Latest Preanalytical Variable to Affect Potassiums: 25-gauge needles
Researchers in Verona, Italy have added another preanalytical factor to the long list of collector-induced variables that alter potassium results: 25-gauge needles. In a study published in Clinical Chemistry, renowned preanalytical researcher Salvagno Lippi and his team compared the variability of 23- versus 25-gauge needles on a wide variety of commonly performed chemistry tests in the clinical lab. The team found increased variability for potassium when drawn through a 25-gauge needle compared to the 23-gauge needle. According to the abstract, "Small-bore needles of 25 G or less cannot be universally recommended when collecting venous blood for clinical chemistry testing and should be reserved for selected circumstances."
The size of the needle increases the long list of preanalytical variables that have been reported to alter potassium results. "It's probably the one analyte that is more affected by how the sample is collected, handled, transported, and processed than any other," says Dennis J. Ernst MT(ASCP), Director of the Center for Phlebotomy Education. "No other test result threatens the laboratory's credibility in the eyes of physicians more than their potassiums."
Ernst is referring to the following partial list of preanalytical factors reported to alter potassium levels:
Earlier this year, Ernst conducted a webinar titled "Potassium Results Your Physicians Can Trust." A recorded version of this presentation will soon be available on the Phlebotomy Channel. (See related article.)
[Editor's note: A potassium troubleshooting checklist containing 43 patient-dependent and preanalytical variables known to affect potassium results is available as part of the Manager's Toolbox.]
Texas Phlebotomist/MLT Needs Kidney
In November of 2008 Stacy Jackson was a 35-year-old phlebotomist working at Grace Clinic in Lubbock, Texas when she was diagnosed with IgA nephropathy. Within months her kidneys stopped working. She now undergoes peritoneal dialysis four times a day, and is praying for a kidney. At the time, she was also pursuing a degree as a medical laboratory technician (MLT) at Amarillo College, and has since completed the program. However, her condition and frequent dialysis only allows her to work 15 hours a week.
Jackson is on several organ donor lists, but has had her hopes dashed eight times so far. While friends and family members with her blood type (B pos) have offered to donate a kidney, all have been systematically disqualified for a variety of reasons. Jackson hopes that those who are aware of her need will consider her should they become aware of the availability of a kidney that matches her blood type. Jackson can be reached at TexasPhlebotomy@yahoo.com.
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:
For subscription rates and to subscribe to Phlebotomy Today, click here. The current month’s issue will be emailed to you immediately upon subscribing.
Q: Our outpatient phlebotomists have begun to use an adhesive gauze wrap as a pressure bandage on our routine outpatients. It seems that our patients are asking for it, thinking that it is better than regular tape, but the question came up that there could be liability if the patient does not remove it in a timely manner. Do you have any information and/or references regarding the use of this type of product?
A: Unless the stretchy gauze wrap is applied so tightly that it restricts circulation, there shouldn’t be any problems associated with a prolonged application. Maybe an in-service would be in order to demonstrate how loosely it should be applied as a way to manage the risk. Another way to limit your liability is to give the patient written post-venipuncture care instructions that tell when to remove the wrap. You might contact the manufacturer for proper use instructions.
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. For information on joining Phlebotomy Central, click here.
Last month’s survey question asked visitors to our website what single attribute they wished their supervisors would improve upon. Since turnabout is fair play, we also asked supervisors to identify one characteristic they would like to see their staff as a whole improve upon.
The number one quality respondents wanted their supervisors to master was to show more recognition and appreciation (28%). Communication was a close second at 20 percent, with trustworthiness and organizational skills tied at 12 percent each. For a complete ranking of responses, refer to Chart 1.
Topping the wish list of what supervisors wanted from their staff was teamwork at 40.9 percent. Professionalism was a distant runner-up at 13.6 percent, followed by a three-way tie between dependability, initiative/time management and interdepartmental cooperation (9.1% each). Supervisor responses are summarized in Chart 2.
So what’s the takeaway message? Regardless of which side of the desk you occupy, for most of us there’s always a little room for improvement.
This month’s survey question:
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.
Of the readers who responded to last month’s case study, two-thirds indicated that they would notify OSHA. One respondent commented that she has personally witnessed staff manually removing needles from the tube holders when the device’s auto-release button didn’t work.
One of our readers, Lee, would handle the situation this way: “Forward the information to the facility Infection Control Department, the Employee Health Department, Pathologist, Human Resources, Products Committee, Lab Director, Administrator, [and] Risk Manager. If they refuse to deal with the issue consider finding another job and reporting the problem to OSHA, the Joint Commission or your State Labor board. Someone there needs to wake up.”
Several studies on tube holder contamination rates have been published. One showed a 9.2 percent visible contamination rate (1), while another study showed that 48 percent of tube holders were contaminated after a single use.(2) A third study found the tube holder blood contamination rate to be 83 percent.(3)
OSHA's Bloodborne Pathogens Standard (29 CFR1910.1030, paragraph (d)(2)(vii)(A)) states: “Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed, unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental procedure.” More specifically, OSHA’s compliance directive, CPL 2-2.69 at XIII.D.5 states, “removing the needle from a used blood-drawing/phlebotomy device is rarely, if ever, required by a medical procedure. Because such devices involve the use of a double-ended needle, such removal clearly exposes employees to additional risk, as does the increased manipulation of a contaminated device.”(4)
In a Standard Interpretations letter dated June 12, 2002 from Richard E. Fairfax, Director of OSHA’s Compliance Programs, Fairfax states the following: “In order to prevent potential worker exposure to the contaminated hollow bore needle at both the front and back ends, blood tube holders, with needles attached, must be immediately discarded into an accessible sharps container after the safety feature has been activated… Removing contaminated needles and subsequently reusing blood tube holders poses multiple potential hazards. The increased manipulation required to remove a contaminated needle from a blood tube holder is unnecessary and may result in a needlestick from either the front or back end of the needle.”(4)
Given the evidence and what’s at stake, there simply isn’t a good reason for reusing tube holders. We echo Lee’s sentiments. Those in authority need to be made aware of the situation and those who condone the practice need to be held accountable. For a concise and articulate response, Lee will receive a free download from our library of articles.
Next month, our What Would You Do? column will be ringing in the New Year with a slightly different format.
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