Scripting Standardizes the Patient Experience

In an attempt to standardize phlebotomist/patient interactions, many healthcare facilities are employing a technique called "scripting" to ensure that all patients are subjected to a standardized protocol that includes questions and comments that should be part of every phlebotomy interaction. When scripting is implemented, patients are assured the most important components of specimen collection procedures are followed—such as proper patient identification, inquiries about latex allergies and problems during prior venipunctures, and warning the patient of the imminent puncture.

Scripting also minimizes collector variables like attitude, interpersonal skills, and varying degrees of professionalism amongst the staff. Scripts consist of statements, actions, and conditional responses or actions, and flow naturally throughout the procedure. Good scripting not only standardizes every patient's phlebotomy experience to a protocol that reflects the facility's procedure manual, but removes variables unique to phlebotomists that patients might not welcome, like being called "hun" or "honey." As a result, patients can receive higher quality venipunctures performed by a more professional appearing staff.

The Center for Phlebotomy Education has developed this sample script for Phlebotomy Today--STAT! subscribers to customize and implement into their blood collection protocol.

Statement: “Good morning (afternoon, evening).”
Action: Pause for response.

Statement: “I am (name) from the laboratory. Your doctor would like me to draw a blood sample from you for the laboratory to run some tests. Have you had blood tests drawn before?”
Action: Pause for response. Respond appropriately to patient’s reply.
Statement: Do you have a latex allergy?
Action: If the patient responds "no", proceed to the next question.

Statement: Have you ever had any difficulties getting your blood drawn?
Action: If the patient indicates a history of passing out, recline the patient for the draw. Address any other difficulties appropriately.
Conditional Response/Action: If the patient requires information about the nature of the test, respond in a general way if you know the nature of the test. Under no circumstances should you provide information about the nature of the test(s) if you are not sure.
Conditional Response/Action: If the patient refuses the test, attempt to explain that the doctor needs the information the test provides to properly treat or diagnose him/her.
Conditional Response/Action:  If the patient continues to refuse, do not pursue further. Instead, tell the patient you understand and dismiss yourself. Notify the nurse/caregiver/physician of the refusal.
Conditional Response/Action: If the patient is cooperative, continue with patient identification process.

Statement: Ask the patient to state (not affirm) his/her name, address, unique identification number, and/or birth date. Ask the patient to spell his/her last name.
Action: Pause for response. Compare information provided with the patient’s identification bracelet, which must be attached to their person, and the test form(s).
Conditional Response/Action: If the patient is unresponsive, ask a family member or a caregiver to identify the patient.
Conditional Response/Action: If the arm bracelet is missing or not attached to the patient, notify the nursing staff of the problem. Do not draw the patient until the arm bracelet has been attached to the patient’s wrist or ankle or the nurse or caregiver has identified the patient verbally. Document the name of the individual who verbally identified the patient.
Conditional Response/Action: If the patient is unable to state his/her name, seek verification of the individual’s identity as above. Document the name of the verifier.

Action: After patient identification has been confirmed, select an appropriate venipuncture site according to facility policy. Prepare the site according to facility procedure and notify the patient of the imminent puncture.

Statement: “You will feel a little poke (alt: ‘stick’ or ‘pinch’), now.”
Action: From this point forward, anticipate that your patient may pass out.
Action: Complete the puncture using the proper order of draw and filling tubes to their stated fill volumes. Release tourniquet, remove the needle, activate the safety feature and discard the sharp immediately. Apply pressure to the puncture site. Do not allow patient to bend arm up as a substitute for pressure. Invert tubes.
Action: Label tubes in the patient's presence. Show each labeled tube to the patient and seek confirmation that they are labeled correctly.
Conditional Response: If patient indicates tubes are not labeled properly, take corrective action.
Conditional Response: If patient is unable or unwilling to confirm labeled samples, compare the labels of each tube to the patient's identification band.

Action: Observe for superficial bleeding and hematoma formation for at least ten seconds after relieving pressure. After assuring that bleeding from both the vein and skin has stopped, bandage the patient.
Conditional Response/Action: If the site continues to bleed either above or beneath the surface of the skin, apply five minutes of pressure, and then check again for bleeding. If bleeding continues, notify the nurse or caregiver responsible for the patient. Do not bandage the site until bleeding has stopped. Provide patient with post-venipuncture-care card.

Statement: “Here are some instructions for you should you notice anything unusual with the venipuncture site after I leave. I would like to ask you to leave this bandage on for at least 15 minutes. Do you have any questions?”
Action: Respond appropriately.

Statement:  “Do you feel okay?”
Action: Regardless of the response, evaluate the patient for signs that they have not tolerated the procedure well.

Statement: “Once again, my name is (name). Here’s my card with my extension number in case you have any questions after I leave. Thank you, Mr./Mrs _____.”

Patients base their impression of the quality of the laboratory on the quality of the one who draws its specimens. As more facilities adopt scripting techniques, it is reasonable to assume that laboratories in general will be held in higher esteem because of the better impressions patients get from those who follow well-drafted scripts.

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, Part 3
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in September including these stories:
• Phlebotomist Fastest Female Finisher in Marathon
• Phlebotomist Generates Bad Press for Profession
• Police Being Trained to Draw Blood from Suspected DUIs
• According to the Standards: Preassembling collection devices
• Tip of the Month:Trick or Treat
• 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.

Featured FAQ: ER blood culture contamination & hemolysis

Q: Our ER has been drawing blood for about three years now and we continue to have trouble with blood culture contamination and hemolysis. I educate and train their techs that will be drawing blood, but the problem seems more with nursing. How do you handle education with emergency room staff?

A: Every ER shares your frustration. A study reported in the Journal of Emergency Nursing describes a similar issue at a hospital like yours where the authors, all nurses, investigated the lab's claim that they were hemolyzing specimens during collection in the ER. The nurses didn't believe they were responsible and conducted their own study to prove it. The results showed the lab was right: their draws were more hemolyzed than laboratory phlebotomists' draws.

Don’t be overly critical of the nurses, however. In the ER, everything has to happen quickly, and they give a priority to expediency. That’s the driving force behind draws during an IV start. Unfortunately, such expediency is at odds with a good specimen, which is the laboratory’s priority. Understanding the difference in priorities is key to working together. Try explaining how draws during IV starts can be more detrimental to the patient than beneficial, especially when the diagnosis and treatment are delayed because of a hemolyzed specimen that has to be recollected by venipuncture.

As for blood culture contamination, the same force is at work. Reinforce that whether the antiseptic is iodine or chlorhexidine, it requires at least 30 seconds of contact in order to decontaminate the site. Expediency here cuts that time short and you end up with skin flora growing inside the culture bottles and presenting a misperception of the patient’s condition.

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, exclusive to Phlebotomy Today® Premium subscribers. For information on joining Phlebotomy Central, visit www.phlebotomy.com/PhlebotomyCentral.html.

Featured Product: Venipuncture Procedure Template

Survey Says

Our latest survey asked Phlebotomy Today STAT! readers: What tricks and techniques have you developed to help you draw blood that aren't in the books? Responses include the following:

• Putting the tourniquet up higher on the person helps out when it is a difficult draw.
• One of my students came up with the following order of draw: Yikes! Big Red Giants Like Grapes! for yellow, blue, red, green, lavender, gray.
• Roll a vein into position while client is holding a fist by slightly turning the wrist either way.
• Two tricks I learned from another phlebotomist is to wet the skin and your feeling finger with alcohol to get a better feel. Also turning the waist but keep the elbow straight will a lot of times make the vein more visible and easier to feel.
• Asking the patient to relax the arm allows me to slightly bend the elbow which often reveals a deeper vein. This is because the muscles are relaxed and the dip in the antecubital fossa is more pliable.
• Rather than having the patient pump their fist, I just take the back of my fingers & with a little pressure sweep up the arm from the wrist to just below the elbow. When you do this you actually feel the vein fill up a little bit so it is easier to find. It also is helpful since many of my patients have arthritis & cannot hold a fist.
• Bend arm slightly up to loosen the skin around the veins. Then, bend arm back down so the veins won't roll and perform the puncture.
• Heat compresses;
• If the patient is cold and its difficult to find their vein, it's best to warm them up with a warm blanket from a blanket warmer/heating pad. It's amazing how the vein react to the heat. They will actually appear.
• Rotating the patient's arm to help locate a vein is always my first move when looking in the A/C area. I have found if I flick the vein like a guitar string it pumps up just as well as the old “slap” technique. However, I am not slapping the patient like they have been bad…

This month’s survey question: Does your facility provide outpatients with an identification band prior to a blood draw?

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.

Surprisingly, this scenario was not uncommonly encountered by those who responded. Reactions varied widely. Thirty-three percent said they would report the snoozing employee to their supervisor. Sixteen percent would issue their coworker a warning, and report a second offense. Another sixteen percent said they'd find someone else to shadow. One respondent admitted that taking a nap was permitted where they used to work. Some comments:

• It depends.  If “sleeping beauty” is off the clock, taking a nap is permissible as long as he/she returns to work at his/her specified shift time and does not depend on a coworker to wake him/her up.
• If the napping employee is on the clock, where I work (it) is not allowed and is grounds for termination.  An employee who is sick or impaired in any way needs to report to his or her supervisor so that a determination can be made as to whether to send the employee home. Sleeping during work hours is unfair to other employees and interferes with quality patient care and workflow.
• It is always hard for a coworker to make the determination of whether to “turn in” another employee for misconduct, but if the problem continues it makes it difficult for the non-sleeping employees to do their job effectively and makes them look bad.
• I have worked at sites that allowed their employees to nap when it is not busy.  However, not everyone wakes up ready to go.  This could be a dangerous practice if the phlebotomist is napping and a trauma arrives in the emergency room.  Speaking as a Supervisor, there is almost always work-related "things" to do.  The employee should be awake and alert for any possible situation.
• (In) a lot of places, sleeping on the job would be a firing. This person should check the rules.  He/she is being paid by the hour, not by the person.  This time should (be used) to clean, restock catch up on education and so-forth. 
• The person could have a problem that might be helped by talking to his supervisor.
• I would let the person know I am shadowing that I would prefer to stay busy and try to find someone else to shadow with. 

Phyllis H. of Colorado tells how she handled this very situation successfully.

"I have actually encountered this situation. My first reaction was to check on my fellow worker to make sure they were feeling okay. After determining that my coworker was fine, I politely explained that this is an unacceptable behavior and we had responsibility and accountability. I would not tolerate this behavior and report it to a supervisor if it occurred again. It worked well and never happened again."

Because of Phyllis's courageous approach and well-articulated response, she'll receive a free download from the Center for Phlebotomy Education’sTo the Point® library of articles.