Phlebotomists and PPE: How Do You Decide?

When it comes to making a decision about Personal Protective Equipment (PPE) in the laboratory, OSHA is pretty clear about how to go about making the selection. The use of risk assessments and task assessments is required by OSHA’s Bloodborne Pathogens standard, and these can be essential tools in making decisions regarding safety throughout the laboratory. The decision-making tools and processes can be applied to the patient collection area as well. You might think selecting PPE for phlebotomists would be straightforward, but in some cases, it is not.

Deciding on gloves for phlebotomists is easy. The Bloodborne Pathogens standard states, “Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood … (and) when performing vascular access procedures.” (The one exception here is when collecting blood at a volunteer donor center, although gloves may be worn there as well.) So, if you have phlebotomists on your team, whether they collect blood on the patient units, at client sites, or in the lab, they all need to be wearing gloves, and it is required that they change those gloves after each patient contact. The gloves should be constructed of latex, nitryl, or another material that prevents the passage blood or body fluids (vinyl gloves should not be used).

Some of the decisions about the use of lab coats and phlebotomists are, unfortunately, more complicated. This first part of this conversation is easy. The BBP standard requires lab coats “in occupational exposure situations.” That means that if phlebotomists perform any work in the lab- if they process blood, spin it down, pour it off, etc. – they are in such an exposure situation and need a lab coat (and face protection if they handle open specimens or chemicals).

The second part is a bit more troublesome. Do phlebotomists need to wear lab coats when collecting blood from patients? According to OSHA, the answer is a clear “no.” A 2007 OSHA letter of interpretation states, “ Laboratory coats… are not typically needed as personal protective equipment (PPE) during routine venipuncture.” The letter does also go on to say that employers should perform risk assessments for any potential exposure situation in order to make decisions about lab coat use.

I do not favor the use of lab coats for phlebotomists, and I have my reasons. In my years of collecting specimens, I never obtained a splash of blood above my wrist, and I believe the risk of such a splash is minimal. As a Lab Safety Officer, I also know the use of a lab coat for phlebotomists creates several issues. If a lab coat is worn as PPE, should the same coat be worn from patient to patient? That would never happen with gloves, so if the lab coat is for protection against blood spatter, should that used and potentially contaminated protection be re-used? If a phlebotomist uses a lab coat while processing specimens in the lab, should that same lab coat be used with patients? No, OSHA says PPE used in the lab should never be worn outside the lab. Will phlebotomists change their lab coats? That is not convenient for them, and it opens the door to regulation violations and potential patient harm.

When having conversations about this topic, I have heard the argument that clothes or scrubs are worn from patient to patient if lab coats are not used. What’s the difference between that and wearing the same lab coat? The difference is that clothes and scrubs are not PPE. They are not designed to offer protection against splashes. Once you use an item as PPE, the OSHA regulations that cover the employee and how it should be viewed change.

On the other side of the coin, however, is a survey that was conducted in 2008 by DenLine Uniforms, Inc.[1] 180 phlebotomists across the country responded to questions about exposure and lab coat use. 64% of those surveyed regularly used semi-impermeable lab coats as PPE while collecting blood. 74% of respondents said they had encountered blood splashing beyond the hand area multiple times during the years they had been drawing blood. Given just this data, it seems clear that there is a high risk of blood exposure while performing venipuncture procedures, and that should mean that a lab coat should be used.

So how do you decide what to do with phlebotomists and lab coats in your lab or hospital? First, start with a risk assessment. Determine the risk of exposure above the wrist based on the collection equipment and procedures used at your location. If the risk is low, you should feel comfortable choosing not to provide lab coats for this process. If you find the risk of splash is high, implement the use of lab coats. Use caution, however, and consider the impact to patients of wearing what you consider to be contaminated PPE from patient to patient. As with all decisions about lab safety, think about the regulations, but if they don’t give you the answer you need, fall back to the choice that offers the best safe practice for your staff.

[1] https://www.denlineuniforms.com/assets/images/pdf/Blood_Draw_Exposure_Survey-October_2008.pdf

 

Scungio 1

Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

ASCP’s 40 Under Forty

ASCP’s 40 under Forty program recognizes forty pathologists, lab professionals, and residents under the age of 40 who are making significant contributions to the fields of Pathology and Laboratory Science. If that sounds like someone you know (or maybe it’s you!) head over the nomination page and start the process. Good luck!

Innovating Phlebotomy Services

If your physician orders a blood test, can you get your blood drawn at home or at the office? Most likely, that answer is “no.” Iggbo, a company based in Virginia, wants to change that. They’ve taken a page out of the Uber/Lyft playbook to provide on-demand phlebotomy services. To read more about it, check out this article on Dark Daily. 

Customer Service—A Global Perspective

Last time we talked about how customer service changes the perspective of our patients/customers, and how they judge the quality of our laboratories by their snapshot visit to the drawing station. Over the years, I’ve seen some good, some bad, and some very ugly customer service practices…one I discovered even in my own laboratory one day, just by having my blood drawn in the outpatient phlebotomy draw station!

There are lots of “best practices” around the world, and it is interesting for me to hear from colleagues or observe practices that I think are worth knowing, and worth sharing. One comes to mind in a favorite place in Africa. The rural clinic was always very busy, people everywhere lined up on benches waiting to be seen or for pharmacy or for a lab/radiology procedure. It looked like every busy primary clinic everywhere, except for the lovely colorful headdresses on the women and the different kinds of “baby carriers.” When you looked closely, many people did not have shoes, and also had their lunch nearby in a tin carrier because they were prepared to spend the day. When you looked even more closely, sometimes you see smiles and congenial conversation…but more often you can see eyes showing pain or illness, tears, fear, compassion and concern on the faces of those there to receive care, and those there for support.

In this particular busy clinic, the laboratory drawing room was down a narrow hall off to one side, and had steel bars on the door with a buzzer for entry. A necessity, but not very inviting. My African colleagues were concerned that patients would be intimidated by the negative appearance, as many of them travelled miles to get there with children or family and often didn’t even speak the dialect of the district. So they decided to do what they called “walk around draws.” Two phlebotomists took turns, one in the “caged drawing room” and one with a lab tray “roaming the waiting room.” The “roamer” would ask if the patient wished to have their blood drawn in the room down the hall, or if they would prefer a “bed side draw” right there where they were waiting. It provided opportunity to smile at the children, reassure a grandmother, speak to a caregiver if the patient was very ill, and greet people around the patient while also (bonus!) talking out loud about lab procedures—VERY important in that culture. The patient felt surrounded by the clinic community, which was parallel to being in the healer’s hut in their village while everyone gathered around to hear and see the care being given. It worked for them, and even improved their drawing room wait times.

As we explore how we can make patients more at ease, more knowledgeable, and provide improved access to our lab services, we tend to think in terms of how it will improve the lab processes. I learned a valuable lesson from my Africa colleagues: we should also think of how to improve the “patient experience” in safe and culturally appropriate ways. There are many stories and observations on how we do things wrong, but this is an enlightened one about how our global colleagues are doing it right!

As I mentioned in my last blog, the next time YOU have to have your blood drawn, take a close look around and notice what your patients and customers see. I guarantee you will always be surprised by something, and will leave the drawing room with at least one idea of how your lab can do it better.   And, if you have a great example of improving the patient experience in the laboratory, let me know at bsumwalt@pacbell.net I’m always in the market for new ideas to share.

 

???????????????????????????????

Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.

ASCP Call for Abstracts

Do you want to present your research at a national meeting? The American Society for Clinical Pathology is currently accepting abstract submissions for their Annual Meeting. This year it’s in October in Tampa, Florida. Soak up the sun while presenting your work and networking with your peers.

Customer Service—The Buck Stops Everywhere!

Laboratories are notoriously hidden in basements, outbuildings, storefronts, and historically have been hard to find, difficult to get to, and in many cases, an afterthought in facility planning. It couldn’t be farther from the truth that “labs should be seen and not heard.” Those of us who live in the lab don’t give it much thought…until we have to get OUR blood drawn, that is!

We all know the scene where someone has a “lab complaint.” It typically centers on having their blood drawn, getting stuck multiple times, having a result not ready, or heaven forbid, having to suffer a “re-draw.” If you think about it, the service we provide that has the customer-facing moment is the specimen collection phase. Our pre-analytical capabilities are where our patients/customers/clients judge the quality and strength of our laboratories. I have often described it to students in this way; if you want to buy a house and its gate is broken, the paint is peeling, the door hinges rusted, and the yard is full of weeds, you automatically assume the house is also “broken down” on the inside. It may have upgraded electricity, brand new appliances and plumbing, and the structure is solid and weather proofed. But you decline to delve further based on the appearance. The second house you see has fresh paint, new hinges on the doors, a little grass and flowers in front, and a nice walkway to the front door with a shiny new mailbox. You are charmed…and, sadly, it has a leak in the main drain, the paint inside is lead-based, the electrical system must be rewired and the structural walls are rotting and soon the stairwell will cave in. Nothing you can really see from the outside, but not something you can judge from the street.

I find that the elements of customer service and the way we present and appeal to our patients/customers is the “face of the laboratory.” Professional presentation and treating each patient and each specimen as if it were your mother’s or your child’s specimen gives our clients the confidence and trust they need to feel good about their test results. Communicating, making eye contact, soothing and reassuring those with “difficult veins” makes any situation go more smoothly. And, since most people are unable to judge the quality of our laboratory work—they have no training or understanding of what goes on in that “black box”—remember the house example. We all tend to judge by our first impressions.

Customer Service is a universal concept, and one that is a challenge in every laboratory, everywhere. One of the most popular international training programs ASCP Global Outreach provides is for pre-analytical phase quality improvement, and it always includes a heavy dose of customer service. Not only with patient engagement, but also with other departments, physicians, hospital staff, and even in community outreach. It is universal all around the world, that customer service makes the difference in how people evaluate the laboratory profession. You may be the best clinical scientist or clinician on the planet and your lab may have won awards for superior performance; but no one will know or care about that if they have a bad pre-analytical experience! The buck really does stop EVERYWHERE!

Next time YOU have to have your blood drawn, take a close look around and notice what your patients and customers see. I guarantee you will always be surprised by something, and will leave the drawing room with at least one idea of how your lab can do it better. Next time, we’ll talk about some ideas I’ve learned about customer service in other countries.  And, if you have a great example of stellar customer service practices, let me know at bsumwalt@pacbell.net I’m always in the market for new ideas to share.

 

???????????????????????????????

Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.