Does your phlebotomist ask you to draw blood from a PICC line for them?

[koinurse]

Hello fellow nurses! I recently transferred to another SNIF as an 11-7 RN and in the am, the labs phlebotomist would keep asking me to sign papers that the pt refused to have blood drawn, and I would go to the pt's room and ask them myself, and they always agree if its me asking ( this in the middle of med pass). I was just particularly irked today because last night was very busy, then at around 6.45am the labs called me to say that the phlebotomist would be late for 20 mins and to hold the residents' breakfasts until she comes! So I go, ok I got all the names of the residents with blood tests and asked the CNAs assigned to hold it (we are on full census!) So here she comes( while I was counting narcs with the incoming nurse) asking me to sign the lab again that the pt refused! I asked her what lab it was, and it was a PT/INR, so no way Im going to allow the pt not to have it. So off I go to ask the pt again, and she agreed, and the phleb brushed me aside(as usual!) saying, "I'll take it from here". Then I was counting with another cart and she interrupts me again saying that another pt with a PICC line wants her blood drawn from her PiCC line, and that I should do it because Im the RN! I absolutely am not comfortable drawing blood from a PICC line, there is so much policy to follow ( 2 pages long) and the pt has good veins! ( someone had informed her that since she is a hard stick, everything can be done with a PICC line). For me, the risks far outweighs the benefits (mainly the pt's comfort and the phlebs' time! sigh...) I hate losing my patience, but off I go to the pt again and asked her to have blood drawn from her other arm, and she said yes! Then here she goes again with her "I'll take it from here" line. I keep losing valuable time with this phleb because I needed to endorse my narcs, and do some more charting! My question is, do your lab rep ever do this to you? The phleb in the previous facility I worked at never asked me to do this! Im just venting and I do like to hear your views. Many thanks in advance!

[Boston-RN, RN]

Sorry....going to have to agree with all the others. The PICC line is there for access both giving and drawing. One of the perceived benefits to the patients is a decrease in lab sticks....even though it's more time for you it's less discomfort to them.

[morte, LPN, LVN]

Thank you for your replies. Just to clarify that the post was meant to say that the phleb would rather have me sign that pt refused rather than try to get the pt to have a stick. We are not a hospital, so our pts do not get sticks all the time. Im just comparing because at the other facility I worked with, the phleb was hospital - based and he got all his labs on time and never a problem with his sticks, even having the time to be nice to the patients, that is all. Again thanks!

oy! no clarification needed for me!.....the phleb is the problem, either no bedside manner, or lying thru his/her teeth. AND, you need a doctor's order to draw blood from a PICC..... Please remember this poster is NOT in hospital!

[CRIMSON]

Draw labs from the PICC line all the time. I would not want lab to touch them. Sorry but it requires assessment of patency and flushing with either NS or heparin (lab cannot push drugs and flushing is considered med administration). Neither of these skills can be delegated.

Ask for a different phlebotomist for your floor if they are a problem and if the PICC line patients want line draws keep some tubes on your floor and draw them as you go in and save yourself a trip. Often if they are not flushed often they clot which requires Cathflo to clear which also requires the RN assessment and administration. They are peripherally inserted but still a central line where the tip lies in the superior vena cava. You wouldn't want lab touch your other triple lumens right?

[koinurse]

WOW! learning a lot! Thanks! :yeah:I've also like to add that I've drawn a couple of vacutainers for her in the past, it's just that I felt uncomfortable with this because the pt has a Dx of CHF and atrial fib, and when she handed me around 6 vacutainers plus the 5-10ml of blood I had to waste, through a line that goes straight to her superior vena cava.... I just got scared I guess, my inexperience showing. Plus the fact that when I told her that she has to be beside me when I do it because that was what the policy stated, she just looked at me and left... so I went to the patient's room and asked the pt if we could draw the blood from her other arm, it's a good thing she agreed, I was suddenly able to breathe. No prob drawing there either, I don't know if it's good but I would only use a PICC as a last resort for her. Thank you for your replies. I have always relied on allnurses ever since I was a nursing student and I've never been dissapointed! Love you all!:redbeathe

[Reno1978, BSN, RN]

If I was a patient with a PICC line in place, regardless of environment or facility, I would choose 10 times out of 10 to have my blood drawn from my PICC versus being stuck with a needle.

Personally, I think you should take this as an opportunity to to familiarize yourself with PICCs, become comfortable drawing blood from them, and advocate for the comfort of your patients.

[IVRUS, BSN, RN]

Well,

Not drawing from a central line, like a PICC, because you don't know how to do it, or you just feel uncomfortable with the procedure is not an appropriate excuse. Speak to your director or staff development person and get training to increase your comfort level and competency. However, I do believe that a blanket policy of always drawing from a central line (when one has one) is wrong. The issues that must be taken into account are these:

1. Each time you enter the hub of the IV catheter, you increase the chances of introducing bacteria into the vascular system, thus increasing CRBSI's.

2. Accuracy of lab results - One shouldn't be drawing coags (PT, PTT) from a heparinized line, if it can be drawn peripherally.

3. In critical care patients, Iatrogenic anemia is a real possibility, unless you draw using the mixing method.

4. Drawing from a PICC increases the chance of clotting the IV catheter... If a PICC line is a 3fr, you don't want to be drawing from it, either.

Now, if there are no peripheral IV sites or you have a pt who is truly needle phobic, then I can understand forgoing the above concerns and drawing from the PICC, but make sure your techniques/process is spot on and you know how to do it to avoid complications.

So, drawing from a PICC, or any other central catheter should be individualized for that patient. It should be a risk vs. benefit thing.

Hope this helps. :)

[DebblesRN, ASN, BSN, RN]

As a former Phleb, I can say that we were not allowed to access picc lines. That is the RN's job. It would infuriate me when a nurse would give me attitude about it. Many of these patients with picc lines have them because they have poor venous access or frequently ordered blood work. I would also get upset when they would cancel a ptt that was ordered for routine 4 am rounds and then not cancel the other routine order (cbc, cmp) so the lab would draw these tubes and then get a stat order 2 hours later for the ptt. So the patient is getting stuck 2 times in two hours instead of having all of the tests done when the ptt was ordered. So much for minimizing blood draws for patients on heparin. And please don't think I don't understand that sometimes blood test are ordered after the routine bloods are drawn, however this happened frequently at the hospital I worked for as a phleb. Very disorganized, and certainly not putting the patients needs first.

What do you think was running through that PICC line?? Heparin right?? How accurate is the PTT gonna be with heparin in the line?? Maybe that is why the patient needed a peripheral stick??

The hospitals I have worked for, there had to be a doctor's order in the chart saying it was okay to draw blood samples from the PICC, otherwise, they had to be stuck by lab.

Depending on what is infusing through the PICC, you can alter lab results.

Honestly, if the patient has accessible veins, they need to be stuck.

While PICCs are inserted on people with poor veins, they ARE NOT for blood draws. Most PICCs are put in for long term IV therapy--such as IV antibiotics, not because the patient has bad veins.

[BittyBabyGrower, MSN, RN]

Only RN and MD can access a PICC at my facility.

[corky1272RN]

I think most of the responses have missed the mark of the OP's question. Mostly the OP wanted to know about the phleb always saying the patient refused. I think you should go into the room with phleb of the patients that are refusing to see how that person is asking or informing the patient of the blood draw. From our reported observarions of her, she appears to not be able to communicate professionally.

For the central/picc discussion:

At my hospital we do draw blood from these lines (only RNs)however there are exceptions: if the line does not aspirate blood, if there are continuous infusions, if there are coags to be drawn, or if there are labs that need to be precise. I contacted the doctor in our interventional radiology department about lines that don't aspirate blood. He said that as long as it flushes and there is no swelling/pain at the site there is no problem with the line. I had a patient that had a single lumen picc, two continuous infusions (Nexium gtt and sandastatin--it was going in a peripheral IV). He had low H/Hs due to active bleeding from a esophageal varices. He was mad when I refused to stop his gtts to draw his labs, "all the other nurses do it". I don't care what all the other nurses do. I told him that if the doctor wrote an order stating that his infusions could be held to draw the labs then I would have no problem, of course the doc wouldn't.

Another patient of mine started refusing glucometer checks and wanted me to draw that drop of blood from her picc :rolleyes:

[catshowlady]

At my hospital we do draw blood from these lines (only RNs)however there are exceptions: if the line does not aspirate blood, if there are continuous infusions, if there are coags to be drawn, or if there are labs that need to be precise. I contacted the doctor in our interventional radiology department about lines that don't aspirate blood. He said that as long as it flushes and there is no swelling/pain at the site there is no problem with the line. I had a patient that had a single lumen picc, two continuous infusions (Nexium gtt and sandastatin--it was going in a peripheral IV). He had low H/Hs due to active bleeding from a esophageal varices. He was mad when I refused to stop his gtts to draw his labs, "all the other nurses do it". I don't care what all the other nurses do. I told him that if the doctor wrote an order stating that his infusions could be held to draw the labs then I would have no problem, of course the doc wouldn't.

:eek: This is so wrong! Lines that don't aspirate often have a fibrin sheath or flap at the end of them that prevents aspiration. This causes an incresed risk of line-related infection. These lines should have Cath-Flo used on them to get rid of the fibrin, not just left alone. That is evidence-based practice.

Re: other issues: It seems that some facilities have different P&P regarding lines and draws. At my facility, only an RN can draw from a central line, whether PICC or TLC. I routinely draw labs from all my lines. I'm ICU, and we even will draw from peripherals if we can, especially on pts who are on heparin requiring frequent draws. I routinely stop infusions to draw from lines, with the exception of pressors. I draw from lines that have heparin infusing if I need to; but I waste 20mL instead of 10. If I had a pt sick enough that iatrogenic anemia was a concern, they'd probably be sick enough to have an art line with a VAMP-type setup that lets you return the waste. Re: blood sugars, we routinely draw a drop from art lines to use for blood sugars, but yeah, you'd waste a LOT of blood drawing from a PICC for blood sugars!

To the OP: it seems like this phleb doesn't have the best approach and may need some guidance on getting pts to be drawn (or may be just plain lazy, not enough info), but I would have done the PICC draw. Why stick when you have a line? Better for the pt. And it's no problem to draw a bunch of tubes from a line at once. I've done 6-7 tubes, plus blood culture bottles, at once. I don't want this to come across as being mean (not my intention!), but you would benefit from becoming more familiar with PICC lines and your facility's policy on their use. I think you would be much more comfortable working with them.

:paw:

[casi, ASN, RN]

The reason someone in LTC would have a PICC is for long term infusions, not because they have cruddy veins. Why access a line more than you need to if they have good veins? Why risk the infection?

Before the OP goes drawing from a PICC line she needs to find out if facility policy lets her and she also needs to find out if she needs an order to draw from a PICC line. In my hospital setting you do need an order.

[classicdame, MSN, EdD]

in my state the access of any central line is restricted to RN's