From a Wasted Vancomycin Order to a Searchable Question: Defining the Problem of Blood Culture Contamination and Framing a PICOT Question for an Emergency Department
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Doctor of Nursing Practice Program, Aspen University
DNP860: Evidence-Based Practice for Quality Improvement
Instructor Name
Month Day, Year
From a Wasted Vancomycin Order to a Searchable Question: Defining the Problem of Blood Culture Contamination and Framing a PICOT Question for an Emergency Department
Evidence-based quality improvement begins with a well-defined problem and a question precise enough to search. Clinicians often experience problems as frustrations long before they describe them as questions. This paper traces that transition for one problem in a composite emergency department: contaminated blood cultures. It describes the frustration, quantifies the problem with local data, explains why it matters, distinguishes background from foreground questions, and develops a PICOT question to guide the evidence search in the next module.
The Frustration
Every few weeks, a patient discharged from our emergency department is called back because a blood culture has grown coagulase-negative staphylococcus, an organism that usually comes from the skin rather than the bloodstream. Some are admitted for repeat cultures and intravenous vancomycin while the result is sorted out; others spend hours in the department waiting for a decision. Nurses who collected the cultures sometimes hear that they "contaminated" them, though no one has shown them what to do differently. The frustration is shared by physicians, who must decide whether to treat, and by patients, who return anxious about an infection they may not have.
Quantifying the Problem Locally
A review of microbiology data for the past 12 months at the composite 48-bed emergency department, which collects about 9,600 blood culture sets a year, found a contamination rate of 4.1 percent, meaning about 390 contaminated sets. Contamination was defined as growth of a common skin organism in only one of two sets. The rate varied by collection method: 5.6 percent for cultures drawn through a newly placed intravenous catheter and 2.4 percent for cultures drawn by separate venipuncture. About 60 percent of cultures were drawn through catheters, usually because the nurse was starting a line anyway and wanted to avoid a second needle stick.
Why the Problem Matters
Blood culture contamination is not a laboratory nuisance. A comprehensive review describes its consequences: unnecessary antibiotic exposure, particularly to vancomycin, additional laboratory tests, longer hospital stays, misdiagnosis, and increased costs, along with an added burden on microbiology laboratories (Doern et al., 2019). The review notes that contamination rates of 3 percent have long served as a benchmark, and that lower rates are achievable. Each contaminated culture is a false alarm that the health system pays for in antibiotics, beds, and trust. At 4.1 percent, our department exceeds even the traditional benchmark.
Background and Foreground Questions
Evidence-based practice separates two kinds of questions. Background questions concern what is generally known about a condition or process; foreground questions seek the specific evidence needed to make a particular practice decision (Melnyk & Fineout-Overholt, 2019). Background questions for this problem include: What causes blood culture contamination? Which organisms are usually contaminants? How is contamination defined? These questions are answered by textbooks and reviews and help the DNP student understand the problem.
The foreground question asks which practice change would reduce contamination in this setting. The Johns Hopkins evidence-based practice model begins its practice question phase by recruiting an interprofessional team, defining the problem, and developing and refining the practice question, often with the PICOT format (Dang et al., 2021). The team for this project includes two emergency nurses, an emergency physician, the microbiology supervisor, and an infection preventionist.
Developing the PICOT Question
The PICOT format breaks a foreground question into five parts, each of which later becomes a set of search terms. Population: adult patients in the emergency department who require blood cultures. Intervention: a collection bundle that requires venipuncture separate from intravenous catheter placement, uses sterile technique with a standardized kit, and diverts the initial portion of blood before filling culture bottles. Comparison: current practice, in which cultures are frequently drawn through newly placed catheters with clean technique. Outcome: blood culture contamination rate. Time: six months after implementation.
The question reads: In adult emergency department patients requiring blood cultures (P), does a collection bundle of separate venipuncture, sterile technique, and initial specimen diversion (I), compared with current collection practice (C), reduce the blood culture contamination rate (O) over six months (T)?
Refining the Question
The first draft of the question was too broad: "How can we reduce false-positive blood cultures?" That version would have retrieved thousands of articles about laboratory methods and rapid diagnostics. Specifying the population as emergency department adults, the intervention as a collection bundle, and the outcome as contamination rate makes the question searchable and aligns it with the local data, which show that collection method matters. The team also considered including physician order practices, such as ordering cultures only when indicated, but decided that this belongs in a separate question to keep the project focused on what nurses control. Secondary outcomes, such as vancomycin starts for contaminated cultures and the true-positive yield, will be tracked to ensure that reducing contamination does not reduce the detection of real infections.
Why This Problem Fits a DNP Project
Not every problem suits a doctoral quality improvement project. This one does for four reasons. It is measurable with data the laboratory already collects, so the project needs no new data system. It is within nursing's control, since nurses collect most emergency department cultures and choose the collection method. It has a plausible, evidence-based solution that can be tested on a small scale, one shift or one pod at a time, before spreading. And it matters to several stakeholders at once: nurses tired of blame, physicians frustrated by ambiguous results, the laboratory burdened by extra work, pharmacy concerned about unnecessary vancomycin, and finance aware of the costs of avoidable admissions. A problem that crosses these interests gives the project allies from the start. It also carries a risk to manage: nurses may hear the project as confirmation that they are the cause. Framing the work as a system redesign of how cultures are collected, rather than as retraining individuals, will be essential from the first meeting.
Conclusion
A recurring frustration, patients called back for cultures that grew skin bacteria, has become a defined problem with a local rate of 4.1 percent, a pattern linked to catheter draws, and documented consequences for patients and the organization. Separating background from foreground questions and applying the PICOT format produced a focused question that can be searched, appraised, and tested. That question will guide the evidence search in the next module.
References
Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2021). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International.
Doern, G. V., Carroll, K. C., Diekema, D. J., Garey, K. W., Rupp, M. E., Weinstein, M. P., & Sexton, D. J. (2019). Practical guidance for clinical microbiology laboratories: A comprehensive update on the problem of blood culture contamination and a discussion of methods for addressing the problem. Clinical Microbiology Reviews, 33(1), Article e00009-19. https://doi.org/10.1128/CMR.00009-19
Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and healthcare: A guide to best practice (4th ed.). Wolters Kluwer.
How this DNP 860 Module 1 example is structured
DNP860 Module 1 samples often turn a clinical frustration into a searchable PICOT question. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example describes the frustration, quantifies it locally, establishes why it matters, distinguishes question types with a named EBP model and builds and refines a PICOT question with balancing outcomes.
DNP860 Module 1 questions, answered
What does DNP860 Module 1 usually ask for?
The first module often asks you to identify a practice problem in your setting, support it with data and frame it as a searchable PICOT question for the evidence-based quality improvement work that follows. Aspen does not publish module deliverables, so your classroom's instructions govern.
What is the difference between background and foreground questions?
Background questions ask for general knowledge about a condition or process, such as what causes contamination. Foreground questions ask for specific evidence to guide a practice decision and are usually written in PICOT format.
What does PICOT stand for?
Population, intervention, comparison, outcome and time. Specifying each element makes a practice question precise enough to search the literature effectively.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.