Utilizing phlebotomists to obtain blood samples through PIVCs

Even though there are nearly 200 million peripheral intravenous catheters (PIVC) placed in patients in the United States annually,¹ the healthcare industry has been slow to accept the process of utilizing catheters as a conduit for drawing blood specimens. It has taken nearly four decades of analyzing the sampling of blood through PIVC to finally demonstrate positive results.² Initial concerns were many, from simple inconsistencies in clinical practice to biochemical errors.^2,3

As the research data improved around blood collection from PIVC, organizations or departments that steer the management of PIVC changed. In 2011, the nursing standards of practice for infusion stated that sampling blood through short peripheral catheters has been found to be reliable.⁴ With these types of standards now the norm, there has been a wave of blood collection through various types of PIVC.⁵

Creating a pilot program

To improve the patient experience, Banner Estrella Medical Center (BEMC) – which is owned by 28-hospital Banner Health in Phoenix, AZ – created a steering team of laboratory, nursing, and vascular-access specialists to create a PIVC blood draw pilot on a nursing unit at BEMC. The initial design was to implement the pilot utilizing nurses to do 100 percent of the PIVC blood collection, utilizing a controlled area and specific supplies to limit the variables. The initial phase of the pilot was to identify successful blood-specimen collection processes without experiencing any adverse outcomes.

For the second phase of the pilot, BEMC wanted to expand to a larger area of the hospital. However, the committee realized that nurses did not have time to take on an additional task of collecting all blood samples. As a result, the pilot steering team decided to evaluate the feasibility of using a centralized phlebotomy team, which was already on hand, to collect the samples. This would also allow for continuity in the blood-sample collection process. If phlebotomists are not successful in PIVC sample collection, they could use a standard venous method – a task nurses do not perform – and not delay patient care.

The nursing phase

In the first phase of the pilot, the nurses in specific units were given training in PIVC blood collection. Special signage was created to let everyone know that this patient could have PIVC blood collection. Laboratory would then be notified of the collection site. Over several months of nurse collection, the pilot was very successful. The nurses had achieved a 60 percent sample-collection success rate, with minimal specimen errors.

However, the initial data also showed that there was some room for improvement because the nurses did not collect patient specimens successfully 40 percent of the time. After reviewing the data in more detail, the steering team also discovered that several patients had the correct PIVC, but it did not get utilized for sample collection because of failed communication. In addition, sample-collection success varied, depending on which nurse was assigned to the task.

Phlebotomy phase

From the steering team’s perspective, the logical and most qualified individuals to collect samples from PIVC would be the phlebotomists. However, use of the PIVC from any professional group other than nursing was not the norm at BEMC. Early in the process, the steering committee had looked at external research to find out what other professional groups perform PIVC blood collection, finding that numerous unlicensed professional groups are collecting samples in this format, including anesthesia techs and emergency department techs, to name a few.⁵

Historically, phlebotomy had not been permitted to collect samples via any other method other than venipuncture/capillary draw. But after reviewing nursing statues and clinical laboratory standards, the steering team did not discover any legal issues that would prevent phlebotomy from performing this task.^6,7 Another issue the team identified was the concern around whether phlebotomy would be able to flush the PIVC after completing the sample collection. To clarify that point, the team asked the pharmacy department if saline was classified as a medication. Pharmacy’s perspective was that flushing a PIVC is a mechanical device and does not involve medication administration, meaning that phlebotomists may perform that task.

The pharmacy department said its conclusion was based on a review of the U.S. Food and Drug Administration (FDA) product classification, which lists a saline flush as a 510(k) product.⁸ Following an extensive review of statues and expert legal opinion, the team determined that there was no legal reason preventing phlebotomists from collecting samples via PIV and flushing the catheter.

Following the approval process, a training course for phlebotomists was developed and implemented. This included everything from biology concepts and historical background to flushing technique. Initial training included completion of a four-hour didactic course followed by precepting with a qualified nurse. Precepting included five successful sample collections via PIVC. Completion of the didactic training and the nurse preceptorship allowed the phlebotomist to collect samples from the PIVC on their own.

Pilot review

Following the training for phlebotomists, the pilot began on the same hospital units where nurses had previously implemented the pilot. After several months, the steering team expanded the pilot to multiple floors of the hospital because the phlebotomy team had collected the samples successfully. A bonus to having the phlebotomy team using the PIVC for collection is that if it was unsuccessful, the phlebotomist has the skill set to try again with a traditional sample collection method. This allowed for zero downtime from an unsuccessful PIVC collection to a venous collection if needed. In the initial pilot period, the nurse would have to submit a request for a venous sample collection to the phlebotomy department if the PIVC collection was unsuccessful, leading to a delay.

Data collection results gathered over a four-month period showed an improved PIVC sample-collection rate utilizing phlebotomy, compared with that of nursing. As mentioned earlier, the collection success rate during the nurse collection period using the same PIVC averaged 60 percent. Using phlebotomy, the success rate for PIVC sample collection averaged 92 percent. During this period, there were no incidents of hemolysis for samples collected. The team had one sample clot out of 472 PIVC collections.

An additional outcome measure was the impact of the sample collection process on the patient experience. A three-question survey was designed to ask patients about their blood-draw experience. The results: One hundred percent of patients said they would prefer their blood be drawn from the PIVC if admitted again. Although the survey is a subjective measure, it does reflect the patient experience as a positive point.

Conclusion

The results for the use of a PIVC for blood collection by a trained phlebotomist are favorable. Success rates of 92 percent without venous complications is a compelling outcome. The entire pilot from nurse collection to phlebotomy collection was approximately nine months in length, and although the pilot is facility-specific and may have internal biases, standard methodologies were utilized for sample collection. The evidence generated during the pilot was strong enough that BEMC moved from a pilot phase to standard practice, including expansion to other facilities within the healthcare system.

References:

1. Brown D, Ewigman B. Optimal timing for peripheral IV replacement. J Fam Pract. 2013, April;62(4): 200-202
2. Mahboobeh T. Blood samples of peripheral venous catheter or the usual way: do infusion fluids alter the biochemical test results? Global J Health Sci. 2016; 8(7): 93-99
3. Frey A. Drawing blood samples from vascular devices. J Infus Nursing. 2003; 26 (5): 285-293
4. Infusion Nursing Standard of Practice Guidelines, J Infus Nursing, 2011; 34, 1S
5. Davies H, et al. Blood sampling through peripheral intravenous cannulas: A look at current practice in Australia, Collegian, 2019; 27(2): 219-225
6. Arizona State Board of Nursing, https://www.azbn.gov. Accessed July 29, 2020.
7. Ernst D, et al. Collection of Diagnostic Venous Blood Samples, Clinical Laboratory Standards Institute, 2017, 7th Edition
8.  U.S. Food and Drug Administration. Medical devices-product classification: saline, vascular access flush https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPCD/classification.cfm?ID=NGT Accessed July 27, 2020.