Phlebotomy Techniques: A Historical Overview PDF

Principles of Medical Laboratory Science Practices 2 #1 Understanding Phlebotomy PHLEBOTOMY: A HISTORICAL PERSPECTVE Hippocrates (460-377 B.C.) – disease as result of excess substance (blood, phlegm, black & yellow bile). Removal of excess would restore balance. Removal and extraction processes beca...

Principles of Medical Laboratory Science Practices 2 #1 Understanding Phlebotomy PHLEBOTOMY: A HISTORICAL PERSPECTVE Hippocrates (460-377 B.C.) – disease as result of excess substance (blood, phlegm, black & yellow bile). Removal of excess would restore balance. Removal and extraction processes became treatment either by expelling disease materials through drugs or by direct removal during surgery. Venesection [Latin: vena - vein; section - cutting] – most common method of general bloodletting; cutting vein with a sharp instrument and releasing blood. Releasing blood = (1) rids body of evil spirits, (2) cleanses bodily impurities, and (3) brings body into proper balance. Means withdrawing large quantities of the patient’s blood to cure or prevent illness and disease. Another word for phlebotomy [Greek: phlebos vein; tome - incision]. Table 1. Phlebotomy through Time Time Stone Age 1400 B.C. Middle Ages 1210 Evidence Crude tools used to puncture vessels and drain excess blood. A painting in a tomb showing leech application to patients evidences bloodletting in Egypt. Barber-Surgeons flourished. Guild of Barber-Surgeons was formed, dividing surgeons into Surgeons of the Long Robe or Surgeons of the Short Robe. Short Robe surgeons were forbidden by law to do surgery except: 1. Bloodletting 2. Wound surgery 3. Cupping 4. Leeching 5. Shaving 6. Tooth extraction 7. Enema administration Blades were wiped clean with a rag; therefore, they readily transmitted a host of blood-borne infections from patient to patient. Fleams – used for general phlebotomy to open an artery or vein to remove large amounts of blood. Leeching – involved enticing the Hirudo medicinalis, a European medicinal leech, to the spot needing bloodletting with a drop of milk/blood on the patient’s skin. Leeches were used for more localized bloodletting and were kept in special vessels (glass, ceramic). Widely practiced in Europe (France) by mid-18th century. Leech Therapy value comes from the worm’s saliva components: (1) a vasodilator, (2) a local anesthetic, (3) and hirudin, an anticoagulant. PHLEBOTOMY TODAY Phlebotomy is performed to: a. Obtain blood for diagnostic purposes and to monitor prescribed treatment. b. Remove blood for transfusions at a donor center. c. Remove blood for therapeutic purposes, such as treatment for polycythemia, a disorder involving the overproduction of red blood cells. Phlebotomy is primarily accomplished by one of two procedures: 1. Venipuncture, which involves collecting blood by penetrating a vein with a needle and syringe or other collection apparatus. 2. Capillary puncture, which involves collecting blood after puncturing the skin with a lancet. The Changing Role of the Phlebotomist in the Emerging Healthcare Environment * Short Robe surgeons placed a striped pole outside their doors to distinguish themselves from Long Robe surgeons. a. Pole – rod patients squeeze to promote bleeding b. White stripe – bandages (also used as tourniquets) 17th and 18th centuries – Phlebotomy was considered a major therapeutic (treatment) process. Lancet – tool used for vein cutting during venesection, most prevalent medical instrument of the times. The usual amount of blood withdrawn = 10 mL, but excessive phlebotomy was common. During this period, phlebotomy was also accomplished by cupping and leeching. Cupping – involved the application of a heated suction apparatus (“cup”) to the skin to draw blood to the surface. The capillaries were then severed by a series of parallel incisions with a lancet/fleam. Phlebotomist – a term applied to any individual who has been trained in the various techniques used to obtain blood for laboratory testing or blood donations. A competent clinical phlebotomist must have: (1) good manual dexterity, (2) special communication skills, (3) good organizational skills, and a (4) thorough knowledge of lab specimen requirements and departmental policies. National Accrediting Agency for Clinical Laboratory Sciences (NAACLS) – approve phlebotomy programs. Official Recognition Certification is a voluntary process by which an agency grants recognition to an individual who has met certain prerequisites in a particular technical area. Indicates completion of defined academic and training requirements and the attainment of a satisfactory score on an examination. Confirmed by awarded title or designation. Table 2. Phlebotomist Title and Initials Awarded by Certification Agency Certification Agency Certification Title Certification Initials Registered American Medical Phlebotomy RPT(AMT) Technologists Technician American Certified Phlebotomy CPT(ACA) Certification Agency Technician American Society for Phlebotomy PBT(ASCP) Clinical Pathology Technician National Center for National Certified NCPT(NCCT) Competency Testing Phlebotomy National Certified Phlebotomy Healthcareer CPT(NHA) Technician Association Licensure – act of granting a license. License – an official document or permit granted by a state agency that gives legal permission for a person to work in a particular health profession. (1) Specific education and experience requirements and (2) passing an examination is needed to be granted a license. Periodic license renewal by reexamination or proof of continuing education. Continuing education – designed to update knowledge and skills of participants. ASCP, American Society for Clinical Laboratory Science (ASCLS), and AMT sponsor programs that award continuing education units (CEUs). 10 contact hours = 1 CEU, most widely accepted CEU standard by the International Association for Continuing Education and Training (IACET). Certifying and licensing agencies require CEUs or other proof of continuing education for renewal of credentials. Patient-Client Interaction The phlebotomist is often the only real contact the patient has with the laboratory. Positive “customer relations” involves promoting goodwill and a harmonious relationship with fellow employees, visitors, and patients. Recognizing Diversity Culturally aware healthcare providers enhance the potential for more rewarding interpersonal experiences. This can lead to increased job satisfaction for them and increased patient satisfaction with the healthcare services they provide. Critical factors in providing healthcare services that meet the needs of diverse populations include understanding the: a. Beliefs and values that shape a person’s approach to health and illness b. Health-related needs of patients and their families according to the environments in which they live c. Knowledge of customs and traditions related to health and healing d. Attitudes toward seeking healthcare providers help from Professionalism Professionalism – defined as the conduct and qualities that characterize a professional person. Conservative clothing, proper personal hygiene, and physical well-being contribute to a professional appearance. Some of the personal behaviors and characteristics that make up a professional image, are as follows: a. Self-Confidence – ability to trust his or her own personal judgement. Factors that affect perceived self-confidence: erect posture, professional appearance, courage, and tactfulness in communication. b. Integrity – personal feeling of “wholeness” from honesty and consistency of character, as seen in one’s actions, values, and beliefs. Professional standards require a person to do what is right regardless of circumstances. c. Compassion – human emotion prompted by others’ experiences and concerns; considered one of the greatest virtues. Being sensitive to a person’s needs and offering reassurance willingly in a caring and humane way. d. Self-Motivation – a direct reflection of a person’s attitude toward life. Takes initiative to follow through tasks, consistently improves and corrects behavior, and takes advantage of learning opportunities. e. Dependability – goes hand in hand with work ethic. Takes personal responsibility for their actions. f. Ethical Behavior – making the right personal choices that help to maintain a high level of respect for yourself, the phlebotomist, and the profession. Patients’ Rights A patient has rights and must be informed of these rights when care is initiated. A patient must sign a statement of the rights being explained and the signed statement must be made a part of the patient’s health record. The American Hospital Association (AHA) published and disseminated a statement of patient rights and responsibilities. The latest revision approved by the AHA Board in 2003 is entitled the The Patient Care Partnership, which replaced AHA’s Patient Bill of Rights. Confidentiality Patient confidentiality is seen as the ethical cornerstone of professional behavior in the healthcare field that protects both patient and practitioner. The healthcare provider must recognize that all patient information is private and confidential. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 required all healthcare providers to obtain a patient’s written consent before disclosing medical information to any unauthorized person. Enacted to secure information and regulate patient privacy. Protect a broad range of health information. Safeguarding the confidentiality of protected health information (PHI) is one of the primary aims. Established national standards for the electronic exchange of PHI. Communication Skills Phlebotomy is both a technical and a people-oriented profession. Favorable impressions result when the healthcare workers (HCWs) respond properly to patient needs, and this occurs when there is good communication between the healthcare provider and the patient. Communication Defined Defined as how information is exchanged/transmitted. One of the most important processes in the healthcare system. Involves three components: (1) verbal skills, (2) nonverbal skills, and (3) the ability to listen. Communication Components – diri taman ang last ANKI A. Verbal Communication Expression through spoken word. Effective healthcare communication should be an interaction where both participants play a role. Involves a sender (speaker), receiver (listener), and a process called feedback. Accurate verbal exchange depends upon feedback. Figure 1. The Verbal Communication Feedback Loop B. Active Listening Means taking positive steps through feedback to ensure that the listener is interpreting what the speaker is saying exactly as the speaker intended. Listening is the foundation of good interpersonal communication. C. Nonverbal Communication 80% of language is unspoken. It is multidimensional and involves the following elements. 1. Kinesics – the study of nonverbal communication; includes the characteristics of body motion and language such as facial expression, gestures, and eye contact. Figure 2. Nonverbal Facial Cues Kinesic slip – verbal and nonverbal messages do not match. 2. Proxemics – the study of an individual’s concept and use of space. Table 3. Territorial Zones and Corresponding Radii Territorial Zone Zone Radius Intimate 1 to 18 inches Personal 1 ½ to 4 feet Social 4 to 12 feet Public More than 12 feet 3. Appearance – the impression the phlebotomist makes as they approach the patient sets the stage for future interaction. 4. Touch – social touching occurs when a person grabs the arm of another while giving advice. It is important to realize that patients are often more aware of your touch than you are of theirs. Effective Communication in Healthcare The phlebotomist must understand the unusual aspects of healthcare communications and its importance in comforting the patient. Recognizing the elements in healthcare communication—such as empathy, control, trust, and confirmation—will help the phlebotomist to interact with the patient successfully. A. Elements in Healthcare Communication 1. Empathy – defined as identifying with the feelings or thoughts of another person. Being empathetic helps patients handle stress, validates their feelings, and fives them a necessary sense of control. 2. Control - essential to an individual’s sense of wellbeing. Sharing control with the patient may be difficult and time-consuming, but awareness of the patient’s need is important. 3. Respect and Confirmation – An attitude that conveys an understanding of the importance of that person as an individual. The effect of honoring and respecting the person as a unique individual is confirmation of the patient’s presence and needs. 4. Trust – Unquestioning belief by the patient that health professionals are performing their job responsibilities as well as they possibly can. By recognizing the elements of empathy, control, trust, respect, and confirmation, the phlebotomist can enhance communication with patients and assist their recovery. B. Telephone Communication To maintain a professional image, every person given the responsibility of answering the phone should review proper protocol. To promote good communication, proper telephone etiquette should be followed. Figure 3. An Example of a Hospital Organizational Chart THE HEALTHCARE SETTING Healthcare personnel who understand how healthcare is organized and financed and their role in the system can help consumers negotiate the system successfully, with minimal repetition of services and consequently at lower cost. Healthcare Delivery Two general categories of facilities, inpatient (nonambulatory) and outpatient (ambulatory), support all three (primary, secondary, and tertiary) levels of healthcare. Ambulatory Care and Homebound Services Changes in healthcare practices that have significantly decreased the amount of time a patient spends in the hospital have led to innovative ways to provide healthcare, including a wide range of ambulatory services defined as medical care delivered on an outpatient basis. These services meet the needs of patients who may still require nursing care, lab tests, or other follow-up procedures after discharge from the hospital. Ambulatory care is generally classified into two types: a. Freestanding medical care settings and hospitalowned clinics. b. Outpatient departments and urgent care facilities. Public Health Service Principal unit under the Department of Health and Human Services (HHS). Its mission is to promote the protection and advancement of the nation’s physical and mental health. Organization of Hospital Services The term hospital can be applied to any healthcare facility that has these four main characteristics: 1. Permanent inpatient beds 2. 24-hour nursing service 3. Therapeutic and diagnostic services 4. Organized medical staff The healthcare delivery system in hospitals has traditionally been arranged by departments or medical specialties. Clinical Laboratory Services Clinical laboratory services perform tests on patient specimens. Results of testing are primarily used by physicians to confirm health or aid in the diagnosis, evaluation, and monitoring of patient medical conditions. Traditional Laboratories There are two major divisions in the clinical laboratory: (1) the clinical analysis area and (2) the anatomical and surgical pathology area. People who do similar tasks are grouped into departments, the goal being to perform each task as efficiently and accurately as possible. A. Clinical Analysis Areas 1. Hematology – performs lab tests that identify diseases associated with blood and the blood-forming tissues. Most ordered hematology test = CBC; performed using automated instruments, such as the Coulter counter, that electronically counts cells and calculates results. A CBC is a multipart assay reported on a form called a hemogram. 2. Coagulation – study of the ability of blood to form and dissolve clots. Coagulation tests are used to discover, identify, and monitor defects in the blood-clotting mechanism. Used to monitor patients who are taking anticoagulants or “blood thinners”. Two (2) most common tests are the prothrombin time (PT) to monitor warfarin therapy, and activated partial thromboplastin time (APPT) to evaluate heparin therapy. 3. Chemistry – performs most lab tests. Often has subsections such as toxicology and radioimmunoassay. Computerized instruments used can perform discrete (individualized) tests or metabolic panels (multiple tests) from a single sample. The most common chemistry specimen is serum. Other types of specimens tested include plasma, whole blood, urine, and various other body fluids. Serology or Immunology – deal with the body’s response to the presence of bacterial, viral, fungal, or parasitic diseases stimulating antigen-antibody reactions. Testing is done by enzyme immunoassay (EIA), agglutination, complement fixation, or precipitation to determine the antibody or antigen present and to assess its concentration or titer. Urinalysis – this department may be housed in the hematology or chemistry area or in a separate section. Specimens may be analyzed manually or using automated instruments. Routine urine test including physical, chemical, and microscopic evaluations. Physical – assesses color, clarity, and specific gravity of specimen. Chemical – performed using chemical reagent strips, screens for substances like sugar and protein. Microscopic – establishes presence or absence of blood cells, bacteria, crystals, and other substances. Microbiology – analyzes body fluids and tissues for the presence of microorganisms, by means of culture and sensitivity (C&S) testing. Important to collect, transport, and handle specimens properly to determine the presence of microorganisms and appropriate identification. Subsections are bacteriology, parasitology, mycology, and virology. Blood Bank or Immunohematology – prepares blood products for patient transfusions. Blood components dispensed include: (1) whole blood, (2) platelets, (3) packed cells, (4) fresh frozen plasma, and (5) cryoprecipitates. Blood samples from donors and recipient must be tested pre-transfusion so that incompatibility and transfusion reactions can be avoided. Transfusion services offered by the blood bank department collect, prepare, and store units of blood from donors or patients. 4. 5. 6. 7. B. Anatomical and Surgical Pathology 1. Histology – pathologists evaluate samples of tissue from surgeries and autopsies under a microscope to determine if they are normal or pathological (diseases). Two most common histological diagnostic techniques in the lab: (1) biopsy and (2) frozen section. Tissues must be processed and stained before evaluation = role of histologist. 2. Cytology – concerned with the structure of cells. Cells in body tissues and fluids are identified, counted, and studied to diagnose malignant and premalignant conditions. Pap smear – for early detection of cancer cells of the cervix and vagina. Named after Dr. George N. Papanicolaou. 3. Cytogenetics – samples are examined for chromosomal deficiencies that relate to genetic disease. DNA histogram is the latest test for genetic and malignant disorders. DNA fingerprinting and molecular genotyping are prevalent forms of scientific testing in forensic medicine. Stat Labs Set up in the emergency department (ED) or emergency room (ER). STAT means “immediately”. Ideally, procedures and tests performed in the ED are those needed to respond to medical emergencies Reference Laboratories Large independent labs receiving specimens from different facilities that provide routine and more specialized analysis of blood, urine, tissue, and other specimens. They offer fast turnaround times (TATs) and reduced costs due to high volume of tests. Clinical Laboratory Personnel a. Laboratory Director/Pathologist – a physician specializing in diagnosing diseases through lab test results in tissues removed at operations and postmortem examinations. o Lab director may be a pathologist or clinical lab scientist with a doctorate. They share responsibilities with the lab administrator for lab management. b. Laboratory Administrator/Laboratory Manager – usually a technologist with an advanced degree and years of experience. Oversees all operations. o Supervises ancillary services such as radiology and respiratory therapy , or all lab functions in a healthcare system. c. Technical Supervisor – responsible for the administration of the are and reports to the lab administrator. o Usually has additional education and experience in one or more of the clinical lab areas. d. Medical Technologist/Medical Laboratory Scientist – has a BS degree plus additional studies and experience in the clinical lab setting. o Responsibilities include performing all levels of testing in any area of the lab, reporting results, performing QC, evaluating new procedures, and conducting preventive maintenance and troubleshooting on instruments. e. Medical Laboratory Technician – individual with associate degree from a 2-year program or certification from a military or proprietary (private) school. o Responsible for performing routine testing, operating all equipment, performing basic instrument maintenance, recognizing instrument problems, and assisting in problem solving. f. Clinical Laboratory Assistant – a person with phlebotomy experience who has skills in specimen processing and basic lab testing. Generalists, responsible for assisting the MLS/MLT with workloads in any area. g. Phlebotomist – trained to collect blood for lab tests necessary for the diagnosis and care of patients. Some facilities use phlebotomists as lab assistants or specimen processors. Other Laboratory Personnel Computer programmers and LIS managers – laboratorians with additional training that are experts in lab computer software. QA manager – detail-oriented MT/MLS collecting statistics for QA purposes. POC coordinator – an MT/MLS working with the nursing staff to ensure quality of POC testing results. Clinical Laboratory Improvement Act Clinical Laboratory Improvement Amendments of 1988 (CLIA ‘88) is a federal law that allows the Centers for Medicare and Medicaid Services (CMS) in the Department of Health and Human Services to regulate all sites performing lab testing in the US. Mandate all labs to use the same standards regardless of location, type, or size, including personnel standards for labs performing moderate- and high-complexity testing. CHAPTER KEY POINTS By recognizing diversity, the phlebotomist promotes goodwill and harmonious relationships that directly improve health outcomes, the quality of services, and public relations. The maintenance of confidentiality is such an important issue in testing for HIV that the patient must sign a consent form before the specimen for the test can be collected. To communicate effectively with someone, it is important to establish good eye contact. A patient or client may be made to feel unimportant and more like an object rather than a human being if eye contact is not established. Phlebotomists will find that when dealing with patients who are ill or irritable, a confident and professional appearance will be most helpful to them in doing their job.