nurses draw blood?
Wayne Mitchell
Our Nursing Department is wanting to institute 'Total Managed Care'
where there are 'nursing technicians' doing much of direct patient
care. This proposal involves our laboratory in that all samples,
including blood samples, would be collected by the nursing technician
and somehow delivered to the laboratory.
We have no pneumatic tube system and our building covers about one
square block and 6 stories high (ground through 5). ICU and special
wound care are on 5, ER, special procedures, and cardiac cath on ground,
with 3 wards per floor on 2, 3, & 4. We are rated at about 150 beds.
Currently, the laboratory collects all blood samples while nursing
collects and delivers all others.
Our concerns are sample quality, sampling TAT, and revenue and
personnel loss.
I'm wondering what others' experiences have been with this kind of
approach to blood sample collection. One source who surveyed our local
region reports it doesn't work very well without a pneumatic tube
system. What pitfalls have you found?
ACzubek
Wayne,
Even WITH a pneumatic tube system, the TAT gets worse. Time from when the
order is written to when the blood actually gets to the lab increases. Plus,
there is the 'joy' of more hemolyzed specimens, labelling errors, wrong tubes
drawn, etc. And guess what, it's still considered a laboratory failure to
deliver the answers in a timely manner! (Remember, the lab is always wrong.)
In our hospital, they have trained nursing assistants to draw blood in some
areas. One that I know said she spent more time learning the dietary parts of
the job than how to draw blood. (Not her idea, just how the training was set
up.)
Good luck,
A Czubek
>From: Wayne Mitchell <wayneem...@worldnet.att.net>
Kar Mona
Wayne Mitchell wrote:
>>Our Nursing Department is wanting to institute 'Total Managed Care'
>where there are 'nursing technicians' doing much of direct patient
>care. This proposal involves our laboratory in that all samples,
>including blood samples, would be collected by the nursing technician
>and somehow delivered to the laboratory.
>
>
I know that 2 yrs ago our 150 bed hospital was looking at several process
changes which included the use of "Care Pairs" in which nurse techs would be
responsible for phlebotomy. The idea was to decrease the number of people a
patient had to deal with. For some political reason, these process changes
never occured.
Now, 2 years later, the same processes are being re-evaluated in the new and
improved "improvement +" plan. Again, the use of a decentralized phlebotomy
staff was considered. However, after exhaustive literature searches, and a
MECON survey which looked at "better performer hospitals", the tendency has
been to return to a laboratory-based phlebotomy team. Those hospitals which
pioneered decentralized "nurse tech" phlebotomy, have found that competency
could not be maintained and patient care actually suffered.
I would highly recommend your facility do some literature review, it is out
there both in nursing, laboratory, and quality management journals. Also,
conduct phone surveys of hospitals of your size for additional first hand info.
Good luck and
PS, invest in a pneumatic tube system, it will more than pay for itself in
increased efficiency for the hospital and especially for the laboratory.
K. Monahan
Lab Coordinator
My Opinions are my Own.
Michael John Gayler
May I give you the English perspective on this?
My hospital, which apart from having fairly small bed numbers in UK
terms (about 200beds) , is pretty typical in its arrangements for
sample collection.
Sample collection is nothing to do with the laboratory, other than we
specify what anticoagulants, and sample bottle types are acceptable.
The sample collection bottles (we use Sarstedt Monovettes) are bought
by the hospital central supplies department, out of the Sterile
Supplies budget. They are distributed to the wards by Central Sterile
Supplies Department.
Routine blood samples (ward and clinic) are collected by trained
phlebotomists (who are paid abysmally low rates) who are organised by
a head phlebo, who in turn is managed by the Out-Patient Departmental manager.
Emergency samples, and special types of samples (eg arterial blood
gases) are collected by the medical staff.
No samples are collected by nursing staff.
The samples are sent to the lab reception area by hospital porter or
by air-tube system. If its an area which doesn't have an air-tube
point, and the sample needs to get to us quickly - often the doctor
will bring the sample.
Certainly a reliable air tube system is a vital component of getting
samples to us quickly - we use it for sending reports out as well
occasionally - but this is less reliable due to the location of the
points which are shared between wards, and sometimes in public areas.
We find the phlebotomists do a pretty good job - once they know what
they are doing! If it's all they are doing they become the experts at
the task. The problem tends to be one of retention of phlebotomists
due to the low pay.
Although these areas are outside of the lab's direct control - there
is a lot of teamwork and we all try to go along with one another -
for example, like a lot of UK hospitals we do not use Vacutainers
(dreadful things!) but after heavy pressure on the phlebotomists by
BD we agreed to the phlebos who were persuaded to give them a try.
Now we both know why we use Monovettes!
I hope that our experiences are of some little use!
Mike
Leicester - UK
P
I'm a Registered Nurse in a teaching hospital in South Carolina (USA). I've
known how to do blood draws for years but never had to do it where I work
now.
Although for early morning labs we still have a phlebotomist until 1330 ,
about a year ago we (nurses) were "given" the duty of drawing blood.
Initially I hated it as one more thing to do, but now I appreciate that I
can see that STATs are really STAT. . I'm very good at what I do and I
have no trouble drawing blood using a vacutainer. BUT if I do, I use a
syringe, a butterfly or whatever it takes. If all else fails we call the
lab and one of the remaining phlebotomists comes to the unit and attempts.
We get the lab tickets on a small bar code printer and send the vacutainers
down by RED tubes in biohazard bags through the pneumatic tube system. We
do fingerstick blood sugars on the unit with a glucometer. And I can know a
blood sugar result immediately.
Hope this helps.
Pat
Steallight
Pat writes
>BUT if I do, I use a
>syringe, a butterfly
Check with the lab to see how many of your syringe and butterfly draws are
hemolyzed, inappropriately clotted, etc. These are poor ways to collect blood.
> We
>do fingerstick blood sugars on the unit with a glucometer. And I can know a
>blood sugar result immediately.
And how often does this "immediate result" change treatment. In my experience,
the major benefit to POC is to keep the physicians happy. I have yet to see a
facility where capillary punctures are not done incorrectly for POC.
Don't think this is nursing service bashing, Pat. My wife and my mother are
both RN's. I respect their nursing ability. My background, training, and
skills are equally impressive, yet I am not a nurse, and realize that by
training and temperment I have no business doing patient care.
Happily dancing in the Phil Zone and scattering Garcia Ashes!
http://members.aol.com/steallight/index/
Healthcare: The bottom line is patients not profits!
Steal...@aol.com is Stev Lenon MT(ASCP) should you care to know.
Gary
I would differ with you on both of your points.
First, although I agree that syringe and butterfly draws are not the
best way to draw blood, they are acceptable when properly done.
Usually these collection methods are last resort, used when no other
approach to venous collection is available. As Pat noted, she uses
these methods when a vacutainer is not feasable as would any
experienced phlebotimist.
Immediate results are often responsible for changes in treatment. An
obvious one is the glucometer. Fingerstick glucoses on the floor can
be shown to directly affect the quality of care given to an
insulin/non-insulin dependent diabetic. The results of these
fingersticks directly determine the amount of insulin given to satisfy
insulin sliding scale orders.
Other POC tests also directly affect patient treatment. ABG results
directly affect ventilator settings. The early symptoms of both
hyperkalemia and hypokalemia are similar, without a stat electrolytes
how can you determine the treatment of choice?
Modern technology has moved many of these tests from a centralized
laboratory setting to a POC situation, usually to the betterment of
patient care. The laboratory should retain and insist upon tracking
the QC of these instruments as well as their maintainance. This is
certainly beyond the scope of practice for nursing personel.
Collecting the specimen and performing the test on this equipment is
not beyond nursing personel capabilities. Using a glucometer or even
a recent model ABG/Lytes machine is simple and straight forward.
The real problem is one of staffing. If these tests are moved to POC,
where does the manpower to run them come from?
SJ Prow
On 12 May 1998 11:51:58 GMT, steal...@aol.com (Steallight) wrote:
Ok, I'll bite.
>Pat writes
>>BUT if I do, I use a
>>syringe, a butterfly
>
>Check with the lab to see how many of your syringe and butterfly draws are
>hemolyzed, inappropriately clotted, etc. These are poor ways to collect blood.
We (at the Johnson Space Center) ROUTINELY collect blood using
butterflies (21g) and occasionally Sarstedt monovette syringes both on
the ground and inflight. We have very very few problems. We also
ROUTINELY draw serial blood samples from 20g catheters (inflight and
on the ground), and have done extensive studies into any differences
this might cause. The only (rare) clotting problems we have ever had
are the result of inadequate mixing in zero-g. Think about it.
Oh, and for the record, many of those "phlebotomists" are military
pilots with extensive training from my partner, Karen. They are very,
very good at it. It's kinda hard to send back to the lab for another
person when you're 200 miles up. Some are MDs, some are DVMs, and
some are Ph.D.s of miscellaneous background (like geology,
astrophysics, etc.)
My point here is twofold:
1. Given the proper training, anyone can draw good samples with a
butterfly needle and syringe, or anything else within reason.
2. Not every facility has the time or resources to put together an
extensive training program like ours, but it'd probably be worth it to
do so.
>> We
>>do fingerstick blood sugars on the unit with a glucometer. And I can know a
>>blood sugar result immediately.
>
>And how often does this "immediate result" change treatment. In my experience,
>the major benefit to POC is to keep the physicians happy. I have yet to see a
>facility where capillary punctures are not done incorrectly for POC.
We use the i-STAT portable analyzer quite a bit (although if they ever
talk about it, they use the NASA acronym PCBA) for research. We have
done both capillary and venous puncture (that's what the monovettes
are for) for analysis depending on what's being done in the
experiment. We have also done a lot of zero-g testing (and still a
lot more to come) on the "vomit comet" with the B-D QBC analyzer
(under the NASA acronym MOCHA), for capillary CBCs. We have also used
a glucometer in the past with capillary samples, and I believe
somewhere on some NASA site there are some excellent photos of
astronauts doing this.
As we say at NASA, "it's a training issue."
Sandra
http://www.MedTek.org
SandyB
Steallight wrote:
> Pat writes
> >BUT if I do, I use a
> >syringe, a butterfly
>
> Check with the lab to see how many of your syringe and butterfly draws are
> hemolyzed, inappropriately clotted, etc. These are poor ways to collect blood.
>
What venipuncture method do you recommend; especially for difficult to draw
patients?
SandyB
(who dislikes vacutainers)
Janmcwb
Our hosp, bed size about 125 beds went to the carepartner route about 2 years
ago. We know have care partners drawing four floors of inpatients. If
administration has decided to go with this route of patient care, try to help
rather than fight, because once their minds are made up, they are not going to
listen ....anyways, some of the initial problems were the expected inadequate
spec., or too much. But I found that if you were helpful and called immediately
with a problem spec, you would be able to talk to the person responsible and be
helpful, My motto in this field is that you must always ask questions, there
are no stupid questions. Make sure that you have a well written required spec.
book on the floors. Blood bank tubes now have to have typenex bands along with
medical record numbers to ensure quality. Our lab also runs a nuts and bolts
session for contuing ed for the care partners and nurses, to keep them updated
on our procedure.. We are so busy now that we are thankful that the floors are
covered. The biggest problem was staffing on the off shifts for lab draws,
presently we are still doing the midnight to 6 am draws and on occasion, the
floors would send people home when slow onthe weekend, never bothering to call
the lab to see if we could help, they would just assume.
Bec Ridges
I work in a small country lab attached to a 120 bed hospital
in Australia.
During the day we have a "bleeding sister" who may or may not
be a registered nurse. Sometimes our "technical assistants"
(clerks who have been trained in venipuncture - most of them
are better than me), will collect in the wards or collect the
outpatients. The nurses in casualty will collect emergencies as
will most of the ICU nurses. The rest of the wards (medical and
surgical) won't (for some unknown reason). If we're really lucky
the doctor or resident will bleed the patient.
It's really handy having the ICU/ER nurses collect, especially when
you're the only one in the lab! However there are the occasional
problems with haemolysis (esp. when they collect in a syringe and
then stab it through the top of the vacutainer and force it through
the needle!) and also with labelling. We are actually not supposed
to accept anything that has a pre-printed label on it because there
have been too many cases of labels going on specimens belonging to
another patient (this is epecially impt for blood banking). They
chuck a wobbly but if you point out to them that you won't take
any responsibility for the transfusion, they will usually recollect
pretty quickly!
Just an Aussies point of view!
Bec
Steallight
>What venipuncture method do you recommend; especially for difficult to draw
>patients?
>
>SandyB
To begin with, I use 22 g multi-sample needles. the ones I prefer have a 21 g
bore. For patients requiring syringe draws, i use the smallest syringe
consistent with the task, 22 or 23 g needles and a feather touch on the
plunger. Blood from syringes is allowed to run down the side of opened tubes
rather than being forced through a cork under pressure. In the event of cap
punctures, I use the side of the finger, not the ball, and go for blood. i
prefer to hurt the patient only once rather than repeat a series of inadequate
jabs. Now, want to talk trauma cases or arterial sticks.
You should know before we go further that I learned my phlebotomy skills in
S.E. Asia long ago. Then I polished them up a bit in various O.R's and
Recovery rooms as well as on many wards and in neonate units. Like everyone
else, I miss from time to time but on the whole, I get what I go for.
Pax, you sound as if you care about the patients more than ,many!
dkwo...@earthlink.net
In article <199805090513...@ladder01.news.aol.com>,
I'm currently a part of one of those "Care Pair" systems. I was trained as a
nurse tech and also received phlebotomy training, training as a respiratory
tech, and training as an EKG tech. The end result of all of this was that the
group of us became extremely overworked and grossly underpaid. I barely make
more now than I made as simply a nurse tech. Sure, having the extra skills are
nice, but the RNs at this hospital had gotten so used to simply passing meds
and leaving ALL of the patient care to the nurse techs that when the
multi-skilled workers were introduced, they became hostile and resentful, not
because we made anywhere near the amount of money that they made, but simply
because our extra duties forced some of the patient care loads upon them. I
mean since when have a nurse not known how to put a patient on a bedpan? You
should have heard the whining, it was pathetic. If nothing else this situation
has allowed the hospital administration to see how inadequate these nurses
really are.
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