A needle, a patient and a tube: The challenge of phlebotomy
Gary L. Milburn, Ph.D.
It is commonly accepted that over 70% of all medical decisions are based on laboratory results and now more than ever those results are used to make rehospitalization decisions. To provide a closer look at some of the challenges faced by long term care service providers, let's explore the role of a key partner in patient care—the phlebotomist. Often the phlebotomist is regarded as just a tool in the healthcare continuum between the patient and the laboratory result. Nothing could be further from the truth; phlebotomists serve an under-appreciated role in the management of the patient and, based on their performance, can actually affect the outcome of the clinical results.
Early Day—Finding the Patient
Phlebotomists are often up long before the sun rises and endure the elements to arrive at their designated long term care (LTC) facility before the nursing day shift begins. They must receive their daily patient draw list and determine where their patients are located. Often the draw patients might have moved rooms, been discharged home, readmitted to the hospital, or engaged in other activities. In some instances, the patients are sleeping or suffering from dementia which limits their ability to identify themselves or assist in the ID process. It's a CLIA (The CMS regulating body for clinical laboratory testing) requirement that each patient be identified and verified—through patient self-identification, (such as what is your full name and date of birth?) and/or by a LTC staff member.
Each specimen tube or sample collection container must have two patient identifiers to comply with the CLIA requirement—otherwise the sample must be rejected and recollected with the proper identification. This delays the result and will most likely trigger an unnecessary second draw.
Right Test—Right Tube—Fragile Patient
Often tests are ordered for a patient with non-descript terms — such as “liver tests” or “clotting tests”, which need to be clarified prior to the blood draw, as each test may require a different type of blood collection tube. For example, a CBC will require a lavender top anticoagulated tube, while a Protime/INR a blue top and a CMP will require a SST clot tube. Often phlebotomists carry up to six different types of tubes in their bag. Furthermore, the order that the tubes are drawn is important and can directly affect the final clinical results.
Pre-analytical factors that may impact the process
- The volume of the blood must meet fill line standards; otherwise the anticoagulant or other additive concentration will not be appropriate for the sample.
- The patient's hydration state can affect the ease of collecting a blood sample. Veins collapse, skin is thin and often the patient is on anticoagulants, which complicates stopping the bleeding following the collection. Bruising is often unavoidable, even with the perfect technique.
- If a test requires a fasting state, patients should be drawn prior to eating which can significantly narrow the time window between when a phlebotomist is allowed in the facility and collection of the blood.
These are just some of the common day-to-day challenges faced by a phlebotomist that can add time to the process and delay results.
Post Collection Processing
Mixing of the tubes following a successful draw is important. Anticoagulated tubes must be inverted at least 5-10 times to insure proper mixing of the blood with the anticoagulant. Clot tubes must be inverted to clot completely and allowed to set for at least 10 minutes before centrifugation. Serum must be separated from the cellular components of blood within 4 hours of collection to yield accurate results. Failure to do so can lead to artifactual high potassium levels and low blood glucose levels.
A PICC line is, by definition per its acronym, a peripherally inserted central catheter. Due to the risk of contamination and subsequent infection, most laboratories require that the nursing staff collect blood from a catheter and prohibit a phlebotomist from collecting from such patients.
However, the catheter must have the heparin flushed prior to the blood draw, otherwise the sample may be over anticoagulated. Again, the nurse-collected sample must have two patient identifiers on the tubes, or the CLIA regulation will require the tube be rejected and recollected.
Urine and stool samples are most often collected by the LTC facility, but once again must be in the appropriate container, labeled with two identifiers, and stored appropriately until picked up and tested.
For many of the intravenous antibiotics, timed draws are requested to quantitate the peaks and troughs of the drug concentrations. The standard is to draw the patient 15 minutes prior to the next dose (trough or lowest blood level) and 1-2 hours following the completion of the IV (peak or highest blood level). This is a challenge for a phlebotomist to time their arrival with the time for the peak and/or trough when facilities do not hang the IV antibiotic at the expected time. Such occurrences frustrate both the LTC staff and the phlebotomist who may have another draw or STAT draw to perform.
Each patient has the legal right to refuse being drawn for blood work. While phlebotomists have to respect that right, the physician ordered the test to best manage the patient's condition, and labs need to work with the clinical staff to comply with the physicians orders. However, if a patient refuses a blood draw three times, the physician should be made aware and rewrite the order for the scheduled test.
Phlebotomists are required to communicate the “unable to obtain” to the staff, and often request a signature for confirmation from a nurse.
Just like any other healthcare setting, consistent staffing is always a challenge. Sickness, car issues and other barriers have a significant impact unless the day is well planned with coverage. The goal of providing a consistent phlebotomist who is familiar with the facility and patients is always optimal and the objective in focus for lab organizations.
Point of Care Testing
Many LTC facilities are looking at performing bedside POC testing for some of their most time-sensitive and frequently ordered tests. While it may seem simple enough to prick a finger and get a result, the financial, documentation and quality control aspects of doing your own testing makes it less attractive.
Furthermore, most studies comparing the results to the gold standard venipuncture results of a clinical laboratory show that the POC result as less accurate and reproducible. A short term gain in cost savings could lead to the higher costs of doing STAT retests and also delaying the best possible treatment for the patient.
Just a blood draw?
To review, you need to have the right patient, right tube, right draw order, full fill, right time for clot, right time for centrifugation and rushing the sample back to the laboratory on-time to get results back to the physician, most often on the same day as the patient was drawn.
As you can see, the importance of a qualified phlebotomist cannot be overstated. To ensure you are working with a qualified phlebotomist there are a few things you should look for. Your current laboratory provider should be CLIA accredited and even better CAP accredited (the highest accrediting authority in the nation). The laboratory should have a long history and ample experience with long term care facilities. Lastly the laboratory should offer some type of extensive training program to new phlebotomists that properly convey the challenges of working in a long term care setting. Working in collaboration with the phlebotomy team helps to support and provide better outcomes for our patients, which is the overreaching goal.
Gary L. Milburn, Ph.D is the Chief Technical Officer for MEDLAB, a laboratory services provider for long- term care.