Psychiatric Bulletin (2004) 28: 120-122. doi: 10.1192/pb.28.4.120
© 2004 The Royal College of Psychiatrists
Psychiatric Bulletin (2004) 28: 120-122
© 2004 The Royal College of Psychiatrists
Domiciliary phlebotomy for elderly people with mental illness
Malcolm Darley, Consultant Psychiatrist
Mersey Care NHS Trust, Liverpool
Catherine Siller, Medical Student
University of Liverpool
David Anderson, Consultant in Old Age Psychiatry
Sir Douglas Crawford Unit, Mossley Hill Hospital, Park Avenue, Liverpool
L18 8BU.Tel: 0151 250 6060; fax: 0151 729 0227
Declaration of interest
None.
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Abstract
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AIMS AND METHOD
This paper reports the evaluation of a pilot domiciliary phlebotomy service
provided by an old age psychiatry service to enhance the management of
patients in their own homes. Clinical and demographic data were collected and
the costs of phlebotomy home visits compared with those of ambulance
transport.
RESULTS
Of 511 phlebotomy visits made to 307 patients, only 8% were unsuccessful. A
subgroup analysis indicated that 70% of patients would have been unable to
leave home unaccompanied to attend for venepuncture. The cost of the
phlebotomist’s travel was comparable with the estimated cost of
providing ambulance transport for patients who would have required it.
CLINICAL IMPLICATIONS
Domiciliary phlebotomy can be a viable method of performing blood
investigations in an old age psychiatry service to support home
assessment.
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Introduction
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Old age psychiatry has seen a move in recent years towards the assessment
and management of people in their own homes and away from traditional
hospital-based out-patient visits in the belief that domiciliary clinics
enhance clinical assessment (Benbow,
1990). Blood investigations are a frequent aspect of these
assessments and require the patient to attend a hospital or general practice
clinic for venepuncture. To support this change in practice, we established a
domiciliary phlebotomy service to remove the need for attendance at hospital
or health centre purely for blood investigations. The taking of blood samples
in patients’ homes has been described as an adjunct to home care
services for older people and as a service to haematology patients (MacKenna
& Niles, 1995).
Establishment of the service was assisted by the enthusiasm of the
phlebotomists to develop their role and their recognition of the inefficient
use of phlebotomy time in hospital clinics. However, there were initial
concerns that the phlebotomists might be mistaken for doctors carrying drugs
of potential misuse and thus be at risk in the community. To reduce this risk,
a case resembling a sports bag was used to carry equipment and samples. It was
established that the National Health Service (NHS) Trust’s insurance
would cover the new service. A request form was introduced, stating the
patient’s name, address, date of birth, investigations required and any
additional information to assist the phlebotomist, e.g. contact points,
directions to a difficult address and notes about unusual circumstances. The
phlebotomist recorded the length of journey, whether the visit was successful,
any difficulties encountered and sometimes clinical feedback. If requested,
the patient was contacted by telephone before the visit. This paper describes
the development of the service and its activity during the first 20
months.
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Method
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A pilot scheme for the patients of one consultant (D.A.) was subsequently
extended to all patients of the Mersey Care NHS Trust’s old age
psychiatry service (four consultant teams). The phlebotomy clinic occupied one
session of phlebotomy time each week. All referrals for domiciliary phlebotomy
in the first 20 months were included. The referral form was used to provide
patient and visit data.
A sample of patients representing all referrals from one consultant (D.A.)
was analysed in more detail. Information was obtained from reviewing the case
notes and from the consultant’s personal knowledge of the patients.
Psychiatric diagnoses were made using ICD-10 criteria
(World Health Organization,
1992). Medical problems causing significant functional impairment
and the patients’ social circumstances were also recorded.
It was important to establish whether the patients would have been able to
attend a hospital phlebotomy clinic, so an assessment was made of how patients
would have travelled to hospital had it been necessary to do so. This was
recorded as ‘independent travel’, ‘escorted by
another’ or ‘hospital transport’. An assessment was also
made of whether the patient was housebound; for the purpose of this report,
this was defined as the person being unable to leave home unaccompanied to
complete purposeful tasks. Whether this inability was due to physical or
psychiatric reasons (e.g. dementia or agoraphobia) was also recorded.
The phlebotomist’s travel expenses were compared with the predicted
cost of ambulance transport for patients who would have needed it to attend a
hospital clinic. The phlebotomist’s time was already contracted for on a
sessional basis and the only additional cost was the purchase of a carrying
case. At the time of the study, travel costs were reimbursed at an average of
£0.39 per mile, and the cost of a return ambulance journey was
£10.36.
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Results
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During the study period, 511 visits were made to 307 patients; 376 visits
were to women (female:male ratio 2.8:1). The age and gender distribution is
shown in Table 1. The
phlebotomy visit was unsuccessful in 41 instances (8.0% of visits). On 34
occasions, the patient was not at home, four patients were in hospital and
three refused to have blood taken. Four patients accounted for 20 (49%) failed
visits.
A sample of 105 patients under the care of one consultant (D.A.) were
examined in more detail. These patients accounted for 240 visits - almost half
of the total. Their psychiatric diagnoses and medical disorders impairing
function are listed in Tables 2
and 3. Of this sample, 33
patients lived alone, 35 with another person, 29 in nursing or residential
homes, 6 in sheltered accommodation and 2 in group homes for the mentally ill.
By the definition used for this study 74 (70%) were considered housebound: 38
for psychiatric reasons, 13 for physical reasons and 23 for both. Thirty-one
(30%) patients would have been able to attend a hospital clinic independently;
15 (13%) would have been unable to attend unaided but had family or carers who
could convey them; 59 (56%) were in neither category and were considered in
need of transport by ambulance.
The total distance travelled by the phlebotomist during the study period
was 730 miles (1.4 miles per visit), incurring a cost of £285
(£0.39/mile). The 59 patients who were predicted to have required
ambulance transport would have incurred a transport cost of £611
(£10.36 per return journey). If this consultant activity were
representative and were applied to the total study population, then 125
journeys would have required ambulance transport at a cost of £1295,
producing an estimated financial saving in travel costs during the study
period of £1010.
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Discussion
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This descriptive study demonstrates the feasibility of providing
domiciliary phlebotomy as part of a community old age psychiatry service.
The failure rate of visiting was low (8%) compared with the non-attendance
rate of 21% for out-patient appointments in the department’s hospital
clinics over the same period. Over four-fifths of the failed visits (34/41)
occurred because the patient was not at home. This does not mean that these
patients would have been capable of attending a hospital or health centre; for
example, the patient might only be able to go short distances or complete
simple journeys. In fact, four patients were responsible for half of the
failed visits and for the vast majority the service was effective.
The phlebotomists felt that most patients preferred the domiciliary
arrangement. This impression is supported by a satisfaction survey conducted
by the phlebotomist of 40 patients, all of whom were equally or more satisfied
with the home service. Patients appreciated the convenience of being seen at
home, compared with the difficulties of attending out-patient departments.
There might also be benefits for relatives and carers who would no longer need
to convey patients to hospital.
A marginal financial saving was calculated for travelling costs in this
particular service. Our predicted use of ambulance transport may be an
underestimate, as Benbow (1990)
reported that this was required for 79.6% of hospital clinic appointments.
However, travelling costs are only one element of the cost of the service. The
purpose of this study was to establish the feasibility of domiciliary
phlebotomy, and it does not claim to demonstrate cost-benefit. Furthermore,
the catchment area of the study is a geographically small inner-city and urban
district, and findings may not apply to large or rural areas.
No practical difficulty was experienced in transporting samples and
anticipated problems did not materialise. Indeed, phlebotomists found this
method of working rewarding and began passing on clinical information to the
doctors about patients they had become used to visiting.
Domiciliary phlebotomy is a logical and feasible development to support the
management of patients in their own homes. In our experience, the number of
failed visits can be minimised by the phlebotomist always visiting on the same
day, and making telephone contact before visiting patients who have had a
previous failed visit.
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References
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BENBOW, S. M. (1990) The community clinic:its
advantages and disadvantages. International Journal of Geriatric
Psychiatry, 5, 119
-121.
McKENNA, D. & NILES, S. A. (1995) Venepuncture: an
adjunct to home care services for older adults. Geriatric
Nursing, 16, 208
-212.[Medline]
WORLD HEALTH ORGANIZATION (1992) The ICD-10
Classification of Mental and Behavioural Disorders. Geneva:
WHO.
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Abstract
Introduction
