Lining and labs/ hemolyzed specimens

Specialties Emergency

Published

So it was decided by our hospital that it is no longer "acceptable" to draw labs when starting an IV--i.e. they have to be peripherally stuck for blood in addition to the stick for the IV start. The supposed reasoning behind this is that too many blood specimens were hemolyzed when drawn during an IV start, especially compared with the hemolysis rate for phlebotomists drawing on the floor.

So, we were 'provided' with a phlebotomist and it apparently showed or hemolysis rate went down when they drew blood. What I find interesting is that they were doing such a great job that, yet they went from working in the ER from 11a-11p to now just working 11a-7p. In addition, we are the first place from which a phlebotomist is pulled if they are short staffed (so that they cover the whole house). A coworker also make an interesting observation. When the phlebotomist draws blood they send it to the lab in a colored biohazard bag, while the biohazard bag that we have in stock is clear plastic with the biohazard logo on it. The coworker suggested that if the specimen shows up in the colored bag, the lab treats it differently so that it does not come back hemolyzed or the ignore minor hemolysis on these specimens, yet they always report even the smallest amount of hemolysis drawn on samples drawn by ER staff. Not sure if I buy into the conspiracy theory, but it is an interesting thought.

I have been told by several ER docs and residents that this is a foolish policy and that they line/lab (all in one stick) "everywhere." One doc, who happens to run the residency program for the hospital system asked me "who came up with such an inane policy?"

Anyway, just looking for comments from other ER nurses. Anyone else have to deal with something so silly?

I have to say that I have seen cases where this is not true. There has been times where the blood is a half a micron below the line on a light blue (coag) tube and I have gotten called saying they could not run the test. There was another time I was helping another nurse with a difficult stick....she only got the tube half full, removed the tube from the line and said "that'll do." Well, lab ran it. So, something has to be going on...

I don't want to argue, or inflame, but I am just offering some perspective.

Coags are a different beast. It only takes about 1/10 of 1 ml of plasma to run a coag test. In this case, it's not a matter of having enough specimen, it is having the right ratio of specimen to anticoagulant. Blue tubes have an exact amount of anticoagulant in them, so that if you fill the tube to the line it is a 1:9 ratio. The machine does not know or check the ratio, it checks to see if there is sufficient specimen. The tech is responsible for checking the ratio. Many will run it short, but then the results are skewed. If it is an emergency, or again when the lab techs just can't handle being cursed out one more time, it can be run, but it is not accurate.

Specializes in Emergency, Telemetry, Transplant.
Coags are a different beast. It only takes about 1/10 of 1 ml of plasma to run a coag test. In this case, it's not a matter of having enough specimen, it is having the right ratio of specimen to anticoagulant. Blue tubes have an exact amount of anticoagulant in them, so that if you fill the tube to the line it is a 1:9 ratio. The machine does not know or check the ratio, it checks to see if there is sufficient specimen. The tech is responsible for checking the ratio. Many will run it short, but then the results are skewed. If it is an emergency, or again when the lab techs just can't handle being cursed out one more time, it can be run, but it is not accurate.

The only point I was making in my post about coags was that some techs will run a tube that is not full, others demand it to be full--in this sense, whether or not a specimen is acceptable depends on the lab tech...just like for hemolyzed specimens.

Specializes in Emergency Room.

I work as a Tech in the ER and we have had a lot of issues with our lab. I usually don't get very many recollects which is why I am furious every time my specimens get recollected unless I know it wasn't a very good draw. There are many reasons why labs can get hemolyzed but some of the main ones I see from the nurses/phlebotomists end are:

Leaving the tourniquet on for too long; when using a syringe, using either too big a syringe on a small vein or pulling forcefully on the syringe; shaking the tubes instead of inverting them gently.

I find that unless it's a really good vein, using the vacutainer with the luer lock for IVs tends to hemolyze the specimens a lot, gently withdrawing with a small syringe tends to work better in my experience. As far as kids are concerned, I never use a vacutainer because the vacuum of the tubes will cause their fragile veins to collapse.

I don't think all of our issues with recollects are completely our fault though because even the travel nurses that work with us frequently say that they get more recollects at our hospital than other places they've worked. Some of the nurses I work with started their careers working in the lab and they talk all the time about how lab techs and CLSs would hemolyze the specimens themselves after they were spun down. Also, our lab has been known to recollect specimens because the results were abnormal, as if people that show up in our ER aren't sometimes very sick. Not to mention that our lab loses specimens all the time, for example, ammonia levels and lactic acids both need to be sent down on ice and one of our nurses sent both tubes down in the same cup of ice. The lab resulted the lactic but told we us we never sent down the ammonia level. It's so frustrating because we all have so much to do already without having to draw patients 2 or 3 times.

Our hospital's protocol is to draw with a syringe before attaching the saline lock. Not pulling through the needless hubs brought our hemolysis rate WAY down.

Specializes in ED.

I haven't read all the replies but....

We went through a period where it seemed like we had a VERY high incidence of hemolyzed specimens. After a lot of back and forth between the lab and ER, it was decided that our t-sets attached to the catheter hub was partly to blame. It was also decided that there was one lab tech that was, basically, too lazy to attempt to run a minutely hemolyzed specimen. It was always the same chick that called to say the specimen was hemolyzed. Always!

Anyway, we got new t-sets and changed our order of draw and we don't have near the amount of recollects.

As far as not getting blood with an IV site, I'd be pretty upset if I were the pt and had to be stuck separately. Now, I realize that sometimes that IV won't draw but will flush or you are already running some med or fluid but to just stick like you are describing is just creating more time-consuming work for me. I really hate when I am forced to work harder and not smarter.

m

Specializes in being a Credible Source.
but to just stick like you are describing is just creating more time-consuming work for me.
Not to mention that every time a needle breaks the skin, there's a non-zero chance of infection, accidental needle stick, blown vein, hematoma, etc, etc.

I'll stick 'em as often as necessary but it's not optimal patient care to routinely require additional sticks when the vast majority of samples drawn by a skilled nurse through a patent IV site are perfectly fine.

1 Votes

Your residency doc who says they line/lab draw (all in one stick) everywhere would do well to be informed that the problem of hemolysis using this method exists EVERYWHERE. From San Fransisco to New, New York; Weslaco, Texas to Detroit, Michigan and everywhere in between.

It takes much more work to reject a sample due to hemolysis, than to run one and release the questionable results.

Specializes in MICU, SICU, CICU.
I work as a Tech in the ER and we have had a lot of issues with our lab. I usually don't get very many recollects which is why I am furious every time my specimens get recollected unless I know it wasn't a very good draw. There are many reasons why labs can get hemolyzed but some of the main ones I see from the nurses/phlebotomists end are:

Leaving the tourniquet on for too long; when using a syringe, using either too big a syringe on a small vein or pulling forcefully on the syringe; shaking the tubes instead of inverting them gently.

just curious, how would a lab tech hemolyze the specimen.

I have been called about hemolyzed specimens when I knew what I sent to lab was a perfectly good specimen.

There are many reasons why labs can get hemolyzed but some of the main ones I see are: Leaving the tourniquet on for too long
I dispute this. There is no mechanism by which the tourniquet duration would result in hemolysis nor have I seen this in my 5 years of drawing blood... and on occasion I've left tourniquets in place longer than is optimal due to multiple sticks in a time-critical patient or placing a particularly difficult ultrasound line.

I have been called about hemolyzed specimens when I knew what I sent to lab was a perfectly good specimen.
I've had the same experience. I know when a sample is possibly hemolyzed.

We had a CLS who was observed by our ED manager shaking the tubes. When she was on-call, I preferred to spin them down myself before she got there so that there could be no argument.

Specializes in Emergency, Telemetry, Transplant.
I dispute this. There is no mechanism by which the tourniquet duration would result in hemolysis nor have I seen this in my 5 years of drawing blood... and on occasion I've left tourniquets in place longer than is optimal due to multiple sticks in a time-critical patient or placing a particularly difficult ultrasound line.

+1 :yes:

Maybe it's certain lab techs.

I dont work in the lab and won't even attempt to know how things go but im willing to bet that most spin the samples and then call me to complain..

Where there's 1 tech that seems to call the instant the tubes arrive and tell me every single 1 is no good.

I would rather redraw 1 tube and know that's the bad tube then redraw a rainbow on a difficult stick..

Any why oh why, when a pt goes outpatient to the lab for testing, do we never hear about hemolyzed labs?

I worked ambulatory 3 years on the telephone and never once had to notify a pt that their labs needed redrawn... Hmmmmm

+ Add a Comment