An e-Network member wrote that there is a small donor center in the hospital's laboratory, and annually about 300-350 units of autologous blood and about 40-50 units of directed donor blood are collected. As an infection control issue they have instructed personnel to wear gloves when collecting blood from these donors. Some of the personnel object to wearing gloves when drawing these donors because they say that it is not necessary at blood donor centers. The inquiring blood banker has enforced the glove wearing policy but wonders what others do during collection of autologous donors within the hospital laboratory setting.

Below are some replies that were submitted in response to the above question. It is quite interesting to read the difference in requirements to wear gloves in hospitals versus community donor centers.

Replies 1- 6 are from Community Blood Donor Centers.

1. The director of a Central California Community Blood Donor Collection Center indicated that at his facility it is optional to wear gloves when collecting units of blood from allogeneic donors. However, when drawing blood from autologous "donors" (who are really patients) his staff is required to wear gloves. Since directed units are also drawn in their "Autologous Center", gloves are worn for directed donors for the sake of uniformity, not medical necessity.

2. The director of another California Community Blood Donor Collection Center (East of Los Angeles) reported that at his center they require their staff to wear gloves only when a patient is involved (and auto donors are patients). Allogeneic and directed donors are not patients and glove use is optional.

3. The medical director of an American Red Cross Blood Service in Northern California reported that their staff is required to use gloves and lab coats for Hgb/hct determinations, phlebotomy, replacing bandages over rebleeds, handling all blood bags (tested or untested), handling all blood samples (stoppered and unstoppered), uncapping or recapping sample tubes. For this last activity face protection is also required, while for the others it is optional. She adds that since they started requiring collection staff to wear gloves to perform phlebotomy, etc. on allogeneic donors it has made little difference in the volume and severity of the complaints we get from the public. In the beginning it was folks aghast that they were not using universal precautions regardless of the fact that the FDA ruled that in this case it was not necessary. Now she reports that they get irate letters about the fact that intact, non-contaminated gloves are not changed between each donor contact.

4. The medical director of an American Red Cross Blood Service in Southern California reports that his facility follows the American Red Cross Blood Services Directive 19.203T, "Exposure Control Plan" which states the minimum acceptable personal protective equipment (PPE) for the various tasks performed by ARC staff. For phlebotomy (all venipunctures, including needle insertion and removal, needle adjustments, bandage application, and donor sample tube collection), the minimum PPE required are gloves and a lab coat or equivalent. Minimum PPE requirements apply for the phlebotomy of all donors and patients including patients known to test positive for a blood borne pathogen. Face protection is listed as optional PPE for phlebotomy tasks.

5. Another blood bank physician reports that at his community blood donor center (also in California) glove wearing is optional (i.e., at the discretion of the employee) in MOST instances involving volunteer blood donors. Following are the only times when gloves absolutely must be worn:

• If the needle has penetrated the skin, and readjustment is necessary, palpation of the skin above the needle may be performed with a gloved finger, only;
• During the "tear down" of apheresis machines;
• During urinalysis procedures;
• When collecting samples of any kind not related to allogeneic blood donations (including when collecting marrow samples);
• When dispensing plasma into a refractometer for total protein determinations;
• When performing therapeutic and autologous phlebotomies;
• When the employee has cuts, scratches, or other breaks of his/her skin;
• During training.

6. At a community donor center in Cincinnati the staff are required to wear gloves when drawing autologous and "therapeutic" donors, irrespective of the setting. (hospital, blood center etc.) Staff are not required to wear gloves while drawing allogeneic or directed donors. If a donor asks us to wear gloves, the S.O.P. mandates that we do so. Otherwise it is an individual choice.

Replies 7 - 13 are from Hospital-based blood donor collection programs.

7. A blood banker at a large community hospital near West Hollywood reported that at her donor program they must follow hospital safety rules, which require gloves to be worn whenever blood is collected, be it from patients or donors.

8. A blood bank physician in a Houston hospital reports that it seems that if one were to accept the philosophy behind requiring all diagnostic phlebotomists to wear gloves, the same logic would apply in formulating policy for personnel who perform phlebotomies on donors -- autologous, directed, and even random. He continues saying that although we generally assume that screened donors have a lower prevalence of blood borne infections than that of hospitalized patients, the phlebotomist has no way of knowing the infectious status of a given donor prior to processing of the unit. Also, keep in mind that the rate of non-penetrative transcutaneous transmission of blood borne pathogens to barehanded phlebotomists, even in the setting of high risk patient populations, was vanishingly low prior to the wide acceptance of "universal precautions" policies. In all cases, the risk is very low, but the same considerations apply to both blood donations and diagnostic phlebotomy. Therefore, the same safety rules should apply to both.

9. A very talented blood bank physician who once lived in Los Angeles, but who now lives in Alabama commented that in a hospital environment it is expected that all employees will follow universal precautions. To her knowledge universal precautions do not differentiate between auto-/allo-/directed- donors. It seems to her that all the above donor categories should be treated equally since at the time of donation no one knows the testing results, which are run after the time of donation. Additionally she comments that we do not want to inadvertently risk infecting a unit from our own flora. She finishes saying that she starts apheresis procedures frequently on otherwise healthy outpatients (i.e. CIDP) and would not think of leaving her gloves aside. There is always a risk of bleeding at the site where she is placing the access and return lines.

10. A blood banker near Bethesda commented that in his opinion the policy of the California blood bank director (shown above in reply #1) is sound. In practice, although wearing gloves is optional for routine blood donations; no staff members choose to wear them. The risk is minuscule and the gloves are a nuisance, especially if one phlebotomist is tending to more than one donor. The responding blood banker reports that they have very few directed donors, but these are handled like routine donors. Autologous donors are treated like patients and they wear gloves in that situation. They, perhaps uniquely, draw blood from research donors and these are handled with gloves since they may be paid and may have been rejected as regular donors. The blood banker finishes by saying the when he works with his staff, he handles them with kid gloves.

11. A blood physician at a county hospital in Southern California commented that this topic should not be a controversy. Since when are universal precautions optional? Until tested, all blood should, as a matter of routine, be considered hazardous and infectious. Even after testing it should be treated with utmost caution. The idea behind universal precautions is that it is not possible to tell which patients or donors are "safe" and which are not. If we treat all of them the same we can keep our employees safer. In addition, she believe that the autologous donors would be more "high risk" due to the brevity of the questionnaire and would be the very population NOT to make glove wearing optional.

12. Another hospital blood banker wrote that they wear gloves to draw all patients. The standard for infection control is that gloves are worn to draw all patients regardless of what they are being drawn for. The theory is how can you tell one person is infectious and another is "clean"

13. A Boston blood banker (who has a very sunny disposition) said that at his place he has faced this issue before. He was surprised to learn that the DONORS preferred that the staff wear gloves ... after all the donors are the folks who get a "break" in the skin ... and the donors felt more protected if the staff wore gloves! They use gloves for all categories of phlebotomy.

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator