Thursday, 31 July 2008

The HSE and Cost Cutting Part 2) Getting a blood test done: Posted by Dr. Jane Doe

“A penny saved is a penny earned.”
“Take care of the pennies and the pounds will take care of themselves.”
“Waste not, want not.”

My grandfather was quite thrifty. He used to love those old chestnuts above. He was a great one for shopping around, and finding a bargain, and loved budgeting etc. Unsurprisingly he was a financial advisor for a large corporation and they loved all the money he saved for them. He grew up in the post WWII days when people were careful with money and businesses kept a hawk eye on the books.

The thing is, even small savings add up over time. Another example that struck me when I first came here was request forms for blood tests. Again, selfishly, I only noticed it because it made my life easier at first, but then I realized how efficient it was and how it must surely be saving money for the system.

In Ireland, every blood test you want to carry out on someone has a different request form. And different hospitals have different forms for the same tests. In Ireland, if you are on a ward round and your consultant asks you to get urea and electrolytes, coagulation screen and a full blood count on someone (this is pretty much a standard admission profile), then in some/most hospitals this requires three different forms. In the first hospital I worked in, the urea and electrolytes went on a blue form, the coagulation on a red form and the haematology on a purple form. There was a green form for miscellaneous things and microbiology requests went on that and sometimes inflammatory markers depending on what ward you were on.

You also had to write in the name of the test you want done, for example if you wanted a thrombophilia screen in a lot of hospitals you had to write in “Anticardiolipin antibodies, antithrombin III, lupus anticoagulant, Protein C, Protein S etc etc” and of course there was one you always forgot to write in.

Sometimes the nurse or occasionally irate phlebotomist would tell you the glycoslyated haemoglobin (HbA1C) went on a miscellaneous form, then the lab wouldn’t accept it because it was supposed to go on a haematology form (the red one). You would be called out of clinic or away from a patient to come and retake the blood yourself and put it on the correct form. “Which one would that be?” you’d ask. Invariably this would take up to half an hour because you’d end up having to run it over to the lab yourself as well as taking it.
Sometimes the ward would have run out of the haematology forms and you could only fill in the biochem forms. You’d have to make time to get one another ward and drop it over later. If you don’t get one in time, the phlebotomist will have come and gone, and you’ll have to take the blood yourself, and run it over to the lab while your bleep goes mad with other “Just to let you know so and so hasn’t had their potassium checked today because you didn’t put out a form” notifications. “Sure I’ll come up as soon as I can. By the way, there weren’t any biochem forms left on the ward today. Would someone be able to order some more please?” Don’t ever say this-the inevitable response will be “That’s not my job.” “I’m not the ward clerk” etc etc. You will get your ass handed to you.

In the second hospital I worked in, haematology requests and coagulation requests were on the same red form. I loved this. So efficient! Now just to fill in the yellow form for the urea and electrolytes. I need to do FSH and LH levels too though, this person looks like they have PCOS. Yellow form? Is that the one? No-it’s the blue form but we don’t keep those here. You’ll have to request one from the lab. The porter won’t get those so you have to run over and grab one yourself and then come back to take the blood because the phlebotomist’s already been and then drop it back over to the lab again.

Hey-this person had a rectal bleed. We should probably do a Group and Hold on him (send a sample for crossmatch and blood typing to the lab in case he needs a transfusion later on). You have to do that yourself. Phlebotomists don’t do those. And you have to drop it down to reception yourself-only a doctor is “covered” to transport those.

AAARRGGHH!!! Anyone remember Michael Douglas in Falling Down? “I’m-having-a-bad-day”.

Down Under, there is one form for all blood tests bar blood bank requests. Want to check glucose levels, urea and electrolytes, FBC, Coagulation, D-dimers (did these go on the red one or the purple one at home? I can barely remember!) and thyroid function tests?

Pick up one of the blood forms. No writing, except for your name and the date. Tick the boxes next to the name of the tests you want. Put it in the box. There are four phlebotomy rounds a day, at 07:30, 11:30, 13:30 and 15:30. The next one will get his bloods done. You check them at noon. His Hb is a bit low, he might need a transfusion. Fill out a group and hold form and stick that in the box. The next phlebotomy round at 13:30 will get it done. He can start his transfusion at 15:00 if he needs it. You haven’t left the ward. No time wasted. All the patients have been seen and blood tested and results checked and acted on appropriately.

Printing off all those different forms and shipping them all off to different hospitals must cost a LOT of money. Three or four different forms for a couple of common blood tests! And all the problems that can cause. All the wasted doctor time, time that you as a patient have to spend sitting in A&E, or Outpatients, or the ward, waiting to be reviewed by a doctor who can’t come review you because they are acting as a phlebotomist despite the fact that we are PAYING phlebotomists so other people won’t have to leave their work to come and take bloods! All the overtime we pay to that doctor who stays late reviewing people who have had to wait all day because of this inefficiency in getting routine things done.

All we need to improve the above situation is:

1) One standardized form for all blood tests in all hospitals all over the Republic of Ireland. Understood by all laboratory staff, and all doctors and all phlebotomists.

2) Several phlebotomy round in a day. Phlebotomists to take all blood tests, Group and Hold samples too. This is not a special God given skill bestowed upon doctors on graduation. You can train anyone to take a blood sample and label it.

Time saved. Happier doctors. Happier patients. Money saved. Over a year or two, maybe quite a LOT of money saved. Enough to pay for at least an extra phlebotomist or two, I’d imagine.

Dr. Jane Doe


  1. Every hospital in England where I have worked has operated an Irish system. Where I currently work there are too many forms to count. The medical time wasted trying to find the right bit of paper is enormous. The problem is beginning to be solved with computerisation of requests. We were born too soon.

  2. Amen! to that Jane... I couldn't agree more

  3. Well-said! Jane

    I'm sure your grandfather would be proud of you for your cost-saving measures.

    Simple ideas which could save the HSE a fortune, without any need to call-in the special advisers at enormous expense.

    The "Ah sure, it'll do" mentality of the Irish is partly to blame here but unless/until the HSE starts to listen to people like you, nothing will change.

    Keep it coming!

  4. That is just crazy (the Irish system)... hospitals where I am in Australia are similar to NZ - one form for all pathology requests (bloods, urine, CSF, micro on anything and everything etc etc) and another form for transfusion requests. All rather easy.

  5. Ok, as a Medical Scientist in a Crossmatch Lab I have to say I disagree with phlebotomists taking Group & Hold/Crossmatch bloods (though I admit this might be purely be because I was raised in the Irish system, as it were, so this is "the norm" and change is bad ;)).

    This is primarily because a transfusion is a prescription, so obviously only doctors can prescribe it. Since that very sample of blood is what we're going to use to provide a unit for that specific patient, we need as much certainty as it humanly possible that we're getting the right blood in the right tube. I'm not sure of the risk of other blood tests being mixed up - I'm sure there is risk, such as treatment being withheld, or inappropriate treatment being given - but if there's a mix up with Crossmatch bloods the patient could at best suffer serious morbidity and at worst die. Ok, so this is obvious to you, you're a doctor, you know the consequences of transfusion f*** ups, but this is why the medics taking G&H bloods is insisted on. It's buck-stopping-here responsibility, and while phlebotomists are a damned sight better at taking bloods than most doctors, and highly educated to boot, I can still understand why it's done the way it's done here.

    Believe me, there are a lot of blood transfusion practices in, say, the US that I wam horrified by. Just because something is being done in another country doesn't necessarily mean that it's better or more advanced or what have you.

    OTOH, if Crossmatch Med Scis were allowed take the bloods, at least the Crossmatch forms'd be filled in correctly ;)

  6. "Ok, so this is obvious to you, you're a doctor, you know the consequences of transfusion f*** ups, but this is why the medics taking G&H bloods is insisted on. It's buck-stopping-here responsibility, and while phlebotomists are a damned sight better at taking bloods than most doctors, and highly educated to boot, I can still understand why it's done the way it's done here."

    The phlebotomist is not prescribing the blood. They are not consenting the person for the blood. They are not administering the blood.
    They are sticking a needle in the patient, getting blood out, and labelling the tube then sticking it in a bag.
    This is not rocket science. If they can't do that- then they shouldn't be phlebotomists. That's what they have to do with all blood samples. It's their ONLY job. They have no distractions. Unlike us, with our bleeps going and nurses and juniors and seniors and patients all wanting that very chunk of our time.
    Explain to me why a doctor is better at sticking a needle in a person, getting blood out and labelling a tube than a phlebotomist. It doesn't take a medical degree to take blood. As for buck stopping responsibility-this is the problem with Irish healthcare-thank you in fact for highlighting that!
    No one wants the responsibility of ANY job in Irish medicine. Anything that can be passed on or shafted to someone else usually is. Phlebotomists will not accept the responsibility that comes with their position, and fob off the parts that worry them onto doctors. In fact they are misinformed, if they mislabel a U&E wrongly, the consequences can be as bad or worse-a potassium level comes back at 6.9 when it's really 2.0 due to mislabelling-you whack in the insulin, dextrose, salbutamol, calcium gluconate, and bang-patient has a fatal hypokalaemia induced arrhythmia.

    This is another huge problem within Irish medicine-SHAFTING jobs onto people that one could do themselves to avoid responsibility. The whole first dose IV drug thing was a way of doing that-in fact, it is usually the second dose that gets people as they have become sensitised-so no logic at all there, but it was a way of passing the buck onto doctors because a certain part of the job involved a perceived small element of risk, and no one wanted the responsibility.
    If phlebotomists cannot handle the responsibility of taking and labelling bloods correctly then they should not be phlebotomists. Hell, we transfuse based on results we get from the CBCs they take! Based on your logic doctors should take all bloods, and indeed, do everything else as they have somehow a deeper level of understanding of the implications of doing something wrong. Is that it?
    If someone is too dumb to understand that people get transfusion reactions, then they have no business working in a hospital. Anywhere in the hospital. I think, however, that you are doing the phlebotomists a disservice. They never mislabel anything. I myself through sheer hurrying and often through unfamiliarity with different Group and Hold forms have filled them in incorrectly. Almost every junior doc I know has done so at some point.
    I don't know of any nurses or phlebotomists who have done so. They two groups above usually receive training we don't get because of attitudes like yours-we have a greater knowledge somehow of procedures surrounding simple blood taking. WRONG. Irish intern did not used to receive any training in cannulation or phlebotomy, we were expected to learn "on the job" which believe me does not work so well. I don't know if they've changed that yet.

    I give up though. Ultimately Ireland will never change its inefficient procedures. It will never look and see where problems are and address them. It will never utilise its staff and their knowledge and experience correctly.
    Change. It's scary. And sure, it's all good.

  7. Here I am trying to get back into work as a phlebotomist and cant get any because of the HSE freeze on employment. The HSE really do not have a clue nor do they care to be honest because if it were me I would be quite happy and capable to train in whatever area needs to be covered. Heck i'd even volunteer but ive been out of it so long that now i need to do the course with the national amublance training but they seem to only let people in who are already working with the HSE .... its all about who you know. Sorry off topic, frustration is showing