Garbage In; Garbage Out: Part IV

Over the last few months, Phlebotomy Today-STAT! has been exploring the many ways those who draw and process specimens can unknowingly alter test results. Last month we explored how specimens drawn from vascular access devices become garbage as well as the affect exercise, fist-pumping, posture, and the timing of blood culture collections have on turning specimens—and the results obtained from them—into garbage. (To access this and other archived issues, visit www.phlebotomy.com/PTSTAT.html) This month we will move our discussion forward with errors committed while the needle is within the vein.

Order of Draw
The proper order in which blood collection tubes should be filled is designed to prevent the carryover of additives from one tube to the next, which can lead to the reporting of erroneous results from patient samples. The order has its origins in the literature as early as 1977 when researchers discovered a potassium level on an asymptomatic patient five times higher than normal. Although there have been various modifications to the order of draw throughout the years, the current Clinical and Laboratory Standards Institute (CLSI) recommendation has been in effect since 2003.

Prompting the revision at the time was the industry-wide substitution of glass collection tubes with plastic. Because a plastic serum tube requires the addition of clot-activating substrates in order for the specimen to clot, CLSI moved its position from before the citrate tube (for coags) to immediately after it. Clearly, clot-activator tubes cannot remain as the first tube in the order of draw preceding sodium citrate tubes, since any carryover may quantitatively affect clotting times.

The order then, established by CLSI to prevent the documented carryover of the additive from one tube into another tube and the effects that carryover can have on test results, is as follows:

First — blood culture tubes or vials;

Second — sodium citrate tubes (e.g., blue tops);

Third — serum tubes with or without clot activator or gel; (e.g., red tops);

Fourth — heparin tubes (e.g., green tops);

Fifth — EDTA tubes (e.g., lavender tops);

Sixth — oxalate/fluoride tubes (e.g., gray tops).

This order is the same regardless of the equipment (e.g., syringe, tube holder, or winged collection set). However, a separate order of draw exists when collecting capillary samples. This is based on the fact that when skin is punctured, platelets are attracted to the site en masse and can exist in the blood specimen being collected in quantities that don’t really reflect what’s really circulating. Because platelets adhere to damaged capillary vessels and clump to each other in order to stop the bleeding, the potential for clumps of platelets to interfere with accurate CBC results increases rapidly after the puncture. In other words, the first few drops from a capillary puncture will more likely reflect platelet concentrations as they exist in the bloodstream than later drops. Therefore, the EDTA tube used for CBCs must be collected first. CLSI established the order of draw for capillary specimens to be as follows:

First — EDTA tubes;

Second — other additive tubes;

Third — non-additive tubes.

Hemolysis
One of the most common and more frustrating preanalytical errors is hemolysis. Many factors can hemolyze a specimen during the draw including:

• improper needle placement;
• excessive pulling pressure on the plunger of the syringe;
• vigorous mixing;
• small needle size;
• inappropriate blood:anticoagulant ratio due to underfilling;
• “milking” the site of a capillary puncture.

As a result, the following analytes can be reported falsely higher than their actual concentration in the patient: potassium, LDH, AST, ALT, phosphorous, magnesium, and ammonia. Hematocrits and red blood cell counts will be falsely lower in hemolyzed specimens. In addition to these analytes, the dilutional affect of hemolysis can potentially alter every test. That’s because when a specimen is hemolyzed, the liquid contents of the cells (hemoglobin and other components) are released into the serum/plasma.

To avoid hemolyzing specimens during the draw, collectors can adhere to the following practices:

• Avoid slow draws that come from improperly positioned needles;
• Avoid pulling too hard on the plunger of a syringe;
• Fill tubes to their stated capacity;
• Gently invert tubes instead of vigorous mixing;
• Avoid using 25-gauge needles or smaller;
• Pre-warm infant heels or the fingers of older children and adults when performing a skin puncture so that excessive squeezing or “milking” of a puncture site is not necessary.

To prevent turning specimens into garbage during the collection process, be mindful of these preanalytical variables that can alter test results. When avoided, specimens will produce reliable information and patients will be subjected to therapies and treatments based on their actual health status. Remember, accurate results begin with you.

Next month: Insufficient volume, inadequate mixing

This Month in Phlebotomy Today

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 8^th year of publication, are reading about this month:

• Feature Article: Journals Ablaze with Venipuncture Studies/Articles
• Ask the Lab Guy: Answers to your questions on customer service.
• How do I deal with patients that have hygiene issues?
  
• Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in August including these stories:
• Phlebotomist Receives "Golden Stitches Award"
• Phlebotomist Donates Kidney to Fellow Phlebotomist
• Texas Plant Fined for Bloodborne Pathogens Standard Violation
• Judge Declares Trooper-Drawn Blood Alcohol Results Unconstitutional
• According to the Standards: Is drawing above an IV acceptable?
• Tip of the Month: The Wizard of Aahs!
• 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.

Featured Product: Blood Specimen Collection FAQ

Featured FAQ: Restraining Children

Q: What are the acceptable means of restraining a child during phlebotomy?

A: Gentle physical restraint is necessary to make sure that the arm to be punctured remains immobile during the venipuncture. Avoid forcefully restraining a child who appears to be calm or only mildly anxious. Kids don’t like to be restrained any more than adults do, and a firm, forceful grip can increase their anxiety. It is best to use only as much assistance as is necessary to assure the success of the procedure, and no more. Regardless of the degree of necessity, restraint should never be applied with a force great enough to cause injury. For outpatients, it is ideal to position the child on the lap of the parent or guardian, who can restrain the free arm of the child while an assistant secures the wrist of the arm to be punctured. For inpatients, or for outpatient situations in which a parent is unable to assist, the patient should lie on a bed or cot with the parent or assistant providing gentle restraint to the legs, the free arm, and the wrist of the arm to be punctured.

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: Phlebotomy Certification

In last month’s survey, we polled visitors to our website about phlebotomy certification. Those who were working outside of California, Louisiana, and Nevada (the only states with mandatory certification requirements) were asked if their employer required certification. If not, those who voluntarily obtained certification for themselves were asked if their employers paid certified phlebotomists more than those who were not certified.

Twenty-three percent of those responding in non-certification states said their employer requires certification even though the law does not. Several of those who chose to comment indicated that, while not required, certification is preferred.

Surprisingly, 62% said that their employers do not pay certified phlebotomists any more than non-certified phlebotomists. One commented “I think a certified phlebotomist should be paid more. We took the time and effort to improve our skills; we should be compensated for that.”

Another respondent expressed doubts about the value of certification. “… more money does not make you a better phlebotomist. It may make you stay there longer, but that is about it.”

In this month’s survey, visitors to www.phlebotomy.com are asked about arterial blood gas specimens.

To participate in this survey, click here.

Waterloo Healthcare Specimen Collection Cart Waterloo Healthcare (Phoenix, Arizona) offers a multi-purpose cart designed especially for specimen collection personnel. Developed under the supervision of phlebotomy professionals working daily in the field, the cart is engineered especially for the needs of hospitals, clinics, surgical centers, and doctor's offices where blood collection procedures are routine. Two sizes of the cart are available. The tall cart measures 26 inches wide by 18 inches deep and is 44 inches tall; the shorter cart has the same width and depth, but is only 37 inches high. Both are made out of a combination of steel, aluminum, and plastic to provide a sturdy yet lightweight solution that keeps specimen collection supplies and equipment in reach at the point of use. The cart can be custom configured with 3-inch, 4-inch, 6-inch, and 9-inch deep drawers. The 3- and 4-inch drawers are trays designed to hold plastic dividers (included) that users can reposition for the most effective use of space. The tall version has an extra full-width 6-inch drawer at the bottom for additional storage. The cart also has 12 clear plastic tilt bins built into the front of the cart that conveniently show their contents for fast and easy access. Waste can be placed into the built-in sharps container that locks inside the cart or the built-in tilt-out waste bin. For more information, contact Waterloo Healthcare at (800) 833-4419 or visit the web site at http://www.waterloohealthcare.com.

Denline Uniforms Conducting Survey

Denline Uniforms, maker of splash- & spray-resistant personal protective apparel for healthcare personnel, is conducting a survey on blood exposures. To encourage participation in the survey, all eligible respondents will be entered into a drawing for a $500 gas card.

The survey is posted online, and asks those who draw blood to provide information on the frequency they have experienced blood splashes or other contact while drawing or processing specimens for testing. Names and demographics of respondents will be kept confidential.

One respondent will be randomly selected by the Center for Phlebotomy Education 60 days after the survey begins for a $500 gas card. Respondents must be 18 years or older. One response per person. Only US residents are eligible. The offer is void where prohibited by law. The winner will be notified by phone, and announced in a future issue of Phlebotomy Today STAT!

To participate in Denline's survey, click here.

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

Everyone who responded to this month’s case study knew how inappropriate it would be to allow a parent with phlebotomy experience draw their child’s blood. Not only would one have to trust the mother as really being the child’s parent, but that she was actually a well-trained phlebotomist when she was in the field. Taking time to find out would not only be impractical, but potentially offensive to the parent who is likely well-intended. Forty percent of respondents suggested the mother should be recruited to calm or stabilize the child during the draw instead of performing it. One wondered if the mother should be given the supplies to draw her child at home, then bring the sample to the lab.

One of the more passionate responses to this month’s case study put it bluntly:

…Does the phlebotomist actually know the person is the child’s mother and/or was a phlebotomist in the past? Let her speak to a supervisor; that's why they're paid the big bucks. Only a fool would yield to this possible set up.”

Then there’s the liability. What if the parent injured the child’s nerve accidentally during the procedure? Who would be liable for the injury? It’s fair to say a jury might not understand how a phlebotomist would relinquish the responsibility to perform a venipuncture properly to a parent of unknown competency.

But not all Phlebotomy Today STAT! readers are in countries as litigious as the US. D.R. of New Zealand writes in this month’s co-winning response:

“This is a situation that has an ethical bearing and would need to be responded with great keen. The mother’s request to draw blood from her own daughter who was already terrified from the procedure cannot be entertained. This gesture alone sparks a conflict of interest and could well be unprofessional on the part of the phlebotomist if such request was approved in the first place. The best thing to do is to maintain a good line of communication and rapport with the mother.It will be best to explain to the mother, that her idea would be detrimental to her child since it could only worsen the child’s fear. She can best play a vital role by keeping the child’s attention diverted while drawing blood.”

Tied for the most articulate response and professional approach came from Kirk G. from Seattle, Washington:

“First, I would thank the mother for her willingness to help me and to help ease her daughter’s anxiety by offering to draw her blood. I would let the mother know it is against our company policy to let non-employees draw our patient’s blood. I would however inform her of my skill set in a way that is polite and does not sound conceited. I would also remind her of the importance of a good pediatric hold and assist and ask her if she could help me in that way. I would finally tell her daughter that her mom is going to be able to hold her and help with having her blood drawn. I believe in this way the mom feels like she is helping and also the daughter knows that mom is being included in her blood draw.”

Because Kirk and D.R. handled this request so tactfully and articulated their responses so concisely, they’ll both be receiving an “Accurate Results Begin With Me!(R)” t-shirt. Thanks to all who responded. Although it’s not possible to publish all responses each month, we never fail to delight in hearing what you have to say.