Coalition strives for phlebotomy personnel standards.

Phlebotomy has been called the most underestimated procedure in healthcare. Why else would most states require a license to curl hair but not to navigate a needle around someone's nerves and arteries in search of a vein for a blood sample?

Unskilled personnel threaten laboratory quality

Laboratories are currently giving specimen-collection responsibilities to individuals from a wide variety of healthcare disciplines--and with ruinous results. Multiple articles and studies show a significant decline in specimen quality and patient satisfaction when blood is drawn by nonlaboratory personnel. (1-6) One hospital reported error rates due to unacceptable specimens drawn by nurses to be three times that of phlebotomists. (6)

"But it is more than just rejected specimens and re-collects that plague laboratories receiving blood drawn by nonlaboratory personnel," says Dennis J. Ernst MT (ASCP), director of the Center for Phlebotomy Education and coordinator of the Coalition for Phlebotomy Personnel Standards (the Coalition). "It is the havoc that poorly collected specimens wreak on clinical laboratory instrumentation and the injuries patients sustain at the hands of the unskilled.

"I have seen patients permanently disabled, even paralyzed, when personnel of every healthcare discipline are not taught the standard of care for collecting blood specimens," he says. "Then there are the transfusion-related deaths we often hear about that are traced back to patient- or specimen-identification errors."

Ernst cites his own firsthand experience to underscore lack of training. He recalls a medical assistant who recently came to his office to draw his blood for a life insurance application. "She would have used a contaminated needle if I had not stopped her," he says. "After uncapping the needle, she sat it point up on a table and proceeded to palpate for a vein. The needle fell over, and the beveled tip touched the surface of the table. She then picked up the now-contaminated needle and was about to insert it into my arm when I stopped her and insisted she change the needle."

That was not all. He explains that she also did not wear gloves, that she had removed the needle from the tube holder, and had left the sharps container in her car. "She left my office with a real education on specimen collection," he concludes.

Poorly trained specimen-collection personnel also often commit preanalytical errors that affect the performance of blood-collection systems, cause laboratory instrumentation problems, and lead to erroneous results that can compromise patient management.

"Any instrument manufacturer will tell you the majority of problems they troubleshoot in the field are caused by poor specimen quality," Ernst says. "By improving the quality of the samples that laboratories receive, we can drastically reduce instrumentation problems caused by fibrin formation, hemolysis, clots, and inadequate centrifugation. If you want to improve the quality of specimens the laboratory receives, you must improve the education of those who draw the blood."

But reducing instrumentation problems is only one of the benefits of an improved specimen-collection workforce. Ernst cites a reduction in what he calls phlebotomy's invisible errors. "Neither the most sophisticated testing instrument nor the best-trained testing staff can extract an accurate result out of a poorly collected specimen," says Ernst. "When a specimen is altered during the collection process due to collection errors, the testing personnel often have no way of knowing that the results do not accurately represent the patient's physiology. The next thing you know, the patient is the victim of a medication error or patient-management mistake that leaves everyone scratching his head."

Coalition seeks improved collection quality

The mission of the Coalition for Phlebotomy Personnel Standards, which Ernst coordinates, is to improve the quality of specimens collected for clinical testing. Among its goals are to promote 1) legislation mandating certification or licensure of specimen-collection personnel, 2) minimum training and ongoing competency requirements, and 3) education in proper blood-specimen-collection and -processing procedures.

Since its formation in 2003, the Coalition has worked to introduce bills establishing professional standards for phlebotomists and other specimen-collection personnel in Kentucky, Connecticut, Massachusetts, and Missouri. It is currently working on draft legislation in Utah and Michigan. Even though the Connecticut and Kentucky bills did not make it out of committee, the Coalition has encouraged sponsors and supporters to reintroduce revised bills in the next legislative session.

California is currently the only state that mandates training for specimen-collection personnel. "The state enacted sweeping legislation requiring minimum training requirements after a phlebotomist was caught rinsing and reusing needles on multiple patients," Ernst says. "That was six years ago, and not one state has followed suit. Will it take similar catastrophes in every state to get legislators to act? We hope not."

The Coalition has over 20 active participants representing certification organizations, professional member associations, manufacturers, and others. The American Society of Clinical Laboratory Sciences, American Medical Technologists, RAM Scientific, the Center for Phlebotomy Education, the National Credentialing Agency for Laboratory Personnel, the National Health Career Association, and Phlebotomy Legislation LLC endorse its position.

One of the Coalition's current objectives is to identify individuals in all states who are interested in promoting minimum training requirements and certification/licensure for specimen-collection personnel through legislation. So far, individuals in 35 states have accepted the group's invitation to meet and work toward establishing such minimum training standards.

"The response has been phenomenal," Ernst says. "There has been a groundswell of support from all corners of the specimen-collection industry."

The Coalition has also initiated a media-relations program. Ernst was recently interviewed about phlebotomy personnel standards by The Washington Post and was approached for an interview on the radio talk show Air America. NBC affiliates in Detroit and Boston have also aired investigative reports on their evening news about the lack of regulations for phlebotomists.

"When it comes to raising public awareness," Ernst muses, "the horse is out of the barn."

References

1. Jones B, Calam R, Howanitz P. Chemistry specimen acceptability: a College of American Pathologists Q-Probes study of 453 laboratories. Arch Pathol Lab Med. 1997;121;19-26.

2. Burns E, Yoshikawa N. Hemolysis in serum samples drawn by emergency department personnel versus laboratory phlebotomists. Lab Med. 2005;5(33):378-380.

3. Q & A. CAP Today. 2002;16(6):114-115.

4. Q & A. CAP Today. 1999;13(11):97-98.

5. Nelson K. Recentralizing phlebotomy services in the clinical lab. Adv Med Lab Prof. 2002;(14)22:21-24.

6. Southwick K. Back to the drawing board: hospitals rethink their phlebotomy staffing practices. CAP Today. 2001;15(2):12-1

By Mac Edwards, Associate Editor

RELATED ARTICLE: Coalition for Phlebotomy Personnel Standards

Position Statement

The Coalition affirms that:

* phlebotomy is an invasive procedure that requires significant skill and training to protect patients from injury and the consequences of results obtained from improperly collected specimens.

* specimens collected by healthcare personnel without proper training threatens the integrity of specimen-collection systems, and compromises the ability of clinical laboratory instrumentation to produce reliable and accurate results.

* specimen-collection personnel who are not trained according to a minimum standard threaten the ability of physicians to properly diagnose, medicate, and manage their patients and can be directly attributable to negative patient outcomes, including death.

* it is in the best interest of the patient, the physician, and the clinical laboratory industry for healthcare personnel with blood-collection responsibilities to be subject to mandatory minimum training requirements, certification/licensure, continuing education, and continued competency assessment.

* because many specimen-collection personnel perform point-of-care testing and direct the training of other healthcare personnel in point-of-care testing, unskilled personnel can contribute to inaccurate results that lead to medication errors and other patient-management errors.

* specimen-collection personnel responsible for training other healthcare personnel are capable of perpetuating medication errors and other patient-management errors when training others to perform the procedure, including nurses and patients themselves.

* specimen-collection personnel who also process specimens prior to testing can significantly alter the specimen so that it renders inaccurate results, which can lead to patient mismanagement, medical errors, and death.

The Coalition is dedicated to:

* improving the quality of blood specimens collected through encouraging legislation that establishes minimum training requirements and certification/licensure for all phlebotomists.

* recruiting the support of organizations, corporations, institutions, and governmental agencies as members and allies in establishing phlebotomy as a regulated profession.

Call to Action

In light of these affirmations and dedications, the Coalition seeks to:

* promote and advance legislation that mandates all healthcare personnel with blood-specimen-collection responsibilities be certified or licensed.

* promote and advance minimum training and ongoing competency requirements for all healthcare personnel with blood-specimen-collection responsibilities.

* promote and advance education in proper blood-specimen-collection and -processing procedures.

* recruit organizations, companies, facilities, and individuals dedicated to improving the quality of specimen-collection personnel to achieve our objectives.

* identify and assist individuals who are interested in advancing phlebotomy certification/licensure legislation.

For more information, visit the Coalition's website at www.phlebotomy.com/CPPS/home.htm, or contact Dennis Ernst by e-mail at [e-mail], or by calling the Center for Phlebotomy Education at 812-633-4636.