Transcript: Clinical Microbiology

Transcript

TRIONA HENDERSON: Good afternoon. My name is Triona Henderson. I am a facilitator for this ECHO Model™ pilot project. I extend a warm welcome to you at the Centers for Disease Control and Prevention here in Atlanta. Thank you for joining us.

The topic for this discussion is clinical microbiology, my favorite. Our expert today is Dr. La' Tonzia Adams, who will present. She is a board-certified pathologist and serves as the medical director of microbiology, chemistry, support services, and is the co-director of the Veterans Affairs program at the Portland Healthcare System in Portland, Oregon. Thank you so much for joining us today.

Here is some technical information about these ECHO sessions. Before introductions, a few things to keep in mind. Please use your video. The purpose of this is to be interactive. We love to put a face to the name. If not possible, you cannot put on your camera, please identify yourself by name and institution when you are speaking. Right now, all microphones are muted. During the discussion session, you will be able to unmute.

If you are connecting by phone only, either rename yourself, if you are able to or if you are connecting by the institution login ID, please rename yourself. We have those frequent flyers to our ECHO session. If you experience technical issues, please send a message to the person waiting right now.

Finally, we design relevant sessions based on your responses. We encourage you to complete the evaluation. For all of the sessions, we are offering credit for those who require them. There are options you can either receive a certificate of participation or a certificate upon completion. If you have any additional comments, please email us.

How are the sessions different than your usual webinar? These are really around discussing cases or a clinical laboratory challenge as the main feature. The subject matter experts will hope to share their work with you that will be translatable to all of you in your individual laboratories. These ECHO sessions will focus exclusively on clinical and public health laboratories in the United States and US territories. Once again, we value the discussion amongst all of you that ensues and want to encourage you to share your own experiences with these challenging topics.

Here is an overview of the process. The subject matter expert will have a presentation; then, I will ask some clarifying questions to the SME, then we'll open up for ideas and shared experiences and comments from the subject matter expert, then we will have closing comments and reminders and then adjourn. Today's session is being recorded. If you do not wish to be recorded, please disconnect now. Closed captioning is also provided, and you can find the link in the Zoom chatbox.

Here is a bio sketch for Dr. Adams. Dr. Adams received her medical degree from Ross University School of Medicine and completed her residency in anatomic and clinical pathology at the University of Illinois Hospital and Health Science System in Chicago. She also completed a Medical Microbiology Fellowship at Johns Hopkin University. In 2019, she was honored by the American Society of Clinical Pathology's (ASCP) 40 Under Forty Program, which recognizes forty high-achieving pathologists and laboratory professionals for professional excellence.

She prides herself as being one of those pathologists who has decided to step from behind the microscope and out of the laboratory. As a Clinical Pathologist, she views laboratory medicine as an integral part of the healthcare system and patient care. She believes too many of our fellow clinicians and administrators look at the laboratory as this "black box" where samples go in and answers come out. It has been her goal to bring awareness and understanding of what the laboratory's actual role is through interdepartmental talks/in-services, serving on facility-wide committees, and using clinical consultations as educational opportunities.

In addition, she believes that there needs to be more exposure to clinical laboratory sciences. She speaks at various elementary, high schools, and colleges in the community on the field of pathology and clinical laboratory sciences. In addition, she serves on the Clinical Microbiology Mentoring Subcommittee for the American Society for Microbiology (ASM). In her spare time, she enjoys playing the piano and bringing advocacy and awareness to Lipedema and other subcutaneous adipose tissue diseases.

Please think about similar situations you have encountered or how you may apply her institution experience. Now we will invite her to begin her presentation.

LA'TONZIA ADAMS: Thank you for that. I am going to be sharing my screen.

Okay. Can you see that? Is that clear to everyone? Great. I'm going to talk about improving blood culture quality for interdepartmental communications. So, as she stated, I work at the Portland Veterans Affairs Healthcare System. We are a 227-bed facility. We serve 95,000 veterans. With that, we have 950,000 outpatients that are in visits a year. This encompasses those from Oregon and Southwest Washington state. We also served ten community-based outpatient clinics. There are other outpatient clinics as well that they will refer to the healthcare system four.

This is our lab. We average 6000 blood cultures annually. We have the BacTAlert culture system. I would like to start with a quote. "The most dangerous phrase in the language, we've always done it this way." That is so true.

I finished my training and I started in January 2016. February 2016, there was a blood culture Gram stain reporting concern that surfaced. While investigating and trying to understand that process, especially as we were in a new facility, more issues arise. This was the epitome of just seeing the tip of the iceberg. The first thing that I would like to do is to explain how I approach the situation. I would like to do this in a step manner. Step one, before I start, there's a few things people should know. It is extremely manual. We use paperwork cards as opposed to electronic systems. There's also an LIS system; it is very secure. We will be changing it soon. Nevertheless, we do the best that we can with what we have.

So, first, we observe the current practice and policies. What I noticed is there are multiple areas of manual documentation of Gram stain reporting. There were also inconsistent specimen labeling processes. Such as some coming with identification and name, that was it. Others had come in with specimen sites that were written down, it was a lot of inconsistencies. There was also inconsistency on the identification.

There was no guidance on when the specimens should arrive to the lab. This resulted in extended transport time between collections and laboratory arrival. There was the practice of daily surveillance blood cultures routinely performed. We had very little feedback given to the provider regarding specimen issues. The blood culture value monitoring was captured once a day per week. That was all that was done to capture that blood culture. Blood culture collection policy, and the laboratory and nursing, it was a minimum of 3 to 5 milliliters collected. Some of them are telling the staff to collect both blood samples from one puncture. Nevertheless, these things made me quite uneasy. So so the next step I chose was to identify specific areas of improvement.

One of them, we needed to streamline the manual blood culture Gram stain reporting process. Next, we needed to update the blood culture environment. We had to better identify the utility purposes, and overall consciously educate and update blood culture collection practices. As for putting emphasis on time to the laboratory of collection, even the method of collection, syringe versus butterfly.

Step three: You want to research best practices. I did a literature search. I consulted the Manual, of course, the Bible of microbiology. I looked at Up-to-Date to see if they were seeing their changes. I spoke with Dr. Weinstein to get his take and get the understanding of further practices. Next, you want to collect your baseline data. This was where what I called the "Blood Culture Deviation Rejection Form" was born. Those specimens arriving to the laboratory greater than two hours after collection, the specimens that were less than 10 milliliters, over 50 milliliters in volume and any labeling areas. From this, out of this time period, 326 of these forms were filled out. Of those forms, 95% of them had under-filled volume. Then, 44% of it also had labeling issues. With this baseline data, you then have the engagement of your stakeholders. You have infection control, nursing, primary care, patient support, laboratory information systems, and the community I'm on controlling those. I took that information and shared it with them to get more of why this was an issue, and it needed to be addressed.

At this meeting that we had, I put together what I called the "Summary of Understanding." This is where we addressed the what, who, why, when, where, and how. What was the problem? What changes are required to meet best practices? Who is being impacted? Who will be responsible for which task? Why is this an issue? Why are the changes necessary? When do we plan to implement changes? When do we start to measure? Where will the changes take place? When will the main focus be? How will we start this change? How will we know if this is a benefit? So, the main goal is to identify these things and to get everyone on the same page. Now we can implement that change. In the system where we started this, the issue was brought to me in February. We had an understanding in March.

To get everyone all together on the same page, going back and forth with various discussions on why those things were the way they were, it took time. When we implemented the change, we had determined that there was only one place for the manual Gram stain reporting. There were, I believe, four different places where they were manually putting down the answers or their results of the Gram stain.

As you can imagine, there are many places for human error. I was able to bring that down on one work card, one sheet. We made a clean copy and gave it to the person that needed to collect and calculate those turnaround times. We updated the laboratory nursing policy to reflect the standard of care. We increase the blood volume from 10 milliliters to 15 milliliters. They should arrive to the laboratory no more than two hours after collection. We also included pictures on the policy and how they should be appropriately labeled with all the information required and how it should be filled out. We also created a blood culture educational PowerPoint. This was for the nursing staff, patient support, and our own phlebotomist.

They updated the deviation form to guide the staff and how to provide feedback. Then, we trained the staff in assessing blood cultures. Then, we went and we had those questions to ask. We also changed the labels. This is how they looked. We have two types of labels. We had a lab collect label, then we have a ward collect label. So, I wanted these components on the label. We were able to work with them and get the actual label to print. When these are printed out, all of these fields are there. It will then cue the phlebotomist to fill out these areas. We also have a picture on how to appropriately label the bottles, where to put it, what to cover, and what not to cover. As far as the staff, we have standardized the way to measure. I picked out these wooden blocks from a fabric store. I then created a measuring tool on the back. You have some inspiration, but you also have utility. These are in various areas where they will receive those blood cultures.

Then, in the educational PowerPoints, there is one for blood culture correction that went step-by-step. It got down to the nitty-gritty details, so there would be no questions. There are periods of time where there were a lot of turnovers. They could always have something to refer to. I put together this PowerPoint. It is mainly for our surgical staff. It showed and explained what we do as a laboratory because, surprisingly, people didn't understand what the lab did. They just thought that they put in orders, and magically the answers emerged. Initially, there was a bit of contention.

When I got there, there was also a culture change that needed to be addressed. The staff were intimidated by the clinicians. They felt afraid. They felt like they didn't have a voice in explaining for projecting the specimens. So, the culture it was, you know, "I'm a physician or the provider, you do what I tell you". That is not necessarily the case. I included this photo to show we are all part of this process in providing patient care. You may be the provider but, this is a pre-analytical step that we have to, in the lab, look and assess to make sure that we analyze that, and we put up those results, and you can rely on those results and trust that these are good results.

So, from that, getting them to realize that the staff felt a bit more empowered and being an example showing that, me personally, I will stand up for my staff and I will show, if anything is wrong, it is not about pointing fingers. This is about education and making sure we are on the same page. In this particular presentation, I wanted to remind them that for us, we are doing the best that we can. We updated the Blood Culture Deviation Rejection Form. I added these post-analytical comments. That way, there is an action to take place for each. If you have a specimen that comes in greater than two hours between collection time and receiving to the laboratory, you put in the comment that it was compromised due to extended transportation time. If there was a volume issue, you would put in there one or more bottles did not meet the minimum required volume, and this reduced the testing. Then, for the other missing data, we will try to ascertain that information and then correct it in the computer.

So, some of the feedback that we received. Within this Summary of Understanding, part of the duties for patient care, nursing, and so forth, was to let them know these are the changes coming. Even without notification, we still got quite a few questions initially after starting this. Some of these were one of these comments: Why is this being put forth? And that was an opportunity for the staff to then have that confidence to explain to them, to educate them. I think that they gave them more confidence to perform their duties effectively. These also brought a bit of accountability to the pre-analytic process. Because now, these are coming down with signatures. You're going to be able to identify if there is a problem; you can trace back that problem. If these are late, and coming back, why was it late? That started to change the culture.

So, afterwards, we want to gather the implementation data to see if we are making a difference. As I stated, there is a long period of starting to implement that. We took a snapshot of the two weeks into this intervention to see if we were making a difference. During that time, we had 191 deviation rejection forms. 76% of them were underfilled, and 80% had labeling issues.

Now when you compare that to the overall data, it is 43% under that. Now, to the baseline data. There were some limitations in that timeframe is much longer with the baseline data which is the post-implementation data. Also, the baseline data we didn't capture the overall number. That would've been better to have. It's a better comparison. But you can still see that the main issues were volume and labeling. Pretty much time stayed the same. I feel that, after that, we went to fine-tune those issues. We are going to standardize how we do the data. We need to identify who should be notified and where to put that focus. We were able to identify this from the ER, the ICU, and patient support. When we looked at the data, we looked at overall data from all the specimens collected. Then, within those things, they figure out what the issue was.

This is January data. You can see that the volume was much better. Those that were underfilled dropped to 60% for overall as opposed to the 45% back in October. Then, for the labeling, it was still a little bit of an issue. As you can see, this is much better than before. Then, six months, this is what we are looking at. The bright blue is October. So, that bar is very high. But as you can see, there is a trend downwards. This goes from October to March of 2017.

The lowest we get down to is the 16th, 17% in January. Overall there was a decrease in that. We were able to see which were having more issues. We found that you also have to provide regular and consistent feedback. Initially, we were reporting monthly back to patient support. Currently, as the situation improved greatly, we now present on a quarterly basis. We're also providing feedback to the laboratory staff. We heavily rely on them to fill out those forms. In order for them to say well, why am I going to do this? They have to fill out some type of ownership that they are making a difference. I always give some type of feedback to make them feel that they are empowered. Something is really being done. Really making them feel valued. This is our last quarterly report. Essentially, the labeling is perfect.

This is quite a difference, it is quite a shock. These numbers represent maybe like one set out of that period of time. This is one blood culture set that was over the two hours, and, if it was, it was maybe 10 minutes. What I was seeing before was in the hours after the two hours allowed. It is quite a bit of significant improvement. With the volume, we are down to 4% to 8% of that total amount of blood cultures.

You know, we made quite a difference in doing this. I feel that, if you take the approach of going from pre-analytic, analytic, post-analytic, looking at the whole picture, you can be a lot more effective. You are getting buy-in from the other departments to let them see what you are doing impacts what they are doing to treat their patients. That is good. If there are any questions, I am right here. We will go to that slide at the end.

Okay. Thank you so much.

HENDERSON: This was awesome. Of course, I had 1 million questions. But for the participants, you can continue to put your questions in the chat. We do prefer that you turn on your camera. This is an interactive discussion. We have a lot of microbiologists and micromanagers, here as well. I do have an informatics question.

First, a lot of things. With data collection, you said with your turnaround time, were you doing that manually, or were you extracting it from your system? Because I feel like our audience is a lot of those practicing in rural areas. Often times, they may not have those resources to have a full dealt with an integrated system of abstracting laboratory data. How did you start that off to even be able to provide the data to your stakeholders so frequently?

ADAMS: As far as the turnaround time, it is unfortunately manually done. When I got there, there were several forms. There are a lot of pieces that are manual, some of them are extracted from the LIS system. But for whatever reason, for the blood cultures, it wasn't as easy as it is for this. This has to do with the lab tech that created that. I don't know; I guess they forgot it.

Micro came in that. There are pieces in there. There are some pieces here that it's not quite perfect. So, we can get some of these. Getting that turnaround time; it's not that great. But when it comes to specifically for blood, it was manual. There was a slip that they were filling out. When it was positive with the result, and how many times it took to contact someone to explain if it was beyond that turnaround time. On that sheet, they would fill it out, another she would get filled out. That would go to one of our secretaries and administrative assistants filling that out and inputting the data into an Excel file.

Then, they are just tabulating all of that. When we have our quarterly patient safety meetings, we would reach out to that person. They would go and create the data for them. [Laughter] What I did was take that sheet, and I would incorporate that into the laboratory microbiology work card. I put that at the very top. That way, whoever was working out the culture; they would have that. They would have a lot. There was so much room for error and confusion. I put it all in one sheet and changed it around.

When that is done, they would make a copy of it. They would then give that copy to an administrative assistant. That way, it was only at one time one place, that's it.

HENDERSON: I'm blown away. That is pretty exceptional that you are collecting that manually.

ADAMS: Yes.

HENDERSON: That says a lot. Another question. For a lot of these quality improvement projects in microbiology, and any of the subspecialty pathology laboratories, we tend to choose one part to work on it and fix it. You guys were able to tackle both and create those processes at the same time. You kind of just ripped off the Band-Aid. You just dealt with it.

Do you have any advice for the community laboratory professionals? How do you get to that culture change?

ADAMS: You have to be persistent. You have to stick to your guns. You also have to choose your battles. You have to figure out which things you are going to fight for.

One key piece of this is having your research. You have to have the information to back it up. You have to have the policies to back it up. One of the issues was, when you look at, at that time, the package insert and some old data, that's what was there. It was the policy. Technically, they follow the policy. It wasn't correct. When I brought that up, well, they said that's not the right way.

We were all just trying to serve the veterans. In this case, we are serving our patients. This is what is best for the patient. Also, you have to look at it from a litigious standpoint. You have to say, that doesn't jar you a bit. What happens if you get sued? What do you do? They are going to ask, are you following best practices? No, you aren't. Why? Because you've done it this way.

You've been doing it wrong; it's no longer correct. You have to change. As far as ripping the Band-Aid off, a lot of people do patch jobs. I could have just ignored everything else that I saw and said well, the issue came from this section. This was related to having multiple areas of writing as a result. I could've said, let me just change it like this. That's it. I could've ignored everything else. It is just my nature. You have to change it all. You have to rip it off.

The key thing is, it may be daunting, but if you are being met with the attitude of "we've always done it this way," it's frustrating. It is just like that quote. How do you move an elephant? One bite at a time. You just set your goals, and you go away at it. You also have to have something that people listen to. I was the new kid on the block. I'm from Portland, Oregon. It's a little bit more laid back here in comparison to where I did my training at Hopkins. It was funny when I went at it. It was like a dog with a bone.

People came to my achievements and said, who is this person? So, you know she's some Hopkins. They were like that's why she's so uptight. [Laughter] It is what it is. You have to do these things. They eventually got it. You are on these committees, that's why you have to get out there. One of my best advocates is the head of infection control. I put a little shout out. Sherry Atherton is great. People listen to her. If I need to make any change, if I can relate it to her, she is my go-to.

Now we work together on the nursing policies. She comes to me. Before this coronavirus hit, that's what we were in the process of doing—making sure that this is the right data references. Then, she gets it out. They listen to her. You just have to do that.

HENDERSON: That's perfect. Thank you. I see a room full of people. I'm putting them on the spot. Let's see if they have a question. Heather?

HEATHER DUNCAN: Hello. How are you?

In regards to the positive back in positive impacts, it's a really large multiscale project. What would you say is, I guess, the hardest-hitting or highest impact improvement that you saw from the improvement?

ADAMS: Honestly, I was shocked at how quickly the blood volumes increased.

It took a little while, but the specimen part, I think what helped with that is we had the support of the LIS. Just changing the labels alone would be able to make that happen. Overall, it's more of the attitude of the people. You have people really genuinely wanting to make a difference and do better.

Then, they just need a little bit of a nudge. The most positive thing was just seeing the change in the blood culture volume. I was shocked to see how quickly it turned over. You know, driving down this, I will give that one before I drop that. But, we stayed around like 7% or 8%. That's pretty good.

DUNCAN: I'm so impressed that you got that piece of this to change like you did. Because that is a major undertaking.

ADAMS: When I got there, you know my background is the private sector. I used to be a microtech. So, that was back in 2005. To give fairness, I don't always compare what we do here. I tried to compare it with the community hospital. You know, it's like, don't you have a barcode scan? Like, oh no. It is slowly trying to get them there.

That is why the whole implementation period was so long. You just have to have patience. You know. It was a learning curve for me. I had to change my approach. It was about how to relate to those people. The environment, it was just so different. I think that is something that some people may have issues with. You come from a certain background, and they aren't getting the results. It's like, let me take a step back and try something else here.

HENDERSON: Exactly. I echo that. We came out of training around the same time. It was exactly that.

ADAMS: Usually for all those microbiology programs, they are all attached to academic institutions. The mindset in the way that you do things is so different. My first job was in a community hospital. It was completely rural. It was chickens and pigs. They said, you know why can't you get this done? And you do have to take a step back and say what else can I change?

You even have to get outside of the clinician realm. You have somebody who is going to champion that change. That is a huge thing in clinical laboratories. I feel like it is one of my passions because you can get so much done when you get everybody involved, and you let people on the front line understand, this is your work. You should own this. This is all of our work. Even if you aren't touching the patient, they are in the test tube. This is my joy.

[Laughter] I don't know, I'm just so passionate. But it matters.

You are basing your results. You are basing your clinical judgment off of that. I don't think that people really appreciate that. I did go to the effort of, like I was telling you, we had a clinician come down. We had a surgery. They wanted it cultured. I was like okay. So they called me, and they were like, what do we do? I was like, you know it's just physics. We can't do that. That was the most recent "help us help you moment."

I actually had the surgeon come down like look; this is what we have to work with. This is our process. Everything is labeled. They know. Sometimes they are so busy they just glaze over it. Education is huge. I learned during my training; it was my job to do stewardship. Test utilization is my passion. When you explain it, and you educate them, don't be so frightened. You know, just like other rare clinical implications on those purchases for what they are asking them for. I think that education is going on. They can then help them figure that out what they need to do, and they are not difficult to be difficult. There is a reason why we are doing it.

HENDERSON: Exactly.

ADAMS: They want to know if you can just put it in a blender. To culture it.

HENDERSON: We have a question from Catherine. I'm going to ask you to introduce yourself. Just go ahead and tell us where you are from.

JOHNSON: Good afternoon. I am Catherine Johnson. I am the training director at the Association of Public Health Laboratories. Thank you for inviting me. I enjoyed your conversation.

I'm in training now. I have always called myself a medic recovering medical technologist. I worked in the clinical laboratories. Seeing your topic today brought back a lot of memories. It was a lot of work with ERs, ICUs, nursing to get the blood volumes correct. I have really appreciated your session.

I do have a question about the slide on the summary of understanding. A couple of questions here. What are those topic areas, in those questions, was the hardest to accomplish. Then, second question is, what other areas have you used this methodology to achieve such a change as you did with the blood culture volumes?

ADAMS: I think, out of all of that, there is the issue of daily surveillance of blood cultures. When I saw that, it came about is addressing that issue. I noticed I kept seeing the same patient over and over. I was like, what is this? For labs. It was multiple blood cultures on the same patient nearly every day. I was like, what is this? So, you know, I did digging. I was like okay. Why are we doing this?

It was to the point where I talked with infection control, and they were like, you know he had staph infection? They were doing it every day, even with treatment. I was like, you know, there are follow-up cultures after antibiotics that you do. That's in certain cases. This patient wasn't a stem cell patient for a transplant patient. You know they didn't have anything like that. Part of doing that, you know, that is a lot back and forth. You know the current practice is this. In certain cases, it's this. People are going away from that. It's too expensive. You can cause more harm by doing these cultures. You don't do this. But this is how you choose your battles.

Part of the issue was the way that the LIM system was set up was that you could put any specimen you want in there and set it up for future cultures. So they would have a purpose for wanting to get daily surveillance cultures, but they would forget. So they are just getting drawn. I took that out. You can no longer do that. But, you have to manually put it in. You have to think. You can't just do it. That was one thing that was definitely back and forth. I reached out to Dr. Weinstein, like, I'm not crazy. I just like your take because you are in microbiology. So, what was your take on it. There are rare instances where that would be the approval. Then, you ask where did you also use this approach.

So, after that, there was the issue of, believe it or not, time of collection. That was flooring. We had issues where the people were blaming the lab for a delay in patient care. When I looked back to track everything, it got to the lab late. But, I noticed that for certain specimens, the time of collection they were the exact same. I was like okay. That doesn't make any sense. So when I looked, there is a feature called, Now. You hit it, and it just self populates all of that. So what they were doing was, if it came out and they didn't have it, they would just Now it. That was only used in the outpatient lab situation.

So when they come in, every time that collection is, it's Now. They were using it for all of these other things that didn't have common collections. That was surprisingly challenging and very frustrating. That wasn't a policy issue. They just went following the policy. Policy is a big thing. It's already in your policy. The message to the lab is that the issue of why that was created is because the policy wasn't being enforced. The reason that the policy wasn't being enforced was because of this culture of "I'm doctor you do what I say". They felt like they didn't have the power to enforce that.

Haven't really struck a nerve, they were finishing up, she called down to the ER, and she tried to enforce the policy. They got very belligerent and not nice. She came to me. I said, it's time to get out. Let's go down to the ER. Let's have a discussion. That took a year. It took a year and a half to come to a resolution. That's when I wasn't letting go.

It affects everything. There's no way around it. I said, if they aren't going to do the collection there, we just will put some of the collection. Basically, you are falsifying. If you are saying now, you put a alse time, you don't know. So just put zero. In that system, it automatically switches things to 000.01. What that does is it throws off all the hematology specimens. That created a larger issue. We couldn't do that. I guess he can't do that, that means the specimens are off.

When I talked to the hematology department, they said, they physically had to get the time of collection because they already assume it's wrong. Like, wait a minute. This is crazy all because somebody didn't follow the policy. No. That one was incredibly challenging. I got it done.

That's my approach to all this. You just take a step back and look at the overall policies. You do some digging and see the need to reach out to. Then you execute and go from there.

JOHNSON: Thank you so much for sharing. Thank you for taking the small steps for laboratory equality.

ADAMS: Thank you.

HENDERSON: I have one final question. Before we wrap up. How do you sustain such a large project? We all know that there is high staff turnover—probably more nursing than the laboratory. It's happening a lot down the laboratory with the gender relations leaving and new ones coming in. How do you sustain such a large project?

I tried this in my previous job. We were good for probably 6 to 8 months. Then we were able to start flipping the numbers of underfilled and increasing the numbers of overfilled. When there was nursing turnover wherever, really being able to capture the data to send it to them, we had a whole plan with nursing and reeducating, they even had a wall of shame of who got targeted. They made it fun. It was like a game. We were good for two-thirds of the year. Then they just reverted. How do you sustain it?

ADAMS: It's just staying persistent. Again, we have to hold people accountable. I think those post-analytical comments make a difference. You have to know that if you put your signature there. So when this started, we required an old signature because we ask for the initial, and they would just scribble. When I found those key people, if there's anything egregious or whatever, they would be held accountable for it. You could look to see who it was when you broke it down by department.

If I see anything surprising, I will say hey, Mindy, we are seeing an increase in these underfilled bottles. Can you see what's going on? Can you recheck? Case in point, we were seeing an increase in the time of delivery from the ER. So, those reports go to the head of the ER and then, the head of the nursing. Then I got my champion, Sherry.

They got on an address at the same way that we do our contamination rates. There was a single uptick in that. We addressed it. Just constant feedback. People are saying while putting these comments here.

At the end of the day, nobody wants to look bad. If you don't want it there, fill the bottle up. Bring it here on time. When you get younger clinicians coming in who are more aware of the practices, they will say, hey why is the specimen compromised? Because it was, you know. Why? It is a form of accountability. The great part is, there is no man time required. The only thing that is required is putting in the specimen. We are doing monthly things to stabilize. Because, at the end of the day, nobody wants to keep getting these reports every month. It's annoying. So just constant feedback. We incorporated in our quality indicator as well.

HENDERSON: That's perfect. Thank you so much. Now that medical schools are requiring quality improvement, patient safety is being included in the curriculum. We will see this transition, as you said, with those younger clinicians coming in. This is a thing. It is required. So, it is a very exciting time for them to see that what we have held so closely with quality improvement. It is now being transitioned outside of that as well. We've been doing quality for a long time.

So with that, I would like to thank you. Could you please switch over to your last slide?

Our next session will be on Wednesday, September 16th, from 1:00 PM to 2:15 PM. The discussion is going to the point of care testing. It's going to be presented by Elsie Yu with the Geisinger Health System in Pennsylvania. We are really excited about that.

It's a different type of healthcare system. I'm sure that this is going to be exceptional. Please visit the website for registration information. Also, to view the rest of the sessions for the year. Thank you all for taking part in our discussion. We hope that you have found it valuable.

We look forward to your participation in future sessions, and we keep you posted on any changes that may occur. We will now adjourn. Thank you, and have a great day.

Additional resources and related publications

1. Khare R, Kothari T, Castagnaro J, Hemmings B, Tso M, Juretschko S. Active Monitoring and Feedback to Improve Blood Culture Fill Volumes and Positivity Across a Large Integrated Health System. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2020;70(2):262-268.
2. Hazen KC, Polage CR. Using Data to Optimize Blood Bottle Fill Volumes and Pathogen Detection: Making Blood Cultures Great Again. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2020;70(2):269-270.
3. Miller JM, Binnicker MJ, Campbell S et al. A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2018;67(6):813-816.
4. Garcia RA, Spitzer ED, Beaudry J et al. Multidisciplinary team review of best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremias, reducing contamination, and eliminating false-positive central line-associated bloodstream infections. American journal of infection control. 2015;43(11):1222-37.
5. Kirn TJ, Weinstein MP. Update on blood cultures: how to obtain, process, report, and interpret. Clinical microbiology and infection: the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2013;19(6):513-20.
6. Beekmann SE, Diekema DJ, Huskins WC et al. Diagnosing and reporting of central line-associated bloodstream infections. Infection control and hospital epidemiology. 2012;33(9):875-82.