Phlebotomy

Course Objectives and Student Learning Outcomes:

I. Acquire a working knowledge of the role of a phlebotomist, including duties, responsibilities, character traits, and professional organizations.

1. Understand the history of Phlebotomy, and the modern requirements for the professional Phlebotomist.
2. Differentiate accreditation, certification, and licensure.
3. Explain the concept of informed consent and confidentiality.
4. List personal qualities that are essential for a Phlebotomist.

II. Understand the composition of a hospital with its various departments and functions. Specifically, learn the role of the clinical laboratory, its function and segregation into specialty areas. Finally, be aware of other clinical settings that require the services of a phlebotomist.

A.        Explain the basic structure of a modern hospital including the branches of Nursing, Fiscal, and Support Services.

B.        Describe the functions and divisions of the Laboratory, and the tasks a Phlebotomist might be required to perform.

C.        Explain the varieties of professionals who may be employed in a clinical laboratory and the role they play.

D.        List the six major laboratory sections, and describe testing that may be performed in each section.

E.         Discuss the role of flow cytometry and molecular diagnostics in laboratory testing.

F.         Elucidate the function of the anatomic and surgical pathology laboratory.

G.        Describe the manner by which laboratories are monitored for quality and 4 agencies involved in this process.     

III. Learn the role of the Occupational Health and Safety Administration, be aware of common safety hazards; know how to read hazardous labeling and how to prevent injuries.          

1. Describe six general safety precautions that can reduce the risk of injury to workers.
2. Define a chemical hygiene plan, the radioactive symbol, and electrical hazards.
3. Describe the 4 classes of fires and the proper extinguishers for each.
4. Describe emergency procures for bleeding, respiratory distress, shock, and latex sensitivity.
5. List the OSHA requirement for items to be included on a hazardous chemical label.
6. List 8 types of safety hazards.
7. Define MSDS sheets, and list 2 other types of labels used to identify hazardous materials.

IV. Define the term Infection Control and its importance in a hospital setting. Become aware of the ways one can break the chain of infection. Understand the role of isolation precautions, and prevention of the transmission of blood borne pathogens.

1. Define nosocomial infections and how they differ from community-acquired infections.
2. Explain how infectious agents are spread, and demonstrate proper hand washing techniques to the others in class.
3. Discuss personal protective equipment and demonstrate proper usage in a group setting, including both wearing and removing the items, as well as correct selection depending on the situation.
4. Comment on blood borne pathogens, the use of standard precautions, and cleaning a blood spill.
5. Discuss OSHA and its role in preventing infection.
6. Define expanded precautions and when they are indicated.
7. Demonstrate understanding of each isolation type and the types of personal protective equipment that are indicated.

V. Familiarize yourself with commonly used medical terminology as used in physicians’ orders and to communicate with medical staff.

1. Correctly define, use, and be able to spell medical terms. Devise your own technique by which to study medical terms.
2. Understand prefixes, suffixes, and roots in order to interpolate the meanings of unknown medical terms.
3. Develop a working knowledge of medical abbreviations.
4. Through the use of case studies, practice translating a medical situation or condition into its appropriate medical linguistic form

VI. Investigate the study of anatomy and physiology of the human body as assigned. Develop a comprehensive knowledge of the body systems, anatomic terminology, cells, tissues, and organs.                                                                                                         

1. Demonstrate comprehension of the major body systems, selected diseases, and the laboratory testing associated with those disease processes.
2. Discuss the organization of the human body, including cells, and tissues, and organ systems.
3. Demonstrate a command of anatomic terminology and the 8 major body cavities.
4. Draw a cell and at least 4 component cellular organelles.
5. Name at least 4 types of tissue and discuss their function.

VII. Conduct an inquiry into the Circulatory, Lymphatic, and Immune Systems, with emphasis on how these systems interrelate with one another.

1. Describe blood circulation, arteries, veins, and capillaries and be able to locate the major arteries and veins in the human body using your own diagrams and comparisons to other systems in nature.
2. Explain myocardial infarction.
3. Explain the role of the 3 cellular elements of the blood and give their function. Include a discussion on the plasma and its components.
4. Define hemostasis and related laboratory testing; include a discussion of diseases that affect RBC/WBC-related problems with hemostasis.
5. Discuss the role of the lymphatic system, differentiating between blood and lymphatic circulation.
6. Discuss nonspecific, humoral, and cellular immunity, including T and B cells and their origin and function.
7. Define sphygmomanometer, systolic and diastolic blood pressure.
8. Discuss heart and vessel diseases.

VIII. Familiarize yourself with phlebotomy equipment, how to use it correctly and safely, and location of veins appropriate for venipuncture.

1. Demonstrate knowledge of the varieties of phlebotomy equipment (syringes, butterflies, vacutainers) and their proper usage; give examples of when and why a certain type of device might be superior to the task at hand than another.
2. Work with a partner to learn and refine tourniquet usage.
3. Discuss test tubes, stopper colors, and tube additives. Define 9 tube additives and their function, and the types of testing performed with each.
4. Discuss testing that must be collected on ice, list examples of testing that require the samples to be protected from light.
5. Demonstrate tube draw order in lab practice.
6. Differentiate between antiseptic and disinfectant, and what types of antiseptics are used in phlebotomy.
7. Locate the bevel, shaft, and hub of a needle, and describe the proper needle angle needed for phlebotomy. Discuss needle gauges and those used for blood collection. Discuss the proper handling and disposal of needles.
8. Compare and contrast the use of syringes and vacuum systems regarding blood delivery into tubes, risk of needle stick, etc.
9. Define whole blood, plasma, and serum.

IX. Assess and interpret a blood test order/requisition. Prepare supplies for a routine venipuncture; then perform this process in practice and on live volunteers.

1. Demonstrate comprehensive knowledge of the steps to performing a proper venipuncture, including patient ID, assembling supplies, usage of tourniquet, patient positioning, appropriate VP sites, site cleansing, correct needle insertion and removal, and tube labeling and handling.
2. Emphasize the importance of patient positioning in blood collection.
3. Discuss the varieties of patients one may encounter, and adjustments that may be made depending on individual patient needs and concerns. 
4. Demonstrate to the class an understanding of patient requisitions and how to select the proper tubes. Perform venipuncture using requisitions provided by the instructor in the student lab.
5. Perform a venipuncture on the lab arms and on a live individual. Assess and evaluate your performance, and that of the other students, then refine the process for techniques correction, if indicated.  
6. Be aware of the importance of time usage in a fast-paced scenario, and the need to maintain accuracy and courtesy in this type of environment.

X. Demonstrate comprehension of the process of dermal puncture on infants, children, and adults.

1. Discuss and perform the steps in a bleeding time test and a bedside glucose test. List in writing the reasons a physician might order this testing. Discuss calibration, QC, and maintenance of glucometer instruments.
2. Perform a dermal puncture correctly and discuss when this procedure is indicated. Differentiate in the type of cut one makes on a finger as opposed to a heel stick.
3. Distinguish between capillary and venous blood. Explain why the doctor must be notified when capillary blood is obtained for testing.
4. Describe the methods used to increase capillary blood circulation at the puncture site, explain why the importance of controlling the depth of puncture depending on the type of patient testing involved.
5. Discuss tube draw order regarding capillary blood, why the first drop of blood should be discarded, and precautions to take when performing this procedure to ensure the integrity of the specimen and the safety of the phlebotomist.

XI. Learn the various complications encountered in venipuncture; sample integrity issues, and causes for specimen rejection.

1. Discuss the barriers to communication with a patient, and other reasons one might have difficulty in accessing the patient for a blood draw. Perform a skit in class showing how to deal with 7 situations that bar the phlebotomist from easy access to the patient for blood collection.
2. List blood collection site difficulties; explain why some sites must be avoided. Understand that patients may refuse a particular site for their own reasons. Understand precautions to be considered when a leg or hand vein is to be used for venipuncture.
3. Discuss tourniquet-related issues and how to avoid these complications.
4. List the reasons why a blood collection may be incomplete, and tell how to address these situations, i.e., collapsed veins, patient faints, accidental arterial puncture, missing the vein, lack of blood flow, no vacuum in tube, etc.
5.  Explain when alcohol is not indicated for antiseptic use and alternative antiseptics that can be used.
6. Describe the appropriate demeanor of a professional phlebotomist that must be maintained despite difficulties in obtaining access to the patient or acquiring the blood.

XII. Identify special considerations that must be made to perform phlebotomy on the pediatric patient. Please include supply selection, acceptable quantities of blood to draw, immobilization issues, and the family of the pediatric patient. Likewise, identify the special needs of the geriatric patient, immobilization issues, family concerns, mental status changes, ideal blood collection techniques for the older population. Review special equipment used in the Intensive Care Unit and the Emergency Room to access blood for the laboratory.

1. List the differences in blood collection in infants and children compared to that from adults. Explain how to ease the anxiety of children and parents when blood collection on pediatric patients is required.
2. Demonstrate comprehension of bilirubin and the proper collection of samples for this testing on infants.
3. List the testing performed on a Newborn screen, formerly known as the PKU test, and proper collection methods and care of the Newborn Screen form.
4. Explain how patient age can affect blood collection techniques.
5. Explain the various types of vascular access devices.
6. Describe several situations and methodologies by which blood can be obtained from vascular access devices from authorized personnel.
7. Demonstrate the appropriate manner in which to collect blood from a patient with an IV.

XIII. Understand the nature of arterial blood as opposed to venous blood, and the difference in collection procedures for both types of blood.

1. Know the arteries approved for blood gas collection, and the proper manner to draw arterial blood. Be able to correctly ascertain the pulse and determine the correct site to puncture.
2. Know the differences between arterial and venous blood.
3. Explain what is measured in arterial blood gas testing and the significance of abnormal test results.
4. List 5 arterial puncture complications.
5. List 7 arterial sample collection errors and how they may affect testing results.
6. Define respiratory steady state and the steps to ensure the patient is in it prior to arterial collection.
7. Define capillary blood gas testing, including procedure, uses, and limitations.
8. Exhibit knowledge of collateral circulation principles and procedures.

XIV. Demonstrate and describe special collection procedures such as glucose tolerance, therapeutic drug monitoring, blood cultures, and therapeutic phlebotomy. Be able to correctly perform these procedures and demonstrate the correct procedures in the classroom.

1. List the steps to performing a 3HR GTT.
2. Know the uses of timed, fasting, and 2HR PP specimens.
3. Define diurnal variations and list some tests affected by this phenomenon.
4. Explain the significance of therapeutic drug monitoring (random, peak & trough levels) and the importance of strict compliance with draw times. 
5. Explain the theory behind blood culture testing. Discuss the timing of blood culture collections and why it is unacceptable to draw 2 sets at the same time from the same site, i.e., one stick.
6. Describe and demonstrate the proper site preparation technique to blood culture collection.
7. Demonstrate knowledge of blood donor collection, autologous donation, and therapeutic phlebotomy techniques.
8. Explain the process of making a blood smear; then perform this technique in class with a nice feathered edge for microscopic examination. Make a proper malaria smear.
9.  Explain the special handling techniques for samples for cryoglobulin, cold agglutinin, and cryofibrinogen testing are to be handled.
10. Demonstrate the correct manner in which to collect samples for legal or forensic reasons.

XV. Be cognizant of the variety of samples the laboratory may test on patients. Know the proper collection techniques for all samples and when relevant, be able to explain to patients, physicians, radiology staff, nursing, respiratory, or other departments/individuals how best to collect and preserve the specimens.

1. Develop competency in the handling and collection processes of non-blood samples from patients, such as urine, cerebrospinal fluid, stool, semen, and other body fluids.
2. Practice public relations skills within the classroom to explain collection procedures to the patients/staff in a professional and accurate manner.

XVI. Understand general guidelines for specimen transport, processing, and rejection.

1. Demonstrate ability to handle specimens in the correct manner so as to provide the lab with a good sample for testing and maintain safety.
2.  Describe sample deterioration that can occur with improper handling.
3. Give examples of samples that must be warmed, chilled, or protected from light.
4. Understand the acceptable time between drawing a sample and processing.
5. Describe the clotting process that occurs in blood, and the importance of allowing this to go to completion prior to centrifugation.
6. Explain centrifugation and the correct manner to employ.
7. Discuss proper stopper removal.
8. List reasons why a specimen must be rejected.

XVII. Exhibit proficiency in Quality Phlebotomy, Laboratory Accreditation, Proper preparation of venipuncture setting, and timely processing of samples.   

1. Define Quality Phlebotomy and how it applies to a phlebotomist’s performance.
2. List precautions that must be taken in phlebotomy with the use of iodine, tourniquet application, and cleansing the site.
3. Discuss the importance of the phlebotomist in patient perception of the hospital/clinic/collection site.

XVIII. Comprehend the nature of legal and ethical issues involved in phlebotomy. Grasp the concept of professional liability and malpractice. Maintain strict confidentiality.

1. Discuss the legal issues involved in phlebotomy and how to avoid malpractice lawsuits.
2. Explain the importance of ethics and confidentiality and patients’ rights to privacy. Include HIPPA in this discussion.

XVIV. Command the concepts of Point-of-Care Testing, Electrocardiography, and CLIA-Waived Testing

1. Define point-of-care testing and explain the pros and cons of this practice.
2. List the various point-of-care tests and their clinical usage.
3. Understand testing as listed: HGB, HCT, PT/INR, glucose, troponin T, cholesterol, blood gases, electrolytes, occult blood, urine chemical ”dipstick” testing, EKG, and pregnancy testing.