An examination of needlestick injury rates, hepatitis B vaccination uptake and instruction on 'sharps' technique among medical students.

A 12-question survey designed to examine venepuncture techniques and instruction and uptake of hepatitis B vaccination was completed by 172 of the 275 medical students to whom it was distributed (a response rate of 62.5%). Seventy-five injuries were reported, at an average of 0.3 per student per year. Of the respondents, 63% resheathed needles after use, a practice frequently cited as a cause of needlestick injury. However, in this sample resheathing was not significantly associated with a higher or lower injury rate (chi 2 = 2.07, P > 0.1). Of the respondents from the most recent intake, only 20 out of 57 had completed a course of hepatitis B vaccinations prior to the commencement of venepuncture duties. There was almost universal ignorance concerning the correct course of action following 'sharps' injury. Recommendations are made concerning hepatitis B vaccination and teaching strategies for medical students.

Phlebotomy in inoculation risk patients: a questionnaire survey of knowledge and practices of hospital doctors in Liverpool.

To assess the knowledge of hospital doctors about patients at increased risk of infection with human immunodeficiency virus (HIV) or hepatitis B virus, and the precautions they took during phlebotomy in such patients, an anonymous postal questionnaire was sent to all 307 hospital doctors working at two District General Hospitals in Liverpool, UK. Two hundred and thirty-eight (77.5%) of the questionnaires were returned. More than 90% of respondents considered a history of male homosexuality, intravenous drug abuse, prostitution or a child of a prostitute to indicate an inoculation risk. There was uncertainty about a previous prison sentence in the 1980s, residence in a home for the mentally handicapped, previous residence in the tropics and hospital treatment in the tropics. Thirty-eight percent of doctors would never enquire about sexual preference, 54.1% about a previous prison sentence and 15.7% about intravenous drug abuse in their clinical history. Although 97.4% of doctors would sometimes or always wear gloves during phlebotomy of an inoculation risk patient, 25.5% always resheathed the needle after phlebotomy and 20.8% would never take the sharps box to the patient. More effort is required to identify accurately inoculation risk patients and greater care is needed in phlebotomy techniques.

Phlebotomists' safety practices. A College of American Pathologists Q-Probes study of 683 institutions.

We report on phlebotomists' safety practices in 683 institutions participating in the College of American Pathologists Q-Probes program. Participants inspected 38,357 phlebotomy tourniquets and 31,952 blood collection tube holders in use and found 2098 tourniquets and 2966 holders visibly contaminated with blood. In 67.8% of the institutions, at least one tourniquet or collection tube holder was contaminated. Needlestick injuries reported by phlebotomists during 1990 through 1992 were analyzed from approximately 11 million inpatient venipuncture procedures. These injuries ranged between 9.2 and 9.8 needlesticks per 100,000 venipunctures per year. Over 99% of the participants had a policy preventing recapping of needles, 45% discarded tourniquets when contaminated with blood, and 3.3% routinely assigned tourniquets to specific patients. Between 1990 and 1992, increasing frequencies of phlebotomists using gloves, replacing gloves between each inpatient phlebotomy, and handwashing after degloving were found. We cite the lack of compliance of handwashing between glove changes as suggesting need for regulatory rereview.

Inpatient phlebotomy practices. A College of American Pathologists Q-Probes quality improvement study of 2,351,643 phlebotomy requests.

We report outcomes of requests for inpatient phlebotomy procedures from 683 institutions participating in the College of American Pathologists Q-Probes programs. Of the 2,351,643 phlebotomy requests analyzed, 93.2% of venipunctures were successful, 1.6% were unsuccessful, 0.4% were partially successful, and 4.9% were not attempted by the assigned phlebotomist. Administrative inefficiencies prevented the assigned phlebotomist from attempting these venipunctures of which the most frequent reasons were patient unavailability (1.4%), patient transferred or discharged (0.9%), followed by the specimen already collected by someone else (0.7%). These results suggest that performance improvement of phlebotomy services, in general, would achieve the greatest gains by focusing attention to specific processes associated with administrative inefficiencies identified, rather than phlebotomists' technical skills.

Emergency department stat test turnaround times. A College of American Pathologists' Q-Probes study for potassium and hemoglobin.

We report aggregate turnaround times (TATs) from phlebotomy to result reporting of emergency department patients' hemoglobin and potassium results for 722 subscribers to the College of American Pathologists Q-Probes program. Approximately 40,000 specimens were obtained for each analyte. Median interinstitutional TAT time of 25 minutes for hemoglobin and 36 minutes for potassium varied little by shift, weekdays, or weekends. The type of personnel collecting the specimen and the method of specimen transport were the most important factors affecting TATs. Specimen transit times accounted for approximately one third of the total TATs, but when couriers transported hemoglobin specimens, the median transit time was equivalent to the median intralaboratory test TAT. The influence of various measures used to improve test transit and TATs is presented.

Laboratory phlebotomy. College of American Pathologists Q-Probe study of patient satisfaction and complications in 23,783 patients.

Outpatients from 630 institutions participated in a phlebotomy module of Q-Probes, a quality assurance program of the College of American Pathologists, Northfield, Ill. This module assessed patient outcome measurements of complications, discomfort, and satisfaction with the phlebotomy procedure. Of the 29,700 ostensibly healthy individuals registered, 80.1% returned postcards containing measurements and assessments they made about the procedure and information recorded by the phlebotomist. The median time required for phlebotomy was 6 minutes, with 25% of patients requiring less than 5 minutes and 10% more than 21 minutes for completion of the procedure. The average number of phlebotomy attempts per patient was 1.03, with 95 patients (0.4%) experiencing three to 11 attempts. Ecchymoses occurred in 4048 (16.6%) attempts, with the median size of ecchymosis being 15.1 mm. On the average, an outstanding employee was identified by patients 46.6% of the time. The discomfort caused by the needle puncture was more than expected by 35.3% of patients. Although 98.6% of the patients were satisfied, 336 patients were dissatisfied with the procedure. We conclude that the technical skills of phlebotomists and patient satisfaction with phlebotomy are outstanding, but that patient discomfort from the procedure needs to be minimized.

Accuracy of fingerstick glucose values in shock patients.

BACKGROUND: Fingerstick blood glucose measurement has become widespread in both hospital and prehospital settings. OBJECTIVE: To determine the accuracy of fingerstick blood glucose measurement in patients with poor peripheral perfusion (shock). METHOD: Results obtained during three methods of glucose analysis (fingerstick blood glucose measurement; bedside and laboratory glucose analysis) were examined prospectively on 38 patients from inpatient medical and surgical critical care units or the emergency department of a large tertiary care referral center. RESULTS: The means of the three glucose measurements were significantly different. Univariate analysis of the mean laboratory glucose value versus the mean fingerstick glucose value was significantly different. The mean venipuncture glucose measured by the bedside glucose meter versus the mean venous laboratory glucose was not significantly different. CONCLUSION: These results suggest that fingerstick blood samples should not be used for bedside glucose analysis in patients who may have inadequate tissue perfusion.

Diagnosis, treatment, and nursing management of the patient with hemochromatosis.

Hemochromatosis results when the body's iron stores progressively increase. Surplus iron stored in body tissues leads to organ dysfunction and death. Warnings that elevated iron stores increase the risk of cancer development necessitate a review of this condition. Two types of hemochromatosis, hereditary and secondary, are diagnosed in today's hematology-oncology practices. Distinguishing the differences with respect to etiology and management is essential to the risk assessment and long-term nursing management of this patient population.

Reducing bruising after venepuncture.

Bruising after venepuncture is undesirable. To verify an apparent increase in bruising after introducing a new venepuncture system in a small district general hospital and to improve the venepuncture service two prospective audits of the incidence and severity of bruising after venepuncture were performed in two groups of 100 consecutive inpatients undergoing venepuncture by phlebotomists. In the first audit bruising was detected in 45 patients, of whom 34(76%) had bruises > 100 mm2 in area. After modification of the technique, whereby the phlebotomists ensured that haemostasis had been attained before leaving the patient, bruising was significantly reduced, occurring in 25 patients only 9 of whom (36%) had bruises > 100mm2 in area (both p < 0.01) in the second audit. Monitoring of standards and simple modification of technique resulted in significant reduction in incidence and severity of bruising, improving the quality of the venepuncture service.

Benefits of HIV testing during military exercises.

During U.S. Marine Corps Reserve summer 2-week active duty for training periods, 6,482 people were tested for human immunodeficiency virus (HIV). Testing at an initial exercise, Solar Flare, trained a cadre of contact teams to, in turn, train other personnel in phlebotomy and the HIV protocol at three other exercises (141 Navy Reserve and Inspector-Instructor hospital corpsmen were trained). Corpsmen could be trained with an indoctrination of 120 minutes and a mean of 15 phlebotomies. After 50 phlebotomies, the administration, identification, and labeling process plus phlebotomy could be completed in 90 seconds. HIV testing during military exercises is both good for training and cost-effective.

Addendum: Safety Standards for Gua sha (press-stroking) and Ba guan (cupping).

Our previous article Safety Standards for Gua sha (press-stroking) and Baguan (cupping) discussed the risk of transfer of blood-borne pathogens with Gua sha and Ba guan, identified Gua sha and Ba guan 'instrument criticality' as semi-critical and offered recommendations for safe practice based on hospital disinfection standards. Based on the article's feedback, we feel the need to clarify that Gua sha and Ba guan instruments, if intended for reuse, must undergo high level disinfection (HLD) or, in the case of 'wet-cupping', sterilization. We update our recommendations to be amenable to both private practice and education settings.

[The effectivity of long-term treatment of porphyria cutanea tarda from a hepatological viewpoint]. / Untersuchungen zur Effektivität der Langzeitbehandlung der Porphyria cutanea tarda aus hepatologischer Sicht.

34 Patients with an ascertained porphyria cutanea tarda who underwent a long-term therapy a comprehensive internal and hepatological diagnosis was made. In these cases for the first time the estimation of the intrahepatic distribution of enzymes and its comparison with the serum enzymes were also performed. The liver histology allowed a division of our patients into three groups, in which cases the reactive hepatitides prevailed and a conspicuously large proportion of normal histological findings were present. The comparison of all data got with the literature made the conclusion possible that the phlebotomy therapy as well as the care in a special dispensary for years lead to very favourable results on liver and skin.

Effect of educational program on compliance with glove use in a pediatric emergency department.

OBJECTIVE: To investigate the effect of an educational program on compliance with glove use in a pediatric emergency department. DESIGN: Without their knowledge, participants were observed for routine use of gloves during vascular access procedures before and after an educational program. Participants with up to 3 years' vascular access experience were defined as less experienced and those with 4 or more years' experience were defined as more experienced. Their success rates performing vascular access procedures with and without wearing gloves were also monitored. SETTING: Inner-city pediatric hospital emergency department. PARTICIPANTS: Twenty-three emergency department registered nurses. INTERVENTIONS: A 30-minute lecture with slides, written materials, and posters addressing the reasons and need for universal precautions, and recommended methods of barrier precautions to prevent skin and mucous membrane exposure when handling sharp instruments. MEASUREMENTS/MAIN RESULTS: For the less experienced registered nurses, the compliance rate before the educational program was 70% and remained at about 93% afterward. For the more experienced registered nurses, the compliance rate before the program was only 15%. After the program, this compliance rate rose to 93%, but declined to only 50% by the fifth month. The registered nurses' success rate on the first attempt at vascular access while wearing gloves was 75% compared with 70% without gloves. CONCLUSION: Educational programs can result in a clinically significant increase in glove use by pediatric emergency department registered nurses. Long-term improvement was less pronounced for the group of more experienced registered nurses. We also observed that glove use does not appear to interfere with the proficient performance of vascular access procedures.