Garbage In; Garbage Out: Part I

Every Monday evening Dennis puts garbage in the trash can and sets it on the curb. Every Tuesday morning, the garbage truck takes the garbage out of the can and gives him his can back. Dennis puts garbage in the can; the waste hauler takes it out and delivers it to a landfill.

Dennis goes to work and fills a tube full of a patient’s blood, making many technical mistakes and processing errors along the way. He sets the tube in the chemistry rack for testing. The tech puts some of the blood into an expensive and sophisticated testing instrument, which turns it into a series of numbers the patient’s physician will use to make decisions on the patient’s diagnosis and treatment. Dennis puts garbage into the chemistry rack, the tech takes the garbage out in the form of inaccurate test results and delivers it to the physician. Garbage in; garbage out.

Despite hundreds of thousands of dollars labs spend on sophisticated testing instrumentation and skilled technical personnel, no device or individual will ever be able to extract an accurate test result from a specimen drawn, transported, handled, or processed incorrectly. Nor will either be able to identify and reject every specimen that doesn’t reflect the patient’s true status. Over the next few months, Phlebotomy Today-STAT! will explore the many ways those who draw and process specimens can unknowingly alter test results. This month: making garbage before the needle is even inserted.

Many collection errors that alter test results occur before the needle is ever inserted into the arm. The following are some of the more significant mistakes collectors can make that turn the information the lab reports on the specimen into garbage.

Misidentification — When patients are treated according to someone else’s results, catastrophes can occur. Make sure all patients are asked to state their name and that the arm bracelet you are using to identify inpatients is attached to their person.

Wrong time of collection — make sure all patients requiring fasting lab work are indeed fasting. By definition, fasting is a complete dietary restriction of everything except water and medication. Fasting for a glucose level must be overnight.

Medication — Unless specifically ordered otherwise, draws for therapeutic drugs should be performed just prior to the next dose. If this is not possible, e.g., outpatients for whom returning at another time would be inconvenient, make sure the time of draw and the time of the last dose are included with the test results for proper interpretation.

Draws during IV infusion — The standards state to avoid all draws from the same arm as an IV infusion. When not possible, have a caregiver managing the IV to shut it off for two minutes, and draw below the infusion site. Discard the first 5 cc if possible. Record the specimen was drawn from the same arm as infusing fluids. CLSI discourages draws above IVs, especially if the specimen is to be tested for analytes that may be in the infusing fluid. If your facility permits draws above IVs, follow facility policy and label the specimen as such. This will help prevent the specimen from being used should inappropriate tests be added on to the order after the specimen is collected.

Next month: Draws from VADs, timing blood cultures, exercise, posture

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: Preventing Repeat Heelsticks
• Ask the OSHA Expert!: an OSHA consultant addresses these burning questions:
• Can a phlebotomist decide to wear PPE on a case by case basis?
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in May including these stories:
• Fasting Senior Turned Away; Department “Too Busy”
• Drivers Declining Breathalyzer Get Venipuncture Instead
• According to the Standards: Bending the Patient’s Arm Up
• Tip of the Month: Sir Lance Alot
• 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: Skin Punctures to the Big Toe

Q: I have clinics that are performing capillary sticks for hemoglobin testing in the doctors' offices. They currently use the big toe on six-month olds. Nowhere in the literature am I able to reference the great toe as an acceptable site. Please advise what the appropriate practice is in this case.

A: In prior versions of the CLSI skin puncture standard, the great toe was included as a recommended site. However, in 2004, it was removed from the list because heels provide such a sufficient number of options that the great toe needn’t be "recommended."
       With that in mind, there is nothing wrong with performing a skin puncture on the great toe, nor are we aware there risks that would make it unacceptable. The reason you aren't finding it in the literature anymore is because reputable texts reflect CLSI's standards.

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.

Waterloo Healthcare Specimen Collection Cart Waterloo Healthcare (Phoenix, Arizona) offers a multi-purpose cart designed especially for specimen collection personnel. Developed under the supervision of phlebotomy professionals working daily in the field, the cart is designed especially for the needs of hospitals, clinics, surgical centers, and doctor's offices where blood collection procedures are routine.      Two sizes of the cart are available. The tall cart measures 26 inches wide by 18 inches deep and is 44 inches tall; the shorter cart has the same width and depth, but is only 37 inches high. Both are made out of a combination of steel, aluminum, and plastic to provide a sturdy yet lightweight solution that keeps specimen collection supplies and equipment in reach at the point of use.      The cart can be custom configured with 3-inch, 4-inch, 6-inch, and 9-inch deep drawers. The 3- and 4-inch drawers are trays designed to hold plastic dividers (included) that can easily be custom configured. The tall version has an extra full-width 6-inch drawer at the bottom for additional storage. The cart also has 12 clear plastic tilt bins built into the front of the cart that conveniently show their contents for fast and easy access. Waste can be placed into the built-in sharps container that locks inside the cart or the built-in tilt-out waste bin. For more information, contact Waterloo Healthcare at (800) 833-4419 or visit the web site at http://www.waterloohealthcare.com.

Specimen Collection Safety: What to do after a needlestick

Sustaining an accidental needlestick from a contaminated sharp is a terrifying experience. Because so much is at stake after the exposure, those who know how to react have the best chance to minimize the potential to acquire a bloodborne pathogen that can dramatically affect their way of life. Because so many variables determine the appropriate and necessary response to an accidental needlestick, every healthcare professional must be aware of the treatment options as dictated by those variables, and be prepared to react accordingly.

By preparing in advance under calm circumstances, healthcare professionals avoid the anxiety of making decisions while coping with the emotional trauma inherent in an exposure. Immediate access to an infection control professional to evaluate the risk and manage an appropriate response is the cornerstone of effective exposure management. Actions that should be taken after an exposure should include:

• Care of the exposure site: Thoroughly wash the site with soap and water to remove any foreign object(s) that may also be in the wound.  There is no need for scrubbing, squeezing, or use of chemicals on the wound.
• Evaluation of the exposure: To determine risk, source testing, and the healthcare professional’s candidacy for postexposure prophylactic (PEP) medication, have an infection control professional evaluate the circumstances around the exposure immediately to determine the appropriate action required;
• Administration of the PEP: If determined to be necessary by the infection control professional, submit to the administration of the PEP within several hours of the exposure.
• Follow-up testing and counseling:  Counseling for the exposed healthcare professional should include immediate therapy options, information on follow-up testing, the potential to transmit pathogens acquired from the exposure to family, patients, and other contacts, ways to prevent such secondary transmissions, the implications of current or future pregnancies if appropriate, symptoms of virus transmission, and side effects of the facility’s prescribed PEP if administered.

The time just after an injury is a time of intense anxiety for the injured. It is just as important to know when testing and treatment are necessary as when they are not. It should not be assumed that the treatment for an accidental needlestick from a needle that had not yet punctured a vein is the same as for that from a needle that had accessed a vein.

Other than prevention, making sure you report the needlestick, treat the wound immediately, and seek the evaluation of the individual who can implement the facility’s exposure control plan is critical to effectively managing the exposure.

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

Given today’s racial tensions, we admit this scenario was a bit risky. But your responses reflected a high degree of professionalism and sound judgment, virtues that have become hallmarks of our readers over the years. Not one respondent would express outrage or offense to the patient in this hypothetical situation, though the scenario would clearly stir emotions. In fact, all the responses we received fell into two categories. Thirty-seven percent said they would talk calmly and rationally to the patient in an attempt to persuade him to submit to the draw. The remaining 63% said they would honor the patient’s request for another phlebotomist. Several readers responded similarly to Amy N.: “All patients have the right to refuse services for any reason.”

Many shared that they’ve experienced this very scenario, some on multiple occasions. Several indicated that they would politely dismiss themselves, then go find another non-white phlebotomist to draw the patient. Although there may be some satisfaction in managing the racist patient in this manner, we’re wondering if sending other African American coworkers into the same scenario causes more problems than it resolves.

This situation is unfortunate, but it plays out more often than we would like to think. While it may be inviting to some to sound off, staying above the fray demonstrates an immunity the potentially hurtful prejudices that society may harbor. Professionals know there’s little that can be accomplished by being drawn into a fight.

We particularly like the response submitted by Daniel L. of California: “I would politely and calmly ask the patient to reconsider. If he doesn't I would let him know that I would get a Caucasian phlebotomist. If the facility doesn't have one and I have to draw the individual’s blood, I would let my supervisor or the patient's nurse speak with the patient to perhaps convince him/her otherwise. One blood draw can not change years of racism, but well chosen, polite words and actions can have a positive impact.” For the articulate way in which Daniel expressed that he would take the high road, we will be sending him a free “Accurate Results Begin With Me!(TM)” t-shirt.

Featured Product: Venipuncture Procedure Template