Phlebotomy Handbook
Blood Specimen Collection from Basic to Advanced
CHAPTER
Phlebotomy Practice and Quality Assessment
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Chapter Objectives
1. 2. 3. 4. 5. 6. 7. Define phlebotomy and identify health professionals who perform phlebotomy procedures. Identify the importance of phlebotomy procedures to the overall care of the patient. List professional competencies for phlebotomists and key elements of a performance assessment. List members of a health care team who interact with phlebotomists. Describe the roles of clinical laboratory personnel and common laboratory departments/sections. Describe health care settings in which phlebotomy services are routinely performed. Explain components of professionalism and desired character traits for phlebotomists.
8.
9.
Describe coping skills that are used for stress in the workplace.
List the basic tools used in quality improvement activities and give examples of how a phlebotomist can participate in quality improvement activities.
10. Define the difference between quality improvement and quality control.
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Phlebotomy Practice and Definition
Clinical decisions are based on:
Standards of practice Diagnostic testing (laboratory tests, x-rays, etc.) Patients history Observation of signs and symptoms
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Phlebotomy Practice and Definition
Clinical laboratory test results
Are performed primarily on blood specimens Give an indication of abnormalities inside the body Help health providers in clinical decision making
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Phlebotomy Practice and Definition
Definition of Phlebotomy
Derived from the Greek words, phlebo, which relates to veins, and tomy, which relates to cutting Synonomous words are venesection or venisection. Definition can be summarized as the incision of a vein for blood letting.
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Phlebotomy Practice and Definition
How are laboratory test results used in clinical decisions?
Diagnosticare there abnormalities or medical conditions affecting the patient Therapeuticis the correct treatment or therapy being utilized Monitoringis the treatment or therapy effective
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Phlebotomy Practice and Definition
Phlebotomy practice
Ranges in scope, depth of detail Can involve clinical, technical, or clerical functions Settings range from inside laboratory to hospital, clinics, or home health care
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Health Care Settings and Health Care Teams
Know the members of the health care team
Learn the specialty and sub-specialty areas of health care and medicine Learn about other health care professionals and their roles and responsibilities Learn about all areas of the clinical laboratory and their functions
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Table 1-1
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Table 1-1 (cont)
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Table 1-1 (cont)
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Table 1-1 (cont)
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Table 1-1 (cont)
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Table 1-1 (cont)
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Health Care Settings and Health Care Teams
Become a professional and mature member of the health care team
Understand the mission of the organization, goals of the group, or project objectives Know skills of team dynamicsactive listening, setting group norms, etc. Understand relevance and commitment to team goals Show reliability and dependability in your work Actively and respectfully participate in decisions Learn to be flexible Manage conflicts in a constructive manner Contribute to the cohesion of the team Contribute to problem solving strategies Support and encourage other team members
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
The Clinical Laboratory and Specimen Collection Services
Clinical pathology: blood and other types of body fluids (and some tissues) are analyzed.
Examples: Blood, urine, sputum, synovial fluid, CSF, skin scrapings
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
The Clinical Laboratory and Specimen Collection Services
Anatomical pathology: autopsies are performed, histologic and cytologic procedures are performed on tissues and fluid specimens, surgical biopsies are analyzed.
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Figure 1-2 The Clinical Laboratorys Workflow Pathway
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
The Clinical Laboratory and Specimen Collection Services
Agencies that oversee clinical laboratories
U.S. Food and Drug Administration (FDA) Centers for Medicare and Medicaid Services (CMS)
Clinical Laboratory Improvement Amendments (CLIA)
Occupational Safety and Health Administration (OSHA) U.S. Department of Transportation (DOT) The Joint Commission College of American Pathologists (CAP) International Association of Blood Banks (IABB) Other credentialing agencies are involved in certifying and/or licensing laboratory personnel.
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
The Clinical Laboratory and Specimen Collection Services
Clinical Laboratory Departments
Administrative Office Supervisory/management personnel Physicians or scientists overseeing specific areas of the clinical laboratory Technical experts and staff perform tests and report results
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
The Clinical Laboratory and Specimen Collection Services
Clinical Laboratory Personnel
Pathologists and/or PhD specialists Administrative/Management staff Technical supervisors or specialists Clinical Laboratory Scientists or Medical Technologists Medical Technicians or Clinical Laboratory Technicians Medical Assistants Phlebotomists Other personnel involved in the clinical laboratory-laboratory information operators/programmers, clerical staff, quality management staff, safety and infection control staff, biomedical equipment specialists, etc.
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Competencies, Certification, and Professionalism for Phlebotomists
Phlebotomy Education & Certification
High school diploma or equivalent Length of training ranges from a few weeks to months Pass a national certification examination Attend continuing education (CE) programs
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Competencies, Certification, and Professionalism for Phlebotomists
Clinical Duties for Phlebotomists
Identify patients correctly Assess patients prior to specimen collection procedures Prepare patients accordingly Perform specimen collection procedures Collect blood specimens into the correct containers/tubes Label blood specimen tubes at the bedside Assess the degree of discomfort, pain, or bleeding Assess the patient after the specimen collection procedure
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Competencies, Certification, and Professionalism for Phlebotomists
Technical Duties for Phlebotomists
Manipulate small objects, tubes, needles Select and use appropriate equipment Perform quality control functions Transport specimens correctly Prepare/process the specimen for testing/analysis Assist in laboratory testing procedures as needed
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Competencies, Certification, and Professionalism for Phlebotomists
Clerical duties for phlebotomists
Print/distribute laboratory requisitions and/or reports Answer the telephone Answer all queries appropriately Demonstrate courtesy in all patient encounters Respect privacy and confidentiality
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Professionalism for Phlebotomists
Respect
Confidentiality Coworkers Courteous behaviors Tolerance of differences Effective communication Service Shift focus from oneself to others Commitment to ones job duties Support Follow organizational policies/procedures Maintain clean work space Report errors or damaged equipment/supplies Respectfully disagree Growth Learn more about your job Learn more about other aspects of your organization
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Professionalism for Phlebotomists
Professional Organizations for Phlebotomists
American Society for Clinical Pathology National Phlebotomy Association American Society for Clinical Laboratory Science National Healthcareer Association Many others as well
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Table 1-3
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Competencies, Certification, and Professionalism for Phlebotomists
Ethical Standards for Phlebotomists
Do no harm intentionally Perform according to sound technical ability and good judgment Respect patients rights
Confidentiality and privacy Right to know about their treatment Right to refuse treatment
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Competencies, Certification, and Professionalism for Phlebotomists
Character Traits for Phlebotomists
Sincerity and compassion Emotional stability and maturity Accountability for doing things right Dedication to high standards of performance and precision Respect for patients dignity, privacy, confidentiality, and the right to know Propensity for cleanliness Pride, satisfaction, and self-fulfillment in the job Working with team members Enjoy communicating with patients
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Competencies, Certification, and Professionalism for Phlebotomists
Appearance, Grooming, and Physical Fitness
Posture Grooming and personal hygiene Personal protective equipment (PPE) Dress code
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Competencies, Certification, and Professionalism for Phlebotomists
Tips for Dealing with Stress
Find time for privacy and relaxation Associate with gentle people Seek humor Exercise (target at least 30 min/day) Nutrition and vitamins Hobbies and social activities Balanced schedule Journal writing Reading Avoid harmful habits (smoking, alcohol or drug abuse) Seek assistance when needed
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Perceptions of Quality
CLSIdegree to which a set of inherent characteristics fulfills requirements Othersexcellence, high standards, or superiority Categories of qualityscientific or technical and nontechnical or interpersonal
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Quality in health care uses three major concepts
Efficacythe health care services provided have a positive impact on the patients health, that is, the patient improves or gets well. Appropriatenessprocedures performed on the patient are the correct ones for that particular condition or illness. Caring functionsservices provided to the patient are available, timely, effective, safe, efficient, respectful, and sensitive to the patients needs.
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Stakeholders/Customers
External stakeholders are individuals or groups outside the organization. Internal stakeholders are individuals or groups within a health care organization itself.
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Quality Initiatives
Standards of practiceCLSI Educational programsNAACLS Certification and licensureASCP, NPA, etc Advocacy groupsASCP, ASCLS Code of ethics Job competencies Continuing education
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
QI Models
Different approaches to quality management and assessment Six Sigma: data-driven; define, measure, analyze, improve, control (DMAIC) Lean Six Sigma: also incorporates speed, efficiency, quick action CLSI: 12 Quality System Essentials (QSE)
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Quality improvement efforts involve
Health care workers technique Patient identification procedures Waiting times, turn around times Complications due to blood collection
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Quality improvement efforts might focus on
Multiple sticks on the same patient Duplicate test orders Customer satisfaction
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Negative impacts (usually preventable) Misidentification of a patient Hospital-acquired infections due to poor cleansing techniques Poor venipuncture technique that causes pain, nerve damage Lengthy waiting time, rude behavior, or messy work sites
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Tools for Quality Performance Assessment
Reviewing the analytic and nonanalytic parts of the laboratory
Check sheets Flow-charts or process maps Run charts Statistical tests
Analytically, clinical laboratory scientists and technicians use data collection to ensure
Test sensitivity Specificity Precision and accuracy
Nonanalytic data can be used to assess the timeliness of responses to
Requests Turnaround time for reporting test results Effective communication
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Figure 1-5 Flow Chart
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Tools for Quality Performance Assessment
Pareto charts:
Bar charts that show frequency of problematic events
Pareto Principle:
80% of the trouble comes from 20% of the problems
Figure 1-6 Pareto Chart
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Tools for Quality Performance Assessment
Cause and effect diagrams Ishikawa diagram Demonstrates the factors that contribute to a specific outcome Plan-Do-Check-Act Cycle (PDCA) Line graphs, histograms, scatter diagrams Brainstorming
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Figure 1-7 Cause-and-Effect Diagram
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Important Factors Affecting Quality in Specimen Collection Services
Phases of the Laboratory Testing Process
Preexamination Examination Postexamination
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Figure 1-8 Laboratory Testing Cycle: Preexamination to Examination to Postexamination
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Basic Requirements for a Quality Specimen
Use standard precautions Identify and assess the patient correctly Use correct anticoagulants and preservatives Label, handle, and transport the specimens appropriately and in a timely manner Correct timing of venipunctures, when necessary Correct processing of specimens No more than 2 sticks
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Quality Control: A Key Component of Laboratory Quality Assessment
QC is a part of everyday laboratory practice QC measures make the testing process more accurate and precise
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
QC measures set the parameters for analytical procedures
Making sure that test results reflect what they are supposed to measure Making sure that test results are reproduced time after time Setting performance standards and acceptable ranges for each test or procedure Differentiating which result is OK to report from and which is not OK to report from
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Quality Improvement and Assessment
Examples of QC
Temperature checks of specimen refrigerators Calibrations for centrifuges Positive and negative controls for screening tests Monitoring expiration dates for venipuncture tubes
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Future Trends in Phlebotomy Practice
Standardization and Globalization (ISO) Electronic Medical Records (EMR) Smaller, Faster Laboratory Testing (nanotechnology) Direct Access Testing (DAT) or Direct to Customer (DTC) Education/Certification
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
Assignment
Read Chapter One of the textbook if you have not done so already. Complete the Chapter One assignment before the start of class on Thursday.
Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced, Eighth Edition Diana Garza, Kathleen Becan-McBride
Copyright 2010 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.
