A quality circle improves pediatric phlebotomy.

Suggestions from a group of problem solvers significantly reduced the number of skin punctures young patients receive.

Askin puncture for blood collection can be one of the most frightening and painful events experienced by a child. The trauma is multiplied at a pediatric hospital, where all the patients are children subjected to repeated phlebotomy.

There are serious medical considerations, too, in drawing blood at neonatal nurseries and intensive care units. Newborn infants have about 80 ml of blood, roughly as much volume as half a cup of coffee. Some sick premature infants can lose their entire red cell mass from multiple blood sampling during their first six weeks of life.

Thanks to enlightenment from the Pediatric Division of the American Association for Clinical Chemistry and the National Committee for Clinical Laboratory Standards, standards for skin puncture and for the manufacture of collection devices are gaining wide attention and acceptance among those concemed with pediatric laboratory medicine."2

At our 185-bed tertiary-care hospital, a seven-member, laboratory-based phlebotomy team performs most of the draws between 6 a.m. and 11 p.m. Respiratory therapists collect the specimens for blood gases, while nurses and physicians handle the phlebotomy for the predominantly Stat and emergency work that comes up between 11 p.m. and 6 a.m.

We realized four years ago that we had to curb redundant and excessive phlebotomy. One child in the emergency room had sustained 30 skin punctures during blood collection for various departments. Another patient developed staphylococcal cellulitis at the site of multiple sticks.

The hospital was promoting the quality circle concept at the time, so a circle was formed to tackle phlebotomy problems. As many as 40 laboratorians, nurses, and physicians participated at one time or another. The laboratory's phlebotomy division head served as chairperson.

Quality circles must have an objective, and ours was to develop a plan that would minimize needle punctures. We even had a motto (suggested by a slogan in an MLO article 3): "For their sake, take a break."

Circle members met periodically to discuss the unique needs of a pediatric laboratory in terms of the types of tests performed, special specimen collection and handling techniques, the urgency of result reporting, and potential complications. They also reviewed the literature to learn about phlebotomy practices at other hospitals.

Through their efforts, we were able to set up an in-service education program and develop a new blood collection protocol, including guidelines for skin, venous, and arterial puncture procedures.

Brainstorming plays a large role in quality circle success. The following observations and procedures grew out ofthe collective deliberations of quality circle members:

*The patient's size and clinical status, the need for multiple lab tests, and the prescribed treatment course all contribute to excessive needle punctures.

* Nursing personnel should serve as the sole coordinators for multiple test orders, for specimens to be drawn prior to intravenous therapy, and specimens to be drawn for such diagnostic procedures as cardiac catheterization. With a little planning, one puncture may suffice for all required diagnostic and therapeutic interventions in a critically ill neonate.

*Communication among physicians, nurses, and laboratorians is essential for the optimum management of sick children. To strengthen these ties and make sure they result in proper phlebotomy, quality circle representatives should visit patients.

When our quality circle started its work, the phlebotomy division chief, the phlebotomy supervisor, a nurse, and a respiratory therapist or two conducted monthly rounds. This continued for a year while the quality circle team published and tested its protocol, collected feedback, and considered the comments.

New procedures have worked so well that regular rounds are no longer necessary. If the number of skin punctures were to climb sharply, however, we could go back to visiting patients.

* It is important to identify early those patients who are likely to require lengthy hospitalization and extensive testing and treatment. A plan of action has to be formulated for them. For example such patients can benefit from an indwelling catheter or heparin lock, which allows frequent administration of medication and puncturefree specimen collection.

* The quality circle flags difficultto-draw patients who have already had multiple skin punctures. Testing of these patients is kept to the minimum needed for medical or surgical reasons.

This process usually starts with a bedside assessment by a phlebotomist, who notifies the charge nurse. They then locate the attending physician and explain the problem. The physician may decideto postpone a particular test for a day or two to give the child a chance to replenish blood and feel somewhat better.

* If a patient is classifi"difficult or unable to draw," the collector is cautioned not to try more than twice. Instead, he or she should "take a break" and ask for help from the most proficient person available. That could be another phlebotomist or a charge nurse. It varies from shift to shift and unit to unit. Generally speaking, those with a special talent for phlebotomy are well known throughout the hospital and easily located.

Sometimes, though, nothing works. When this happens, the charge nurse calls the attending physician for an altemate course of action-perhaps an arterial puncture (if not already requested), venous cut-down, or umbilical vessHel catheterization.

*When one or more consulting physicians are involved in a case, the nurse coordinator compiles all their test orders and calls the laboratory to determine how much blood is actually needed. If this amount represents more than 10 per cent of the child's blood volume (we have a chart that lists blood volume by height and weight), the physicians are asked to prioritize the tests and cancel some until the patient's clinical condition stabilizes. A blood transfusion is sometimes indicated to avoid an anemic episode after multiple specimens are drawn.

*Nursing personnel must record the amount of blood drawn each day. This monitors the patient's total volume and provides a double control for such test results as a low hematocrit, which might indicate an anemic state.

* All personnel involved in collection of blood specimensnurses and respiratory therapists as well as phlebotomists-must demonstrate their procedural and technical proficiency and should be continuously supervised. The phlebotomy division head holds an in-service every two weeks for newcomers to the nursing staff. Respiratory therapists have a separate presentation, and laboratorians learn proper phlebotomy procedures as part of the lab's orientation program.

Blood collectors are also expected to exercise sensitivity and responsibility regarding patients and be willing to consider the concems and suggestions of parents or guardians. The hospital has a patient-family representative who visits each child several times during a hospital stay. Comments and complaints are encouraged and addressed. Happily, there have been virtually no phlebotomy-related complaints since our new protocol began.

*By way of positive reinforcement, the quality circle team confers "Tiny Foot Awards" to individuals or units that apply these principles and improve patient care. The plaques are awarded with the hoopla they deserve, as nursing, laboratory, medical, and administrative personnel look on.

The first award went to the baby unit, which cares for the less critically ill infants. The second year, the unit for our critically ill hematology and oncology patients took top honors. And last year's award? We didn't give one because all the units deserved special recognition!

Together, these practices have significantly reduced the number of skin punctures our patients receive, making their hospital stays more tolerable. Although we haven't conducted a formal study, the phlebotomy division head did make weekly rounds with nursing education staff members for six months before the quality circle was formed and for another six months afterward. Counting the number of punctures and checking to see whether the sticks were in an appropriate location, they concluded that phlebotomy had improved greatly. Our quality circle continues to meet once a year to insure that unnecessary sticks remain a thing of the past.

The tools and techniques for reducing pediatric blood sampling are available to all medical centers. These tools serve no purpose, however, unless human resources are mustered to support the concept of "For their sake, take a break."