by Dennis Ernst • May 03, 2018
The newly revised venipuncture standard released by the Clinical and Laboratory Standards Institute in April, 2017 is the most comprehensive revision in the document's history. With over 140 new mandates, facilities have a lot of changes to implement. This series discusses one or more substantive changes each month.
Almost every phlebotomy trainer and educator teaches the meticulous practice of cleansing a venipuncture site in concentric circles of increasing diameter. If that includes you, it's time to abandon the practice. The standards no longer require it, not even for blood culture collections.
Where the origins of this technique came from is unclear. Even though the CLSI venipuncture standard has made it a requirement for 38 years, the passage has never been referenced. That's probably because no study has ever proven, or even attempted to prove, that circular cleansing prepares a venipuncture site any better than random, directionless friction. Since it is not an evidence-based practice, the CLSI committee revising the 7th edition of the popular standard removed it as a requirement.
"We didn't remove it just because it wasn't evidence-based," says committee Chairholder Dennis J. Ernst MT(ASCP), NCPT(NCCT). "We removed it because we found reliable peer-reviewed sources that said back-and-forth friction was more effective." Those sources, referenced in the new standard, include Infection Control Today the Critical Care Nursing Quarterly, and the American Society of Microbiology's Cumitech 1C.
The most common word-of-mouth rationale for concentrically circular cleansing seems to be based on the movement of organisms away from the center of the site towards the periphery. "The prevailing explanation for circular cleansing is that, by starting in the center with the antiseptic and moving outward, the bacteria on the skin is 'pushed away' from the center where the puncture will take place," says Ernst. "Perceptually, the center would then seem to have fewer organisms than the periphery, since the applicator never comes back to the center where the needle will be inserted.
"However, if you think about it, any organism that comes in contact with the antiseptic, whether it's an alcohol pad or chlorhexidine scrub, will be denatured or killed, respectively. It's not the pushing out that prevents site contamination, it's mere contact with the antiseptic, which takes every organism out of the picture no matter what direction you apply it."
The current CLSI venipuncture standard now simply states friction is required when cleansing sites, and calls attention to the studies that have found a back-and-forth pattern to be more effective.
Editor's note: Readers are urged to obtain their own copy of the standard as soon as possible and begin implementing all new provisions immediately. The document, Collection of Diagnostic Venous Blood Specimens (GP41-A7), is the standard to which all facilities will be held if a patient is injured during the procedure or suffers from the consequences of an improperly performed venipuncture. It can be obtained from CLSI or the Center for Phlebotomy Education, Inc.
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