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Phlebotomy Today

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May, 2017

CLSI Releases New Venipuncture Standard

GP41_cover_400wThe Clinical and Laboratory Standards Institute (CLSI) has just released the long-awaited seventh edition of the venipuncture standard. 

"This revision is the most comprehensive in the document's history," says Dennis J. Ernst MT(ASCP), NCPT(NCCT), who chaired the committee that revised the standard. "Four years in the making, every passage was intensely scrutinized by some of the most highly respected authorities in the industry. I had a real dream team working on this document."

Features of the revision include:

  • A comprehensive literature review of over 400 articles and studies
  • 56 new references
  • 149 new mandatory requirements for the procedure
  • A new reader-friendly design in full color with more images, tables, and graphic elements
  • Complete reorganization as a Quality Management Systems document

The committee also added new appendices that provide detailed guidance on maximum blood volumes to be collected on patients susceptible to iatrogenic anemia, drawing from pediatric, elderly, obese, oncology, needle-phobic, and cognitively impaired and combative patients, and preventing syncope.

"Any facility that isn't using this as a basis of their procedure manual is putting themselves at risk of operating beneath the standard of care," says Ernst. "Users of GP41 are more likely to provide patients with a standardized phlebotomy experience, maintain sample quality, prevent patient injury, and release test results that accurately reflect the patient's health status. Not only that, but they have the confidence their procedure manual is based on a standard established by the consensus of highly respected authorities from some of the most prestigious organizations on the planet."

The standard is available from CLSI and, by special arrangement, the Center for Phlebotomy Education. Click here to purchase and download your digital copy. (Hard copies will be available in September.)

[Editor's note: having chaired this revision, I can tell you it is a solid document. My committee, a preanalytical dream team if there ever was one, let no passage or reference escape our rigorous scrutiny. If I had to list what I feel are my most significant contributions to the industry so far, this would in the top three.]


Needle-free Blood Collection Device Raising Eyebrows

Shutterstock_28191238Pop quiz: what method of drawing blood causes more rejected samples than any other? Answer: line draws.

Enter PivoTM, a new product raising eyebrows in the vascular access and laboratory industry that reduces the potential for rejected samples drawn from vascular-access devices (VADs). Velano Vascular, the San Francisco company developing the device, says Pivo gives healthcare professionals a better alternative to conventional line draws while reducing the stress and anxiety for patients, their caregivers, and loved ones. 

The device attaches to an existing line through its luer connection. To the other end is attached the tube holder or syringe, and the blood withdrawn just like for any line draw, except for the hemolysis VADs are notorious for creating. The company touts the advantages of using Pivo as fewer venipunctures, more satisfied patients, higher quality samples, and more rest for patients who don't have to be awakened in the early morning for a venipuncture. They also point to the potential for fewer accidental needlestick rates since the device prevents the necessity for needles on patients who have an existing line.

According to an article reposted on velanovascular.com, Pivo consists of a narrower and sturdier length of tubing, which is inserted into the existing VAD and extended further into the vein and past the tip of the indwelling catheter where hemolysis typically occurs. The nurse then withdraws as much blood as is needed, and withdraws and discards the device. The VAD retains its primary purpose, which is to continue infusing fluids.

Although the company's web site makes no claim Pivo reduces hemolysis or prevents venipunctures, clearly that is the underlying message. According to an article in VentureBeat, Velano Vascular's CEO says Pivo "turns an existing IV into a two-way conduit for drawing high quality blood samples." 

Last year, Fortune magazine published an article on Pivo describing Velono Vascular's president's motivation in developing the device. Pitou Devgon, M.D., an internal medicine physician, was confronted by a patient who insisted on knowing why she had to be stuck so many times when her blood could have been drawn through her IV. Her complaints stuck with him so to speak, and five years ago he came up with the answer: bypass the red-cell damaging cannula with friendlier tubing.

The device has complete FDA approval, and is being used in several U.S. hospitals and healthcare systems including Intermountain Healthcare, University Hospitals of Cleveland, Sutter Health, Children's National Health System, Griffin Hospital, and Brigham and Women's Hospital in Boston.

Since Pivo only benefits patients with existing lines, venipunctures will still be necessary in healthcare. But for those with difficult-to-access veins and needle phobia who are receiving IV fluids, Pivo seems poised to make hospitalization a little less traumatic. 


Phlebotomy Supervisor's Boot Camp Now "Global Summit"

The Phlebotomy Supervisor's Boot Camp is now the Global Summit on Best Practices in Preanalytics.

After eight wildly successful Boot Camps, the event is expanding in 2017 to include an entirely redesigned agenda including breakouts, more presenters, and a panel of summit-level authorities who will discuss the most stubborn problems plaguing laboratories today. 

While the Center for Phlebotomy Education will still be involved in the Summit, the event's management, coordination and production is being transitioned to Greiner Bio-One North America, Inc., the Boot Camp's exclusive sponsor since 2014. The Center's director, Dennis J. Ernst, will continue to be deeply involved in the Summit as the event's moderator, conference consultant and a presenter.


"I have been working closely with Greiner over the last four months to completely redesign this powerful event, and I can tell you I'm blown away by their vision and energy," says Ernst." With their resources and expertise, they've already exceeded my expectations of what Boot Camp could become. When attendees come to Charlotte for this year's event, they should prepare to be amazed."

Ernst wants to personally invite Phlebotomy Today subscribers and past Boot Camp attendees to attend this year's Global Summit. "When I step up to the podium on October 24 I hope to see familiar faces and new attendees from my inner circle of friends. This will be the most ambitious and powerful preanalytic event ever produced."

To register and for more information.


What Should We Do?: Syringe overuse

SyringeDrawQuestion: One of our phlebotomists always uses a 20ml syringe to draw patients requiring many tests. It seems to me she needs to be trained to use tube holders instead. According to the standards, are there any circumstances in which a syringe would be preferred over a tube holder system?

Our Response: The CLSI standards don't address device selection with one exception: it states syringes with needles should be avoided whenever possible due to the increased risk of needlesticks.

That's because syringes are the device in use when most healthcare professionals sustain accidental needlesticks. So the phlebotomist's choice is pretty much a matter of personal preference unless it is established in the facility's policy. We agree syringe use should be minimized. Besides the safety concern, a 20cc syringe adds to the cost of the procedure and should only be used when the vein selected requires it, i.e., is fragile or anticipated to collapse when the full vacuum of the tube is applied.

Perhaps the person feels more comfortable with syringes, and uses them on every patient. That, then, becomes a matter of retraining for versatility. Sarstedt (Newton, North Carolina) offers a blood collection product that incorporates the evacuated tube method and syringe-draw process into one system where the tube itself can be filled via aspiration, similar to a syringe draw.

If one-on-one coaching won't decrease use and changing systems is not possible, you should put it into your policies and procedures so that syringe overuse is easier to discipline.


The Empowered Healthcare Manager: Exterminating the rat pack

RatA rat pack is a gang of employees who are allowed to bestow authority upon themselves, and use it to intimidate and manipulate coworkers, even their supervisors, for personal gain. They traffic in broken spirits; their currency is power.

Rat packs don't just happen, they rise up when managers look the other way too often. They test your authority in little things, then wait. If you look the other way, their tests get bigger and bigger. Before long, they've assumed the power you lack, and begin applying it to their coworkers in the form of bullying and intimidation.  As long as you're looking the other way, they're applying their ill-gotten power on those around them. As soon you fix your gaze on them, they become angelic pillars of the workforce.

The more you look the other way---away from dissent, disobedience, and disregard for policies and procedures---the faster and bigger the pack forms and the more power they siphon from you. Wait too long to disband them and they'll convince your manager you have to go. 

If you're convinced you have a rat pack in your house, first find the leader. He/she is often gifted at avoiding detection and slick at diverting your suspicion elsewhere, most likely at his/her next target. They're masters at turning you into their accomplice without your even realizing it.

Rat pack leaders are masters at manipulating their managers. It's not uncommon for the leader to accumulate accolades from her superiors. This year's Employee of the Year could be the most feared member of your staff. 

To disband the rat pack, all you have to do is convert the leader. She's already proven she has leadership skills. Your job is to refocus them in a positive, constructive direction. Remember, her currency is power. If she can get it legitimately, she'll be just as happy. Change her method of obtaining power from destructive intimidation to team-focused cooperation and the other rats will follow.

But first, you have to stop looking the other way. 


This Month in Phlebotomy Today

PhlebotomyTodayCover_0417_1000wHere's what subscribers to Phlebotomy Today, the Center for Phlebotomy Education's flagship newsletter currently in its 17th year of publication, are reading about this month:

Feature Article

Journal Roundup, Part 2

On the Front Lines
Changing the order of draw for emergencies?

From the Editor's Desk
One patient's healthcare nightmare, courtesy of preanalytical errors

Customer Care Corner

Test Talk
Parathyroid hormone

An update on an article from the inaugural issue of Phlebotomy Today

Phlebotomy Supervisor's Boot Camp Now "Global Summit"

Subscribe to Phlebotomy Today and get this issue immediately. 

LMBP Seeking Iatrogenic Anemia StrategiesBlood drop

The Centers for Disease Control and Prevention is continually striving to identify and promote best practices in laboratory medicine. As part of this effort, the Laboratory Medicine Best Practices (LMBPTM) Workgroup conducts one systematic review each year to identify, evaluate, and recommend best practices for the field.

This year, the LMBP focus is on preventing iatrogenic anemia (IA). In addition to appointing an Evidence Review Panel to assist in reviewing and locating published studies, the agency is seeking input from laboratories and healthcare professionals who have assessed the impact of their interventions that have reduced the risk for IA among patients in ICUs and NICUs.

"We will work with the expert panel to identify sources of unpublished data, such as internal QA data from hospitals or data from completed but unpublished studies," says Mark L Graber, MD, FACP, who is coordinating the Expert Panel. "We would love to hear from Phlebotomy Today readers who might have unpublished data in this regard.

Readers with pertinent information can contact Dr. Graber at mgraber@rti.org.

Survey Says: Errors and omissions

Lady listeningLast month we asked our readers and visitors to our web site which of the 28 steps of a basic venipuncture that we listed are most commonly omitted, or performed incorrectly, where they work. The answer surprised us. The most frequently omitted step: asking about prior complications/incidents with blood draws. A full 40 percent omit this step. The second most commonly neglected step was releasing tourniquet within one minute (32 percent) followed by not recleansing the site after repalpating, omitted by 30 percent. (Total percentages exceed 100 due to multiple responses by each participant being permitted.)

Rounding out the top five were filling all tubes to the fill line (27.5) percent and observing the site for bleeding for at least five seconds prior to bandaging (27 percent). 

The following, in order of the single most commonly omitted step, are the runners up: 

  • examine both arms for most prominent and appropriate vein (22 percent)
  • gently invert each tube immediately after filling (22 percent)
  • comparing labeled tubes with the ID band (or asking patient to confirm labeling is correct) (21 percent)
  • not permitting patient to pump the fist (19 percent)
  • introduce self and state purpose (18 percent)
  • seeking patient identification from a 3rd party when patient cannot communicate (17 percent)
  • ask about latex allergies (where latex is in use) (16)
  • label samples in the presence of the patient (14.5 percent)
  • anchor the vein from below only (14.5 percent)
  • not allowing patient to bend the arm up as a substitute for pressure (14 percent)
  • identify patient properly (9 percent)
  • fill tubes in the proper order of draw (9 percent)
  • cleanse the site properly (7 percent)
  • put gloves on (6.5 percent)
  • position the patient properly (recumbent or on a chair with side arm rests, minimum) (6.5 percent)
  • insert the needle at 30-degrees or less (3.6 percent)
  • immediately concealing and disposing of the contaminated sharp (3 percent)
  • select a device with a sharps-injury protection feature (3 percent)
  • tighten tourniquet (3 percent)
  • establish a base of support when inserting the device (2 percent)
  • cover the site and remove the needle (2 percent)
  • bandaging patients (when appropriate) (2 percent)
  • gather/assemble supplies (1.5 percent)

What we find most disturbing with this survey is that nine percent of those responding said one of the biggest errors specimen collection personnel make when drawing blood samples is failing to follow the proper protocol for identifying patients. This squares with a study that found eleven percent of all transfusion-related deaths occur because the phlebotomist didn't properly ID the patient or sample. That study was published in 2001, suggesting not much progress has been made in that regard.

This month's survey: Did your facility celebrate Lab Week last month? If not, why not? If so, were phlebotomists recognized in some unique way?

Take the survey.


Tip of the Month: Phlebotomy Road Trip

Click here for this month's featured Tip of the Month from our rich library of archived Tips.