Compassion For First-time Phlebotomy Patients
From the Journal of American College Health--Washington. "Compassion for First Time Phlebotomy Patients," Volume 53, No. 4, Page 191-2. Reprinted with permission of the Helen Dwight Reid Educational Foundation. Published by Heldref Publications, 1319 18th Street, NW, Washington, DC 20036-1802. www.heldref.org.
Venipuncture, generally referred to as a routine laboratory procedure, is performed daily in thousands of offices, clinics, hospitals and laboratories across the world. In the United States, it has become an expected, albeit unwelcome, part of a physical exam or a quick stop at the college health center. Nurses, medical technologists, and phlebotomists generally perform the task of collecting the specific specimen required for the lab work. Phlebotomy is not as difficult as a surgical procedure or differential diagnosis, yet it is certainly a fine art and an integral part of good healthcare.
The amount of information that a health professional can gather from blood is invaluable. When coupled with the relative ease, low risk, and a small time commitment, it is easy to see why blood testing is so common. Venipuncture is a quick, moderately painless procedure that is the key to routine laboratory testing and the wealth of information it provides. The high-yield, low-cost nature of blood testing has contributed to the addition of lab testing to many, if not most, annual physicals as well as more urgent office visits.
Healthcare professionals, however, may be unaware of the anxiety some patients feel during a venipuncture experience. For many people, especially young adults, venipuncture is the first healthcare procedure they encounter that seems more traumatic than taking a pill or rubbing on a cream. On occasion, some students' desire to avoid venipuncture is viewed as cowardice. The clinician must remember that the extent of the students' experience with phlebotomy is a description of a steel needle inserted into his or her arm. Students are not being cowards, they are trying to avoid a one-inch needle being stuck into the vein in their elbow. Many times, the person doing the sticking is a complete stranger. This is not cowardice, it is common sense.
Many people associate blood tests with vaccines because both require needles in the arm and are referred to as quick sticks. Tetanus vaccines hurt. For many, tetanus is the only vaccine they remember receiving because the other routine vaccinations were administered when they were very young. The association between the unknown blood-test needle and the last needle experience---a tetanus booster---is natural and quite understandable. With that association, the pain of venipuncture is assumed to be similar. The pain is associated with the needle, not with the liquid in the syringe.
The build-up to the venipuncture procedure is much more involved than a routine vaccination. Vaccinations require that the person roll up a sleeve, and the clinician clean the skin with alcohol and puncture the skin. Phlebotomy involves rolling up the sleeve, having a tourniquet applied, palpating to locate a suitable vein, cleaning the area, applying traction to anchor the vein, and, finally, puncturing. The build-up is substantially longer and, as with any waiting period just before the event, the person's anxiety will increase.
Some may argue that people who have undergone venipuncture many times, such as those on anticoagulant regimens, view blood tests with apathy or indifference, and this is indicative of the absurdity of shying away from the phlebotomy chair. However, such people have the fortune, or misfortune, of prior experience with this exercise. First-time phlebotomy patients are nervous about the unexpected; they are scared of what has been described to them: a needle being inserted into a vein. Students are submitting to the fear of the unknown. In the university setting, they may be encountering this situation for the first time away from the comforts of their home environments.
Healthcare professionals should not look at students who are distressed about the phlebotomy experience with disdain or impatience. Instead, they must treat the student compassionately. The student may be having the test for a measles-mumps-rubella (MMR) titer, but to them, that needle is awfully intimidating. In today's environment of respect for patients and their decisions, clinicians must remember to address the unique needs of all patients, not just the sickest.
The easiest way for a provider to alleviate the student's fear is to ask whether he or she has had blood drawn before, or to answer any questions the student might have about common phlebotomy procedures. Other suggestions include having a comfortable, well-lit room and a proper phlebotomy chair for drawing blood. When verifying the student's demographic information immediately before collecting the sample, the phlebotomist should always discuss the procedure with the patient. Although the procedure is simple, these suggestions will go far in helping to calm a nervous patient, and will assist the clinician in obtaining a proper blood sample for testing.
New Standard Issued on Patient/sample ID
CLSI has just released a new standard on patient identification and sample labeling. All laboratory managers, phlebotomy supervisors and clinical laboratory educators should be modifying their procedures and training materials according to this standard to ensure compliance.
Accuracy in Patient and Sample Identification (GP33-A2) specifies the processes required to ensure accurate patient and specimen identification in manual and electronic systems across the health care organization. The document replaces the first edition, which was published only as a guideline. This second edition, upgraded to a standard, defines the proper protocol for identifying patients for all laboratory procedures and for labeling all diagnostic samples including blood and non-blood specimens.
The processes detailed in GP33 include considerations for designing patient ID systems, differences in requirements for patients with and without identification bands, and provisions for patients with communication barriers.
The volunteer committee tasked with revising the document was chaired by Dennis J. Ernst MT(ASCP), NCPT(NCCT) with Anne Marie Martel, T.M. of Ordre Professionnel Des Technologistes Médicaux Du Québec serving as the committee's Vice Chairholder. Other members of the committee included:
Deirdre Astin, MS, MT(ASCP)---New York State Dept of Health
Nancy Dubrowny, MS, MT(ASCP)SC---BD Preanalytic Systems
Sheri Hearn, BC, MPH---Oregon Public Health Laboratory
Peggy Mann, MS, MT(ASCP)---The University of Texas Medical Branch
Estelle Ninnemann, MT(ASCP)---ACL Laboratories
George Souza, BS, CPT, CPI---Massachusetts General Hospital
Sheryl Thiessen, BSMT, MT(ASCP), MLT(CSMLS), CLQM---British Columbia Agency for Pathology and Laboratory Medicine.
Thomas Dew---Taylor Healthcare
Sharon Johnson---Mayo Clinic
The standard is available from CLSI or, by special arrangement, directly from the Center for Phlebotomy Education, Inc.
What Should We Do?: RPM & RCF
Dear Center for Phlebotomy Education:
Is there a CLSI document that sets the requirement for clinical labs.? If not, is there any other source that you recommend? We are running in to mixed information about the RPMs and RCFs that need to be set for our centrifuges. What should we do?
CLSI document GP44-A4 (Procedures for the Handling and Processing of Blood Specimens for Common Laboratory Tests) contains some information on centrifugation, specifically RPM (revolutions per minute) and RCF( relative centrifugal force). It was published in 2010 and is currently under revision. But there are two other sources of important information you also need to look at. One is the Instructions for Use (IFU) from the manufacturer of the tubes you use. They set the RCF required for their tubes based on their own data. Once you know the RCF the tubes must be subjected to, then you need to consult with the IFU from the manufacturers of the centrifuges you have in use. They will tell you the RPMs necessary to meet the tube manufacturer's recommended RCF.
Every model of centrifuge will require a different RPM to attain the recommended RCF. That's because the RCF is dependent upon the distance from the centrifuge's rotor to the bottom of the tube as it spins. Tube manufacturers have no idea what centrifuges their tubes will be spun in, so the lab must make the RPM calculation. CLSI puts an RCF nomograph in GP44 to help, but you still need to know the RCF the tube manufacturer recommends for each tube type.
[Editor's Note: The Center for Phlebotomy Education posted a Tip of the Month a while back that provides more information on sample handling. View Specimen Handling: Fact or Fiction?]
Preanalytic Conference Fast Approaching
What's Wrong Here?
What's wrong with this picture (left)? We guarantee something isn't as it should be. The answer will be in next month's issue. (Click image to enlarge.)
Last week's image (right) depicted a blood culture bottle being filled directly from a syringe. The practice of filling any tube or blood culture bottle with the same needle used to perform the puncture is unsafe and against OSHA guidelines. Even if the tube or bottle is pierced while upright in a rack and the other hand safely out of harm's way, the other hand will ultimately enter back into the danger zone to hold the tube or bottle when the needle has to be pulled from the stopper. The old procedure of changing the needle before puncturing the stopper is not acceptable and does not reduce your risk of an accidental needlestick by a contaminated needle, yet that procedure is still in use at some facilities. To be compliant with OSHA guidelines, make sure nobody at your facility is still performing bottle inoculation in this fashion.
Instead, the safety feature of the needle should be activated, the needle removed and discarded, and a safety transfer device attached to the syringe. Tubes and bottles can then be safely filled without risking an accidental needlestick.
From the Editor's Desk
Question: What do all these organizations have in common:
- Burlington Liar's Club
- Sigma Chi Fraternity
- Professional Photographers of America
- Clinical and Laboratory Standards Institute
- Southern Indiana Writers
- Harrison County Preppers
- The Jet Club
Answer: they all allowed me to be a member.
Actually, the last three had to accept me because I was one of the founders. Of the remaining, the least prestigious is probably the Burlington Liar's Club. They'll accept anyone who can tell even the tiniest white lie. The Sigma Chi Fraternity is probably the one that had the greatest impact on my life, and still does today, because of the lifelong friendships that rose from my four years as an active member of the Alpha Pi Chapter at Albion College. Receiving the Significant Sig award earlier this year from the national fraternity for my professional accomplishments certainly secures my perpetual endearment to the organization whose Three Great Aims have become my own: friendship, justice and learning.
I was only a member of the Professional Photographers of America for three years, back when I was working on the side as a freelance portrait and nature photographer. Fueled by a couple Best-of-Show awards at juried art fairs, I almost abandoned the laboratory profession in the 1980s to pursue a photography career. But I realized if I were to make it big as a nature photographer I'd have to travel far and frequently to capture the full bounty of nature's beauty. As a single dad with two precious children around whom my world revolved, it wasn't time. But one of my PPA membership benefits was this really cool pocket calendar, so my membership dues weren't completely wasted.
The one organization with whom I have been involved longer than any other, though, is CLSI. It's also the most dynamic, fulfilling, appreciative and impactful on a global scale. As the phlebotomy instructor at the University of Louisville School of Allied Health in the 1990s, H3-A3 (aka the venipuncture standard) was my go-to document for developing course materials. My first encounter with the face of the organization was in 1999, right after the standard was revised.
I received a mailer from NCCLS (their former acronym) announcing a conference in Raleigh, North Carolina on the new standard. Though I was dirt-poor at the time, wild horses couldn't have held me back. I hopped into my old beat-up truck and drove 12 hours to Raleigh the day before the event. I just had to see what this organization was like, and to be among those who revised the standard that had become my bible.
After the event, I went up to meet the presenters, all committee members who crafted the standard upon which my curriculum would be based. to me, Roger Calam, Ray Olesinski and Joan Wiseman were the pillars of my profession, as legendary in phlebotomy as Ansel Adams, Matthew Brady, and Dorothea Lange were to photography. I felt I was standing amidst giants. I was full of questions and they were full of answers. Out of respect for their time, I cut it short and thanked them for such a great event.
"Why don't you join us for dinner?" Dr. Calam asked.
I just about fell to the floor. I was a nobody, a measly little lab rat who would have been satisfied with the crumbs that fell from their table. But an hour later there I was, dining with giants of the industry. From that moment on, I knew I had to be involved with the organization, and that standard in particular.
I never forgot how it felt to be so readily welcomed into their circle. As my interactions with NCCLS became more frequent, I came to learn that welcoming newcomers is in their DNA. It's part of their culture. I've never known any organization to be so genuinely welcoming and sincerely hospitable. Not even the Jet Club. (That's because my two brothers and I started it in a shed in our back yard one day when we were kids. Girls were not allowed.)
Since that first introduction to the face of what is now CLSI, I've been involved on 11 volunteer committees writing various preanalytic (preexamination) standards and guidelines, chairing six of them. This is my 4th year as a member of CLSI's Consensus Council (the consensus body responsible for managing the development of all CLSI consensus documents and products), and my second year its Chairholder. I say this not to boast. In fact, all this talk about my accomplishments makes me quite uncomfortable. My whole point of this is to show you how one act of kindness can change a person's entire trajectory in life, and certainly within his/her profession.
Consider this my attempt to change yours.
Earlier this month, CLSI issued a "Call for Volunteers." I am extending their invitation to become my invitation to you personally. Being a CLSI volunteer has been one of the most rewarding and fulfilling experiences in my life. I want that for you. The staff and leadership are likely to be the most dynamic, dedicated and appreciative people you will ever meet. I want you to know them. Being involved on CLSI committees will put you in the midst of giants. I want you to become one of them.
If you want to be part of something bigger than yourself, if you need to feel like you're making a difference in patient care on a global scale, if you want to surround yourself with people who share your passion, expertise and ambition, answer the call. Become a volunteer. You will meet people who exemplify all that is good with our industry. People with whom you can connect professionally in ways and to a degree you could not otherwise connect. People who want laboratory practices to improve on a grand scale. People like you.
There are openings on CLSI's Awards, Finance, and Nominating Committees. Committee members are also being sought for the Consensus Council and at least two document revisions. If none of these call to you, committees within your area of expertise form on an ongoing basis, so make sure you're put on the list for notifications by joining CLSI today. If your facility is already a member, ask to be included in their communications or join as an individual.
I'm not asking you on behalf of CLSI. My appeal to you is sincere and from the heart. I just know what it can to for you personally and professionally.
Like me, you've probably joined a lot of organizations in your life. Some good, some bad. Some with great pocket calendars, others with schwag to goes right into the trash. Trust me when I tell you being a volunteer on industry standards and guidelines can give your career new meaning and may even change your trajectory. That's no lie; I know this first-hand. Besides, I left the Burlington Liar's Club a long time ago.
Dennis J. Ernst, editor
Advice From the OSHA Expert: Sharps containers
Dan the Lab Safety Man
As a phlebotomist, you already know through your training the importance of needle safety devices and their proper disposal. You know that sharps containers are used to hold contaminated needles and other sharps, and that these containers must be closed and properly discarded when three-fourths full. But have you ever considered why there seems to be so many regulations in place about sharps containers?
Several of the guidelines have to do with your personal safety. OSHA states that disposable sharps containers must be replaced regularly so that they do not become overfilled. The Centers for Disease Control and Prevention (CDC) is more specific and says containers should not be filled more than three-fourths full, with many manufacturers placing a fill line as a visual indicator on their containers. One reason for this is so that during the disposal process, your risk of obtaining a needlestick is minimized. Should you suffer an accidental exposure from an object protruding from an overfilled sharps container, the source would be unknown. Without the ability to test the source patient, you may have to undergo treatment as if exposure to HIV or hepatitis occurred. This treatment can be painful and personal, and should be avoided, if possible.
The expense of waste removal should also be considered when using sharps containers. In some areas, it can cost eight to ten times more to dispose of sharps containers than it does to dispose of other regulated medical waste (biohazardous trash). Often, the cost of disposal is based on weight. That's one reason why you should never place items in a sharps container that do not belong there, such as tourniquets, gauze, and bandage wrappers. Also, since used tourniquets, gauze and wrappers can be thrown away in regular trash in most areas, doing so helps the environment by reducing the size of biohazard landfills.
One last thing to consider is the use of sharps containers by phlebotomists or other healthcare personnel who travel offsite. OSHA tells us that those sharps containers need to be closed while in transit and supported in such a way to prevent tipping. These containers must also be replaced when filled to 75 percent of their capacity.
The next time you change out your sharps container, remember that the regulations created surrounding its use were designed to protect the environment, your patients, and you!
1. OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030(d)(4)(iii)(A)(2)(iii). Accessed 6/3/19.
2. OSHA Bloodborne Pathogens Standard 29 CFR 1910.1030(c)(1)(iv)(B). Accessed 6/3/19.
You can contact Dan Scungio, "Dan the Lab Safety Man" at firstname.lastname@example.org.
Shop Talk: Stephanie Ponti
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!
Are accrediting agencies failing to take a close look at the pre-analytical aspects of clinical laboratory testing? If so, is it sending a signal that training and continuing education for the phlebotomist is of secondary importance?
Throughout my career, I have participated in a variety of accreditation inspections. I am always shocked by the limited focus inspectors place on sample collection and handling. Typically, the inspections are heavily focused on the analytical phase of testing. In 30 years, I have rarely seen an inspector interview or observe a phlebotomist or specimen processor, much less go offsite to a patient service center.
As a phlebotomy instructor and supervisor, I always share what students and staff may see out in the real world, and why they need to stand up and do the right thing. Recently, I was reminded why standing on that soapbox and preaching about ethics and quality is so important.
A former student, "Sue" called recently to say she appreciated the training she received and the stories about what she may encounter in the workplace. Sue was shocked when my predictions came true. Sue had just started a new job as a phlebotomist in a state that does not require phlebotomy certification. Sue was working with another phlebotomist at a patient service center and realized after the patient had left that only a serum separator tube (SST) had been drawn. The physician's order called for a CBC to be collected along with the chemistry panel. Sue stated to her co-worker that she needed to call the patient back. The co-worker replied, "We don't call the patient back, we can just pour some specimen from the SST into the EDTA."
My former student found herself in the exact situation I had described early on in her training. That of an employee being asked to do something, knowing it will negatively affect the quality of the sample collected. Does she speak up, call her supervisor, or go with the flow and not make waves? I have always challenged my students and co-workers to treat each patient sample as though it were from someone they loved. Sue spoke up. She explained that pouring the sample from the SST, which contains a clot activator, into an EDTA tube would jeopardize the quality of the sample, as micro-clots and platelet clumps may have formed. That doing so could delay or prevent the provider from correctly diagnosing the patient and initiating appropriate treatment in a timely manner. Eventually, the patient was recalled.
On another occasion Sue noted that a plain, red-top tube was not collected for a therapeutic drug level that requires serum from a non-gel separator tube. Again, Sue suggested the patient be called back. She was told "No, just let the SST clot upside down. It will be fine!"
When phlebotomists make these kinds of decisions in the field, we have to wonder the reason. Is it a matter of ethics (i.e., what you do when no one is looking)? Or is it due to a lack of proper training, with clinical laboratories contributing to the problem by not providing regular and comprehensive competency checks? My guess is, in most cases, it is the latter.
If it were an ethics issue, the unorthodox practices described would not be so widespread. When new phlebotomists are taught improper technique by senior staff members, it demonstrates a general lack of understanding of preanalytical errors and their causes. The importance of specimen quality and the "accuracy depends on me" mentality is missing. Laboratories must invest in staff members who are responsible for the quality of blood sample collection and handling. A Clinical Laboratory Scientist (CLS) can perform the assay and report the result, but if the blood in an SST was poured into an EDTA tube a few minutes after collection, is the CLS reporting an accurate result? Or, if the SST was allowed to clot upside down (as suggested), then spun and poured off, is the reported therapeutic drug level going to assist the provider in properly dosing and treating the patient? On both accounts, the answer is "no."
What happens at your facility? Are the proper preanalytical processes followed or improvised? Are serum samples allowed to fully clot and then centrifuged within the appropriate time frame? Are specimens spun, refrigerated, or frozen in accordance with test requirements? Are patient samples stored in such a way to maintain integrity until and during transport to the testing laboratory? Are remote patient service centers equipped with a centrifuge, refrigerator and freezer?
If inspectors asked more of phlebotomists and processors, laboratories would be forced to place more emphasis on education and training. When facilities invest in the ongoing education of their pre-analytical staff, the investment produces knowledgeable and skilled healthcare professionals who more readily recognize and fulfill the crucial role they play in delivering accurate results.
Stephanie Ponti, CPT1 is a Phlebotomy Supervisor at Dignity Health and Phlebotomy Instructor at Cuesta College in San Luis Obispo, California.
Test Talk: Lactate
A 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.
Lactate, also referred to as lactic acid, is produced by muscles, red blood cells, in the brain, and in other tissues when oxygen levels are insufficient. Lactate levels are ordered when physicians suspect their patient is not getting sufficient oxygen (hypoxia) or other conditions for which high lactate levels are symptoms. Such conditions include sepsis, congestive heart failure, shock, liver disease, chronic alcoholism, Reye's syndrome, uncontrolled diabetes, and kidney disease.
An elevated lactate level is not diagnostic by itself, but contributes to a diagnosis with other supportive indicators.
Lactates should be collected in heparin tubes (green stopper) and placed on ice immediately. If kept at room temperature, levels within the sample increase dramatically within minutes. Some studies limit room-temperature stability to two hours.
Significant confusion exists in regards to the effect of tourniquet constriction on lactate levels. A thorough review of the literature is inconclusive. No study shows lactates are affected when the tourniquet is applied and released within one minute, as required by industry standards, however, one study found lactate increases when the tourniquet is constricted for five minutes. The current CLSI venipuncture standard suggests lactate increases with venous stasis, but provides no reference. Follow facility policy.
- LabTestsOnline. American Association for Clinical Chemistry. AACC.
- CLSI. Collection of Diagnostic Venous Blood Specimens; Approved Standard—Seventh Edition. Clinical and Laboratory Standards Institute. Document GP41-A7 Wayne, Pennsylvania 2017.
- CLSI. Procedures for the Handling and Processing of Blood Specimens for Common Laboratory Tests; Approved Guideline—Fourth Edition. GP44-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.
Tip of the Month: What's For Dinner?
Click here for this month's featured Tip of the Month from our rich library of archived Tips.