Mobile App Puts Phlebotomists on Call
Note to Veebot: Seek Technical Advice
The Empowered Healthcare Manager: a good day
Product Spotlight: free shipping
Canadian Standards Organization Offers Preanalytical Tool Kit
This month in Phlebotomy Today
Survey Says: Gauze or cotton?
What Should We Do?: Underfilled and fed up
Tip of the Month: Tangled Web
Mobile App Puts Phlebotomists on Call
A Richmond, Virginia startup company has created an app that is changing the way physicians connect their patients with phlebotomists when lab tests are needed. The app is similar to software used by Uber and other on-demand services. Here's how it works:
A physician (or his/her staff) logs on to the Iggbo app requesting the services of a local phlebotomist. Phlebotomists who have signed up with Iggbo in advance log on to the platform and are notified of requests for their services in the area. The phlebotomist drives to the doctor's office or patient's home, draws the sample and ships or delivers it to the lab of the physician's choice.
The lab pays Iggbo for the phlebotomy service. Iggbo then pays the phlebotomist a percentage. The service is free to doctors and their patients.
According to the company's web site, "Iggies" have full control over their schedule, by accepting as many or few appointments as they wish. doing so automatically or with a just a couple of clicks. Everything that a phlebotomist needs is provided by Iggbo including training, a smartphone preloaded with the software. connections to suppliers, and professional services.
Interested phlebotomists can sign up at www.iggbo.com.
Our View: venipuncture robot needs technical advisor
One would think if you're going to develop a robotic device that performs an automated venipuncture you'd learn a little bit about the procedure.
Veebot, the latest in a long line of auto-venipuncture robots, recently released a new video demonstrating it in action. As reported in MedGadget, the Veebot continues to be developed with hope of ultimately perfecting the art of phlebotomy. If it's latest video is any indication, perfection is a long way away.
In a prior video, released several years ago and still playing on the Veebot web site, the device is seen surveying the antecubital area for veins and promptly violating the standards by selecting the vein associated with the highest risk of nerve injury, the median basilic or basilic vein. According to CLSI's venipuncture standard, the basilic vein should only be used when no other vein in the antecubital area is accessible due to its proximity to vulnerable nerves. In the video, the safer median cubital and cephalic veins are visible alternatives. It appears Veebot's selection algorithms did not consider the industry standards.
In a newly released video, the vein choice is not obvious. However, what is obvious is the assistant overseeing the procedure never removes the tourniquet after the procedure is complete. He is seen bandaging the patient with the tourniquet still in place. Though not a flaw with Veebot's technology, it underscores a primary problem with robotic venipunctures: competent phlebotomists are irreplaceable.
The Empowered Healthcare Manager: The value of humility
Every month, Phlebotomy Today-STAT! reprints one of the prior month's posts to The Empowered Healthcare Manager blog, written by Dennis Ernst.
A good day for a healthcare manager is when nobody calls in sick;
A good day for an empowered healthcare manager is when someone asks to stay overtime to help with an overwhelming workload.
A good day for a manager is when not one patient or physician lodges a complaint about the phlebotomy staff;
A good day for an empowered manager is when someone hunts them down to tell them what a good job their staff did.
A good day for a manager is when nobody takes an extended lunch break;
A good day for an empowered manager is when someone worked through lunch to help an overwhelmed coworker.
A good day for a manager is when a high blood-sample rejection rate doesn't go even higher;
A good day for an empowered manager is when the rejection rate drops for yet another new low.
A good day for a manager is when nothing terrible happens at work;
A good day for an empowered manager is when something happens at work that reinforces why they work there.
A good day for a manager is when they have the day off;
A good day for an empowered manager is every day they get to work for their employer, their staff, and their patients.
Subscribe to The Empowered Healthcare Manager.
Product Spotlight: free shipping
There's something missing from the Center for Phlebotomy Education's shipping room. Fees.
Standard shipping rates to all U.S. locations on orders over $50 have been eliminated, international rates have been reduced, and all handling fees have been discontinued.
"We know facilities are under tight budgets," says Anita Schultz, the Center's Office and Accounts Manager. "We want to make it easier for managers, educators and healthcare professionals to get what they need."
Schultz senses the spiraling costs of shipping is giving customers pause. "I talk to a lot of customers and what I'm hearing is that more and more are having to function with less and less. By absorbing U.S. standard shipping fees for all but the smallest orders, we hope it lets them know we're listening."
While some shipping fees may be missing from the Center's shipping department, something else is lurking.
Canadian Organization Offers Preanalytical Tool Kit
In 2012, Group CSA, (Canadian Standards Association) published the country's first standard for blood sample collection and handling. Since then, the CSA's working group of the Subcommittee on Specimen Procurement has been developing a comprehensive collection of documents to assist in implementing the provisions of Z316.7-12. The Tool Kit for Sample Collection Facilities and Medial Laboratories was release earlier this year.
The Center for Phlebotomy Education has had an opportunity to review the publication and find it to be an outstanding document of benefit to laboratories and sample collection centers in any country.
The Tool Kit provides customizable concise and user-friendly templates providing laboratories with guidance in applying the provisions of Z316.7-12. Its 29 templates and examples of manuals, procedures, policies, checklists, forms and instructions can not only be adapted for compliance with to this standard, but many are universally applicable.
A partial list of what's in the Tool Kit includes:
- Quality manual
- Standard Operating Procedure (SOP) template
- List of required Standard Operation Procedures (SOPs)
- Policy template
- List of necessary policies
- Non-conformities and incidents form and log
- Root cause analysis and corrective/preventive actions report
- Facility conformity checklist
- Environmental conditions log
- Supplier evaluation form
- Equipment identification and maintenance form
- Example of a job description
- Orientation process checklist
- Competency assessment form
- Infection prevention and control checklist
- Primary sample collection manual
- Temporary identification form
- Example of collection instructions
- Blood collection volume form
- Sample rejection form and receipt log
The Tool Kit is provided as a free download by Group CSA.
This Month in Phlebotomy Today:
Here's what subscribers to Phlebotomy Today, the Center for Phlebotomy Education's flagship newsletter currently in its 16th year of publication, are reading about this month:
A "Simple" Blood Draw"
On the Front Lines
Canadian Needlestick Rates Declining
Sticks, Staph, and Stuff
About your face
The Empowered Manager
Explosions and implosions
All veins are fair game
Subscribe to Phlebotomy Today and get this issue immediately.
Survey Says: Gauze or cotton?
In this month's survey, we asked what compress our readers use to apply post-venipuncture pressure, (i.e., gauze or cotton balls), how you store them prior to use, and to what extent you check the site for bleeding before you bandage.
Clean gauze was the clear winner, in use by almost 70 percent of those who responded. Surprisingly, sterile gauze is the preferred compress by 21 percent even though the CLSI standards don't require sterile gauze for post-venipuncture care. Eight percent use cotton balls, which the standards discourage due to the potential for the cotton fibers to become bound in the fragile fibrin and platelet plug as the wound seals. Sterile cotton balls are used by only one percent.
Here are some comments from those who participated:
I can't stand using cotton balls. Most of the time when the patient removes the cotton ball the puncture site opens back up.
The fibers of the cotton ball can become entangled in the clot and when removed the bleeding continues.
Our facility requires a sterile gauze on all babies when drawing PKUs.
Gauze was sterile, then placed in clean container in drawer.
We use sterile gauze for blood cultures, otherwise clean gauze.
Cotton balls have shown to negatively impact results.
We also asked how our readers and visitors to our web site store their compresses. Thirteen percent indicated their gauze is individually wrapped. Sixty-four percent store their gauze in an opened sleeve or container that contains multiple pieces while 23 percent keep multiple pieces a closed container.
Finally, we asked about the extent of pressure they apply with the compress prior to bandaging. Sixty-one percent said they lift the compress and watch for at least five seconds before bandaging. Twenty percent indicated they lift the compress up momentarily, put it back and apply the bandage if it doesn't bleed immediately. Two percent said they apply the bandage over the compress without looking for bleeding.
After my draw, I hold pressure for about 10-20 seconds, check before bandaging, and change my gauze if it is stained with blood. Saturated gauze tends to harden and stick to the patient's skin leading to discomfort.
After the draw is complete, while I label my tubes I have the pt apply pressure until I am done labeling, I then look at the site and bandage with 1-inch coban and let the pt know to leave on for 10-15 mins.
I hold pressure for a minute then check to see if bleeding still occurs. Apply more pressure before bandaging. If patient is on coumidn/heparin (sic). I hold even longer.
I always apply a pressure dressing. If the patient says they do not want a bandage I do it anyway and tell them they can remove it immediately if they choose. I have seen too many non or under bandaged patients start to bleed from the site before leaving my facility and too many that end up with a hematoma without a pressure dressing.
I gently pull the skin to make sure the bleeding has stopped
I am a managers worst nightmare.....I love coband (sic). It seems to work for many of my patients as they rarely bruise.
I lift the compress, observe for a few seconds, wiggle the skin to ensure stasis is complete, tape over gauze if it is, more pressure if not.
Pressure is applied for 1 minute, then visually checked. if patient still continues to bleed, I raise their arm and hold till bleeding stops, bandage, release patient
According to the CLSI standards, collectors must "observe for hematoma" formation, which requires a visual inspection. The current draft of the revised venipuncture standard requires a minimum of ten seconds of observation. The final revision will be released later this year. Phlebotomy Today-STAT! will announce its availability.
Five years ago, we conducted a survey on hand hygiene. To see if practices have changed, we're asking about it again this month. If you have patient contact, do you wash your hands between patients or use alcohol-based gels? If not, what's preventing you?
Take the survey
What Should We Do?: Underfilled and fed up
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: We're having trouble with compliance from our staff on fill volumes. Many heparin tubes drawn on morning rounds come down with less than 2 mLs of blood. Our new phlebotomists say blue tops were the only tubes they were told in their training that that had to be filled all the way. The chemistry instrument won't take an underfilled tube, but the phlebs and their manager seem to feel it is no big deal for the tech to pour off plasma into a nesting cup. I am having a hard time getting support from their supervisor and other management staff. Nothing seems to get through and at this point, I am actually considering leaving this company in frustration.
Any suggestions on how I can address this with the phleb manager/supervisors?
Our response: It sounds like you are a beacon of light in an otherwise dark abyss. With no respect from those beneath you and no support from those above, you have a difficult choice to make. The only way you will find job satisfaction is if you change the culture where you work or find work where there's a culture of excellence.
Changing the culture where you work is not impossible, but it will take time and won't be easy. We suggest starting with your subordinates. Assume they don't know underfilled tubes threaten test results and give an inservice in which you share the consequences to the patient of submitting underfilled tubes. Make sure they know even half-filled heparin tubes have been shown to significantly alter ALT, amylase, AST, lipase, potassium, troponin, CK and GGT. 1,2,3 Your staff must be aware inaccurate test results can alter the course of how patients are treated, medicated, and diagnosed in your facility. That includes any of their friends who have lab work there and members of their own families.
Once everyone knows, submitting underfilled tubes in the future will have to be considered intentional. Make sure you stock every tray with short-draw tubes that don't require as much blood to be fully filled for their difficult draws.
Next, apologize for not enforcing minimum-draw requirements in the past, and proclaim things will be different going forward. Establish the consequences for submitting underfilled heparin tubes and implement those consequences without exception. Difficult draws should be handled on a case-by-case basis. Consequences must not exclude the supervisor, who is currently enabling the phlebotomists to compromise sample quality.
You will be tested. If it requires your biggest offenders to spend a day with the chemistry tech to see first-hand how disruptive pouring off a sample can be to the workflow, it will be time well spent. At all times you want to be seen as the leader who will take your lab to higher levels, not the ogre bent on punishment. That means you'll need to reward incremental gains as the rate of underfilled tubes decreases and recognize those who show the greatest turnaround.
You will also have to educate the testing personnel on the risks to the result they take by not rejecting underfilled heparin tubes. Provide the same information on affected tests as you did for the phlebotomists. You'll need the support of their supervisor on this, so work to secure it. As long as the testing personnel accept underfilled heparin tubes, your staff will always submit them.
You'll not likely get the support of your peers without the support of your superiors. That will be the harder challenge. Make sure you articulate the scope of the problem, the negative outcomes. In addition to the threat inaccurate results pose to patient care, cite how it erodes physician confidence in your lab's results, delays TATs from rejected samples, and threatens the morale of all involved. Then lay out your plan to turn things around and articulate your vision for higher quality in the form of every metric you can find that reflect progress.
If it seems insurmountable, it isn't. You just need a plan. If every element is against you, you'll need to find a workplace that celebrates excellence, team work, and high ambition instead of striving for mediocrity and falling short.
1) Donnelly JG, Soldin SJ, Nealon DA, Hicks JM. Is heparinized plasma suitable for use in routine biochemistry? Pediatr Pathol Lab Med. 1995 Jul-Aug;15(4):555-9.
2) Tietz Guide to Clinical Laboratory Tests WB Saunders, St. Louis, MO (2006).
3) Lippi G, Avanzini P, Cosmai M, Aloe R, Ernst D. Incomplete filling of lithium heparin tubes affects the activity of creatine kinase and gamma-glutamyltransferase. Br J Biomed Sci 2012;69(2):67-70.
Each month, our "What Should We Do?" panel of experts collaborates on a response to one of the many compelling problems submitted by our readers. Panelists include:
Got a challenging phlebotomy situation or work-related question?
Email us your submission at WSWDpanel@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)
Tip of the Month
Click here for this month's featured Tip of the Month: Tangled Web