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Blood Sample Processing
Blood Sample Processing
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Abstract and large hospitals and reference laboratories. Keywords: low blood volume, blood sample
A group of leading clinical laboratory scientists Discussion focused on recent key issues that have processing, microtubes, automated processing,
met in New York City on November 11, 2010, to arisen in blood sample processing, dynamics laboratory management
provide perspectives on a range of issues related associated with automated processing, working
to blood sample processing. The panel consisted with low blood volumes, and a range of timely Note: This article is based on a roundtable
of practicing laboratorians and educators from professional issues. discussion held November 11, 2010, in New
a range of institution types, including small York, NY.
I
n recent years, as technology has increased in avail- Laboratorians have also needed to learn how to get more
ability and complexity, medical laboratorians have out of less as industry pressures to increase blood conserva-
been presented with a range of both opportunities and tion have intensified. Unnecessarily large blood samples can
challenges. Automated processing enables technologists pose significant health risks for anemic and other vulnerable
to perform a greater variety of tests on smaller sample patients. In recognition of these risks, in early 2010 the Joint
quantities with greater accuracy of outcomes. It also Commission announced the pilot implementation of a series
allows highly skilled medical laboratory scientists to of blood management initiatives at hospitals across the United
avoid repetitive logistical tasks in favor of higher-level analytic States.1 Blood conservation is a core priority area of this pro-
activities. Because automated processing requires fewer skilled gram. Following analysis of the pilot test results, a technical
personnel to run, it also helps laboratories to reduce operating advisory panel will review the data and make a recommenda-
costs and eliminates the necessity of hiring additional staff in tion to the National Quality Forum for endorsement. The
times of labor shortages. Given these advantages, an increasing likely outcome of this program will be a continued emphasis
number of laboratories are connecting hematology and chem- on increasing conservation, thereby decreasing the need for
istry analyzers to automated platforms. some transfusions and also reducing operating costs associated
Yet while automated process technologies have enhanced with biological waste disposal.
workflow efficiency and outcomes in many laboratories, many The No. 1 2010 National Patient Safety Goal2 of the
others have encountered compatibility concerns between ana- Joint Commission is improving the accuracy of patient
lyzers and the tubes used to contain the samples. In addition, identification (ID). Reducing the number of ID-dependent
some tubes used for an automated process have been designed procedures decreases the risk of misidentification. In addition,
to function in manual processing. Process stoppages caused by given the potential risks to patients of blood sample misiden-
incompatible equipment can have significant negative impacts tification, eliminating ID labeling errors has also become a
on workflow efficiency, laboratory maintenance costs, and cornerstone of medical laboratory scientist and technician
time to disease diagnosis and treatment. Participants agree training. However, as blood sample sizes have decreased, mi-
that there must be an industry-wide movement to establish crotubes accommodating smaller sample quantities have come
and document greater compatibility between collection de- into routine use. These smaller tubes have imposed additional
vices and analyzers. challenges for laboratorians as they require the use of special
miniaturized labels that do not include complete informa-
tion or larger labels wrapped around the tube that must be
removed in the lab.
8
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to perform multiple thorough and accurate tests. Participants institutions following a 3- to 4-year payback period. These
agree that not having sufficient volumes for analysis can raise cost savings can be even more substantial for institutions
operating costs and place significant stress and demands for currently relying on manual handling of microtubes, which
additional vigilance on laboratory staff, who in some cases increases the per-test cost because the current microtube of-
must ask blood collection staff to obtain repeat draws from ferings are not automation compatible. Though the initial
neonatal or medically fragile patients. capital outlay for the necessary equipment proves difficult for
Another driver of decisions to resample is sample degra- many small- to mid-sized institutions to manage, automation
dation. There was consensus among participants that gener- is a desirable goal for most facilities.
ally samples older than 12 hours should not be relied on for
accurate analyses. For example, 1 important area of concern
in the analysis is blood glucose levels, because glucose levels
decrease in whole blood within a few hours following sample
collection. Participants agree that the need to redraw based on
sample degradation is particularly difficult to justify to blood
collection staff.
Consistent problems with point-of-care (POC) testing,
which is performed by non-laboratory staff, seem to have
yielded some sympathy among collection staff for the chal-
lenges involved in medical laboratory testing, including pres-
sures to perform multiple tests on low-volume samples. There
was general consensus among participants that most errors
occur in the pre-analytical and post-analytical phases, either
in sampling or in the interpretation of results.
Automated Processing
Automated processing further reduces errors but also im-
poses special challenges for testing low-volume samples. One
participant used the analogy of upsetting a retail shopping
queue by proffering cash instead of a credit card. Introducing
a microtube into an automated process often has the same
outcome: it impairs workflow efficiency by introducing a
manual procedure into an automated process. This problem
is especially pronounced for participants from larger facilities
relying on automated processing to save time in the course
of hundreds or thousands of sample processing cycles each
day. Another participant maintained that he needed to place
microtubes within larger tubes to accommodate a full-size
(non-miniaturized) label. Participants agreed that a microtube Training and Laboratory Management
designed for automated processing and capable of accommo-
dating a full standard-size patient ID label would be a valu- Participants also offered perspectives on a range of key
able innovation and would “absolutely reduce errors.” industry trends, clinical laboratory management issues, and
Although participants agree that using microtubes does potential areas of process improvement.
not increase the likelihood of an error, they also note the per-
centage of processing problems is higher with microtubes due
to the manual processing and labeling required. One issue of An Aging Workforce
particular concern is increased handling time. Laboratories Given the increasing importance of technological
are constantly under pressure to improve turnaround time for know-how among clinical staff, it is interesting to note the
samples. It is standard procedure for clinical laboratorians to nationwide average age of a clinical laboratory scientist is
limit the frequency of directly handling or combining samples between 47-49, and many are approaching retirement age.3
because each additional manual step increases handling time At 1 participant’s facility, the average age is 57. In 2004 the
as well as the likelihood of an accidental exposure to blood- American Society for Clinical Pathology (ASCP) issued The
borne pathogens. Participants agreed that minimizing the Medical Laboratory Personnel Shortage, a seminal report on
handling of tubes should remain a top priority for clinical this alarming trend.4 Since then, the organization has estab-
laboratories and in staff training. lished scholarships and academic partnerships to combat the
The most valuable benefit of automation, particularly growing shortage of qualified new clinical laboratory staff.
for larger facilities, is the standardization of processing time. Nevertheless, as of 2010 the U.S. Bureau of Labor Statistics
Participants agree that increasing the predictability of the maintains that, among medical laboratory scientists and tech-
analysis cycle can have a significant positive impact for overall nicians, “the number of job openings is expected to continue
workflow efficiency. This added efficiency is especially impor- to exceed the number of jobseekers.”5 Participants agree that
tant for facilities using smaller sample sizes. In addition, there an infusion of young, well-educated, and technologically savvy
are moderate operating cost savings associated with automa- laboratorians is critically important for the industry as auto-
tion, estimated as approximately 5%-10% annually for larger mation process technologies become more common.
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Introducing New Technologies and Products collection. While rigorous national certification standards
Participants agree that medical laboratory professionals exist, it is common for someone to be hired as a phlebotomist
are generally able to teach each other when a new or unfa- with no certification at all. Moreover, there is too much reli-
miliar product or technology is introduced. However, there ance on on-the-job training and informal peer instruction,
were significant differences in the latitude granted to par- and there are very limited continuing education opportunities.
ticipants by their institutions in terms of product choice. In Compounding these problems is a growing trend toward staff
some facilities, product choice is dictated by vendor contracts downsizing and elimination of dedicated phlebotomy teams,
with little clinical input, while other institutions allow staff thereby involving phlebotomists in blood sample collection
to purchase virtually any products they wish so long as they only in cases of a difficult draw.
demonstrate the economic value of products and stay within A less direct but still substantial factor is the “pay and
“old-fashioned capital budgets.” prestige gap” that often exists between phlebotomists and
other clinicians. Participants indicated that phlebotomists are
often “low on the totem pole” in hospital and laboratory set-
tings. Professional disregard for the phlebotomy profession
was noted to be especially inappropriate given the pivotal
Participants agree that the health care function of these professionals in patient care and in obtain-
industry’s push toward smaller blood sample ing and handling specimens.
sizes has created a range of special challenges
Conclusions
for laboratory staff. Clinical laboratory scientists involved in diagnostic or
clinical analysis confirm there is increasing pressure from
health care policymakers and hospital management to reduce
blood volume in sampling. They also note that blood collec-
tion or medical staff, especially phlebotomists and nurses who
There are also significant differences in the product work in ICUs and neonatal ICUs (NICUs), widely support
approval process by institution. In some cases, institutional this goal. While recognizing the benefits in terms of reduced
review board (IRB) approval and exhaustive parallel studies waste and improved patient comfort and safety, laboratory
are required. One participant added that these studies can be scientists report continuing challenges in efforts to analyze
difficult or impossible to perform when they involve non-con- samples where volumes are insufficient or where the amount
senting populations such as neonates. Yet in general, medical of anticoagulant is not appropriate for the volume of blood,
laboratory scientists and technicians and even some laboratory potentially compromising the sample. There are also opera-
directors have little say in materials management decisions. tional difficulties associated with the incompatibility of most
“In reality,” 1 participant argued, “hospital administrators” currently available microtubes with automated processing
make these decisions, and the decision-making process can technologies. Factors such as redraws caused by insufficient
result in “some pretty tough battles.” While some participants blood sample volumes, questionable sample quality, labeling
reported relatively effective coordination between their institu- errors, and manual handling of microtubes that cannot be
tion’s administration and laboratory staff, for most medical processed using automated technologies continue to have a nega-
laboratory professionals, the value proposition for a new prod- tive impact on analytical accuracy and laboratory efficiency. LM
uct must be substantial to justify the stress associated with the
approval process.
Though participants understand the necessity of a rig-
orous review process, they also strongly believe that most 1. The Joint Commission. Patient Blood Management Performance Measures
institutional review processes can be streamlined. In addition, Project. Available at: www.jointcommission.org/patient_blood_management_
performance_measures_project/. Accessed January 6, 2011.
clinical laboratory personnel should have more influence in
2. The Joint Commission. 2010 National Patient Safety Goals. Available at:
the proposal and approval of new products within their pro- http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed
fessional purview. Undertaking these 2 steps will yield multiple January 6, 2011.
significant benefits for workflow efficiency and overall 3. American Society for Clinical Pathology. Updated February 2009. Available
analytical outcomes. at: http://www.ascp.org/MainMenu/AboutASCP/Newsroom/NewsReleases/
ASCP-Partners-to-Highlight-Lab-Careers.aspx. Accessed January 6, 2011.
4. American Society for Clinical Pathology. Available at: http://www.ascp.org/
pdf/MedicalLaboratoryPersonnelShortage.aspx. Accessed January 6, 2011.
Pre-analytical Variability and Personnel Training 5. U.S. Department of Labor, Bureau of Labor Statistics, Occupational Outlook
One specific area of achievable improvement in the blood Handbook. 2010-11 Edition. Available at: http://www.bls.gov/oco/ocos096.
sample collection and analysis process lies in the pre-analytical htm#outlook. Accessed January 6, 2011.
phase with phlebotomists6 and other medical staff who col- 6. Giuseppe L, Simundic AM, Mattiuzzi C. Overview on patient safety in
healthcare and laboratory diagnostics. Biochemia Medica. 2010;20:131-143.
lect laboratory specimens. Participants agree and studies show Available at: http://www.biochemia-medica.com/content/overview-patient-
that the pre-analytical phase is where most of the errors in the safety-healthcare-and-laboratory-diagnostics. Accessed January 6, 2011.
diagnostic process occur. Though estimates in the clinical lit- 7. Ernst D. Applied Phlebotomy. Philadelphia: Lippincott Williams & Wilkins;
erature vary significantly, from 56%7 to 93%8, pre-analytical 2005. Available at: http://findarticles.com/p/articles/mi_m3230/is_9_38/
ai_n27005642/?tag=content;col1. Accessed January 6, 2011.
variability accounts for a clear majority of diagnostic errors. 8. Lippi G, Guidi GC, Mattiuzzi C, et al. Preanalytical variability: The dark side
Participants agree the most likely reason for pre-analytical of the moon in laboratory testing. Clin Chem Lab Med. 2006;44:358-365.
variability is lack of professional training related to sample
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