Top Ten Ways to Injure a Patient, Part 2
Last month we began our countdown of the top ten ways to injure a patient. Could your technique stand up to scrutiny should a patient be injured and seek compensation? Could your lab's procedure manual? The answers to these and other questions will determine your potential, and that of your facility, to inflict a phlebotomy-related injury that could lead to litigation. But avoiding lawsuits should not be the driving force to ensure standards are met; preventing injury should. No injury, no litigation.
Let's continue our countdown with #7.
7. Turn your back on the patient
Statistics tell us that up to five percent of patients will pass out during or immediately following a venipuncture. The problem is they don't come with a sign on their forehead proclaiming "I will pass out." Phlebotomists and other healthcare professionals with blood collection responsibilities who are routinely vigilant for the signs of an imminent loss of consciousness won't allow themselves to turn their back on patients before releasing them from their care. Such signs include pallor, perspiration, hyperventilation, and anxiety, and may be clues that the patient is going down. Another sign is when a patient goes from talkative to silent. Should a legal proceeding unfold, the standard to which you will be held instructs all collectors to be prepared to react. Being inattentive by turning your back to the patient, or leaving the immediate area prematurely, is not consistent with the required vigilance, and is one of the most common ways healthcare professionals who draw blood and their employers can be held responsible for injuries sustained during a venipuncture procedure.
6. Draw from an artery
Not only is arterial blood and venous blood different in terms of the concentration of some analytes, but drawing from an artery is riskier to the patient. Besides the risk of nerve injury, arterial punctures are slower to seal and much more likely to lead to massive hematoma formation if adequate pressure is not applied. That's because the pressure within an artery is significantly higher than that within a vein. Therefore, post-puncture care requires far more caution, attention, and time when an artery has been pierced. According to the standards, arterial punctures should not be considered as an alternative to venipuncture in difficult draws. It increases the risk of complications, and litigation, significantly.
5. Bandage in a hurry
This is the step of the venipuncture procedure that too many phlebotomists rush. Keep in mind that a bandage is not a substitute for pressure. The standards insist that we don't bandage a patient unless we are assured stasis is complete. That means we need to slow down, remove the gauze, and perform a two-point check for bleeding. The first observation is for superficial bleeding from the skin; the second is for hematoma formation. Sometimes the skin seals before the puncture in the vein closes, resulting in a rapidly forming hematoma. A quick peek under the gauze for superficial bleeding is never sufficient. After lifting the gauze, observe the site for five to ten seconds to see what happens. Look for the raising or mounding of tissue, which indicates the vein is leaking into the tissue. Merely checking for visible blood coming from the site fails to protect the patient from a hematoma that can not only leave an unsightly bruise, but exerts pressure on the nerves in the area. Such "compression nerve injuries" often lead to Complex Regional Pain Syndrome, which can be permanently disabling.
Next month, we'll conclude our countdown in Part 3 of Top Ten Ways to Injure a Patient.
Product Spotlight: Lab Week giveaways
National Medical Laboratory Professionals Week is April 21-27, 2019. Do those who draw blood samples in your facility feel appreciated? Let us help you celebrate those who collect the samples that keep your lab up and running. Phlebotomy instructors have found their students always appreciate receiving these to help them learn and as a way to celebrate their upcoming career as an important member of the laboratory team.
If you're looking for giveaways, consider any of our Order of Draw reminders. Pens, badge tags, and pocket-size Tips On Specimen Collection cards are tasteful graphic reminders of one of the most important aspects of drawing blood samples.
- Put an Order of Draw Pen in every pocket so the correct order in which tubes must be filled is also right at their fingertips.
- The Phlebotomy Tips card is a pocket reminder of key concepts in phlebotomy including the order of draw, and tips on specimen collection. The reverse shows the anatomy of the antecubital area featuring veins, arteries, and nerves.
- Our Order of Draw Badge Tags attach to your staff's or students' ID clip or lanyard so the order of draw is always in front of them.
- The Lab Draw Answer Book is the gift that keeps on giving ANSWERS. Almost 400 to be exact. Put this in the hands of your top performers and mentors. If you have an entire staff of top performers, quantity discounts are available.
We've been helping you educate for over 20 years. Now let us help you celebrate.
What Should We Do?: Phlebotomists with HIV
Dear Center for Phlebotomy Education:
I run a phlebotomy school and have a student who is HIV-positive. I know there are HIPAA rules that prevent the sharing of health information with those who don't need to know, but I'm not sure it applies to schools. Am I obligated to make sure the other students are aware of her HIV status? The other question is whether or not this person would be employable in phlebotomy. I don't want for her to go through all this training and expense only to be someone nobody would hire. When we are aware of a trainee's HIV status, what should we do?
There's a lot to unpack here, but we're glad you asked.
Generally, student health information is not subject to HIPAA regulations. However, it may be covered under FERPA regulations (Family Educational Rights and Privacy Act). The U.S. Department of Health and the Department of Education have an informative document that distinguishes between the two. Regardless of the applicable regulation, it is our opinion the privacy of the health information of all students should be respected and kept confidential.
There's a far greater risk a student will become infected from an HIV+ patient than a patient become infected by an HIV+ phlebotomist. So we don't think the risk should cause any concern. HIV is far less transmissible than Hep C (0.3% versus 30%). In fact, most patients with Hep C don't even know they have it since it can be dormant for decades before attacking the liver. That's why it's important for you to drive home standard precautions and make sure your students treat every patient as potentially infectious.
Your question about whether or not an HIV+ student is employable in your area is a far different question. Be aware there are a lot of misperceptions about this. You should call several of the larger employers in your area and survey them to see if there's any hesitance to hire HIV+ phlebotomists. There shouldn't be, but you should check.
Line Draw Device Prevents 30,000 Venipunctures at Centura Health
Image courtesy of Velano Vascular
According to an online article posted by Modern Healthcare, patients in the Centura Health System have been spared almost 30,000 venipunctures by having their blood drawn from their IV lines using technology designed specifically for line draws. Last July, administrators at Centura implemented PIVO, a device for drawing blood samples from patients with IVs, at Centura Littleton Hospital as a precursor to rolling out the procedure system-wide .The elimination of nearly 30,000 venipunctures took place over a 6-month period in three of Centura's 17 hospitals.
PIVO, developed by Velano Vascular (San Francisco, CA), consists of a small-diameter canula that the phlebotomist or nurse inserts into the existing VAD and extends further into the vein, past the tip of the indwelling peripheral IV catheter where hemolysis typically occurs. The user then withdraws as much blood as is needed and retracts and discards the device. The vascular access device (VAD) retains its primary purpose, which is to continue infusing fluids.
According to an article in VentureBeat, Velano Vascular's CEO says PIVO "turns an existing IV into a two-way conduit for drawing high quality blood samples." Without PIVO, samples drawn from VADs are widely known to be hemolyzed and rejected by the laboratory. As a result, patients have to be redrawn by venipuncture, causing significant delays in their test results. Faster results are not the only benefit of performing line draws with a device designed for the purpose. Patients at Centura's Littleton, Colorado hospital are recording higher satisfaction scores than before the device was adopted. The Modern Healthcare article reports that answers to a Press Ganey survey question assessing staff compassion administered before and after PIVO implementation showed an impressive 13.4-point increase (71.4 to 84.8).
Since PIVO is a needleless blood collection system, Centura employees using the device reported no blood draw-related needlestick injuries during the same period, marking an improvement in employee safety. Centura plans on deploying PIVO in all 17 of its hospitals by the end of this year.
Velano Vascular was named one of 2019's Ten Most Innovative Companies in Biotech by Fast Company for "making blood draws less painful, and possible without needles."
[Editor's note: Phlebotomy Today first reported on PIVO in the May, 2017 issue of Phlebotomy Today-STAT!.]
Global Preanalytics Summit Open for Registration
The Global Summit on Best Practices in Preanalytics will be held at The Mirage Hotel and Casino in Las Vegas on October 8-10, 2019. This conference is the best educational opportunity for phlebotomy educators, laboratory directors, and phlebotomists. Over the course of three days, experts from all over the country will teach attendees about everything from how to "Six Sigma Your Lab" to "The Small Things You Didn't Know Could Affect Your Sample."
Whether you are a phlebotomist yourself or you manage a team, this conference should not be missed. Early bird rates are available now through August 1st so take advantage of this great educational opportunity. If you have attended the Phlebotomy Supervisors Bootcamp™ or The Summit in the past, get an additional 10% off your registration. Register today at http://bit.ly/GlobalSummit2019.
What's Wrong Here?
How are your powers of observation? What's Wrong Here? is a new column testing your powers of observation. Each month, we'll post an image in which something isn't quite right. Consider it a photo-quiz for you and your coworkers to scrutinize and discuss during down time or at staff meetings. Some errors will be obvious, some will be subtle, but all will test your familiarity with the standards.
What's wrong with this picture? We guarantee something isn't as it should be. The answer will be in next month's issue.
(Click image to enlarge.)
Venipuncture DVD Widely Adopted
Basic Venipuncture, 3rd Edition has only been out since October, and it's already incorporated into hundreds of training programs around the world. As the only training DVD filmed in high-definition, current with industry standards, and closed-captioned for ADA compliance, Basic Venipuncture is the gold standard in venipuncture training videos.
Is your phlebotomy training video up to date? If it's not the 3rd edition of Basic Venipuncture from the Center for Phlebotomy Education, you're staff and students are learning how to comply with yesterday's standard. They deserve more, and so do the patients they will draw. Update your video today.
From the Editor's Desk
Everyone knows I hold phlebotomists in high regard. You are the most underappreciated professional in healthcare. That's why I created a tribute video a few years ago and posted it to our web site and YouTube channel. As we celebrate Medical Laboratory Professionals Week April 21-27, I urge you to watch it again. If you're a manager or educator, show it to your staff and students again, or for the first time.
If you're a manager, there's no better time than Lab Week to remind your staff how important they are to the laboratory's ability to run smoothly. I encourage you to set aside Tuesday of Lab Week as Phlebotomist Appreciation Day. There's no limit to what you can do to make these critical professionals feel appreciated. Some suggestions:
- Offer preferred parking for phlebotomists on their day.
- Encourage your testing personnel to take a phlebotomist to lunch as their own way to appreciate their contribution to the laboratory.
- Give them something that improves them like a gift certificate to take a phlebotomy certification exam.
- Have a pathologist or physician give an uplifting, motivational presentation or inservice on the importance of proper specimen collection to patients and their physicians.
- Introduce a "Me and My Shadow" mentoring program this month where every tech on staff is assigned to spend a day shadowing a phlebotomist, and then the phlebotomist spends a day in the life of the same tech. After one month, you'll be amazed at how well the two divisions of the laboratory work together as a team.
- Put your valued staff on display by constructing and posting a bulletin board in the hospital lobby, outpatient waiting area, cafeteria, etc., displaying photos of your phlebotomists. Title it "Phlebotomist Appreciation Day: Drawing Attention to Our Collection Team."
Only high-quality samples can produce the accurate numbers that physicians need to diagnose, medicate, and manage their patients properly; only a staff that feels appreciated will consistently provide the quality samples your lab needs to run smoothly.
If you're a phlebotomist and your employer or manager isn't the type that recognizes team members, take this to heart: while recognition is nice and makes you feel more valued, it's irrelevant to the true professional. For true professionals, satisfaction comes from within. Knowing deep down you do good and important work should fill your well with an abundance of self-satisfaction despite anyone's ambivalence about what you do. Sure, recognition feels good, but those who depend on outside sources for recognition are often disappointed. Assigning it for someone else to provide is always risky and gives some of your power away.
I urge you to embrace your vocation so that your joy doesn't depend on someone embracing it for you. Embrace the truth and be satisfied. The truth is you are indispensable to every lab and every patient. You know it and I know it. If you employer knows it and shows it, that's a bonus and a blessing not everyone will receive this month. Lucky you.
Before I sign off, this is a good month to link to our "Recipe for a Phlebotomist," a free download available on our Free Stuff page. Feel free to share this link and the PDF. Everything on our Free Stuff page is yours to distribute, so print it and post it where you work.
Dennis J. Ernst, editor
Shop Talk: Jesse Harris
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!
Phlebotomy was not my original plan for a career, but it has become one of the many hats I've worn since 1978, when I began my career in the medical field as part of an ambulance crew in the wilds of Alaska. I learned to place IV's and perform CPR while we navigated rough, snow covered logging roads or… moose trails. My phlebotomy career began in 2003 right after M.A. school. My instructor told me I had a natural talent. I went with that and haven't regretted it.
There have been so many changes in procedures since then. When I began, we had to write (a lost art) on requisitions and tubes. Now, everything is computerized, from EMRs to those nifty labels that magically appear from a printer, with all the patient information embedded - some even have the required tube for the test(s) listed right on them. The names of a variety of tests have changed. Collection and processing requirements have changed immensely. The standards and protocol regarding phlebotomy change regularly to reflect more modern thinking. But, the one thing that has not changed anywhere in the medical field, especially phlebotomy, is the importance of bedside manner.
Good bedside manner requires us to realize every patient is different, and that each day is different for every one of them. .It's a critical skill that an excellent phlebotomist uses every day with every patient. Phlebotomy is a direct, and personal interaction with a patient and one of their biggest fears---the needle. There are so many things to remember during the performance of a venipuncture, never mind through the course of our day at work. Bedside manner should always be at the top of that list.
Bedside manner can improve a patient's attitude toward a blood draw. It can also be a great thing to utilize when we are new to the field and haven't yet honed our technical skills. Most patients appreciate concern and regard for their well-being, even if the draw isn't our best one that day. Genuine apologies for a venipuncture that didn't turn out so well are received much better if we can somehow correct the situation. Bedside manner can help smooth things out.
Understanding human behavior, along with our deep-seated fear of the unknown, is critical. Regardless how many times a person has had their blood drawn, that fear is just under the surface of even the most stoic of patients. Adults can be a tough crowd. We have preconceived ideas about needles, and our experiences in the past can color our reactions. Excellent bedside manner can reduce the fear, or at the very least, temper it. Children are affected by their parents' fears and their words. Bedside manner can calm a child, and their parent.
Phlebotomists don't just stick needles in people. We use large doses of psychology during each patient interaction. We need to be technically savvy regarding our procedures. Most of us are required to know how and when to perform CPR. We must know how to react should a patient faint. We must be alert to aggression or negativity toward the procedure. We must try hard not take anything personally. Should we do something that must be remedied - bedside manner is key. It's projected in our demeanor, our facial expressions, our touch, and our words - throughout the procedure. And, we must do these things simultaneously.
As a patient, I can tell immediately if a phlebotomist is impersonal and does not care about my well-being. I'm put off by a Phlebotomist who exhibits an attitude of superiority due to their position. I expect an excellent bedside manner, and have the right to refuse any Phlebotomist should I feel uncomfortable. So do the patients we come in contact with, wherever we work.
Personally, I want to treat every patient that comes to me with the respect they are due, so that they will see my profession in a better light. When my patients come to me with the knowledge that I take very good care of them… then I have performed my job flawlessly.
Jesse Harris has experience as a paramedic, MA, CNA and phlebotomist. He currently works as a phlebotomist at Country Doctor Community Health Clinics in Seattle, Washington. In his spare time he enjoys writing and helping organizations provide elder care for the LGBT community in the Seattle area.
Test Talk: Folate
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.
Folate is a vitamin the body cannot produce. The term is often used interchangeably with folic acid, but there's a subtle difference. Folate is naturally occurring in foods; folic acid is the synthetic form of vitamin B9 found in supplements and fortified foods. Regardless, neither is produced in the body and dependent on dietary intake to perform its function.
Folate serves many purposes. It's essential for proper brain function, impacting one's mental and emotional health. It aids in developing the body's genetic material. Folate works closely with vitamin B12 to help make red blood cells and help iron work properly in the body. Therefore, folate deficiency is often suspected when patients experience cognitive changes, mental abnormalities, and other related neuropathies. Conditions that cause folate deficiencies include malnutrition, alcoholism, inflammatory bowel disease (IBD), and celiac disease. It is also suspected when a CBC reveals a low red blood cell (RBC) count and a high MCV (mean corpuscular volume), suggesting anemia with large red blood cells.
Because red blood cells store 95% of circulating folate, a RBC folate test may be ordered instead of a folate test to measure the folate level within RBCs instead of that within serum. Vitamin B12 is often ordered simultaneously with folate since their deficiencies produce similar symptoms, and the two vitamins work in concert, orchestrating some of the same functions. Because red blood cells store 95% of circulating folate, a test to measure the folate level within RBCs may be used in addition to or instead of the serum test.
Samples for folate and Vitamin B12 are typically serum samples, although RBC folates require an EDTA-preserved sample. Overnight fasting is recommended. Hemolyzed samples should not be tested. If testing will be delayed beyond 8 hours, the sample should be protected from light.
After centrifugation, the serum or plasma should be frozen. Some references suggest freezing is required when testing will not be performed within 30 minutes (WHO). Preanalytical decreases have been noted when serum was subjected to contact with cells for 72 hours. Follow your facility's policy.
- LabTestsOnline. American Association for Clinical Chemistry. AACC. https://labtestsonline.org/understanding/analytes/vitamin-b12/tab/sample.
- 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.
- Wu A. Tietz Clinical Guide to Laboratory Tests---Fourth Edition. Elsevier. St. Louis, Missouri. 2006.
- World Health Organization. Use of Anticoagulants in Diagnostic Laboratory Investigations. WHO. Geneva, Switzerland. 2002.
- CDC. Laboratory Procedure Manual, Folate/Vitamin B12,, Serum and Whole Blood, Method: Bio-Rad Laboratories' "Quantaphase II Folate/Vitamin B12" Radioassay Kit. https://www.cdc.gov/nchs/data/nhanes/nhanes_03_04/l06_c_met_folates-b12.pdf. Accessed 4/1/2019.
Tip of the Month: Everyone is Someone's Loved One
Click here for this month's featured Tip of the Month from our rich library of archived Tips.