Repetitive needlesticks are impacting patient care, according to this survey.
Repetitive needlesticks can be a challenge in hospitals, from both a nurse and patient perspective.
A recent survey conducted by the Harris Poll revealed that out of the participants with a recent hospital stay, 59% of patients needed multiple needlestick attempts for IV insertion, and 71% for blood draws, with 11% needing 10 or more sticks to obtain a single blood sample.
These numbers are representative of a major issue. According to the survey, more than half of Americans report some fear of needles, and a top reason is fear of multiple insertions. The survey also reported that 77% of patients are not aware that they should expect no more than two needlestick attempts from one clinician, no matter what condition they have.
Here's what you need to know about the reality of repetitive needlesticks.
A new study by the Cleveland Clinic finds that clinicians tend to prescribe more antibiotics in virtual care visits than they do in person. Researchers say it's the fault of the platform, not the provider.
Healthcare organizations with robust virtual care programs should invest in antibiotic stewardship resources to prevent overprescribing, according to the results of a recent study.
The study, conducted by researchers at the Cleveland Clinic Health Systems and published in Oxford Academic, found that urgent care virtual visits for treatment of respiratory tract infections were far more likely to result in antibiotic prescriptions than the same visits conducted in person.
Others are disputing that suggestion, and the Cleveland Clinic study follows that route. Researchers there say the telemedicine platform may be at fault, as clinicians don't have the ability to see a patient in person to conduct a thorough analysis, which might rule out antibiotics or lead to a different treatment.
"To our knowledge, this is the first to attempt to isolate the role of the platform in antibiotic prescribing," the Cleveland Clinic team reported. "That we found higher prescribing in virtual care suggests that it is the limitations of the platform, and not the clinicians or the health system, that drive higher antibiotic prescribing."
The Cleveland Clinic team used EHR data to analyze 69,189 in-person visits and 19,003 virtual care visits for RTI treatment conducted by the health system between 2018 and 2022, with COVID-19 visits excluded. According to that data, 58% of the virtual visits led to an antibiotic prescription, compared to 43% of in-person visits. More specifically, 34% of the virtual care visits were diagnosed as sinusitis, and 95% of those led to a prescription, while only 13% of the in-person visits led to a sinusitis diagnosis, and 91% of those resulted in a prescription for antibiotics.
Many hospitals and health systems already include special training for clinicians who use virtual care. Studies like that conducted by the Cleveland Clinic are evidence that those programs should include protocols for virtual prescribing, monitoring of virtual prescribing habits, and antibiotic stewardship tools.
Despite the slight bump, rural and underserved facilities may see significant decreases in their reimbursement payments.
The Centers for Medicare & Medicaid Services (CMS) has issued a final rule increasing Medicare inpatient prospective payment system rates by 2.9% for FY2025.
According to the agency, the update reflects a hospital market basket increase of 3.4%, and a productivity cut of 0.5%. Payments are expected to increase by $2.9 billion and new medical technology payments to increase by $300 million.
However, rural health payments could decrease by $400 million, should legislators decide not to extend the Medicare-dependent hospital and enhanced low-volume adjustment programs. Disproportionate share hospital payments are expected to decrease by $200 million, which is attributed to a decrease in the uninsured rate.
The finalized rate is 0.3% higher than the previously proposed 2.6% increase, which providers have criticized for being too low. Despite the slight bump, their feelings remain unchanged.
The situation is particularly concerning for rural and underserved communities. A statement from the American Hospital Association says the update will “exacerbate” the difficulties hospitals are experiencing as they seek to stabilize their operating margins.
“We are troubled that the final long-term care hospital outlier threshold is nearly 30% higher than it is currently,” Molly Smith, group vice president for public policy, said in a statement.
“Since FY 2021, this figure has increased by more than 180%, which forces these hospitals to absorb hundreds of thousands of dollars in additional losses when caring for the sickest patients.”
Smith added that the increase will negatively impact healthcare access, putting more pressure on acute-care hospitals and other providers who don’t usually care for rural and underserved groups.
Providers and professional groups alike have long been vocal in their criticism of CMS’ low payment rates. Reimbursement payments not covering the cost of care is a continual issue.
In addition to the rates not keeping pace with inflation and rising labor costs, the payments themselves don’t cover the cost of care.
Nurse practitioners, nurse anesthetists, and physician assistants represented nearly one-in-four (23%) of the 2,138 searches conducted from April 1, 2023, to March 31, 2024 by Texas-based recruiters AMN Healthcare.
Family physicians topped AMN's physician searches for the 18th straight year, second only to APPs among all searches. The average starting salary for family physicians was up 6.27% year-over-year, from $255,000 in 2023 to $271,000 this year.
However, while primary care physicians remain very much in demand, that demand is cooling as the demand for APPs heats up. Only 14% of AMN's searches this year were for primary care physicians, down from 17% last year, while 23% of search engagements were for APPs, up from 19% last year.
AMN says the transition away from recruiting primary care doctors and toward APPs reflects the ongoing patient migration from traditional care venues.
"NPs are filling needs created by the physician shortage and are used to staff a growing number of urgent care centers, retail clinics, and telemedicine platforms. In addition, more specialty medical practices are employing them," AMN says in its 2024 Review of Physician and Advanced Practitioner Recruiting Incentives, breaks down salaries, signing bonuses, and relocation allowances.
The high demand for NPs was reflected in starting salaries, which rose 8.6% year-over-year, from $158,000 2024 to $164,000 in 2024. By comparison, the rate of inflation in the U.S. economy as measured by the Consumer Price Index was 4.06% in 2023 and 3.2% in 2024, federal data show.
The review also found that:
• Starting salaries for physicians and APPs were up year-over-year, with increases seen in 13 of the 20 specialties.
• Orthopedic surgeons were paid the highest average starting salary ($686,000). Pediatricians were paid the lowest ($244,000).
• The average signing bonus for physicians was $31,473. The average bonus for APPs was $11,758.
• In addition to salary and signing bonuses, physicians and APPs often got relocation and continuing medical education allowances. The relocation allowance for physicians averaged $11,284, and the allowance for APPs was $7,910. The CME allowance for physicians averaged $3,969 and $3,195 for APPs.
• Most AMN searches this year (63%) were for physician specialists, including OB-GYNs, gastroenterologists, radiologists, cardiologists and other specialists.
• OB/GYNs were 2nd on the list of AMN's most requested physician search engagements this year, up from 4th last year. Demand for OB/GYNs remains strong, but the supply may be inhibited by the U.S. Supreme Court's Dobbs vs. Jackson decision, which discouraged medical school graduates from pursuing OB/ GYN residencies.
• Nearly three-quarters (71%) of searches were in communities of 100,000 people or more, which AMN says shows that demand for physicians and APPs is not limited to small and/or rural communities.
If you remove nurses, it's "no man's land," says this nurse leader.
On this episode of HL Shorts, we hear from Katie Boston-Leary, director of nursing programs at the American Nurses Association, and HealthLeaders Exchange member, about different ways that health systems could reflect the value of nursing in their budgets. Tune in to hear her insights.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
HealthLeaders Innovation Editor Eric Wicklund talks with Dane Hudelson, Senior Director of Enterprise Data & Analytics at Sanford Health and a member of the HealthLeaders Mastermind Program on AI in Revenue Cycle and Finance Operations, about how the health system has built its AI capabilities in-house and developed a strong strategy for future growth and innovation.
Repetitive needlesticks might no longer be necessary with new technology, say these nurse leaders.
Several new care delivery models are taking over the nursing industry and streamlining daily nursing practices, now including needlestick procedures.
Repetitive needlesticks can be a challenge in hospitals, from both a nurse and patient perspective. A recent survey conducted by the Harris Poll revealed that out of the participants with a recent hospital stay, 59% of patients needed multiple needlestick attempts for IV insertion, and 71% for blood draws, with 11% needing 10 or more sticks to obtain a single blood sample.
Impact on patients
These numbers are representative of a major issue. According to the survey, more than half of Americans report some fear of needles, and a top reason is fear of multiple insertions. The survey also reported that 77% of patients are not aware that they should expect no more than two needlestick attempts from one clinician, no matter what condition they have.
However, IV and blood draw procedures are a necessary part of the hospital stay, and according to Anna Kiger, system chief nurse officer at Sutter Health, they make the patient experience less positive.
"It is one of the most frequent tasks that a nurse or phlebotomist does," Kiger said, "so if you come for healthcare, it's a high probability we're going to stick you at least once, if not more."
There are several factors that can also make needlestick procedures more difficult, Kiger explained.
"Whether it's in the emergency department or later on in the acute care setting, we do need to obtain blood samples from them for a variety of reasons," Kiger said, "and unfortunately, due to the acuity of their diagnosis and their age, obtaining a clean single needlestick to get the blood can be very difficult."
According to Michele Acito, executive vice president and chief nursing officer at Holy Name Medical Center, repetitive needlesticks impact patients in both the short and long term. Not only do needlesticks increase anxiety and pain among patients, but incorrect vascular access practices in general can impact health literacy and lead to potential rehospitalizations or disease progression.
"When patients are more anxious, they're less likely to understand the procedures that are being explained to them," Acito said. "Short term, they're not hearing about their care, about their needs, about their diagnosis, and long term, they're not hearing about the things they need to do upon discharge."
Needlestick alternatives
Luckily, alternatives to repetitive needlesticks are on the horizon.
According to Kiger, there is now a device that can provide needleless blood draws.
"This particular technology, which allows a nurse to obtain a direct blood draw through an IV catheter, does eliminate the need for a needlestick," Kiger said, "and that particular device can be used in the ED or in the inpatient setting."
This new technology is called the PIVO™ device, currently owned by BD, which essentially enables a small tube to enter the blood vessel through the IV to avoid an additional needlestick when blood draws are necessary.
"It's an IV with a tail essentially coming out of it," Acito said. "The patient should expect one stick when they come into the hospital and they have the IV inserted, unless they need a special test like blood cultures, then this PIVO™ device would be used."
In patients Kiger has observed, the experience with the device is painless and the blood samples taken with it are of the same quality as those obtained through a needle aspiration.
"If you can remove the needle and obtain a quality blood sample and get to the test result that is required for a physician to make a decision, then I'm all in favor of doing that," Kiger said, "because it's one less penetration of the skin, which is our protection from infections, and the patient gets an entirely different experience, a painless experience for most, obtaining blood."
Acito said they oftentimes employ licensed practical nurses (LPNs) to do the blood draws with the device, which can greatly benefit them as well as the patient.
"This allows [the LPNs] to work at the top of their license, while reinforcing education that has already been provided to the patient, interacting with the patient, providing other needs while they're in the room," Acito said.
In addition to the PIVO™ device, Acito emphasized the importance of good IV care to help decrease repetitive needlesticks.
"Once you put in the IV, if you maintain it well and you choose the site properly, you can use devices that help you find the vein so that there's a decrease in the number of sticks," Acito said. "How many blood draws you get is really determined by your diagnosis and the number of tests that need to be run to find [it] or to see if the treatment is working."
There have already been positive outcomes from using this device as well, according to Acito.
"The positive outcome is that you don't waste more resources trying to find a vein, [and] trying to stick the patient," Acito said. "When you walk in, no longer do you have to check this arm and check that arm and find that vein. You already have access."
The bottom line is that it's better for the patient, Acito explained, because it decreases exposure to excessive bleeding, bruising, or infection.
"They know when they come in and they get that PIVO™ device because of education from the nurse that this is going to be the site where [they] get [their] medications [and] IV fluids, and it's also where we're going to draw [their] blood from," Acito said.
Training and education
Both nurses and patients need to be educated about needlesticks and vascular access procedures and their alternatives.
CNOs must ensure that nurses receive the proper training on how to make patients feel more comfortable during a needlestick experience.
"I think it's really important for the nurse to always recall for themselves what it would be like or even a personal experience with having had an IV," Acito said. "Completely engage the patient, distract them, [and] make sure that the patient is fully educated on what to expect."
Kiger said the most important thing leaders can do is educate other nursing and hospital leaders about the new technology alternatives that do allow for successful needleless blood draws, like the PIVO™ device.
"First of all, basic education, getting more literature out, getting more published research out, getting the experiences of those who actually use a device like this in clinical practice, and then also getting the patient's perspective out there," Kiger said. "Then I think it becomes a matter of showing that over time, this is actually an easier way to draw blood."
Primary care providers are struggling. Can augmented intelligence tools give them the support they need to enjoy healthcare again?
Editor’s Note: Michael S. Barr, MD, MBA, MACP, is a board-certified internist and the former executive vice president for the Quality Measurement & Research Group at the National Committee for Quality Assurance (NCQA).
Primary care is in trouble
According to a report from the Milbank Memorial Fund, The Physicians Foundation, and the Robert Graham Center about the crisis facing primary care:
The number of primary care physicians per capita has declined from 68.4 primary care physicians (PCPs) per 100,000 people in 2012 to 67.2 PCPs per 100,000 in 2021.
Only 15% of all physicians who enter residency training practice primary care three to five years after residency.
Nearly half of family physicians rate the usability of electronic health records (EHRs) as poor or fair, and more than one-third are unsatisfied with their EHRs.
KFF Health News journalist Elisabeth Rosenthal put it best when she wrote:
“American physicians have been abandoning traditional primary care practice — internal and family medicine — in large numbers. Those who remain are working fewer hours. And fewer medical students are choosing a field that once attracted some of the best and brightest because of its diagnostic challenges and the emotional gratification of deep relationships with patients.”
Much of the frustration experienced by physicians relates to burnout. The American Medical Association (AMA) defines burnout as “a long-term stress reaction that can include emotional exhaustion, depersonalization (i.e., lack of empathy for or negative attitudes toward patients), [or the] feeling of decreased personal achievement.”
According to the Agency for Healthcare Research and Quality (AHRQ), “Burnout can also threaten patient safety and care quality when depersonalization leads to poor interactions with patients and when burned-out physicians suffer from impaired attention, memory, and executive function.” An AMA survey in 2022 identified that primary care physicians (Internal Medicine, Family Medicine, Pediatrics) were among the top six physician specialties with the highest burnout (52% to 58%).
What causes burnout?
EHRs, administrative burdens, and organizational factors are the leading contributors to frustration and physician burnout. This Harvard Health Blog, written to educate patients, includes the following apt description:
“The causes of physician burnout are complex, but have to do in part with increasing workload, constant time pressures, chaotic work environments, declining pay, endless and unproductive bureaucratic tasks required by health insurance companies that don’t improve patient care, and increasingly feeling like cogs in large, anonymous systems. Parasitic malpractice lawyers are always circling, which causes us to waste an enormous amount of time with defensive documentation. The transition from paper charts to electronic medical records, which seemingly were designed to maximize revenues instead of clinical care, has created a technological barrier between doctor and patient, and between doctors.”
Michael S. Barr, MD, MBA, MACP, former executive vice president of the Quality Measurement & Research Group at the National Committee for Quality Assurance (NCQA). Photo courtesy NCQA.
The American College of Physicians (ACP) and other medical professional societies are focused on addressing this issue through policy and advocacy. A 2017 position paper from ACP titled “Putting Patients First by Reducing Administrative Tasks in Healthcare” takes an analytical approach to categorizing administrative tasks to identify and mitigate their adverse effects on clinicians, patients, and the healthcare system, pointing out that:
“Tasks that become burdensome may differ from payer to payer; appear one month without notice, then reappear modified or changed the next; and often result from not using documentation that already exists in the medical record.”
Can AI help?
Given AI’s ubiquity, most people will tell you that it stands for artificial intelligence. Most of us have given a lot of thought to how AI is poised to affect our lives and livelihoods in the years to come. Many fear that AI-powered software might eventually make their jobs redundant.
The AMA takes a more optimistic approach. They’ve decided to use AI as an acronym for augmented intelligence, “as a conceptualization of artificial intelligence that focuses on AI’s assistive role, emphasizing that its design enhances human intelligence rather than replaces it.”
That framing is useful, because augmented intelligence is actually emerging as a potentially valuable “partner” for clinical teams to help address common challenges in primary care – many of which contribute to burnout and frustration in practice.
An AMA survey report (2023) found enthusiasm for AI in healthcare, with 65% of physicians surveyed seeing an advantage to AI. The report found particular enthusiasm for AI tools that can help reduce administrative burdens such as documentation and prior authorization, and to support diagnosis and workflow. At the same time, 41% of physicians reported equal excitement and concern, with their ambivalence stemming mostly from the potential impact to patient-physician relationships and patient privacy.
When appropriately trained, maintained, and implemented in the clinical workflow, proponents of AI in healthcare have hopes and expectations it will produce significant benefits by:
Reducing the documentation burden (e.g., ambient AI generating progress notes via ambient AI, drafting replies to patient messages, completing prior authorization requests, producing referral notes and discharge summaries).
Identifying at-risk/high-risk populations for early, proactive interventions and support.
Producing actionable patient summaries and reports.
Supporting improvements in risk adjustment and appropriate coding.
Providing diagnosis support to reduce missing, delayed, or incorrect diagnoses.
Suggesting treatment plans based on clinical conditions accounting for patient needs, preferences, and other factors.
Handling repetitive and predictable administrative tasks (e.g., eligibility checks, appointment reminders, standard reports).
Providing translation services.
The effectiveness and success of AI in healthcare will depend on the appropriate and ethical application of the technology. This includes transparency about its limits, biases, and potential to cause unintentional harm. Importantly, clinical recommendations and summaries should link to the source documentation to allow clinical teams the opportunity to review and confirm the accuracy and validity of the information.
Other considerations include user acceptance of the technology (i.e., the usability of the AI interfaces and reports), the cost to implement and maintain, and potential liability from inaccurate guidance that could lead to patient harm. Data privacy and security is another important concern: clinical teams and health systems must be confident that appropriate protections are in place and consistent with HIPAA and other regulations.
Future of Health: The Emerging Landscape of Augmented Intelligence in Health Care, a research paper produced by AMA in collaboration with Manatt Health, provides a good framework for understanding the issues, identifying use cases, and planning for AI implementation in practice. Many of the use cases highlighted are non-clinical – that is, they address the administrative hassles and tasks at the root of clinician burnout.
Will AI make a difference in primary care?
There are good indications that AI, appropriately designed and implemented in the workflow of busy clinicians, can reduce the stress associated with administrative tasks, documentation, and clinical care. .
However, integrating AI into healthcare must be done carefully, ethically, and with an understanding of its promise and limitations. Organizations such as the new Coalition for Health AI (CHAI) are focused on developing guidelines “to drive high-quality healthcare through the adoption of credible, fair, and transparent health AI systems.” The CHAI Blueprint for Trustworthy AI Implementation Guidance and Assurance for Healthcare provides an excellent academic approach to addressing these imperatives.
But primary care needs help now. I am optimistic that AI systems can address many tedious administrative tasks that cause significant frustration in practice. With appropriate transparency, usability testing, and sufficient clinician training, AI systems could also be used to support clinical documentation, quality gap closure, population health initiatives, and risk adjustment.
But clinicians and their team members will always need to be able to view the clinical evidence used by AI systems to generate inferences and recommendations. Those systems are there to augment physicians–not to replace them. Decision-making and clinical interventions will always remain the responsibility of clinicians.
To ensure big data is used to influence outcomes that are meaningful to the nursing profession, nurse executives need to act as data visionaries and architects. But how?
Have you ever found yourself poring over stacks of data, feeling more like a statistician than a nurse? If you have, welcome to the world of big data.
"You have all of these different data sources coming at you on a weekly, monthly, quarterly basis. The CFO has a stack of data for you, your productivity-management engineer people have a stack of data for you, HR has a stack of data for you, and then your quality director, your clinical folks, have a stack of data for you," Jane Englebright, former chief nursing executive and senior vice president at Nashville, Tennessee-based HCA, previously told HealthLeaders.
"And your job is to sort through all that data and synthesize it in some way and come up with brilliant conclusions about how to run the organization," she said.
But how can it be done efficiently and effectively?
When a CNE is analyzing and synthesizing data, it's typically done manually and is a very time- and labor- intensive process, in part, because technology systems have traditionally been built in silos. "Often they don't even call the units the same thing. They don't name them the same thing. They don't necessarily define them the same way," Englebright said.
For example, the definition of a day may vary from system to system and the way a month is calculated in the finance systems may differ from how it is calculated in the payroll system.
Trying to "figure out how to keep up with your agency hours and what the cost of your agency is in the finance system versus the scheduling system," Englebright says, is "just a nightmare, trying to make all of these different things sync."
The lack of data standardization can also make it challenging for a CNE to assess how the organization or a particular unit is performing and to make well-informed decisions about what to change. Having good data is key to making effective changes.
"For those of us who grew-up studying the biological sciences, we understand that we have taken a very linear, Newtonian-approach to data over something that's really much more like a biological system," she explains. "When you perturb one part of our system… it has ripple effects throughout the entire organization."
Failure to recognize how this data interacts throughout the system has been a limitation in the types of data analytics that have been put forth.
"The frustration that we often have as nurse leaders in looking at this data, is [that] some of the variables we care about the most, aren't even in the data," Englebright says. "We don't have something that measures nursing competence, for example. We don't have something that measures how committed the nurses are. We don't have something that measures if the patient really [is] going to do the stuff we just invested all this time in teaching them to do."
Because of this, CNEs end up having to advocate for the things they care about in a person-on-person debate, rather than being able to make a persuasive business case based on data, she says.
For all its current stumbling blocks, big data holds the potential to change healthcare delivery for the better. But for that to happen, nurse executives need to act as data visionaries and architects.
To support CNEs in doing this a workgroup that grew out of the University of Minnesota's annual Nursing Knowledge: Big Data Science Conference developed the CNE Big Data Checklist.
It outlines three main areas where nurse executives should become leaders in driving the use of big data:
To create a culture that thrives on data
To develop big data competencies for the organization
To create an operation infrastructure to support big data use
This article is part of HealthLeaders’ How Do I? series. Read the entire article here.
Organizations have a responsibility to understand how nurses contribute, says this nurse leader.
HealthLeaders spoke to Katie Boston-Leary, director of nursing programs at the American Nurses Association, and HealthLeaders Exchange member, about her thoughts on the prospect of nurse reimbursement and how organizations can demonstrate the value of nursing.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
