Lining and labs/ hemolyzed specimens

Music in My Heart · Jan 17, 2013

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.

XmasShopperRN, ASN, RN · Jan 17, 2013

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....

merlee · Jan 17, 2013

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!

psu_213, BSN, RN · Jan 17, 2013

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.

Esme12, ASN, BSN, RN · Jan 17, 2013

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.

JamieBasil · Jan 17, 2013

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.

TinaSpradleyParks · Jan 17, 2013

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...

TinaSpradleyParks · Jan 17, 2013

@ 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!!

TinaSpradleyParks · Jan 17, 2013

@music in my heart:

I can understand your reasoning ; however, those slow draws I would really be leary of. Our stat lab (ED lab) is just around the corner and if I have had a slow draw, I literally walk it over in 5 minutes and they are calling me to tell me that it is clotted or hemolyzed. I always have that fear, especially in the older population who are very dehydrated. If I see that it is slow, I always notify the physician first and get the ok to call the phlebotomist to come draw the patient. 99.9% of the time the physician gives the okay. If not, the physician comes to the bedside with ultrasound and starts the IV or places a central line depending on patient acuity.

VICEDRN, BSN, RN · Jan 17, 2013

My old ER was pushing this double stick policy on us and I think its a violation of a nurse's ethical values. Double sticking people for labs does not produce significantly different lab results. For example, a big deal is made of out of elevated potassiums due to hemolysis so I went and looked it up. The MOST a potassium ever really changes is 1 due to lysis and as a physician pointed out to me when I went and argued with the nursing director, 1 is not a significant change in the patient's condition to cause any real harm.

Example: You get a reading of 6.0 so you treat it. If cells were lysed, it might have been 5.0 BUT treating K at 5.0 will only drop it to 4 so no real significant different is made in patient condition even you are wrong. If its a critical value, say like 7.7 in a non dialyzer, you can redraw specimen.

This double stick thing is stereotypical of the "a little knowledge can be so dangerous" in people who are undereducated and illprepared to understand what is really going on with the patient's health and IT DRIVES ME CRAZY! Can't see the forest for the trees!

Frankly, I agree with Esme. If you draw straight from the hub with no cap on it, you reduce hemolysis anyway. Our lab definitely knew who collected labs because the phleb collected her in the lab computer for them which we couldn't do and you bet they drew from lines and got fewer hemolyzed results.

For my money, I go in there, educate the patient about the potential dangers of double sticking and variations of lab results. If they refuse, and they always do, I would tell the director that the patient refused. Period. End of story.

gonzo1, ASN, RN · Jan 17, 2013

I have worked in many ERs and in almost all of them we draw from the IV start. In drawing thousands of labs this way I have had maybe 10 come back hemolyzed. You do have to be careful about how fast you draw back on the syringe and you do have to draw from the hub of IV for best results. But most labs were drawn from the J-loop. some times we just let the hub drip into the tube if needed. When I worked at one ER that had a dedicated lab I would sometimes go get her and together we would decide on a good vein and we had great success doing this. For more info you might look up the Infusion nurses association and check out their info.

Overland1, RN · Jan 17, 2013

Using a syringe with a soft/slow "pull" can work quite well, especially if you let the inherent vacuum of the tube draw the sample from the syringe. Using a direct (catheter to tube) adapter is probably stillthe best method, if at all possible. After all this, promptly send the samples to the lab, and there should be no problem.