Phlebotomy refusing to draw

[Lame]

Last night I received an admit on heparin & amio drips. He had an IV on the right hand & AC. Blood draws couldn't be done on the left because he had a fistula. When the phlebotomist came to draw blood, she informed me that she couldn't draw his blood above his IV even tho I had stopped both infusions for the last 5-10 min. She could try his fingers because they were below the IV but of course the pt refused. She told me it was now a standard of practice that none of the phlebotomists could draw above an IV even if it was saline locked, but didn't know why. Other phlebotomists informed me that it's always been a standard but recently someone actually got fired for drawing above an IV.

I was lucky to be able to use the heparin line. Discarding about 20 cc of blood gave me what seemed to be an accurate PTT.

Has anyone heard of this before? Couldn't find the policy & none of my colleagues knew the reasoning why. I emailed my manager to ask as well. It's just scary especially when the pt is on these life saving drips.

[Julius Seizure]

Here's an interesting article on the subject of PICCS and puts with CKD.

http://therenalnetwork.org/qi/resources/HospitalSystemChangeConcept_Tools/GuidelinesForPICCAvoidanceInChronicKidneyDisease-TipSheet.pdf

You learn something new every day! Thanks for the info!

[NotYourMamasRN]

I once had a patient with one ischemic arm, one arm with a fistula, no legs, and a hard EJ stick. I had the primary care physician who sent him as a direct admit riding ME on the phone for lab draws and getting an IV started. It was the weekend and we had no resources for anything in the hospital. One ER doc came up and tried EJ several times. Everyone was too "busy" to try a central line. The charge told me to just deal with it. That was the most aggravating day of my life.

[iluvivt, BSN, RN]

You need to avoid placing PICCs in HD patients as CKD ( stage 3=5 patients) need to have their veins preserved per the K/DOQI guiddlines.That does not mean that these patients cannot have a PICC but a risk vs benefit analysis needs to take place.If I have an 85 yr old HD patient that is unlikey to survive then we will most likely be placing that PICC.There are also guidelines on where to place PIVs in this group.Often the best place in this group for long term access and the recommendation is to use the IJ and preferablypreferably with a tunneled catheter.

[Apple-Core, ASN, BSN, RN]

One potential rationale is that, if the phlebotomist draws from the same vein or an immediate collateral vein distal to an infusing IV, and that vein is damaged in the process, there's potential for whatever is infusing through the line to extravasate, potentially causing tissue damage and, depending on the location of the IV within the extremity, rendering essentially the entire extremity compromised. This would be an even greater concern if a distal IV is infusing amiodarone, which is a known vaso-irritant and vesicant.

Could you head over to the thread about "How much do YOU think nurses are worth? and post this to the people who consider nurses "just another set of eyes" and "glorified waitresses"?

[verdeacres]

Renal access fistulas and grafts are very susceptible to clotting off. The patient is taught to listen for the bruit everyday. A lot of the patient wear a bracelet on their access arm in case they are hospitalized or in a squad so that the arm is not used for an iv or blood draw. If the bruit is not heard by staff or patient, if they can be seen by a special procedures lab at a hospital, they might be able to get it opened up again. Good luck in your first year!

[Double-Helix, BSN, RN]

Could you head over to the thread about "How much do YOU think nurses are worth? and post this to the people who consider nurses "just another set of eyes" and "glorified waitresses"?

I would, but I also subscribe to the belief that, "You can't fix stupid."

[Asystole RN]

Out of curiosity, was the patient CKD? I quickly scanned the thread but did not see a confirmation on it.

Not all patients with a fistula or graft have them placed solely for dialysis. I have had several patients that had one placed for frequent infusions or blood draws like therapeutic phlebotomy.

IJs are quick and easy to place with ultrasound guidance, sounds like a good candidate.

[Asystole RN]

This is a patient with a fistula, which leads me to believe that he is chronically ill and also by default already has limited IV access because we are down to just one arm. Also, amiodarone can cause phlebitis. It would seem to me that he would somebody who should be considered for a PICC simply based on the fact that we don't want to ruin whatever good vessels that he has left. I don't know much about hemodialysis fistulas, but cant they stop working? Might he need one in the other arm then?

I realize that a PICC line carries an infection risk....but sometimes IVs can't just be moved if there's no where left to move them. I'm surprised they weren't more open to the idea.

A sad reality is that PICCs and other central lines are looked down upon because of the whole CLABSI issue. In reality all vascular access devices including peripheral IVs carry the risk for CRBSI...just that PICCs and other central lines are reportable so they tend to be reserved.

Makes me angry thinking that less than optimal care is being provided to patients because hospitals have to actively dodge fines, sometimes for things entirely out of their control.

[KatieMI, BSN, MSN, RN]

A sad reality is that PICCs and other central lines are looked down upon because of the whole CLABSI issue. In reality all vascular access devices including peripheral IVs carry the risk for CRBSI...just that PICCs and other central lines are reportable so they tend to be reserved.

Makes me angry thinking that less than optimal care is being provided to patients because hospitals have to actively dodge fines, sometimes for things entirely out of their control.

It is CLABSI as well as pretty much hunting for space within one single human being. I often take care of patients who have to have:

1) access for HD (if it is extremity fistula, it effectively bumps the hand or leg out of consideration;

2) other extremity "reserved" by HD because # 1) can thrombose at any moment;

3) central access kept solely for chemo/TPN (not always active, but "reserved" anyway, with exressive order "not to use for anything but "that");

4) something small suitable for drips/abx/lytes/etc.,;

and,

5) high-power line like large caliber PICC suitable for contrast/blood/boluses/monitoring needs, also "reserved" by specialty. Permission to draw blood from it needs an order.

Counting that, basically, there are just so many magistral veins in a human being, one runs out of blood draw places pretty quickly. Especially if combined with some more or less idiotic evidence non-supported schmolicy, according to which after a mastectomy done 30 years ago it is OK to push high power line in ipsilateral upper hand but not ok to draw blood from superficial vein there.

Sometimes, I spend three or four hours a day just negotiating between specialty services so that chest port can be used for blood draws

[Apple-Core, ASN, BSN, RN]

I would, but I also subscribe to the belief that, "You can't fix stupid."

I may have to do it on your behalf then!!