Phlebotomy training: Does your program pass the test?

Sept. 1, 2011

Sure, your new phlebotomists are taught not to leave the tourniquet on for longer than one minute, but do they know why? You also teach them about proper patient identification, but are you also telling them why it is so important to positively identify their patients? You teach the “what” — but do you teach the “why?” If not, it might be time to put your training program to the test.

With no requirements on what training content your new phlebotomists should receive (excluding California), it is up to each facility to determine what gets included in its training and what gets left out. To see if your training program makes the grade, determine which of these statements describes your program, then make the necessary changes so that all those who draw blood in your facility are in the know.

1. New hires are taught the names and locations of the veins, arteries and nerves of the antecubital area and why they must observe precautions in certain areas. Yes __ No __

An excellent phlebotomy training program places a high priority on trainees knowing the anatomy of the arm. It tests trainees on the location of veins, arteries, and nerves by name and any contraindications in drawing from particular areas. New phlebotomists must understand that probing blindly in hopes of finding a vein is never acceptable, is extremely painful to the patient, and puts the patient in danger of sustaining a disabling injury. A stray needle can slice veins and arteries, resulting in large hematomas or hemorrhage. When a nerve is damaged, patients can suffer from Complex Regional Pain Syndrome, Type II a disabling injury that may last a lifetime.

2. New staff members are taught why it is important to follow CLSI standards when obtaining blood specimens from patients with infusing IV fluids. Yes __ No __

IVs are probably the most common and frustrating obstacle new personnel are going to encounter. Trainees must understand why drawing blood from an arm with infusing IV fluids (including blood products) has the potential to cause erroneous and misleading test results. Whenever possible, blood should be drawn from the opposite arm. According to CLSI standards, blood specimens should not be collected from a limb with infusing fluids unless there is no alternate site available and the tests are critical to the care of the patient. If so, appropriate precautions must then be taken.

3. Trainees are taught how to handle the various types of emergency situations that could occur during a blood-specimen collection and why understanding their early symptoms are important. Yes __ No __

There are many emergencies that can occur during a blood-specimen collection. New hires should understand why they must observe for the symptoms of an impending event and take steps early on to prevent patient injury. For example, CLSI standards discourage the use of ammonia inhalants for fainting patients associated with adverse effects. New phlebotomists must also be trained to recognize and appropriately handle situations in which patients have asthma attacks, hyperventilation, nausea, vomiting, seizures, and strokes.

4. New employees are taught why it is so important to immediately activate the needle safety device upon removal from the patient and dispose of it. Yes __ No __

A needlestick injury occurs in the blink of an eye. That is why phlebotomists must, in one continuous motion, activate the safety feature and dispose of the device immediately. In order to accomplish this, disposal containers must be within reach. Used devices, even when their safety has been activated, should never be set down for later disposal. There remains a potential, however small, for a device to cause injury even after the sharp is concealed. An excellent training program always uses a wide variety of safety devices for classroom practice.

5. New personnel are taught why they must use a transfer device to fill tubes after a syringe draw. Yes __ No __

Why risk an unnecessary needle stick? Because of the potential for an accidental needlestick, the needle of a blood-filled syringe must not be pushed through the rubber stopper to fill tubes. A bloodborne pathogen exposure could also result from removing the tube stoppers to fill the tubes. A blood transfer device must always be used to move a blood specimen from syringe to tubes.

6. New phlebotomists are taught the order of draw by the additive within the tubes and why there is an order of draw.

Yes __ No __

An excellent phlebotomy training program sees to it that trainees understand the concept of additive carryover and why the tubes are drawn in a certain order. Trainees should know the “order of draw” according to the additive in the tube and the impact each additive can have if drawn in the incorrect order. They should be instructed to use the same order of draw whether they are using a tube holder with multisample needle, a winged collection device, or a syringe with transfer device.

7. Trainees are taught why they must avoid draws from the same arm as a dialysis fistula. Yes __ No __

These new staff will likely come in contact with patients who have an artificial shunt for dialysis. A great big blood-filled vessel can be tempting when there are few other veins available from which to collect a specimen. An excellent phlebotomy training program will address draws from dialysis patients and why obtaining a specimen from a shunt, or drawing from any vein in the same arm is not allowed.

8. Trainees are taught what hemolysis and hemoconcentration are and why they must prevent them from occurring. Yes __ No __

Hemolysis and hemoconcentration are concepts that can be difficult for trainees to grasp. Knowing what each means and how they impact patient care is critical. An excellent phlebotomy training program will create visual aids to illustrate these concepts so new hires will understand why they must take steps to prevent hemoconcentration and hemolysis.

9. New phlebotomists are taught why they must maintain a dress code that includes pant legs that are no closer to the floor than one inch. Yes __ No __

Trainees must portray a professional appearance, and pant legs that drag across the floor do not. More importantly, pant legs that drag on the floor are an infection-control nightmare. When scrub pants touch the floor healthcare personnel parade a plethora of pathogens from patient to patient.

10. New employees are taught why they should never draw a specimen while the patient is sitting up on the bed or exam table. Yes __ No __

Patients who are sitting on any surface that does not have arms and a back are at high risk for injury should they faint during a phlebotomy procedure. A fainting patient could fall in any direction. Without a way to secure the patient in place, a fall and serious injury could result. Patients must never have blood drawn while sitting on the side of a bed, on an exam table, in a chair without arms, or in a chair with wheels.

11. New staff members are taught why they must avoid the preanalytical threats to accurate specimen results.
Yes __ No __

It is not enough to teach trainees to avoid actions which could introduce preanalytical errors into their specimen collections. They must also know why. By understanding why preanalytical errors alter test results and, ultimately, patient care, they will want to perform the procedure correctly.

If you answered “no” to any of the statements, you may want to consider explaining the rational for all you cover in your phlebotomy training program. If you answered “yes” to all of the above, your program can go to the head of the class! Teaching the “whys” as well as the “whats” is important. As your trainees begin their careers, they will observe others who may not know or follow proper procedure. Phlebotomists who do not know the “whys” may begin to do as they see, not as they were taught. A phlebotomist who knows the “whys” is a great advocate for excellent patient care.

Catherine Ernst, RN, PBT(ASCP), is the business manager at the Center for Phlebotomy Education in Corydon, IN, having founded the Center’s School of Phlebotomy where she serves as the program’s administrator and co-instructor.