Dear Center for Phlebotomy Education:

We're struggling with how we use tourniquets at our facility. We have on hand some extra wide and extra long (18") orange tourniquets for bariatric and obese patients that works very well for many patients, not just bariatrics. But using them on every patient is not cost effective, so some phlebotomists are cutting them into shorter pieces and getting three wide, but shorter tourniquets out of one so they can use them on non-obese patients instead of the conventional blue tourniquets. Because they are wider, the modified orange tourniquets work well for geriatric patients with crepe-paper skin and other difficult situations.

Now our quality control people are telling us to stop altering the product. They cite concerns over modifying a medical device, claim the wider band constricts too much, and infection control issues. We like the wider bands, but using them without modification for every patient would be cost-prohibitive. Some of us have taken to doubling up on a standard tourniquet, using two instead of one, but that's also being thwarted as being potentially too tight for patients. Blood pressure cuffs and other alternatives have not generally been available. What should we do?

My response:

This is a very interesting question. We're not a big fan of cutting tourniquets to make them shorter. If wider bands were acceptable and equally functional, manufacturers would already be making them that way, but they don't. That tells us they're either not effective or not marketable. We would discourage the practice as well. We would also discourage the practice of doubling tourniquets. There's no evidence supporting that as being an effective means of providing constriction. It's what I call a "homemade modification" to an established practice.

The bigger issue is that your fellow phlebotomists are taking it upon themselves to change things without authorization (or so it seems). If they are making these quirky changes because they think they have a better way, there's no telling what other aspects of the procedure they are modifying, some with potentially detrimental consequences and impacts. We strongly advocate sticking to the procedure your facility has established, and if anyone wants to change things it should be brought to the manager's attention for consideration.

For the elderly crowd with crepe skin, one way to make it more comfortable is to make sure to wrap the tourniquet on top of the sleeve. The skin is less likely to pinch and cause discomfort.

To reduce costs, you might have your facility implement a practice where every patient is given a tourniquet upon admission that stays with them and is used only on them. That way they won't be transmitting pathogens from one patient to the next.