October, 2008

Copyright 2008 Center for Phlebotomy Education, Inc.
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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.

Clot happens
When clotting takes place in a specimen for which clotting is not intended, it isn’t always detectable by the testing personnel. If missed, it can lead to erroneous test results or wreak havoc with the delicate testing instrumentation in today’s laboratories.
       Specimens drawn into syringes are especially vulnerable to clotting. The moment blood enters the barrel of the syringe, the clotting process begins. Any delay in getting the specimen evacuated from the syringe into the tube can result in clot formation before the transfer. One common delay is when the needle is not positioned correctly in the vein, and blood slowly trickles into the syringe. If it takes a considerable amount of time to collect the specimen and transfer it into the tubes, significant clotting may take place. Not only will clotting make it difficult to evacuate the specimen, but if the clots are small enough to go undetected they can alter the results without notice.
       Clotting can also occur during a vacuum-assisted draw when tubes containing anticoagulants are not inverted 5 to10 times immediately after collection. Regardless of whether the tubes are using a syringe or tube holder, without an immediate inversion of tubes that contain anticoagulants, partial or complete clotting can occur. Inversions are also necessary after filling tubes with clot activators so that the additive can perform its function of facilitating complete clotting to the fullest extent.
        Too often, specimen collection personnel merely tilt the tubes back and forth a couple times, then set them down. One complete inversion is defined as turning the tube completely over, waiting for the air bubble within to travel back to the top, then uprighting it again. That’s one. Most tube manufacturers recommend 5-10 of these down-and-up inversions. Shaking the tubes vigorously can result in hemolysis and must be avoided. If not inverted upon filling, invert the tubes as soon as the venipuncture has been completed.
         Particularly vulnerable to clot formation are the small capillary tubes used for CBCs. If not mixed periodically during collection, they are almost certain to form clots and prompt recollection, or form undetectable clots that alter results and affect patient care. Capillary tubes that are open on top during collection can be mixed during collection by tapping gently and periodically on a hard surface, but not so forcefully that blood splatters. Closed systems can also be mixed by tapping, or with a gentle flicking motion to the bottom of the tube.

Fill or Fail
The amount of anticoagulant manufacturers place in their tubes is calculated to provide the proper blood:anticoagulant ratio when completely filled. Underfill the tube and you potentially cheat the patient out of an accurate result. Not on purpose of course, because you may not have had it put in those terms before. But knowing the potential to disrupt the physiology of the specimen makes you ever so unlikely to submit anything but completely filled tubes in the future, right? Bottom line: all tubes should be filled to their stated volume and/or according to the manufacturer’s minimum fill recommendations. If not possible because of a difficult draw or a limited volume of blood has been obtained by syringe, make sure you stock your tray with smaller volume tubes. That way, when your patient delivers less than you suspected, you can obtain the lesser volume and still achieve optimum filling.
       The tube most sensitive to underfilling is the sodium citrate tube (blue top) used for coagulation studies. (Editor’s note: a detailed article titled “What Every Healthcare Professional Must Know About Drawing Coags” appears in the October issue of Phlebotomy Today. To purchase this single issue, Click Here) Any citrate tube filled less than 90 percent of its stated volume will yield falsely lengthened PTT values and can result in the physician adjusting anticoagulant dosage to a degree that risks serious complications.(1)

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.)
Unfortunately, testing personnel have no way of knowing when a full tube contains the contents of two underfilled tubes. It’s not about avoiding specimen rejection; it’s about avoiding erroneous test results that can cheat the patient out of proper care. Underfilled tubes should be rejected at the bedside. Remember, physicians rely on laboratory results for 70 percent of the objective information they receive on their patient’s status. When that 70 percent is incorrect, the patient is at risk of being mismanaged. When it comes to proper tube filling, two halves don't make a whole, they make garbage.

Blood Cultures: All or Nothing
Organisms in the bloodstream that cause septicemia can be in concentrations as low as one organism per milliliter of blood. That’s why it’s imperative that blood culture bottles and vials be filled to the manufacturer’s recommendation or not at all. Submitting an underfilled blood culture bottle does a disservice to the patient. The more blood that is collected for a blood culture (up to the maximum), the better the chances are of harvesting the causative organism that is making the patient ill.

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

Reneke J, Etzell J, Leslie S, Valerie L, Gottried E. Prolonged prothrombin time and activated partial throboplastin time due to underfilled specimen tubes with 109mmol/L (3.2% ) citrate anticoagulant. Coag and Transf. Med. 1997;9(6):754-7.

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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:

  • Feature Article: What Every Healthcare Professional MUST Know About Drawing Coags
  • Ask the Lab Guy!: Answers to your questions on customer service.
    • Is it okay to assemble the syringe and needle before I get to the patient?
  • Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in September including these stories:
    • CLSI Publishes New Skin Puncture Standard
    • Phlebotomist Wins Award for Outpatient Idea
    • ER-Based Phlebotomist Helping Reduce Turnaround Times
    • Accidental Needlesticks in India: 2700 every day
  • According to the Standards: Post-Mastectomy Patient
  • Tip of the Month: Five Truths about Post-Venipuncture Care
  • 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.


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.


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.


Featured Product: Free Infant Foot Training Models with Video Purchase

For the month of October, the Center for Phlebotomy Education is including a free set of three infant heel training models with every purchase of the Skin Punctures & Newborn Screens DVD, released earlier this year. The feet are made of compressed foam, and designed for training staff or students to perform infant heelsticks properly and practice appropriate squeezing techniques when drawing specimens on infants less than one year old. The recommended sites for heel punctures according to CLSI are indicated by green ovals on the medial and lateral aspects of each heel.

For more information, a preview, or to place your order click here

Infant Heelstick Models

Skin Punctures & Newborn Screens


Accuvein Introduces Compact Vein Locator

Venipuncture, the most common medical procedure, is attempted 2.7 million times in the U.S. every day. As many as 33 percent of attempts require multiple sticks. With the goal of helping healthcare personnel perform venipunctures more efficiently, accurately, and safely, a new medical device company hopes to take the guesswork out of finding a vein.

AccuVein (Cold Spring Harbor, NY) is introducing the AV-300, a new handheld vein illumination device that detects veins within human tissue and maps their position on the surface of the skin for a visual guide that aids caregivers in precise needle placement. The product, scheduled for launch in January 2009, locates hard-to-find veins, facilitating blood collection and IV insertion.

AccuVein’s AV-300 allows veins to be located instantly for patients in almost any setting, and is expected to simplify all venous access procedures, improve staff efficiencies, increase patient comfort, and decrease the costs associated with lost productivity and wasted supplies.

In advance of the launch of the AV-300, healthcare practitioners and health system organizations can learn more by visiting www.accuvein.com.

Accuvein AV-300


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.
P.O. Box 161
Ramsey, IN 47166
Fax: 812-633-2346

For more information, contact the Center at 866-657-9857.


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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


Last Month’s Case Study:
Young Interpreters

You enter a patient’s room to find an adorable, well-behaved 8-year-old boy sitting in the visitor’s chair smiling and swinging his legs playfully. Your intended patient is in the bed. You ask the patient to state his name, and he looks at you without responding. Suddenly the boy pipes up “Grandpa doesn’t speak English. I’ll ask him for you.” You’ve never communicated with a patient through an interpreter before, much less an 8-year-old interpreter. What would you do?


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.
     “First I would say ‘thank you. I'm sure you're a great help to your grandpa. Where are your parents?’ Then I would check his ID bracelet and consult with his nurse to verify the patient's identity.”

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.)


This Month’s Case Study:
Catch 22

You've just completed the phlebotomy program at your local community college and passed your certification exam. With formal education and certification under your belt, you apply for a phlebotomy position at two area hospitals. Later you learn that both hospitals only hire phlebotomists with previous work experience. But you can't gain work experience without landing a job.
What would you do?

Tell us what you'd do in this case. Submit your response by the 20 th of the month and send it to this address and this address only: WWYD@phlebotomy.com. Submissions sent to any other address will not be considered. Keep your suggested solutions less than 100 words. Although you don’t have to be an English scholar to be considered for inclusion, submission with proper grammar and punctuation will be given priority. If you’re not sure of the appropriate solution, check your facility’s procedure manual or ask your manager. Who knows, you might be presented with the very same dilemma tomorrow.


From Our Esteemed Readers

Beginning with this issue, we will publish selected comments from our readers. Address all comments to editor@phlebotomy.com.

Patricia J. of Baltimore, Maryland sent in a suggested Phlebotomist’s Prayer:

Dear God,
Grant me the patience and understanding to deal with my patients. Give me the wisdom and knowledge in order to perform my duty as a phlebotomist. Guide my hand through the anatomy of one’s body. Govern my mind and attitude to reflect a radiance of love. Go with me as I journey the floor as my light and peace. And when it’s over, and the day has come to an end, there is a sudden peace letting us remember to give thanks to the Almighty God. Amen.


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Newsletter Information:

PT STAT! is a free, monthly educational service provided by the Center for Phlebotomy Education, Inc., the most respected authority in phlebotomy. For a complete company profile and product list for all healthcare professionals who perform, teach or manage specimen collection procedures, visit us on the Internet at: http://www.phlebotomy.com.
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Copyright 2008, Center for Phlebotomy Education, Inc. All rights reserved. Newsletters may contain links to sites on the Internet owned and operated by third parties. The Center for Phlebotomy Education, Inc. is not responsible for the availability of, or the content located on or through, any such third-party site. Information in this document is provided "as is," without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability, fitness for a particular purpose and freedom from infringement. The user assumes the entire risk as to the accuracy and the use of this document. We will not be liable for any damages of any kind arising from the use of this information, including, but not limited to direct, indirect, incidental, punitive, and consequential damages.