Pilot study: Adequacy of follow up of positive blood culture reported by microbiology laboratory in an urban teaching hospital
Nessrine Ktaich, M.D., Carl Urban, Ph.D., James J. Rahal, M.D.
Infectious Disease Section, Department of Medicine,New York Hospital Queens, Flushing, N.Y.
Background: Clinical laboratories have always considered quality control techniques to be the basis for assuring quality results for patient care. This is a process-oriented approach, concerned mainly with activities within the laboratory (lab). The microbiology lab must assure quality at several levels, starting from identifying the right patient, then processing the sample as per CLSI guidelines, reporting data correctly, and finally, delivering results to the responsible physician. Certainly, inadequate communication and lack of promptness in data delivery to physicians, particularly regarding blood isolates, will delay intervention by the physician and may lead to poor patient outcomes.
Objectives: Our primary objective was to assure timely communication of positive blood culture results between the microbiology lab and the responsible physician. A second objective was to determine whether an appropriate and timely intervention is made.
Methods: The microbiology lab records of all positive blood cultures were observed every other day, and patient names were recorded. Phone calls were made to the resident physician caring for the patient to determine awareness of positive blood cultures within 24 hours after the initial report and to evaluate subsequent management.
Results: During the four-week period from July 27, 2008 to August 12, 2008 and from October 15, 2008 to October 28, 2008, 139 patient blood isolates were recorded. Sixteen were considered to have had inadequate follow up. One had been seen by an infectious disease physician who was not aware of the blood culture result. Fourteen of the 16 cases with inadequate follow up had been reported verbally by the lab technician to a nurse, and one to a ward clerk. All reports were documented by the name of the recipient. In five instances, the responsible resident physician did not become aware of the positive blood culture. These cultures yielded B. cepacia, S. aureus, S. epidermidis, Pseudomonas aeruginosa and Bacillus sp. In three cases, the responsible resident incorrectly assumed that appropriate therapy had been given. In another instance, a physician’s assistant remained busy with two other patients after being informed of a positive blood culture by the ward clerk. Another six patients were treated by resident physicians with an appropriate antibiotic, but with an inadequate dose without supervision by a senior resident or attending physician. In an additional case, a patient was found with positive blood culture after being discharged without being called to return to the hospital for further intervention. (See Table)
Conclusion: Current routine methods of reporting positive blood cultures to the responsible physician do not assure adequate initial quality of care to all bacteremic patients. This is due to either inadequate communication to the treating physician, or to inadequate supervision of initial therapy.
Inadequate initial quality of care in 16 of 139 bacteremic patients
Case # / Bacteremic species / Recipient of report/ Reason for inadequate initial care
1 / B. cepacia / Nurse
2 / S. aureus / Nurse / Resident physician unaware
3 / S. epidermidis / Nurse / Resident physician unaware
4 / Bacillus species / Nurse / Resident physician unaware; patient left the hospital
5 / Klebsiella pneumoniae / Nurse / Inadequate initial therapy
6 / S. epidermidis / Ward clerk / Physician’s assistant was caring for other patients; therapy delayed
7 / S. aureus / Nurse / Inadequate initial therapy
8 / S. epidemidis / Nurse / Inadequate initial therapy
9 / Enterococcus faecalis / Nurse / Inadequate initial therapy
10 / Corynebacterium species/ S. hominis / Nurse / Inadequate initial therapy
11 / Pseudomonas aeruginosa / Nurse / Resident physician unaware/ Inadequate initial therapy
12 / S. dysgalactiae / Nurse / Inadequate initial therapy
13 / CoNS / Nurse / Inadequate initial therapy
14 / CoNS / Nurse / Inadequate initial therapy
15 / Proteus mirabilis / Physician / Inadequate initial therapy
16 / S. capitis/hominis / Nurse / Inadequate initial therapy