[Editor's Note: due to a pandemic of vacations in our office, this month's issue contains two articles from our archives. The remainder of this month's issue is new material. Thanks for allowing us this luxury.]
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Fingersticks on Mastectomy Patients
Is it acceptable to perform fingersticks on the same side as a mastectomy? Is it acceptable to perform venipunctures on mastectomy patients if the patient gave permission? Answers to these commonly asked questions have their roots in the CLSI standards. The rule against drawing from the same side of a prior mastectomy is hard and fast: such draws require physician’s permission. The risk is that the body’s ability to fight an infection in the affected limb is compromised because of lymph node removal during mastectomy. Trauma and/or infection to the affected side can result in long-term lymphedema, which can lead to an attorney’s three favorite words: pain and suffering.
Some argue that mastectomies are done with less removal of lymph nodes today than in the past, so there is less likelihood of complications from a venipuncture. That’s true. The problem is that some mastectomies are still radical. It depends on the surgeon and the extent of the metastasis. How is the person who is about to draw blood from a mastectomy patient supposed to know?
It’s not prudent for the phlebotomist to assume lymph nodes have been preserved. The standard for venipunctures published by the Clinical and Laboratory Standards Institute (CLSI), document H3, states physician’s permission must be obtained before drawing on the same side of the mastectomy. The physician is in the best position to know the extent of lymph node removal, not the phlebotomist.
Because this rule is so prevalent in the literature, if a patient develops complications and seeks compensation, the facility doesn’t have much of a legal leg to stand on. Even if the patient gives permission—verbal or in writing—it may not exonerate the facility should complications develop. If the patient provides permission, then sues for pain and suffering, her attorney can effectively argue that the patient was not aware of the risks involved, and was not in a position to give informed consent. Signed waivers may not be bullet proof.
Without a thorough knowledge of the standards, it’s difficult to know the risk. Make sure you know the standards, and operate within them and according to your procedure manual at all times.
Empowered Healthcare Manager:
Elements of the Empowered
Starting next month, Phlebotomy Today-STAT! will run one of the many posts that appeared during the prior month on The Empowered Healthcare Manager
blog. Below is the blog’s inaugural post.
The empowered manager: One who has the ability, permission, desire, humility, and courage to lead the willing and transform the unwilling.
ability—You can because you want to. The rest is just focusing the skills you have to the task before you, and acquiring the skills you don’t. Empowered managers say “I want to.” Managers say “I want to, but....”
permission—Those who manage you give you free range to transform your staff and the culture where you work. Those who you manage do, too. They trust you, they believe in you, and they share your vision. Every empowered manager knows the importance of securing the permission to lead from those above and below them on the ladder.
humility—You realize it’s not about you, it’s about those you serve, those who have entrusted their well-being to you: your staff and the patients they serve. Your staff trusts you to make their livelihood meaningful, secure, and rich with opportunity. The patients they serve trust you have properly prepared your staff for their interaction.
courage—You turn away applicants who won’t fit even though they look good on paper. You terminate or reassign those who sabotage your efforts even though they are technically proficient. You dare to have a vision that’s way over everyone’s head, and a plan to take them there.
...to lead the willing—the easy part.
...to transform the unwilling—the hard part.
Suscribe to The Empowered Healthcare Manager.
Phlebotomy Supervisor’s Boot Camp
This was the best program I have attended, and I have been in phlebotomy since 1981!
I would recommend that this program be available regularly. For anyone training phlebotomists it should be a required course.
I had a staffing challenge with a trainee when I returned from Boot Camp. I am happy to say that without the tools that were provided during this seminar I would not have had the courage or confidence to do what needed to be done. Thanks to all of you so much!
Those are just a few examples of the outpouring of positive comments from those who attended past Phlebotomy Supervisor’s Boot Camps. Over 200 of the world’s most dedicated laboratory managers, phlebotomy supervisors, educators, and trainers have already completed the powerful 3-day event.
The next Boot Camp takes place on November 12-14, 2014 in San Francisco, California.
The Boot Camp’s faculty includes the Center’s own team of national and international lecturers including Program Administrator Catherine Ernst, RN, PBT(ASCP), Program Coordinator Lisa Steinam, PBT(ASCP), and Executive Director Dennis J. Ernst MT(ASCP), NCPT(NCCT).
This faculty of world-class presenters will conduct 17 presentations and moderated group discussions with continuing education credit over the course of three days, teaching attendees strategies to help:
- Reduce expenses by cultivating satisfied, long-term employees;
- Cut costs through process improvement;
- Nurture professionalism and responsibility among your staff;
- Understand different learning styles for effective teaching;
- Mentor students and new staff...and more.
“We know managers are struggling with high staff turnover, low morale, soaring specimen rejection rates and plunging patient-satisfaction surveys,” says Program Coordinator Catherine Ernst RN, PBT(ASCP). “It’s time to wage war against mediocrity.” According to Ernst, the event is designed to empower managers, supervisors, trainers and educators to change the preanalytical culture where they work and the caliber of phlebotomists they train. Past participants have glowing comments.
For more information on this unique opportunity to learn from the most respected authority in the industry, call: 866-657-9857 toll-free or visit the seminar’s website.
Managing Patients Who Lose Consciousness
Those who draw blood specimens must constantly be aware of the signs and symptoms of an impending loss of consciousness and be prepared to react. Signs can include pallor, perspiration, hyperventilation and/or anxiety. A proper response to such signs is key to protecting the patient from falling and the injuries that can result. However, collectors can prevent an injury before it happens if they take the following precautions:
- make sure that all outpatients are drawn from chairs with arm rests that can stop a fainting patient from falling to the floor;
- inpatients should be drawn while recumbent or sitting in arm chairs.
- patients with a history of fainting during a blood draw should be drawn while they are in a recumbent position;
- never turn your back on a patient, especially after you have completed the draw. Many patients give no warning before passing out.
- should a patient become dizzy or lose consciousness during a collection, release the tourniquet, remove the needle, and activate the safety feature at once. Presence of mind must be maintained so that you don’t sustain an accidental needlestick in the process.
- if the patient loses consciousness, support him/her from falling to the floor and summon assistance. Lower the patient’s head below the level of the heart to facilitate blood flow to the brain. This can also be accomplished by carefully, and with assistance, lowering the patient’s head between the knees or by lowering the patient to the floor, being careful not to allow the patient to fall and sustain an injury.
- avoid the use of ammonia inhalants. Patients who are asthmatic may develop respiratory distress as a result.
Statistics say 2.5 percent of patients will pass out during or immediately after a blood draw. Being prepared significantly reduces the risk of injury and complications secondary to the loss of consciousness.
This Month in Phlebotomy Today
Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 15th year of publication, are reading about this month:
When You Miss a Vein….
We wanted to know what most of our readers did when they failed to obtain a blood flow upon initial needle insertion. So we asked the following questions:
What do you do when you miss the vein?
Eighty-six percent said they only relocate the needle under certain circumstances; 9.5 percent said they always relocate; five percent indicated they never relocate the needle.
Of those who relocate, 71 percent said they do so only if they think they know where the vein is and only if it isn’t near anatomical structures that could be damaged. 17.6% relocate only if they think they know where the vein is. Twelve percent will relocate if the patient gives them permission, Here are some of their comments:
I will not pull out to reposition but will go in a little further or back up a little if I feel I am there otherwise it is better just to start over.
Sometimes [I] just need to rotate the needle to relocate the bevel or pull back a bit.
I only reposition after carefully palpating. If I discover I have really missed the vein, I would rather pull out and do a re-draw for my sake and the sake of my patient.
I repalpate vein, adjust needle w/o causing injury.
Our question “where in the antecubital area are there anatomical structures that could be damaged if you re-positioned a needle, and what are those structures?”
The correct answers are those that approximate the lateral (inner) aspect of the antecubital area near the brachial artery where two tracts of the median antebrachial cutaneous nerve reside. Most of those who responded were reasonably close.
peripheral nerves located in the antecubital area - radial and median nerves pass through the antecubital fossa.
radial nerve and brachial artery;
The inner vein;
nerves, brachial artery, a central tendon;
possible nerve and tissue damage;
Top side/anterior of elbow medial/ lateral superior Brachial and ulner arteries, brachialis muscle tissue;
I am always aware of the nerves and the underlying artery in the basilic area.
Also, the median area’s tendon may be located too close to the vein.
inner aspect antecubital space – nerves;
artery, tendon, nerve;
Basilic nerve and artery;
f you are using the basilic vein, there is the chance of being near the artery and there is also a nerve near this vein which could cause a painful draw;
Brachial artery, lateral and median antebrachial cutaneous nerves
We then asked “Do you ever take the needle out and reinsert it nearby”? We are proud to see that not one respondent admitted to sticking the same patient nearby without first changing the needle. (But then, our readers are above average on many levels!) Sadly, though, 38% indicated they are aware of others where they work who use the same needle twice or more on the same patient when they miss. Comments include:
One colleague has been seen doing this. They know it’s not acceptable. When I witnessed this, I told the supervisor immediately.
I have seen it but the person said they did not realize the needle came all of the way out of the skin when they repositioned it was brought to a supervisors attention.
I have not seen this done by any phlebotomists, but I have seen nurses do this while starting an IV.
Horrified to observe this however I don’t say in front of the patient as they are stressed enough when a ’miss’ occurs, possibly in pain.
Of those who responded, 38.5% said their facility has a policy against resticking the same patient with the same needle.
This month’s survey question is about drawing a “rainbow” of tubes just in case. The questions: How often do you draw extra tubes of blood on patients just in case additional tests are ordered? In what wards/departments do you draw extra tubes most often? Does your facility have a policy permitting extra tubes to be drawn just in case?
Participate in the survey.
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What Should We Do?
[Editors’ Note: “What Should We Do?” gives you the opportunity to ask our team of technical experts for advice on your most pressing phlebotomy challenges.]
This Month’s Case Study
When Residents Wreak Havoc
One reader writes:
We have new residents entering orders and it’s wreaking havoc on us and our patients. In the morning, a CBC is ordered then a few hours later chemistries are ordered. Is it ok to draw an extra gold when we draw the lavender?
Technically, yes. Ethically, we’re not so sure. Economically, definitely not.
From a technical standpoint, drawing an extra tube doesn’t put the patient at risk unless, of course, he/she is already anemic. Performing a venipuncture when no tests have yet been ordered would most certainly be against the standard of care, but drawing an additional tube is not the same. Ethically, some may argue that taking blood that isn’t required raises concerns about patients’ rights. That’s a question for your facility’s C-suite to discuss.
From an economic standpoint, drawing extra tubes on every patient adds up in a hurry. According to an article in MLO magazine, one facility found only four percent of the extra tubes were ever used for testing, each tube taking nearly two minutes to process. They also discovered the staff was spending more time drawing and processing extra tubes than they were saving by not having to perform a second venipuncture. After calculating the additional costs to draw and manage tubes without orders, the cost of the extra tubes, and their disposal, the facility estimated a cost savings of $200,200 per year by discontinuing the practice.
A better approach would be every time a new batch of residents show up, they should be versed on lab utilization practices that prevent wasted resources and frustration. This requires constant communication, and strong support from laboratory management, including pathologists.
Each month, our “What Should We Do?” panel of experts collaborates on a response to one of the many compelling problems submitted by our readers. Panelists include:
Dennis J. Ernst
Got a challenging phlebotomy situation or work-related question?
What Should We Do? is your opportunity to ask us for suggestions on the best way to handle your real-life dilemmas. Your name and facility will be kept confidential.
Do you have a problem you’d like our panel to discuss? Send an email to WSWDpanel@phlebotomy.com.
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