Garbage In; Garbage Out: Part V
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 discussed the order of draw and hemolysis. (To access this and other archived issues, visit www.phlebotomy.com/PTSTAT.html) This month we will continue with errors committed after the tubes are filled focusing on underfilling tubes and improper mixing.
Garbage in; garbage out. Just ask anyone in the laboratory. If a poor quality sample enters the laboratory, a poor quality result goes out. In a blood collection tube, quality is largely undetectable. Some samples can provide visible clues as to their integrity, but most of the errors committed during specimen collection, processing and transportation go undetected.
Despite the phenomenal investment in testing instruments and personnel, no degree of testing sophistication can pull an accurate result out of a specimen that wasn’t properly collected or handled. Only when armed with the knowledge of how blood responds when it isn’t properly mixed and when the concentration of additive in the tube is altered due to underfilling can those who draw blood prevent patients from being treated according to inaccurate results. If you send garbage into the laboratory in the form of poorly drawn specimens, they’ll send garbage back out in the form of inaccurate results.
Fill or Fail
The range of differences between the results of an underfilled versus properly filled EDTA tube can be substantial enough to change a physician's diagnosis and course of treatment. When the ratio of EDTA to blood is too high, the red cells tend to shrink. As a result, hematocrit, mean cell volume (MCV), and the mean corpuscular hemoglobin concentration (MCHC) will be affected.
The contents of two tubes should never be combined into one, even if they contain the same anticoagulant. Doing so changes the concentration of additive to blood so dramatically that it can alter test results in the same way that submitting an underfilled tube does. Too often, those not trained to recognize the potential consequences of this technique are under the impression that a full tube is all that matters… However, a full tube of blood combined from two partial tubes is a full tube of blood that should not be tested. (Note: tubes containing clot activators may be less sensitive to this risky technique. Follow manufacturer’s recommendations.)
Blood Cultures: All or Nothing
Most blood culture bottle manufacturers recommend the optimum volume per set for adult patients to be 20cc of blood evenly distributed between two bottles. If a draw obtains less than 20cc of blood on an adult patient, evacuate up to the maximum recommended volume into the aerobic vial instead of dividing lesser amounts between two vials. (Ninety-eight percent of all septicemias are a result of aerobic organisms or facultative anaerobes, i.e., anaerobic organisms that can tolerate aerobic environments). Collectors should be careful not to exceed the manufacturer’s recommended fill of the culture vials since overfilling can cause some detection instrumentation to identify negative cultures as positive due to the interference of excessive white blood cells.
Next month: Processing Delays, Storage Conditions, & Improper Centrifugation
This Month in Phlebotomy Today
Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 9th year of publication, are reading about this month:
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.
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!
Featured FAQ: Transporting aPTTs
Q: What is the proper transportation temperature for coagulation studies, particularly aPTTs? We have been transporting them on ice for a long time, but a new phlebotomist is telling us that it’s “old school.”
A: According to CLSI, citrate tubes for aPTT testing can be transported at either refrigerated or room temperature. However, transporting protimes on ice is no longer recommended. Chilling such specimens can lead to cold activation of Factor VII, altering protime results. Temperature is not as much of a concern for aPTTs as time is. Specimens from patients on unfractionated heparin must be centrifuged and separated from the cells within one hour and tested within four hours. Specimens from patients not on heparin must be centrifuged, separated, and tested within four hours. After four hours, aPTTs are not stable unless they’ve been centrifuged, separated and the plasma frozen at -20°C (two-week stability). Protimes are much more forgiving. They can be stored at room temperature for up to 24 hours, even uncentrifuged, as long as the stopper has not been removed. Once detached, evaporation takes place, changing the pH and impacting test results.
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.
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Free Archive CD with every new Phlebotomy Today subscription
Looking for more phlebotomy news? Subscribe to Phlebotomy Today, the Center for Phlebotomy Education’s flagship newsletter, currently in its 9th year of publication and receive a free archives CD containing 8 years of back issues. Every new subscriber to Phlebotomy Today (single-user or institutional subscription) will receive the interactive CD containing 81 back issues spanning back to the first electronic version published in March of 2000 through December of 2007 (while supplies last). Are you looking for articles on hemolysis? Type “hemolysis” in the search window and no fewer than 18 issues containing “hemolysis” are immediately accessible. Potassium? Twenty six issues. Articles mentioning centrifugation? Seven issues.
Each issue is accessible in printer-friendly (pdf) format and compatible with Windows XP systems or earlier. (Archives CD not compatible with Windows Vista operating system.) To view a sample issue of Phlebotomy Today or for more information, visit www.phlebotomy.com/Newsletter.html.
Editor to Speak at Northeast Laboratory Conference
Dennis J. Ernst MT(ASCP) editor of the Phlebotomy Today family of newsletters, will be presenting two lectures at the upcoming Northeast Laboratory Conference in Portland, Maine. “Protecting Yourself from Phlebotomy-Related Lawsuits” will discuss the most common errors specimen collection personnel make that lead to patient injuries and litigation. The second presentation, “Top Ten Threats to Specimen Integrity,” discusses those preanalytical errors that are most likely to alter the test result, and lead physicians to mismanage their patients.
This marks the fourth time Ernst has presented at this conference, the largest of its kind in the northeast. Conference attendees will also have an opportunity to visit with Mr. Ernst and see the latest educational products for those who perform, teach, and manage specimen collection procedures at the Center for Phlebotomy Education’s booth in the exhibit hall. For information on attending the conference, visit www.northeastlaboratoryconference.com.
Center Seeking Experts in Phlebotomy
Each month, the Center for Phlebotomy Education, Inc. receives multiple requests from attorneys to review cases involving phlebotomy-related injuries. Due to time constraints, such requests are respectfully declined. But because of the demand for authoritative opinions on the standard of care as it applies to specimen collection, the Center is developing a list of referrals, i.e., healthcare professionals who know the standards for the procedure and have an interest in working as expert witnesses.
Expert witnesses provide valuable insight to the legal profession on the merits of cases involving their expertise. The responsibilities of an expert witness include reviewing medical records, establishing verbal and written opinions on the standard of care as it applies to the case, and defending those opinions in depositions and in the courtroom if necessary. Phlebotomy Today readers who know the standards for blood specimen collection inside out, and want to apply that expertise in a new and valuable way are encouraged to serve the legal profession as an expert witness.
If you are a knowledgeable healthcare professional with an astute familiarity with the standards, polished writing and oral communication skills, and confidence in your expertise, send your résumé to the Center for consideration at the following address:
Center for Phlebotomy Education, Inc.
For more information, contact the Center at 866-657-9857.
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
Readers didn’t find this scenario all that unusual. Of those who responded, nearly 50% said they’d call for their facility’s interpreter. Thirteen percent said they’d let the boy interpret, but would seek a nurse for confirmation. Another 13 percent said they’d let the boy interpret and rely on his responses. One respondent said the identification bracelet would provide the two bits of data recommended for proper patient identification. (Editor’s note: CLSI requires the patient, caregiver, or family member to state the patient’s name in case the identification bracelet is on the wrong patient.) Twenty-seven percent said they’d check the identification bracelet, and then seek confirmation from the caregiver. One respondent suggested using an “interpreter phone.”
Melinda K. shared her reaction: “Due to changes in our patient population, we have actually experienced this issue recently. Our facility sought assistance from staff and asked those who spoke other languages to form an interpreter’s call list. We now have interpreters available that speak Spanish, Russian and German. We have had to rely on family members to communicate with the patient in emergency situations and in our OB unit. Sometimes, you just can't wait on an interpreter.”
People like Nancy R. found the shortest distance between two points. Her response mirrors the CLSI protocol for identifying patients who cannot speak their name, which is to find a caregiver or family member who can state the patient’s name on his behalf.
Obviously there are many potentially correct answers to this scenario. What’s most important is that the patient’s identification can be ensured beyond doubt, and in a way that doesn’t compromise his right to keep his medical information confidential. Darnita W. of Louisiana said it very succinctly:
“Children are not permitted to serve as translators for their parents when healthcare issues are discussed. Phlebotomists should be knowledgeable of the applicable laws and their organization`s policies and practices regarding translations. In many organizations, there are personnel available to assist with translations; additionally, online translation services and/or written instructions in languages other than English can be made available.”
For her answer, Darnita will receive a free “Accurate Results Begin With Me! ®” t-shirt.
(Editor’s note: cumulative percentages reported in this article exceed 100% due to multiple approaches submitted by some respondents.)
From Our Esteemed Readers
Beginning with this issue, we will publish selected comments from our readers. Address all comments to firstname.lastname@example.org.
Patricia J. of Baltimore, Maryland sent in a suggested Phlebotomist’s Prayer:
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