April, 2015

Excessive Blood Draws Exsanguinating Cardiac Patients
ASCP Posts Podcasts on Hemolysis, Management
The Empowered Healthcare Manager
Product Spotlight: Boot Camp 2015
Sloppy Technique Threatens DUI Cases
On a Personal Note
Free Webinar on Centrifugation Set for April 9.
This Month in Phlebotomy Today
Survey Says
What Should We Do?
Tip of the Month

Excessive Blood Draws Exsanguinating Cardiac Patients

According to an article in Cardiology Today, patients undergoing cardiac surgical procedures lose the equivalent of two units of red blood cells just from phlebotomy draws for laboratory testing.

Researchers at the Cleveland Clinic evaluated blood sampling data from 1,894 patients undergoing cardiac surgery and found the cumulative median volume of blood withdrawn for diagnostic blood sampling throughout their hospital stay was an astonishing 454 mL. 

Patients undergoing bypass procedures (CABG) and valve procedures at the same time were tapped for 653 mL throughout their stay as opposed to 448 mL for bypass alone. Patients in the ICU had a median of 332 ml removed for lab testing versus 118 mL for patients outside those units.

Arterial blood gases analyses, coagulation studies, complete blood counts and metabolic panels were the most prevalent laboratory tests conducted. Not surprisingly, the frequency of transfusions thought to be directly proportional to diagnostic sampling. Forty-nine percent of patients in the study received red blood cell transfusions. 

Minimizing blood volumes lost to phlebotomy was thought to be possible by using smaller tubes, better blood-conservation devices and noninvasive monitoring.

ASCP Posts Podcasts on Hemolysis & Management 

The American Society for Clinical Pathology recently posted two interviews with Center for Phlebotomy Education director Dennis J. Ernst MT(ASCP) in its LabMed podcast series. In "Empowered Managers" Ernst defines what an empowered healthcare manager does and how he/she serves those above and below them by having the "ability, permission, desire, humility, and courage to lead the willing and transform the unwilling."

In "Hemolysis in Patient Specimens" Ernst discusses the biggest culprits in the collection process that hemolyze samples with an emphasis on draws during IV starts and through vascular access devices. The podcasts can be accessed on the Lab Medicine podcast archive page.

The Empowered Healthcare Manager: 
Capable of doing better, but choosing not to 

Every month, Phlebotomy Today-STAT! reprints one of the prior month's posts to The Empowered Healthcare Manager blog, written by Dennis Ernst. 

Not long ago, we hired a general contractor to work on our home renovation who we knew had high standards. When it came time for drywall, he recommended the same guy who had done the walls in the office space we were leasing. They were riddled with nail pops, unpatched divots, unsanded patches, and cracks at the ceiling joints. Our contractor was surprised to hear of his poor workmanship under someone else's scrutiny.

It's a classic example of someone who is capable of doing excellent work, but chooses not to. You'll find them in every industry, even healthcare. They do outstanding work for some people, but barely mediocre work for others. Who they are working for determines the quality of work they produce.

Do you have employees who perform beneath the level of which you know they are capable? Why are they unmotivated to give you their A-game, the game you hired them for and pay them to deliver?

There are dozens of reasons people choose not to deliver their best efforts. Until you find out otherwise, you have to assume it's their general contractor. That's you. The empowered manager is never comfortable not knowing why they get mediocrity from those capable of excellence.

 Subscribe to The Empowered Healthcare Manager.

Product Spotlight: 
Boot Camp 2015 

One person said it was the best seminar they've attended in her 35-year career. Another said the event gave her the courage and confidence to tackle a staffing problem. A third said attendance should be required for anyone training phlebotomists.

Hundreds of healthcare managers and educators from some of the most prestigious institutions around the world have graduated from the Phlebotomy Supervisor's Boot Camp since 2012. It's time you do, too.

The 2015 Boot Camp will take place in Charlotte, North Carolina on November 4-6. Besides two-and-a-half days of intensive instruction, interaction and training, this year's event will have a special twist. Tube- and blood-collection device manufacturer Greiner Bio-One will lead guided tours of their state-of the-art manufacturing facility in nearby Monroe where attendees will see how blood collection tubes are made.

Last year's event in San Francisco filled up, and we expect the same for Charlotte. For the seminar agenda and more information, including registration options, visit www.phlebotomy.com/bootcamp.

Sloppy Technique Threatens DUI Cases

A defense attorney in Austin, Texas is questioning the validity of blood alcohol results obtained from samples drawn in DUI cases since 2010. According to an article in Statesman, Austin police registered dozens of complaints about the careless and sloppy technique of phlebotomists provided by a contracted temp agency. 

DUI defense attorney Bristol C. Myers obtained emails, memos and contract documents from Austin police department to the temp agency complaining about the conduct and punctuality of the staffing agency's phlebotomists. Myers suggests the documents calls into question the validity of all test results conducted on samples drawn by the agency. 

The documents reflected an instance when one phlebotomist made eight failed venipuncture attempts to draw a blood-alcohol sample. In another instance, the phlebotomist took nearly two hours to respond to a request to draw from a DUI suspect.

On a Personal Note...

They say what goes around comes around. My wife and I are learning that the hard way. If  you have a moment, follow me.

Free Webinar on Centrifugation Set for April 9

Center for Phlebotomy Education director Dennis J. Ernst MT(ASCP) will deliver the second in a series of free webinars jointly produced by Drucker Diagnostics and Greiner Bio-One. Part 2 of "Best Practices in Blood Collection" will take place April 9th at 1:00: p.m. EST.

Ernst will discuss the pros and cons of fixed-angle versus swing-bucket (horizontal) centrifugation, clarify the difference between g-force and RPM, and contrast serum versus plasma as samples for laboratory testing. The event free and qualifies registrants to receive 1 P.A.C.E. continuing education credit awarded by Greiner Bio-One.

Registration is open to anyone through Greiner Bio-One's web site. Register here.

Part 1 of the series in February drew over 1500 registrants. The recording of the event is open to anyone and can be accessed here. Those who miss the April 9 webinar may access the recording here. 

This Month in Phlebotomy Today  

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s flagship newsletter currently in its 15th year of publication, are reading about this month:

Feature Articles
How Vulnerable Are You to a Needlestick?
Phlebotomy Products That Just Didn't Catch On

On the Front Lines
Can We Draw from the Palm?

Sticks, Staph, and Stuff
"X" Marks the Spot?

The Empowered Manager
Make This Happen Where You Work

Myth Busted
Are Certified Phlebotomists Better Than Those Who Aren't?

What's Wrong Here? 
Drawing without gloves

For subscription rates and to subscribe to Phlebotomy Today, click here.

Survey Says:  
Pet Peeves

Let's face it, sometimes patients get under our skin while our needle is getting under theirs. We wanted to know what Phlebotomy Today-STAT! subscribers' consider to be their pet peeves when interacting with patients. The most commonly admitted peeve was when patients request butterflies. We were quite impressed that nearly as many commented that they're tolerant of patients' quirks, and are not bothered. Comments include:

• When they feel they can say anything to us and we're not supposed to get insulted or take things personally. I don't unless they personalize it. For instance, I'm undergoing chemo and a patient looked me up and down and with a sneer on her face asked me if I cut my hair that short. She judged me based on my "haircut". Another patient asked me if my husband liked fat women. Not appropriate but I kept a smile on my face and proceeded to perform my job.
• When they tell me how to do my job, as in "previous phlebotomist said that you should always use a butterfly on me"
• Patients who tell you have one shot and that's it.
• Bad breath and body odor.
• I really hate the whole "vampire" label. Someone give me a good comeback that politely sends the message that it's degrading!
• We have many providers in our practice and we continue to grow as a primary office to keep up with the demands of the Medicare and Tricare insurance patients. So, as a phlebotomist I will hear comments that put down or question the morals of the owner of the practice because of the growth stating that he is just in it for the money. He is about the most moral and nonjudgmental man I know, as well as a superior doctor, so it really irritates me when they think they know him better and can freely give such unsolicited and ignorant comments.
• Telling me that I have to use a butterfly! I'm a professional; I know what I'm doing--let me determine the most appropriate equipment for the situation. Most patients who insist on a butterfly needle don't need it, and some of these patients don't even know what one looks like. 
• When the don't bathe and stink
• What irks me most is when patients are mad at ME for them needing blood work done. I am just here to do my job and help [you].
• That they hate needles but are covered in tattoos.
• Patients who over-direct you unnecessarily when it is obvious that you know what you're doing.
• Adult patients that work themselves into hysteria before the draw.
• When they try to tell me how to draw their blood or they tell me that no one ever is able to draw their blood.
• When a patient tells me what type of needle we "have to" use and the exact spot we "have to" stick. I don't mind them volunteering information but don't make it a "have to" I think my experience and expertise can figure it out. 
• Smelling smokers' breath.
• When they are completely upset and you did everything you possibly could to make the patient happy/comfortable/less aggravated. As a phlebotomist that makes it a lot harder to get them on the first try because the patient screams at you and all you can do is say you're sorry. But your nerves are at their highest when someone yells at you.
• When they turn their face toward me and cough.
• When patients who do not need it demand that we use a butterfly on them. 

We then asked what our readers love most about interacting with patients. 

• Hearing their stories. Being uplifted by the knowledge that by doing my job correctly I'm helping the providers diagnose and treat the patient. Having patients ask for me by name.
• Everyone has a story, I think that helps me to have more empathy, to envision what it is like to "walk in their shoes".
• Making them feel like we care about their well-being.
• Love the jolly ones coming in cracking jokes.
• I do my best, and that feels good.
• Presenting myself in very professional manner and talking to my patients and explaining the whole procedure.
• The relationships I have built with my patients is priceless. When they ask me as much as I do about their well-being and states of mind, I feel like they become friends and family instead of patients.
• I love getting to chat with patients as I draw their blood, and on slower workdays I often stay an extra few minutes with inpatients to visit. Many patients, especially the elderly, are lonely, and they visibly brighten to see a smile and a friendly face and a person who is genuinely interested in them. I've met many interesting people at the hospital and have heard some fascinating stories. Knowing that I've been able to bring a bit of encouragement while serving people medically is a special treat and more than makes up for times when patients and staff are crabby.
• Knowing they are a person and have feelings too. Some are scared, some are anxious, some are at peace.
• I love being able to cheer them up and make them feel like they are cared about. I love making a difference in people lives; even in a small way.
• Being part of their road to wellness and being able to supply them with necessary information.
• Reassuring them and making them feel at ease.
• Interesting individuals and their admirable inner resources in dealing with what life has given them.
• Those sweet faces that tell you it didn't hurt even when you blow the vein and have to restick.
• The appreciation when you do a good job.
• When they compliment you on a job well done or just simply the patient leaves with a smile or is very pleased with their visit.
• I like to believe that in some small way maybe I made their day brighter with a good report so they could go home or sometimes with a touch to an elderly patient that is upset and or confused. 

Finally, we gave readers an opportunity to tell us what they like best about those they work with. More respondents said teamwork was the element they like most in their coworkers than anything else. More comments:

• Good phlebotomists who take pride in their quality of work
• Accepting me as a equal. For example, just because you are a Med Tech doesn't make you a better person.
• We see so much of each other every day that we really do start to feel like a family and really do have the best of intentions at the end of the day.
• I like that my coworkers in the lab are generally very willing to help each other out, whether it's with a hard stick for an inpatient or a sudden rush in our outpatient clinic. They also look out for patient well-being by keeping tabs on lab orders--watching for duplicate and mistaken orders and consulting nurses about consolidating some scheduled draws in order to keep the patient from unnecessary sticks.
• They are ALWAYS willing to help. No matter what it is, I've never been denied help.
• How we love it when we are successful with a tough stick.
• Kind hearts. Genuinely caring about the patients and the staff.
• Love it when they are committed to the work and focused on patient care.
• When they come to me to ask for additional instruction because of my years of experience and not just because someone told them that they had to ask me.
• The original 5 of us work together like a well-oiled machine and we really are friends and care about each other.
• I love those employees who understand that being an excellent phlebotomist is about so much more than just sticking a needle in someone's arm.

This month's survey asks "Do those certified in phlebotomy perform better than those who aren't?  Take the survey.

What Should We Do?:
Butterflies and Syringes

What Should We Do? gives you the opportunity to ask our team of technical experts for advice on your most pressing phlebotomy challenges. Whether technical or management in nature, we’ll carefully consider solutions and suggestions based on the industry’s best practices so that you and those in other facilities with the same problem can benefit, all the while maintaining your facility’s anonymity. What Should We Do? is your opportunity to ask us for suggestions on the best way to handle your real-life dilemmas.

This month's case study: We have members of our staff who are using multiple syringes when they draw with butterfly sets. They fill the first syringe, pinch the tubing, take the full one off and put on a new syringe and fill that one. They do this as many times as it takes to get enough blood. My management team knows this isn't right, but needs help telling the staff why they shouldn't draw this way. What should we do?

Our response:  We can't imagine they were trained to pinch the tubing of a butterfly to interrupt the flow.  Such an unorthodox practice is not only likely to be against the manufacturer's instructions for use (IFU), it seems inevitable you'll be dealing with a bloodborne exposure. Should the constriction be inadequate, blood would drip, or even flow freely, from the luer end. You need to find out why your staff feels this is the preferred method instead of a tube holder adapter that would fill the tubes directly. There is at least one product on the market that incorporates a crimping device on their butterfly's tubing for that very purpose, your question suggests you don't have such a device.

If a syringe must be used, make sure it's for a good reason, and find out why a single 20 cc syringe is not sufficient. We're hard-pressed to imagine a draw that requires multiple syringes from a butterfly device unless a blood culture is ordered. A single 20-cc syringe should be enough for most routine orders. If it's not, you should make sure every phlebotomy tray and draw station is stocked with low-volume tubes so more than 20 cc is not required.

If blood cultures are ordered, the proper procedure would be to use a tube holder adapter on the butterfly, not multiple syringes that require manual crimping of the tubing.

There could be many reasons this practice is thriving among your staff, so be sure to listen intently to all voices, and logically work through them toward a safer, more logical process together. After you've agreed on a modified process that is safer, make sure your procedure manual spells out the proper method. Then any other method can be disciplined as insubordination.

 Each month, our “What Should We Do?” panel of experts collaborates on a response to one of the many compelling problems submitted by our readers. Panelists include:

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.)

Tip of the Month: How Cultured Are You?

Click here for this month's featured Tip of the Month from our rich library of archived Tips. ------------------------------------------------------------------------------