Hemoconcentration

As a phlebotomist, have you ever:

1) Drawn blood from a patient who had gone from laying down to sitting upright immediately prior to the draw?

2) Left the tourniquet on for more than 60 seconds?

3) Instructed the patient to pump his or her fist?

If so, you may have caused what is known as hemoconcentration.  Hemoconcentration is a decrease in plasma volume, which causes a simultaneous increase in the concentration of red blood cells and other commonly tested constituents of the blood. Hemoconcentration can be induced internally as a function of the body’s natural physiology, or externally by specimen collection personnel. Regardless, all who draw blood specimens must be aware of how it can alter test results, and work to prevent it.

     Internally induced physiological hemoconcentration is caused by hormones when a patient changes position, for example, when going from lying down to sitting up. With a posture change from recumbent to upright, the body realizes the blood pressure must increase to keep the brain supplied with oxygen-rich red blood cells now that it is elevated higher than the heart. As this occurs, water and smaller analytes migrate from the capillary beds into tissue. Cells and larger analytes, such as proteins or anything bound to protein are too large to pass through the porous capillary walls and accumulate within the blood in increasingly higher concentrations.

     Fortunately, in these situations the changes are temporary, and many of the analytes are not affected in a clinically significant way.  For others, the change can be significant enough to present a misleading picture to the physician of the patient’s health status, e.g., a falsely elevated white blood cell count.

     Externally induced hemoconcentration is that which a phlebotomist can cause, and can have the same effect on test results. Applying the tourniquet too tightly or leaving it on for too long causes the blood to become hemoconcentrated below the constriction. Changes to the blood below the tourniquet occur within one minute. Therefore, if the phlebotomist is having difficulty locating a vein, the tourniquet should be removed and the blood in the limb be allowed to return to its basal state for two minutes before continuing the collection.  To facilitate relocation once the tourniquet is reapplied, the phlebotomist can note locators such as moles, freckles, or contours of the skin as guideposts prior to inserting the needle so vein location and access can occur within one minute.

      When people donate a unit of blood they’re often asked to pump their fist to assist the collector in vein location. However, fist pumping prior to collecting blood for clinical testing can dramatically change the patient’s test results. Not only does it facilitate hemoconcentration, but repetitive muscle contraction elevates analytes such as potassium and ionized calcium almost immediately in the bloodstream. Therefore, phlebotomists should discourage patients from pumping their fist, and inform them that it can alter their test results. Educating the patient in this manner may help prevent it from happening in the future.

      The analytes altered during hemoconcentration can lead to erroneous results that cause physicians to treat a condition the patient may or may not have. Should hemoconcentration cause an analyte that is abnormally low to be reported as normal, a potentially serious situation can go undiagnosed and untreated.

This Month in Phlebotomy Today

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 8^th year of publication, are reading about this month:

• Feature Article: Discernment and the Difficult Draw
• Ask the OSHA Expert!: an OSHA consultant addresses these burning questions:
• Must lab coats be worn for routine venipuncture?
  
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in May including these stories:
• UK Phlebotomist Sticks and Kicks
• One in Five Potassiums Inaccurate When Shipped
  
  
• According to the Standards: Drawing Patients on Exam Tables
• Tip of the Month: Just a Phlebotomist
• On a Personal Note: Thoughts from Tim Randolph on a Medical Mission to Haiti.
• 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 FAQ: Changing hands during the draw

Q: I switch my hands after inserting the needle so that I can use my dominant hand to change tubes. My new supervisor insists I don’t switch hands anymore. I am 50 years old and have ten years of experience, but now my hands are beginning to develop some arthritis. Following her suggestion would be more painful for me. Since I’m as proficient as anyone in the office, does my employer have the right to dictate what technique I use to hold the tube holder?

A: There is nothing in the standards or any text that prefers your employer's technique over yours, or vice versa. Which hand you use to change tubes is a matter of individual preference.
     The one-handed technique your supervisor is suggesting (i.e., holding the tube holder with the same hand with which you inserted the needle for the duration of the draw) is a good way to teach new phlebotomists who are less sure of themselves to draw blood. Those new to the procedure are more likely to dislodge the needle should they change hands in the middle of the draw. But for veteran phlebotomists like you who are comfortable with the switch, and can do so smoothly without displacing the needle, the request is a little irrational, and suggests there are underlying issues.

        If you are just as successful as other phlebotomists who use the "same-hand" technique, there’s no reason to make you change. Having said that, an employer can insist you follow facility policy, even if you disagree with that policy. To resist subjects you to charges of insubordination.
       If it is the facility’s policy to use the same-hand technique, then you ultimately have no choice. If you have addressed your concerns tactfully and diplomatically, and your employer still instructs you to use their method, there’s not much you can do if you want to continue working there. If it boils down to either being right or being employed, it's your call. You sound like a very dedicated phlebotomist. Don’t let this disagreement prevent you from continuing to provide quality patient care. Your patients need you.

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.

Specimen Collection Safety: Handwashing

Each year, 2 million healthcare-associated infections cause nearly 88,000 deaths in America. Even though most come from the hands of healthcare personnel, studies show compliance with the CDC’s guidelines for handwashing--the single most effective means of controlling nosocomial infections--is woefully neglected.(1) According to the CDC's Guideline for Hand Hygiene In Healthcare Settings, "Failure to remove gloves after patient contact or between 'dirty' and 'clean' body-site care on the same patient must be regarded as nonadherence to hand-hygiene recommendations."(2)

     According to the OSHA Bloodborne Pathogens Standard and the CDC guidelines, specimen collection personnel must wash their hands between every patient.(1,3) In areas where access to handwashing facilities is not possible, alcohol-based gels can serve as an adequate substitute for handwashing unless the hands are visibly contaminated.

     The guideline states hands should be washed with either a non-antimicrobial soap and water or an antimicrobial soap and water if visibly dirty, contaminated with proteinaceous material, or soiled with blood or other body fluids.(2) If not visibly soiled, an alcohol-based hand rub can be used for routinely decontaminating hands in all other clinical situations.

     When decontaminating hands with an alcohol-based hand rub, the guideline also recommends applying the product to the palm of one hand and rubbing hands together until dry, covering all surfaces of hands and fingers. When washing hands with soap and water, hands should be wet first with water, and an amount of product recommended by the manufacturer applied to hands. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, then rinse with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Avoid using hot water as repeated exposure to hot water may increase the risk of dermatitis.

Adherence to these guidelines and standards, as well as your facility’s policy on handwashing, is the best means of keeping you from spreading deadly bacteria that threatens every patient you draw.

References

1) Bartley J, Olmsted R. Are healthcare facilities safe for patient care? Healthcare Purchasing News Nov. 2003:38-40.
2) Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Healthcare Settings.  http://www.cdc.gov/handhygiene. Accessed 5/1/08.
3) US Department of Labor and Occupational Safety and Health Administration (OSHA). Occupational exposure to bloodborne pathogens; final rule (29 CFR 1910.1030). Federal Register.1991;Dec 6:64004-64182.

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

Apparently, this scenario is not that uncommon. We were surprised how many of our readers have experienced rabid physicians demanding results. Most responders stated that when they encountered physicians who have reached their boiling point, they’d politely end the conversation, look up the results, and return the call. Twenty-one percent said they’d apologize to the physician for the delay; one said she’d request an apology from the physician. An additional 21 percent said they’d request a more respectful tone before continuing the conversation. Nearly 30 percent said they’d report the abusive caller to their administrator for disciplinary action. One even admitted that this action, coupled with the threat to file charges against the physician, publicizing the case in the local media, resulted in the physician’s suspension of admitting privileges and his eventual relocation to another hospital. Today, she’s enjoying the calm.

We particularly liked one respondent who shared the story of when a livid physician demanded the name of her supervisor, she responded, “God.” The physician calmed down and apologized.

But the winner of this month’s t-shirt is Joan D. In two sentences, she summarized what we feel is the most professional and assertive reaction to such venomous callers.

“I would ask for the patient's name & birth info, tests ordered MD name, number & fax Number. Then I would ask the MD to hang up take a few deep breaths to lower his blood pressure and expect a call within a half hour which he will answer politely.”

It’s not just physicians, but anyone with anger management issues can be irrational and vulgar, lashing out at those who get in their way, however innocent. Usually, the only purpose it serves is the erosion of respect for the individual who descends to such ancestral impulses. How we handle such personalities defines our own level of professionalism. Descending into their verbal gutter by trading obscenities only takes our power away and takes us down to their level. Maintaining the high ground while under fire may not be easy, but it provides leverage and establishes the upper hand, at least on the civility scale.

     Calmly acknowledging the caller’s displeasure, gaining the information you need to look into the problem, and promising to call back as soon as you have an answer is the best approach. After the immediate issue is resolved, however, steps should be taken to address the caller’s offensive and inappropriate tactics. Bringing it to the attention of those with the authority to levy consequences for future unacceptable behavior is the very least that should happen after the fact. Requesting a formal apology from the offending party is a fair request. Sometimes, an apology is such a humbling experience for those who verbally assault others on a regular basis, they’ll think twice before putting themselves in that position again.

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