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Phlebotomy Today

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January, 2017

Reducing Hemolysis Saves Thousands

HemolysisThe Cleveland Clinic recently reduced their ED hemolysis rate from 13 percent to 2 percent, saving the facility $73,000.

Armed with the results of a CDC study on emergency department hemolysis, the reduction took a concerted effort between the laboratory and ED administrators and about a year to accomplish. According to an article in CAP Today, the facility's aggressive approach attempted to apply the strategies assessed by the CDC. Among them: 1) the elimination of draws during IV starts in favor of performing separate venipunctures and 2) the use of low-volume tubes when drawing during IV starts. While they were unsuccessful in getting the ED nurses to agree to a separate venipuncture for lab draws, the switch to low-volume tubes during IV starts brought a dramatic reduction in hemolysis.

The CDC was unable to establish the use of low-volume tubes as a Best Practice due to the lack of sufficient evidence in the literature. (In order to establish a Best Practice, the CDC requires three valid studies meet their stringent criteria and that show the same effect. Only two could be found.) However, the use of low-volume tubes is now the standard practice for draws during IV starts at the Cleveland Clinic. Because low-volume tubes have a lesser vacuum, the red blood cells are subjected to far less pressure when filling and are less likely to rupture, hemolyzing the sample.

Not only did they find hemolyzed samples to be expensive, the impact on the patient was significant. On average, a hemolyzed sample was found to delay an ED patient's admission by 49 minutes, and a discharge by 23 minutes. Educating the staff was also felt to be an important contributor of their reduction in hemolysis rates. 

Read the CAP Today article. (See Page 22.)

[Editor's note: The Center for Phlebotomy Education has produced a training video that details an effective strategy to reduce ED hemolysis incorporating the CDC's Best Practice designations into a comprehensive facility-wide approach. Our Director, Dennis J. Ernst, participated in the CDC Evidence Review Panel on hemolysis and coauthored the article that launched the Cleveland Clinic's hemolysis-reduction project.]

Just for Phlebotomists


A Softer Approach to Stabilizing Blood Samples

Butterflyhands13_SSTufts University researchers have found a new use for silk: stabilizing blood samples. 

Long known for its softness and strength, silk has been around as long as there have been silkworm moths. Scientists have known the protein in silk, fibroin, is effective in stabilizing antibiotics and vaccines, but Tuft's researchers only recently tested its usefulness in stabilizing blood samples. The results suggest silk could change the way blood samples for laboratory testing is collected and stored.

Tufts engineers mixed plasma from centrifuged samples with a powder of purified fibroin extracted from silk. They then air-dried the plasma and stored it between 22 and 45 degrees Celsius (71.6 to 1130F), rehydrating and testing portions of the stored plasma periodically. Some biomarkers were successfully analyzed after 84 days of storage at 1130F.

These results show silk provides better protection for some tests that require transportation over long distances in harsh enviro
nments than the traditional approach of dried spots on paper. Much work remains before applying the properties of silk to large-scale laboratory testing, but the potential for transforming how blood is collected and stored is enormous, and especially beneficial in rural settings without electricity and refrigeration, or where traditional laboratory storage environments are unreliable.

More information.

Product Spotlight: 22 months of in-house CE exercises

Do you struggle every month to find good material to put in front of your students or specimen collection staff? Those days are over.

We've just packaged 22 months of our popular Abbreviated Teaching Modules (ATMs) in one download, and priced it well under what you've budgeted for continuing education this year.

Our ATMs are short 1-2-page articles on a wide variety of phlebotomy topics your collection staff should know. Simply distribute one exercise to your staff each month, collect their answers to the accompanying quiz, grade it, file it, and get on with your day.

The 22-module set is downloaded immediately after your online purchase as zipped PDFs with answer keys for each exercise. That's almost two years of monthly in-house CE exercises for you to administer to your staff at a fraction of what you've been paying from other sources. Titles include:

  • ATM_CompleteSetThe Order of Draw
  • Hematoma Prevention
  • Tourniquet Time
  • Needlestick Prevention
  • Hemolysis
  • Patient Identification
  • Acceptable Sites for Venipuncture
  • Blood Cultures Done Right
  • Hemoconcentration: What is it?
  • The Aggressive Patient
  • Infants and Toddlers in the Healthcare Environment
  • Communicating With Elderly Patients
  • Give Your Patients Their Personal Space
  • Tips for Successful Capillary Collection
  • Non-verbal Communication: What Message Are You Projecting?
  • Phlebotomist's Guide to PICC Lines, Central Catheters, and Imbedded Ports
  • Therapeutic Drug Monitoring
  • Customer Service Excellence
  • Bloodborne Pathogens Review
  • Are You a Pathogen Parade?
  • Drawing From Young Children

Stop scouring the Internet for mediocre resources just to meet your monthly staff requirement. All ATMs are highly researched and reflect industry standards and guidelines. 

Sample ATM and more information.

Survey Says: Reducing phlebotomy pain and anxiety

Lady listeningLast month we got curious about pain and anxiety. Researchers are reporting a dramatic increase in the number of needle-phobic patients and those who express significant anxiety about needles in healthcare. So we asked our subscribers and visitors to our web site what they are using to reduce the pain and anxiety of phlebotomy on pediatric and adult patients. 

For pediatrics, over 70 percent of those responding said they use verbal distraction (conversing, small talk, etc,)(85%), parental comforting (81%), use of a 23-gauge needle or smaller (79%), and visual distraction (71%). If survey participants had to choose only one technique from our list of 13 strategies, verbal distraction received the most votes (27%).

For adults, 91 percent said they used verbal distraction making it the most popular strategy in our survey. Explaining the procedure in advance is used by 64 percent of respondents, while visual distraction is used by 51 percent. The single most preferred technique for reducing anxiety on adults is verbal distraction, preferred by 72 percent of those who responded.

Other strategies offered by those responding include:

  • "having patients count in multiples of three"
  • "Getting it done quickly & efficiently"
  • "relaxation techniques,"
  • "being personable and getting the venipuncture over with as quickly and efficiently as possible"
  • There is nothing better than being calm and soothing to any patient. Never tell them it doesn't hurt, of course with infants that's different."

Seventy-two percent of respondents said the frequency of patients with needle fear has not changed much since they entered healthcare.

Pediatric girl afraidComments include:

  • More adults are admitting their fear. Some insist on butterfly [needles], which, in reality, ARE NOT needed.
  • Parent's behavior and demeanor seem to feed an already anxious kid. I think it is a learned behavior.
  • We need to demand more training and higher standards for phlebotomists!
  • Allowing young patients to watch what is happening if they would like to often reduces their anxiety quite a bit if they can see what is happening.
  • We have just introduced Skin to Skin for newborns.at our hospital.
  • Having everything prepared and ready to go before entering the room. Delay while I get set up adds to anxiety. 
  • Our local Children's Hospital uses Pain Eaze; local NICU units use Sweet-Eaze
  • Suggesting to medical assistants to inform parent to purchase the topical anesthetic, and apply topical & cover with clear medical tape 30 mins before blood draw!
  • I despise using topical anesthetics and ice as they just don't seem to work.
  • Have inflated gloves like a balloon.
  • Have child sing.
  • We use Buzzy, small talk, games, age appropriate search-and-finds, singing, having the nurse dip the pacifier in sucrose, bubbles, tablets with videos & games, comfort positioning, training with specialised (sic) child-life in-services, and we have a child life specialist on-call for outpatient and impatient collections at all times.

Next month's survey asks about your productivity. How many patients do you typically draw per hour? Does your employer have an expectation about how many you should be able to draw per hour or per shift (i.e., a quota)? Take the survey. 


The Empowered Healthcare Manager

EmpoweredManagerWelcomeScreenShot_500wEvery month we run an excerpt from our editor's popular blog, The Empowered Healthcare Manager.


Taking Inventory of Your Staff 

Last month, many companies conducted their annual inventory for tax purposes. As an empowered manager, you should inventory the assets you have, too. Human assets.

To get you started, here are some categories in which you should be well stocked:

Team leaders---Kept in the light at all times with inspiration, communication, and challenges, this stock item is a staple for every workplace. Don't let your quantity of Team Leaders get too low or stagnant from inactivity or mixed messages. This item is on backorder at most workplaces and cannot be easily replaced.

Team players---Team Leaders need Team Players. Not every human asset in your inventory wants to lead, so don't let this item run low. Keep them warm with compliments and in the light of their leaders.

Born educators---­­­Only a few of these will suffice, but they are one of your most precious assets. Keep this item in front of people, preferably a classroom. They thrive best when provided with current material, training tools, and support. Don't make them use flawed, error-­riddled resources. The materials you let them use tells them about how much (or little) you value their efforts.

Standards aficionados---This stock item knows the standards and refuses to deviate from them. It thrives where diversions and exceptions to the procedure are disciplined, and will have a short shelf ­life where it's not.

Customer Service Concierges---­­­Patients ask for this product by name. It creates the kind of word-­of-­mouth that drives more work through your front door. Keep them in well-­lit places with many opportunities for interaction with the public and other departments.

Problem Solvers­­­---This inventory item bring problems to your attention and also propose solutions that work.

LMHs­ (­­Loyal Human Machines)---These components of your inventory are automatons. They are self-­operating machines with big hearts and fierce loyalty to you, your company, and your policies. Without them, you can't stay in business for long. Keep plenty on hand.

Everything else in your inventory should be sold off at a deep discount. They are your tax. Empowered healthcare managers don't pay taxes on their human resource inventory.

 Subscribe to the Empowered Healthcare Manager blog.

What Should We Do?: Patient wants to pick the vein

Man in hospital gown

Question: We have patients who want to tell us where to draw their blood from, and insist the vein they pick is the only place they'll let us draw them from. Is there any legal document we can have them sign releasing us from liability should anything happen? My staff tells me the patient will go so far as to get up and leave if they don't have their way. What should we do?

Our response:  It's nice to be able to honor a patient's wishes, but ultimately it's not the patient's choice.

According to CLSI, you must survey both arms, if accessible, for the presence of a vein in the center of the antecubital area before selecting the basilic vein since veins in the center are least likely to be near vulnerable nerves or the brachial artery. The standards make no mention of giving patient preference a priority. Even getting permission from the patient in writing to draw from a high-risk area when a safer vein is accessible won't release you from liability should an injury occur. The patient's attorney can successfully argue that the patient wasn't knowledgeable enough about the risks involved to be given the authority to select a specific site or vein. They'll claim, rightly so, the phlebotomist has the expertise to make a better judgment of the venipuncture site.

If the patient becomes insistent, your staff should be told to contact a supervisor before taking it upon themselves to operate beneath the standard of care. Some diplomacy will be required, for sure, but at the end of the day it's best for the patient to find another facility willing to violate the standards than for you to consider it a customer-service issue.

Here's something else to consider: all an addict has to do to fund his/her addiction is to study the standards and get someone to deviate from them. If the phlebotomist takes the bait, the addict feigns an injury and you have no defense. Stranger things have happened.

Tip of the Month: Countdown to Safety

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