Forum topic

You are absolutely correct on drawing blood samples increasing hub manipulation and thus increasing the risk for CRBSI. I am assuming you are asking about a maximum number of times that blood can be drawn from the line in a 24 hour period. There is lots of information in the critical care literature about reducing blood sampling practices, however their goal is to prevent iatrogenic blood loss and anemia. I would also love to know the answer to your question about limitations on sampling.

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

It's an unpopular approach in our system, but our facility has taken the psoition that blood is to be drawn from central lines only if peripheral sticks have been unsuccessful. We require the phleb to assess peripheral potential at each lab draw before approaching the RN to access the CL. This policy was put in place to reduce the incidence of CRBSI, and we have experienced only 2 CRBSI's in the past year. The position is explained to the patients when the line is placed, and is written into the informational paperwork presented to them prior to placement. My experience has been that given this explanation, most patients are willing to have the peripheral stick.

Rob Burr, RN

Kathy Kokotis

Bard Access Systems

I rarely post anymore but now have to voice my thoughts on blood draws via central lines.  I personally would want my blood drawn from my line and not endure additional needlesticks.  To not draw from a line due to risk of infection states that we cannot triust our RN's to do the right thing so we limit their interactions with the VAD.  Therefore we limit the patient's risk of infection.  Sounds like this is a care issue and not one of incresing infection due to manipulations.  I suggest all RN's this year bother to google Harnage (Zero PICC infections for three years).  The hospital facility does draw labs from PICC lines and is over 300 beds doing over 2,600 PICC lines a year.  One must stop and ask themselves how do they have a zero infection and draw labs from their PICC lines.  I want to be a patient at this hospital as it reflects the nursing care is exceptional in regards to manipuating a central line.

Going back to my thoughts:  not using a central line for lab draws and drawing peripherally is harming the patient.  It is called losing vascular access.  A peripheral lab draw is not without its complications in infection, arterial puncture, nerve injury, and loss of access.  Are we protecting the patient by not drawing their blood from a central line.  I cannot agree persoanally with this practice.

A re-vamp of the care and maintenance is a hospital is needed in order to reduce risk in manipulations.  My mom has had three PICC lines and thank goodness the hospital draws her labs from her line.  She has very limited access at 75.  To date no CR-BSI.  But than the CR-BSI rate is less than 3/1,000 catheter days.  Over 90% of patients do not currently get a CR-BSI but 100% are penalized to peripheral lab draws.  Hospitals making such policies I often wonder is it for the patient or the fact that they do not want to report a CR-BSI.  One must step back and become he patients.  Individuals making such rules I believe should spend a week in a bed and become the patients.  I have always like that episode on scrubs where the doctors had to be the patient for a week and get all the procedures that were ordered.  At the end of the week I am sure labs would be drawn out of a central line.

 Yes, a policy that is described as drawing no labs from a central line is un-popular.  Not with just myself but I am sure with the patients.

My dissertation is done and you can see this is a hot topic for me of emotion having had several family members with central lines over the last ten years. When I see thier blood drawn from a central line I am very thankful that they did not have to endure more pain and discomfort.

Kathy 

Wendy, thanks so much for your post on this issue. This is what I have taught for many years. You can not have a blanket policy that all CVCs will be used for blood draws. It is a patient-specific decision after assessing the risk and benefits. Sorry Kathy, I understand your desire to decrease needlesticks for the patient but there are times when it is not appropriate to use every CVC for all blood draws. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

 Does any one have any experiences or opinions to share on attaching a "VAMP"-type device to a CVC or PICC for blood draws? They are easy to use,don't involve wasting blood and require minimal manipulation and no opening of the catheter system. We use them on all of our arterial lines but not CVC's but I have heard that this is done in some places.

David Longseth,RN

Trauma Life Support Center

University of Wisconsin Hospital

 PICC's (4fr and greater), acute CVC's, tunnelled CVC's, and ports are all indicated for drawing blood samples. To claim a direct correlation on increased or decreased CRBSI's and occlusion rates when utilizing or not utilizing central access for lab draws without considering variables of aseptic technique or post flushing compliance can be misleading (in my opinion). I agree each patient deserves a specific risk/benefit analysis and not every CVC is appropriate for blood drawing. However, I believe there are other risk factors for CRBSI and occlusions that need just as much passionate attention, i.e. proper hub antisepsis, compliance with flushing protocols, compliance with needleless connector changes, compliance with timely tubing changes (primary and intermittent) to just name a few. Please do not misinterpret me, there are many leaders in the industry advocating all of those.

Any vessel trauma leads to clotting action, repeated venipunctures therefore results in increased clotting action. Upper extremity thrombus or DVT can be caused by repeated venipunctures. In my experience, I have deferred many PICC's to a surgeon for alternate access due to either symptomatic swelling and doppler revealed thrombus/DVT or ultrasound prescan revealed noncompressible veins suitable for access. These patients consistently exhibited the bruising, swelling, and tenderness of repeated venipunctures or attempts. Not to mention potential other injuries associated with venipuncture i.e. nerve damage, arterial puncture, hematoma, lack of vein preservation.

I am not posting to take one side or another, just provide another view. I agree with Kathy, google Harnage and review her stats. I work PRN at a facility with 0% PICC CRBSI >6 consecutive months (only 1 acute cvc involved CRBSI) and labs primarily drawn from CVC's.

Timothy L. Creamer, RN

Clinical Specialist, Bard Access Systems

Florida Division

It is our policy to sample through CVADs, but I've been educating RNs and MDs to consider this on a case - case basis for higher risk patients.  It's a difficult assessment, for all of the reasons everyone has posted here. 

Mari Cordes, BS RN 

Hi,

I'm not a vascular/infusion nurse, but am an Emergency Nurse at a major academic medical center with many "special populations" of very complex patients. Vascular access is a major problem for many patients who do not have a port or line. Even obtaining peripheral blood cultures or access on patients with a vascular access device can be nearly impossible.

We are very adept, but are often forced into multiple attempts, even with ultrasound availability. Yet, we have had patients whose port remained functional for ten years. I would favor avoiding blanket proscriptions, case by case evaluation in problematic patients, and skillful use of VADs to prevent peripheral vascular damage (and place them early in the course of disease) so as to prospectively manage access and preservation of peripheral access.

All these patients will return with some complication or super-imposed problem and will need management of their disease and peripheral access (especially, if there is concern for line-infection or non-functioning of the VAD). Using up all the veins is not a good option. Safe sampling can be done with good technique and thereby preserve the vasculature for future use, and greater comfort for the patient in the meanwhile.

Sincerely,

Tom Trimble, RN CEN

What about drawing coags from VADs?  Our hospital wants to eliminate drawing all coags from lines due to the fact that many of them need to be repeated due to heparin contamination and skewed results.  I think we just need to do more nursing education on how to properly draw these without contaminating the sample.

I am curious about the stance of other hospitals on this issue...how do other organizations handle this issue?

kathy mohn-las vegas

As a patient who had a PICC for over a year, I agree wtih Kathy Kokotis.  When the facility where I got my IV treatments changed their blood drawing practice to insisting that blood be drawn peripherally when I had a perfectly functional PICC-I went through the roof and raised heck with my doctor who  changed the orders on my chart to include blood draws from the PICC only.  No amount of education to a patient will justify the number of painful peripheral sticks to which they are subjected.  It also seems to me that we are penalizing patients to accomodate unacceptible practice from Nurses.  I also would object in my community to allowing Phlebotomists to make vascular access decisions  for me or my paitents.  Why are we Nurses abdicating our responsibilities????

I am in total agreement with Kathy Kokotis on this one.  I think hospitals today are more concerned with the "reporting" of BSI"s rather than the comfort of patients. I work at a hospital where we do a little over 1000 PICC's/year.  Since the inception of my program 6 years ago, we have stayed well below the national average for infections, have had 2 in the last 6 months and we draw ALL lab work from our PICC lines.  Our patients are absolutely thrilled at not having the daily "sticking", once their line is inserted. Do you think those infections we got were from drawing blood?  I highly doubt it.  It can be from numerous reasons, one of them being poor care.  I do monthly education on the care and maintenence of PICC lines, as well as proper flushing techniques and managing occlusions.  In addition to this , on my daily rounding of these lines, I am constantly preaching about care.  And again, can we all just get back to basics and treat these lines as if they were in us!!  By the way , my hospital policy states all blood work is to be drawn from the PICC line unless otherwise indicated from the PICC Team.