Answering your questions on a standard workload for phlebotomists, POL training videos, and IV heparin monitoring.
Q Our laboratory is tying to increase the number of phlebotomists to match the volume of patients. Can you give me a recommendation or reference as to how many minutes it should take phlebotomists to perform "normal" phlebotomies in both inpatient and outpatient settings? One of our pathologists remembers reading that spending less than 6 minutes per phlebotomy is unsafe, but I can't find confirmation. That would mean that one phlebotomist should do 10 phlebotomies per hour, and we are currently performing more than that.
A In the past, workload units were used to standardize procedures. Every billable task was assigned a unit based on its complexity and the amount of time required to execute the task under normal circumstances. Some facilities used "time and motion" studies to make the same assessments. Both of these techniques are now out of favor and are seldom used. They were expensive to employ and were too mechanical for an industry that was evolving away from worker robotics.
Today, establishing a length of time to perform the average phlebotomy is difficult because the number of variables involved are facility dependent. I know of no standards that can be universally applied. It may be best and more accurate to establish your own standards by conducting a small study that takes into account those variables that are unique to your facility and that measures the procedure as you want it delineated. Time your personnel in the performance of phlebotomies according to your chosen parameters. Consider the following questions when designing a study. When does the procedure begin? At the time the lab receives the order? At the time the phlebotomist leaves the lab or arrives at the bedside? When does it end? Should capillary punctures and heelsticks be studied separately from venipunctures? Should the study measure the time it takes veteran phlebotomists to perform punctures, or should it include those new to the procedure as well?
As you can see, the time allotted per phlebotomy should be customized so that you measure exactly what you intend to measure. I suggest randomly timing "phlebotomies" as you define them over a 2-week period. Then, incorporate all the variables you think should be considered in determining your standard. Make sure you include enough measurements to make the sampling data a fair representation of the performance of the procedure in your facility. This may include sampling on all shifts.
Dennis Ernst, MT(ASCP)
The Center for Phlebotomy Education Ramsey, IN
POL training videos
Q Do you have any information on where I can find a training video for POL staff on bloodborne pathogens and laboratory safety? I know you offered them a number of years ago, but I can't seem to find them in your magazine now.
A The best source I found for listings of educational videotapes is the Video Source Book, 22nd edition. Detroit, MI: Gale Research; 1999. This is a 4,000-page, 2-volume set that lists videos by subject. Our hospital library had a copy. A number of videos on lab safety and bloodborne pathogens are listed in this reference. Most are relatively expensive, around $300 to purchase, but the listings indicate that some could be rented. Your local public library, educational institution, or hospital library may have some that could be borrowed.
Video production companies that have listings for these topics include:
* AMS Distributers, Inc.
* Barr Medical Group
PO Box 7878, Irwindale, CA
91706 (no phone listed)
* Bergwell Productions
* BNA Communications, Inc.
* Emergency Film Group
* Film Library
* JJ Keller and Associates
* Medfilms, Inc.
* Media Resources
Daniel M. Baer, MD
Professor Emeritus of Laboratory Medicine
Oregon Health Sciences University
IV heparin monitoring
Q What are the guidelines for drawing blood for partial thromboplastin times (PTTs) when monitoring intravenous heparin therapy? Can the specimen be drawn from below the site of the IV, or must it be drawn from the opposite arm?
I'd also like to ask the same question for patients with central lines. When heparin is being administered through those lines, can the coagulation studies be drawn from the central line after discarding the first 10 mL of blood?
A At the CAP conference on laboratory monitoring of anticoagulant therapy, it was recommended that "specimens used for monitoring heparin therapy should be collected from a different extremity than the one used for heparin infusion."  The NCCLS guideline for collection of blood for coagulation testing cautions that "if the blood must be drawn through an indwelling catheter, possible heparin contamination should be considered."  But these only partially answer your questions.
This has been a problem for quite some time. A number of rules have been proposed regarding the flushing of the catheter with saline and the volume of blood to be discarded before collecting the specimen.  First of all, however, it should be noted that the dead space volume of indwelling catheters varies from one brand to the next, so the appropriate discard volumes will vary. Does one discard 1, 2, 3, or more dead space volumes before collecting the specimen? Unnecessary discarding of blood, especially in critically ill patients, should be avoided. Also, we should remember that some catheters are coated with materials that resist clotting and which, conceivably, affect coagulation tests, as well as other studies. Heparin locks can also affect coagulation tests if not used properly.
Therefore, your hospital should determine its own guidelines, taking into consideration the catheters used there. We did a number of studies on the catheters used at our hospital to check the effects on common coagulation tests (PT, PTT, and fibrinogen) when drawn from IV lines in heparinized patients.
In conclusion, if at all possible, it is best to draw these specimens from the opposite extremity. Otherwise, you would be well advised to carry out some experiments that will corroborate your laboratory practices.
John A. Koepke, MD
Professor Emeritus of Pathology
Duke University Medical Center
Daniel M. Beer is professor emeritus of laboratory medicine at Oregon Health Sciences University in Portland, OR, and a member of MLO's editorial advisory board.
(1.) Olson, JD, Arkin CF, Brandt JT, et al. Laboratory monitoring of unfractionated heparin therapy. Arch Path Lab Med. 1998;122:782-798.
(2.) Collection, transport, and processing of blood specimens for coagulation resting and performance of coagulation assays. Approved Guideline H21-A3. Wayne, PA: NCCLS; 1998.
(3.) Specimen collection from vascular access lines (Tip 3-2). Tips on Specimen Collection II. Supplement to MLO. Montvale, NJ: Medical Economics Co.; 1998.