The Ten Commandments of Phlebotomy

Part of being human is obeying established rules in order to get along and to remain in the good graces of our superior(s). Just ask Moses. When it comes to drawing blood for laboratory tests, there are also established rules. In fact, there are so many rules to drawing blood that if they were to be carved on stone tablets, it would take weeks to carry them down from the mountaintop two by two. Lucky for all of us the rules for drawing blood are carved into our procedure manuals and, hopefully, into our cortex.

In order for us to stay in the good graces of those who have bestowed upon us the rules for drawing blood specimens—and for patients to get along down the road to good health—something akin to commandments is necessary. If there were a modern-day Moses who could only propose ten such “commandments,” we think they’d go something like this:

I Thou shalt protect thyself from injury.  Using gloves, needle disposal units, and proper technique can minimize your risk of becoming one of the hundreds of thousands of healthcare workers who will experience an accidental needlestick this year. Thousands will contract some form of hepatitis. Fifty to sixty of them will acquire HIV.

II Thou shalt identify thy patients.  This means referring to an identifying bracelet affixed to the patient and asking the patient to state his or her name. When this is not possible, have the patient’s caregiver identify the patient and document the name of the verifier.  No other methods are acceptable.

III Thou shalt puncture the skin at about a fifteen-degree angle.  Most textbooks and standards agree on a fifteen- to thirty-degree angle of insertion.  Injure a patient while puncturing at a greater angle and you will have a difficult time convincing the jury that you are immune from the standards.

IV Thou shalt glorify the medial vein.  The medial vein is the vein of choice for four reasons: 1) it’s more stationary; 2) it hurts less; 3) it’s usually closer to the surface of the skin; and 4) it isn’t nestled amongst nerves or arteries.  Keep the basilic vein as a last resort.  Most nerve injuries and arterial nicks result from misguided punctures into this vein.

V Thou shalt invert tubes with anticoagulants immediately after collection.  A high percentage of blood specimens rejected by testing labs are due to clots in lavender- or blue-top tubes.  A quick inversion after collection prevents a second puncture.

VI Thou shalt attempt to collect specimens only from an acceptable site. Antecubital and hand veins are acceptable unless their use is precluded by intravenous infusions, injury, or mastectomy.  Any other site should be approached with great trepidation.  Should an injury occur, your puncture site had better be defensible in court.

VII Thou shalt label specimens at the bedside.   This means complete identification, not just temporary identifiers to help you when you find time to label them more completely later.  Find time NOW!  Patients have died as a result of mislabeled specimens.

VIII Thou shalt stretch the skin at the puncture site.  This accomplishes two functions: it anchors the vein and it minimizes the pain of the puncture.  Your patients will thank you for considering their suffering.

IX Thou shalt know when to quit.  Not everyone can draw blood from every patient. Even those who elevate phlebotomy to an art form can have difficulty from time to time.  After two failed attempts, one should seriously consider sending in someone else.  It may be the answer to your patient’s prayers.

X Thou shalt treat all patients as if they were family.  In a hospital, the only peace many patients experience is that which you bring them by your kind words, gentle technique, and your smile. Regardless of what you might think, you have been assigned to healthcare by a higher authority because of the comfort you can offer to the sick and injured. You haven’t been employed; you’ve been ordained.

Click here for a 16x20 full-color poster depicting these proposed commandments.

This Month in Phlebotomy Today

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 9^th year of publication, are reading about this month:

• Feature Article: Joint Commission Moves Toward Stricter Patient ID Requirement
• Just Write for Lab Week
• From the Editor's Desk
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in February including these stories:
• Phlebotomists Being Tapped to Help Labs Through Recession
• MRSA Susceptible to Blue Light
• Phlebotomist Arrested for Stealing From Patient
• Phlebotomist Rallies Strangers to Save Man’s Life
• Needlestick Injury Rates Hit Plateau
• Newborn Screening Shows Tremendous Growth Since 2005
• According to the Standards: Heelstick, depth of puncture
• Tip of the Month: What’s in it for you?
• CEU questions (institutional version only).

Buy this issue for only $9.95.

For subscription rates and to subscribe to Phlebotomy Today, visit www.phlebotomy.com/PhlebotomyToday.html. The current month’s issue will be emailed to you immediately upon subscribing.

Featured Product: Skin Puncture Procedure Template

Featured FAQ: Order of Draw with Capillary Gases

Q: Do you know if there is a recommended order of draw when performing heelsticks on children, particularly on our preemies? We’ve been told that the hematology specimens should be collected first because of the risk of clots beginning to form if the collection becomes lengthy. But it’s also recommended that the capillary blood gas be obtained before the baby begins to scream and cry too much as that activity will affect the blood gas results. Are you aware of a particular protocol for these draws?

A: You are correct on both accounts. Once the capillary beds are arterialized and the puncture is performed, the blood emerging becomes increasingly more venous and less arterial. So if the ABG is delayed in the order of draw, the results obtained will be increasingly inaccurate.
      Likewise, if the collection of the CBC is delayed, there is an increased likelihood of erroneous cell counts due to platelet clumping. When properly arterialized, the ABG should be collected relatively quickly. The potential for platelets to clump should be minimal. If you want to assure both tests are as accurate as possible, you might consider performing separate punctures.

Each month, PT--STAT! will publish one of the hundreds of phlebotomy FAQs in the growing database of questions and answers available in Phlebotomy Central, the members-only section of the Center for Phlebotomy Education's web site. For information on joining Phlebotomy Central, visit www.phlebotomy.com/PhlebotomyCentral.html.

Just Write for Lab Week

Managers and trainers looking for an inexpensive but uniquely educational gift for their students and staff can keep the recommended order of tube collection right at their fingertips. Just in time for National Medical Laboratory Professionals Week (April 19-25), the Order of Draw pen is comfortable and attractive with the order of draw illustrated in full color on the barrel for easy reference. Many studies have proven that when blood collection tubes are filled in the wrong order, test results can vary, sometimes wildly, from the patient’s actual condition. Those who follow the prescribed order of draw collect specimens that are less likely to yield misleading test results that impact how the patient is diagnosed, medicated, and managed. Reinforce the importance of the order of draw with phlebotomists, nursing personnel, medical assistants, the ED staff, and all those who draw blood specimens in your facility by putting this constant reminder in every pocket. The pens are available for immediate delivery in packs of 12 for $19.95. For more information or to order, click here.

New Device Takes Guesswork Out of Venipuncture

Survey Says

In last month’s issue we asked Phlebotomy Today STAT! readers
“What mnemonic do you use to remember or teach the proper order of draw? (example: "Studious Boys Rarely Get Low Grades" = Sterile, blue, red, green, lavender, gray.)”

Readers were really working the alphabet last month on this challenge. The reminders people use are listed below. Keep in mind, those responding to the survey designated the first tube used for blood cultures as an “S” for “sterile,” “W” for sterile or “white” tubes, or “Y” for yellow-stoppered (ACD) tube, and. Among the suggestions:

• Young Boys Rarely Get Low Grades
• Sweet Babies Really Good Little Girls
• Young Boys "R" Still Getting Low Grades
• Watermelon Bright Red, Guinea Pigs Gray
• Be a Really Good Phlebotomist (blood cultures are omitted, but are always drawn first)
• Stop Light Red Green Light Go
• And our personal favorite: Stop Buying Roses; Girls Love Gold

This month’s survey question: Does your facility have a formal career ladder for phlebotomists who want to progress into positions with increasing responsibilities, authority, and/or pay?
Click here to participate in the survey.

What Would You Do?

Each month, What Would You Do? presents a different case study, then asks readers to contribute their ideas as to how each situation would best be handled. The following month, selected responses will be chosen by the editor and published (sender will be identified by first name and state only). The most accurate, well written response will receive a free "Accurate Results Begin With Me!^® t-shirt. The exercise will conclude with a review of the selected submissions and a discussion of the standards pertinent to the case study

This month’s case study reflects scenarios that readers have experienced first hand. Thirteen percent of those who responded indicated that such a scenario isn’t likely at their facilities because all patients are immediately banded upon arrival, long before specimens are drawn. However, others noted that they are present in trauma rooms before the patient even arrives and have to coordinate patient identification with the trauma team.

The largest category of responses (80%) included those who would not draw the patient until an ID bracelet was applied. Of those, half would insist the nurse applies an ID band before the venipuncture could be performed while the other half would apply one themselves. Seven percent said they would not only insist the nurse puts the ID bracelet on, but would also ask the nurse to identify the patient verbally. While this approach seems most comprehensive and likely to prevent misidentification, we took favor with Jessica L. from Wisconsin who provides this month’s winning entry:

I have actually come upon this type of situation. Fortunately that patient was not at high risk but need to have surgery right away. The call came into the lab, at the hospital I used to work at, and I volunteered to go down and draw the patient. Our protocol required lab staff to be present in the ER when an emergency arrived at the hospital.
       As I stood there waiting for the signal to draw blood, the room was quite frantic. CPR was being preformed, vitals were being measured etc., etc., and then they needed blood.

As I approached the patient, I overheard a conversation of the phone that surgery is ready as soon as lab gets blood. I proceeded to look for an ID band but there was none on the patient. I told a RN that I cannot draw without the proper ID of this patient. She shrugged in disgust and asked if she could just show me the ID bands, I told her, "no they needed to be placed on the patient themselves". She complied. I will never draw a patient without proper ID. This will ensure me that I am doing MY JOB correctly even if someone else is not doing theirs.

According to the Clinical and Laboratory Standards Institute’s venipuncture standard (H3), the unidentified patient should be provided with a temporary designation until positive identification can be made. The procedure for identifying unidentified emergency patients is as follows:

1. Assign a temporary identification number to the patient; the ID number must be attached to the patient.
2. Record the appropriate test request forms with the temporary ID number;
3. Apply completed labels containing the temporary ID number to the tubes and forms;
4. Cross-reference the temporary ID number to the permanent number when available, and correlate with test results.

Because of her stalwart defense of the standards under extreme pressure and her articulate response to this week’s case study, Jessica will receive a complimentary gift from the Center for Phlebotomy Education’s catalog. Nice work, Jessica!