February, 2008

Copyright 2008 Center for Phlebotomy Education, Inc.
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Professionalism in Healthcare: The Eye of the Beholder

Phlebotomy Today-STAT! continues our series on professionalism in healthcare. This month, we discuss how our personal appearance affects the patient's perception of the quality of care he/she receives. Future topics will include attitude, phone etiquette, and professional certification.

They say beauty is in the eye of the beholder. When you're a patient, confidence is, too. Every patient wants to be confident that they are being treated with the utmost respect for their well being. The image we project says a great deal about us and the quality of work we produce.
Regardless of your position in healthcare, if you draw blood, you serve as a representative of the laboratory. Right or wrong, the patient will perceive the quality of work conducted on the specimens you draw based on the impression you provide. A good impression brings confidence to the patient while a negative impression costs the laboratory whatever confidence it may have worked hard to establish with the patient.

Much of the impression patients develop is based on our appearance. The following is a list of the many ways in which personal appearance affects a patient's perception of the care he/she will receive.

Your clothing
One of this year's most popular Super Bowl commercials was Tide's talking-stain. In the spot, an applicant was being interviewed for a position with a company. Every time he spoke, a stain on his shirt would become animated and speak over him in gibberish, making the applicant's articulate responses completely indecipherable. The message: no matter how articulate you are, stains on your clothing will speak louder than you about your fitness for the job. What do your scrubs or lab coat say about you to your patients? Are they speaking louder than your pleasant personality and skill? If so, it might be time to change into something quiet.

Your grooming
There's nothing wrong with flamboyant hairstyles and untamed facial hair, but in healthcare it distracts from the professional image most healthcare facilities want to project. Unkempt hair can be interpreted by patients as a lack of attention to detail, a disregard for hygiene (yours and theirs), the elevating of individuality above conformity and, by extension, a nonconformity with medical procedures. That's not you, but that might be the perception.

Nails and piercings
Just like with grooming, there's nothing wrong with being flamboyant. Nail salons can do some amazing things with your digits. Unfortunately, bacteria think they're pretty cool, too. The Centers for Disease Control and Prevention tells us healthcare workers with artificial nails are more likely to harbor gram-negative pathogens on the fingertips---both before and after hand washing---than those who have natural nails. More than likely, your skill in specimen collection is well honed. When presented with nail art and excessive piercings, patients may think you're more obsessed with appearances than venipuncture technique, and that costs you their confidence.

Does your personal appearance include gloves? If not, your patients could be thinking of you as more of a threat than an ally in his/her fight for health and well being. Patients read papers. They know that over 100,000 patients die in the US every year from hospital-acquired infections. To them, your inability to locate and access a vein with gloves is irrelevant. To project that you have a healthy respect for nosocomial infections, make sure your appearance is one that proves it.

Your hygiene
Back in the day, an advertisement for a hair cream proclaimed "a little dab'll do ya." The same goes for perfume, deodorant, breath mints, and whatever other aromatherapy you might apply before going to work. Overwhelm patients with your personality and skill, not odors or the products that conceal them.

Your smile
Motivational speaker Chris Frings says a smile is the shortest distance between two people. It's amazing how fast a smile works to give patients the confidence that you are the right person to be putting a needle in their arm. This powerful, free addition to your uniform can do more to tell the patient of your confidence and comfort with the procedure you are about to perform than all the letters you could possibly assemble after your name. It won't undo the damage to your patient's confidence that other elements on this list inflict, but the more you wear one on the outside, the more likely your patient is wearing one on the inside because it's you drawing his/her blood instead of someone with stained scrubs, no gloves, nine-inch nails, twenty eyebrow rings, green frizzled hair and bad breath.

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Editor To Address Armed Forces Conference

Dennis J. Ernst MT(ASCP), editor of the Phlebotomy Today family of newsletters and director of the Center for Phlebotomy Education, will address the annual conference of the Society of Armed Forces Medical Laboratory Scientists this month in New Orleans. The assembly will consist of hundreds of military personnel representing medical facilities functioning under all branches of the armed forces.

Ernst will present a lecture titled "Avoiding Phlebotomy-Related Injuries and Litigation." The topic will detail specimen collection errors that can injure patients and lead them to file lawsuits against the employer. Ernst will refer to his files as an expert witness in phlebotomy-related litigation to illustrate key concepts in risk management. A video containing the presentation's content is available from the Center for Phlebotomy Education at www.phlebotomy.com/Video3.html

Product Spotlight: Skin Punctures & Newborn Screens

      In February, the Center for Phlebotomy Education, Inc. will release its long-awaited Skin Punctures & Newborn Screens training video. With stunning graphic animation that shows the proper location for fingersticks, simulates the affect of platelet clumping on specimen quality, and illustrates other key concepts, Skin Punctures & Newborn Screens demonstrates the proper procedure for performing fingersticks, heelsticks, and newborn screens according to the CLSI standards.
“We’ve spared no expense in time or talent to make this video the most comprehensive and accurate ever produced,” says the Center’s director Dennis J. Ernst MT(ASCP). “The degree of difficulty in developing a video of this nature is incredible, but we filmed every scene until it was perfect. Compromising accuracy and quality for the sake of expediency is just not an option with us.”

      Filmed in hospital nurseries and outpatient laboratories in Indiana and Kentucky, the video includes online access to CE questions for in-house continuing education as well as an option for submitting completed exams for P.A.C.E. credit. The estimated release date is February 20. To order Skin Punctures & Newborn Screens or for more information, visit www.phlebotomy.com/Videos.html.

Skin Punctures & Newborn Screens DVD from the Center for Phlebotomy Education, Inc.
Click here for a preview.

This Month in Phlebotomy Today

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter (currently in its 9th year of publication), are reading about this month:

  • Feature Article: Newborn Screens: Why and How? Part II
  • Ask the Expert!: An OSHA consultant addresses these burning questions:
    • Is the usage of safety devices on needles deemed mandatory by OSHA?
  • Phlebotomy in the News: a synopsis of articles on phlebotomy and phlebotomists who made Internet headlines in January including these stories:
    • Phlebotomist Calms Needle-Phobic Patient
  • According to the Standards:Separate Order of Draw for Syringes?
  • Tip of the Month: Anticipation or Precipitation?
  • On a Personal Note: (Now accessible from our home page!) I have nothing against iPods, but there's a good reason I don't have one.
  • CEU questions (institutional version only).

Buy this issue for only $9.95.

For subscription rates and to subscribe to Phlebotomy Today, visit www.phlebotomy.com/PhlebotomyToday.html. The current month’s issue will be emailed to you immediately upon subscribing.

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Featured FAQ: Order of Draw with Citrate Tubes

Question: It is my understanding CLSI changed the order of draw in 2003 so that it is now 1) blood cultures; 2) blue tops; 3) red tops; 4) green tops; 5) purple tops; 6) gray tops. It is also my understanding that if a blue top is the only tube to be drawn, it no longer needs a waste tube unless it is being drawn with a butterfly. This is contrary to several things I had read in the past (i.e., that the clot-activator tubes should not be drawn before anticoagulant tubes because of possible contamination, and also that tissue thromboplastin in the needle could interfere with a blue top drawn by itself). Can you help clarify this for me please?

Response: No study has ever proven that tissue thromboplastin interferes with coagulation studies. It’s always been speculation until the late 1990s when studies proved that drawing a discard tube before the citrate tube made no difference in protime and aPTT results. Therefore, CLSI discontinued their recommendation for a discard tube in 1998 when drawing a protime or aPTT.(1,2)

      However, studies have not been conducted on any affect of tissue thromboplastin on special factor assays. CLSI guidelines and standards, therefore, state that evidence of tissue thromboplastin contamination is consequential at best, and that facilities should establish their own policy in regards to special factor assays.

      There is certainly no harm done when drawing a discard tube, it's just not necessary when testing for protimes and aPTTs. Of course, discard tubes are still recommended when drawing with a butterfly set and the blue top is the first or only tube drawn. This is to prevent short sampling when the air in the tubing enters the citrate tube. The discard tube need not be filled, but only applied long enough to prime the line of the winged collection set. The discard tube can be another citrate tube or a plain, non-additive tube. As far as the clot activator contaminating an anticoagulant tube, there is no evidence in the literature that this occurs or that it affects results.


  1. NCCLS. Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays; Approved Guideline—Fourth Edition. CLSI Document H-21-A4. Wayne, PA: Clinical and Laboratory Standards Institute; 2003.
  2. CLSI Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard—Sixth Edition. H3-A6. Wayne, PA: Clinical and Laboratory Standards Institute; 2007.

Each month, PT--STAT! will publish one of the hundreds of phlebotomy FAQs in the growing database of questions and answers available in Phlebotomy Central, the members-only section of the Center for Phlebotomy Education's web site. For information on joining Phlebotomy Central, visit www.phlebotomy.com/PhlebotomyCentral.html.

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What Would You Do?

Each month, What Would You Do? presents a different case study, then asks readers to contribute their ideas as to how each situation would best be handled. The following month, selected responses will be chosen by the editor and published (sender will be identified by first name and state only). The most accurate, well written response will receive a free "Accurate Results Begin With Me!® t-shirt. The exercise will conclude with a review of the selected submissions and a discussion of the standards pertinent to the case study.


Last Month’s Case Study:
A Sharp Dilemma

You report to work and immediately have patients to draw blood from. You go to the collection tray you usually use and find that the last person who used it overfilled the sharps container. Contaminated needles are protruding above the opening. What would you do?


(Editor's Note: I have a personal experience with the very scenario described. When I encountered an overfilled sharps container, I took it upon myself to seal and dispose of it. While forcing the lid down to lock the container, a contaminated sharp poked through the bottom of the hard plastic and into my thumb. Had I listened to many of you first, that would not have happened. Hopefully, my esteemed readers will not repeat my mistake.)

     Responses to January 's scenario reflect a well-informed PT-STAT! readership. We were impressed with the quality and quantity of responses. But our favorite response came from Kenneth Laycock of Australia. It also happens to be the most correct and articulate. We don't judge responses based on humor, but Kenneth secured his prize-winning response with a dash of spunk.

"Firstly, I would don the accoutrements of a medieval knight and then proceed to remove the offending article in an empty and sturdy very thick plastic container with a secure lid, which I would then deposit in an appropriate diposal bin ready for incineration. I would then find the last culprit who was negligent and place them in the wheelie bin together with the protected sharps holder to contemplate what might have been should some unfortunate soul come into contact with the cocktail of spent sharps and blood products. In all of this I would re-educate all the staff with the prospect of a life with the things you wouldn't discuss with your friends."

     For his wit and wisdom, Kenneth will receive a free Accurate Results Begin With Me!® t-shirt. Kenneth was not alone in his angst against the offending party. Fifteen percent reported that they would personally hunt down the culprit who put them at risk. Interestingly, only 45 percent said they'd report an overfilled sharps container. Of those, two thirds would also dispose of the hazard themselves. But it's the means of handling the overfilled container that we found surprisingly varied. Of the 75 percent who would dispose of the hazard themselves, 80 percent would carefully place the overfilled container inside a larger sharps disposal unit. Other suggestions were to fish out the overflow with a hemostat and move them into an empty container, dump the overflow into a empty container, or just simply close the container.

Typical of most comments is this one:

"You should never attempt to stick another needle into the bin as you are risking a needle stick injury from an unknown source. Contact the housekeeping or correct department for handling sharps bins or medical waste and report the matter in accordance to your hospital's policies. You should also report it...."

     According to OSHA, sharps containers should be "replaced routinely and not be allowed to overfill." Therefore, overfilling is an OSHA violation. Outside of OSHA jurisdictions, overfilling violates every healthcare worker's right to a safe working environment. OSHA states "When moving containers of contaminated sharps from the area of use, the containers shall be...closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping." Clearly that can't be accomplished when the device is overflowing.

     OSHA doesn't provide too many details on how to handle an overfilled sharps container, but the suggestion of respondents to place it inside a larger sharps container seems to be the most popular. In fact, OSHA states that sharps containers should be "placed in a secondary container if leakage is possible." It seems that "leakage" would include contaminated needles that prevent closure. However, moving an overflowing sharps container into a secondary container is not without risk. If contaminated sharps are overflowing to an extent that movement may cause a sharp to fall out and pierce the hand carrying it, then grasping and relocating the container with a mechanical device such as a pair of large tongs instead may be safer. Depending on the extent of overfill, using hemostats to remove enough overflowing sharps into an empty container until the lid can be sealed might be the safer option. Facilities should establish and publicize their protocol for handling overfilled sharps containers to prevent the riskiest options from being exercised. This may mean the notification of specialized medical waste handlers in your facility to eliminate the hazard.

     The Compliance Directive OSHA issues to its inspectors to provide guidance on enforcement of the Bloodborne Pathogens Standard states "The Compliance Officer should ensure that sharps containers are being replaced routinely to prevent overfilling." It indicates a potential for two citations to be issued should an inspector find an overfilled sharps container; one for the hazard and one for inadequate training. Here's the text from the Compliance Directive:

Overfilling of sharps containers should be cited under paragraph (d)(4)(iii)(A)(2)(iii). A citation for inadequate training on work practices, paragraph (g)(2)(vii)(F), should be grouped with the citation for this paragraph if the overfilled containers are present because of lack of training.

     OSHA doesn't insist overfilled sharps containers be reported. However, managing the risk of exposure to bloodborne pathogens requires those who can modify behavior in your facility to be made aware of the potential so that preventative measures can be taken. Failure to report such risks only serves to preserve and perpetuate them. How will you feel if next week someone at your facility was exposed to a contaminated sharp in an overfilled container because you failed to report one last week? If it's not your facility's policy to report such hazards, make it your own moral obligation. Otherwise, one of your coworkers may soon be paid a visit by an Australian medieval knight named Kenneth pushing a wheelie bin.


This Month's Case Study:
A "Pour" Excuse
You're a new employee at one of the most reputable hospitals in the region. You were hired right out of a 6-month training program at an accredited college and recently passed your certification exam with flying colors. You've wanted a job at this hospital for as long as you can remember, and now your dream has come true. Because you are new, the lead phlebotomist is shadowing you as you draw a difficult patient. All you need is a coag tube for a protime and an aPTT, but the flow stops when the tube is only half-full. You put on another tube. Same thing. You terminate the draw. While bandaging the patient, you notice the lead phlebotomist combining the contents of both tubes so that one tube is completely filled. She tells you to label it. What would you do?

Tell us what you'd do in this case. Submit your response by the 20 th of the month and send it to this address and this address only: WWYD@phlebotomy.com. Submissions sent to any other address will not be considered. Keep your suggested solutions less than 100 words. Although you don’t have to be an English scholar to be considered for inclusion, submission with proper grammar and punctuation will be given priority. If you’re not sure of the appropriate solution, check your facility’s procedure manual or ask your manager. Who knows, you might be presented with the very same dilemma tomorrow.


Center Offers Free Phlebotomy Today Archive CD

     Ever since the first issue of Phlebotomy Today---the paid-subscription parent of PT-STAT!---was published online in 2000, thousands of healthcare professionals around the world have been clamoring for access to the archives. Are you one of them? If so, you'll be happy to know the Center for Phlebotomy Education is releasing all eight years of our back issues on CD.

     The Archive disc contains all 93 issues, and includes the inaugural February 2000 issue through December 2007. Users can search all articles by keyword or browse each individual issue. Do you want every article we've published on hemolysis? Type it in the search window and you'll be presented with links to 19 specific back issues. Enter "potassium" and you'll find links to 26 issues that discuss potassium ready for your review. The archives are in printer-friendly PDF format and will require Adobe Acrobat 7.0 to view and print. (A link to Acrobat is provided on the CD.) The CD also includes all of the editor's popular "On a Personal Note" essays.

     As a special to PT-STAT! readers, all new subscribers to Phlebotomy Today will receive a copy of the archive CD free. The special applies to individual as well as institutional subscriptions. (To view a sample issue of Phlebotomy Today, visit www.phlebotomy.com/Newsletter.html.) For readers who only want the archive CD, it can be purchased for $49.95 from the Center's 2008 catalog (being mailed this month) or web site. The scheduled release date is February 20.

(Editor's note: Although each issue includes the "Tip of the Month", the single-page, printer-friendly version is not included in the archive CD. That's because the Center is in the process of compiling an attractively designed collection of the Tips for release later this year.)

For more information on the archives CD, visit www.phlebotomy.com/PhlebotomyToday.html#ArchivesDisc


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Copyright 2008, Center for Phlebotomy Education, Inc. All rights reserved. Newsletters may contain links to sites on the Internet owned and operated by third parties. The Center for Phlebotomy Education, Inc. is not responsible for the availability of, or the content located on or through, any such third-party site. Information in this document is provided "as is," without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability, fitness for a particular purpose and freedom from infringement. The user assumes the entire risk as to the accuracy and the use of this document. We will not be liable for any damages of any kind arising from the use of this information, including, but not limited to direct, indirect, incidental, punitive, and consequential damages.