Improving Paediatric Blood Culture Documentation | QI Project

A Quality Improvement (QI) audit on paediatric blood culture documentation. Learn about clinical impacts, audit results, and Cerner EPR interventions.

#paediatrics#quality-improvement#blood-culture#medical-audit#sepsis#healthcare-it#patient-safety#clinical-documentation

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NHS TRUST

Quality Improvement Project

Improving Documentation of Paediatric Blood Culture Collection

FY2 Doctor

Department: Paediatrics

April 2026

QI Audit

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Background

Why Blood Cultures Matter

Blood cultures are essential in diagnosing sepsis

Contamination is a common and costly issue

Accurate documentation is required to:

Interpret results correctly

Identify contamination vs true infection

What Happens Without It

Poor documentation can lead to:

Unnecessary antibiotic use

Missed diagnoses

Compromised patient safety

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The Problem

Concerns were raised about possible contaminated blood cultures in the paediatric department.

Who?

Who took the cultures?
(clinician not documented)

How?

Technique used
(aseptic? non-aseptic?)

Why?

Indication for taking the culture
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Documentation was found to be inconsistent across the board

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Quality Improvement

Project Aim

To assess and improve documentation of paediatric blood culture collection.

Retrospective Audit

Paediatric Department

Documentation Standards

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Methods

Study Design

Retrospective audit

Data collected from electronic patient records

101 entries identified → 96 included after exclusions

Variables Assessed

Clinician

Time of collection

Collection site

Skin cleaning method

Technique used

Clinical indication

Volume collected

Timing relative to antibiotics

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Results: Documentation

n = 96

blood cultures audited

Documentation Variable

Completion Rate (%)

Score

Clinician

34%

Time

34%

Site

33%

Skin cleaning

32%

Technique

30%

Priority Areas for Improvement

Indication

Volume

Before antibiotics

Audit Cycle 1

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Key Finding

27%

of blood cultures had COMPLETE documentation

73%

were INCOMPLETE

In 64% of cases, the collecting clinician was not documented at all

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Results Interpretation

Consistent Poor Documentation

Documentation was poor across ALL domains assessed in this audit.

Critical Gaps

Indication: 0%

Volume: 0%

Before Antibiotics: 3%

Clinical Consequences

Therefore →

Difficult to accurately interpret culture results

Impossible to confidently distinguish contamination from true infection

"These gaps directly undermine the clinical utility of blood cultures"

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Clinical Impact

Unnecessary Antibiotic Use

Risk of antimicrobial overuse and resistance

Prolonged Admissions

Patients kept in hospital longer due to uncertain results

Missed True Bacteraemia

Real infections potentially dismissed as contamination

Lack of Accountability

No record of who performed the procedure

Reduced Patient Safety

Overall compromise of clinical care quality

Poor documentation = real clinical risk

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Quality Improvement Project

Intervention

Teaching Session

Short focused teaching session for junior doctors on blood culture documentation requirements

Cerner Auto-Text

Structured auto-text template introduced in Cerner EPR to prompt complete documentation at time of collection

Documentation Reminders

Reminders on: aseptic technique documentation, clinical indication, timing relative to antibiotics

Goal: make complete documentation the default, not the exception

QI Audit

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