Update: Draws From Mastectomy Patients
One of the most commonly asked questions among healthcare professionals with blood collection responsibilities is where do I draw blood from if my patient has had a mastectomy? It's been a while since Phlebotomy Today addressed this issue, so an update is in order. When the revised venipuncture standard was published last year by CLSI, the section on mastectomy draws had been completely updated with new references and considerations.
The argument for allowing draws from the same side of a prior mastectomy is that lymph-node preservation is given a high priority during mastectomies today more than ever before. Since the risk to patients when lymph nodes are removed is lymphedema and a lessened ability to fight infections, many feel venipunctures ought to be safer when lymph nodes are left intact. Unfortunately, evidence in the scientific literature on the safety of venipunctures performed on today's mastectomy patient is not conclusive. Besides, how many healthcare professionals who draw blood samples know the details of every patient's mastectomy? Not many.
Therefore, the rule against drawing from the same side of a prior mastectomy remains hard and fast: physician's permission is required in writing. The physician is in the best position to know the extent of lymph node removal, not the one drawing the blood.
It's not just the tourniquet that is the problem, it's any break in the skin on the affected side. That includes venipuncture or capillary puncture. The American Cancer Society's web site even cautions mastectomy patients against sewing without a thimble.
Even if the patient gives permission, verbal or in writing, it may not release the facility from liability should complications ensue. Her attorney can effectively argue that the patient was not aware of the risks involved and was not in a position to give informed consent. However, in difficult draw situations, you can escape liability if you get the physician to put his/her permission in writing, as required by the standards. For the record, evidence in the literature is inconclusive that test results obtained from a limb are affected by mastectomy.
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Device Company Partners with Center in Education Collaborative
Magnolia Medical Technologies, Inc. and the Center for Phlebotomy Education announced a collaborative training and education partnership dedicated to the prevention of blood culture contamination today at the HealthTrust Innovation Summit in Tucson, Arizona. The partnership is being formed to provide education on the challenges with current practices and techniques used for blood culture collection, and new best practices to prevent contamination with the goal of improving patient safety, quality of care, driving antibiotic stewardship and reducing hospital costs.
Supporting these efforts, the continuing education course "Preventing Blood Culture Contamination with a Closed-System Mechanical ISDD®" is immediately available. This web-based course provides registered nurses, physician assistants, phlebotomists, hospital administrators and other licensed healthcare providers with the latest evidence-based best practices for preventing blood culture contamination. The course also analyses the impact of sepsis misdiagnosis on unnecessary and inappropriate antibiotic treatment, patient safety, and hospital costs as well as strategies to improve quality of patient care. Each participant will earn one CEU credit hour toward their annual training and education requirements.
"We are excited to be partnering with Magnolia Medical to address one of the biggest problems plaguing our healthcare system today," said Dennis Ernst, Founding Director of The Center for Phlebotomy Education. "Steripath® Gen2 is the evidence-based technology solution to a problem many thought could never be solved. This training and educational program effectively demonstrates the clinically proven combination of technique and technology to empower hospital staff to seize control of blood culture contamination rates and improve the lives of over a million people each year, all while saving the healthcare system billions of dollars."
Each year, tens of millions of patients in the U.S. require a blood culture to help diagnose sepsis and other potentially deadly bloodstream infections. However, when current standard practices are followed, an average of 40 percent of positive results are actually false positives due to blood culture contamination.
A preassembled sterile, closed-system device, the Steripath Gen2 Initial Specimen Diversion Device® mechanically diverts, sequesters, and isolates the initial 1.5-2.0 mL of blood, the portion known to contain contaminants. The device then opens an independent sterile blood flow path for specimen collection. The technology has been clinically proven in peer-reviewed published controlled clinical studies to virtually eliminate blood culture contamination that can lead to the misdiagnosis of bloodstream infections like sepsis.
With the launch of this formal partnership, Magnolia Medical and The Center for Phlebotomy Education join forces to provide the most advanced training and educational program to help drive practice change for blood culture collection. The collective goal of both organizations is to establish a new standard of care by resetting the benchmark false positive rate for blood culture results, which currently stands at 3%, to below 1%.
"The Center for Phlebotomy Education has been a true innovator and leader in healthcare practitioner education for over two decades. Our respective organizations share common goals: improve patient safety and quality of care, prevent healthcare-associated conditions, enable antibiotic stewardship and reduce unnecessary costs. We are thrilled about the opportunity to deliver on each of these key pillars with the launch of this industry-leading educational program," said Greg Bullington, CEO of Magnolia Medical.
"It is truly an honor to formalize this partnership with Dennis and his team as we combine efforts and focus with a shared commitment to eradicate false positive sepsis test results," said Bullington.
What Should We Do?: Clotted samples from NICU
Dear Center for Phlebotomy Education:
We have a situation where our NICU performs all of their lab draws, but an inordinate number are clotted. They believe without a doubt lab is clotting the specimen when we receive it. Do you have any suggestions that would help us with this issue? Do you know of any articles we could reference for our review? We performed a literature search but could not find anything that discussed clotted specimens from the NICU. What should we do?
It never ceases to amaze us how some nurses think the lab intentionally sabotages blood samples so they have to be recollected. Not only does it smack of contempt for the laboratory and the professionals who work there, but it demonstrates a lack of understanding of preanalytic physiology.
There isn't anything in the literature specific to NICU draws in regards to sample rejection. Most studies in that regard don't get that specific. You didn't mention whether the samples you are receiving are venipuncture or skin puncture samples. For the record, we aren't finding much on capillary sample rejection specific to any age group, either. What this means is that you'll need to tackle this with an educational initiative that teaches why samples clot before the lab receives them and how to prevent it.
If the problem is with venipuncture samples, the typical culprits are failure to mix the tubes properly, pouring the blood from a red top into any other type of tube, and filling syringes only to set them aside for filling the tubes later.
If the problem is with clotted capillary samples, the problem is more than likely the failure to mix the samples as they are filling. However, it could also be filling microcapillary tubes in the wrong order. The EDTA tubes must always be filled first, before the platelets start clumping and activating the clotting cascade.
We suggest observing some of the draws for a first-hand view of what is actually happening, then conduct in-services based on your findings and develop a one-page "Troubleshooting Clotted Samples" graphic for posting and distributing throughout the NICU (e.g., in break rooms, at the nursing stations, wherever the nurses gather). You'll need a champion on the nursing team to help you eliminate the blame-game.
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.)
From the Editor's Desk
Earlier this fall, I rented a trencher from our local rental center. I knew winter was coming and didn't have much time left before the ground would freeze and make trenching impossible until spring. My project was to dig a shallow trench about 100 feet long to help drain water in our yard, which slopes precipitously from the house to the pond. Without it, heavy rains would continue to wash the sandy beach into the pond. The ground was already wet from heavy fall rains, but time was running out if I wanted to get it done before winter froze the ground solid, which I did.
It's not the first time I've rented a trencher, but I hope it's the last. It never seems to go well.
The last time I trenched was at a previous home when I needed to run a water line 300 yards through the woods to an elevated storage tank. The home was very remote and at a place where power outages were frequent, so a backup solar-powered system was necessary. Tree roots are no problem for a trencher, especially the size I rent, but bedrock is another matter. The first 100 feet went smoothly, then I hit rock about six inches down. I tried another route that would take the line around the buried boulder, thinking it was small in diameter. That was not the case. So I started from the other end of the trench line and worked towards the obstinate obstacle to see how close I could get. Just like before, I hit rock after the first 100 yards. That meant the middle 100 yards was bedrock that I had to cut through somehow.
The next weekend I rented a power saw with a diamond-tip blade for cutting through concrete. All I accomplished was ruining an expensive blade and a perfectly good weekend. This meant war.
Next, I hired a local excavator to bring in a backhoe and a jack hammer. To clear a path for his heavy equipment, I cut a wide swath through the woods with my chain saw, taking down about 12 trees. They died in vain. The rock was so hard and thick that after three days he waived his white flag, took his weapons and went home. We were both defeated. Humiliated, actually.
I still managed to bury the water line, though, but not by carving through rock. My only option short of dynamite was to pile enough dirt on top of the line so that it wouldn't freeze in the winter. That required six dump-truck loads of dirt, wheeled into the woods one scoop at a time in the bed of a four-wheeler. It took about 50 trips. The home is now supplied with some of the most expensive water on the planet, but it worked.
I no longer live there, but the lesson learned lingers: there's always a way, but it may not always be worth it.
A dear friend of mine always told me to "go through the open doors." The point being that if it takes a herculean effort to get something done, you ought to reconsider if it's really something you ought to be doing. Sometimes obstacles are thrown in our paths for a reason. If it requires kicking a door down, maybe you're not supposed to go through it. Maybe there's an unlocked door just to the left or right or across the room that will take you to a better place.
Had I known then what I know now, I never would have installed the backup water source. At the time I thought we'd be living in that home forever, so it was going to be a good investment in time and money. Forever turned out to be three years. I should have listened to the rock; it was trying to tell me something.
On the other hand, some struggles are necessary and bear great fruit when perseverance is applied. What if Edison gave up on inventing a bulb that cast continuous light after his first hundred filaments failed? What if the Wright brothers thought it was too hard to sustain flight? This list of "what-ifs" is endless, but we all know great effort doesn't always bear fruit. History is littered with epic failures. So the question we all have to ask ourselves when we find ourselves up against what seems to be insurmountable obstacles is does my vision require persistence or reconsideration?
When irresistible force (your vision) meets immovable object (your obstacles),It's a tough call whether you should trench, saw and jack-hammer your way through or find a path with less resistance. Knowing the difference between your will and your fate---where you want to go and where you should go---isn't easy. I can tell you this, though: once you accept that some doors are closed for your own good and well being, things start working out for the better.
So when I got the 500-pound trencher stuck in the mud this time before I could even get to the area I wanted to work, I was again presented with two choices: persist or reconsider. I assessed the situation for about two seconds, then promptly hooked chains up to my SUV, pulled out the trencher and returned it to the rental center. The trench could wait until spring.
Had I persisted, I envision my trenching idea once again descending into Dante's 7th level of hell, making an unholy mess of our entire back yard, getting the trencher hopelessly stuck in the sandy mud near the water's edge where no vehicle could possible reach it until next summer, and still never getting the stupid trench dug. I wasn't trying to invent the light bulb here or seeing if man could fly. I was only trying to dig a trench in the mud before winter. Reconsidering it felt like the right if not fateful thing to do.
By next fall, I hope to have the project completed and a nice sandy beach established for the next owners. New doors are opening for us and we hope to be in a new dwelling this time next year. I only have one requirement of our next piece of property: it cannot require any trenching.
Dennis J. Ernst, editor
Advice From an OSHA Expert
[Editors' Note: This month, Phlebotomy Today launches a new column: Advice From an OSHA Expert. We're pleased to welcome safety expert and columnist, Dan Scungio, MT (ASCP), SLS, also known as "Dan the Lab Safety Man" as our newest contributor.]
Many phlebotomy exposures occur each year because the safety feature of the needle was not activated in a timely manner. During a blood collection, things can happen that can take your mind off of the needle. The patient may faint, become combative, the venipuncture site may bleed more than expected, or a tube might be dropped on the floor. When these situations occur, be sure your initial response is to activate the needle's safety device.
The Centers for Disease Control and Prevention (CDC) reports that 42% of needlestick exposures occur after the venipuncture (38% occur during the draw).(1) That is a large number of exposures that can be eliminated if you make it your practice to always activate the needle's safety device immediately after the draw. If the needle comes out of the vein unexpectedly, there are several actions that must be taken. The tourniquet needs to be released, the bleeding needs to be stopped, and if it is a combative patient, you may need to protect yourself, the patient, and the nearby tubes or supplies. However, the first thing you need to do before any of those steps is to activate your safety device.
In today's high-productivity world, you may feel rushed to get to the next patient. I have seen many exposures for phlebotomists whose regular practice is to hurry and not activate the safety device. Skipping this important step in order to save a few seconds can result in months of uncertainty for the collector and expense to the employer. For the individual, the follow-up to an occupational exposure can be difficult, worrisome, and very personal. All of this can be easily avoided with one simple action: as soon as the needle is removed, activate that safety device!
You can contact Dan Scungio, "Dan the Lab Safety Man" at firstname.lastname@example.org
1. Centers for Disease Control and Prevention. The STOP STICKS campaign. https://www.cdc.gov/niosh/stopsticks/safersharpsdevices.html. Accessed 11/12/18.
Empowered Healthcare Manager
Every month we run an excerpt from our editor's popular blog, The Empowered Healthcare Manager.
The Path to Management is Irrelevant
Those who manage front-line healthcare workers often rise from among them. They didn't get where they are because they obtained a masters in management. They got there by being technically proficient, a team player, showed leadership potential, and demonstrated the ability to make good decisions. Rising from the ranks offers no prerequisites for managing people, though. The ability to manage comes later. Sometimes much later. Sometimes never.
Those who enter healthcare with strong management training know what motivates people, how to get lean (and Lean), and why economies of scale work. But they may not have the technical skills to do the job of those they manage. Grasping the technical proficiencies of their staff comes later. Sometimes much later. Sometimes never.
Arguing which origin makes the better manager is futile. But which does your staff prefer? Do they want a manager who can step in and do the work or one who can manage the chaotic interface of human nature and group dynamics (a.k.a. immovable object meets irresistible force)? They can't have it both ways.
If your staff wants you to know how to do their job more than they want you to know how manage, you're in trouble. If they grouse because you don't know how to do their job and they somehow think you should in order to be managing them, you're in trouble, too. Either way, your staff is rejecting you as a manager.
If your staff appreciates your authority and how you use that authority to keep order within the ranks so they can do the work, you're in a rather good place. That leaves you free to pursue profitability, strengthen the team, and set big, hairy audacious goals.
No manager can be all things to all people. Whether you rise from the ranks into a management position or get there via formal training, it doesn't matter to a staff that wants to be led. It only matters to those who don't.
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Tip of the Month: The Spice is Right
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