Venipuncture: An Adjunct to Home Care Services for Older Adults

EDUCATIONAL OBJECTIVES: ARTICLE 2 TEST I.D. NO.: 0 6 6 5 8 8 CE CREDIT : 1

C O S T : $ 1 0

On completion of this article, the reader should be able to: 1. Describe three benefits of nurse-provided venipuncture in the home.

2. Identify four considerations for venipuncture.

3. Explain the issues in coordination and effective transport of blood specimens,

4. Identify two key points in patient/caregiver education in the safe disposal of needles and syringes.

NOTE: If you choose to take the quiz that follows this article, be sure to mark test spaces 11-20 on the answer sheet.

Venipuncture and meticulous specimen collection in the home ensure accurate laboratory data as the basis of home care.

B Y D I A N E M C K E N N A / S H E I L A A . N I L E S

A ccording to the Medical Expenditure Survey, home care has grown at the rate of 12% per year since 1991. This survey further identified that skilled

nursing is the most prevalent service offered by home care agencies. 1 Integrated within nursing services is the in- creasing need for skilled venipuncture and knowledge of specimen collection in the home. While hospitals and nurs- ing homes frequently enlist the services of phlebotomists for specimen collection, home care nurses are often re- quired to perform venipunctures in their daily and weekly visits to patients. This article describes one home care agency's procedures for venipuncture and specimen col-

DIANE McKENNA, BSN, RN, is the manager of managed care at the Visiting Nurse Association of Cleveland. SHEILA A. NILES, MSN, RN, C, is director of Community Projects and Elder Health at the Visiting Nurse Association of Cleveland and on the clinical faculty at the Frances Payne Bolton School of Nursing, Case Western Reserve University, in Cleveland. GERIATR NURS 1995;16;208-12. Copyright © 1995 by Mosby-Year Book, Inc. 0197-4572/95/$5.00 + 0 34/1/64359

lection, staff training, and the ongoing coordination re- quired to ensure accuracy in patient laboratory values and home care nurse competence.

Review of the Literature

Older adults are frequent consumers of health care, and more than half of home care recipients today are over 65 years of age. 2 As seen in Figure 1, multidiscipli- nary skilled home care services enable older adults to avoid extended hospitalization and hospital readmis- sions, and to remain at home, where they regain their health. Multiple medical problems, such as diabetes, hy- pertension, cancer, and cardiovascular and respiratory diseases, often necessitate the taking of interval blood serum levels to monitor the disease process and detect change. Al though the review and reporting of patient laboratory values has been a component of nursing prac- tice, there is relatively little information in the literature regarding nurse education and skills verification for venipuncture services in the home.

208 McKenna and Niles September/October 1995 GERIATRIC NURSING

FIGURE 1. Multidisciplinary home care enables elderly patients to avoid extended hospitalizations and readmissions.

Benefits

The ability of a nurse to collect physician-ordered blood specimens in the home provides an energy- conserving service for older adults. A single trip to an outpatient laboratory facility is often difficult and ex- hausting for elders who are essentially homebound as a result of limited mobility and physical endurance and a lack of transportation. Responses to diet, fluid intake, and medications are not often apparent to anyone but the nurse who visits the older adult in the home. Assessment of the patient's recovery and health status--including al- terations in diet, fluid intake, mental status, and the pre- scribed medication regimen--are observed during the home visit. Teaching and reinforcement strategies are im- plemented in conjunction with specimen collection. It is the nurse's assessment, monitoring, and evaluation that differentiates this task from routine specimen collection by a phlebotomist.

Staff Training

The Staff Development and Training Department of the Visiting Nurse Association (VNA) of Cleveland is re- sponsible for the orientation and inservice training of all registered nurses. Even though a few nurses may have phlebotomy skills before entering the home care service, all nurses undergo a baseline training and skills verifica- tion for venipuncture and specimen collections as part of a comprehensive 3-week orientation to home care. Venipuncture orientation includes guidelines regarding age-specific laboratory values, blood precautions, speci- men handling, sharps disposal, and multiple laboratory

"drop-off" sites. In addition, there is a self-study pro- gram that reviews venous anatomy, venipuncture proce- dures, and potential complications and appropriate responses. Box 1 identifies specific considerations with venipuncture. 3 A nurse must demonstrate a score of 80% or higher on the venipuncture written examination before entering the "hands-on" training class. The supervised venipuncture hands-on session provides the home care nurse the opportunity to develop or improve skills. A 4- hour experience is scheduled for the nurse to work with a phlebotomist in the laboratory outpatient department of

The nurse's assessment,

monitoring, and evaluation

differentiates this task from

routine specimen collection

by a phlebotomist.

a large medical center. This experience provides multiple opportunities for closely supervised venipunctures, with timely feedback on techniques. If needed, additional in- home phlebotomy experience is arranged on request. This is rare, however, as nurses have indicated a high level of confidence in their skills after the initial hands- on session. Nurses who have problems with venipunc- tures (for example, as a resu l t of an older adult 's dehydration or sclerosed veins) have the option of con-

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FIGURE 2. Typical home care kit.

sultation with the VNA's Infusion Therapy team. These nurses are certified IV specialists who manage challenging venipunctures.

Coordination

In 1994 the VNA of Cleveland provided 354,000 home visits to 12,000 patients in an eight-county area. Therefore it is essential that the nursing staff have current informa- tion on multiple laboratory drop-off sites and laboratory procedural changes. One of the major factors that has con- tributed to successful specimen collection and transport in this home care agency has been the ongoing communica- tion among hospitals and independent laboratories. Each laboratory has its own requisitions, hours of service, and guidelines. A VNA-designed handbook is carried by each nurse in the field as a quick reference to the most fre- quently needed information regarding specimen collection.

This information includes the following: procedures, addresses, and telephone numbers of multiple "drop-off" sites, guidelines for specific tests, and information on which color-topped blood tube to use for specific blood samples. Every attempt is made to deliver specimens soon after the venipuncture is drawn. This is an important fac- tor because research on collected blood glucose speci- mens, for example, indicates that glucose levels decline during the first hour after being drawn, and further decline after an additional 4 hours. 4 Nurses are assigned to pa- tients by geographic census tracts. Therefore each nurse has the opportunity to become familiar with the drop-off sites in his or her census tract area and establishes a rap- port with laboratory personnel. For convenience, the nurse has the option of delivering the specimen to the

BOX 1. VENIPUNCTURE: CONSIDERATIONS

1. Wash hands. Don gloves. Position patient comfortably in bed with arms resting at sides or upright in chair with arm supported on armrest or table.

Avoid drawing blood from extremity used for I.V. infusion. If you must collect blood near an I.V. site, choose a location below it.

Most common venipuncture sites are the antecubital fossa, wrist, and dorsum of the hand. Apply tourniquet. Have patient make a fist several times to enlarge the vein. May use warm, moist compresses for vein distention. Apply compress for 15 minutes before venipuncture.

Release tourniquet as soon as blood begins to f low into vacutainer tube.

Label tube with patient's name, physician's name, date, and time drawn. Label specimen slip with the patient's name, the physician's name, address, and phone number, the name of person drawing the specimen, and the diagnostic analysis requested.

Check type of sample to collect and appropriate color-coded tube.

General order of sample collections:

° First draw-tubes with no additives

• Second draw-coagulat ion tubes

• Third draw- tubes with other additives

Vacutainer cannot be used to collect specimens for blood culture. Sterile needles/syringe method must be used.

Source: Visiting Nurse Associations of America, The Nursing Procedure Manua/, 1993. By permission.

2.

3.

4.

5.

6.

7.

8.

VNA Headquarters or one of its branch offices. An identi- fied area at these offices contains supplies, requisitions, laboratory directories, a centrifuge, and a refrigerator for designated specimens. Laboratory couriers make prescheduled pick-ups to these offices during the day.

Supplies

Each nurse carries a supply of equipment that may be needed to obtain ordered specimens. These supplies in- clude vacutainers, needles, butterfly IV sets, and various collection tubes. As seen in Figure 2, a zippered insulated bag is issued to each nurse for transporting filled specimen tubes to the laboratory. There are several types available in medical supply houses.

The bags should be soft sided, with a rigid inner container and a hot/cold gel pack. This allows the specimen to be kept cool during transport despite changing seasons and variable weather conditions. The procedure is further defined:

• Filled tubes are sealed in double-sided clear plastic zippered bags before being placed in the rigid contain- ers for transport in the zippered bag.

• Computerized patient labels are used, with the nurse adding his of her initials, the date, and the time of the specimen draw.

• Requisitions are then placed in the front pocket of the

210 McKenna and Niles September/October 1995 GERIATRIC NURSING

BOX 2. VENIPUNCTURE: AFTERCARE

1. Separate needle and tube holder. Dispose of needle in puncture-proof container. Discard used equipment in impervious bag. Remove gloves; discard. Close bag securely.

2. Wash vacutainer in soap and water, then wash in 1:10 bleach:water solution. If possible, leave vacutainer in patient's home. Use new vacutainer for each patient.

3. Wash hands.

4. Transport labeled sample to the laboratory or office as soon as possible. If delayed more than 1 hour, specimen must be refrigerated.

5. Document in patient's record:

a. Specimens drawn.

b. Venipuncture site. c. Laboratory where specimens have been sent.

d. Patient's tolerance to procedure. source: Visiting Nurse Associations of America, The Nursing Procedure Manual, 1993. By permission.

zippered bag, thereby avoiding direct handling once the specimen is obtained.

• Bright red "Biohazard" labels are used as a safety precaution and to Comply with the Centers for Disease Control and Prevention guidelines on Universal Blood and Body Fluid Precautions. 5

Box 2 describes specific steps in venipuncture after- care. The majority of patients are instructed on the use of coffee cans or other puncture-proof containers for needle disposal. Standard needle disposal containers are also available to the nurse and may be left in the patient's home. Nurses do not transport used needles or containers in their cars. Patients are instructed in proper disposal of medical waste according to local guidelines, and they are given a printed handout published by the Environmental Protection Agency. 6 Ongoing teaching and reinforcement of sharps disposal are done during the initial visit and as often as indicated. Box 3 identifies key points in educa- tion. Computerized laboratory reports are sent directly to the physician and to the VNA nurse. These reports are re- viewed by the nurse, with physician follow-up as indi- cated, and then placed in the patient's record.

BOX 3. VENIPUNCTURE: DISPOSAL OF NEEDLES AND SYRINGES

1. Instruct patient and caregiver to use a puncture-resistant container, such as coffee can or empty paint can with a lid. (A plastic bottle is not puncture resistant.)

2. Instruct patient and caregiver that needles and syringes should not be clipped, bent, or recapped, but disposed intact into this container.

3. Instruct patient and caregiver that before disposal of the container containing used needles and syringes to secure the lid to the container (by taping down). Then the container may be disposed of into the household trash. (Tape cannot be used in place of a lid.)

Source: Visiting Nurse Associations of America, The Nursing Procedure Manual, 1993. By permission.

Summary

Attention to policy and procedure development spe- cific to home care, and strong communication and col- laboration with laboratory personnel at multiple sites have been essential in supporting venipuncture services within a home care agency. Orientation, inservice train- ing, skills verification, updated supplies, and the concise information kept in each nurse's field handbook have supported comprehensive quality services to an older, frail, homebound population. In addition, our quality evaluations from physicians, patients, caregivers, and laboratories indicate a greater than satisfactory level of performance and quality care for this skilled service. •

REFERENCES

I. Altman B, Walden D. Home health care: use, expenditures, and sources of pay- ment (ACHPR Pub. No.93-0040). National Medical Expenditure Survey Research Findings, 15. Rockvine, Maryland: Public Health Service, 1993.

2. National Association of Home Care. Basic statistics about home care, 1993. Washington: National Association of Home Care, 1993.

3. Visiting Nurse Associations of America. The nursing procedure manual. Denver: Visiting Nurse Associations of America, 1993.

4. Bannon R. The effects of improper handling of lab tests. Med Lab Observ 1988;20(10):42-7.

5. Update: universal precautions for prevention of transmission of human immun- odeficiency virus, hepatitis B virus, and other blood-borne pathogens in health care setting. MMWR Morb Mortal Wkly Rep 1988;37(24):377-82, 387-8.

6. US Environmental Protection Agency. Disposal tips for home health care (EPA530-F-93-027B). Washington: US Environmental Protection Agency, 1993.

TARGET AUDIENCE This article is intended for registered nurses working in home care.

CE QUESTIONS Select the single best answer. Be sure to m a r k spaces 11-20 on the answer sheet.

11. Components of staff education and in-service for venipuncture includes:

A. Age-specific laboratory values B. Hands-on training C. Specimen handling and sharps disposal D. All of the above

12. Procedures for multiple specimen drop-off sites require:

A. On-going communication with each site B. Updating of the field handbook on a regular basis C. A and B D. None of the above

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