Central venous catheters (CVC) are a frequent cause of healthcare-associated bloodstream infections. During root-cause analysis of CLABSI, our team observed positive blood cultures obtained from CVC devices when the peripheral culture result was negative. CVCs are often colonized, increasing the likelihood of a false-positive culture. Our health system is comprised of 9 hospitals and over 4000 practicing physicians supported by one unified electronic medical record (EMR) platform. The current blood culture order did not limit options for site selection, allowing variability and inconsistent performance affecting patient outcomes.

We reviewed events from June 2018 through October 2019 to determine how many CLABSI were identified based on specimens collected from CVC vs peripherally. We itemized available EMR order selections and identified multidisciplinary stakeholders and frontline providers to influence peers on proposed EMR changes. Infection Prevention proposed modifying the blood culture order to guide the provider to select peripheral source.

36% of CLABSI were identified from a CVC source with a negative peripheral culture. The current order allowed free selection of options for specimen source in the EMR. It took over 12 months to approve and implement a re-designed blood culture order across a large hospital system. When a provider selects a CVC source for blood culture collection, additional questions are required to complete the order. These include: unable to obtain from peripheral source OR peripheral source positive and suspecting central line infection.

Unanticipated adverse events can be caused by poorly designed systems that allow users multiple choices without consciously considering relevant information. Limited, forced functions guide clinicians to select CVC blood culture only when clinically indicated for diagnosis of catheter-related bloodstream infection. System change is successful when a multidisciplinary team led by a physician champion can manage organizational culture to support patient outcomes.