Court Rules Phlebotomy Instructors Don't Need to be Qualified
The Illinois Supreme Court recently ruled phlebotomy instructors in the state do not need to be qualified to teach the procedure.
In a stunning decision, the court dismissed a case brought by Kenrick Roberts, a former Malcolm X College employee who was responsible for making sure the school hired qualified teachers. Roberts claims he was wrongly fired for complaining to administrators about the college's recurring practices of hiring of phlebotomy instructors who lacked the qualifications to teach the subject. He sued the college in 2015 for wrongful termination and violations of the Whistleblower Act.
Attorneys for Roberts argued their client was trying to protect the college's Title IV eligibility to receive federal loan and grant funding by ensuring all instructors were qualified to teach their subjects. As evidence, Roberts observed the appointed instructors were not qualified according to NAACLS. However, in writing his May 23, 2019 majority opinion, Chief Justice Lloyd Karmeier stated that NAACLS wasn't an accepted accrediting agency for Title IV eligibility in 2015.
The opinion went on to state Roberts didn't prove the college made any promises about the qualifications, training or experience of the instructors. While Roberts claimed the instructors weren't qualified, he failed to show evidence that the college promised they were, according to the Chief Justice's opinion.
"There is no allegation, much less supporting authority, that students must be taught by certified phlebotomists/EKG technicians in order to become a certified phlebotomist or EKG technician," Karmeier wrote. Roberts failed to prove that students who are taught phlebotomy by unqualified instructors would be unable to meet phlebotomy certification guidelines.
Read the full story.
Product Spotlight: Answer Book Discount
The Lab Draw Answer Book is now 33% off through August.
Published by the Center for Phlebotomy Education, The Lab Draw Answer Book contains answers to nearly 400 commonly asked questions on blood sample collection and handling, and managing phlebotomy services and personnel. Written by Dennis J. Ernst MT(ASCP), NCPT(NCCT) and Catherine Ernst RN, PBT(ASCP), the husband-and-wife team hopes their work helps place a guru in every lab, nursing department and classroom.
"I've been called the phlebotomy guru many times," says Dennis. Everything I know about performing and managing blood collection procedures is in this book. It's like having my brain on your desk, but without the formaldehyde."
The 440-page full-color reference book fully reflects CLSI's current venipuncture standard and the Standards of Practice of the Infusion Nurses Society as it pertains to blood sample collection from vascular-access devices.
Chapters in the book include:
- Safety and Infection Control
- Training, Management and Certification
- Skin Punctures, Heelsticks, and Pain Management
- Patient Identification, Vein Selection, & Site Prep
- Tourniquets & Butterflies
- Order of Draw & Discard Tubes
- Hemolysis and Potassium Issues
- Blood Cultures
- Labeling and Post-venipuncture Care
- Line Draws & IV Starts
- Processing, Storage, & Transportation
- Patient Injuries & Complications
- Unorthodox Techniques
Whether you're already a phlebotomy guru or want to become one, the Lab Draw Answer Book can make you the person everyone climbs the mountain to seek the truth about drawing blood samples for laboratory testing.
To order or to preview pages.
Compliance With Phlebotomy Standards in Tunisia
Researchers in Tunisia set out to determine the relative rate of compliance with industry standards among healthcare professionals who draw diagnostic blood samples. Their results, published last year in La Tunisie Medicale show the need for a nation-wide improvement plan, according to the authors.
The research team audited 330 phlebotomy procedures by observation at the 667-bed Hôpital Universitaire Sahloul Sousse, Tunisia in 2015. They referred to practice guidelines published by the World Health Organization and the European Federation for Laboratory Medicine's Preanalytical Working Group, which reflected CLSI's venipuncture standard GP41-A6. All scoring was conducted by two public health nurses practicing in the Prevention and Health Care Department of CHU Sahlou. No mention was made in the study of the type of healthcare personnel performing the phlebotomy procedures. The auditors scored each procedure according to five categories with multiple sub-categories. Compliance ranged from 20% (glove use) to 94% (patient prescribing and preparation).
- Patient prescribing and preparation (94.4% compliant);
- Equipment preparation (85.3% compliant);
- Hand hygiene (28.0% compliant);
- Glove use (20.0% compliant);
- Use of antiseptics (44.4% compliant);
- Collection procedure (45.1% compliant);
- Sample identification (64.3 % compliant);
- Laboratory worksheet (76.9% compliant);
- Transport (49.4% compliant).
The overall compliance rate was 57.7%. Ninety-one percent of all draws were successful on the first attempt. The results motivated the researchers to propose an improvement plan for blood collection procedures with the ultimate goal of improving the quality of care.
Read the study.
From the Editor's Desk
It's August, the time of year most people north of the Equator take vacations. Unfortunately, that doesn't include me.
Don't get me wrong, I love vacations; I just don't take them. I suppose it has a lot to do with the fact that I love my job and am not anxious to escape from it. On the other hand, I fully realize that one needs to take time away from the routine even when the routine is enjoyable. It revives the spirit, renews the soul, and provides a perspective one cannot have when the nose is close to the grindstone. One of my favorite sayings is "if you win the rat race, your'e still a rat." Only in my case, it' a lab rat.
I know it would be good for me to get away, unplug from my work. Maybe I will afford myself a real vacation someday---the Lord knows I need it---but for now it will have to be a day here and a day there. I will share with you I am taking four days off in September to welcome our newest grandson into the world. That will be a gloriously refreshing diversion, and one that will most certainly refresh my soul. So if your September issue is late, now you know why.
Filming begins soon on the 3rd edition of our popular Preventing Preanalytical Errors video. It's long overdue, for sure, and I'll tell you why in a future column. Suffice it to say that relocating the Center for Phlebotomy Education 600 miles north to Northern Michigan played a big part in it. Now that we're settled into new office space, please change our address in your records and/or with your purchasing department so our vendor information is up-to-date as follows:
Center for Phlebotomy Education, Inc.
107 E. 10th Street
Mio, Michigan 48647
Our phone, emails, and web address remain unchanged.
We are exceedingly grateful to Covenant Healthcare in Saginaw, Michigan for allowing us to film the preanalytical video in their fine facility. There's a back-story to this that I will also share in the coming months that I find very fulfilling and personally satisfying.
That said, I'm cutting this month's editorial short and taking the afternoon off. I only hope you're better at giving yourself permission to take a vacation than I am. At the same time I hope you, like me, find your work so enjoyable that you don't really need one.
Take care, my friends,
Dennis J. Ernst, editor
Phlebotomy CE Day Fast Approaching
Registration is open for the 6th annual Phlebotomy CE Day, jointly presented by AUMT Institute and the Center for Phlebotomy Education taking place in San Diego, California on Saturday, September 21, 2019.
All topics will be presented by the Center's Director, Dennis J. Ernst MT(ASCP), NCPT(NCCT) and will include:
- The Ten Commandments of Phlebotomy
- What's New in Phlebotomy (and What Isn't!)
- Ending Hemolysis in the ED... and Everywhere Else
- What Would You Do? (Case studies)
"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 collaborating with AUMT again, 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. 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.
Advice From the OSHA Expert: When OSHA Comes to Visit, Part 2
Dan the Lab Safety Man
Last month I discussed what a typical OSHA inspection could look like should one occur in your facility. You know how to handle the inspector, but how do you prevent a finding and therefore a fine? What types of violations would OSHA fine in a specimen collection area? What is a typical fine from OSHA and how can it be calculated?
Each fine from OSHA for a workplace violation starts at $13,260 per day. If there are multiple violations, and if the violations last for several days, that monetary amount will add up quickly. If the violation is considered willful (on purpose), the fine amount is multiplied by four.
Let's look at some examples. If a phlebotomist throws a needle assembly out into a trash can rather than into a sharps container, that would be one incident resulting in a fine of $13,260. Now multiply that by four if the employer can prove that training occurred. The phlebotomist knew that needles should go into a sharps container, so that is now a willful violation. The fine has become $53,040.
If a phlebotomist disposes of a needle and fails to activate the safety device, that is considered a willful violation. Needle safety devices must be activated as soon as possible after a blood collection. That is clearly for both the phlebotomist's and the patient's safety, but not doing so can incur a $53,040 fine each time it happens.
Can you think of other possible OSHA violations in a phlebotomy area? What about not using Personal Protective Equipment (PPE) such as gloves? Some phlebotomists also process specimens. Lab coats and face protection should also be worn. Do you have chemicals in your area? You need to consider chemical hygiene standards such as proper labeling and training.
As I stated last month, just be calm when an OSHA inspector arrives and starts to look around. However, you also have to remember to follow the rules, especially when it comes to safety. That's the best way to keep yourself from harm and to keep your employer from receiving huge fines!
You can contact Dan Scungio, "Dan the Lab Safety Man" at firstname.lastname@example.org.
Stage Set For World-Class Preanalytic Summit
Test Talk: GGT
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.
Gamma-glutamyltransferase (GGT or gamma-GT) normally exists in low concentrations in the blood. While many organs produce this enzyme, elevations are primarily associated with liver damage or liver disease. It is also one of the first tests physicians order when suspecting problems with their patients' bile ducts. That's because GGT is typically the first liver enzyme to increase in concentration when bile ducts become obstructed by tumors or stones.
Both GGT and ALP are increased in liver diseases, but only ALP will be increased with diseases affecting bone tissue. Therefore, GGT can be used as a follow up to an elevated ALP to help determine if the high ALP result is due to liver or bone disease.
If the physician notices a high alkaline phosphatase (ALP) level on a patient, he/she may order a GGT to investigate the cause of the elevation. GGT and ALP are typically higher in patients with liver diseases, but only ALP is elevated when bones are affected by disease. Therefore, GGT is important in evaluating whether an elevated ALP is due to liver or bone disease. Cardiovascular disease and hypertension can also elevate GGT levels. Patients with high GGT levels are thought to have an increased risk of dying from heart disease.
GGT is conducted on serum samples. It is stable for 48-72 hours at room temperature prior to centrifugation, and up to a month once centrifuged and removed from the cells. Since GGT levels fall after eating a meal, some facilities require this test to be fasting. Since it is also used to assess alcohol abuse, some patients are asked to restrict alcohol intake prior to having their blood drawn for this test. Smoking also elevates GGT levels.
1. Lab Tests Online. American Association for Clinical Chemistry. AACC. www.labtestsonline.org. Accessed 8/6/2019.
2. CLSI. Procedures for the Handling and Processing of Blood Specimens for Common Laboratory Tests; Approved Guideline—Fourth Edition. H18-A4. Clinical and Laboratory Standards Institute. Document H18-A4 Wayne, Pennsylvania 2010.
3. Wu A. Tietz Clinical Guide to Laboratory Tests---Fourth Edition. Elsevier. St. Louis, Missouri. 2006.
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 month's image (right) depicted a phlebotomist transferring serum from the pilot tube to a transport tube without using face protection. Whenever an exposure can be reasonably anticipated---as is the case when stoppers are removed and the sample manipulated---face protection must be used. Full goggles or safety glasses will suffice. Alternatively, an acrylic shield can be positioned between the sample and the face.
What Should We Do?: Blood mixup
Dear Center for Phlebotomy Education:
We had a situation where a phlebotomist collected blood from patient A, labeled the tubes and puts them in the rack next to the outpatient drawing chair. Then she drew the next patient, Patient B, and put each tube in the same rack. Before removing the needle from Patient B, she wanted to add more blood to one of the tubes, so she picked it out of the rack and pushed it back into the tube holder to fill further. That's when she discovered the tube she picked up was from Patient A, not Patient B.
Obviously, samples from both patients need to be recollected. But what we're wondering about is the potential for Patient A's blood to backflow into Patient B's vein. The phlebotomist used a tube holder and multi-sample needle. What should we do?
This was really unfortunate. We're sure the phlebotomist felt terrible about this mistake, and we applaud her for bringing it to your attention. It would have been easy for a phlebotomist of lesser integrity to keep it to herself. But she put the patient's safety ahead of her own concerns. She should be recognized for the courage to speak up.
Keeping this from happening again is as simple as changing your processes so that tubes from multiple patients are never in the same rack. For outpatients, that could mean two racks, one designated for prior patients and one designated for the patient in the chair. Alternatively, you could require tubes to be taken out of the draw stations between patients and delivered to the processing area or pneumatic tube station. For inpatients, it would require a second rack or other receptacle for previously drawn patients so that the current patient's tubes are not commingled. In this unfortunate case, the fact that Patient A's tubes were labeled was not enough of a distinction to prevent one from being placed into the tube holder being used on Patient B. A better mechanism is required.
Now, on to the more serious issue. Whether or not Patient A's blood backflowed into Patient B's vein, carrying potential pathogens with it, is hard to say. It depends on how Patient A's tube of blood was oriented when it was put into the tube holder being used on Patient B. If the partially filled tube of Patient A was oriented with the cap upward, Patient A's blood would not have come in contact with the stopper, nor the needle that pierced it. However, if the tube was angled downward, the blood in the tube would have come in contact with the stopper, and the needle piercing it could have allowed some of Patient A's blood to reflux into Patient B. We realize the phlebotomist probably has no recollection of how the tube was oriented, though.
But if it was oriented downward, two facts suggest the risk is real.
1) Most manufacturers of blood culture bottles do not recommend their blood culture bottles to be inverted inserted directly into a tube holder/multi-sample needle assembly because of the potential for broth to backflow into the patient. It stands to reason, therefore, that if broth has the potential, so does blood from a blood tube.
2) In Section 184.108.40.206, GP 41 states "If possible, ensure the patient's arm or other venipuncture site remains in a downward position to prevent reflux or "backflow" from the collection tube into the vein." It cites a 1975 article from the Can Med Assoc Journal. It's an old reference though.
So you'll need to weigh these carefully along with all the other ramifications when determining whether to notify the patient.
Tip of the Month: The Cure for Hemolysis
Click here for this month's featured Tip of the Month from our rich library of archived Tips.