Can Someone with HIV or Hepatitis Still Draw Blood?
One of the most common questions received at the Center for Phlebotomy Education is whether or not someone with hepatitis or HIV can work as a phlebotomist or draw blood in any other capacity. Until recently, current information on the subject has been scant and vague.
Last month, an updated guideline was published from the Society for Healthcare Epidemiology of America (SHEA) for managing healthcare providers who are infected with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or the human immunodeficiency virus (HIV).(1) Founded in 1980 to advance the application of the science of healthcare epidemiology, SHEA’s mission is to prevent and control infections in healthcare settings.(2) The guideline replaces those published in 1997.
In this update, SHEA:
Infected healthcare providers who meet or exceed these viral concentrations are subject to three categories of venous access procedures based on the risk of bloodborne pathogen transmission associated with each as follows:
Generally, SHEA recommends all infected healthcare professionals who meet or exceed the viral load minimums should use double-gloving for all invasive procedures, all contact with mucous membranes or non-intact skin, and during all patient-care activities for which gloving is recommended. They should not perform phlebotomy procedures on patients who are likely to bite or in certain emergency situations (see Category III procedures in the Table above). Such circumstances are associated with a risk for provider-to-patient transmission even when infection control measures are followed.
SHEA recommends infected healthcare workers with a circulating viral burden below the stated cut-off (HBV viral load less than 104 GE/mL; HCV viral load less than 104 GE/mL; or an HIV viral load less than 5 x 102 GE/mL) be allowed to perform Category III procedures if the employee:
*Note: The expert review panel, at a minimum, should include representation from Hospital Epidemiology, Infectious Diseases, the healthcare professional’s specialty or subspecialty, Occupational Medicine, hospital administration, and perhaps legal counsel.(1)
Restricting Assigned Tasks
Although SHEA’s stance is that otherwise competent infected specimen-collection personnel not be prohibited from participating in patient-care activities solely on the basis of an infection with a bloodborne pathogen, the updated guideline also provides additional criteria facilities can use to evaluate an infected employee’s specific transmission risks. In addition to determining the viral load of the healthcare professional, factors to consider include the employee’s ability to properly perform assigned tasks, any documentation that a serious harmful event has occurred (i.e., the employee is known to have transmitted HBV, HCV, or HIV), and the employee’s ability and willingness to comply with established protocols to prevent disease transmission. SHEA recommends that reasons for limiting an employee’s job duties should be in agreement with the facility’s existing impaired-employee and disability guidelines.
[Editor’s Note: Correspondence regarding the contents of this guideline should be addressed to David K. Henderson, MD, Deputy Director for Clinical Care, Clinical Center, National Institutes of Health, Bldg. 10, Room 6-1480, 10 Center Dr., MSC 1504, Bethesda, MD 20892-1504 (firstname.lastname@example.org).]
Recognizing Phlebotomists During Lab Week
Is it possible to go overboard when recognizing those who collect, process, and deliver blood samples in your facility? We don't think so. National Medical Laboratory Professionals Week is April 18-24. As a service to our readers, the editors of Phlebotomy Today have some suggestions on how to make sure your team of phlebotomists knows they are appreciated above and beyond the donuts and free lunches everyone else in the lab gets.
Set aside Tuesday of Lab Week as Phlebotomist Appreciation Day
Take a phlebotomist to lunch
Offer preferred parking for phlebotomists on April 20
The chance to earn credentials
Introduce a "Me and My Shadow" mentoring program
Put your valued staff on display
These and a multitude of other ideas will help your staff feel recognized and valued as members of your department and facility.
This Month in Phlebotomy Today
Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 11th year of publication, are reading about this month:
For subscription rates and to subscribe to Phlebotomy Today, click here. The current month’s issue will be emailed to you immediately upon subscribing.
Question: We are struggling to get our hemolysis rate down. It would be helpful to know what the rate of hemolysis is industry wide as a percentage of all specimens drawn. That way, I can tell how serious our problem really is. Does such a benchmark exist?
Answer: At least four studies have measured the frequency of hemolysis in emergency department (ED) draws, but only one on overall draws. Generally, the range of hemolysis during venipuncture in the ED is 0.3 percent to 3.8 percent. The summaries of the articles and citations are below.
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, click here.
Our latest survey polled visitors to our website regarding the use of glass blood collection tubes in their facilities. The results are below:
1.) Does your facility stock glass blood collection tubes (not including blood cultures)?
2.) Which tests, if any, are drawn into glass blood collection tubes in your facility (excluding blood cultures?)
Therapeutic drug monitoring (6)
Routine chemistry testing (5)
Cord blood studies (3)
Lead levels (2)
Trace metals (1)
Type & screens (1)
Blood bank (1)
Vitamin B & D levels (1)
Ferritin & folate levels (1)
Hepatitis tests (1)
Herpes tests (1)
HIV tests (1)
Chromosome analysis (1)
Genetic testing (1)
Tissue typing (1)
Platelet function analysis (1)
Drug screen (1)
Waste tube for aspirin and Plavix® resistance tests (1)
3.) Are blood cultures drawn into glass or plastic bottles/vials?
4.) Is your facility in the U.S.?
Editor's note: According to OSHA's Bloodborne Pathogens Standard Compliance Directive, the document its inspectors use to interpret the standard, “where engineering controls will reduce employee exposure either by removing, eliminating or isolating the hazard, they must be used.” Richard Fairfax, the overseer of all enforcement and compliance related activities for federal OSHA, was questioned on the clinical laboratory’s use of glass versus plastic tubes in 2003 in an article published in MLO magazine.(1) "[A] plastic tube would be considered an engineering control because plastic is much less likely to break than glass. Since plastic tubes are readily available, a facility that is not using them would have to justify why they are not being used to the satisfaction of our inspectors. That justification would have to appear in their exposure control plan and [be] supported by reliable evidence."
This month’s survey question:
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 editors and published (sender will be identified by first name and state only). The most accurate, well written response will receive a free download from the Center for Phlebotomy Education’s library of download articles. The exercise will conclude with a review of the selected submissions and a discussion of the standards pertinent to the case study.
The majority of PT-STAT! readers who responded to last month’s case study recognized the potential for injury with patients who have a history of passing out during phlebotomy procedures and the importance of properly positioning the patient. Sixty-seven percent of our respondents would explain the safety risks and consequences to Roger should he faint while seated in an upright position. Interestingly, 33% would still perform the draw on Roger even if he couldn’t be convinced to lie down, with 13% stating they would seek additional assistance from a coworker.
According to CLSI’s venipuncture standard (H3-A6), those who collect blood samples should anticipate a possible loss of consciousness in every patient and be prepared to react according to institutional policy. Part of that preparation includes having a venipuncture chair available that is equipped with a safety feature (i.e., adjustable armrests) that will prevent the patient from falling should he/she pass out. Under no circumstances should a patient be drawn while seated upright on an exam table. Should the patient lose consciousness, there is nothing to break his/her fall, which could result in serious injury to both the patient and collector.
For individuals who report a history of fainting, placing the patient in a recumbent position before the draw greatly reduces the potential for injury and subsequent legal liability, as described by one reader:
Doreen E. described her approach this way:
“During many years of working as a phlebotomist I have met a lot of patients like Roger who insist they will be okay sitting in a chair, only to find that they of course are not and duly faint. My approach now is to explain that I am not comfortable to bleed them unless they lie on the couch, as I am a small female and it would be impossible for me to hold them and be very dangerous if there was a needle in their arm. I also tell them that it is much more relaxing for both of us if there is no danger of them falling. During the procedure I chat to them all the time and usually everything is okay and they go away very positively because they feel perfectly okay. If they insist on sitting in the chair I simply refuse to 'bleed' them.”
Another reader has found that describing the amount of paperwork required should the patient pass out to be an effective means of persuading resistant patients to cooperate. “First I ask the patient to follow protocol as a favor to me, thereby taking ownership of the situation. Next I will describe a consequence for the patient if he doesn't do what I am asking. In this case I would ask the patient to lie down to help me out because if he faints I would have "a lot of paperwork" to do. I get better compliance this way because the generic phrase "paperwork" implies that the patient will have to stay to complete his portion.”
Keeping the faint-prone patient engaged in conversation was a method of distraction mentioned by 13% of our readers. Also noted in 20% of the responses was the importance of being sensitive to and lessening the embarrassment Roger may feel. Christine S. offered the following alternative:
“We have reclining phlebotomy chairs rather than exam tables…Drawing the patient in one of those allows him to remain seated, and not be embarrassed--which is probably the reason he doesn't want to have to lie down for the draw--but if he does faint, he is just needs to be reclined. This works great for us. Our chair also has wheels, so if we have "a Roger" that doesn't tell us he sometimes faints, a quick call to a coworker and the chair can be wheeled over so when the patient regains consciousness we can have them lie down for a while.”
According to Dean from Indiana, exploring all options can result in a win-win outcome. “I think it is important to communicate to Roger that I respect his request sit up, however; his safety is paramount. I like to empower the patient as much as possible. There might be another alternative that would be safe and not require him to lie down. We have a chair that lays back that is used for Autologous Donation that would not require Roger to be flat on a bed, yet still position him safely in the event that he passed out during the procedure. Seeking other acceptable alternatives – thinking outside the box – and straying from disempowering the patient leads to exemplary customer service.”
Because of his “power to the patient” approach that strikes a balance between ensuring the patient's safety while delivering good customer service, Dean will receive a free download from the Center for Phlebotomy Education’s library of download articles.
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