(Relatively) painless downsizing.

When fewer patients and falling test volumes mandated downsizing, this lab cut staff by almost 40% - and saved $3.50 per stick in the process.

During the summer of 1994, our hospital experienced a substantial decrease in patient volume and consequently in test orders. Because this trend negatively affected the hospital's bottom line, all areas of our facility had to reduce staff and cut other expenses. Every department was given a target number of FTEs. Our lab was asked to cut staff by almost 40% by October. Rolling up our sleeves, our management team (five supervisors, including myself) plunged right in.

Our first goal was to set targets for each lab section. We used the College of American Pathologists' Laboratory Management Index Program (LMIP) statistics to determine the target number of technical versus non-technical staff required to maintain lab operations. When the dust settled, my sections (phlebotomy, specimen processing/sendouts, reception) were reduced from 12.8 to 7.2 FTEs. Next we had to staff areas using the new targets.

Inpatient phlebotomy

Our lab serves about 1,800 outpatients per month and an additional 1,000 nonregistered outpatients (e.g., specimens collected by physician offices, visiting nurses). My first concern was keeping the reception area, which handles those patients and specimens, well staffed. I also needed one person seven days a week to handle sendouts.

After staffing the outpatient and sendout areas, I realized we didn't have enough people to handle our inpatient phlebotomy needs. We were averaging 2,800 inpatient sticks per month on the first shift. We also did not have a sufficient number of laboratorians to cover second-shift phlebotomy, and our current test volume did not justify a third-shift phlebotomist. After speaking to the nursing directors in late August, we decided our best bet would be for nurses to perform inpatient blood collections.

The hospital's nursing CQI coordinator performed time and cost studies to determine how this shift in duties would affect individual nursing units. We wanted to ensure the existing nursing staff could work blood collection into their schedules and that we were not raising the cost for blood collection by giving this task to nurses (who we all know are paid more).

Timed studies found it takes about six minutes for phlebotomists to draw blood samples on the units (excluding travel time to and from the lab). Cost studies found it cost approximately $5 per stick for the lab to collect blood specimens with current staff. This amount was calculated by dividing the total hours spent on all three shifts collecting specimens by the average salary of the collecting staff. (Some early-morning specimens were collected by med techs.) This calculation considered the time phlebotomists spend waiting for the next timed order and for Stats to print.

In comparison, the cost for a nurse to collect a blood specimen on the units was calculated at $1.50 - a saving of $3.50 per stick.

Next I conducted a detailed study of phlebotomy workload for the month of July by examining phlebotomy signout sheets. Phlebotomists sign out to each floor before they leave the lab as well as record how many sticks they perform with each signout. This information enabled me to chart the average volume of sticks per hour for each hospital unit. The volume varied greatly between units and also within each unit according to the hour of day.

Maintaining proficiency

The next step was to meet with each nursing director individually to discuss what tests nurses on their units would collect and how this work would affect their areas. We learned personnel from several units (e.g., recovery room, surgery) had not been receiving an adequate volume of collections to maintain their proficiency. Recovery room staff are not trained to do collections (surgery specimens are collected by anaesthesiologists). I was particularly concerned about specialized test collections (blood cultures, blood bank specimens). We wanted to make sure the staff who were trained to collect these specimens had an adequate volume to maintain their proficiency.

We decided only our oncology, emergency department, labor and delivery, and preadmission center staffs would collect blood bank specimens. Emergency department staff would be trained to collect blood cultures as well. The lab would continue performing the specialized collections for all other units and provide backup for "couldn't gets" and emergency situations (e.g., difficult deliveries) on first and second shifts. Patient care coordinators (shift supervisors) would handle specialized collections and provide backup for the third shift. Additionally, we would train respiratory therapists to perform venipunctures; they were already doing arterial punctures.

Our next task was to begin training the nurses so we could have several units ready when staffing reductions took place in October. Again I met with the nursing directors to design a training program that would meet all staffing needs. They felt having a video to review before the actual training session would be helpful. They also asked nurses be given cheat sheets to help them remember what tubes to draw until they became used to procedures.

At this meeting, we also discussed how to transport specimens and what modifications we needed in our hospital and lab computers to make collections easier. For instance, several changes had to be made to the computer system. The system was reconfigured so specimen pickup sheets would print in the nursing units when blood tests were ordered. Nurses use these sheets as their collection documents. We also use them as collectors' documentation. Currently, our lab system does not allow us to enter another person as the collector; however, we plan to change this as we begin looking at new systems.

Training preparation

Developing cheat sheets for the nursing units was next on our agenda. The nursing directors asked that these sheets be laminated to preserve them and made pocket size for ease of use.

The format, generated on a PC, included test name, type of tube, and minimum volume for each test. The front of the cheat sheet is the same for all nursing units. The back has specific tests tailored to the needs of each unit (e.g., a listing of cardiac drugs for critical care units and data on pediatric minimum volumes for the nursery and pediatrics). Instructions for specialized blood bank collections, blood cultures, and line draws are included on the appropriate sheets.

I created supply order forms for each nursing unit. Nurses needing supplies simply fill out these forms and submit them to the lab. We then place their supplies on the lab's dumbwaiter. Fortunately, our hospital is configured as a single tower, so our dumbwaiter is accessible from all floors.

We also supplied each unit with phlebotomy baskets. Individual units are responsible for keeping their baskets stocked. As of this writing, our lab is setting up an inventory system; once in place, nursing units will be able to order phlebotomy supplies from the hospital's warehouse.

I worked with our education department to develop a video. We wanted to create a learning tool specific to our hospital, so we decided against using a commercially prepared product. I began this task by writing an outline of the skills that had to be covered in training. I then decided which skills could be taught using a video format and which would require face-to-face instruction.

Next I wrote learning objectives for both the video and lecture portion of the training (see Figure 1). Working with a staff member from the education department and another lab supervisor (who graciously volunteered her arm for the demonstration), we shot the 15-minute video in two hours. Although Hollywood has nothing to fear, we felt the end product was an effective, concise presentation of pertinent material.

After the video was ready and we had the computer and transport details ironed out, we began planning the lecture portion of the inservice. I and a former lab employee who now works in education conducted the training. The lecture portion covered coagulation and anti-coagulants, labeling and transport, how to use the cheat sheets and laboratory guide, our catalog of tests, and how much blood to draw. Also among the topics we discussed were causes of clotting and hemolysis and how to avoid them. Where appropriate, we demonstrated how to armband specimens for blood bank testing and blood culture collection and discussed how to collect samples from indwelling lines or ports. We reviewed difficult sticks and what to do in the event of a "couldn't get."

At the end of the training, staffers were given the opportunity to practice on each other or on us. We issued certificates for staff members to store in their education files. Participants were asked to evaluate the program. Overall, the evaluations were positive despite that many staffers were unhappy about their new blood collection duties.

Practice makes perfect

Once the training was completed, it was time to practice on actual patients. For the first few weeks, our phlebotomists continued to go to each unit as usual. When they arrived, they asked who needed to practice. They accompanied nurses to the bedside and helped when necessary. These phlebotomists were true professionals during this time; some knew their jobs were being eliminated, yet they were willing to help with the training process.

Once the nurses felt comfortable with their new responsibilities, we performed a simple competency that involved having a phlebotomist or other proficient staff member observe their venipuncture techniques. Some nurses were given suggestions for improvement and asked to practice and then try again. Others caught on quickly and became leaders of their units; soon their coworkers were looking to them for guidance.

Since starting the program, I have begun writing a monthly "Phlebotomy Update" newsletter that discusses how to avoid many common phlebotomy problems and includes tips for easier collections. I'm confident that the nurses are reading the publication because we have seen significant improvements in several of the areas I have covered in the updates.

Furthermore, we continually monitor clotting, hemolysis, and wrong tubes as a part of our quality assurance program. While we have seen an increase in rejected specimens, we're pleased overall with the quality of the samples.

Reflections

We trained about 250 nurses in five months. New hires will be trained to draw blood as part of their employee orientation.

We watched the volume of inpatient collections performed by the lab drop from a high of 3,139 in August 1994 to 736 in February 1995 [ILLUSTRATION FOR FIGURE 2 OMITTED]. At the same time, nurses' phlebotomy skills improved. Currently our phlebotomists are only called in on difficult sticks.

While revamping our outpatient services was a difficult transition, especially since we had to train employees who had never entered outpatient orders before, we continue to serve our outpatients well. In February 1995, we performed an outpatient turnaround time study that measured the interval from the time patients sign into the lab to specimen collection. We found 78% of patients had their specimens collected within 15 minutes. In the near future, we will be repeating a physicians' office survey we conducted back in October 1993 that measured customer satisfaction with our lab reception services.

This article covers only one piece of the many changes we've implemented over the course of nine months. The task our lab management team faced back in August 1994 seemed impossible, and we spent many sleepless nights wondering if our plans would work out. We're happy to report most have - thanks, in large part, to laboratorians' and nurses' willingness to work together as a team in the name of patient care.

Figure 1

Venipuncture training objectives

(Lecture goals)

The trainee will be able to:

1. Discuss the anticoagulants used in the collection of blood specimens and their use for various types of tests

2. Label blood collection tubes with the lab-required information

3. Discuss the paper flow for blood specimen collection

4. Discuss transport times for blood specimens

5. Find collection information in the lab guide for tests not included on their cheat sheets

6. Convert serum and plasma volumes found in the lab guide to whole blood volumes

7. List problems that occur during specimen collection and how they can affect lab testing

8. Perform a successful venipuncture

9. List blood volumes that need to be discarded when collecting specimens from lines

10. List tests and the volumes that need to be discarded from lines when heparin contamination is a concern.

(Video goals)

The trainee will be able to:

1. Assemble the equipment used for venipuncture

2. Discuss the venipuncture procedure and contrast venipuncture collection with other venous-access procedures

3. Discuss conditions that might preclude venipuncture collection from a certain site

4. List order of collection for various types of tubes.

Cindy G. Jenkins is laboratory supervisor at St. Mary's Hospital in Decatur, Ill.