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Phlebotomy Today

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September, 2016

Another Texas Infant Scalded in Heelstick Incident

DanaMartinezMonsarrat_AustinTXDana Martinez took her baby to a Texas Hospital for her two-week newborn screening collection. The baby left with second-degree burns on her heel from the prewarming.

According to a report posted on KXAN-Austin, the medical assistant performing the puncture at Children's Health Center in Marble Falls put a gel pack into a microwave to warm it up prior to application. In the KXAN interview, Martinez claims the baby immediately began to cry when the pack was put onto her heel. After the draw, the medical assistant left the room to get the doctor, who inspected the heel and found the infant was burned.

Martinez complained to the Texas Medical Board, which ruled there was no violation in the standard of care, and did not launch an investigation. She started a petition to stop the use of plastic gels in pediatrician offices.

"We are appalled that this kind of preventable injury continues to happen," says the Center for Phlebotomy Education's director, Dennis J. Ernst MT(ASCP), NCPT(NCCT). "For regulators and legislators and medical boards not to demand minimum training requirements for specimen collection personnel after seeing things like this is dereliction of duty."

A similar incident took place in Houston last summer when a nurse prewarmed a newborn's heel by warming a wet diaper in a microwave. 

The industry standards limit the temperature for prewarming capillary puncture sites to 42-degrees Celsius. 

View the KXAN news clip. 

Ernst To Keynote Mayo Phlebotomy Conference

Phleb2017-300x500-1Center for Phlebotomy Education Director Dennis J. Ernst MT(ASCP), NCPT(NCCT) will be giving the keynote address at the 2017 Mayo Clinic Phlebotomy Conference. The conference is devoted exclusively to phlebotomy and preanalytic topics.

"We are very pleased that Mr. Ernst will be one of our speakers in 2017 as he is a very well-known and respected authority on the subject of phlebotomy," says Darci Block, Ph.D, a consultant for Mayo Clinic's Clinical Core Laboratory and member of the Mayo Medical Laboratory Phlebotomy Conference Planning Committee. "No one will want to miss it!"

Ernst will be discussing the forthcoming revision of the CLSI venipuncture standard as well as providing an inspirational overview of the phlebotomy profession. "When it comes to educational events, the annual Mayo conference is one of the industry's crown jewels," says Ernst. "I'm thrilled to be presenting."

The event takes place April 20-21, 2017 in Rochester, Minnesota.

VA: Nurses Are Qualified to Run Our Labs

NursesThe U.S. Department of Veterans Affairs (VA) is considering a rule change that expands the scope of practice for Advance Practice Registered Nurses (APRN) by qualifying them to perform lab tests and supervise and direct laboratory testing in VA healthcare facilities. The announcement sent shock waves throughout the laboratory industry.  

According to the proposed rule change:

"... a CNP [certified n urse practitioner] would have full practice authority to provide the following services: Comprehensive histories, physical examinations and other health assessment and screening activities; diagnose, treat, and manage patients with acute and chronic illnesses and diseases; order, perform, supervise, and interpret laboratory and imaging studies; prescribe medication and durable medical equipment and; make appropriate referrals for patients and families; and aid in health promotion, disease prevention, health education, and counseling as well as the diagnosis and management of acute and chronic diseases."

The American Society for Clinical Laboratory Science (ASCLS) and other laboratory groups mobilized their members to issue their objections to the change. The Center for Phlebotomy Education joined the chorus and registered its concerns with the agency. 

"Nurses are the backbone of healthcare," says the Center's Director Dennis J. Ernst. "But laboratory testing is enormously complex and heavily regulated. The nursing profession is not prepared academically or experientially to safely oversee the complexities of clinical laboratory testing. Just like phlebotomy, running a lab properly is not as simple as it seems." 

The rule change also permits APRNs to perform, supervise and interpret diagnostic images. Diagnostic imaging groups are just as adamantly opposed 

Read the proposed rule change.

Sign the ASCLS/BOC petition urging CMS to reconsider the ruling.

More information.


Boot Camp Looking For a Few Good Managers (and Educators)


Patient Sues for Injury During Venipuncture

Gavel with cashA Louisiana patient is suing for damages allegedly sustained during a routine venipuncture.  According to an online article from the Louisiana Record, the patient had her blood drawn on July 30, 2015. The suit claims an employee of the lab injured the medial antebrachial cutaneous nerve of her left arm. The suit accuses the lab of negligence by failing to train its employees and failing to safely draw blood. 

In Louisiana, those who draw blood samples are required by law to be certified and licensed. However, the Louisiana statute exempts clinical laboratory personnel, those under the direct supervision of a physician, and those for whom phlebotomy procedures are within their scope of practice.

 Full story. 

Product Spotlight: Phlebotomy Central membership


We've been building it for years; now it's enormous. We're talking about the most comprehensive collection of blood specimen collection information on the Internet. 

Join Phlebotomy Central and your facility will not only receive an Institutional subscription to Phlebotomy Today, our flagship newsletter, but you'll have 24/7 access to the most comprehensive body of knowledge on blood specimen collection ever assembled online.

Sections include:

  • PCTVlogin_screenshotPhlebotomy Today archives--- almost 200 back issues going all the way back to 2001;
  • ATMs---Almost 2 years worth of monthly articles to satisfy your inhouse CE requirement (quizzes and answer keys included).
  • The Manager's Toolbox – a growing list of documents, SmartCharts™, competency checklists, literature reviews and procedure templates that managers and educators can use to enhance their understanding of preanalytical processes and manage their staff more effectively;
  • FAQs – Exclusive to Phlebotomy Central members, answers to hundreds of the most frequently asked questions, searchable by keyword or phrase;
  • To The Point® download articles – 18 in-depth detailed articles in PDF format covering a wide range of specimen collection topics for in-house credit (quizzes included; answer keys available upon request);
  • To The Point Volumes 1-5--- a compilation of our To The Point downloads into booklets worth up to 6 PACE or CE Broker credits each. (Certificate processing fee required) or for implementing in-house (no PACE or CE Broker certificate awarded).

If purchased separately on our web site, it would cost over $1200, but as a Phlebotomy Central member, you get them all for only $399/year. 

It's often been said the next best thing to knowing a fact is knowing where to find it. Phlebotomy Central, you'll find it here. For more information on what we've packed into your Phlebotomy Central membership, click here, or call us toll free at 866-657-9857. 


Survey Says: Bandaging practices

Lady listeningThis month we asked our newsletter readers and visitors to our web site what they use for bandaging venipuncture and skin puncture sites, and if their employer has a policy on inquiring about adhesive allergies.

Latex versus non-latex

We were delighted to see less than one percent of those responded still use latex bandages. Most in this survey use non-latex bandage or surgical tape with a folded gauze pad (57%), while 29 percent use an adhesive wrap (e.g., Coban). Seven percent use a commercial non-latex adhesive bandage, while, surprisingly, five percent use a non-latex spot bandage for venipuncture sites. What we found troubling is that two percent admitted to not bandaging venipuncture sites, which deviates from the standards.


Some comments:

  • Usually non latex spot bandage but for geriatric patient will prefer to gauze wrap with Coban Or don't apply any bandage depending on skin condition
  • Technically co-flex (a more user friendly Coban). But also non-latex adhesive bandage or gauze and paper tape if requested.
  • Non latex coban and gauze
  • If the patient is not on a blood thinner we use a non latex spot bandage. If the patient is on a blood thinner or has any clotting problems we use non latex Co-ban
  • CO-BAN on every patient.
  • I use coban on the elderly because of skin tears from tape and also men with hairy arms.(they appreciate it very much)
  • No ugly tape!!! Silk and surgical tape can damage delicate skin. Gauze and paper tape - gauze and latex-free coban if patient is on coumadin
  • We wrap the gauze around the patient's arm then securely apply non-latex tape on top of the gauze so that the tape does not touch the patient's skin.
  • paper tape and gauze pad

Fingersticks and heelsticks

For fingersticks on infants 2 years of age, thirty-six percent use commercial non-latex adhesive bandages, while 21 percent use some other non-latex adhesive with a folded gauze pad. Four percent use latex bandages on infant fingers, while a whopping 14 percent don't bandage fingerstick sites at all.

Seven percent of newborns get latex bandages applied after their heelsticks by our survey participants, while nine percent get non-latex commercial bandages. Forty-three percent get non-latex adhesive strips with gauze pads. Twenty-four percent got non-latex spot bandages. 

BandagesSome comments:

  • On premies I use gauze and a "Posie"
  • bandaid with folded gauze
  • paper tape with folded gauze
  • No bandage used. apply pressure until bleeding stops. Choking hazard.
  • Co-flex wrap with folded gauze
  • We usually just hold pressure on the puncture until the bleeding stops
  • must check with parent/guardian first
  • Never surgical tape on a neonate! gauze and paper tape

Adhesive allergies

Forty-four percent of those responding said their facility has a policy on asking patients if they have an adhesive allergy. The same percentage said theirs did not. Twelve percent weren't sure. Of those who said they had a policy, 94 percent said they always follow it. Of those who have no policy where they work, sixty-eight percent said they sometimes or always ask the patient anyway. 

Some comments:

  • Patient who have allergies will inform us
  • Any patient I have encountered with an adhesive issue has been quick to inform me up front - even before I begin the collection procedure.
  • Patients are always advised to remove the tape after a hour to avoid sensitivity issues usually the patient mentions it if he is allergic
  • We ask about latex but not adhesive.
  • We stock ONLY latex free adhesive, no need to ask about allergies
  • I use co-ban on every patient, no adhesives ever.
  • I work in a hospital, it is nursing responsibility to ask
  • Our bandages are hypoallergenic. If the patient has an issue, they generally inform us. I advise them to remove the bandage after 20 minutes, or 5 minutes if they have sensitivity or bruising issues. If they have issues, I fold up gauze and keep it in place with tubigrip.

This month, we're asking the Mother of All Survey Questions: Would you recommend the phlebotomy profession to your friends and acquaintances? Why or why not? Take the survey.

The Empowered Healthcare Manager: Being firm

A good question to ask all applicants is when was the last time you had to be firm with someone? It reveals character, the ability to stand up for what's right, the strength to defend (laws, rules, a code-of-conduct, decency, oneself, etc.).

It's also good for managers to ask themselves the same question. 

It's a mistake to think empowerment can only be bestowed. True empowerment comes from within. Sure, administrators have to empower their managers, but if the manager shrinks from using it, he/she remains a mere manager, destined to be yoked to a legacy of having been promoted by mistake.

Empowered healthcare managers, on the other hand, accept the gift of empowerment and give themselves permission to transform their position, their staff, and their organization. They give themselves permission to be firm. Here's what it sounds like:

  • No, you can't have that day off. It will compromise the team.
  • If I hear one more whisper of gossip, you'll be suspended.
  • I've told you three times to hem up the cuffs of your scrubs. Find some safety pins and pin them up now. The next time you come in with them sweeping the floor you'll be sent home.
  • I appreciate you letting me know of problems that require my attention. Going forward, I'd like for you to also to propose solutions at the same time. 

Firm is the enemy of mediocrity; mediocrity is the enemy of the empowered. The enemy of your enemy is your friend.

Subscribe to the Empowered Healthcare Manager blog.

What Should We Do?: Butterfly overuse

Butterflyhands19Question: Are there benchmarks on the percentage of straight vs butterfly needles that should be used? We'd like to see how we compare on in-house patients, outpatients, and nursing home usage. We conducted a study here that found 57% of draws were done using butterflies. Once people were aware and conscious of the issue, we were able to improve our numbers. We don't want to have to sign out butterfly needles yet as they do in other places. Do you have any ideas or tricks you can suggest to help us keep the rate dropping?

Our response: We are not aware of any national statistics on butterfly usage overall, much less on specific patient populations. We've conducted numerous surveys, however, and wrote many articles on the topic in this newsletter. (See links below.) We feel your 57% is high for an acute care facility. It's hard to believe most of your patients require them. You are to be commended for taking steps to get the rate down, as it is a hugely expensive problem. 

Assume you pay 20 cents for every tube holder/needle assembly and $1.25 for every butterfly set. For every phlebotomist who uses a butterfly when a tube holder assembly would suffice, you lose $1.05.

Now assume your phlebotomists average 6 patients per hour throughout the day. For an 8-hour day, that's 48 patients. If they're using butterfly sets on half the patients, and only half of them actually require it, it's costing your facility $12.60 per person for every 8-hour shift. Multiply that by the number of shifts and the number of phlebotomists at your facility, and over the course of a year you're burning through $5000 unnecessarily. Plug in your own numbers, but it's easy to find that butterfly overuse costs the average employer hundreds of dollars every day, and tens of thousands every year. Ouch.

You've probably already taken some of these steps, but we recommend bringing everyone together and articulate the problem in resource management you are experiencing, and how its crippling your facility. (Don't be afraid to mention how perpetuating butterfly overuse prevents administration from approving raises and benefit packages.) Let them know they are the collective solution, and you really need their help. The team, management included, have to feel this is only conquerable as a team. No individuals are exempt.

Set your benchmark, then set incremental goals, and your overall goal. Be ambitious and aggressive. Report progress, or lack thereof, toward the goal weekly from the outset, then monthly once you're getting good traction. Just like hemolysis and blood culture contamination, this is about process improvement, and the effort never ends. Above all, reward your team early and often when progress is made. Without it, your efforts will be futile. 

[Editor's note: each year, one of the most highly acclaimed presentations at the Phlebotomy Supervisor's Boot Camp is the "Squandered Resources and Low Hanging Fruit" presentation where we articulate strategies in detail to reduce butterfly overuse, hemolysis rates and blood culture contamination rates.]

 Related articles appear in these back issues of Phlebotomy Today-STAT!:

Got a challenging phlebotomy situation or work-related question? Email us your submission at WSWDpanel@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)