Drawing Blood After Transfusions
Physicians who transfuse patients often want to know the effect of the infusion immediately. Yet drawing blood during or after a transfusion subjects the specimen to many variables and increases the risk of obtaining results that don't accurately reflect the patient's condition. When can a post-transfusion sample accurately reflect the benefit of the transfusion? What analytes are affected by transfusion? What is the best way to coordinate specimen collection with a transfusion? The answers to these questions are largely a function of what is being drawn and why.
Cell counts drawn during a transfusion provide little useful information except in trauma cases where the patient's condition is changing rapidly and must be monitored frequently. Once all donor cells have been transfused, accurate cell counts may be obtained immediately after transfusion. However, waiting an hour post-transfusion may yield more accurate results because of the many variables that affect donor cell distribution.(1)
The main objective in collecting a post-transfusion specimen is to acquire a homogeneous sample of patient blood and donor cells. A multitude of variables determine homogeneity including the status of the patient's heart, kidneys, and circulatory system, the patient's pre-transfusion blood volume, and the age and volume of the transfused cells. The homogeneity of circulating blood does not occur in patients receiving blood due to an acute hemorrhage until all hemorrhaging has been stopped.
The levels of several chemistry analytes can be elevated for prolonged periods after transfusion. During storage of a donor unit, a significant percentage of red blood cells can hemolyze. Therefore, post-transfusion specimens can have elevated levels of plasma hemoglobin, potassium, ammonia, urea nitrogen, uric acid, vitamin B12, LD, and serum iron.(2,3,4) These levels can remain elevated up to 24 hours, depending on the patient's kidney function and other variables. Laboratories testing post-transfusion specimens for these analytes should consider documenting the potential affect of the transfusion on these tests when releasing results.
The Clinical and Laboratory Standards Institute (CLSI) has not established criteria for drawing post-transfusion cell counts. However, its venipuncture standard (GP41-A7) details the proper procedure for drawing blood from a patient receiving IV fluids of any kind, including donor blood.(5) The standard states drawing above an active IV is rarely acceptable and should be considered with great caution. (5-7)
Draws from the same arm as an infusion are to be avoided if at all possible. When unavoidable due to difficulty in accessing other veins, CLSI suggests having the infusion temporarily shut off (2 minutes) prior to the puncture, tightening the tourniquet below the IV site and performing the puncture below the tourniquet. Draws from the same arm in which fluids are being infused must be documented to accompany test results, including what was being infused.
In summary, drawing samples during or immediately following a blood transfusion is critical to managing anemic patients. While the results have a limited validity, they provide critical information on the effects of the transfusion and drive lifesaving medical decisions. When delaying the draw for an hour or two after the transfusion(s) have completed does not threaten the responsible management of the patient, the results will be more accurate and be valid for a longer period of time post-collection.
1 Becan-McBride K, Eisenbrey A, Haraden L. Venipuncture after transfusion. Adv. Med Lab Prof. Q&A column. January 25, 1999:4.
2 Narayanan S. The preanalytic phase an important component of laboratory testing. Am J Clin Pathol 2000;113:429-452.
3 Mayhre B. Iron values after transfusion. Tips on specimen collection. MLO. Montvale, NJ. 1997.
4 Young D. Effects of Preanalytic Variables on Clinical Laboratory Tests. AACC Press; Washington, DC:2007.
5 CLSI. Collection of Diagnostic Venous Blood Specimens, Approved Standard, GP41-A7, Clinical and Laboratory Standards Institute. Wayne, PA. 2017.
6 Watson R, O'Kell R, Joyce J. Data regarding blood drawing sites in patients receiving intravenous fluids. Am J Clin Pathol. 1983;79(1):119-121.
7 Read D, Huberto V, Arkin C. Effect of drawing blood specimens proximal to an in-place but discontinued intravenous solution. Am J Clin Pathol. 1988;90(6):702-706.
Staying Compliant With Industry Standards
Phlebotomist Credited With Saving 2 Lives in 9 Days
A hospital in Eaton Rapids Michigan is glad they have Ashley Wing as one of their phlebotomists. Twice this summer over a nine-day period, Wing administered CPR, saving the lives of a patient in the facility's parking lot and a coworker sitting next to her in a break room.
Employed in the lab at Eaton Rapids Medical Center, Wing performed CPR within seconds of witnessing both emergencies. Authorities at the facility say neither person would have survived if she wasn't at the right place at the right time.
On June 22, Wing was conversing with a coworker when she grew silent and fell to the floor. She noticed her lips turning blue, called the ER and administered CPR. Her friend and coworker had suffered a cardiac arrest. After four days in the hospital and six weeks recovering, she returned to work, forever grateful Wing was not only at her side when she needed her, but prepared to act.
On July 1, only nine days later, Wing was near the front doors of the hospital when a man ran in yelling about someone in a parked car who had stopped breathing. Instinctively, she sprung to action again, performed CPR, and called the emergency department on her cell phone. The patient survived.
Wing credits her experience in healthcare and her employer's CPR training program for knowing what to do and not having to stop and think about it.
Read the full story and view Wing's account of the event.
Product Spotlight: Basic Venipuncture DVD Now Shipping
As of October 2, the industry's most popular venipuncture training video is now available on DVD.
The DVD version replaces the Second Edition, which was released in 2010 and has since become the most widely used venipuncture training video in the industry. Facilities and academic institutions in 20 countries around the world use Basic Venipuncture to train their staff and students to perform venipunctures. The title was released in streaming format in August on the Phlebotomy Channel.
Features of the 3rd edition include:
- Completely updated to reflect the newly revised CLSI venipuncture standard;
- Completely new script, narrator, and organization of the material;
- Filmed in high-definition;
- 12-minutes longer than the 2nd edition;
- Closed captioned by the National Captioning Institute.
"Basic Venipuncture is the gold standard for venipuncture training," says Dennis J. Ernst MT(ASCP), NCPT(NCCT) who wrote, produced and directed the video. "I've poured my heart and soul into this to make it impeccably accurate and graphically appealing. After 18 months of development and filming, and 15 rounds of editorial revisions, this is one of the most polished productions I've ever released. The gold standard just became platinum."
A preview clip is available on the Center's web site.
From the Editor's Desk
I'm often puzzled by products and inventions that everyone must have, but for which I have no use. Watches for example. Almost every man wears one, yet I haven't had a use for one in over 30 years. If you look around, clocks are everywhere---in your car, on your phone, and in every public place. They're built into your stove, microwave, TV, computer... so why strap one to your wrist?
Although I've never been arrested and have no intention of finding out what it's like to wear handcuffs, to me it would feel a lot like wearing two watches. That perception alone is enough for me to commit to a life of civil obedience.
As unnecessary as I find watches to be in this world, I have to confess I own one. Just one, and not just any watch. It's the gold watch my Grandfather was given when he retired from the railroad.
I don't know much about what he did for the railroad or even what railroad he worked for except that was in Elkhart, Indiana. I also know he didn't retire completely, just from the railroad. After that he moved to Richmond, Michigan and worked at a car dealership in Detroit. The full story is now lost, but at some point the dealership swindled him out of some money, so he quit and opened Ernst Auto Sales in Richmond where he became known for his kindness, generosity and genuine compassion for people. He would often accept chickens and other farm animals as down payments on new and used Fords. Based on those values, his reputation spread and his business flourished.
I don't remember much about Grandpa Ernst except for the day and manner of his death. I was 10. As my mother recalls, he was still employed in some capacity with his dealership when a dispute developed between his company and the Ford Motor Company. I've never seen him lose his temper, but apparently he drove down to Ford headquarters in Dearborn, Michigan and blew his stack. On his way back to his car he suffered a massive heart attack in the parking lot and died.
My grandfather on my mother's side also received a gold watch, which has been entrusted to my brother. His was awarded for many years of service to the Macomb County Road Commission. He was a legendary road-builder known throughout the Commission as "Grader Ben" because he had an eye for grading new roads to be perfectly level and crowned. He was a kind and gentle man as well. Much of what I know about being a grandpa I got from him.
Grandpa Ernst's time ran out suddenly in a parking lot at the Ford Motor Company while Grandpa Niebauer's time ran out much more slowly. Alzheimer's took him from us one memory at a time over a period of many years. I was blessed to have two grandpas that left me with precious memories of our time together. Though they were each quite different in nature, both were endearing in unique and special ways. I am doubly blessed to have had them in my childhood.
I won't have a gold watch to pass down to a grandchild that I will receive whenever I retire. Not that I don't have grandchildren; I have plenty. It's just that my employer is too cheap. I can say that because I own the company. Even though I've worked here for 20 years---longer than I have worked anywhere else---giving myself a gold watch at the end of my run would be self-serving. Not only that, but a gold watch like my grandfathers received would cost over $1000 today. I can think of a lot more things to do with a grand than that.
Working here has its own rewards that make gifting myself not only conceited, but unnecessary. My recognition, appreciation, satisfaction, and sense of purpose comes every day from those I interact with in the industry. A gold watch can't possibly express the appreciation and thanks I receive from answering technical questions, allocating time to help other organizations, and knowing the materials we create are helping people improve patient care. It's the best job I've ever had, and no engraved, gold-plated timepiece could ever reward me for my loyalty more than I'm already rewarded.
Besides, I have no use for watches.
Dennis J. Ernst, editor
Global Summit Setting New Attendance Record
Registrations for next week's Global Summit on Best Practices in Preanalytics are setting a record for the 3-day event. Taking place October 15-18 in Charlotte, North Carolina, the Summit continues to build on the successes from prior years. "This year's event will be bigger and better than ever," says Greiner's conference organizer Mackenzie Farone-Waite. "We will be providing all new educational topics as we bring back some of your favorite speakers and include new experts in the field of preanalytics.
With 13 presenters discussing 17 topics, the agenda is the most ambitious yet. Some of the topics to be discussed by a panel of highly respected authorities include:
- The Cost of Errors: Patient Outcomes, Cost, and Safety
- Top 10 Reasons Hemolysis Happens
- Reducing Phlebotomy Draw Volumes
- Error Proofing Your Lab
- Training Preceptors to Train Your Staff
- Stop Bullying and Start Team-building
For more information or to register, visit the Summit website or contact Greiner-Bio One North America for more information.
Advice From an OSHA Expert
[Editors' Note: This month, Phlebotomy Today launches a new column: Advice From an OSHA Expert. We're pleased to welcome safety expert and columnist, Dan Scungio, MT (ASCP), SLS, also known as "Dan the Lab Safety Man" as our newest contributor.]
Are you part of an inpatient phlebotomy team? Do you draw blood outside of a hospital but bring specimens into the lab? Do you receive or process specimens in the laboratory? Whether you are actually a lab employee or not, the personal protective equipment (PPE) you wear when you draw, handle, and process blood samples is the same.
The work hazard assessment conducted by the employer determines what PPE employees are required to wear when working on patient units or when collecting outside of the hospital setting. At a minimum, OSHA requires glove use during vascular access procedures. However, it is not acceptable to work in the laboratory without a lab coat and gloves if you are at a bench where specimens are handled. If you are processing specimens, taking them out of transport bags, operating a centrifuge, you absolutely need a lab coat and gloves. Face protection is required as well if you are opening samples.
Take a look around the lab. The other staff there should be using their PPE, and they should provide it for you if you do work at that site. If you are unfamiliar with the lab, ask for safety training and for your own safety, ask for PPE.
What if you have a specimen processing area that is located in the same space where blood collection occurs? If that is your situation, you do need to wear a closed lab coat whenever you process specimens. To always be protected, in addition to gloves wear a lab coat whenever you are in the department and when drawing patients. If permitted by facility policy, the other option would be to have a lab coat ready to don whenever specimen processing occurs. To keep yourself safe whenever you are drawing and handling those specimens inside and outside the lab, make sure you know and follow your facility's PPE requirements.
You can contact "Dan the Lab Safety Man" at firstname.lastname@example.org
US Department of Labor and Occupational Safety and Health Administration (OSHA). Bloodborne Pathogens (29 CFR 1910.1030). Link. Accessed 10/5/18.
What Should We Do?: Co-worker too "chummy" with patients
Dear Center for Phlebotomy Education:
I work with someone who thinks it's okay to call patients with whom she's familiar 'sweetie, honey, or even 'darlin.' She also asks them borderline-prying questions and share way too much of her own personal life. She has a loud voice, which carries down the hall. Other members of our professional team have commented that they do not want to hear such conversations and agree that they're unprofessional. I have asked my manager to address this, but she won't address it because she says she hasn't witnessed it herself. What should we do?
We agree the banter you described is overly "cozy" and unprofessional. Your coworker is likely a very congenial person and thinks she's providing a compassionate, caring experience for her patients. Being congenial has its limits, though, especially in healthcare. It's likely that she's never been coached on what's considered appropriate customer service and what isn't. It should be an easy fix.
There's three likely reasons your supervisor isn't taking action: 1) she's non-confrontational and doesn't want to find out if your claims are true; 2) the staff complains to her so frequently about co-workers that she's turning a deaf ear to your concern; and 3) she doesn't share your view that the conversations are unprofessional.
If she's avoiding a potential conflict that requires her to correct an employee, that's a problem. Non-confrontational managers are begging staff to go over their heads to a higher authority to manage the problem, inviting friction above and below her position and creating the potential for even more conflict. It's an untenable proposition for which there's no easy answer, and one in which you cannot impact.
If she's turning a deaf ear because she's tired of hearing from a complaint-happy staff, she should be taking steps to curtail the steady stream of accusations and perpetual dissent among her subordinates. Supervisors are obligated to investigate all complaints from their staff whether they're credible or not. If she hears so many complaints from her staff that she considers petty, she needs to take steps to end it rather than bury her head in the sand.
If her view is that the banter is acceptable, the phlebotomist's style will perpetuate and everyone on staff would have to accept it as a difference of opinion. You are to be commended for wanting a more professional working environment, and it may be difficult for you to continue working without this facet that's important to you in the workplace. If that's the case, there are likely many other examples of a lack of professionalism that could require a change in employment for you. Eagles don't want to fly with turkeys, and thoroughbreds don't want to run with donkeys.
What should happen here is your supervisor investigates your claims. All she has to do is position herself within earshot of a few encounters to verify or refute your observations. If the phlebotomist's personal banter is as frequent as you suggest, she'll hear it and, if she agrees with your assessment, counsels the employee. End of problem.
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
Every month we run an excerpt from our editor's popular blog, The Empowered Healthcare Manager.
Profession-ism in the lab
Do those who perform the testing in your laboratory butt heads with your phlebotomists? Just as professionism maintains a wall between laboratory and nursing departments, it has the same affect within the laboratory.
Do your phlebotomists feel like the lab's neglected stepchildren? You won't know for sure unless you practice some good old-fashioned MBWA (management by walking around). Listen to how the analytical staff speaks to the preanalytical staff. Observe their body language. See what's in their eyes. Simultaneously, observe how the preanalytical staff goes about their duties. Do they invite the contempt?
If you detect even a hint of incivility, trust there's an iceberg of phenomenal proportions beneath the surface. It's at the root of most of your personnel issues and it's likely what's causing mediocre performance. It's hard for any faction of your staff to soar with the eagles when they feel surrounded by turkeys.
If you've tolerated it too long, this weekend think about drawing a line in the sand on Monday. Start the week with firm resolve to stop the incivility, arrest the behaviors that encourage it, and articulate the consequences. Make sure you provide recent examples of the kind of behaviors that have to stop.
Nothing good comes from a workplace dynamic that tolerates one profession thinking itself above another. That's what's known in HR circles as a hostile work environment. As long as professionism reigns, people will call in sick when they're not and you'll always work short.
Your lab will never get its hemolysis rates down, blood culture contamination minimized, or sample rejection rates controlled as long as your collection staff feels like second-class citizens.
If you want quality food to come out of the kitchen, you don't curse the cook.
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Tip of the Month: Meet Stan Derds
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