Phlebotomy

By Group 1Cejas, Lequerica, Zambrano, Milian, Joseph

NMT 1312Marshel

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Objectives

• Define phlebotomy and describe phlebotomy services

• List professional competences for phlebotomists

• List skills for effective communication

• Describe basic principles of quality and list examples of quality assessments for phlebotomy

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Definitions

• Phlebotomy is derived from the Greek words phlebo, which relates to veins, and tomy, which relates to cutting.

• Phlebotomy is the incision of a vein for the purpose of collecting blood

• A phlebotomist is the individual who performs phlebotomy

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Duties• Primary Function

– To assist the health care team in the accurate, safe, and reliable collection and transportation of specimens for clinical laboratory analyses

• Other functions– Assist in the collection and

transportation of specimens other than venous blood such as

• Arterial blood• Urine• Tissues• Sputum

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Typical Clinical Duties

• Identify the patient correctly• Assess the patient before blood

collection• Prepare the patient accordingly• Perform the puncture• Withdraw blood into the correct

containers/tubes• Assess the degree of bleeding & pain• Assess the patient after the

phlebotomy procedure

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Typical Technical Duties

• Manipulate small objects, tubes, and needles

• Select and use appropriate equipment

• Perform quality control functions

• Transport the specimens correctly

• Prepare/process the sample(s) for testing/analysis

• Assist in laboratory testing procedures, washing glassware, and cleaning equipment

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Typical Clerical Duties• Print/collate/distribute laboratory

requisitions and reports• Answer the telephone• Answer all queries as appropriate• Demonstrate courtesy in all patient

encounters• Respect privacy and confidentiality

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Job Sites for Phlebotomists

• Hospital Settings– Acute Care Hospitals– Specialty Hospitals such as psychiatric,

pediatric or cancer centers– Hospital based clinics

• Ambulatory Care– Health department clinics– Community health centers– School based clinics– Prison health clinics– Home health agencies– Insurance companies– Physician practices– Mobile vans for blood donations– Rehabilitation centers

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Competency• Phlebotomists must be able to

– Apply knowledge of:• Principles of basic and special procedures• Potential sources of error• Standard operating procedures• Fundamental biological characteristics

– Select appropriate:• Course of action• Equipment/methods/reagents

– Prepare patient and equipment– Evaluate

• Specimen and patient situation• Possible sources of error or inconsistencies• Quality control procedures• Common procedural/technical problems• Appropriate actions and methods• Corrective actions

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Other responsibilities

• Adherences to organizational policies– Safety– Infection control– Fire & safety

• Communication skills– Verbal– Nonverbal– Listening skills

• Efficiency and quality– Productivity– Quality

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Standards of Ethical Conduct for Health Care

Professionals• Do no harm to anyone

intentionally• Perform according to sound

technical ability and good judgment

• Respect patient rights• Have regard for the dignity

of all human beings

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Expected Character Attributes

• Sincerity and compassion• Emotional stability and maturity• Accountability for doing things right• Dedication to high standards of

performance and precision• Respect for patients dignity, privacy,

confidentiality, and the right to know• Propensity for cleanliness• Pride, satisfaction, and self fulfillment

in the job• Working with team members• Take pleasure in communicating with

patients

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Competencies & Certifications

• Phlebotomists must obtain– A high school

diploma or equivalent

– Phlebotomy training via hospital, community college, or technical school

– Employers require phlebotomy certification via national certification examination

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Organizations• American Society for Clinical Pathology (ASCP)• National Phlebotomy Association (NPA)• American Society for Clinical Laboratory Science

(ASCLS)• National Credentialing Agency for Laboratory

Personnel (NCA)• American Medical Technologists (AMT)• American Society of Phlebotomy Technicians (ASPT)• National Accrediting Agency for Clinical Laboratory

Sciences (NAACLS)• National Healthcare Association (NHA)

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These Organizations• Have an interest in promoting and improving the practice of

phlebotomy• Develope competency statements• Provide guidelines for healthcare organizations to provide

standard operating procedures• Provide professional standards and code of ethics

– NPA• Provide annual or other certification examinations

– NPA– ASCP– ASCLS– NCA– AMT– ASPT– NHA

• Provide educational programs– ASCP– ASCLS

• Accrediting of phlebotomy educational programs– NAACLS

• Credentialing for laboratory personnel– NCA

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Communication• Consists of:

– 10 to 20% verbal messages

– 80 to 90% non verbal messages

• Face to face communication is the most effective form of communication and is a part of a phlebotomist’s job every day

• Verbal interactions can be depicted as a communication loop.

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Basic Communication• Requires:

– Sender– Receiver– Message

• Is complete:– when the sender receives

feedback• Involves:

– Showing empathy– Showing respect– Building trust– Establishing rapport– Listening actively– Providing specific feedback– Conveying the right

message– Using a professional tone

of voice– Using appropriate

language

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Communication Loop

• Starts when the message leaves the sender and reaches the receiver

• The receiver completes the loop by providing feedback to the sender

• Without feedback the sender has no way of knowing whether the message was accurately received or was somehow blocked by extraneous factors that can “filter out” meaning from a message

• Filters can be damaging to effective communication because they do not allow the loop to be completed

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Communication’s 3 Components

• Verbal communication– The actual words that are

spoken, the tone of voice

• Nonverbal communication– Body language, gestures

• Active listening– Using verbal & non verbal

information to assess the situation

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Verbal Communication• Must use simple, everyday vocabulary particularly with

children– Avoid complex medical jargon

• Pt’s must not be told “this won’t hurt”. – Patient should be forewarned and prepared for pain.

• Efforts must be made to insure that sensory impairments such as deafness or blindness are overcome– Ask “Do you understand?” or “Do you want me to

explain the procedure again?” to verify that you are being heard & understood

• Must make efforts to communicate with patients who speak other languages– Locate translators or translation services

• Tone of voice should match the words that are spoken.– Avoid sarcasm– Use calm soothing confident tones

• In emergency situations– Require extra speed and accuracy without jeopardizing

personal touch– Be conscious of a patient’s privacy, dignity and

individual needs• Bedside manner

– Pleasant facial expression– Neat appearance– Minimize negative effects of the situation

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Basic Procedures When Encountering A Patient For The First Time in

Hospital• Knock gently on the patient’s door• Introduce yourself and state that you are from the

hospital or laboratory, whichever is the case• Inform the patient that his or her specimen must be

collected for a test order by the physician– Indicate that this is a routine hospital procedure– Avoid lengthy discussion of why a test was ordered.

Refer this to the physician• Remain calm, compassionate, and professional and

limit conversations to essential information• Let the patient know how the procedure is going

– “This is going well”– “it is almost over”

• Do not be distracted from the phlebotomy procedure by excessive talk or unrelated issues

• Before leaving the room, thank the patient for cooperating

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In A Clinic Or Home• You must also

– Direct patient to sit in a chair with sides and arms or recline during the procedure

– Take time to find the nearest bathroom and bed in case of complications

– Find a phone or bring a cell phone to clarify lab orders

– Puncture site must be cared for appropriately and assurance must be made that patient is not bleeding.

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Patient Identification• Is essential• In a Hospital

– Must be accomplished by two of the following:

• Checking if the test requisition labels and a unique identification number on the pt’s armband match

• Verbal confirmation from the patient

• Positive confirmation by a unit nurse

• In a clinic or home– Should done meticulously

and cautiously by: • Using drivers license or

identification cards• Confirming birthday,

home address or social security

• This process should be well documented

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Telephone Communications• Incoming Calls

– Answer no later than 3rd Ring– Try to smile & reflect positive phone

voice– Speak clearly and courteously– Identify the department or doctor’s

office– Identify yourself stating your name

& title– Ask how you may help the caller– Acquire information from the caller

& record date & time– If you cannot provide the proper

response ask for assistance– Ask the caller before putting them

on hold– Do not leave on hold for more that n

30 seconds without checking back– Read back message to caller to

ensure that you have the correct info

– Allow caller to hang up first• Outgoing

– Do not call to socialize– State your name, where you are

calling from & the purpose of your call

– Leave preferred times & phone numbers where you can be reached

– Thank receiver for taking your message

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Nonverbal Communication

• Composes 80 to 90% of Communication

• Can be – Positive

• Facilitates understanding

– Negative• Hinders communication

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Positive Body Language• Includes:

– Face to face positioning

– Relaxed hands, arms, shoulders

– Erect posture– Eye contact, eye level– Smiling– Appropriate zone &

comfort• Its Effects:

– Aids communication– Can make

interactions more pleasant

– Can set stage for open lines of communication

– Promotes a sense of trust and honesty

– Prevents from making the patient feel neglected

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Zone of Comfort• Is the area of space around a patient where they feel

comfortable in an interaction.• If that zone is crossed, feeling of uneasiness may occur• For most western cultures, there are four zones

– Intimate space• Direct contact up to 18 inches• For close relationships and health care workers who bathe,

feed, dress, and perform venipunctures– Personal space

• 18 inches to 4 feet• For interactions among friends and for many patient

encounters– Social space

• 4 feet to 12 feet• For most interactions of everyday life

– Public space• More than 12 feet• Lectures, speeches, etc.

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Negative Body Language

• Includes– Slouching, shrugged shoulders– Rolling eyes, wandering eyes– Staring blankly or at the ceiling– Rubbing eyes, excessive blinking– Squirming, tapping foot, pencil, etc.– Deep signing, groaning– Crossing arms, clenching fist– Wrinkling forehead– Thumbing though books or papers– Stretching yawning– Peering over eyeglasses– Pointing finger at someone

• It’s Effects– Is distracting– Prevents effective communication– Caused discomfort, uneasiness– Can convey boredom, negative or

defensive emotions– Can make patients nervous, hurried or

anxious

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Active Listening• Helps close the communication loop by

ensuring that the message sent can indeed be repeated and understood

• May have important ramification in the test results

• Steps include– Get Ready by concentrating on the speaker– Pause occasionally to mentally summarize what

you have said– Verify that you are listening by letting the

speaker know using phrases such as “Oh” “very interesting” “I see”

– Avoid making hasty judgments– Verify the conversation with feedback– Pay attention to body language– Maintain eye contact– Use encouragement– Practice, practice , practice

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Cultural Sensitivity• Culture influences

decisions and behaviors in many aspects of life

• If a healthcare worker is unsure or unaware of acceptable patterns of behaviors for a patient, the recommended action is to “follow the patient’s lead”

• Observe mannerisms, gestures and facial expressions.

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Professional Appearance• Good Posture

– Erect posture conveys confidence and pride in job performance

– Poor posture conveys laziness and apathy

• Grooming– Instills confidence in a

person– Examples:

• Neatly combed hair • Clean fingernails • Pressed uniform

• Hygiene– Is important in

preventing the spread of infectious disease

– Examples:• Clean teeth, hair and

body• Clean, wrinkle free

clothes

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Nutrition, Rest, & Exercise

• Good Health Improves the health care worker’s:– Appearance– Attitude– Job performance– Ability to cope with

stress• Good health can be

achieved by:– Appropriate eating

habits– Rest during lunch &

break periods– Off-duty exercising

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Family & Visitors• Family members & Visitors are

often more difficult to deal with than the patient.

• Any requests made beyond your scope of work should be referred to the appropriate health care team member

• If there are several visitors in the room while blood specimens are being drawn they may be asked to step into the hall

• Family members can be asked to stay during a procedure if the patient feels they need emotional support

• Children should be accompanied by a parent of legal guardian

• Blood should not be drawn when a physicians, priests, or chaplain is meeting in private with the patient, unless it is a “timed” or STAT specimen.

• Family and visitors are NOT permitted in the laboratory

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Quality Assurance

• The area where phlebotomists have the greatest impact is on constantly improving services that are provided to stake holders or customers

• Quality improvement efforts of phlebotomy services often involve evaluating the following:– The health care worker’s technique– Complications, such as hematomas– Recollection rates resulting from

contamination– Multiple sticks on the same patient

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Stakeholders(Customers)

• External– Local community– Insurance companies that pay for

services– Employers who pay for services

for their employees– Grant agencies and/or

foundations that provide funding– Federal or state agencies –

OSHA,CDC, etc.– Accrediting agencies- Joint

Commission for the Accreditation of Healthcare Organizations (JCAHO), CAP

– Advocacy groups – AARP• Internal

– Inpatients & outpatients– Patient families and friends– Patient support groups– Clinical laboratory staff– Pathologists and other medical

doctors– Students– Research staff– Volunteers

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Quality Assessment• Quality Assessment for phlebotomy involves

reviewing:– Structures

• Physical structure– Facilities where service is provided– Supplies & equipment

• Personnel structure– Staff – directors & supervisor

• Management & administrative structure– Procedural manuals– Record keeping

– Processes• What is done to the patient or client• Involves evaluation of patient records for

complications, correct technical skills, correct documentation procedures, etc.

– Outcomes• What is accomplished for the patient• Involves chart reviews

– Customer satisfaction• Via questionairre, mailout, or telephone call

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Tools & Exercises for Performance Assessment

• Flow Charts• Breaks process into components

• Pareto Charts• Shows frequency of problematic events

• Cause and Effect (Ishikawa) Diagrams• Identify interactions between equipment, people

methods, supplies, etc.• Plan-Do-Check-Act cycle (PDCA)

• For assessing and making positive changes• Line graphs, histograms, scatter diagrams.

• Represent performance trends• Brainstorming

• Used to stimulate creative solutions in a group

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Phases of Specimen Collection

• Preanalytical Phase– Happens before testing

• Analytical Phase– Happens during testing

• Post Analytical Phase– Happens after testing

• Phlebotomists are primarily involved in the preanaylitical phase

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Preanalytical Phase• Outside the laboratory

– Patient identification and information

• Correct venipuncture or skin puncture

– Isolation techniques• Appropriate use of

supplies and equipment– Standard precautions

• Appropriate transportation and handling

• Inside the laboratory– Sample treatment

• Identification of aliquots– Specimen registration and

distribution• Appropriate storage

– Centrifugation

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Analytical & Postanalytical Phases

• Analytical– Testing the

specimen

• Postanalytical– Reporting

results• Appropriate

follow-up • repeat testing

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Basic Requirements for a Quality Control Specimen

• Use universal standard precautions• Identify, assess, and properly prepare the patient• Avoid medication interference if possible• Collect specimens from the correct patients and label

appropriately• Use correct anticoagulants and preservatives • Collect a sufficient amount of blood• Use devices that minimize accidental needle sticks• Handle specimens carefully• Collect fasting specimens in a timely fashion and verify

that they are actually fasting samples• Allow specimens without anticoagulants to stand 30

minutes• Transport specimens to the clinical laboratory in a timely

fashion• Document

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Quality Assessment For Specimen Collection Services

• Worker response time• Patient waiting time• Time required for completion of the phlebotomy

procedure• Percentage of successful blood collections on the

first attempt• Number of successful blood collections on the

second attempt• Daily blood loss per patient due to venipunctures• Number and size of hematomas• Number of patients who faint• Amount of time spent and number of telephone

calls needed to acquire appropriate identification• Number of redraws due to inadequate specimens• Turnaround times of designated laboratory tests• Number of incomplete forms, documents, logs, etc.• number of specimens received in incorrect tubes• Contamination rate for blood cultures• Patient satisfaction questionnaires• Frequency complaints

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Important Factors Affecting Quality• Anticoagulants and preservatives

– Phlebotomists are responsible for • filling specimen tubes in the correct order so that carryover of

anticoagulants to other tubes will not occur• mixing the specimens wit the anticoagulant promptly after blood is

drawn– When restocking

• collection tubes with a shelf life nearest the current date at the front of the shelf so that these tubes are first

• be cognizant of expiration dates– Phlebotomists should know how to store or preserve specimen

tubes if the blood specimen is not to be tested immediately• Number of blood collection attempts

– if consecutive unsuccessful attempts on different patients, his her technique must be reviewed, modified, or improved

• Blood loss due to phlebotomy– when too much blood is taken for laboratory analysis, the

patient may become anemic, so blood conservation become priority

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Equipment & Preventative Maintenance

• Phlebotomist must participate in quality control checks and preventative maintenance of laboratory instruments such as– Thermometers– Sphygmomanometers– Centrifuges

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Summary• A phlebotomist is someone who collects blood specimens

primarily via venipuncture• Phlebotomists duties include clinical duties such as the

venipuncture & patient care, technical duties such as quality control & specimen transport, and clerical duties such as answering phones & filling out proper documentation

• A phlebotomist must have proper training, at least a high school diploma and carry national certification

• Phlebotomists must be mature, accountable, work with the highest ethical standards, adhere to organizational policies, and be able to apply their knowledge correctly, efficiently, and precisely

• Communication involves sender, receiver & message and is complete when the sender receives feedback from the receiver

• Verbal & nonverbal communication as well as active listening are the components of communication

• Verbal communication should be face to face, in calm & confident tones, avoiding negative language and should be used effectively when: encountering & identifying the patient and using the telephone.

• Nonverbal communication should be positive not negative and makes up 80-90% of all communication

• Personal hygiene, zone of comfort and culture should also be factored when dealing with a patient

• Quality assurance is the area where phlebotomists have the greatest impact on their field

• Phases of specimen collection include the preanalytical, analytical & postanalytical phases with the preanalytical phase being the one most relevant to phlebotomy

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Questions• Phlebotomy is derived from the greek words

phlebo which relates to ________ and tomy which relates to cutting.

• Veins• To become a phlebotomist you must have at

least a high school diploma, training, and ___________.

• National certification• The three components of communication are

verbal, nonverbal and _________.• Active listening• When do you know a message has been

communicated?• When the senders receives feedback• Non verbal communication makes up

__________ % of all communication.• 80 – 90 %• Phlebotomists are usually involved in which

phase of specimen collection?• Preanalytical

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Sources

• Phlebotomy Handout– Chapter 1 – Phlebotomy

Practice and Quality Assessment Basics

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THANK YOU

HAVE A GREAT DAY!