School Closures Threaten Phlebotomy Workforce
The outbreak of Covid-19 and the resultant social distancing mandate is having a profound impact on the pool of trained phlebotomists entering the workforce.
Since phlebotomy and many other allied healthcare programs rely heavily on hands-on training and one-on-one mentoring, the need for close contact has forced many schools to close their classrooms until the pandemic passes. While that may seem to be the most prudent approach from a public welfare standpoint, the impact it has on the workforce cannot be understated. When students are unable to complete their required training and clinical rotations, the workforce suffers proportionally from an immediate and critical shortage of qualified applicants.
A recent Associated Press article, "For Trade Students, Online Classes Can't Replicate Hands-on," discusses the problem phlebotomists and other technical students face in the interruption of their training. Instead of graduating and entering the workforce immediately, most are having to accept they won't be able to finish their training and become marketable in the workplace until the fall. The delay can be devastating, especially for those in households whose income from other wage-earners has already been ravaged for the same reason. For some, the interruption of training in a highly marketable skill, like phlebotomy, forces students back to unskilled positions, perhaps indefinitely.
It's not just phlebotomists. Cosmetology, massage therapy, law enforcement, welding, nursing and scores of other professions are being challenged to bring students to workforce-ready amid today's Covid restrictions. According to the article, 8.4 million students are seeking post-secondary certificates and degrees in career and technical education fields. Not only is an interrupted education devastating to the student, it's devastating to the healthcare industry. Should even half of them experience delayed entry into the workforce, a huge vacuum of qualified candidate threatens to cripple healthcare employers and their ability to deliver healthcare safely and effectively.
At a time when phlebotomists are becoming increasingly critical as front-line responders to the Covid-19 crisis, the bottleneck in the conversion of new students to qualified applicants couldn't have come at a worse time. Unfortunately, solutions to this problem are linked and limited to the recommendations and restrictions of federal and regional governments and agencies. Time, however, will ultimately open the bottleneck, releasing students at long last to become employed in the profession of their choice, if they can hang on. Then comes the double-whammy, The sudden release of a backlog of students will create a huge pool of job-seekers flooding the market. The increased competition between applicants will be fierce. What's unclear at this writing is whether the release of students into their clinicals and hence the workforce will be as intense as a breaking dam or as gradual as a rising tide.
Read the full AP article.
Product Spotlight: Streaming Videos Around the Clock
Hardly a day goes by when someone isn't watching a video on the Phlebotomy Channel. In the last two years alone, over 40,000 views were logged by healthcare professionals, trainers, and educators around the world. Are you among them? If not, you should be.
The Phlebotomy Channel is where you can access 17 full-length videos that go way beyond what you'll ever find on YouTube, and far more accurate (unless, of course, you're viewing our YouTube Channel!). The difference can be compared to that between a snack and a meal. Our YouTube channel offers quick bites; the Phlebotomy Channel is a banquet.
Designed for facilities, academic programs and healthcare systems, the Phlebotomy Channel streams the most current phlebotomy training videos to your staff and students flawlessly wherever there's a high-speed Internet connection. If you're currently assembling trainees in one room to watch a DVD, assign them to watch the streaming version at their convenience, freeing yourself to accomplish your more pressing tasks. That's good time management.
Once you subscribe to the Phlebotomy Channel, you'll not only get more productive, you'll get:
Seventeen of the most popular phlebotomy training videos on the planet;
Instant access anytime anywhere;
The most current versions, even when the industry standards change;
An insanely affordable cost-per-view.
See why schools and hospitals around the world trust the Phlebotomy Channel to flawlessly deliver high-caliber training videos on demand. Plus, with real-time tracking, you'll get a full report on who watched the videos you assigned and when. You'll also be able to assess their comprehension with the CE quiz accompanying every title. Start streaming. You'll be amazed how convenient it is.
Should CBCs and Coags be Fasting?
One doesn't usually think of complete blood counts (CBCs) or coags to require the patient to fast. Researchers in Latin America, however, found evidence to the contrary.
Twenty healthy volunteers participated in their study on the effect breakfast has on routine hematology and coagulation laboratory testing. A breakfast containing a standardized amount of carbohydrates, proteins, and lipids was consumed 1, 2, and 4 hours before blood sampling for routine hematology and coagulation testing. Statistically significant differences were found two hours after breakfast for red blood counts, hemoglobin, hematocrit and mean corpuscular volume. Four hours after ingesting the breakfast meal, statistically significant differences were found for red blood cells, hemoglobin, hematocrit, mean corpuscular volume, white blood cells, neutrophils, lymphocytes, monocytes, mean platelet volume, and activated partial thromboplastin time.
The authors concluded fasting needs to be carefully considered prior to drawing CBCs and coagulation tests and recommend it for coagulation testing.
Read the full study.
[Editor's note: implementing the results of any singular study with a small sample size may not be warranted without further and more comprehensive evidence from multiple studies reach the same conclusion.]
YouTube Video of the Month
The Center for Phlebotomy Education's YouTube Channel features high-quality, standards-based educational and inspirational content for anyone who performs, teaches or manages blood collection procedures. This month's featured video helps phlebotomists and other healthcare professionals who draw blood samples respond appropriately to the common patient request for a butterfly needle.
From the Editor's Desk
When you live in the north woods where the winters are long and brutal, there's nothing like wood heat. Besides, the fuel is free as long as it's on your property and you don't mind working for it. Not that I need to heat the house in June, but the snow will return soon enough so I'd better start stocking up and stacking up. The one caveat with heating with wood is that you've gotta have dry, seasoned wood. To that end, I've been constructing a wood shed to replace the ragged tarp that's been not so good at keeping my fuel dry.
She's going to be a beauty; not because I'm the designer, engineer, builder, inspector and painter, but because grand is my brand. Go big or go home, I say. This shed will be 10' x 20' with a 12/2 architecturally shingled roof made from nothing but the finest materials. It helps that I live right next to Beach Depot.
Beach Depot, that's what we call it, is a stretch of beach about 100 yards from our home on Lake Huron where almost everything a person might need to build a woodshed has washed ashore.
Lake Huron has 3,827 miles of shoreline. With water levels at historic highs, docks and decks are falling into it like canned goods from a grocery shelf during an earthquake. Plucked from who knows where by nature's sticky fingers of erosion and floated wherever Huron's fickle currents please, plenty of it somehow becomes inventory at my neighborhood Beach Depot. And the shipments just keep coming. Not that I revile in the erosion of someone else's waterfront and the floating away of their platforms, ramps and staircases, but finding and notifying the owners of such flotsam in order for them to retrieve it is impossible. So it either lies there littering the sand or becomes part of a woodshed.
The Beach Depot has saved me many trips to the local lumber yard in constructing my shed. I love the nice wide aisles, self-checkout, and the variety. What I like best are the prices (everything is free), the store hours (it never closes), and the lack of competition from other shoppers (I'm the only customer). And you can't beat the selection. I've been able to score 2x4s and 2x10s for my shed so far. all just a short walk away from my construction site. How convenient is that! Oh, and I don't have to worry about wearing a mask and social distancing. Unless, of course, it's the seagulls I need to distance from. But then, they seem to be distancing from me on their own.
If I had the projects for them, I could bring home corrugated pipe, treated 4x4 posts, stringers, deck boards, landscaping stones, gravel and sand, plenty of sand. I only need one project at a time, though---I'm building a woodshed, remember. But when it's done I'll wander the aisles and see what I might be able to construct from what's still there. I'm sure there's something else I need to build. It's just that I don't know I need it yet.
Take care, my friend,
Dennis J. Ernst, editor
CLSI's Blood Collection Trilogy
Three documents from the Clinical and Laboratory Standards Institute (CLSI) comprise the bedrock of phlebotomy procedures and training materials around the world.
GP33---Accuracy in Patient and Sample Identification (2019)
GP41---Collection of Diagnostic Venous Blood Specimens (2017)
GP48---Essential Elements of a Phlebotomy Training Program (2017)
Each document is highly referenced and developed by committees chaired by Dennis J. Ernst MT(ASCP), NCPT(NCCT), director of the Center for Phlebotomy Education and editor of Phlebotomy Today.
"Any facility that isn't using this as a basis of their procedure manual is putting them at risk of operating beneath the standard of care," says Ernst. "Users of these documents are more likely to provide patients with a standardized phlebotomy experience, maintain sample quality, prevent patient injury, and release test results that accurately reflect the patient's health status. Not only that, but they have the confidence their procedure manual is based on standards and guidelines established by the consensus of highly respected authorities from some of the most prestigious organizations on the planet."
By special arrangement with CLSI, print and digital copies of these documents are available on the 'Standards" page of the Center for Phlebotomy Education's web site. They are also available directly from CLSI for about the same price.
Discernment and the Difficult Draw
If 6.4 percent of all venipuncture attempts require more than one stick, that's a lot of frustration on both ends of the needle.(1) What can make the difference between a failed attempt and a successful collection? Discernment. Discernment is the quality of being able to grasp and comprehend what is obscure; a power to see what is not obvious. For those who draw blood samples, discernment allows the well-trained and experienced phlebotomist to rely upon more than just what meets the eye during site selection.
More than meets the eye
A physical limitation phlebotomists routinely see in their patients is veins that are not visible or easily palpated. This is common with obese patients where adipose tissue can be mistaken for a vein in the antecubital area. As with any difficult draw, discerning collectors should take their time in locating a vein, relying on their tactile survey of the area—specifically, the spongy, resilient nature of veins when palpated—to successfully discriminate between structures below the skin's surface. To increase filling and palpability of difficult-to-find veins, lower the patient's arm below the plane of the heart. Just be sure to avoid such techniques as slapping the patient's skin, since this is considered overly aggressive and unprofessional. Another way to increase blood flow and aid vein location is by applying a warm compress for several minutes to the area being surveyed. Once identified, creases, freckles or contours in the skin can serve as visible guideposts to the vein's location, helping collectors resist the temptation to repalpate the cleansed site.
Rolling, rolling, rolling
Just because a vein is visible doesn't mean you're home free. Veins that are not properly anchored during the draw, referred to as "rolling veins," are a frequent cause for failed venipunctures. Insightful phlebotomists can compensate for veins that are not naturally stationary by stabilizing every vein selected prior to the puncture. This is accomplished by pulling the skin taut with the thumb of the free hand from below the intended puncture site. Techniques that anchor the vein from above and below the puncture site should never be used, as these methods place the collector's index finger at greater risk for an accidental needlestick. If the vein is missed, a calculated relocation of the needle can be attempted by pulling back slightly or advancing the needle farther into the vein.(2) However, lateral (side-to-side) relocation of the needle is considered probing and is not recommended. Because of the close proximity of nerves and the brachial artery, needle relocation should not be attempted in the area of the basilic vein.
When presented with small or fragile veins, as is often the case in pediatric and geriatric patients, a successful venipuncture requires a delicate balance between technique and the correct equipment. Selecting a smaller bore needle, such as a 23-gauge needle and applying less vacuum are two ways to reduce the stress to fragile veins. If the vein is suspected to have collapsed while using a tube holder method, trying a pediatric tube may salvage the draw. When assessing the difficulty of a draw, a syringe offers the most control over the negative pressure asserted within the vein. Should a vein collapse while using a syringe, momentarily release the pressure on the plunger, then gently pull back again. If this does not restore blood flow, terminate the venipuncture and select another site. In the event of hematoma formation, terminate the draw immediately and apply firm pressure to the puncture site until bleeding has ceased. Provide proper post-venipuncture care, according to your facility's protocol.
Outside your element
Collections in unconventional settings come with their own set of unique challenges. Failure to properly position a patient can complicate the procedure, given that most draws of this nature are performed without benefit of a phlebotomy chair or other personnel. Should the patient experience an adverse reaction, the risk of injury can be significant in such uncontrolled environments. Perceptive phlebotomists know to always position the patient for safety's sake by either seating patients in a chair with two arms or reclining them on a sofa or bed. But proper placement doesn't just refer to the patient. Also crucial to the success of the draw is the accessibility of supplies, which should be within easy reach. This prevents the collector from having to stretch or reach across the patient in the event another tube is needed or supplies are dropped or forgotten. Discerning phlebotomists anticipate the difficulties that improper positioning can create in such situations, and make it their motto to never draw blood from a patient who is standing or seated on an armless chair, exam table, or stool.
Fear and loathing
A patient's level of apprehension can take a what should be a routine draw and escalate the difficulty exponentially. It has been estimated that up to 20% of the population is predisposed to needle phobia.(3) Given that knowledge, perceptive phlebotomists remain on the lookout for the tell-tale signs of shock reflex in their patients, such as fainting, dizziness, pallor, perspiration, and nausea while the patient is in their care. Although there are various alternatives available to minimize a patient's physical discomfort and anxiety, one of the simplest methods to manage needle phobia patients is to lay them flat with the legs raised and apply an ice pack to the intended puncture site for 10 to 15 minutes prior to the venipuncture.(4) Regardless of the age or level of emotion demonstrated by the patient, collectors should respond with compassion and patience rather than scolding or ridicule. Employing age-appropriate strategies to calm fears can further prevent a patient's encounter with a needle from becoming a life-altering traumatic event. However, there are times when no amount of coaxing or cajoling can secure cooperation. Always seek assistance when drawing from combative patients, cognitively impaired patients, or those under the influence of mind altering substances using appropriate restraint as necessary.
Lost in translation
Astute phlebotomists who always use an active method of patient identification—where the patient is asked to state his/her name and other unique patient identifiers rather than merely affirm what the collector states—will quickly detect if a patient is hard of hearing or does not speak the language. Every patient deserves the right to hear and be heard. For patients who do not speak the language of the collector, interpreter services should be available to ensure proper identification, answer any questions, and provide post-venipuncture care instructions to the patient.
1) Howanitz PJ, Schifman RB. Inpatient phlebotomy practices. A College of American Pathologists Q-Probes quality improvement study of 2,351,643 phlebotomy requests. Arch Pathol Lab Med. 1994;118(6):601-5.
2) CLSI. Collection of Diagnostic Venous Blood Specimens; Approved Standard—Seventh Edition. CLSI document GP41-A7. Wayne, PA: Clinical and Laboratory Standards Institute; 2017.
3) What patients must know about needle phobia. Phlebotomy Today. 2003;4(8).
4) Ernst D. Applied Phlebotomy. Lippincott, Williams & Wilkins. Philadelphia, PA. 2005.
[Editor's Note: The Center for Phlebotomy Education has produced a video titled Successful Strategies for Difficult Draws, available in DVD and streaming versions, both available on the Center's web site. More information.]
Test Talk: Calcium
It's amazing how many metabolic processes depend on calcium, making it an essential test not only for assessing well being, but for disease diagnosis.
Only about one percent of the body's calcium circulates in the bloodstream. Half of that is free (ionized); the rest is bound to albumin or anions like phosphate. Vitamin D and parathyroid hormone (PTH) are responsible for maintaining blood calcium levels in a narrow range. That's why physicians often order Vitamin D and PTH levels on patients that have abnormal calcium results. When the balance between bound and free calcium is disturbed, a total calcium result is not very helpful, in which case the physician orders an ionized calcium level.
Besides being part of a routine metabolic panel for wellness screening, abnormal calcium levels are associated with conditions affecting the kidneys, bones, thyroid, parathyroid, heart and nerves. With so many systems depending on this mineral to function properly, it's no wonder it's so frequently ordered.
Conditions and diseases in which total calcium levels become abnormal include kidney stones, thyroid and parathyroid disorders, malnutrition, malabsorption, bone diseases, and neurological disorders. Conditions in which ionized calcium provides better diagnostic information include recently transfused and infused patients, critically ill patients, patients undergoing major surgery, and those with abnormal blood proteins or protein levels.
Calcium levels are lowest in the bloodstream between 2:00-4:00 a.m. and highest at 8:00 p.m.
Total calcium is typically tested on serum samples whereas ionized calcium can be drawn into heparinized tubes as well. Neither require the patient to be fasting. Fist-pumping elevates ionized calcium levels. Serum to be tested for calcium is stable at room temperature for 48 hours before centrifugation, but heparinized samples for ionized calcium have an uncentrifuged room temperature stability of only two hours. After centrifugation, total calcium is stable for seven days at room temperature and ten days if kept refrigerated. Some studies suggest a 3-week stability for total calcium when stored in a refrigerated environment.
- LabTestsOnline. American Association for Clinical Chemistry. AACC. Accessed 6/5/2020.
- 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. 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.
What's Wrong Here?
What's wrong with this picture? (Click image to enlarge.) We guarantee something isn't as it should be. The answer will be in next month's issue.
Last month's "What's Wrong Here?" image (right) depicted a conventional needle, i.e., one without a safety feature. In the United States and countries within the European Union, it's required by law to use only devices with a sharps-injury protection feature.
According to EPINet, an occupational exposure surveillance system developed by Dr. Janine Jagger, hospitals surveyed reported an average of 38 needlesticks per 100 occupied beds the year before the revised Bloodborne Pathogens Standard was issued. After it became effective, the average rate of needlesticks plunged 36 percent to just under 24 per 100 occupied beds.
Putting safety needles into the hands of users is one thing, but getting them to activate the safety feature is not to be assumed. According to the most recent EPINet data, 64.3 percent of all reported accidental needlesticks involving a safety needle occurred with a device that was not activated. Nearly 21 percent occurred with a partially activated device. With the multitude of safety devices available for both venipuncture and skin puncture procedures, unsafe practices are becoming the greater challenge to those who manage specimen collection personnel. Enforcement of the facility's policies on safe practices, the proper use of personal protective equipment, and full compliance with the Bloodborne Pathogens Standard are critical to achieve the lowest exposure rate possible.
Tip of the Month: Respect the Needle
Click here for this month's featured Tip of the Month from our rich library of archived Tips.