Dear Center for Phlebotomy Education:

I'm trying to implement the new CLSI requirement that butterfly sets be secured throughout the procedure. My staff is arguing that it defeat the purpose of the winged set, which is to so that the patient can move a little without the user having to be perfectly synchronized with his/her movements and not lose the vein. They're saying they'd prefer to use a straight needle if they have to hold the winged set the whole time. They are also arguing that the requirement means every time you plan to use a winged set they will probably need another phlebotomist because they're not going to tape the winged set on a child's skin. Pulling off tape is almost as bad as the needle itself for many kids. They envision a second person to hold the device and the other person to fill multiple syringes. What should we do?

Our response: You're really getting some serious push back with this new provision, but we feel most of their objections are unfounded.

The intent of the passage in the standard is to prevent damage to the vein should it move when released, as many winged collection sets do. When a beveled needle moves within the vein, it slices everything it comes in contact with. It can also reposition itself in a manner that causes the vein to collapse onto the needle's opening. By securing the device, injury is prevented and draws are more likely to be successful. Keep in mind, the committee that wrote the standard included representatives from three major international manufacturers who make and market butterfly devices, and were in agreement with the passage.

Ask your staff this question: when they let go of the butterfly device, do they have control of the needle? Of course not. A good phlebotomist must be able to use both hands to perform the task of obtaining blood samples; one hand holds the winged collection device in place while the other one changes out tubes, just like they do when they use a straight needle.  

A syringe can be filled with one hand by holding the barrel in the palm of the hand and using the thumb to push the plunger up. Exchanging syringes might require assistance, but not your staff uses a tube holder adapter instead. Where a syringe is necessary because a large volume of blood is required, a larger syringe would negate the need for an exchange.

     We also disagree that removing tape can be more painful than the puncture itself. The tape need not be long, nor firmly pressed onto the skin. Where the standard requires "securing" the device, the purpose is to keep the needle in place instead of flopping around, as many butterfly sets do when released. Light pressure is all that's needed on the tape, making removal virtually painless.

Lastly, if your staff is willing to use a straight needle instead of a butterfly set so they don't have to secure the device, they should. Butterfly use should be minimized whenever possible. If another device can be used, it should be used. Not only does butterfly overuse waste healthcare resources because of their higher cost per unit, but they are associated with higher accidental needlestick rates when improperly activated and discarded.

 Got a challenging phlebotomy situation or work-related question? Email us your submission at [email protected] and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)