Blood Collection Variables are a Risk to Patients
Blood collection, storage and transportation needs to be the best quality that we can provide for our patients sake. Quality blood leads to quality results and better care. We need to develop a best practice and update current standards to include all sources of blood collection. Do you know the standards? Have you been properly educated? Instead of reinventing the wheel do you know of any facility that is doing it right? Are they willing to share there program with others?
The quality of blood specimens is the problem. Nurses rarely if ever get formal training on how to properly collect blood, how to follow the standards or even know that there are blood collection standards. We get our training by learning from our coworkers when the opportunity arises. The result is that there are many different ways that we collect blood when there should only be one way.
One best practice. The CLSI (Clinical& Laboratory Standards Institute) has a venipuncture standard on how we are supposed to draw blood. Joint Commission, CAP(College of American Pathologist) and other organizations routinely review compliance with this standard during their certification process. The education and competency of nurses drawing blood has not been part of the certification process. I don’t think we can lay blame anywhere… I think it is something that just fell through the cracks. Regardless of the whys, we need to bring our blood collection methods up to standards for our patient’s sake.
I have been a critical care RN for over 20 years. I recently discovered this issue when doing research for the LABAGAITOR, an invention that I was working on. I stumbled onto the CLSI standards and was troubled by what I found. I found that collecting, storing, transporting and analyzing blood is a highly controlled and technical process. Any deviation from the process is a variable. Variables can and do cause bad lab values. Bad lab values can cause delays in care, unnecessary treatment, longer stays, higher cost to patients, higher cost to hospitals and it can even cause harm to our patients. Not following the national recognized standards can be tough to defend in a lawsuit.
The vast majority of the variables or errors happen in the preanalytical phase. Somewhere around 80% of the variables are in this phase. The preanalytical phase includes the collection, storage and transportation of blood to the lab. I believe that every hospital, where nurses draw blood, need to have a comprehensive training program along with periodic review to ensure compliance.
Here are just a few of the many potential variables, that when done correctly will help improve the quality of blood being sent to the lab, hence quality results:
- Order of Draw
- Invert each vacuum tube immediately after drawing and before drawing the next tube
- Invert each tube the proper amount of times according to CLSI standards.
- Get specimens to the lab as soon as possible.
- Don’t under or over fill blood culture tubes(usually 5 to 10 ml). More than 10 can cause false negatives. Draw the Aerobic before the anaerobic tube.
- Etc. See the CLSI Venipuncture Standards and manufactures recommendations.
Standards cover venipuncture collection. Standards for drawing off of devices like PICC line, central lines, implanted ports, dialysis access, alines etc... are almost nonexistent. Here is what we can do:
1. Hospitals can bring nurses up to standards through education.
2. We(nurses) need to become involved in the standards making process to ensure that all forms of blood collection are covered under the standards. This would include having nurses represented on any standards committee where the standard has an impact on nursing.
I was working on an invention called the LABAGAITOR and the ONICE when I found the CLSI venipuncture standards. The information that I found shocked me. Why didn't I know that there were standards? I have done a couple of small surveys and I it confirmed that nurses are not educated on proper lab collection methods. My patent attorney said that I needed to share my findings with a major hospital system and they are making positive steps. I would like to hear what your experience is or has been. Did you know that there are standards for collecting blood? If you are well trained please share so others can use to your experience to improve their practice. #bestpractice
About Nerd eNurse, ADN
I am a RN with a background in manufacturing and business. I am also an inventor working on products that will help mankind. I was working on an invention(LABAGAITOR) to improve the way we transport patient specimens and I discovered that we need to improve the quality of blood collection.
Joined: Sep '15; Posts: 80; Likes: 93
RN/Inventor; from US
Specialty: 24 year(s) of experience in CVICU/ICUMar 17, '16I'm curious if you know of any objective studies which indicate that there exists a significant problem with the quality of nurse-drawn blood specimens.
Anecdotally, systematic errors based on technique appear to be minimal.Mar 17, '16I was taught that it was imperative nurses know how to perform lab draws correctly, what tests went into what vials, and how to safely transport them. I monitor the blood culture contamination rates at our facility as part of quality and infection control. When new nurses come on board the nursing skills instructor does specific classes on how to draw labs, transfuse blood, and perform blood cultures. If I see a trend in an area beginning to have a higher contamination rate I meet with the nurse educator and lab people and we refocus our education or do some one-on-one teaching. As with any skill that is not done on a daily basis, sometimes nurses need a refresher class. Blood draws are also covered when educating about central line care.Mar 17, '16Thank you for the input. I am not beating up on nurses... I am a nurse. I recently discovered the CLSI venipuncture standards and feel they are important. I have spoken with a major healthcare organization and they feel that it is important. I want nurses to take the lead so that the standards reflect our practice also.
Three major components to correct blood collection is the "Order of the Draw", inverting the tube immediately after filling and inverting the vacuum tube the proper number of times. These are basic components of the CLSI standasrds which The Joint and CAP use as the gold standard for certifying compliance to proper blood collection. If the above are not being done right the lab will still give you a result of the blood that is submitted. They don't know if we have collected it properly. AS far as studies go yes they are out their and it gets complicated. I am hoping to nudge some organization like the ANA etc. to take the lead in getting nurses involved in the standard making process.
An example of why the Order of the draw is important is because when you draw a vacuum tube a little bit of the blood inside the tube squirts back into the collection device and gets sucked up into the next tube. That is why the blue tube needs to be drawn before any tube that has heparin in them. The number of inversions is important because if you don't mix the chemical that is inside the tube immediately the chemicals will react to a small portion of the blood and the reaction may be over before you mix it with the rest of the blood causing bad results. Here is a link Inverting a blue tube more that 4 or 5 times increase your chance cell breakdown. Inverting needs to be gentle and we should all be doing it the same way as directed by the manufacture.
Here is an article by the chairman of the CLSI Venipuncture Standards Committee: http://www.phlebotomy.com/pt-stat/stat1011.html
Thanks again and please keep the comments coming!Thanks for the comments.Mar 17, '16Thank you for the comments. You don't know what you don't know. That is what this rticle is about. I was surprised to find out that there are actually standards on how to draw blood. This is an effort to share and find out how many nurses fit into my category. Do you know if they teach blood collection according to the standards? I am searching for a program that includes the CLSI standards so that I can pass it around to the many facilities that I have worked that don't have a program. See the link in the message above for an idea of what the standards include if you don't know already. You can private message me a link to your policy or class information if you can't share it publicly. I have been reaching out for a while and I haven't found a hospital that includes lab drawing standards to their IV program. That will be my next article. Please share this article.Mar 17, '16Quote from GaitorI wanted to add another feature I bring into educating the nurses, I ask the lab to help do the teaching about the lab. They truly are the experts and can give the rationals for so many things. Good luck with your project.Thank you for the comments. You don't know what you don't know. That is what this rticle is about. I was surprised to find out that there are actually standards on how to draw blood. This is an effort to share and find out how many nurses fit into my category. Do you know if they teach blood collection according to the standards? I am searching for a program that includes the CLSI standards so that I can pass it around to the many facilities that I have worked that don't have a program. See the link in the message above for an idea of what the standards include if you don't know already. You can private message me a link to your policy or class information if you can't share it publicly. I have been reaching out for a while and I haven't found a hospital that includes lab drawing standards to their IV program. That will be my next article. Please share this article.Mar 17, '16Here are a couple of published studies.
Most errors are miss labeling, Hemolysis and contamination of blood cultures. You don't see much published because this is mostly an internal QI and Risk Management issue. I've seen this start to pop up in annual skills fairs on the correct order of the draw.
Nursing blood specimen collection techniques and hemolysis rates in an emergency department: analysis of venipuncture versus intravenous catheter c... - PubMed - NCBI
[COLOR=#0066cc]http://www.jenonline.org/article/S00...397-1/fulltext[/COLOR]Mar 18, '16I was a phlebotomist and worked in the lab before becoming a nurse and you have no idea how clueless some nurses are on blood collection. It is not their fault because it is something not taught in school and they are lucky if they are properly trained on the job.
If using a butterfly needle and you need to draw a PT or PTT (blue top tube) you must use a no-additive discard tube first to displace the air that is in the tubing of the butterfly needle. If not, the air will cause the blue tube to underfill which will disrupt the 1:9 ratio of sodium citrate to blood and the machine wont run and if it does, the results may not be accurate. Also, they trained us to always use the no-additive tube before the blue tube. Some phlebs are lazy and use the chemistry tube with the gel before the blue but this tube contains a clot activator which can interfere with coagulation tests.
Allow the chemistry samples to clot before centrifuging. Usually this takes 10-15 minutes but for those on blood thinners it may take longer. Electrolytes will be out of wack if you dont. You dont want to wait too long either though. Wait more than an hour and glucose levels will be falsely low. For every hour that serum is allowed to sit on the red cells, glucose levels will decrease by 10%. The cells are metabolically active and continue to exchange nutrients. We had nurses that forgot to send down blood through the tube system all day and wanted us to run the tests as if there would be no problems.
If you are collecting from a line and have to transfer blood from a syringe to the tube, still follow the correct order of draw. Also, never push the blood into the tube. I dont know how many times I have received blood from the floors and the blue top tube was way over filled. The tubes have vacuum so will automatically stop where they should. The other tubes dont matter as much but your blue coag tube MUST be at the black line!
If you are going to mix any tube, mix the lavender EDTA tube used for CBCs! If there is a clot, the lab will reject the sample because it wont be possible to get an accurate blood count. The EDTA is sprayed throughout the tube so it doesnt mix as well as the sodium citrate which is a good amount of liquid and mixes easily with blood. If you're drawing somebody and the blood is coming slow, take the tube out, invert the tube with whatever blood you have in it, and stick it back in and continue filling. If using a butterfly, its easy to invert it while its still filling. No stagnant blood!
If blood is hemolyzed beyond a certain degree, it will be rejected, the test cancelled, and will need to be redrawn. Hemolysis signifies the rupture of RBCs which mean their entire cellular components are now contaminating the serum. Potassium that is intracellular is now extracellular and if the lab were to release those results, the levels would be critically high. Usually, it happens with a hard stick or if the blood was coming slow (the vacuum of the tube caused pressure which destroyed RBCs). If the blood is coming but the flow is iffy, its not a bad idea to draw an extra tube for good luck. You'd be surprised, some tubes from the same patient would be grossly hemolyzed yet others would be clear.
Lactic acid must be collected on ice and sent immediately. If I get a sample and its sitting in a bag of water and mostly melted ice, I would call back and ask when exactly it was drawn. The techs use the ABG machine on these specimens so it is very fragile and time sensitive. After 10 minutes, they were no longer good.
Oh, and if you make a mistake and put someone elses label on a tube, dont put the correct patient's label OVER it and think it will be ok. That is an error and will be rejected. Completely remove the wrong label. If you need to put another label on the tube and its the correct patient already, dont cover the name. The lab will assume you are trying to cover up a mistake. Make sure the new label is under the name of the old. Make sure 2 patient identifiers are on each tube. Name and DOB. I cant count how many times nurses would send unlabeled, misslabed, partially labeled specimens. Then I would call and tell them we needed the sample to be redrawn and they would get mad at me. Some didnt believe they made a mistake and had to see it for themselves!
This one doesnt have an effect on lab values but its something else I remember from my phleb days. When drawing blood cultures, show the bottles to your patient before you draw from them and tell them you just need a little bit of blood to mix with each bottle. If you draw their blood and they see those red filled bottles, they will think you filled the entire bottle with their blood and FREAK.Mar 18, '16Thank you for all the great post. I didn't realize how technical drawing labs needed to be until I started looking into the standards. Now that I have researched the CLSI standards and communicated with leaders in the industry I understand what needs to be done and am ding something about it. One of the biggest variables that I find is most of the poolicies say to collect a lactic acid "On Ice". That is wrong. I spoke to BD the Vacuum tube company and it is spelled out in the CLSI standards. Lacitc acids are to be placed in an "Ice Slurry". When we place the specimen in just ice the specimen can freeze renduring the specimen useless. I am making a video demonstration of this. You can see BD's recommendations by clicking on the following link: BD Chilled SpecimensMar 18, '16Thanks for the input. I enjoyed the articles. I saw somewhere they recommended asking the patient in the ER: If they would like you to draw off the IV to save them some pain with a 10%(?) chance of needing to have to poke them anyway because of hemolized specimens. With the rates in the article you posted I would think drawing off a line should be the exception and not the rule.
One thing I am not sure about but I would like to learn more about are tube systems. I read somewhere that they are suppose to be certified in order to be usable for sending labs through the system. Every time I hear the KACHEWNK of the tube being dropped from the tube system into the rack I have a hard time believing it doesn't affect the vacuum tubes. Let me know if you have any references.Mar 18, '16I have drawn blood for five different hospitals as a nurse, but only got training in my last one. My rate of erroneous results hasn't changed. Inverting a tube exactly five times instead of two, drawing in a particular order, releasing a tourniquet within one minute, in extreme cases probably make a difference, say if I give all my tubes a good shake, and tourniquet for 5 minutes. Sometimes it makes sense because of the patient condition to draw cbc, and chemistries first because you NEED them, and may not get enough blood for PTT. Those laws are more guidelines, in my opinion.Mar 19, '16I can understand where you are coming from, that was my initial response. I found it hard to believe. When I dug deeper I found that the lab machines will give you a value on the blood that you give whether it is high quality blood or low quality blood. If someone shakes the vacuum tubes and someone else inverts the vacuum tubes, the medical lab scientist and the machines don't know the difference, but the values can be significantly different. The engineer in me loves process because process brings about a chain of command. If there are problems the problem, is easier to identify. If you want to do studies the standards limit the variables. There are specific reasons for the CLSI standards and the INS standards even if they are minor.... they bring order and consistency to a very fragile and highly technical process. An everyday example would be making bread out of sequence. If you activate the yeast you will get consistent results. The bread probably will rise. If you don't activate the yeast you will have varied results. Or paint the house and then use the primer. Simple but necessary steps.
I am curious, how do you know the error rate hasn't changed? What are you using to validate this?
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