Feature Story

Back to the drawing board

Hospitals rethink their phlebotomy staffing practices

February 2001
Karen Southwick

One of the oldest practices in hospital care -drawing a patient’s blood for testing-remains in an unsettled state at many institutions, beset by questions as to who should do it, when, and under what type of supervision.

Two trends have combined to upset the established model of maintaining a dedicated team of trained phlebotomists directed by the laboratory to handle blood drawings. The first trend is patient-focused care, and the second is cost-cutting, which in this context means cross-training support personnel, such as nursing assistants, in a variety of tasks.

Not surprisingly, "the lab community generally opposes the move to have nursing oversee phlebotomy," says Peter Howanitz, MD, laboratory director at State University Hospital of New York, Brooklyn. The laboratory’s opposition is not primarily a desire to protect its turf, says Dr. Howanitz, a quality assurance expert in phlebotomy who has written numerous articles on the subject. Rather, it’s a quality of care issue because nursing-directed programs result in more errors, greater need for redraws, and more needle-stick injuries to personnel.

Nursing supervisors who oversee phlebotomy report that they didn’t necessarily want the additional task; it was thrust upon them by administrative directives. The supervisors maintain, however, that once a good training program and a core of trained phlebotomy staff is in place, quality climbs to acceptable levels. And, they say, nursing personnel are more attuned to the working rhythms of a hospital unit and can provide better service than laboratory personnel adhering to a set schedule.

At three hospitals run by Bon Secours, Richmond, Va., nursing oversees all inpatient phlebotomy in a model that has evolved over the last six to seven years. "Bon Secours was very much into patient-focused care," says Billie Vaughn, administrative director of HealthPartners Laboratories, the laboratory subsidiary of Bon Secours Richmond. "It was an administrative directive to move toward having fewer caregivers interacting with the patients."

Consequently, HealthPartners’ inpatient phlebotomists were transferred to the outpatient side, which stayed under the laboratory, or given other jobs. No one was laid off, says Sherrill Bryant, HealthPartners’ manager for patient care centers, which are outpatient facilities affiliated with the hospital.

All nursing personnel-about 500 people-were trained to do phlebotomy. With assistance from the laboratory, the training was handled on a unit-by-unit basis. Staff members had to do a prescribed number of successful venipunctures before they could work on patients unsupervised.

During this transition, "nursing still had the support of the lab," says Sue Duffee, support services coordinator for HealthPartners. The laboratory phlebotomists would be called on for difficult draws, such as infants in the special care nursery or psychiatric patients. Duffee says weaning the nursing department from dependence on the laboratory is a delicate balancing act. "We found that once we started offering support, like the special care nursery, they would call us more and more. You have to be very careful about how much support you give."

The nursing staff now performs most of the routine inpatient draws, while medical technicians do the job in the hospitals’ rapid response facilities. "The bulk of the [nursing] draws are being done by the same group of people," says Vaughn, on a schedule beginning around 3 AM. Errors such as clotted, hemolyzed, and mislabeled specimens initially spiked, but these have gradually subsided. Vaughn says the laboratory continues to see problems on weekends, when units are staffed by temporary personnel less experienced in phlebotomy.

The laboratory intervenes when problems surface in a unit. If statistics show an unusual number of errors, says Vaughn, "we take immediate remedial action," such as meeting with the supervisor and scheduling special training sessions for staff. All new nursing employees receive phlebotomy training, and refreshers are provided through nursing skills fairs conducted monthly on a unit-by-unit basis.

Notes Vaughn: "As time passes, nursing is being asked to assume more and more responsibility. As that happens, phlebotomy becomes more of an issue." However, as per administrative direction, "we’re standing firm that it’s not coming back to the lab unless we start seeing patient risk issues."

St. Joseph Mercy Hospital, a 530-bed facility in Ann Arbor, Mich., also has adopted nursing-directed phlebotomy. Part of a larger health system that operates two other hospitals, St. Joseph performs about 350,000 inpatient blood draws annually, all overseen by nursing. The smaller hospitals and the system’s 10 outpatient centers in three counties remain under pathology- directed phlebotomists.

Five years ago, while trying to improve the quality of patient care, St. Joseph found that "one of the chief complaints from patients was that in a three-day hospital stay, they never saw the same person twice. Different people were doing their blood draws, delivering the food, taking blood pressure.... It was a major dissatisfier," says Samuel Hirsch, MD, head of the Department of Pathology and director of clinical laboratories at St. Joseph.

As a result, the hospital centralized these functions under nursing, cross-training patient care technicians, or PCTs, to handle such tasks as respiratory therapy, basic nursing, and phlebotomy, as well as deliver food. (The smaller hospitals, with far fewer caregivers, didn’t adopt such a model.)

At St. Joseph, Dr. Hirsch has seen a pattern similar to Bon Secours’: At first, the patient care technicians would request that the laboratory provide backup on tough draws. Today that dependence has substantially diminished. "We have a group of PCTs who have been here for four or five years," says Dr. Hirsch. "There’s a learning curve [in phlebotomy] for the first year or two. After that, the proficiency of the PCTs will approach that of phlebotomists."

But the biggest problem isn’t skill in drawing blood, where the abilities of experienced PCTs now equal those of phlebotomists, Dr. Hirsch says. "It’s adhering strictly to our [laboratory] policy on patient identification." Mislabeled or unlabeled specimens continue to be a greater problem with PCTs than with laboratory-based phlebotomists, he adds.

"We try to drill into our PCTs to ask the patients their name and birthdate and label the blood tube with that information before they leave the bedside," Dr. Hirsch says. In the press of other duties, however, the PCTs sometimes leave the labeling to the ward clerk, and multiple samples can get mixed up.

Sherry Simpson, a nursing-based education specialist in phlebotomy, says PCTs are retrained annually on laboratory procedures. And special training is provided to any unit that has unusually high error rates.

For Dr. Hirsch, the key to making nursing-directed phlebotomy work is training. The inpatient PCTs initially hone their skills by working with the laboratory’s outpatient phlebotomists, who perform about 75 draws a day. The PCT and phlebotomy functions are considered entry-level, with personnel often moving into nursing or medical school. St. Joseph, like other institutions, struggles with turnover, which is about 10 percent annually, Dr. Hirsch estimates, making training all the more critical.

Simpson adds that St. Joseph has worked with the local community college to establish a training course in phlebotomy that incoming PCTs are required to take. When new PCTs first start performing blood draws, a nurse supervises them. In addition to performing phlebotomy, they dress simple wounds, start IVs, put in catheters, administer nebulized mist treatments, handle baths, and feed and walk patients. "The idea was to create this multifaceted caregiver," Simpson says. The establishment of PCTs "was driven by an administrative redesign, not by nursing," she emphasizes.

On the outpatient side, the laboratory continues to oversee phlebotomy, which is performed by specialists. Linda Pope, St. Joseph’s manager of outpatient laboratories and phlebotomy services, supervises the team of about 60 full-time equivalents who handle phlebotomy at two smaller hospitals and 10outpatient clinics. Because there’s no nursing assistant position in the outpatient setting, "we wanted to keep phlebotomy lab-focused," she says. Outpatient blood draws can be performed by phlebotomists or entry-level lab technicians, who also handle processing, such as spinning and separation.

At one outpatient site, radiology technicians are being cross-trained to do the blood draws, while phlebotomists are cross-trained to do EKGs, Pope says. "This is to make the workflow better there, but it’s not something that would be feasible everywhere," she adds. "You need high volume in both radiology and phlebotomy."

Dr. Hirsch says one model that hasn’t worked well is having the laboratory send phlebotomists to local physician offices. The patient volume isn’t high enough to keep the phlebotomists busy, yet federal regulations prohibit them from performing any other duties in the physician office.

"Even in a busy office practice, a phlebotomist will do no more than about 40 draws a day," Dr. Hirsch says. "The productivity isn’t there."

Lab-directed phlebotomy

Other institutions have stayed with the traditional phlebotomy model-a team of lab-directed specialists. Among these is Children’s Hospital, a 130-bed pediatric care facility in Omaha, Neb. While the suggestion to change arises occasionally, "we’ve never seriously considered it," says Deborah Perry, MD, director of pathology. "We’ve had the pediatric phlebotomy team for over 20 years."

Today that means 10 FTEs who cover three shifts, providing 24/7 availability to the inpatient and outpatient settings. The medical technologists can operate as backup phlebotomists in a pinch. "We want our technologists to be good phlebotomists," says Dr. Perry. "It makes them appreciate the difficulty of specimen collection."

Children’s has a core group of four phlebotomists, each of whom has at least 10 years of experience with pediatric draws. "They’re the backbone of the entire team," says Karen Butler, laboratory manager. At Children’s, as in most institutions, nurses handle the line draws, in which blood is collected from intravenous lines in intensive care or critical care units. Error rates due to "unacceptable specimens" are 0.1percent for phlebotomist-collected blood and 0.3 percent for nursing.

Two years ago, Children’s invited a consultant group to evaluate its performance. One system they looked at closely was phlebotomy. "We had focus groups with the nursing staff, the bedside caregivers, not just management," says Butler. "The nursing staff on both the inpatient and outpatient sides unanimously said the lab-based phlebotomy service was working fine and nursing didn’t have the time for it."

While the consultants discussed the potential cost savings of combining phlebotomy with nursing, "we pointed out that a nurse’s time is more expensive than a phlebotomist’s," Butler says. In addition, "getting blood out of a screaming two-year-old or an 800-gram neonate requires a certain level of experience" that nurses or assistants who do limited numbers of draws might not have. "If we get a bad specimen," she adds, "we’ve wasted time, equipment, and reagents, and delayed result turnaround time."

Eliminating phlebotomists might reduce the laboratory budget for FTEs, but at the same time, it boosts costs because of the need for a greater number of redraws. "Relationships between the lab and nursing can become very strained if you have to call them all the time to ask for another specimen," Butler says. While nursing assistants, called child care partners, could conceivably perform phlebotomy, there are more than 70 of them, presenting a training challenge. "You would be taking the expertise of one of my phlebotomy specialists and diluting it," she says. "They would only be doing it one-seventh as well."

Then, too, the pediatric hospital was reluctant to change because drawing blood from children is notoriously difficult. "It’s not just the limited volume of blood you can draw but the ability to get a quality capillary specimen," says Butler.

Adds Dr. Perry: "Someone who’s a very good adult phlebotomist might not be good with children, where you have to be very empathetic. And you have to deal with the entire family, not only the patient. Interpersonal skills are really key." Most of the complaints from parents are not about the blood draw itself but because "somebody didn’t smile or brushed them off."

Children’s will often send two people to handle a draw, "one to hold and one to draw," says Dr. Perry. Incoming phlebotomists spend six to 12 weeks in training before they work independently. And every phlebotomist undergoes annual refresher training.

Children’s tries to avoid drawing more blood than is necessary. Says Dr. Perry: "We don’t want to draw a drop more than we need. Anemia [due to excess blood draws] can be a problem with children, especially in intensive care units." Phlebotomists will review all the orders and work with nurses and physicians to eliminate duplication and downsize the volume and frequency of draws.

Across the street from Children’s is 385-bed Methodist Hospital, which primarily cares for adults. Methodist also considered moving to a nursing-based phlebotomy system but largely rejected it.

Methodist went through a re-engineering process in which one recommendation was to move toward care technicians who would handle phlebotomy and nursing assistant duties. "We agreed to try that model in the emergency room," recalls laboratory manager Marilyn Thomsen. "The care techs were supposed to meet the same kind of quality standards with no greater number of redraws" than the lab-directed phlebotomists. If the experiment had succeeded, care technicians might have taken over phlebotomy throughout the hospital.

"What we found was that the nurses really didn’t like worrying about phlebotomy," says Thomsen. The redraw rate in the emergency room is about twice that of the lab-directed phlebotomy team. Although care technicians continue to handle phlebotomy in the ER, "they call on us routinely to back them up or to do the hard draws."

Diane Wolff, phlebotomy team leader for Methodist, says the care technicians struggle to meet the laboratory’s quality guidelines. "There are a lot of mislabeling problems and specimen integrity problems," she says. Wolff meets periodically with the care technicians to review procedural changes and guidelines.

Given the performance of the care technicians in the ER, "obviously we haven’t seen much pressure by nursing to do phlebotomy anywhere else," says Thomsen. "The lab has retained inpatient and outpatient phlebotomy," including training.

To reduce turnover, Methodist has designed a career track for phlebotomists. At the first level, a phlebotomist handles the routine procedures-venipunctures, finger and heel sticks, and bedside glucose. A level-two phlebotomist also handles arterial punctures and assists pathologists in bone marrow procedures. A level-three phlebotomist is certified with one of the national registries, such as the American Society of Clinical Pathologists. That individual performs all the duties of level-one and -two phlebotomists and takes responsibility for an ongoing project, such as teaching phlebotomy to medical technologist students.

"They’re rewarded for these extra skills" with additional pay and responsibility, says Thomsen. "This was a way to develop a ladder for those who want to make phlebotomy a career."

The Mayo Clinic, Rochester, Minn., has stuck firmly with the traditional model of lab-directed phlebotomy for the inpatient and outpatient settings. "There’s never been any reason to change," says pathologist Paula Santrach, MD, who directs phlebotomy at Mayo.

Dr. Santrach has a team of 240 FTEs to handle Mayo’s collections, about 1 million annually, including venipuncture, arterial puncture, and line draws. The redraw rate averages 0.2 percent. The laboratory provides outpatient phlebotomy service from 6AM to 9PM and inpatient service 24/7.

Even in the traditional stronghold of nursing, line draws, "their redraw rates are significantly higher than the lab phlebotomists’," Dr. Santrach says. "We’re in the process of moving to phlebotomy-assisted drawings," where the nurse deals with the line but the phlebotomist verifies that the correct amount is collected and labeled.

In outpatient clinics, nonphlebotomists have been cross-trained to handle routine draws. For preoperative evaluation, nurses or respiratory therapists perform blood draws for CBCs and electrolytes. Nurses also handle collections at Mayo’s General Clinical Research Center, but 95 percent of phlebotomy is under the laboratory’s control, according to Dr. Santrach.

Phlebotomists are trained in two ways. They can attend a semester-long course established at the local college with Mayo’s help. Half the semester is spent in the classroom and the other half at Mayo doing clinical work. Mayo also offers in-house training: an intensive two weeks in the classroom and about two months of supervised training on the units.

Because the phlebotomy staff is so large, "we have significant turnover-between 10 to 20 percent," says Dr. Santrach. "We’re continuously training people. And we do mass interviewing and hiring every one to two months." When hired at Mayo, a phlebotomy student must commit to work at least a year before seeking another position.

One initiative this year will be to implement bar-coding for patient identification in an effort to further reduce labeling errors. "We want to generate the label at the bedside using a patient ID bar code," Dr. Santrach says.

Among Dr. Santrach’s staff, 46 are vascular access technicians who perform not only routine phlebotomy, but also arterial collections, line collections, and point-of-care procedures, such as blood gases. The remainder of the staff can handle routine POC testing, like pH and glucose. Because Mayo offers high-level tertiary care, "we do a lot of very esoteric testing, and nurses were reluctant to take that on when we have a phlebotomy team," she says. "Our volume, our breadth of testing, and our [low] redraw rates have kept the team together."

Hybrid models

The University of California at San Francisco Medical Center adopted patient care assistants, or PCAs, in 1995 and cross-trained them in phlebotomy and other duties, such as food and linen service. Until then, a lab-directed team of phlebotomists had handled all the draws, except in the ICUs, where nurses handled them.

When the PCAs began performing phlebotomy, "we thought we’d see a huge increase in misdrawn specimens and in labeling problems because these people were no longer under our control," says Tim Hamill, MD, director of clinical laboratories for the 480-bed teaching hospital. But that didn’t prove to be the case, in part because many of the lab phlebotomists moved into the PCA ranks. And the laboratory was actively involved in training the first team of PCAs who performed phlebotomy.

In contrast to other institutions, where phlebotomy error rates tended to fall with time on the job, "we started to see more problems after about six months to a year," says Dr. Hamill. In the highly competitive San Francisco job market, UCSF had a tough time retaining PCAs. And as new people came onto the job, error rates rose.

The solution: Take a core team of the PCAs most skilled in phlebotomy and establish them as the specialists. This core team of about a dozen PCA/phlebotomists performs all draws in general medicine and surgery. Nurses do the ICU draws, and outpatient phlebotomy remains under the laboratory’s control. "Now we’ve swung back to having a dedicated group of people doing most phlebotomy," though they remain under nursing rather than the laboratory, says Dr. Hamill.

UCSF adopted a core of specialist PCA/phlebotomists in fall 2000. From July 2000 to Jan. 1 of this year, 57 percent of the errors due to mislabeled or unlabeled samples from inpatients were nursing draws, Dr. Hamill says. "PCAs accounted for only one percent of the 428 errors noted by the lab staff," he adds.

By location, the emergency department accounted for 18 percent of the total errors, and the seven critical care units combined accounted for an additional 31 percent of the errors. "Both of those areas are drawn almost exclusively by nurses," Dr. Hamill notes. Consequently, he is urging hospital administrators to institute a bar-code scanning method to make sure specimens are labeled at the bedside.

Lynn Dow, a nurse educator at UCSF who handles training for the PCAs, says quantity matters in developing a skilled phlebotomist. With 150 PCAs trying to do phlebotomy, "we found that some people might only be doing one or two draws a day," she says. "Getting them to the right skill level was taking a lot of our resources. You get better the more you do. That’s why we decided to limit the number who would do it."

Although Dow acknowledges that mixed feelings remain after all the changes, one benefit of having nursing oversee phlebotomy has been that draws are scheduled at times that are more convenient for the units. "The lab would do morning draws, but they weren’t readily available after that," she says. "Nursing would prefer to keep phlebotomy under us, because with a team that’s here constantly, we can provide better coverage."

Like UCSF, State University Hospital of New York, a 376-bed teaching hospital, experimented with various phlebotomy models before arriving at a hybrid. "Every year during budget preparation, we consider re-engineering our phlebotomy services to PCAs/ nursing services to save FTEs and money," says Maria Mendez, who, as senior associate administrator, oversees the laboratories and phlebotomy. "I have been successful in keeping it largely under the lab," she adds, in part because a hospital across the street that changed entirely to nursing-led phlebotomy had problems with specimen collection and labeling.

With five full-time employees and eight part-timers, the laboratory covers three blood draws per day at State University Hospital, while nursing handles the line draws and all draws on the midnight to 8AM shift. Nursing took over the midnight to 8AM draws from residents because "many of the draws then were IV anyway," says Mendez. Residents or nurses do the stat draws. In addition, State University’s emergency room uses PCAs to draw specimens.

The compromise system made everybody reasonably happy. The laboratory was able to retain its team of phlebotomists, while nursing was able to add extra staff to perform the night draws. And the error rate declined because "when the residents drew, we had a lot more problem specimens that were mislabeled or clotted," she says. "The doctors depend on our rounds now and try to have their orders in. They know that phlebotomy is a designated service at certain times."

The laboratory has thus far retained outpatient phlebotomy, serving 28 clinics with five blood-drawing stations. Mendez says five phlebotomists backed up by laboratory technicians cover the stations, which are active from 8AM to 7PM six days a week. Some phlebotomists have been cross-trained to handle outpatient EKGs as well. While there is pressure to have nursing-supervised PCAs take over phlebotomy and EKGs, "we haven’t moved to that model yet," she says.

As with many institutions, the laboratory is able to argue for retaining jurisdiction of phlebotomy based on a low error rate, which contributes to cost-effective care. For inpatient and outpatient phlebotomy, "we do an average of 10,000 blood draws a month," says Mendez, "with no more than a two-per-day error rate."

Karen Southwick is a freelance writer in San Francisco.