Hello, everyone. Thank you for joining us today on this OneLab Network call. We're going to give folks just another minute or two to join in. We've got a lot registered today. So, hang tight, and we'll get started very shortly. Thank you so much again for joining Hello, everyone. We're going to give people just one more minute to join in. Thank you so much for joining today we'll get started very soon.  

All right, you got a good number of folks on the call. So, let's go ahead and get started. Thank you again for joining the OneLab Network call today, Diagnostic Excellence a New Quality Tool to Prevent Adult Blood Culture Contamination. So, my name is Chelsea Parsons, and I'm a consultant with Guidehouse, supporting CDC's OneLab Initiative. I've got a couple of notes for us before we get started in the webinar.  

If you're having any technical difficulties throughout the session today joining in, or if you have a colleague that's having trouble joining in, you can email us at onelab@cdc.gov. That is onelab@cdc.gov. You'll see that come up in the chat now. We'll be keeping an eye on that in case anyone needs any help or support throughout the call. If you have any questions throughout the session, you can feel free to input those in the Q&A.  

You'll see in the bottom banner of your Zoom box that there is a Q&A section. That is where we ask you to put any questions that you have for today's session at any point in time in the call. We'll have a short Q&A session at the end of the main presentation to see if we can answer all the questions. If we don't get around to your question, we'll do our best to shoot you an email response. Just please submit non-anonymously if you'd like a reply. But we'll do our very best to get through as many as we can.  

You're about to see in the chat a link to the live captions. If you'd like to access live captions today, we'll have them throughout the entirety of the call. Just to note that you'll need to keep this Zoom window open as well as that live caption window. So, let's go ahead and take a look at the agenda for today. So, we'll go through some new and relevant resources, introduce you to our main presenter today. We'll have that main presentation as we mentioned. And then we will break for that Q&A like mentioned as well.  

And then we do have a couple of rules of engagement for the chat box. So, I see many of you are already interacting in the chat box. Thanks so much for doing so. We ask that you follow these rules of engagement. So, we'd like if you can take the opportunity to connect with others, react to what you're hearing, share experiences, ask questions to fellow participants. If you have questions for the presenter, however, we please ask that you use the Q&A function, not the chat. So that's that Q&A function.  

Additionally, please engage with respect and professionalism. Any inappropriate language, improper conduct, or any form of discrimination may result in removal from the webinar. So please ensure your comments are relevant to the topic. And if a moderator gives direction regarding the chat behavior, please comply accordingly. Lastly, please notify moderators if you experience any technical difficulties or observe any disruptive behavior. You're welcome to chat us individually in that Zoom chat function. Let us know if you're having any issues. So, I'll turn it over to our OneLab Network lead, Alicia Branch to share some of our new and relevant resources. Alicia?  

Thank you, Chelsea. Before we start, well, I will go into talk about some OneLab Network resources relevant to today's presentation as well as introduce a new course. We have made the following job aids blood and body fluid exposure, glove removal, and hand hygiene from our Ready Set Test booklet as standalone, customizable, and printable documents.  

These job aids serve as a quick reference guide for outlining the steps and procedures in the event of an exposure to blood or bodily fluids, how to remove your disposable gloves safely and properly, the steps to properly hand wash your hands. You can scan the QR codes on the screen now or check out these job aids on won OneLab REACH.  

Next slide, please. I want to highlight a new OneLab basic course, The Fundamentals of Handling Compressed Gas Cylinders Safely, which introduces clinical and public health laboratory and safety professionals and others to the physical and chemical hazards associated with compressed gas and compressed gas cylinders, control measures to mitigate risk, and how to work safely with compressed gases and gas cylinders in the laboratory. You can register for this course on OneLab for each.  

Next slide, please. I will read through our disclaimer and then introduce today's speaker. CDC, our planners, and our presenters wish to disclose we have no financial interest or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial support. Next slide, please. I'm excited to introduce today's presenter, Mr. Jake Bunn. Jake is a board-certified American Society of Clinical Pathology Medical Laboratory scientist.  

He holds a Master of Business Administration, as well as a Lean Six Sigma Black belt from Georgia Institute of Technology, a Bachelor of Science in medical laboratory science from the University of Cincinnati, and an associates in applied science in medical laboratory technology from the Community College of the Air Force.  

Before joining the CDC, Mr. Bunn was the Clinical Microbiology Manager and the Laboratory System Safety Officer for Children's Healthcare of Atlanta. He continues to work as a microbiology medical technology at Children's as needed. Jake is a United States Air Force veteran, having served abroad during Operation Enduring Freedom and the support of United Kingdom's Ministry of Defense and National Health Services during the 2009 H1N1 pandemic.  

His career focus is advocating for clinical laboratory medicine, technologies, and capabilities. He is very excited to speak about the CDC work to improve blood culture collection, patient safety, and outcomes. First, Jake would like to say thank you for your service. And our speaker for today is Mr. Jake Bunn.  

Hi, everybody. Just give me one second to get set up here. And thank you so much for being here. As Dr Branch just mentioned, my name is Jake Bunn. I'm a clinical laboratory scientist with CDC's Division of Laboratory Systems. As a federal employee, I must share that the content that you're about to see is that of my own and doesn't necessarily reflect the views of CDC.  

And I would also like to share that although I have the opportunity to share this project with you all, this work involves numerous members of our division and agency and external partners. Our division manages a Diagnostic Excellence Initiative which is led by Dr. Ira Lubin. And specifically, I want to give a call out to Dr. Nancy Cornish who has been my battle buddy on this journey. We will get to the quality tool. But first, we must talk about why and how we got here. So, let's first start. I'll briefly introduce you to blood cultures. Blood cultures are the gold standard of--  

Hey, Jake, we're not seeing your screen.  

OK sorry. Try that again. How about now?  

We see it. Thank you.  

Perfect. OK, blood cultures are the gold standard, a bloodstream infection diagnosis and are based on the detection of viable microorganisms present in the blood. So, blood is drawn from a patient and inoculated into blood culture bottles. If a microorganism is detected, we should be able to pick it. If a microorganism is present, we will be able to detect that in the laboratory.  

However, there are significant diagnostic errors that should be considered when dealing with blood cultures. False negative blood cultures result due to inadequate volumes of blood collected can result in misdiagnosis, delayed therapy, and put patients at heightened risk of morbidity and mortality from bacteremia. Likewise, the presence of commonly occurring bacteria or fungi on human skin or commensal organisms can increase the risk of false positives, compromising care by leading to mistreatment of patients due to unnecessary antibiotic therapy and prolonged hospitalization.  

In January of 2020, a clinical microbiology review was published by the American Society for Microbiology, which called out all of these problems with blood cultures and these potential patient safety events. This review calls out the CDC as an agency who should work to address this problem nationally. Although we couldn't necessarily jump on this project right in January 2020, as you all know what happened in that year, but in the Spring of 2021, we got the team together and started to take on this call out.  

And as we prepared to approach this, we investigated the current state of blood culture quality monitoring. So, the first thing we wanted to do is since laboratories in the United States are regulated, we needed to look into what laboratories are required to do for the Clinical Laboratory Improvement Amendments, or CLIA. So have a good book here. And I'll just briefly read a couple of the standards that may apply or do apply.  

So, the first would be the standard for specimen submission handling and referral. CLIA states the laboratory must establish and follow written policies and procedures for each of the following if applicable, patient preparation, specimen collection, specimen labeling, including patient name or unique patient identifier, and in the case of microbiology, which is very important, the specimen source.  

There's also the standard for pre-analytic systems quality assessment, which says the laboratory must establish and follow written policies and procedures for an ongoing mechanism to monitor, assess, and when indicated, correct problems identified in the pre-analytic systems. The pre-analytic systems quality assessment must include a review of the effectiveness of corrective actions taken to resolve problems, revision of policies and procedures necessary to prevent reoccurrence of problems, and discussion of pre-analytic systems, quality assessment reviews with appropriate staff.  

Monitoring the blood culture contamination rate can serve as a proxy measurement of the effectiveness of the blood culture collection procedures. It basically looks back to the pre-analytic phase. Now, I'm not saying that blood culture quality monitors are specifically called out in CLIA at this point in time, but these standards are applicable. We also are aware that there are laboratories that currently evaluate and report blood culture contamination and blood culture volume for adults. The volume is for adults.  

So, we wanted to see where those laboratories are and are not. So here is a map of the United States of America and our territories. This map shows all the clinical laboratories associated with the hospital, those with inpatient settings, and therefore likely to collect blood cultures. On the map, you see some dark gray rural areas. And those are defined as rural areas. So once again, clinical laboratories are regulated and per CLIA are inspected and accredited by CMS directly or by CMS deemed accreditation agency organization.  

The certificate of compliance laboratories are inspected and accredited by CMS. Those are shown in purple on this map. Certificate of accreditation laboratories are inspected and accredited by one of the CMS deemed accreditation organizations and are shown here in yellow. The College of American Pathologists is just one of the deemed accreditation organizations able to inspect an accredited laboratory, and those are shown here in green. So, find your dot on this map, and think about what's going on in that area.  

Currently, only the College of American Pathologists laboratories have standards for blood culture contamination rate and adult blood culture volume. And not exclusively, but these college of American Pathologists laboratories are more typically found in urban versus rural areas. And what we want to get at is that currently, they account for only 25% of hospital-based clinical laboratories nationwide.  

The next thing that we did is we performed a CDC library literature review. These opportunities with poor blood culture collection are well studied. Numerous publications have cited this issue going back decades. The publication that's highlighted here in orange is from Dr John A Washington II, who's the considered to be and is the father of blood cultures. And this was published in September of 1986.  

So, let's talk about 1986 for a minute. The month this publication came out, top billboard songs were Venus by Bananarama, and Take my Breath Away by Berlin. In 1986, many on this call were just beginning their distinguished careers. Many were not even born yet. Surprisingly, there was some Congressional action around this as well. And it's important to call out that the VA was directed by Congress to prioritize development and implementation for blood culture contamination based on recommendation of less than 1%.  

And the Department of Health and Human Services, we received a letter also from Congress urging CMS to take meaningful action to reduce blood culture contamination, which represents an immense and avoidable economic and public health burden. So, putting all this together, we can confirm blood culture collection processes may lead to adverse patient safety events. There is also a need to standardize blood culture collection and establish quality monitors across the United States to ensure every patient has local access to equal quality health care and to be able to compare studies among institutions.  

In order to help promote the importance of the need to reduce blood contamination and improve the collection of blood cultures, we have recently leveraged the CMS consensus-based entity measure process to establish blood culture contamination rate as a national patient safety measure. These consensus-based entity measures are widely viewed as a gold standard for the measurement of health care quality. And this is the first laboratory-based national patient safety measure and is a new approach to address patient safety problems using laboratory data.  

Our goal is to optimize the clinical laboratories' approach to handling blood culture contamination by increasing communications with clinicians and pharmacists, introducing methods to monitor, induce blood culture contamination, and improve the collection of blood cultures. So, a few comments about measures is first, we cannot improve what we do not measure. Quality measures do not replace clinical decision making but can serve as a means to improve it.  

And ultimately, this project is a continuous improvement project starting with adults and may evolve to include all age groups as we get a handle on the measure as it is. So, let's go through the measurement endorsement process. First, it's important to note that it is a statutory requirement from Congress that there is a government contractor to serve as the consensus-based entity for measure endorsement and maintenance.  

The National Quality Forum served as his contractor during the measure development. And we will now work with Battelle, the new contractor for measure maintenance. These next two slides demonstrate the National Quality Forum's measure endorsement process. But from what we understand, Battelle will follow either the same or a very similar process.  

So shown here is each evaluation criteria you have to meet for endorsement. Each has to pass a standing committee vote to be considered for endorsement. So first, the importance, is this measure meaningful and important to patients? Does it address an aspect of health care where there is a gap in performance or measurement? Feasibility, do the benefits of this measure outweigh the potential burdens associated with reporting on it?  

Scientific adaptability, does it produce consistent results that accurately distinguish good care from poor quality care? Does it measure what it purports to measure? Use and usability, to what extent can patients, clinicians, hospitals, or other stakeholders use information from the measure to inform performance or improve accountability and care delivery? And finally, harmonization, are there existing measures that have data elements in common with this measure? If so, to what extent can this measure leverage those data elements to reduce the burden associated with implementation and reporting?  

I'll say as far as importance and validity, we highly relied on systematic reviews, and they were critical to measure endorsement. We understand these are costly to perform but are needed to connect a laboratory to patient outcomes. So, we're so grateful for societies like the American Society for Microbiology and others for making these available.  

So now, here's the measure timeline. There are strict timelines and deadlines. And you must pass each of these phases, or you basically go back to ground zero. There are two opportunities for public comments. For our measure, we didn't receive any negative ones. There were positive comments submitted, which certainly supports endorsement. So, what exactly are we measuring?  

Blood culture contamination is defined as a commensal organism, a bacteria or fungi that normally colonizes human skin without causing disease that is isolated from only one blood culture set out of two or more sets collected within a 24-hour period. This is considered a false positive test result. So, you can perform the calculation by taking your numerator, which is the total number of blood culture sets with growth of a skin commensal without the same organism in other sets collected with 24 hours and then divide that by your denominator, which would be the total number of eligible blood culture sets collected.  

To be considered for calculation and contamination, you have to have at least two blood culture sets collected within that 24-hour period. Blood culture contamination occurs in the pre-analytical phase of testing during specimen procurement. And adults with suspicion of a bloodstream infection, two to three blood culture sets should be obtained in an evaluation of each septic episode, which is defined as a 24-hour period. There is a target blood volume of 40 to milliliters.  

When only one blood culture set is collected out of the two to three recommended sets, this is called a single set blood culture. A single set blood culture in a 24-hour period is not an adequate volume of blood to make a bacteremia diagnosis and could lead to false negatives. Also, per the definition, blood contamination cannot be evaluated unless at least two blood culture sets have been collected as the definition of blood culture contamination is a single set positive out of two or more sets collected.  

Therefore, to work in the blood volume, the measure also includes a sub measure for single cell blood cultures. And here's the calculation. So, you have in your numerator the total number of single blood cultures without another set collected within 24 hours divided by the total number of blood culture sets collected. After we established the measure specifications, we then collaborated with our colleagues in CDC's Division of Health Care Quality Promotion to analyze blood culture data from 259 facilities spanning the nation.  

In this analysis, we discovered gaps in care and found that higher bacterial contamination was identified in rural areas as compared to urban areas, facilities with less than 300 beds as compared to larger facilities with greater than 300 beds, and summer seasons as compared to winter, spring, and autumn. With the patient always in mind, we also assess patient characteristics from over 5.2 million blood culture episodes and discovered of all patients from whom blood cultures were obtained, Black non-Hispanic unmarried males were significantly more likely to have a contaminated blood culture.  

Patients 60 years or older were also more likely to have a contaminated blood culture. Regardless of the population served, and no matter where a patient or caregiver chooses to seek out medical care, all patients and caregivers should be able to expect equal quality health care across the United States. We identify these gaps using laboratory data not typically leveraged to improve patient outcomes. Our analysis of blood cultures, which is just one of the numerous laboratory tests that are routinely ordered does not support the existence of equal quality health care.  

So, this is a question we have for the OneLab Network. How are we going to address this? One idea is stewardship. Pre-analytic errors account for most blood culture contamination events. These errors mostly occur outside the laboratory. But per CLIA, the laboratory is responsible for all phases of testing. Often in health care settings, the laboratory is left out of decision making that impacts patient care. And diagnostic stewardship is crucial to reduce patient safety events and enhance quality health care.  

There are many interventions available to reduce blood culture contamination rates mainly focus on collaboration of all health care partners involved in evaluating and treating patients for bacteremia. But this collaboration will only work if the laboratory has a permanent seat at the table. Fortunately, there is a collaboration platform within a hospital, the Antibiotic Stewardship Team, which is required by CMS.  

This team is suited to champion a team-based approach to improve antibiotic therapy as it is ideally composed of infectious disease clinicians, infectious preventionists, nursing managers, pharmacists, laboratory professionals, and other health care professionals. This multidisciplinary group have the tools and expertise to evaluate these rates and take a collaborative approach to implement interventions to improve the collection of blood cultures.  

Given that diagnostic stewardship is an approach to reduce diagnostic errors, it is integral to antibiotic stewardship teams and should also be incorporated with antibiotic stewardship efforts to ensure the right test for the right patient at the right time. Diagnostic stewardship aims to not only ensure the right test is done, it ensures the right test is done correctly.  

To promote stewardship, in 2022, CDC published a quality improvement tool intended to help infection control and antibiotic stewardship programs work with their laboratories to improve the blood culture total testing process. This past summer, our division published an additional tool to provide an overview of the measure for clinical laboratories and to point them towards antibiotic stewardship teams. This way, both tools and all teams are pointed at each other.  

In this tool, available to the public as a web page and downloadable PDF, we included an overview of the measure given the purpose and the why. We provided some applicable CLIA regulations, some that I already called out, such as the standard for specimen submission handling referral, standard for pre-analytic systems quality assessment. And we also have the standard for specimen integrity and identification.  

We also included some critical steps to include in your standard operating procedures. You should note that this does not account for all considerations that might be in your unique institutional policies. But we outline the critical steps as called out in the clinical Laboratory Standards Institute and the Infectious Disease Society of America. We also included the calculations for blood culture contamination and single set rates. And we provided some information on how to classify microorganisms using the National Health Safety Network's common commensal list.  

So how did we land on the NHSN commensal list? First, we needed a controlled publicly available list. So, this list is maintained by a surveillance branch. And an expert panel weighs in on removing or adding organisms from this list. You can download it as an Excel file. So, users can use the search function to quickly identify microorganisms that are present on this list. And if your microbiology lab-- if your laboratory identifies a commensal organism out of one or two sets collected, contamination should at least be considered.  

We understand there are some opportunities with the NHSN list. Even as of last week, ASM published this really great mini review and called out some of those opportunities when considering the use of this list, which we love. And users can always reach out to us or NHSN directly to voice concerns. And to our friends listening from NHSN, we're here to help support those questions and concerns. So please lean on us.  

In this tool, we also included some suggested nudges to inform clinicians of low blood volume and blood culture contamination. So, let's look into those nudges. So, these comments can serve as post-analytic nudges to educate clinicians on what we are seeing in the laboratory. Because remember, the clinicians see the patient. We see the specimens the patient trusts us with and the microorganisms that may be present.  

These comments can help inform clinical decision making by reporting possible contamination or inadequate volume and provides the full picture of what's going on or what we're seeing in the laboratory. Because sometimes, a nudge in the right direction is all we need. Another thing is that at this point, when the comment goes out in the report about a potential contaminant or low blood volume, this could be the time that you could also follow up with the collector instead of waiting till the end of the month when they might not recall this case.  

Blood culture contamination is considered to be a patient safety event. So, we need to think about what you would do if there was a patient fall, which is also a patient safety event. Do you wait until the end of the month or end of the week or end of the quarter to look into what happened? Or do you respond immediately? So please start thinking about these as patient safety events and how best to respond.  

Also, this summer, CDC published the sepsis core elements. And this resource calls out blood culture contamination and single set rate metrics as examples for tracking sepsis, epidemiology management, and outcomes. It also calls out microbiology, laboratory medicine, and phlebotomists among those who should be at the table.  

So next steps of the measure, we'll talk about some promotional efforts, some training toolkits, and data collection. So, this is our first year, our initial year of measure promotion. So, we've been targeting the following. This list is not inclusive.  

But we're looking at accreditation organizations, professional societies, hospital administrators, the stewardship committees, anyone involved in patient safety and quality, laboratory directors, and those who are involved in the blood culture total testing process, nursing, phlebotomist, clinicians, whomever that might be involved in the blood culture collection process, also looking at value analysis professionals who have a hand in this as well. And we've been promoting, but mostly we've been listening and learning from these groups.  

We're also working on creating a training toolkit. We have a goal to develop a suite of training tools that could be infographics. We hear a lot about bit-sized learning. So, we're working to identify what currently exists, what is not working and why, inquiring with those blood culture collection professionals inside and outside of the laboratory because we want to integrate laboratory and clinical considerations. We want to get very granular. We want to tell the why.  

For example, please don't place patient labels over the barcodes on blood culture bottles. This stops workflows. This creates manual work and introduces opportunities for mismatching errors. That might be something that's not really recognized outside of laboratory. But those little things like that are things that can make kind of all of our lives easier and make sure that we're taking care of our workflows and our patients the best we can.  

And then finally, we're working to establish data collection structures for blood culture collection, quality monitoring through the CDC National Health Care Safety Network, and our measure will be back up for measure maintenance in the Spring of 2026. So, we will be deep diving into all this data and putting together a new package. And we'll look forward to keep going at that point in time.  

So that brings me to the end of the talk. But once again, I must take the time to thank everyone involved in the work that was just presented. The experts we have consulted with are mostly volunteers. They're extremely passionate about this project. And we are very grateful for their time and all of your time. So, Alicia, I'll turn it back over to you for the Q&A kickoff.  

All right, let's get started. We have quite a few questions. And again, if we do not get an opportunity to answer your question today, we will do our best to respond via email that you provided your question-- used your actual name to ask the question. And if you have any questions after today, please feel free to email the OneLab inbox at onelab@cdc.gov.  

Let's go. OK, let's go. The first one, what are your views on using mask and hair coverings during blood culture collection?  

Yeah, thank you so any type of PPE is always based off a risk assessment. So, it would depend on your specific situation. Maybe that specific patient as far as doing it all the time, once again, that's a decision that would be a facility-based decision. But look at, do a risk assessment, and make that call based off of that.  

OK, the next question, what is the best way to adapt the information to outpatient office draws that can only draw a single set?  

Great consideration. This measure right now focuses on inpatients. We understand how large and involved this is, all the different facilities, all the different patient types, all the different inpatient outpatient emergency department, or urgent cares all that type of thing. So, the measure is focused on inpatients at this point in time. But when you're considering ordering a blood culture, you need to think about what the results are going to tell you.  

So, if you're only collecting a single set, you might not be getting the answer that you're looking for. You could miss a false negative. So, I would strongly encourage the group to look into that. And you need to get two sets, one, so we can be able to determine if it's a contaminant and two, to be able to ensure that the patient is getting the right volume collected so we can confidently say yes or no if they have a bloodstream infection.  

The next one, they're a medical laboratory technician. They're trained to do blood culture collection, which has very strict procedure. However, they've read that blood culture is rarely collected in diagnostic process, of course, due to sepsis, likely to interfere when there is evidence of organ failure or organs being compromised. Can you speak to the tendency based on your data or experience?  

I may not understand that question. I think I have it here. I don't understand. I have read that blood culture is rarely collected in the diagnostic process. I mean, it's based off patient, the indications for testing. There's the CLSI, the Clinical and Laboratory Standards Institute have a table included on when a blood culture is indicated. So, I could point you towards that.  

Because OK, let's go with the next one to see. Because we have quite a few. Are there any efforts for the CDC can encourage the Joint Commision to include blood culture contamination as a quality metric? They are a Joint Commision inspected laboratory hospital and need more support to prioritize reducing blood cultural contamination.  

What I can say about that is yes, we would like every accreditation organization to look for this and monitors like this to ensure that the pre-analytic systems are intact and are right, and the patient is having the best outcomes, and these patient safety events are eliminated and reduced and eliminated. This measure was and this talk, a version of this talk was actually just presented to CLIAC, which is the Clinical Laboratory Improvement Advisory Committee last month, where a Joint Commision and the other, I think all the accreditation organizations were either physically present or present virtually.  

There will be some recommendations that came out of that committee meeting that was passed on by the members. And I can't speak to that yet because it's not publicly available. But I can say, look out for that information. That will probably be posted in February of this year on the CLIAC website.  

OK. Let's see. What are the major concerns that should be addressed to avoid contamination?  

We aim to capture those in our quality tool. That's what we laid out in the standard operating procedure. Most of these events do occur during blood culture or specimen procurement. What we're finding is maybe the wrong skin disinfectant was used or not used correctly. You're supposed to clean the actual top of the blood culture bottles with 70% isopropyl alcohol before you actually collect the blood culture, which we found that some folks aren't doing.  

What you really, first, you need to see make sure you have an SOP. What we're finding as we're talking to people, they don't even have an SOP. Or maybe the SOP is like a patient care SOP that the nurse's reference, but don't necessarily include the laboratory. So, places that I worked before, I've served on clinical practice councils and that type of thing fortunately where we raise our hands as laboratorians like hey, this is something we think should be included.  

So, we strongly recommend stewardship. We strongly recommend pulling together all of your publications. And nurses and clinicians tend to use Lippincott and Mosby and that kind of thing. We tend to rely on CLSI and IDSA and that kind of thing. They all need to start saying the same thing, and we all need to be on the same page.  

So just please check out the quality tool, and make sure at least those high points are in there. And then go to your institution and determine what those institutional policies should be as well and make sure that they're available and that people are trained and aware of what they are and held accountable.  

The next question, is there a possibility of true positives from one positive and negative from another bottle not due to colonization?  

True positives, saying-- let me read that. I can read it. Can you just read that one more time?  

I think they may need to resubmit. I think they're missing something in there. We'll go to another one. We can. This is a good one. Do we need 40 to 60 mils for one bottle?  

No, the 40 to 60 mils comes from the set, so the two blood culture set. So, each bottle, I mean, you have to look at your manufacturer. But typically, each bottle needs about 10 mils. So, once you have the aerobic and anaerobic bottle, that's one set. So, you'll have 10 mils in the aerobic, 10 mils in the anaerobic. That's 20 mils in that one set. And then when you have the two sets, that would then equal 40 mils.  

Some institutions require three sets collected, that's where the 60 milliliters come from. So, one set is 20 milliliters, two sets, 40, three sets, 60. The target blood volume per the guidelines is 40 to milliliters within a 24-hour period to be able to adequately detect and diagnose bacteremia.  

OK, we'll take a few more because we're still kind of ahead of time. Do you have a national average contamination rate, or do you know the national average?  

National average, no, when we looked at our data, it was 259 facilities around 5.2 million patient blood culture episodes. Now, our data showed all that combined, the average was about 2.99%, which falls under the 3%, which is for a long time has been kind of the consensus benchmark. Folks that have been doing it for a long time think that number is pretty arbitrary. That's why CLSI has recommended that.  

When best practices are followed, you should be able to get that below 1%. That was one question that we had when going through the endorsement process because the folks on the standing committee were like, hey, the national benchmark is 3%. You're at 2.99%. Where's the deal? Well, that represented almost 200,000 blood culture contamination events. That is not zero and as you know in health care, any one is not zero. So, any event needs to be addressed and acted on.  

And we'll have more information on national averages as we collect more data through NHSN. But there are many groups out there that have reported on this for a long time. So, I would point you towards the literature.  

Wow let's see. They would like to know would there be a list of common microorganisms classified as contaminants?  

That's what the NHSN list that we're pointing everyone to has. There's a tab on there for common commensals. Now, this list is used for CMS inpatient quality reporting for collapses. And I think there's a tab for UTIs for CAUTIs on there as well. As I mentioned, there are some opportunities with this list. There may be some microorganisms that the laboratory may consider to be a contaminant no matter if it is-- or not a contaminant no matter if it is isolated from one set or not.  

There are some organisms that are not on the list for CLABSI and considerations that could potentially be on the list. As I just said, the ASM mini review called out those considerations, which will take on and consider going down the road. But it's definitely as everyone has, not everyone, but as laboratories now incorporate MALDI-TOF, where you're getting all of these organisms that you may have never heard of, it's really nice to be able to just go through this list and at least see if it's on there.  

We're not saying just because it's on this list, the laboratory is done. what we're saying that if it's on this list, and it's only one set out of two collected, it should at least be considered for contamination. And there should be some type of conversation between the laboratory and the clinician on what needs to happen next.  

OK. This is a very good question. They are a developing professional. They're in school for a medical laboratory scientist, and they understand that they have patients' age when they come into the hospital or for lab care. But do you have access to the race or-- somebody moved the question. Hold on. The question moved. OK, it disappeared. Let me see if I can find it.  

Basically, they wanted to know if you had access to their ethnicity as a scientist. If the answer is yes, then is the percentage of African American males over the age of 60 contamination rate deliberate?  

Wow. So usually, here's the thing. Laboratories can have impact on health equity. And a lot of people are probably sitting there and thinking like, OK, how do we do that. We receive the specimens in the laboratory. We follow our processes, and we're done. We report them, and then that's it. We don't look at patients' names and decide to do things differently. What we found, it's very important to get very granular with this data in order to be able to introduce interventions to get rid of this problem.  

We were surprised when we found the disparities and the gaps in care that we did find. And unfortunately, I think if you looked at any laboratory test, you might find these, disparities and these gaps. So, I would encourage anyone when you're reporting any type of data to get granular into it. We're focused on patients. So why wouldn't we look into patient characteristics?  

Right. This is a good one. Since everything in the lab has moved to automation, when I started working in the lab, we didn't have as many automated pieces of equipment. So, they want to know how does automation assist in blood culture contamination?  

Yes, so there are blood culture instruments now that can detect blood volume for you now. They do it automatically. And there may be some kind of Crystal Reports or some type of reporting that can come out of those as well, same thing for your laboratory information systems. yes, it does require dedicated personnel that know what they're doing, which not everyone has, which is unfortunate. And we want to try to work with manufacturers to help there.  

But we want everything to be as easy as possible and feasible as possible. One of the things we put in the measure we were going through the process about feasibility is that all this information was maintained in the laboratory information systems that all laboratories have to be able to report results. So, the information is there. The best way to do it, you will have to come back onto your stewardship teams and your operational capabilities. But there are methods that can be-- the laboratory information systems can be leveraged to create these automatic reports for you.  

We'll take one last question, and your remaining questions we'll answer offline. Do you recommend using sterile gloves to collect blood cultures?  

That's one of the interventions that was listed in the clinical micro review article that I called out on slide three or whatever. There was like eight interventions that were listed there, same thing as a question about mask and hairnets, risk assessment. So, if you're doing a risk assessment, and your risk assessment shows that sterile gloves is where you all want to go, then yes, please, please do it.  

We're not really recommending any specific intervention except stewardship, that being that everyone should sit down, pull their heads together, their expertise together, and talk about these events and work together to resolve it.  

I'd like to thank you again, Jake, for this great presentation. And we look forward to you coming back in 2024.  

Yes. Thank you so much, everyone. Happy holidays. And please reach out to us with any questions, comments, or concerns. We want them. We need them. And we value them, so thank you all so much.  

OK, we are offering one PACE credit for today's webinar. To receive PACE credit, visit the link and use the passcode posted in the chat to complete the evaluation within two weeks. You will receive an email containing these instructions if you missed the link and passcode. We invite you to-- next slide, please. We invite you to register for the upcoming OneLab Network event on January 17 at 12:00 noon.  

This event is the laboratory onboarding template pilot test by the Guam Public Health Laboratory. It will explain how the Guam Public Health Laboratory used the CDC's laboratory onboarding template to develop a new employee standard operation procedure to onboard their new employees. It's a structure they created their own SOP that's structured and streamlined the process on onboarding the new employees as well explain the details and objectives of working in the public health laboratory and a provided a roadmap to navigate the day-to-day activities. The registration link is posted in the chat.  

Again, as a reminder, the slides and the audio recording of this event will be posted and on our website within two weeks from today. And lastly, if you or someone you know have any training materials on diagnostic testing for chronic kidney disease, we ask that you email the OneLab inbox. That's at onelab@cdc.gov. The OneLab email address is posted in the chat for easy access. And again, we'd like to thank you for joining us, and have a great rest of your day.