Pop Quiz

Surprise! As ardent readers of Phlebotomy Today-STAT!, you'll more than likely ace this self-assessment pop quiz. That's why we've thrown in some trick questions for you. Work through this exercise at your leisure, and grade yourself with the answer key at the end of this issue. If you're a manager or educator, administer this test to your staff or students to see where they need reminders of proper technique. Whether you're a new subscriber or a long-term member of our family of readers, you're bound to learn something new or have your expertise reinforced.

1. When drawing blood, I should routinely release the tourniquet: (circle one)

a. Within 30 seconds
b. Within 1 minute
c. Within 2 minutes
d. As soon as the draw is complete without regard for time

2. Sometimes I ask the patient pump his/her fist to help me locate veins.

a. True
b. False

3. According to the CLSI standards, it is acceptable to draw above an IV: (circle all that apply)

a. For any test ordered
b. Without shutting off the IV temporarily
c. When no other veins are available
d. If it's permitted by facility policy
e. None of the above

4. Drawing blood samples for routine lab work from a central line... (circle all that apply)

a. ...does not require flushing in advance
b. ...does not require a discard volume
c. ...is just as good as drawing them by venipuncture
d. ...should be attempted whenever possible to save the patient a stick

5. When I have to draw a “rainbow” of tubes including a blood culture, the order in which I fill the tubes: (circle all that apply)

a. Doesn't affect the test results enough to matter
b. Affects every test result significantly
c. Is random
d. Is the same for every patient as follows:
   1.______________
   2.______________
   3.______________
   4.______________
   5.______________
   6.______________

6. When I don't have enough blood for all tubes: (circle all that apply)

a. I "borrow" blood from other tubes until each is at least half full
b. I redraw the patient as many times as necessary to get full tubes
c. I have smaller tubes on hand that take less blood to fill completely
d. I redraw the patient, then pool the blood from both draws as long as the tubes have the same color stopper

7. After routine chemistry specimens have been drawn: (circle all that apply)

a. they should be refrigerated until they can be centrifuged
b. they should be centrifuged until they can be refrigerated
c. they should be kept at room temperature until they can be centrifuged
d. they should be kept warm until they can be centrifuged
e. there is no limit to how long they can stand before centrifugation
f. they can be centrifuged more than once if needed
g. they can be centrifuged without stoppers

8. After drawing tubes: (circle one)

a. I invert them after leaving the patient
b. I invert them a couple times as soon as they are filled
c. I invert them 5-10 times as soon as they are filled
d. I don't invert them since the blood mixes with the additive as the tube is filled

9. The person who writes this e-newsletter:

a. should get the Pulitzer Prize
b. needs a vacation
c. is obviously not a phlebotomist
d. is honored that you find it worth reading every month

Joint Commission Set to Relax Patient ID Requirements

As reported in the May issue of Phlebotomy Today-STAT!, Joint Commission appears ready to remove a key component in their National Patient Safety Goals (NPSG) for laboratories. Noticeably absent from the pre-publication draft of the 2010 NPSGs is the requirement for active patient involvement when identifying patients from whom laboratory samples are being collected, which was included in the 2009 NPSGs for the first time.

The 2010 NPSGs require healthcare professionals only to "Use at least two patient identifiers when administering blood or blood components; when collecting blood samples and other specimens for clinical testing;...", but permits both identifiers to come from the identification bracelet. The pre-publication 2010 NPSGs no longer include active patient involvement.

Statistics have shown that up to 16 percent of identification bands have erroneous information.(1,2) Additionally, it has been estimated that 160,000 adverse patient events occur each year in the US because of patient or specimen identification errors involving the laboratory.(3) Eleven percent of transfusion deaths occur as a result of the phlebotomist not properly identifying the patient or mislabeling the tube of blood.(4)

Asking patients to state their name, an additional requirement in the Clinical and Laboratory Standards Institute's blood collection standards, protects patients who may be wearing an incorrect ID bracelet.

Responding to Joint Commission's request for comment on its proposed NPSGs, the Center for Phlebotomy Education submitted a four-page letter urging the agency to reinstate the provision, underscoring the importance of actively engaging the patient during the identification process when drawing blood samples.

In response to a more recent plea from the Center to reinstate the requirement, Joint Commission's Associate Director of the Standards Interpretation Group Megan E. Sawchuk, MT(ASCP) responded, "We do appreciate the concerns raised by the Center for Phlebotomy Education related to revisions of The Joint Commission's National Patient Safety Goal, NPSG.01.01.01. We also agree that active patient involvement is a best practice for patient identification." In an attempt to explain the agency's removal of the requirement, Sawchuk provided the following excerpt from an internal correspondence:

"The deletion of EP 1 is not intended discourage use of active patient involvement or minimize its value. However, the requirement as written lacks enforceability and does not adequately address managing patients who are not able to participate in the identification process."

Concern for situations that require specimen collection personnel to seek confirmation of the accuracy of the identification bracelet from other caregivers or family members led the agency to conclude, "When this requirement is understood by our clients, most find this to be burdensome and unnecessary, and arguably subject to additional error when relying upon the memory of a third party. Two identifiers on the armband are considered equally and possibly more reliable than a third party identification process."

Unaddressed in the transcript of the internal discussion made available to the Center is the inability to detect armband errors without the requirement, and if the agency's clients would consider the sentinel events such undiscovered errors can precipitate to be as equally "burdensome and unnecessary" as this singular step to prevent them.

Because of this and other factors, the communication closes with "...it was determined that the EP was rendered not surveyable or enforceable through the accreditation process. This is the reason behind the deletion. We continue to support active patient involvement in the identification process as a best practice and will encourage organizations to use such an approach when it is reasonable to do so."

According to the agency's web site, questions about the laboratory standards and lab requirements can be sent to Megan Sawchuk, MT(ASCP), and Cherie Ulaskas, M.A.S., MT(ASCP), associate directors in the Standards Interpretation Group. They can be contacted by phone at (630) 792-5900 or through the agency's online question form.

References

1. Paxton, A. Stamping out Specimen Collection Errors. CAP Today. May, 1999.
2. Howanitz PJ, Renner SW, Walsh MK. Continuous wristband monitoring over two years
   decreases identification errors: a College of American Pathologists Q-Tracks study. Arch
   Pathol Lab Med 2002.
3. Ford A. Catching ID errors where it counts---in the lab. CAP Today, 2005;19(9):34-40.
4. Sauer D, McDonald C, Boshkov L. Errors in transfusion medicine. Lab Med 2001;4(32):205-7.

This Month in Phlebotomy Today

Here's what subscribers to Phlebotomy Today, the Center for Phlebotomy Education's paid-subscription newsletter currently in its 9^th year of publication, are reading about this month:

• Feature Article: Eight Questions Everyone Who Draws Blood MUST Answer Correctly, Part 2
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in August including these stories:
• Study Reports Demographics of the Needlestick Prone
• Wearing of Scrubs in Public Scrutinized
• Discard Not Necessary for Blood Cultures Drawn From VADs
• Phlebotomists Picket ARC Office
• Palm Veins Used as Positive Identification Metric
• Frequently Drawn Patient Becomes a Phlebotomist
• California Waives Certification Requirement for HIV Counselors
• According to the Standards: Outpatient drawing areas
• Tip of the Month: You and Gauze: a Love Story
• 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.

Ernst to Speak at NC Conference

Dennis J. Ernst MT(ASCP), Director of the Center for Phlebotomy Education, will be the featured speaker at the fifth annual North Carolina State Laboratory of Public Health's "Clinical Laboratory Day." Ernst will be presenting "Four Cornerstones of World-Class Phlebotomy," comprised of four presentations on key aspects of blood specimen collection including preanalytical error prevention, needlestick prevention, customer service, and avoiding phlebotomy-related lawsuits.

Clinical Laboratory Day takes place annually and is co-sponsored by the North Carolina State Laboratory of Public Health and the Texas Health Institute. This will be Ernst's second appearance at the event, which also features exhibits and door prizes. The day-long conference will take place October 9 at Wake Technical Community College's main campus in Raleigh, and is open to all interested healthcare professionals. For more information, contact Kristy Osterhout at 919-733-7186.

Featured FAQ: Discard volumes when drawing above an IV

Q: I am writing to confirm whether or not it is appropriate to draw 5-7 mLs of blood as a discard tube when drawing above an IV that has been shut off for at least 5 minutes. According to other publications and our own Laboratory Manual, it is supposed to be done. When I reminded everyone in a staff meeting, our lab manager and some of my employees challenged me. Can you help me form an authoritative answer for them?

A: The real underlying question here is why your facility allows blood to be drawn above an IV at all. Studies show that certain analytes can be falsely elevated when drawn above active IVs that have been temporarily shut off.(1,2) It's not that there is a dilution factor, but that if the IV contained analytes that are being tested, they can lead to falsely elevated results. According to the CLSI standards, facilities should establish their own policies after taking this potential into consideration.

Theoretically, you can successfully draw above a temporarily discontinued IV as long as you are not drawing for analytes that were being infused. The problem with this policy, though, is twofold:

What if you draw above a temporarily discontinued IV for analytes not being infused, and then the physician adds on tests later for analytes that happened to be infused at the time of the draw? For example, a metabolic profile is added to a specimen previously drawn above a temporarily discontinued IV for a liver panel. The lab tech pulls the specimen without knowing it was drawn above an IV, reports out an elevated potassium that prompts the physician to react in ways that can be potentially tragic to the patient. Even though CLSI's latest venipuncture standard requires the specimen to be labeled as such, not all facilities have caught on to the requirement.

What if you work in a facility in which specimens are drawn by laboratory-based phlebotomists and nurses? Let's say the nurse in the intensive care unit couldn't get a blood sample, so she called for the laboratory to send up a phlebotomist. The phlebotomist has the nurse shut off the IV, waits two minutes (the recommended time to wait after shutting off an IV), then draws the tests because she knows that the tests ordered do not include any analytes that were being infused. The nurse watches the phlebotomist draw above the IV and assumes it's okay to do so with all patients, not knowing the exceptions. The next week she draws a metabolic panel above a temporarily discontinued IV thinking it must be okay since she watched the lab phlebotomist do it last week. The next thing you know, an erroneous test results prompts the physician to react inappropriately with potentially tragic results. It's an all-around risky policy.

But if you must draw above an IV, the recommendation is to discard up to 5 mL before collecting the specimen to be tested. CLSI requires specimens drawn above or below an IV to be labeled as such.(3)

References

1. Read D, Viera H, Arkin C. Effect of drawing blood specimens proximal to an in-place but discontinued intravenous solution. Am J Clin Pathol 1988;90(6)702-706.
2. Savage R. (ed.) Q&A. CAP Today 2002;16(4).102-3.
3. CLSI. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture. Approved Standard—Sixth Edition H3-A6, Wayne, PA: Clinical and Laboratory Standards Institute; 2007.

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 Procedure Template with Skin Puncture Video

Survey Says: Who Picks the Vein?

Our latest survey asked Phlebotomy Today-STAT! readers: How much influence do your patients have when it comes to selecting the vein or site from which you will draw their blood? The three categories of responses include:

• I always honor the patient's request as long as I'm confident I can get the blood.
• I let the patient suggest a site or vein, but I get the final say.
• Patient preference has no influence on where I choose to insert the needle.

Sixty-two percent of those who responded indicated the patient's choice takes priority when selecting a vein from which to draw blood as long as they feel confident. Thirty-five percent said they get the final say, but will consider the patient's request, while three percent indicated the patient's preference is not a factor. Comments include:

Many times my patient is experienced and I am grateful to them to share their experience with me. I have had the occasional patient that says the vein is right under that particular freckle or mole, only to find it in a much different spot. In general I find that a patient is more comfortable if they feel I'm listening to them.

I believe that patients know the best site to collect their blood. I've been doing phlebotomy for several years and patients that have routine blood work KNOW where they can be stuck. For those who haven't had to have blood work on a regular basis I will ask the patient which arm do they prefer. And if able I go for it... otherwise I check both arms for the best site and explain this to the patient to avoid anxiety for the patient.

I do try to accommodate requests, but I ultimately have to be comfortable and confident that I can safely and successfully perform my job.

Allowing patients to select the vein from which you attempt access can be considered performing beneath the standard of care. According to the CLSI standards, draws to the basilic vein should only be considered when the safer medial and cephalic veins are not accessible. Patients don't have the knowledge to know the basilic vein they might prefer typically lies in close proximity to nerves and the brachial artery. Should the collector allow patient priority to take precedence over the standards and an injury occur, the facility could be liable for the injury and its complications, which can be a long-term disability.

This month's survey question: What tricks and techniques have you developed to help you draw blood that aren't in the books?

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 To the Point® 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.

All responses to last month's case study fell into two categories: send the drunk coworker home and warn him/her to never come in drunk again (12%), or report the drunk to the supervisor, and work past your shift until a sober replacement arrives (88%). Most of those in the former category adopted a two-strike rule. They would cover for their coworker or find someone else to, and issue a warning not to come in drunk again. Comments include:

I would take the person to the side and tell them to act sick and go home. They are putting the patient in jeopardy. If said person refuses, notify a supervisor.

If I had a co-worker that came in drunk to relieve me for third shift and she reeks of alcohol, I would pull her to the side and inform her that she reeks and that she needs to go home sick and let someone else cover her shift. I would inform her as a friend that this should not ever happen again and if she has a problem she needs to seek help.

Assuming this is the first time this has happened, I would suggest to the co-worker that they call in sick and then call someone to drive them home. I would stay until a replacement arrives. The next day I would call the drinker at home and let them know that the incident will be kept between the two of us, but should it happen again, I will go the HR to report the problem.

The vast majority of respondents said they would take the responsibility of staying past the end of their shift to cover for the inebriated coworker. Most would also report the individual to the house supervisor or their manager. Here's a typical response:

Obviously one without question should notify their supervisor immediately. However in a case like this where your co-worker is suspected of being intoxicated, you must be careful in how you approach it. People under the influence can easily become aggravated or violent when confronted. So I would tell them I had a tough shift, was exhausted, and couldn't possibly drive home without a coffee, and ask them to go and get you one. Or any tactic or any viable excuse you can use to get them out of sight or hearing distance long enough for you to call your supervisor.... If you suspect the individual of being drunk, and you don't do anything about it, it's an extremely hazardous situation to everyone and everything around this person. Even if the person was a functional drunk and could manage to stick, their judgment across the board is still impaired.

Tiffany M. of Louisiana put it most succinctly:

I would stay with the drunk phlebotomist and work until someone else would come in and relieve her to go home, after I call the supervisor and explain what's going on . I think it would be irresponsible on my part if I just left and let my co-worker continue to work, knowing that he/she is drunk and could harm his or herself and/or the patients.

Interestingly only one respondent indicated the drunk should not be allowed to drive home, but would find a ride for him/her. Should the drunk have an accident after being dismissed for suspected intoxication, a savvy attorney could blame the facility for knowingly releasing the employee to go home under the influence of alcohol.

For her articulate response, Tiffany will receive a free download from the Center for Phlebotomy Education's To the Point® library of articles.

Answers to the Pop Quiz

If you got any of these questions wrong and want to know why, more than likely you'll find your answer in a back issue of either of our e-newsletters. Simply go to www.phlebotomy.com and enter a key word from the question you need more information on in the search window. You'll likely find a multitude of documents to refer to. You should also consider our Blood Specimen Collection FAQs book, which contains answers to hundreds of commonly asked questions on phlebotomy, including the one you got wrong. For a peek at the inside pages of the book, visit http://www.phlebotomy.com/FAQ.

1. When drawing blood, I should routinely release the tourniquet: (circle one)
b. Within 1 minute. After one minute, hemoconcentration start changing the nature of the blood below the constriction so drastically that the laboratory report is likely to mislead the physician about the patient's status.

2. Sometimes I ask the patient pump his/her fist to help me locate veins.
b. Hopefully, this statement is false. Fist pumping dramatically elevates the concentration of potassium and ionized calcium in the blood below the tourniquet. Studies have not determined how long after fist-pumping they remain elevated, so play it safe and only permit patients to clench and hold their fist, not pump.

3. According to the CLSI standards, it is acceptable to draw above an IV:
d. If it's permitted by facility policy. CLSI warns against drawing above temporarily discontinued IV, but leaves it up to facilities to establish a protocol that protects patients from being treated according to laboratory results that could be contaminated by IV fluids.

4. Routine lab work drawn from an existing central line, PICC line, arterial line, etc:
Here's the trick question. None of the answers are correct. You may have been tempted to circle " Do not require a discard volume" since a study just published in the Journal of Clinical Microbiology showed that blood cultures don't require a discard volume to prevent contamination; but blood cultures are not considered "routine lab work." Gotcha!

5. When I have to draw a “rainbow” of tubes including a blood culture, the order in which I fill the tubes:
d. is the same for every patient as follows: 1. blood cultures; 2) citrate tube; 3) serum tube; 4) heparin tube; 5) EDTA tube; 6) oxalate/fluoride tube.

6. When I don’t have enough blood for all tubes:
c. I have smaller tubes on hand that take less blood to fill completely. Submitting underfilled tubes tinkers with the delicate blood/additive mixture and threatens accurate test results.

7. After routine chemistry specimens have been drawn:
c. They should be kept at room temperature until they can be centrifuged. None of the other answers are correct.

8. After drawing tubes:
c. I invert them 5-10 times as soon as they are filled. If you don't, you should.

9. The person who writes this e-newsletter:
Actually, all of the possible answers are true. Here's why:
a. should get the Pulitzer Prize—Hey, it's not easy spelling phelbotomy.
b. needs a vacation—After 10 years of writing newsletters he just found out there's more to life than phlebotomy. We're working with the authorities to find out who let him out of his cage long enough to see the light of day. Dang!
c. is obviously not a phlebotomist—Actually, this is true; he's not a phlebotomist. We just hope it isn't obvious. Truth be told, he's a phlebotomist trapped in a med tech's body.
d. is honored that you find it worth reading every month—nothing could be closer to the truth.