Lining and labs/ hemolyzed specimens - page 2

by psu_213 8,061 Views | 64 Comments

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... Read More


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    I have been a phleb for 20 yrs...(grad from lpn school 3 yrs ago). Have to say that I agree with beingcaitlin; can't really think of a reason why any reputable lab would 'ignore' even slight lysing of cells in a spec as it can cause inaccurate results to be reported. This could result in potential harm to a patient (via treatment plans changing based on labs, etc). The last thing lab staff want to do is have that happen, or be reported to any of our regulatory commisions for such an incident. (Talk about the PG scores going bad...lol).

    Maybe a more reasonable approach from the OP's mgmt may be to specify policy that prohibits line labs under certain patient conditions i.e., he's suspected or known to already have existing problems with K, serious anemias, etc. Don't know how "real world" that might work but just a thought.

    Sorry for lack of paragraphs-new to posting here and trying to navigate the ins and outs
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    I find the lab is often out of touch with the realities of patient care. In the peds hospital I worked at, the lab was insistent that we use vacutainers to draw blood from while starting an IV. The problem is, in a fragile, little vein that you were lucky to sink a 24 in to, the vacutainer often blows the line from the pressure. The labs are important, but so is having that line and access so the general practice is to ignore the lab and do syringe draws on smaller patients to protect the IV site while getting the labs. And guess what, most of those specimens are just fine. And a vacutainer is by no means a guarantee that the labs won't get hemolyzed on draw anyway.

    I've also worked places where the labs insist on very large amounts of blood in order to do various tests. Fine when you're dealing with an adult, but in a teeny patient, that blood does add up when these are labs that get repeated over the course of hospitalization (plus, little veins, dehydrated kids, etc often simply do not give you the volume of blood the lab desires). I've had labs insist you need 10cc of blood in a culture tube to culture. Seriously? No, you don't.

    And don't get me started on calling the lab to find out why the results are taking WAY longer than usual to have the lab say "oh, the specimens only *just arrived.* BS. I walked that bag over and dropped it in the window personally because we needed the labs ASAP

    Anyway. I've worked in multiple hospitals and the lab always seems completely inflexible to the reality that sometimes we just have to do the best with what we are able to get on patients. I would not be surprised if those red bags are "stat" bags and the phlebotomist's samples get run first.
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    That policy is absurd.

    I've always drawn blood from lines, if at all possible. In my former position, I ~always~ drew into a syringe - and I still do if it's a slow draw. I can think of about 5 times out 1,000 draws or more that have been hemolyzed.
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    The ER I worked in was really trying to push this double stick for line and labs. If the patient had decent access and I had the time, I'd place an IV and straight stick for labs. But a large portion of the patients were difficult sticks at best whether d/t IVDA or edema, etc. So in those cases, or in peds, one stick for both was all they got from me. This ER had a designated phlebotomist, but would appreciate if the nurses could take care of the labs with the IV starts. It seemed that the rate of hemolysis drastically went up on weekends regardless how labs were obtained. Someone explained to me that because there was a specific weekend lab staff as compared to during the week, the lab machines could theoretically be calibrated different based on who was working.
    Also, there was a policy in place where if the patient was a tough stick, the level of hemolysis wasn't too significant and the K+ wasn't a crucial lab value (not a dialysis pt, no digoxin toxicity suspected) the ER attending could give verbal consent to the lab to process that sample.
    Oddly enough when the charge nurse would intervene about how many hemolyzed labs were being refused by the lab and requested them to check their machines, there was often a sudden decrease in the amount of hemolyzed samples returned by the lab....
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    I have been a patient too many times in recent years, and I don't appreciate too many unnecessary sticks. That first one better be to draw labs and place a lock at the same time. And I will ask that you continue to draw blood from that site as long as possible.

    No matter how often I try to tell whoever is sticking me that my one decent vein is very shallow, inevitably they want to go deep. Aside from being a former IV nurse, and later a dialysis nurse, I know my own body.

    As a home health nurse, I drew many specimens over the years and rarely had one to hemolyze.

    In my little old people with tiny veins I would get an order for pediatric specimens whenever possible. I carried pedi-vacutainers and the holders, and didn't crush their arms with the tourniquet.

    Schlepped many specimens in my little cooler back to the lab.

    I miss those days!
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    Quote from XmasShopperRN
    It seemed that the rate of hemolysis drastically went up on weekends regardless how labs were obtained. Someone explained to me that because there was a specific weekend lab staff as compared to during the week, the lab machines could theoretically be calibrated different based on who was working.
    I had pt who was a tech in our hospital's lab. He told me that whether or not the specimen is 'deemed' hemolyzed depends on who in lab processes the specimen--that it varies from person to person.
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    Quote from 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?
    I like that...that lab treats it differently! I will tell you that there is a phlebotomy charge that lab charges....so there is incentive. We had a problem once and we decided to stop drawing through the needle-less hub....we used claves.....and drew labs right off the IV hub....and found our hemolysis rate dropped as well. We also had less hemolysi with pedi tubes but they are expensive.
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    I work on a Pediatric floor. We stick for the lab all the time either from the iv line initial start. On occasion we have to end up sticking for lab for their normal daily labs also sometimes just for the fact that the phlebotomist is scared of sticking the child. Had them actually tell me this. Either way we always try to draw labs on initial sticks just to save patient more times being stuck. Of course if we have trouble getting blood from what we believe is a good idea we simply change an already flushed line in and use the iv and lab then must draw cause an iv most times are a lot harder to get and stay than having just a venous puncture and out for labs.
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    Oh My Goodness... where do I start?? At my hospital, the lab is ALWAYS RIGHT! They will swear up and down that you have mislabeled a specimen when they have about 20 requisitions on the counter... but its our fault. In our ED, we line/lab and we continue to draw our labs out of the IV line so that the patient's do not have to get stuck again. The floor, however, is not allowed to put a tourniquet on he patient and draw from the line. This is a policy that I believe is ridiculous.

    Our lab does not do outpatient labs that I know of so they have to have something to do. Even the hardest patient's to stick cannot get their blood drawn from their IV and we always put in a 20ga or better. Our patient's leave and look like they are pin cushions. I have to agree that the policy at your hospital is a little more ridiculous than some of the ones at my hospital but we have a doozy of a blood bank.

    Here is the blood bank policy: The label on the tube much match EXACTLY what is written on the patient's ID band. (we are near the border of Mexico) We have alot of people that have very long names and sometimes this is difficult. The requisition must be signed by the person who actually drew the blood as the primary person. The double check person must sign underneath, they cannot sign as primary because if they do, then the blood is thrown out and you have to draw the blood again. I had a patient that was stuck three times because the blood bank would not accept her blood because of a "typographical" error.

    I feel your pain...
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    @ beingcaitlin: This I absolutely agree with. I am an ER nurse and if I see at any point in my blood draw when I start an IV that it is difficult to get blood, then I salvage my IV and I am not too humble to call the lab. I have been a nurse for 17 yrs and you have to use your judgement when doing these things. Some people do not know when to say when. There are those that think they "know everything." The day and time that I walk into a hospital and think that I "know everything" is the day that I am hanging the stethoscope up because that will be the day that I made a fatal mistake. I know my limitations even though I am a great stick, but sometimes we get patients that you just cannot get, so you have to call on the experts in getting their blood and that would be the lab.

    Thank you for this post, It was great and I completely agree!!
    Last edit by TinaSpradleyParks on Jan 17, '13 : Reason: forgot to put to whom I was speaking to.
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