Hemolysis of Blood Specimens: Increasing Throughput Time In The Emergency Department? Julie Hiles, RN and Sherry Young, RN CEN, EMT-P Purpose

Due to overcrowding in the Emergency Department, (ED) patient throughput flow is a hot topic. To enhance efficiency of patient flow, nurses often perform phlebotomy via a newly established intravenous (IV) site, to reduce the number of patient venipunctures when blood specimen and IV therapy is ordered. (Burns & Yoshikawa, 2002). SOMC’s ED nurses noted an increased incidence of hemolysis of blood specimens after adopting the practice of nurses obtaining blood specimens via a newly established IV site. Purpose

Hemolysis: the breakdown of red blood cells resulting in the release of hemoglobin; can be due to mechanical trauma (Mosby, 2002) “Average Throughput Time” is an ED service indicator and Magnet indicator Benchmark: 2.6 hours SOMC ED: Average for Fiscal Year 2011 as of September was 2.9 hours Purpose

The purpose of this study was to determine if there was a significant difference in the proportion of hemolysis of blood specimens obtained from a newly inserted IV using a 20 g Advant IV safety catheter and blood specimens obtained from a 21g-23g straight needle venipuncture. Setting

Study conducted in Level 2 ED of a 220-bed community teaching Appalachian hospital, located in Southern Ohio ED has approximately 53,000 annual visits. Design

Non-experimental Quantitative Descriptive Design No manipulation of variables Review of hemolysis log Describe method of specimen collection/hemolysis Subjects Convenience sample of 100 hemolyzed blood samples drawn in the ED January, 2009- November 2009. (N = 101 were recorded) Exclusions Any ED patient under the age of 18 Dialysis patients Mastectomy patients Obtained approval from institutional IRB Methods

Specimen Collection Randomly selected ED nurses with 2 or more years of ED experience: IV site draw Randomly selected ED techs II with 2 or more years of ED experience: Venipunture ED lab techs maintained record of all hemolyzed blood specimens drawn until N=100 (total of 101 were recorded). Methods Blood specimens were analyzed for hemolysis using a Hitachi automated spectrophotometer and visual inspection by the lab technologist. Hemolyzed specimens were stratified according to method of specimen retrieval: Group A = Veinipuncture Group B = IV Site Chi-Square, SPSS Results

Of the 101 hemolyzed specimens, 65 (64.4%) were drawn by newly placed 20 g IV catheter, while 36 (35.6%) were drawn by 21 – 23 g venipuncture needle. There was a significant difference in the proportion of hemolysis in the two specimen collection methods χ2 (1, N = 101) = 8.327; p < .01 Implications

A decreased hemolysis rate would result in improved ED throughput, reduced length of stay for the patient, fewer recollections (saving in both time and materials), and better patient satisfaction. (Running a hospital: Fixing bad blood tests website November, 2008). Hemolysis can affect the patient’s length of stay in the ED setting due to delay in diagnosis and treatment while blood specimens are collected and analyzed again (Halm & Gleaves, 2009) Implications

IV Nurses Society Standards do not support the practice of drawing blood specimens from peripheral IV lines (Nursing Research Council of United Hospital, 2004)

Policy developed for SOMC named Obtaining Blood for Lab Specimens Lack of consistency in method of IV blood draw (site selection, discard/no discard spec, sequence of tube selection) Implications

As this study was in process, systematic review of literature was published supporting venipunture as best practice for collecting blood samples, (Halm & Gleaves, 2009) supporting findings of this study and strengthening researchers’ recommendations Recommend: SOMC ED develop an evidence based practice protocol regarding blood draws only to be obtained via venipuncture or arterial stick, not from newly started or established peripheral IV Obtaining Blood for Lab Specimens Policy in the Emergency Department

Policy effective date was June 1, 2010

Staff members received education in shift briefings from Assistant Nurse Managers

All blood draws are to be done by venipuncture Collaborative Effort

Southern Ohio Medical Center Shawnee State University Ohio University Centers For Osteopathic Research And Education (CORE) References Arzoumanian, L. (2003). What is hemolysis? BD Tech Talk, 2 (2).

Burns, E., & Yoshikawa, N. (2002). Hemolysis in serum samples drawn by emergency department personnel versus laboratory phlelbotomists. Lab Med, 33(5), 378-380.

Bush, V. (2003). The hemolyzed specimen: Causes, effects, and reduction. ED Lab Notes. 1, 2-5.

Cox, S., Dages, J., & Hazelett, S. (2004). Blood samples drawn from iv catheters have less hemolysis when 5-ml (vs. 10-ml) collection tubes are used. Journal of Emergency Nursing. 30(6), 529-33.

Dugan, L., Leech, L., Speroni, K., & Corriher, J. (2005). Factors affecting hemolysis rates in blood samples drawn from newly placed iv sites in the emergency department. Journal of Emergency Nursing. 31(4), 338-45.

Grant, M. (2003). The effect of blood drawing techniques and equipment on the hemolysis of ed laboratory blood samples. Journal of Emergency Nursing. 29(2), 116-21. References

Gruber, E. (2002). College of american pathologists reports (Hemolysis) (18). Retrieved July 24, 2008 from www.cap.org.

Halm, M., & Gleaves, M. (2009). Obtaining blood samples from peripheral intravenous catheters: Best practice? American Journal of Critical Care, 18, 474-478.

Kennedy, C., Angermuller, S., King, R., Noviello, S., Walker, J., Warden, J. (1996). A comparision of hemolysis rates using intravenous catheters versus venipuncture tubes for obtainingblood samples. Journal of Emergency Nursing, 22(6), 566-9.

Lowe, G., Stike, R., Pollack, M., Bosley, J., O’Brien, P., Hake, A. (2008). Nursing bloodspecimen collection techniques and hemolysis rates in an emergency department: Analysis of venipuncture versus intravenous catheter collection techniques. Journal of Emergency Nursing, 34(1), 26-32.

Mosby’s Medical, Nursing, & Allied Health Dictionary. (2002). 6th ed. St. Louis: Mosby.

Tanabe, P., Kyriacou, D., & Garland, F. (2003). Factors affecting the risk of blood bank specimen hemolysis. Academic Emergency Medicine, 10(8), 897-9.

(nd). Southern Ohio Medical Center. September 18, 2008, http://www.somc.org. Questions?