Abstract
Background:
Hemolytic samples are one of the most challenging preanalytical issues in laboratory medicine. Even causes leading to hemolytic specimen are various, including phlebotomy practices. Respective educational interventions as well as the reduction of the number of people involved in blood collections are claimed to influence the sample quality for the better. In our hospital 70 junior doctors were in charge of routine phlebotomy until 2012, when this task was shifted to 874 nurses, including a preceding training in phlebotomy and preanalytics. Our aim was to evaluate the impact of this training effect and the increase of people involved on sample quality.
Methods:
The hemolysis index (HI) of 43,875 samples was measured before (n=21,512) and after (n=22,363) the switch of blood collection responsibilities. Differences in overall hemolysis rates and the amount of plasma samples with a concentration of free hemoglobin (fHb) above 0.5 g/L and 1 g/L were calculated.
Results:
Overall HI as well as the percentage of samples with an fHb concentration >0.5 g/L decreased after the responsibility for phlebotomy changed. The rate of samples with an fHb concentration >1 g/L remained unchanged.
Conclusions:
Hemolysis rates were reduced upon passing phlebotomy tasks from untrained physicians on to a trained nursing staff. We therefore conclude that the number of people performing phlebotomy seems to play a minor role, compared to the effect of a standardized training. However, whether a reduction in the number of people involved in blood collection could lead to further improvement of sample quality, remains to be investigated in future studies.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
References
1. Cadamuro J. Internal quality assurance for preanalytical phase. In: Guder WG, Narayanan S, editors. Pre-examination procedures in laboratory diagnostics. Berlin: De Gruyter, 2015:345–51.10.1515/9783110334043-040Search in Google Scholar
2. Plebani M, Sciacovelli L, Aita A, Chiozza ML. Harmonization of pre-analytical quality indicators. Biochem Med (Zagreb) 2014;24:105–13.10.11613/BM.2014.012Search in Google Scholar PubMed PubMed Central
3. Clinical and Laboratory Standards Institute. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture. Approved Standard – 6th edition: Clinical and Laboratory Standards Institute, 2007.Search in Google Scholar
4. World Health Organisation. WHO guidelines on drawing blood: best practices in phlebotomy. Geneva, Switzerland: WHO Press, 2010.Search in Google Scholar
5. Goswami B, Singh B, Chawla R, Mallika V. Evaluation of errors in a clinical laboratory: a one-year experience. Clin Chem Lab Med 2010;48:63–6.10.1515/CCLM.2010.006Search in Google Scholar PubMed
6. Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S, Palicka V, et al. Haemolysis: an overview of the leading cause of unsuitable specimens in clinical laboratories. Clin Chem Lab Med 2008;46:764–72.10.1515/CCLM.2008.170Search in Google Scholar PubMed
7. Specimencare. Available at: http://www.specimencare.com. Accessed 8 Nov 2015.Search in Google Scholar
8. Young D. Effects of preanalytical variables on clinical laboratory tests, 2nd ed. Washington, DC: AACC Press, 1997.Search in Google Scholar
9. Cadamuro J, Fiedler GM, Mrazek C, Felder TK, Oberkofler H, Kipman U, et al. Reply to: Cadamuro et al. In-vitro hemolysis and its financial impact using different blood collection systems. J Lab Med 2016;40:59–61.10.1515/labmed-2015-0078Search in Google Scholar
10. Cadamuro J, Fiedler GM, Mrazek C, Felder TK, Oberkofler H, Kipman U, et al. In-vitro hemolysis and its financial impact using different blood collection systems. J Lab Med 2016;40:49–55.10.1515/labmed-2015-0078Search in Google Scholar
11. Soderberg J, Jonsson PA, Wallin O, Grankvist K, Hultdin J. Haemolysis index–an estimate of preanalytical quality in primary health care. Clin Chem Lab Med 2009;47:940–4.10.1515/CCLM.2009.227Search in Google Scholar PubMed
12. Simundic AM, Cornes M, Grankvist K, Lippi G, Nybo M, Kovalevskaya S, et al. Survey of national guidelines, education and training on phlebotomy in 28 European countries: an original report by the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) working group for the preanalytical phase (WG-PA). Clin Chem Lab Med 2013;51:1585–93.10.1515/cclm-2013-0283Search in Google Scholar PubMed
13. Simundic AM. Who is doing phlebotomy in Europe? In: Guder WG, Narayanan S, editors. Pre-examination procedures in laboratory diagnostics. Berlin: De Gruyter, 2015:90–4.10.1515/9783110334043-015Search in Google Scholar
14. Dorotic A, Antoncic D, Biljak VR, Nedic D, Beletic A. Hemolysis from a nurses’ standpoint–survey from four Croatian hospitals. Biochem Med (Zagreb) 2015;25:393–400.10.11613/BM.2015.039Search in Google Scholar PubMed PubMed Central
15. Milutinovic D, Andrijevic I, Licina M, Andrijevic L. Confidence level in venipuncture and knowledge on causes of in vitro hemolysis among healthcare professionals. Biochem Med (Zagreb) 2015;25:401–9.10.11613/BM.2015.040Search in Google Scholar PubMed PubMed Central
16. Wang H, Liu X, Kuang L, Shi H, Jiang Y. Establishing professional phlebotomist group for quality control of the preanalytic variables of clinical laboratory. Clin Chem Lab Med 2012;50:1841–2.10.1515/cclm-2012-0127Search in Google Scholar PubMed
17. Sciacovelli L, Plebani M. The IFCC Working Group on laboratory errors and patient safety. Clin Chim Acta 2009;404:79–85.10.1016/j.cca.2009.03.025Search in Google Scholar PubMed
18. IFCC Working Group on laboratory errors and patient safety (WG-LEPS). Quality indicators project. Available at: http://www.ifcc-mqi.com. Accessed 19 Nov 2015.Search in Google Scholar
19. Plebani M, Lippi G. Hemolysis index: quality indicator or criterion for sample rejection? Clin Chem Lab Med 2009;47: 899–902.10.1515/CCLM.2009.229Search in Google Scholar PubMed
20. Giavarina D. Low volume tubes can be effective to reduce the rate of hemolyzed specimens from the emergency department. Clin Biochem 2014;47:688–9.10.1016/j.clinbiochem.2014.02.019Search in Google Scholar PubMed
21. Goegebuer T, Debrabandere J. Influence of the serum collection system on hemolysis. Focus Diagnostica 2008;16:22–5.Search in Google Scholar
22. Lippi G, Avanzini P, Aloe R, Cervellin G. Reduction of gross hemolysis in catheter-drawn blood using Greiner Holdex tube holder. Biochem Med (Zagreb) 2013;23:303–7.10.11613/BM.2013.036Search in Google Scholar
23. Lippi G, Bonelli P, Cervellin G. Prevalence and cost of hemolyzed samples in a large urban emergency department. Int J Lab Hematol 2014;36:e24–6.10.1111/ijlh.12135Search in Google Scholar PubMed
24. Unger J, Filippi G, Patsch W. Measurements of free hemoglobin and hemolysis index: EDTA- or lithium-heparinate plasma? Clin Chem 2007;53:1717–8.10.1373/clinchem.2007.091421Search in Google Scholar PubMed
25. Dolci A, Panteghini M. Harmonization of automated hemolysis index assessment and use: is it possible? Clin Chim Acta 2014;432:38–43.10.1016/j.cca.2013.10.012Search in Google Scholar PubMed
26. Glick M, Ryder K, Vroon D, Masters B, Sonntag O. Practical uses of serum indexes to reduce errors from lipemia, icterus, and hemolysis. Clin Chem 1990;36:1008.Search in Google Scholar
27. Simundic AM, Church S, Cornes MP, Grankvist K, Lippi G, Nybo M, et al. Compliance of blood sampling procedures with the CLSI H3-A6 guidelines: An observational study by the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) working group for the preanalytical phase (WG-PRE). Clin Chem Lab Med 2015;53:1321–31.10.1515/cclm-2014-1053Search in Google Scholar PubMed
28. Alsina MJ, Alvarez V, Barba N, Bullich S, Cortes M, Escoda I, et al. Preanalytical quality control program-an overview of results (2001–2005 summary). Clin Chem Lab Med 2008;46:849–54.10.1515/CCLM.2008.168Search in Google Scholar PubMed
29. Salinas M, Lopez-Garrigos M, Flores E, Santo-Quiles A, Gutierrez M, Lugo J, et al. Ten years of preanalytical monitoring and control: synthetic balanced score card indicator. Biochem Med (Zagreb) 2015;25:49–56.10.11613/BM.2015.005Search in Google Scholar PubMed PubMed Central
30. Jones BA, Calam RR, Howanitz PJ. Chemistry specimen acceptability: a College of American Pathologists Q-Probes study of 453 laboratories. Arch Pathol Lab Med 1997;121:19–26.Search in Google Scholar
31. Lippi G, Mattiuzzi C, Guidi GC. Laboratory quality improvement by implementation of phlebotomy guidelines. MLO Med Lab Obs 2006;38:6–7; author reply.Search in Google Scholar
32. Lillo R, Salinas M, Lopez-Garrigos M, Naranjo-Santana Y, Gutierrez M, Marin MD, et al. Reducing preanalytical laboratory sample errors through educational and technological interventions. Clin Lab 2012;58:911–7.Search in Google Scholar
33. McGrath JK, Rankin P, Schendel M. Let the data speak: decreasing hemolysis rates through education, practice, and disclosure. J Emerg Nurs 2012;38:239–44.10.1016/j.jen.2011.01.015Search in Google Scholar PubMed
34. Bolenius K, Soderberg J, Hultdin J, Lindkvist M, Brulin C, Grankvist K. Minor improvement of venous blood specimen collection practices in primary health care after a large-scale educational intervention. Clin Chem Lab Med 2013;51:303–10.10.1515/cclm-2012-0159Search in Google Scholar PubMed
35. Burns E, Yoshikawa N. Hemolysis in Serum Samples Drawn by Emergency Department Personnel versus Laboratory Phlebotomists. Lab Med 2002;33:378–80.10.1309/PGM4-4F8L-2P1M-LKPBSearch in Google Scholar
36. Davidson DF. A survey of some pre-analytical errors identified from the Biochemistry Department of a Scottish hospital. Scott Med J 2014;59:91–4.10.1177/0036933014529056Search in Google Scholar PubMed
37. Ong ME, Chan YH, Lim CS. Observational study to determine factors associated with blood sample haemolysis in the emergency department. Ann Aca Med, Singapore 2008;37:745–8.10.47102/annals-acadmedsg.V37N9p745Search in Google Scholar
38. Ahmad MI, Ramesh KL, Kumar R. Preanalytical quality in clinical chemistry laboratory. Clin Lab 2014;60:87–92.Search in Google Scholar
39. Southwick K. Back to the drawing board. CAP today/College of American Pathologists 2001;15:12–4, 6, 8.Search in Google Scholar
40. Simundic AM, Topic E, Nikolac N, Lippi G. Hemolysis detection and management of hemolyzed specimens. Biochem Med (Zagreb) 2010;20:154–9.10.11613/BM.2010.018Search in Google Scholar
41. Goegebuer T. Influence of the serum sample tubes on hemolysis. Focus Diagnostica 2008;16:22–5.Search in Google Scholar
42. Lippi G. Systematic Assessment of the Hemolysis Index: Pros and Cons. Adv Clin Chem 2015;71:157–70.10.1016/bs.acc.2015.05.002Search in Google Scholar PubMed
43. Plebani M, Sciacovelli L, Aita A, Pelloso M, Chiozza ML. Performance criteria and quality indicators for the pre-analytical phase. Clin Chem Lab Med 2015;53:943–8.10.1515/cclm-2014-1124Search in Google Scholar PubMed
©2016 Walter de Gruyter GmbH, Berlin/Boston
