Preventing Repeat Heelsticks
Many phlebotomists dread seeing newborns on their draw list who need blood specimens collected. No one wants to cause such a small, fragile human being pain in any way. 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 improper technique or errors in the process lead to an inadequate volume of unacceptable sample of blood.
Errors that force recollections and potential complications can originate anywhere along the continuum of care from the ordering physician all the way to through specimen testing. But since most errors occur during the preanalytical phase of laboratory testing, it's the phlebotomist who can prevent the necessity for most recollections. The best way to reduce repeat heelsticks is to obtain a suitable specimen the first time.
How specimen collection personnel position the infant can make a significant difference in the ease in which the specimen is obtained. If possible, position the infant so that the foot is on a plane lower than the heart, recognizing gravity is your friend. This can be accomplished by elevating the head of the bassinet slightly. Before making such an adjustment, check to see if the baby's crib accommodates such repositioning, and that you are permitted to do so by facility policy. For inpatients as well as outpatient newborns, lowering the foot between the collection of each drop can help the capillary beds fill more quickly and completely, making an adequate volume of specimen easier to obtain.
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
Where you choose to puncture the heel is critical. The CLSI skin puncture standard lists the medial and lateral portions of the bottom surfaces of the heels as acceptable. Cleanse the site first with an alcohol prep and allow it to dry completely. Wet alcohol will cause the baby unnecessary pain when the lancet punctures the skin.
Heel bones in infants are much closer to the skin, so the lancet should puncture less than 2.0 mm deep. Osteomyelitis is an inflammation of the bone that 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.
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 and then non-additive tubes. 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. Filling it first increases the lab's ability to provide the physician with an accurate platelet count. Mixing tubes with additives during the collection, especially for EDTA tubes, helps ensure the sample won't clot before testing. If the microcollection tube is open, e.g., a scoop design, gently tap the tube on a hard surface between drops. If it is a closed system, e.g., incorporating a funnel or straw, gently flick the bottom of the tube between drops.
Quantity and Quality
Physicians serve their patients best when they have accurate lab results, which can only come from specimens that are not compromised during the collection process. 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.
To fill tubes fully, use only gentle pressure to ease blood from the puncture site. After collecting the drop, release the pressure 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 being applied to the foot. 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 greater than those that have not been prewarmed. The result: an adequate flow of blood into the collection tube with minimal 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 painful to the patient, could hemolyze cells, and forces tissue fluid into the sample.
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 can have a significant impact in making their new world a more welcoming place.
Product Spotlight: Phlebotomy Central membership
We've been building it for years; now it's enormous. We're talking about the most comprehensive collection of blood specimen collection information on the Internet, fully updated to reflect the newly revised CLSI venipuncture standard.
Join Phlebotomy Central and your facility will have 24/7 access to the most comprehensive body of knowledge on blood specimen collection ever assembled online with over 500 articles and resources to help you teach, train, and manage specimen collection personnel.
- Phlebotomy Today archives--- over 200 back issues going all the way back to 2001;
- ATMs---Almost 2 year's worth of monthly articles to satisfy your inhouse CE requirement (quizzes and answer keys included).
- The Manager's Toolbox – a growing list of documents, competency checklists, SmartCharts™, and procedure templates that managers and educators can use to enhance their understanding of preanalytical processes and manage their staff more effectively;
- FAQs – Exclusive to Phlebotomy Central members, answers to hundreds of the most frequently asked questions, searchable by keyword or phrase;
- To The Point® downloads – 18 in-depth detailed articles in PDF format covering a wide range of specimen collection topics for inhouse credit (quizzes included; answer keys available upon request);
- To The Point Volumes 1-6--- a compilation of our To The Point downloads into booklets worth up to 6.5 PACE credits each with or without PACE credit. (Certificate processing fee required to receive PACE credit).
It's often been said the next best thing to knowing a fact is knowing where to find it. You'll find it in Phlebotomy Central.
Arrest Made in Phlebotomy Certificate Scam
Federal charges were filed against a professor at City University of New York (CUNY) for selling bogus course completion certificates in phlebotomy and other healthcare courses for up to $1000.
Federal prosecutors allege biology professor Mamadouh Abdel-Sayed held unauthorized medical and health-related courses in empty classrooms on campus and sold bogus course completion certificates for $25-$1000 printed on stationery he bought and embossed himself. They say little to no training ever took place, textbooks weren't used and students weren't graded.
According to an online article posted by NBC 4 New York authorities also believe Abdel-Sayed provided fake certificates for phlebotomy, EKGs, CPR, sonography and patient-care technician from at least 2013 through 2017.
After federal authorities raided Abdel-Sayed's office last summer, he allegedly told one of his "students" to return the certificates, and, if questioned, to tell authorities the only course he took was pathophysiology, which Abdel-Sayed is authorized to teach. If convicted on all five counts including solicitation of bribes, wire fraud and obstruction of justice, Abdel-Sayed faces up to 80 years in prison.
Related story in the New York Post
Order of Draw Badge Tags
Do those who draw blood samples in your facility realize the order of draw is critical to accurate results, or do they think it's a myth? If they think it's a myth, the Center for Phlebotomy Education can help dispel it.
First, print our PDF titled Do I have to Follow the Order of Draw from our Free Stuff web page and post it where everyone who draws blood can see it.
Secondly, distribute our Order of Draw Badge Tag to your staff to attach to their ID badge so the order of draw is always in front of them. The Order of Draw Badge Tag graphically depicts the order of draw and explains why it's necessary. On the reverse are nine tips on proper tube filling and handling including:
- Fill all tubes according to the proper order of draw
- Mix all tubes with a gentle inversion 5-8 times, 3-5 times for citrate tubes
- Never combine the contents of two tubes
- Fill all tubes to the manufacturer's fill line
- Never refrigerate tubes to be tested for K+ prior to centrifugation
- Allow serum tubes to clot upright for 20-30 minutes prior to centrifugation
- When filling tubes from a syringe, always use a safety-transfer device.
The Order of Draw Badge Tag is printed in full color and laminated for durability. Each 10-pack contains 10 identical copies of the card for distribution to phlebotomists, nurses and all on staff who draw blood samples.
More information and to order.
Standards Update: Continuing education
The newly revised venipuncture standard released by the Clinical and Laboratory Standards Institute in April, 2017 is the most comprehensive revision in the document's history. With over 140 new mandates, facilities have a lot of changes to implement. This series discusses one or more substantive changes each month.
Do you participate in continuing education (CE) exercises in phlebotomy? If not, it's no longer optional.
As of April, 2017 when the revised venipuncture standard was released, those who do not complete continuing education exercises and engage in professional development are not in compliance with the standard. The standard does not require employers to provide CE credit, but requires CE exercises to be documented for employees who performs venipunctures.
Because continuing education is associated with competence, attorneys representing patients who claim to be injured during venipuncture procedures invariably check employment records for indications the facility is ensuring competency among its personnel. Now that CE is a standards requirement, failing to meet this requirement not only suggest incompetence, but falls beneath the standard of care.
- CLSI. Collection of Diagnostic Venous Blood Specimens---Approved Standard, GP41-A7. Clinical and Laboratory Standards Institute, Wayne, Pennsylvania. 2017.
Editor's note: Readers are urged to obtain their own copy of the standard as soon as possible and begin implementing all new provisions. The document, Collection of Diagnostic Venous Blood Specimens (GP41-A7), is the standard to which all facilities will be held if a patient is injured during the procedure or suffers from the consequences of an improperly performed venipuncture.
Read an interview by CLP Magazine with Dennis J. Ernst MT(ASCP), NCPT(NCCT) about the revised standard.
From the Editor's Desk
Last month in this column I talked about our imminent relocation almost 600 miles north, and that when something feels right, you do it no matter how irrational it sounds. Such is the case with this uprooting. By the time you read this, though, I hope to be unpacking in our forever home, and will share my observations next month.
Something else that seems irrational but feels right is taking a profitable, widely read, highly regarded newsletter and making it free. That's what we're doing with Phlebotomy Today in March.
I know it sounds crazy, but let me explain. As you likely know, I've been writing two newsletters monthly for ten years now---Phlebotomy Today and Phlebotomy Today-STAT! The two publications combined take at least a week each month to research, edit, format and deliver. I know you appreciate the time I put into making each issue, but it's become clear to me the demands they place on my schedule are not sustainable. Once I decided to merge the two publications as Phlebotomy Today, I had to answer the next logical question: do I charge a subscription fee as I have been for Phlebotomy Today, or do I keep it free as I have been for Phlebotomy Today-SAT!?
An inner voice immediately provided the answer in the form of another question: Do you want to be profitable or relevant?
And so the dialog began.
Me: I want to be both.
Inner Voice (IV): Of course, you do, but a person cannot pursue one to the exclusion of the other without eventually being neither.
Me: When I left the bench in 1998 to start the Center for Phlebotomy Education, it was in search of relevance.
IV: As it should have been.
Me: But I wasn't relevant or profitable at the time. I may have had a steady income, but as a single dad I lived paycheck to paycheck.
IV: But you gave up your steady income anyway, didn't you? That's how important relevance was to you. How did that decision work out?
Me: It worked out beautifully. I felt almost instantly relevant.
IV: And profitable?
Me: That took many years, but ultimately I was able to pay myself a salary, move the office out of our house, and hire a staff of six.
IV: So only when you achieved relevance did you achieve profitability, is that correct?
Me: Yes. That's the way it works. But "profit" doesn't have to be just financial in nature, at least for me. It can also come in the form of doing meaningful work, impacting patient care, solving problems for people, and helping other companies succeed.
IV: You mean, being relevant.
It's conversations like these that make my decisions easy, and why your newsletter will become a free publication after the merge. When the choice is between charging several hundred subscribers or writing a free publication for tens of thousands, all I had to do was think back to when I felt irrelevant. Those days ended the minute I started serving you, my readers, in 2000 when I released the first issue of Phlebotomy Today. It was free then and it'll be free again in March with the first merged issue. With today's tight budgets in healthcare, I'm sure you need it that way.
Funny how things work out. In order for me to get what I want, I have to give you what you want. There's something very logical about that.
Dennis J. Ernst MT(ASCP)
What Should We Do?: Are arterial draws instead of venipunctures okay?
Dear Center for Phlebotomy Education:
We have a policy that venipunctures cannot be performed on an arm with an IV. So our staff has been performing arterial punctures from the same arm when no other site is accessible. This came to light recently when a patient with a low hemoglobin was given a transfusion. The post-transfusion hemoglobin was abnormally high. We learned later the pre-transfusion hemoglobin came from arterial blood drawn from an arm into which fluids were being infused into a vein.
We have no policy against drawing from an artery in this circumstance, only veins. So, is it acceptable to perform an arterial stick from an arm receiving fluids into a vein?
The standards are clear that arterial draws must never be performed when venous draws are not possible. The risk of injury and complications is far greater than for venipunctures, and the test results are not likely to be comparable.
It's hard to blame the low hemoglobin on the arterial draw. The more likely scenario is that the post-transfusion draw came too soon after the transfusion, and the transfused cells hadn't homogenized in the bloodstream yet. Regardless, arterial draws should only be performed for arterial blood gases.
Clearly, you staff did not violate your policy, but you policy should be revised. Banning venous draws from arms with infusing fluids is too restrictive. Venous draws below IVs are permitted in the standards. We recommend changing your policy to state arterial draws are not acceptable alternatives to venous draws, and that draws below IVs are permitted as long as the fluids are turned off for at least 2 minutes. A discard is optional, but recommended.
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.)
Empowered Healthcare Manager
Every month we run an excerpt from our editor's popular blog, The Empowered Healthcare Manager.
Allow No Distractions
It's Friday. Unless you were on vacation you probably started the week with a list of goals to accomplish by the end of the day today. How did you do? What got in the way? Separate the obstacles into two categories: those you allowed to stand in your way and those you had no control over. Be honest. On Monday, make a new list for the week and put "allow no distractions" at the top.
When a potential distraction comes up, empower someone to manage it. You've likely surrounded yourself with capable people. Exploit their talents, push them to the edge of their comfort zones, and extend their leash. Then get back to your list. Over time, you'll have fewer distractions and a department that moves forward because you have time to move it.
If you don't start the week with a list of objectives, are you winging it every week? Waiting to see what crises will crop up to occupy your time, consume your days, and squander your productivity? If so, you're not managing your department you're managing crises, and likely getting nowhere on major projects.
Next week has to be different if you ever hope to move your department forward. Make a list on Monday. At the top, write "allow no distractions."
Then don't, and start surrounding yourself with capable people.
Managing a department is a whole lot more fun than managing crises.
Subscribe to the Empowered Healthcare Manager.
Tip of the Month: The Right Stuff
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