Whyyyyy? Rant from a Lab Tech

[raianne]

Hi! I am not a nurse yet. I start an accelerated BSN program in August. I have been a lab tech for five years. I read urines and run the machines that do coags and blood gases and chemistry panels and all that fun stuff. After college, I lived with two roommates who were nurses, and before I became a lab tech, they would always come home from work and talk trash about the lab. It was helpful to me to be able to talk to them when I got this job, because I feel like there's a lot of miscommunication between the nurses and lab techs, and it's nice to talk to someone on the other side. Anyway, here's my rant of the night.

When we have a critical value on a patient, or a value that seems suspicious, we call the nurse. They have to accept the value before we enter it in the computer. Once they accept the value, give us their last name and we end the call, that value is getting entered in the computer and we are not allowed to take it out. I can not tell you how many times I've called a nurse, gave them the value, asked them if they accepted it, gotten their name, and entered the value in the computer only to get a call back in the next five minutes saying it was wrong and asking if we can take it out. We can't!!!! That's why we're calling in the first place!!!! Whyyyy does this happen?

Tonight I had a critical vanco trough on a patient. A lot of times, when that happens, the patient actually has vanco running when the trough is drawn, so I called the nurse to check. I told her the value and said that it was really high for a trough and asked if the patient had vanco running. She started freaking out about how nobody told her the patient had a trough drawn and asked when it was drawn. I said 2040. She said now she was going to have to call the doctor and she can't believe no one told her he had a trough done. I said, "so you're accepting it?" She said yes and gave me her last name. I hung up, entered the value, and five minutes later I get a call back. "Did you just call me about a vanco trough? What time was that drawn?" "2040" (I already told her that the first time.) "Oh, that patient has had vanco running since 2000. Can you take it out of the computer?" "No, I can't, I'm sorry." "Ok fine bye" (in a cranky voice.)

I know that she probably had fifty million things to do and this value was the least of her worries, but this happens so often that it just gets annoying. I needed to vent. Thanks for listening!

[cherrybreeze, ADN, RN]

i just want to know how you get the lab to come and draw your tests within a window that narrow!

vent accepted and noted. i've heard myself on the phone with the lab more than once saying something stupid like "so why are you calling me with this hemoglobin of 7.9? the last one was 6.5 and this is a definite improvement! you'd think the lab would take a look at the trends before calling a "panic level." but it's not their job to look at the trends. it's mine. and it's mine to notify the provider.

although in my previous job, i'm sure the coag lab had a dart board with various excuses taped to it: "tube wasn't full," "specimen clotted", "specimen not recieved", etc. that they would "consult" rather than running the test.

i dont' think it's necessarily that narrow of a window....that's just our protocol, i guess, that troughs are put in for 15 minutes before the med is scheduled. i am not sure how else you would schedule it (and i'm seriously asking that). would you schedule it for an hour before? for accuracy purposes, we try to get them as close to the next dose (and as far from the last dose) as we can. since obviously the lab has lots of places to be in all at once, that's why we try to touch base, to avoid the med being hung before the draw.

i know what you mean, too, ruby, about calling with a "critical" lab that's actually improved, but i think they just have values that are considered critical meaning a call, no matter what. that's their protocol. what we do with it, is our decision.

[klone, MSN, RN]

vent accepted and noted. i've heard myself on the phone with the lab more than once saying something stupid like "so why are you calling me with this hemoglobin of 7.9? the last one was 6.5 and this is a definite improvement! you'd think the lab would take a look at the trends before calling a "panic level." but it's not their job to look at the trends. it's mine. and it's mine to notify the provider.

yes, i always chuckle internally when the lab calls with a critical mag level of 7. they often sound a bit panicked. it's okay, really! that's a therapeutic level!

[Ruby Vee, BSN]

i dont' think it's necessarily that narrow of a window....that's just our protocol, i guess, that troughs are put in for 15 minutes before the med is scheduled. i am not sure how else you would schedule it (and i'm seriously asking that). would you schedule it for an hour before? for accuracy purposes, we try to get them as close to the next dose (and as far from the last dose) as we can. since obviously the lab has lots of places to be in all at once, that's why we try to touch base, to avoid the med being hung before the draw.

i know what you mean, too, ruby, about calling with a "critical" lab that's actually improved, but i think they just have values that are considered critical meaning a call, no matter what. that's their protocol. what we do with it, is our decision.

we order ours two hours before the dose is due, and then results are back about the time the dose is due -- plus or minus half an hour. the only thing we do immediately before the dose is fk-506.

[Coffee Nurse, BSN, RN]

although in my previous job, i'm sure the coag lab had a dart board with various excuses taped to it: "tube wasn't full," "specimen clotted", "specimen not recieved", etc. that they would "consult" rather than running the test.

one of my favorite lab conversations was when a coworker had to call about a gentamicin level she had sent down about two hours earlier, and the result was still not up in the computer. according to her, the lab tech told her "it was either not enough, or it was clotted...or --" and something here about "maybe the specimen evaporated."

seriously?

[fiveofpeep]

I dont have any issues with the lab...but dont get me started on the pharmacy. Pharmacists--love em, always answering my questions. Getting my antiseizure med six hours late after three med requests and three phone calls--dont love so much.

[Kooky Korky, BSN, RN]

The nurse should know not to start the dose when they do not knowing the trough level! If it is important enough to order the test, it is important enough to check the value. If it was not important it would not be done. The Lab person should not have to check to see that the nurse is doing their job correctly, as the vancomycin should not be infusing before the trough results are known.

As for the results being recorded all I can say is **** in, **** out. The lab can only report out the results on the specimen they were given, they cant make results up and they can't disregard a potentially critical value. The lab tech does not want to stop and call you the result and have you get upset with them, it is more work for them (most of the time they know you screwed up the collection, but without proof they can only report what they have, as you may given the wrong dose or double dosed the patient, or in this case already started the med) they don't have this information they are not on the floor with the patient.

The trough isn't drawn around each dose. Maybe the nurse missed it.

It seems ironic to me - it's expected that the nurse will catch doctors' errors, lab errors, and many errors from many other sources, but we can't hope for someone to have our back?

And I still think the lab tech should not go sticking someone without looking to see what's infusing and/or ask the nurse when the last dose was so they know they are getting a true trough level. What is so hard about that? Yes, it takes time. Everything takes time. Why not that? Just another safeguard for the patient to not have to get stuck unnecessarily.

[Jokerhill]

i just want to know how you get the lab to come and draw your tests within a window that narrow!

vent accepted and noted. i've heard myself on the phone with the lab more than once saying something stupid like "so why are you calling me with this hemoglobin of 7.9? the last one was 6.5 and this is a definite improvement! you'd think the lab would take a look at the trends before calling a "panic level." but it's not their job to look at the trends. it's mine. and it's mine to notify the provider.

when i did work in the lab, i looked at trends on every spec i could as it was just pushing the letter "f" and i could see the last five results very easy to do. but just like in nursing i had procedures to follow and i had to record a name on the result of who was notified. i wanted to know that what i reported out was correct before i put my name on it as well. i do realize some labs report out any result the get as it there is no report they don't get paid, but i hope that is the exception and not the rule.

although in my previous job, i'm sure the coag lab had a dart board with various excuses taped to it: "tube wasn't full," "specimen clotted", "specimen not recieved", etc. that they would "consult" rather than running the test.

now, the fact that nurses believe this is a bitter spot for me! do you think the lab is getting out of something by having to call a bad specimen report? i just means more work for them, they have spent 20-30 minutes trying to work on getting the specimen prepared for testing. then they have to spend 5-10 min. on the phone trying to find someone to take the report, then take another couple of min to put in the cancellation report. then you just send another specimen and they have to repeat the process all over. they could have reported out the first specimen a lot easier and not worry if the result was correct but they went the extra mile to get a good specimen, and did double the work. i don't care who you are you don't want to do double the work for fun, you do it because it is the right thing to do for the patient. so the lab never wants to cancel a test because you just order it again so the lab will get double the work. and the truth of it if a test gets canceled it is your fault 95% of the time and lab error 5% and human error 99% of the time.

the lab is not perfect but they try hard to be. jeff

[cherrybreeze, ADN, RN]

we order ours two hours before the dose is due, and then results are back about the time the dose is due -- plus or minus half an hour. the only thing we do immediately before the dose is fk-506.

how is a trough drawn 2 hours before the dose is due considered accurate? i am honestly curious, is all. any info i can find recommends drawing a trough right before a dose is due....i would think, especially if a person is getting vanco every 8 hours as opposed to daily, etc, that 2 hours before would not be a true trough. that would affect the ordered dose?

[BabyLady, BSN, RN]

Hi! I am not a nurse yet. I start an accelerated BSN program in August. I have been a lab tech for five years. I read urines and run the machines that do coags and blood gases and chemistry panels and all that fun stuff. After college, I lived with two roommates who were nurses, and before I became a lab tech, they would always come home from work and talk trash about the lab. It was helpful to me to be able to talk to them when I got this job, because I feel like there's a lot of miscommunication between the nurses and lab techs, and it's nice to talk to someone on the other side. Anyway, here's my rant of the night.

When we have a critical value on a patient, or a value that seems suspicious, we call the nurse. They have to accept the value before we enter it in the computer. Once they accept the value, give us their last name and we end the call, that value is getting entered in the computer and we are not allowed to take it out. I can not tell you how many times I've called a nurse, gave them the value, asked them if they accepted it, gotten their name, and entered the value in the computer only to get a call back in the next five minutes saying it was wrong and asking if we can take it out. We can't!!!! That's why we're calling in the first place!!!! Whyyyy does this happen?

Tonight I had a critical vanco trough on a patient. A lot of times, when that happens, the patient actually has vanco running when the trough is drawn, so I called the nurse to check. I told her the value and said that it was really high for a trough and asked if the patient had vanco running. She started freaking out about how nobody told her the patient had a trough drawn and asked when it was drawn. I said 2040. She said now she was going to have to call the doctor and she can't believe no one told her he had a trough done. I said, "so you're accepting it?" She said yes and gave me her last name. I hung up, entered the value, and five minutes later I get a call back. "Did you just call me about a vanco trough? What time was that drawn?" "2040" (I already told her that the first time.) "Oh, that patient has had vanco running since 2000. Can you take it out of the computer?" "No, I can't, I'm sorry." "Ok fine bye" (in a cranky voice.)

I know that she probably had fifty million things to do and this value was the least of her worries, but this happens so often that it just gets annoying. I needed to vent. Thanks for listening!

I was totally with you until that last paragraph.

Just because you get someone on the phone and report the value, doesn't mean that they are 'accepting' it...it just means that they were unlucky enough to answer the phone.

The problem we have with our lab is that they don't seem to factor common sense and have the "get'er done" attitude, regardless of what is going on.

What the nurse was trying to communicate with you is that the lab was probably incorrect and she was probably going to get an order to have the trough redrawn, unless protocol allows her to do it anyway...you run the labs, but if a nurse tells you that a particular value is virtually impossible, then it is wise to listen to that advise and consider that an error may have occurred...the lab isn't as perfect as they claim to be.

[Jokerhill]

I was totally with you until that last paragraph.

Just because you get someone on the phone and report the value, doesn't mean that they are 'accepting' it...it just means that they were unlucky enough to answer the phone.

The problem we have with our lab is that they don't seem to factor common sense and have the "get'er done" attitude, regardless of what is going on.

What the nurse was trying to communicate with you is that the lab was probably incorrect and she was probably going to get an order to have the trough redrawn, unless protocol allows her to do it anyway...you run the labs, but if a nurse tells you that a particular value is virtually impossible, then it is wise to listen to that advise and consider that an error may have occurred...the lab isn't as perfect as they claim to be.

The lab will never be perfect and they know when a result is not consistent with life like a PT result greater than 35 sec as most humans start to spontaneously bleed out at that point. Or a potassium level of 10 they are pretty sure it is contaminated but they can't prove it so it has to get reported, they have to trust at some point the person collecting the specimen knew what they were doing.

Now FYI, the phebomists drawing the blood are not lab techs they can have as little as a 60 hour class 12 blood draws and a high school education then they are on your floor.

Ultimately it can not be up to the lab scientist running the test to interpret the result they can only report out what values they get and it is up to the MD's to decide if this matches the clinical presentation of the patient, the scientist running the test has no access to that information. If you send a bad spec to the lab to start with, you will get a bad result in the end.The person running the test was not even the person drawing the sample from the patient and is totally removed from the bedside. The lab can only cancel a test when the sample can be proven to be unsuitable for testing such as a clotted CBC or a hemalyzed K level or a insufficient spec for a coagulation test as they can see these and prove them to be a fact they are very limited in this area, because what if the value was right and the patient was bleeding out they don't know this information. The scientist can not prove someone collected the spec with drug such as gent already running or from a line infusing TPN they can't see that in the lab. That is where they have to report out the value they received and rely on the medical staff to make that determination.

That said, Never Never should a patient be treated based on one lab value, the collection could be faulty, the lab could have mixed up the specimens or what ever. Always Always question any result that does not match the clinical presentation of the patient. There are Many Many ways the results could be contaminated the lab knows this and so should you. You have more information available to you than the scientist back in the lab does you have to use all of the information you have, and the test result is only a small part of any diagnostic care.

And if you are unlucky enough (I say responsible enough) to answer the phone and you have a license and then you repeat back the value you are accepting responsibility for that result right or wrong. The scientist in the back running the test already knows the result is incompatible with life or outside the realm of possibility (they spent as many or more years studying lab values as you spent in nursing school) they just cant prove the value wrong, all they can do at this point is report it to you. It is then up to you to do something with it if you know it was collected wrong repeat it or if you don't know what the problem was it is your responsibility to report it to the MD's. It is not meant that you accept the value as fact, it is you accept responsibility to do something about it.

[BabyLady, BSN, RN]

And if you are unlucky enough (I say responsible enough) to answer the phone and you have a license and then you repeat back the value you are accepting responsibility for that result right or wrong. The scientist in the back running the test already knows the result is incompatible with life or outside the realm of possibility (they spent as many or more years studying lab values as you spent in nursing school) they just cant prove the value wrong, all they can do at this point is report it to you. It is then up to you to do something with it if you know it was collected wrong repeat it or if you don't know what the problem was it is your responsibility to report it to the MD's. It is not meant that you accept the value as fact, it is you accept responsibility to do something about it.

This is where you are incorrect.

The lab at my hospital is required too talk to the nurse that is responsible for that patient, not anyone else. Just because you get a warm body on the phone with a nursing license and rattle off a lab value and get a name, doesn't mean that you did your job correctly.

All that does is send the message throughout your facility not to answer phone calls from the lab with your name.

[Ruby Vee, BSN]

how is a trough drawn 2 hours before the dose is due considered accurate? i am honestly curious, is all. any info i can find recommends drawing a trough right before a dose is due....i would think, especially if a person is getting vanco every 8 hours as opposed to daily, etc, that 2 hours before would not be a true trough. that would affect the ordered dose?

we give our vanco every 12 or 24 hours, and, if we've boxed the kidneys, maybe every 36 or 48 hours, based on the trough level. many times we'll do a trough every 12 hours until the level is low enough to repeat the dose.