Patients Per Hour: How Many Should You Draw?
How many patients should phlebotomists be expected to draw per hour? As you might expect, it depends. What can be reasonably expected from one employer is not likely to be an appropriate expectation somewhere else. That's because every facility has its own unique variables that can't be fairly applied anywhere else. Those variables include the use of a pneumatic tube system, the distance for the collector to travel to and from the patient, the percentage of difficult draws due to varying patient types, test/patient complications, etc. All of these and more must be factored whenever assessing the productivity of any specimen collection staff. Because it's been a while since Phlebotomy Today did a literature review on phlebotomy productivity, this article explores new and previously discussed studies from peer-reviewed journals.
Clinical Leadership Management Review
Researchers in Hong Kong audited the turnaround time (TAT) of their phlebotomy service to see if they were satisfying the needs and expectations of external and internal customers.(1) A survey form was given to phlebotomists to provide data using the honor system. Out of 1,867 phlebotomy requests received by the laboratory, the average time phlebotomists recorded that it took to respond to the request and draw the blood sample was 23.4 minutes. Breaking it down, it took an average of 7.4 minutes to "respond" to the request, 5.6 minutes to arrive at the patient, and 10.4 minutes to complete the draw. Ninety-seven percent of the draws were completed on the first attempt.
Canadian Journal of Emergency Medicine
Twenty-three minutes for a routine inpatient might be considered acceptable in some facilities, but what about emergency department (ED) patients? One study timed nurse-draws in the ED and found that it took 11 minutes on average between the time the test was ordered and the collection was complete.(2) The turnaround time for reporting hemoglobins from the time of collection to the time of resulting was 18 minutes. Potassiums were turned around in 49 minutes.
LabMedicine (2 studies)
The author of an article in LabMedicine shared how a phlebotomy system linking phlebotomists on the floor with the laboratory information system (LIS) increases the staff's efficiency and patient safety.(3) Despite the focus of the study (efficiency and safety), it revealed interesting statistics on the amount of time required to draw inpatients once they arrived at the bedside. Without the use of the linked system, phlebotomists could collect a patient in three minutes versus 4.5 minutes with the system's handheld device. However, the linked system reduced collection errors that were costing up to 45 minutes of lost productivity.
Can your phlebotomists draw patients in 3 minutes? Should they? Given the amount of time it takes to perform hand hygiene and post-venipuncture care, is it even possible? Not according to researchers at the UCLA Medical Center. They found a more realistic estimate for entering and leaving an inpatient's room is closer to six minutes.(4) Twenty-five percent of patients in the study required less than 5 minutes, and ten percent required more than twenty-one minutes. Although the study is a bit dated (1992), it provides the most detailed study on record as to how long a venipuncture should take.
In a second LabMedicine article, a team of researchers at Calgary Laboratory Services in Calgary, Alberta published a study that provides a far more reliable benchmark than hearsay.(5) The authors set out to establish the distribution of phlebotomy "cycle times" at four acute care hospitals in Calgary. One-hundred and ten phlebotomists, separated into groups according to their experience, were observed performing four to six phlebotomies each. Each procedure required the successful completion of 14 steps, including hand hygiene (before and after), applying pressure post-venipuncture, and donning gloves. Transit times going to and from the patient and laboratory were not included. The average time to perform the required steps of a routine, uncomplicated venipuncture was four minutes, nineteen seconds per patient with a standard deviation (SD) of 52 seconds.
The 52-second SD allowed them to recommend an acceptable range for performing a venipuncture to be between 3:16 and 6:44, or ten patients every hour, not including travel to and from the patient's location.
Archives of Pathology and Laboratory Medicine (5 studies)
Ten minutes per patient is exactly what researchers at Brigham and Women's Hospital in Boston also determined to be realistic for 90 percent of their outpatient draws as reported in CAP Today.(6,7) At the time of the study, the hospital had a total of 38 outpatient phlebotomists covering 14 outpatient draw sites. Collectively, the staff performed approximately 150,000 venipunctures per year. The study's authors created a staffing tool based on their outpatient volume and the number of available phlebotomists to accurately assess staff capacity and improve patient wait times to ten minutes or less.
Setting your own productivity benchmark
Every healthcare facility has a mix of those who are seasoned in the procedure and those who are new. Seasoned personnel are so comfortable with the procedure they barely have to think about it. They gracefully move from step to step as fluid and natural as a well-crafted poem. They're on auto-pilot. Those new to the procedure, however, are more calculating and deliberate. They spend more time between steps mentally processing what comes next. Expecting the same productivity from those new to the procedure as from seasoned personnel would be unreasonable. Therefore, any estimate on the duration of a phlebotomy procedure must consider the individual's expertise. Failure to do so risks an overly stressed staff that feels pressured to cut corners. It must also take into consideration the type of procedure (venipuncture versus capillary), and complications that might arise. Therefore, much goes into establishing an internal benchmark for phlebotomy-staff productivity if it is to be fair and reasonable.
Some argue the best way for a facility to establish its own expectations is to conduct an internal survey that takes into consideration the facility's unique variables. Establish a workload benchmark by conducting a study that takes into account the variables that are unique to your facility. Set up a study that times your staff in the performance of their regular duties according to the standards, your facility's procedure, and the CDC's handwashing guideline recommending hand cleansing between patients. Determine exactly when the procedure begins (e.g., the time of the order, the time the employee leaves the lab or the time they arrive at the patient's side). Then define what constitutes the end of the procedure (e.g., bandaging and leaving/dismissing the patient). Include a wide variety of personnel with a wide variety of experience at a wide range of times during the day.
Conduct an internal assessment. Include seasoned and new staff, venipunctures and skin punctures, and a variety of patient locations and types. Consider tracking draws with vastly different dynamics separately. For example, the time it takes to complete oncology and neonatal venipunctures should not be logged with uncomplicated venipunctures; capillary draws should not be tracked with venipuncture times. Make sure the staff is completing every step of the procedure, including hand hygiene between patients. Unless the procedure is standardized throughout the facility, the benchmark will be flawed.
- Leung AC, Li SW, Tsang RH, Tsao YC, Ma ES. Audit of phlebotomy turnaround time in a private hospital setting. Clin Leadersh Manag Rev. 2006 May 30;20(3):E3.
- Fernandes CM, Worster A, Hill S, McCallum C, Eva K. Root cause analysis of laboratory turnaround times for patients in the emergency department. CJEM. 2004 Mar;6(2):116-22.
- Sullivan E. Hospital automates phlebotomy department for efficiency and patient safety. Lab Med. 2005:36(9):528. Accessed 5/4/2020
- Howanitz PJ, Steindel SJ, Cembrowski GS, Long TA. Emergency department stat test turnaround times. A College of American Pathologists' Q-Probes study for potassium and hemoglobin. Arch Pathol Lab Med. 1992 Feb;116(2):122-8.
- Jones K, Lemaire C, Naugler C. Phlebotomy cycle time related to phlebotomist experience and/or hospital location. LabMed 2016;47(1):83–86.
- O'Reilly K. Lab shoots for better phlebotomy service, satisfied patients. CAP Today. 2016;30(3).
- Mijailovic A, Tanasijevic M, Goonan E, Le R, Baum J, Melanson S. Optimizing Outpatient Phlebotomy Staffing: Tools to Assess Staffing Needs and Monitor EffectivenessArch Pathol Lab Med. 2014;138(7):929-35.
Product Spotlight: Anatomy Poster Discounted
Through May, the Center for Phlebotomy Education's popular Blood Collection Sites and Precautions wall atlas is on sale for nearly 30% off.
Already on display in over a thousand healthcare facilities and academic programs around the world, it's the only poster of its kind that identifies the nerves, veins and arteries of the antecubital area.
This full-color laminated poster depicts the two most common anatomical variations of veins as they pass through the antecubital, the "H" and the "M" configurations. Approximate locations of nerves, veins, and the brachial artery as they pass through the antecubital area are identified and accompanied by detailed text that discusses the precautions all specimen collection personnel must know when drawing blood for clinical testing to prevent patient injury.
A section on alternative venipuncture sites discusses mastectomy patients, foot/ankle veins, and other alternatives. All text and illustrations reflect the current standards of the Clinical and Laboratory Standards Institute and the Infusion Nurse's Society. This 17" x 22" laminated poster is designed to be posted in classrooms, laboratories, medical offices, healthcare facilities, and other specimen collection environments.
Obtain your copy.
Chewing Gum: Does it Affect Test Results?
Your next patient arrives for a fasting metabolic profile. She says she has been fasting since she went to bed the night before, but you notice she's chewing gum. Is she fasting or isn't she?
Most laboratories consider "fasting" to be the complete dietary restriction of everything except water and medications for 10-12 hours. But when patients chew gum, elements of the gum are dissolved by saliva and ingested. A new study just published shed long-overdue light on the often-debated topic.
It is well known that the action of chewing gum causes the stomach to increase its acid concentration in anticipation of incoming food. In fact, the stomach produces as much acid in chewing-induced anticipation as it does to process a cheeseburger.(1) Such acid production has been linked to a simultaneous extraction from the blood of the commonly tested analytes chloride, sodium and CO2. To determine whether the changes in circulating blood during gum-chewing merit its inclusion in fasting instructions, researchers in Lithuania set out to quantify its affects.
Twenty-two healthy volunteers fasted overnight for 12 hours, then had their blood drawn between 8:00 and 8:30 a.m. for a multitude of commonly ordered laboratory tests. After the samples were drawn, subjects were instructed to chew sugar-free gum for 20 minutes. At 1, 2, and 4 hours after chewing the gum, subsequent blood samples were collected and analyzed for differences in the concentrations of 53 analytes.
Statistically significant differences were noted for the following: cortisol, insulin, C-peptide, triglycerides, uric acid, urea, amylase, alanine aminotransferase, lipase, creatine kinase, total bilirubin, direct bilirubin, phosphate, iron, potassium, thyroid stimulating hormone, red blood cell count, hematocrit, hemoglobin, mean cell volume, red cell distribution width, white blood cell count, lymphocytes, neutrophils, and eosinophils. Coagulation tests were not impacted by chewing sugar-free gum.
Chemistry results not affected by chewing gum include glucose, total protein, cholesterol, HDL cholesterol, albumin, CRP, creatinine, ALP, AST, GGT, LD, calcium, sodium, chloride and free T45. Monocytes, basophils and platelet counts were the hematological parameters not affected.
The authors concluded patients should be instructed to avoid chewing gum before blood collection for laboratory tests.
Helman C, Chewing Gum Is as Effective as Food in Stimulating Cephalic Phase Gastric Secretion. Am J Gastroenterol. 1988;83(6):640-2.
Read the full study.
From the Editor's Desk
These are strange times, indeed.
Being told to stay home is not something I'm used to. Nor did I think anyone could do that to me at my age. Back when I was a kid it was called being grounded, and I didn't like it then, either. Fortunately, I love where I live, so being told to stay here isn't even close to punishment. In fact, it's a gift. But still, being told I can't leave my house seems just plain weird.
Weirder yet is being told that if I want to go to church, even when it's empty, I have to fill out a form from the government first. Until last week, if you had a vacation home you were not allowed to go there. Walk into Wal-Mart and you'd encounter aisle after aisle roped off preventing you from buying such "non-essential" items like mosquito repellent and folding chairs. Some poor guy went to Lowe's to buy mulch and got fined $1000 for going out to buy something the stated determined to be non-essential.
How did it come to this? It's not like I live in a Covid-19 hotspot; to date, my county has reported a grand total of 19 cases.
Here in the People's Republic of Michigan, it seems like we're living through some kind of social experiment. Maybe you feel the same way where you live. We didn't bring any of this on ourselves, you or I. We may not have chosen the situation we've found ourselves in, but we certainly can choose how we react to it. For me, I'm reacting by not reacting.
My daily routine remains largely unchanged from before all this came about. Because we consider our work essential, we still go to the office. We've yet to be challenged. I prefer my home office, which is far more comfortable and has a much better view. I have yet to be fined for going down stairs. Perhaps that's coming, but for now I'm working where I prefer to work, not where I'm mandated.
There have only been two downsides to these crazy times. My 94-year-old mother is in assisted living in a county where the virus is thriving, 5789 cases as of today (up 52 from yesterday). At last count, there were 23 cases in her facility. None on her wing, but we all know it respects no boundary. (If you think I'm concerned, that's the understatement of the year.) To visit her, I'm limited to standing outside her window where we can see each other and talking by phone; hardly what I call visiting.
The other thing that unsettles me is the restriction against going to Sunday Mass. I spent 20 years avoiding church when I was consumed by a false sense of autonomy. Now that I got over myself, I have a lot of skipped Masses to make up for. I have a ways to go yet, and don't even know how much time I have left to catch up, which is why this government-imposed lockout is so troubling.
Other than that, life here is not much different from the norm. Sure, my hair is getting a bit longer than I like, but I'm convinced self-quarantined hair is better than self-hacked hair. You'll see what I mean the next time you check into our YouTube channel. Ever since we recovered it from the Internet hacker who stole it back in January, I've been freshening it up and adding new stuff. My locks may be longer than you're used to seeing me with, but trust me, it's temporary.
Oh, and by the way, I've created a new YouTube channel. For the last 23 years, everything I've written and produced has been about phlebotomy. I'm really not much fun at parties because that's all I know to talk about. Perhaps that's why my wife never takes me anywhere anymore. Not that I mind; phlebotomy is my favorite subject. But, lately, it occurred to me that I need to l turn my creative mind loose on something other than drawing blood. So I launched Studio E last month. It's my place to tinker with ideas that have been incubating in me all these years without an outlet. I hope it will be wildly diverse, always aesthetic, and safe for all ages and intellects. I've only completed one video so far, but others are percolating now that they know they'll see the light of day sometime soon. If you have a moment, and don't mind something spiritual every now and then, follow me.
If you are tired of obeying your stay-at-home order and need to demonstrate a little harmless civil disobedience, come up to Northern Michigan---the place coronavirus forgot and the land of plenty of executive orders. We'll sit out at the fire pit overlooking the lake and talk phlebotomy, insurrection, or whatever else comes to mind. I've got some brand new illegally-purchased folding chairs I can't wait to put to use, and some highly potent contraband mosquito repellent that I happen to think is essential.
Some regulations just beg to be defied.
Take care, my friend,
Dennis J. Ernst, editor
YouTube Video of the Month
This new feature in Phlebotomy Today will showcase the Editor's Choice of phlebotomy-related YouTube videos. If you have a candidate you'd like us to consider, send an email to Phlebotomy.Today@phlebotomy.com.
This month's featured video did not come from YouTube at all, but Facebook. Thanks, Jeremy Vine, for posting this gem.
Phlebotomy and the "Cough Trick"
Researchers in Germany recently studied the effect of coughing during a venipuncture as a pain-reduction strategy. The premise of the "cough trick" is to ask the patient to induce one or two voluntary coughs at the same time the venipuncture needle is inserted into the arm. The cough is intended to serve as a means to trick the pain receptors in the brain to process the cough instead of the needle piercing the vein. The team speculated the underlying mechanism to be more than just a distraction for the patient, but activation of the endogenous opioid system to temporarily scramble pain receptors.
To conduct the study, 54 healthy male volunteers were placed into three groups, each receiving a different pain reduction strategy. One group was asked to squeeze a soft rubber ball (weak distraction), a second group was subjected to what the authors referred to as "strong" distraction in the form of constriction inflated to 200 mmHg, likely a blood pressure cuff. A third group had no distraction technique employed. The extent of pain was determined by a visual scale.
The intensity of pain in the group employing the cough trick was significantly less than that of the control group (no distraction intervention) and the group subjected to weak distraction (squeezing the rubber ball). There was no significant difference in the pain assessments for those who employed the cough trick and those who were subjected to the inflated constriction (strong distraction). Therefore, the researchers concluded the cough trick to be an effective means of minimizing the perception of pain during venipuncture.
Those subjected to the cough trick were also assessed for pain after being injected with naloxone, which inhibits the effects of opioids. If the cough trick works because the body's production of natural opioids during the cough, the effect of coughing would be negligible if naloxone was administered prior to the draw. It was. Therefore, the authors concluded the lack of a reduction in pain during a voluntary cough after naloxone was administered is likely due to the involvement of the body's endogenous opioid system.
Read the entire study.
[Editor's note: This is not the first time we've reported on this technique. In the October, 2012 issue of this newsletter we shared the results of a similar study, which came to the same conclusion in regards to the effect of coughing on venipuncture pain.]
What Should We Do?: Draws during transfusions
Dear Center for Phlebotomy Education:
I have a question about drawing chemistries during a transfusion. Our lab policy has always been to wait 30 minutes post transfusion for ALL blood collections. A former pathologist once said that if the patient is having chest pains or a suspected transfusion reaction, we can draw stats. But lately we've been challenged to draw TDMs during a transfusion as well. As the collection expert, we wanted to get your thoughts and opinion. The Lab Draw Answer Book doesn't really say whether it is okay or not. What should we do?
This is a great question. You rightly observed the Lab Draw Answer Book exercises an abundance of caution in the response to that question, splitting the hair so to speak, by not saying it's okay and not saying it isn't.
Here's why: It's understandable why physicians need information on their patient's status without waiting for a transfusion to complete. We never want to put the patient at risk in that regard. So, while it is best to wait so that we may obtain more accurate test results, it's not always in the patient's best interest. In other words, we don't want the perfect to be the enemy of the good.
Therefore, if your current policy states not to draw blood during a transfusion, we would recommend a modification such as "...unless the ordering provider accepts the results may be compromised by the transfusion" or words to that affect. Whatever phrasing makes it possible only on a case-by-case basis. We would also strongly recommend the results obtained by any specimen drawn during a transfusion have the circumstances be documented along with the results and identify the physician who okay'd it. The more information that accompanies the result the more likely it will be interpreted properly.
Got a challenging phlebotomy situation or work-related question? Email us your submission at Phlebotomy.Today@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)
Test Talk: Cholinesterase
Cholinesterases, also known as SChE and S-pseudocholine esterase, are enzymes that help the nervous system function properly. Physicians order cholinesterase levels to diagnose pesticide poisoning, monitor pesticide exposure, and assess liver function. Since pesticide toxicity affects the lungs, kidney and/or gastrointestinal tract, patients with the following symptoms may have SChE ordered: diarrhea, vomiting, respiratory distress, headaches, syncope, and nausea. Patients who work with pesticides may not have any of these symptoms, but are monitored for signs of pesticide toxicity before it becomes clinically apparent.
Cholinesterase levels are tested on serum. Therefore, they are drawn into red top tubes. Levels are stable at room temperature for six hours, and for one week at refrigerated temperatures. Hemolysis interferes with testing.
- LabTestsOnline. American Association for Clinical Chemistry. AACC. https://labtestsonline.org/. Accessed .5/6/2020.
- Wu A. Tietz Clinical Guide to Laboratory Tests---Fourth Edition. Elsevier. St. Louis, Missouri. 2006.
- World Health Organization. Use of Anticoagulants in Diagnostic Laboratory Investigations. WHO. Geneva, Switzerland. 2002.
What's Wrong Here?
What's wrong with this picture? We guarantee something isn't as it should be. The answer will be in next month's issue. (Click image to enlarge.)
Last month's image (right) depicted an overflowing sharps container. Whenever a biohazardous waste receptacle is overfilled, especially one that holds contaminated sharps, every healthcare professional who handles it is put at risk. Such containers should be closed and discarded when they reach 2/3 of their capacity. When allowed to overfill, sharps containers pose a serious risk to all who encounter it and those who eventually discard them. Closing the lid on an overfilled container is a risky procedure and must be prevented.
Those who encounter overfilled devices should report them to their immediate supervisor or safety officer so that the situation isn't repeated. Discarding overfilled devices must be done with extreme caution and only with proper training to manage the risk.
Tip of the Month: What If?
Click here for this month's featured Tip of the Month from our rich library of archived Tips.