CAP Requirement TRM42290

If therapeutic phlebotomies are performed by blood bank staff, a qualified physician has

accepted medical responsibility for the procedures.

Evidence of Compliance:

1) Written policy defining medical director/designee responsibility for therapeutic phlebotomy

procedures AND

2) Patient records/charts documenting director/designee review.

Does this mean therapeutic phlebotomies performed by staff (who are NOT RNs) need to have their patient chart/record reviewed by the director/designee??

Is this because therapeutic phlebotomies are considered patient procedures. Meaning that Med Techs need additional review and supervision while RNs don't.

Can anyone clarify this for me??

Stephanie

I came across that as well when getting ready for my CAP/AABB inspection and had to change the therapeutic phlebotomy procedure. And one our pathologists reviews each one new doctors script, as well as, after each therapuetic phlebotomy is drawn. We didn't get cited and the CAP inspector didn't say anything about us doing to much work. She did look through our therapuetic records to make sure that they were signed off as being reviewed by one of the pathologists here.

And the reason why they have to I don't know for sure but I think it has to do with any adverse reactions that could occur from performing the procedure and techs, unlike RN's, are trained/certified to be able to help treat the reactions. If any adverse reaction happens here (which is rare) a pathologist needs to be notified immediatly so they can come in and assess what needs to be done.

At your facility does techs perform therapeutic phlebotomy procedures??

We had techs perform the procedure up until recently and only because the 2 techs that performed them either retired or left. Now our phlebtomists draw them so the pathologists still have to review each one.

I have 2 or 3 phlebotomists that have been deemed competent to perform these procedures, but then again the bb path has to review. Of course, we only do inpatients. Plus, we have only done 1 this year.

We've always had phlebotomist or tech performing thera phleb. We make our own flow sheet to track the vitals we take as well as Hgb or crit, as applicable. Also a place to keep the scrip from the ordering MD. BB med director reviews each BB chart after the fact. We do several/week. Never had a deficiency. The standard does not specifically state that RN need to do this. I think it applies more to the fact that in some hospitals, ther phleb is NOT performed in the BB, so is not covered by the CAP requirements.