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Justifying termination of pregnancy

Description: The court considers whether termination of pregnancy is in the best interests of a young woman who lacks capacity.
Url: /HealthProfessionals/Clinical-law-updates/Justifying-termination-of-pregnancy.aspx

UHS adult major trauma guidelines

Description: Adult Major Trauma Guidelines University Hospital Southampton NHS Foundation Trust Dr Mark Baxter Director of Major Trauma, Consult
Url: /Media/SUHTExtranet/WessexTraumaNetwork/UHS-adult-major-trauma-guidelines.pdf

Resources

Description: Auto Generated Title Take a look through our useful resources, helping you fund your research, keep up to date and access the informa
Url: /ClinicalResearchinSouthampton/For-researchers/Education-and-training/Resources/Resources.aspx

Papers Trust Board - 10 September 2024

Description: Agenda Trust Board – Open Session Date 10/09/2024 Time 9:00 - 13:00 Location Conference Room, Heartbeat/Microsoft Teams Chair
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2024-Trust-documents/Papers-Trust-Board-10-September-2024.pdf

Welcome to Ward E2 Easy read - patient information

Description: Easy read information about Ward E2
Url: /Media/UHS-website-2019/Patientinformation/Heartandlungs/Welcome-to-Ward-E2-Easy-read-3488-PIL.pdf

Annual-report-2018-19

Description: ANNUAL REPORT AND ACCOUNTS 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-2018-19.pdf

Annual report 20-21

Description: 2020/21 Incorporating the quality report University Hospital Southampton NHS Foundation Trust Annual Report and Accounts 2020/21 Presented to Parliament
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Annual-reports-and-quality-accounts/annual-report-20-21.pdf

Cemiplimab

Description: Chemotherapy Protocol SKIN CANCER Cemiplimab (350mg) Regimen  Skin – Cemiplimab (350mg) Indication  Metastatic
Url: /Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Skincancer/Cemiplimab.pdf

Papers Council of Governors 20 July 2022

Description: Agenda attachments 1 CoG Agenda - 20.07.2022.docx Date Time Location Chair Agenda Council of Governors 20/07/2022 14:00 - 15:30 Microsoft Teams Jenni Douglas-Todd 1 Chair’s Welcome and Opening Comments 14:00 2 Declarations of Interest 14:02 3 Minutes of Previous Meeting 14:03 Approve the minutes of the previous meeting held on 27 April 2022 4 Matters Arising/Summary of Agreed Actions 14:04 5 Strategy, Quality and Performance 5.1 Chief Executive Officer's Performance Report 14:06 Receive and note the report Sponsor: David French, Chief Executive Officer Attendee: Gail Byrne, Chief Nursing Officer 5.2 Strategic Objectives (Oral) 14:26 Review and feedback on the Strategic Objectives Sponsor: David French, Chief Executive Officer Attendee: Christine McGrath, Director of Strategy and Partnerships 6 Governance 6.1 Non-Executive Director Reappointment and Appointment of Deputy Chair 14:41 • Approve Tim Peachey’s reappointment as a non-executive director for a second three year term commencing on 1 October 2022 on the same terms and conditions as his current appointment • Approve the recommendation to defer the appointment of a deputy chair to the meeting on 19 October 2022 following a recommendation made by the newly appointed chair Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 6.2 Amendments to the Constitution 14:51 Approve the proposed amendments to the Trust’s constitution Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 6.3 Appointment of Lead Governor 14:56 Note the proposal to appoint the Lead Governor Sponsor: Jenni Douglas-Todd, Trust Chair Attendee: Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 7 Membership Engagement and Governor Activity 7.1 Membership Engagement 15:01 Receive the report Sponsor: David French, Chief Executive Officer Attendee: Karen Burwell, Communications and Marketing Manager 7.2 Feedback from Governors' Nomination Committee 15:06 Chair: Jenni Douglas-Todd, Trust Chair 7.3 Feedback from Strategy and Finance Working Group 15:09 Chair: Tim Waldron 7.4 Feedback from Patient and Staff Experience Working Group 15:12 Chair: Forkanul Quader 7.5 Feedback from Membership and Engagement Working Group 15:15 Chair: Bob Purkiss 8 Review of Meeting 15:18 Review and feedback on the content of this meeting Sponsor: Jenni Douglas-Todd, Trust Chair 9 Any other business 15:23 Raise any relevant or urgent matters that are not on the agenda 10 Date of next meeting: 19 October 2022 15:28 Note the date of the next meeting 11 Resolution regarding the press, public and others 15:29 Agree, as permitted by the National Health Service Act 2006 (as amended), the Trust's Constitution and the Standing Orders of the Council of Governors, that representatives of the press, members of the public and others not invited to attend to the next part of the meeting be excluded due to the confidential nature of the business to be transacted Sponsor: Jenni Douglas-Todd, Trust Chair Page 2 3 Minutes of Previous Meeting 1 3 COG Minutes Draft - 27.04.2022 final.pdf Minutes - Council of Governors (CoG) Date Time Location Chair Present In attendance Apologies 27 April 2022 14.00-16.00 Microsoft Teams Jane Bailey, Interim Chair Jane Bailey, Interim Chair Dr Diane Bray, Appointed, Solent University Dr Nigel Dickson, Elected, New Forest, Eastleigh and Test Valley Helen Eggleton, Appointed, NHS Hampshire, Southampton and Isle of Wight CCG Harry Hellier, Elected, New Forest, Eastleigh and Test Valley Kelly Lloyd, Elected, Health Professional and Health Scientist Staff Councillor Alexis McEvoy, Appointed, Hampshire County Council Robert Purkiss, Elected, Rest of England and Wales (until item 6.4) Forkanul Quader, Elected, Southampton City Catherine Rushworth, Elected, Isle of Wight Councillor Rob Stead, Appointed, Southampton City Council (until item 6.5) Werner Struss, Elected, Medical Practitioners and Dental Staff Amanda Turner, Elected, Non-Clinical and Support Staff Quintin van Wyk, Elected, Rest of England and Wales Sam Dolton, Events and Membership Officer Karen Flaherty, Associate Director of Corporate Affairs Ian Howard, Chief Financial Officer (for items 5.1 and 5.2) David French, Chief Executive Officer (for item 5.3) Tim Peachey, Non-Executive Director (NED) Karen Russell, Council of Governors’ Business Manager Asa Thorpe, Associate Director – Commercial (for item 5.2) Theresa Airiemiokhale, Elected, Southampton City Katherine Barbour, Elected, Southampton City Professor Mandy Fader, Appointed, University of Southampton Tim Waldron, Elected, Southampton City JB DB ND HE HH KL AM RP FQ CR RS WS AT QvW SD KF IH DAF TP KR ATh TA KBa MF TW 1 Chair’s Welcome and Opening Comments The Chair welcomed everyone to the meeting and, in particular, WS who was attending a meeting of the CoG for the first time since becoming a governor. 2 Declarations of Interest There were no new declarations of interest relating to matters on the agenda. 3 Minutes of Previous Meeting The minutes of the meeting held on 26 January 2022 were approved as an accurate record of the meeting. 4 Matters Arising/Summary of Agreed Actions The updates on the actions in the paper were noted. The review of the CoG’s 1 composition had been considered by the CoG Membership and Engagement Working Group at its most recent meeting and a progress update would be provided later in the meeting. 5 Strategy, Quality and Performance 5.1 Operational Plan 2022/23 IH, who was attending the meeting to present this item, advised that the operational plan for 2022/23 had also been presented to the CoG Strategy and Finance Working Group at its meeting on 21 April 2022. The purpose of the paper was to inform the CoG about aspects of the Trust’s operating environment and plan for 2022/23. The following areas were summarised: • the Trust’s income for 2022/23 was broadly level with 2021/22 and the expectation was that 104% of the 2019/20 levels of elective activity would be delivered with this level of funding, through increased efficiency improvement valued at £33 million; • there were planned operating deficits across the NHS and the Trust’s deficit of £19.5 million was attributable to factors outside of its control, including costs associated with COVID-19, increased energy prices and general inflationary pressures; and • there were plans for continued recruitment and retention to increase employed staff by a further 478 full-time equivalent staff, to be funded through planned reductions in the use of bank and agency staff hours. In response to questions raised IH confirmed: • the Trust’s specialities with the patients waiting longest (over 18 months and two years) were: o trauma and orthopaedics, where procedures were of lower clinical priority and had been deferred for that reason; and o ear, nose and throat, where activity had reduced because of infection prevention and control measures related to aerosol generating procedures; and • although recruitment to fill vacancies was continuing there was no funding for new posts, however, additional investment in staffing would be required in 2023/24 and 2024/25 to meet the expected increase in elective activity to reduce waiting lists further. 5.2 Non-NHS Activity This item had also been discussed by the CoG Strategy and Finance Working Group at its meeting on 21 April 2022. The Trust’s private patient income for 2021/22 was forecast to be approximately £6.4 million, which represented just under 0.7% of the Trust’s overall income. The growth in activity had been due to more complex patients being treated, whilst maintaining the prioritisation of clinically urgent procedures in the context of the unprecedented pressure on core NHS services. Private patient activity was expected to remain at similar levels for at least the next six months. The income from non-NHS activity, including private patient activity, was reinvested into NHS services and to support further innovation and activity. Non-NHS income was also derived from the following: • the commercialisation of Trust-derived intellectual property with an expected forecast of at least £140,000 in 2022/23; • the co-development of innovative medical technology, for which the income forecast was £150,000 for 2022/23; and • advertising income from the electronic screens located in patient areas 2 around the hospitals. Details of a range of the innovative therapies, treatments and projects being developed by the Trust were shared with governors. Decisions: • The CoG confirmed that it was satisfied that the Trust’s non-NHS activity would not significantly interfere with its principal purpose, which was to provide goods and services for the health service in England, or the performance of its other functions. • The CoG authorised the Trust Chair to inform the board of directors (Board) of its decision. 5.3 Chief Executive Officer’s Performance Report DAF joined the meeting to present the performance report and provided an update since the period of December 2021 to February 2022 covered by the report. He highlighted that: • March and April 2022 had been very challenging for the NHS nationally due to the high levels of COVID-19 among patients in hospital for other reasons, and in norovirus reflecting the prevalence of these viruses in the community; • the Trust’s staff absence rates had increased to 6% at times from approximately 3% normally due to staff having COVID-19 or self-isolating; • there were consistently 180 patients in the hospitals who were medically optimised for discharge (MOFD), however, continuing levels of staff absence in community and domiciliary care services and in care homes were leading to delays in discharge for patients needing further support following discharge or with longer-term care needs; • attendances in the emergency department were increasingly high and the Trust’s emergency access performance had been impacted negatively by the number of attendances, including the Trust’s approach to ambulance handovers, which resulted in fewer ambulances queuing but more patients in the department; • the volume of non-elective urgent activity and the number of patients MOFD had regrettably led to the cancellation of elective activity, which had both a practical and emotional impact on those patients whose surgery was delayed; • cases of COVID-19 and norovirus in the Trust had dropped substantially in the previous two weeks and the focus had moved to delivering the Trust’s programme of elective activity; • the number of patients waiting over 104 weeks had reduced to five by the end of March 2022 and the Trust was confident that this would be zero by July 2022; • the Trust had increased both physical and workforce capacity through investment over the previous few years, however there was still insufficient capacity, and this was being addressed through the creation of clinical networks with partners and improvement programmes in theatres, outpatients and patient flow through the hospitals; and • recruitment and retention of staff was more difficult in an increasingly competitive employment market, however, in the NHS staff survey 2021, the Trust had scored highly among staff recommending it to care for family and friends (fifth in its peer group) and recommending it as a place to work (seventh in its peer group). In response to a question from CR, DAF confirmed that the Trust did offer incentive payments to staff who worked additional shifts, however, substantive recruitment 3 was the solution to ensure a good work life balance and overall wellbeing for staff. In response to a query from FQ regarding the expected performance of the Trust in six months’ time, DAF agreed it was difficult to predict however, he hoped that there would significantly fewer cases of COVID-19 and elective activity would return to levels achieve previously and the Trust could deliver comparative performance in the top quartile. The next few years would be very difficult for the NHS generally as it reduced waiting times and the number of patients waiting. While the Trust’s plans to reduce waiting lists were achievable, capacity would continue to be an issue for the Trust. The number of patients who were MOFD would have a bearing on this so the Trust would continue to work closely with health and social care partners to facilitate the timely discharge of patients. The plans to open a new elective hub at Winchester Hospital within the next 18 months would also provide additional capacity and clinical, managerial and finance teams at the trusts involved were committed to making this work. In response to a question from RP, DAF advised that the maternity friends and family test score had improved substantially in January and February 2022 as a result of an improvement plan put in place in the antenatal ward, and progress had been closely monitored by the Board. The response time for complaints had been increased from 35 to 55 days to recognise the demands upon clinical staff during the latest wave of the COVID-19 pandemic. There had also been a number of changes to personnel within the patient advice and liaison service (PALS) as staff had moved into other roles in the Trust. 5.4 Draft Quality Report and Annual Report Timetable NHS England and NHS Improvement (NHSE/I) had published the timetable for the 2021/22 annual report and accounts and associated guidance. While this had removed the requirements to produce a separate quality report, the quality accounts requirements set out in The National Health Service (Quality Accounts) Regulations 2010 still applied requiring trusts to produce quality accounts, including circulation of the quality accounts to commissioners, local authorities, local Healthwatch and the CoG for comment by the end of April 2022. The Trust had taken the decision to produce the annual report and accounts and the quality accounts on the same timetable as a single document by the submission deadline of 22 June 2022. However, due to the additional work required to complete the value for money external audit, the quality accounts were to be published as a separate document by 30 June 2022. The annual report and accounts would be published after they had been laid before Parliament, which was expected to occur at the beginning of September 2022. The timing of the meeting of the CoG at which the final annual report and accounts (including the quality accounts) and the external auditors’ report were to be presented would be later than usual to allow for these to be laid before Parliament as this would normally take place in July. An update would be provided to the CoG in a closed session of its meeting in July 2022 to mitigate the impact of this delay. The date of the annual members’ meeting would be finalised at a later date to ensure that the annual report and accounts were laid before Parliament before the annual members’ meeting took place. Governors had been invited to provide comments or feedback on the draft quality accounts for 2021/22 by 29 April 2022 and the formal response to the consultation from the CoG would be co-ordinated by RP as Lead Governor. 4 6 Governance 6.1 Non-Executive Director Reappointment The first three year term of office as a NED for Dave Bennett was to come to an end on 14 July 2022. NEDs were eligible for reappointment for a second three year term subject to reappointment by the CoG. When considering the reappointment of a NED, the CoG should consider: • the outcome of the NED’s appraisals since appointment; • their other commitments and the time available for the role; and • independence. The most recent appraisal of Dave Bennett was carried out in February 2022. Following appraisal, the then Chair, Peter Hollins, confirmed that Dave Bennett’s performance as a NED continued to be effective and demonstrated his commitment to the role and that he would have no hesitation in recommending Dave Bennett for reappointment to the role. Since his original appointment, Dave had ceased his commercial consultancy business, Davox Consulting Ltd, and had been appointed to the following NED/trustee roles: • Chairman, Royal College of General Practitioners (RCGP) Enterprises Ltd • Chairman, RCGP Conferences Ltd • NED, Faculty of Leadership and Medical Management (FMLM) • Director, FMLM Applied Ltd • Director/Trustee and Chair, YMCA Fairthorne Group. Dave had indicated his willingness to be reappointed for a further three year term and confirmed that he continued to have the time to commit to the role. The Governors’ Nomination Committee (GNC) had met on 26 April 2022 and had agreed to recommend that the CoG approve the reappointment without any need for process of open competition. Decision: The CoG approved Dave Bennett’s reappointment as a NED for a second three year term commencing on 15 July 2022 on the same terms and conditions as his current appointment. 6.2 Review Terms of Reference – Council of Governors and Working Groups The terms of reference for the Council of Governors and its working groups should be reviewed regularly, and at least once annually, to ensure that these reflected the purpose and activities of the CoG and each of the working groups. The terms of reference for the GNC were reviewed by the CoG at its meeting in October 2021 and so were not presented for review at this meeting. The terms of reference for the CoG’s working groups had been reviewed by the relevant working group prior to submission to the CoG. Minor changes were proposed to reflect changes to practice and strategies since the terms of reference were last reviewed. Decision: The CoG approved the revised terms of reference for the: • CoG; • CoG Membership and Engagement Working Group; • CoG Patient and Staff Experience Working Group; and • CoG Strategy and Finance Working Group 5 6.3 Council of Governors’ Election 2022 A number of vacancies within the CoG would arise on 1 October 2022 as current governors reached the end of their terms of office, following agreement of the CoG to fill existing vacancies at the scheduled election in 2022 and as a result of proposed changes to the composition of the CoG taking effect from 1 October 2022. Elections would take place in the following areas of the public constituency and classes of the staff constituency: • Isle of Wight - one vacancy; • Southampton City - five vacancies; • New Forest, Eastleigh and Test Valley - three vacancies for a term of three years and one vacancy with a remaining term of office of one year; • Rest of England and Wales - one vacancy with a remaining term of office of two years; • Non-clinical and support staff class - one vacancy; • Nursing and Midwifery staff class - one vacancy; As a result of the proposed changes to the composition of the CoG taking effect from 1 October 2022, a vacancy that would have arisen in the Rest of England and Wales public constituency would not be filled as the number of governors representing this constituency was to be reduced by one. The timetable for the elections had been prepared in accordance with the guidance specified in the model election rules. The elections would be conducted by an independent election service provider acting as the returning officer on behalf of the Trust. Four election service providers had been invited to provide a quote and three quotes had been received. A meeting had been held with each of the three providers on 27 April 2022 and a decision on which to appoint would be made by 29 April 2022. 6.4 Council of Governors’ Expenses Reimbursement Protocol The CoG expenses reimbursement protocol had been updated and reformatted and additional clarification had been added in a number of areas not previously included in the protocol. The protocol was required to approved by the Board in accordance with the Trust’s constitution. Clarification for governors was requested in relation to: • how costs for printing would be reimbursed; and • whether governors who had been issued with permits for staff car parks could continue to use these when attending CoG meetings at the main hospital site. Actions: KR would review the issue of printing costs and the parking arrangements at the Trust for when meetings resumed in person. 6.5 Consultation Regarding Timings of Council of Governors’ Meetings At the CoG meeting on 22 January 2022, it had been agreed that a survey of governors would be carried out to identify the preferred times of day for CoG meetings with a view to varying the times of future meetings. This followed the resignation of two staff governors who had been unable to regularly attend meetings of the CoG due to work commitments. Ten responses to the survey had been received. There was a slight preference expressed for meetings to be held at regular times, although no overall majority in favour of regular or varied meeting times. Most governors identified meetings held in the mornings or afternoons to be more convenient and meetings held in the 6 evenings were less convenient for most governors. The CoG was asked to consider: • whether they would like to hold some or all CoG meetings in the morning; • whether they would prefer to hold CoG working group meetings in person when meetings in person were able to resume or whether to continue holding these meetings virtually using Teams would be preferable in terms of securing good attendance; and • if CoG working group meetings were held in person would it most convenient to schedule these on the same day as CoG meetings so that all meetings would be held in person on the same day. Some governors felt virtual meetings made it possible for them to attend more regularly as travelling time was not required and it was noted that attendance at meetings had increased since the introduction of virtual meetings. Virtual meetings also had benefits in terms of reducing congestion on the hospital sites and contributed positively to the delivery of the Trust’s green plan. It was more beneficial to hold meetings in person where these could be combined with a visit to an area of the hospital. Decision: The CoG agreed to retain a mix of meetings in the mornings and afternoons and a combination of face-to-face and virtual meetings once face-to-face meetings could resume. 7 Membership Engagement and Governor Activity 7.1 Membership Engagement SD introduced the membership engagement report highlighting that: • since the last CoG meeting in January 2022 there had been regular engagement with members; • in March 2022 members were informed of the appointment of Jenni Douglas-Todd as new chair of the Trust from July 2022; • as demand for hospital services had increased during April 2022 members had been kept up to date with the latest position and how they could assist by sharing messages to ensure that those who need medical treatment used the most appropriate service; • the Connect newsletter was sent in February and April 2022, with the latter edition split into versions for different constituencies for public members and staff and included details of which governors represented their area and an interview with one of the elected governors; • emails had been sent to all members aged 18 to 30 directly inviting them to take part in a study comparing COVID-19 vaccine doses when used as a third dose at the end of January 2022 and to other members asking them to help share information about recruitment to the study; • targeted emails were sent to members under 30 years of age to publicise a University of Southampton study into the kind of voluntary work, community activities and informal work that young people may have been doing during the pandemic; • the Trust advertised a listening event regarding children and young people with a learning disability organised by our patient involvement team for members with a specific interest in children’s services; • in February 2022 an online survey was launched to help shape the future of the Trust’s membership programme and governors who had provided feedback on the survey prior to its launch were thanked for their support; • KR and SD had attended a listening lunch for carers in Southampton earlier in April 2022, which was organised by the experience of care team; • weekly governor updates including a summary of key staff briefing 7 messages continued to be sent; and • since the last CoG meeting on 26 January 2022, 19 new members had joined the Trust. Future plans included: • supporting the upcoming CoG election in four public constituencies and two staff constituencies; • planning and executing a virtual event for members focusing on research at the Trust in May 2022; • taking part in upcoming community events to promote UHS membership and communicate key Trust messages; and • producing an edition of Connect in June 2022. 7.2 Governors’ Nomination Committee Feedback Feedback from the GNC meeting on 26 April 2022 was provided earlier in the meeting. 7.3 Feedback from Strategy and Finance Working Group In the absence of TW, KR advised that the Strategy and Finance Working Group had met on 21 April 2022. Topics considered had included: • the operational plan 2022/23; • an overview of non-NHS activity; • an update on the annual report and accounts; the process of annual self-certification of the Trust's licence conditions; and • a review of the Strategy and Finance Working Group terms of reference. 7.4 Feedback from Patient and Staff Experience Working Group FQ advised that a meeting of the Patient and Staff Experience Working Group had been held on 20 April 2022. This had been a very interesting session with presentations of the Trust’s new people strategy, the results of the NHS staff survey 2021 and the NHS maternity survey 2021 results. A review of the Patient and Staff Experience Working Group terms of reference was also carried out. 7.5 Feedback from Membership and Engagement Working Group RP advised that a meeting of the Membership and Engagement Working Group had been held on 26 April 2022. The following areas had been covered at the meeting: • SD had attended to provide a membership update and feedback on events held since the last meeting and also provide information on future events; • proposals to introduce an appointed governor for students as part of the composition of the CoG; and • a review of the Membership and Engagement Working Group terms of reference. CR was planning to engage with constituents in the Isle of Wight and RP suggested that all governors be supplied with some paper copies of Trust membership application forms for distribution amongst their constituents. Action: SD would provide a supply of Trust membership application forms to KR for distribution to governors. 8 Any Other Business There was no other business. 8 9 Date of Next Meeting – 19 July 2022 To note the date of the next meeting. RP suggested the meeting was held at its usual time of 2pm, immediately following the separate meeting between the governors and NEDs. There being no further business, the meeting concluded. 9 4 Matters Arising/Summary of Agreed Actions 1 4 Summary of Agreed Actions.docx List of action items Agenda item Assigned to 13 July 2022 10:55 Deadline Status Council of Governors 27/04/2022 7.5 Feedback from Membership and Engagement Working Group 687. Issue of a supply of Trust membership forms for distribution by governors Karen Russell 20/07/2022 Complete Explanation action item RP suggested that governors could be issued with a few Trust membership forms for distribution to promote membership. It was agreed that KR would send a supply to each governor. Explanation Russell, Karen A supply of Trust membership forms were issued to governors on 10 May 2022 as agreed. Council of Governors 27/04/2022 6.4 Council of Governors' Expenses Reimbursement Protocol 686. Reimbursement of printing costs and availability of parking Karen Russell 20/07/2022 Complete Explanation action item RP asked whether governors could be reimbursed for printing papers at home. A further query was raised regarding the availability of parking when face to face meetings resumed. Explanation Russell, Karen As part of the UHS Green Plan and wider sustainability, we want to avoid any unnecessary printing and we would also like to avoid any governors having to incur printing costs when printing at home. To facilitate this, at face to face meetings there will be a free wi-fi connection and a paper copy of the agenda only will be provided. Supporting papers will be displayed on the screen in the meeting room where necessary to support the discussion. On any other occasion which governors are attending an interview or other event where paper copies of any information may be required, these can be printed and provided by the Trust on a more cost-effective basis. A full response was circulated to governors on 23 May 2022. 13 July 2022 10:55 With regard to the availability of parking when attending face to face meetings, KR has arranged with Travelwise to cordon off an area of one of the car parks for use by governors when attending CoG meetings and exit car passes will be provided free of charge for use at these meetings. In view of this governor parking permits will no longer be required. KR will circulate details of the car park which should be used in advance of the next face to face meeting. Council of Governors 31/03/2021 5.5 Amendment to the Trust's Constitution - CCG Merger 444. Review the Council of Governors' Composition Helen Potton/Karen Russell 19/10//2022 Pending Explanation action item A review of the Council of Governors' composition is to be carried out to check that it still remains appropriate. The review was presented to the CoG at the meeting on 21 July 2021. The CoG agreed that volunteers for a task and finish group would be sought to consider the composition of the CoG in more detail. If no volunteers were forthcoming it would be referred to the Membership and Engagement Working Group for further review. Explanation Russell, Karen Following discussions by the Membership and Engagement Working Group, proposals for a change to the composition of the CoG relating to the New Forest, Eastleigh and Test Valley, and Rest of England and Wales constituencies will be presented for approval at the CoG meeting on 20 July 2022. Suggestions regarding young governor representatives were discussed further at the Membership and Engagement Working Group meeting on 27 June 2022. Proposals are to include two young governors as full members of the CoG, one each from the University of Southampton and the UHS Young Adults Group. This will be considered in more detail by a sub group and proposals will then be presented to the CoG. Page 2 5.1 Chief Executive Officer's Performance Report 1 5.1i Report template UHS CoG July 2022.docx Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Chief Executive Officer’s Performance Report 5.1 David French, Chief Executive Officer Jason Teoh, Director of Data and Analytics 20 July 2022 Assurance Approval or reassurance Ratification Information Y Issue to be addressed: Information about Trust performance supports the Council of Governors in their role. Response to the issue: This report is intended to inform the Council of Governors about aspects of the Trust’s performance. Implications: Risks: This report provides performance information relating to a broad range of Trust services and activities, there are no specific implications. This report is provided for the purpose of information. Summary: This report is provided for the purpose of information. Page 1 of 1 1 5.1ii Chief Executive's Performance Report Jul 2022 FINAL.docx UHS Council of Governors 20th July 2022 Chief Executive’s Performance Report 1. Purpose and Context The purpose of this report is to summarise the Trust’s performance against a range of key indicators. This report covers data from the period from March to May 2022, noting that performance in relation to some of the targets is reported further in arrears. Notable features of the period included: • An increase in the number of COVID-19 inpatients through the period as rates of infection increased across the country. There was also a corresponding increase in the number of hospital-acquired COVID-10 infections. • Extremely high volume of attendances to the Emergency Department, averaging 378 patients per day, an 18% increase on the same period the prior year. • A significant number of patients not meeting the criteria to reside (formerly medically optimised for discharge), usually between 180 – 200 patients, continuing to occupy hospital beds, restricting flexibility in our elective programmes. The number has been as high as 229. Such patients are typically waiting for care to be provided in the community to continue their recoveries or meet long term needs in their home setting. • Referral volumes have exceeded pre-pandemic levels, and despite an increase in hospital activity, the RTT waiting list continues to increase. So far in 2022, the waiting list has grown by 10%. • High numbers of referrals have also been seen for patients with suspected cancer, which have impacted our 2 week wait and 62 Day performance. However, for both metrics, we continue to benchmark in the upper quartile of our teaching hospital peers. • A longer-term trend in higher staff sickness absence continues to rise, with an underlying 0.6-1% of absences in any given week being related to COVID-19. Page 1 of 7 2. Safety Infection Control Clostridium Difficile infection MRSA Bacterium infection Target 95.0% ≥ 90.0% Mar 2022 Apr 2022 67.5% 70.4% 76.9% 79.5% May 2022 67.5% 77.3% Attendances to the main (Type 1) Emergency Department (ED) have continued to increase throughout this period, averaging 378 per day (up 18% on the same period the previous year). UHS four-hour performance has deteriorated; however, we continue to benchmark well against other trusts.. In the period of March to May 2022, UHS ranked in the top quartile of the 16 teaching hospitals that we benchmark against (Type 1 attendances). A related, national, issue is ambulance handover times. UHS continues to maintain timeliness in accepting the handover of patients from ambulance staff, despite challenges this may create within our own department on some occasions. We have maintained handover time between March to May 2022 (despite higher attendances). Referral to Treatment (RTT) % incomplete pathways within 18 weeks in month Total patients on a waiting list Target => 92% Mar 2022 67.7% 46,318 Apr 2022 66.4% 48,458 May 2022 68.1% 49,283 Since December 2021, the number of patients on the RTT waiting list has increased by 10%. Referrals have returned to, and are now exceeding, pre-pandemic levels. This means that despite UHS’s activity having increased, we continue to see growth within the waiting list. However, we have made good progress in reducing the longest waiting patients. At the end of May, we only had 10 patients who had waited over two years for treatment (four of which were patient related delays). By the end of June – in line with the NHS requirements – we will have no patients waiting over two years for treatment, apart for any patient requested delays. Cancer Urgent GP referrals seen in 2 weeks Breast symptomatic patients’ referral seen in 2 weeks Treatment started within 62 days of urgent GP referral Target => 93% => 93% => 85% Mar 2022 90.4% 63.6% 72.3% Apr 2022 87.2% 91.7% 74.7% May 2022 86.9% 100% 69.5% There has been improvement within our two week wait (2WW) capacity, particularly within our Breast service as additional consultants have started and the service has run multiple weekend sessions through 2022. There remain some challenges within the Gynaecology and Head & Neck tumour sites – mainly due to higher referrals and staffing challenges. However, despite these performance issues, we continue to benchmark in the top quartile for performance relative to our teaching hospital peers. As a result of referral and treatment challenges, our 62 day cancer treatment performance has been adversely impacted. This is partly due to higher referral volumes, alongside late tertiary referrals, but also highlights some challenges that we have within existing pathways. We are working with the Wessex Cancer Page 5 of 7 Alliance to review, and optimise, relevant cancer pathways. Despite the challenges, UHS continues to benchmark in the upper quartile compared to our peer teaching hospitals. 5. Finance The Trust has now submitted its annual accounts to NHS England and NHS Improvement for 2021/22 reporting a small surplus of £0.05 million from a revenue position of over £1.2 billion, once items deemed as “below the line”, such as impairments to the valuation of our fixed assets, were removed. This met the national minimum breakeven mandate required for NHS organisations. Supporting this delivery was the achievement of £15 million of efficiencies in year, which, although below previous years’ levels, was a significant achievement given the level of operational pressure. Operating income increased £160 million from the previous financial year with significant funding increases related to the UK Health Security Agency saliva mass testing programme contract and also increases in research and development income due predominantly to COVID-19 vaccine studies. Additionally, NHS income continued to grow both in line with funding settlements and inflationary awards together with service expansions and elective recovery funding. Spend increased in equal measure however, with pay spend increasing by £57 million from the previous year. The trusts capital programme for 2021/22 also closed on plan with delivery in full to capital departmental expenditure limits (CDEL). Spend totalled £65 million, including investment in new theatres, expanding our emergency department and expanding our ophthalmology capacity. The underlying financial position of the trust is however more challenging, with inflationary pressures particularly within energy costs, a continuation of covid spend mainly on staff sickness/absence backfill, and drugs cost growth in excess of block funding levels, all creating financial pressure. The trust has however submitted a breakeven plan for 2022/23 which is predicated on the delivery of cost improvement plans totalling £45m (4%). For April and May the YTD position is a £5m deficit which is £2.2m below planned levels as a deficit had been anticipated in earlier months of the year knowing that traction on the trusts savings programme would take time to establish. The gap to plan is mainly driven by covid costs greater than forecast in addition to slower than anticipated delivery of cost improvement plans. Increased focus is now being applied in this area to ensure financial improvement is delivered and the breakeven plan for the year can be achieved. Capital spend is on plan year-to-date however much of the spend is profiled to later months with wards developments, MRI replacements and theatres expansion all planned for the second half of the year. Page 6 of 7 6. Human Resources Indicator Target Staff FFT - % of staff who agree or strongly agree that they would recommend UHS as a place to work Staff recommending UHS as a place to receive care/treatment => 75.5% => 85.0% Q4 21/22 73.8% National Average (Acute / Acute + Community Trusts) Picker average 58.4% 59.2% 84.9% 66.9% 66.8% The national NHS Staff Survey 2021 opened from September to November 2021 inclusive. Results are sent to individual trusts January to March, with embargo lifted in March 2022. Staff Survey results are now aligned to the NHS People Promise themes. UHS had a response rate of 56.2% (6,985 staff), representing a 6% increase from 2020. UHS scored average or above average on all seven themes. Our aim is to continue to improve, strive to increase our scores where all scores are above average in 2022, and aim for being the “best” scoring wherever possible thereafter Indicator Turnover (internal target) Sickness absence 12 month rolling (internal target) Nursing Vacancies (Registered Nurse only in clinical wards) (internal target) Target <=12% <=3.4% <=15% Mar 2022 14.3% 4.5% 12.8% Apr 2022 15.8% 4.6% 13.0% May 2022 14.9% 4.7% 13.6% Primarily reasons for sickness included: Covid-related sickness (including long Covid); work-related stress; and MSK. There has also been a recent increase in short-term sicknesses. End. Page 7 of 7 6.1 Non-Executive Director Reappointment and Appointment of Deputy Chair 1 6.1a Non-Executive Director Reappointment and Appointment of Deputy Chair front sheet v2 updated.docx Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Non-Executive Director Reappointment and Appointment of Deputy Chair 6.1 Jenni Douglas-Todd, Trust Chair Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 20 July 2022 Assurance Approval or reassurance Y Ratification Information Issue to be addressed: Response to the issue: Implications: Risks: Summary: The first three year term of office as a non-executive director for Tim Peachey will come to an end on 30 September 2022. Non-executive directors are eligible for reappointment for a second three year term subject to reappointment by the Council of Governors. One of the roles of the Governors’ Nomination Committee is to make recommendations to the Council of Governors on the reappointment of non-executive directors. The constitution provides for the appointment of a deputy chair. Jane Bailey is the current deputy chair and has resigned from that role as at the end of July 2022. It is proposed that Tim Peachey is reappointed for a second three year term of office. The attached paper provides details of the outcome of appraisals, changes to commitments and ongoing independence and commitment to the role. In terms of the deputy chair position it is proposed that a recommendation is made to the Council of Governors at their meeting on 19 October 2022. The appointment and reappointment of non-executive directors is one of the statutory responsibilities of the Council of Governors role following recommendation by the Governors’ Nomination Committee. The appointment of the deputy chair is one of the responsibilities of the Council of Governors. 1. Failure to ensure an appropriate balance of executive and independent non-executive directors in accordance with the Trust’s Constitution and The NHS Foundation Trust Code of Governance. 2. Ensuring the appropriate balance of skills and experience among the non-executive directors on the Board. 3. Ensuring the effective functioning of the Board. The Council of Governors is asked to approve Tim Peachey’s reappointment as a non-executive director for a second three year term commencing on 1 October 2022 on the same terms and conditions as his current appointment. The Governors’ Nomination Committee will be Page 1 of 2 asked to review the proposed reappointment at its meeting in July 2022 and will provide its recommendation to the Council of Governors. The Council of Governors is asked to approve the recommendation to defer the appointment of a deputy chair to the meeting on 18 October 2022 following a recommendation made by the newly appointed chair. Page 2 of 2 1 6.1b NED Reappointment and Appointment of Deputy Chair paper v2 updated.docx Non-Executive Director Reappointment and Appointment of Deputy Chair 1 Non-Executive Director Reappointment Background In September 2019 the Council of Governors (CoG) appointed Tim Peachey as a nonexecutive director for an initial three year term commencing on 1 October 2019. Nonexecutive directors are eligible for reappointment for a second three year term subject to reappointment by the CoG. When considering the reappointment of a non-executive director, the Governors’ Nomination Committee and the CoG should consider: • the outcome of the non-executive director’s appraisals since appointment; • their other commitments and the time available for the role; and • independence. Annual appraisal Tim Peachey has been subject to satisfactory appraisal annually since his appointment in 2019. Governors have had the opportunity to contribute to the appraisal of the non-executive directors each year by providing feedback through the Lead Governor. The most recent appraisal was carried out in February 2022. Following appraisal, the then Chair, Peter Hollins, confirmed that: • following formal performance evaluation, Tim Peachey’s performance as a nonexecutive director continued to be effective and demonstrated his commitment to the role; and • he would have no hesitation in recommending Tim Peachey for reappointment to the role following the appraisal process. Other commitments Since his original appointment, Tim has ceased his role as clinical safety officer of Block Solutions Ltd and taken on the role of Health Advisory Board member at Palantir Technologies UK, Ltd. Tim currently performs the following roles in addition to his role as a NED for the Trust: • Director, TP-Medcon Ltd • Clinical Advisor, Bolt Partners Ltd • Associate - Mediator, Problem Resolution Ltd • Non-Executive Director and Chair of Quality Committee, Isle of Wight NHS Trust • Health Advisory Board member, Palantir Technologies UK, Ltd. Tim has indicated his willingness to be reappointed for a further three year term and confirmed that he continues to have the time to commit to the role. This has been demonstrated through his attendance at meetings, which was considered as part of the appraisal process. 1 Independence Non-executive directors should be independent in character and judgement. Tim Peachey was considered to meet the requirements for independence applicable to a non-executive director on appointment. In his performance as a member of the Board of Directors and Audit and Risk Committee, chair of the Quality Committee and as the non-executive Maternity Safety Champion, Tim has continued to demonstrate his independence and constructive challenge. Since his appointment Tim has been subject to annual fit and proper persons checks and declaration processes applicable to directors to confirm ongoing compliance with the requirements. Recommendation Subject to recommendation by the Governors’ Nomination Committee, the Council of Governors is asked to reappoint Tim Peachey as a non-executive director for a second three year term commencing on 1 October 2022 on the same terms and conditions as his current appointment, including the current annual fee of £14,000 as remuneration for the role and the fee of £2,000 for additional chairing responsibilities in respect of the Quality Committee. 2 Appointment of Deputy Chair Background The appointment of the Deputy Chair is made by the Council of Governors. The current postholder, Jane Bailey, has advised that she intends to step down from the role as at the end of July 2022. When considering the appointment of a new Deputy Chair it would be usual for the view of the Chair of the Trust to be taken into consideration and a recommendation for approval be made. Recommendation Following the recent appointment of Jenni Douglas-Todd to the position of Chair of the Trust, it is recommended that a paper would be presented to the Council of Governors on 19 October 2022 with a recommendation in relation to the appointment of a Deputy Chair. 2 6.2 Amendments to the Constitution 1 6.2a Amendments to Constitution - cover sheet v2 updated.doc Report to the Council of Governors Title: Agenda item: Sponsor: Author: Date: Purpose Issue to be addressed: Amendments to Constitution 6.2 Jenni Douglas-Todd, Trust Chair Karen Flaherty, Associate Director of Corporate Affairs and Company Secretary Helen Potton, Interim Associate Director of Corporate Affairs and Company Secretary 20 July 2022 Assurance Approval or reassurance Y Ratification Information Following a review of the composition of the council of governors of the Trust, the council of governors has agreed to alter the number of governors elected by the areas of the public constituency to ensure that these remain representative of those to whom the Trust provides services. Having reviewed the current areas of the public constituencies and the proportion of patients seen by the Trust from those areas, the following proposed changes have been agreed: • to reduce the number of governors representing the Rest of England by one governor; and • to increase the number of governors representing New Forest, Eastleigh and Test Valley by one governor. The council of governors has also agreed to maintain a representative on the council of governors from local commissioners as an appointed governor, following the transfer of functions from NHS Hampshire, Southampton and Isle of Wight Clinical Commissioning Group to NHS Hampshire and Isle of Wight Integrated Care Board taking effect on 1 July 2022. Other minor changes are proposed to be made to the current constitution identified as part of this review and to correct minor typographical and other errors. These changes include: • to reflect the transfer of functions from Monitor/NHS Improvement to NHS England from 1 July 2022; • to update the model election rules attached at annex 4 to the constitution to those published by NHS Providers in August 2014 (these have not yet been updated to reflect the transfer of functions from Monitor to NHS England, however references to Monitor should be read as referring to NHS England); • to remove appendix 4 to annex 8 as it duplicates provisions in paragraph 25 of the constitution, as amended, and the terms of reference for the governors’ nomination committee; • to remove references to registers in paragraph 35 that are no longer maintained, or required to be maintained, by the Trust; • to all
Url: /Media/UHS-website-2019/Docs/About-the-Trust/Trust-governance-and-corporate-docs/2022-Trust-documents/Papers-Council-of-Governors-20-July-2022.pdf

STHW841-V1-Biomerieux-Blood-culture-guidance

Description: BLOOD CULTURE A key investigation for diagnosis of bloodstream infections OUR SPECIAL THANKS GO TO Dr Susan M. Novak-Weekley Ph.D. D(ABMM), S(M)ASCP Vice-President, Medical Affairs, Qvella, Carlsbad, CA, USA Wm. Michael Dunne, Jr. Ph.D. D(ABMM), F(AAM, CCM, IDSA, PIDJ) Senior Fellow, Clinical Microbiology, Data Analytics Group, bioMérieux, Inc., Durham, NC, USA Adjunct Professor of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA Adjunct Professor of Pediatrics, Duke University School of Medicine, Durham, NC, USA for their helpful advice and comprehensive review of this booklet. INTRODUCTION “…the laboratory detection of bacteremia and fungemia remains one of the most important functions of clinical microbiology laboratories... A positive blood culture establishes or confirms that there is an infectious etiology of the patient’s illness. Moreover, it provides the etiologic agent and allows antibiotic susceptibility testing for optimization of therapy.”1 The laboratory detection of bacteremia and fungemia using blood cultures is one of the most simple and commonly used investigations to establish the etiology of bloodstream infections. Rapid, accurate identification of the bacteria or fungi causing bloodstream infections provides vital clinical information required to diagnose and treat sepsis. Sepsis is a complex inflammatory process that is largely underrecognized as a major cause of morbidity and mortality worldwide. There are an estimated 19 million cases worldwide each year,2 meaning that sepsis causes 1 death every 3-4 seconds.3 Early diagnosis and appropriate treatment make a critical difference when it comes to improving sepsis patient outcomes. Chances of survival go down drastically the longer initiation of treatment is delayed. If a patient receives antimicrobial therapy within the first hour of diagnosis, chances of survival are close to 80%; this is reduced by 7.6% for every hour after. Yet, if a patient initially receives inappropriate antimicrobial treatment, they are five times less likely to survive.4 This booklet aims to: a nswer key questions commonly asked in relation to blood culture p rovide practical recommendations for routine blood culture procedures o ffer an illustrated step-by-step guide to best blood culture collection practices. This booklet is intended to be a useful reference tool for physicians, nurses, phlebotomists, laboratory personnel and all other healthcare professionals involved in the blood culture process. DEFINITIONS Bacteremia: the presence of bacteria in the blood. It may be transient, intermittent or continuous. Blood culture: blood specimen submitted for culture of microorganisms. It enables the recovery of potential pathogens from patients suspected of having bacteremia or fungemia. Blood culture series: a group of temporally related blood cultures that are collected to determine whether a patient has bacteremia or fungemia. Blood culture set: the combination of blood culture bottles (one aerobic and one anaerobic) into which a single blood collection is inoculated. Bloodstream Infection (BSI): an infection associated with bacteremia or fungemia. Contaminant: a microorganism isolated from a blood culture that was introduced during specimen collection or processing and is not considered responsible for BSI (i.e., the isolates were not present in the patient’s blood when the blood was sampled for culture). Contamination: presence of microorganisms in the bottle that entered during sampling but were not actually circulating in the patient’s bloodstream. Fungemia: the presence of fungi in the blood. Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection.5 Septicemia: clinical syndrome characterized by fever, chills, malaise, tachycardia, etc. when circulating bacteria multiply at a rate that exceeds removal by phagocytosis.6 Septic episode: an episode of sepsis or septic shock for which a blood culture or blood culture series is drawn. Septic shock: a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality.5 Source: Wayne, P.A. Principles and procedures for Blood Cultures; Approved Guideline, CLSI document M47-A. Clinical and Laboratory Standards Institute (CLSI); 2007 unless otherwise specified. 2 TABLE OF CONTENTS 1 BLOOD CULTURE ESSENTIALS p. 2 1 What is a blood culture? p. 4 2 Why are blood cultures important? p. 4 3 When should a blood culture be performed? p. 5 4 What volume of blood should be collected? p. 6 5 How many blood culture sets should be collected? p. 8 6 Which media to use? p. 10 7 Timing of blood cultures p. 11 8 How to collect blood cultures p. 12 9 How many days of incubation are recommended? p. 14 10 Is it a contaminant or a true pathogen? p. 15 2 SPECIAL TOPIC : INFECTIVE ENDOCARDITIS p. 18 3 PROCESSING POSITIVE BLOOD CULTURES p. 20 4 INTERPRETATION OF RESULTS p. 22 5 BLOOD CULTURE/ SEPSIS GUIDELINES p. 24 REFERENCES p. 26 RECOMMENDATIONS FOR BLOOD CULTURE COLLECTION p. 30 3 1 BLOOD CULTURE ESSENTIALS 1 What is a blood culture? A blood culture is a laboratory test in which blood, taken from the patient, is inoculated into bottles containing culture media to determine whether infection-causing microorganisms (bacteria or fungi) are present in the patient’s bloodstream. v B lood cultures are intended to: Confirm the presence of microorganisms in the bloodstream Identify the microbial etiology of the bloodstream infection 3 MAIN AIMS OF BLOOD CULTURE*: Help determine the source of • Confirm infectious etiology infection (e.g., endocarditis) • Identify the etiological agent P rovide an organism for • Guide antimicrobial susceptibility testing and optimization therapy of antimicrobial therapy * Adapted from ESCMID (European Society of Clinical Microbiology and Infectious Diseases) guidelines, 2012.7 2 Why are blood cultures important? Blood culture is the most widely used diagnostic tool for the detection of bacteremia and fungemia. It is the most important way to diagnose the etiology of bloodstream infections and sepsis and has major implications for the treatment of those patients. A positive blood culture either establishes or confirms that there is an infectious etiology for the patient’s illness.3 A positive blood culture also provides the etiologic agent for antimicrobial susceptibility testing, enabling optimization of antibiotic therapy.3 Sepsis is one of the most significant challenges in critical care, and early diagnosis is one of the most decisive factors in determining patient outcome. Early identification of pathogens in the blood can be a crucial step in assuring appropriate therapy, and beginning 4 BLOOD CULTURE ESSENTIALS effective antibiotic therapy as early as possible can have a significant impact on the outcome of the disease.8, 9 v P roviding adequate antibiotic therapy within the first 24-48 hours leads to:10-14 Decreased infection-related mortality (20-30%) Earlier recovery and shorter length of hospital stay Less risk of adverse effects Reduced risk of antimicrobial resistance Cost reduction (length of stay, therapy, diagnostic testing) Figure 1: Fast effective antimicrobial therapy increases survival chances Adapted from Kumar A, et al. Crit Care Med. 2006;34(6):1589-96.15 Total patients (%) Patient survival rate (%) 100 Patients with e ective antibiotic therapy 80 60 40 20 0 0 hours 1 2 3 4 5 6 9 12 24 36 Time to antibiotics 3 When should a blood culture be performed? Blood cultures should always be requested when a bloodstream infection or sepsis is suspected. v C linical symptoms in a patient which may lead to a suspicion of a bloodstream infection are: undetermined fever (≥38°C) or hypothermia (≤36°C) shock, chills, rigors s evere local infections (meningitis, endocarditis, pneumonia, pyelonephritis, intra-abdominal suppuration…). abnormally raised heart rate low or raised blood pressure raised respiratory rate 5 BLOOD CULTURE ESSENTIALS v B lood cultures should be collected: as soon as possible after the onset of clinical symptoms; ideally, prior to the administration of antimicrobial therapy.16 If the patient is already on antimicrobial therapy, recovery of microorganisms may be increased by collecting the blood sample immediately before administering the next dose and by inoculating the blood into bottles containing specialized antimicrobial neutralization media. 4 W hat volume of blood should be collected? The optimal recovery of bacteria and fungi from blood depends on culturing an adequate volume of blood. The collection of a sufficient quantity of blood improves the detection of pathogenic bacteria or fungi present in low quantities. This is essential when an endovascular infection (such as endocarditis) is suspected. The volume of blood that is obtained for each blood culture set is the most significant variable in recovering microorganisms from patients with bloodstream infections.17, 18 Blood culture bottles are designed to accommodate the recommended bloodto-broth ratio (1:5 to 1:10) with optimal blood volume. Commercial continuously monitoring blood culture systems may use a smaller blood-to-broth ratio ( 200 4 2 6 12.8-36.3 28-80 > 800 10 10 20 > 36.3 > 80 > 2,200 20-30 20-30 40-60 % of patient’s total blood volume 4 4 3 2.5 1.8-2.7 7 BLOOD CULTURE ESSENTIALS 5 H ow many blood culture sets should be collected? Since bacteria and fungi may not be constantly present in the bloodstream, the sensitivity of a single blood culture set is limited. Using continuous-monitoring blood culture systems, a study investigated the cumulative sensitivity of blood cultures obtained sequentially over a 24-hour time period. It was observed that the cumulative yield of pathogens from three blood culture sets (2 bottles per set), with a blood volume of 20 ml in each set (10 ml per bottle), was 73.1% with the first set, 89.7% with the first two sets and 98.3% with the first three sets. However, to achieve a detection rate of > 99% of bloodstream infections, as many as four blood culture sets may be needed.22 Figure 2: Cumulative sensitivity of blood culture sets22 Adapted from Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of Bloodstream Infections in Adults: How Many Blood Cultures Are Needed? J Clin Microbiol 2007;45:3546-3548. Detection sensitivity 100% 90% 89.7% 98.3% 80% 73.1% 70% 20 ml 40 ml 60 ml A single blood culture bottle or set should never be drawn from adult patients, since this practice will result in an inadequate volume of blood cultured and a substantial number of bacteremias may be missed.3, 22 8 BLOOD CULTURE ESSENTIALS A contaminant will usually be present in only one bottle of a set of blood culture bottles, in contrast to a true bloodstream infection, in which multiple blood culture bottles/sets will be positive. Therefore, guidelines recommend to collect 2, or preferably 3, blood culture sets for each septic episode.3, 7, 16 If 2 to 3 sets are taken and cultures are still negative after 24-48 hours incubation, and the patient is still potentially septic, 2 to 3 additional cultures may be collected, as indicated in the following diagram.16 Figure 3: Recommended number of blood culture sets Adapted from Baron EJ, Cumitech 1C, Blood Cultures IV. Coordinating ed., E.J. Baron. ASM Press, Washington, D.C. 2005 Collect 2 to 3 sets of bottles (aerobic + anaerobic) for each septic episode If culture is negative after 24-48 h incubation and patient is still potentially septic without an identified source Collect 2 to 3 additional sets of bottles (aerobic + anaerobic) If culture is negative after 24 h incubation Repeat protocol Prolong if necessary incubation Investigate non-microbial etiology 9 BLOOD CULTURE ESSENTIALS 6 W hich media to use? Microorganisms causing bloodstream infections are highly varied (aerobes, anaerobes, fungi, fastidious microorganisms…) and, in addition to nutrient elements, may require specific growth factors and/or a special atmosphere. In cases where the patient is receiving antimicrobial therapy, specialized media with antibiotic neutralization capabilities should be used. Antibiotic neutralization media have been shown to increase recovery and provide faster time to detection versus standard media.23-26 It is recommended that each adult routine blood culture set include paired aerobic and anaerobic blood culture bottles. The blood drawn should be divided equally between the aerobic and anaerobic bottles. If an anaerobic bottle is not used, it should always be replaced by an additional aerobic bottle to ensure that a sufficient volume of blood is cultured.27 v A blood culture medium must be: sensitive enough to recover: - a broad range of clinically relevant microorganisms, even the most fastidious (Neisseria, Haemophilus…) - microorganisms releasing small amounts of CO2 (Brucella, Acinetobacter…) versatile: able to provide a result for all types of sample collection (adults, infants, patients receiving antibiotic therapy, sterile body fluids…) v Which bottle should be inoculated first? If using a winged blood collection set, then the aerobic bottle should be filled first to prevent transfer of air in the device into the anaerobic bottle. If using a needle and syringe, inoculate the anaerobic bottle first to avoid entry of air. If the amount of blood drawn is less than the recommended volume*, then approximately 10 ml of blood should be inoculated into the aerobic bottle first, since most cases of bacteremia are caused by aerobic and facultative bacteria. In addition, pathogenic yeasts and strict aerobes (e.g., Pseudomonas) are recovered almost exclusively from aerobic bottles. Any remaining blood should then be inoculated into the anaerobic bottle.8 * For recommended volumes, see page 6 “What volume of blood should be collected? 10 BLOOD CULTURE ESSENTIALS 7 T iming of blood cultures Studies have shown that the time interval between collecting two blood culture samples is not considered to be a critical factor as the diagnostic yield remains the same.7 Guidelines recommend that the first two/three sets (2 bottles/set) of blood culture be obtained either at one time or over a brief time period (e.g., within 1 hour) from multiple venipuncture sites.1,16 Drawing blood at spaced intervals, such as 1 to 2 hours apart, is only recommended to monitor continuous bacteremia/fungemia in patients with suspected infective endocarditis or other endovascular (i.e., catheterrelated) infections.16 Two to three additional blood culture sets can be performed if the first 2-3 blood cultures are negative after 24-48 hours incubation in cases of severe infection or in order to increase detection sensitivity (in cases of pyelonephritis for example). This also depends on the microorganisms involved: while sensitivity is relatively good for organisms like Escherichia coli or Staphylococcus aureus, it is lower for Pseudomonas aeruginosa, streptococci or fungi.28 8 H ow to collect blood cultures Sample collection is a crucial step in the blood culture process. Standard precautions must be taken, and strict aseptic conditions observed throughout the procedure. Compliance with blood culture collection recommendations can significantly improve the quality and clinical value of blood culture investigations and reduce the incidence of sample contamination and “false-positive” readings. A properly collected sample, that is free of contaminants, is key to providing accurate and reliable blood culture results. It is recommended that blood cultures should be collected only by members of staff (medical, nursing, phlebotomist or technician) who have been fully trained and whose competence in blood culture collection has been assessed.29 11 BLOOD CULTURE ESSENTIALS 10 Key Steps to Good Sample Collection: For an illustrated step-by-step, see page 30. 1 Prior to use, examine the bottles for evidence of damage, deterioration or contamination. Do not use a bottle containing media which exhibits turbidity or excess gas pressure, as these are signs of possible contamination. 2 Check the expiry date printed on each bottle. Discard bottles that have expired. 3 S trictly follow the collection protocol in use in the healthcare setting, including standard precautions for handling blood at the bedside. 4 Blood culture bottles should be clearly and correctly labelled, including patient identification, date and collection time, puncture site (venipuncture or intravascular device). 5 E ach blood culture set should include an aerobic and an anaerobic bottle. 6 Blood for culture should be drawn from veins, not arteries.30 7 It is recommended to avoid drawing blood from a venous or arterial catheter, since these devices are often associated with higher contamination rates.31 12 BLOOD CULTURE ESSENTIALS 8 Carefully disinfect the skin prior to collection of the sample using an appropriate disinfectant, such as chlorhexidine in 70% isopropyl alcohol or tincture of iodine in swab or applicator form.1 9 Transport the inoculated bottles and the completed blood culture request to the clinical microbiology laboratory as quickly as possible, preferably within 2 hours per CLSI.1 Any delay in testing the inoculated bottles may potentially lead to an increased risk of false negative results. If delays are expected, it is important to refer to the manufacturer’s Instructions for Use (IFU) for guidance. As an example for guidance regarding delays, the ESCMID guidelines recommend that blood culture bottles for testing in continuous monitoring systems should be stored temporarily at room temperature, whereas bottles for manual testing should be incubated as soon as possible.32Again, refer to the manufacturer’s IFU for guidance. The use of vacuum tube transport systems can facilitate the rapid transmission of bottles to the microbiology laboratory. However these systems should be used with caution if using glass bottles.33 10 All blood cultures should be documented in the patient’s notes, including date, time, collection site and indications. 13 BLOOD CULTURE ESSENTIALS 9 H ow many days of incubation are recommended? The current recommendation, and standard incubation period, for routine blood cultures performed by continuous-monitoring blood systems is five days.34 However, published data suggest that three days may be adequate to recover over 97% of clinically significant microorganisms. A study by Bourbeau, et al. (JCM, 2005) showed the number of significant microorganisms isolated per day for 35,500 consecutive blood cultures collected over 30 months, of which 2,609 were clinically significant isolates and 1,097 were contaminants.35 Figure 4: Clinically significant isolates per day35 Adapted from Bourbeau PP, Foltzer M. Routine incubation of BACT/ALERT* FA and FN blood culture bottles for mo10re0t%han 3 days may not be necessary. J Clin Microbiol. 2005;43:2506-2509. 80% 74.1% 60% 40% 19.7% 20% 3.6% 1.7% 0.9% 0% Day 1 Day 2 Day 3 Day 4 Day 5 These results demonstrate that 97.4% of clinically significant isolates were recovered within the first 3 days of incubation and 93.8% within 2 days of incubation. v Incubation of Fastidious Microorganisms Another study by Cockerill, et al. (CID, 2004) demonstrated that, when using a continuous-monitoring blood culture system, 99.5% of non-endocarditis bloodstream infections and 100% of endocarditis episodes were detected within 5 days of incubation.19 This data suggests that extended incubation periods previously recommended for detection of the fastidious microorganisms* that sometimes cause endocarditis, are no longer necessary when using continuous-monitoring blood culture systems.16 * including Brucella, Capnocytophaga and Campylobacter spp., and the HACEK group (Haemophilus (except H. influenzae) species, Aggregatibacter (previously Actinobacillus) species, Cardiobacterium hominis, Eikenella corrodens and Kingella species)36 14 BLOOD CULTURE ESSENTIALS 10 I s it a contaminant or a true pathogen? Contamination of blood cultures during the collection process can produce a significant level of false-positive results, which can have a negative impact on patient outcome. A false positive is defined as growth of bacteria in the blood culture bottle that were not present in the patient’s bloodstream, and were most likely introduced during sample collection. Contamination can come from a number of sources: the patient’s skin, the equipment used to take the sample, the hands of the person taking the blood sample, or the environment. Collecting a contaminant-free blood sample is critical to providing a blood culture result that has clinical value. Certain microorganisms such as coagulase-negative staphylococci, viridansgroup streptococci, Bacillus spp, Propionibacterium spp., diphtheroids, Micrococcus spp. rarely cause severe bacterial infections or bloodstream infections. These are common skin contaminants, and a though they are capable of causing serious infection in the appropriate setting, their detection in a single blood culture set can reasonably be identified as a possible contaminant without clinical significance. However, it is important to consider that coagulase-negative staphylococci are the primary cause of both catheterand prosthetic device-associated infections and may be clinically significant in up to 20% of cases.37 The most difficult interpretation problem for the physician is whether the organism recovered from a blood culture is a true pathogen causing bloodstream infection, or a contaminant. If it is a contaminant, the patient may be treated unnecessarily with antibiotics, leading to additional patient risks. Interpretation of true pathogen versus contaminant should be based on whether the blood has been collected with a venipuncture or an intra-vascular device, and multiplicity of isolation of the same species. This illustrates the crucial nature of having collection site information included with the blood culture request sent to the laboratory. 15 BLOOD CULTURE ESSENTIALS In contrast to patients with infective endocarditis or other true positive bloodstream infections, patients whose blood cultures grow contaminants usually have only a single blood culture that is positive. This information is of great practical value for physicians, and underlines the importance of taking two to three blood culture sets from different anatomical sites.16 Contamination rates can be most effectively reduced by strict compliance with hand hygiene rules and best practices for blood collection, particularly during the stages of skin antisepsis, venipuncture and sample transfer to blood culture bottles. However, even when the best blood collection protocols are used, it may not be possible to reduce the contamination rate below 2%.38 The American Society for Microbiology and CLSI recommend targeting contamination rates not exceeding 3% of the total of collected sets.1, 16 v Impact of contamination rates A contaminated blood culture can result in unnecessary antibiotic therapy, increased length of hospitalization and higher costs. It has been found that each false positive result can lead to: Increased length of stay - on average 1 day.39 39% increase in intravenous antibiotic charges.39 $5,000 to $8,720 additional charges.40, 41 20% increase in laboratory charges.39 3 days longer on antibiotics.39 16 BLOOD CULTURE ESSENTIALS Figure 5: E xample of a laboratory-based algorithm to determine blood culture contamination42 Adapted from Richter SS, Beekman SE, Croco JL, Diekema DJ, et al. Minimizing the workup of blood culture contaminants: implementation and evaluation of a laboratory-based algorithm. J Clin Microbiol. 2002;40:2437-2444. Potential contaminant* isolated from blood culture Additional draws +/48 hours? NO YES Positive with same organism? NO YES Evaluation by qualified personnel Probable contaminant; AST** not performed unless requested Viridans group streptococci? NO YES Evaluation by qualified personnel Pathogen; set up AST† * Microorganisms such as coagulase-negative staphylococci, Streptococcus viridans, Bacillus spp, Propionibacterium spp., diphtheroids, Micrococcus spp. † AST: Antimicrobial Susceptibility Testing 17 2 SPECIAL TOPIC: INFECTIVE ENDOCARDITIS Blood culture is essential in the diagnosis of infective endocarditis (infection of the heart valves). In this elusive disease, blood cultures may need to be taken repeatedly during febrile episodes, when bacteria are shed from the heart valves into the bloodstream. For patients with infective endocarditis, positive blood cultures will be obtained in greater than 90% of cases, if optimal culture conditions are respected.43 v Acute Infective Endocarditis This is a fulminant illness progressing rapidly over days to weeks, which may be caused by highly virulent pathogens, such as Staphylococcus aureus. When suspected, the severity of this disease requires blood cultures to be drawn immediately to avoid unnecessary delays in treatment. Multiple blood culture sets should be drawn during a 30-minute period prior to administration of empiric antimicrobial therapy.44 v Subacute Infective Endocarditis If sub-acute infection is suspected, there is usually not an urgent need to initiate empiric therapy. It is more important to attempt to establish the microbiological diagnosis. Multiple blood culture sets should be obtained prior to initiation of antimicrobial therapy, with sets spaced 30 minutes to one hour apart. This may help document a continuous bacteremia, and could be of additional clinical value.3 v Fungal Infective Endocarditis Once a rare occurrence, the incidence of fungal endocarditis is increasing considerably.45 Candida species are the most common fungal pathogens involved in infective endocarditis.46 If optimum collection conditions are observed, the yield for positive blood cultures in fungal endocarditis for Candida spp. is 83 to 95%.47 18 SPECIAL TOPIC: INFECTIVE ENDOCARDITIS v How many cultures? In order to distinguish between contamination and true bacteremia, a total of three to five blood culture sets should be sufficient. Initially, two to three blood culture sets should be obtained from patients with suspected infective endocarditis. If the first 2-3 sets are negative after 24-48 hours, collect two to three more sets of cultures.3 Often patients with suspected infective endocarditis have been put on antibiotics prior to blood collection. This is the most common reason for “culture-negative” infective endocarditis. It is therefore important to use a blood culture medium that has antimicrobial neutralization capacity in order to sustain microbial growth in the presence of antibiotics (see page 10 “Which media to use?”).48,49 However, “culture-negative” endocarditis may also be due to fastidious microorganisms, such as Aspergillus spp., Brucella spp., Coxiella burnetii, Chlamydia spp. and HACEK* microorganisms. S ince current continuous-monitoring blood culture systems can recover all HACEK and other fastidious organisms within a 5-day period, extending incubation beyond this period is no longer considered to be necessary. However, if all blood culture bottles are negative after 5 days, and infectious endocarditis is still suspected, all bottles should be subcultured to chocolate agar.50 19 3 PROCESSING POSITIVE BLOOD CULTURES Today, continuously-monitored blood culture systems provide the optimum solution for blood sample processing. Generally accepted incubation periods can vary from 5-7 days, with 5 days being most popular.27 The study discussed in Figure 4 shows that 98% of all positive specimens were detected within the first 3 days (see page 14).35 Patients who progress to septic shock have a 7.6% increase in mortality every hour while not on appropriate therapy.15 Following an instrument-flagged positive event, the bottle is removed from the system and a Gram stain and subculture is performed. If the sample is Gram stain positive, the morphology of the organism should be reported immediately to the physician. Subcultures or rapid techniques (e.g., molecular diagnostics) should be initiated immediately in order to provide further organism identification and antibiotic susceptibility testing should be performed as soon as possible. If a sample is Gram stain negative, no report is made to the clinician unless there is growth on subculture. A positive blood culture is a critical result and must be reported as soon as available, due to the immediate impact on patient care decisions. When reports are delivered rapidly, studies have shown broadly improved outcomes and efficiencies in patient management.51, 52 A study by Barenfanger, et al. (Am J Clin Pathol. 2008) validated that Gram stains of positive blood cultures are a very important factor influencing appropriate therapy and patient outcomes. The study documented a statistically significant increase in the mortality rate for patients who had blood cultures processed after a delay (i.e., Gram stain performed ≥1 hour after being detected as positive; P= 0.0389). The timely removal and reporting of Gram stain results have a positive impact on patient care and this study supports the need for 24/7 coverage of blood culture instruments.53 20 PROCESSING POSITIVE BLOOD CULTURES Recent technological advances such as MALDI-TOF (Matrix-Assisted Laser Desorption Ionization Time of Flight) provide the ability to rapidly deliver definitive organism identification. Molecular diagnostics can identify the most common pathogens in positive blood cultures as well as specific antibiotic resistance genes associated with bloodstream infections. Rapid identification allows physicians to prescribe more targeted and effective antimicrobial therapy earlier to positively influence outcomes.54-56 Additionally, antibiotic susceptibility testing techniques should be performed on positive blood cultures to provide the clinician with a complete result. Appropriate use of antibiotics is crucial in cases of bloodstream infections and sepsis. Accurately determining the antimicrobial resistance profile of the causative pathogen in order to select the most effective antibiotic therapy can have a significant impact on patient outcomes. When processed correctly, blood cultures provide clinically relevant information that can help improve patient outcomes, decrease length of hospital stay and reduce use of antibiotics. 21 4 INTERPRETATION OF RESULTS The microbiology laboratory can provide useful information to clinicians to help them determine whether a blood culture sample is a true positive or a false positive (contaminant). For example, the identity of the micro- organism isolated can help determine if the culture is contaminated, and the number of Figure 6: Example of interpretation algorithm for blood culture results 1 More than one positive bottle monomicrobial culture + clinical symptoms (e.g., endocarditis, meningitis, pneumonia…) polymicrobial culture (from the appropriate clinical setting (e.g., transplants, intraabdominal infection, immunocompromized patient…) bloodstream infection probable bloodstream infection 3 Negative blood cultures but clinical symptoms 22 INTERPRETATION OF RESULTS cultures positive with the same organism can help predict true infections.57 Time to positivity is also a factor used to determine potential contamination as contaminants usually have a delayed (longer) time-to-detection due to a lower overall bio-load. Laboratories should consult with their medical director to create an algorithm which helps determine whether or not an isolated organism is a contaminant vs. an infective agent. Models, such as the algorithm below, can give guidance only on the interpretation of blood culture results.42, 57, 58 These guidelines should be used in conjunction with clinical guidelines e.g., patient’s full blood count, presence of catheters, radiological findings, etc. 2 Only one positive bottle if pathogenic organism: Listeria, S. aureus, Brucella, Haemophilus, Enterobacteriaceae, … if normal skin flora: Propionibacterium, corynebacterium, Bacillus, coagulase-negative staphylococci if viridans streptococci or coagulase-negative staphylococci and consistent with clinical setting (e.g., indwelling catheter, prosthetic heart valve, immunocompromized patient) probable bloodstream infection probable contamination probable bloodstream infection Repeat blood samples Consider non-infectious etiology Investigate viral etiology or non-culturable microorganism 23 5 BLOOD CULTURE/SEPSIS GUIDELINES v International Guidelines WHO guidelines on drawing blood: best practices in Phlebotomy. World Health Organization 2010. http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Dellinger RP., et al. Crit Care Med. 2013;41:580-637. http://www.survivingsepsis.org/guidelines/Pages/default.aspx The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Singer M., et al. JAMA. 2016;315(8):801-810. http://jama.jamanetwork.com/article.aspx?articleid=2492881 v National Guidelines COUNTRY/ REGION GUIDELINES Australia Clinical Excellence Commission. SEPSIS KILLS Adult Blood Culture Guideline Updated September 2016. SHPN (CEC) 160406. http://www.cec.health.nsw.gov.au/__data/assets/pdf_ file/0005/259412/adult-blood-culture-guideline-updated-sept2016.pdf Brazil Elmor de Araujo MR, Hemocultura: recomendações de coleta, processamento e interpretação dos resultados, J Infect Control 2012; 1: 08-19 http://www.iqg.com.br/pbsp/img_up/01355393320.pdf Europe European Society for Clinical Microbiology and Infectious Diseases, European Manual for Clinical Microbiology, 1st Edition, 2012. https://www.escmid.org/escmid_publications/manual_of_microbiology/ 24 BLOOD CULTURE/SEPSIS GUIDELINES COUNTRY/ REGION France GUIDELINES REMIC 2015. Automatisation des cultures microbiennes : quel cahier des charges ? Chapitre 11 http://www.sfm-microbiologie.org/ Germany Reinhart K, Brunkhorst FM, Bone HG, Bardutzky J, et al., Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S-2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e.V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (DIVI). German Medical Science, 2010, Vol. 8: 1-86 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899863/pdf/ GMS-08-14.pdf South Africa Guideline for the optimal use of blood cultures. SAMJ 2010; Vol. 100, No. 12: 839-843 SAMJ https://www.fidssa.co.za/Content/Documents/Guideline_for_the_optimal_use_of_blood_cultures.pdf UK UK Standards for Microbiology Investigations. Investigation of Blood Cultures (for Organisms other than Mycobacte- rium species). Bacteriology | B 37 | Issue no: 8 | Issue date: 04.11.14 | Page: 1 of 51. Issued by the Standards Unit, Health Protection Agency, PHE. https://assets.publishing.service.gov.uk/government/uploads/sys- tem/uploads/attachment_data/file/372070/B_37i8.pdf Taking blood cultures - a summary of best practice: Saving lives reducing infection, delivering clean and safe care. London: Department of Health; 2007. http://webarchive.nationalarchives.gov.uk/20120118171812/http://hcai. dh.gov.uk/files/2011/03/Document_Blood_culture_FINAL_100826.pdf USA American Society for Microbiology: Cumitech 1C, 2005 (EJ Baron et al.) ASM Press Clinical and Laboratory Standards Institute (CLSI®), document M47-A, Vol 27, 2007 (ML Wilson et al.) E mergency Nurses Association (ENA). Clinical Practice Guideline: Prevention of Blood Culture Contamination https://www.ena.org/docs/default-source/resource-library/practice-resources/cpg/bcccpg2c37f1815b664d2fa8d7e9fd0f475a41.pdf E .Septimus.CDCClinicianGuideforCollectingCultures.2015 https://www.cdc.gov/antibiotic-use/healthcare/implementation/clinicianguide.html 25 REFERENCES 1. P rinciples and procedures for Blood Cultures; Approved Guideline, CLSI document M47-A. Clinical and Laboratory Standards Institute (CLSI); Wayne, P.A. 2007 2. Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet 2010;376(9749):1339–1346. 3. WSD fact sheet 2013. www.world-sepsis-day.org 4. Kumar A, Ellis P, Arabi Y, et al. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest. 2009;136(5):1237-1248. 5. Singer M, Deutschmann CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. 6. Koneman EW. Color Atlas and Textbook of Diagnostic Microbiology. Third Edition. 7. European Society for Clinical Microbiology and Infectious Diseases, European Manual for Clinical Microbiology, 1st Edition, 2012 8. Garey KW, Rege M, Pai MP, Mingo DE, et al. Time to Initiation of Fluconazole Therapy Impacts Mortality in Patients with Candidemia: A Multi-Institutional Study. Clin Infect Dis. 2006;43(1):25-31. 9. Khatib R, Saeed S, Sharma M, Riederer K, Fakih MG, Johnson LB. Impact of initial antibiotic choice and delayed appropriate treatment on the outcome of Staphylococcus aureus bacteremia. Eur J Clin Microbial Infect Dis. 2006; 25(3):181185. 10. K ollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999;115(2):462-474. 11. H arbarth S, Garbino J, Pugin J, Romand JA, Lew D, Pittet D. Inappropriate initial antimicrobial therapy and its effect on survival in a clinical trial of immunomodulating therapy for severe sepsis. Am J Med. 2003;115(7):529-535. 12. Lodise TP, McKinnon PS, Swiderski L, Rybak MJ. Outcomes analysis of Delayed Antibiotic Treatment for Hospital-Acquired Staphylococcus aureus Bacteremia. CID 2003;36:1419-1423. 13. Kang CL, Kim SH, Kim HB, et al. Pseudomonas aeruginosa bacteremia: risk factors for mortality and influence of delayed receipt of effective antimicrobial therapy on clinical outcome. Clin Infect Dis. 2003; 37(6): 745-51 14. Forrest GN, Mankes K, Jabra-Rizk MA, et al. Peptide Nucleic Acid Fluorescence In Situ Hybridization Based Identification of Candida albicans and Its Impact on Mortality and Antifungal Therapy Costs. J Clin Microbiol. 2006;44(9):3381-3383. 26 15. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-1596. 16. B aron EJ, Weinstein MP, Dunne Jr. WM, Yagupsky P, Welch DF, Wilson DM. Cumitech 1C, Blood Cultures IV. Coordinating ed., E.J. Baron. ASM Press, Washington D.C. 2005. 17. M ermel LA, Maki DG. Detection of bacteremia in adults: consequences of culturing an inadequate volume of blood. Ann Intern Med. 1993;119:270-272. 18. Bouza E, Sousa D, Rodriguez-Creixems M, Lechuz JG, Munoz P. Is the volume of blood cultured still a significant factor in the diagnosis of bloodstream infections? J Clin Microbiol. 2007 45:2765-2769. 19. Cockerill FR 3rd, Wilson JW, Vetter EA, et al. Optimal testing parameters for blood cultures. Clin Infect Dis. 2004;38:1724-1730. 20. K ellog JA, Manzella JP, Bankert DA. Frequency of low-level bacteremia in children from birth to fifteen years of age. J Clin Microbiol. 2000;38:2181-2185. 21. Freedman SB, Roosevelt GE. Utility of anaerobic blood cultures in a pediatric emergency department. Pediatr Emerg Care. 2004;20(7):433-436. 22. Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of Bloodstream Infections in Adults: How Many Blood Cultures Are Needed? J Clin Microbiol. 2007;45:3546-3548. 23. Lee DH, Kim SC, Bae IG, Koh EH, Kim S. Clinical Evaluation of BACT/ALERT FA Plus and FN Plus Bottles Compared with Standard Bottles. J Clin Microbiol. 2013;51(12):4150-4155. 24. Amarsy-Guerle R, Mougari F, Jacquier H, et al. High medical impact of implementing the new polymeric bead-based BACT/ALERT FA Plus and FN Plus blood culture bottles in standard care. Eur J Clin Microbiol Dis. 2015:34(5):1031-1037. 25. Kirn TJ, Mirrett S, Reller LB, Weinstein MP. Controlled Clinical Comparison of BACT/ ALERT FA Plus and FN Plus Blood Culture Media with BACT/ALERT FA and FN Blood Culture Media. J Clin Microbiol. 2014;52(3):839-843. 26. Doern CD, Mirrett S, Halstead D, Abid J, Okada P, Reller LB. Controlled Clinical Comparison of New Pediatric Medium with Adsorbent Polymeric Beads (PF Plus) versus Charcoal-Containing PF Medium in the BACT/ALERT Blood Culture System. J Clin Microbiol. 2014;52(6):1898-1900. 27. R iley JA, Heiter BJ, Bourbeau PP. Comparison of recovery of blood culture isolates from two BACT/ALERT FAN aerobic blood culture bottles with recovery from one FAN aerobic bottle and one FAN anaerobic bottle. J Clin Microbiol. 2003;41:213-217. 27 REFERENCES 28. W einstein MP,Towns ML, Quartey SM, et al. The clinical significance of positive blood cultures in the 1990s; a prospective comprehensive evaluation of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults. Clin Infect Dis. 1997;24:584-602. 29. U K Department of Health: Taking Blood Cultures – A summary of best practice. 2007 30. W einstein MP. Current blood culture methods and systems: clinical concepts, technology, and interpretation of results. Clin Infect Dis. 1996;23:40-46. 31. E verts RJ, Vinson EN, Aholla PO, Reller LB. Contamination of catheter-drawn blood cultures. J Clin Microbiol. 2001;39:3393-3394. 32. Cornaglia G, Courcol R, Hermann JL, Kahlmeter G. European Manual of Microbiology. ESCMID-SFM 2012. 33. K irm TJ, Weinstein MP. Update on blood cultures: how to obtain, process, report, and interpret. Clin Microbiol Infect. 2013;19(6):513-520. 34. W ilson ML, Mirrett S, Reller LB, Weinstein MP, Reimer LG. Recovery of clinically important microorganisms from the BACT/ALERT blood culture system does not require testing for 7 days. Diagn Microbiol Infect Dis. 1993;16:31-34. 35. Bourbeau PP, Foltzer M. Routine Incubation of BACT/ALERT FA and FN blood culture for more than 3 days may not be necessary. J Clin Microbiol. 2005;43:2506-2509. 36. S chlossberg D, ed. Clinical Infectious Disease. Cambridge University Press, 2015. 37. Hall KK, Lyman JA. Updated Review of Blood Culture Contamination. Clin Microbiol Rev. 2006,19(4):788. 38. D unne Jr. WM, Nolte FS, Wilson ML. Cumitech 1B, Blood Cultures III. coordinating ed. Hindler JA. ASM Press. Washington, D.C. 1997. 39. Hall KK, Lyman JA. Updated review of blood culture contamination. Clinical Microbiology Reviews. 2006;19:788-802. 40. Bamber AI, Cunniffe JG, Nayar D, Ganguly R, Falconer E. The effectiveness of introducing blood culture collection packs to reduce contamination. Br J Biomed Sci. 2009;66(1):1-9. 41. Gander RM, Byrd L, DeCrescenzo, Hirany S, Bowen M, Baughman J. Impact of Blood Cultures Drawn by Phlebotomy on Contamination Rates and Health Care Costs in a Hospital Emergency Department. J Clin Microbiol. 2009;47:1021-1024. 42. Richter SS, Beekman SE, Croco DJ, et al. Minimizing the workup of blood culture contaminants: implementation and evaluation of a laboratory-based algorithm. J Clin Microbiol. 2002;40:2437-2444. 43.T owns ML, Reller LB. Diagnostic methods: current best practices and guidelines for isolation of bacteria and fungi in infective endocarditis. Infect Dis Clin N Am. 2002;16:363-376. 44. Osborn TM, Nguyen HB, Rivers EP. Emergency medicine and the surviving sepsis campaign: an international approach to managing severe sepsis and septic shock. Ann Emerg Med. 2005;46:228-231. 45. R ubenstein E, Lang R. Fungal endocarditis. Eur Heart J. 1995:16(Suppl B):84-89. 46. E llis ME,Al-Abdely H, Sandridge A, Greer W,Ventura W. Fungal endocarditis: evidence in the world literature, 1965-1995. Clin Infect Dis. 2001; 32:50-62. 28 REFERENCES 47. M cLeod R., Remington JS. Fungal endocarditis. In: Rahimtoola SH et al., eds. Infective Endocarditis. New York, NY: Gune & Stratton.1978:211-290 48. Z iegler R, Johnscher I, Martus P, Lenhardt D, Just HM. Controlled Clinical Laboratory Comparison of Two Supplemented Aerobic and Anaerobic Media Used in Automated Blood Culture Systems to Detect Bloodstream Infections. J Clin Microbiol. 1998;36:657-661. 49. Pohlman JK, Kirkley BA, Easley KA, Basille BA, Washington JA. Controlled Clinical Evaluation of BACTEC Plus Aerobic/F and BACT/ALERT Aerobic FAN Bottles for Detection of Bloodstream Infections. J Clin Microbiol. 1995;33:2856-2858. 50. B aron EJ, Scott JD,Tompkins LS. Prolonged incubation and extensive subculturing do not increase recovery of clinically significant microorganisms from standard automated blood cultures. Clin Infect Dis. 2005;41:1677-1680. 51. Beekmann SE, Diekema DJ, Chapin KC, Doern GV. Effects of rapid detection of bloodstream infections on length of hospitalization and hospital charges. J Clin Microbiol. 2003;41:3119-3125. 52. Munson EL, Diekema DJ, Beekmann SE, Chapin KC, Doern GV. Detection and treatment of bloodstream infection: laboratory reporting and antimicrobial management. J Clin Microbiol. 2003;41:495-497. 53. B arenfanger J, Graham DR, Kolluri L, et al. Decreased Mortality Associated With Prompt Gram Staining of Blood Cultures. Am J Clin Pathol. 2008;130:870-876. 54. Timbrook T, Boger MS, Steed LL, Hurst JM. Unanticipated Multiplex PCR Identification of Polymicrobial Blood Culture Resulting in Earlier Isolation, Susceptibilities, and Optimization of Clinical Care. J Clin Microbiol. 2015;53(7):2371-2373. 55. Bauer KA, West JE, Balada-Llasat JM, Pancholi P, Stevenson KB, Goff DA. An Antimicrobial Stewardship Program’s Impact with Rapid Polymerase Chain Reaction Methicillin-Resistant Staphylococcus aureus/S. aureus Blood Culture Test in Patients with S. aureus Bacteremia. Clin Infect Dis. 2010;51(9):1074-1080. 56. Dierkes C, Ehrenstein B, Siebig S, Linde HJ, Reischl U, Salzberger B. Clinical impact of a commercially available multiplex PCR system for rapid detection of pathogens in patients with presumed sepsis. BMC Infect Dis. 2009; 9(1):126 57. Weinstein MP. Blood Culture Contamination: Persisting Problems and Partial Progress. J Clin Microbiol. 2003;41:2275-2278. 58. Weinstein MP, Towns ML Quartey SM, et al. The clinical significance of positive blood cultures in the 1990s: a prospective comprehensive evaluation of the microbiology, epidemiology and outcome of bacteremia and fungemia in adults. Clin Infect Dis. 1997;24:584-602. 59. Ernst DJ. Applied Phlebotomy. Dennis J. Ernst (MT(ASCP)). Lippincott Williams & Wilkins, 2005. 60. Lieseke CL, Zeibig EA. Essentials of Medical Laboratory Practice. F.A. Davis, 2012. 61. Q amruddin A, Khanna N, Orr D. Peripheral blood culture contamination in adults and venipuncture technique: prospective cohort study. J Clin Pathol. 2008;61:509513. 29 RECOMMENDATIONS FOR BLOOD CULTURE COLLECTION A) USING WINGED BLOOD COLLECTION SET (preferred method of collection)59-61 1 PREPARE BLOOD COLLECTION KIT Confirm the patient’s identity and gather all required materials before beginning the collection process. Do not use blood culture bottles beyond their expiration date, or bottles which show signs of damage, deterioration or contamination. It is recommended to identify the Fill-to Mark or mark the target fill level on the blood culture bottle label about 10 ml above the media level. 2 PREPARE BOTTLES FOR INOCULATION Wash hands with soap and water then dry, or apply an alcohol hand rub or another recognized effective hand rub solution. Remove the plastic “flip-cap” from the blood culture bottles and disinfect the septum using an appropriate and recognized effective disinfectant, such as chlorhexidine in 70% isopropyl alcohol, 70% isopropyl alcohol, or tincture of iodine in swab or applicator form. Use a fresh swab/applicator for each bottle. Allow bottle tops to dry in order to fully disinfect. 30 3 PREPARE VENIPUNCTURE SITE If skin is visibly soiled, clean with soap and water. Apply a disposable tourniquet and palpate for a vein. Apply clean examination gloves (sterile gloves are not necessary). Cleanse the skin using an appropriate disinfectant, such as chlorhexidine in 70% isopropyl alcohol or tincture of iodine in swab or applicator form. The venipuncture site is not fully clean until the disinfectant has fully evaporated. 6 OTHER BLOOD TESTS If blood is being collected for other tests, an insert placed into the adapter cap may be required. The insert is used to guide blood collection tubes onto the needle. If other blood tests are requested, always collect the blood culture first. 4 VENIPUNCTURE Attach a winged blood collection set to a collection adapter cap.* To prevent contaminating the puncture site, do not re-palpate the prepared vein before inserting the needle. Insert the needle into the prepared vein. 5 CULTURE BOTTLE INOCULATION Place the adapter cap over the aerobic bottle and press straight down to pierce the septum. Hold the bottle upright, below the level of the draw site, and add up to 10 ml of blood per adult bottle and up to 4 ml per pediatric bottle.† Ensure the bottle is correctly filled to the Fill-to Mark or target fill level. Once the aerobic bottle has been inoculated, repeat the procedure for the anaerobic bottle. 7 FINISH THE PROCEDURE Discard the winged collection set into a sharps container and cover the puncture site with an appropriate dressing. Remove gloves and wash hands before recording the procedure, including indication for culture, date, time, site of venipuncture, and any complications. Ensure additional labels are placed in the space provided on the bottle label and do not cover the bottle barcodes, and that the tear-off barcode labels are not removed. If additional labels contain a barcode, they should be positioned in the same manner as the bottle barcode. Inoculated bottl
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