Diana Carter and Professor James E. Kohl, Nursing

Introduction

The ability of registered nurses and healthcare providers to correctly quantify blood and fluid loss is an important factor in providing quality care as it often directs healthcare interventions. Underestimation of blood and fluid loss can lead to delays in treatment and can be detrimental to the patient. Overestimation can lead to needless, wasteful, costly and often times dangerous treatments placing the patient at risk for harm and additional comorbidities. Multiple studies have shown that blood loss is overestimated in small amounts, and underestimated in large amounts. As blood and fluids are lost, the mean arterial pressure may decrease to the point where the patient enters hypovolemic shock (Ignatavicius & Workman, 2012). Therefore, it is crucial that healthcare team members are able to perform accurate estimates of blood and fluid losses.

A limited number of scientific studies have addressed the variance in accuracy of healthcare professionals to estimate external blood loss. Non-healthcare professionals are least likely to accurately judge the loss of blood followed by nurses and then physicians (Tebruegge, Misra, Pantazidou, Maity, Dwarakanathan, Donath, …. & Nerminathan, 2009). Highly trained trauma and emergency physicians also significantly misjudge the loss of blood (Ashburn, Harrison, Ham, & Strote, 2012). There are several methods currently available to evaluate the amount of blood and fluid loss from patients including visual estimation, direct measurement, gravimetry and photometry. While the latter three can be expensive and time consuming visual estimation remains the most common method to evaluate the loss (Schorn, 2009). A more accurate method of estimating loss is the gravimetric method, which consists of weighing collected fluids on pads and other collection materials and then subtracting the known weight of the materials. The error rate in blood/fluid loss estimation between the gravimetric method and nurse estimation is approximately 30% (Hanan, Bedayah, & Hani, 2011).

The initial literature review revealed multiple obstetric studies researching the accuracy of blood loss estimation, but there were few studies estimating blood and fluid loss in the emergency department, intensive care unit, and medical-surgical unit. Nurses and other team members in multiple care settings must be able to accurately estimate the quantity of blood loss from their patients in order to provide quality care.

Methodology

Participants included volunteer student nurses from the Brigham Young University College of Nursing and registered nurses, physicians, and ancillary staff from the emergency, medical-surgical, and OB/labor and delivery floors of various Intermountain Healthcare (IHC) hospitals in Utah County. Individuals who visualize and document the estimation of blood and fluid loss from patients were also included in the study. Individuals were excluded if they did not meet the above criteria. Subjects were recruited through fliers, posters, email, classroom announcements, and a convenience sample during the times of data collection. Consent was obtained through the use of an implied consent from given to the participants. Participants were allowed to withdraw from the study at any time.

On the days of data collection seven scenarios with varying degrees of simulated blood and fluid loss were set up at the college or hospital. The scenarios are as follows: 25 mL of simulated blood spilled onto a 10-pack of 4 x 4-inch gauze pads, 115 mL of simulated blood spilled onto an ABD pad and four 4 x 4-inch gauze pads, 575 mL of simulated blood spilled onto a white sheet, 350 mL of simulated blood spilled onto a white t-shirt, 85 mL of simulated vomit spilled into a bowl, 285 mL of simulated vomit spilled onto a white t-shirt, 145 mL of simulated urine spilled into an adult diaper, and 760 mL of simulated urine spilled into an adult diaper. Subjects were brought into a private room and given a questionnaire asking the following questions: gender, years of clinical experience post graduation, degree and/or certifications, current area of practice, years worked in current area of practice, past areas of practice, years worked in past areas of practice, and their estimated volume of simulated blood and/or fluid in each of the scenarios outlined above. Subjects were told to assess all scenarios alone to avoid influence from other subjects.

Results

Due to delayed IHC IRB approval, the study is still in the data collection stage. Data has been collected from the BYU College of Nursing students and some emergency and medical-surgical nurses. Data collection is scheduled to continue through January 2014. After we have completed our data collection we will use the SPSS statistics software to analyze our data. With the assistance of a statistician we will then compare the accuracy among healthcare team members and student nurses in estimating blood/fluid loss. We anticipate that the professional healthcare employees will demonstrate greater accuracy than the student nurses, but that all subjects will overestimate the small volumes and underestimate the large volumes of blood/fluid loss. Upon completion of this project, an updated final report will be submitted discussing the results and implications for future research.

Scholarly Sources

• Al Kadri, H., Al Anazi, B., & Tamim, H. (2011). Visual estimation versus gravimetric measurement of postpartum blood loss: a prospective cohort study. Archives Of Gynecology And Obstetrics, 283(6), 1207-1213.
• Ashburn, J., Harrison, T., Ham, J., & Strote, J. (2012). Emergency physician estimation of blood loss. Western Journal of Emergency Medicine. 13(4): 376-9
• Ignatavicius, D., & Workman, D. (2012). Medical surgical nursing. (7 ed., p. 814). St. Louis, Missouri: Elsevier.
• Schorn, M. (2009). Measurement of Blood Loss: Review of the Literature. Journal of Midwifery & Women’s Health. 55(1): 20-27
• Tebruegge, M., Misra, I., Pantazidou, A., Maity, S., Dwarakanathan, B., Donath, S., Curtis, N., & Nerminathan, V., (2009). Estimating blood loss: a comparative study of the accuracy of parents and health care providers. Pediatrics. 124(4): e729-36