Fingersticks on Mastectomy Patients

Is it acceptable to perform fingersticks on the same side as a mastectomy? Is it acceptable to perform venipunctures on mastectomy patients if the patient gave permission? Answers to these commonly asked questions have their roots in the CLSI standards. The rule against drawing from the same side of a prior mastectomy is hard and fast: such draws require physician's permission. The risk is that the body's ability to fight an infection in the affected limb is compromised because of lymph node removal during mastectomy. Trauma and/or infection to the affected side can result in long-term lymphedema, which can lead to an attorney's three favorite words: pain and suffering.

Some argue that mastectomies are done with less removal of lymph nodes today than in the past, so there is less likelihood of complications from a venipuncture. That's true. The problem is that some mastectomies are still radical. It depends on the surgeon and the extent of the metastasis. How is the person who is about to draw blood from a mastectomy patient supposed to know?

It's not prudent for the phlebotomist to assume lymph nodes have been preserved. The standard for venipunctures published by the Clinical and Laboratory Standards Institute (CLSI), document H3, states physician's permission must be obtained before drawing on the same side of the mastectomy. The physician is in the best position to know the extent of lymph node removal, not the phlebotomist.

Because this rule is so prevalent in the literature, if a patient develops complications and seeks compensation, the facility doesn't have much of a legal leg to stand on. Even if the patient gives permission—verbal or in writing—it may not exonerate the facility should complications develop. If the patient provides permission, then sues for pain and suffering, her attorney can effectively argue that the patient was not aware of the risks involved, and was not in a position to give informed consent. Signed waivers may not be bullet proof.

Without a thorough knowledge of the standards, it's difficult to know the risk. Make sure you know the standards, and operate within them and according to your procedure manual at all times.

DenLine^® Introduces New Lab Coat

DenLine^® Uniforms, Inc., (Quincy, IL) introduced a new style of lab coat ideal for specimen collection and processing personnel. The DL176 Protective gown was introduced last month at the Clinical Laboratory Management Association (CLMA) conference and exhibition in Houston, Texas. Made of DenLine’s Protection Plus^® splash & spray resistant fabric, the gown offers higher protection and comfort when compared with traditional front opening coats and meet OSHA’s Bloodborne Pathogens Standard requirements.

Features of the gown include: One-piece seamless front provides complete frontal protection from the neck to below knees, also over top of legs when seated (no separation). Hidden side seam pockets prevent blood and OPIM from splashing into pockets (as with patch pockets). Tapered Sleeves eliminate rolled cuffs that catch on things. When overgloved, the spun woven polyester cuffs protect the forearm. Full cut unisex design provides improved air circulation to upper body by allowing air past the hips from below.

The gown is available in 41" length (pictured), sizes XS through 3XL, and come in White and Royal. For Information, contact Dennis Adams, DenLine Uniforms, Quincy, IL (800-336-5463).

Visit denline.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 8th year of publication, are reading about this month:

• Feature Article: Recognizing Phlebotomists During Lab Week
• Feature Article: If Tubes Could Talk, Part I: Interview with a Blue Top
• Ask the Safety Lady: OSHA consultant addresses these burning questions:
• I am beginning to notice a rash on my hands from using latex gloves. What causes this and what options do I have?
• The rate of nosocomial (hospital-acquired) infections has risen in our facility. There is a lot of finger pointing and the phlebotomy team is taking the brunt of it. What can we say or do?
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in March, including these stories:
  • Phlebotomist Sues Hospital Over Race Discrimination
  • College Recruits Phlebotomy Students with Pigs' Feet
• According to the Standards: ammonia inhalants
• Tip of the Month: Recipe for a Phlebotomist
• On a Personal Note: Have you ever been to that Big Fat Greek Home Improvement Store?

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: Butterfly Overuse

Question: What are your thoughts on the high usage of tube holders with butterflies by specimen collection personnel who are required to draw blood? I keep thinking that if you have to use the butterfly, it's because the vein is too small/fragile for a tube-holder draw, so why would you put a vacuum at the end of the butterfly.

Response: Butterfly over-usage is a problem everywhere. I agree with you that they should be reserved for fragile veins and used with a syringe. If a tube holder can be used, there's no need for the butterfly in most cases. CLSI isn't going to stick their neck out and recommend when butterflies are appropriate and when they're not. They prefer safer territory and leave it up to the facilities to enforce conservative use of these devices.

I suspect your staff overuses them for the same reason everyone else does: they're very maneuverable, patients request them, and they require less of a steady hand to maintain placement during the draw. However, they are also associated with a high rate of accidental needlesticks (EPINet data). Perhaps you might recruit your infection control nurse to launch a campaign on appropriate use of butterflies, but you will still have to provide butterflies for those difficult geriatrics and pediatrics. That means they'll still be stocked and available for overuse. There's no way around this dilemma, I'm afraid. But if you could get the point across about butterflies and accidental needlesticks (no pun intended), you might be able to induce a behavioral change. I hope this helps.

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.

Specimen Collection Safety: Sharps Disposal Units

Do you have a sharps disposal unit available at the point of use? Any pause in disposing a contaminated needle incorporates a dangerous delay into your routine. Sharps containers should be available at the point of use so that there is little or no delay from when the needle is removed from the patient until it is permanently disposed of. Healthcare workers who draw blood in long-term care facilities or patients' homes have a wide variety of sharps containers to choose from that can be taken from home to home for use at the patient's side.

Featured Product: Lab Week Items

The Center for Phlebotomy Education offers polos, travel mugs, buttons, Sharpie® markers, and notepads, all imprinted with every laboratorian's mantra: Accurate Results Begin With Me!® Ideal as Lab Week gifts for phlebotomists and all laboratory testing personnel, the logo is a colorful starburst of collection tubes imprinted on all products, and embroidered on white 100% cotton polo shirts.

"This design proudly expresses the important contribution phlebotomists and testing personnel make to accurate test results and, hence, quality patient care," says Center Director, Dennis J. Ernst MT(ASCP). "It expresses pride in performance and serves as a reminder to patients and others of one's dedication to specimens of uncompromised quality and test results of pinpoint accuracy." The products are an addition to the Center's Accurate Results Begin With Me!® product line that has been recognizing phlebotomists and certified phlebotomists as important members of the healthcare team since 2002. You can browse these products at www.phlebotomy.com/AccurateResults.html