Introduction To Phlebotomy

What is Phlebotomy? The drawing of blood in a clinical setting for clinical testing. A balancing act between the comfort of the patient and the quality of the sample(s).

What is Phlebotomy? It is the job of the phlebotomist to maintain comfort for the patient while obtaining the appropriate sample(s) to complete the tests ordered.

3 purposes for collection and analysis of laboratory samples: Diagnostic testing – what’s wrong with the patient? Therapeutic assessment – is the drug at the right therapeutic level? Monitoring patient’s condition – is the patient getting better?

Overview Good phlebotomy begins with finding an appropriate draw site. Knowledge of the anatomy of the draw site is vital. A good phlebotomist is familiar with many different potential sites on the arm and hand.

Overview Veins grow in response to pressure and follow NO exact pattern. The basic idea is to look for a draw site TWICE as long as you actually perform the venipuncture.

What is a Phlebotomist? A phlebotomist is a medical technician trained specifically to take blood samples from patients He/she performs basic laboratory tasks including setting up samples for analysis and might also enter lab results into a computer system

What is a Phlebotomist? While many medical professionals practice in addition to other skills, especially in small offices, many major medical centers and blood donation organizations maintain a staff of phlebotomists to handle blood samples and collection

What is a Phlebotomist’s role in a healthcare facility?

They collect blood primarily by performing venipuncture and, for collection of minute quantities of blood, finger sticks. Blood may be collected from infants by means of a heel stick. Specially trained phlebotomists collect arterial blood samples from the radial artery of the wrist or brachial artery in the antecubital area (bend in the arm).

Traits and Abilities Must possess manual dexterity and apply proper body mechanics to perform proper blood sampling techniques and handle related equipment and instruments, have a thorough understanding of the venous anatomy of the limbs, and know proper procedures when it comes to handling and processing specimen containers and kits.

Traits and Abilities Since phlebotomists work primarily with patients, it is essential that they have good people skills. They should be friendly, have good oral and written communication skills, and they should be able to work in a stressful environment.

Adequate training in blood and urine specimen collection is essential!

An improperly collected sample will lead to false lab results and errors that can harm the patient, or even cause their death. Only through skillful and careful blood drawing procedure can a quality blood sample be obtained and reliable results be recorded.

Phlebotomists’ Duties Duties and responsibilities center around the obtaining and proper handling of human blood. Basic services include taking blood samples from patients and correctly cataloging them for lab analysis The importance of the phlebotomist is far more critical than this simple description implies.

Examples of Duties: Draws blood specimens from patients by using finger stick, heel stick and/or venipuncture.  Collects throat culture specimens.  Greets patients and instructs them in proper specimen collection methods. 

Examples of Duties: Labels specimens for identification purposes and enters specimen data into computer.  Prepares specimens for reference laboratory by using centrifuge to spin blood. 

More Duties: Answers telephone calls and routes calls to appropriate member of the medical or laboratory staff. 

More Duties: Writes test results sent from reference laboratory into patient report; distributes report to clinicians.  (Many labs now send patient reports via computer - with EMR/HER software - electronic medical/health records).

More Duties: Inventories and requisitions medical laboratory supplies; stocks work area as needed.  Keeps work areas clean and orderly.

Critical Responsibilities: Phlebotomists have an extremely high potential to be exposed to blood borne diseases and contaminants, the level of caution and expertise they use in the execution of their duties is critical to their own safety as well as all others that may be exposed to the fluid samples they draw.

Critical Responsibilities: Prior to collection, it is the phlebotomist’s responsibility to assure that all collection instruments and environments are sterile and of first use. Any error in the job of a phlebotomist can have consequences that range from misdiagnosis to fatal contamination.

Additional Duties: Some duties, for example those that conduct home care visits, will also include being responsible for transportation of fluid samples between the sample site and the laboratory. In some cases duties will also include being responsible for performing certain functions to process blood samples for further analysis by attending medical professionals.

Additional Duties: Phlebotomists that work in a laboratory environment have the added task of ensuring that samples are correctly analyzed by enforcing quality control and safety measures to prevent the contamination of samples during analysis.

A phlebotomist must understand that each person is different, each situation is unique, know all possible problem areas and complications, and prevent procedural errors from occurring.

Must be able to perform the proper technique to prevent unnecessary errors, especially false laboratory results or findings. Proper technique will also prevent injuries to patients. Injuries such as hematomas, anticoagulant reflux and nerve injury have to be prevented at all costs. Using proper phlebotomy techniques will prevent samples from being compromised.

Along with the basic skills in venipuncture, finger stick and capillary puncture, must be keenly aware of the client’s general health, gender, culture, allergies and medications taken. Prior to getting a blood sample, the client must be prepared and be instructed properly. If the primary site for venipuncture does not become viable, you must know another site where to puncture best. Good phlebotomists know the safety regulations and infection control procedures and techniques to avoid injuring others and themselves.

Phlebotomy is one of a variety of allied health or lab technician fields vital to the work of a hospital or medical practice.  Doctors rely on blood samples to diagnose a wide variety of diseases and in order to assess the general health of their patients.  Phlebotomists are also essential to every blood bank in order to collect each community’s supply of plasma and whole blood for transfusions and other medical procedures and surgeries.

WHERE DO PHLEBOTOMISTS WORK? Phlebotomists can find work in a wide variety of medical settings including (but not limited to): hospitals, commercial laboratories, medical practices and clinics, blood banks, home health care agencies, prison hospitals, military base hospitals, hospices, visiting nurse organizations, pharmaceutical and research labs, home health agencies, and public health clinics.

HISTORY OF PHLEBOTOMY Phlebotomy until the mid-nineteenth century was the ancient practice of bloodletting. Ancient physicians believed that the blood was one of the “humors” that caused illness.  They employed barbers and sometimes an insect called a leech to bleed individuals thought to suffer from a blood-related disease. 

HISTORY OF PHLEBOTOMY Often bloodletting weakened the patient and caused death. Occasionally, the bloodletting procedure actually brought relief, as in the case for those with high blood pressure. The barber’s red and white barber pole is an ancient symbol of the combination of red for drawing of blood and white for the tourniquet that kept the blood from flowing out of control.

Bloodletting Performed by a cut into a vein with a sharp instrument to drain blood The lancet was the most popularly used instrument Aseptic practices were not known, so the lancet was reused for several patients

Removing blood from veins dates back to about 1400 B. C Removing blood from veins dates back to about 1400 B.C. when leeches were applied to the skin of sick people. In the early 1800’s, medicinal leeches were used for the procedure known as bloodletting. Bloodletting was typically performed by barbers or anyone claiming medical training.

Phlebotomy at a Glance Phlebotomy means to cut into a vein. This procedure of cutting or puncturing a vein is performed by a phlebotomist. Primary role is to obtain blood specimens for testing. Other roles include packaging urine specimens, accepting incoming specimens, and routing specimens to other departments.

Modern - Day Phlebotomy Profession emerged as a result of technology and expansions in laboratory function Performed by trained professionals Standards of practice set by the Clinical and Laboratory Standards Institute (CLSI)

PATIENT IDENTIFICATION Check armband or ID label in acute care settings Check driver’s license or picture ID in outpatient settings

PATIENT IDENTIFICATION IS A 3-STEP PROCESS: ASK COMPARE VERIFY/VALIDATE

Specimen Collection METHODS Physician orders indicate type of specimen and time of collection DERMAL PUNCTURE Use of a puncture device to obtain capillary blood by pricking the skin VENIPUNCTURE Insertion of a needle into a vein to remove blood MOST COMMONLY USED COLLECTION METHODS

Professionalism Personal Hygiene Dress Neat, well-groomed appearance Jewelry Many institutions require that phlebotomists wear a lab jacket and specified shoes to meet OSHA guidelines.

Communication Verbal and nonverbal Avoid the use of slang Speak in a calm, clear voice Avoid inappropriate terms Maintain eye contact Respect personal space

Clinical Laboratory Improvement Amendment (CLIA) Established in 1988 to ensure that all laboratories receiving federal funds, regardless of size, would meet the same standards As of 1992, this legislation became the main regulatory body for all laboratories Establishes qualifications for phlebotomists

CLIA 1988 Congress passed the Clinical Laboratory Improvement Amendments (CLIA) in 1988 establishing quality standards for all laboratory testing to ensure the accuracy, reliability and timeliness of patient test results regardless of where the test was performed. 

Clinical Laboratory Improvement Amendments (CLIA) of 1988 are United States federal regulatory standards that apply to all clinical laboratory testing performed on humans in the United States, except clinical trials and basic research. In accord with the CLIA, the CLIA Program sets standards and issues certificates for clinical laboratory testing. CLIA defines a clinical laboratory as any facility which performs laboratory testing on specimens derived from humans for the purpose of providing information (1) for the diagnosis, prevention, or treatment of disease or impairment, and (2) for the assessment of health.

Regulatory Agencies Centers for Disease Control (CDC) Occupational Safety and Health Administration (OSHA) Clinical and Laboratory Standards Institute (CLSI)

Regulatory Agencies Healthcare Finance Administration (HCFA) Department of Health and Human Services (DHHS) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the College of American Pathologists (CAP) help ensure a high standard of care for patients. JCAHO is the main accrediting agency for hospitals. Now called THE JOINT COMMISSION

Laboratory classifications are based on the complexity of testing Waived Moderately Complex Highly Complex

There are over 25,000 possible laboratory tests, with around 500 performed in most institutions. http://www.ascls.org/labtesting/index.asp POCT – testing at bedside, may be performed by phlebotomist

IN SUMMARY: The art of phlebotomy has evolved from the use of leeches to modern-day certified phlebotomists. Phlebotomists are responsible for collecting, processing, and transporting blood specimens. Professionalism involves a positive attitude and appearance, proper communication to the patient, and providing quality customer service. Phlebotomists are employed at hospitals, rehabilitation centers, nursing homes, clinics, physician’s offices, ambulatory care centers, blood banks, and reference labs.

IN SUMMARY: There are many regulating agencies for phlebotomy including CLSI, JCAHO, HCFA, CDC and OSHA. Errors that can occur during the collection and handling of blood specimens are potentially numerous. Standards for venipuncture can reduce or alleviate many of these errors in much the same way that quality control standards have reduced errors within the laboratory.