How to teach a phlebotomy primer.

To prepare our facility for the expansion in Indianapolis of managed care, among other changes affecting reimbursement, the administration of our midsize metropolitan hospital felt the time was right for redefining several job functions. Phlebotomy was among those areas slated for change under this work redesign initiative.

As a result, in the summer of 93, staff members from the laboratory and nursing were given the formidable task of training more than 1,000 employees (including nurses, student nurses, nursing aids, as well as respiratory care staff) to perform all inpatient blood collections. Our time-frame for completing what appeared at the time to be an overwhelming mission: less than one year.

Getting it off the ground

We launched our phlebotomy project by holding a meeting for nursing, respiratory care, and laboratory personnel to discuss the feasibility of such a project and the specific roles we each would play in getting the initiative off the ground. We considered issues such as the number of phlebotomies performed per day, busiest times of the day for blood draws, blood specimen transportation, and requisitions. It didn't take long to determine a great deal of education would be necessary for our group of nonlaboratory staffers.

Nursing appointed two nurse clinicians from the medical/surgical areas and one clinical nurse specialist from a critical care unit to work on the project with members of our laboratory. Since these nurses provide orientation, continuing education, and competence assessment for all nurses at our facility, they were ideal for the job. Together we developed an initial curriculum, taking into consideration the knowledge base of our participants. Some of our prospective students had no experience with venous access, while others were very skilled in this procedure. Anticipating resistance from some "students," we worked hard to design a nonthreatening lesson plan. The employee in our laboratory with an allied health education background put together the material for a pilot program, which we presented to a group of nurse clinicians to critique.

The first class, slated to run three to four hours, was presented by two laboratory representatives. The curriculum included:

* A brief history of phlebotomy

* Phlebotomy supplies and equipment

* Venipuncture procedures

* Indwelling lines

* Capillary puncture techniques

* Skills practice session.

It became clear at the end of this session a full-day class would be required.

Creative learning tools

The manufacturer that provides our lab with most of our phlebotomy supplies proved to be an extremely helpful resource. One of the sales reps supplied us with wall charts, handouts, slides, and videotapes for class. Staff technologists designed posters as well One poster highlighted information on minimum and maximum amounts of blood to be drawn with Vacutainers and Microtainers (Becton Dickinson, Vacutainer Systems, Franklin Lakes, N.J.). Actual colored tubes filled with nonhazardous liquid were attached to this poster with velcro. Another poster targeted order of blood draw; a third, lancets (sizes and appropriate uses for each); and a fourth spotlighted newborn screen cards and pediatric draws. (See the photo, above, as well as the one on the facing page for sample posters.)

Class instructors also used a specimen requirement book, which is kept for nonlab staff on each of the hospital units. This reference includes sections on:

* Phlebotomy procedures

* Specimen requirements

* Combined tests

* Labeling requirements

* Stock supplies.

Program packets made up for each participant in the phlebotomy program included:

* Schedule information and lecture times

* Class objectives

* Lecture outline with accompanying illustrations

* Case study information

* Handout on hemostasis 

* Quiz

* Laboratory brochure

* Evaluation form

* Competence assessment criteria and checklists.

These handouts, printed on different colored paper, were distributed in pocket folders. Placing participants' names on the folders in advance, and our sign-in roster, helped keep track of our more than 1,000 students. Managers from each of the nursing specialty areas at the hospital (e.g., maternity, critical care) were responsible for scheduling their own employees for a particular class.

Because classes were held in different rooms and taught by several instructors, a cart was assembled containing supplies needed for skills practice; a file box with a copy of all lectures, class rosters, and completed evaluation forms; appropriate audiovisuals; copies of the posters mentioned earlier; and specimen requirement books. This way, before starting a class, an instructor could wheel the cart into her room easily and set up for the day's events.

Back to school

Our nurse clinicians, who were instrumental to the initial planning phase of this project, taught most of the phlebotomy classes. Laboratorians helped with the hands on skills practice activities slated for afternoon sessions and acted as substitute teachers. Appointing the nurse clinicians as instructors seemed to make the most sense since nurses are used to getting CE instruction from these professionals, and since nursing has positions dedicated to staff education.

Each instructor had at least one alternate instructor and, ideally, two backup instructors. Because it had been predetermined respiratory care personnel also would be trained in phlebotomy, the respiratory care educator was appointed an alternate instructor.

Training began with a review of the history of phlebotomy. To lighten the mood a bit, we started things off with some interesting anecdotes. For instance, we talked about the history of the red-and-white-striped barber shop pole. According to Phlebotomy Essentials (L.B. Lippincott Co., Philadelphia, 1993), European barbers of the 13th century performed therapeutic bloodletting while customers received hair cuts. The pole symbolized the staff that customers grasped during the procedure. The staff became blood stained and was wrapped in white bandages after being used, causing the red and white stripes we know today.

According to another story taken from this text, excessive phlebotomy was common during the 17th and 18th centuries. It was believed, in fact, excessive phlebotomy may have contributed to George Washington's death. Legend has it a physician removed nine pints of blood in 24 hours trying to cure a throat infection.

Next, phlebotomy equipment was discussed, followed by a short practice session on tying a tourniquet, finding veins, and placing a needle on the Vacutainer holder. This exercise was designed to promote student confidence before actually performing venipuncture.

An instructor then explained requisition and venipuncture procedures and discussed indwelling lines and their proper use in drawing blood samples.

After lunch, the third and final instructor reviewed the morning session by showing a video on venipuncture. A discussion on the capillary puncture was next (covering both fingerstick and heel puncture techniques), followed by a video on capillary puncture. At the end of the video, a quiz covering everything learned that day was administered. At the same time, participants were given a case study to work through. After grading their own quizzes, participants were able to ask questions about both the quiz and the case study.

Nursing staff was then responsible for conducting the fingerstick check-off portion of the skills practice session. Lab personnel took charge of the venipuncture check-offs. Participants qualified in IV were checked off in class as they performed actual venipunctures. Those who were not yet qualified simply practiced the procedure in class and were monitored on their individual units at a later date as they began performing phlebotomy. All participants were checked off in class for performing capillary punctures.

We required participants to match arm bands and requisitions as they do on the units. Students also were required to use the appropriate tube in their collection and to change tubes at least once during a procedure to ensure competence. All skills checklists, quizzes, case studies, and completed evaluation forms were filed on the cart, sorted, and sent to unit managers to be placed in employee files.

Looking back

If we were to run this program again, we would require all personnel working in the various service areas at our hospital to attend class. Some area managers did not support sending their employees to all-day class due to staffing issues. Excluding certain employees from our training also resulted in procedural inconsistencies from department to department, communication problems, ID errors, and a larger percentage of unacceptable specimens. For those who plan to undertake a project such as ours, we recommend the standard for training be kept constant across the organization.

Because we were given so little time to complete this training initiative, staff members from the maternal/child department were not included in the initial planning stage. This proved to be a serious mistake since pediatric phlebotomy is so different from standard adult draws. Had someone represented this department early on, age-population and specimen requirement differences could have been addressed right away, rather than our having to revise our curriculum once the program was under way.

Unfortunately, we learned the hard way for such a project to be a success, all major areas affected must be represented from the word go, and there must be maximum buy-in from all involved parties.

On a positive note, while individual units were being trained and brought on-line, a phlebotomy action team -- now called our phlebotomy task force -- was formed to work through common problems, disseminate new information, and assess staff competence on an on-going basis. This action team is composed of representative unit managers, nurse clinicians, respiratory care staff, and lab personnel. The team facilitated the writing of the nursing phlebotomy policy and the final protocol for obtaining help with hard-to-draw patients. We monitor unacceptable specimens and requests for help and share our compilation of data with unit managers. Subsequent training needs are identified and follow-up inservices given by our nurse clinicians.

For a while, we tried to switch over from a classroom format to a self-study arrangement. This change was short-lived, however. It became obvious during employees' competence demonstrations on the individual units that our classroom lectures and hands-on training better prepared personnel for phlebotomy techniques. Our class, now scheduled twice a month for new hires, has not changed much from the one started two years ago.

Today, various services within our facility are being reorganized and various support divisions formed to support focused patient care -- the cornerstone of our initiative. Our laboratory, for instance, has become part of ancillary services. All in all, continuous quality improvement has become an integral part of everything we do.

Working with other health care professionals on this phlebotomy project has proven to be a worthwhile experience and has enhanced our CQI initiative greatly. The alliances forged during this project surely will endure for a long time.