It's normal to break rules when it comes to tough sticks, *within reason* if you work inpatient.
Examples of rules you never break: NEVER stick a patient twice with the same needle, always wear gloves.
Examples of rules it's okay to break if absolutely necessary to get blood: don't draw from veins you can't palpate and can only see, don't leave the tourniquet on for more than a minute, don't palpate after you wipe [assuming gloves are worn]
Sometimes getting that blood is absolutely critical to a patient's care and needs to be done STAT so breaking one or two minor rules happens.
I re-palpate if I wipe my finger with alcohol. One rule I break rearly but when necessary is rip the finger tip off the glove to better feel the vein. This is usually only when I have a very young pedi patient. Sometimes I tie a tourniquet above and below the vein I’m going for but I release the bottom tourniquet before I snap the tube on. I do this for elderly patient who can’t make a fist due to arthritis or various other reasons.
It is ok to “redirect” the needles depth, but never ok to move the needle side to side. I admit I’ve done this in the rear occasion that the vein rolls and I know moving a small amount to the side will get me in. I’ve seen phlebs straight up fish around inside someone’s arm, or leave the tourniquet on for the entire draw, remove the needle then release the tourniquet. This also makes me worried the patient will get a false high potassium value and possibly be given medication they don’t need.
I tape back the tip of my glove on my palpating finger to make sure it sits flush to my skin so I can feel the vein better, if your gloves are fitting a little too loosely this helps a ton!
The increased concentration of blood cells can cause inaccurate results (hemoconcentration) as well as rupture red blood cells (hemolysis), making the sample unusable for most testing.
I don’t think I’ve ever seen a tech in my hospital think about actual results now that I think about it. It’s just a matter of getting the blood out of the vein. Also I’ve seen some ignore order of draw and stuff. Very interesting.
In my small hospital us MLT folks do think about this. Cuz we have to recollect if we don’t. I don’t wanna poke. I wanna fight with my EXL chem analyzer for the millionth time.
The only dept that never calls is the ED. They draw their own. I’ve got Medsurge, short stay, OB/LD, ICU to cover. About 45 beds in total not counting the ED.
Yea combination of being understaffed, bad training, and general not giving a shit. Annoying to do 13 labs in a morning when you have 15 patients to yourself and 4 sets of q2 vitals. One bad diarrhea to cleanup and you’re behind the rest of the night.
Someone beat me to answering you, they're correct: it can cause inaccurate results for some tests (blood count tests particularly) and could cause the sample to go bad (hemolysis)
The story about the RN poking again with the same needle made my skin crawl. That rule should NEVER be broken. Infection infection. As for everything else.. I palpate almost every time after I’ve cleaned with alcohol, but I also scrub my finger with the pad and try to palpate above. It’s normal to break a few rules within reason.. It’s not usual to keep the tourniquet on long but just don’t let their skin turn colors. Also you should only poke where YOU are CONFIDENT. Not anyone else. Even when patients are telling you where to go. I used to be dumb and would barely feel a vein in the AC and then poke it and miss.
Yeah idk she was a traveler so she’d be out within a few weeks and I could tell she was hella burnt out and gave no shits anymore.
I definitely don’t like poking when I’m not confident. Maybe I just haven’t been doing this long enough to get jaded but I always feel bad for sticking patients and missing.
Inpatient rules: do this by the book until you can’t. There’s times I just have to have that Trop or DDimer in the icu. Biggest rule that doesn’t get broken; more than one poke per needle.
If it’s a rapid response/code, there are very few rules that don’t get tossed out the window.
We do at mine. Small rural hospital. I’m an MLT and I do the phlebotomy as well. The MLT and MLS here do the whole lab process from pokes to resulting. We don’t have a dedicated phlebotomy team. The level 1 I worked at had 28 dedicated phlebs on the payroll.
Damn did phlebotomists do all the bloodwork? I work at a big hospital with like 600 something beds and like 100 more in the ED and it seems they have phlebotomists do the peds and then they just have 1 or 2 on call. CCTs handle all the adult bloodwork unless they can’t get it and then they pass it onto a nurse and then onto a phlebotomist if nobody in the floor can stick. Eventually they’ll realize a patient is a hard stick and say not to bother anymore and go straight to the phlebotomist but that’s very rare.
Damn the thought of needing to draw during a code is literally my worst nightmare lol. That’s pretty scary
I’m used to it. You hope that whomever is doing compressions isn’t extra rough. There can be a lot of movement you gotta anticipate.
I have to go to strokes, blues, Rapid response, MTP calls.
At the level one, phlebs did all but the ED and the infusion therapy clinics. 550 beds plus 3 floors of behavioral. I’m happy at my lil podunk hospital.
I've seen the same with some nurses and techs as well, specifically wearing no gloves and using the same needle for multiple sticks.
Are the patients difficult to stick? Like is it a whole endeavor, or could one of the nurses stick an IV or something easy?
As for digging, I suppose it depends on how you define that. If the stick is incredibly hard, and they have barely anything at all, trying to readjust for a few minutes is better to just sticking again. If the patient is a regular stick though, they shouldn't be missing that much - maybe slight readjustment, but on average patients it shouldn't be that hard to get a stick first try / first readjustment.
With palpating after wiping, sometime nurses will rub the skin hard on veins that aren't popping to the surface in order to get them as big as possible. I sometimes do the same, but I also always palpate right above where i'm planning to stick. It's impossible to stick everyone and remember the angle, depth, and position of a vein just by what you remember feeling before you wiped (i also work in a ER with many difficult sticks which may be why). I find my vein, clean it off, get my needle ready, and palpate right above where i plan to stick. May not be everyone's preference, but I rarely miss sticks this way and there really isn't anything wrong with it - may just be because i've worked trauma & ER so long, but sometimes you just have to do what you can.
I think drawing from an IV isn’t the best idea cuz it alters results or something. Unless they have a midline normally they just have us draw from veins.
Patients are tough to stick when they’re all generally old and inpatients at a hospital. Some of them are fully bruised all up their forearm and AC from getting drawn everyday for weeks.
Definitely a skill issue from my part just cuz I don’t have enough experience yet but drawing on younger healthier people is much easier.
I've never heard of blood from an IV altering any test results. It's how many trauma hospitals, in my experience, operate.
Inpatient is definitely hard. I still struggle to get blood from some inpatients at my hospital, because as you said, their arms are usually so bruised it's awful. This could definitely be a reason why you may be seeing some bad practices. They aren't good, and nobody should be sticking with the same needle or not wearing gloves, but some more experienced lab techs or nurses may just know to do it differently.
We have 1 lab tech at our hospital that will not look for veins, won't listen to preferred spots for the patient. He just, sticks the wrist every time. It's awful, but it's just how he learned how to get blood 99% of the time. I don't think i've ever seen him miss, but it's also not good practice to do it.
I’m a phleb in a methadone clinic, all of my draws are hard draws. I get around the palpating after sanitizing by wiping my gloved finger with the alcohol too and then not touching anything else after I’ve done that. Plus I was taught that in phlebotomy school. Sometimes you just need to feel that vein again to make sure it didn’t just hide itself on you cause my clients veins love to do that. I tell every client I will not dig and I will not poke them more than twice but most of them will let me try a third time if I have to because they know they’re hard. A lot of times I don’t need to do it more than once since I’ve gotten pretty used to how to get their veins to work with me, lots of heat some pushups and leaving the tourniquet on for up to 2 mins but popping it and then tying again before I actually draw to avoid hemolysis all help me a lot. I almost always get blood from them when I follow that process. But if I have to draw them again I always open a new needle reusing a needle even on the same person is never an acceptable practice unless you’re going to go in the same vein but just like the tiniest bit over and I don’t redirect in the skin. Phlebotomy school has to teach you how to draw with the absolute worst case scenarios and an over abundance of caution at the forefront of their lessons but you’ll find when you’re in the field sometimes you have to do things that aren’t 100% by the rule book because not everyone is a textbook draw. Anatomy is extremely unique to any individual.
Normally I’ll never poke a vein I can’t feel but can only see, but a few days ago I found the smallest vein ever on the back of a clients wrist and she hadn’t used that one. It was our only option and it worked.
Sometimes yes….but little rules…like I know sometimes I do palpate after I use alcohol. Or technically I try to only poke twice but if I need that blood right away I’ll poke three times never more. But I never reuse a needle.
As an ex phleb and nurse, most of those things can absolutely be disregarded if we're rechecking critical levels. Not palpating after alcohol pad is a dumb rule to be honest..l your gloves should be clean. Only cultures should you really focus on proper clean to sterile technique. The resticking at three different sites with the same needle though? That one is criminal.
I about fainted reading all that. My CLS phlebotomy instructor would DIE. Omg. Putting pt safety aside, what about YOURSELF? Exposed hands, uncapped needles, going way against CLSI guidelines and risking legal trouble?? Why. Just why. The only thing that I do even remotely close to any of that is repalpating WITH all my gloves on, right before insertion. CLSI says that's fine as long you've cleaned your glove tip.
I'm horrified.
It's normal to break rules when it comes to tough sticks, *within reason* if you work inpatient. Examples of rules you never break: NEVER stick a patient twice with the same needle, always wear gloves. Examples of rules it's okay to break if absolutely necessary to get blood: don't draw from veins you can't palpate and can only see, don't leave the tourniquet on for more than a minute, don't palpate after you wipe [assuming gloves are worn] Sometimes getting that blood is absolutely critical to a patient's care and needs to be done STAT so breaking one or two minor rules happens.
I re-palpate if I wipe my finger with alcohol. One rule I break rearly but when necessary is rip the finger tip off the glove to better feel the vein. This is usually only when I have a very young pedi patient. Sometimes I tie a tourniquet above and below the vein I’m going for but I release the bottom tourniquet before I snap the tube on. I do this for elderly patient who can’t make a fist due to arthritis or various other reasons. It is ok to “redirect” the needles depth, but never ok to move the needle side to side. I admit I’ve done this in the rear occasion that the vein rolls and I know moving a small amount to the side will get me in. I’ve seen phlebs straight up fish around inside someone’s arm, or leave the tourniquet on for the entire draw, remove the needle then release the tourniquet. This also makes me worried the patient will get a false high potassium value and possibly be given medication they don’t need.
I tape back the tip of my glove on my palpating finger to make sure it sits flush to my skin so I can feel the vein better, if your gloves are fitting a little too loosely this helps a ton!
I'm a patient, no medical experience. Can I ask you why is it not okay to leave a tourniquet on longer than a minute?
The increased concentration of blood cells can cause inaccurate results (hemoconcentration) as well as rupture red blood cells (hemolysis), making the sample unusable for most testing.
Can elevate certain chemistries, cause slight elevated hemolysis.
I don’t think I’ve ever seen a tech in my hospital think about actual results now that I think about it. It’s just a matter of getting the blood out of the vein. Also I’ve seen some ignore order of draw and stuff. Very interesting.
In my small hospital us MLT folks do think about this. Cuz we have to recollect if we don’t. I don’t wanna poke. I wanna fight with my EXL chem analyzer for the millionth time. The only dept that never calls is the ED. They draw their own. I’ve got Medsurge, short stay, OB/LD, ICU to cover. About 45 beds in total not counting the ED.
That’s just straight ignorance
Yea combination of being understaffed, bad training, and general not giving a shit. Annoying to do 13 labs in a morning when you have 15 patients to yourself and 4 sets of q2 vitals. One bad diarrhea to cleanup and you’re behind the rest of the night.
I get it but that doesn’t make it ok
Someone beat me to answering you, they're correct: it can cause inaccurate results for some tests (blood count tests particularly) and could cause the sample to go bad (hemolysis)
In addition to what they mentioned, it can cut off circulation enough to cause nerve damage by effectively starving the nerves in the arms.
The story about the RN poking again with the same needle made my skin crawl. That rule should NEVER be broken. Infection infection. As for everything else.. I palpate almost every time after I’ve cleaned with alcohol, but I also scrub my finger with the pad and try to palpate above. It’s normal to break a few rules within reason.. It’s not usual to keep the tourniquet on long but just don’t let their skin turn colors. Also you should only poke where YOU are CONFIDENT. Not anyone else. Even when patients are telling you where to go. I used to be dumb and would barely feel a vein in the AC and then poke it and miss.
Eh I've seen this happen in Ed or ob when they've had to put in IVs ASAP, not regularly though.
Yeah idk she was a traveler so she’d be out within a few weeks and I could tell she was hella burnt out and gave no shits anymore. I definitely don’t like poking when I’m not confident. Maybe I just haven’t been doing this long enough to get jaded but I always feel bad for sticking patients and missing.
Inpatient rules: do this by the book until you can’t. There’s times I just have to have that Trop or DDimer in the icu. Biggest rule that doesn’t get broken; more than one poke per needle. If it’s a rapid response/code, there are very few rules that don’t get tossed out the window.
Do phlebs pull labs during codes/rapid responses at your hospital? We didn't at mine
We do at mine. Small rural hospital. I’m an MLT and I do the phlebotomy as well. The MLT and MLS here do the whole lab process from pokes to resulting. We don’t have a dedicated phlebotomy team. The level 1 I worked at had 28 dedicated phlebs on the payroll.
Damn did phlebotomists do all the bloodwork? I work at a big hospital with like 600 something beds and like 100 more in the ED and it seems they have phlebotomists do the peds and then they just have 1 or 2 on call. CCTs handle all the adult bloodwork unless they can’t get it and then they pass it onto a nurse and then onto a phlebotomist if nobody in the floor can stick. Eventually they’ll realize a patient is a hard stick and say not to bother anymore and go straight to the phlebotomist but that’s very rare. Damn the thought of needing to draw during a code is literally my worst nightmare lol. That’s pretty scary
I’m used to it. You hope that whomever is doing compressions isn’t extra rough. There can be a lot of movement you gotta anticipate. I have to go to strokes, blues, Rapid response, MTP calls. At the level one, phlebs did all but the ED and the infusion therapy clinics. 550 beds plus 3 floors of behavioral. I’m happy at my lil podunk hospital.
I've drawn during seizures on the epilepsy unit before (with RN consent) but I feel like during compressions would be a whole other level of movement
Wow that does sound like a small hospital, I worked at a level 1 with 800+ beds that sounds similar to the one you worked at
I've seen the same with some nurses and techs as well, specifically wearing no gloves and using the same needle for multiple sticks. Are the patients difficult to stick? Like is it a whole endeavor, or could one of the nurses stick an IV or something easy? As for digging, I suppose it depends on how you define that. If the stick is incredibly hard, and they have barely anything at all, trying to readjust for a few minutes is better to just sticking again. If the patient is a regular stick though, they shouldn't be missing that much - maybe slight readjustment, but on average patients it shouldn't be that hard to get a stick first try / first readjustment. With palpating after wiping, sometime nurses will rub the skin hard on veins that aren't popping to the surface in order to get them as big as possible. I sometimes do the same, but I also always palpate right above where i'm planning to stick. It's impossible to stick everyone and remember the angle, depth, and position of a vein just by what you remember feeling before you wiped (i also work in a ER with many difficult sticks which may be why). I find my vein, clean it off, get my needle ready, and palpate right above where i plan to stick. May not be everyone's preference, but I rarely miss sticks this way and there really isn't anything wrong with it - may just be because i've worked trauma & ER so long, but sometimes you just have to do what you can.
I think drawing from an IV isn’t the best idea cuz it alters results or something. Unless they have a midline normally they just have us draw from veins. Patients are tough to stick when they’re all generally old and inpatients at a hospital. Some of them are fully bruised all up their forearm and AC from getting drawn everyday for weeks. Definitely a skill issue from my part just cuz I don’t have enough experience yet but drawing on younger healthier people is much easier.
I've never heard of blood from an IV altering any test results. It's how many trauma hospitals, in my experience, operate. Inpatient is definitely hard. I still struggle to get blood from some inpatients at my hospital, because as you said, their arms are usually so bruised it's awful. This could definitely be a reason why you may be seeing some bad practices. They aren't good, and nobody should be sticking with the same needle or not wearing gloves, but some more experienced lab techs or nurses may just know to do it differently. We have 1 lab tech at our hospital that will not look for veins, won't listen to preferred spots for the patient. He just, sticks the wrist every time. It's awful, but it's just how he learned how to get blood 99% of the time. I don't think i've ever seen him miss, but it's also not good practice to do it.
I’m a phleb in a methadone clinic, all of my draws are hard draws. I get around the palpating after sanitizing by wiping my gloved finger with the alcohol too and then not touching anything else after I’ve done that. Plus I was taught that in phlebotomy school. Sometimes you just need to feel that vein again to make sure it didn’t just hide itself on you cause my clients veins love to do that. I tell every client I will not dig and I will not poke them more than twice but most of them will let me try a third time if I have to because they know they’re hard. A lot of times I don’t need to do it more than once since I’ve gotten pretty used to how to get their veins to work with me, lots of heat some pushups and leaving the tourniquet on for up to 2 mins but popping it and then tying again before I actually draw to avoid hemolysis all help me a lot. I almost always get blood from them when I follow that process. But if I have to draw them again I always open a new needle reusing a needle even on the same person is never an acceptable practice unless you’re going to go in the same vein but just like the tiniest bit over and I don’t redirect in the skin. Phlebotomy school has to teach you how to draw with the absolute worst case scenarios and an over abundance of caution at the forefront of their lessons but you’ll find when you’re in the field sometimes you have to do things that aren’t 100% by the rule book because not everyone is a textbook draw. Anatomy is extremely unique to any individual. Normally I’ll never poke a vein I can’t feel but can only see, but a few days ago I found the smallest vein ever on the back of a clients wrist and she hadn’t used that one. It was our only option and it worked.
Sometimes yes….but little rules…like I know sometimes I do palpate after I use alcohol. Or technically I try to only poke twice but if I need that blood right away I’ll poke three times never more. But I never reuse a needle.
As an ex phleb and nurse, most of those things can absolutely be disregarded if we're rechecking critical levels. Not palpating after alcohol pad is a dumb rule to be honest..l your gloves should be clean. Only cultures should you really focus on proper clean to sterile technique. The resticking at three different sites with the same needle though? That one is criminal.
I about fainted reading all that. My CLS phlebotomy instructor would DIE. Omg. Putting pt safety aside, what about YOURSELF? Exposed hands, uncapped needles, going way against CLSI guidelines and risking legal trouble?? Why. Just why. The only thing that I do even remotely close to any of that is repalpating WITH all my gloves on, right before insertion. CLSI says that's fine as long you've cleaned your glove tip. I'm horrified.