Phlebotomy Today

Phlebotomy Distance Learning During Pandemic

Friends,

Many, if not all of you are in the throes of dealing with the Covid-19 pandemic. Since education is at the core of what we do, it should come as no surprise that the Center for Phlebotomy Education has perfected the art of streaming videos for those of you who now must consider distance learning options in order to reduce your staff and students' exposure to this virus.

The Phlebotomy Channel streams 17 phlebotomy training videos including:

• Basic Venipuncture (43 minutes)
• Preventing Preanalytical Errors (42 minutes)
• Avoiding Phlebotomy-Related Lawsuits (38 minutes)
• Skin Punctures & Newborn Screens (30 minutes)
• Arterial Blood Gas Collection (29 minutes)
• Safety Survey: How Vulnerable Are You to a Needlestick? (47 minutes)
• Delivering World-Class Customer Service (37 minutes)
• Seizing Control of Blood Culture Contamination Rates (44 minutes)
• Ending Hemolysis in the ED... and Everywhere Else (47 minutes)
• Mastering Pediatric Phlebotomy (47 minutes)
• Potassium Results Your Physicians Can Trust (43 minutes)
• Successful Strategies for Difficult Draws (38 minutes)
• Managing the Risk of Patient Injury (39 minutes)
• The Ten Commandments of Phlebotomy (52 minutes)
• Preanalytical Errors: Real Patients, Real Suffering.(6 minutes)
• Nightmare on Phlebotomy Street (15 minutes)

As the subscribing admin for your program or department, simply log in and use the built-in email function to assign any of the titles to your staff or students. Viewed remotely, anyone who is "sheltering in place" can continue their training and education from any computer with a high-speed Internet connection. All videos have an assessment to measure comprehension.

You have better things to do right now than to squander your valuable time looking for good distance-learning options. The Phlebotomy Channel was designed, created and perfected for crises just like the one we're currently enduring. It may be many months before we can all come out from seclusion and feel safe about getting back into the classroom, orientations, and/or group training/continuing education. The professional development of your staff and students shouldn't have to wait. 

Subscribe or for more information.

 

Preventing Repeat Heelsticks

Most phlebotomists dread having to draw newborns. No one wants to cause such a small, fragile human being pain. To treat and prevent illness, however, it’s a necessary discomfort. What isn’t necessary, however, is when we have to restick a newborn because of improper technique or errors in the process. Unfortunately, many babies experience multiple heelsticks. Poor blood flow can be caused by many factors, but knowing how to maximize the volume of blood from a heelstick is critical to minimizing the number of repeat punctures. So, naturally, the best way to reduce repeat heelsticks is to obtain a suitable specimen the first time. By being attentive and vigilant, we can eliminate unnecessary and painful repeat heelsticks for our smallest patients. 

Gravity is your friend

How specimen collection personnel position the infant can make a significant difference in how easily the specimen is obtained. If possible, position the infant so that the foot is on a plane lower than the heart. This can be accomplished by elevating the head of the bassinet or car seat (for outpatient draws) slightly. Before making such an adjustment, however, check to see if the baby’s crib or car seat accommodates such repositioning, and that you are permitted to do so by facility policy. Additionally, keeping the foot as low as possible throughout the collection can help the capillary beds fill more quickly and completely making an adequate volume of specimen easier to obtain. For outpatients held by a parent, instruct the parent to keep the baby as upright as possible throughout the procedure.
     Babies tend to wiggle away from things they don’t like. Most infants will reflexively pull their foot away from stimulation. To maintain control, firmly encircle the ankle with two fingers, ensuring your grip does not restrict blood flow.

Site Selection and Equipment

The precise location you choose to puncture the heel is a very important decision. The CLSI skin puncture standard lists the medial and lateral portions of the bottom surface of the heel as acceptable.(1) Heel bones in infants are close to the surface of the skin, so the lancet should puncture less than 2.0 mm deep. Osteomyelitis is an inflammation of the bone can lead to complications and disability. CLSI also states that a previously punctured non-healed site should be avoided. The chosen site should also not be bruised, scarred, or show signs of infection.

Cleanse the site first with an alcohol prep and allow it to dry completely. Wet alcohol can cause the baby unnecessary pain when the lancet punctures the skin.

The order of draw for capillary collections is also important, and different from venipunctures. After wiping away the first drop of blood with clean gauze (to prevent tissue fluid from contaminating the sample), the EDTA tube should be collected first followed by other additive tubes. Non-additive tubes are filled last. Incorrectly placing the EDTA tube later in the order risks platelet clumping, a natural occurrence when skin is punctured. Since this process is not immediate, the first tube filled is less likely to contain clumped platelets than later tubes. Because the EDTA tube is the one used to count platelets as part of the complete blood count (CBC), filling it first increases the lab’s ability to provide the physician with an accurate platelet count.

To ensure proper mixing, gently invert all additive tubes 5-10 times according to the tube manufacturer’s recommendations. One inversion is defined as upending the tube, then returning it to an upright position. Each time the tube is overturned, make sure the contents flow to the opposite end before uprighting so the additive mixes well with the sample. EDTA tubes are especially prone to clotting during sample collection, so it is prudent to gently tap the tube on a hard surface to agitate the sample during collection. 

Quantity and Quality

Use only gentle pressure to ease blood from the puncture site. If the site was prewarmed, gentle pressure should be all that's necessary for a consistent and adequate flow. After collecting the drop, release the pressure applied to the site and give the capillary bed time to refill. If you find you are constantly squeezing and “milking” the foot to obtain enough blood, be aware that you are likely hemolyzing the specimen and contaminating it with tissue fluid. It’s also painful to the infant. If excessive squeezing is required, you should terminate the collection. The likelihood that the specimen will render accurate results decreases proportional to the force squeezing the heel. To make milking unnecessary, prewarm the heel with a warm compress not to exceed 42-degrees Celsius. The flow of blood through the capillary beds will be seven times more than that through sites that have not been prewarmed. The result: an adequate flow of blood into the collection tube with minimal or no squeezing.

If the device you use incorporates a scoop into its design, CLSI recommends the device not be scraped across the puncture site in an effort to force blood to the opening. Forceful scooping is also painful to the patient and forces tissue fluid into the sample.

Before terminating the draw, make sure the collection meets minimum fill requirements. Short samples cheat the patient out of an accurate test result, and often force testing personnel to request the specimen be recollected. Fill all tubes to their stated volume every time. Some specimens require special handling during and/or immediately after collection. Make sure you are prepared to protect light-sensitive specimens from exposure using amber light-blocking tubes or a light-tight wrap. If the specimen is to be immediately chilled, have an ice slurry available before you begin the procedure. Any delay or improper handling could force the laboratory to request a recollection due to the potential for a mishandled specimen to produce erroneous results.

Babies have it rough enough coming into the world. Unnecessary repeat collections only cause additional trauma. Those who draw their blood properly and compassionately can have a significant impact in making their new world a more welcoming place.

References
1. CLSI. Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens: Approved Standard - Sixth Edition. GP42-A6 Wayne, PA, 2008.

 

Customer Service for Phlebotomists

World-class customer service is what every patient expects and deserves. Are you delivering it? Is your staff? Will your trainees and students?

To make sure, the Center for Phlebotomy Education has produced a video teaching phlebotomists and other healthcare professionals who draw blood samples how to make sure every patient encounter leaves them satisfied and confident. Because those who draw blood samples are the laboratory's ambassadors, they deliver the only impression to the patient of what the lab is like. If they are to have confidence in the quality of work that is performed on their blood samples and the accuracy of the test results, the phlebotomist must provide a professional, courteous, and compassionate impression.

Delivering World-Class Customer Service discusses key concepts in customer service excellence in a phlebotomy perspective. Emphasis is placed on telephone etiquette, behaviors that reflect and detract from professionalism, positive patient interactions, and dealing with difficult/demanding patients and co-workers. Positive and negative patient experiences are contrasted to illustrate their impact on the patients' perception of the laboratory, and the quality of care they receive. The presentation concludes with a discussion on how managers can inspire a culture of customer service excellence. The 37-minute, closed captioned  video is part of the Center's Applied Phlebotomy Lecture Collection, and is narrated by Dennis J. Ernst MT(ASCP), NCPT(NCCT). Access to online CE questions for inhouse use is provided on the jacket.

More information and a preview. 

 

Studies Find aPTTs Less Stable Than Previously Thought

Recently published results from two studies shed new light on the stability of activated partial thrombopladstin times (aPTT) suggesting samples must be tested much sooner than what is currently the practice. The latest issue of Thrombosis Research includes a study in which multiple coagulation assays were collected by venipuncture and tested after delays of 2, 4, 6, 12, and 24 hours. Assays included prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen concentration, antithrombin activity, D-dimer concentration and thrombin time.

Significant differences and large variations were observed between the various time intervals in the study. The authors found PT and INR results remain stable for up to 24 hours. Fibrinogen, antithrombin, D-dimer and thrombin demonstrated stability up to 4 hours. The current CLSI standards limits the time from collection in which aPTTs must be tested to four hours.

An editorial in the same issue written independent of the study came to the same conclusion.

These articles pose significant challenges to laboratories drawing from hepaninized patients at long-term care facilities, at home, or any other location remote from the testing facility. Excessive transit times can lead to falsely prolonged results and inappropriate adjustments to the patient's dosage that could be life-threatening.

Read the full study.

Read the editorial.

 

Product Spotlight: Phlebotomy Answer Book

The  Lab Draw Answer Book, published by the Center for Phlebotomy Education, contains answers to nearly 400 commonly asked questions on blood sample collection and handling, and managing phlebotomy services and personnel.

The 440-page full-color reference book fully reflects CLSI standards, OSHA guidelines, and the Standards of Practice from the Infusion Nurses Society. The second edition is co-authored by Dennis J. Ernst MT(ASCP), NCPT(NCCT) and his wife Catherine Ernst, RN, PBT(ASCP)^CM.

Chapters in the book include:

1. Safety and Infection Control
2. Training, Management and Certification
3. Skin Punctures, Heelsticks, and Pain Management
4. Patient Identification, Vein Selection, & Site Prep
5. Tourniquets & Butterflies
6. Order of Draw & Discard Tubes
7. Hemolysis and Potassium Issues
8. Blood Cultures
9. Labeling and Post-venipuncture Care
10. Line Draws & IV Starts
11. Processing, Storage, & Transportation
12. Patient Injuries & Complications
13. Unorthodox Techniques
14. Miscellaneous

Copies are currently only available from the Center for Phlebotomy Education. More information and preview pages.

 

From the Editor's Desk

Marie Moorhouse & friend

Friends,

Never underestimate the power of a rubber chicken. Seriously.

Marie Moorhouse is one of the most dynamic and delightful people I've ever met, not just in my professional circles, but in life. I first met Marie in 2015 when she came to our Phlebotomy Supervisor's Boot Camp in Charlotte, North Carolina. When she walked into the room, we had no idea how much energy and hilarity she would bring to the 3-day event. Having produced seven Boot Camps across the U.S. by then, they were becoming rather routine. Not that we don't like routine, we do. In fact we vastly prefer it to drama or chaos, both of which we've had plenty at prior Boot Camps. 

It soon became obvious that Marie was a real spitfire, packed with spunk, sparkle and sass. Between sessions, during round tables, and at the Q&A sessions she had everyone busting up, most of all, my wife Catherine and I. Marie brought just the right blend of levity and professional passion to the conference that made her presence a Godsend for all. We know the event would have been smashing success without her, we had gotten pretty good at producing a satisfying event for our attendees, but with her it was so much more. 

Prior to the Charlotte event, Catherine and I decided we were going to start a new Boot Camp Tradition. The Rubber Chicken Award would be presented at closing of the event to the attendee who made it the most fun for us. Marie was without question the first recipient. It would not be the last time she made a difference for me and for the phlebotomy community... including you. 

As you know, I have been trying to revise our popular Preventing Preanalytical Errors video for at least two years. What you don't know is that I've run into nothing but obstacles from the get-go. It's as if I had embarked upon something that refused to happen. In fact, a more fitting title would be The Video That Does Not Want To Be Made. By the time filming finally started in February at Covenant in Saginaw, Michigan it should have already been completed and streaming. But over the years I've learn that everything takes longer than you think it should. If it's a video, plan on it taking even longer.

We filmed in the laboratory at Covenant Healthcare in Saginaw, Michigan (ironically and appropriately the same facility at which I completed my medical technology internship many years ago). It took a full day to capture sample handling closeups and some pretty good footage in outpatient and inpatient environments. But our Applied Phlebotomy videos are complex, requiring multiple days of filming narrations and simulations, and reshooting scenes that didn't meet my standards of perfection from the first day. A second day of filming was planned for March. Then along came Covid-19, locking me and my film crew out of any and every healthcare setting... understandably so. Every month or so I'd check in to see if filming could resume. It couldn't. The delay in returning to the facility seemed indefinite.

Marie & me on filming day

I'm a firm believer that if you keep banging on a door that won't open, you should stop banging and move along to a door that will. That's how I felt in July when nothing was working out. Maybe the video wasn't meant to be revised. Maybe it's time to work on something else. Something easier. I had no location, no narrator, and my film crew had a limited geographic circumference in which they could now work. Then I thought of Marie. 

Like a thunderbolt, it struck me that she worked her magic at the University of Michigan in Ann Arbor, just four hours away. I had nothing to lose, so I reached out. It was a long shot, for sure. Covid still had its grip on the nation, and especially Michigan. What it was going to take to get this video back into production was something I didn't have. It required someone with spitfire, someone with award-winning spunk. someone who can make things happen. It required Marie Moorhouse.

And just like that, the door opened. Marie arranged for us to complete our filming in July, and the 3rd edition of Preventing Preanalytical Errors is now in the final phase of production. It should be available to you and other healthcare professionals and educators around the world sometime in November.

It's no coincidence Marie came to Charlotte in 2015. Our paths were destined to cross, and for good reason. Namely, so that those who draw, handle, process and transport blood samples for diagnostic testing around the world can do so properly, safely, and in a manner that assures all their patients are treated according to accurate laboratory results.

Marie will be the first to tell you her path to becoming the Lead Training Specialist over the phlebotomy services at one of the nation's most prestigious healthcare systems was predestined, but not what she had planned. Nor did she plan on coming home from Charlotte in 2015 with a rubber chicken, the power of which is not to be underestimated.

 

Take care, my friend,

Dennis

 

Blood Culture Collection Device Named Best Product in 2020

An innovative technology solution for reducing blood culture contamination was recently named as a Best Infection Prevention Product of 2020. The device, Steripath® Gen2 Initial Specimen Diversion Device® developed by Magnolia Medical Technologies was selected in partnership with The Leapfrog Group, an independent nonprofit organization that evaluates health care quality.

The device functions by diverting and sequestering the initial 1.5-2.0 mL of blood collected for culture, which is the portion known to most likely contain contaminants. Blood cultures are then collected through a second independent blood flow path, creating a vein-to-bottle closed collection system.

The selection committee evaluated each product using 4 specific criteria: effectiveness, safety (to both patients and health care workers), successful real-world implementation, and the stability of the company. When assessing safety and effectiveness, evaluations from the Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA) were considered, along with published research studies.

“We are honored to have been selected by Newsweek as one of the Best Infection Products of 2020,” said Greg Bullington, CEO of Magnolia Medical Technologies. “We are impressed with The Leapfrog Group’s fact-based methodology utilizing publicly available clinical data and independent market research to inform their selections.” Bullington concluded, “As a company we are dedicated to providing technology solutions that enable sepsis testing accuracy to reduce unnecessary antibiotic treatment, prevent patient harm and decrease hospital-acquired infections.”

The patented Steripath® Gen2 ISDD® is the only FDA-cleared device indicated to reduce blood culture contamination. This exclusive indication was cleared by the FDA based on peer-reviewed published controlled clinical studies demonstrating Steripath’s ability to reduce blood culture contamination by 83 and 88%.

Recently, the company also announced an initiative to reset the national blood culture benchmark from three percent to below 1.0%. The "Mission to Zero" initiative challenges healthcare professionals in clinical laboratories, emergency departments, critical care units, and infection prevention teams to pledge to work as a unified team to eliminate blood culture contamination.

"Magnolia is committed to diagnostic accuracy and the prevention of patient harm," said Bullington. "Scientific and clinical evidence proves that we can significantly improve diagnostic accuracy for sepsis testing. This data underlies our commitment to raising the bar for performance nationally with the belief that we as an industry should be targeting zero preventable diagnostic errors."

In 2005, the American Society for Clinical Microbiology established a 3% threshold for blood culture contamination. Since then, multiple peer-reviewed published studies established that a rate well below 1% is attainable with the right technology. Additionally, a multi-discipline consensus manuscript was published in Clinical Microbiology Reviews in January with a call-to-action to establish a new blood culture contamination benchmark of less than 1%.

"We are proud to introduce the Mission to ZERO initiative, empowering all healthcare workers to have a direct impact on helping prevent the risk of patients experiencing a misdiagnosis of sepsis while further enabling driving antibiotic stewardship," said Bullington. "We will achieve this mission through a combination of supporting change in national guidelines and benchmarks, Steripath® technology solutions and a strong partnership with our healthcare community – which begins with each individual patient, healthcare worker and hospital uniting as one team. As a team, we can help stop the significant clinical and economic challenges associated with false-positive blood culture results."

Blood culture contamination has been shown to increase a patient's length of stay up to 3.3 days, add up to $8720 per event, and result in an average of three days of unnecessary antibiotic administration.

More information.

 

YouTube Video of the Month

The Center for Phlebotomy Education's YouTube Channel features high-quality, standards-based educational and inspirational content for anyone who performs, teaches or manages blood collection procedures. This month's featured video instructs how to properly identify patients before drawing blood and establishes the Golden Rule of Patient Identification. 

 

 

TestTalk: HLA B27

A column that features a different laboratory test each month, what it measures, why physicians order it, and any collection handling restrictions and requirements that must be met.

 Human Leukocyte Antigen B27 is a protein that coats white blood cells in patients with autoimmune diseases. It also refers to the gene that codes for this protein. It is found in about 6% of the U.S. population. Those whose leukocytes are coated with HLA-B27 are more likely to develop an autoimmune disease such as ankylosing spondylitis, juvenile rheumatoid arthritis, and reactive arthritis. It's also been linked to inflammatory bowel disease. HLA-B27 does not cause these disorders, but patients with them are more likely to have the protein coating their white blood cells than those who don't (6% in the general population versus up to 90% in those with these conditions).

Previous bacterial infections seem to play a role in HLA-B27's autoimmune response connection. Some researchers speculate similarities between the HLA-B27 antigen and the antigens on the surface of certain microbes signal the immune system to attack both the microbe and the patient's own tissues. After the infection, the autoimmune disorder is triggered.

HLA-B27 is drawn into EDTA tubes and, occasionally, ammonium heparin tubes. Stability at room temperature is one day or less. No patient preparation is required (e.g., fasting, recumbent, timing, etc.)

References

1. LabTestsOnline. American Association for Clinical Chemistry. AACC. Accessed.
2.  World Health Organization. Use of Anticoagulants in Diagnostic Laboratory Investigations. WHO. Geneva, Switzerland. 2002.

 

What's Wrong Here?

What's wrong with this picture? (Click image to enlarge.) We guarantee something isn't as it should be. The answer will be in next month's issue.

Last month, the picture we chose for your scrutiny (right) showed a patient being drawn by a healthcare worker with unprotected arms. OSHA does not specifically mandate arms to be fully covered when drawing blood samples unless the employer determines it to pose a risk of exposure. However, in the June 2009 issue of Phlebotomy Today we published the results of a survey that showed the risk is worth considering.  Approximately 134 of the 180 survey participants (74%) reported one or more incidents of blood splatter beyond the wrist when performing venipuncture procedures. Those who reported splatter beyond the hand area averaged 6.9 occurrences per person. For that reason, we consider the right to "bear arms" not to be part of anyone's constitution if phlebotomy is one of their responsibilities.