Blood Collection Variables are a Risk to Patients

[Nerd eNurse]

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

• Hospitals can bring nurses up to standards through education.
• 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.

[Nerd eNurse, ADN]

I 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?

[MunoRN, RN]

Gaitor said:

Thank 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 policies 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 rendering the specimen useless. I am making a video demonstration of this.

The reason why lactate tubes should be cooled using an ice slurry is actually because it gets the sample colder faster, not because it cools the sample less. Water transfers heat much better than air does, so when a tube is placed in a bag or other container with just ice cubes, there is relatively little direct contact between the tube and the ice. Adding some water ensures more surface area contact and transfer of heat between the ice and the tube.

There's actually not good evidence that drawing tubes in the wrong order is a risk to patients. There have been incidental findings in some studies that indicated further research into the order of tubes, but those studies didn't actually find clinically significant changes in the results.

Those are only focused on lab quality control are concerned with statistically significant variations in results, what the focus should be in patient care is different. What we're worried about is what is best for the patient overall, and clinically significant variability. For instance, if a way of obtaining blood that is quicker might have a variability in potassium level of +/- 0.1 mEq/L, but another might much more accurate (+/- 0.02) but take additional time to obtain. Which is better for the patient, knowing their potassium level is 1.6 right now, even though it could actually be anywhere between 1.5 and 1.7, or knowing that it is exactly 1.6 an hour or two from now?

[bgxyrnf, MSN, RN]

I maintain that Mr./Ms. Gaitor is making this out to be much more complicated than it is.

[canoehead, BSN, RN]

Gaitor said:

I am curious, how do you know the error rate hasn't changed? What are you using to validate this?

The labs that I draw have not been coming back with results that are insanely different from what is expected. I haven't had tubes rejected for hemolysis. Twice in seven years lab has been asked to redraw a specimen after me because of unexpected results, and they got the same wonky values. Actually my current hospital didn't pull labs off fresh IVs until I got here. They saw it saved the techs time, and the patients didn't need a second stick, but the results were acceptable, so they decided to provide training for all the ER RNs.

[Nerd eNurse, ADN]

MunoRN You are right in saying that the water makes for better contact. I have not seen evidence that it cooled the grey top faster. When doing my research I spoke with a large vacuum tube company and they have specific parameters on how deep a grey vacuum tube is to be submerged. I have found that some nurses place the tube in the fingertip of a vinyl glove then in a Styrofoam cup of ice. Some put the tube in a zip-lock bag and then inside another bag of chipped ice. My guess would be that a tube fully submerged in ice will cool faster than a properly submerged tube in an ice slurry. Properly submerged meaning to the height of the blood in the tube per the manufacture. I was told that ice coming in direct contact with the tube can freeze the blood at the point of direct contact and that freezing was bad because freezing damages cells. They also told me that pre-chilling the tubes was not recommended because cooling too quickly can also damage cells.

What is needed is consistency throughout the process.

Thank you for the input.

[Nerd eNurse, ADN]

KindaBack I didn't create the standards(CLSI or INS). I just recently realized they existed. The organizations that we work for are certified and following the standards is part of the review process to be and stay certified. The WHO has recommends following standards: WHO Link The standards are there and I we should be following them. What does gender have to do with it?

[bgxyrnf, MSN, RN]

You're saying that it's a risk to the patients but can't point to any evidence that it is, in fact, a risk.

Sure, the standards are there but even those are simple to the extreme. 'Stirred, not shaken'

so to speak kind of plays itself out in an obvious way... hemolysis and abnormal potassium values. Clotted specimens. Inadequate fills on coag tubes. All this stuff has a feedback loop... lab calls to say they're rejecting the specimen and it needs to be redrawn. A nurse figures out pretty quickly what works and what doesn't.

And honestly, although I habitually draw my coag tube after a waste to prime the line, I see many people who don't and I'm not aware of any skewed values and really, looking at it mechanistically, it would be hard to contaminate the specimen given that the only potential contact with the citrate or what-have-you is via the needle puncturing the diaphragm.

From a process control viewpoint (and I was a process engineer for many years), I agree that a standardized process is desirable but this particular process seems to be pretty robust and tolerant of deviation.

I maintain that you're making this out to be a much bigger issue than it is in actuality.

Gender is irrelevant which is why I used the universal gender pronouns 'Mr.' and 'Ms."

[Altra, BSN, RN]

I understand that you have only recently learned of the existence of standards for blood specimen collection. Learning something new can significantly alter your perspective, and that's a good thing.

Now, incorporate that learning into a larger clinically relevant framework. Consider just your hospital, no matter how large or small. How many different lab specimens are drawn and processed in just one day? From how many different patients, by how many different staff members? What are all the variables present in all of these scenarios? What are the various ways these specimens are transported to the lab? Are alternative point-of-care tests sometimes also used? Has the existence of all of those variables affected aggregate results in any statistically significant way?

Were any deficiencies in lab process noted in the last survey by JC, your state department of health, or other accrediting body? What internal quality control processes are in place, and does analysis of those processes reveal any deficiencies which are clinically relevant to your patient population as a whole?

[Nerd eNurse, ADN]

KindaBack said:

You're saying that it's a risk to the patients but can't point to any evidence that it is, in fact, a risk.

Sure, the standards are there but even those are simple to the extreme. 'Stirred, not shaken'

so to speak kind of plays itself out in an obvious way... hemolysis and abnormal potassium values. Clotted specimens. Inadequate fills on coag tubes. All this stuff has a feedback loop... lab calls to say they're rejecting the specimen and it needs to be redrawn. A nurse figures out pretty quickly what works and what doesn't."

There are many variables with countless research studies done. Here is one a line to one: Link NCBI

I am not sure why you are downplaying the standards, you just made my case by identifying that "hemolysis and abnormal potassium values. Clotted specimens" happens. If proper training is done before we start collecting blood then the variables would be even lower. I don't see what is wrong by saying that nurses should have formal training on "Order of Draw" "How to Agitate" "When to Agitate" "How Much to Waste and When" "Aerobic before Anaerobic" Don't Under Fill or Over Fill BC" "Tourniquet for 1 Minute Max" "Get Samples to the Lab in Less Than 1 Hour" "Don't Store Chilled Specimens Near Regular Specimens" "Don't Use Alcohol wipe When Doing a Alcohol Level" "Don't Have Pt Pump Fist When Drawing Labs" "Shut Off IVF for 2 Minutes before drawing" "If Drawing Off Heparinized Line Flush and Then Draw Back 6X the Dead Space" "Invert Don't Agitate!" "Special Considerations When Drawing up With A Syringe" "The Preferred Line to Draw Off of" etc. etc.etc.

I didn't realize that variables were even an arguable point. What is a variable is. What I was hoping would happen, is that we would embrace what is already in practice. Sort out fact from fiction and create or improve standards. We can create a Best Practice. This would only benefit our patients.

[Nerd eNurse, ADN]

Altra said:

Now, incorporate that learning into a larger clinically relevant framework. Consider just your hospital, no matter how large or small. How many different lab specimens are drawn and processed in just one day? From how many different patients, by how many different staff members? What are all the variables present in all of these scenarios? What are the various ways these specimens are transported to the lab? Are alternative point-of-care tests sometimes also used? Has the existence of all of those variables affected aggregate results in any statistically significant way?

Were any deficiencies in lab process noted in the last survey by JC, your state department of health, or other accrediting body? What internal quality control processes are in place, and does analysis of those processes reveal any deficiencies which are clinically relevant to your patient population as a whole?

My quest is more global. Nurses have not been properly educated on drawing blood. Ihave started local and moving global by working with a major hospital chain to correct that. I am looking for any nurse that feels that they were properly trained or know of a program that they would like to share with the rest of us. If we follow a process and we all do it the same then we can accurately identify glitches in the system. When some like it shaken and some like it stirred it is hard to quantify results. I do see that every organization that has taken the initiative to correct lab errors have had success through training and process.

Thank you so much for the input and helpful comments.

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?

[brdbat416]

Hello,

I know this is an old post, but was wondering where you are in this process? I am a Medical Laboratory Scientist and found it very troubling that nurses don't have more training in this area. My hospital lab started training new employees in phlebotomy with mixed results. I know nurses don't have a lot of extra time, but getting an ASCP certification in phlebotomy may be interesting/worth it to some. As a MLS, thank you for being proactive in drawing quality labs.