Phlebotomy. A Profession in Transition/

FEATURE Terri Yablonsky, MA Phlebotomy A Profession in Transition/ o n today's hospital ward, phlebotomists perform tasks never imagined five years ago including electrocardiograms (EKGs), respiratory care, and point-of-care tests. Once employees who drew blood exclusively, phlebotomists are on the fast track to an expanded scope of responsibility, a trend that may gain momentum as we enter the new millennium. In the midst of financial pressures stemming from managed care and the desire to reduce the number of workers a patient encounters during a hospital stay, many health care institutions are reconfiguring patient care staffs and blending functions. Often phlebotomists cross-train to perform tasks traditionally assigned to nursing assistants, respiratory therapy technicians, and EKG technicians while continuing to draw blood on a limited basis. In some institutions, the function of phlebotomy is entirely redeployed to nursing or respiratory therapy departments. The impact of these changes is resonating throughout the health care workforce. Some workers and managers embrace the idea of cross-training it's an opportunity to learn new skills, spend more time with patients, and make more money. Others are frustrated as they watch employees in other disciplines take over what they view as their professional domain. Fears are that errors and unacceptable specimens will increase. Employers struggle with ways to best cross-train phlebotomists and other professionals. The examples that follow illustrate how some institutions have redeployed the function of phlebotomy sometimes with success, often with resistance. The stories share a common theme: the need for ongoing training and monitoring of results. Pholo by Gus Salma Many health care institutions are redeploying phlebotomy and redefining the role of the phlebotomist. How is it working? May LABORATORY MEDICINE VOLUME 27, NUMBER 10 OCTOBER 1996 6 6 6

and respiratory care entered a voluntary eight-week training program to learn to draw blood, interpret heart rhythms, and carry out lowerlevel respiratory care procedures such as pulse oximetry, and aerosol and oxygen therapies. After participants demonstrated competency, they began performing their new tasks in the patient care units. Individuals from two home departments were assigned to work in each unit. Though the program seemed to work well in the beginning, things became a little rocky during the next few months, according to Dohnal. A Matter of Preference "We found that if you weren't already a phlebotomist, you didn't want to become involved in the program," Dohnal says. Respiratory therapists in particular tended to resist crosstraining because they didn't like to draw blood. The EKG technicians were more successful at cross-training, but they still weren't fond of drawing blood. Phlebotomists by far Phlebotomists and other health care workers cross-train to perform myriad functions. Opposite page: Anabel Galvan of St Luke's Episcopal Hospital in Houston places telemetry pads on a patient to measure his heart rate and heart rhythm. This page, top: Lou Henry monitors a patient's breathing at Evanston Hospital, Evanston, III; bottom: Selma Sanders prepares to draw blood from a patient at St Luke's Episcopal Hospital. Success Depends on the Functions You Mix Evanston Hospital If you can draw blood, chances are you can be trained to perform other patient care functions as well, according to James Dohnal, PhD, assistant director of biochemistry at Evanston Hospital in Evanston, 111. Evanston Hospital launched its patient care technician (PCT) program in April 1994. The institution's goals were to improve patient care by reducing the number of employees who visited a patient and to reduce costs through more efficient use of staff. Employees from the "home" departments of phlebotomy, cardiac graphics, OCTOBER 1996 VOLUME 27, NUMBER 10 LABORATORY MEDICINE e c 0 I (A

were happiest with the change: as PCTs, they found themselves integrated into the patient care unit, paid more, and better received by patients, Dohnal says. "We had very little trouble teaching phlebotomists to perform other functions, but had a great deal of difficulty teaching respiratory therapists to draw blood," Dohnal says. While capable of drawing blood, respiratory therapists never developed a positive attitude toward the task, he says. Knowing When To Shift Gears As the program progressed, salary levels for PCTs began to rise industrywide. Administrators soon realized that salaries for PCTs and entry-level respiratory therapists were about the same. Respiratory care supervisors and hospital administrators determined it was no longer worthwhile to employ PCTs with limited training in respiratory care in light of the small salary savings. It was time to make a change. Early in 1996, administrators decided not to hire or train any new PCTs and decided that respiratory care staff would perform all inpatient phlebotomy. "Given the attitude that we have seen by many respiratory therapists toward performing phlebotomy, we're uncertain as to how well this will work out," Dohnal says. Phlebotomists continue to work as PCTs on units that do not require respiratory care. "The multifunction employee will be a part of the future of health care, but success depends on what functions you mix," Dohnal says. "If you have a group of functions that employees will buy into, the group is much more flexible and useful from the patient care viewpoint. If you view cross-training as a way to save money, your program will have a lot of trouble." Monitoring Is Key St Luke's Episcopal Hospital Before it got wind of any staffing crunch, St Luke's Episcopal Hospital in Houston decided to redeploy phlebotomy to the nursing staff. The year was 1992, and most of the financial pressures now common in health care organizations were just beginning. About one quarter of the hospital's 40 phlebotomists volunteered to train as patient care associates (PCAs) to work in teams on the units. Others resigned or chose to process specimens in one of two outpatient clinics. Patient care associates draw blood; perform bedside tests such as blood glucose, fecal occult blood, dipstick, and activated clotting time; and perform EKGs and basic nursing care assistant and respiratory care tasks. Each department trained PCAs in its respective discipline cardiology staff in EKG procedures, nursing care assistants in basic home health care functions, respiratory care technicians in respiratory care procedures, and physical therapists in ambulation of patients. The Future of j After the dust of change has settled, what lies ahead for phlebotomy? Laboratory Medicine asked managers, educators, and other professionals their views on what changes the profession of phlebotomy may undergo in the future. Kathleen Becan-McBride, EdD, MT(ASCP The University of Texas Houston Health Science Center, Houston As virtual reality is perfected for realworld applications, new, noninvasive techniques to measure analytes in a patient's body w i l l follow quickly. With the advent of wands to scan the body for the heat of chemical interactions of enzymes, skin biosensors to detect genetic defects, and ion-selective electrodes for saliva analytes, health care providers will spend less time collecting blood microsamples for laboratory analysis. Versatility w i l l become a major factor in the success of all health care providers. Each provider will be required to interact and work effectively with other team members to achieve patientcentered care. To achieve cost-effective patient care, the patient care technician, clinical assistant, nurse, medical assistant, or physician w i l l perform the noninvasive analysis, collect the blood microsamples, or both. Two medical technologists will oversee an automated regional reference laboratory serving 25 hospitals. These individuals will not have time to collect patient samples, but instead will troubleshoot preanalytic problems with sample collection. Due to the proliferation of interdisciplinary health care teams and the decreased need for blood collection, the position of phlebotomist w i l l become obsolete. Venipuncture no longer will be necessary, because picoliters of whole blood will be used in laboratory testing. The Occupational Safety and Health Administration will require the use of the completely closed skinpuncture technique to avoid exposure to the highly infectious antibiotic-resistant diseases that w i l l be so prevalent. The ASCP Board of Registry (BOR) will consider three new categories of certification examinations for multiskilled technicians that encompass blood collection, patient care skills, and laboratory testing. Certification solely covering phlebotomy will be phased out. The BOR will become the nation's first certification agency to offer these and its other examinations through "real-time" clinical simulations. All multiskilled certification examinations w i l l include a section on closed skin-puncture phlebotomy. The BOR will consider an examination category based on the newer, noninvasive techniques. The cliche "change is constant" w i l l be as appropriate for health care providers of the future as it has been in the past LABORATORY MEDICINE VOLUME 27. NUMBER 10 OCTOBE

Phlebotomy The laboratory trained nurses to draw blood. Twelve or more hours of lectures were followed by hands-on experience in which nurses were to successfully draw at least 20 samples from each other or from patients, with supervision. About one year later, nursing staff assumed responsibility for phlebotomy training. Feedback Is Essential Dennis J. Ernst, MT(ASCP) Ernst & Associates Healthcare Consultants, New Salisbury, Ind It's the year 2010. Phlebotomy no longer is a profession unto itself. Venipunctures are performed by a team of patient care technicians (PCTs) who also start intravenous infusions and conduct other technical procedures. The patient who in the past encountered the phlebotomist, respiratory therapy technician, electrocardiogram technician, nursing assistant, and physical therapy technician, now sees only the PCT, a trend that began in the 1990s. The health care team seems less fragmented and has become more of an integrated unit working toward one objective. Patients in rural communities are able to go to the local hospital instead of being routed to the nearest metropolitan conglomerate. Responsible management decisions have kept the local hospital financially secure. The patient finds comfort in being healed in his or her community, and the community enjoys knowing that immediate and convenient care remains available to its citizens. The patient enjoys wellness clinics, free screenings, and the latest affordable technology, because the community hospital has implemented efficient staffing strategies. Just as phlebotomists of the 1990s were forced to change, so too were the organizations that certified them. Ten years into the new millennium, most states require certification for PCTs. In response, organizations that once certified phlebotomists now certify PCTs. The size of the institution now determines who performs outpatient phlebotomy. Some laboratory managers have returned this responsibility to bench technologists, whose jobs are simplified greatly by technologic advances and the growth of reference laboratories. Some laboratory managers retain a phlebotomist who also orchestrates specimen transport from the nursing units to the laboratory; others delegate outpatient venipunctures to a phlebotomy coordinator who monitors specimen integrity, specimen transport, training and education, inventory control, and outpatient collection. The transition of phlebotomy from a laboratory-based function to a nursing-based function has impacted the jobs and health care of millions. Technologists and phlebotomists who remain flexible in the changing face of health care management emerge as facilitators of this historic transition. Minimizing the negative impact this change has on patients and laboratorians demands creative and sensitive strategies. We need to maximize the benefits that effective use of staff brings not only to hospitals, phlebotomists, and technologists, but to the patient whose ongoing needs for affordable quality care brought us together in the first place. The laboratory monitors quality assurance and tracks problems through a computerized system, according to Linda Wesley, MA, MT(ASCP), administrative director of pathology and chair of the TeamCare patient focused care project at St Luke's. Nurses receive feedback through comments entered into the computer regarding difficult blood draws, redraws, specimen acceptability, mislabeling, and patient satisfaction. "We track by patient care unit, and we target units with the greatest opportunity for improvement," Wesley says. The laboratory plans to track performance quarterly as well as to conduct follow-up training to ensure proficiency. For example, from January through March 1996, the laboratory staff noticed a dip in patient satisfaction in the blood skill area and realized they had to focus on training. The laboratory has a cooperative relationship with nursing. "We're sending a phlebotomist to work with registered nurses and PCAs in the early morning to train them in performing difficult blood draws," Wesley says. I It took nearly six months for nurses to become proficient in drawing blood, according to Suzy Fella, MT(ASCP), manager of hematology and the central dispatch area at St Luke's. Nurses initially resisted drawing blood and some still do. According to Fella, "Most accept the challenge and understand it's just another facet of their profession." The laboratory continues to provide backup. Nurses can respond quickly to patient needs. Some errors have occurred, mostly in mislabeling specimens, Fella says. Most originate from the use of barcode labels to identify patients. Nurses labeled tubes at the nursing station, rather than in a patient's room, creating the chance for error. Today, fewer than 1% of samples must be recollected, Fella says. Phlebotomists had difficulty with the transition as well. "They felt as if their profession was completely eliminated or would be," Wesley says. Direct patient care was traumatic for phlebotomists, because they had never performed these tasks before, she says. "They felt they had lost their phlebotomy skills because they were performing general tasks." Administration is considering establishing a pool of experts composed of nurses and laboratory staff for around-the-clock assistance. VOLUME 27, NUMBER 10 e o (0 Change Takes Time BER 1996 LABORATORY MEDICINE 669

One Phlebotomist's Story Mark Vines is one phlebotomist who had an exceptional experience in cross-training. Trained as a phlebotomist in 1991 through the medical assistant program at the Texas School of Business, Vines cross-trained at St Luke's two years later. "I felt that cross-training would improve my skills greatly because it's so task-oriented," Vines says. The program provided an overview of patient care functions, including how to perform EKGs, interpret heart rhythms, insert catheters, change sterile and nonsterile dressings, take vital signs, and perform secretarial tasks. Training lasted six months and is ongoing. "The nurses enjoy having me because I can serve as a reference in drawing blood," he says. Vines provides in-services on difficult blood draws and use of correct procedures. "Even now, people remember my roots as a phlebotomist, and if there is a difficult patient or blood draw, I'm there." Before, the only way to get help on the unit was by calling the main laboratory. Vines' background prepared him to monitor the quality of phlebotomy performed by nurses. For example, he checks after sticks for hematomas and collects feedback from patients about their experiences. As a result, the quality of venipunctures has improved greatly, he says. Perhaps the greatest advantage of having one person perform many different patient care tasks is the effect on the patient. "The patient responds better to a primary caregiver coming in to draw blood as opposed to several individual strange faces throughout the day," Vines says. "There's a trust and bond that grows between patient and caregiver with continuity of care, so we work with the same patient throughout his or her stay." Today, Vines is a nursing student at North Harris County Community College in Houston. What Worked, What Didn't Experience may be the best teacher. If she were to implement the project again, Wesley says, she would have planned for more support during the transition. Wesley says increased patient satisfaction coupled with a reduction in costs has made the project worthwhile. Incident reports (most of which concerned getting the phlebotomist to the patient care unit) have decreased substantially, because staff on the unit are drawing blood when they receive the order. The institution began with 38 full-time-equivalent employees in phlebotomy and now has only a few. "We all know that the people who do a job again and again are the best," Wesley says, "but this must be weighed against the fact that patient-focused care reduces the number of people entering patients' rooms, thus improving patient satisfaction." In addition, she says, the inefficiency and downtime of phlebotomists waiting for orders affects the overall cost of laboratory operations. Phlebotomy will continue to be an important skill as the institution expands its services into outpatient business, Wesley says. It may be the end of phlebotomists in The Future of Phlebotomy (continued) Mary Ellen Corfeas, PBT(ASCP) Manager of Laboratory Support Services Children's Hospital, Boston Certainly, phlebotomists and phlebotomy departments are undergoing as many changes as health care in general is undergoing. Despite these changes, the role of the phlebotomist as we know it w i l l endure, with the addition of some tasks and responsibilities to meet the demands of the future. Because phlebotomy generally does not require completion of a degree program nor is it subject to licensing regulation, the phlebotomist appears to be a natural candidate for the role of the multiskilled clinical assistant. This person w i l l perform patient care tasks such as phlebotomy, electrocardiograms, and activities of daily living (dressing and bathing). Phlebotomists will find roles in outpatient settings and reference laboratories. Staff whose primary function is to draw blood will serve as a resource in areas where phlebotomy is practiced to a lesser degree. Specialty areas w i l l remain, such as pediatrics and geriatrics, where expert phlebotomists are essential. Phlebotomists w i l l be ideal candidates for performing point of care testing, because they have experience in the principles of quality control, specimen collection, and testing. Key to the success of phlebotomy in any setting is open and continuous communication between the laboratory and patient care providers. At Children's Hospital in Boston, the nursing department considered redeploying phlebotomy from the laboratory to its clinical assistant program. The laboratory helped develop the plan to incorporate phlebotomy skills into the clinical assistant role. The nursing department reviewed the logistics and potential consequences of this change and opted to leave phlebotomy under the supervision of the laboratory. Nursing administrators feared the dilution of the phlebotomy expertise would result in increased errors and the need for additional specimens from our younger patient population. Open and cooperative communication between laboratories and direct caregivers w i l l help us find new ways to provide services to patients and to maintain the quality that experienced phlebotomists provide. LABORATORY MEDICINE VOLUME 27, NUMBER 10 OCTO Anne C. Mason, MS, MT(ASCP)SM Clinical Instructor of Microbiology, Laboratory Education, St Vincent Hospital Laboratory Services, Indianapolis In the new millennium, the muititalented health care professional w i l l be in great demand. Due to hospital downsizing, mergers, and the ever-present health care reform, hospitals w i l l ask fewer people. to perform more tasks and to take on

more roles. The physician who wants to provide as much patu care in the office as possible will hire nurses and medical assistants who have multiple skills, including phlebotomy. Phlebotomy by itself no longer will be a career. Skill in drawing blood will be considered an enhancement for those in other health professions pharmacy technicians, respiratory technicians, and medical laboratory technologists. My role as an instructor is to provide quality training to these individuals so they correctly and skillfully perform the tasks asked of them. A new program of study may be developed, complete with a specific certification, for this newly emerging career as a health care technician. Skills taught will include phlebotomy, general nursing, pharmacy, and certain respiratory, laboratory, and electrocardiogram procedures. This formal training program will ensure that a standard of knowledge and skill level has been achieved and maintained.._ ajj/* " v *" a. 0-' -* '. ^ I Keith Nelson, MBA, MT(ASCP)PBT Via Christi Regional Medical CenterSt Joseph Campus, Wichita, Kan I As the laboratory's primary ambassador I to the public, the phlebotomist has ^ k ^*%. fl l always played an important role in cus^ ^ tomer service. Excellent interpersonal and technical skills are key characteristics of the competent phlebotomist. In the future, economic constraints and ^ " technologic advances will result in new opportunities for this individual. The phlebotomist w i l l be a multiskilled phlebotomy technician. This person w i l l be involved in point-of-care (POC) testing because relaxed CLIA '88 regulations will encourage nontechnologist testing. Managed care also will encourage use of POC testing as more timely access to laboratory information becomes necessary to reduce lengths of stay. As laboratories move into niche markets, the phlebotomy technician will find opportunities to increase test volume. Urine drug screen collections, breath alcohol analyses, and nursing home collections will be a few examples of outreach. Phlebotomy technicians w i l l work at health fairs collecting and processing specimens; taking patient histories, blood pressures, and weights; and performing POC tests. As health care institutions strive to create cross-functional, multitask work units, new dynamics will emerge that demand a core team based on nursing units. These teams will be involved in phlebotomy; POC testing; and radiology, occupational therapy/physical therapy, and pulmonary services. The properly trained phlebotomy technician will be an essential member of this team. There is a strong need for an adequate number of phlebotomy technician programs that prepare the phlebotomist to meet these increased demands. Laboratory managers will find a win-win situation as institutional or internal phlebotomy programs are developed to meet the challenges of the future. the inpatient setting, she says, but some will always be needed in the laboratory. "It's a real skill to be able to draw blood," Wesley says. "We have to find our niche for the future." Training Is Key Central DuPage Hospital It's taken two years, but patient care services now oversees phlebotomy at Central DuPage Hospital in Winfield, 111. In May 1994, the hospital implemented a patient care technician (PCT) program to reduce the number of workers a patient encounters and to improve operations. The PCT is a member of the patient care team or the nursing team. The PCT draws blood and performs basic certified nursing assistant (CNA), lower-level respiratory care, and some EKG procedures. In the first year, the hospital trained 150 people. All were high school graduates. Some had CNA experience, some were phlebotomists, and others had college degrees and were seeking to change careers. Phlebotomists who chose not to cross-train became support technicians for the laboratory, were laid off, or resigned. "We did a lot of work developing the training program," says Sally Moser, MT(ASCP), coordinator of decentralized laboratory services at Central DuPage Hospital. The laboratory interacts closely with the nursing department and provides training in drawing blood, which consists of one-and-a-half weeks of lectures followed by clinical training in the nursing unit. Students must complete 50 successful blood draws in the presence of a preceptor (someone who has completed training, has experience, and has been observed by a teacher). To complete the program, the student must be deemed by the preceptor to be competent in phlebotomy. Keeping a Watchful Eye Management is spending a great deal of time collecting information about the program. "We collect data about acceptability of specimens; timeliness of transport; completeness of labeling, ordering, and collections; and misidentified specimens," Moser says. The decentralized laboratory services committee reviews all data. This multidisciplinary committee is composed of a patient care director, patient care manager, a registered nurse, a representative from the laboratory, Moser, two PCTs, and one administrative associate. The group meets every other week to review the data collected, suggest ways to improve services, and request that noncomplying units submit remedial action plans. Errors have decreased, such as partially filled tubes for coagulation testing and incomplete labels on sample tubes, Moser says. Some problems were operational, involving transmission of specimen collection data and the use of a bar-code system for patient identification. Overall quality of specimens has improved. Most of all, skill of personnel has improved. There are fewer requests for assistance, and early morning specimens are received BER 1996 VOLUME 27. NUMBER 10 LABORATORY MEDICINE 871

Phlebotomists' Roles Are Increasing... Do Your Phlebotomists Have the Credentials? In these times of health care reform and downsizing, the role of the phlebotomist is changing. That's why it's even more important than ever that the phlebotomists in your laboratory distinguish themselves as experts- by receiving their BOR Phlebotomy Technician certification, PBT(ASCP). The phlebotomy examination, like all BOR exams, is offered by computerized testing, which provides a variety of advantages including: convenience you schedule your testing time to fit your own schedule; the test is offered throughout the year. time-savings computerized testing requires less time than a standard paper and pencil exam. ease you don't need computer knowledge to take the test. The instructions are easy to follow and you can even change and check your answers at the end of the test. quick results you'll receive your results in just 10 working days. For more information or for an exam application, simply call the Board of Registry at: 1-800-621-4142, press 1 then x440 (In IL, 312-738-1336) in the laboratory on time. There is still a need for continuing education and attention to detail, Moser says. Early on the turnover rate for PCTs was approximately 14%; it has increased to nearly 20%. Some PCTs find jobs in physician's offices, and others enter nursing training. Exit surveys of patients revealed an initial decrease in patient satisfaction, which has returned to levels consistent with when the project started, according to Moser. The Parkside survey, a national standardized survey of hospitals, however, reveals overall increased patient satisfaction. "The phlebotomist who chooses to work as a PCT likes that role, because he or she is a people person," Moser says. Many are now receivers in the laboratory, that is, they receive specimens from the units, log them into the computer, and deliver them to the appropriate place. As receivers, they have no contact with patients. Mutual Respect All in all, the transition has been successful, Moser says. The biggest problem has been maintaining open communication between the laboratory and nursing and an appreciation of the other's expertise. "We have good synergy there now," Moser says. "It could be better and it will be better. Staff in nursing and phlebotomy must understand that each has its own skill area, each is important, and both must be combined in this one position." What's Lies Ahead? Only time will tell what approaches to redeploying phlebotomy work best for all involved patients, health care workers, and administrators. One thing is certain: health care institutions must be flexible and willing to make changes when needed. The experiences just described may help other institutions avoid the pitfalls of redeploying phlebotomy and find an approach that works best for them. Terri Yablonsky is features editor for Laboratory Medicine. Acknowledgments The author thanks Dennis J. Ernst, MT(ASCP), and Virginia Faber, MLT(ASCP), for research assistance. Suggested Readings Best ML. Medical technologists: changing roles in a changing environment. Lab Med. 1993;24:399-401. Burton A. Climbing the phlebotomy career ladder. Lab Med. 1994;25:71-72. Check WA. How point of care is playing out. Cap Today. July 1993. Ernst D. Diversity the name of the game for phlebotomists. Advance for Medical Laboratory Professionals. Feb 5, 1996;8. Ernst D. Integrating phlebotomy services. Advance for Administrators of the Laboratory. March 1996:47-49. Krienitz J. How accelerated regulations will affect point-of-care testing. MLO. 1991;23:47-51. Limsdon K. Mean streets: five lessons from the front lines of reengineering. Hospitals and Health Networks. Oct 5, 1995:44-52. Mass D. Medical technologists of the future; new practice, new service, new functions. Lab Med. 1993;24:399-401. Moore ID Jr. Morale hits new low. Modern Healthcare. Dec 11,1995:52-58. Perlman D, Takacs GJ. The 10 stages of change. CLMR. May/June 1993. Rock RC. Why testing is being moved to the site of patient care. MLO. 1991;23:2-5. LABORATORY MEDICINE VOLUME 27. NUMBER 10 OCTOBER 1996 on 28 04 May July