Do you think it is good practice to draw bloods in the field?

[Carlos Danger]

When blood is drawn in the hospital, there are policies regarding the way the tubes are handled, part of which is strict labeling requirements. The Joint Commission and the agencies that accredit the labs have plenty to say about this.

Considering that drawing blood in the field is going to have no impact on the patients outcome, it just isn't worth the expense and risk of doing it in the field.

 

[EpiEMS]

Considering that drawing blood in the field is going to have no impact on the patients outcome, it just isn't worth the expense and risk of doing it in the field.

While I think I can follow your reasoning, @Remi, and I tend to agree that prehospital blood draws seem pretty limited in value, isn't it possible that prehospital drug (especially antibiotics) or fluid administration could impact lab values from the point of injury or initial illness such that it might adversely impact ongoing management?

Just thinking out loud here.

 

[Akulahawk]

When blood is drawn in the hospital, there are policies regarding the way the tubes are handled, part of which is strict labeling requirements. The Joint Commission and the agencies that accredit the labs have plenty to say about this.

Considering that drawing blood in the field is going to have no impact on the patients outcome, it just isn't worth the expense and risk of doing it in the field.

One of the bigger reasons why field draws aren't done more frequently is exactly because of this. Also since most field providers aren't employees of the hospitals, the hospitals can't say to TJC that field draws are done and handled exactly according to hospital policy and any slip-ups can't therefore result in retraining of prehospital personnel by that hospital. The hospitals and their labs aren't willing to bet the loss of their accreditation because your draws are done outside of their purview/control.

 

[E tank]

Drawing blood cultures in the field is just a bad idea.

 

[Carlos Danger]

While I think I can follow your reasoning, @Remi, and I tend to agree that prehospital blood draws seem pretty limited in value, isn't it possible that prehospital drug (especially antibiotics) or fluid administration could impact lab values from the point of injury or initial illness such that it might adversely impact ongoing management?

I probably wouldn't worry so much about that, just about the necessity of drawing labs in the field vs. the potential drawbacks that come with passing off unlabeled tubes and such.

Generally, the time saved by having labs drawn enroute vs. shortly after arrival just isn't going to make any difference in the care provided in the ED. Initial treatment for pretty much any life-threatening problem is provided based on clinical and/or standard point-of-care (i.e, ECG) information, and labs basically just confirm the diagnosis and help guide ongoing treatment.

The one exception I can think of might be drawing cultures before giving prehospital ABX in sepsis. On the other hand, my understanding is that outcomes from sepsis don't improve with earlier ABX administration, so giving them prehospital might be completely unnecessary anyway. And expecting nearly flawless aseptic technique in the field might be a bit of a tall order.

 

[reaper]

Drawing blood cultures in the field is just a bad idea.

Why?

Sent from my VS985 4G using Tapatalk

 

[E tank]

Why?

Sent from my VS985 4G using Tapatalk

If pre hospital abx are not going to be given, the hospital is a better place to get a sterile blood culture than someone's living room or the back of an ambulance. Obviously, in systems where abx are part of a sepsis identification protocol, it is what it is.

 

[reaper]

I agree on only drawing them on pts that are getting abx. The contamination rate is not really an issue, if crews are taught correct procedures.

Sent from my VS985 4G using Tapatalk

 

[E tank]

I agree on only drawing them on pts that are getting abx. The contamination rate is not really an issue, if crews are taught correct procedures.

Sent from my VS985 4G using Tapatalk

What is the pre hospital blood culture contamination rate?

 

[reaper]

We ran the pilot study for it. Average was 4.7%. Equal to the ED rates. Actually had two months with 0%. Lab stated that it had never seen that before. We ran strict procedures for it. So the providers paid closer attention to sterile environment.

Sent from my VS985 4G using Tapatalk

 

[E tank]

We ran the pilot study for it. Average was 4.7%. Equal to the ED rates. Actually had two months with 0%. Lab stated that it had never seen that before. We ran strict procedures for it. So the providers paid closer attention to sterile environment.

Sent from my VS985 4G using Tapatalk

what was the n?

 

[reaper]

Here is a presentation that was done on it.
https://www.dropbox.com/s/rzf6mwxibduiwbe/Walchok_EMS ABX_2016_Short.pdf?dl=0

Sent from my VS985 4G using Tapatalk

 

[E tank]

So the overall contamination was 5 %. That isn't horrible, as 2-3% is the generally accepted contamination rate for hospitals. What is not so great is that that number represents 20% (check that, closer to 17%) of the positive growth cultures overall, if I'm reading that correctly. For the hospital to be no better than field draws suggests some training might be in order for them too.

Interesting. Thanks for the link.

 

[Altitudes]

I work in a lab that tests blood samples...I think you guys would be surprised at the amount of blood we throw away. I've personally tossed 5-6 4mL tubes of a single patient's blood before.

Also, blood in sodium heparin (green) or EDTA (purple/pink) tubes shouldn't coagulate. I've only seen a few samples in these tubes that have clots.

Field draws would also require the drawer to know what tests are going to be done...certain tests can't be done with samples that were drawn into a lithium heparin or EDTA tube, such as MA tests for example. Transport temperatures are an issue, tests have to be performed within a certain number of hours of the draw, etc.

 

[Bullets]

.

Field draws would also require the drawer to know what tests are going to be done...certain tests can't be done with samples that were drawn into a lithium heparin or EDTA tube, such as MA tests for example. Transport temperatures are an issue, tests have to be performed within a certain number of hours of the draw, etc.

We draw redx2, blue, purple and green for the trauma center. We know that they will type and match, a CBC and CMP, so we give the extra red.

 

[Tigger]

I've never heard of pre-hospital blood draws for lab use in this area, though the idea of putting iSTATs on trucks has been tossed around. From the ER perspective, it would be a QA nightmare. Between hemolyzed samples and contaminated blood cultures, it would be difficult to educate those who need it. Additionally, I'm sure billing would also be a nightmare.

None the less, I feel the logistics of it all would really hinder the process and only result in wasted expenses on both sides.

Our hospital networks supply us with blood tubes and an ID bracelet. Draw the tubes, put a numbered sticker on each tube, then put the rest of the stickers (which are on a bracelet) on the patient. The hospital networks actually worked with each other to develop kits that can be used regardless of the receiving facility's network. Early (and unpublished data) suggests that EMS samples are contaminated or otherwise unusable at a rate comparable to the ED's.

EMS field draws...I feel like these are an old-school practice. I'm suspicious because I can't exactly follow the cost/benefit calculus. Not to mention, there is a paucity of evidence.

The hospitals want us to do to it so they can speed their lab times. They supply the tubes, and there aren't really expectations though they want chest pains and abdominal pains done if we are going to start an IV anyway. Our EMTs start IVs and can draw as well. We are forbade from drawing on trauma activation patients to ensure that delaying transport or other treatment for an IV is not justified with "well the hospital would have wanted blood."

Drawing blood cultures in the field is an excellent idea and one that I'm all for! Per the post I was responding to, the service I was questioning was providing ABX prior to drawing blood cultures due to one hospital not giving them the blood culture tubes they use. That's what is hurting or "screwing over" patients, giving ABX before the blood cultures. Unless there's a crazy long transport time, it's better to hold off on the ABX and let the hospital draw them before they start treatment.

Greenville SC has some pretty good data on prehospital cultures and ABX administration, I have an academic poster that they did somewhere. ETA: It's a summary of what @reaper posted.

 

[agregularguy]

Our hospital networks supply us with blood tubes and an ID bracelet. Draw the tubes, put a numbered sticker on each tube, then put the rest of the stickers (which are on a bracelet) on the patient. The hospital networks actually worked with each other to develop kits that can be used regardless of the receiving facility's network. Early (and unpublished data) suggests that EMS samples are contaminated or otherwise unusable at a rate comparable to the ED's.


The hospitals want us to do to it so they can speed their lab times. They supply the tubes, and there aren't really expectations though they want chest pains and abdominal pains done if we are going to start an IV anyway. Our EMTs start IVs and can draw as well. We are forbade from drawing on trauma activation patients to ensure that delaying transport or other treatment for an IV is not justified with "well the hospital would have wanted blood."



Greenville SC has some pretty good data on prehospital cultures and ABX administration, I have an academic poster that they did somewhere. ETA: It's a summary of what @reaper posted.

While I don't have the exact data on it on hand, I know when I interviewed with Greenville last month and was asking about that, they said that the mortality rate in hospital for sepsis prior to the starting of prehospital abx was around 50% and following the start of the program it dropped I wanna say to under 10%. Don't quote me on the exact figures though.

 

[GMCmedic]

While I don't have the exact data on it on hand, I know when I interviewed with Greenville last month and was asking about that, they said that the mortality rate in hospital for sepsis prior to the starting of prehospital abx was around 50% and following the start of the program it dropped I wanna say to under 10%. Don't quote me on the exact figures though.

I have the initial study somewhere in my email from when we started our sepsis protocol. Ill see if I can dig it up.

Sent from my SAMSUNG-SM-G920A using Tapatalk

 

[GMCmedic]

It was a ~13-26% reduction in mortality with a 5.89% contamination rate for cultures

Sent from my SAMSUNG-SM-G920A using Tapatalk

 

[EpiEMS]

If anybody can find the study, I'd love to see it. What was the n?


Sent from my iPhone using Tapatalk