Survey Says
Butterfly Use

Our latest survey certainly struck a chord with visitors to our website. We asked about the limits, if any, facilities place on the use of winged-collection (butterfly) sets by specimen collection personnel. Responses were so passionate and informative, we thought it merits a promotion to become this month’s feature article.

Over the years, butterfly use and utilization has been a very popular and polarizing topic among the Center for Phlebotomy Education’s website visitors, conference attendees, and healthcare professionals around the world who seek our counsel. Some love ‘em; some don’t. Among those who don’t are managers and supervisors who are held accountable to their budgets and must constrain their use. Among those who love ‘em are patients; and there lies the rub.

Clearly, some situations require butterfly use. For example, chemotherapy and geriatric patients whose veins are fragile and difficult to access, and pediatric patients for whom precise needle placement is essential to the success of the procedure. Winged-collection sets are lightweight, easily maneuverable, and allow for a lower angle of insertion. But these benefits come with a price that’s up to ten times the cost of conventional safety needles. Therefore, using them when they’re not required can be a real budget-buster. Further complicating the issue for managers and supervisors is a revelation from those who answered our survey that some schools teach their students to draw blood using butterfly sets exclusively.

How do you handle butterfly use? Do patient requests trump the extra expense? Does your facility limit their use? If so, how do you reach a practical compromise on these issues so that neither staff nor patients feel slighted? Every facility handles this issue differently. We hope the survey results, comments, and analysis below help readers formulate a strategy in their facilities everyone can live with.

Survey Question #1.
Does your facility limit the number of winged-collection (butterfly) sets specimen collection personnel can use per month?

Yes: 32.8%

No: 67.2%

Although the majority of those who responded to the survey indicated that their facilities do not currently impose strict limits on butterfly use (67.2%), 13% within this group commented that they have thought about it or are in the process of setting a limit. Another 11% of the “no limit” responses stated that while winged-collection sets are not withheld when requested, their facilities actively monitor usage and/or have implemented a “gate-keeper” system where staff must obtain butterfly needles through another individual, such as the lead phlebotomist, lab manager or lab director.

Sample Comments:

• “We don’t limit exactly. We monitor. We have a checkout log in the manager’s office where each phlebotomist notates the number of butterfly sets they are checking out.”
• “We control usage by making each phlebotomist come to the manager’s office to get their supply.  Currently, 20% of all venipunctures are done using butterflies in my institution. Prior to the control I’ve instituted, 58% were done using butterflies.”
• “We were told that this is an illegal practice due to limiting what the phlebotomist feels comfortable with. We have tried to be more proactive with training new phlebotomists with straight needles/syringes before introducing them to butterflies.”
• “We inform the staff of the cost of those sets vs. other methods of collection, but leave it to them which device to choose for what patient. As a Laboratory Educator, I would never want to assign them a maximum number only to have them use their quota and then be unable to use another if it was truly called for.”
• “We limit the staff to signing out 5 at a time in the lab director’s office. Any supervisor can sign the log as they are taken. We do not ask why. Once this was started usage dropped 35%. Staff is not limited to how many they use, if they need more, they can sign more out. Usage per employee per shift worked is checked periodically and staff members that use the most are reminded that syringes are also available. Usage is also noted on annual evaluations. Staff would prefer this not be done, but cost reduction is a major facility goal. If it is jobs vs. supply control, they are a little more understanding of my decision. The biggest issue is the arguments with the patients who refuse to let staff draw without a butterfly.”

Survey Question #2.
If so, what is the limit per month (per individual or per department)?

In facilities where access to winged-collection sets is restricted, responses regarding the specific number of devices made available to staff varied greatly. One survey participant stated having to request butterfly needles as needed from a charge tech, with 14% of this group reporting their maximum at 10 butterflies per month. Twenty-one percent gave a limit ranging from three to six butterflies per shift, while another 14% reported a cap of one box of butterflies per phlebotomist (or draw station) per month. At the high end of the winged collection spectrum, one respondent reported a personal butterfly limit of 200 sets per month, with another 21% of survey participants giving a threshold anywhere between 45-100 devices per month. However, without additional information including the total number of blood samples collected, the patient populations served, the difficulty of the draws performed and other crucial details, readers should use caution so as not to make comparisons that are out of context or may be inappropriate for their particular patient settings.

Sample Comments:

• “The phlebotomists usually have to borrow from one another if they run out and have a really hard stick.”
• “I think this is not fair to some patients who are difficult sticks and may need to have blood drawn from the hand…”
• “It was per day! You were given 3! We had to sneak them out of supplies if we went over the allotted amount…I left that company. It was too restrictive. With the amount of elderly and pediatric patients, you cannot limit the amount of butterflies one person can use.”
• “We try and limit how may butterflies that we supply to non-lab personnel (home health, offices, etc.). We are considering not supplying them at all.”

With 32.8% of those surveyed affirming that a limit on winged-collection sets is in place in their facilities, what may be more telling than the actual device thresholds is identifying what prompted the restriction in the first place. Survey comments point to three main reasons:

1. Overuse by inexperienced or improperly trained collection staff
2. Cost
3. Public/customer demand

Sample Comments:

• “We had a phlebotomist [who] used butterfly sets for all her patients! Once this was discovered, a limit was set to discourage this expensive habit.”
• “Winged-collection set use increased tremendously when [the] Phlebotomy Team discontinued and Nursing began making collections. The facility has discouraged the use of winged sets mostly because of the cost. As a phlebotomy educator, I teach using the 21- or 22-gauge in classes because most of Nursing has only used the winged set. It is an uphill battle.”
• “Why are so many new phlebotomists being trained almost exclusively to select winged collection devices?”
• “Expensive.”
• “I am a supervisor in a multi-site laboratory. We strive to work with our patients to provide excellent service. Unfortunately, many patients are recognizing that these devices are being used and are now requesting them all of the time. It is a fine line between quick, lower-cost collections and customer satisfaction.”
• “The patients are coming in insisting that we use a butterfly, either because of chemo or small veins.”

The following respondent comment illustrates how all three factors (skill of blood collection staff, cost control, and public demand) may intersect creating a winged-collection device conundrum:

“With our current economic challenges, all businesses are seeking reduction of operating costs of which winged-collection (butterfly) sets are one…the public has become more knowledgeable on the equipment being used and will demand the use of such a system of collection. It has put the phlebotomist in a difficult position, where on the one hand we are instructed not to get into any conflicts with the patient …Yet, newly trained phlebotomists are learning poor habits of overuse of these winged-collection systems, especially with the volume of patients being drawn today and the fast pace that goes with it.”

Clearly, the proper management of winged-blood collection set usage is a multi-faceted issue with no single approach that will work for all facilities. What works in your environment may be as much a function of personal preference as it is financial responsibility. This much is certain: nothing stirs the emotions of blood-collection personnel quite like a survey on butterfly utilization.

[Editor’s note: because it generated such interest, this survey remains open. Readers who have not already participated may continue to register their responses here. If warranted, a follow-up article may appear in a future issue.]

This month’s survey question: Does your facility stock glass blood collection tubes (not including blood cultures)? Which tests if any are drawn into glass blood collection tubes in your facility (excluding blood cultures)? Are blood cultures drawn into glass or plastic bottles/vials?

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 18-24), 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 10 for $19.99.

For more information or to order, click here.

Featured FAQ
Hemolysis in the ED

Q: We have been working on a chronic hemolysis problem from our ER. We've explored many options, including the various connecting devices in use in that department. Lately the ER nurses have started to put the blame on the lab. Although we doubted that possibility, we've been investigating ourselves in all fairness. We discovered that there are conflicting recommendations about how blood should be stored and transported. The CLSI guideline H18 mentions keeping tubes in an upright position. Is there any evidence supporting this?

A: Tube orientation is not likely contributing to your hemolysis rate. Your story mirrors almost exactly a study reported in the Journal of Emergency Nursing where the authors, all nurses, investigated the lab's claim that they were hemolyzing specimens during collection in the ER. The nurses didn't believe they were responsible and conducted their own study to prove it. But what they proved is that their draws actually were more hemolyzed than those drawn by laboratory phlebotomists. Here's the reference:

Kennedy C, Angermuller S, King, R, Noviello S, Walker J, et al. A comparison of hemolysis rates using intravenous catheters versus venipuncture tubes for obtaining blood samples. J Emer Nurs 1996;22(6):566-569.

More than likely, your nurses are hemolyzing specimens drawn during IV starts. If you can discourage this practice, your hemolysis rates would plummet. Vascular access devices simply aren't designed for blood to be withdrawn but for fluids to be infused. So when used for a purpose for which they're not intended, you’re going to get the results you're getting. The problem is worse when hemolysis is not detected and the compromised results are released, as for CBCs and H&Hs released by the hematology department. Unless the specimen is centrifuged—which CBC specimens aren’t—there's no way to tell that it’s hemolyzed.

If you run into resistance, try having them use syringes instead of tube holders so that the pressure at the tip of the line is minimal and less likely to rupture red cells, or to limit draws only to larger gauge cannulas (such as 18 gauge or larger).

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, click here.

Featured Product
Phlebotomy Tips Cards

Center Seeks Phlebotomy Program Coordinator

The Center for Phlebotomy Education is recruiting a full-time coordinator for its School of Phlebotomy in Corydon, Indiana. The successful applicant will possess a comprehensive understanding of phlebotomy procedures according to the CLSI specimen collection and processing standards, as well as classroom teaching experience, computer and communication skills, and polished professionalism. Responsibilities include classroom teaching, development of material, maintaining relationships with clinical sites, administering and grading exams, counseling students, new student recruitment, marketing, and other duties to assist the program administrator.

The position requires relocation to Corydon, Indiana, a charming rural community in southern Indiana two hours south of Indianapolis and 30 minutes west of Louisville, Kentucky. Corydon is a vintage mid-American farming community with historical significance as Indiana’s first state capital and the site of the only Civil War battle to occur on northern soil besides the Battle of Gettysburg. Nestled in gently rolling countryside in a county that has the Ohio River as its southern border, Corydon is home to Cousin Willie’s Popcorn, Butt Drug Store, the Corydon Jamboree, and, of course, the Center for Phlebotomy Education.

The School of Phlebotomy serves the southern Indiana and Louisville, Kentucky metropolitan area, and has developed a reputation among clinical sites for producing high-caliber applicants. Interested educators should contact the Center for Phlebotomy Education toll free at 866-657-9857.

Joint Commission Announces Free Teleconference

The Joint Commission will host a complimentary teleconference for both accredited and non-accredited labs on Wednesday, March 10, 2010 from 1:00-2:30 PM Central Standard Time. Topics will include laboratory accreditation program updates for 2010, the 2010 lab standards, frequently asked questions, and survey tips. There will be a chance for listeners to ask questions of the three Joint Commission speakers.

As previously reported in Phlebotomy Today, the accrediting agency rescinded its requirement for healthcare professionals to actively involve the patient prior to drawing blood samples in its 2010 National Patient Safety Goals. This teleconference provides laboratorians an opportunity to express their concerns.

Phlebotomy Certification Act Fails In Utah

On March 1, 2010, Utah legislators failed to pass House Bill 437 Phlebotomy Certification Act sponsored by F. Jay Seegmiller. The bill would have set minimum training and certification requirements for Utah phlebotomists. There were 24 votes in support of the bill and 47 against. An audio link of the legislature discussing the bill is below. Scroll down to HB 0437 and click "view."
http://le.utah.gov/asp/audio/index.asp?Sess=2010GS&Day=35&House=H

European Committee Conducting Hemolysis Survey

With hemolysis being the number one reason for blood specimen rejection, the European Preanalytical Scientific Committee (EPSC), in collaboration with the International Federation of Clinical Chemistry (IFCC) Working Group on Patient Safety, has designed a survey to collect data on prevalence and management of hemolytic specimens referred to clinical laboratories for clinical chemistry testing. The EPSC solicits your input on this important project. To participate in this survey, go to https://forms.bd.com/schs/index.sp.

This Month in Phlebotomy Today

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 11^th year of publication, are reading about this month:

• Feature Article: Cops Drawing Blood: Coming to a Sobriety Checkpoint Near You?
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in February including these stories:
• Patient Sues Hospital over Phlebotomist’s Sexual Misconduct
• Newborn Blood Spot Research Raises Ethics Issues
• Syringes with Detachable Needles Increase Hepatitis C Survival Rate
• Technology Gives Hand Hygiene a Hand
• U.S. DOL Doles Out $5 Million to Middle Tennessee for Healthcare Training
• Inmate Appeals Payment for Injuries Inflicted on Phlebotomist
• According to the Standards: Site prep solutions for blood alcohol levels
• Tip of the Month: How to Hemolyze a Blood Sample
• CEU questions (institutional version only).

Buy this issue for only $9.95.

For subscription rates and to subscribe to Phlebotomy Today, click here. The current month’s issue will be emailed to you immediately upon subscribing.

A Tribute to Kim Baker PBT(ASCP)

The Center for Phlebotomy Education lost a valuable member of its team last month with the sudden passing of our phlebotomy school's instructor and program coordinator. We've posted a tribute to Kim Baker PBT(ASCP) on our website.

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 download from the Center for Phlebotomy Education’s Library of Download Articles. The exercise will conclude with a review of the selected submissions and a discussion of the standards pertinent to the case study.

Helen may be a fictional character but based on the responses received, PT-STAT! readers know her type well. Seventy-nine percent of those who responded to this case study stated they would explain facility policy to Helen, with 36% emphasizing the requirement to label blood samples at the patient’s side. Others also noted that labeling tubes in the presence of the patient assures Helen that the information on her samples is correct. Over half of the respondents (54%) would take the opportunity to educate the patient regarding the consequences of not providing proper post-venipuncture care, including bruising and hematoma formation. Thirty-six percent also mentioned the risk of soiled clothing due to bleeding from the puncture site.

Although 18% of readers would ask permission to “at least bandage” the site prior to releasing the patient from their care, collectors should not rely on a pressure bandage as a substitute for applying direct pressure. Kudos to those who, even under pressure, would stick to the standards and insist on performing the required two-point check prior to bandaging and releasing the patient. It’s the only way to guarantee that bleeding has ceased at the skin’s surface and that the vein has sealed.

According to Dean from Indiana, empathy and efficiency also go a long way in such situations:

 “…The other day I collected blood from a patient who told me they had to be at work in a half an hour and appeared anxious about how long the procedure was going to take. I simply restated to the patient that I understood their need to be in and out as soon as possible and promised to "be as efficient as possible." I gave continuous communication regarding the procedure, all the while making an efficient use of my time by reinforcing the importance of proper identification of their sample for their safety, making a thorough search for a vein so only one stick is needed, and showing my ability to multi-task by holding direct pressure on the site while labeling and reconfirming all necessary paperwork is complete. My ultimate goal is to 'wow', and deflect the patient's attention with my knowledge and efficiency so he or she has a full understanding of each phase of the procedure and is appreciative that I was so attentive.”

One of our readers, Cathy H., described her approach this way:

“I think it is important for all of us to recognize that a patient’s time is valuable. We should make every effort to appear organized and efficient. Any fumbling or hesitation as we draw from a patient like Helen, who is already fretting about the time she is spending in a doctor’s office, will only compound her feelings of time–wasted. Having said that, it is vital that our protocols are followed to assure that the test quality is good, tubes are properly labeled, etc.That means that we cannot take short-cuts. I would suggest that the phlebotomist acknowledge that the patient’s time is valuable while remaining very professional and efficient in manner. One tactic I often take to slow a well-dressed, busy executive-type from trying to leave the chair too early is to state that I am concerned about preventing a potential blood stain on their nice clothing. I will continue with an explanation of how the appropriate pressure, time, and bandage will prevent additional bleeding and an unnecessary trip to the dry-cleaners!”

For her articulate response and strategy to prevent a hurried patient’s hasty exit from the phlebotomy chair, Cathy will receive a free download from the Center for Phlebotomy Education’s Library of Download Articles.