In-house Phlebotomy CE Exercises
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What Should We Do?: Heelsticks during breastfeeding
Dear Center for Phlebotomy Education:
At our facility, the OB staff wants top keep mothers and babies together as much as possible, especially in the first five days. So our phlebotomists are being asked to perform heel sticks while the baby is nursing, not take them away from the mother and into the nursery for the draw. They say is also helps with with pain management. I'm not opposed to this, but some of our male phlebotomists are uncomfortable with it. I'm also concerned about the choking risk. What should we do?
Our response:
Many studies have found that a nursing baby feels significantly less pain during a heelstick than non-nursing infants. The standards don't advise against it, so you should consider working with the nursing staff in this regard and facilitating the bonding experience that is so important between the mother and her newborn.
Studies show the pain-reduction benefits of oral sweeteners like sucrose and dextrose to be equivalent to breastfeeding as a pain reduction strategy. You might want to consider this approach if a compromise is necessary. You may also consider using a combination of cold and vibration as a pain reduction strategy. The scientific literature contains many studies confirming the effectiveness of devices that employ this technique like the Buzzy. MLO has an excellent article in their archives on pain reduction during infant phlebotomy that our director authored.
Aside from that, there are positioning issues that have to be addressed when drawing from an infant that is nursing. Remember, it's always important to maintain the infant’s heel in a downward position if you want the draw to go smoothly and quickly. If the baby is being cradled in a horizontal position, the flow of blood is less than if the foot is below the plane of the heart and will make the collection difficult. But if the baby is positioned in such a way that the legs are lower than the heart, the flow of blood through the feet will be greater.
As for the male phlebotomists being uncomfortable with the scenario, perhaps it might be prudent to send only female phlebotomists to draw nursing babies. Keep in mind there may also be a cultural taboo for the mother to have a male phlebotomist drawing from a nursing baby.
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What's Wrong Here?
What's wrong with this picture? We guarantee something isn't as it should be. The answer will be in next month's issue. (Click image to enlarge.)
Last month's What's Wrong Here? image depicted an auto-release tube holder being activated with the contaminated sharp falling into the biohazardous waste receptacle. In the U.S. this practice violates the OSHA Bloodborne Pathogens Standard, which states "Contaminated needles and other contaminated sharps shall not be bent, recapped or removed unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental procedure."
The agency further galvanized the ban in the infamous Kline letter.
Outside the U.S. needles can be removed from their tube holders without violating regulations. However, the more important violation is to the safety of those who disassemble devices and who handle contaminated sharps downstream from the point of disposal.
The user who disassembles the needles from the tube holder and misses the sharps container is suddenly in the top tier of risk for an exposure. Handling a disassembled sharp and placing it into the sharps container puts the individual in direct contact with a contaminated needle. The only thing that separates him/her from the back end of the needle is a vinyl sleeve, which offers no protection.
For those who handle biohazardous waste receptacles, the back end of the disassembled needle also poses a significant risk of injury. Should the sharps container fail and disassembled needles require manual manipulation into a secondary container, the risk is significant and magnified far beyond that presented when a sharps container full of assembled devices fails.
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Climbing the Phlebotomy Ladder: Look within
Phlebotomists looking to advance in their profession should look within. Do you appeal to those who offer positions with greater responsibility? Do you provide your employer with good reasons to eliminate your position, or are you the kind of person managers will fight to keep on staff? Conduct this self-assessment to see if you have any internal obstacles that could be preventing you from reaching new heights or even keeping your current position.
Do you make your manager's job easier or harder?
The right answer is obvious, but take a serious look at yourself as your manager sees you. If you quit your job yesterday, would your manager hire you back today? If you think he/she wouldn't, your job's in jeopardy. Think of the reasons you wouldn't be rehired, and fix them. Consider employment at your facility to be a privilege, not a right. Strive to earn that privilege every day by making your supervisor's job easier. It's not "sucking up to the boss" if your motive is sincere and selfless, so forget what your coworkers might think. You don't work for them, anyway. Besides, they have no authority to invite you up the ladder or to secure your employment. Don't like your boss? Then you only have two choices: find something to like about him/her or find employment elsewhere. If you stop looking at the negatives about that person and focus on the positives, you might start looking more like a long-term employee in his/her eyes and less like someone who needs to be the object of a "staff reduction."
Do you deal with difficult people with poise or poison?
According to author and management speaker Dale Dauten, every tenth person is a jerk. If one of them is your boss, deal with it. That means not focusing on their jerky-ness, but focusing on your job. Jerks usually self-destruct. When that happens, make sure you're in a position to step up. You'll never be in that position if you're known for your contempt of authority, however detestable the jerk is. If you focus like a laser beam on your responsibilities and making your jerk-boss's job easier, you've taken the high road, which usually lined with ladders to even higher roads. If the jerk is a physician or patient, the same rules apply. Remember, everyone has a story, and chances are you have no idea what makes the jerk-of-the-day so difficult. Difficult people are difficult to everyone, so don't take it personally. Deal with jerks with poise, not poison.
Do you present problems without solutions?
When a problem comes up in your department and you bring it to you supervisor's attention, pose a solution at the same time. Sure, your manager's job is to solve problems, but make it your job, too. Proving you are a problem solver is the first step to being considered for a position that involves problem solving... like Lead Phlebotomist or Phlebotomy Supervisor. Even if you're happy with your current position, helping to solve problems is the hallmark of a team player. Should there come a time when staffing needs to be cut, team players are the last to be considered.
Do you take on extra work?
There's no rule that says you must only perform those tasks within your job description. What do you do when you're not drawing blood? If you're cleaning your department, stocking trays and draw stations, neatening up all those things that make your work area messy, and performing tasks everyone else avoids, then you have a right to be optimistic about your career and your job security. If you sit and chat, surf the Internet, tap dance your fingers incessantly on your smart phone, or conduct any other time-killing activities, you don't. If you can't find anything to tidy up, ask your manager for a menial task that will bore you to tears. If it has to be done, it has to be done. Every moment of your work day can't be filled with joyful activities. That's why they call it "work."
Do you shun gossip?
Nothing erodes morale like hearsay. It's not just telling gossip that makes you guilty. In order for gossip to be gossip, there must be ears willing to listen. If those ears are mounted on your head, you're contributing. How do you know if it's gossip? Here's the test: if it's second-hand information of a personal or trivial nature that creates a negative impression of that person, it's gossip. Get up and walk away. If you're brave enough, comment on the nature of the conversation being inappropriate in the workplace. Prepare to be ostracized by gossipers and held in higher regard by everyone else. If you are a party to gossip, you're contributing to a destructive workplace environment.
Are you a living example of your facility's mission statement?
If so, you have a tall ladder to climb with slip-proof rungs. If not, the steps of your career ladder with that employer are greased, and you're likely to come crashing down. If your ambition is based on serving others, expect to be well-fed with opportunity. Self-serving ambition, on the other hand, can't be fed for very long before it gives you bad breath.
If you did well on this assessment, chances are you are career-ladder material. Even if you're not striving for a higher position, mastering these elements will make you a cherished and valued employee in the eyes of those who pull the strings. They're the same people who cut the strings, turning the employed into the unemployed. Should the economic climate force your managers to consider a staff reduction, valued employees keep their jobs.
If you want to take this self-appraisal a bit further, take Dale Dauten's "Promotability Index" assessment online.
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Test Talk: Bilirubin
Patients have high bilirubin levels for many reasons, almost always indicative of issues with the liver. Newborns often have high bilirubin levels because their liver takes a few days after birth to "wake up" and do what a liver is supposed to do, mainly cleanse the blood as it comes from the digestive tract. For adults, it's often indicative of liver disease, tumors, cancer, sclerosis, hemolytic anemia, blockage of the bile ducts and other liver pathologies.
Bilirubin is a pigment and a by-product of digestion and red blood cell destruction. When the liver isn't working properly, the blood isn't being filtered of waste products. Because it is a pigment, when significantly elevated, patients appear jaundiced, i.e., their skin and whites of their eyes take on an amber color. Normal bilirubin levels are well below 2.0 mg/dl. Concentrations above 15 mg/dl lead to brain damage in neonates.
Since bilirubin degrades when exposed to light by as much as 50 percent per hour, it's critical to protect blood samples from exposure to daylight and artificial light as soon as the sample is collected. Since excessive bilirubin concentrations can cause brain damage, failure to protect samples from light can prevent infants from receiving critical phototherapy (bili-lights) that break down bilirubin at the capillary level.
Bilirubin exists in two forms: conjugated and unconjugated. Conjugated bilirubin is measured by the direct bilirubin test, while unconjugated bilirubin is measured by an indirect bilirubin assay. When elevated, each form is diagnostic of different diseases and conditions, and can assist physicians in pinpointing the cause of an elevated total bilirubin result.
Samples for bilirubin are typically serum samples, and have a stability of about two days at room temperature. Prolonged contact with red blood cells does not seem to affect test results. Devices exist that measure bilirubin transdermally without the need for a blood sample.
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Blood Collection Errors and their Impact on Patients
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You know that you shouldn't leave the tourniquet on longer than one minute, but do you know what can happen to your patient if you do?
- You know you should draw a discard volume when drawing through an IV line, but do you know how it can affect the care your patient receives?
- You know you shouldn't underfill tubes, but do you know what it can do to your patient?
Most phlebotomists and other healthcare professionals with blood collection responsibilities know the do's and don't's of drawing blood, but not everyone knows why the procedure must be followed exactly as they were taught. As a result, there's a disconnect between cause and effect that leads healthcare professionals to underestimate the importance of every standardized detail when drawing blood samples for clinical testing. Without a thorough understanding of why certain details of a venipuncture or skin puncture must be followed, the missing can't prevent a modification that can profoundly impact not only their patient's care and safety, but their own well-being.
You may know the how, but do you know the why?
Take time to review some of the most common blood collection errors in the chart below and the ultimate consequences they can have on patients. By connecting the dots from a self-styled deviation to the potential impact it can have on the patient, you'll gain a better understanding of why you do what you do, and why you shouldn't do what you shouldn't.
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Blood Collection Errors |
Potential Consequences to Patient |
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Failure to properly identify the patient |
Transfusion- or medication-related death. Patient mismanagement due to being treated according to the results of another patient. |
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Unnecessary administration of antibiotic & extended length of hospitalization due to false-positive blood culture. |
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Prolonged tourniquet application beyond one minute |
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Patient allowed to pump fist |
Seizure, death, patient mismanagement. Fist pumping significantly increases potassium* and ionized calcium levels in blood being drawn. |
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Underfilling coagulation tube |
Stroke due to unwarranted decrease in blood thinner dosage necessitated by falsely prolonged coagulation times. |
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Underfilling EDTA tube |
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Underfilling heparin tube |
Patient mismanagement/misdiagnosis from altered potassium, sodium, ALT, AST, amylase, and lipase results. |
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Underfilling blood culture bottles |
Death from septicemia due to false-negative result. |
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Failure to properly mix tubes |
Patient mismanagement due to delays when anticoagulated tubes contain clots and must be recollected. |
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Incorrect order of draw |
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Seizure, death, medication errors, and patient mismanagement should these practices hemolyze samples causing the contents of red cells to be released into serum/plasma. Hemolysis falsely lengthens prothrombin times and elevates the reported levels of potassium,* LDH, AST, ALT, phosphorous, magnesium, and ammonia. Hemolysis falsely shortens aPTT times and decreases RBC counts, fibrinogen, and hematocrit. |
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Specimen drawn above IV |
Death, medication errors, & patient mismanagement due to contamination by IV fluids of samples tested. |
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Inadequate discard volume drawn when collecting blood through vascular access device |
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Failure to properly label the specimen |
Transfusion- or medication-related death, and patient mismanagement due to being treated or transfused according to the results obtained from another patient's blood. |
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Failure to label the specimen at the patient’s side |
Transfusion- or medication-related death, and patient mismanagement due to being treated or transfused according to the results obtained from another patient's blood. |
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Pouring contents of one tube into another |
Patient mismanagement/misdiagnosis & medication errors based on altered results, especially potassium.* Stroke/hemorrhage due to unwarranted modification to blood thinner dosage. |
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Drawing timed specimens at the wrong time |
Patient mismanagement/misdiagnosis & medication errors. |
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Delays in drawing blood cultures based on fever spike |
Septicemia, death. Since fever spikes ̴̴ 30 minutes after bacterial shedding into the bloodstream, any delay in fever-based blood culture collections limits the ability of the laboratory to grow and identify the causative organism in a timely manner. |
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Chilling/refrigerating samples to be tested for potassium prior to centrifugation |
Seizure, death, patient mismanagement due to falsely elevated potassium level.* |
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Seizure, death, patient mismanagement due to falsely elevated potassium levels from platelets and/or red cells remaining in serum or plasma.* |
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Delay in transporting/testing coagulation specimens |
Stroke caused by unwarranted modification to blood thinner dosage based on inaccurate aPTT result. |
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Transporting sodium citrate tubes on ice |
Hemorrhage, death, medication errors. Cold activation of Factor VII causes a falsely shortened prothrombin time, which may mislead the physician into increasing blood thinner dosage. |
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Delay in centrifuging samples to separate serum from cells |
Seizure, death, patient mismanagement. Prolonged serum/cell contact causes a falsely elevated potassium level to be reported.* Other analytes affected include glucose, LD, phosphorous, creatinine, folate, vitamin B-12, ALT, AST, and ionized calcium. |
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Specimen not protected from light |
Newborn suffers irreversible brain damage because bilirubin deterioration leads to falsely lower result, which prevents physician from ordering phototherapy. |
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*Patients whose reported potassium levels are falsely elevated (pseudohyperkalemia) are at risk whether their reported value is in the normal range or elevated. Actual potassium levels that are below normal (hypokalemic) but falsely elevated into the normal range by collection errors may be inappropriately cleared for surgery due to the "normalizing" of their potassium. Such patients are at risk for seizures and other complications when subjected to anesthesia. Other hypokalemic patients whose potassium levels are falsely elevated into the normal range may require rapid intervention, but go untreated. Such patients are at risk for developing cardiac arrhythmia. Patients whose potassium levels are actually normal but reported as elevated (hyperkalemic) due to collection errors may be treated for a high potassium level unnecessarily. |
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| © Center for Phlebotomy Education. All rights reserved | |
[Editor's note: The Center for Phlebotomy Education has developed Blood Collection Errors and Their Impact on Patients, a 20" x 28" laminated poster containing this and much more information for managers to display in their facilities to facilitate their staff's understanding of the impact preanalytical errors have on patient care.]
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Product Spotlight: New standard on patient, sample identification
In July of this year, CLSI released a new standard on patient identification and sample labeling. All laboratory managers, phlebotomy supervisors and clinical laboratory educators should be modifying their procedures and training materials according to this standard to ensure compliance.
Accuracy in Patient and Sample Identification (GP33-A2) specifies the processes required to ensure accurate patient and specimen identification in manual and electronic systems across the health care organization. The document replaces the first edition, which was published only as a guideline. This second edition, upgraded to a standard, defines the proper protocol for identifying patients for all laboratory procedures and for labeling all diagnostic samples including blood and non-blood specimens.
The processes detailed in GP33 include considerations for designing patient ID systems, differences in requirements for patients with and without identification bands, and provisions for patients with communication barriers.
The volunteer committee tasked with revising the document was chaired by Dennis J. Ernst MT(ASCP), NCPT(NCCT) with Anne Marie Martel, T.M. of Ordre Professionnel Des Technologistes Médicaux Du Québec serving as the committee's Vice Chairholder. Other members of the committee included:
Deirdre Astin, MS, MT(ASCP)---New York State Dept of Health
Nancy Dubrowny, MS, MT(ASCP)SC---BD Preanalytic Systems
Sheri Hearn, BC, MPH---Oregon Public Health Laboratory
Peggy Mann, MS, MT(ASCP)---The University of Texas Medical Branch
Estelle Ninnemann, MT(ASCP)---ACL Laboratories
George Souza, BS, CPT, CPI---Massachusetts General Hospital
Sheryl Thiessen, BSMT, MT(ASCP), MLT(CSMLS), CLQM---British Columbia Agency for Pathology and Laboratory Medicine.
Thomas Dew---Taylor Healthcare
Sharon Johnson---Mayo Clinic
The standard is available from CLSI or, by special arrangement, directly from the Center for Phlebotomy Education, Inc.
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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.
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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!:
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.)
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Nursing Group Nixes Draws During IV Starts and Line Draws
The revised standards from the Infusion Nurses Society (INS) instruct nurses and IV therapists to perform venipunctures instead of obtaining blood samples from existing lines or during the insertion of short peripheral catheters. The new standard is a dramatic departure from the prior standard, published in 2011, that advocated draws during IV starts and from vascular access devices (VADs).
"This is a huge development," says Center for Phlebotomy Education's Director, Dennis J. Ernst MT(ASCP) NCPT(NCCT). "Drawing during IV insertions was never a good idea, and often created more problems than it solved." Ernst is referring to the frequency of hemolysis when drawing from IV catheters. "Four years ago, the CDC made it a Best Practice perform a venipuncture instead of drawing during an IV start. I'm thrilled the INS has worked it into their standards." Ernst was a member of the CDC's Evidence Review Panel that made the Best Practice recommendation.
Infusion Therapy Standards of Practice cites hemolysis as the main reason venipunctures should be performed instead of draws from IV sets. It specifically states the standard applied regardless of the sampling device attached to the IV catheter. However, it suggests practitioners consider obtaining a blood sample from an indwelling short peripheral catheter for pediatrics, patients with difficult veins or bleeding disorders.
"When we draw blood from an IV catheter, we could be using a medical device for a purpose for which it was not intended," says Ernst. "Not all devices are approved for drawing blood samples. If it's not in the catheter manufacturer's Instructions for Use, it shouldn't be used for that purpose."
One study showed draws through IV devices hemolyze samples eight times as frequently as when collected by venipuncture.
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