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. 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.
–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.