We have the ability to do blood draws at the service I do ride alongs with but it is usually only done with the doctors orders since they usually toss them anyway. In the hospital this job usually goes to the medics so yes medics in my area can do it but in the pre-hospital world it's quite rare.
Prehospital Blood Draws
- Thread starter mikie
- Start date
CLIA, the same agency that has made one exception to allow glucometers on ambulances and that was a biggy, ensures that hospital labs are up to providing quality and accurate lab results.
Unless the ambulance or EMS service can provide adequate proof of some EDUCATION for blood draws, that hospital probably shouldn't even consider accepting a field draw. A hospital lab can easy have its license suspended and a contract company will have to take over until all the issues and penalties are resolved. This is not a good thing for any hospital to allow happen.
The same thing can also happen in EMS if the ambulance agency does not provide complete and accurate records for the QC on a glucometer in accordance with their Limited Lab Registration. Those that have glucometers should understand the regulations and responsibilities of doing a diagnostic test on a sensitive piece of equipment and treating by it.
You should see the paper work required for the exception to the iSTAT for Flight or CCT that is not affiliated with a stationary lab which wants to accept responsibility.
The proper labeling with the pt. name, time and site of draw should be done by the Paramedic who did the draw. Taping a bunch of tubes to an unlabeled IV bag, even if it is attached to a patient, is NOT enough. Fluid bags can be quickly changed out and confused with another in a busy ED. Even in a slow ED, two ambulances at one time may create confusion.
An RN that takes responsibility for blood he/she did not draw or witness the draw by labeling it with her/his own initials is asking for big problems if there is ever an adverse event. This can include the suspension of the RN's license and the Paramedic may be in the clear because he/she can claim to not have gotten the proper training for the procedure. In other words, you can place the blame on the RN who blindly trusted you.
Treating a lab value from a sample that may have been handled incorrectly or mislabeled can cause a deadly result. With the ability to do STAT labs in many EDs, very little time is wasted by drawing a sample with the correct procedure by people who have their training/education certs on file. This proof of training/education can be presented as a show of good faith that an attempt was made by the hospital to provide quality care if there is a medical error.
There are many reasons why Phlebotomists now have a national certification which is becoming a mandate for some states. The training/education starts at a minimum of 140 hours and some may require 1040 hours of experience.
Originally Posted by rmellish
Definitely not the way to handle blood. Besides the reasons already mentioned in another post, the transfer of blood into the tubes presents a hazard to the healthcare provider from needle stick or splash.
quote by Sasha
Restarting a field stick has been policy in most hospitals since the beginning of EMS. Some hospitals had up to 24 hours to restart it and others wanted it done in the ED before being admitted to the unit or floors. A few hospitals have gotten lax and let the policy slide a little if the site "looked good". However, with Medicare now refusing to pay for any acquired infections, my hospital system is enforcing that no field stick leaves the ED if at all possible.
Unless the ambulance or EMS service can provide adequate proof of some EDUCATION for blood draws, that hospital probably shouldn't even consider accepting a field draw. A hospital lab can easy have its license suspended and a contract company will have to take over until all the issues and penalties are resolved. This is not a good thing for any hospital to allow happen.
The same thing can also happen in EMS if the ambulance agency does not provide complete and accurate records for the QC on a glucometer in accordance with their Limited Lab Registration. Those that have glucometers should understand the regulations and responsibilities of doing a diagnostic test on a sensitive piece of equipment and treating by it.
You should see the paper work required for the exception to the iSTAT for Flight or CCT that is not affiliated with a stationary lab which wants to accept responsibility.
The proper labeling with the pt. name, time and site of draw should be done by the Paramedic who did the draw. Taping a bunch of tubes to an unlabeled IV bag, even if it is attached to a patient, is NOT enough. Fluid bags can be quickly changed out and confused with another in a busy ED. Even in a slow ED, two ambulances at one time may create confusion.
An RN that takes responsibility for blood he/she did not draw or witness the draw by labeling it with her/his own initials is asking for big problems if there is ever an adverse event. This can include the suspension of the RN's license and the Paramedic may be in the clear because he/she can claim to not have gotten the proper training for the procedure. In other words, you can place the blame on the RN who blindly trusted you.
Treating a lab value from a sample that may have been handled incorrectly or mislabeled can cause a deadly result. With the ability to do STAT labs in many EDs, very little time is wasted by drawing a sample with the correct procedure by people who have their training/education certs on file. This proof of training/education can be presented as a show of good faith that an attempt was made by the hospital to provide quality care if there is a medical error.
There are many reasons why Phlebotomists now have a national certification which is becoming a mandate for some states. The training/education starts at a minimum of 140 hours and some may require 1040 hours of experience.
Originally Posted by rmellish
Definitely not the way to handle blood. Besides the reasons already mentioned in another post, the transfer of blood into the tubes presents a hazard to the healthcare provider from needle stick or splash.
quote by Sasha
Restarting a field stick has been policy in most hospitals since the beginning of EMS. Some hospitals had up to 24 hours to restart it and others wanted it done in the ED before being admitted to the unit or floors. A few hospitals have gotten lax and let the policy slide a little if the site "looked good". However, with Medicare now refusing to pay for any acquired infections, my hospital system is enforcing that no field stick leaves the ED if at all possible.
artman17847
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only one of our local hospitals will accept blood draws from the field.
OP
OP
mikie
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Maybe an advantage?
For a medical patient, getting the blood before major meds/fluids (not saying to withhold treatment) are administered might show the blood chemistry before ER arrival (which I would imagine someone might want to see)..
I'm not a medic [yet] so this may be totally off...:unsure:
For a medical patient, getting the blood before major meds/fluids (not saying to withhold treatment) are administered might show the blood chemistry before ER arrival (which I would imagine someone might want to see)..
I'm not a medic [yet] so this may be totally off...:unsure:
gillysaurus
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Same here, draw on everyone (for the most part) before giving an IV. Private service.
mycrofft
Still crazy but elsewhere
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Only reason for a field draw would be to do some field test.
Can't think of any needing more than drops of blood (Hemocue, glucometer, various dipsticks). So why draw?
If you could hang on the wall like a fly after you drop your pt, you might be shocked at how much of what you do is tossed, ignored, or even denigrated. I was the day I watched them throw out our enroute vitals right in front of us...
Can't think of any needing more than drops of blood (Hemocue, glucometer, various dipsticks). So why draw?
If you could hang on the wall like a fly after you drop your pt, you might be shocked at how much of what you do is tossed, ignored, or even denigrated. I was the day I watched them throw out our enroute vitals right in front of us...
Doesn't bother me if that's the case.
Although, that being said, I see the blood we bring in taken to the lab by someone each time, so I'm optimistic.
But for a cardiac incident, for instance, checking Troponin levels and all. Enzymes, etc. I'm told it speeds up the process and saves techs and nurses time and effort by the nurses themselves, so...
mycrofft
Still crazy but elsewhere
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Here is an online reference, Quest Diagnostics
http://cas2.questdiagnostics.com/scripts/dos.wls?wlapp=DOS
Select a lab in a big city (where they do the most varieties of labs), then look up a particular lab alpahbetically on the left side to see collection and handling properties.
By the way their turnaround on a troponin is 2 to 3 days.
http://cas2.questdiagnostics.com/scripts/dos.wls?wlapp=DOS
Select a lab in a big city (where they do the most varieties of labs), then look up a particular lab alpahbetically on the left side to see collection and handling properties.
By the way their turnaround on a troponin is 2 to 3 days.
mycrofft
Still crazy but elsewhere
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PS: 140 hrs to learn to draw blood?! Spare me!!
Then an adult using a flush toilet must be a three day seminar.
Then an adult using a flush toilet must be a three day seminar.
I do think it makes a difference that I work in a very rural area with a small community hospital. They appreciate the draw a bit more, because it saves them effort and time.
But in the same company, in the city, they don't even carry the necessary equipment to draw blood, because the hospital does not accept it.
So it's a difference of area in my case.
But in the same company, in the city, they don't even carry the necessary equipment to draw blood, because the hospital does not accept it.
So it's a difference of area in my case.
Are you trying to start an argument against the hospital labs?
I believe you are from Central CA?
I'm from FL and I would imagine Central CA gets almost as warm at least during the summer as it does here.
Imagine leaving those specimen tubes in a hot truck waiting to be used. Or, lying on the hot pavement or hood of a car after a draw for several minutes while you continue to work on the patient. What assurance does the hospital lab have about the quality of the specimens? Do you think a lab wants to put their license on the line?
And, why haven't you found out more information from the lab to get the extra training or see what could be done PROPERLY if you think there might be a way to prevent the specimens from being tossed? Instead, it seems like you would rather complain about it like you have no idea why anyone would toss the nice medic's offerings.
If the specimens aren't being used, it is a waste. Find out what the hospital policies are. See what can be done to get your agency and the lab together if it is reasonably possible.
This us against them crap is stupid especially if you make it sound like they have something personal against prehospital providers and their efforts. Know the regulations before you pass judgement on other people just trying to do their job and provide quality results for patient care.
We do NOT wait 2 to 3 days for troponin results. When was the last time you worked in a hospital?
Read California's Phlebotomist requirements. This is YOUR own state.
Why are you bashing education and quality control?
Things may have changed a little since you actually worked in a hospital.
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UGA_Medic8714
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Not Anymore...
We used to draw labs in the field, but the nurses would just toss our labs in the trash and draw their own. Ugh. We never draw labs for law enforcement.
We used to draw labs in the field, but the nurses would just toss our labs in the trash and draw their own. Ugh. We never draw labs for law enforcement.
BillB
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I work for a hospital based service.Almost all patients that get IV's in the field get blood drawn.We act as ER techs back at the hospital so,9 times out of 10 we would be doing them there anyway.It's one less thing to do when we get back and one less poke for the PT.
vquintessence
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Alright, can agree with field IV's get tossed after 24 hours. How long is the life of an in-hospital IV anyways? a few days? I have no idea and can't find the info.
Tossing our labs is completely understandable and justifiable, but cannot really agree with indiscriminate, immediate, on the spot, nullification of field IV access. Granted medicare is stricter now than ever, but how are they proving that MRSA came from an ambulance instead of the hospital, a school, or a restaurant? Did the phlebitis arise from EMS stick or the phlebotomist/RN/whatever? Were the bed sores acquired during my pts rough 15min transport or the week long hospital stay? It's just a money blame game with some mildly justifiable reasoning; the tail wagging to dog.
Tossing our labs is completely understandable and justifiable, but cannot really agree with indiscriminate, immediate, on the spot, nullification of field IV access. Granted medicare is stricter now than ever, but how are they proving that MRSA came from an ambulance instead of the hospital, a school, or a restaurant? Did the phlebitis arise from EMS stick or the phlebotomist/RN/whatever? Were the bed sores acquired during my pts rough 15min transport or the week long hospital stay? It's just a money blame game with some mildly justifiable reasoning; the tail wagging to dog.
Buzz
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This is slightly off the blood draw topic, but as far as field samples go:
I will never get tired of the look on people's faces when I hand them a canister with random stuff in it. Such as this one time when a doc decided to come into the room to take a report because the nurses were busy and I handed him a container with bright red bloody stool in it--looked kind of like taco sauce, actually. The look on the doc's face was priceless.
I will never get tired of the look on people's faces when I hand them a canister with random stuff in it. Such as this one time when a doc decided to come into the room to take a report because the nurses were busy and I handed him a container with bright red bloody stool in it--looked kind of like taco sauce, actually. The look on the doc's face was priceless.
UGA_Medic8714
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72 Hours is the limit I think... or maybe it's 48. Hell I can't remember... I just know mine get's them in the door.
Do you understand the mortality rate for infections in a hospital? This is a very serious problem and shoudn't be taken as just a cost thing or some way cooked up to just point fingers at EMT(P)s. Unfortunately, Medicare had to get someone's attention on the issue somehow and money is a good motivator.
Here's some reading to do for more information.
http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?printable=true
http://www.ihi.org/ihi
We are also changing out field ETTs in my hospital system and there are others doing the same thing. Some of the reasons include VAP and the predicted length of needing a tube. Hospitals may electively switch to a tube that is easier on the tissues of the trachea and have subglottic suctioning capabilities as well as the possibility of the tube laying in dirt prior to intubation or the number of times that tube saw the esophagus before the trachea.
Many of the reasons IVs and ETTs are changed come from the EMS providers themselves. The bragging and talk about how those in EMS have to "do it dirty" and don't have time to clean a site properly have given the hospital every reason not to trust your IVs and tubes.
Even during a clinical rotation in the ED, we may have to retrain a student Paramedic's way of thinking, at least while in the ED, when they just do one swipe with the alcohol and start to insert the needle. When asked about their technique, many will proudly say they are taught the "EMS way" and don't have time for all that cleaning and care the hospital does. EMS is just different as if that gives one a cert to not practice good medicine.
Infection control is everybody's issue. Whatever can be done to prevent a patient from dying from the type of care they receive versus the complaint they came in with is a plus especially for THE PATIENT.
I have posted several articles about infection control on an ambulance but rarely are they commented on or even read because that is the boring stuff. Yet, most will admit they have gotten little to no infection control information in their EMT(P) classes or from their employers. Hospital staff of all titles get this information tossed at them constantly from their orientation classes, yearly updates, department meetings and infection control staff monitoring every procedure. Every invasive procedure that is done in a hospital is now monitored. It has been proven that one little missed step in procedure can result in a very lengthy and costly hospital stay with the potential of death resulting from it.
Because hospitals have rules pertaining to restarting field IVs and not accepting blood, some seem to believe it is a conspiracy plot of some kind against EMS providers.
Yes, decubitus ulcers are a big factor and the ED RN must also do a skin integrity check for any potential of this happening if a patient has been immobilized for even a short time. Rather than placing blame on who or what caused it, action is taken to see it doesn't develop further. No one is out to blame EMS providers but to recognize potential for complications and prevent them from causing harm to THE PATIENT.
When will egos go to the wayside in EMS and the attention is directed toward THE PATIENT?
These issues are not about the EMS provider but rather being able to control the quality of patient care. If there is any chance of error from one not being properly trained, improper handling or mislabeling, that presents a risk in the care of THE PATIENT.
Patient care is about THE PATIENT.
BTW, you can ask any nurse that works on the med-surg floors or ICU how often they change their IV sites. It is amazing how much information some in EMS can learn if they come out of their isolated world and talk to other healthcare professionals.
rescuepoppy
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This is not a brag but if you look at the way we have to do things in the field it is no wonder hospital staff changes IVs and ET tubes. Out of need we do not always have the best of environments to work in. That is a good reason to do things in a more controlled manner to better serve the patient. yes in my area we do do blood draws on some patients sometimes that blood goes to the lab sometimes not. That is not my call I don't set the standards for in hospital care. So i don't get upset or question their reasons behind it. All I can assume is that the hospital staff has the patients best interests in mind.
vquintessence
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Fair enough and thanks for the article Vent. I typically find the New Yorker very snide but that was a great article.
Regarding us versus them, hospital versus EMS, I'm not crying foul play and that we're being fingered for all hospital acquired infections. I'm only stating that EMS is given absolutely minimal credibility when it comes to competence and professionalism.
As far as infection, I'm not trivializing it, just the lack of trust regarding the view of hospital vs field. Is my truck dirtier than the hospital room? Sometimes, but I also wouldn't intend to use supplies picked off the floor of a hospital either. Do I use expired equipment? Nope. Do I ensure the site is clear of debris and then cleanse the site with ever increasing concentric circles and do I use alcohol or betadine? Yep, all the time everytime. And like you said, it's for the patient.
Those students who you have had to re-educate because they're "street medics" or whatever, well they should be slapped up the side of the head. Same for the veterans who say "there's was no time to cleanse the site". Utter BS, especially coming from them. Any healthcare provider pretending there's no time for a truly sick/trauma pt to cleanse the site isn't excusable by any standard. It's ALWAYS easier to spot the idiot.
It's always the few morons who screw the majority. Applies to every occupation, every situation. Just because there was a student who doesn't care (he knew, he just didn't care/think) doesn't mean he wasn't taught. Or that EMS, hell healthcare providers, do that as a whole.
A coworker works in a NH ED. A pt became altered/lethargic, wife drives husband to hospital. Uncontrolled A-fib c profound hypotension. Coworker argued for cardioversion, denied. Pt given diltiazem. Pt coded. Pt stayed dead. Most correct initial treatment?
While shadowing saw a late 20'ish Y/O obese female comes in acute SOB, no hx asthma. Pt just had a knee replacement about a week ago, not med compliant s/p surgery, pt smokes, pt + birth control. Parents worried, called their PCP, he said call 911, parents drove to ED instead. RN had pt wait after even more after initial triage for 5+ minutes until pt collapsed in waiting room. Wasn't a big hospital (about 25 beds in the ED) and not a super busy day. Acceptable having pt wait for focused triage?
Everyone here can give a similar story, be it in the field, in the air or in the hospital. The only difference is that the end result wasn't to have every invasive procedure be rendered null and void by another branch of care.
I don't beat my chest and roar after each tube and I especially don't feel insulted when my ETT is removed in front of me. I can understand. I only take offense when it's becomes policy to ASSUME I licked the site prior to venipuncture.
The New Yorker article spoke of how each ICU pt requires thousands of individual steps to keep a pt healthy and give them a speedy recovery. Regardless of what anybody says or likes, EMS is a part of those steps, and like the other healthcare professionals who are working in unison, EMS should be respected and invited into the process as well. And like you said about eight times, it's about the pt, and I believe it's the best interest of the pt to have a UNIFIED approach to care. Not EMS blaming public & education, not ED belittling EMS, not OR over stepping ED priorities, not ICU criticizing OR procedures, not rehab blaming ICU conditions.
Regarding us versus them, hospital versus EMS, I'm not crying foul play and that we're being fingered for all hospital acquired infections. I'm only stating that EMS is given absolutely minimal credibility when it comes to competence and professionalism.
As far as infection, I'm not trivializing it, just the lack of trust regarding the view of hospital vs field. Is my truck dirtier than the hospital room? Sometimes, but I also wouldn't intend to use supplies picked off the floor of a hospital either. Do I use expired equipment? Nope. Do I ensure the site is clear of debris and then cleanse the site with ever increasing concentric circles and do I use alcohol or betadine? Yep, all the time everytime. And like you said, it's for the patient.
Those students who you have had to re-educate because they're "street medics" or whatever, well they should be slapped up the side of the head. Same for the veterans who say "there's was no time to cleanse the site". Utter BS, especially coming from them. Any healthcare provider pretending there's no time for a truly sick/trauma pt to cleanse the site isn't excusable by any standard. It's ALWAYS easier to spot the idiot.
It's always the few morons who screw the majority. Applies to every occupation, every situation. Just because there was a student who doesn't care (he knew, he just didn't care/think) doesn't mean he wasn't taught. Or that EMS, hell healthcare providers, do that as a whole.
A coworker works in a NH ED. A pt became altered/lethargic, wife drives husband to hospital. Uncontrolled A-fib c profound hypotension. Coworker argued for cardioversion, denied. Pt given diltiazem. Pt coded. Pt stayed dead. Most correct initial treatment?
While shadowing saw a late 20'ish Y/O obese female comes in acute SOB, no hx asthma. Pt just had a knee replacement about a week ago, not med compliant s/p surgery, pt smokes, pt + birth control. Parents worried, called their PCP, he said call 911, parents drove to ED instead. RN had pt wait after even more after initial triage for 5+ minutes until pt collapsed in waiting room. Wasn't a big hospital (about 25 beds in the ED) and not a super busy day. Acceptable having pt wait for focused triage?
Everyone here can give a similar story, be it in the field, in the air or in the hospital. The only difference is that the end result wasn't to have every invasive procedure be rendered null and void by another branch of care.
I don't beat my chest and roar after each tube and I especially don't feel insulted when my ETT is removed in front of me. I can understand. I only take offense when it's becomes policy to ASSUME I licked the site prior to venipuncture.
The New Yorker article spoke of how each ICU pt requires thousands of individual steps to keep a pt healthy and give them a speedy recovery. Regardless of what anybody says or likes, EMS is a part of those steps, and like the other healthcare professionals who are working in unison, EMS should be respected and invited into the process as well. And like you said about eight times, it's about the pt, and I believe it's the best interest of the pt to have a UNIFIED approach to care. Not EMS blaming public & education, not ED belittling EMS, not OR over stepping ED priorities, not ICU criticizing OR procedures, not rehab blaming ICU conditions.
This is not a New Yorker magazine exclusive but rather it took an article from the medical journals and made it an interesting read.
This article was required reading in almost every hospital and has been discussed at great lengths on other health professional forums.
When working in a hospital your work is scrutinized many times by many different professionals. But, all those pairs of eyes can decrease medical errors and make us aware of our mistakes so that we can provide better care. It also doesn't mean that those working in a hospital are a bunch of screw ups either.
If a patient is brought out to Rehab too early and crashes, a follow up will be done to determine what might have prevented this. If the OR dumps a fixin' to die patient, another review will be done to see what could have been differently and not just accept the "no one dies in my OR" fact. Examining mistakes to see where they can be improved is what the IHI is about. This organization is the one helping hospitals across the country to perfect their Rapid Response Teams.
EMS providers are just too comfortable having only one patient at a time and their own space where the idea of what happens in the ambulance stays in the ambulance. Criticism from the public and other health care professionals is hard to take when you are used to not having anyone examining your work. It is fairly well known that some EMS agencies fail to monitor the quality of their employees' work or proficiency at some skills. Thus, we now have some skills in question as to whether EMS is actually qualified to perform them and this includes intubation.
Do the best you can to provide excellent patient care and don't take things so personally. To do what is best for the patient and be successful in medicine, you may have to grow a thick skin and hear how your own techniques could be better.
There's always room to improve regardless of how perfect one thinks they are already.
My statements in this post are not necessarily directed at you vquintessence but to those that whine when an ED doctor or nurse asks them why they did something even if just for conversation or curiousity and not making an accusation.
Back to the blood draw issue.
When drawing blood specimens, do you know when the samples you just drew will probably be not acceptable just by the way the blood is flowing? Do you bother to mention this to the hospital staff or just allow it to go to the lab? Afterall, its blood and you did your part, right? Do you know how much time is lost by the time the lab notifies the ED that your sample produced questionable results and a redraw is necessary?