Feature Article: Phlebotomy Myth Busters
We thought this month would be a good time to investigate some of the more notorious phlebotomy myths and misinformation that haunt healthcare facilities around the globe. Our goal: to exterminate the ill-conceived notions and bad techniques listed below that have the power to harm you or your patients.
1. All veins are fair game. According to CLSI, the preferred venipuncture site is the antecubital fossa. Of which, the safer median and cephalic veins should be ruled out first before selecting the basilic vein due to its close proximity to the median nerve and brachial artery. When veins in the antecubital area of both arms are unavailable, veins on the back of the hand and thumb-side of the wrist are acceptable alternatives. Above all, phlebotomists should be aware of the potential for injury associated with each vein and prioritize site selection accordingly. Other sites, such as veins of the lower extremities, should not be used without physician permission because of the risk of serious complications.
2. Draws on the side of a mastectomy are okay if the patient gives permission. Because a patient may not fully comprehend the potential for injury associated with draws to the same side of a prior mastectomy, it could be successfully argued that the patient cannot give informed consent. In cases of a bilateral mastectomy, always consult a physician before collecting the sample. This includes fingersticks, too, as any break in the skin on the affected side can lead to complications from lymphostasis.
3. Patients should be allowed to pick the device with which you draw their blood. You wouldn't tell your dentist which drill bit to use, so why should patients be allowed to select the device you should use for their venipuncture? You're the phlebotomist. As such, you have infinitely more training and/or experience from which to draw in order for the procedure to be successful... and safe. Although patients often suggest, even demand, certain devices such as butterfly sets, you get the final say. Do you really want to subject yourself to the increased risk of an accidental needlestick that comes with butterfly use just so that the patient gets his/her way? Sure, it's a customer service issue, but your safety should not take a lower priority, especially when another device will be just as successful in your hands, even more so. Be diplomatic, be cordial, but above all, don't allow patients to compromise your safety.
4. Patients should be allowed to select the site from which you draw their blood. This myth is only true if the patient knows and applies what the CLSI standards say about site and vein selection. (See myth #1.) Since most don't, you should have the final say. Even if he/she selects a vein in the antecubital area, drawing from it may go against the standards if it's the basilic vein and you haven't done a thorough survey of all acceptable veins in both arms. That's because most nerve injuries caused during venipuncture occur during attempts to access the basilic vein. Should the patient select that vein, it's against the standards not to exhaust all other antecubital options first.
5. Refrigeration is the preferred method of preserving blood prior to centrifugation. While refrigeration might be best for fish and vegetables, that's not always the case for blood samples. Especially if they're to be tested for potassium. That's because red blood cells are rich in potassium. In fact, the concentration of potassium in red cells is up to 25 times that of serum or plasma. At refrigerated temperatures, potassium rushes out of the cells and contributes significant quantities to that in the serum or plasma to be tested. The result: patients can be misdiagnosed and improperly medicated. The solution: refrigerate samples to be tested for potassium only after they have been centrifuged and the serum or plasma to be tested has been separated by a gel barrier or by transferring an aliquot into an appropriately labeled transfer tube.
6. A bandage is an acceptable substitute to applying direct pressure to a puncture site. Not true. According to the CLSI standards, those who draw blood samples must make sure stasis is complete before bandaging. That means being assured not only has the puncture to the skin sealed, but the puncture to the vein as well. This requires patience and observation. Instead of rushing a bandage onto the site and hoping it applies enough pressure to prevent bleeding (it won't), remove the gauze and observe the site for 10-15 seconds. Any sign of bleeding or hematoma formation demands additional pressure.
7. Having the patient pump his/her fist is the best way to find hard-to-locate veins. While this may be true for donors, when you're drawing blood from patients this technique can dramatically alter test results. In fact, some studies have shown pumping the fist can double the potassium level to be reported to the physician. Instead, have the patient clench and hold the fist, but only if necessary. While clenching and holding hasn't been found to increase potassium levels in the same arm, pumping certainly will.
8. Anchoring from above and below the venipuncture site is the recommended way to prevent a vein from rolling. Using this so-called "C-hold" or "windows" technique might do a fine job of anchoring the veins and stretching the skin, but it also does a fine job of increasing your risk of an accidental needlestick, too. When your finger is placed above the intended puncture site, it's in harm's way should the patient jump or should you be bumped from behind at the wrong moment. If you've used this technique for years without a needlestick and feel you've mastered the technique safely, you're long overdue for an exposure.
9. A separate order of draw is required for syringe collections. Although one lone textbook continues to perpetuate this annoying myth, the need for a separate order of draw for syringes has no basis in the literature. This falsehood has never appeared in the CLSI standards. In fact, the standards have clearly stated that a separate order of draw is unnecessary.
10. If an outpatient responds to his/her name being called, you know you have the correct patient. Operating under this false pretense can have devastating consequences to the patient. Many names sound alike. Call for Mr. Snyder and Mr. Schneider steps forward. Ask for Mrs. Brown and Mrs. Braun comes your way. Beckon Robert and Roger takes a seat in the outpatient chair. Speaking a name and expecting the right patient to respond is setting up a trap that both you and the patient can fall into. While you may summon a patient from a full waiting room this way, you simply must give the patient who responded an opportunity to verbalize his/her name. If the patient is hard of hearing or cognitively impaired, or if there's a language barrier, have a family member or caregiver verbalize the patient's name for them, and document the name of the individual.
11. ED blood draws during IV insertion are more efficient because they save the patient a stick. While this may be true for some patients, studies show that up to 25% of draws during an IV start will be hemolyzed. Depending on the size and composition of the catheter, it could go up to 55%. When that happens, you've just added an hour delay to the physician getting the results. How efficient is that? By the time the sample is centrifuged and hemolysis detected, at least two minutes have passed. Add another 25 minutes to dispatch a phlebotomist, perform a venipuncture, return to the lab, and centrifuge the sample, and the attempt to save the patient a stick has done him/her a disservice instead. While 75% of draws during an IV start may be acceptable, Murphy's Law tells us those whose blood ends up hemolyzed will be the patients whose physician needs results the fastest.
12. Wearing gloves won’t reduce your risk of an accidental needlestick. Actually, it will. A recently published report indicates healthcare workers who wear gloves are 66% less likely to sustain an accidental needlestick than those who don't. And that's not all. Should you sustain a needlestick while wearing gloves, the glove material wipes off up to 86% of the blood that would otherwise go into your tissue if you weren't wearing gloves at the time. That means your risk of acquiring HIV, hepatitis or any of the other 18 pathogens that have been known to be transmitted by a blood exposure is drastically reduced. Need another reason? No you don't.
13. It's okay to palpate a site prepped for a blood culture collection as long as I cleanse the tip of my gloved finger first. Not so. Gloves used during phlebotomy procedures aren't usually sterile. And even if you were to cleanse with the same antiseptic used to cleanse the site, most people aren't going to wait the 30 seconds it takes for the antiseptic to be effective. Instead, palpate above and below the intended puncture site, but not directly on it.
Ernst, Ballance Giving Benchmark Presentation
How many patients should a phlebotomist draw in one hour? What's the average hemolysis rate for ED draws? How many rejected specimens per month are other facilities experiencing? If you've ever wondered about any of these, speakers from the Center for Phlebotomy Education will answer them in Portland, Maine this month.
Dennis J. Ernst MT(ASCP) and Lisa O. Ballance, BSMT(ASCP) CLC(AMT) are co-presenting "Preanalytical Benchmarks" on October 19 at the annual Northeast Laboratory Conference, sponsored jointly by the Maine chapter of the Clinical Laboratory Management Association, Maine/New Hampshire state society of American Medical Technologists, and the Maine chapter of the American Society for Clinical Laboratory Science.
Benchmarks being discussed include rates for sample rejection, blood culture contamination, hemolysis, misidentified samples/patients and customer satisfaction indicators. Mr. Ernst will share data culled from the published literature on these five quality indicator categories while Mrs. Ballance will discuss process improvement strategies to improve preanalytical quality.To register, visit http://www.northeastlaboratoryconference.org.
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.
Q: Is there a recommended time standard for applying pressure to the artery during either a routine stick for blood gases or an inadvertent arterial puncture? Does the standard apply to laboratories only or does it apply to physician-office draws, too?
A: The standard for pressure on an arterial puncture is 3-5 minutes, then check for bleeding and hematoma formation and apply additional pressure if necessary.(1) The standard is the same regardless of who draws the specimen or the type of facility they work in. The standards are established by the Clinical and Laboratory Standards Institute (CLSI) (www.CLSI.org) and should be reflected in any procedure manual.
1.) CLSI. Procedures for the Collection of Arterial Blood Specimens; Approved Standard - Fourth Edition. CLSI document H11-A4. Wayne, PA; Clinical and Laboratory Standards Institute; 2004.
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.
Our latest survey polled visitors to our website about their facility's policy on performing heelsticks or fingersticks on infants under one year of age. When asked "What determines if you perform a heelstick versus a fingerstick on an infant?" Sixty-three percent said age, 17 percent said whether or not the child is walking, while 11 percent indicated the child's weight was the determining factor.
While 17 percent used walking as the determining factor, performing fingersticks on children less than one year of age, even if they are walking, is contrary to the Clinical and Laboratory Standards Institute's skin puncture standard, which prohibits fingersticks on infants younger than one year.(1) The rationale is that the ability to walk is not a guarantee that the depth of the tissue in the fingers is enough to prevent bone penetration by the fingerstick device. Since bone penetration by the sharp can lead to infection and gangrene, adhering to the CLSI standard is good risk management.
Although the heels of children who are walking may be more difficult to obtain blood from because the tissue is thicker, prewarming heels will increase the flow of blood through the capillary beds sevenfold.
When asked "Does your facility have a policy in writing that puts an age restriction on fingersticks?" 47 percent said "no" while 28 percent said "yes." A full 25 percent didn't know if their facility had a policy or not. Of those who indicated their facility had a policy, 29 percent indicated the policy at their facility was to perform heelsticks on infants under six months. One respondent said heelsticks were performed on infants up to three months of age; another indicated heelsticks were performed up to two years.
One-hundred percent of those responding indicated they always follow their facility's policy.
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 editor 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 To the Point® library of articles. The exercise will conclude with a review of the selected submissions and a discussion of the standards pertinent to the case study.
Phlebotomy Today STAT! readers are well versed in drawing from geriatric patients like the one described in last month's case study. Half of those who responded indicated they would draw from an alternative site. One suggested the top of the arm, while others suggested hand veins. Among the responses was this suggestion from Honora:
“Often it is possible to palpate the [median cubital vein] with the elbow flexed. I take blood from quite a few arthritic patients and it is not uncommon for them to be unable to extend their elbows. I would request them to make a fist and rotate their fist so that it is facing downwards rather than in the classic anatomical position. Often the [median cubital vein] is then able to be identified. If this is not effective, then I would look elsewhere as there are many other sites available as options. As an aside I reassure the patient that her effort to straighten her arm is good enough for me as she is doing her best to help. As she is a frail lady I would use a finer needle and make sure she doesn’t have a bleed or haematoma (sic) forming post venipuncture.”
Toby made an excellent suggestion on how to prevent the tourniquet from damaging the patient's paper-thin skin.
"This may be a time when a forearm or hand vein may be a better option, provided one is easily found. In regards to the paper-thin skin, placement of a wash cloth or other barrier between the skin and the tourniquet may help to prevent skin tears. Also, ABSOLUTLEY NO TAPE on the patient’s skin."
All responses to last month's case study were first-rate, but this one from Kim L. of Illinois appealed to us the most:
"I work at a specialty hospital and about 80% of our patients are what you described. I would use one of her hands with a small gauge butterfly needle. I would also hold her hand until she stopped bleeding and then wrap a piece of gauze around, so that the tape or band aid would not stick to her paper thin skin. Most of our patients will wind up getting a central line because of all their medications and fluids that they are on."
For being selected as this month's preferred response, Kim will receive a free download from our To the Point® library of articles..
Help Us Help You
Each month, participation in our "What Would You Do?" scenarios gets lower and lower. Before we consider discontinuing this column, we'd like to hear from you. Please take time to complete this survey to help us decide if this column has run its course.
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