Phlebotomy Today

Center's YouTube Channel Hacked

NOTE: If you are not one of our YouTube subscribers, you may disregard this notice.

Friends,

It has just come to our attention that the Center for Phlebotomy Education's YouTube Channel has been pirated by a hacker in Singapore. It is no longer under our control. Since many of our newsletter subscribers also subscribe to our YouTube Channel, this is the only way we can notify our YouTube subscribers to be wary of any emails from YouTube about our Channel.

Just this morning, the hacker sent emails to all of our YouTube subscribers announcing new videos have been uploaded. If you received such an email from NOREPLY@YOUTUBE.COM announcing new videos to our channel ,  DO NOT CLICK ON ANY LINKS IN THE YOUTUBE EMAIL.

We have taken aggressive steps to recover our channel. While YouTube has terminated the channel upon our notification of suspicious activity, the hacker is still sending emails to our YouTube subscribers.

This does not affect your Phlebotomy Today newsletter subscription, just our YouTube channel. 

We regret that this has happened to our valued YouTube subscribers and apologize for any inconvenience. We hope to have our YouTube channel reinstated and will let you know when that occurs in a future issue of Phlebotomy Today. 

Again, if you are not one of our YouTube subscribers, you may disregard this notice.

 

Respectfully,

Dennis J. Ernst, editor

Is Your Draw Station Designed for Safety?

Too often outpatient draw stations are designed for looks, convenience, or available space rather than the safety of the patient or collector. Are your draw stations designed for your convenience at the expense of your patients' safety? Take a look at them with fresh eyes and consider how their layout, design, and furnishings may be inviting a preventable incident or injury.

Designing drawing rooms with the input of phlebotomists and others who use them afford the collector with the safest drawing environment possible. But there's one more critical source to consult: the industry standards for draw stations. Are your draw stations compliant or a liability? Do they work for or against your patients? Do they invite or prevent injuries and accidents? Use this checklist to see how you can improve your outpatient drawing environments and limit your legal liability.

• Arm rests. Do all of your outpatient drawing chairs have armrests? They should. According to the Clinical and Laboratory Standard Institute's venipuncture standard (GP41-A7), side armrests are required to prevent accidental falls should the patient lose consciousness.(1) If you draw from patients seated in chairs without armrests, discontinue the practice today. Replace unacceptable chairs with those that have at least two armrests, one on each side. Although not required, a third barrier that locks in place in front of the patient provides even more protection.
       If you draw patients sitting upright on a hospital bed or exam table, have them recline to a recumbent position instead. Drawing patients who are sitting upright on tables, hospital beds, or cots fails to meet the standard, and creates a dangerous situation should they lose consciousness. Statistics show that up to five percent of patients pass out during or immediately following a venipuncture. Unfortunately, they don't come with warning signs. The standards also require patients with a history of fainting be recumbent during the draw. This is not negotiable, not even if the patient refuses to recline. 
       It is not advisable to ask patients if they've ever fainted. Studies show the mere mention of the word "faint" doubles the likelihood that they'll pass out during or following the draw. Instead, inquire if they've ever had any "problems" with prior blood draws.  
  
  
• Reclining chair, cot or gurney. If your outpatient phlebotomy chairs don't recline, is there a bed, cot, or gurney nearby for patients who need to lie down during the draw? If not, how are you complying with the CLSI requirement for patients who tell you they have a history of passing out during a blood draw? What about a patient who needs to be restrained for whatever reason? Having reclining phlebotomy chairs in every draw station or a place for patients to lay is not only a good idea, it's good risk management.
  
• 
  The layout. Being fully prepared means not only seating patients in chairs with armrests or reclining them, but being vigilant at all times. This means not turning your back on the patient or distancing yourself from them so that you cannot react in a timely manner. If your supplies are more than an arm's reach from the patient, you are creating at least two potential problems, both of which put the patient at risk. First, should you need another tube the room's layout puts you in a precarious position. You may well have to terminate the puncture and repeat the procedure resulting in an inconvenience to the patient, the loss of confidence from the patient, and your own lost productivity. Even worse, you may be tempted to stretch to such an extreme degree that the needle within the patient's arm lacerates tissues and structures beneath the skin. Both of these options are undesirable.
       Secondly, if the area is designed in such a way that requires the collector to leave the side of the patient to label the tube or discard of the needle, the collector is no longer able to react in a timely manner should the patient lose consciousness. Without being within arm's reach, a patient can quickly pass out, fall from the chair and suffer injuries. Being vigilant means being within arm's reach of the patient until he/she is released from your care.
  
  
• Ammonia inhalants. Do you have ammonia inhalants within reach of the draw chair? If so, remove them. CLSI doesn't permit their use on patients who get dizzy or pass out due to the risk that they may be asthmatic. If so, and you use ammonia to revive them, you may trigger an asthmatic attack.
  
  
• Squeeze toys. Do your draw stations have rubber balls or other devices patients can squeeze to make their veins more visible? If so, get rid of them before one of your patients is treated according to a falsely elevated potassium level. Fist pumping has been shown to increase potassium levels up to 2.7 mmol/L.(2) Have your patients clench and hold their fists, but only when necessary. Never ask patients to pump the fist if the blood you are drawing will be tested for potassium. If fist pumping is required to locate a suitable vein, release the tourniquet after finding the vein and allow two minutes to pass before reapplying constriction. This will allow the blood in the limb to return to its basal state.
  
  
• Being well-stocked. Do your draw stations include a wide variety of tube sizes? They should. If you limit the volume of tubes accessible, you limit your potential to draw the difficult patient successfully. Should the patient's vein collapse under the excessive pressure a large-volume tube exerts, a well-stocked collection of supplies will permit you to remove the slowly filling tube from the tube holder and replace it with a smaller tube with lesser vacuum. The ultimate objective is to submit full tubes to the laboratory so that the tests aren't affected by an excessive concentration of additive. Since some patients prove to be unpredictably difficult to fill large-volume tubes from, an ample supply of smaller tubes might save you both from a second attempt.
  
  
• Sharps containers within reach. Draw station safety isn't just about the patient. Protecting the collector should take equal priority. If the sharps container is not within reach of the point of use, the area isn't engineered for exposure prevention a well as it could be. According to OSHA's Bloodborne Pathogens Standard, a sharps container must be "as close as is feasible to the immediate area where sharps are used...." Having to carry a contaminated sharp across the room, or from one room to another, increases the window of vulnerability a healthcare worker has to an exposure.(3) Even if the sharp is concealed by a safety feature that was activated immediately, its disposal should be just as immediate. According to OSHA's Compliance Directive (the document it issues to inspectors in the field to interpret and enforce the standard) "if an employee must travel to a remote location to discard a sharp, it will increase the possibility of an accidental needlestick and increase the chances that needles and sharps will be improperly discarded and create potential hazards for other staff members."(4)
  
  
• Call button. Is there a mechanism for phlebotomists or other specimen collection personnel to call for help should a routine draw develop complications? Call buttons or assist lights are good ideas for draw stations that may be remote to other personnel who may be needed during emergencies.
  
  
• A clean well-lit place. Don't underestimate the importance of good lighting that can facilitate an uneventful draw. Often lighting is the least-considered factor when designing or reevaluating draw stations. However, specimen collection personnel operating under good lighting conditions likely have fewer complicated draws. In addition, a well-lit drawing area can give the patient the impression that he/she is in a cleaner, more professional facility than one that is dimly lit and shadowy.
  
  
• Sink for handwashing. Do your draw stations permit easy compliance with the prevailing recommendations on handwashing? OSHA and the Centers for Disease Control and Prevention (CDC) require that collectors perform hand hygiene immediately or as soon as feasible after gloves or other personal protective equipment are removed.(3,5) While the use of hand gels are acceptable, soap and water are required if the hands are visibly soiled with blood or other potentially infectious material or if the patient is known to be infected with spore-forming bacteria such as B. anthracis or C. difficile. Therefore, a handwashing sink must be accessible.
  
  
• Housekeeping. It’s the employer’s responsibility to ensure the work site is maintained in a clean and sanitary condition. A well designed draw station means materials used are of such a nature that they can be regularly cleaned and decontaminated. Carpet, porous surfaces, and cloth chairs provide a considerable challenge to maintaining a sanitary environment. If your draw station is carpeted, contaminated areas should be easily and readily replaced.
  
  
• Did you hear that? Is your drawing area in a dedicated room or is it incorporated into other areas? Without a dedicated area for specimen collection, facilities run the risk of trampling on their patient's privacy rights. When a patient interaction is overheard by other employees or visitors, confidential information may be inadvertently passed on, which can be a violation of the Health Insurance Portability and Accountability Act (HIPAA). Safety includes protecting a patient's right to privacy.
  
  
• Elbow room. Another potential problem of incorporating a drawing station into areas used for other purposes is the effect that traffic can have on the procedure. Make sure your drawing area is well away from those who might pass by and accidentally bump a collector trying to steady a needle within someone's vein.
  
  

Whether you're a manager, safety officer, or phlebotomist, take a walk around your outpatient drawing areas with new eyes as soon as possible. Consider the list above to be your checklist for safety, compliance and risk management and make any changes as soon as possible. If changes require a significant redesign, expedite a renovation. Most of the items mentioned in this article are more than a matter of convenience and must be addressed if your facility is to be safe, patient-friendly and standard-compliant. 

Editor's Note: CLSI requirements and recommendations for draw stations are included in Standard GP41-A7, accessible from CLSI or the Center from Phlebotomy Education's "Standards"  page.

 

References:

1) CLSI. Collection of Diagnostic Venous Blood Specimens; Approved Standard—Seventh Edition. CLSI document GP41-A7. Wayne, PA: Clinical and Laboratory Standards Institute; 2017.

2) Narayanan S. The preanalytic phase an important component of laboratory testing. Am J Clin Pathol 2000;113:429-452.

3) Occupational Safety and Health Administration. (1991) Occupational exposure to bloodborne pathogens: Final rule. 29 CFR 1910.1030. Federal Register, 56, 64003-64282.

4) Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=2570. Accessed 2/18/08.

5) Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Healthcare Settings. https://www.cdc.gov/handhygiene/providers/guideline.html. Accessed 1/8/2020.

 

Lab Draw Answer Book: New Price for 2020

 

 

What Should We Do?: A twist on drawing blood gases

Dear Center for Phlebotomy Education:

When my staff runs out of ABG syringes, they improvise by drawing the sample with a butterfly needle. When I asked about the air in the line affecting results they observed that even with an ABG syringe some air enters so air in the tubing of a butterfly set shouldn't matter. They claim it's easier to obtain ABG’s this way, especially with combative patients. It won't be long before our respiratory department (RT) takes over ABG collections, and we will be training them. The RT supervisor has never heard of their improvised technique and doesn’t want us to train his staff that way. Neither do I. 

The other wrinkle in all this is that I noticed the CLSI standards state that arterial blood should not be used as an alternative to venous blood due to the concentrations of analytes  being different. When I asked the Chemistry supervisor about this, she couldn’t find anything in Tietz or anywhere about constituents varying. Many of our draws in the ICU come from arterial lines, so I really need to know from you what's the bottom line. I can always count on phlebotomy.com for clarity. What should we do?

Our response:

Whenever we hear the word "improvise" in a procedural context we cringe. There's a standard protocol for every blood collection procedure. When staff starts contriving what they think are better ways to do things, it always has repercussions.

If it were acceptable for your staff to draw ABGs with a syringe/butterfly set, it would be in your procedure manual and the industry standards. If your SOPs reflect the CLSI standards, it's not in either. So not only is your staff going against the standards, but they're going against your procedure manual. Unless you step in, they're about to train RT to do the same. Deviations from the standards and your established procedures should always prompt warnings and discipline. It's hard telling what else they've decided "works better" than your standard protocol. We've seen a lot of renegade techniques over the years. Without exception, they always need to be squelched. Staff simply can't be modifying established procedures.

So if they're drawing ABGs through a butterfly, is a syringe attached or a tube holder? If it's a syringe, how they are heparinizing it? Please don't tell us they're transferring it into a heparin tube or even drawing it directly into a heparin tube with a tube holder attached to the butterfly set. Sending ABGs to the lab in heparin tubes goes against the standards. It's the wrong kind of heparin and exposes the sample to subatmospheric pressure in the vacuum tube, altering results. Not only shouldn't they be submitting heparin tubes for ABGs, the techs should know better than to run them. This must be clearly articulated to not only your staff and techs, but to the RT staff.

As for arterial values that differ from venous values, what you said about the CLSI standard is correct. Arterial blood and venous blood differ in concentration significantly for hemoglobin, RBCs, and hematocrit, packed cell volume, lactic acid, ammonia, plasma chloride and glucose. We included this information with references in our latest book, the Lab Draw Answer Book. We just reduced the price, so get a copy for your other supervisor's, too.

 

Got a challenging phlebotomy situation or work-related question? Email us your submission at WSWDpanel@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)  

 

Product Spotlight: The Whole Phlebotomy Enchilada

For years, the Center for Phlebotomy Education has put everything we've ever created into two subscription-based online platforms: The Phlebotomy Channel and Phlebotomy Central. What's the difference? 

• The Phlebotomy Channel---A library of 17 training and inspirational videos streamed to any computer with a high-speed Internet connection.
  
  
• Phlebotomy Central---This online membership section provides access to just about everything we've ever written, published and produced... except videos.

Now you can get both for the price of one! Effective immediately, all new subscribers to an All-access Pass to the Phlebotomy Channel  get a free one-year subscription to Phlebotomy Central.

This offer is for new Phlebotomy Channel All-Access-Pass subscribers only and ends February 29,2020.

So, if you're not already a Phlebotomy Channel All-Access subscriber, for the rest of the year you and your staff and students can have the  the whole phlebotomy enchillada. That's both subscription-based platforms for the price of one. Whether you're a reader or a watcher, this much is for sure: you'll be infinitely more knowledgeable about blood specimen collection and handling at the end of the year than you are now... unless, of course, you already subscribe to both. 

Simply add both to your shopping cart and the discount will be applied immediately. To subscribe or for more information.

 

Is There a Bully in the House? (Part 1)

What follows is a true story.

Kelly (not her real name) walked into the ICU to draw a stat. While she was there, the lead phlebotomist entered and asked her if she had taken her break. Kelly responded that she hadn't received the lead phlebotomist's text message to do so, as was the protocol. The lead phlebotomist went ballistic in front of the ICU staff, the patients, and their families. To say Kelly was bullied doesn't begin to explain the aggression she endured.

As is typical for bullies, this is not the first time the lead phlebotomist unloaded on Kelly. The Workplace Bullying Institute (WBI) defines workplace bullying as "repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators."¹ How phlebotomists and laboratory personnel interact with each other and with other members of the healthcare team influences job satisfaction and profoundly impacts patient safety. Studies show intimidating and disruptive behaviors, like the display of temper directed at Kelly, set medical errors in motion and increase the cost of patient care and risk of legal liability.²

When disruptive, bullying behaviors lead to breakdowns in communication, patients suffer. Research conducted from 1995 to 2005 found that ineffective team communication is the root cause for almost 66 percent of all medical errors.³ But facilities that have better communication---as would be expected where bullying is not tolerated---function at a higher level in many regards. Studies show when the exchange of information is effective and respectful within and across department lines, not only does the patient benefit, it promotes a culture of safety and mutual support in the workplace, reducing staff turnover and improving job satisfaction.^2,3 

Bullying Behaviors

The Agency for Healthcare Research and Quality (AHRQ) identifies disruptive behavior as any behavior that shows disrespect for others, including any interpersonal interaction that hinders the delivery of patient care. According to Gerald B. Hickson, MD, director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, TN, disruptive behavior can include:^2,4 

• Verbal abuse/outbursts
• Sexual harassment
• Yelling
• Profanity
• Vulgarity
• Threatening words or actions

Bullying can also present as work interference or sabotage, which prevents work from getting done.¹ This can be particularly risky for patients caught in the middle, where accuracy, timeliness and precision in specimen collection, processing and testing are crucial in producing a meaningful test result and proper diagnosis.

Equally harmful and disruptive to patient care are passive-aggressive actions, such as refusing to perform assigned duties or quietly exhibiting uncooperative attitudes during routine activities. Such subtle but deliberate tactics are frequently demonstrated by healthcare professionals in positions of power, with 72 percent of bullies being bosses.^2,5 Kelly's was one.

The Joint Commission, the primary accrediting body for American healthcare organizations, identifies the following as passive-aggressive behaviors:²

• Reluctance or refusal to answer questions
• Failure to return phone calls or pages
• Condescending language or voice tone
• Impatience with questions

Contributing Factors

Why does bullying occur? One reason is healthcare occupations have long been known to be highly stressful compared to many other jobs. Healthcare professionals are exposed to numerous demands, ranging from staffing shortages, time pressures, shift work, budget constraints, and fatigue, all while caring for difficult and ill patients in a high-stakes environment.⁶ Given the pressures, it’s no surprise that individuals who possess characteristics such as self-centeredness, immaturity, or defensiveness are more likely to demonstrate bullying behavior due to their lack of coping or conflict management skills.² Add to the mix unrealistic expectations and fear of lawsuits, and the workplace can quickly become a caustic cauldron of blame and bad behavior. When intimidation and disrespect are allowed to boil over within and among departments, communication and trust erodes, jeopardizing patient safety. 

The Laboratory Perspective

A 2010 survey conducted by the Center for Phlebotomy Education found that over 63 percent of respondents did not feel respected by other healthcare professions.⁷ Reasons given include the perception that phlebotomists and/or laboratory personnel are less educated and are thereby undervalued by other healthcare professions. One surveyed phlebotomist lamented “they never include us or speak to us.” A phlebotomy manager commented that “some nursing and physician staff look upon phlebotomy as beneath their profession.”

Even when credit is due, the laboratory’s efforts in providing quality patient care are sometimes overlooked, as described by one MT (ASCP) phlebotomy supervisor: “Whenever our hospital publishes an article featuring how an ED or surgical patient was successfully treated, there is no recognition of the laboratory’s contribution to the diagnosis or follow-up therapy.” Such attitudes are not only disrespectful, they demoralize. They can also lead to conflict between professions over proper procedures, as illustrated by the following comment from a laboratory assistant: “I represent the lab and lab policies when I draw blood. Many times lab policies are questioned and in some instances nurses and/or doctors refuse to believe and follow them.”

On the Receiving End

So what are the personal effects of bullying on phlebotomists and laboratory personnel? Some tell-tale signs include:⁸

• Feeling sick before your work week starts
• Obsessing about work at home
• Using paid time off for “mental health breaks"

Phlebotomists and other healthcare personnel who are on the receiving end of bullying can experience fear and anxiety, depression, and develop a type of post-traumatic stress disorder leading to psychological harm and actual physical illness.⁹ The cost can be high to both one’s physical health and career. According to a 2007 WBI-Zogby Survey, 45 percent of those targeted by bullies suffer stress-related health problems.¹⁰ A 2010 national survey revealed that two-thirds (66%) of bullied employees had to lose or give up their jobs in order to make the bullying stop.¹¹

Frequency

Unfortunately, menacing behaviors in healthcare environments are not rare. Multiple surveys reveal that the majority of patient care providers have experienced or witnessed bullying in the workplace, with one survey finding 40 percent of clinicians have kept quiet or remained passive rather than question a known bully.^2,5,9 Studies show healthcare workers are 10 times more likely to be assaulted, with bullying being the most common form of violence against women.¹²

While most research focuses on bullying and unprofessional behaviors among doctors and nurses, such conduct is not limited to one gender, and occurs among laboratory staff as well. A British survey of more than 1,000 clinical and administrative healthcare workers found that 44 percent of nurses and 35 percent of other staff reported experiencing "peer bullying" in the workplace within the previous year. Allied health professionals are bullied by doctors, each other and patients.^2,12 Especially upsetting for students and new graduates is horizontal violence, a peer-to-peer form of bullying where senior staff consider bullying a rite of passage during clinical rotations. Among students:¹²

• 53% report they have been insulted;
• 40% report being humiliated;
• 34% report rude, abusive or unjustly critical behavior.

Bullying in the workplace is also a global problem. A worldwide survey found 64 percent of respondents claimed to have been bullied, with Europe having the highest rate at 83 percent compared to 65 percent of Americans.¹²

Kelly brought the lead phlebotomist's aggressive behavior to the attention of her manager to no avail. Her confrontation in the ICU was the last straw. She cleaned out her locker that day and left for good. "I couldn't go on working in a place that allowed such unprofessional behavior to continue," she said.

[Editor’s Note: Next month, we’ll continue with a discussion of the malpractice risk associated with bullying, along with tips for organizations in addressing intimidating and disruptive behaviors in the workplace.]

 

References

1. Workplace Bullying Institute. Definition of workplace bullying. workplacebullying.org/individuals/problem/definition Accessed 1/08/20.
2. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. Issue 40, July 9, 2008.https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-40-behaviors-that-undermine-a-culture-of-safety/ Accessed 1/8/20.
3. Impact of Communication in Healthcare. Institute for Healthcare Communication. July 2011. http://healthcarecomm.org/about-us/impact-of-communication-in-healthcare/ Accessed 1/8/20.
4. Hernandez, JS. Confronting Conflict in the Lab. How Managers Can Curb the Effects of Disruptive Behavior. Clin Lab News. July, 2011; 16-17.
5. Workplace Bullying Institute & Zogby International. U.S. Workplace Bullying Survey. September 2007. http://workplacebullying.org/multi/pdf/WBIsurvey2007.pdf Accessed 1/8/20.
6. Centers for Disease Control and Prevention (CDC). Exposure to Stress: Occupational Hazards in Hospitals. http://www.cdc.gov/niosh/docs/2008-136/pdfs/2008-136.pdf Accessed 1/8/20.
7. Center for Phlebotomy Education, Inc. Survey Says: Respect from Other Healthcare Professions. Phlebotomy Today-STAT! https://www.phlebotomy.com/pt-stat/stat0710.html.  Accessed 1/8/20.
8. Workplace Bullying Institute. Early signs of bullying. http://www.workplacebullying.org/individuals/problem/early-signs/ Accessed 1/8/20.
9. Riggio R. Cutting Edge Leadership. Workplace Bullying: Applying Psychological Torture at Work. Psych Today. http://www.psychologytoday.com/blog/cutting-edge-leadership/201002/workplace-bullying-applying-psychological-torture-work Accessed 1/8/20.
10. Workplace Bullying Institute. Who gets targeted. http://www.workplacebullying.org/individuals/problem/who-gets-targeted/ Accessed 1/8/20.
11. Workplace Bullying Institute. Bullying Contrasted With Other Phenomena. http://www.workplacebullying.org/bullying-contrasted/ Accessed 1/8/20.
12. Dellasega C. Bullying Among Nurses. Am J Nurs. 2009; 109(1):52-8. http://www.nursingcenter.com/prodev/ce_article.asp?tid=1156786 Accessed 1/8/20.
    
    

From the Editor's Desk

Friends,

This month's What Should We Do column reminds me about all the creative and cringe-worthy modifications to the basic venipuncture technique I've heard of over the years. Do you know someone who has introduced you to a new twist to your blood collection technique? Have you devised one yourself? If you're one of the many who have made modifications to the standardized procedure without approval or justification, you may be putting your patient and employer at risk. 

Let's face it. Drawing blood is a standardized procedure. It is based on intense literature research and maintained by a highly respected authoritative body, the Clinical and Laboratory Standards Institute. Every five years, the organization assembles a group of experts in the field from a wide variety of backgrounds to review and revise the standards for drawing blood by skin puncture and venipuncture (among dozens of other laboratory processes).

Calling upon their collective expertise and the published body of knowledge, the working group spends thousands of hours collectively researching, perfecting and updating the standards to reflect the prevailing literature and current thinking. After a standard is revised by the working group, it undergoes intense scrutiny by peer reviewers who work daily in one clinical laboratory capacity or another. Their comments are considered and the standard is further revised. Upon publication, laboratories around the world obtain the document and update their own procedure manuals to reflect the new standard.
     When frontline healthcare professionals take it upon themselves to "improve" this highly refined and well established technique with their own homespun modification, they are thumbing their nose at the expertise of literally hundreds of authorities.

When a departure from the standardized procedure results in injury, or alters test results to a degree that impacts how patients are treated, diagnosed, medicated, and managed, patients suffer and employers can be held accountable for the consequences. So I need to implore you to ask yourself this question: Are my creative blood collection practices placing patients and my employer in jeopardy?

In my latest book, The Lab Draw Answer Book, I devote an entire chapter on "unorthodox techniques"  It discusses 15 quirky, homespun ideas I've heard about that have worked themselves into practice in the real world. There's some real doozies in this chapter, such as:

• Inserting the needle with the bevel down---This makes no sense. Don't try it. The standards say "bevel up." End of discussion.
• Letting blood drip from an arterial line into the tube---This makes the heads of most infection control nurses explode, and it should. Why risk almost certain blood exposure by employing this technique when a syringe will keep the collection system closed? Oh, because you wear gloves and you won't be exposed if blood drips onto your hands? Not so fast. The HIV virus can pass through the micropores of most gloves.
• Double tourniquet technique---Some confused trainers actually teach their students to tighten one tourniquet above the antecubital area and another one around the wrist. This begs the question: why would constricting the blood below the antecubital do anything but minimize the blood in the veins above it? Knowledge is power; a little knowledge is dangerous.
• “Harvard” stick---This technique, obviously created in the dark, portends that if you hold a patient's arm a certain way, then insert the needle in a precise location in the antecubital area, you'll get the vein every time. Mind you it's never been studied, reported, or appeared in any reputable publication. That alone makes it spooky enough for me to put in the book.
• Reopening a skin puncture site for more blood---Believe it or not, someone actually thinks a previously punctured fingerstick or heelstick site can be physically reopened with an alcohol prep to collect more blood instead of using a lancet on another location. This constitutes evidence that not everyone should be allowed to draw blood.
• Smearing petroleum jelly on skin puncture sites---it has been concocted by someone with unbridled creativity that smearing a petroleum jelly product like Vaseline® on the patient's skin prior to the puncture prevents a messy collection. Never mind that the petroleum jelly could contribute to an inaccurate test result. Somebody go get the bridle.
• Bending the needle---On more than one occasion, I've heard of physicians teaching their staff to bend the needle prior to inserting it into the vein to decrease the angle of insertion. Sounds a little "kinky" to us.
• Using a tourniquet to apply pressure---If you're looking for evidence that humans are incredibly creative, look no further. This practice was brought to my attention as one facility's permitted substitute for applying pressure to the puncture site whenever the patient cannot assist. The tourniquet is tightened around the arm to hold the gauze in place until the collector can tend to the wound. Perhaps it's time tourniquets come with instructions on how not to use them.
• Pouring off blood from one tube to another---Phlebotomy Today readers know better, but not every healthcare worker subscribes yet. Therefore, let it be written and handed down from generation to generation: tubes with additives cannot be combined, even if they have the same color stopper. Some argue that the contents of clot activator tubes can be combined with that of another clot activator tube, but do you really want to go down this slippery slope? All it takes is for someone to be seen pouring the contents of one tube into another, and the assumption is made that it's acceptable for all tubes. Don't go there.

Even if you're convinced one or more of these techniques is a harmless improvement on the traditional method, you'll be hard-pressed to justify your modification to a jury should an injury or medical error occur. Rest assured, should you be involved in a legal case in which your technique is called into question, any deviation from the standard is likely to be exploited by the patient's attorney... even if it's not pertinent to the case. Being caught with one foot out-of-bounds is an irresistible invitation to cast you as a renegade who spends most of her time there. Give 'em an inch, and they'll take whatever the jury awards.

Here's a New Year resolution everyone should adopt: stick to the standards... literally and figuratively. Trust me, you do NOT want me reviewing a case in which you created your own unique twist to a well-established industry standard. I love my readers, make no mistake. But the only needles you should be creative with involve knitting.

Respectfully,

Dennis J. Ernst, editor

Test Talk: Prolactin

Prolactin, as well as estrogen and progesterone, stimulate breast milk development during pregnancy and in nursing women, maintaining the breast milk supply. As a hormone produced by the pituitary gland, it's often ordered by physicians to diagnose the production of breast milk in non-pregnant or breast-feeding women, male infertility, menstrual irregularities, and pituitary disorders.

Elevated prolactin levels are also seen in patients with hypothyroidism, under physiologic stress, with chest wall trauma, seizures, and lung cancer and use of marijuana. Drugs that can cause an elevated prolactin include estrogen, tricyclic antidepressants, opiates, amphetamines, hypertension drugs, and some drugs that are used to treat gastroesophageal reflux.

Physicians also order prolactin levels when their patients have a condition that affects dopamine production or is taking medications that affect dopamine production.

Some healthy patients have elevated prolactin levels due to the presence of macroprolactin in their blood (prolactin bound to protein). Physicians who receive lab results with elevated prolactins may request additional tests to see if the elevation is due to macroprolactin, which is inert and non-diagnostic.

Prolactins reach their peak in the blood stream in the morning, and should be drawn 3-4 hours after the patient wakes. As a serum-based test, it is usually collected into a tube without anticoagulants, or with a clot activator. Some facilities draw prolactins into heparin tubes. The hormone is stable for two days prior to centrifugation, and five days after centrifugation at room temperature (six days with refrigeration).

 

References

1. LabTestsOnline. American Association for Clinical Chemistry. AACC. Accessed 1/8/20.
2. CLSI. Procedures for the Handling and Processing of Blood Specimens for Common Laboratory Tests; Approved Guideline—Fourth Edition. H18-A4. Clinical and Laboratory Standards Institute. Document H18-A4 Wayne, Pennsylvania 2010.
3. Wu A. Tietz Clinical Guide to Laboratory Tests---Fourth Edition. Elsevier. St. Louis, Missouri. 2006.
4. World Health Organization. Use of Anticoagulants in Diagnostic Laboratory Investigations. WHO. Geneva, Switzerland. 2002.

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The Empowered Healthcare Manager

Being Firm

A good question to ask all applicants is when was the last time you had to be firm with someone? It reveals character, the ability to stand up for what's right, the strength to defend (laws, rules, a code-of-conduct, decency, oneself, etc.).

It's also good for managers to ask themselves the same question. 

It's a mistake to think empowerment can only be bestowed. True empowerment comes from within. Sure, administrators have to empower their managers, but if the manager shrinks from using it, he/she remains a mere manager, destined to be yoked to a legacy of having been promoted by mistake.

Empowered healthcare managers, on the other hand, accept the gift of empowerment and give themselves permission to transform their position, their staff, and their organization. They give themselves permission to be firm. Here's what it sounds like:

• No, you can't have that day off. It will compromise the team.
• If I hear one more whisper of gossip, you'll be suspended.
• I've told you three times to hem up the cuffs of your scrubs. Find some safety pins and pin them up now. The next time you come in with them sweeping the floor you'll be sent home.
• I appreciate you letting me know of problems that require my attention. Going forward, I'd like for you to also to propose solutions at the same time. 

Firm is the enemy of mediocrity; mediocrity is the enemy of the empowered. The enemy of your enemy is your friend.

Subscribe to the Empowered Healthcare Manager blog.

What Should We Do?: Butterfly overuse

Question: Are there benchmarks on the percentage of straight vs butterfly needles that should be used? We'd like to see how we compare on in-house patients, outpatients, and nursing home usage. We conducted a study here that found 57% of draws were done using butterflies. Once people were aware and conscious of the issue, we were able to improve our numbers. We don't want to have to sign out butterfly needles yet as they do in other places. Do you have any ideas or tricks you can suggest to help us keep the rate dropping?

Our response: We are not aware of any national statistics on butterfly usage overall, much less on specific patient populations. We've conducted numerous surveys, however, and wrote many articles on the topic in this newsletter. (See links below.) We feel your 57% is high for an acute care facility. It's hard to believe most of your patients require them. You are to be commended for taking steps to get the rate down, as it is a hugely expensive problem. 

Assume you pay 20 cents for every tube holder/needle assembly and $1.25 for every butterfly set. For every phlebotomist who uses a butterfly when a tube holder assembly would suffice, you lose $1.05.

Now assume your phlebotomists average 6 patients per hour throughout the day. For an 8-hour day, that's 48 patients. If they're using butterfly sets on half the patients, and only half of them actually require it, it's costing your facility $12.60 per person for every 8-hour shift. Multiply that by the number of shifts and the number of phlebotomists at your facility, and over the course of a year you're burning through $5000 unnecessarily. Plug in your own numbers, but it's easy to find that butterfly overuse costs the average employer hundreds of dollars every day, and tens of thousands every year. Ouch.

You've probably already taken some of these steps, but we recommend bringing everyone together and articulate the problem in resource management you are experiencing, and how its crippling your facility. (Don't be afraid to mention how perpetuating butterfly overuse prevents administration from approving raises and benefit packages.) Let them know they are the collective solution, and you really need their help. The team, management included, have to feel this is only conquerable as a team. No individuals are exempt.

Set your benchmark, then set incremental goals, and your overall goal. Be ambitious and aggressive. Report progress, or lack thereof, toward the goal weekly from the outset, then monthly once you're getting good traction. Just like hemolysis and blood culture contamination, this is about process improvement, and the effort never ends. Above all, reward your team early and often when progress is made. Without it, your efforts will be futile. 

[Editor's note: each year, one of the most highly acclaimed presentations at the Phlebotomy Supervisor's Boot Camp is the "Squandered Resources and Low Hanging Fruit" presentation where we articulate strategies in detail to reduce butterfly overuse, hemolysis rates and blood culture contamination rates.]

 Related articles appear in these back issues of Phlebotomy Today-STAT!:

• April, 2007
• December 2008
• March 2010
• May 2010
• March 2011

Got a challenging phlebotomy situation or work-related question? Email us your submission at WSWDpanel@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)