Pediatric Phlebotomy: Princes and little devils
Drawing blood specimens demands the blended wisdoms of many sciences. It requires a working knowledge of anatomy (to avoid injuring patients during venipunctures), physiology (to understand the effects of hemoconcentration, fasting, posture and exercise on analytes), cryptology (to decipher physicians' handwritten orders), and many fundamentals of physics (vacuum pressure, trajectory, velocity, resistance, turbulence, shear forces, centrifugal force, molecular decay and the effects of time, temperature and light on analytes).
But one of the most important sciences that must be mastered---especially for pediatric patients---is child psychology. Although it may seem easier to move a river than to calm a terrified child, those who understand how fear affects children know what is required to turn the Tasmanian Devil into Prince Valiant.
The phlebotomist performing a child's first venipuncture is in a powerful position to affect how the child views every subsequent venipuncture for life. Make the first experience uneventful, and the next experience will be considerably easier for both patient and the collector. But a traumatic first experience can guarantee the next needle event will be just as traumatic. Worse, the child could become needle phobic for life.
Most of us have an innate fear of the unknown; for children, this fear is especially acute. Because capillary punctures are far less invasive and can be less traumatic for pediatrics, they should be considered before venipunctures for extremely apprehensive patients. However, when venipunctures are necessary, the importance of addressing and defusing a child's apprehension is critical to success.
Not all parents are skilled at preparing children for the event. They may have detailed the procedure in unpleasant terms, or not at all. Your pediatric patient may have heard of traumatic blood collection experiences from their parents, siblings, friends or classmates, and have come to expect his/her own blood test will be similarly torturous. Of course, many young patients are well prepared, but those who are apprehensive deserve an extra measure of patience. The approach to preparing the pediatric patient for a venipuncture is age-specific. Because it is beyond the scope of this article to discuss all age groups, we will focus on the difficult age group of 4 years old and up.
Preparing the pediatric patient begins the moment your eyes meet. Children can detect compassion or indifference in your face and body language just as you can read anxiety or complacency in theirs. How well you interpret and react to the patient's state of mind plays an important role in being able to successfully manage the child's experience.
In the case of a blood test, the fear of the unknown can often be defused in less than one minute. Here's how:
The effect of a towering, uniformed authority is intimidating. Establish a rapport with the child by getting down to her eye level and introduce yourself. Engage in kind small-talk with a tone of voice that reflects compassion and caring. Ask questions to assess their potential to have needle phobia.
"There's nothing wrong with coming right out and asking a person how they feel about needles," says Amy Baxter, MD, CEO and Founder of MMJ Labs in a 2017 podcast. "If there is any response other than 'they don't bother me, then I would start a dialog with the patient about what works best for them. And then whatever they tell you, actually do it. Start a dialog with them and ask what works best for them, what makes it easier."
Another critical step to defusing apprehension is to walk the child through the procedure step-by-step.
Step 1: In simple terms appropriate to the child's age, explain how the tourniquet will be applied. Approximate the sensation by squeezing the child's upper arm with your hand where the tourniquet might be applied and to the degree it will be tightened. Ask the child to make a fist.
Step 2: Giving the child ownership in the process turns her from the subject of the procedure to a participant in it, and has a powerful calming effect. Point to the antecubital area, explaining that that's where you will look for a vein, then explain that you will cleanse the site with something "cold and smelly." Give the child the opportunity to look the other way when the needle comes out of the sheath. Some pediatric patients won't mind watching. Baxter calls these "attenders." Others tolerate the procedure best when they are distracted. Positioning a poster board with bandages and stickers from which she can make her selection will help provide a distraction. So will distraction cards and interactive games.
Step 3: Explain to the patient that he/she will feel a little "pinch" or "mosquito bite." Give the child an approximation of the sensation by gently pinching the antecubital area. Then assign her a role to play in the process: to start counting when she feels the pinch. Explain that you will probably be done by the time he/she gets to 10 and that you will then put pressure on the site for a few minutes and eventually bandage it.
By explaining this procedure in advance, you turn the unknown into the known, and the fear melts away. It only takes one minute or so to walk a child through the procedure, but when the patient knows what to expect, the venipuncture has a much greater chance of proceeding without incident. Of course it remains essential to immobilize the arm during the puncture to prevent unanticipated reactions. Remember, an explosive reaction can lurk just beneath the surface of composure.
Despite your best efforts to calm an anxious child, some cannot be calmed. Should anxiety escalate to a tantrum-like refusal, all hope for an uneventful experience is lost. If a parent is available and willing, assistance may be necessary so that the procedure can be done quickly and without injury. If not, seek coworkers to assist. Under no circumstances should a puncture be attempted on a child without the assistance necessary to immobilize the intended puncture site and to protect the patient and collector from injury. But avoid applying restraint forcefully unless it is necessary to protect yourself and the patient from injury. Kids don't like to be restrained any more than adults do. A firm, forceful grip often precipitates increased anxiety and the loss of cooperation. It is best, therefore, to use only as much assistance as is necessary to assure the success of the procedure, and no more. If the patient cannot be restrained without risking injury to the patient or collector, the physician should be notified of the difficulty in obtaining a specimen safely.
Turning the Tasmanian Devil into Prince Valiant is not easy. But with the proper training, the right level of compassion, and a rudimentary knowledge of child psychology, a painful puncture can be reduced to fantasy.
Ernst Joins Velano Vascular Advisory Panel
Velano Vascular (San Francisco, California) recently announced the addition of Dennis J. Ernst MT(ASCP) NCPT(NCCT) to its advisory panel.
According to a recent press release, the vascular access technology innovator "continues to aggressively expand in pursuit of its mission to dramatically remake blood collection as a more efficient, effective and safer standard of patient-centered care." Among Velano's products is the award-winning PIVO™ needle-free blood collection device, designed to reduce the frequency of venipunctures and their associated risks, as well as the potential for hemolysis when drawing from vascular access devices.
Ernst, who serves as the director of the Center for Phlebotomy Education, was appointed along with Kim Henrichsen, former Intermountain Healthcare Senior Vice President of Clinical Operations and Chief Nursing Executive.
"Kim and Dennis are true industry experts and pioneers whose insights and guidance will be invaluable as our team brings PIVO to hospitals around the world," said Velano Vascular Chief Executive Eric M. Stone.
PIVO was developed by Velano Vascular's Chief Medical Officer & Co-Founder, Pitou Devgon, MD who sought to expand the use of peripheral IV lines for frequent, high quality blood draws. Together with Stone, they founded the company to deliver virtually painless, compassionate care for hospital inpatients, a safer practice for caregivers, and a more financially responsible alternative for health systems. Earlier this year, the MedTech Breakthrough Awards named Velano's PIVO™ the "Best Overall Medical Device Solution."
"We're thrilled to have Dennis join the Velano team as a member of our Advisory Board," says Dr. Devgon. "There is an urgent need to address the growing challenge of vascular access in medicine today. His unique clinical insights and experience as both an industry expert and educator will further enable our mission to create a new, more humane and effective standard in blood collection."
Product Spotlight: The guru-maker
Do you have a phlebotomy guru on staff? You know, the person everyone goes to with the toughest questions on drawing blood and knows they'll get the right answer. If you do, they probably already have a copy of the Lab Draw Answer Book. If you don't, pick someone and give them a copy. Better yet, get one for yourself and become the go-to person on phlebotomy. This book is the guru-maker.
The Lab Draw Answer Book, published by the Center for Phlebotomy Education, 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 for a Christmas gift, or to preview pages.
Researchers Study Effect of Hemolysis on Coags
Researchers in Italy studied the effect of hemolysis on five commonly-ordered coagulation tests at 15 Italian hospitals.
Two-hundred-sixty-nine hemolyzed samples were tested and compared with results from non-hemolyzed samples drawn from the same patient. All samples were tested within four hours of collection. The greatest variation occurred with aPTTs and D-dimers. Fibrinogens and antithrombins were less effected, however, still to a significant degree. Protimes were only slightly influenced.
The mean differences were as follows:
- protimes---0.1 second
- aPTTs---1.1 seconds
- D-dimers---1025 ng/mL
- fibrinogen---0.04 g/L
The degree of hemolysis was rated "moderate to severe" in more than 95% of the samples. However, the researchers found no correlation between the degree of hemolysis and its affect on any of the four assays. Therefore, no correction factor can be reliably applied. They also found there to be no agreement between an objective visual assessment of hemolysis and the objective measurements reported by the coagulation instrument.
In conclusion, the researchers recommend continued rejection of hemolyzed samples for most coagulation tests and that visual assessments of hemolysis are unreliable.
Read the full article
From the Editor's Desk
As you know, my wife and I moved 600 miles north last January to live in Northern Michigan. One of our first priorities was to find a place of worship. We had many options in the area, and spent several months "church shopping." By March, we had settled on the one we felt was right. Not the one that felt right for us, but the one that felt right. Big difference.
We didn't choose the one with the friendliest people, the nicest building, or the most dynamic priest. If those were the criteria, we'd have chosen a parish other than the one we did. Instead, we chose the one that felt like it was where we were supposed to be, the one placed in our hearts to join for a purpose that would be revealed over time. Nine months later, the purpose is starting to become clear. That's another column, but it reminds me of when I went shopping for my first job at a hospital laboratory.
I was only three years out of my med tech internship and working at the Michigan Community Blood Center in Saginaw, Michigan. I was growing bored with performing only one test day in and day out. Night after night it was my job to test donor units for hepatitis B. I needed a new challenge and fast, so I set up interviews at hospitals in Champaign, Illinois, Corydon, Indiana, and three cities in Ohio. I received offers from all five facilities.
I didn't choose the one with the nicest building, the friendliest people, the highest wage or the most dynamic manager. I chose the one where I felt I was supposed to work, the one placed in my heart to be employed for a purpose that would be revealed over time. The one that felt right. In fact, when I called to accept their offer, they said they made a mistake when they quoted my salary. My starting wage would actually be fifty cents lower per hour than what they first told me. I took the job anyway. When something's placed in your heart, those things don't matter.
I worked there for 13 years, and lived in the same area for 36 years, until last January. Taking the position at the 68-bed hospital in Southern Indiana was a pivotal decision that determined the path my life would take. Because of that choice, many more paths opened up before me that would not have otherwise opened had I accepted a position elsewhere. Not all of them were walks through the park, though. Some took me deep into dark forests filled with predators and picker bushes. I'm sure you've had similar paths through life, ones you wish weren't necessary. None of us have a monopoly on tribulation.
Looking back, without the darkness I never would have found the light. Without the painful paths I would have never chosen the right ones, the ones that would ultimately lead me to where I am and the purpose, and people, I now serve. Even though I followed my heart by accepting the job in Indiana, getting lost in the woods seems to have been necessary because I certainly love where life has taken me since.
So I guess what I'm saying is that in order to be truly happy, which I am, I had to have been truly sad first. In order to be fully whole I had to be emptied out. To be fixed I had to be fully broken, and to see the light I had to know darkness. Had I chosen another hospital, would I still have gone through all of that? I don't know. Maybe. Had I known what lay ahead of me when I chose the Indiana path, would I still have chosen it? I think the answer to that question is obvious. I even have evidence.
When it came to finding a church in Northern Michigan, if we did not believe that following the path placed in our heart takes priority over what we want for yourselves, we would have chosen the nicer church with the more dynamic priest and the friendlier parishioners. While we knew the possibility that we may have chosen the more painful path, we also knew the best choice is often the most difficult one, the one with less pizzazz, and that's least self-serving. Funny how the path that is least self-serving always seems to serve you best.
So as we close out this year, I want to thank you for indulging me in a bit of philosophical, big-picture gazing. It's been another enjoyable year serving you as a resource in this capacity. Immersing myself in preanalytics is not something I ever planned, mind you, but the result of hundreds of paths chosen because they felt right. Mine is truly the niche of all niches. A more specialized specialty I could never have chosen.
Nor could I have ever found a more appreciative body of professionals who have likewise followed their hearts down a path that would, thankfully, intersect with mine. A path to one of the most noble, others-serving vocations on the face of the earth.
Robert Frost put it perfectly:
Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.
Merry Christmas and Happy Holidays, my good friends. See you next year.
Dennis J. Ernst, editor
Advice From an OSHA Expert: the combative patient
[Editors' Note: 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.]
Phlebotomists work in many environments, including outpatient draw centers, doctor's offices, law enforcement centers, nursing homes, public health facilities, and hospitals. Combative patients can be encountered in all of these settings, creating dangerous situations for everyone involved. So how do you prevent a needlestick or other injury when dealing with a potentially combative patient? In most cases, combative patients can be drawn safely if the right steps are taken.
The first step involves communication. If family members are present, ask them (politely and discreetly) if there may be potential issues when collecting from the patient. Ask the patient's nurse as well, if possible. Knowing about your patient before you attempt a blood draw can make the procedure go much more smoothly.
Communicating directly with the patient is also key to gaining and assessing cooperation. For example, when approaching dementia patients or those with poor eyesight, make sure that the room is well lit so that the patient can better interpret what they are seeing. An unfamiliar figure standing in the shadows can be frightening to cognitively impaired individuals. Also, speaking calmly and clearly to patients hard of hearing or with mental impairment can be comforting, and may make them less hostile to the procedure.
In an outpatient collection area, a family came in with a mentally-challenged child. They did not inform the staff of the possibility of combative behavior. When the patient became violent, a phlebotomist sustained a needlestick exposure, and the patient was injured as well. Having the information and the correct safety measures in place could have helped to prevent that incident.
Never attempt to draw a known combative patient by yourself. If help is not available, then postpone the collection until adequate assistance can be obtained. In addition to gloves and a lab coat, face protection should be considered necessary PPE, particularly if the patient is likely to spit during the procedure. In terms of equipment, using a winged collection set or "butterfly" needle may provide the phlebotomist more control and maneuverability over the needle.
The dangers of drawing a combative patient are many. Even with the proper information, approach, equipment, and assistance, there are some draws that cannot be safely performed without physician intervention. In such situations, physician notification is necessary. To attempt a blood draw when the patient cannot be adequately and safely subdued places the patient and collector at risk for injury, and the facility at risk for legal liability.
What Should We Do?: Labeling with or without gloves?
Dear Center for Phlebotomy Education:
After drawing a blood sample, is it good practice to remove our gloves before picking up a pen to write tube labels, or is it better to leave gloves on while writing/labeling, then removing gloves? This would be when drawing blood on non-isolation patients. My staff is arguing that if you label with the gloves on, the pen is then contaminated with the patient's bacteria as well as the paperwork and the clean area of the bench. Others argue that you shouldn't handle filled tubes without gloves. What should we do?
This is a great question. CLSI's venipuncture standard doesn't state when to remove gloves, only that they must remain intact throughout the procedure. In our mind, that includes labeling. But keep in mind, the venipuncture standard is not an infection control document. That said, we don't think any CLSI guideline is that specific for non-isolation patients.
Keep in mind, gloves for venous access are primarily to prevent exposure to bloodborne pathogens, not bacteria from other sources. Besides, the pen you're picking up is not sterile to begin with. There's probably not a sterile pen anywhere in any healthcare setting (except for surgery, perhaps). While we appreciate your concern about phlebotomists spreading HAIs, focusing on pens is far less important than the role tourniquets and hand hygiene play, neither of which are being effectively managed in most facilities.
All that being said, there's nothing wrong with keeping the gloves on for the labeling, especially if it's done prior to bandaging. In fact, we would recommend you require it. Sooner or later the pen will be used without gloves, anyway, so it could be argued either way. If your staff is performing proper hand hygiene, it shouldn't matter. If you think they're not, I'd leave the gloves on until the patient is dismissed.
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 Manager
The Rotten Fruit of Preventable Crises
Do you find your productivity is squandered by crisis management? You set out on Monday with high ambitions to complete Project A, B, & C. As the week unfolds, you are distracted by Crisis 1, 2, & 3. By Friday, you've managed all the crises, but they robbed you of so much time you were only able to accomplish Project A.
Next week will play out like this week, ad infinitum. The only way this pattern will ever stop repeating is when you stop thinking all crises are spontaneous. They're not.
Your three biggest preventable crises revolve around:
1) customer service issues (internal and external customers);
2) policy/procedure violations (non-conforming events);
3) interpersonal friction.
None of these are spontaneous. The seeds of each are sown at the hiring and orientation of the employee(s) involved, fertilized during every minor incident that went uncorrected, and flower in the apparent tolerance of indifference throughout the staff. Today it bears fruit and now rots on your doorstep. Instead of accomplishing Projects A B & C, you have to clean it up.
That all stops today.
Every time a preventable crises crops up and pulls you away from your goals for any more than 30 minutes, you're going to write it down or create a spread sheet to record it. You're going to log the amount of time you spend managing each distraction over the course of the week or weeks, and you're going to record their causes and how each could have been prevented. This is your root cause analysis. It's critical in order for you to ever break out of your endless, productivity-robbing crisis-management cycle.
When you have enough data, show your manager how much time you're wasting due to indiscriminate hiring practices, timidity toward discipline, and tolerance of substandard behaviors. Then request unfailing support for your aggressive assault against all three, and tell your staff it's not business as usual anymore.
Within months, you'll find accomplishing Projects A, B, & C are the rule, not the exception. You'll also stop finding rotten fruit at your doorstep.
Tip of the Month: It's a Wonderful Life!
Click here for this month's featured Tip of the Month from our rich library of archived Tips.