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February, 2016 (Volume 17, Number 2)

by Dennis Ernst • February 10, 2016

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Best Practices in Tube Handling, Part 1

TubeMix 400wHandling all the threats to blood-sample integrity is an enormously complex undertaking. Human blood is complicated. We’ve been studying it for centuries and we still don’t know everything there is to know about it. And what we do know is exceedingly difficult to apply every time we handle a sample.

That’s because the preanalytical phase, or pre-examination phase, is predominantly a manual process that requires human programming. At the point of collection, machines don’t draw blood, mix blood, or label samples. In most places their handling is manual. That’s where the “practices” of Best Practices comes in. We’re talking about human behavior here, and how people practice the art of drawing and handling samples.

Happy tube, happy test
A test result is accurate only if the tube is properly filled and handled. A happy tube means a happy test. Tubes leave their manufacturer happy, but what happens when they get to your place? Do they lose their good nature? Does the way you handle them make them cranky? Stubborn? Nervous? Let’s take a look at what we might be doing that changes their disposition.

One cannot discuss tube handling completely without first addressing how to handle tubes before they’re filled. Tube manufacturers sweat this part because once the tubes are in your hands, how they perform is completely and entirely out of their control. While they’re made with high tolerances for a wide variety of environments, they still have to be handled properly before they’re filled.

Make sure you’re rotating your stock, first in/first out. An expired tube on your shelf or in your draw stations or phlebotomy trays is not only hard to explain to inspectors, but not likely to fill to the proper level.

According to the CLSI standard on tubes and additives (GP39-A6), at the end of a tube’s shelf life, the draw volume shall be no more than 10% below the stated draw volume. So you’re assured an in-date tube will fill at least 90 percent. With an expired tube, there’s no guarantee.

One of the most commonly overlooked pre-collection tube handling aspects is their storage temperature. Has your facility’s air conditioning units ever failed? When they do, and they will, are you certain someone is tasked with checking the impact the high temperature might have had on the tubes in stock? If not, when tubes start underfilling three months later, will it be traced to the a/c failure or blamed on the tube manufacturer or phlebotomy team? Connect the dots early and you’ll solve big problems before they even happen.

Tubes in storage should always be kept away from sunlight and direct heat, as well. They can wreak the same havoc as a malfunctioning a/c unit. Direct sunlight will be easy to detect, but are your stored tubes in close contact with heating ducts? If so, relocate them or have your facility-management team redirect the air flow so that tubes are not directly impacted. Don't forget about tubes used by a courier or mobile draw team. Are they subjected to high temperatures prior to use? If so, put a procedure in place to keep your transient inventory of tubes at the manufacture’s stated temperature range. 

If your altitude is more than 5000 feet (1500 meters) above sea level, make sure the tubes you stock are high-altitude versions. Altitude affects the tubes’ vacuum in no small way, so don’t underestimate the importance of this factor.

All these factors will reduce the vacuum in the tubes. So if you’re finding a sudden increase in the number of underfilled tubes, ask yourself these questions:

  • Is our inventory being properly rotated or are we using expired tubes?
  • Are the tubes exposed to higher temperatures, or were they in the last few weeks or months?
  • For those of you above 5000 feet: are we using high-altitude tubes, or did we accidentally receive regular tubes?

 Filling factors

ImpactOn to tube-handling tips during the draw. Are you careful about how the blood enters the tube? You should be. Some patient's red blood cells are more delicate than others, Think of your red blood cells as fragile crystal orbs that don’t tolerate a lot of force, Instead of letting the blood directly impact the bottom full-force, angle the tube so the incoming stream hits the side at an angle. It's as easy as raising the tube with a finger just enough to let the blood impact the side instead of the bottom.(See right.)

No discussion on tube handling is complete without stressing the importance of the order in which tubes must be filled. The order for venipunctures, which has not changed since 2003, is as follows: 1) blood cultures, 2) citrate, 3) serum, 4) heparin, 5) EDTA, 6) glycolytic inhibitors. The order is the same for syringes as it is for tube holders. For capillary draws, the order is 1) EDTA, 2) other additive tubes, 3) serum tubes. This order has not changed since at least 1999. [Editor's note: answers to questions on the order of draw may be found by entering "order of draw," including the quotation marks, in the search window at]

One way to tell is the order of draw was not followed is if the laboratory's chemistry department starts questioning the reliability of their potassium results. When the EDTA tube is filled before a serum or plasma tube to be tested for potassium, EDTA, which is rich in potassium, can carry over and contaminate the next tube. The same contamination can happen---to a much greater degree---if the contents of an EDTA tube (lavender stopper) is poured into a tube to be tested for potassium.

Mixing by the numbers

InvertBDsmallProbably one of the most frustrating problem any laboratory has is when samples aren’t mixed properly. Not only can clots wreak havoc on sensitive laboratory instruments, it delays test results by at least an hour waiting for a new sample. Mixing isn’t hard. In fact, it’s so simple that a lot of people think it isn’t important. Don't be one of the many who underestimate this important step. Mixing must be slow and deliberate. No sideways jiggles and no furious shaking. Tubes with additives must be inverted all the way down, paused for the air bubble to rise to the top, and all the way back up again. That’s one inversion. Follow your tube manufacturer's recommendation, but serum, EDTA, and heparin tubes should be inverted 5-10 times, and citrate tubes 3-5 times.

If you're an educator or trainer, drive the point home using visual images. Take a filled anticoagulated tube and show trainees how the air bubble rises as the tube is inverted. Explain it’s the air bubble that erodes the additive off the wall and into the blood, and if that bubble isn’t allowed to rise all the way to the top, it can’t do the job. That’s why inversions have to be slow and deliberate, with a pause every time it’s turned over.

Fill 'er up

Citrate tube fill lines: Greiner (L), BD (Center), Sarstedt (R) Click to enlarge.

The last tube handling issue to address during the draw is filling the tube sufficiently. Do you and those who work with you or for you know what the fill lines on the label represent? Are they the minimum, maximum or the ideal volume? If the mark on the tubes you use represents the minimum and someone thinks it’s the maximum, then they’re going to submit short samples thinking there’s a fudge factor they get to work with. Just remember, manufacturers put a carefully calibrated quantity of anticoagulant into their tubes. There’s a certain sweet spot with the concentration of every additive. Stay within that sweet spot and the tube performs as it should. Tinker with the concentration by overfilling or underfilling and the blood no longer represents the patient’s status. 

Make sure you and your staff or students know how to interpret these lines. Greiner Bio-One uses a black arrow on it's label. The point of the arrow indicates 100 percent of the stated volume. The top and bottom of the arrow represent a ten-percent variance. If the level of the filled blood tube is above or below the upper and lower extremes of the arrow, the tube should not be submitted for testing. The BD Vacutainer® Plus sodium citrate tube has an etched line on the plastic itself that indicates the minimum fill line. Tubes with a blood level that falls below this line should not be submitted. For Sarstedt tubes, the line on the label indicates the optimal fill.

Submitting underfilled citrate tubes risks adjustments to the patient's blood thinner that may put him/her at risk of stroke or other complications from circulating clots that can be catastrophic, even deadly.

It's not just coags that are affected by underfilling. The following analytes are affected when underfilling a heparin tube: ALT, AST, amylase, LDH, lipase, potassium, troponin, CK and GGT. It’s not just speculative.(1-3) On the other side of the equation, is your lab testing underfilled tubes for analytes known to be affected? If so, those who test underfilled samples are not being managed properly.

UnderfilledCBCgboHow much can you underfill an EDTA tube and not affect results? Underfill an EDTA and you get falsely lower hematocrits and MCVs because EDTA in excess concentrations shrink the red blood cells. But at what level of underfill does it become significant? Studies on this are scant, which is why we must adhere to the tube manufacturer's recommendations. To avoid underfilling, stock a wide variety of tubes in your trays and draw stations that include low draw-volume tubes. That way when there’s a difficult draw, the phlebotomist can employ tubes that have lower vacuum and submit lower volume tubes filled to their sweet spot, the only place that can possibly render an accurate lab result.

It's no surprise whey we refer to phlebotomy as the most underestimated procedure in health care. There’s so much to it, and most of the mistakes we make when drawing or handling a sample that changes the test result can’t be fixed by the lab. Most of the time they can’t even be detected. Make this your mantra for the month: Best practices proactively protects patients, or BP4 for short.

Next month we'll discuss Best Practices as they relate to transportation conditions. 


  1. Donnelly JG, Soldin SJ, Nealon DA, Hicks JM. Is heparinized plasma suitable for use in routine biochemistry? Pediatr Pathol Lab Med. 1995 Jul-Aug;15(4):555-9.
  2. Tietz Guide to Clinical Laboratory Tests WB Saunders,  St. Louis, MO (2006)
  3. Lippi G1, Avanzini P, Cosmai M, Aloe R, Ernst D. Incomplete filling of lithium heparin tubes affects the activity of creatine kinase and gamma-glutamyltransferase. Br J Biomed Sci. 2012;69(2):67-70. 


High-powered Talent

High-powered Talent is intended to inspire employees to become the one asset on staff their managers can't imagine working without and the one professional every patient hopes will draw their blood.

SpaceShuttle_modifiedHigh-powered talent is a state of mind. It seeks, finds, and seeks some more.

Low-powered talent seeks and rests.

High-powered talent is laser-focused on helping, working, serving and raising people up.
Low-powered talent is focused on texting, gossiping, avoiding and belittling. 

High-powered talent is often requested by patients, and given additional responsibilities.
Low-powered talent is often reprimanded by supervisors and given suspensions.

High-powered talent covers and works late when others call in sick
Low-powered talent calls in sick when they're not.

High-powered talent sacrifices breaks to help a coworker with a tough stick.
Low-powered talent rushed to an early break to avoid helping with a tough stick.

High-powered talent arrives early and stays late.
Low-powered talent arrives late and leaves early.

High-powered talent helps her boss be an effective supervisor.
Low-powered talent bosses her supervisor and everyone else.

High-powered talent has a voracious appetite for anything pertaining to phlebotomy.
Low-powered talent won't read anything related to work unless consequences are applied.

High-powered talent is humble, apologetic, other-focused, and servant to all they encounter.
Low-powered talent is prideful, unapologetic, narcissistic and insists on being served.

Print and post an attractive pdf defining High-powered Talent.


 Product Spotlight: Boot Camp VIII date and location announced

BootCampCandids_200wQuestion: What are you doing November 8, 9, & 10, 2016?
Answer: Attending the most empowering, transformative seminar you've ever attended.

At least that's what past attendees to the Phlebotomy Supervisor's Boot Camp have said about the event. "I had a staffing challenge with a trainee when I returned from Boot Camp," said Karen McKinney of Cameron Hospital in Angola, Indiana. "I am happy to say that without the tools that were provided during this seminar I would not have had the courage or confidence to do what needed to be done."

Benjamin Galay from UCSF in San Francisco said "I only regret not inviting other lab supervisors to join me. The information and material were great. I feel I have something new that will not only impact our productivity but create a better work environment and culture." According to Laura Singley from Rogue Valley Phlebotomy School in Medford, Oregon, "You have done a phenomenal job with this Boot Camp. Very inspiring!" Jim Harrington from Cape Cod Hospital in Hyannis, Massachusetts said "The Center for Phlebotomy Education has truly outdone themselves with this program. I enjoyed every moment spent!"

Boot Camp VIII takes place November 8-10, 2016 at the Embassy Suites--Ayersley, in Charlotte, North Carolina. The same location as Boot Camp VII. "The venue is "suite," puns Dennis J. Ernst MT(ASCP), NCPT(ASCP) who give the keynote and presentations on coaching customer service, reclaiming your lab's squandered resources, and preventing preanalytical litigation. "The reviews from our attendees about this hotel were over the top. This property is new and the staff is exceedingly polished and professional." 

The Center for Phlebotomy Education is shuffling the faculty for this year's event, bringing in Rosemarie S. Brichta MT(ASCP), formerly the Education Coordinator at Alverno Clinical Laboratories. Returning for her second Boot Camp by popular demand will be Beth Warning, MS, MT(ASCP), an adjunct instructor with the University of Cincinnati Medical Laboratory Science Program in Cincinnati, Ohio.

Attendees at the 2015 Boot Camp raved about the tour of the Greiner Bio-One tube manufacturing facility." The company is on board for conducting tours again for Boot Camp VIII. 

So what are you doing November 8-10th this year? We hope you're going to Boot Camp. For more information and to register, visit

Free Webinar on Urine Collection

UrineContainers_400wGreiner Bio-One is offering a free webinar titled "Revisiting a Common Lab Test: Urinalysis and Urine Culture." The presenter will be Beth Warning, MS, MLS (ASCP) with the MLS Program at the University of Cincinnati. Warning is also a faculty member at the Center for Phlebotomy Education's Phlebotomy Supervisor's Boot Camp. 

The webinar takes place March 17 at 1 p.m. EST. Warning will describe the preanalytical requirements for urine and urine culture, identify current practices in analytical testing of urine, and describe the process of urine culture for select patient populations. One P.A.C.E. continuing education credit will be awarded to all attendees. 

Registration and more information.


On the Front Lines: Newborn screens in the order of draw

Dear Center for Phlebotomy Education,Cap53

Upon reviewing the CLSI standards for capillary collections (GP42-A6), I found the following: 

Newborn screening specimens should be collected separately, after prewarming and puncturing a second site. (Refer to CLSI document LA04 for details.)

If a newborn screening is ordered in conjunction with additional lab tests, is it really necessary to perform a separate puncture? If so, is it recommended to collect the newborn screen first prior to any other collection? I did refer to LA04, which has been replaced by NBS01-06 and did not find any additional information. 

Our response:  NBS01-A6 came out after GP42, the skin puncture standard. I suspect when the skin puncture standard is revised, it will no longer reference NBS01. That said, you are correct with your interpretation. A second puncture needs to be performed for additional tests when a NBS is ordered with other lab work. It doesn't matter which is collected first, the additional lab work or the NBS, but two procedures are necessary. As such, the order of draw doesn't apply.

Doing all collections from the same puncture is problematic. If the NBS circles are filled first, the flow of blood will likely cease before every tube is filled. Most heels don't bleed that profusely even when prewarmed. Even if the blood flows profusely after all the circles are filled, the latter drops are likely to be full of clumped platelets, which would interfere with CBCs.

If the NBS card is filled after additional orders are satisfied, you're not likely to sufficiently fill the circles for the same reason.


 From the Editor's Desk


As many of you already know, I made my television debut last Friday night on Dateline NBC. I didn't tell the producer this, but I've never seen Dateline. Still, when you get a call like that wanting you to get on a plane the next morning to New York City for an interview that will air in prime time, you don't say no.

I'm not the reason NBC enjoyed its highest rated Friday Dateline since November 2014 with 4.7 million viewers, but I will say it was a good night for phlebotomy. For those of you who don't know the case, you can view the entire documentary here. I come in at about the 30:00 mark. 

If you can't watch videos where you work or don't have the time, here's the Cliff's Notes. Steven Avery was wrongly accused for assaulting a woman and spent 16 years in prison before DNA tests proved his innocence. He filed a $36 million lawsuit against the Manitowac County. Two years later he was back in prison, convicted of murder. He claims the county framed him to avoid the lawsuit over his wrongful imprisonment. Part of the "frame-up" was an "aha moment" his attorney had when he noticed a puncture mark in the stopper of an EDTA kept as evidence from his assault case. The attorney feels the puncture hole suggests the sample was tampered with. Specifically, Avery's blood was withdrawn from the EDTA tube and planted in the victim's vehicle. The case was made widely popular by the Netflix series, "Making a Murderer."

All that led to a phone call last Monday at 3:45 p.m. from Tom Keenan, a producer for Dateline NBC. I was on a plane to their studios at the Rockefeller Plaza in New York City at 6:30 the next morning. 

IMG_20160126_101155215Although the city was walloped by a massive snow storm two days earlier, the driver of NBC's contracted car service who met me at LaGuardia navigated traffic and ten-foot snowbanks deftly. In true New York fashion, now and then he'd flip off other drivers with a smile just as easily as you and I might wave a "thank you." I think it means the same thing there. 

Tom met me at the elevators at 30 Rockefeller Plaza and walked me around NBC's massive studio complex. I was astounded at the level of production going on. Rows and rows of computers and millennials editing footage, monitoring the newswires, and working the NBC web sites. Make no mistake, this was a manufacturing facility. The product this week: a one-hour documentary on the Steve Avery case to be aired in 3 days, and I hadn't even been interviewed yet. 

Tom briefed me on the aspect of the EDTA tube's stopper the defendant's attorney thinks had evidence of tampering. When he pointed to an image of the stopper with the puncture mark on his monitor, I had one word for him: "So?" With that we went for a cup of coffee and discussed how my upcoming interview with correspondent Andrea Canning would unfold. I would be asked general questions about how a blood draw is performed, why stoppers have puncture marks, and general information. He was pleased I brought some equipment to help demonstrate.

IMG_20160126_112033127I was seated in the studio at noon and met the camera crew. The set was simple. Two chairs turned 45-degrees toward each other with a bar stool draped with black cloth in front for my supplies. Behind the chairs hung a large black cloth from ceiling to floor as our backdrop. Three cameras were set up on tripods, one to record Andrea's closeup, one for mine, and the third would film the two of us full-frame. Above both chairs were 3x3-foot light boxes suspended on booms and positioned to hover no more than a foot above our heads. Other light boxes provided front lighting. One cameraman wired me up while another applied my makeup. You'll be glad to know having makeup applied was a first for me.

MollyBrownWell, sort of. I used to do a lot of community theater back in the day, playing characters such as the Kralahome in the King and I, Johnathan Brewster in Arsenic and Old Lace, Christmas Morgan in The Unsinkable Molly Brown (left), and (my personal favorite) the Tin Man in The Wizard of Oz. But I applied my own makeup then, and poorly so. So that doesn't count. 

Andrea stepped in. Although I had never seen her or Dateline, I knew it was her immediately. People who spend their lives in front of cameras just have this look about them. She introduced herself and sat down to discuss the nature of her questions, texting on her phone now and then. As she was being wired for sound and her makeup applied, I gave her the rundown on how blood is drawn, with both a tube holder and syringe. She thought a syringe was likely used to draw Steve Avery's blood, so we settled on that for my demonstration once the cameras started rolling.

I explained how a safety transfer device would have (should have) been used by the prison nurse, Even though safety needles were not mandated in the U.S. at the time the sample had been drawn, Andrea understood that I could not demonstrate removing a non-safety needle from the syringe because it was not something that was appropriate for me to demonstrate. For the purpose of my demonstration, a safety needle would suffice.


The interview lasted an hour. I was granted the obligatory pose with the correspondent, and was released to wander mid-Manhattan, taking my bite of the Big Apple. Tom would call me if he needed me to come back later for any retakes while I was in town. He didn't.

My first stop was in St. Patrick's Cathedral to spend time in prayer, thanking Him for the opportunity to serve in this capacity. When I left the bench on December 13, 1998 looking for another way to work within my chosen profession, I never intended, nor could I have predicted, I'd have ended up where I found myself on January 26, 2016. Nor do I fool myself into thinking it's a big deal. My one-hour interview was distilled into a 34-second clip in one show on one channel for one night. In the grand scheme of things, that's a nothing burger. Of far more importance is opportunity to inform. If you know me, you know that's what I live for. It doesn't matter to me whether it's to 4.7 million on Dateline, 100 at Boot Camp or one email to you, the pursuit of the opportunity to inform consumes me. 

Just between you and me, I didn't seek this pursuit, it sought me. I wasn't born to create the Center for Phlebotomy Education, nor was I qualified to start it. When I quit my full time lab tech job on December 13, 1998, it wasn't because I knew a lot about blood collection. It was because I wanted to. Phlebotomy was the one thing---the only thing---about being a lab tech I enjoyed. God blessed me with a wife who believed I could do something with that passion, and allowed me to answer the calling that ultimately brought me to service to you, and the few viewers who didn't blink when I came on Dateline last week.

Call the qualified+_1000There's a sign sitting above my work station that reads "God does not call the qualified, he qualifies the called." If you have a calling, and it's not what you're currently doing, answer the call. Even if you don't think you're qualified, you will become so. It won't be easy and it won't be instant, but what other option do you have? You can spend the rest of your life asking yourself "what if?" or taking the leap and seeing for yourself. Having been there, I can tell you finding out is a whole lot better than wondering.



Dennis J. Ernst MT(ASCP)
[email protected]


 Sticks, Staph, & Stuff: EpiNET updates needlestick stats

As a healthcare professional, one of your greatest risks is of being exposed to pathogens. Your patients face the same risk. Each month, Sticks, Staph & Stuff will discuss ways you can protect yourself from a bloodborne-pathogen exposure and your patients from exposure to pathogens you're capable of transmitting that can lead to healthcare-acquired infections (HAIs).

Bacteria in blooodRecently, EpiNET updated their statistics for needlestick rates in the U.S. The exposure surveillance program based at the University of Virginia posted data from 2012 and 2013 showing rates continue to decline after the 2001 OSHA mandate for safety devices.

Rates peaked in 1999, two years before the OSHA mandate, at 34 per year for every 100 occupied beds. By 2013, the rate dropped to 21.4, representing a 37 percent decrease. For phlebotomy, the rates of injuries sustained during butterfly use remains significantly higher than when tube holders are used, in some years, five times higher. In 2013, the needlestick rates for butterfly devices jumped 142 percent from to the prior year, from 1.4 percent of all sharps exposures to 3.4 percent. For the same period, tube holders were in use during 0.8 percent of all reported exposures in 2012 versus 2.4 for 2013.

Similar declines are being reported in Canada where needlestick rates in Ontario declined by 31% in hospitals between 2004 and 2012. Rates at long term care facilities dropped 67 percent. Legislation mandating safety devices was passed in 2006 and became effective in 2011.


What's Wrong Here?

Shutterstock_96466841What's wrong with this picture? (Click image on the left to enlarge.) We guarantee something isn't as it should be. The answer will be in next month's issue.

Shutterstock_37758193Last month the image we posted (right) was a train-wreck of errors. The most glaring is the way the index finger is positioned above the needle, holding the gauze in place. That's asking for a needlestick. The flow of blood in this image is already in process, so even if the index finger was used to stretch the skin above and below the intended puncture site as the needle was inserted (which it should never be, but that's another discussion), keeping the finger above the needle puts it in harm's way.

Also not the arm is bent. A slight bend is sometimes necessary to locate the vein, but the bend depicted here is far too extreme, making it impossible to effectively anchor the vein and stretch the skin. Also an issue is the manner in which the tube holder is being held. Since no needle should be inserted when held in this manner, switching to this awkward position after the vein is accessed requires significant manipulation, risking needle movement and an unintended relocation that may be injurious, or at least render the draw unsuccessful.

Finally, the device is missing a safety feature and the collector's arms are not protected with sleeves. Other than all that, there's nothing wrong here. 

Tip of the Month

Each month we post a "Tip of the Month" on our web site from our rich library of archived Tips. 

This month's Tip: "Short-changed by Short Draws"


  CE Questions 

 1. What's wrong with the picture in this month's "What's Wrong Here?" column? (fill in)



2. Besides potassium, the following additional analytes are affected when tubes are underfilled:
a. ionized calcium, glucose, and sodium

b. ALT, AST, and LDH
c. ALT, glucose, and triglycerides
d. Sodium, bilirubin, and AST

3. The frosted line on BD's sodium citrate tube signifies:
a. the maximum fill volume
b. the minimum fill volume
c. the optimum fill volume
d. the tube is expired

4. When newborn screening (NBS) is ordered with other lab work:
a. they can be collected from the same puncture, but the other lab work is collected first
b. they can be collected from the same puncture, but the NBS is collected first
c. two separate collection procedures are necessary
d. it is necessary to wait at least one hour between collections

5. in Canada,needlestick rates in Ontario declined by _____ in hospitals between 2004 and 2012:
a. 13%
b. 31%
c. 45%
d. 60%

6. High-powered talent: 
a. is laser-focused on helping, working, serving and raising people up
b. is often requested by patients, and given additional responsibilities
c. sacrifices breaks to help a coworker with a tough stick
d. all of the above

7. If the patient's arm is bent significantly at the elbow, 
a. it's impossible to effectively anchor the vein and stretch the skin 
b. the puncture will be less painful
c. veins are less likely to roll
d. potassium levels will be elevated


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