Literature Review of Newly Published Studies: Part I

Here at the Center for Phlebotomy Education, we have our nose in the news every day. Not a day goes by when we don't hear of something newsworthy in the media or peer-reviewed journals. That's how we keep ourselves, our products, and our readers up-to-date in the world of phlebotomy. If it's new and pertinent, you'll find out about it here first.

Since our literature review last fall, some interesting studies have been published in journals you might find interesting, even helpful. Over the next two months we’ll share with you what's been added to the body of knowledge since November:

Parental reassurance during venipuncture ineffective
Researchers in Halifax, Nova Scotia investigated whether children perceive their parents as fearful when they attempt to reassure their children during painful medical procedures. The study says telling a child "it's okay" is associated with increased child distress, whereas distracting a child increases their ability to cope with the procedure. One hundred children between the ages of five and ten were videotaped during venipuncture procedures in which the parents provided either reassurance or distraction. The children viewed the recording and rated their perception of the parents' level of fear and happiness. The children rated their parents more fearful when they attempted to reassure them than when they attempted to distract them from the venipuncture.
Abstract

Adverse reactions during blood donation
Researchers in Italy set out to monitor adverse events during blood donations. Out of over 89,000 units of blood collected, the rate of adverse events was nearly 0.6 percent. Fifteen percent of the reactions were related to the venipuncture, the majority of which were hematomas. Seventy-seven percent of the reactions were vasovagal. Nine percent of all adverse reactions were classified as severe. Three donors required hospital care.
Abstract

Discard tube for special factor assays
Long-time readers of Phlebotomy Today newsletters know that the Clinical and Laboratory Standards Institute says it may be advisable to draw a discard tube during a venipuncture when collecting special factor assays (but not protimes and aPTTs). Researchers in The Netherlands demonstrated special coagulation testing can be exempt as well.
     Eighty-eight subjects were drawn for antithrombin, protein C, and factors II, V, VIII, IX, and X. Although the differences with and without a discard tube showed a small statistically significant bias, in all cases it was found to be clinically irrelevant. The authors recommended a discard tube for these assays is not required.
Abstract

Preanalytical errors at 77%
Researchers in India studied the frequency of errors committed by the clinical laboratory. Data from samples obtained by over 67,000 venipunctures were studied over the course of one year. Only eight percent of the errors occurred in the analytical (testing/examination) phase, while fifteen percent occurred in the postanalytical phase. However, over 77 percent of errors occurred between the ordering and testing phases (preanalytical). Elements of this phase include accessioning, sample collection, transportation, processing, handling, and storage practices.
Abstract

Glucose meters fickle about venous catheter blood
Mayo Clinic researchers  sought to determine why some glucose meters report higher results when the blood tested is drawn through central venous catheters. In 27 patients, outliers occurred approximately twice as often on the Roche Inform meter than on the Nova StatStrip. When the authors compared plasma results obtained from catheter samples to that obtained by venipuncture, they concluded contamination of catheter samples with exogenous (infusing) glucose was uncommon.
Abstract

Featured Product
Blood Specimen Collection FAQs book

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: CDC Makes Phlebotomy Best Practices Recommendations
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in June including these stories:
• FDA Levies Multimillion Dollar Penalty against Red Cross
• Infection Control Measures Fall Short at Outpatient Surgery Centers
• Doctors’ Neckties Tied to Pathogens
• Compartment Syndrome Associated with Failure to Remove Tourniquet
• Improved Patient Satisfaction Scores a Result of Innovative Strategies
• Newborn Blood Spots a Hot Commodity
• High-Tech Lab Coats No Safe Harbor for Bacteria
• According to the Standards: Sodium citrate carryover/Sample labeling by hand
• Tip of the Month: Phlebotomy’s Seven Deadly Sins
• 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.

Director to Give Safety Presentations at AACC

Center for Phlebotomy Education director Dennis J. Ernst MT(ASCP) will be giving booth presentations at the Clinical Lab Expo this month in Anaheim, California. His presentation, titled "How Vulnerable Are You to an Accidental Needlestick?" will discuss common preanalytical behaviors that put healthcare professionals at risk of exposure. The 20-minute presentation will be conducted twice, on July 27 at 10:30 a.m. and again on July 28 at 2:30 p.m. at the Greiner Bio-One booth in the exhibit hall. The Expo is conducted in conjunction with the annual meeting of the American Association of Clinical Chemists (AACC), and is expected to draw 20,000 clinical laboratory professionals from around the world.

Center Featured in MLO Cover Story

An article written by the Center for Phlebotomy Education’s Director of Online Education is featured in this month's cover story in the Medical Laboratory Observer (MLO). The cover story, Blood Safety: Win, Lose, or Draw, features an article by Lisa O. Ballance, MT(ASCP), CLC(AMT) on blood-splash exposures during venipuncture. The piece summarizes the findings of a recent national survey jointly conducted by the Center and DenLine Uniforms of Quincy, IL. To read the cover story, click here.

Center Embraces Social Media

Phlebotomy Today readers now have the opportunity to interact with the Center for Phlebotomy Education on Facebook and Twitter.

Launched this month, the Center's Facebook Page provides all healthcare professionals who have blood collection responsibilities with a place to join discussions, leave comments or questions, post suggestions, learn about upcoming events, meet the staff of the Center for Phlebotomy Education, and keep current with day-to-day developments and newsworthy events that can impact the industry, the profession, and the way blood collection procedures are to be performed. We are still brainstorming on other activities for the page, so please drop by and let us know if you have any ideas for how we can make our Facebook presence most useful for you.

To get connected visit the Center's Facebook Page and click the "Like" button. After you "Like" our page, you can post on our Wall, and get Updates from the Center in your News Feed. The page will be monitored and updated regularly, providing you a forum with not only the most reliable authority on blood collection procedures and specimen collection management in the industry, but with other phlebotomists and healthcare professionals who share your interests in the most commonly performed medical procedure in healthcare.

Additionally, our Twitter-savvy readers can Follow their editor and the Center's director, Dennis J. Ernst MT(ASCP) as he tweets his observations on the industry, company updates, and current events impacting the performance and management of blood sample collection. Followers can also send questions and comments to @Phlebotomy, and connect with others with similar interests.

Center for Phlebotomy Education on Facebook
Phlebotomy Today Editor on Twitter

Center Posts Free Order of Draw Article

In keeping with our tradition of providing high-quality technical content for free, the Center for Phlebotomy Education recently uploaded a new Needle Know-How article on its website.

"Do I Have to Follow the Order of Draw?" discusses the necessity for filling blood collection tubes in a certain order and how deviating from that order can significantly alter test results reported to physicians. The article also explains how additive carryover occurs, and how the order has changed over the years. The document is available as a free download in pdf format, and is designed to be printed and posted in sample collection areas or distributed facility-wide to those with blood collection responsibilities. A link to the free article appears on the right-side panel of the Center’s website at www.phlebotomy.com.

Featured FAQ
Blood cultures from line draws

Q: I’m having an argument with some of our staffers on blood cultures. They prefer to draw from a central line or arterial line if they can rather than to subject the patient to another stick. I disagree. What do you think? If I’m wrong, what is the best way to draw blood cultures from a central line?

A: You’re not wrong. There is no shortage of articles in the literature that advise against drawing cultures from vascular access devices (VADs). VADs are notorious for contamination from bacteria that colonize around the cannula. Whenever drawing a set of blood cultures from a VAD, there must always be a set drawn by venipuncture to confirm/rule out the positive culture.
     But here’s the problem: if it so happens that the peripheral draw site was not adequately prepared or was contaminated by repalpation, then your patient has two false-positive blood cultures, neither of which is from bacteria infecting the bloodstream. As a result, the physician is likely to give the patient antibiotics unnecessarily. Having said that, in many cases there are no options to drawing from VADs. In such cases, sterile technique plus a 5-10 cc discard will minimize the potential of a positive culture due to colonization, but it will never eliminate it completely.

Editor's Note: the July issue of Phlebotomy Today includes an article summarizing the CDC's best-practice guidelines, which establishes venipunctures over line draws as the recommended method to avoid contamination when collecting blood cultures. The issue can be purchased for $9.99.

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.

Survey Says
Respect from Other Healthcare Professions

Last month’s survey question asked visitors to our website, regardless of their profession, about the respect they feel from others in the healthcare field, and the basis for their response.

1. Do you feel respected by other healthcare professions? Why or why not?

Yes:   36.7%
No:     63.3%

According the majority of last month’s survey participants (63.3%), respect from other healthcare professions is generally lacking. Reasons given include the perception that phlebotomists and/or laboratory personnel are less educated and are thereby undervalued by other healthcare professions, as reflected in the participant comments below:

• “Most other healthcare professionals…feel that phlebotomists are uneducated or undereducated and could not make it in other healthcare fields…but they always call us when they are unable to properly perform a venipuncture.” – Phlebotomy Specialist
• “They take us for granted and act as though anyone could do this job. That is, until they need help ordering a test.” – Medical Laboratory Assistant
• “…the nurses and MDs think that lab personnel are uneducated; that we did not go to school to do our jobs. They think we are trained-on-the-job employees.” - Phlebotomist
• “I represent the lab and lab policies when I draw blood. Many times lab policies are questioned and in some instances nurses and/or doctors refuse to believe and follow them. Personally, my skills are appreciated and respected, but my job as a whole is not.” – Lab Assistant 2
• “I don’t feel that other healthcare professionals have a clue about what we really do or the amount of education we have and the certification necessary to do our jobs…” - Evening Laboratory Supervisor
• “Here in Australia, no phlebotomy registration exists. Thus, registered healthcare providers regard us as more of an annoyance than a valuable healthcare resource.” - Senior Phlebotomist/Phlebotomy Training Officer
• “Some nursing and physician staff look upon phlebotomy as beneath their profession.” – Phlebotomy Manager
• “We are made to feel like the ‘poor man’s nurse’.” - Phlebotomist

When it comes to showing respect, what’s in a name? Actually, quite a lot. Some survey participants lamented over the anonymity with which they are addressed by others, often being identified only by their department:

• “…Many staff people don’t know our names. “From-the-Lab” is the common last name we all have, or just ‘Lab’.” - Supervisor
• “…I get tired of being referred to as the ‘lab girl’.” - Evening Laboratory Supervisor
•  “They never include us or speak to us.” - Phlebotomist

Even when credit is due, the laboratory’s efforts are sometimes overlooked, as described by one MT (ASCP) Phlebotomy Supervisor: “Whenever our hospital publishes an article featuring how an ED or surgical patient was successfully treated, there is no recognition of the laboratory’s contribution to the diagnosis or follow-up therapy.”

Fortunately, all the news isn’t bad. A feeling of respect across healthcare disciplines was reported by over a third of survey participants. Sample comments from those who responded in the affirmative include:

• “I feel that over the years I have proven my worth in the quality of my work. I have also learned a lot from your newsletter. I believe continuous learning in the key.” - Project Coordinator for Studies and Clinical Trials
• “I have worked in Phlebotomy for 35 years at the same hospital, which is approximately 150 beds. Everyone knows everyone.” – Phlebotomy Supervisor
• “[I feel respected] because I’m competent and confident.” – Staff Nurse
• “…we often have the correct answer and people respect the truth.” – Laboratory Manager
• “They understand that we provide a service that they would have to take time to do if we were not available.” - Phlebotomist

In terms of job title, 71% of survey participants who identified themselves as phlebotomists or medical lab assistants reported a lack of respect, versus 29% who feel respected. For those self-identifying in supervisory roles (i.e., phlebotomy or laboratory supervisors/managers), the numbers were a little more evenly split; 57% versus 43%, respectively.

One phlebotomist/lab tech summed up the situation this way: “Phlebotomists are not respected in the healthcare field. They play a major role in healthcare and should be treated with respect. They earn low salaries and put themselves in harm’s way every day. They are exposed to all kinds of diseases and bloodborne pathogens. They are “up close and personal” with each patient, who hates to see them coming because who likes needles? They are expected to get the blood on the first attempt with great skill and accuracy and return to the lab with an ideal specimen every time. Hats off to them. They should be praised a lot more. Have you thanked your phlebotomist today?  You should!” 

We couldn’t agree more.

This month’s survey question: 
Does your facility have a written exposure control plan (ECP) in place?

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 download from the Center for Phlebotomy Education’s library of articles. The exercise will conclude with a review of the selected submissions and a discussion of the standards pertinent to the case study.

Without question, the vast majority of PT-STAT! readers who responded to last month’s scenario would honor the patient’s request and obtain a new gauze pad that had not come in contact with any surface. Many respondents viewed this as a minor accommodation on their part and an opportunity to provide good customer service and reassurance to their patient.

Sample Comments:

• “I would throw that gauze out and get another gauze pad.”
• “Our patients don't know that we clean our chair surfaces after every patient. I would get a new gauze pad and inform my patient about our policy...It's no big deal and your patient will thank you for it.”
• “I would grant him his request, and obtain a piece of gauze that was fresh and that had not touched anything, including the phlebotomy chair.” 
• “…You are there for the patient & the patient’s comfort makes the draw go much smoother. I often get asked by patients if the needles are reused & if everything is new & clean for them. I always let the patient see me break the seal on the needle & get a new gauze pad before I start.” 
• “I would give them a fresh gauze pad; it's very good customer service to accommodate the patient when you are able.”

Nathalie from Florida described her technique this way: “First, always make sure you have a couple of gauze pads so that the bottom one laying on whatever surface won't be the one that you are putting on the patient's site. This way you are always utilizing fresh gauze that hasn't touched any surface. Basically I wouldn't do to the patient what I myself wouldn’t want done to me.” This method of using the top piece of gauze from a stack of two or more gauze pads was mentioned by 13% of respondents.

Another reader stated that she would “flip” the gauze over before applying to the patient so that the side that was in contact with the armrest would not be placed next to the patient’s skin. Handling gauze in this manner might work with some patients. But some wouldn’t appreciate the explanation of the top side of the gauze being used if what they really want is a new piece of gauze.

Interestingly, 9% of our respondents referenced using cotton balls rather than gauze for applying pressure to the puncture site. According to CLSI’s venipuncture standard, H3-A6, the use of cotton balls for post-venipuncture care is discouraged. This is because cotton fibers may become imbedded in the fibrin plug that forms at the puncture site. When the cotton ball is removed, the plug may be removed as well.

Except in the case of blood culture collections, performing a venipuncture is not considered a sterile procedure. However, in this age of MRSA and hospital-acquired infections, patients are more concerned than ever about their personal risk, whether real or perceived. Phlebotomists who strive to view transmission risks from the patient’s perspective, evaluate their work practices, and implement appropriate infection control measures not only assure a safe environment for their patients, they help foster good relations with the public they serve.

One of our readers, Tom, provided the following summary: “A good phlebotomist does whatever it takes to put the patient at ease, so long as it does not violate the principles of good phlebotomy. We all know there are only three sterile aspects of the venipuncture: the alcohol pad, the needle, and the bandage. And the alcohol pad does not sterilize, it only cleanses. Unless you're using individually wrapped dressings, your gauze pads are not sterile. Even if you pull them, one by one, from the bag. Most phlebotomists put their pads in some sort of box, within easy reach. It would simply be bad form to have one sitting out on the arm of the chair.”   

For his articulate response and consideration for the patient, Tom will receive a free download from the Center’s library of articles.