Registed Nurses' Association of Ontario

Capillary blood sampling hemolysis in the NICU: A quality improvement project to promote evidence-based practice and improve patient outcomes

Jennifer Stockdale, RN, BScN, MScN (student)
Hamilton Health Sciences, McMaster Children’s Hospital

Summary of fellowship and overall learning objectives:
The NICU at McMaster Children’s Hospital (MCH) is the second largest NICU in Canada, caring for approximately 1500 infants annually. The patient population is very acute, requiring vigilant monitoring by the interdisciplinary team. One of the most common procedures performed in order to monitor and obtain various types of laboratory data is capillary blood sampling. All team members rely on this data in order to make crucial decisions relating to interventions, treatments, and care. Unfortunately, capillary blood sampling is prone to hemolysis, which influences the accuracy and reliability of certain laboratory tests, especially those for sodium, potassium, bilirubin, and lactate. These inaccurate results can delay or affect treatment decisions, or potentially require the sample to be re-drawn in order to obtain an accurate result. Given this, it is vitally important to limit hemolysed samples in any NICU environment.

As a RN in the NICU, I have noticed that drawn capillary blood samples frequently result in laboratory error messages, including “sample hemolysed, may falsely increase test result” or “sample hemolysed, unsuitable for testing.” In light of this, it was also noted that the NICU at MCH had a 75% hemolysis rate for all capillary blood samples drawn over the past year. While it was not possible to determine how many of these samples had to be re-drawn, a 75% hemolysis rate is a clinically significant percentage, making it necessary to address this issue.

The overall focus of this Fellowship was to lead a quality improvement project in order to reduce the rate of capillary blood sampling hemolysis within the NICU.As a first step to identify possible causes of hemolysis, evidencesuggests that improper technique used during capillary sampling—including how the infant’s foot is held and the way the blood is allowed to leave the puncture site—is a leading cause of sample hemolysis. Therefore, the work of this Fellowship sought not only to reduce the rate ofsample hemolysis, but to also ensure nursing practice was based on current best evidence. This was done through the implementation of a multifaceted knowledge translation intervention, including multi-modal education strategies to transfer best evidence into current nursing practice.

My own learning objectives for this Fellowship were multifaceted. As part of myMScN studies at McMaster University, I completed a 12-week placement with a Clinical Nurse Specialist (CNS), which helped me conclude that I intend to pursue a career as a CNS. Recognizing that I do not yet have all the skills necessary for such a role, I focused on developing knowledge, skills, and expertise in areas that would assist in preparing me for such a career. I thus chose theLeadership skill development stream, with a sub-focus on Education. Guided by a dedicated mentorship team comprised of a CNS, Nurse Practitioner, Clinical Educators, Clinical Manager, and an Associate Professor in the School of Nursing at McMaster University, the knowledge and experiences I gained were significant and extensive.

To start, I developed knowledge, skills and expertise in designing, implementing, and evaluating a quality improvement (QI) project. Doing so allowed me to address my learning goal of gaining CNS experience, since leading QI projects is listed by the Canadian Nurses Association as a necessary competence for CNSs. Leading the QI project enhanced my leadership skills by allowing me to challenge “the norm”, advocate for evidence-based practice, and promote the best care for our patient population. It also allowed me tocommunicate, collaborate, and learn from inter-professional and leadership team members within the NICU in a way that I had never done previously.

As the QI project focused on nursing staff education, I also furthered my knowledge, skills, and expertise in adult teaching and learning principles, strategies for educating novice to expert nurses, and creating and disseminating multi-modal resources to meet various learning needs. These resources included creating a brief educational video and updating the corporate clinical policy document regarding capillary blood sampling, both of which were new experiences for me. Developing these educational resources also provided me with the opportunity to further my skills in educating nurses in a clinical setting through pod in-services and lunch-and-learn sessions. I also gained experience in evaluating the effectiveness of the educational interventions to establish if staff members required further support.

Outcomes achieved:
The work associated with this Fellowship has positively impacted the nursing staff, patients, and family members within the NICU at MCH, and resulted in several expected and unexpected outcomes.In order to reduce the rate of capillary sampling hemolysis and ensure nursing practice is based on current best evidence, a multifaceted knowledge translation intervention was developed, which included: an analysis and synthesis of the literature to determine best practice for capillary blood sampling; an evaluation of current technique used by RNs in the NICU; the development and execution ofeducation strategies to transfer best evidence into current nursing practice; and a comparison of hemolysis rates and RN technique before and after the interventionin order to evaluate the project.

The assessment of capillary sampling practices was done through self-reported measures via an online survey. A pre-intervention survey was administered to all RNs regarding their
knowledgeand technique used during capillary sampling. Participation rates wereremarkably high, with over 60% of RNs completing the survey (116 responses). Unsurprisingly, results indicated great variability in practices, which helped to shape the resulting educational resources to address gaps in knowledge. These resources were multi-modal in order to be effective, and included a step-by-step guide with tips, tricks, and pictures; a short video demonstrating best practice for the procedure; an update of the clinical policy document regarding capillary blood sampling; andhands-on clinical support through in-services and lunch-and-learn sessions. A similar survey was then administered post-intervention, which assessed nursing knowledge and technique, as well as the effectiveness of educational resources. Participation was slightly lower, at 86 responses; however, theses responses indicated great improvements in practice, as indicated by the following results:  a44% increase in proper technique for holding the infant’s foot  a48% increase in proper technique for drawing blood out of the foot  a19% increase in proper technique for filling the laboratory container Further, written feedback from staff indicated that the educational materials provided were beneficial andassisted in changing theirpractice. Given this success, my Director and I have discussed providing the same intervention to other units within MCH, which will also assist in the sustainability of my learning.

Despite the improvements in nursing practice, hemolysis rates post-intervention have not changed, which is disappointing. After debriefing with my mentorship team it was determined that this could be due to a number of factors. For instance, an unexpected outcome of the Fellowship included the discovery that a validation of the pneumatic tube system that carries blood samples to the lab has not been done for capillary samples. As evidence suggests that the use of a pneumatic tube system can potentially lead to sample hemolysis, a validation is now being scheduled.Depending on the results, samples may need greater protection before they are placed in the pneumatic tube. Another possibility is that nursing staff need moretime to adjust to the new technique, depending on how drastically their practice differed from best practice evidence. Regardless, my hope is that capillary sampling hemolysis rates will continue to decrease, and sustainability efforts will focus on monitoring hemolysis and nursing technique for the next 3-6 months at minimum.

Finally, a portion of the Fellowship focused on parental experience around capillary sampling, in order to assess parents’ attitudes and feelings towards the procedure. A written survey was distributed to parents at the beginning and the end of the Fellowship, and scores were compared to determine if improvements had been made. Overall, scores increased from “neutral” to “somewhat positive”, indicating success in this measure. However, the surveys also indicated that parents had surprisingly little knowledge ofcapillary sampling in terms of what it was, why it was done, and how they could be involved by providing comfort measures to their baby. Considering capillary sampling is one of the most common procedures performed in the NICU, this was an unexpected outcome. Recognizing this, it was subsequently discovered that there were no patient teaching materials regarding the procedure, and so a teaching sheet was created with the assistance of my fellowship team and the HHS patient education team. The resource is now available in the NICU, as well as on the patient education website to be used by other units within MCH.

Overall Experience:
I am tremendously grateful to the RNAO for funding this opportunity and to my fellowship team for their guidance, support, and mentorship. Although undeniably challenging, the rewards for completing the ACPF are numerous and the feeling of accomplishment is immense. As a result of this opportunity, many doors have opened for me that will enhance my future career and bring me closer to my career goal. For instance, I am now a member of several committees within the NICU that I was not a part of previously, including a monthly blood work/lab meeting that discusses our blood work practices more generally and works to improve the care provided to our patient population. I was also personally asked to fill a maternity leave for one of our Clinical Educators within the NICU, which I accepted. I am looking forward to taking the learning I have gained from this experience and applying it in this new role.

Although I have gained much from this opportunity, I feel as if my learning has just begun.My future objectives will work to sustain my learning through posteror oral presentation at conferences, several of which I have already applied to. I will also continue to support my fellow colleagues by providing regular updates and further education as necessary, and will also continue to monitor our hemolysis rates.

My final hope is that this Fellowship has demonstrated to other nurses within the NICU, McMaster Children’s Hospital, and Hamilton Health Sciences that they have the power to enact change, pursue their goals, and become a leader.