blood specimen collection: impact on therapuetic …

BLOOD SPECIMEN COLLECTION: IMPACT ON THERAPUETIC DRUG LEVELS

ACCURATE CENTRAL VENOUS ACCESS DEVICE BLOOD SAMPLING

Joy Selchow, MSN, RNNurse ManagerIV TherapyVirginia Mason Medical Center, Seattle,WA

Objectives

• Discuss strategies for obtaining blood specimens for accurate drug-level testing

• Identify factors that may falsify test results

Virginia Mason Medical Center

•Integrated health care system•501(c)3 not-‐for-‐profit•336-‐bed hospital•Nine locations•500+ physicians

Virginia Mason•5,500+ employees•Graduate Medical Education•Research Institute•Foundation•Virginia Mason Institute

Adopting Standard Work

Variation STANDARDIZATION Improvement

“Without Standards There can be no Improvement” – Taiichi Ohno

(Founder of the Toyota Production System)

Standard Work

Standard Work is an agreed upon, repeatable sequenceof work assigned to a single operator at a pace that meets customer demand

“Without standards, there can be no improvement”

Taiichi OhnoFounder of the Toyota Production System

Improvement Work around Central Line Blood

Draws• 2013 Kaizen Blood Draw Standard created

– Hand hygiene and scrub hub– Vacutainer – Waste amount 6ml

• Designated waste tube

• 2015 Kaizen Central Line Blood Draw– Lab and nursing collaboration– Decrease operators? vs NO blood draws from

central lines?

2013 Blood Draw Process

• Male Vacutainer:– Hook directly to line– Decrease blood exposure

• Alternative: – Syringe method– Female vacutainer

Interprofessional Collaboration

• Team effort:– Registered Nurses– Laboratory Technicians– Doctors– Administrators– Infection Preventionists

• Focused on inpatient units

Eight Wastes of Information

WasteInvisibilityHidden or incomplete

information

ComplicationComplicated

information being sent or received

WaitingInformation must wait to be delivered,

approved, verified or completed

RedundancyDuplicate work or same information kept in more than

one area

Process Variation

Everyone sets their own pace and does the work they choose

Re-input/TyposHuman Error

PaperworkProducing any unnecessary

documentation and forms

Re-workHaving to do it over or repeating prior

work

Specimen Defects Addressed

• Hemolysis– Gently inversion of tubes– Natural vacuum into tube not forced

• Clotted– Inverting specimen tubes (8)

• Possible contamination– Flushing appropriately– Correct tube draw order– Designated lumen for blood draws– Wasting appropriate amount

• Insufficient Quantity– Additive mixture– Analyzers require certain amount

Central Line Blood Draw

Type of Line

Hand Hygiene

Scrub the Hub

Clean Technique Flushing Inversion

of Tubes Comments Timing

R IJ Y Y Y

did not flush lumen (brown more distal) with medication just clamped and drew out of blue lumen

N 13'42"

R Port Y N Y

only flushed with 10CC after blood draw and rehooked up medication

N

Removed CUROs, then scrubbed with Alcohol pad, and then did the reverse when complete yet did not scrub the hub with visible blood prior to

needleless connector replacement

7'58"

R PICC TL Y Y Y Y (yet did not flush all lumens) N no full inversions just a back and forth motion 12'04"

R Port Y N N Y Y Even flushed all ports :) NO it takes 2 prior to blood draw 6'25"

L Hickman Y N Used white cap on flush to cap medication

Patient with TPN should receive 20cc prior and after blood draw yet only received 10cc

N No it takes 2 prior to draw 5'55"

L PICC N Y N Y Y changed gloves d/t bathroom needs of patient yet no HH between glove change 10'50"

R PICC DL Y Y Y Y N 5'50"

L Hickman Y N Used white cap on flush to cap medication Y N patient had infusion through both lumens, when

disconnected did not Scrub the Hub 6'28"

L hickman Y N

Prepared all draw items at nurse's station. Did not cap infusion during draw just held onto

Y Y patient had infusion through both lumens, when disconnected did not Scrub the Hub 6'58"

Plan. Do. Study. Act. (PDSA)

• How do we do this work?

–continuously test/refine ideas– focus on results

•Who can do this work? –How often is it currently being done–Can competency be maintained

Observe and develop a new vision

Study the results

Awareness:a changein thinking

Rapid implementation– give it a try

PDSA Cycle

Blood Draw Validation/Proficiency

Criteria:• High users: 4-6 blood draws per staff/month

– Staff will be trained to draw own blood draws from central line

• Low Users: <50 blood draws/month/unit– Charge Nurse, ANM (assistant nurse manager) to be trained– IV Therapy back up for all

• Validators:– ANMs– Charge Nurses– Light Duty Nurses

• Master Trainers:– IV Therapy– ANMs

Data

• Restricting operators– Less variation, targeted education, & proficiency

Training Within Industry (TWI)

“If the worker hasn’t learned the instructor hasn’t taught”

Job Instruction is a way to getto do

a person to quickly remember a

job:

trainingwithinindustry.net

Education & Training

• Blood Draw Kit Visuals• Validation Checklist• RN Study Guide• Teaching Script

Blood Draw Kit Visuals

IV: DRAWING BLOOD FROM CENTRAL VENOUS CATHETERS

VALIDATION CHECKLISTq Verify lab order to gather appropriate tubesq Gather supplies: Blood Draw kit and tubesq Verify the patient – “It Takes Two.”q Explain the procedure.q If applicable, stop all medications or solutions infusing through the CVC and clamp IV tubing. If stopping an infusion would contribute to

hemodynamic instability, obtain specimens from an alternate site.q Perform hand hygiene and don clean gloves.q If applicable, apply sterile cap to end of IV tubing.q Remove CUROs cap OR Disinfect the catheter hub or needleless connector with alcohol for a minimum of 15 seconds. Allow to dry for

at least 5 seconds for maximum effect.q If the CVC has clamps and multiple lumens, clamp all lumens not utilized for the blood draw. Select the largest lumen (most distal) available

for blood draw.q If nothing is infusing, attach normal saline syringe and aspirate for blood return to check patency. If a vasoactive or anticoagulant drug

is infusing, withdraw 5 mL before flushing to avoid a medication bolus.q Flush with 10 mL of normal saline using pulse-pause technique. Flush with 20 mL if TPN was infusing through the CVC. (Use the lumen not

infusing TPN, antibiotics requiring troughs, anticoagulants to decrease contamination risk.)q Attach Luer vacutainer directly to the catheter hub or needleless connector. After initial flush, allow 30 seconds to pass before drawing

samples.q Insert 6 mL vacutainer waste tube to withdraw discard.q Draw specimens in correct order (see chart). Gently invert tubes per recommendations.q If blood or debris is present in needleless connector, remove and apply a new needleless connector using aseptic technique.q Flush lumen used for blood draw with 20 mL of normal saline. For central lines with multiple lumens not in use, flush additional lumens with

10 mL normal saline. If heparin is required, refer to Vascular Catheter Maintenance policy or physician order.q Apply New CUROs cap OR Disinfect the needleless connector with alcohol for 15 seconds. Allow to dry for maximum effect.q As applicable, reconnect IV tubing to needleless connector.q Label specimens according to standard process.Validators Name & Signature:……………………………………………………………………………………………………….…………Employee Name & Signature:………………………………………………………………………………………………………………….Date:…………………………………..

q Remove CUROs cap OR Disinfect the catheter hub or needleless connector with alcohol for a minimum of 15 seconds. Allow to dry for at least 5 seconds for maximum effect.

If a vasoactive or anticoagulant drug is infusing, withdraw 5 mL before flushing to avoid a medication bolus.

Central Line Blood DrawRN Study Guide

1. You are drawing the following labs. Put them in the correct order for draw by indicating which is first, which is second, etc. – Tube Order

• CBC (light purple)• Coags (blue)• Metabolic panel (mint)• ESR (black)

2. What is the correct amount of discard to draw?a) 20 mLb) 10 mLc) 6 mLd) It doesn’t matter

3. After flushing the line, you can draw the discard tube and labs immediately. T or F4. Which is true for a patient with TPN running?

a) I can’t draw blood from his central lineb) I don’t need to wait after flushing to draw labsc) I need more than 6 mL discardd) I need to flush with 20 mL

5. Use of the discard tube is important for what reasons (select all that apply)?a) Increases health care costsb) Helps prevent hospital-acquired anemia by standardizing discardc) Reduces staff exposure to bloodd) Adds an extra stepe) Makes my manager happy

6. When drawing blood cultures, a discard tube is still collected. T or F7. In patients receiving vasoactive medications, how much should be withdrawn prior to flushing?

8. The vacutainer cannot be used on PICC lines. T or F9. Where is the central line blood draw kit located? 10. How many times should you invert lab tubes?________________11. You does not matter how full you fill the lab tube? T or F

What is the below tube order:CBC (light purple)Coags (blue)Metabolic panel (mint)ESR (black)

Central Line Blood DrawTeaching Script

• Q: What is this training about?• A: This training is to highlight proper technique for drawing blood

samples from all central lines (centrally and peripherally inserted). You will see the revised policy and equipment that makes the task easier.

• Q: Why is this important?• A: Preventing central line associated blood-stream infections (CLABSI) is

critical for our patients. CLABSI increases the risk of mortality (mortality rate 12-25% per CDC), extends length of stay, and costs up to $16,550 per patient to treat. Not only does the hospital not get reimbursed for the costs to treat the infection, but elevated CLABSI rates reduce our overall reimbursement from Medicare.

• http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm

Action Rationale/CommentsStop infusions• Stop all medications or solutions and clamp IV tubing• Pause or Delay pump• If stopping is not possible, use alternate site

*Ensures blood is drawn, not IV fluid.*Prevents bolus of medication when flushing.*If pausing pump do not silence during draw as you are breaking the clean process

Hand hygiene• Performs hand wash per hospital protocol • Dons gloves

*Hand hygiene needs to be performed immediately before touching a central line to minimize infection risk.

Sterile end cap• Attach a sterile end cap to the end of IV tubing if

disconnecting*Maintaining a aseptic connection to minimize infection risk

Performs 15-second scrub of hub • Scrubs hub or needleless connector with alcohol swab

for 15 seconds.• Not necessary if access point covered with Curos cap

*Failure to perform adequate scrub time can increase risk of contamination (WHO guidelines on drawing blood).*Allow to dry for maximum effect.

Flushes line• Flushes line with 10 mL normal saline• Flushes with 20 mL if TPN infusing

*Ensures patency and clears line for blood draw.

Wait 30 seconds• Waits 30 seconds prior to drawing sample *Ensures sample is not diluted by saline.

Attaches Luer vacutainer after flushing central line• Attaches blue Luer vacutainer *A closed system minimizes the risk of infection and blood exposure

Discards correct amount of blood• Discards 6 mL waste (per hospital policy) into waste

tube*Incorrect discard can lead to inaccurate results.*Excess discard can lead to hospital-induced anemia.

Performs 15-second scrub of hub • Scrubs hub or needleless connector with alcohol swab for 15 seconds.

• Not necessary if access point covered with Curos cap

*Failure to perform adequate scrub time can increase risk of contamination (WHO guidelines on drawing blood).*Allow to dry for maximum effect.

Action Rationale/CommentsDraws tubes in correct order

ORDER of DRAW*Draw tubes in correct order to avoid cross-contamination of additives between tubes (WHO guidelines on drawing blood).

Fill tube appropriately*Tubes require a specific amount of blood to additive ratio

*Analyzers require a certain amount of blood to run the test

*“Insufficient Quantity” will result in a redraw

*Blue top is the one most effectedInversion of tubes• Invert all blood tubes 8 times *do not shake* *Inversion prevents clotting and appropriately mixes additives within the tubes

with the blood(i.e. Citrate, EDTA, Heparin & Clot Activators)

*Purple top is the one most effected

Flushes line correctly• Flushes line used for draw with 20 mL normal saline • Flushes other lumens with 10 mL NS not in use• Use heparin per policy if applicable

*Incorrectly flushed lines can occlude, or develop a fibrin sheath that can lead to a thrombus. Proper flushing may decrease infection as thrombi and fibrin deposits are potential sites for microbial growth (Oncology Nursing Secrets).

Maintain aseptic technique during procedure• Does not touch hub with non-sterile gloves after it is cleaned. • If changing the hub, scrub the outside of the top of the IV line

well in a clockwise and counter-clockwise motion.Swab again for 15 seconds• Swab hub for 15 seconds OR• Attach Curos cap

*Removes residual contaminants.*Keeps hub protected and sterile.

Fill tube appropriately*Tubes require a specific amount of blood to additive ratio

*Analyzers require a certain amount of blood to run the test

*“Insufficient Quantity” will result in a redraw

*Blue top is the one most effected

Inversion of tubes

*Inversion prevents clotting and appropriately mixes additives within the tubes with the blood(i.e. Citrate, EDTA, Heparin & Clot Activators)

*Purple top is the one most effected

Results

Metric (units of measurement) Baseline Target Day 230 days

July 29, 2015

60 days

Aug 29, 2015

90 days

Sept 29, 2015

%Change

Lead TimeFrom the choice of a peripheral or CVC access to draw completeTime measured in minutes or seconds as appropriate to the process being studied

6 min 30sec

6 min 30sec

6 min30 sec

6 min30 sec

6 min30 sec

6min30 sec 0%

Quality Measure (aka defect measure)(%)Number of CVC drawn specimen defects due to technique432 of 19708

CLABSI rate CCU 1.02 - NHSN 25thpercentile 0CLABSI rate Med Surg 1.05 – NHSN 25th percentile 0

2.2%

1.021.05

0%

00

2.2%

1.021.05

3.5%

1.280.90

2.4%

1.400.98

1.9%

1.050.84

14%

3%20%

Data Collection Information: NHSN data obtained for a rolling 12 months from Infection Prevention. Rates were through April of 2015. The defect data was from the nurse draw information from the Lab data base. The numerator are the defects of hemolyzed, insufficient quantity, possible contamination or clotted from all nurse draws from Jan 2014 through April 2015. The denominator includes all RN draws during that same time period. The data excludes ED, OBs and PCU and includes all inpatient units including CCU.

Results

Time Total RN Draws Defects Percent defects per total RN draws

October 2015 2239 62 2.8%

November 2015 2259 57 2.5%

December 2015 2367 62 2.6%

January 2016 2262 18 0.8%

February 2016 2199 42 1.9%

Next Steps

• Rollout training to procedural areas and emergency department

• After hospital transition reassess:– Who has been trained– Who needs to be trained

• Do we reassess NO blood draws from central lines?

• Strive for ZERO defects

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