understand how they defined the aseptic technique (Gould et al, 2020).

The results concluded enormous disparity. Few participants mentioned ANTT® and an even smaller number appeared to be fully conversant with ANTT®. The differences in participants perception, the aim of aseptic technique, its purpose, and with those in the community questioning whether the technique is necessary, demonstrates the need for further work in this area. 

Blood culture collection – the gold standard

Collecting higher volumes of blood for blood cultures has been shown to improve pathogen yield and antimicrobial stewardship for adult patients with suspected serious bacterial infection. The NHS national review highlighted three key actionable priorities to optimise infection prevention (NHS England, 2023):

• Two bottle sets of 2x blood cultures should be collected from each patient with suspected sepsis i.e. two aerobic and two anaerobic bottles;
• Collect at least 40ml of blood culture per patient;
• Bottles should be incubated in an analyser as soon as possible within four hours of collection.

Adherence to evidence-based guidance is key to improving the delivery of safe, effective, and efficient patient care. To do this, a programme of continued education and training is key to supporting national guidelines and adherence.

The sepsis agenda – framework for collaboration

The sepsis agenda and role of blood cultures in management and diagnosis are rarely discussed in the same forums, yet improving blood collection techniques can reduce the risk of further infections.

Claire Burnett: “Once blood samples are collected and sent off to the lab, A&E nurses don’t have sight of the results and the tremendous effect their role played in blood culture collection or the impact it has had on their patient. We can do more to show how their role can help improve outcomes through knowledge sharing and education to nursing teams – in particular those who are at the beginning of the patient pathway. For example, offering contextualised improvement feedback to nursing communities has been hugely motivating whilst ensuring best practice compliance.”

Leanne Pratico: “We support our NHS partners through a number of actionable programmes, including surveillance tools, to capture point prevalence practice. These help trusts identify the gaps in adherence to best practice before a programme of training and change can be implemented and adopted. Continuous surveillance is important to sustain and provide evidence of clinical practice improvement.”

Our commitment to diagnostic excellence

Leanne Pratico: “We really value these partnerships with NHS trusts as part of our commitment to improve further diagnostic excellence. We can achieve this through a number of ways – robust collaboration, through research-based training programmes, educational materials and resources, the provision of diagnostic solutions and MHRA-approved applicator products. The continued work with healthcare trusts and leaders like the Royal Berkshire Hospital and Claire are key to improving patient and diagnostic excellence to drive meaningful change and to improve the welfare and care of patients in their community.”

Sepsis continues to be a leading cause of mortality and critical illness in the UK, with at least 245,000 cases detected annually causing up to 48,000 deaths per year (The UK Sepsis Trust, 2023). This is why recognising the vital role of the nurse is key along with getting the right patient the right treatment at the right time.

References

Chua WL et al (2023) Nurses' knowledge and confidence in recognizing and managing patients with sepsis: A multi-site cross-sectional study. Journal of Advanced Nursing; 79, 2: 616-29.

Clare, S, Rowley S (2021) Best practice skin antisepsis for insertion of peripheral catheters, British Journal of Nursing; 30: 1, doi: 10.12968/bjon.2021.30.1.8.

Doern GV et al (2019) Practical guidance for clinical microbiology laboratories: A comprehensive update on the problem of blood culture contamination and a discussion of methods for addressing the problem. Clinical Microbiology Reviews; 33: 1, e00009.

Gould D et al (2020), Understanding Aseptic Technique: An RCN investigation into clinician views to guide the practice of aseptic technique. Royal College of Nursing.

Kumar A et al (2006) Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Critical Care Medicine; 34: 6, 1589-1596.

NHS England (2023) Improving the Blood Culture Pathway: A national review of blood culture pathway processes to support better antimicrobial stewardship and improved patient safety. NHSE.

NHS England (2015) Improving Outcomes for Patients with Sepsis: A cross-system action plan. NHSE.

Palavecino E et al (2023) Laboratory approaches to determining blood culture contamination rates: an ASM Laboratory Practices Subcommittee report. Journal of Clinical Microbiology; 62: 2, e0102823.

The UK Sepsis Trust (2023) About. sepsistrust.org (accessed 5 January 2024).