Garbage In; Garbage Out: Part II

Over the next few months, Phlebotomy Today-STAT! will explore the many ways those who draw and process specimens can unknowingly alter test results. Last month we explored how specimens become garbage before the needle is even inserted into the vein. (To access this and other archived issues, visit www.phlebotomy.com.) This month we will continue with errors committed before collection.

Draws from VADs

IV lines, central (intravenous) lines, arterial lines, and other such vascular-access devices (VADs) are a convenient way to obtain blood specimens without subjecting the patient to a venipuncture. However, they are associated with an increased likelihood of blood culture contamination, specimen contamination with IV fluids, hemolysis, the potential for an air embolism, the risk of introducing bacteria into bloodstream, and line occlusion. Prior to the procedure, when one is deciding whether to perform a venipuncture or draw from a VAD, these risks must be considered.
      Because bacteria can colonize within and around the tip of IV cannulas, they can be pulled into blood culture specimens making the patient appear to have a bacterial infection of the blood, when it’s the cannula that is infected, not the patient. Unless the bacteria also exist systemically in the patient’s circulatory system, growth of bacteria in the cultures can mislead the physician into ordering antibiotics when they are not necessary. Therefore, blood culture collections from vascular access devices should be avoided, and, when obtained, must always be followed by a second culture drawn by venipuncture.

To minimize the risk of contaminating the specimen with IV fluids, collectors should consider that such draws require the discarding of calculated volumes of blood prior to obtaining the specimen that will be sent to the testing facility. This volume is widely accepted to be twice the dead space volume for non-coagulation testing and 5 cc of blood or six times the dead space volume for coagulation studies. A 5 cc saline flush is often recommended prior to withdrawing the discard volumes.
       Preventing hemolysis when drawing through VADs is difficult. The potential must factor heavily into one’s decision to draw through a device intended for the infusion of fluids, but not for withdrawing blood samples. When unavoidable, hemolysis can be minimized by using a syringe instead of a tube holder, and withdrawing the plunger slowly and steadily.
       Finally, the risk of introducing an air embolism into the patient’s circulatory system when drawing through a VAD must be considered. When choosing this option, only healthcare professionals trained in the use and maintenance of VADs should perform the collection.
       Because of these risks, line draws should be avoided whenever possible. When not possible to avoid, a thorough knowledge of the risks of the procedure is required to minimize the potential for inaccurate results and the delays in testing that can compromise patient care.

Timing blood cultures

When blood cultures are ordered, the timing of their collection is critical to recovering the bacteria that could be infecting the patient.  Whenever blood cultures are ordered because the patient’s temperature exceeded a predetermined level, timing is critical. Typically, the fever spikes 30 minutes after bacteria have shed into the bloodstream and reached its peak concentration. Any delay in the collection diminishes the concentration of bacteria in the sample, and delays the time it takes for them to multiply to detectable levels within the blood culture bottle.         

Exercise & fist pumping

Outpatients are more likely to have engaged in strenuous activity immediately prior to coming to the draw station for a blood test than inpatients. Exercise can temporarily increase a patient’s ACTH, bilirubin, CK, cortisol, creatinine, HDL, LDH, the percentage of neutrophils in a CBC, uric acid, and the WBC count. Therefore, it’s best to avoid collecting a blood specimen right after the patient has had a strenuous workout.  If unavoidable, make a notation to accompany the results so that the physician can interpret them in the proper context. Likewise, patients should be instructed not to pump their fist prior to specimen collection. Studies show fist pumping can increase a patient’s potassium as much as 20%, in addition to ionized calcium.

Posture

Most reference ranges the laboratory includes on test results for physicians to consider as “normal” are established from ambulatory patients. Since most inpatients have their specimens drawn while lying in bed, their results are usually being compared against what is normal for healthy people who are up and walking around. For most tests, that is not critical, but for others, it is.
       It’s all about hemoconcentration. When your patient goes from lying down to standing up, the body responds by releasing hormones into the bloodstream that increase the blood pressure so that the brain, now elevated, can continue being supplied with oxygenated blood. With the increase in blood pressure comes an increase in blood volume, making the capillary beds swell and become increasingly porous. Water and smaller compounds migrate through the capillaries in greater concentrations, leaving large substances like cells, proteins and molecules attached to protein in the bloodstream. This sudden porosity of the capillary beds works like a fishnet, trapping only the larger blood components in the veins. This is what we know as hemoconcentration. Drawing specimens during this change can cause a higher test result than if the patient were drawn while recumbent. When your laboratory’s test requirement states the specimen should be drawn while the patient is lying down, posture is critical to accurate results.

When the blood specimen is as good as garbage in representing the patient’s actual health status, the actions the physician takes based on the results that come from it can lead to over- or undermedication, misdiagnosis, or general patient mismanagement. Those who draw blood specimens must always be aware of the changes they can impose on the blood before, during and after collection.

Next Month: turning specimens into garbage with a tourniquet and mistakes preparing the site.

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: Tourniquets Tied to MRSA Threat
• Ask the OSHA Expert!: an OSHA consultant addresses these burning questions:
• Can a nonemployee inspire a unannounced inspection?
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in June including these stories:
• Belfast Hospital under Scrutiny for Hygiene
• According to the Standards: Hand-labeling specimens
• Tip of the Month: What Kind of Fly are You?
• 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.

NCCT now accepting CEUs from CPE

The National Centerfor Competency Testing (NCCT) and the Center for Phlebotomy Education recently announced an agreement to make selected continuing education (CE) exercises developed by the Center eligible for NCCT recertification.

The courses now accepted by NCCT include the Center’s popular To The Point™ series available in bound booklets. Volume 1, subtitled Collection Protection, discusses specimen collection safety while Volume 2 contains articles on phlebotomy-related lawsuits, preanalytical errors, & blood culture contamination. Each exercise is available exclusively from the Center and is worth three clock hours.

 “Since all our credentialed professionals are required to participate in continuing education, we help assure the employers and the public that NCCT professionals are maintaining their competence,” says Lucia Johnson, Director of Continuing Education at NCCT. “The quality of the To The Point™ exercises is exceptional and well within our high standards.” The agency has certified more than 200,000 individuals by examination throughout the U.S. since 1989.

NCCT-certified phlebotomists and other healthcare professionals who obtain P.A.C.E.® continuing education credit through the series can receive NCCT Clock Hour credit by sending NCCT a photocopy of the P.A.C.E.® certificate issued by the Center demonstrating successful completion.

The To The Point ™ series is authored by Dennis J. Ernst, MT(ASCP), the Center’s director. Considered the world’s leading authority in blood specimen collection procedures, Ernst has been involved in phlebotomy for over 25 years as a medical technologist, educator, legal consultant, and international lecturer.

Featured FAQ: Tattooed sites

Q: I've got a friend with tattoos. He said most phlebotomists usually look at the tattoo (thin lines, over veins, but not covering veins completely), then go to his other arm. What's your take on drawing through tattoos? Not new tattoos, but old, well established ones?

A: Some texts advise against drawing from tattooed areas on the grounds that dyes may interfere with testing, they are more prone to infection, or have impaired circulation. This is largely perceptual and without supporting evidence in the literature. CLSI makes no mention of restrictions on such sites, new or old.

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.

Featured Product: Free DVD Player with Video Purchase

Survey Says: Accidental Needlesticks

Earlier this year, we launched a quarterly survey on our home page asking healthcare professionals to weigh in on different aspects of specimen collection in their facility. This quarter’s survey results are in. We think you’ll find the results interesting.

Question: Have you had an accidental needlestick with a used phlebotomy needle within the last 20 years and if so, did you report it?

Responses: Needlestick?

Yes: 72.5%

No: 27.5%

Past studies found laboratory personnel to have the highest percentage of unreported accidental needlesticks, up to 92 percent, in fact. The results of this survey provide more optimism, but also support prior evidence that not everyone takes a needlestick seriously. When OSHA revised the Bloodborne Pathogens Standard in 2001, the Government Accounting Office (GAO) predicted a reduction in accidental needlestick rates by 69,000 (17%).(1) Although current accidental needlestick rates are difficult to come by, some suggest the rate has been cut in half.(2)

Among nurses, Infection Control Today reported 2007 statistics showing 79 percent of those surveyed who sustained an accidental needlestick actually reported it, down from 86 percent in 2006.(3)

Many respondents expressed gratitude in being fortunate enough not to have experienced an accidental needlestick despite drawing thousands of patients and/or drawing for many years.

Sadly, at least one felt ostracized for reporting an exposure. One respondent said no treatment or follow-up was offered after reluctantly reporting the needlestick, and received lower scores on the next employee evaluation. When the individual suffered a second needlestick, it went unreported.

References:

1) GAO Estimates Needlestick Bill Will Prevent 69,000 Exposures. Phlebotomy Today. 2001;2(2):1-2.

2) Are we Still in the Dark Ages of Sharps Safety? www.infectioncontroltoday.com. Accessed 7/8/08.

3) Needlestick Injuries, Workplace Safety among Top Concern of Nurses, New National Study Reveals. www.infectioncontroltoday.com. Accessed 7/8/08.

     The current survey asks about increased pay for certified phlebotomists. To respond (anonymously), visit www.phlebotomy.com and click on the link to the survey in the right panel.

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

Not surprisingly, everyone who responded to last month’s What Would You Do? case study indicated that uttering such an observation audibly is unacceptable and a violation of the patient’s right to privacy. But what is surprising is that 36 percent said they’d ignore the statement, continue working, and not report it. Fifty-four percent said they’d diplomatically and/or sternly remind the phlebotomist that making such a statement is a violation of HIPAA and facility policy, but gave no indication that they would then report the violation. (However, some in this category are supervisors or directors, so reporting the phlebotomist would not be necessary.) This statement is typical of the comments in this category:   “I would turn around and say, I’m sorry but I heard you mention someone's name. Do you remember the HIPAA oath we took?”

The most thought-provoking response came from one commenter who rationalized not reporting the phlebotomist this way: “I would not report it to any others in the facility for fear that the information at hand would be of higher invasion of privacy to Tina.”

An interesting point, but since Tina is the phlebotomy supervisor, she’d be the appropriate person to whom a privacy violation committed by one of her staff should be reported. Or would she? Would Tina, as the victim of the invasion, be fair in her discipline? Or would it be more appropriate to report the phlebotomist to someone higher up the chain of command so as not to involve the person whose right to privacy was violated, i.e., Tina? If so, the commenter makes an excellent point in questioning the prudence of reporting the infraction to her supervisor, who would then be privy to Tina’s confidential medical information. This is one editor who is glad that this is only a hypothetical situation.

But our favorite response came from Jay P. of Minnesota:

“The person downloading the information should be reminded that what they said, even though not directed toward anyone, was overheard by you and possibly others. This is a breach of confidentiality and right to privacy…. The incident should be reported to a supervisor and the person investigated as to what level of breach this imposes, as well as work place problems for the supervisor in the rumor mill. The report should be [directed to] someone above or lateral to your supervisor, so that rational decisions can be made.
       The person/patient who is involved should be notified by the supervisor or manager investigating and not by you. It is important to use the right channels to prevent this practice from being done by others.
       All patients should have the confidence to know that absolutely none of their information will be shared or talked about.”

Right on, Jay! We agree that such breaches, if not reported, could perpetuate, bringing the potential for legal action that can cripple the employer and the laboratory’s credibility with its patients. For his articulate and decisive response, we’ll be sending Jay a free "Accurate Results Begin With Me!® t-shirt.