Phlebotomy and Healthcare Notes
Essential Terms and Learning Outcomes
Phlebotomy: The process of cutting into a vein.
Healthcare Learning Outcomes:
Summarize the definition and history of phlebotomy.
Explain the role of the phlebotomist in various healthcare facilities.
Describe inpatient and outpatient healthcare facilities and their relationship to phlebotomy.
Identify healthcare providers and other healthcare team members who interact with phlebotomists.
Outline the organization of the medical laboratory.
Recognize the agencies that regulate hospitals and medical laboratories.
List the qualities and characteristics of a phlebotomist.
Introduction to Phlebotomy and Healthcare
Phlebotomist's Role: Phlebotomists play a vital role in healthcare delivery, performing duties in various healthcare settings and understanding different disciplines, including the medical laboratory.
Specimen Regulation: Governmental agencies regulate the collection, handling, and testing of specimens.
1.1 Phlebotomy
Definition: Phlebotomy involves cutting into a vein; the word comes from the Greek words phlebos (vein) and tome (to cut).
Procedure: Phlebotomists perform an invasive procedure, involving an incision into the skin and blood vessels.
Importance of Lab Results: Laboratory testing results are crucial for quality healthcare, influencing over 70% of medical decisions.
Primary Role: The main role of a phlebotomist is to obtain blood specimens for testing chemicals (e.g., glucose, proteins, drugs), blood cell counts, antibodies, and infectious diseases.
Methods: Blood is collected via venipuncture (puncturing a vein) or dermal/capillary puncture (puncturing the skin).
Interchangeable Terms:
Phlebotomy and venipuncture
Dermal puncture and capillary puncture
History of Phlebotomy
Ancient Practices: Removing blood from veins dates back to 1400 BC; Egyptian tomb paintings depict leeches applied to the skin of sick individuals.
Bloodletting: Ancient people believed bloodletting rid the body of impurities and evil spirits.
Hippocrates: The ancient Greek physician viewed bloodletting as a way to balance the body.
Hippocratic Oath: Hippocrates, known as the father of medicine, originated the Hippocratic Oath.
1800s Practices: Anyone with claimed medical training could perform bloodletting.
Barber-Surgeons: Barbers commonly performed bloodletting procedures.
Barber Pole Symbolism: The barber pole's red color represents blood, white represents bandages, and the pole symbolizes a stick squeezed by patients to make veins prominent.
Medicinal Leeches: By the early 1800's, an enormous demand existed for leeches, which led to the establishment of leech farms to breed them under controlled conditions.
Modern Use of Leeches: Leeches are now prescribed to remove blood from newly transplanted tissue sites.
Microsurgery: Leeches help to decrease the swelling following microsurgery.
Properties of Leeches: Leeches contain anticoagulant and vasodilation properties.
Venesection: In bloodletting, veins were pierced with lancets to drain blood.
Lancet Popularity: During the 1800s, the short, wide, pointed blade, called a lancet was a popular medical instrument.
Cupping: Another bloodletting method involved vacuum effect by pulling blood to the capillaries under a heated glass cup, followed by piercing the skin with multiple blades.
Emergence of Phlebotomy: The phlebotomy profession emerged in the 1980s and 1990s due to technological advancements and expanded laboratory functions.
Delegation of Specimen Collection: Specimen collection was delegated to trained professionals, including medical assistants, nurses, paramedics, and phlebotomists.
CLSI Principles: Phlebotomists must demonstrate mastery of principles and techniques established by the Clinical and Laboratory Standards Institute (CLSI).
Checkpoint Questions 1.1
What does the word phlebotomy mean?
To cut into a vein.
What is the difference between venipuncture and dermal (capillary) puncture?
Venipuncture involves puncturing a vein, while dermal puncture involves puncturing the skin.
Which organization established the principles and techniques that professional phlebotomists must master?
Clinical and Laboratory Standards Institute (CLSI).
When did phlebotomy first emerge as a profession?
1980s and 1990s.
1.2 Phlebotomist's Role
Healthcare Team Member: A phlebotomist is a member of the healthcare team, responsible for collecting, processing, and transporting blood specimens to the laboratory during the preexamination (preanalytical) phase.
Other Roles:
Removing blood from donors
Removing blood from patients with polycythemia to decrease blood viscosity
Giving patients instructions on urine or fecal specimen collection
Properly packaging specimens (blood, urine, fecal, cultures, and body fluids)
Accepting incoming specimens
Logging specimens into the computer system
Routing specimens to the proper departments for testing and analysis
Inpatient Facilities: Duties as patient care technicians (PCTs) may include:
Delivering meal trays
Assisting with patient transport.
Outpatient Facilities: Duties as medical assistants (MAs) may include:
Taking vital signs
Assisting healthcare provider with patient examinations
Patient Advocacy: Providing assistance to patients who are confused or overwhelmed by healthcare needs include:
Helping a patient schedule a needed appointment
Providing directions within or to a healthcare facility
Other Healthcare Team Members: Various healthcare team members are also trained to perform phlebotomy, such as physicians, nurses, medical assistants, paramedics, and patient care technicians.
Other Duties:
Transporting other specimens (arterial blood, urine, sputum, and tissue) to the laboratory for testing
Providing basic first aid and performing CPR
Assisting other healthcare professionals with specimen collection
Training new staff
Interpretation of laboratory test orders
Providing results to healthcare providers
Point-of-Care Testing (POCT): Performing POCT, such as blood glucose monitoring, at the patient's bedside or work area using portable instruments.
Benefits of POCT: POCT assists physicians in making quicker diagnoses, which reduces the length of stay for hospitalized patients.
Other Responsibilities: Phlebotomists also perform quality control testing and various clinical and clerical duties.
Quality Specimens: The phlebotomist must be familiar with the process, equipment, and variables involved in venipuncture and dermal (capillary) puncture procedures to obtain quality specimens while maintaining patient safety.
Patient Safety: The most important thing to consider in healthcare delivery.
Specimen Quality: The quality of the specimens sent to the laboratory determines the accuracy of the test results obtained.
Compromised Specimens: There is nothing laboratory scientists can do to obtain accurate results on compromised specimens.
Phlebotomy Training
Entry Requirements: Typically requires a high school diploma or its equivalent.
Training Programs: Usually offered at hospitals, technical and private schools, community colleges, and continuing education courses.
Course Length: Can vary from a few weeks to a few months, depending on the program.
Accrediting Standards: Agencies such as the National Accrediting Agency for Clinical Laboratory Sciences (NAACLS) and American Medical Technologists (AMT) have established standards to which approved programs must adhere.
Programmatic Approval: Ensures that students are qualified to take a certification examination.
Certification and Licensure: In some states, phlebotomists must be both certified and licensed.
Checkpoint Questions 1.2
Briefly describe the role of the phlebotomist in the delivery of healthcare.
A phlebotomist collects, processes, and transports blood specimens to the laboratory during the preexamination (preanalytical) phase.
What is point-of-care testing?
Point-of-care testing is performed at the patient's bedside or a work area using portable instruments.
What is the most important duty and concern of the phlebotomist?
Patient safety.
1.3 Healthcare Facilities
Two Main Categories: Inpatient and outpatient services.
Employment Settings: Phlebotomists are employed in both inpatient and outpatient settings, as well as in special settings.
Inpatient Facilities
Include: Hospitals, nursing homes, and rehabilitation centers, where patients stay for one night or long term.
Teamwork: Phlebotomists employed at inpatient facilities work directly with several members of the healthcare team.
Roles:
Medical laboratory staff
Patient care technicians (PCTs)
Process: Physicians order specific tests to assist with the evaluation of the patient's condition, and the phlebotomist's role is to collect the blood, properly label the specimen, and transport it to the laboratory.
Outpatient Facilities
Include: Physician offices, ambulatory care centers, and blood collection centers, where patients visit for a short time and leave the same day. Hospital emergency departments are also considered outpatient facilities.
Other Settings:
Home healthcare agencies.
Veterinary offices.
Health maintenance organizations (HMOs).
The American Red Cross.
Insurance companies.
Consistent Duties: Collecting and processing blood specimens are consistent duties throughout every type of healthcare facility the phlebotomist encounters.
Fastest-Growing Settings: Ambulatory care centers are the fastest-growing outpatient settings. These sites are walk-in facilities that patients can go to not only during the day but also after business hours and on weekends, when most physician offices are closed.
Common Lab Tests: Lab tests involving chemistry, hematology, urinalysis, serology, coagulation studies, and microbiology are ordered to assist with the diagnosis and treatment of minor conditions, such as sore throat, urinary tract infection, and therapeutic drug monitoring.
Other Responsibilities: Phlebotomists collect urine, stool, and blood specimens, as well as provide patient education and perform lab tests and quality control checks.
Physician Offices: Phlebotomists and medical assistants are responsible for collecting and labeling a variety of specimens in the physician office, which are then transported to a reference laboratory (off-site laboratory) for testing.
Physician Office Laboratory (POL): POLs perform only basic lab tests according to the certification it has been granted by the Clinical Laboratory Improvement Amendments (CLIA).
Waived Tests: Waived tests are the most common and, as defined by CLIA, are "simple laboratory examinations and procedures that have an insignificant risk of erroneous result."
Blood Banks and the American Red Cross: Employ phlebotomists to collect donor blood for blood transfusions. The collected blood becomes a unit that might be used for a blood transfusion.
Mobile Venipuncture: Some medical centers provide mobile venipuncture, in which the phlebotomist goes to the patient's home to obtain blood specimens.
Insurance Agencies: Hire phlebotomists to perform in-home phlebotomy as a way of determining a customer's overall health before an insurance policy is written.
Other Facilities: Facilities that hire phlebotomists include complementary and alternative medicine (CAM) settings, such as chiropractor offices.
Critical Measures: Proper collection, labeling, and handling of all specimens are critical measures for ensuring accurate test results.
Checkpoint Questions 1.3
Name two types of inpatient facilities.
Hospitals and nursing homes.
List at least four types of outpatient facilities in which phlebotomists may work.
Physician offices, ambulatory care centers, blood collection centers, and home healthcare agencies.
1.4 The Healthcare Team
Importance of Awareness: Whether they are members of the laboratory staff or a nursing unit, phlebotomists must be aware of the healthcare specialties and the professionals found in medical settings.
Anesthesiology: Anesthesiologists and nurse anesthetists provide management of pain before, during, and after surgery.
Cardiology: Cardiologists specialize in the study, diagnosis, and treatment of conditions pertaining to the heart and cardiovascular system.
Diagnostic imaging (radiology): Radiologic technicians and technologists produce diagnostic images using ionizing radiation, X-rays, and specialized procedures. These images are then interpreted by radiologists who specialize in diagnosing and treating disease using radiation and imaging processes.
Electrocardiography: Nurses, medical assistants, or ECG technicians place electrodes on the skin and record electrical patterns, which are interpreted by cardiologists.
Electroencephalography: Nurses and EEG technicians place electrodes on the scalp to study electrical activity of the brain. Neurologists, who are physicians specializing in nervous system disorders, interpret brain activity recordings.
Emergency Department: Physicians and nursing staff specialize in the delivery of acute care for initial treatment of life-threatening or otherwise unplanned medical events. Phlebotomists may need to interact with various healthcare professionals in the emergency department as they respond to trauma assessment and treatment needs.
Endocrinology: Endocrinologists are medical doctors specializing in disorders of the hormone-producing organs and tissues.
General medicine (family practice): Family practice physicians, physician assistants, and nurse practitioners provide general care of patients of all ages.
Geriatrics: Gerontologists are medical doctors specializing in disorders of elderly individuals.
Internal Medicine: Physicians who are internists provide diagnosis and treatment of disorders related to the internal organs.
Neonatology: Nurses and other healthcare professionals care for newborns, treated by neonatologists, who are medical doctors specializing in disorders of newborns and prematurely born infants.
Nephrology: Physicians specializing in kidney disorders may be nephrologists or urologists.
Neurology: Neurologists are medical doctors specializing in disorders of the brain and nervous system.
Nuclear Medicine: Medical radiation physicists and physicians specializing in radiotherapy customize treatments for patients based on their disease state and the needs of their particular anatomy.
Nutrition and Dietetics: Registered dietitians supervise food preparation, develop modified diet plans, and provide special nutrient preparations to patients unable to consume food normally.
Obstetrics/Gynecology: Physicians who are obstetricians and/or gynecologists, as well as nurse practitioners, provide the study, diagnosis, and treatment of the female reproductive system
Occupational Therapy: Occupational therapists and occupational therapy assistants provide this service to people of all ages by using everyday activities as a part of therapy.
Oncology: Oncologists are medical doctors specializing in the study of cancerous tumors.
Orthopedics: Physical therapists provide rehabilitation services under the direction of an orthopedic specialist.
Pathology: Medical laboratory personnel often work closely with pathologists.
Pediatrics: Pediatricians are medical doctors specializing in disorders of children.
Pharmacy: Pharmacists and pharmacy technicians dispense physician-prescribed medications and use laboratory results in monitoring appropriate dosages.
Physical Therapy: Physical therapists and physical therapy assistants provide this service to people of all ages, particularly to those whose movement and functionality are threatened by aging, injury, disease, or environmental factors.
Psychiatry: Psychiatrists are medical doctors specializing in affective, behavioral, cognitive, and perceptual disorders.
Respiratory Therapy: Respiratory therapists, also known as respiratory care practitioners, provide this service through airway management and mechanical ventilation.
Surgery: General surgeons and surgeons specializing in a specific type of procedure provide this service and are assisted by surgical nurses and surgery technicians.
Urology: Physicians specializing in these disorders may be urologists or nephrologists.
Diverse Group of Medical Specialists: Cooperate and function as a healthcare team in order to achieve the greatest benefit for the patient (customer).
Checkpoint Questions 1.4
Match the following medical specialties with their role in healthcare.
cardiology: c. diagnosis and treatment of heart conditions
pharmacy: a. monitoring and adjustment of medication dosages
physical therapy: b. restoration of movement and functional ability
psychiatry: e. study and treatment of mental disorders
respiratory therapy: d. assessment and treatment of breathing disorders
1.5 The Medical Laboratory
Organization: Most hospitals have their own laboratories, which are referred to as medical or clinical laboratories because they perform a wide range of tests in several specialties.
Organizational Charts: Used to show the chain of accountability in the medical laboratory.
Segmentation: A hospital laboratory is typically segmented into clinical pathology and anatomical pathology departments.
Clinical pathology: The laboratory analysis of body fluids and body tissue for the diagnosis of disease.
Anatomical pathology: Involves the examination of surgical specimens and in some cases the whole body (autopsy) to investigate disease and/or cause of death.
Laboratory Manager (Director): An administrative medical laboratory scientist who is usually responsible for the overall operation of the laboratory.
Pathologist: A medical doctor who is usually responsible for the operation of the anatomical or clinical portion of the laboratory; may vary based on state regulations.
Supervisors: Oversee operations for each of the main sections of the laboratory.
Lead Technologists: Responsible for the daily functions of laboratory sections where regional supervisors are used.
Technicians and Scientists: Perform laboratory tests requested by patients’ physicians.
Role of Phlebotomists: Phlebotomists collect and provide the specimens on which these tests are performed.
Medical Laboratory Specialties
Cytology: Is the investigation of human cells for the presence of cancer. The most common specimens examined by cytologists are gynecological specimens known as Pap smears.
Histology: Is the study of human body tissues and cells. Surgical specimens are sent to histology to be prepared and stained by histology technicians.
Clinical Chemistry: Is the evaluation of the chemical constituents of the human body. Laboratory personnel determine levels of enzymes, glucose, hormones, lipids, proteins, vitamins, iron and other nutrients, therapeutic drugs, drugs of abuse, and trace elements, such as lead.
Hematology: Is the study of blood and blood-forming tissues; it also includes evaluation of hemostasis (coagulation system). Laboratory personnel perform complete blood counts, coagulation tests, bone marrow analysis, body fluid cell counts, and special tests for red blood cell and white blood cell disorders.
Immunohematology (blood bank): Involves collection and preparation of donor blood for transfusion. Donor phlebotomists screen donors and collect units of blood. Laboratory personnel perform blood group and type analysis and cross-matches, prepare and issue blood products, and conduct transfusion reaction investigations.
Immunology and Serology: Are the study of the body's resistance to disease and defense against foreign substances. Some of the immunology tests that laboratory personnel perform include antinuclear antibody (ANA), Monospot, rapid plasma reagin (RPR), and rapid tests for Group A streptococcus (strep), HIV, Flu, RSV, and SARS (COVID-19).
Medical Microbiology: Is the study of medically significant microscopic organisms. In the clinical setting, laboratory personnel perform techniques to identify pathogenic bacteria, fungi, parasites, and viruses. In addition, they identify microorganism resistance or susceptibility to specific antibiotics.
Molecular Diagnostics: Is the detection and classification of disease states using molecular and DNA-based testing. Laboratory personnel may perform molecular tests for infectious diseases, such as chlamydia, gonorrhea, gastrointestinal pathogens, respiratory pathogens (including COVID-19) and human papillomavirus (HPV). Some molecular labs perform flow cytometry procedures for classification of leukemia and lymphoma; and DNA-based tests, such as gene mutations and tumor cell ploidy analysis.
Toxicology: Is the detection and study of the adverse effects of chemicals on living organisms. Laboratory personnel evaluate blood and body fluids for the presence of trace elements, toxic substances, and drugs.
Urinalysis: Is the examination of urine for physical, chemical, and microscopic characteristics. Laboratory personnel perform routine urinalysis and special confirmatory tests. The urinalysis section may also be responsible for pregnancy testing and testing of other body fluids. Urinalysis may be performed in the general laboratory or a specific department of the laboratory, such as chemistry or hematology. Urinalysis may also be performed in a physician office laboratory.
Medical Laboratory Personnel
Medical office staff: Greet and assist outpatients needing laboratory services.
Medical transcriptionists: Prepare pathologist-dictated reports.
Medical laboratory assistants (MLAs): Are phlebotomists trained to perform low-complexity testing or assist laboratory staff in other ways.
Histologic technicians (HTs): Prepare small sections of surgical specimens for microscopic examination by a pathologist.
Histologists (HTLs): Perform more complex functions of the histology laboratory and are responsible for the technical aspects of the histology laboratory as well as new procedure evaluation.
Cytologists (CTs): Perform microscopic examination of human cells in order to detect cancer and other diseases. In addition, some laboratories employ professionals with master’s degrees or PhDs in specific disciplines, such as microbiology or molecular pathology.
Pathologists: Are medical doctors who specialize in the study of disease, which includes anatomical and clinical pathology. An anatomical pathologist provides diagnoses on surgically removed tissue. A clinical pathologist oversees the interpretation of blood and body fluid test results produced by MLTs and MLSs. Some pathologists also have subspecialties in the various disciplines within the medical laboratory.
Pathologists’ assistants (PAs): Examine surgically removed tissue samples and collect and examine autopsy specimens. They assist pathologists in the identification of disease states.
Medical laboratory technicians (MLTs): Have a minimum of an associate’s degree and can perform low-complexity and some moderately complex laboratory testing other than cytology and histology.
Medical laboratory scientists (MLSs): Have a minimum of a bachelor’s degree and can perform high-complexity testing other than cytology and histology. They are responsible for the technical aspects of the medical laboratory as well as new procedure evaluation. MLSs also have specialties in one or more of the laboratory sections.
Checkpoint Questions 1.5
Match the following medical laboratory sections to their laboratory testing responsibility.
cytology: d. detects cancer in gynecological and other specimens
hematology: e. studies the blood-forming tissues
immunohematology: b. prepares donor blood for transfusion
serology: c. studies the body’s resistance to disease
toxicology: a. studies the adverse effects of chemicals
1.6 Regulatory Agencies
Purpose: Regulatory agencies routinely visit and inspect laboratories and medical offices to evaluate quality control and quality assurance.
Centers for Medicare & Medicaid Services (CMS): The main regulatory body for all laboratories and established qualifications for phlebotomists.
CLIA Standards: All laboratories receiving federal funds must meet the same standards and be certified by the federal government.
Quality Assurance Programs: Laboratory facilities must have these in place to ensure that tests are effective and accurate.
Laboratory Classifications: Based on the complexity of testing performed and the associated patient risks if the tests are not performed properly.
Waived Laboratories: Some laboratories are categorized as waived and are not subject to inspections because they perform only simple tests that have minimal associated patient risks, such as dipstick urine testing.
Medium and High Complexity Laboratories: Both are inspected, but inspections are stricter for higher-complexity laboratories.
Personnel Qualifications: Specified for various levels of test complexity, which are outlined in the CLIA '88 regulations.
Consequences of Non-Compliance: Failure of any institution to comply with these regulations may result in termination of Medicare and Medicaid reimbursements as well as loss of privilege to perform the procedure
Hospital and POL Regulations: Provide rules and guidelines for quality patient care.
The Joint Commission (TJC): The main accrediting agency for hospitals which helps ensure a high standard of care for patients.
College of American Pathologists (CAP): Specifically accredits medical laboratories.
Department of Health and Human Services (HHS): Oversees the Centers for Medicare & Medicaid Services (CMS).
Commission on Office Laboratory Accreditation (COLA): For accrediting physician office laboratories (POLs). Physician offices must keep records for quality control, temperature readings, and equipment maintenance logs.
Clinical and Laboratory Standards Institute (CLSI): A nonprofit, private, educational organization that develops and publishes national and international standards for clinical laboratory testing procedures
CLSI Standards Categories: preexamination, examination, and post-examination.
Centers for Disease Control and Prevention (CDC): Implements public health regulations and reporting requirements for the clinical laboratory and other healthcare providers. The CDC is responsible for categorizing newly developed laboratory tests as waived, moderately complex, or highly complex.
Occupational Safety and Health Administration (OSHA): Regulates concerns over worker safety for the clinical laboratory. As employees of the clinical laboratory, phlebotomists have the right to a safe working environment and can report concerns regarding unsafe work practices to OSHA without fear of retaliation.
Environmental Protection Agency (EPA): Ensures that healthcare providers follow the Medical Waste Tracking Act (MWTA).
Department of Transportation (DOT): Establishes requirements for safe packaging and transport of biologically hazardous and other hazardous materials (HAZMATs), such as used or expired laboratory chemicals.
Nuclear Regulatory Commission (NRC): Regulates handling and disposal of radioactive materials (radionuclides used in therapy).
Food and Drug Administration (FDA): Approves medical and diagnostic equipment, pharmaceuticals, reagents (chemicals used for testing), and diagnostic tests before these can be marketed. The FDA also regulates collection, processing, and content-labeling requirements through the current Good Manufacturing Process (cGMP) regulations. Blood and blood products are considered pharmaceuticals.
American Association of Blood Banks (AABB): Is an international, not-for-profit association that develops standards and educational programs that focus on blood donor and recipient safety. The AABB also specifically accredits blood banks.
Checkpoint Questions 1.6
Which regulatory agency is most concerned with the quality of laboratory tests performed in physician offices?
Commission on Office Laboratory Accreditation (COLA)
What is the purpose of CLIA '88?
Regulatory agencies establish qualifications and inspection that a laboratory must meet during inspections.
1.7 Qualities of a Phlebotomist
Professionalism: A practicing phlebotomist must be professional and display professionalism at all times.
Public Image: Along with excellent communication and customer service skills, is a necessary quality of this occupation.
Professionalism: Includes a sincere interest in providing healthcare, a standard of excellence, training, accountability, and pride in your work.
Appearance: Having a well-groomed and professional appearance demonstrates to others a sense of pride in yourself, your workplace, and your overall profession.
Dress Code: Compliance with the dress code established by your facility is important for establishing a professional public image.
Public Image: The phlebotomist may be the only laboratory contact person a patient encounters, so a positive public image is important not only for the credibility of the individual but also for the laboratory department and institution.
Customer Service and Communication: The healthcare industry is service-oriented, so you want your customers (patients) to be pleased with both the services you provide and the manner in which you deliver them.
Communication Loop: positive communication is key to customer service. The communication loop involves four basic elements: (1) the sender, (2) the message, (3) the receiver, and (4) feedback.
Verbal Communication: the use of language or words to express ideas.
Nonverbal Communication: begins with attire and includes overall mannerisms and behaviors.
Personal Space: the proximity or distance between individuals a person prefers when interacting with others.
Checkpoint Questions 1.7
Name four examples of positive nonverbal communication.
Good body posture, eye contact, neat appearance, and respect of personal space.
What is customer service?
providing customer satisfaction through professionalism, positive communication, and an attitude that promotes resolution of problems.