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Phlebotomy Today

©2019 Center for Phlebotomy Education, Inc. All rights reserved.                                   

November, 2019

Study Recommends Practices To Reduce Risk of Iatrogenic Anemia

Shutterstock_276381731The results of a year-long literature review designed to establish recommendations to reduce the risk of iatrogenic anemia (anemia from excessive diagnostic sampling) was recently published in the August issue of Critical Care..

The study was part of the CDC's Laboratory Medicine Best Practices (LMBP) initiative. The LMBP process involves the establishment of an Evidence Review Panel to participate in a review of published studies that demonstrate a consistent and positive impact on laboratory practices and patient outcomes related to laboratory practices. 

The extensive literature review considered 2,564 studies published in peer-reviewed journals since 1990 about blood loss and iatrogenic anemia. Twenty-one of these met the LMBP's rigorous criteria for further evaluation. In order for a practice to be recommended, the LMBP method requires at least two studies that are rated by the method as good quality and of a substantial effect size. If there are three or more studies with such ratings, the overall strength of the evidence is judged to be high for recommending a practice.
     Five types of interventions were evaluated in the 21 studies: the use of small volume tubes, implementing closed blood-sampling devices that eliminate blood waste when drawing samples from vascular-access devices, the use of point-of-care testing, leveraging education and institutional policies to guide the staff, and bundling two more interventions including blood conservation devices. 

Evidence was insufficient that point-of-care testing, implementing education/policy changes, and bundled interventions were singularly effective in reducing the risk of anemia and the need for transfusions.
     Evidence for the use of low-volume tubes and bundled interventions (as long as one of the bundled interventions included the use of closed blood sampling devices), however, was suggestive in both cases of reducing anemia and blood loss (70%) respectively. According to the authors, published evidence suggested either practice could be beneficial, but the data was insufficient to make a recommendation regarding their use.

     The intervention found to be the most effective among the five was the use of closed blood-sampling devices, which reduced blood loss by 25% among ICU patients. Because of the overall moderate strength of evidence, the report recommends the use of blood conservation systems to eliminate blood waste when drawing blood for testing.

Dennis J. Ernst MT(ASCP), NCPT(NCCT), director of the Center for Phlebotomy Education, served on the Evidence Review panel and was one of the coauthors of the study.
     "Since 90 percent of critical care patients develop anemia within three days of their ICU/CCU admission, this literature review and the CDC's recommendation provides insightful guidance for laboratories and nursing professionals to take aggressive steps to reduce this risk," says Ernst.

Read the full article. 

In-house Phlebotomy CE Exercises



Climbing the Phlebotomy Ladder: Look within

Mirror with self-imagePhlebotomists looking to advance in their profession should look within. Do you appeal to those who offer positions with greater responsibility? Do you provide your employer with good reasons to eliminate your position, or are you the kind of person managers will fight to keep on staff? Conduct this self-assessment to see if you have any internal obstacles that could be preventing you from reaching new heights or even keeping your current position.

Do you make your manager's job easier or harder?

The right answer is obvious, but take a serious look at yourself as your manager sees you. If you quit your job yesterday, would your manager hire you back today? If you think he/she wouldn't, your job's in jeopardy. Think of the reasons you wouldn't be rehired, and fix them. Consider employment at your facility to be a privilege, not a right. Strive to earn that privilege every day by making your supervisor's job easier. It's not "sucking up to the boss" if your motive is sincere and selfless, so forget what your coworkers might think. You don't work for them, anyway. Besides, they have no authority to invite you up the ladder or to secure your employment. Don't like your boss? Then you only have two choices: find something to like about him/her or find employment elsewhere. If you stop looking at the negatives about that person and focus on the positives, you might start looking more like a long-term employee in his/her eyes and less like someone who needs to be the object of a "staff reduction."

Do you deal with difficult people with poise or poison?

According to author and management speaker Dale Dauten, every tenth person is a jerk. If one of them is your boss, deal with it. That means not focusing on their jerky-ness, but focusing on your job. Jerks usually self-destruct. When that happens, make sure you're in a position to step up. You'll never be in that position if you're known for your contempt of authority, however detestable the jerk is. If you focus like a laser beam on your responsibilities and making your jerk-boss's job easier, you've taken the high road, which usually lined with ladders to even higher roads. If the jerk is a physician or patient, the same rules apply. Remember, everyone has a story, and chances are you have no idea what makes the jerk-of-the-day so difficult. Difficult people are difficult to everyone, so don't take it personally. Deal with jerks with poise, not poison.

Do you present problems without solutions?

When a problem comes up in your department and you bring it to you supervisor's attention, pose a solution at the same time. Sure, your manager's job is to solve problems, but make it your job, too. Proving you are a problem solver is the first step to being considered for a position that involves problem solving... like Lead Phlebotomist or Phlebotomy Supervisor. Even if you're happy with your current position, helping to solve problems is the hallmark of a team player. Should there come a time when staffing needs to be cut, team players are the last to be considered.

Do you take on extra work?

There's no rule that says you must only perform those tasks within your job description. What do you do when you're not drawing blood? If you're cleaning your department, stocking trays and draw stations, neatening up all those things that make your work area messy, and performing tasks everyone else avoids, then you have a right to be optimistic about your career and your job security. If you sit and chat, surf the Internet, tap dance your fingers incessantly on your smart phone, or conduct any other time-killing activities, you don't. If you can't find anything to tidy up, ask your manager for a menial task that will bore you to tears. If it has to be done, it has to be done. Every moment of your work day can't be filled with joyful activities. That's why they call it "work."

Do you shun gossip?

Nothing erodes morale like hearsay. It's not just telling gossip that makes you guilty. In order for gossip to be gossip, there must be ears willing to listen. If those ears are mounted on your head, you're contributing. How do you know if it's gossip? Here's the test: if it's second-hand information of a personal or trivial nature that creates a negative impression of that person, it's gossip. Get up and walk away. If you're brave enough, comment on the nature of the conversation being inappropriate in the workplace. Prepare to be ostracized by gossipers and held in higher regard by everyone else. If you are a party to gossip, you're contributing to a destructive workplace environment. 

Are you a living example of your facility's mission statement?

If so, you have a tall ladder to climb with slip-proof rungs. If not, the steps of your career ladder with that employer are greased, and you're likely to come crashing down. If your ambition is based on serving others, expect to be well-fed with opportunity. Self-serving ambition, on the other hand, can't be fed for very long before it gives you bad breath.

If you did well on this assessment, chances are you are career-ladder material. Even if you're not striving for a higher position, mastering these elements will make you a cherished and valued employee in the eyes of those who pull the strings. They're the same people who cut the strings, turning the employed into the unemployed. Should the economic climate force your managers to consider a staff reduction, valued employees keep their jobs.

If you want to take this self-appraisal a bit further, take Dale Dauten's "Promotability Index" assessment online.


Product Spotlight: New standard on patient, sample identification

GP33_Cover_400wIn July of this year, CLSI released a new standard on patient identification and sample labeling. All laboratory managers, phlebotomy supervisors and clinical laboratory educators should be modifying their procedures and training materials according to this standard to ensure compliance.

Accuracy in Patient and Sample Identification (GP33-A2) specifies the processes required to ensure accurate patient and specimen identification in manual and electronic systems across the health care organization. The document replaces the first edition, which was published only as a guideline. This second edition, upgraded to a standard, defines the proper protocol for identifying patients for all laboratory procedures and for labeling all diagnostic samples including blood and non-blood specimens.

The processes detailed in GP33 include considerations for designing patient ID systems, differences in requirements for patients with and without identification bands, and provisions for patients with communication barriers.

The volunteer committee tasked with revising the document was chaired by Dennis J. Ernst MT(ASCP), NCPT(NCCT) with Anne Marie Martel, T.M. of Ordre Professionnel Des Technologistes Médicaux Du Québec serving as the committee's Vice Chairholder. Other members of the committee included:

Deirdre Astin, MS, MT(ASCP)---New York State Dept of Health
Nancy Dubrowny, MS, MT(ASCP)SC---BD Preanalytic Systems
Sheri Hearn, BC, MPH---Oregon Public Health Laboratory
Peggy Mann, MS, MT(ASCP)---The University of Texas Medical Branch
Estelle Ninnemann, MT(ASCP)---ACL Laboratories
George Souza, BS, CPT, CPI---Massachusetts General Hospital
Sheryl Thiessen, BSMT, MT(ASCP), MLT(CSMLS), CLQM---British Columbia Agency for Pathology and Laboratory Medicine.
Thomas Dew---Taylor Healthcare
Sharon Johnson---Mayo Clinic

The standard is available from CLSI or, by special arrangement, directly from the Center for Phlebotomy Education, Inc. 


From the Editor's Desk

SanFrancisco2007 skyNow that I've given my last conference presentation, my focus can shift from catching flights to catching up... and  I have a lot of catching up to do.

Tops on my list is catching up with my readers and colleagues in the industry, but in ways that don't involve cramped coach cabins, long layovers, and hotel horror stories. I've had my fill of all three, but after over 500 conference presentations in almost every state and 11 countries, the joys of being with "my people" far outweigh the tribulations of travel. The good news is that by taking myself off the speaking circuit, I will have significantly more time to serve the phlebotomy community, you in particular.

On average, I spend about 40 hours preparing for each speaking engagement before I even print my boarding pass. Those who recruit me and attend my presentations expect a highly polished, impeccably well-researched presentations. In order to deliver the expected product, A-list speakers have to have a commanding grasp of the material and a comfort level in presenting it that exudes confidence and expertise. That means no matter how many times you've presented the material, you always check every known resource and update your content as needed.
     Besides the hours spent on slide prep and notes, I typically spend 5-10 hours per event making handouts that are professional in appearance (readable, graphically appealing with room for notes and a cover page) and booking my airfare, lodging and ground transportation. When you combine the preparatory work with the days spent travelling to, from and at the venue, my investment in time per event averages about 5 days. Conference organizers rarely factor that in when compensating A-listers.

Make no mistake, though, I'm never happier than when I'm with my people. The last 20 years of podium-hopping has taken this once-disenchanted lab rat to places I never dreamed I would ever go, and to some of the most beautiful places on earth. Some of the more memorable highlights include:

  • Sitting in a hotel lounge in Salt Lake City during a CLEC conference when a woman across the room points to me and shouts "It's him! The man in the movie!"
  • Having dinner with the CEO of a company exhibiting at a conference when he pulls out my business card from his jacket pocket and uses it to pick his teeth;
  • Speaking to a grand total of three attendees at my breakout in Hannibal, Missouri;
  • Speaking to hundreds of attendees at annual meetings Oslo, Norway, Banff, Alberta, and Montreal, Quebec;
  • Speaking to over a thousand attendees of a webinar on tube handling and centrifugation;
  • Having an attendee in the front row take a cell phone call during my presentation in Santa Barbara, California;
  • Dining with friends after our presentations in Portland, Maine when a 4.2 magnitude earthquake rattled the restaurant.
  • Telling a joke to a friend while my mic was still on, which projected it into the adjacent conference room full of attendees. (Thankfully it was a clean joke!)
  • Losing my luggage on the train from Vienna to Linz, then losing my voice;
  • Coming down with pneumonia upon arriving in Austria to speak the next day; speaking anyway;
  • Giving written and practical exams to all of Aruba's Public Health phlebotomists on the top floor of a luxury hotel with a 360-degree view of the island and surrounding Caribbean Sea;

While I'd love to continue adding to this list, I would also like to see what I can accomplish if I reallocated the time spent as a speaker to other ways to educate and consult. Last year I gave 32 presentations at 12 conferences. If my calculations are correct, that's two full months of preparing and delivering education in person. It's exciting to think of what I could do with that time by connecting in other ways from the comfort of my own office.
     Rest assured, I will find ways to continue our connection outside of this newsletter. I'll be exploring ways to set up free monthly video conferences, open forums, or Q&A sessions for all who care to chat about our favorite subject. With the time that gets freed up, I'll be able to create and post more YouTube videos and other media formats in which we can connect. I may be stepping away from the podium, but I'm stepping into ways to engage with you even more.

If things go as planned, more of you will likely be seeing my smiling face, maybe not in person, but through the magic of the Internet. Unfortunately, I won't be seeing your smiling faces as often. because of  the limits of 2-way videoconferencing to large groups. But at least we will be able to connect in live webcasts. I suppose there is a bright side to not seeing the attendees I'm talking to.  You can answer your cell phone and pick your teeth with my business card and I won't even know it.


Take care, my friend,

Dennis J. Ernst, editor


Test Talk: Bilirubin

BloodTestTextGraphicPatients have high bilirubin levels for many reasons, almost always indicative of issues with the liver. Newborns often have high bilirubin levels because their liver takes a few days after birth to "wake up" and do what a liver is supposed to do, mainly cleanse the blood as it comes from the digestive tract. For adults, it's often indicative of liver disease, tumors, cancer, sclerosis, hemolytic anemia, blockage of the bile ducts and other liver pathologies. 

Bilirubin is a pigment and a by-product of digestion and red blood cell destruction. When the liver isn't working properly, the blood isn't being filtered of waste products. Because it is a pigment, when significantly elevated, patients appear jaundiced, i.e., their skin and whites of their eyes take on an amber color. Normal bilirubin levels are well below 2.0 mg/dl. Concentrations above 15 mg/dl lead to brain damage in neonates.

Since bilirubin degrades when exposed to light by as much as 50 percent per hour, it's critical to protect blood samples from exposure to daylight and artificial light as soon as the sample is collected. Since excessive bilirubin concentrations can cause brain damage, failure to protect samples from light can prevent infants from receiving critical phototherapy (bili-lights) that break down bilirubin at the capillary level.

Bilirubin exists in two forms: conjugated and unconjugated. Conjugated bilirubin is measured by the direct bilirubin test, while unconjugated bilirubin is measured by an indirect bilirubin assay. When elevated, each form is diagnostic of different diseases and conditions, and can assist physicians in pinpointing the cause of an elevated total bilirubin result.

Samples for bilirubin are typically serum samples, and have a stability of about two days at room temperature. Prolonged contact with red blood cells does not seem to affect test results. Devices exist that measure bilirubin transdermally without the need for a blood sample. 


What Should We Do?: Heelsticks during breastfeeding

Dear Center for Phlebotomy Education:

Babies (22)At our facility, the OB staff wants to keep mothers and babies together as much as possible, especially in the first five days. So our phlebotomists are being asked to perform heel sticks while the baby is nursing, not take them away from the mother and into the nursery for the draw. They say is also helps with pain management. I'm not opposed to this, but some of our male phlebotomists are uncomfortable with it. I'm also concerned about the choking risk. What should we do?

Our response:

Many studies have found that a nursing baby feels significantly less pain during a heelstick than non-nursing infants. The standards don't advise against it, so you should consider working with the nursing staff in this regard and facilitating the bonding experience that is so important between the mother and her newborn. 
     Studies show the pain-reduction benefits of oral sweeteners like sucrose and dextrose to be equivalent to breastfeeding as a pain reduction strategy. You might want to consider this approach if a compromise is necessary. You may also consider using a combination of cold and vibration as a pain reduction strategy. The scientific literature contains many studies confirming the effectiveness of devices that employ this technique like the 
Buzzy. MLO has an excellent article in their archives on pain reduction during infant phlebotomy that our director authored.

Aside from that, there are positioning issues that have to be addressed when drawing from an infant that is nursing. Remember, it's always important to maintain the infant's heel in a downward position if you want the draw to go smoothly and quickly. If the baby is being cradled in a horizontal position, the flow of blood is less than if the foot is below the plane of the heart and will make the collection difficult. But if the baby is positioned in such a way that the legs are lower than the heart, the flow of blood through the feet will be greater.

As for the male phlebotomists being uncomfortable with the scenario, perhaps it might be prudent to send only female phlebotomists to draw nursing babies. A light blanket draped over the feeding child and breast is likely to make your male phlebotomists and the nursing mother form comfortable. Keep in mind there may also be a cultural taboo for the mother to have a male phlebotomist while she is nursing.


What's Wrong Here?

Teen girl patient_SS What's wrong with this picture? We guarantee something isn't as it should be. The answer will be in next month's issue. (Click image to enlarge.)

  AutoRelease2 smallLast month's What's Wrong Here? image depicted an auto-release tube holder being activated with the contaminated sharp falling into the biohazardous waste receptacle. In the U.S. this practice violates the OSHA Bloodborne Pathogens Standard, which states "Contaminated needles and other contaminated sharps shall not be bent, recapped or removed unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental procedure."

The agency further galvanized the ban in the infamous Kline letter.

Outside the U.S. needles can be removed from their tube holders without violating regulations. However, the more important violation is to the safety of those who disassemble devices and who handle contaminated sharps downstream from the point of disposal. 

The user who disassembles the needles from the tube holder and misses the sharps container is suddenly in the top tier of risk for an exposure. Handling a disassembled sharp and placing it into the sharps container puts the individual in direct contact with a contaminated needle. The only thing that separates him/her from the back end of the needle is a vinyl sleeve, which offers no protection.

For those who handle biohazardous waste receptacles, the back end of the disassembled needle also poses a significant risk of injury. Should the sharps container fail and disassembled needles require manual manipulation into a secondary container, the risk is significant and magnified far beyond that presented when a sharps container full of assembled devices fails.



Tip of the Month: Bug Bombs

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