Quality improvement project: Reducing non-conformities of the samples for haemostasis testing in a secondary healthcare centre through the nurses' education in phlebotomy

Introduction

Poor compliance to the current guidelines and lack of knowledge among nurses about proper blood sampling is set as the study hypothesis. Here is presented a quality improvement project with following aims: a) to identify the most prevalent non-conformity of the samples for haemostasis testing, b) to identify the cause of sample non-conformity, c) to perform corrective action(s) and d) to assess the effectiveness of the corrective action(s).

Materials and methods

The rate of non-conformity of samples collected for haemostasis tests was established for hospital wards with inpatients. Phlebotomy practice was audited throughout anonymous questionnaire among hospital’s nurses who perform phlebotomy. Education about blood sampling was performed as a 1-hour lecture in different small groups each working day within one month. Education effectiveness was assessed through the evaluation of sample quality and is considered effective if more than half of the hospital wards significantly reduced their sample non-conformities rate.

Results

Clotted sample constituted 84% of sample non-conformities. The questionnaire revealed nurses’ poor knowledge in phlebotomy. There was no difference in nurses’ knowledge regarding the level of education or work experience. Reduction in sample non-conformities was observed in 7 out of 9 wards 4 months after education; this improvement was statistically significant for 5 wards.

Conclusion

Clotted sample as the most prevalent non-conformity of the samples for haemostasis testing is caused by the lack of knowledge of the nurses in several parts of the phlebotomy process. Specific education of the motivated personnel in small groups was successful and long-term effective.

Hemolysis has no influence on routine coagulation tests in subjects without anticoagulant therapy - a referral Romanian emergency hospital laboratory experience

The aim of this study was to determine the rate of hemolyzed specimens sent to our laboratory for coagulation testing, assess the interference of hemolysis on coagulation for patients without anticoagulant therapy and to determine the reference intervals for PT, INR and aPTT for our laboratory in order to test our own limitations.

Methods: To determine the hemolysis rate, 1,689 specimens were evaluated on a visual scale and with the hemolysis icterus lipemia (HYL) test on Architect c4000 instrument. 125 blood samples collected from subjects without anticoagulant therapy were hemolyzed in vitro and the PT, INR and aPTT results were compared before and after hemolysis.To determine reference intervals (RI) for PT, INR and aPTT in our population, 125 apparently healthy human subjects (according to CLSI C28-A2) were enrolled and tests were performed on Sysmex CS 2000i, using Siemens reagents.

Results: Out of 1,689 samples, 9.46% were assessed as hemolyzed by the visual scale, while HYL test showed a 6.63% hemolysis rate. We found a shortening of 0.1s for PT, a diminution with 0.01 units for INR and a prolongation with 0.9s for aPTT from in vitro hemolyzed compared to non-lyzed samples. As to the reference intervals, we obtained in our laboratory versus reagents producer: for PT 9.8-13.9 s vs 9.8-12.1 s, and for aPTT 19.1-31.5s vs 23-31.9 s respectively; 28.38% more PT results and 13.44% more aPTT results were within range when we used local laboratory RI, compared to the manufacturer’s RI.

Conclusions: The rate of hemolyzed coagulation samples in our laboratory is higher than the rate found in the literature. Nevertheless, for patients without anticoagulant therapy hemolyzed samples should be processed. Using our own reference interval leads to a significant reduced number of abnormal results.

The impact of venepuncture training on the reduction of pre-analytical blood sample haemolysis rates: A systematic review

BACKGROUND

Venepuncture involves the introduction of a needle into a vein to collect a representative blood sample for laboratory testing. In the pre-analytical phase, haemolysis (the rupturing of erythrocytes and release of their contents into the extracellular compartment) has safety, quality and cost implications. Training in correct venepuncture practice has the potential to reduce in vitro haemolysis rates, but the evidence for this notion has yet to be synthesised.

DESIGN

Systematic review (PRISMA Checklist).

METHODS

Published studies on the effectiveness of venepuncture training on haemolysis rates were searched in relevant databases. The McMaster critical appraisal tool was used to assess methodological quality. The GRADE tool was used to evaluate the body of evidence in relation to the research questions. Implementation fidelity was also scrutinised in each study.

RESULTS

Eight out of 437 retrieved studies met the inclusion criteria. None were randomised controlled trials (RCT). Between-study heterogeneity in design, intervention characteristics and the biochemical threshold for haemolysis precluded a meta-analysis. Post-training reductions in haemolysis rates of between 0.4%-19.8% were reported in four of the studies, which developed their intervention according to a clear evidence base and included mentoring in the intervention. Rises in haemolysis rates of between 1.3%-1.9% were reported in two studies, while the intervention effect was inconsistent within two other studies.

CONCLUSION

There are no RCTS on the effectiveness of venepuncture training for reducing haemolysis rates, and findings from the existing uncontrolled studies are unclear. For a more robust evidence base, we recommend more RCTs with standardisation of haemolysis thresholds and training-related factors.

RELEVANCE TO CLINICAL PRACTICE

While venepuncture training is an important factor influencing quality of blood sample in clinical practice, more robust evidence is needed to make specific recommendations about training content for reduction of haemolysis rates. Standardisation of haemolysis thresholds would also enable future meta-analyses.

Making sense of a haemolysis monitoring and reporting system: a nationwide longitudinal multimethod study of 68 Australian laboratory participant organisations

Background:

The key incident monitoring and management systems (KIMMS) quality assurance program monitors incidents in the pre- and postanalytical phases of testing in medical laboratories. Haemolysed specimens have been found to be the most frequent preanalytical error and have major implications for patient care. The aims of this study were to assess the suitability of KIMMS for quality reporting of haemolysis and to devise a meaningful method for reporting and monitoring haemolysis.

Methods:

A structured survey of 68 Australian KIMMS laboratory participant organisations was undertaken. Quarterly haemolysis reports (2011–2014) were analysed.

Results:

Among 110 million accessions reported, haemolysis rates varied according to the reporting methods that participants used for assigning accessions (16% of participants reported haemolysis by specimen and 83% reported by episode) and counting haemolysis rejections (61% by specimen, 35% by episode and 3% by test). More than half of the participants (56%) assigned accessions by episode and counted rejections by specimen. For this group, the average haemolysis rate per 100,000 episodes was 177 rejected specimens with the average rate varying from 100 to 233 over time. The majority of participants (91%) determined rejections using the haemolysis index. Two thirds of participants (66%) recorded the haemolysis manually in laboratory information systems.

Conclusions:

KIMMS maintains the largest longitudinal haemolysis database in the world. However, as a means of advancing improvements in the quality of the preanalytical laboratory process, there is a need to standardise reporting methods to enable robust comparison of haemolysis rejection rates across participant laboratories.

Hemolysis rates in blood samples: differences between blood collected by clinicians and nurses and the effect of phlebotomy training

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.

Patient identification and tube labelling - a call for harmonisation

Venous blood sampling (phlebotomy) is the most common invasive procedure performed in patient care. Guidelines on the correct practice of phlebotomy are available, including the H3-A6 guideline issued by the Clinical Laboratory Standards Institute (CLSI). As the quality of practices and procedures related to venous blood sample collection in European countries was unknown, the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase conducted an observational study in 12 European countries. The study demonstrated that the level of compliance of phlebotomy procedures with the CLSI H3-A6 guideline was unacceptably low, and that patient identification and tube labelling are amongst the most critical steps in need of immediate attention and improvement. The process of patient identification and tube labelling is an essential safety barrier to prevent patient identity mix-up. Therefore, the EFLM Working Group aims to encourage and support worldwide harmonisation of patient identification and tube labelling procedures in order to reduce the risk of preanalytical errors and improve patient safety. With this Position paper we wish to raise awareness and provide recommendations for proper patient and sample identification procedures.

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.

Hemolysis from a nurses' standpoint--survey from four Croatian hospitals

INTRODUCTION

Hemolysis can occur during sample collection, handling and transport. It is more frequent when the non-laboratory staff performs sampling. The aim of this study was to assess nurses' knowledge on the causes of hemolysis and consequential impact on the laboratory tests results. Additionally, the differences in knowledge, related to work experience, professional degree and previous education about hemolysis were explored.

MATERIALS AND METHODS

An anonymus survey, containing 11 questions on demographics, causes of hemolysis, its impact on biochemical parameters and nurses' attitude towards additional education in preanalytics, was conducted in four Croatian hospitals. The answers were compared by Chi-squared and Fischer exact test.

RESULTS

In total, 562 survey results were collected. Majority of nurses declared familiarity with the term "hemolysis" (99.6%). There were 77% of correct answers regarding questions about the causes of hemolysis, but only 50% when it comes to questions about interference in biochemical tests. The percentage of correct answers about causes was significantly lower (P=0.029) among more experienced nurses, and higher (P=0.027) in those with higher professional degree, while influence of previous education was not significant. Also, higher percentage of correct answers about interferences was encountered in nurses with longer work experience (P=0.039). More than 70% of nurses declared that additional education about preanalytical factors would be beneficial.

CONCLUSION

Croatian nurses are familiar with the definition of hemolysis, but a lack of knowledge about causes and influence on laboratory test results is evident. Nurses are eager to improve their knowledge in this field of preanalytical phase.

Laboratory Diagnostics and Quality of Blood Collection

Diagnostic blood samples collected by phlebotomy are the most common type of biological specimens drawn and sent to laboratory medicine facilities for being analyzed, thus supporting caring physicians in patient diagnosis, follow-up and/or therapeutic monitoring. Phlebotomy, a relatively invasive medical procedure, is indeed critical for the downstream procedures accomplished either in the analytical phase made in the laboratory or in the interpretive process done by the physicians. Diagnosis, management, treatment of patients and ultimately patient safety itself can be compromised by poor phlebotomy quality. We have read with interest a recent article where the authors addressed important aspects of venous blood collection for laboratory medicine analysis. The authors conducted a phlebotomy survey based on the Clinical and Laboratory Standard Institute (CLSI) H03-A6 document (presently replaced by the GP41-A6 document) in three government hospitals in Ethiopia to evaluate 120 professionals (101 non-laboratory professionals vs. 19 laboratory professionals) as regards the venous blood collection practice. The aim of this mini (non-systematic) review is to both take a cue from the above article and from current practices we had already observed in other laboratory settings, and discuss four questionable activities performed by health care professionals during venous blood collection. We refer to: i) diet restriction assessment; ii) puncture site cleansing; iii) timing of tourniquet removal and; iv) mixing specimen with additives.

Personnel's Experiences of Phlebotomy Practices after Participating in an Educational Intervention Programme

Background. Blood specimen collection is a common procedure in health care, and the results from specimen analysis have essential influence on clinical decisions. Errors in phlebotomy may lead to repeated sampling and delay in diagnosis and may jeopardise patient safety. This study aimed to describe the experiences of, and reflections on, phlebotomy practices of phlebotomy personnel working in primary health care after participating in an educational intervention programme (EIP). Methods. Thirty phlebotomists from ten primary health care centres participated. Their experiences were investigated through face-to-face interviews. Findings were analysed using qualitative content analysis. Results. The participants perceived the EIP as having opened up opportunities to reflect on safety. The EIP had made them aware of risks in relation to identification procedures, distractions from the environment, lack of knowledge, and transfer of information. The EIP also resulted in improvements in clinical practice, such as a standardised way of working and increased accuracy. Some said that the training had reassured them to continue working as usual, while others continued as usual regardless of incorrect procedure. Conclusions. The findings show that EIP can stimulate reflections on phlebotomy practices in larger study groups. Increased knowledge of phlebotomy practices improves the opportunities to revise and maximise the quality and content of future EIPs. Educators and safety managers should reflect on and pay particular attention to the identification procedure, distractions from the environment, and transfer of information, when developing and implementing EIPs. The focus of phlebotomy training should not solely be on improving adherence to practice guidelines.

Preanalytical quality improvement: in quality we trust

Total quality in laboratory medicine should be defined as the guarantee that each activity throughout the total testing process is correctly performed, providing valuable medical decision-making and effective patient care. In the past decades, a 10-fold reduction in the analytical error rate has been achieved thanks to improvements in both reliability and standardization of analytical techniques, reagents, and instrumentation. Notable advances in information technology, quality control and quality assurance methods have also assured a valuable contribution for reducing diagnostic errors. Nevertheless, several lines of evidence still suggest that most errors in laboratory diagnostics fall outside the analytical phase, and the pre- and postanalytical steps have been found to be much more vulnerable. This collective paper, which is the logical continuum of the former already published in this journal 2 years ago, provides additional contribution to risk management in the preanalytical phase and is a synopsis of the lectures of the 2nd European Federation of Clinical Chemistry and Laboratory Medicine (EFLM)-Becton Dickinson (BD) European Conference on Preanalytical Phase meeting entitled "Preanalytical quality improvement: in quality we trust" (Zagreb, Croatia, 1-2 March 2013). The leading topics that will be discussed include quality indicators for preanalytical phase, phlebotomy practices for collection of blood gas analysis and pediatric samples, lipemia and blood collection tube interferences, preanalytical requirements of urinalysis, molecular biology hemostasis and platelet testing, as well as indications on best practices for safe blood collection. Auditing of the preanalytical phase by ISO assessors and external quality assessment for preanalytical phase are also discussed.

The effective reduction of tourniquet application time after minor modification of the CLSI H03-A6 blood collection procedure

Introduction:

The phlebotomists’ procedures are a still source of laboratory variability. The aim of this study was to verify the efficacy of minor modification in procedure for collection of diagnostic blood specimens by venipuncture from CLSI H03-A6 document is able to reduce the tourniquet application time.

Materials and methods:

Thirty phlebotomists were invited to participate. Each phlebotomist was trained individually to perform the new venipuncture procedure that shortens the time of tourniquet release and removal. The phlebotomy training program was delivered over 8h. After training, all phlebotomists were monitored for 20 working days, to guarantee the adoption of the correct new procedures for collection of diagnostic blood specimens. After this time frame the phlebotomists were evaluated to verify whether the new procedure for blood collection derived from CLSI H03-A6 document was effective to improve the quality process by decrease in tourniquet application time. We compared the tourniquet application time and qualitative difference of phlebotomy procedures between laboratories before and after phlebotomy training.

Results:

The overall mean ± SD tourniquet application time before and after this intervention were 118 ± 1 s and 30 ± 1 s respectively. Minor modifications in procedure for blood collection were able to reduce significantly the tourniquet application time (−88 s, P < 0.001).

Conclusions:

The minor modifications in procedure for collection of diagnostic blood specimens by venipuncture from CLSI H03-A6 document were able to reduce the tourniquet application time. Now the proposed new procedure for collection of diagnostic blood specimens by venipuncture could be considered usefulness and should be put into practice by all quality laboratory managers and/or phlebotomy coordinators to avoid preanalytical errors regard venous stasis and guarantee patient safety.

Impact of a large-scale educational intervention program on venous blood specimen collection practices

BACKGROUND

Phlebotomy performed with poor adherence to venous blood specimen collection (VBSC) guidelines jeopardizes patient safety and may lead to patient suffering and adverse events. A first questionnaire study demonstrated low compliance to VBSC guidelines, motivating an educational intervention of all phlebotomists within a county council. The aim was to evaluate the impact of a large-scale educational intervention program (EIP) on primary health care phlebotomists' adherence to VBSC guidelines. We hypothesised that the EIP would improve phlebotomists' VBSC practical performance.

METHODS

The present study comprise primary health care centres (n = 61) from two county councils in northern Sweden. The final selected study group consisted of phlebotomists divided into an intervention group (n = 84) and a corresponding control group (n = 79). Both groups responded to a validated self-reported VBSC questionnaire twice. The EIP included three parts: guideline studies, an oral presentation, and an examination. Non-parametric statistics were used for comparison within and between the groups.

RESULTS

Evaluating the EIP, we found significant improvements in the intervention group compared to the control group on self-reported questionnaire responses regarding information search (ES = 0.23-0.33, p < 0.001-0.003), and patient rest prior to phlebotomy (ES = 0.27, p = 0.004). Test request management, patient identity control, release of venous stasis, and test tube labelling had significantly improved in the intervention group but did not significantly differ from the control group (ES = 0.22- 0.49, p = < 0.001- 0.006). The control group showed no significant improvements at all (ES = 0-0.39, p = 0.016-0.961).

CONCLUSIONS

The present study demonstrated several significant improvements on phlebotomists' adherence to VBSC practices. Still, guideline adherence improvement to several crucial phlebotomy practices is needed. We cannot conclude that the improvements are solely due to the EIP and suggest future efforts to improve VBSC. The program should provide time for reflections and discussions. Furthermore, a modular structure would allow directed educational intervention based on the specific VBSC guideline flaws existing at a specific unit. Such an approach is probably more effective at improving and sustaining adherence to VBSC guidelines than an EIP containing general pre-analytical practices.