Is Phlebotomy Part of the Dark Side in the Clinical Laboratory Struggle for Quality?

Assessing an aflatoxin exposure biomarker: Exploring the interchangeability and correlation between venous and capillary blood samples

Exposure to dietary aflatoxins has been recognized as a potential threat to child nutrition and growth, in addition to being a known carcinogen. The ability to accurately assess concentration of aflatoxin in the blood of at-risk individuals is therefore very important to inform public health policies and on-the-ground programs around the world. Venous blood is frequently used to quantify biomarkers of exposure such as AFB1-lysine adducts. However, venous blood collection methods are invasive, requiring highly trained staff, which makes this method challenging to implement, especially in resource-limited settings. In contrast, capillary blood collection by fingerprick is less invasive and has the potential for application in point-of-need monitoring. The aim of this exploratory study was to investigate the correlation and interchangeability of capillary and venous human blood samples in the quantification of AFB1-lysine adduct concentration. A total of 72 venous and capillary blood samples were collected from 36 women of reproductive age (16-49 years) in northern Uganda. All sample specimens were analyzed using high-performance liquid chromatography with fluorescence detection. Regression analysis and Bland-Altman analysis were performed to compare AFB1-lysine concentrations between venous and capillary sample pairs. Bland-Altman analysis of albumin-normalized AFB1-lysine data-bias was -0.023 pg/mg-albumin and the 95% limits of agreement were 0.51 to -0.56 pg/mg-albumin for log-transformed data. There was a positive correlation between albumin-normalized venous and capillary AFB1-lysine concentrations with r of 0.71 (p < .0001). A lack of any accepted clinical cutoff for aflatoxin exposure makes definition of an 'acceptable' limit for statistical analysis and comparison of methods challenging. Our data suggests a positive correlation between albumin-normalized AFB1-lysine concentrations in venous and capillary sample pairs, but relatively weak agreement and interchangeability based on Bland-Altman analysis.

Preanalytics and Precision Pathology: Pathology Practices to Ensure Molecular Integrity of Cancer Patient Biospecimens for Precision Medicine

Biospecimens acquired during routine medical practice are the primary sources of molecular information about patients and their diseases that underlies precision medicine and translational research. In cancer care, molecular analysis of biospecimens is especially common because it often determines treatment choices and may be used to monitor therapy in real time. However, patient specimens are collected, handled, and processed according to routine clinical procedures during which they are subjected to factors that may alter their molecular quality and composition. Such artefactual alteration may skew data from molecular analyses, render analysis data uninterpretable, or even preclude analysis altogether if the integrity of a specimen is severely compromised. As a result, patient care and safety may be affected, and medical research dependent on patient samples may be compromised. Despite these issues, there is currently no requirement to control or record preanalytical variables in clinical practice with the single exception of breast cancer tissue handled according to the guideline jointly developed by the American Society of Clinical Oncology and College of American Pathologists (CAP) and enforced through the CAP Laboratory Accreditation Program. Recognizing the importance of molecular data derived from patient specimens, the CAP Personalized Healthcare Committee established the Preanalytics for Precision Medicine Project Team to develop a basic set of evidence-based recommendations for key preanalytics for tissue and blood specimens. If used for biospecimens from patients, these preanalytical recommendations would ensure the fitness of those specimens for molecular analysis and help to assure the quality and reliability of the analysis data.

Role of public-private partnerships in achieving UNAIDS HIV treatment targets

Background

Despite progress towards achieving UNAIDS 90–90-90 goals, barriers persist in laboratory systems in sub-Saharan Africa (SSA) restricting scale up of early infant diagnosis (EID) and viral load (VL) test monitoring of patients on antiretroviral therapy. If these facilities and system challenges persist, they may undermine recorded gains and appropriate management of patients. The aim of this review is to identify Public Private Partnerships (PPP) in SSA that have resolved systemic barriers within the VL and EID treatment cascade and demonstrated impact in the scale up of VL and EID.

Methods

We queried five HIV and TB laboratory databases from 2007 to 2017 for studies related to laboratory system strengthening and PPP. We identified, screened and included PPPs that demonstrated evidence in alleviating known system level barriers to scale up national VL and EID testing programs. PPPs that improved associated systems from the point of viral load test request to the use of the test result for patient management were deemed eligible.

Results

We identified six PPPs collaborations with multiple activities in select countries that are contributing to address challenges to scale up national viral load programs. One of the six PPPs reached 14.5 million patients in remote communities and transported up to 400,000 specimens in a year. Another PPP enabled an unprecedented 94% of specimens to reach national laboratory through improved sample referral network and enabled a cost savings of 62%. Also PPPs reduced cost of reagents and enabled 300,000 tested infants to be enrolled in care as well as reduced turnaround time of reporting results by 50%.

Conclusions

Our review identified the benefits, enabling factors, and associated challenges for public and private sectors to engage in PPPs. PPP contributions to laboratory systems strengthening are a model and present opportunities that can be leveraged to strengthen systems to achieve the UNAIDS 90–90-90 treatment targets for HIV/AIDS. Despite growing emphasis on engaging the private sector as a critical partner to address global disease burden, PPPs that specifically strengthen laboratories, the cornerstone of public health programs, remain largely untapped.

Pre-analytical phase management: a review of the procedures from patient preparation to laboratory analysis

The pre-analytical phase encompasses all the procedures before the start of laboratory testing. This phase of the testing process is responsible for the majority of the laboratory errors, since the related procedures involve many sorts of non-laboratory professionals working outside the laboratory setting, thus without direct supervision by the laboratory staff. Therefore, either correct organization or management of both personnel and procedures that regard blood specimen collection by venipuncture are of fundamental importance, since the various steps for performing blood collection represent per se sources of laboratory variability. The aim of this (non-systematic) review addressed to healthcare professionals is to highlight the importance of blood specimen management (from patient preparation to laboratory analyses), as a tool to prevent laboratory errors, with the concept that laboratory results from inappropriate blood specimens are inconsistent and do not allow proper treatment nor monitoring of the patient.

The impact of fist clenching and its maintenance during venipuncture on routine hematology testing

BACKGROUND

Prevention of a disturbance of the blood vessel allows phlebotomists to collect a blood specimen by venipuncture that will truly mirror the patient condition. This study was aimed to evaluate the impact of repeated fist clenching and maintenance of the fist during blood collection by venipuncture for routine hematology testing.

METHODS

Blood were collected from 16 healthy volunteers with two separate sequential procedures, entailing standard venipuncture with hand opened throughout blood collection, or clenching the fist six times before venipuncture and maintaining the fist until completion of blood collection. The parameters tested included red blood cell (RBC) count, hemoglobin, hematocrit, mean corpuscular volume (MCV), RBC distribution width, white blood cell count and differential, including neutrophils, lymphocytes, monocytes, eosinophils, basophils, large unstained cells, platelet count, mean platelet volume, and reticulocytes. The results were reported as median and interquartile range. The comparison of data obtained with the two different venipuncture procedures (i.e., with or without fist clenching and closed hand) was performed with Wilcoxon-Mann-Whitney ranked-pairs test. The degree of statistical significance was set at P<.01.

RESULTS AND CONCLUSION

Fist clenching and maintenance during blood collection for routine hematology testing was effective to increase the MCV by 1.2% (P<.001). All others hematological parameters were not significantly biased by fist clenching, though hematocrit, neutrophils, eosinophils, and reticulocytes displayed mindful of trends. We hence advise patients against clenching their fist before blood collection for hematology testing.

Targeting Rejection: Analysis of Specimen Acceptability and Rejection, and Framework for Identifying Interventions in a Single Tertiary Healthcare Facility

OBJECTIVES

Assessment of specimen rejection rates is an important laboratory quality measure for laboratories because of a potential negative impact on patient care. Here, we examined reasons for specimen rejection at a single, tertiary care healthcare institution and propose a framework for designing an efficient intervention.

METHODS

During a 1-year period, we identified all specimens rejected at our hospital and performed an analysis of a wide range of associated variables: reason for rejection, patient location, type of phlebotomist, tests ordered, priority status, collection container used, transport time.

RESULTS

Clotted and hemolyzed specimens accounted for the majority of rejected specimens, but significant differences in reasons for specimen rejection existed between patient care areas. Eighty-five percent of rejected specimens came from the Emergency Department and eight other inpatient care areas. Registered nurses drew approximately 85% of rejected specimens, while laboratory phlebotomy staff drew only 4%.

CONCLUSIONS

While hemolysis and clotting are primary causes for specimen rejection, collection of all available data regarding specimen rejection data is essential for laboratories determining which factors are most significant causes of specimen rejection.

Findings of Phlebotomy Practices in Kenya in 2010: Need for Action

BACKGROUND

Phlebotomy, a commonly performed medical procedure in healthcare, is essential for disease diagnosis and patient management. However, poorly performed phlebotomy can compromise patient safety, healthcare worker (HCW) safety, and specimen quality. We carried out a study between June and July 2010 to assess knowledge, quality and safety of phlebotomy before implementation of a public-private partnership between Becton, Dickinson and Company and the US President's Emergency Plan for AIDS Relief.

METHODS

This was a cross-sectional observational study in 8 healthcare facilities within 4 regions of Kenya. HCWs were observed conducting venous and capillary blood collections, and pre- and posttests were offered during HCW training.

RESULTS

Of 283 blood samples obtained, 194 were venous draws conducted by 72 HCWs and 89 were capillary draws performed by 33 HCWs. Based on 12 preset quality-associated criteria, none of the 194 observed phlebotomies met the standard. In total, 91 HCWs were trained in phlebotomy. The mean knowledge increase between pre- and posttraining test was 41%, ranging from 39% to 45% (95% confidence interval, 29.3%-53.5%;P< .001).

CONCLUSIONS

Inadequate knowledge and imperfect phlebotomy procedures were noted. This formed the basis for the safe phlebotomy partnership to address these deficiencies. To ensure sustainability, safe phlebotomy practices were integrated into preservice training.

Processing of diagnostic blood specimens: is it really necessary to mix primary blood tubes after collection with evacuated tube system?

BACKGROUND

The preanalytical phase is considered the most vulnerable phase in biopreservation, biobanking, and laboratory diagnostics. Accurate mixing after blood collection is claimed to be important and recommended by the manufacturers.

OBJECTIVE

To evaluate whether it is really necessary to mix the primary blood tubes immediately after blood collection by means of evacuated tube systems.

MATERIAL AND METHODS

Blood from 300 outpatients was equally and randomly divided into three groups: G1, sodium citrate vacuum tubes; G2, lithium heparin vacuum tubes; and G3, K2EDTA vacuum tubes. All vacuum tubes were processed using three different procedures. Procedure 1: Gold Standard (P1): All specimens mixed gently and carefully by inverting five times as recommended; Procedure 2: Rest time (P2): All specimens remained 5 min in the upright position, followed by gentle careful mixing by inverting five times; Procedure 3: No mix (P3): All specimens were left in upright position without mixing afterwards. The influence of the primary mixing tube procedure was evaluated for clinical chemistry, hematology, and coagulation parameters by paired t-test. The bias from the mixing procedure was also compared with quality specifications derived from biological variation.

RESULTS

Significant differences (p<0.017) were found for: i) red blood cell count and hematocrit when P1 was compared with P2; ii) alanine aminotransferase and erythrocyte sedimentation rate when P1 was compared with P3; iii) red blood cell count, hematocrit, and hemolysis index when P2 was compared with P3. Surprisingly, clinically significant differences were found only for sodium when P1 was compared with P2, and P1 was compared with P3. No fibrin filaments or microclots were observed in any samples.

CONCLUSION

Primary blood tubes mixing after collection with evacuated tube system appears to be unnecessary.