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June, 2011


Copyright 2011 Center for Phlebotomy Education, Inc.
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Emory Study Highlights Importance of Centralized Phlebotomy

Dedicated phlebotomy improves the quality of patient care in the Emergency Department (ED) setting. So says Emory Healthcare in Atlanta, GA, based on the outcomes realized from an initiative aimed at alleviating ED congestion by the addition of a laboratory phlebotomist.

During the first phase of a two-part study, dedicated phlebotomists were assigned to the ED weekdays from 2 pm to 10 pm, during peak patient workload hours.(1,2) Assigned phlebotomists were tasked with drawing ED patient samples and assuring samples were given priority by the testing laboratory. In addition, phlebotomists performed support services for ED clinicians, such as tracking and follow up on laboratory reports.

Data gathered during the survey period consisted of ED patient encounters where at least one of the following tests was ordered: CBC count, chemistry panel, prothrombin time (PT), troponin or blood culture. During the study, measured indicators of patient care included laboratory turnaround times and specimen quality.

Turnaround times for four of the tests (CBCs, chemistry panels, PTs and troponins) were calculated from the time of order request to results reporting, comparing total turnaround times for each test with baseline data, which was collected from non-laboratory personnel for six months prior to the study’s launch. A turnaround time of less than one hour was set as the goal for each of the four tests, with blood sample collection and transport estimated to require 20 minutes.

Figure 1 compares total turnaround times for the hospital’s calculated baseline and ED phlebotomist collections. Times shown represent the 90th percentile total turnaround time from order to result reporting.


For blood cultures, contamination rates were the benchmark, comparing rates for samples drawn by dedicated ED phlebotomists versus non-laboratory personnel. For blood cultures collected by non-laboratory personnel, the contamination rate was 5.0 percent. For blood cultures collected in the ED by dedicated phlebotomists the contamination rate was 1.1 percent. In the Emory study, 25 to 33 percent of all blood cultures collected in the hospital were drawn in the ED, with an estimated 5,972 blood cultures collected annually in the ED. By dedicating onsite phlebotomists to the ED, Emory Healthcare estimates that the annual cost savings realized by reduced contamination rates exceeds $400,000.

When blood samples were collected by dedicated phlebotomists, ED patient wait times to be seen by a physician were also reduced by 24 minutes when compared to collections performed by non-laboratory personnel on the same shift.(2)

In summary, outcomes from the study include:(1,2)

  • Reduced laboratory turnaround time (decreased by > 46 minutes);
  • Decreased blood culture contamination rates (from 5.0% to 1.1%);
  • Lowered patient wait-times to be seen by a physician (decreased 24 minutes);
  • Increased patient satisfaction scores.

The findings of the study conducted by Emory Healthcare were published in American Journal of Clinical Pathology in 2008, and were presented during an American Association for Clinical Chemistry (AACC) webinar in 2010.(1,2)

References

  1. Fantz, C. Expert Access – Dedicated Phlebotomy Improves Patient Care in ED Setting. AACC webinar. 2010. Link. Accessed 6/11/11.
  2. Sheppard C., Franks N., Nolte, F., Fantz, C. Improving Quality of Patient Care in an Emergency Department. Am J Clin Pathol 2008; 130:573-577.


Ernst Appointed to CDC Best Practices Panel

The Center for Phlebotomy Education's Executive Director, Dennis J. Ernst MT(ASCP) has accepted an invitation to participate in the CDC Laboratory Medicine Best Practices (LMBP) Expert Panel on Reducing Blood Sample Hemolysis in Emergency Departments.

One role of the Evidence Review panel in which Ernst will participate is to recommend and review summaries of published and unpublished evidence about the effectiveness of specific practices on reducing emergency room hemolysis, and suggest recommendations about adopting these practices. The panel will also guide CDC staff in identifying practices, refining the research questions, and specifying relevant process or patient outcome measures.

The LMBP initiative was launched in 2006 by the CDC, Laboratory Science, Policy and Practice Program Office to develop new evidence-based review and evaluation methods for identifying pre- and post-analytic laboratory medicine practices that are effective at improving health care quality.

This is the second CDC Best Practices Expert Panel in which Ernst has participated. Last year's participation on a panel focusing on blood culture collection and patient identification led to the establishment of the following best practices:

  • The performance of venipuncture vs. intravenous catheter for collecting blood cultures where the option exists in the clinical setting;
  • The use of dedicated phlebotomy teams for sample collection to reduce or eliminate blood culture contamination; 
  • The use of barcode systems and scanners to reduce or eliminate patient sample ID errors by consistently linking patients to their samples and/or test results.

The CDC's final report on these best practices can be viewed here.

Phlebotomy Today-STAT! will report the outcome of the panel's best practices recommendations when released by the CDC.

 

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Featured Product
Blood Specimen Collection FAQs Book

  • Is it acceptable to draw blood without orders?
  • What are the effects of underfilling heparin tubes?
  • How long after a blood transfusion should you wait to drawing blood for routine testing?
  • Can we ship unspun chemistry and coag samples to a reference lab overnight and expect accurate results?

Answers to these and hundreds more of the most commonly asked questions on sample collection are now available in Blood Specimen Collection FAQs. Published by the Center for Phlebotomy Education, this 376-page soft cover reference book is already at the fingertips of healthcare professionals around the world providing authoritative answers to nearly 300 of the most frequently asked phlebotomy questions. If you perform, teach, or manage blood sample collection procedures, it should be at your fingertips, too.

Compiled from the thousands of inquiries we’ve received over the years, every answer in this reference is thoroughly researched and reflects the current CLSI standards, OSHA regulations, and published literature. Topics covered in Blood Specimen Collection FAQs include preventing hemolysis, recollects and bruising benchmarks, drawing during IV infusions, investigating falsely elevated potassium results, safety and infection control, professionalism, venipuncture pain management, patient injury and complications, specimen handling & transportation, unorthodox techniques and much more.

In use throughout North America and over a dozen countries including Thailand, Australia, Ireland, Indonesia, Spain, Dubai, Singapore, France, and New Zealand, this desk reference is a welcome and informative resource for anyone who performs, teaches, or supervises phlebotomy.

For more information and an interactive preview click here.

This Month in Phlebotomy Today

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 12th year of publication, are reading about this month:

  • Feature Article: How to Become a Better Phlebotomist, Part VI: Conquering the Difficult Draw (oncology patients)
  • Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in May including these stories:
    • OSHA Levies $72K Fine after Needlestick Injury
    • Staff Reminders Help Reduce Lab Orders
    • New York Considers Dress Code Bill to Lower HAIs
    • Americans Expect Lab Results Fast
    • Patient Near Collapse While Waiting for Blood Test
    • Phlebotomist to Compete in Skateboarding World Championship
    • Healthcare Job Postings on the Rise
  • According to the Standards: Drawing from the underside of the arm
  • Tip of the Month: The Backbone of the Laboratory
  • CE 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.

 

CLSI Publishes New Standard on Specimen Labels

Last month, the Clinical and Laboratory Standards Institute (CLSI) released Specimen Labels: Content and Location, Fonts, and Label Orientation (AUTO12-A), a new standard aimed at reducing human errors associated with non-standardized methods of sample labeling. The creation of this standard was prompted by published literature regarding the high rate of mislabeled specimens in U.S. laboratories.

Each year, more than 160,000 adverse events occur in the U.S. as a result of laboratories testing misidentified specimens. An estimated one in 18 identification errors leads to some type of negative event for the patient. It is clear that specimen identification errors contribute to patient safety issues across all laboratory disciplines. Until now, no standard format has existed for clinical laboratory specimen labels.

The document identifies essential information that must appear on specimen labels, as well as how the information should appear on the label, promoting consistency in formatting. Laboratories and healthcare providers who adopt this standard will help decrease the number of mislabeled samples, improving the quality of patient care through more timely and accurate patient test results.

CLSI is a volunteer-driven, membership-supported, nonprofit organization dedicated to developing standards and guidelines for the healthcare and medical testing community through consensus, balancing the perspectives of industry, government, and healthcare professions.

Click here for more information.

Featured FAQ
Thumb versus finger for applying pressure

Q: What is the difference between using the thumb versus the index finger to hold the gauze in place when withdrawing the needle?

I like the students to use the index finger because:

  • they are less likely to press too hard before the needle has actually exited the arm; (students seem to have more control of the index finger versus the thumb).
  • the pressure would start to be applied ahead (away from) the actual needle exit point with the index finger, rather than over the exit point with the thumb;
  • they are less likely to poke themselves, as the thumb is actually closer to the exiting needle than the index finger would be;
  • I like the looks of it.

A: This could be argued either way. The index finger seems more like the natural way to apply pressure. Using the thumb sounds awkward. Since nothing is written on it, it's personal preference. Your rationale makes perfect sense.

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 website. For information on joining Phlebotomy Central, click here.

 

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Survey Says
Facility Policies: Help or Hindrance?

Last month, visitors to our website were asked how policies at their facilities impact personal job performance. Eighty-three percent of respondents indicated that the policies in place help them perform at their highest level, while 17 percent consider facility policies to be a deterrent to carrying out their duties.

Sample Comments:

  • “They provide a safe environment for the patient and worker.”
  • “Our facility has high standards for the performance of each phlebotomist. Only after extensive training and supervision are the phlebotomists allowed to perform advanced procedures such as PIC line draws, IV insertion, and pediatric draws.”
  • “They help by creating high standards, with both patient and employee safety in mind.”
  • “We make sure we do the procedure right every time.”
  • “They take into account the latest literature. They have been amended to address situations not previously covered. They also give me something to fall back on if a patient wants us to do something that is against our policies.”
  • “They provide the structure needed to help maintain a culture of safety and provide guidance when there are questions as to how to proceed.”
  • “The only one that hinders my ability sometimes is the use of butterflies instead of syringes. They do not offer syringes. A butterfly and a Vacutainer® tube is not always the best way to get blood if the veins are very small and fragile.”
  • “The policy seems to be ‘speed over anything else’ or ‘do what it takes.’ I would rather have a smaller number of sticks done right in an hour, than a large number done without consideration to the patient's comfort.”

When asked how closely they adhere to their facilities’ policies, the vast majority of survey participants believe in playing (and working) by the rules (94%), stating that they follow facility policy without exception.

Sample Comments:

  • “Our facility has policies for a reason— the safety of my patients and me.”
  • “Our facility's policies help us provide an exceptional experience.”
  • “I find it in my best interest to follow my hospital’s policies to avoid any unnecessary problems later.”

When it comes to policy enforcement, nearly two-thirds of respondents stated that policies at their facilities are strictly and consistently enforced, while 35% indicated that violations often go unaddressed or policies are randomly applied (see Figure 2.)

Sample Comments:

  • “Our facility educates all staff on policies to be sure everyone is aware of the policies and follows them consistently.”
  • “They are consistently enforced in the Laboratory. Nursing staff is not as stringent.”
  • “Depends on the phlebotomists... there are a lot of favorites where I work and the favorites unfortunately get away with a lot. The rest of us are penalized when we do the same thing.”
  • “The policies at this facility are addressed depending on who you are. If you are a nurse...they are not. If you are a phlebotomist...always to the letter.”

This month’s survey question:
You need to draw one blue top (sodium citrate) tube on your patient. Under what circumstances is it your routine practice to draw a discard tube?

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What Should We Do?

[Editor’s Note: "What Should We Do?" gives you the opportunity to ask our team of technical experts for advice on your most pressing phlebotomy challenges. Whether technical or management in nature, we'll carefully consider solutions and suggestions based on the industry's best practices so that you and those in other facilities with the same problem can benefit, all the while maintaining your facility's anonymity. What Should We Do? is your opportunity to ask us for suggestions on the best way to handle your real-life dilemmas.]

 

This Month’s Case Study:
Drawing Blood from a Corpse

Is there a legal issue with phlebotomists drawing blood from dead bodies? The full scenario is a body was found, there was an exposure to a first responder and the deceased body was brought to the ER where a phlebotomist was requested to draw blood from the body. This body was never registered as a patient and was deceased at least several hours. Our concern is with the body never being a "patient" in our system. I would appreciate any advice you can provide on this.

 

While clearly the facility's counsel needs to assess the legal aspects of the situation, in our opinion, phlebotomists are not the ones who should have been put to the task of blood specimen collection. If attempted, such a draw could be emotionally traumatic for the phlebotomist, not to mention being beyond their job description and training.

Blood is not generally drawn from a corpse unless it is done by the medical examiner and that is usually a direct cardiac draw. Peripheral blood draws won't be easily done. The primary issue with the case presented would be to determine if an exposure occurred, then proceed as if the source was unknown. Post-exposure prophylaxis would be provided based upon the risk of exposure and immunization status of the exposed first responder. The protocols for this situation would be no different from any other time when blood from the source individual could not be immediately obtained.

 

Wanted:

Your most challenging phlebotomy situations and work-related questions.

Send your submission to WSWD@phlebotomy.com and you just might see it as a future case study.

 

 

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PT STAT! is a free, monthly educational service provided by the Center for Phlebotomy Education, Inc., the most respected authority in phlebotomy. For a complete company profile and product list for all healthcare professionals who perform, teach or manage specimen collection procedures, visit us on the Internet at: http://www.phlebotomy.com.
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