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Phlebotomy Today

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July, 2018

Nursing Home Etiquette for Phlebotomists

Elderly ladyMost phlebotomists spend their entire professional careers in the laboratory/hospital setting. Few have the opportunity to work in a long-term care environment. While nursing homes have a number of similarities to the hospital/clinic locale, there are also a number of dissimilarities of which the phlebotomist must be aware and appreciate.

  1. A nursing home is actually a collection of homes. The room in which each resident stays is not a hospital room; it is their home. This is where they live. The phlebotomist should be mindful of this and always knock on the door and wait for an invitation before entering. It's a courtesy you afford to those who live on your street; homes in long-term care facilities should be afforded the same consideration. If an invitation to enter isn't issued, consider the resident may be hard of hearing, asleep, on the commode, not prepared for a visitor, or not even in the room. Enter carefully and respectfully.
  2. Never assume that all elderly individuals are suffering from hearing impairment. Some do, but others can hear perfectly. Communicating to everyone in a loud voice may be welcomed by some, but irritating to others. Determine your patient's hearing ability and adjust the volume and tone of your voice accordingly. Speak distinctively and make eye contact when you are speaking to them. Even if they have difficulty hearing, many can understand what you are saying by reading your lips.
  3. Always present a pleasant and professional image in your appearance and disposition. People don't like to be stuck with a needle, particularly if it includes being aroused from a peaceful sleep. Patients won't be any more the lighthearted if the phlebotomist sticking them is an old grouch. Add a complement if appropriate. If they have flowers in the room, or have on a pretty bathrobe, a compliment might brighten their day.
  4. Often the aging process results in "tissue-paper" skin and fragile capillaries. It is important for the phlebotomist to make sure the tourniquet doesn't pinch the skin by tightening it over clothing. Since many of these patients are on anticoagulants, it is vital that you make sure that there is no bleeding or blood seepage at the venipuncture site prior to bandaging. The standards require at least five seconds of observation. Make it 15, just to be sure. Consider using a non-adhesive wrap instead of an adhesive bandage for less trauma to the skin and more comfort to the patient.
  5. Dementia and loneliness can present both problems and perplexity for the phlebotomist in a nursing home. It is important to always approach both situations with a professional and sympathetic demeanor. Sometimes elderly men may reach out and touch female phlebotomists in an inappropriate manner. Many times they are simply reaching out for a human touch and don't have any idea that the touch was inappropriate. The appropriate reaction on your part is imperative. In most cases, you can quietly take their hand into yours and hold it for a moment; then tell the person that you need for them to keep their arm in a certain position so you can get their blood. If this fails, calmly remove the person's hand and quietly leave the room. Explain your problem to the nursing staff and seek their assistance. Avoid overreacting. The person may already be confused and this will only aggravate the problem.
         On the other side of the spectrum, some individuals don't like to be hugged or touched by strangers. Be cautious about your physical conduct. Addressing the resident is also significant. Always call the occupant by their name, for example, Mrs. Smith, or Mr. Jones, NEVER as "Sweetheart," "Sugar," "Darling," or some other affectionate name. It may not be welcome.

  6. Remember that you are an ambassador for your employer. When you come in contact with both nursing home residents and the nursing staff, they should see a person who is professional, competent, caring, and who's integrity is beyond question.
  7. Last but certainly not least, be considerate. If you have an infection, particularly an upper-respiratory one, stay away from the nursing home. Elderly patients usually have an impaired immune system. It doesn't take much for them to become ill and the illness can become life-threatening.

    Adapted from an original article by Garland Pendergraph Ph.D, SM(ASCP), author of Phlebotomy and Patient Services Techniques.

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Standards Update: Recording volumes of blood drawn

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.

GP41_cover_400wFor many years, CLSI and other agencies have required facilities to monitor the volume of blood withdrawn from neonates and other patients susceptible to iatrogenic anemia without recommending a limit. With the release of the latest version of CLSI's venipuncture standard, we now have guidelines. 

Until now, only two charts were available for facilities to reference. They appeared in Phlebotomy Handbook (Pearson) And So You're Going to Collect a Blood Specimen (College of American Pathologists). In both cases, the charts were reprinted from those in use at two respective hospitals, but neither publication mentioned the basis on which the limits were established.

In 2010, the World Health Organization researched the limits in use at 30 healthcare facilities in Europe, and published their recommendation that facilities should establish a limit of between 1-5 percent of the patient's total blood volume during a 24-hour period and 10 percent over an eight-week period. The revised venipuncture standard also makes this recommendation.

Since 90 percent of critical-care patients develop iatrogenic anemia by their third day in a critical care unit, it is essential for facilities to comply with this new standard provision.

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: New CE exercise just released

This month, the Center for Phlebotomy Education announces the release of Volume 7 in its popular To the Point CE library of downloads. Volume 7 is a single PDF containing five articles on a variety of phlebotomy topics with corresponding test questions awarding 6.0 contact hours of P.A.C.E. continuing education credit.* . Article titles include:

  • TTP7_cover_1000wBest Practices in Tube Handling

  • Reducing Pain During Infant and Pediatric Venipuncture

  • What Every Phlebotomist Must Know About Hand Hygiene

  • Ergonomics from a Phlebotomist's Perspective

  • If Tubes Could Talk

  • Troubleshooting the Failed Draw

  • About Your Draw Stations

The To the Point series provides two affordable continuing education options: 1) for managers to implement in-house, and 2) for individual phlebotomists and other healthcare professionals who draw blood samples to meet their CE requirements by obtaining formal P.A.C.E. credit.* For in-house use, managers/instructors distribute the lesson and quiz, then grade their staff/student's answers as an internal education exercise.

Illustrated and highly researched, all material provided is current and consistent with the latest CLSI standards and OSHA guidelines.

*To earn 6.0 contact hours of P.A.C.E. credit, individuals should purchase the P.A.C.E. version of the download, read all five articles, record their answers to the test questions and lesson evaluation, and submit the completed form to us for processingA test score of 70% or higher is required.

Click here to order and download.


From the Editor's Desk


Running has always played a big part in my life ever since high school track. I never won a race for the team, but I did earn a healthy craving for the activity. Those of you who run know what I mean. For those of you who don't, let me try to make some sense of what you may consider to be senseless: running for the sake of running. Forrest Gump understood it, you should, too.

My first experience in running was as a "tweenager." Every night after dinner, Dad would take me and  my brothers to the horse track in our small town and run laps. That's where I learned you should never run right after a meal. A gut full of food punishes runners of all ages by stabbing them from the inside. It's a wonder the excruciating evening "side stitch" didn't prompt a vow to never run for the rest of my life.

I answered the calling next in high school when I joined the track team. After three weeks of practice, the coach discerned each member's individual assets and placed them in the event for which we were best suited, I was placed in the mile run. Not because that's where my talents would help the team win meets, but because the mile was the dumping ground for gangly teens who didn't have any talent at all. Kinda like Forrest.

It wasn't until after college, marriage and fatherhood that I finally discovered the joy of running and worked it into a daily routine. I would run in all seasons, conditions, temperatures and terrains. Eventually, I would enter races, not to win, but to add an interesting element to what had become for me that decent diversion all husbands and fathers should afford themselves. But eventually I did win a local 10K race in my age group, started training for longer distances, and completed three mini-marathons. For all the country and city miles I've run, I've only been bitten by a dog once. But that's one more than Forrest Gump ever got.

There's something innate about running. For many of us, it's calling of the highest order---maybe primordial, maybe divine---that cannot be suppressed, not even by a merely excruciating stitch in the side. Walking doesn't answer the call. It's not exhausting enough. In fact, exhaustion is at the heart of the obsession. Merely getting tired isn't enough; you have to get exhausted, fully spent, completely drained of energy, sweat and will. Runners run to be emptied of it all. Then we quit and call it good.

It's good because the process of pursuing sheer exhaustion takes us to a place we can get to no other way. It removes obstacles to clear thinking. It's a fog-lifter that invites reason, insight, logic and perspective that is otherwise obscured, even disallowed in a state of rest. It facilitates clear thinking and right judgment. Every pivotal decision I've ever made while pursuing exhaustion has been the right one, and I've made plenty. I don't know the physiology of it all, but it happens, and makes us lifelong runners. It may not be the same as a "runner's high," but it's high enough for me.

Unfortunately, I had to hang up my Nikes after 30 years of pounding the pavement. Hip fatigue was setting in, making it painful for hours after each jaunt. I went more than ten years without the benefits---or the pain---of running long distances. I missed it and the clear thinking greatly. Recently, however, I rediscovered the joy of being spent when I purchased a Giant Escape road bike,

Once again, I can spend over an hour pursuing exhaustion, getting all the benefits but without the impact. It's not the same as putting one foot down after the other mile after mile, but it's not far from it. Aptly named, my Escape helps me do just that. Cruising the roads of northern Michigan in 24th gear takes me where I've longed to be for over a decade. A place every person needs to visit for clear thinking as often as possible. Pouring myself out on the road does for me what no gym can ever do. Best of all, now I can outrun most dogs. 

And that's all I've got to say about that.


Dennis J. Ernst, editor

Phlebotomy Answer Book


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What Should We Do?: Staff wants to pre-assemble devices

Dear Center for Phlebotomy Education:

I'm an avid believer in standards, and am implementing the new provisions of the revised venipuncture standard and need your help. I'm getting push-back from my staff about the requirement that we are not to assemble our collection devices prior to greeting the patient. We draw a lot of blood from children, and it's been established long ago to have everything ready in advance and keep devices out of sight. Assembling the equipment in front of them not only adds time, if they happen to see it it can trigger their fear. What should we do?

Our response: We disagree that it saves time. It takes only a few seconds to assemble a device, five max. If these few seconds are perceived to be critical to the success of the procedure, we think the staff is rushing things a bit much. We advocate slowing down for pediatrics, attending to their fears and anxiety, explaining the procedure, establishing rapport and trust.... All these contribute to a better, more positive experience, and certainly aren't worth the risk of a child or parent thinking a needle left behind from the last patient was used on them.

We've experienced firsthand the agony patients go through when they thought a leftover device was used on them. It's mortifying and entirely preventable.

Your staff perceives needle phobic patients don't need to see the needle. However, according to pediatric pain expert Dr. Amy Baxter, 20 percent of pediatric patients prefer to watch the procedure and do better than if they were prevented from observing. Your staff should be assessing the child's emotions in advance, and acting accordingly. One question Dr. Baxter highly recommends healthcare professionals ask pediatric patients before drawing their blood is "how do you feel about needles?" For those who express apprehension, there are ways to assemble the device without letting the child see.

Have a long conversation with your staff about pre-assembling devices, and let them air their concerns. Make sure you articulate why it's necessary to assemble the device in the presence of the patient (besides being required by the standards) and provide strategies to conceal device assembly from the view of those pediatrics they suspect to be- needle phobic.

Editor's note: Listen to our Podcast with Dr. Amy Baxter on reducing pediatric pain.

 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 ManagerEmpoweredManagerWelcomeScreenShot_500w

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

The Jekylls and Hydes of the Workplace 

Every manager has had it happen: the person you interviewed and hired wasn't the same person who showed up for work. It's inevitable. Jekyll interviews and Hyde comes to work.

Don't kick yourself for not seeing the handwriting on the wall. No system will filter out the unsavory nuances of human nature every time. It's what you do after you hire the right person that makes them really right. On their first day they're only potentially right.

Management consultant and author Dale Daughten put to rest one of the most often repeated management mantras in business: hire the right person and then get out of their way. Instead, Dauten says we should hire the right person and then show them how to be better. Merely getting out of people's way isn't leadership, it's an invitation to wreak havoc in the workplace.  Your work on that person isn't over when you hire them. Getting out of the way is a cop out. Everyone needs direction, feedback and guidance. Everyone. Especially Hyde, since Jekyll was just the front man.  

Hiring the right people and making them better (even the Hydes) can only happen when an employer knows the expectations, needs and goals of every new hire and vice versa. With that established, becoming better for each other is merely a matter of communication. Merely.

It's only "merely" if Jekyll is the one who comes to work. If Hyde shows up for work it's not over, but it's time to get out the tough sled because that's what you've both got coming ahead. Mere communication won't salvage the hiring mistake. All you can do is interview Hyde and see what you really brought into the house.

Restate your expectations and reassess Hyde's. Point out any incidents, behaviors, or statements that contradict or mischaracterize Jekyll. Abandon all hope of Hyde reverting to Jekyll, it isn't going to happen. It's Hyde you have, and Hyde you have to make better. Find whatever might be worth building upon.

Somewhere between Jekyll and Hyde is your common ground, your employee worth keeping. It's up to Hyde to let you take him there or to make you show him the door and take his tough sled with him.

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Tip of the Month: An Army of One

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