Lining and labs/ hemolyzed specimens

[psu_213]

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?

[PacoUSA, BSN, RN]

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

^^^^^^ This!!

Sent from my iPad using allnurses

[e102587]

Outpatients do occasionally need to be recollected due to hemolysis. You never hear about it, because the lab takes care of calling their own redraws back. It might be a HIPPA violation for this data to be published. Tubes for most chemistry tests are definitely spun down first; this is how the serum or plasma is obtained to perform testing. Plus, this is really the only way to tell if tubes are hemolyzed. Veteran lab scientists can tell by the way the blood coats the tube when, they rock it, whether it's hemolyzed. Also, some parameters of the CBC are grossly elevated when the tube is hemolyzed, MCHC for instance. The big reason the tubes drawn with an IV start are hemolyzed better than fifty percent of the time is that the lumens are designed to introduce liquid fluid into the body NOT to TAKE IT OUT. Red blood cells are solid and very small, and when they strike the surface of the IV device they rupture and spill their CK, potassium, LDH. Sometimes the pressure when pulling tubes with a syringe does this too. It is not a conspiracy. This is a world-wide problem; hemolyzed IV draws in an emergency room, or any other setting. It takes more time and involvement to have a hemolyzed sample redrawn than to submit marginally credible results obtained from a hemolyzed specimen. Many RN's have figured out a good technique that works for them and they use it. As healthcare providers, we need to consolidate correct drawing procedure and stick with it. We owe this to our patients!

[psu_213, BSN, RN]

Outpatients do occasionally need to be recollected due to hemolysis

I've also seen docs send their patients to the ED since they had a K of 6.4. Once we look up the result directly from the lab (if possible--if not we do our own), we see that the specimen was hemolyzed (or we get a normal result on our own draw). Not sure if that is on the doc or the lab. But then again, neither the lab nor the doc has to pay the pt's copay for an ED visit.

[psu_213, BSN, RN]

because the lab takes care of calling their own redraws back

Not always true, at least not in my part of the world (see above).

[e102587]

Thank you for pointing out the importance of hemolysis in lab tests. Outpatient centers do usually arrange for their own recollects. The story you tell of all the patients with critical (6.4) potassiums you see come into ER is really different. Lab informs physician potassium is critical, but, hemolyzed which can contribute to falsley elevated potassium. Physician sends patient to ER- better safe than sorry. You write "not always true," and very few things in life are always true.

[RN_rescue_ninja]

This is ridiculous. it is counterproductive, a waste of time, causing unneeded pain for the pt to name a few. Wouldn't the logical first step to resolve this issue be to have an in-service for the nurses/techs (if applicable) on how to prevent hemolyzed samples from IV starts? BTW, the colored bags are supposed to be the "stat" ones; the ones the lab treats with priority. Another issue with hemolyzed specimins is that it could be from the samples sitting for longer than needed, as you pointed out, also because they are often drawn and the order for tests for them is not put in immediately, so they sit in the lab. The way to avoid this as much as possible is with the nurses putting in as many protocols as they can, to speed things up and not let the sample sit in the lab any longer than what they should. As for pulling the phlebs, this is silly as the ED, being and EMERGENCY department, should have priority, although I can see the argument that nurses can do the sticks, too. I have only been a nurse for a little over 3 months, but I already hate when the "high-up" admin make decisions for the whole hospital that affect the ED, when in reality, the ED is so different (and has to be) that you really cannot apply these principals and make them work in the best interest of the patients. Also, no phelbs on night? What's up with that? Nights are just as busy as days.

Your director and charge nurses should be pulling together with some arguments and facts to bring to whomever made this decision, to come up with an alternative.

[RN_rescue_ninja]

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.

Yes! All this is definitely true. One thing I have noticed (when I have time to stop and think about these things long enough ) is that when the catheter flushes,but does not draw back, it is because the catheter is not an optimal size (i.e. too big). It presses against the wall of the vein tight enough where it creates a vacuum effect and blood either will not come out or is hemolyzed, even if you "fiddle" with the catheter. It's also hard for venous blood to get around the catheter, if it is that tight of a fit. There's articles that are well researched about this, too.

The big reason the tubes drawn with an IV start are hemolyzed better than fifty percent of the time

Fifty percent? Absurd. I draw nearly all of my labs through patent IVs and it's rare that I have hemolyzed samples... And this is true of the other 120 nurses in my department.

the lumens are designed to introduce liquid fluid into the body NOT to TAKE IT OUT.

Oh, in what way is that? X

As healthcare providers, we need to consolidate correct drawing procedure and stick with it. We owe this to our patients!

We owe to our patients to minimize the number of times that we stick needles in them...

Drawing blood through IV catheters is not a problem.

This is just one of those "urban legends" that persist in nursing.

[e102587]

Have you ever heard of the Journal of Emergency Nursing? They published a study in 2012 addressing the high rates of hemolysis occurring when obtaining labs during IV placement.

[e102587]

"This is just one of those "urban legends" that persist in nursing."

Plus see Clinical Biochemistry (2012) 45 1012-1032[COLOR=#2f2777],

One of the countless published studies addressing hemolysis in ED's IV lab draws worldwide.

The Journal of Emergency Nursing has the IV lab draw hemolysis rate at around 32% and the Clinical Biochemistry study has the value between 40 and 70% citing different studies. A far cry from an "urban legend."

"Oh, in what way is that? X"

The hemolysis occurs during IV lab draws in ER due to the tubing, hub size, pressure applied to syringe, proximity of IV set bevel to interior of vein and overall difficulty of obtaining the draw.

"We owe to our patients to minimize the number of times that we stick needles in them..."

If a patient is in ER and may be having an MI, correctly drawn blood samples are very, very important. Foolish concern over an additional needle stick lab draw can needlessly prolong treatment time.

[Sassy5d]

I don't use a syringe. I attach my vaccutainer directly to my fitted j-loop.

The order in which you draw your rainbow can ruin your entire draw.

[icuRNmaggie, BSN, RN]

I occasionally have hemolysis drawing from a 20g, but never or hardly ever with a new 18g. Anyone else notice this?