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Phlebotomy Today

©2019 Center for Phlebotomy Education, Inc. All rights reserved.                                   

February, 2019

Protecting Yourself from Coughing Patients

SneezeYou're bent over with a needle in your patient's arm and he suddenly has a coughing fit, filling the air you breathe with viruses and bacteria. You hold your breath as long as you can to avoid breathing them in, but you can't complete the draw in time. Now it's up to your immune system.

It's flu season. The risk of acquiring any of the myriad respiratory infections that fester within the patient's you'll encounter is real and significant. Influenza-related illness and complications lead to more than 20,000 hospitalizations and 36,000 deaths each year. Some of those patients will come to your drawing area–potentially infecting everyone they come into contact with including you and other patients. A pandemic flu could lead to more than 700,000 hospitalizations and 42 million outpatient visits. This translates into healthcare costs of up to $166 billion.

The Centers for Disease Control and Prevention (CDC) recommends signage at healthcare facility reception areas asking coughing patients to wear a mask or cover their mouth with tissues when they cough. The CDC also requires healthcare facilities to provide a waste can to discard masks and tissues as well as hand sanitizers so that patients may disinfect their hands after each cough. With the threat of pandemic flu growing, taking steps to promote respiratory hygiene is more important than ever. Visually and verbally reminding coughing, sneezing and wheezing patients and visitors of these simple precautions are now a required obligation for healthcare providers, thanks to CDC's Respiratory Hygiene/Cough Etiquette Guidelines.Cdc_cough

A patient continues to hack and wheeze, and can't seem to consistently cover his cough despite signage and repeated warnings from the receptionist. What should you do to protect yourself? Wear a mask? If so, what kind of mask? Coughing, sneezing patients might only have a common cold; but they could also have a disease as ominous as TB or pandemic flu. So, it is paramount that healthcare professionals who encounter such patients require them to practice respiratory hygiene by either donning a surgical mask or covering their face with a tissue. The healthcare professional should also wear a surgical mask; N-95 masks are only necessary when working in close proximity with TB or pandemic flu patients (the government will issue a pandemic flu warning if it reaches the US).

If not required by your employer, consider getting the flu vaccine annually. Although less than half of health care workers actually get it, the CDC also advises employers to offer free flu vaccine in the workplace to all eligible personnel (including students) during all shifts.

Preventing the spread of respiratory infections requires teamwork between healthcare workers and patients. After you get your flu vaccine this year, remember your role in breaking the chain of respiratory infections: recognize and require coughing patients to wear masks or cover their coughs, and wear a mask yourself when working directly with infected patients. 


Is Your Venipuncture Training Video Up-To-Date?


OSHA Increases Fines

Dollar sigh and up graphAre you or your phlebotomists drawing blood without gloves or ripping off the tip of the glove for better palpation? Are you/they failing to activate the safety feature on phlebotomy needles, or using needles or lancets without any safety feature at all? Such safety infractions are referred to by OSHA as "willful violations," i.e., the employee knowingly violated a regulation, and it can cost your employer a pretty penny. An employee who designates by signature that he/she has read the facility's policy, but then disregards it will be deemed to have willfully violated the policy. The fines have always been hefty, but it's even more so now.

Due to inflation, OSHA can now levy a fine on your facility for up to $132,598 (up from $124,709), and that's for each occurrence. If an inspector decides to look inside your sharps container and finds 15 non-safety devices, that comes to almost $2 million in fines, plus a citation. Violations categorized as merely "serious" go up to $13,260 per occurrence, up from $12,934.

The hike is the first increase in four years, and is due to adjustments for inflation. 

More information.


Shop Talk: Shanise Keith

Our subscribers have a collective expertise in phlebotomy that exists nowhere else on the planet. This column is your opportunity to share what you know and how you feel about your skill, the profession, or whatever you want to share about the nature of your work. Tips, rants, joyful experiences are all welcome. If you want to submit an article for consideration, send your 400-700-word article to us at Editor@phlebotomy.com. We reserve the right to edit the document for grammar, punctuation, and clarity, but those that don't require much "fixing" will be given top consideration. Go for it!

Shanise Keith

One of the most difficult things for a new phlebotomist to learn is how to handle the pain, fear, and complications with patients that are bound to arise. A phlebotomist's job sometimes inflicts unavoidable pain for a medical purpose. It's the nature of the procedure. I have many students who are petrified of causing discomfort, pain from drawing blood, and the potential to even injure the patient is terrifying to the new phlebotomist. Such fear makes it difficult for them to be effective, and can cause a venipuncture to be more painful than it should be just because of their paranoia. While worrying about our patients' wellbeing is very important, letting fear keep us from doing what is necessary is an obstacle to success, a detriment to the procedure, and a disservice to the patient.

So how can we be sure we're not going to hurt our patient? Unfortunately, we can't. At least some pain is going to be unavoidable during most of our draws. However, there are ways to minimize it:

  • Avoid high risk veins such as the basilic vein, wrist veins, or veins in the fingers and thumb;
  • Pull firmly to tighten the skin so the needle enters the skin easier;
  • Avoid digging or redirecting improperly;
  • Stop the draw if the patient begins to form a hematoma;
  • Tell your patient you need to know if the draw starts to hurt, or if they wish for you to stop;
  • Insert the needle smoothly and fairly quick. The faster the needle gets through the skin, the less your patient will be in pain. Be careful not to go too fast, however.

By using these tactics, you can eliminate most of the pain associated with a venipuncture. Perform your venipunctures carefully, and confidently, and listen to your patient. Most of the time as soon as the needle has passed through the skin the pain goes away, or is at least is minimized. As you become more comfortable with your sticks you may even hear those magic words that are music to every phlebotomist's ears: "I didn't even feel that!".

Shanise Keith has been an instructor of phlebotomy at Mountainland Technical College for eight years and has taught hundreds of students. She has worked in various healthcare professions spanning more than ten years including an emergency department EMT-A and a forensic phlebotomist. She has a love of service. Her favorite thing about her teaching job is seeing the progression of her students to proficiency, and watching them succeed as phlebotomists all over the nation.


22 Months of In-house CEs

Do you struggle every month to find good material to put in front of your students or specimen collection staff? Those days are over.

We've just packaged 22 months of our popular Abbreviated Teaching Modules (ATMs) in one download, and priced it well under what you've budgeted for continuing education this year.

Our ATMs are short 1-2-page articles on a wide variety of phlebotomy topics your collection staff should know. Simply distribute one exercise to your staff each month, collect their answers to the accompanying quiz, grade it, file it, and get on with your day.

The 22-module set is downloaded immediately after your online purchase as zipped PDFs with answer keys for each exercise. That's almost two years of monthly in-house CE exercises for you to administer to your staff at a fraction of what you've been paying from other sources. Titles include:

  • ATM_CompleteSetThe Order of Draw
  • Hematoma Prevention
  • Tourniquet Time
  • Needlestick Prevention
  • Hemolysis
  • Patient Identification
  • Acceptable Sites for Venipuncture
  • Blood Cultures Done Right
  • Hemoconcentration: What is it?
  • The Aggressive Patient
  • Infants and Toddlers in the Healthcare Environment
  • Communicating With Elderly Patients
  • Give Your Patients Their Personal Space
  • Tips for Successful Capillary Collection
  • Non-verbal Communication: What Message Are You Projecting?
  • Phlebotomist's Guide to PICC Lines, Central Catheters, and Imbedded Ports
  • Therapeutic Drug Monitoring
  • Customer Service Excellence
  • Bloodborne Pathogens Review
  • Are You a Pathogen Parade?
  • Drawing From Young Children

Stop scouring the Internet for mediocre resources just to meet your monthly staff requirement. All ATMs are highly researched and reflect industry standards and guidelines. 

Sample ATM and more information.


Advice From the OSHA Expert

Dan the Lab Safety Man

Twenty years ago, I worked with people who didn't wear gloves when drawing blood. Today that's not an option. It should be non-negotiable that gloves are always worn as personal protective equipment. For phlebotomists in the U.S., glove use during vascular access procedures is mandated by OSHA's Bloodborne Pathogens Standard. Given the potential for an occupational exposure, it is obviously the best practice to don gloves. But how do you know which gloves are right for you?

The three most common types of material used in the manufacture of medical examination gloves are vinyl, latex, and nitrile. Vinyl gloves are used for many tasks, from medical exams to food handling. They are my least favorite type of glove for phlebotomists for many reasons. While they are typically not associated with allergic reactions, many brands fit loosely and provide the thinnest layer of protection. Because vinyl gloves are not very pliable, they also rip easily. Compared to latex and nitrile, powdered and powder-free vinyl gloves are the least durable when tested. In my experience, these factors make it difficult to provide your patient with the smoothest and safest blood collection experience.

Latex gloves are becoming less commonly used in the medical field because so many people – patients and healthcare professionals alike – have developed allergies to latex. Latex provides a stronger barrier than vinyl, and fits nicely on your hands. Several types of latex gloves are available on the market.

Another glove material is nitrile, a type of rubber that differs from latex, enough so that few people encounter nitrile allergies. Nitrile gloves offer the strongest protection, yet they are thin enough to provide a phlebotomist with the tactile sensitivity needed to palpate a vein. They are also the gloves recommended when handling chemicals such as acids, which may be used to prepare 24-hour urine collection containers.

On average, these glove types may last three to five years on the shelf unopened, given proper storage conditions. Not all glove manufacturers mark their packages with expiration dates, so you should note the receiving date on the box. Gloves should be stored in a cool, dry area with no direct exposure to sunlight or fluorescent lighting (which can emit some UV rays).

Regardless of the type of glove selected, to minimize defects created during use it's important to consider other variables, such as the use of hand creams and fingernail length. Be sure to check with the glove manufacturer before using personal hand creams when wearing gloves. Some ingredients in hand lotions can break down the glove barrier or even start a reaction that can cause allergy symptoms in some individuals. Because long fingernails can also compromise glove integrity, it's recommended that phlebotomists keep their fingernails short.

No matter what type of glove your employer provides, be sure you store them appropriately and use them consistently. After all, personal protective equipment and safety go together, hand in glove.

You can contact Dan Scungio, "Dan the Lab Safety Man" at samaritan@cox.net.


From the Editor's Desk


In our profession, we'd be lost without tourniquets. It's a simple device that costs mere pennies, but without them patient care comes to a screeching halt. Without tourniquets, we'd fail to draw blood on most of our patients, depriving physicians of critical data by which to diagnose, medicate and manage their patients. No tourniquet, no blood test. 

Over the years, I've written plenty of columns and articles about tourniquets. They're an essential tool of the trade. You wouldn't think something as simple as a tourniquet would have many precautions, but it does. It requires its user to be well aware of a multitude of risks and precautions, any one of which, if neglected, can cause problems that range from mild discomfort to catastrophic consequences. For example:

  • They should be applied over clothing when possible to prevent the patient's skin from being pinched;
  • Leaving them on for more than one minute can significantly alter the blood in the limb before it's even drawn in ways that no longer represent the patient's health status;
  • Up to 25 percent of tourniquets are contaminated with MRSA after just one use;
  • Latex-sensitive patients can go into anaphylactic shock if a latex tourniquet is applied for phlebotomy;
  • Failure to use a tourniquet can lead to improper vein selection, which can precipitate an injury to nerves and arteries that lead to permanently disabling complications.
Click to enlarge

Given all that, why is it tourniquets do not come with manufacturer's instructions? I bought a plastic water pitcher not long ago that included a page of instructions that including these helpful tips *(click on image at right to enlarge):: "Fill with beverage and serve," "Do not overfill," and "Place on surface away from the edge to avoid drops and spills." Seriously, if a plastic pitcher needs instructions, wouldn't a tourniquet that constricts a patient's blood flow need some basic instructions for use?

Instead, it's up to those who train healthcare workers to articulate all that must be known about proper tourniquet use. If it were up to me, I'd not only include the precautions I listed above, but I'd add the following:

  • Do not launch across the room at coworkers; 
  • Not to be used as a slingshot;
  • Not intended to be used with gauze as a substitute for a bandage;
  • Do not allow patients or their children to play with the tourniquet;
  • Using two tourniquets does not double the constriction;
  • Do not apply one tourniquet at the wrist and one above the elbow.
  • Do not use for months on end;
  • Do not eat.

Okay, I might be getting a little silly here, so let's get serious. There's one more precaution that we have to discuss: forgetting to remove the tourniquet. . Forgotten tourniquets are a major risk in healthcare. When inadvertently left behind, the continuous constriction of the limb can lead to serious complications including nerve injury, tissue necrosis, deep-vein thrombosis, embolism, compartment syndrome, amputation and death. 

In 2017, the California Hospital Patient Safety Organization (CHPSO) issued a report citing the complications of forgotten tourniquets and preventative measures. One of them is the use of brightly colored tourniquets that are extra long to enhance visibility. In the June 2018 issue of Phlebotomy Today, I extrapolated from published data that healthcare professionals forget tourniquets on nearly 3,000 patients every year.   

Now we have one more weapon in our arsenal against the forgotten tourniquet. Recently our friends at MarketLab designed a sticker phlebotomists and other healthcare professionals can place on a patient's clothing prior to the draw that serves as a visible reminder a tourniquet is in place. Printed in highly visible caution-yellow, the label reads "Forgetting Something?" and includes instructions to the patient should the sticker also be left behind.

Sometimes the simplest solutions are the best. Given the magnitude of the consequences that can come from leaving a tourniquet in place, applying this simple reminder to an inpatient's gown or outpatient's clothing is a simple, cheap, and effective risk management tool. Not only can this help ensure phlebotomists retrieve their tourniquet before leaving the patient, but if every sticker is removed before leaving the patient and then counted upon arrival back in the laboratory, the number of stickers retrieved should equal the number of patients drawn. If not, returning to every patient for a tourniquet check can prevent an incident from becoming a serious problem.

Unlike tourniquets and plastic pitchers, MarketLab's tourniquet reminder doesn't require instructions for use. Simply apply it before the draw and remove it after; simple as that.

Just don't eat it.



Dennis J. Ernst, editor


What Should We Do?: Marking the skin

Dear Center for Phlebotomy Education:

I am the Phlebotomy team leader and would like to inquire about the usage of surgical skin markers for use in phlebotomy. Specifically, to help assist with drawing accuracy by marking on the skin where you find the vein. We're concerned about the potential for cross contamination from one patient to the other. I want to update our procedures with the latest thinking on this. What should we do?

Our Response:

AlcoholPrepCornerSM-1We understand the difficulty with some patients to relocate the vein once we've found it. We take our time palpating and palpating, and finally locate what we think is a vein. But the tourniquet has been on so long we have to release it to prevent hemoconcentration from corrupting the sample. So we let two minutes pass as the standards require, reapply the tourniquet and palpate all over again, trying desperately to find the vein again and insert the needle within the one-minute window. It's frustrating.

We realize how tempting it is to mark the skin, making it easier to relocate the vein after we cleanse the site, but we're not sure marking up the patient is the best strategy. Surgical pens are for surgery, not phlebotomy. That said, the standards do not prohibit it, and we've yet to see anything in the literature about transmitting infections, although it's plausible. Nor are we aware of any facility that has adapted surgical markers for phlebotomy. So we wonder if it's really necessary. Because of these reservations, we advocate locating skin markers and making note to where the veins lie in relation to them instead of marking up the patient. An alcohol prep can also be used as a "pointer" after locating the vein. After locating the vein, cleanse the site and place the pad on the skin with the corner pointing towards where the vein was located.

Remember, surgical sites are prepped extensively with strong antimicrobial solutions after the site is marked. Not so for venipunctures, which are not considered sterile procedures (unless blood cultures are being drawn). Fungus and yeast, which may not be affected by an alcohol prep, could be transferred. So we have more questions than answers for you about this, and for that reason we're hesitant to advocate the use of skin markers for phlebotomy.

Got a challenging phlebotomy situation or work-related question? Email us your submission at WSWDpanel@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)  


Test Talk: Cortisol

A new column that features a different laboratory test each month, what it measures, why physicians order it, and any collection handling restrictions and requirements that must be met.

BloodTestTextGraphicCortisol is a hormone produced and secreted by the adrenal glands, which sit atop each kidney.  It has many functions, but mostly plays a role in metabolizing proteins, lipids, and carbohydrates. They hypothalamus and pituitary gland in your brain tells the adrenal glands when to release cortisol. 

Normally, the level of cortisol in the blood peaks early in the morning, then declining throughout the day. It is at its lowest level about midnight. This is referred to as a "diurnal variation."  Cortisol is one of the few tests a physician orders that rises and falls according to the time of day, which is why phlebotomists should draw cortisols at the time the physician requests. Usually 8 a.m. Cortisols drawn randomly are not of much diagnostic use.

This gets a little complicated, but stay with it. When the hypothalamus senses the patient's blood cortisol level is falling too low, it secretes corticotropin-releasing hormone (CRH), which signals the pituitary gland to produce ACTH (adrenocorticotropic hormone). ACTH stimulates the adrenal glands to produce and release cortisol.

So when physicians order a cortisol level, it's to diagnose adrenal insufficiency (Addison's disease). It can also be used to help diagnose Cushing syndrome, a condition associated with excess cortisol. When an abnormal level is reported, the physician will likely order additional testing to determine exactly why it is abnormal, such as CRH and/or ACTH, which would identify the status of the hypothalamus and pituitary gland.

Cortisols can be tested on serum or heparinized plasma. Tubes should be centrifuged within 2 hours as a general practice, but cortisols drawn into heparin tubes are stable at room temperatures for six hours uncentrifuged.(1) When drawn into serum tubes, stability is up to 48 hours.(1)  After centrifugation, serum or heparinized samples have a stability of 48 hours.(2) 


  1. CLSI. Procedures for the Handling and Processing of Blood Specimens for Common Laboratory Tests; Approved Guideline—Fourth Edition. H18-A4. Clinical and Laboratory Standards Institute. Document H18-A4 Wayne, Pennsylvania 2010
  2. Wu A. Tietz Clinical Guide to Laboratory Tests---Fourth Edition. Elsevier. St. Louis, Missouri. 2006.


The Empowered Healthcare ManagerEmpoweredManagerWelcomeScreenShot_500w

Every month we run an excerpt from our editor's popular blog, The Empowered Healthcare Manager. 

It's Not the Baggage...

Rhonda was a phlebotomist with baggage. So was Brittany.  

Rhonda's parents always minimized her accomplishments, and pointed out her flaws. She's been pointing out everyone else's flaws ever since. Day after day, she belittled her coworkers, considered policies to be suggestions, and found fault with everyone, patients and managers included. Her incessant gossip and bullying caused good workers to quit. Deep down she was unhappy.

Brittany survived the worst drunk driving accident in U.S. history. Twenty-seven of her friends were killed in Carrollton, Kentucky when a drunk crossed the expressway and struck the gas tank of her church bus. Few of her coworkers ever knew. They just thought she was quiet. Day after day, she pushed through her shift, reserved, withdrawn, quiet, and a phenomenal employee. She didn't participate much in idle chatter, but engaged each patient with polished professionalism. She had very few recollects, rarely contaminated a blood culture, and never had a complaint lodged against her. Deep down, she was unhappy.

Brittany suppressed her baggage before her shift and dealt with it on her own time. Rhonda let it play out 24/7. 

Your staff has baggage. Some can handle it, some can't. As empowered healthcare managers, it's not ours to judge whose baggage is heavier, nor to remove it.  It's ours to help them keep it from interfering with the reason we hired them.  

It's not always the weight of the baggage, but the way it's carried.


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