Professionalism in Healthcare: The Patient's Perception of Care

This month Phlebotomy Today-STAT! begins a series on professionalism in healthcare. Topics will include personal appearance, attitude, phone etiquette, and professional certification. This month, we launch the series with how our appearance and behavior mold the patient's perception of the quality of care he/she receives.

 We are all walking advertisements for whatever it is we do for a living. The image we project says a great deal about us and the quality of work we produce. Although the old saying "you can't judge a book by its cover" is true, it’s human nature to draw conclusions based on whatever information we have available, however scant.

If your work involves drawing blood specimens, to the patient, you represent the laboratory. After all, you are drawing blood for the lab. Because most patients never see the laboratory, the patient’s impression of the quality of work conducted on the specimens you draw is based completely and entirely on his or her impression of you. If the collector is sloppy, patients suspect that the laboratory is sloppy. If the person who draws the blood is cold and inconsiderate, patients suspect that the work performed on the specimen will be conducted without much passion for precision.  If the collector lacks skill, confidence and professionalism, the impression is that the specimen will be processed haphazardly.

Here are some examples of the perceptions patients may acquire based on their observations:

Observation: The lab coat on the person who drew my blood was clean and neat.
Perception: The laboratory must be clean and neat.

Observation: The person’s scrubs were dirty and flecked with blood.
Perception: The laboratory must be dirty. Those who test my blood must be sloppy.

Observation: Healthcare personnel wear gloves during phlebotomy procedures.
Perception: The laboratory will process my specimen with caution and respect.

Observation: The person drawing my blood isn’t wearing gloves. They don’t know much about infection control here.
Perception: I wonder if this person has caught hepatitis yet. I wonder if he’s passing an infection on to me!

Observation: The person who drew my blood spoke knowledgably and considerately to me.
Perception: The laboratory must be staffed with knowledgeable and considerate people. 

Observation: The person who drew my blood didn’t seem to know much.
Perception: The laboratory staff isn’t very educated.  

Observation: The phlebotomist was pleasant and smiled often.
Perception: The laboratory must be staffed by friendly people who care about my health.

Observation: The person who drew my blood was cold and insensitive.
Perception: The laboratory must be staffed by cold and insensitive people. I wonder how that will affect how they test my blood.

Observation: The collector made sure the tubes were labeled before leaving my side.
Perception: They take specimen identification seriously here.

Observation: The collector left the room without labeling my blood.
Perception: My test results might get mixed up with someone else’s.

Once a poor impression is imbedded, patients may wonder if they are being treated and managed according to inaccurate results or results that may belong to another patient. Does the image you project give the patient confidence that the blood you're drawing will be handled properly and tested accurately?

Specimen Collection Safety: Lab Coats & Scrubs

Do you wear a gown or lab coat when you’re drawing or processing blood to protect your arms and clothing from accidental splatter? Do you keep it closed in front? You should. Consider the following passages from the OSHA Bloodborne Pathogens Standard:

Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or similar outer garments shall be worn in occupational exposure situations…. Protective clothing shall not be worn outside of the work area.

But what about scrubs? Can they be worn on the job instead of lab coats? OSHA defines personal protective equipment as "...clothing or equipment worn by an employee for protection against a hazard." Further, the agency states "General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment." Therefore, scrubs are usually worn in a manner similar to street clothing, and normally should be covered by appropriate gowns, aprons or laboratory coats when splashes to skin or clothes are reasonably anticipated.

Can blood splatter be reasonably anticipated during blood collection procedures? OSHA leaves that up to the employer. According to the document OSHA field inspectors use to interpret and enforce the standard, "the employer must evaluate the task and the type of exposure expected and, based on the determination, select the 'appropriate' personal protective clothing...." For example, laboratory coats or gowns with long sleeves must be used for procedures in which exposure of the forearm to blood or other potentially infectious material is reasonably anticipated to occur. OSHA consultants maintain that compliance with this passage requires specimen collection personnel to wear protective clothing when processing blood samples. OSHA consultants say protective clothing may not be required when drawing blood, any processing activity warrants a lab coat.

Healthcare workers who think they’re complying with the standards just by simply wearing a coat and leave it open in front for comfort and ventilation are not using the protective garment properly and could be in violation of the Bloodborne Pathogens Standard. Lab coats have to be closed in front when an employer determines that a procedure warrants their use.

When coats have been penetrated by blood or other potentially infectious material, they must be removed and laundered before being reused. When they are visibly contaminated but not penetrated, it becomes a question of professionalism and infection control. The standard also states employers must be responsible for purchasing, maintaining and laundering clothing used as personal protective equipment, such as lab coats. Employees are not to take lab coats home. Instead, they are to remain in the work area until laundering is required.

OSHA also insists employees remove any contaminated clothing before leaving a work area, i.e., before they may enter designated lunchrooms or break rooms. A work area is generally considered to be an area where work involving occupational exposure occurs or where the contamination of surfaces is likely. The standard would not require employees to change PPE when traveling, for example, from one hospital laboratory area to another, provided the connecting hallway is also considered to be a work area. However, OSHA would consider the following scenario to be a violation: "An employee wearing contaminated gloves exits from a pathology laboratory to use a public telephone located in a public hallway of the hospital. Under such circumstances, it can be reasonably anticipated that another employee, without benefit of gloves or knowledge of the potential surface contamination, could use the phone and unwittingly become contaminated."

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: Newborn Screens: Why and How? Part I
• Ask the Expert!: An OSHA consultant addresses these burning questions:
  • After a patient has a bone scan injection (radioactive), is it safe to draw his/her blood?
  • Is there an OSHA regulation for tourniquet usage that states they can only be used once on each patient and then must be discarded?
• Phlebotomy in the News: a synopsis of articles on phlebotomy and phlebotomists who made Internet headlines in December including these stories:
  
  • Former Phlebotomist Appointed as Judge
• According to the Standards: Nursing Home Identification
• Tip of the Month: Wanted!
• On a Personal Note: A nearsighted decision made over 30 years ago seems to have been farsighted after all.. (Now accessible from our home page!)
• 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: Greasing up the heel?

Question: I heard recently that some people use petroleum jelly to smear on a baby’s foot to prevent the blood from running away while collecting. Have you heard of this?

Response: Yikes! If blood running off the foot is a problem, then the foot isn't positioned properly. One should position the puncture site fully downward, at its lowest point relative to gravity, so that the blood doesn't have anywhere to run except in the collection tube. The concern with coating the area with petroleum is that it will interfere with the results. If this technique is to be used, a thorough study of its impact on test results should be conducted in a double-blind study using the appropriate controls and for all tests that might be ordered on specimens collected in this manner. It's easier just to position the foot properly.
     This classifies as "homemade phlebotomy," i.e., one of those things people make up because it sounds good or seems right, but that you'll never find in a textbook or the standards. I tend to discourage such home-spun techniques.

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.

 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 "Accurate Results Begin With Me!^® t-shirt. The exercise will conclude with a review of the selected submissions and a discussion of the standards pertinent to the case study.

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.

Most of those who responded to November's What Would You Do? admit to having encountered such demanding patients. Over half stated that they would request permission from the patient to look elsewhere for a safer vein. Twenty percent of those responding provided the answer we were looking for, and the one required by the CLSI standards: they would absolutely not draw from the basilic without at least looking somewhere else. However, the most accurate and succinct came from Sherry in Missouri:

"I would inform the patient, that as the phlebotomist it is my responsiblity to search both arms and find the best vein to perform the venipuncture on.  I would also indicate the particular vein they wish to be drawn from is not usually the best or first choice.  If the patient had a better vein, I would use it, unless the patient still refused, then I would consult with a supervisor and follow their directions. Most patients will concede on issues like this if you explain to them your reasoning for what you are doing.  You need to treat the patient with respect for their wishes when possible and explain when not possible why you cannot follow their wishes."

For her accurate and well-written response, Sherry will be receiving a free "Accurate Results Begin With Me!^® t-shirt. Congratulations, Sherry.

Typical of other appropriate responses include this one:

"Ask them if I could look for other locations such as the backs of hands, or their other arm. If the patient is has been sufficiently been put at ease I generally have no trouble getting them to let me take a look."

Ten percent of the responses said they'd seek physician permission. Ten percent would defer the draw to another phlebotomist. Some responses, however, give the patient too much authority. In fact, one third of respondents admitted that they'd honor the patient's request. This approach could be problematic from a risk management standpoint.

According to the CLSI standards, the basilic vein should only be considered after the availability of the safer medial and cephalic veins in both arms has been ruled out. Although placating the patient may be considered good customer service, it can also be considered performing beneath the standard of care. Should there be an injury, the patient's attorney could effectively argue that the patient didn't possess the knowledge of the anatomy of the antecubital area required to be allowed to select the vein. That knowledge, and the judgment based upon it, resides in the person trained to draw blood specimens.

Some respondents suggested that those skilled in venipunctures can prevent nerve injury when accessing the antecubital area by being "careful." However, that approach is problematic as well. Nerves lie in close proximity to the basilic vein, and can pass over the vein, just beneath the surface of the skin. No matter how cautious one may be, it's impossible to avoid the nerve since nerves cannot be palpated. The only sure-fire way to avoid the nerve is to avoid the vein.

Featured Product: Skin Punctures & Newborn Screens

In February, the Center for Phlebotomy Education, Inc. will release its long-awaited Skin Punctures & Newborn Screens training video. With stunning graphic animation that shows the proper location for fingersticks, simulates the affect of platelet clumping on specimen quality, and illustrates other key concepts, Skin Punctures & Newborn Screens demonstrates the proper procedure for performing fingerstick and heelsticks according to the CLSI standards.                  “We’ve spared no expense in time or talent to make this video the most comprehensive and accurate ever produced,” says the Center’s director Dennis J. Ernst MT(ASCP). “The degree of difficulty in developing a video of this nature is incredible, but we filmed every scene until it was perfect. Compromising accuracy and quality for the sake of expediency is just not an option with us.” Filmed in hospital nurseries and outpatient laboratories in Indiana and Kentucky, the video includes online access to CE questions for in-house continuing education as well as an option for submitting completed exams for P.A.C.E. credit. Until February 1, 2008, the Center is pre-selling this video at a $50 discount. The estimated release date is February 15. To order Skin Punctures & Newborn Screens at the discounted pre-release price or for more information, visit www.phlebotomy.com/Videos.html.

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