Reacting to Reactions: How to Handle Patient Complications

You've selected and cleansed the site for your venipuncture. You're engaging in a pleasant conversation with the patient about the weather. You anchor the vein, remove the needle's sheath, warn the patient of the imminent puncture, and insert the needle. Suddenly, he becomes nauseous, or passes out, or faints, or has a seizure, or screams in pain, or demands you stop. What do you do?

Doing the right thing might make the difference between a mere incident or much worse. Are you prepared to handle any patient reaction appropriately? Do you know what your facility's policy says about reacting to these reactions? If not, now's a good time to brush up. Here's what you need to know about reacting to five not uncommon patient reactions.

Nausea — If your patient becomes pale, begins to sweat, or states he's feeling sick or nauseous, you have been given a warning. The patient may be on the verge of passing out or vomiting. Although you'd like to be able to fill the tubes or syringe, now is not the time. Instead, use the warning as an opportunity to safely remove and dispose of the needle, and provide your patient with an emesis basin. Then call for assistance to get the patient on a cot or gurney until his symptoms subside. Never leave nauseous patients unattended. Perhaps the patient has a needle phobia; perhaps he is diabetic or has been fasting too long; perhaps he can't stand the sight of blood. Regardless, an uneventful outcome demands your immediate termination of the procedure before things get worse. Be thankful you have time to remove the needle before he passes out or vomits on your shoes. Not everyone is so lucky.

Fainting — If you're a believer in statistics, you'll appreciate knowing that studies show 2.5 percent of patients pass out during or immediately following a blood collection procedure. The problem is they don't come with a label on their forehead that reads "I will pass out today." Therefore, be prepared for all patients to faint without warning. That means drawing outpatients in a chair with side armrests (minimum) and never drawing any patient who is sitting upright on exam table or bed. If a chair with armrests isn't available, have the patient lie down on a cot, bed, or gurney.
      That's being proactive. Now for being reactive. Should your patient lose consciousness, keep your wits about you and protect her from falling. Call for help. Trying to lower the patient to the floor yourself, or reclining the patient onto a cot or gurney without assistance can injure both you and the patient. Stabilize the patient's position until assistance arrives. If possible, lower the patient's head below the plane of her heart. Avoid using ammonia inhalants since the patient may be asthmatic or have some other respiratory disorder the ammonia could worsen. When assistance arrives, the patient should be placed horizontally and medical evaluation sought. Above all, follow your facility's policy. If your facility doesn't have a well-defined protocol, assist in developing one.
       Protecting the patient from injury is critical, but protecting yourself is just as important. Should your patient pass out while the needle is in her arm, have the presence of mind to remove it, activate its safety feature immediately, and release the tourniquet, if still applied. You can discard it later, but at the very least, conceal the sharp. Don't forget the contaminated sharp not only poses a risk to your patient should it slice a vein, artery, nerve or tendon, but to you as well. Not only can it impale you or lacerate your skin, it can deliver bloodborne pathogens deep into your tissue.

Seizures — Seizures are not caused by venipunctures, but can occur during them for reasons unrelated to the draw. There's no way to predict or prevent them in the patients you draw, so be mindful that this reaction can occur randomly and without warning. Should your patient go into a seizure, give the same high priority to removing the needle and activating its safety feature as described under "fainting." Immediately call for help. Attempts to restrain the patient may not be advisable, but keep the patient from potential injury by preventing falls and limiting movement of the limbs. Medical evaluation should be immediate.

Shooting pain — When properly performed, venipunctures can be mildly uncomfortable. But when the patient expresses excruciating, unusual, or shooting pain, discontinue the draw immediately. Extreme pain can indicate needle contact with nerves or other structures, which, if damaged, can lead to disabling injuries. Any expression of pain distant to the insertion point indicates nerve involvement. The proper reaction to shooting, electric-like pain is to terminate the attempt. Even indications that the patient feels tingling in the fingers indicates the needle could be coming in contact with the nerves. Immediate needle removal is the best way to prevent permanent injuries.

Demands to remove the needle — Sometimes patients demand the needle be removed. Such requests constitute a withdrawal of consent, and must be honored. To fully protect your employer from legal claims of battery or operating beneath the standard of care, commands such as “Stop!,” “Quit!,” or “Take it out!” must be obeyed.

Knowing how to react to reactions is important for every healthcare professional with blood collection responsibilities. Being prepared for the reactions discussed in this article will help you keep calm and have the presence of mind to do the right thing if and when one of your draws goes in a direction you didn't anticipate. Just remember, when you expect the unexpected, the unexpected never happens.

This Month in Phlebotomy Today

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 10^th year of publication, are reading about this month:

• Feature Article: Eight Questions Everyone Who Draws Blood MUST Answer Correctly
• NCA and ASCP Board of Registry Merge
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in July including these stories:
• Phlebotomist Killed in Afghanistan
• Deaf Phlebotomist Wins Beauty Pageant
• NHS in UK Delays Safety Needle Legislation
• Patients Urged to Check Labels on their Blood Tubes
• According to the Standards: Skin punctures to the big toe
• Tip of the Month: Short-Changed by Short Draws
• CE 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 Product: Order of Draw Pens

Featured FAQ: Discard volume for heparinized line draws

Q: When drawing from lines in which heparin is being infused, our policy is to flush with saline, draw off 5 mL of waste, then collect the specimen for testing. The nurses consistently pull off lesser volumes. I would really like us to be consistent with the standards. What do they say?

A: CLSI recommends we avoid drawing through lines infused with heparin if at all possible. If not possible to avoid, the line should be flushed with 5 mL of saline followed by the withdrawal and discarding of twice the dead-space volume of the vascular access device (VAD) for non-coagulation testing, and six times the dead-space volume, for coagulation tests.
            These standards and guidelines provide a descriptive, step-by-step procedure for the collection of diagnostic blood specimens by venipuncture. Special considerations include pediatric patients, line draws, blood culture collection, and isolation situations. They serve as the basis for any laboratory procedure, including phlebotomy, and apply to all healthcare personnel. Just keep in mind that the standards do not change just because a nurse is performing the procedure. It's still a laboratory procedure and the laboratory is responsible for the quality of the specimens it tests. CLSI standard H3 is available for a fee as an immediate download or bound publication from the Center for Phlebotomy Education’s web site or directly from the Clinical and Laboratory Standards Institute at CLSI.org. Guideline H21 is available only from CLSI. For additional information, please refer to:

1. CLSI. Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays and Molecular Hemostasis Assays; Approved Guideline—Fifth Edition. CLSI document H21-A5. Wayne, PA: Clinical and Laboratory Standards Institute; 2008.
2. CLSI. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard—Sixth Edition. CLSI document H3-A6. Wayne, PA: Clinical and Laboratory Standards Institute; 2007.

Each month, PT-STAT! will publish an excerpt from our newly released book Blood Specimen Collection FAQs. For a preview and for information on obtaining your copy, visit www.phlebotomy.com/FAQ.

Survey Says: Centralized vs. Decentralized Phlebotomy

Our latest survey asked Phlebotomy Today STAT! readers: In your facility, is phlebotomy centralized ( i.e., phlebotomists perform all routine blood collections) or decentralized (e.g., staff of various disciplines are cross-trained to draw blood)?

Sixty percent of those responding indicated specimen collection is centralized in their facilities (drawn by phlebotomists), whereas 40% have a decentralized system. Here's a sampling of the comments:

• Nursing staff in our ED, NICU, L&D, & the OR's are cross trained and perform phlebotomy.
• We have been decentralized since 1992 and for us, it works. Our redraw rates are about the same as when we were centralized.
• Specimens obtained from non-laboratory personnel are rarely collected with quality, whether it is a blood draw or some other type of specimen. We have been working with our nursing educators and managers to try and improve aseptic collections with blood cultures and quality specimens for routine blood testing. This has been both accepted and challenged by nursing. But we will not surrender!
• Decentralized. Lots of errors too.
• We trained over 300 nurses at our hospital and after 4 years there were so many labeling errors that they had to hire phlebotomist back to take the floors back over (in-house). In my opinion, nursing has enough on their plate without adding what people think is such a quick and easy job to their list. What folks don't realize, this is a very challenging job and a continually educating job.
• [We are] primarily centralized with specialty units decentralized.
• In our lab we have phlebotomists who draw outpatients and inpatients in the hospital, we also have cross-trained MA's to draw in the clinic rooms and ER techs to draw in the ER. This works very well as long as the training is adequate.
• Our emergency departments and maternity nursing staff cover their units 24/7. Our laboratory phlebotomists do morning rounds from 5AM to 9 AM. After 9AM, our phlebotomists cover central processing and are available for difficult sticks throughout the rest of the 24 hour period.
• We are still decentralized in the ED. The Laboratory recollects ED hemolyzed specimens. The frequency of ED hemolyzed samples is between 15-25% due to collection through IV starts. The ED mind set is they draw from IV starts to keep the patient from being stuck twice. Patient comfort is more important than specimen quality.
• Phlebotomists do all the draws except for heparin-flushed ports or PICC lines, where the RN's do the draw and 99% of the time the phlebotomist is present to hand her the tubes and label etc.
• We do it all, preparing reqs, collecting co-pays and collection of blood samples!
• I would love to have centralized phlebotomy services at our hospital but do not see that occurring anytime in the near future.
• We have highly trained phlebotomist, and strongly encourage certification (not mandatory yet).  They do ALL the hospital, Clinic, ED, ICU collections. Best yet, we have a great relationship throughout the disciplines.
• Laboratory phlebotomists draw all patients with the exception of Emergency Department and the Outpatient Laboratory.
• Nursing in certain departments are allowed to draw blood if they are starting an IV (i.e. ED, Infusion Center, Oncology, Surgical Services).

The healthcare facilities represented in this survey were roughly divided in terms of centralization (60%) versus decentralization (40%) of blood specimen collection responsibilities. However, implementing and maintaining a successful decentralized approach to phlebotomy—as determined by an institution’s redraw rate for hemolyzed samples, its contamination rate for blood cultures, etc.—may prove more challenging than in centralized settings, based on the comments received. Such benchmarks should be actively monitored in every facility with employee education, feedback, and staff collection duties evaluated accordingly.

Regardless of your facility’s current strategy, kudos to all of you who strive to keep quality in every collection by making phlebotomy training and ongoing continuing education an integral part of the workplace for anyone who draws blood. Patients want to have their blood drawn by knowledgeable and competent healthcare professionals. They might not know who you are, but when it comes to inserting steel in their flesh, they do care about what you know.

This month’s survey question: Do you let your patients select the vein or site from which you draw their blood?

 

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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 engineered 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 users can reposition for the most effective use of space. 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.

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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 To the Point® download. The exercise will conclude with a review of the selected submissions and a discussion of the standards pertinent to the case study.

Rude Dude is no stranger to some of you who participated in this month's case study. It seems similar scenarios have played out where you work. A whopping 87 percent of respondents said they would personally approach the Dude to explain the inappropriateness of such behavior and to ask if there was something wrong. Most of those said that if the behavior didn't improve, it's time to bring Dude's attitude to the attention of the supervisor or physician. Dean S. in Indiana epitomized the sentiments of the majority.

“I believe it is only fair to my coworker that I am up-front and honest. Otherwise, resentment can build up, which ultimately affects job performance. I would always present the positive with any criticism. Something like, "I wanted you to know that I noticed you spoke with a negative tone or words that takes away from the great job you do in drawing patients' blood. One thing I do that helps ensure individualized care to every patient is using canned comments." They are always appropriate and a great initiator of great customer service. Canned comments also assist us when we are unsure of what to say.”

Several who shared Dean's approach said that if Rude Dude didn't respond to their personal intervention, they'd tell patients to complain to the physician or manager. Thirteen percent said they'd go directly to the supervisor with their observations without confronting their rude coworker.

While correcting a coworker can be difficult and risks being ostracized by the offender, a team pulls together for the greater good. Where management nurtures a team concept in the workplace, peer-to-peer interaction may be the most effective. In facilities that maintain a strong hierarchy of management or chain of command, approaching managers to address such issues may be the protocol. Regardless, the right answer is to address the issue immediately. The longer people like Rude Dude go unchecked, the faster a facility's reputation and morale decays.

While many readers responded with well-articulated approaches to last month's case study, we liked this one submitted by Tina of Oregon:

“If I had a co-worker that was being rude to the patients and they were requesting that I do their blood draws, I would go to my co-worker and make sure that person was OK and wasn’t having some type of problem that was making it hard for them to perform their duties in a more compassionate manner. If this was not the case then I would let them know that the patients were feeling that this person was not giving them the respect and care that was expected. I would be sure to approach this in a positive manner and not a negative one. If my co-worker wasn’t able to change their behavior then I would go to the supervisor or manager in charge.”

For her well-penned solution to last month's case study, Tina will receive a free download from the Center for Phlebotomy Education’s To the Point® library of articles.