Skin Puncture or Venipuncture? Pros & Cons, Part 2
Skin puncture or venipuncture? That's one of the first questions every healthcare professional with specimen collection responsibilities must answer when approaching every patient. What goes into your decision-making process?
For most patients, the volume of blood required mandates a venipuncture. But for many others, it's the collector's choice. What factors must be considered when making the decision? Those pertaining to specimen quality were covered last month in Part I in this series. This month we look at the pros and cons of each method of specimen collection as they pertain to patient and collector safety.
Stability and collector safety
Because venipunctures require precise placement of the needle in the vein throughout the procedure, patient stability is critical to its success. Patients who are apprehensive (e.g., needle-phobic patients, pediatric patients, etc.) may be collected more successfully by skin puncture, provided the volume of blood required is minimal. Although skin punctures may be more painful than a properly performed venipuncture, stabilizing the puncture site after the piercing the skin is less critical to the success of the procedure. Collectors must carefully weigh the benefits of minimizing venipuncture pain against the potential for patients to move their arm during the procedure, and determine which procedure is most likely to be successful.
Table 1: Venipuncture Pros and Cons
| direct access to the circulatory system
|| greater likelihood of sustaining an accidental needlestick
| potentially less traumatic to the patient
|| greater potential for patient injury
| the ability to draw larger volumes of blood
|| potential for hemoconcentration to affect test results
| faster than obtaining capillary blood
|| increased potential for hematoma formation
| less likely to be contaminated by tissue fluid
|| requires greater patient stability
| less likely to be hemolyzed
|| multiple venipunctures precipitate iatrogenic anemia
|| difficulty detecting nerve damage in infants
In addition, because venipunctures to patients whose arms are not properly immobilized put the collector at risk of sustaining an accidental needlestick, collectors should consider the potential when deciding which procedure to perform. Capillary punctures or incisions are less likely to result in accidental exposures regardless of patient stability since OSHA mandates the use of retractable skin puncture and incision devices. Such devices do not expose the collector to the contaminated sharp.
However, the pros and cons of performing a skin puncture bear no less consideration. Table 2 lists the benefits and detriments.
Capillary procedures may also be safer for patients at risk of developing iatrogenic anemia (anemia induced by diagnostic blood sampling). Newborns and geriatric patients are most vulnerable to red blood cell depletion should the cumulative volume of blood drawn by venipuncture be excessive. Collectors who consider iatrogenic anemia as a potential complication when selecting the method of specimen collection reduce this risk and enhance the quality of care the patient receives.
One of the most important factors to keep in mind when deciding which procedure to perform is the likelihood that the procedure could injure the patient. Since venipuncture to the antecubital area, specifically to the basilic vein, can involve underlying nerves and the brachial artery, collectors should weigh the potential for injury to these structures, especially in patients with hard-to-find veins. In newborns, the risk of complications from nerve injury when performing a venipuncture is even greater than for older children and adults. In an older patient, the pain associated with the needle coming in contact with a nerve is obvious. In newborns, reactions to extreme pain are difficult to differentiate from reactions to mild pain. Therefore, collectors performing venipunctures on newborns do not have the benefit of the same differential pain response that signals nerve involvement as in older patients, and are less likely to terminate a venipuncture immediately when a nerve is involved. The loss of the ability to differentiate pain in infants can lead to the potential for a permanent nerve injury.
Table 2: Skin Puncture Pros & Cons
| patient stability less critical
|| hemolysis more likely
| requires less precision
|| specimen clotting more likely
| minimizes iatrogenic anemia
|| more painful to the patient
| patient injury less likely
|| yields smaller volumes of blood
| decreased risk of accidental needlestick
|| potential for tissue fluid contamination
||may take longer to complete
An additional patient safety consideration is the likelihood of hematoma formation. When blood leaks from a vein into the surrounding tissue during or after a venipuncture, the potential for more than unsightly bruising exists. Hematoma formation can exert pressure on the nerves that pass through the antecubital area and lead to Complex Regional Pain Syndrome, Type II. If hemorrhaging is severe, other complications can develop. Capillary sampling does not risk complications from hematoma.
Since the risk of complications from skin punctures is minimal in comparison to venipunctures, the safety of the patient should be considered with all the other variables discussed when determining the most appropriate blood collection procedure. Collectors should be mindful of this risk along with the other variables discussed in this series in order to make a professional judgment as to which procedure is in the best interest of the patient in terms of safety and specimen quality. Continuing education on these and other specimen collection issues is critical to providing accurate results and quality patient care.
Basic Venipuncture, 3rd Edition Now Streaming
The industry's most popular venipuncture training video is now streaming on The Phlebotomy Channel.
The first edition of Basic Venipuncture was released 2004 and instantly became the gold standard for venipuncture training in facilities and academic programs around the globe. Since it's debut, it's been viewed by hundreds of thousands of healthcare professionals and students learning the most commonly performed invasive medical procedure in healthcare. The third edition, released in July, updates the popular video with the newly revised venipuncture standard published last year by CLSI, and took 18 months to produce.
"Phlebotomy is a highly detailed procedure," says Dennis J. Ernst MT(ASCP) NCPT(NCCT) who wrote, directed, and produced the video. "To reach perfection, we held seven filming sessions, revised the script 15 times, had 13 rounds of post-production edits, recruited eight actors and spent hundreds of hours of preparation, execution, direction, and footage review."
Ernst provides script assistance
to narrator Angie Glotzbach.
Features of the 3rd edition include:
- Completely updated to reflect the newly revised CLSI venipuncture standard;
- Completely new script, narrator, and organization of the material;
- Filmed in high-definition;
- 12-minutes longer than the 2nd edition;
- Closed captioned by the National Captioning Institute.
Currently, Basic Venipuncture's 3rd Edition is only accessible to Phlebotomy Channel Subscribers. In addition to Basic Venipuncture, the Phlebotomy Channel hosts a library of 16 other titles on a wide variety of blood collection topics. Most are full-length features ranging from 29- to 52-minutes, but several compelling short clips are also accessible.
"In the healthcare industry, VHS tapes gave way to DVDs 15 years ago," says Ernst. "Now we're seeing a dramatic shift toward streaming as DVDs are becoming more and more obsolete." According to Ernst, Basic Venipuncture, 3rd edition will still be released on DVD but in limited quantities. He expects them to be available later this month or early October.
Global Summit: Last Call
Standards Update: Codifying the obvious
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.
It's hard to imagine a venipuncture standard not requiring some of the aspects of the procedure we all know to be necessary. Such was the case when the CLSI committee tasked with the revision got to work. For example, prior versions of the standard did not mention:
- Using a needle only once---this means once the needle has been removed from the patient, it cannot be reinserted in the case of a missed vein or any other reason.
- using a safety transfer device when transferring blood from a syringe into a tube---OSHA established this as a practice in 2002. Tube stoppers cannot be pierced and the tube filled with the same needle that performed the puncture when using a syringe.
- assembling devices in the presence of the patient---Patients need to see the device assembled in their presence in order to have the confidence the needle is not left over from the last patient. Devices preassembled by the manufacturer and shipped in sterile packaging are acceptable, but the sterile package must be opened in the presence of the patient.
- gloves must remain intact throughout the procedure---this codifies the ban on tearing the tip of the glove's finger off in order to palpate the vein.
- tubes must be filled to their stated volume---This has always been a best practice. Now it's against the standards to underfill a tube.
- the contents of tubes cannot be combined---Also a best practice, and now banned by the standards.
Codifying all these common-sense concepts is long overdue in a global standard. This, and every other revision mentioned in this series makes the new CLSI venipuncture standard (GP41-A7) the most comprehensive, rigorous, and perfected version in the document's history, which goes back to 1977.
Editor's note: This completes this series on revisions to the CLSI venipuncture standard. 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: Preanalytic Poster Set
The Center for Phlebotomy Education offers special pricing on its set of five preanalytic posters that vividly portray sound specimen collection techniques that reinforce key concepts with your staff and students. The set consists of:
- Blood Specimen Collection Sites and Precautions wall atlas
- Ten Commandments of Phlebotomy
- Order of Draw
- Accurate Results Begin With Me!®
- Blood Collection Errors and Impacts
The Blood Specimen Collection Sites and Precautions wall atlas illustrates the anatomy of the antecubital area, depicting acceptable sites for blood specimen collection and text describing the risks of venipuncture. It is the only poster that shows nerves, veins, and the brachial artery of the antecubital area. The Ten Commandments of Phlebotomy proposes 10 rules all specimen collection personnel should consider to be "commandments" for performing the procedure.
The Order of Draw poster shows the order in which blood collection tubes must be filled to prevent additive carryover from altering testing results. Accurate Results Begin With Me!® lists 30+ tips on specimen collection embedded within a starburst design that draws attention. Blood Collection Errors and Impacts, the largest in the collection, lists over 40 errors that can be committed during the collection, transport, and handling of blood samples. A corresponding column lists the impact each error has on the test result and patient.
All five posters are printed in full color and laminated for durability. By displaying these posters in your outpatient draw stations and collection areas, you communicate to your patients that your facility is committed to assuring specimen quality and patient safety.
To order or for more information
MarketLab Declares September "Phlebotomist Appreciation Month"
Phlebotomists have a special place in the hearts of those at MarketLab, Inc., a laboratory supply company with global distribution based in Caledonia, Michigan. That's why they've declared September as Phlebotomist Appreciation Month.
It only stands to reason that the company would put healthcare's most underestimated profession on the pedestal this month. MarketLab first took root as a phlebotomy-only supply company laboratorians may remember as Phlebotic, LLC. Since then, they've grown to become one of the industry's most innovative suppliers, serving healthcare facilities and educators around the world.
To celebrate phlebotomists everywhere, MarketLab is conducting a "Love for Phlebotomy" contest. The person who best answers the question "Why do you love phlebotomy?" will receive a modular phlebotomy tray. Simply write your answer in 150-200 words and send it to MarketLab by September 30. The judges are looking for passion and detail, so don't hold back.
For more information, visit MarketLab's Phlebotomist Appreciation Month web page.
Empowered Healthcare Manager
Every month we run an excerpt from our editor's popular blog, The Empowered Healthcare Manager.
What's your BHAG?
Do you have one? If not, it's time you do.
Jim Collins introduced us to Big Hairy Audacious Goals in his landmark book Built to Last. BHAGs are game-changing, courageous, meaningful, slightly insane, and seemingly impossible to everyone but you. If you don't have one yet, it's time.
It gets you up in the morning excited about your work, it obliterates the boundaries of what others think you're capable of, and it adds a tightrope to your daily career walk. If you want safe, BHAGs aren't for you. If you don't want to be noticed, BHAGs are best left to those who do. If you're content with occupying your position instead of transforming it, stop reading now. Your status quo needs maintaining.
But if you want to be part of something bigger than yourself, a BHAG's your ticket out of the mundane, the safe, the numb. Try one of these game-changing, courageous, meaningful, slightly insane, and seemingly impossible goals:
- A 1% or less blood culture contamination rate in your facility;
- A 75% reduction in turnover among your phlebotomy staff;
- Cut your sample rejection rate in half over the next three months, then cut it in half again.
- Find a way to have every nurse in your facility who draws blood samples shadow a lab employee for a day. Then reverse it.
- Create your own in-house phlebotomy school, then hire the cream of the crop.
- Conduct monthly (or quarterly) educational events and invite your counterparts from other facilities in the area to increase the size of your community.
- Find out what your staff hates the most (or likes the least) about their job and eliminate it (or make it more interesting). Then ask again.
- Offer every outpatient a guided tour of your laboratory after their draw.
- Identify your three most undependable employees and make them your most dependable in 12 months. The next year, pick your next three and do the same.
If none of these grab you, close your office door, shutter the blinds, and put on whatever music helps you reflect deeply. Think about the one thing you dread about your work, loathe about your department, or regret about your staff, then construct your own BHAG. Don't be timid. Block out that little voice that tells you it's impossible. Imagine what it would be like without it darkening your day and suppressing your spirits. If the alternative reality you envision suddenly gives you butterflies, that's your BHAG.
If you imagine it, it's already half-happened.
Subscribe to The Empowered Healthcare Manager blog.
Phlebotomy Answer Book
To order or for more information....
Tip of the Month: Recipe for a Phlebotomist
Click here for this month's featured Tip of the Month from our rich library of archived Tips.