Can Someone with HIV or Hepatitis Still Draw Blood?

One of the most common questions received at the Center for Phlebotomy Education is whether or not someone with hepatitis or HIV can work as a phlebotomist or draw blood in any other capacity. Until recently, current information on the subject has been scant and vague.

Last month, an updated guideline was published from the Society for Healthcare Epidemiology of America (SHEA) for managing healthcare providers who are infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or the human immunodeficiency virus (HIV).(1) Founded in 1980 to advance the application of the science of healthcare epidemiology, SHEA’s mission is to prevent and control infections in healthcare settings.(2) The guideline replaces those published in 1997.

Noted Trends
Although over 20 infectious diseases have been known to be transmitted by needlestick injuries, HBV, HCV, and HIV remain the greatest concern in terms of provider-to-patient transmission. Despite widespread use of the hepatitis B vaccine, HBV continues to be the most commonly transmitted bloodborne pathogen in healthcare settings. But hepatitis C is not far behind, due largely to its rise worldwide and the lack of a vaccine against HCV. In terms of the rates of provider-to-patient transmission, the data and experience collected over the past two decades offer some encouragement. Although not zero, the risk for transmission is exceedingly small.(1)

Guideline Highlights
In the revised guideline, SHEA continues to recommend separate management strategies for healthcare workers infected with HCV, HBV, and HIV, and provides the rationale. First, the risk for transmission after a single parenteral exposure (any exposure route other than the digestive tract, i.e., via inhalation, mucous membranes, non-intact skin or injuries involving contaminated sharps) is estimated to be 10- to 100-times higher for HBV than for HIV, with HCV transmission rates falling somewhere in between.  Another factor is the advancement in post-exposure management and treatment strategies for each of these infections.

In this update, SHEA:

• Stresses the use of appropriate infection control procedures to reduce exposure of patients or healthcare providers to blood;
• Emphasizes that transfers of blood from patient-to-provider and from provider-to-patient, be avoided; and
• Recommends that infected specimen-collection personnel not be totally prohibited from participating in patient-care activities solely on the basis of an infection with a bloodborne pathogen.

Viral Thresholds
SHEA’s recommendations on what procedures infected healthcare personnel can perform depend on the concentrations of each circulating virus, i.e., they are based on the viral loads stated below:

• HBV – healthcare workers who test either positive for HBV “e” antigen (HBeAg) or negative for HBeAg but who have circulating HBV burdens of greater than or equal to 10⁴ genome equivalents (GE) per mL of blood;
• HCV – healthcare workers with viral loads greater than or equal to 10⁴ GE/mL;
• HIV – healthcare workers who demonstrate viral burdens greater than or equal to 5 x 10² GE/mL.

Infected healthcare providers who meet or exceed these viral concentrations are subject to three categories of venous access procedures based on the risk of bloodborne pathogen transmission associated with each as follows:

Generally, SHEA recommends all infected healthcare professionals who meet or exceed the viral load minimums should use double-gloving for all invasive procedures, all contact with mucous membranes or non-intact skin, and during all patient-care activities for which gloving is recommended. They should not perform phlebotomy procedures on patients who are likely to bite or in certain emergency situations (see Category III procedures in the Table above). Such circumstances are associated with a risk for provider-to-patient transmission even when infection control measures are followed.

SHEA recommends infected healthcare workers with a circulating viral burden below the stated cut-off (HBV viral load less than 104 GE/mL; HCV viral load less than 104 GE/mL; or an HIV viral load less than 5 x 102 GE/mL) be allowed to perform Category III procedures if the employee:

• is not known to have transmitted infection to patients;
• obtains advice from an expert review panel*;
• is routinely assessed by occupational medicine staff or public health official, with semi-annual testing to ensure the viral burden remains below the established cut-off;
• is evaluated by a personal physician who has expertise in managing HBV, HCV, or HIV infections, as appropriate;
• grants permission for the personal physician to communicate with the expert review panel about his/her clinical status;
• obtains expert consultation regarding infection control measures;
• strictly adheres to all recommended procedures; and
• signs a written agreement from the expert review panel that defines his/her responsibilities.

*Note:  The expert review panel, at a minimum, should include representation from Hospital Epidemiology, Infectious Diseases, the healthcare professional’s specialty or subspecialty, Occupational Medicine, hospital administration, and perhaps legal counsel.(1) 

Restricting Assigned Tasks
Students and trainees who are known to be infected with a bloodborne pathogen present a special challenge to their training institutions. SHEA recommends that each situation be confidentially evaluated on a case-by-case basis, with input from legal counsel, infection control professionals and representatives of the training institution.

Although SHEA’s stance is that otherwise competent infected specimen-collection personnel not be prohibited from participating in patient-care activities solely on the basis of an infection with a bloodborne pathogen, the updated guideline also provides additional criteria facilities can use to evaluate an infected employee’s specific transmission risks. In addition to determining the viral load of the healthcare professional, factors to consider include the employee’s ability to properly perform assigned tasks, any documentation that a serious harmful event has occurred (i.e., the employee is known to have transmitted HBV, HCV, or HIV), and the employee’s ability and willingness to comply with established protocols to prevent disease transmission.  SHEA recommends that reasons for limiting an employee’s job duties should be in agreement with the facility’s existing impaired-employee and disability guidelines.

[Editor’s Note:  Correspondence regarding the contents of this guideline should be addressed to David K. Henderson, MD, Deputy Director for Clinical Care, Clinical Center, National Institutes of Health, Bldg. 10, Room 6-1480, 10 Center Dr.,  MSC 1504, Bethesda, MD 20892-1504 (dkh@nih.gov).]

References

1. Henderson, D, Dembry, L, Fishman, N, et al.  SHEA Guideline for Management of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus.  Infection Control and Hospital Epidemiology 2010;31(3):203-232. Accessed on 3/15/10 at:
   http://www.premierinc.com/quality-safety/tools-services/safety/safety-share/02-10-downloads/12_HBV_HCV_HIV.pdf
2. SHEA website. http://www.shea-online.org/about/mission.cfm. Accessed on 3/24/10.

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Center Announces 2010 Webinar Schedule

Recognizing Phlebotomists During Lab Week

Is it possible to go overboard when recognizing those who collect, process, and deliver blood samples in your facility? We don't think so. National Medical Laboratory Professionals Week is April 18-24. As a service to our readers, the editors of Phlebotomy Today have some suggestions on how to make sure your team of phlebotomists knows they are appreciated above and beyond the donuts and free lunches everyone else in the lab gets.

Set aside Tuesday of Lab Week as Phlebotomist Appreciation Day
Without specimens, the laboratory ceases to exist. Without properly collected specimens, the laboratory exists, but is irrelevant. Make sure those who draw blood samples for your lab know how important they are to patient care by setting aside one day of Lab Week where they share the spotlight with no one. Distribute fliers throughout the hospital and place table tents in the cafeteria or other public areas stating, "April 20, 2010 is Phlebotomist Appreciation Day. Thank a Phlebotomist Today!" or words to that affect. There is no greater feeling for a staff member than to be singled out for helping you fulfill your mission statement.

Take a phlebotomist to lunch
Encourage your testing personnel to take a phlebotomist to lunch on April 20th as their own way to appreciate their contribution to the laboratory. Make sure "thank-you for your dedication to quality specimens" is part of the conversation. Not only does this make phlebotomists feel appreciated, but it serves to break down the walls that sometimes emerge between those who collect specimens and those who test them.

Offer preferred parking for phlebotomists on April 20
Space may be limited at many facilities, but for those with the opportunity, preferred parking may be easy to implement. It might mean politely requesting certain physicians or administrators---coddled with reserved parking spots year-round---to give their parking place up for one day.

The chance to earn credentials
This would be a perfect time to present your specimen collection staff with a gift certificate to take a phlebotomy certification exam. Removing the barrier of cost might be all your staff needs to achieve professional credentials through examination, and feel the pride that comes with being deemed competent by a nationally recognized certifying body. Other suggestions on improving their professional profile include:

• an uplifting, motivational presentation (e.g., customer service, achieving one's potential, making a difference, etc.) presented by a local speaker, or prominent member of the community;
• an inservice on the importance of proper specimen collection to the physician presented by a pathologist or staff physician;
• displaying educational posters in all blood draw areas to reinforce proper collection technique.

Introduce a "Me and My Shadow" mentoring program
During the next month, assign every member of your technical staff to spend a day shadowing a phlebotomist. The following month, have the phlebotomist spend a day in the life of the same tech. After one month, you'll be amazed at how well the two divisions of the laboratory work together as a team. You may be short staffed now and then, but it's temporary. If you currently have a disconnect between your collection and testing personnel (and who doesn't), this may be a short-term solution to a long-term problem.

Put your valued staff on display
Construct and post a bulletin board in the hospital lobby, outpatient waiting area, cafeteria, etc., displaying photos of your phlebotomists. Title it "Phlebotomist Appreciation Day: Drawing Attention to Our Collection Team."

These and a multitude of other ideas will help your staff feel recognized and valued as members of your department and facility.

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: The Patients’ Bill of Rights: A Healthy Afterlife
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in March including these stories:
• PBT Students Named among ASCP Scholarship Recipients
• New York Closes Loophole in State’s DWI Laws
• “Certified Phlebotomist” Removed from Indiana DWI Laws
• Study Links Half of Infection Deaths to Nosocomial Infections
• Pennsylvania Hospital Names Phlebotomist as Employee of the Year
• FDA Issues Centrifuge Recall
• Missed Phlebotomy Appointments Contribute to Fiscal Waste
• Hospital Implements New Strategy to Boost Hand Hygiene Compliance
• According to the Standards: Skin Puncture Through Bruised Heels
• Tip of the Month: What’s in Your Suitcase?
• 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.

Featured FAQ
Frequency of hemolysis

Question: We are struggling to get our hemolysis rate down. It would be helpful to know what the rate of hemolysis is industry wide as a percentage of all specimens drawn. That way, I can tell how serious our problem really is. Does such a benchmark exist?

Answer: At least four studies have measured the frequency of hemolysis in emergency department (ED) draws, but only one on overall draws. Generally, the range of hemolysis during venipuncture in the ED is 0.3 percent to 3.8 percent. The summaries of the articles and citations are below.

•     the hemolysis rate in blood drawn during ED venipunctures was found to be 3.8%.(1)
•     hemolysis in ED samples drawn by venipuncture was <1%.(2)
•     0.3% of samples drawn in the ED by venipuncture were hemolyzed.(3).
•     specimens drawn by laboratory-based phlebotomists showed a 1.6% hemolysis rate.(4)
•     3.3 percent of all specimens collected for clinical testing are hemolyzed.(5)

References

1. 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 Emerg Nurs 1996 22(6):566-569.
   
2. Grant M. The effect of blood drawing techniques and equipment on the
   hemolysis of ED laboratory blood samples. J Emerg Nurs. 2003;29(2):116-21.
   
3. Lowe G, Stike R, Pollack M, Bosley J, O’Brien P, et al. Nursing blood
   specimen collection techniques and hemolysis rates in an emergency department: analysis of venipuncture versus intravenous catheter collection techniques. J Emerg Nurs. 2008;34(1):26-32.
   
4. Burns E, Yoshikawa N. Hemolysis in serum samples drawn by emergency
   department personnel versus laboratory phlebotomists. Lab Med 2002;5(33):378-80.
   
5. Jones BA, Calam RR, Howanitz PJ. Chemistry specimen acceptability. A College of American Pathologists Q-Probes study of 453 laboratories. Arch Pathol Lab Med 1997;121:L19-26.

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.

Survey Says

Editor's note: According to OSHA's Bloodborne Pathogens Standard Compliance Directive, the document its inspectors use to interpret the standard, “where engineering controls will reduce employee exposure either by removing, eliminating or isolating the hazard, they must be used.” Richard Fairfax, the overseer of all enforcement and compliance related activities for federal OSHA, was questioned on the clinical laboratory’s use of glass versus plastic tubes in 2003 in an article published in MLO magazine.(1) "[A] plastic tube would be considered an engineering control because plastic is much less likely to break than glass. Since plastic tubes are readily available, a facility that is not using them would have to justify why they are not being used to the satisfaction of our inspectors. That justification would have to appear in their exposure control plan and [be] supported by reliable evidence."

Reference

1. Ernst D. Richard Fairfax of OSHA talks about the Bloodborne Pathogens Standard. MLO. 2003;35(2):32-34.

This month’s survey question:

If your blood collection staff covers multiple shifts, how would you describe the shift change?

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 editors 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.

The majority of PT-STAT! readers who responded to last month’s case study recognized the potential for injury with patients who have a history of passing out during phlebotomy procedures and the importance of properly positioning the patient. Sixty-seven percent of our respondents would explain the safety risks and consequences to Roger should he faint while seated in an upright position. Interestingly, 33% would still perform the draw on Roger even if he couldn’t be convinced to lie down, with 13% stating they would seek additional assistance from a coworker. 

According to CLSI’s venipuncture standard (H3-A6), those who collect blood samples should anticipate a possible loss of consciousness in every patient and be prepared to react according to institutional policy. Part of that preparation includes having a venipuncture chair available that is equipped with a safety feature (i.e., adjustable armrests) that will prevent the patient from falling should he/she pass out. Under no circumstances should a patient be drawn while seated upright on an exam table. Should the patient lose consciousness, there is nothing to break his/her fall, which could result in serious injury to both the patient and collector.

For individuals who report a history of fainting, placing the patient in a recumbent position before the draw greatly reduces the potential for injury and subsequent legal liability, as described by one reader:
“I would explain to Roger, given his history of fainting that collecting a blood specimen from him sitting up would put him, me, and our organization at significant risk. In light of the risk, I would not collect a blood specimen from him until he lies down. In responding to Roger in this manner, I have taken control of the safety issues and risks associated with the specimen collection and given him the freedom to choose whether he wants his blood drawn or not.”

Doreen E. described her approach this way:

“During many years of working as a phlebotomist I have met a lot of patients like Roger who insist they will be okay sitting in a chair, only to find that they of course are not and duly faint. My approach now is to explain that I am not comfortable to bleed them unless they lie on the couch, as I am a small female and it would be impossible for me to hold them and be very dangerous if there was a needle in their arm. I also tell them that it is much more relaxing for both of us if there is no danger of them falling. During the procedure I chat to them all the time and usually everything is okay and they go away very positively because they feel perfectly okay. If they insist on sitting in the chair I simply refuse to 'bleed' them.”

Another reader has found that describing the amount of paperwork required should the patient pass out to be an effective means of persuading resistant patients to cooperate. “First I ask the patient to follow protocol as a favor to me, thereby taking ownership of the situation. Next I will describe a consequence for the patient if he doesn't do what I am asking. In this case I would ask the patient to lie down to help me out because if he faints I would have "a lot of paperwork" to do. I get better compliance this way because the generic phrase "paperwork" implies that the patient will have to stay to complete his portion.” 

Keeping the faint-prone patient engaged in conversation was a method of distraction mentioned by 13% of our readers. Also noted in 20% of the responses was the importance of being sensitive to and lessening the embarrassment Roger may feel. Christine S. offered the following alternative:

“We have reclining phlebotomy chairs rather than exam tables…Drawing the patient in one of those allows him to remain seated, and not be embarrassed--which is probably the reason he doesn't want to have to lie down for the draw--but if he does faint, he is just needs to be reclined. This works great for us. Our chair also has wheels, so if we have "a Roger" that doesn't tell us he sometimes faints, a quick call to a coworker and the chair can be wheeled over so when the patient regains consciousness we can have them lie down for a while.”

According to Dean from Indiana, exploring all options can result in a win-win outcome. “I think it is important to communicate to Roger that I respect his request sit up, however; his safety is paramount. I like to empower the patient as much as possible. There might be another alternative that would be safe and not require him to lie down. We have a chair that lays back that is used for Autologous Donation that would not require Roger to be flat on a bed, yet still position him safely in the event that he passed out during the procedure. Seeking other acceptable alternatives – thinking outside the box – and straying from disempowering the patient leads to exemplary customer service.”

Because of his “power to the patient” approach that strikes a balance between ensuring the patient's safety while delivering good customer service, Dean will receive a free download from the Center for Phlebotomy Education’s library of download articles.