Tourniquets: Always Necessary, Sometimes Forgotten
Throughout history, tourniquets have been used to restrict blood flow. It's one of the simplest and most effective medical devices ever created, yet has changed very little over time. While the material tourniquets are constructed from have evolved from vines and rope to a non-latex elastomers of many colors, little else has changed. Because they constrict circulation, tourniquets save lives by stopping hemorrhages, and make venipunctures and IV therapy possible.
Tourniquets also have a dark side.
When forgotten after a venipuncture, a tourniquet that continues to restrict blood flow often leads to deep vein thrombosis (DVT), a dangerous and life-threatening complication that can cause permanent injury, even death.
National statistics are hard to come by, but healthcare facilities in the state of Pennsylvania alone reported 125 incidents of forgotten tourniquets in one year. In one third of the incidents, tourniquets were left on up to 18 hours. Extrapolating that statistic to the entire US, healthcare professionals forget tourniquets on nearly 3,000 patients every year. Many lead to complications and litigation. Complications include pain, swelling, skin sores, varicose veins, post-thrombotic syndrome, amputation, pulmonary embolism and death.
Performing venipunctures without tourniquets is not an option. Constriction of the circulation causes veins to distend as they fill up with blood that can no longer circulate. Distended veins are easier to palpate and access. The standards also require a thorough survey of available veins so that those most likely to be near nerves can be avoided. Without tourniquet constriction, a thorough survey cannot be conducted. [Editor's Note: many are under the false impression that lactates must be drawn without a tourniquet. However, no study has shown lactates to be affected by tourniquets applied for one minute, as is the case for routine phlebotomies. Only when left on for five minutes or longer, which is against the standards, are lactates affected.]
To prevent forgotten tourniquets and the complications that can ensue, facilities should adopt aggressive strategies. Some suggestions include:
- using neon- or brightly colored tourniquets that are easier to notice before leaving the patient;
- adding a step to the venipuncture procedure mandating a visual check for the tourniquet before leaving or dismissing patients;
- instituting effective consequences for those leaving tourniquets in place after the draw;
- request patients who are willing and able to count down from 60 after the tourniquet is applied as an audible reminder to the phlebotomist that the tourniquet should be released.
Deep vein thrombosis is a life-threatening risk everyone who draws blood samples must take seriously. Some of the above measures may seem drastic. Given the potential for patient death, drastic is often required.
Read a related story.
Phlebotomy CE Day Date & Location Announced
AUMT Institute and the Center for Phlebotomy Education have just announced the date, location, and agenda for the 5th annual Phlebotomy CE Day. The event will be conducted in San Francisco, California on Saturday, September 8, 2018.
AUMT is hosting the event in collaboration with the Center for Phlebotomy Education again this year. Topics will be presented by the Center's Director, Dennis J. Ernst MT(ASCP), NCPT(NCCT) and will include:
- The Ten Commandments of Phlebotomy
- Tube Handling Best Practices
- Mastering Pediatric Phlebotomy
- Top Ten Preanalytic Threats to Accurate Results
"Speaking to my phlebotomy friends in California at CE Day has become one of my favorite annual events," says Ernst. "I'm particularly looking forward to being back in the Bay area and collaborating with AUMT, one of the finest phlebotomy programs in the country."
Attendees present at all sessions will earn six P.A.C.E.® CE credits, which satisfy the biannual requirement for California phlebotomists. Lunch will be provided and an evening social hour is scheduled after the event concludes. Discounted registration will be available for groups of four or more who register at the same time. All healthcare professionals throughout the U.S. and Canada are invited to attend this lively and informative event. As the event coordinator, AUMT will be managing the event, processing all registrations, communicating with all registered attendees, and providing P.A.C.E. certificates.
For more information and to register visit AUMT's CE Day web site or contact AUMT by phone at (424) 278-9442 or email at CEday@AUMT.org.
Standards Update: Post-venipuncture care
The newly revised venipuncture standard released by the Clinical and Laboratory Standards Institute in April, 2017 is the most comprehensive revision in the document's history. With over 140 new mandates, facilities have a lot of changes to implement. This series discusses one or more substantive changes each month.
One of the most critical aspects of performing a venipuncture is post-venipuncture care. Bruising is not only unsightly and impacts patient satisfaction, but hematomas can cause permanently disabling injuries when they exert pressure on nearby nerves. The committee that revised the CLSI venipuncture standard instituted a comprehensive rewrite of the section on caring for the venipuncture site.
While the popular standard always instructed collectors to "observe for hematoma," prior to this version the document never defined what "observe" really meant. Merely lifting the gauze for a millisecond would suffice. However, a quick peek won't alert the collector to a site that is still bleeding. Worse yet, it would be impossible to know if a hematoma is forming. As a result, a patient could be bandaged too quickly, and continue to bleed into the tissue, causing not only an unsightly bruise, but inflict a permanent nerve injury from the pressure of a subcutaneous hemorrhage. Yet technically the standard would have been followed.
The standard now instructs healthcare professionals to observe the site for hematoma formation by watching the skin for at least 5-10 seconds. That should be enough time to detect the telltale mounding of the skin at the puncture site, which indicates blood is leaking from the vein into the tissue. If observed, or if blood is seen pooling on the skin, the standard requires additional pressure to be applied until the bleeding has stopped. At least five minutes of additional pressure is required if bleeding from the brachial artery is suspected, and the nursing staff and physician must be notified.
The revision continues to forbid patients from being allowed to bend their arm up after the draw as a substitute for direct pressure. Neither cotton nor rayon balls can be used for applying pressure, only clean gauze.
Cooperative patients can be allowed to apply direct pressure. However, it is the responsibility of the collector to ensure pressure is adequate in order to prevent bruising and any bleeding into the tissue that could lead to complications. If necessary, collectors must provide adequate pressure themselves if patients are unable.
When the collector is sure bleeding has stopped---both superficially and subcutaneously---the site can be bandaged, preferably with a hypoallergenic bandage or wrap. The patient should be instructed to leave the bandage on for at least 15 minutes, and cautioned against using the arm with exertion for several hours.
Editor's note: Readers are urged to obtain their own copy of the standard as soon as possible and begin implementing all new provisions immediately. The document, Collection of Diagnostic Venous Blood Specimens (GP41-A7), is the standard to which all facilities will be held if a patient is injured during the procedure or suffers from the consequences of an improperly performed venipuncture. It can be obtained from CLSI or the Center for Phlebotomy Education, Inc.
Product Spotlight: Order of Draw badge tags
Do those who draw blood samples in your facility realize the order of draw is critical to accurate results, or do they think it's a myth? If they think it's a myth, the Center for Phlebotomy Education can help dispel it.
First, print our PDF titled Do I have to Follow the Order of Draw from our Free Stuff web page and post it where everyone who draws blood can see it.
Secondly, distribute our Order of Draw Badge Tag to your staff to attach to their ID badge so the order of draw is always in front of them. The Order of Draw Badge Tag graphically depicts the order of draw and explains why it's necessary. On the reverse are nine tips on proper tube filling and handling including:
- Fill all tubes according to the proper order of draw
- Mix all tubes with a gentle inversion 5-8 times, 3-5 times for citrate tubes
- Never combine the contents of two tubes
- Fill all tubes to the manufacturer's fill line
- Never refrigerate tubes to be tested for K+ prior to centrifugation
- Allow serum tubes to clot upright for 20-30 minutes prior to centrifugation
- When filling tubes from a syringe, always use a safety-transfer device.
The Order of Draw Badge Tag is printed in full color and laminated for durability. Each 10-pack contains 10 identical copies of the card for distribution to phlebotomists, nurses and all on staff who draw blood samples.
More information and to order.
How Underfilling Tubes Cheats Patients
You're drawing blood into a syringe. Everything is going fine when suddenly the blood stops flowing. You stop pulling on the plunger for a moment, thinking that maybe you were pulling too hard and the vein collapsed, but that doesn't help. You relocate the needle ever so slightly and pull again. Nothing. You need a CBC, chemistry panel and coags and you only have half the blood you need. What do you do?
If you were wise enough to stock your tray with a wide variety of collection tubes, you don't have a problem. That's because you have smaller volume tubes that you can fill completely with what little blood you have. Without them, you have what we call a dilemma.
You know that the EDTA and the citrate tube have a calculated amount of anticoagulant placed in them by the manufacturer to provide accurate results when the tube is filled to capacity. If they're underfilled, it's anyone's guess on whether the results will be accurate or not. Your dilemma is to either restick the patient---which you don't really want to do since his veins and his good nature are both in short supply--- or you underfill the specimens and hope the testing personnel don't reject the specimen. Suddenly, two pieces of advice enter your mind simultaneously. One is from your mother who always said that the right decision is usually the harder one; the other is from your phlebotomy instructor who told you a hundred times: "Every patient is someone's loved one." You redraw the specimen.
Properly filling collection tubes is not just a good thing when you can do it, it's a bad thing when you can't. That's because underfilling tubes with additives alters the balance between blood and additive and tinkers with the chemistry. Such tinkering can wreak havoc with results even when it's a dry additive. For example, underfilling a dry EDTA tube can result in excessive anticoagulation and erroneous results. When the ratio of EDTA to blood is too high, as in an underfilled tube, the red cells tend to shrink. As a result, hematocrit, mean cell volume (MCV), and the mean corpuscular hemoglobin concentration (MCHC) will be affected. It's in the best interest of the patient to submit for testing only tubes that have been filled to capacity.
The tube most sensitive to underfilling is the sodium citrate tube (blue top) used for coagulation studies. Any citrate tube filled less than 90 percent of its stated volume will yield falsely lengthened coagulation results and can result in the physician adjusting the patient's anticoagulant dosage downward to a degree that risks serious complications including blood clots and stroke. Collectors who submit a tube that does not reach the manufacturer's minimum fill volume puts the patient at risk of being diagnosed, medicated and/or treated according to erroneous results with the potential for serious complications.
When heparin tubes are underfilled, the accurate results of many critical analytes are at risk. According to a study published in the May/June 2006 issue of Clinical Laboratory, when the concentration of lithium heparin is three times what it is when the tube is properly filled, the following analytes exhibit changes when compared with results obtained from serum: ALT, AST, amylase, lipase, and potassium. If a half-filled tube doubles the heparin concentration, it stands to reason that filling it less than 50 percent will approach a concentration three times the optimal strength. Excess heparin is also reported to cause falsely lower sodium, CK and GGT levels. The authors conclude that all anticoagulant tubes should be filled to prevent erroneous results.
Underfilling blood culture bottles also cheats the patient out of an accurate result. The optimum volume for adult patients is 20cc of blood evenly distributed between two bottles, not to exceed 10ml each. Collecting 1cc of blood for every year of life per set of blood cultures is the recommended blood culture volume for pediatrics.The sample should be inoculated into pediatric blood culture bottles.
Organisms that cause septicemia can be in concentrations as low as one organism per milliliter of blood. Therefore, when blood culture specimens are short-sampled, the bacteria causing complications in the patient may take longer to detect, delaying antibiotic therapy and leading to complications including death. There is also the chance that the causative organism will not be detected at all in underfilled blood culture bottles.
Therefore, the more blood that is collected for a blood culture, the better the chances are of harvesting the causative organism of bacteremia. If a collection yields less than 20cc of blood on an adult patient, evacuate up to the maximum recommended volume into the aerobic vial instead of dividing lesser amounts between two vials. (98% of all septicemias are a result of aerobic organisms or facultative anaerobes, i.e., anaerobic organisms that can tolerate aerobic environments).
Not all draws go as planned. When posed with draws that yield less than the optimum volume of blood, healthcare personnel with specimen collection responsibilities can maintain the integrity of the specimen and the subsequent results by always having a supply of lesser volume tubes available. Preparing for lesser volumes helps to assure your patients that they will not be cheated by underfilled tubes, but diagnosed, treated and medicated according to accurate results. It also prevents you from having to redraw patients whose veins have already proven to be difficult. When posed with the options of either submitting underfilled tubes for testing or having to redraw your patient, a well stocked tray with smaller volume tubes may save you from the dilemma. Your mother and your phlebotomy instructor will be proud.
[Editor's Note: For an attractive PDF of this article, visit the FREE STUFF page of the Center for Phlebotomy Education's web site.]
From the Editor's Desk
Fresh voices, new faces, and infectious passion. That's what laboratory conferences hunger for in their preanalytic speakers. Next year, their appetite will become voracious.
That's because I've decided to step away from the podium at the end of this year.
The photo to the right was taken in 1997, about the time I started lecturing while still employed at University Hospital in Louisville, Kentucky. I left in December of 1998 to start the Center for Phlebotomy Education. At that time, I had no idea the path I was about to do down, or that it would lead me throughout North America and in 10 other countries,
Flash forward to today. Over 500 conference presentations later, 35 this year alone, it's time to focus my time and energies elsewhere. Make no mistake, I'm not retiring. What I do is too much fun to be called "work," so I have nothing to retire from. That makes me one of the luckiest people alive. I was born to do what I do, and there's still a lot of work to be done on prenanalytical education, promoting the phlebotomy profession, and helping other companies succeed.
I will still honor my existing speaking commitments and may even accept invitations to a few select events like CE Day. But my days as a conference presenter need to be over for many reasons.
- Everything I have to say, I've already said;
- My wife deserves to have me home more often;
- I would like to spend more time in her company;
- My closest airport is now a 2-3 hour drive from home;
- The speaking circuit needs fresh voices, new faces, and infectious passion.
Even though my portfolio of over 25 presentations will be retired at the end of this year, I plan on repurposing my time in ways that continue to impact patient care through advances in preanalytic education and innovations..Instead of spending hundreds of hours every year preparing and updating PowerPoints and handouts, I plan on making great progress:
- updating our videos to reflect the revised CLSI standards;
- creating more short clips for our YouTube channel;
- being more effective with our social media platforms;
- educating more non-laboratory professions that draw blood samples, especially the dental professions;
- helping innovative companies bring products to the marketplace that solve serious problems.
This shift in my focus comes with a price, though. What I will miss the most is the very thing that has made cramped airplanes, grungy hotel rooms, and bad restaurant experiences worth tolerating: seeing what I refer to as "my people."
Because of my extensive travel, my close friends don't live down the street or even in a 20-mile radius of where I live. They live across North America and around the world. It's been that way for 20 years, and I've grown accustomed to being a stranger in my neighborhood but well-known far-away. Conferences are the only place I ever see those I call my dearest friends. You know who you are, and I will greatly miss hanging out with you.
So it goes.
Unless you'll be at a future CE Day, Global Summit, or CLSI conference, our only connection will be by phone, email, social media and this newsletter. Rest assured, you add value to my life even if we cannot occupy the same physical space.
I have to share with you that I have a funny feeling inside about stepping away from the podium. I sense that speaking over the last 20 years was preparing me for something else, something different, something more, and something totally unrelated. That's all I can tell you because that's all I know. I could be wrong, but it's a gut feeling that seems more inevitable than fleeting. Rest assured, if it is meant to be resistance will be futile.
Dennis J. Ernst MT(ASCP), NCPT(NCCT)
What Should We Do?: Securing butterflies
Dear Center for Phlebotomy Education:
I'm trying to implement the new CLSI requirement that butterfly sets be secured throughout the procedure. My staff is arguing that it defeat the purpose of the winged set, which is to so that the patient can move a little without the user having to be perfectly synchronized with his/her movements and not lose the vein. They're saying they'd prefer to use a straight needle if they have to hold the winged set the whole time. They are also arguing that the requirement means every time you plan to use a winged set they will probably need another phlebotomist because they're not going to tape the winged set on a child's skin. Pulling off tape is almost as bad as the needle itself for many kids. They envision a second person to hold the device and the other person to fill multiple syringes. What should we do?
Our response: You're really getting some serious push back with this new provision, but we feel most of their objections are unfounded.
The intent of the passage in the standard is to prevent damage to the vein should it move when released, as many winged collection sets do. When a beveled needle moves within the vein, it slices everything it comes in contact with. It can also reposition itself in a manner that causes the vein to collapse onto the needle's opening. By securing the device, injury is prevented and draws are more likely to be successful. Keep in mind, the committee that wrote the standard included representatives from three major international manufacturers who make and market butterfly devices, and were in agreement with the passage.
Ask your staff this question: when they let go of the butterfly device, do they have control of the needle? Of course not. A good phlebotomist must be able to use both hands to perform the task of obtaining blood samples; one hand holds the winged collection device in place while the other one changes out tubes, just like they do when they use a straight needle.
A syringe can be filled with one hand by holding the barrel in the palm of the hand and using the thumb to push the plunger up. Exchanging syringes might require assistance, but not your staff uses a tube holder adapter instead. Where a syringe is necessary because a large volume of blood is required, a larger syringe would negate the need for an exchange.
We also disagree that removing tape can be more painful than the puncture itself. The tape need not be long, nor firmly pressed onto the skin. Where the standard requires "securing" the device, the purpose is to keep the needle in place instead of flopping around, as many butterfly sets do when released. Light pressure is all that's needed on the tape, making removal virtually painless.
Lastly, if your staff is willing to use a straight needle instead of a butterfly set so they don't have to secure the device, they should. Butterfly use should be minimized whenever possible. If another device can be used, it should be used. Not only does butterfly overuse waste healthcare resources because of their higher cost per unit, but they are associated with higher accidental needlestick rates when improperly activated and discarded.
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.)
The Empowered Healthcare Manager
Every month we run an excerpt from our editor's popular blog, The Empowered Healthcare Manager.
Assets and Liabilities
Any staff is composed of those who add value to the organization and those who subtract from it. There is no middle. People are either assets to your mission or liabilities to it.
Empowered managers don't invest in liabilities, they invest in assets and in transforming liabilities into assets. Investing in liabilities doesn't work in your stock portfolio; it won't work in your portfolio of human resources, either.
Consider your organization's benefit package as the money it has available to purchase assets that will return dividends, i.e., your staff. If the facility, through your recommendation, purchases an asset that turns out to be a liability, your employer's portfolio loses value and so does the worth of your department. Continually investing in that liability without trying to turn it into an asset is squandering your employer's working capital.
Turning a liability into an asset requires a change in the market forces that affect its value. The stock price of a company that makes umbrellas skyrockets when a monsoon hits. The value of an employee skyrockets when his/her manager (i.e., the market force) creates the market condition that turns the liability into an asset.
Those conditions: encouragement, example, patience, guidance and discipline.
Subscribe to The Empowered Healthcare Manager blog.
Tip of the Month: "Defend Your Ear-Space"
Click here for this month's featured Tip of the Month from our rich library of archived Tips.