What Should We Do?: NICU staff questioning our heelsticks

The nurses in our NICU have recently become critical of the placement of our heelsticks on newborns, the frequency of bruising, and the volume of blood we can collect from one stick. Our staff is very well trained and most of the phlebotomists have 5+ years' experience. I have had our trainer observe the staff and confirm they are placing the lancet correctly. Heelsticks are going to bruise, so I don't think there's any way around that. As for volume, the unit manager is stating that there should be a limit to how much blood can be obtained from one skin puncture, beyond which we need to perform a venipuncture, but still put the blood into microcapillary containers rather than collection tubes. It seems to me as long as the blood is flowing we should be able to continue collecting. What should we do?

Our response: We wonder why the nurses seem to think your trainer's assessment isn't acceptable. If the criticism is only recent, could it be originating from a new staffer who is misinformed about proper heelstick locations, and is spreading his/her misperceptions? Perhaps you need to show him/her the image in the CLSI skin puncture standard showing the acceptable areas of the heel. Support for his/her perception of the correct location should also be pursued.

Bruising, however, is another matter and should not be accepted as the norm. If you can confirm the frequency and degree, then a conversation with your staff on prewarming and applying pressure is in order.

As for volume limits, we feel confident there is no limit to the amount of blood that should be obtained by one skin puncture or incision. The manager will be hard-pressed to provide evidence in the literature to support his/her position. Tell him/her the committees that write and revise the industry standards for skin puncture and venipuncture are comprised of highly regarded authorities in the industry. Tell him you've contacted the chairholder of both documents, and that we've seen no evidence that the volume of blood obtained from a skin puncture should be limited to a level at which a venipuncture should be performed. As long as the blood is flowing well, there is no issue. 

Transferring venous blood into microcapillary containers seems like a clumsy, dangerous, and unnecessary alternative. We would recommend squelching the idea as an approved technique. 

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