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May 2011

Editor:
Fredrick L. Kiechle, MD, PhD

Question Q. Who is responsible for obtaining consent for transfusion and reviewing the transfusion reactions? I just attended an Ohio Hospital Association Joint Commission Resources in-service and was told that nursing can obtain consent and explain the issues. I was also told that nothing has been sent down from the Centers for Medicare and Medicaid Services, the Joint Commission, the AABB, or the CAP stating that a physician has to obtain the consent. Eighty-five percent of the people attending the in-service said nursing still obtains the consent from the patient. Yet our lab director says physicians have to get the consent.

A. I am unaware of any accreditation requirement that states that consent for transfusion must be obtained by a physician. However, the person who explains the risks, benefits, and alternatives would need to be versed in all of these as they pertain to a particular patient’s situation. Otherwise, the claim could be made that the patient had not been fully informed. Few nurses have the training to do this, unfortunately. (A few hospitals do have nurses who operate as transfusion safety officers and who would probably be able to answer most questions, but that is not the norm.) Therefore, I believe that an informed physician would be able to provide the best information for the patient, and the facility would be in the best position to defend its actions (and claim the consent was valid) if it were the physician who had obtained consent.

In most cases, transfusion is given (or contemplated) in the course of surgery or in intensive care or hematology situations. In my experience, all of these situations bring the physician in close contact with the patient or the family, allowing the necessary information to be conveyed without it taking substantial additional time.

James P. AuBuchon, MD
Puget Sound Blood Center
Seattle

Former advisor, CAP Transfusion
Medicine Resource Committee

Question Q. In the March 2011 issue of CAP TODAY, there is the article "Sticking points—how to handle difficult blood draws." There is reference to “Iimitations” on the site selection for a blood draw. As a pathologist and addiction medicine specialist, I have had many IV drug addicts who, having destroyed—“burned out”—all available veins in all extremities, resorted to skillful IV drug injection innumerable times into more central venous foci without complications. With the assistance of such patients, I have been able to obtain blood by “autovenipuncture (where the addict draws his own one-tube specimen) without a single complication. Do CLlA standards prohibit a blood draw from more central sites, such as external jugular, upper brachioaxillary, or femoral veins? If permitted, are such alternative/unorthodox sites permissible in an outpatient/clinic setting, such as a drug-treatment facility?

A. Whether a site is considered unacceptable, as the article “Sticking points” suggests, depends on the credentials of the health care professional performing the procedure and his or her scope of practice. The article’s context was the standard of care as it applies to phlebotomists and other non-physician health care professionals. While it would be difficult to argue that it is within the phlebotomist’s scope of practice to draw from an axillary jugular, etc., a physician may be working well within his or her realm to do so. Nevertheless, physicians cannot ignore the risk-management aspect of an “all veins are fair game” approach. Neither CLIA regulations nor the current CAP checklist make mention of acceptable versus unacceptable blood collection sites, but the venipuncture standard published by the Clinical and Laboratory Standards Institute does. It lists the acceptable sites as the antecubital, the back of the hand, and, with physician permission, ankles or lower extremities.1 According to the CAP’s phlebotomy manual, drawing from a site other than an arm “requires special instruction” and compliance with facility policy.2 Neither the CLSI’s standard nor the CAP’s guide lists the axillary jugular as an acceptable site, nor does either accommodate autovenipunctures. Both publications forbid draws to the underside of the wrist.

The CLSI standard contributes to, but does not by itself constitute, the prevailing standard of care for physicians performing venipunctures. Nevertheless, it is likely to be argued as such during legal proceedings should an injury be sustained during a draw from other sites. Therefore, regardless of the credentials of the individual performing the procedure, one must be prepared to defend the choice should an injury occur.

Having the drug addict draw his or her own sample, however, is another matter. While it is true addicts intimately know every entry point into their circulatory system, they don’t know the risks of the procedure or how to prevent injury. Should an addict be allowed to perform an autovenipuncture and accidentally impale a nerve, perforate an artery, or cause a hematoma that leads to compression nerve injury, the complications can be permanently disabling.3 Should a legal remedy be pursued, one would have to explain why the procedure was handed over to someone who was not properly trained. Defendants may be hard-pressed to provide a precedent that supports patients performing their own medical procedures, especially those who could be under the influence at the time.

Although IV drug abusers subject themselves to this risk routinely, when physicians play a role they open themselves up to liability should the patient claim an injury. In a society where there is no shortage of professional victims, litigation, however frivolous, could be exploited. While an autovenipuncture may be considered a solution for the physician, the potential for it to be considered an opportunity for the addict cannot be discounted.

References

1. CLSI. Procedures for the collection of diagnostic blood specimens by venipuncture; approved standard—sixth edition. CLSI document H3-A6. Wayne, Pa.: Clinical and Laboratory Standards Institute; 2007.

2. So You’re Going to Collect a Blood Specimen: An Introduction to Phlebotomy. 13th ed. Northfield, Ill.: College of American Pathologists; 2010.

3. Ernst D. Applied Phlebotomy. Philadelphia, Pa.: Lippincott Williams and Wilkins; 2005.

Dennis J. Ernst, MT(ASCP)
Director, Center for Phlebotomy Education Inc.
Corydon, Ind.


Dr. Kiechle is medical director of clinical pathology, Memorial Healthcare, Hollywood, Fla.