Garbage In; Garbage Out, Part VIII: Improper Storage & Add-on Requests

This is the final installment of a series exploring the many ways those who draw and process specimens can unknowingly alter test results converting them into garbage for the physician. No device or individual will ever be able to extract an accurate value from a specimen drawn, transported, handled, processed, or stored incorrectly. Nor is any laboratory able to identify and reject specimens that don’t reflect the patient’s true status. Last month we explored how inadequate centrifugation can alter test results. (To access this and other archived issues, visit www.phlebotomy.com/PTSTAT.html.) This month we will conclude with improper storage of specimens and adding tests that may not be appropriate to previously collected specimens.

Effects of light
Some analytes deteriorate when exposed to light. The most commonly encountered light-sensitive analyte is bilirubin, which has been shown to undergo up to a 50% reduction in concentration when exposed to light for one hour.(1) Other light-sensitive analytes include carotene, RBC folate, and vitamin B12. For newborns, bilirubin levels can be preserved in amber, light-blocking capillary collection tubes. For light-sensitive specimens drawn by venipuncture, protection can be accomplished by wrapping the specimen in aluminum foil or by encasing the tube in a light-tight canister immediately after collection. 

Delays in processing
As soon as blood is removed from the body, significant and irreversible changes begin to take place.(2,3,4)  Additives manufacturers place in tubes are designed to ensure the result reported is as close as technology can get to the concentration of that analyte in the patient, but as long as serum or plasma remain in contact with red blood cells, some analytes will change in their concentration. Refrigeration accelerates the change.

To prevent the affect cell contact has on serum or plasma, all tubes for chemistry testing should be centrifuged as soon as possible after collection, and the serum/plasma removed. Some analytes are stable in contact with the cells for up to 72 hours at room temperature. However, many analytes are not, including albumin, ALT, AST, calcium (ionized), chloride, CO2, creatinine, folate, glucose, HDL cholesterol, iron, LDH, potassium, phosphorous, total protein, and vitamin B12.(2,4,5) Once the serum/plasma is removed, it should be kept at room temperature no longer than eight hours without refrigeration and no longer than 48 hours without freezing in order to preserve the concentration of the analytes.(2)

EDTA tubes for cell counts can be refrigerated up to 24 hours, however automated differential counts are much less stable and dependent upon the instrument.(6,7) For sed rates, unrefrigerated EDTA specimens should be tested within four hours, or 12 hours if the specimens are refrigerated.(8) Reticulocyte counts drawn into EDTA tubes are considered stable for up to six hours at room temperature, 72 hours if kept refrigerated.(9)
      For coagulation studies, sodium citrate tubes should not be placed on ice if routine coagulation studies are to be performed.(3) Activated partial thromboplastin times (aPTT) should be tested within four hours. However, if the patient is on heparin the plasma must be removed from the cells within one hour and tested within four hours. The only way for aPTT results to be accurate beyond four hours is for the tube to be centrifuged and the plasma removed from the cells and frozen until testing can occur. Unless separated and frozen, aPTT results obtained more than four hours after collection cannot be considered reliable. Protimes are stable for up to 24 hours at room temperature, even uncentrifuged.

When adding is subtracting
Laboratory personnel are often asked to add certain tests to blood already collected so that the patient doesn’t have to undergo an additional venipuncture. However, not all requests can be honored, especially if the test being added is for an analyte that has already deteriorated. The following is a partial list of add-on requests that should not be honored:

• Retics on specimens kept at room temperature >6 hours;
• Retics on refrigerated specimens >72 hours old;
• Sed rates on EDTA specimens kept at room temperature >4 hours;
• Sed rates on refrigerated EDTA specimens >12 hours old;
• Protimes on specimens >24 hours old;
• aPTTs on specimens >4 hours old unless plasma is separated and frozen;
• aPTTs on specimens >1 hour old from heparinized patients unless plasma is separated and frozen;
• Potassiums on uncentrifuged specimens >2 hours old.

Adding these tests to an already-drawn specimen without assessing the analyte’s stability can subtract from the quality of care the patient receives. Make sure you recollect specimens for those add-on tests that won’t be accurate if performed on specimens drawn earlier in the day... or week.

Whenever you put garbage into a testing instrument, you get garbage out in the form of test results that don’t really tell the true story about the patient’s health status. Because physicians rely on laboratory test results for 70 percent of the objective information they receive on their patient’s health status, shouldn’t you make sure garbage stays out of the tubes you collect and send to the lab? By continuing your quest for knowledge on specimen collection errors and implementing what you’ve learned in this series of articles, you can prevent mistakes before they happen.

Whether you draw blood specimens, process them, or both, your role in patient care is critical. Keeping garbage specimens out of the lab is your gift to every patient whose tubes of blood pass through your hands.

References:

1. Kiechle F. Q&A response. Cap Today. December, 1998.
2. NCCLS. Procedures for the Handling and Processing of Blood Specimens.  Approved Standard, H18-A3 Wayne, PA; 2004.
3. CLSI. Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays and Molecular Hemostasis Assays; Approved Guideline, Fifth Edition. H21-A5: Wayne, PA;2008.
4. Narayanan S. The preanalytic phase an important component of laboratory testing. Am J Clin Pathol. 2000;113:429-452.
5. Becan-McBride K. (ed) Preanalytical Phase and Important Requisite of Laboratory Testing. Advance for Med. Lab. Prof. Sept. 28,1998:12-17.
6. Young D. Effects of Preanalytical Variables on Clinical Laboratory Tests. AACC Press. Washington, DC. 1997.
7. Gulati G, Hyland L, Kocher W, Schwarting R. Changes in automated complete blood cell count and differential leukocyte count results induced by storage of blood at room temperature. Arch Pathol Lab Med 2002;126:336-42.
8. Baer D. (Ed) Tips from the clinical experts. MLO 2000;32(5):14.
9. Koepke JA. Update on reticulocyte counting. Lab Med;1999;(30):339-343.

Ernst Recognized by Needlestick Prevention Group

The International Sharps Injury Prevention Society (ISIPS) has recognized Center for Phlebotomy Education, director and Phlebotomy Today editor Dennis J. Ernst MT(ASCP) in its 2008 International Sharps Injury Prevention Awards.

Ernst received an Honorable Mention for his contributions to reducing the number of healthcare workers and others who are injured by needlestick and other sharps injuries each year. Nominations were reviewed by a nominating committee, comprised of representatives from Terumo Medical, Retractable Technologies Inc., Qlicksmart, Smartstream Pty Ltd, Managing Infection Control magazine and the International Sharps Injury Prevention Society (ISIPS). The awards are part of the International Sharps Injury Prevention Awareness Month activities that were commemorated during December.

This Month in Phlebotomy Today

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 9^th year of publication, are reading about this month:

• Feature Article: Is Your Draw Station Kid-Friendly?
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in December including these stories:
• Phlebotomist Summoned for DUI Draw Shows up Drunk
• Phlebotomists Losing Ground in Latest Salary Survey
• Physicians Overtake Nurses in UK Needlesticks
• Patients Suing Hospitals for Nosocomials
• Air Force Feeling Faint
• Healthcare an Increasingly Risky Profession
• Wearing Scrubs to Work? Think Again.
• Safety Needles Cut Accidental Sticks 59%
• According to the Standards: Finger Positioning
• Tip of the Month: Begin with the End in Mind
• CEU questions (institutional version only).

Buy this issue for only $9.95.

For subscription rates and to subscribe to Phlebotomy Today, visit www.phlebotomy.com/PhlebotomyToday.html. The current month’s issue will be emailed to you immediately upon subscribing.

Web Fertile Ground for Deception, Misinformation

If you search the Internet for phlebotomy information and products, what you see may not be what you get. Unscrupulous web sites offer myriad products and materials on blood specimen collection that are inaccurate at best and deceptive at worst. For example, last year the Center for Phlebotomy Education discovered its logo, several of its registered trademarks, and copyrighted materials were being used by a California phlebotomy instructor to sell his own products illegally and deceptively through his own web site and through 29 other e-commerce sites. Customers thought they were getting the materials developed by the Center for Phlebotomy Education, but received something different and vastly inferior. The Center filed a lawsuit claiming the defendant used the Center’s copyrighted materials and registered trademarks in violation of federal copyright, trademark, unfair competition, and false advertising laws. The suit has since been settled.

“We are of the opinion that copyright and trademark infringement constitutes theft of the owner's rights and a fraud on the public,” says the Center’s Director, Dennis J. Ernst MT(ASCP). We work hard to create and distribute accurate and informative educational materials for all who perform, teach and manage blood specimen collection procedures. But when a company’s products and intellectual property are used inappropriately, there is little choice but to take the necessary steps to protect them.”

While some sites and self-proclaimed authorities violate federal copyright law to promote their expertise online, others just don’t do their homework. One site providing instruction online states that 1) patients should be told to pump their fist (which falsely elevates potassium levels), 2) to get ready to remove the needle when the tube is two-thirds full (which underfills tubes and risks inaccurate results), and 3) to insert the needle at one angle, then lower it before advancing it up the vein (i.e., using an IV insertion technique to perform a venipuncture). Another site states that an infant’s heel should never be punctured deeper than 2.4 mm. (According to the CLSI skin puncture standard, punctures deeper than 2.0 mm risk bone penetration.)

YouTube.com may be a great place to teach ear piercing (3,000+ videos) and braiding hair (1,940 videos), but don’t count on phlebotomy (176 videos) or venipunctures (46 videos) to be demonstrated according to CLSI standards. It’s home to some of the most abysmal techniques including:

• “Dave Attempting Venipuncture” - Sure, it’s a training arm, but the instructor in this clip apparently slept through his own lecture.
• Here's another “lecturer” drawing a blood specimen without gloves or a safety needle.
• If you want to see how a dinner napkin can double as gauze to cover the wound upon needle removal, there’s this one.
• Drawing a patient who is standing is generally discouraged, but apparently not everyone agrees to everything… except being filmed.
• In this gem, the phlebotomist is apparently unaware the patient is recording the event. We counted at least four procedural errors including failure to identify the patient.

To be fair, YouTube isn’t intended to be an educational site, visitors who don’t know the proper technique aren’t likely to learn it there except for a few stellar examples. (including excerpts from the Center for Phlebotomy Education’s Applied Phlebotomy videos).

“The best advice for relying on the Internet for instruction is to confirm and challenge,” says Ernst. “If something doesn’t sound quite right or looks deceptive, confirm the claim or promotion with reputable authorities and web sites, and challenge those you can’t confirm.” Sites that claim the current CLSI venipuncture method is outdated (as one does) and/or present their own quirky alternatives to the standard protocol (as several do) are either uninformed or fancy themselves to be charlatans, says Ernst. “Being misinformed is one thing, but deceiving the unwary…especially by infringing on copyrights and trademarks… is just flat wrong.”

Featured FAQ: Draws after radiologic dyes

Q: I read an article that said drawing blood at the same time that dyes for radiological procedures are being, or have been recently, infused should be avoided. What are the specific limitations to such dyes?

A: According to one text, creatinine, cortisol and digoxin are affected by fluorescein dye used in angiography.(1) The following article is cited:

Elin R, Bloom J, Herman D, et al. Interference by intravenous fluorescein with laboratory tests. Clin Chem 1989;35(6):1159.

One reference book summarizes the literature on preanalytical errors, and points to a study that shows fluorescein increases bilirubin, creatinine, digoxin (on the Abbott TDx), urine protein, and retic counts. It's listed as decreasing ionized calcium and urine creatinine.(2)

References:

1. Garza D, Becan-McBride K. Phlebotomy Handbook 7th Ed. Upper Saddle River, NJ: Prentice Hall; 2005.
2. Young D. Effects of Preanalytical Variables on Clinical Laboratory Tests. AACC Press. Washington, DC. 1997.

Each month, PT--STAT! will publish one of the hundreds of phlebotomy FAQs in the growing database of questions and answers available in Phlebotomy Central, the members-only section of the Center for Phlebotomy Education's web site. For information on joining Phlebotomy Central, visit www.phlebotomy.com/PhlebotomyCentral.html.

Survey Says?

In last month’s survey, phlebotomy.com asks visitors “After drawing blood into a syringe, do you use a safety transfer device to fill tubes?”

As we travel around speaking to healthcare professionals and conducting workshops, we are constantly amazed at how often we encounter specimen collection personnel who aren’t aware of the necessity to use safety transfer devices. That’s why it comes as a surprise that a full 88% of those responding to last month’s survey said they routinely use safety transfer devices when evacuating blood from a syringe into tubes. Four percent said they do sometimes while 8 percent said they don’t use them at all. Of the eight percent who don’t use them, four percent stated their facility does not provide them. That means four percent of healthcare professionals responding to the survey have safety transfer devices available where they draw blood, but don’t use them. One respondent commented that they do not use syringes to draw blood in their facility.

This month’s survey question: Do you have ammonia inhalants on your collection trays or in your outpatient drawing areas? Click here to participate in the survey.

Featured Product

What Would You Do?

Each month, What Would You Do? presents a different case study, then asks readers to contribute their ideas as to how each situation would best be handled. The following month, selected responses will be chosen by the editor and published (sender will be identified by first name and state only). The most accurate, well written response will receive a free "Accurate Results Begin With Me!^® t-shirt. The exercise will conclude with a review of the selected submissions and a discussion of the standards pertinent to the case study

As expected, this topic generated passion on both sides of the issue. In one camp are those who feel the patient’s wishes take precedence regardless of the phlebotomist’s preferred device. Sixteen percent of all respondents stated they would honor the patient’s request without resistance. Typical comments of these customer service champions include:

“I believe we should respect their wishes and use a butterfly no matter what our opinion of their vein is. It's their body, and we don't know their history or what they've been through to know enough to make this request. It is absolutely a matter of patient service and comfort, and I don't think the cost of supplies should be a factor at all.”

“… it's better to show the patient you respect their experience and views than it is to save money for your employer.”

In the other camp are those who diplomatically resist patient attempts to dictate the device they should use in their specialty (72%). Twelve percent said they would inform the patient that butterflies are only used when the phlebotomist feels it’s necessary, while eight percent said they’d probe for the patient’s reasoning and work from there. The arguments used to sway requests away from butterflies include “I’m more comfortable with a straight needle,” “non-butterfly needles are less painful,” “butterfly needles are more commonly used by novices,” “butterfly sets are more likely to hemolyze the blood,” “the diameter is the same as my preferred needle,” and “I’m more likely to be successful with a different style of needle.” Some sample comments:

“We have taken to explaining to the patient the exact difference between butterflies and straight needles.”

“Butterflies come in all of the same sizes as do all of the other needles that are available to phlebotomists. The difference lies only in the tubing being attached to that needle, and the convenience to the phlebotomist. If the phlebotomist feels that they will do a better job with a smaller needle that is attached to a different set-up than the butterfly, [patients] seem to listen and appreciate the difference. It never fails that when they learn that what they are really asking for is a smaller needle, and not truly the set-up of the butterfly, that they feel much more comfortable with the phlebotomist's choice….”

However, one reader who uses that technique shared her account on how it didn’t really change the patient’s attitude toward butterflies. She explained to the patient that she feels very confident she will obtain the blood with the straight needle (non-butterfly). The patient submitted to the draw, which was successful. The next week, the same patient returned for another blood test, and was seated by a different phlebotomist. She again requested a butterfly, and voiced her observation that other phlebotomists were avoiding butterflies in order to save their employer’s money.

Thirty-two percent said they would ultimately honor the patient’s request if he/she insisted. Stephanie H. of Michigan penned the typical response of this group:

“I believe that every blood collection facility faces this issue on a daily basis…. As a general rule, after I have located the site, I gently inform the patient that butterflies are used as a personal preference of the phlebotomist and do not always provide the best sample. I would appreciate it if they would allow me to use what I felt was best suited, and I would use the smallest needle if possible. Of course there are times when they refuse and I would definitely use the butterfly, but for the most part patients allow me to use my best judgment. Thankfully, I have not missed very many!”

I would explain to the patient that the butterfly gauge and the regular needle gauge that our organization uses are the same size and since I am trained and more proficient with the needle than the butterfly I feel that I could do a better job drawing her blood with the regular needle. I would assure her that I would not stick her if I did not feel confident and ask if it is ok to proceed. If she refused then I would let her know that someone could be sent to take a look.

Barb C. of Indiana submitted the most articulate and interesting response this month:

“…this exact question was discussed among my staff and someone had this discussion a few years back with the patient (the patient happened to be a painter). The phlebotomist asked the patient what he prefers to use when painting a wall.  The patient stated he preferred a roller instead of a brush because he liked the way it went on the wall and he felt he could do an excellent job. The phlebotomist then asked what he would do if the homeowner asked him to use a brush on their walls?  He stated, ‘You have a good point!  Proceed with the needle you handle best!’”

For her response, Barb will receive a free Accurate Results Begin With Me™! t-shirt.