In 2017, nursing and medical providers at the Mayo Clinic Arizona infusion center reviewed institutional policies and practices regarding RN-performed bone marrow aspirations and biopsies (usually performed together as a single, two-part procedure) to ensure we were engaged in safe practice and using an evidence-based approach. Although many publications on bone marrow aspiration and biopsy were identified in a literature search, including articles about advanced practice nurse–led procedures (clinical nurse specialists and NPs), only two were specific to RNs performing bone marrow procedures. One article focused on the use of a battery-powered bone marrow driver system.1 The second described a successful RN-led program in Orlando, Florida, in which 1,975 bone marrow procedures were performed during an 18-month period in 2012–13.2 The Arizona State Board of Nursing published an advisory opinion in 2015, indicating that bone marrow aspiration and biopsy are within the scope of an RN's practice if specific criteria are met3; however, other state boards of nursing don't specify whether bone marrow procedures are within RNs’ scope of practice. Therefore, to supplement the limited available evidence, we conducted an in-depth program review at our institution, which we present here to assist other institutions and state boards seeking to implement RN-performed bone marrow procedures.
Bone marrow procedures are invasive, requiring access to the marrow space to withdraw bone marrow (aspirate), a bone core (biopsy), or both. These procedures are performed for the purposes of diagnosis, staging, and monitoring of hematologic diseases, such as leukemia, lymphoma, myeloma, and amyloidosis, as well as myelodysplastic syndromes and myeloproliferative disorders. They may also be performed for nonhematologic indications, such as unexplained fever or disseminated infection.
A trained and competent health care provider with a thorough understanding of anatomy, physiology, and potential adverse events, such as infection, bleeding, and nerve and tissue damage, performs the bone marrow procedure.4 The preferred site is the posterior iliac crest, with the patient placed in a prone or side-lying position. Although other sites such as the anterior iliac crest or sternum may be used, these are discouraged because of the increased risk of procedural trauma.4 Generally, only a physician may access the sternum for bone marrow examinations. The patient is typically offered a local anesthetic or oral or iv sedation to allay discomfort and anxiety. The provider makes a small incision (1 to 2 cm) over the selected site and uses a bone marrow biopsy needle—manually or with a power driver—to penetrate through the incision and tissue and into the periosteum and cortex.4 When the bone marrow needle is in the marrow cavity, the provider removes the stylet from the hollow center of the needle and attaches a syringe to withdraw liquid marrow (aspirate). The provider then withdraws the needle a little and redirects it, rotating the hollow device through the bone to obtain a 1.5 to 2 cm core biopsy.4
Rationale for RN-performed procedures. Physicians, physician assistants, NPs, and clinical nurse specialists frequently perform invasive procedures such as bone marrow aspiration and biopsy; however, these procedures require dedicated time away from the clinic and from caring for acutely ill patients at the hospital. Each year, more than 1,000 bone marrow procedures are performed at our institution. A single procedure requires the use of multiple resources, including personnel, space, and time. In our program review period (2010 through 2017), the average duration of each procedure was 13 minutes, equal to a minimum of 217 hours of provider time annually. Notably, this estimate does not account for the additional time required to obtain informed consent, to position the patient, to identify appropriate anatomical landmarks, and for postprocedure recovery. According to the Bureau of Labor Statistics (BLS),5 in 2017 the mean hourly wages for an RN and a physician were $34.70 and $97.04, respectively (the BLS updates these data annually); therefore, RN-performed procedures could have saved our institution at least $13,528 that year.
The Institute of Medicine's 2011 report The Future of Nursing: Leading Change, Advancing Health detailed many ways in which nurses can work to transform the health care system and achieve better patient-centered care. The report's first “key message” is: “Nurses should practice to the full extent of their education and training,” and it notes that “the constraints of outdated policies, regulations, and cultural barriers, including those related to scope of practice, will have to be lifted.”6 RNs are highly trained professionals who are capable of performing specialty procedures, as highlighted by a recent article on RN-performed lumbar puncture.7 Additionally, using a small team of nursing proceduralists (those trained in performing a specific procedure) provides a unique opportunity to improve consistency in practice, which may result in better quality control and, ultimately, boost patient safety.
Before 2000, another hospital in our health care system successfully implemented a program in which RNs performed bone marrow procedures. In the late 1990s, our hospital implemented selective RN-performed bone marrow procedures after an oncology nurse proposed the practice change; at that time, physicians and advanced practice nurses were becoming increasingly busy in both inpatient and ambulatory clinics, and they had limited ability to perform procedures in a timely manner. By 2008, hospital leadership realized nurses were performing these procedures successfully and safely, and they elected to implement a fully RN-led clinic; today, the majority of bone marrow procedures are performed in this clinic. By enabling RNs to work to the full extent of their scope of practice, more patients gained access to care and our institution saved on the costs associated with more highly paid providers.
Our hospital-based infusion center has 25 treatment bays and 41 RNs who work rotating 12-hour shifts. The infusion center offers patient services including collecting blood samples for laboratory tests, providing infusions and peripherally inserted central catheter (PICC) insertions, and bone marrow aspiration and biopsy. All nurses are trained to work in the infusion center, and nurses are further expected to cross-train in at least one specialty area, such as PICC placement, care for blood and marrow transplant patients, or bone marrow aspiration and biopsy. Staff members select their own specialties; however, nursing leadership approves all choices before training begins. As of 2018, 15 RNs had been trained and were competent to perform bone marrow procedures.
The infusion center has a dedicated space for bone marrow procedures, which includes three private rooms with stretcher beds plus the necessary procedural and monitoring equipment. An electronic calendar is used to schedule up to eight patient procedures per day, Monday through Friday. Each appointment slot includes time for patient preparation, obtaining informed consent, performing the procedure, and patient recovery. One additional procedure slot is reserved each day for emergent patient cases (to rule out acute leukemia, for example).
Interventions. After an RN is identified as a new member of the bone marrow team, the infusion center's RN team leader initiates training, which is then overseen by the center's nursing supervisor. In accordance with the Arizona State Board of Nursing advisory opinion, training includes didactic and supervised practice elements.3 The new RN team member starts with a prework assignment, which consists of a thorough review of all bone marrow procedure orders, policies and practices, the informed consent process, and applicable research protocols for the institution. After completion of the prework assignment, the team leader initiates didactic training, which includes an in-depth overview of anatomy and bone marrow function and instruction on how to perform the bone marrow procedure. Didactic sessions also cover other principles, such as medications (local anesthetics and oral and iv sedatives, for example) and appropriate documentation.
Hands-on training, which begins after completion of the didactic instruction, includes two phases. The first phase is simulation training with a bone marrow needle, a powered driver, and an artificial bone block. A skeleton model is used to demonstrate manual identification of the pelvis and appropriate anatomical landmarks. In the second phase, the new RN is assigned to work with an experienced bone marrow procedural RN who serves as a preceptor. A minimum of 10 procedures must be successfully completed with the preceptor's direct supervision before the RN performs a final supervised procedure with the RN team leader. Once the RN team leader agrees that the new RN has successfully demonstrated competency, the RN may perform bone marrow procedures independently. Competency is documented via an electronic competency checklist that is subsequently included in the RN's employment file. Figure 1 shows the checklist used to document that all training items have been completed.
The bone marrow team uses an Excel spreadsheet to track quality and practice data for all procedures. The spreadsheet was established to validate practice when the nurses first started performing bone marrow procedures, and it evolved over time as the program became more robust. Initially, data such as the date of the procedure, name of the RN performing the procedure, patient location (inpatient or ambulatory clinic), patient position (prone or side-lying), pain rating, and complications (intraprocedure or postprocedure) were included.
In January 2016, the nurse manager and team leaders reviewed the spreadsheet and added additional elements to capture patient characteristics, procedure start and stop times, anatomic location and laterality of procedure (left, right, or bilateral), and hematopathology specimen quality ratings. The nurse manager added the specimen quality ratings for tracking and trending purposes and to provide RNs with consistent feedback about the clinical adequacy of the specimens they obtained. Prior to this, the hematopathologist had been completing clinical review of samples and documenting them in the patient's electronic health record (EHR) without necessarily commenting on specimen adequacy. To improve communication and ensure consistency, the hematopathologist established specific criteria for aspirate and biopsy samples. A good biopsy specimen was greater than 1.5 cm in length with no artifacts, whereas an inadequate specimen was insufficient for diagnosis. A good aspirate required more than two particles present and evenly distributed on all stained slides, whereas an inadequate aspirate had no bone marrow cells and the specimen was clotted or otherwise insufficient for diagnosis. The RNs now receive written feedback about the adequacy of specimens for every bone marrow procedure performed. This practice has allowed us to track potential issues, such as whether specimens are inadequate as a result of a disease process or procedural technique. By providing regular feedback to all procedural nurses, the team identified practice and education gaps. The team also initiated routine multidisciplinary education sessions and quarterly reporting of quality data to the RN team members and other key stakeholders (including institutional nursing leadership councils).
Measures. The spreadsheet was used to track the total number of procedures performed, procedure duration, basic patient characteristics, patient satisfaction with preprocedure education, complication rates, and the quality of the aspiration and biopsy specimens. Because additional elements were added to the spreadsheet in January 2016, as described above, we only have data on these variables from that time.
An RN was assigned to complete an in-depth chart review of the procedures performed in 2016. The nurse manager reviewed and cross-checked the data the RN collected. When appropriate, the hematopathologist was consulted to provide clarification, such as when the RN identified information in the EHR that seemed incongruent with the information on the spreadsheet (a certain diagnosis, for example). The nurse manager worked with the RN to review the chart and discuss findings, and the hematopathologist independently reviewed the EHR and provided final clarification. The data from this chart review were used to capture data for diagnoses and disease groups.
Analysis. Discrete or categorical data included patient diagnosis, patient sex, procedure location, specimen quality ratings, patient satisfaction ratings, and postprocedure complications. Continuous data included patient age, procedure duration in minutes, number of procedures completed annually, and pain levels before and after the procedure. Together, these data represented the safety and quality of the program and facilitated our review of the nursing practice.
Ethical considerations. This retrospective program evaluation was deemed exempt from review by our institutional review board.
From January 2010 through December 2017, RNs performed a total of 10,867 bone marrow procedures in the infusion center. During this period, patient satisfaction ratings were monitored; specifically, we asked patients to indicate their satisfaction with the education provided before the procedure, which included what to expect during the procedure, the potential adverse effects, and postprocedure care. Patient satisfaction ratings were recorded as excellent, satisfactory, or poor. Each year, more than 80% of patients rated their satisfaction as excellent; more than 90% reported excellent satisfaction for five consecutive years.
The number of patients with postprocedure bleeding or a need for urgent medical care within 24 hours of the procedure is represented in Figure 2. The numbers were consistently low in both categories. In 2013, we noted a slight increase in patients seeking care within 24 hours of the procedure; as a result, the nurses received additional education on procedure technique, which successfully decreased postprocedure issues. From 2010 through 2017, 25 patients (less than 1%) had postprocedure bleeding that required a dressing change before the patient left the clinic (notably, in 2015 there were no cases of immediate postprocedure bleeding), and 70 patients (less than 2%) required urgent medical care within 24 hours after the procedure. Reasons for urgent care were tracked closely, and in many cases the patient's need for such care was not related to the bone marrow procedure itself but to another medical issue, such as side effects of prescribed medications or neutropenic fever. Any time a potential procedural issue was identified, the nurse manager implemented an action plan, which usually consisted of notification and education for the procedural nurse or nurses involved.
Although patients may have had pain from causes unrelated to the bone marrow procedure, pain ratings were monitored before and after the procedure. All pain scores were obtained by using a standard pain scale (possible scores ranged from 0 to 10). The RN who performed the procedure obtained a preprocedure pain score when the patient arrived at the clinic and a postprocedure pain score immediately after the bandage was applied and the patient was repositioned to supine in bed. More than 90% of patients rated their preprocedure pain between 0 and 4, and more than 95% of patients rated their immediate postprocedure pain between 0 and 4. Less than 2% of patients rated their pain 5 or higher after the bone marrow procedure. Patients were also asked to rate their pain 24 hours after the procedure, and these ratings were similar to those given immediately after the procedure, with more than 90% of patients rating their pain between 0 and 4.
In 2016, RNs completed a total of 1,480 bone marrow procedures. Patients’ mean age was 61.1 years (SD, 13.9; range, 18 to 92 years), and 1,313 procedures (88.7%) were completed in the ambulatory clinic. Rarely, based on urgent patient need, the team performed bone marrow procedures in the inpatient clinic (160 procedures, 10.8%) or in the operating room (seven procedures, less than 1%). The operating room was used only when patients had a previously scheduled surgery that was concurrent with the bone marrow procedure. The average duration of each procedure was 13 minutes (range, seven to 75 minutes), as measured from the time of local anesthetic administration through postprocedure application of the bandage. Occasionally, procedures required an extended length of time (more than 30 minutes, for example) for reasons such as difficulty penetrating the bone cortex, difficulty collecting the marrow aspirate or bone specimen, patient discomfort during the procedure, and bilateral or research study procedures that required multiple specimens.
In 2016, we had diagnostic data for 979 (66.1%) of the 1,480 patients; data for the rest of the patients were missing or unknown, or multiple diagnoses made those patients difficult to categorize. That year the most common diagnoses were leukemia (n = 173, 17.7%), myeloma (n = 170, 17.4%), myeloproliferative disorders (n = 120, 12.3%), myelodysplastic syndrome (n = 77, 7.9%), lymphoma (n = 66, 6.7%), plasma cell disorders (n = 48, 4.9%), and polycythemia vera (n = 7, 0.7%). In some cases, follow-up testing after successful treatment showed no evidence of disease (n = 318, 32.5%).
RNs consistently obtained bone marrow specimens that were adequate for clinical review. The RN team established the expectation that at least 95% of specimens would be deemed clinically adequate for evaluation. In 2016 and 2017, a total of 2,893 bone marrow samples were obtained by RNs and reviewed by the hematopathologist. In 2016, more than 98% of aspirate samples were adequate for clinical review, and in 2017 the quarterly average of clinically adequate samples exceeded 97%. Similarly, the data for biopsy specimens showed that the RN team had obtained a high proportion of clinically adequate samples (99% in both 2016 and 2017).
This program review shows that the bone marrow procedural team developed a robust program that includes specific methods for training, monitoring, and giving feedback. Team members are selected and approved by nursing leadership. Training continues to be multifaceted and includes didactic, hands-on, and supervised clinical practice. Nurses who perform bone marrow procedures receive direct feedback on all specimens from the clinical hematopathologist, and they can discuss procedural issues and receive real-time education as needed. The team routinely reviews quality data to facilitate ongoing practice improvement efforts. The results underscore the team's history of safety and high quality of care, with nurses consistently obtaining clinically adequate specimens and achieving high rates of patient satisfaction and low rates of complications and adverse events.
Benchmarks for rates of adequate specimen quality are difficult to ascertain from the literature because of heterogeneity among medical centers. The International Council for Standardization in Hematology's guidelines describe standard collection, preparation, and reporting processes, but they do not describe rates for benchmarking.8 The World Health Organization's guidelines for classification of myeloid neoplasms recommend including a core biopsy specimen of at least 1.5 cm in length,9 but likewise, do not include performance rates. In terms of procedure-related morbidity and mortality, the literature suggests that the overall rates are low. In a report published in the United Kingdom, Bain reviewed 54,890 bone marrow procedures; the most common adverse events were hemorrhage (14 events, including one death), needle-related incidents such as intraprocedural breakage (7), and infection (3).10 Valebjørg and colleagues reviewed 184 procedures and identified 18 patients with moderate bleeding and two incidents of secondary bleeding after discharge; however in all patients, bleeding stopped with manual pressure.11 As described above, in our experience with 10,867 procedures, the RN team had 25 patients with bleeding and 70 who sought urgent medical care within 24 hours of the procedure (regardless of whether the care was directly related to the bone marrow procedure).
We noted that a particular strength of this program is the relationship and communication between the nursing and laboratory staff, including the hematopathologist. All team members recognized the process as a team effort, rather than thinking of her or his role as singularly important. The team has created a bond that facilitates open and honest discussion, particularly regarding opportunities for improvement. Additionally, the lead hematopathologist continues to be strongly supportive of the nurse-led procedure team and allocates time to ensuring its success through routine meetings with nursing leadership, direct education of procedural nurses, and participation in group quality improvement sessions. The team initially had annual meetings with the hematopathologist, but these are now held quarterly. Topics of discussion have included case reviews, discussions on technique, and team workflows.
Limitations. This program description may have limited generalizability because it is an RN-led program in an adult-only tertiary care facility that includes inpatient, ambulatory, and procedural services in a single location. The facility has large hematology, oncology, and infectious disease practices, with more than 30 physicians on staff. Elsewhere, resources (such as staff and space) and patient demand for bone marrow procedures may vary widely by location and health care system.
In this retrospective review, data collection presented several challenges. The spreadsheet dated back to RN-led bone marrow procedures conducted in the early 2000s. For the purposes of the review, we looked at data from 2010 onward. However, several elements had been tracked only since 2016, which created inconsistencies in the available data. Individual chart reviews would have been required to capture some of the elements, such as patient diagnosis, for example, which was not included in the spreadsheet initially but was an important element of our programmatic review.
Nursing implications. The ability of RNs to perform invasive bone marrow procedures and the institutional support they receive for doing so varies by state. Many state nursing boards are silent on whether this practice is within an RN's scope of practice. Although several states have posted practice advisories specifying what RNs may and may not do, most do not name specific procedures, such as bone marrow biopsy. Further, at least five states do not have any advisories for nurses to consult. Arizona's board posts a clear, specific advisory opinion on the state nursing board's website, and it includes details of expected training and supervised practice to demonstrate competency.3
We advise RNs who live in a state that has not deemed bone marrow procedures to be within a nurse's scope of practice but who are interested in pursuing this practice—or any other practice not currently supported—to take a well-organized approach. We suggest the following steps: identify key stakeholders within the organization to discuss the feasibility of the proposed practice change; include patient needs, resources, costs, and potential cost savings in your discussion; gather materials describing procedural steps; develop an in-depth training and recruitment plan; and only then, having covered these preparatory steps, approach the state's board of nursing. Boards vary in operational style, and each state may have a different method to determine scope of practice. In Arizona, any nurse who has a question regarding scope of practice may begin by submitting an online query through the board of nursing's web page. The nurse may be asked to attend a scope of practice committee meeting and provide a presentation to augment the discussion of whether the specific practice in question should be included in an advisory opinion.
As health care becomes increasingly complex, nurses must lead the way in developing innovative practices and expanding their scope of practice. Access to health care continues to be a national issue complicated by many factors, including limited provider availability. Despite limited evidence in the literature supporting the practice of bone marrow procedures performed by RNs, our program review demonstrates that implementing a nurse-led bone marrow procedural clinic can increase access to provider care and support the principle of allowing nurses to work to the full extent of their practice.