Blood draws from Peripheral Catheters

1. Blood draws from Peripheral Catheters

2. April Bennett, Anthony Nye, Amanda Sells, Amy Wade, Kevin Wagner University of Oklahoma College of Nursing

3. Routine & serial blood collection: Common Currently obtained by traditional phlebotomy Repetitive painful procedures: Increased pain Stress Negative patient experience The Problem Routine & serial blood collection Are common in acute patient populations & are Currently obtained by traditional phlebotomy Repetitive painful procedures contributes to: Stress Increased pain intensity which can create a negative experience Routine & serial blood collection Are common in acute patient populations & are Currently obtained by traditional phlebotomy Repetitive painful procedures contributes to: Stress Increased pain intensity which can create a negative experience

4. Hospitals are trending away from specialized phlebotomy teams Utilizing nurses to draw labs Magnitude of the issue Hospitals are trending away from specialized phlebotomy teams In many institutions nurses now draw labs Important to evaluate current procedures & consider alternatives to save money, time, and provide best practice. Hospitals are trending away from specialized phlebotomy teams In many institutions nurses now draw labs Important to evaluate current procedures & consider alternatives to save money, time, and provide best practice.

5. Utilize peripheral intravenous catheters for blood draws: Streamline / efficient Less needle sticks Decrease risk for infection Improve patient satisfaction Reduce needle stick injury May reduce cost A possible solution Utilize peripheral intravenous catheters for blood draws Streamline / efficient Less needle sticks Decrease risk for infection Improve patient satisfaction Reduce needle stick injury May reduce cost Utilize peripheral intravenous catheters for blood draws Streamline / efficient Less needle sticks Decrease risk for infection Improve patient satisfaction Reduce needle stick injury May reduce cost

6. �Is it just as effective in the adult population to draw labs from a peripheral intravenous line as it is by traditional veni-puncture?� An EBP Question Is it just as effective in the adult population to draw labs from a peripheral intravenous line as it is by traditional veni-puncture? Is it just as effective in the adult population to draw labs from a peripheral intravenous line as it is by traditional veni-puncture?

7. Population� Adults with PIVs and requiring blood draws for lab Intervention Drawing blood from PIVs Comparison Traditional veni-puncture Outcome Is drawing blood from PIVs as effective as veni-puncture PICO Population� Adults with PIVs and requiring blood draws for lab Intervention Drawing blood from PIVs Comparison Traditional veni-puncture Outcome Is drawing blood from PIVs as effective as veni-puncture Population� Adults with PIVs and requiring blood draws for lab Intervention Drawing blood from PIVs Comparison Traditional veni-puncture Outcome Is drawing blood from PIVs as effective as veni-puncture

8. PIV blood draws may: Decrease frequency of needle punctures Decrease cost Importance of this question Importance of this question PIV blood draws may: Decrease the frequency of needle punctures decrease pain decrease potential of infection decrease trauma to tissues decrease the incidents of needle stick injuries Increase patient satisfaction Decrease cost decreased time investment of health care workers decrease materials/supplies Importance of this question PIV blood draws may: Decrease the frequency of needle punctures decrease pain decrease potential of infection decrease trauma to tissues decrease the incidents of needle stick injuries Increase patient satisfaction Decrease cost decreased time investment of health care workers decrease materials/supplies

9. Environments in which patients have both: Peripheral intravenous line Require serial or frequent hematological studies Clinical areas applicable EVERWHERE Emergent care Surgical Intensive care units Acute care EVERWHERE Emergent care Surgical Intensive care units Acute care

10. Review of the Literature

11. A great deal of research was conducted on this topic in the late 90�s Since the 90�s the higher prevalence of central lines has muted discussion Study of the question A great deal of research was conducted on this topic in the late 90�s, however, a clear position and accompanying procedure has never been incorporated into common practice. Since the 90�s discussion has unfortunately fallen by the wayside, due to the use of central lines. A great deal of research was conducted on this topic in the late 90�s, however, a clear position and accompanying procedure has never been incorporated into common practice. Since the 90�s discussion has unfortunately fallen by the wayside, due to the use of central lines.

12. Comparison of laboratory values obtained by phlebotomy versus saline lock devices. (2007) � Comparison of blood sampling methods in anticoagulation therapy: venipuncture and PIV. (2006) � Use of peripheral venous access devices for obtaining blood samples for measurement of aPTT. (2006) � Blood sample collection from a peripheral catheter system compared with phlebotomy. (2000) A Survey of Relevant Research Four peer-reviewed papers were assessed, evaluating hemolysis rates and the accuracy of lab values. Four peer-reviewed papers were assessed, evaluating hemolysis rates and the accuracy of lab values.

13. Conclusion: �Coagulation tests can reliably be drawn from peripheral venous catheters.� �However, more studies are needed to obtain definite and profound results.� The Zengin and Nuray study in 2006 compared prothrombin time and activated partial thrombin time values in concurrent blood samples obtained by direct venipuncture and form a peripheral venous catheter. They concluded that �Coagulation tests can be drawn from peripheral venous catheters.� -- �However, more studies are needed to obtain definite and profound results.� This conclusion is based upon the peripheral samples being obtained neither from lines continually delivering medications nor lines delivering heparin. The Zengin and Nuray study in 2006 compared prothrombin time and activated partial thrombin time values in concurrent blood samples obtained by direct venipuncture and form a peripheral venous catheter. They concluded that �Coagulation tests can be drawn from peripheral venous catheters.� -- �However, more studies are needed to obtain definite and profound results.� This conclusion is based upon the peripheral samples being obtained neither from lines continually delivering medications nor lines delivering heparin.

14. Conclusion: �Obtaining samples for determination of hematocrit, electrolytes, serum glucose, and cardiac enzymes (CPK and troponin) from a saline lock device using a needleless vacutainer system is an accurate method of obtaining serial lab values.� The Atallah et. al study of 2007 was a prospective study using comparative design. This study concluded that drawing from a peripheral IV via a vacu-tainer is an accurate method of obtaining lab values for hematocrit, electrolytes, serum glucose, and cardiac enzymes.The Atallah et. al study of 2007 was a prospective study using comparative design. This study concluded that drawing from a peripheral IV via a vacu-tainer is an accurate method of obtaining lab values for hematocrit, electrolytes, serum glucose, and cardiac enzymes.

15. The Atallah et. al study of 2007 was a prospective study using comparative design. This study concluded that drawing from a peripheral IV via a vacu-tainer is an accurate method of obtaining lab values for hematocrit, electrolytes, serum glucose, and cardiac enzymes.The Atallah et. al study of 2007 was a prospective study using comparative design. This study concluded that drawing from a peripheral IV via a vacu-tainer is an accurate method of obtaining lab values for hematocrit, electrolytes, serum glucose, and cardiac enzymes.

16. Conclusions: �K+, Na+, and Cl- assay results were not clinically different or result in a treatment change for any sample sets.� 10% failure-to-draw rate compared to 0% for phlebotomy. 21% hemolysis rate compared to 0% for phlebotomy. The Seeman and Reindhardt study of 2000 was a small quasi-experimental study that compared electrolyte results from samples drawn from peripheral catheters compared with phelbotomy. A two-tailed evaluation performed to an alpha level of 0.05. Although they concluded that �K+, Na+, and Cl- assay results were not clinically different�, they did identify a 10% failure-to-draw rate compared to 0% for phlebotomy, and a 21% hemolysis rate compared to 0% for phlebotomy. The Seeman and Reindhardt study of 2000 was a small quasi-experimental study that compared electrolyte results from samples drawn from peripheral catheters compared with phelbotomy. A two-tailed evaluation performed to an alpha level of 0.05. Although they concluded that �K+, Na+, and Cl- assay results were not clinically different�, they did identify a 10% failure-to-draw rate compared to 0% for phlebotomy, and a 21% hemolysis rate compared to 0% for phlebotomy.

17. (Seemann & Reinhardt, 2000) Comparative potassium assays

18. (Seemann & Reinhardt, 2000) Comparative chloride assays

19. (Seemann & Reinhardt, 2000) Comparative sodium assays

20. Pros Reduced injury to the healthcare workers Reduced pain and discomfort for the patient Reduced tissue injury Reduced collection time Pros Development of a protocol would decrease the risk of needle-stick injury to the healthcare worker Minimize procedural pain and discomfort for the patient Saves healthcare workers time by decreasing the need to find a suitable vein.Pros Development of a protocol would decrease the risk of needle-stick injury to the healthcare worker Minimize procedural pain and discomfort for the patient Saves healthcare workers time by decreasing the need to find a suitable vein.

21. Cons Increased incidence of hemolysis Potential damage to the IV catheter Infection rates not studied Cons Associated with a higher incidence of hemolysis, Increases chances of damaging the I.V catheter and necessitating starting a new line. No research studies that assessed rate of infection or catheter damage could be found. Cons Associated with a higher incidence of hemolysis, Increases chances of damaging the I.V catheter and necessitating starting a new line. No research studies that assessed rate of infection or catheter damage could be found.

22. Studies varied: Amount of blood wasted Size of catheter Dwell time Anatomical location Studies revealed: Modest statistical differences No clinically significant differences Research Critiqued Comparison of Research Critiqued All of the studies varied as to procedural requirements such as amount of blood wasted before the sample was obtained, or sizes of catheter, and length of time the catheter had been in place. Although a review of the studies revealed a statistical difference it was found that no clinically significant difference between traditional veni-puncture and drawing from peripheral lines. Comparison of Research Critiqued All of the studies varied as to procedural requirements such as amount of blood wasted before the sample was obtained, or sizes of catheter, and length of time the catheter had been in place. Although a review of the studies revealed a statistical difference it was found that no clinically significant difference between traditional veni-puncture and drawing from peripheral lines.

23. Conclusions: General acceptance of the practice More clinical studies are needed Summary of Research While generally advocating for the acceptance of the practice based on current research, we feel more clinical studies are needed to form a definite conclusion. While generally advocating for the acceptance of the practice based on current research, we feel more clinical studies are needed to form a definite conclusion.

24. Peripheral IV draws are acceptable Good nursing judgment always takes precedent Our Recommendation For example, blood should not be drawn from a peripheral IV that has heparin infusion. For example, blood should not be drawn from a peripheral IV that has heparin infusion.

25. No significant clinical differences Medical treatment was not affected Patient outcomes/satisfaction improved Hemolysis rates can be controlled Rationale Current evidence identifies no significant clinic differences in various lab values that resulted in disparities in medical treatment or patient outcomes. However, evidence did reveal a higher number of hemolysis through peripheral IV blood draws. Rates of hemolysis can be controlled with established techniques and training. Current evidence identifies no significant clinic differences in various lab values that resulted in disparities in medical treatment or patient outcomes. However, evidence did reveal a higher number of hemolysis through peripheral IV blood draws. Rates of hemolysis can be controlled with established techniques and training.

26. Increase patient comfort and satisfaction Decrease risk for infection Decrease bleeding and tissue injury Reduce needle stick injury Improve efficiency Evaluating Effectiveness Patient satisfaction and comfort is increased due to decreased needle sticks. Hospitals are graded and pained on the new patient care satisfaction. Decrease risk for infection and anxiety. Increase patient comfort. Nurse and patient preference � patients don�t like needles and nurses are holistic and want to provide patient comfort Eliminates risk of superficial bleeding, irritation, pain and anxiety caused by venipucture. Saves time from having to obtain blood from an additional site. Patient satisfaction and comfort is increased due to decreased needle sticks. Hospitals are graded and pained on the new patient care satisfaction. Decrease risk for infection and anxiety. Increase patient comfort. Nurse and patient preference � patients don�t like needles and nurses are holistic and want to provide patient comfort Eliminates risk of superficial bleeding, irritation, pain and anxiety caused by venipucture. Saves time from having to obtain blood from an additional site.

27. Success rates are dependant upon: Catheter size Dwell time Anatomical location Method of transport Other approaches to study Other approaches to studying the identified problem? Catheter size Dwell time Anatomical location Method of transport Other approaches to studying the identified problem? Catheter size Dwell time Anatomical location Method of transport

28. Method of aspiration Infection rates Patient satisfaction Rate of needle stick injuries Cost New research questions As a result of our research, it has become evident that considerations for the method in which samples are withdrawn needs to address, infection rates of peripheral lines, patient satisfaction with method of withdraw needle stick injury rates, and cost to health care institution of unsuccessful draws to determine which method proves most beneficial to clinician and patient. And become best practice.As a result of our research, it has become evident that considerations for the method in which samples are withdrawn needs to address, infection rates of peripheral lines, patient satisfaction with method of withdraw needle stick injury rates, and cost to health care institution of unsuccessful draws to determine which method proves most beneficial to clinician and patient. And become best practice.

29. � Attallah, H., Bijur, P., Corbo, J., Fu, L., Silver, M. (2007). Comparison of laboratory values obtained by phlebotomy versus saline lock devices. Academic emergency medicine,14(1), 23-27. � Neriman, Z., & Nuray, E. (2006). Comparison of two blood sampling methods in anticoagulation therapy: venipuncture and peripheral venous catheter. Journal of Clinical Nursing, 17:386-393. � Prue, Kathy, AN (2006). Use of peripheral venous access devices for obtaining blood samples for measurement of activated partial thromboplastin times. Critical Care Nurse (26): 30-38. � Seemann, S., & Reinhardt, A. (2000). Blood sample collection from a peripheral catheter system compared with phlebotomy. Journal of Intravenous Nursing, 23(5):290-297. References