The Art of Hemolysis
Red is such a pretty color... unless it tinges the serum or plasma of the specimen you collected. Then it's ugly.
It's ugly because it usually means the time you spent drawing the specimen was wasted and the draw will have to be repeated. But it's more than a time killer. Having to recollect a hemolyzed specimen that is incapable of rendering accurate and useful results to the physician delays treatment, diagnosis, and/or much-needed medications. In critical situations, time isn't just money, it can be life itself.
Hemolysis has been reported to be the number one cause of rejected chemistry specimens. In fact, six times more specimens are rejected because of hemolysis than the second-most common reason, insufficient sample volume. But before we master the art of preventing hemolysis, we have to understand how it occurs.
"Hemo" means blood, of course; "lysis" means to rupture or the destruction of cells. So hemolysis is literally the destruction of blood cells, specifically red blood cells. When red cells rupture, they spill their contents, mostly hemoglobin, into their surroundings. Hemoglobin is a respiratory pigment that has an insatiable passion for oxygen and gloms onto every molecule it can hold while passing through the lungs, then dumps it off into the tissue where it's needed for cellular functions.
Hemoglobin is also what makes blood red. So naturally, when red cells burst, it tinges the liquid portion of the blood. If red cells burst during specimen collection, the blood being tested is not the same as the blood circulating in the patient. It's as different as night and day. Because red blood cells contain 23 times as much potassium as the liquid portion of the blood, when red cells rupture during collection, the specimen being submitted for testing is spiked with potassium. In fact, it's spiked with so much potassium that, if tested and reported, the results can send the physician into a sheer panic, forcing him or her to react with orders that can be ultimately unfavorable to the patient. Or, if the patient's circulating potassium is actually too low, hemolysis can spike the specimen into a normal range and lead to inaction when action is necessary.
But it's not just potassium that hemolysis affects. These other tests are affected when hemolyzed specimens are submitted for testing: LDH, AST, ALT, phosphorous, magnesium, ammonia, RBC, hemoglobin and hematocrit. Not only these analytes, but virtually everything that could be tested. That's because hemoglobin is a liquid protein which dilutes the serum or plasma being tested. The greater the hemolysis, the greater the dilution.
Suffice it to say hemolysis is just all-around nasty. So how do those who collect specimens prevent the lab from reporting inaccurate results? Check your practices to minimize these seven top causes:
- Avoid line draws---IV devices are notorious for hemolyzing red cells. Perform a venipuncture instead;
- Avoid vigorous mixing---think of red cells as fragile crystal orbs that fracture with the least amount of disturbance;
- Avoid excessive pulling pressure when using syringes---red cells don't tolerate the excessive turbulence from forcefully withdrawing the plunger of the syringe;
- Don't rim clots---rimming clots to remove fibrin invariably ruptures red cells at the same time;
- Position the needle properly---a needle partially occluded by the vein wall is a needle that hemolyzes red cells;
- Prewarm skin puncture sites---this reduces the need to excessively squeeze the tissue, which hemolyzes red cells;
- Fill tubes fully---an excessive concentration of anticoagulant when tubes are underfilled is hard on fragile red cell membranes.
Using these and other techniques can minimize your potential to hemolyze specimens. Since accurate results begin with the collector, those who draw blood specimens are in the best position to
make sure patients are treated according to results that are not delayed or altered because of hemolysis.
The real art of hemolysis is in avoiding it in the first place.
Editor's note: an attractive PDF of an expanded version of this article is available at phlebotomy.com in our FREE STUFF section.
Phlebotomy Q&A Book
Standards Update: Assembling devices in advance
The newly revised venipuncture standard released by the Clinical and Laboratory Standards Institute in April, 2017 is the most comprehensive revision in the document's history. With over 140 new mandates, facilities have a lot of changes to implement. This series discusses one or more substantive changes each month.
Phlebotomists and other healthcare professionals who like to assemble their collection devices in advance of greeting the patient will have to dial it back a bit. The newly revised venipuncture standard strictly prohibits assembling blood collection devices prior to the patient identification step.
"Many phlebotomists are so organized, they want to be ready to go as soon as they greet their next patient," says Dennis J. Ernst MT(ASCP), NCPT(NCCT), who chaired the revision. "That's all well and good, but it only saves a couple seconds. What gets compromised, though, is the patient's confidence the device was not left over from the last patient, and used on them by mistake."
Ernst has first-hand experience in what can happen when phlebotomists assemble the device in advance. He recounts a patient at a facility where he worked as a medical technologist who thought the phlebotomist picked up a used tube holder assembly on her. "She didn't say anything during the draw, but by the time she got to the registration desk on her way out, it had sunk in, and she was mortified. She didn't see the needle assembled from its packaging, and was certain the needle used on her was left over from the last patient. It took a long time and a lot of explaining to convince her that's not what happened."
According to Ernst, his CLSI committee felt it was important to make sure patients see the devices that are going to be used on them assembled in their presence. "You're only going to save a couple seconds, so instead let that patient see you assemble your device from the sterile environments of their packaging. When we assemble our devices in the presence of the patient, we eradicate the potential for them to go away thinking that they might have just been drawn by a needle left over from the last patient. As long as you're preassembling devices before you get to the patients side, there will always be the potential for the patient to be fearful of the care they received."
Editor's note: Readers are urged to obtain their own copy of the standard as soon as possible and begin implementing all new provisions. The document Collection of Diagnostic Venous Blood Specimens (GP41-A7), is the standard to which all facilities will be held if a patient is injured during the procedure or suffers from the consequences of an improperly performed venipuncture.
Global Preanalytic Summit
Ernst Receives Professional Achievement Award
Center for Phlebotomy Education Director Dennis J. Ernst MT(ASCP), NCPT(NCCT) was recently awarded the BioRad Professional Achievement Award for phlebotomy.
Each year, BioRad recognizes laboratory professionals of various disciplines for their contributions to the profession. Ernst was awarded the designation for his volunteer participation in legislative activities related to phlebotomists, developing industry standards, serving on CDC Expert Review Panels for Laboratory Medicine Best Practices (LMBP), attending over 60 state and national meetings, holding leadership positions with CLSI, giving 400 presentations at state, national and international conferences and workshops throughout his career, and authoring five books and over 80 articles on blood sample collection for laboratory testing.
Product Spotlight: Realistic training model
If you've ever looked through the Center for Phlebotomy Education's catalog, you'll notice all but two of the products are of our own creation. That's because few products on the market meet our strict quality standards. One of them is the newly redesigned Advanced Venipuncture Training Aid. Completely upgraded, this training aid costs far less than the anatomical-looking arms, and provides a far superior real-patient experience. What we like the most (besides the price) is that needle tracks are not nearly as obvious as they are with anatomically designed trainers.
The latex-free Dermalike™ vein block has four simulated veins in three different sizes, with the fourth vein deeply placed. As the needle enters the vein, a realistic "flashback" of simulated blood confirms proper needle placement, helping students and staff develop hand-eye coordination, confidence, and competence. Durability for this model is rated at 5,400 sticks with a 22-gauge needle.
What Should We Do?: Should I tattle?
Dear Center for Phlebotomy Education,
I play by the rules, but not everyone here is as cautious against needlesticks as I am. I often see coworkers breaking off the safety feature from their needles, ripping the tip off their gloves, and other dangerous practices. I usually look the other way, but it's bothering my conscience more and more. Last week I saw the lead phlebotomist tear off the fingertip of her glove. I am not a tattler, but I know this isn't right or safe. Should I suffer in silence or speak up and risk losing my job?
Our response: For some, this is a tough call; for others it's a no-brainer. We side with the latter.
We feel strongly that every safety infraction should be reported. If the immediate supervisor is unsympathetic, go up the chain until you find someone of authority who has the courage to enforce policies. If you lose your job, at least you can sleep at night knowing you've heightened awareness of serious safety practices that can cost lives. Or you can look at it from the opposite perspective. What if you keep quiet and someone accidentally sticks themselves with a contaminated needle after removing the safety feature? How will you feel when you find out he/she acquired hepatitis or HIV? Pretty terrible, we're sure. Either way, whether you report violations or not, it's going to be hard. If you choose to report it, you will likely incur the wrath of your coworkers and/or supervisor, yet it could save a life; if you choose not to, no one will rise up against you, but your conscience could haunt you.
Here's the thing: being terminated for reporting unlawful behaviors is illegal; working in a hostile environment is also a labor law violation. If you feel either is possible, you're probably not a good fit with your employer and vice versa. Ultimately, your job satisfaction will head south for other or additional reasons, so you might as well do what your heart is telling you to do and report it. It's the right thing to do. (The right thing is usually the harder option; that's how you can tell.)
Take the high road and see what happens. You might just start a chain of events that changes the culture of safety where you work. Remember these words often attributed to Andrew Jackson: "One man with courage makes a majority."
Got a challenging phlebotomy situation or work-related question? Email us your submission at WSWDpanel@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)
Empowered Healthcare Manager: What's your product?
Every month we run an excerpt from our editor's popular blog, The Empowered Healthcare Manager.
Companies sell products. In the minds of economists, products are either "goods" (durable and non-durable) or "services." Regardless of which your employer produces, every manager sells a service that helps deliver whatever it is the company sells. Your staff is that service; your staff is your product.
What product do healthcare managers provide for their employer?
- If you manage a clinical laboratory, it's a staff that delivers test results in Six Sigma fashion.
- If you're a phlebotomy manager, your product is a staff that draws, delivers, and processes samples capable of rendering accurate test results from patients satisfied with the encounter.
- If you're a nurse manager, your product is a staff that flawlessly implements physicians' orders and the care plan that makes and/or keeps their patients well.
Your staff produces the end product, the one customers want from your company. You produce the staff that can create it. If you find yourself creating the end product because your staff isn't capable, what do you need them for?
Worse, if you have to do the work your staff should be doing, what does your manager need you for?
Survey Says: Attribute wish list
Last month we asked our readers and visitors to our web site what attribute they wish their supervisor would improve upon? For supervisors, we asked what they'd like to see their staff improve upon. We last asked this question in 2010, and it appears the priorities of those who responded has changed.
In 2010, the top four attributes supervisors wished their staff would acquire were:
- initiative/time management
This year, the wish list's top four include:
- technical knowledge/skill
Among front line staff, the top four attributes they wish their supervisors would acquire in 2010 were:
- organizational skills
This time around, the top four were:
- discipline/enforcement of policies
- staff advocacy.
- She has a favorite..... not cool. This person spends most of the day texting, I've brought it to the Manager many times .... it still continues
- We constantly are short staffed and put under a lot of pressure. When the expectation is to follow policy and procedures which are time consuming and to get thru a massive work load something has to give and mistakes occur.
- Being transparent and explaining to everyone, when there are changes in protocols, procedures, and changes in lab personnel that will be working in an area. Too many times, it's "well, we will tell you more when we have more decisions made" or a statement that really says nothing at all about the question asked.
- Working as a team and helping each other. Doing your job and not making others do it for you.
- Get out from behind the desk and work a total shift with us!! Be a phlebotomist for the day!! Because not everything on paper works in the real world as planned.
- Stop the gossip and stop playing favorites. It's sad when it's so prevalent in the work place.
- None of my managers (5 different ones) have ever seen me doing phlebotomy, not once in six years. I'm a good and conscientious phlebotomist, but not all of my colleagues are. The managers need to come out of the office and observe how we do our jobs.
This month's survey: This month, we're asking how you feel about phlebotomy certification.
Take the survey.
Tip of the Month: Listen to the Skin
Click here for this month's featured Tip of the Month from our rich library of archived Tips.