Phlebotomy Surveys Prove Surprising and Insightful
In the three years the Center for Phlebotomy Education has been conducting surveys on its website, the responses to the questions posed have been sometimes surprising, sometimes predictable, and always insightful. Take, for example, the survey on tourniquets that showed a surprising number of facilities are discarding them after one use. Then there's the one where we asked if you ever tear the tip off of your glove's finger when looking for a vein. Tsk-tsk-tsk. And let's not forget those of you who said you would not look to your own employer to provide your healthcare services.
We think there's no better way to celebrate the third anniversary of our Survey Says column than to summarize the more interesting surveys to date. Links are provided to the archived issue of Phlebotomy Today-STAT! that discussed the results and associated comments.
This Month in Phlebotomy Today
Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 12th year of publication, are reading about this month:
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Q: Is it acceptable to label a tube by hand, then apply a permanent label later when you have more time?
A: Handwriting on the tube labels is fine as long as it is done after the tubes are filled and includes all the proper information. And of course all specimens must be labeled at the patient's side. No exceptions. None. According to CLSI document H3, the completed label must be attached to the tube after the draw and before leaving the side of the patient. Later in the document it states that the collector must compare the labeled tube to the identification bracelet, or have the patient confirm that it was properly labeled whenever possible.
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 website. For information on joining Phlebotomy Central, click here.
In last month's survey, we asked PT-STAT! readers and visitors to our website about their powers of observation. We wanted to know if people were in the habit of observing the tip of every needle for burrs and defects before use. We also wanted to know if collectors are observing both arms for a vein other than the risky basilic vein, which lies in close proximity to nerves and the brachial artery. Finally, we asked how long those who responded typically take to observe the site for bleeding prior to applying a bandage. All these observations have well established provisions in the CLSI standards, but are often neglected. We think you'll find the results as interesting and revealing as we did.
Question: Do you observe the tip of every needle for burrs and defects before using?
Here are some of the comments:
Commentary: While the standards have recommended this check for at least 13 years, according to this survey, the practice is not as common as it should be. It only takes a brief moment after removing the needle's sheath to hold it up for inspection; getting in the habit takes much longer. To make this your regular practice, consider all needles to be defective until you observe them to be otherwise.
Question: Do you observe the antecubital areas of both arms (if available and accessible) for the presence of other veins before selecting the basilic vein for a venipuncture?
Commentary: Too often we neglect this power of observation in favor of expediency. It takes time to survey both arms, and we're always in a hurry. However, failing to observe for all available veins, and selecting the basilic vein just because it's the first good vein we see is doing the patient a great disservice. Not only that, it's beneath the standard or care.(1)
If the basilic vein (on the inside aspect of the antecubital area) wasn't perilously close to the brachial artery and median nerve, it wouldn't matter. But it is and it does. Surveying both arms for medial or cephalic veins, which are less risky, is a power of observation every patient is entitled to.
Question: After the venipuncture is over, how long do you typically observe the site for bleeding prior to bandaging?
I apply a pressure bandage over the gauze without looking at the puncture site: 12%
Commentary: We rarely know if a patient is on blood thinner, has compromised hemostasis, or takes aspirin for their heart, which prevents clotting. So we should assume all patients will have prolonged bleeding from our venipuncture. The standard requires us to apply pressure and then "observe for hematoma" formation.(1) That means we should apply pressure---or have cooperative patients apply pressure---and then remove the gauze (cotton balls are not acceptable for applying pressure) and watch the site long enough to determine the vein isn't leaking into the tissue.(1) This would be indicated by a raising or mounding of the tissue beneath the puncture site. If observed, additional pressure is required.
How long should we exercise this power of observation? If we merely lift up the gauze, see no blood emerging from the wound, and then apply the bandage, that's not long enough. The superficial wound might seal, but the vein could still be oozing. Therefore, observe the tissue for at least 10 seconds.
And by the way, patients should not be allowed to bend their arm up as a substitute for direct pressure.(1) That will not provide adequate pressure under all circumstances. Instead, apply direct pressure yourself or have cooperative patients provide pressure, and then monitor that the pressure they apply is adequate while you're mixing and labeling the tubes.
This month’s survey question:
What Should We Do?
[Editor’s Note: "What Should We Do?" gives you the opportunity to ask our team of technical experts for advice on your most pressing phlebotomy challenges. Whether technical or management in nature, we'll carefully consider solutions and suggestions based on the industry's best practices so that you and those in other facilities with the same problem can benefit, all the while maintaining your facility's anonymity. What Should We Do? is your opportunity to ask us for suggestions on the best way to handle your real-life dilemmas.]
Our response: Obviously, the patient is requesting you operate beneath the standard of care. That's because the Clinical and Laboratory Standards Institute clearly states in its venipuncture standard that draws to the same side of a mastectomy require physician's permission. Note that it doesn't say "patient's permission." Should there be complications as a direct result of the puncture, such as lymphedema, it could be effectively argued that the standard of care was breached. It would also likely be argued that the patient is not the individual who is trained to prevent the risk of injury and complications of a routine venipuncture, and therefore provided consent without the full knowledge of those risks as they applied to her. Even if the patient provided consent in writing, the facility is not likely to escape liability. Healthcare workers should never accept a patient's invitation to violate the standard of care. Only physicians, who have full knowledge of the patient's condition and the risks involved, can approve draws to the same side as a prior mastectomy.
The patient should be told that, while you appreciate her permission, it's the facility's policy to obtain approval from the physician, which is what the standards require. Once patients realize they are asking you to violate facility policy, they are likely to understand the repercussions you could be subjected to. A thorough search for veins in the other arm should be conducted.
But wait, there's more. Our reader states that the patient has had a bilateral mastectomy, and therefore wonders if that precludes the necessity for obtaining physician permissions since there are no other alternatives.
Our response: Just because the patient has had bilateral mastectomies doesn't remove the necessity to obtain physician permission. There are other options.
The risk of lymphedema, which can be painful, long-term, and disabling, still exists. More than likely the physician will permit the draw, but let's not forget about the possibility of drawing from another acceptable site: the feet or ankles. According to CLSI's venipuncture standard, draws to the lower extremities are acceptable, but, just like draws to the same side as a mastectomy, only with physician's permission. The risks include tissue necrosis should the patient be diabetic and thrombophlebitis should the patient have a coagulopathy. Regardless, permission to draw from such alternative sites is required. Bottom line: draws to the antecubital on the same side of a mastectomy or to the lower extremity both require physician permission, not patient permission.
But wait, there's more. Our reader says the bilateral mastectomy patient is also wheelchair bound, and because circulation in her lower extremities is so decreased, she wears pressure hose on both legs round the clock. The reader wonders if a fingerstick is an option.
Our response: So much for other options. In this case, the physician must be asked to approve a draw from either arm. Even if the volume of blood required by the order is low enough to be obtained by fingerstick, the risk of lymphedema still exists, and physician's permission is still required. Given the circumstances, it will likely be easily obtained.
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