At our Magnet® hospital, nurses solved a clinical practice problem by substituting a humble heating pad for expensive temperature-controlled "hot boxes" to promote blood draws. We’re sharing our story to challenge nurses to solve practice problems with thoughtful, creative, and safe approaches to care.
The Clinical and Translational Research Center (CTRC) at the Hospital of the University of Pennsylvania (HUP) in Philadelphia is an eight-bed inpatient unit dedicated to conducting specialized multidisciplinary research. Sponsored by the National Institutes of Health and the U.S. Department of Health and Human Services, CTRC is one of 60 such units across the country. Located in a discrete part of the hospital, it has a procedure room equipped with complex monitoring devices, an outpatient area, core laboratories, and a research bionutrition kitchen. CTRC staff nurses are trained in research designs and procedures involving human subjects. They’re capable of delivering highly specialized care that demands strict adherence to research protocols.
Typically, more than 200 active research studies are conducted in the CTRC at any given time. Several studies involve frequent (every-minute to every 5-minute) blood draws obtained from a peripheral venous catheter. Often, heat must be applied to subjects’ skin to promote vasodilation and to "arterialize" venous samples. While a direct arterial sample would be ideal, obtaining one isn’t always realistic in research practice, especially with consenting healthy volunteers, who might be deterred from participating. Heating hand veins offers an alternative to obtaining arterial sampling, making it possible to obtain a venous blood sample that approaches the chemistry values of arterial blood. What’s obtained isn’t arterial blood but an “arterialized” venous sample drawn from a catheter distally placed in the dorsal hand vein. The more distal the site, the greater the "arterialization" of venous blood. To further promote withdrawal of these samples, a retrograde I.V. line (a catheter placed counterflow or backwards) is placed in the dorsal vein, if possible.
At HUP, the CTRC now uses heating pads instead of the traditional (and expensive) acrylic, temperature-controlled "hot boxes" typically used in research for purposeful hand heating. Heating pads give easier access for the nurse to manipulate the I.V. site during blood withdrawal. Also, we’ve found heating pads are more comfortable for research participants. Although "hot boxes" can generate higher heat, heating the hand above 102.2° F (39° C) brings no benefit. (Note: We’re using heating pads in controlled situations for research, not therapeutic purposes. Results of many studies would be jeopardized if heating pads were banned from research practice.)
Establishing and implementing a policy
Because HUP lacked a nursing practice policy on heating pad use, the unit council chair (author Kathlyn Schumacher) seized on the chance to develop one. A policy would protect research participants and nurses while guiding safe nursing practice. She and coauthor Elizabeth Leonard drafted a policy and presented it to the CTRC unit council; then a final nursing practice policy was approved. To help guard against heating pad risks, the policy requires skin assessments every 5 minutes.
The policy was submitted to the hospital’s nursing practice council, which approved it with the provision that a worksheet reflecting frequent documentation of skin assessments (every 5 minutes) accompany the policy. A "Heating Pad Use—Skin Assessment Documentation" worksheet was created, modeled after HUP’s existing restraint use form.
Then the worksheet was submitted to the hospital’s forms committee, which provided valuable feedback. With assistance from a committee representative and graphics manufacturer, the CTRC "Heating Pad Use—Skin Assessment Documentation" form was finalized.
The next step was to inform CTRC nurses of the new policy. Several educational sessions were held to review the procedures outlined in the policy and introduce the skin assessment documentation form. In October 2009, the policy on use of heating pads for frequent blood draws in the CTRC became official.
With the help of the unit associate director, we created a poster on CTRC heating pads, which we presented at the International Association of Clinical Research Nurses conference in November 2010. It was well received, and other CTRC research nurses showed an interest in our policy supporting this practice. The poster was selected as a finalist in the Leadership category at the First Annual National Nursing Patient Safety Awards held in April 2011 in Washington, D.C.
Looking back, we recognize many hours were invested in creating a policy and related paperwork for the purpose of protecting research subjects and nurses. The high risk of skin damage with heating pads prohibits their use in clinical care at HUP. However, in the CTRC, heating pads play an important role in collecting critical data. Frequent skin assessments and documentation, as well as other precautions defined in our policy, help protect research subjects from harm. It was well worth our time and effort to support this best practice.
Our hospital’s Magnet journey aided this process. In its quest for Magnet designation, HUP had created unit councils. The CTRC unit council provided the forum needed to make the voice of clinical nurses heard, promoting development of a policy reflecting current nursing practice.
Our leadership journey demonstrates the ability to create change in a Magnet hospital, where nurses are considered the true experts in matters pertaining to patient care. Sometimes simple solutions exist—but these solutions may require considerable work in developing nursing policies and vetting these policies through various committees.
Being a clinical practice leader has its rewards. One of the greatest rewards is influencing practice not only in your own organization but in other practice settings across the country.
Visit www.AmericanNurseToday.com for a complete list of references.
The authors work in the Clinical and Translational Research Center at the Hospital of the University of Pennsylvania in Philadelphia. Kathlyn J. Schumacher is a nurse practitioner. Elizabeth A. Leonard is a clinical nurse III.