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September, 2010


Copyright 2010 Center for Phlebotomy Education, Inc.
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Survey Says: Glove Use

[Editor's note: Our monthly online survey was so overwhelmingly popular last month that we couldn't help but promote it as this month's feature article. If you participated, thank you. But whether you did or not, we think you'll find the results fascinating.]

In 1991, the Occupational Safety and Health Administration (OSHA) released its Bloodborne Pathogens Standard mandating glove use for all U.S. employees who perform vascular access procedures.(1) Fast forward to 2010. The results of our latest survey on glove use completed by visitors to our website indicate that facilities are still falling short of 100% compliance nearly 20 years later:

Survey Question #1: How would you describe your glove use during phlebotomy procedures?

  • I always wear gloves – 90.5%
  • I usually wear gloves – 4.2%
  • I seldom wear gloves – 4.2%
  • I never wear gloves – 1.1%

Survey Question #2: Do you ever tear the fingertip off your glove to palpate a vein?

  • Yes – 17.9%
  • No – 82.1%

Always, Always, Always
The good news is the vast majority of survey participants (90.5%) indicated that they always wear gloves during phlebotomy procedures. The bad news is that 15% of those promptly rip off the fingertip to palpate for a vein. Overall, nearly 18% of all survey respondents do the same.

Not only does OSHA mandate glove use during venipunctures, but whenever it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infections materials, mucous membranes, and non-intact skin.

Sample Comments:

  • “Putting on my gloves is the first thing I do when I enter a patient’s room, besides telling the patient who I am.”
  • “When wearing gloves was first instituted, I did not feel real sure of palpating the veins. But with time and keeping the gloves on for the entire procedure, you WILL be able to palpate a vein.”

So if it violates OSHA regulations, why do some choose to draw blood without gloves? Not all who responded fall under OSHA jurisdiction. Of the 9.5% who reported that they do not always wear gloves during phlebotomy procedures, nearly half (44%) reside outside the U.S. where OSHA regulations don't apply. But for the rest, reasons for shunning gloves include the inability to find a vein, not liking the type of gloves available, underestimating the potential for exposure to pathogens, and skepticism regarding the actual protection gloves provide, as illustrated by the following comments:

Sample Comments:

  • “Occasionally, if I have a really hard stick and I can’t feel the vein with my glove on, I will take my glove off, only after explaining to the patient why.”
  • “I honestly do not like wearing gloves.”
  • “Most gloves my employer provides have textured fingertips…not good for finger sensation.”
  • “It’s difficult to feel the vein through our gloves. I’ve requested a thinner glove without success.”
  • “The current debate within my organization is when using an evacuated system, you would rarely get blood on your hands. If you are doing many venepunctures (sic) in a day, taking gloves off and on can be an issue to the staff, not to mention the cost to the environment.”
  • “Currently, the management allows us not to wear gloves with patients who are not at risk or have a contact-borne infection e.g., MRSA, scabies, norovirus.”

When is a Glove Not a Glove?
Factoring in the "tip rippers," the actual percentage of those surveyed who always wear intact gloves is only 76%. Since gloves by definition have fingers, removing a fingertip essentially removes the glove and creates only an illusion of compliance with OSHA’s Bloodborne Pathogens Standard. When a fingertip is removed from a glove, its intended purpose as personal protective equipment is lost. According to OSHA, “disposable (single use) gloves… shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.”(1) Interestingly, many of those surveyed had a lot to say about themselves and their coworkers when it comes to removing the fingertips from their gloves.

Sample Comments:

  • “Many of our phlebotomists and nurses do tear the fingertip out or take off the glove so they can feel the veins better.”
  • “Gloves are required by the facility I work for, even though some don’t always adhere to this policy.”
  • “How do you get coworkers to stop tearing the fingertips off their gloves?”
  • “I never tear the fingertip off my glove but I work with several phlebotomists who do.”
  • “I tear the fingertip off my glove only as an absolute last resort…I do stress to the phlebotomy staff that this is not acceptable. I guess it’s a double standard and no one—not even myself—should be doing this.”

It’s All About Timing
While glove use in the U.S. is mandatory, it doesn’t have to be a barrier to performing phlebotomy procedures. OSHA does not specifically state when during the course of a venipuncture the gloves must be donned. To aid compliance, the Clinical and Laboratory Standards Institute (CLSI) instructs collectors to put on gloves after site selection and just before site preparation.(2) One exception being draws performed on patients in isolation.

Sample Comments:

  • “If I can’t feel anything with my glove on, I take it off and feel. Once I have a vein, I try to find a beauty or other mark on the body to use as a general target. Then I reapply my glove for the actual blood draw.”
  • “If I have a difficult time finding a vein, I may remove my gloves to try to find a vein (then washing my hands, reapplying new gloves and then proceeding) but I find the best way is to leave your gloves on and TAKE YOUR TIME.”
  • “I choose to find a vein before I glove.”

Glove Protection: Facts and Fallacies
If you think gloves are unnecessary because blood splashes and splatters don’t occur during phlebotomy procedures, think again. In 2008, DenLine Uniforms, Inc., of Quincy, IL in conjunction with the Center for Phlebotomy Education conducted a national survey of healthcare professionals who perform blood specimen collection as part of their assigned responsibilities in the workplace. One of the objectives was to determine if during phlebotomy procedures blood from a patient splashes beyond the hand area of the collector. The results of the study found over 74% of blood collection personnel surveyed reported one or more instances of blood splash or spatter occurring beyond their hands. Those who reported splatter beyond the hand area averaged 6.9 occurrences per person.(3)

Have you heard the old argument that gloves won’t prevent an accidental needlestick? That may be true, but a new study conducted by Canadian and U.S. researchers indicates that glove use by healthcare workers may result in a 66% reduction in risk of experiencing a sharps injury.(4) It has also been reported that gloves can reduce the volume of contaminated blood delivered to the healthcare worker's flesh by up to 86%.(5) With the reduced inoculum, less of the potentially contaminated blood infects the healthcare worker. So, donning gloves might not offer 100% protection, but the risk reduction they provide may be much greater than you think.

Students and Donor Phlebotomy
All students are exempt from the Bloodborne Pathogens Standard since OSHA regulations only apply to employees in the workplace. Although not federally mandated, it is prudent for phlebotomy educators to require glove use in the classroom. Kudos to the instructor who provided the following comment: “My students are instructed to (and do) always wear gloves.” Only under certain conditions does OSHA exempt volunteer blood donor centers from mandatory glove use.(1)

The Price of Noncompliance
Surveys and statistics are great for making a case or proving one’s point. But the human anguish of not wearing gloves can be incalculable if a healthcare worker contracts or transmits a pathogen, as evidenced by one survey participant’s comment about coworkers tearing the fingertip off their gloves.
—“I watch many nurses and imaging techs do this in our facility when starting IVs. They may or may not wash their hands. It makes me crazy! My own father has and will ultimately die from hospital-acquired infection(s). We have gone to management of our lab and they call it a departmental issue. I hope for a patient to complain someday so maybe things will improve.”

Another cost of noncompliance comes in the form of OSHA fines. In the twelve months ending July 31, 2010 OSHA levied fines in excess of $490,000 for violations to the Bloodborne Pathogens Standard.

Don’t make those most vulnerable and in need of healthcare services wait for “someday”. Do yourself a favor and commit to wearing gloves without exception and not tearing off fingertips. And be your facility's advocate for exposure prevention by nurturing a culture of compliance. Let's face it; some people need to be protected from themselves. Everyone who draws blood without gloves has loved ones depending on them. How will you feel if a coworker acquires a life-threatening pathogen, an exposure you could have prevented had you only brought the behavior to the attention of someone who had the authority to change the behavior? Consider it tough love. Friends don't let friends draw gloveless.

References

1. Occupational Safety and Health Administration.(1991) Occupational exposure to bloodborne pathogens: Final rule. 29 CFR 1910.1030. Link. Accessed 8/31/10.

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.

3. Ballance, L. Survey Sheds New Light on Blood Splash Exposures. Phlebotomy Today. 2009;10(6).

4. Branswell, H. Love the Glove: Glove use in hospitals appears to cut risk of needlestick injury. Winnipeg Free Press.7/31/10. Link. Accessed 8/31/10.

5. Mast ST, Woolwine JD, Gerberding JL. Efficacy of gloves in reducing blood volumes transferred during simulated needlestick injury. J Infect Dis 1993; 168(6):1589-1592.

[Editor's note: For a copy of the CLSI venipuncture standard, H3-A6, "Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture," visit the “Books & References”  section of the Center for Phlebotomy Education's website at www.phlebotomy.com/product/8250.cpe ]

This month’s survey question:
What determines if you perform a heelstick versus a fingerstick on an infant?

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Featured Product
Phlebotomy Today® Single-User Subscription Offer

Through October 15, 2010, Phlebotomy Today—STAT! readers can purchase a single-user subscription to Phlebotomy Today for just $79.00. That’s a 20% discount off the regular subscription price. With the single-user subscription, individuals have access to the world’s only monthly e-newsletter devoted to blood sample collection news and information (Review our Terms of Use.).

Features include one full-length article painstakingly researched and reflective of CLSI standards and OSHA regulations and five departments and columns:

  • Tip of the Month;
  • According to the Standards;
  • Phlebotomy in the News;
  • From the Editor’s Desk;
  • Product Spotlight.

Subscribe now and don’t miss another month of what other healthcare professionals around the globe have been trusting since 2000 as a dependable source of phlebotomy information.

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Conference Spotlight

UVa Sponsors Needlestick Safety Conference
The International Healthcare Worker Safety Center at the University of Virginia, in cooperation with U.Va.'s Office of Continuing Medical Education, is sponsoring a conference, Tenth Anniversary of the Needlestick Safety & Prevention Act: Mapping Progress, Charting a Future Path. The conference is scheduled for November 5-6, 2010 at the Omni Hotel located in Charlottesville, VA. Session topics address gaps in safety engineered devices, surgical sharps safety, challenges of effective OSHA enforcement, and advancing healthcare worker safety in developing countries. Speakers include Janine Jagger, Elise Handelman, Ramon Berguer, Lisa Black, and Gina Pugliese, with the keynote address by John Howard, MD, MPH, Director of NIOSH. The conference is funded in part by a grant from the National Institute for Occupational Safety and Health. For more information contact Jane Perry, Associate Director, International Healthcare Worker Safety Center at 434-982-3763 or janeperry@virginia.edu

For registration information, you can view their registration form (pdf).

 

Conference Calendar

This fall, healthcare professionals looking for conferences and web presentations have a multitude of options. We've assembled a rundown of all the preanalytical presentations we could find being given this fall in hopes you will find one or more worthy of your presence.

2010 Fall Conference Schedule

Date

Location

Event/Host organization

Title

Speaker

Web

9/9/2010

Web

Center for Phlebotomy Education

Mastering Pediatric Phlebotomy

Dennis J. Ernst MT(ASCP)

Link

9/24/2010

Oklahoma City, Oklahoma

ASCLS-OK and OKSSAMT

Phlebotomy and the Law  

Sandra Butler, CLPlb  

Link

9/30/2010

Web

Center for Phlebotomy Education

Potassium Results Your Physicians Can Trust

Dennis J. Ernst MT(ASCP)

Link

9/30/2010

Indianapolis

ASCLS-IN & GICLMA

Phlebotomy Workshop (3 presentations)

Dennis J. Ernst MT(ASCP)

ASCLS-IN

GICLMA

10/1/2010

Scottsdale, Arizona

COLA

Effect of Pre-analytical Conditions on Clinical Results

Toni Clinton, PhD (BCLD), MT(ASCP)

Link

10/7/2010

Atlanta

ASCP Workshops for Laboratory Professionals

 

Shrita A. Smith, MS, MT(ASCP)

Lorraine L. Tyndall, MS, MT(ASCP)

Link

10/8/2010

Rochester, Minnesota

ASCLS Region IV

Errors in the Laboratory: What's a Person To Do?

Paula J. Santrach M.D.

Link

10/14/2010

Portland, Oregon

Northwest
Medical Laboratory
Symposium

Microcollection, Review of Specimen Quality Issues
Including Phlebotomy and Processing

Tricia Cass idy, MT(ASCP)

Link

10/19/2010

Portland, Maine

Northeast Laboratory Conference

Preanalytical Benchmarks

Dennis J. Ernst MT(ASCP)

Link

10/26/2010

Web

Center for Phlebotomy Education

Delivering World-Class Customer Service

Dennis J. Ernst MT(ASCP)

Link

10/30/2010

San Francisco

ASCP annual conference

Hemolysis – New Approach to an Old Problem

Ana K. Stankovic, MD, PhD, MSPH

Link

11/16/2010

Web

Center for Phlebotomy Education

Successful Strategies for Difficult Draws

Dennis J. Ernst MT(ASCP)

Link

Ernst to Give Keynotes at Alverno, Geisinger
Phlebotomy Today editor and Director of the Center for Phlebotomy Education will be giving two keynote addresses this fall to phlebotomists and other healthcare professionals. On September 22, Ernst addresses attendees at Alverno Clinical Labs in Crowne Pointe, Indiana at its annual Phlebotomy Day. Alverno Clinical Labs staffs 22 hospitals and draw stations in Northern Indiana and Illinois. His presentation titled "Phlebotomy: High Art or Folk Art" discusses the importance of adhering to the established standards, and includes some "quirky diversions" that he's experienced over the years as an industry observer.

In November, Ernst travels to Danville, Pennsylvania to deliver the keynote address to the 2010 graduating class of Geisinger Health System's School of Phlebotomy, which was newly established last year. Ernst will motivate graduates to lead by example, and become leaders within the profession.

 

This Month in Phlebotomy Today

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 11th year of publication, are reading about this month:

  • Feature Article: Hand Hygiene – What Every Phlebotomist MUST Know, Part II
  • Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in August including these stories:
    • Glove Use Reduces Incidence of Sharps Exposure
    • Nurse Donates Kidney to Phlebotomist Coworker
    • “Stop the Line” Strategy Helps Hospital Lower Patient ID Band Errors
    • New Antimicrobial Coating Effective Against MRSA
    • Phlebotomy Clerk Fired for Alleged HIPAA Violations
  • According to the Standards: Spot Bandages on Coumadin Patients
  • Tip of the Month: Immunizing Yourself Against HPV (HIPAA Patient Violations)
  • 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.

 

Featured FAQ
Prelabeling tubes

Q: Is it acceptable to pre-label all collection tubes with the patient’s information, prior to performing a venipuncture?

A: Not at all. The standards are solidly against this practice. The risk is that labeled but unused tubes could be inadvertently left behind and accidentally used on another patient. Let’s say it’s your practice to prelabel tubes before the draw. The venipuncture is unsuccessful after two attempts and you leave the inpatient’s room, forgetting to discard the tubes from your tray. (Or, worse yet, leaving them in the room for someone else to use.) You’ve created a situation that opens the door for all kinds of medical mistakes.
      If you look at the CLSI venipuncture standard (H3-A6), it lists in chronological order the steps of the venipuncture procedure. Labeling tubes is step 15, which comes after the specimen is drawn. Later in the document, it states that the labels should be placed on the tubes after collection is complete. Finally, on page 18, it states the tubes must not be labeled before they are filled. So it’s quite clear that prelabeling is not acceptable. You should work to establish firm language in your policies against prelabeling.

Reference
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 latest publication Blood Specimen Collection FAQs. For a preview and for information on obtaining your copy, click here.

 

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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 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.

 

Last Month’s Case Study:
Family First?

Your sister delivered her first baby at the hospital where you work. The baby is jaundiced and is having bilirubin levels drawn at regular intervals. Your sister is very anxious about the baby having to remain hospitalized and has asked you to find out what the last total bilirubin result was. What would you do?

 

Readers who responded to last month’s case study sure know a lot about protecting patient confidentiality. They also agree that blood is not thicker than the bonds of professional ethics. While several readers expressed sympathy for their sister’s situation, none would allow emotion or family ties to cloud their professional judgment. The two main reasons given for denying the request to access the baby’s test results were 1) it’s a violation of facility policy, HIPAA and/or patient privacy laws (76%), and 2) such action is grounds for termination (38%). One reader shared that such employee queries are periodically audited by their facility, concluding that “it’s not a smart move.” Instead of granting their sister’s request, over 90% stated they would refer her to the nurse or attending physician who could provide not only the baby’s bilirubin result, but its meaning in proper context.

Protecting a patient’s health information is serious business with serious consequences if compromised. Although some readers considered this to be a clear-cut scenario, it’s not an unfamiliar one. Mary from Wisconsin shared “…My own relatives have made similar requests of me in the past until I enlightened them...”

Here’s how another reader described the personal/professional dilemma: “This is a difficult position that many MLTs have found themselves in over the years. On one hand you want to do anything you can to help your family and friends, but on the other hand you have a responsibility to maintain a code of ethics and confidentiality. Having been put in this position myself in the past, I simply explained that I am not qualified to offer this information and that they should speak with their physician or nurse. I also try to calm their worries by explaining that by doing this test, their healthcare provider is offering the best care possible to the patient.”

Heather from Kentucky summed it up this way: “…As a medical laboratory technician, or a phlebotomist, we do not have the right to diagnose, report, or instruct any patient with regard to their laboratory results. HIPAA states that medical information is shared with healthcare givers only on a "need-to-know" basis. In no way is the bilirubin result pertinent to the job of a phlebotomist, even if the lab worker is related to the patient. In this particular case, I would advise my sister that I understand her anxiety with regards to the baby's test results, but she needs to direct all of her questions to the nurse caring for the baby or the doctor that ordered the blood work. It seems to be in the best interest of the medical facility and the healthcare worker to never personally involve yourself in the treatment or care of a close friend or family member. This may help with the temptation to find out information that otherwise is prohibited.”

For her detailed explanation of what every health professional needs to know, Heather will receive a free download from our library of articles

 

 

This Month’s Case Study:
An Age Old Problem

You receive a request for a CBC, metabolic panel, and coagulation studies on a new admission. When you arrive at the patient's room you find a frail, elderly lady with bruising on both arms. After you identify the patient and attempt to survey the antecubital area, the patient is unable to fully extend her arm at the elbow and her skin appears paper-thin. What would you do?

Tell us what you'd do in this case. Submit your response by the 20 th of the month and send it to this address and this address only: WWYD@phlebotomy.com. Submissions sent to any other address will not be considered. Keep your suggested solutions less than 100 words. Although you don’t have to be an English scholar to be considered for inclusion, submission with proper grammar and punctuation will be given priority. If you’re not sure of the appropriate solution, check your facility’s procedure manual or ask your manager. Who knows, you might be presented with the very same dilemma tomorrow.

 

 

 

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