An emergency department’s quality improvement project aims to reduce errors and improve care.
Takeaways:
- Rates of hemolysis decrease with the implementation of proper blood draw procedures.
- Using venipuncture for blood draws reduces medical errors and improves the patient experience.
- Reducing hemolysis rates improves time for results and patient disposition and reduces organization financial loss organization.
Consider the following disturbing statistics from Seemann and Nybo: If medical error was categorized as a disease, it would be the third leading cause of death in the United States; 70% of medical errors are the result of laboratory results; and of those laboratory errors, 75% occur in the preanalytical (blood draw) phase. When analyzing the hemolysis rates at my inner-city hospital, I found them to be significantly higher in the emergency department (ED) than in any other department. Based on the success of other continuous quality improvement (CQI) initiatives I discovered in a literature review, I proposed initiating a CQI project in our ED to reduce blood sample hemolysis rates.
Objectives
The CQI’s objective was to determine whether hemolysis rates for blood draws of patients in the ED decreases after education is provided on blood draw best practices. The CQI’s purpose was to decrease lab error (and therefore medical error) risk to improve patient outcomes, enhance staff time management, increase treatment efficiency, and reduce ED costs. Patients would be spared multiple blood draw attempts, and accurate test results would be available to providers in a timely fashion, ensuring a shorter turnaround time for treatment.
Methods
A literature review was conducted to determine the best evidence-based blood draw techniques for reducing hemolysis rates. Fifteen nurses and critical care technicians (CCTs) from the ED volunteered to participate in the CQI. Their hemolysis rates were tracked for 6 months before initiating the new techniques and then for 6 months after they were taught how to use them. (See Blood draw best practices.) Hemolysis rates for the entire ED were also tracked for 6 months before and after project implementation. Hemolysis rates were compared by corresponding month from the year before and during the current year to factor in seasonal ED patient population trends.
After a literature review in search of blood draw best practices, the emergency department volunteers who participated in the hemolysis reduction continuous quality improvement project were taught to:
- collect blood from an I.V. catheter at initial catheter insertion (but not for redraws) to decrease the risk of a slow draw, which is a cause of hemolysis
- perform venipuncture for all other blood specimens
- choose the needle size that best correlates with vein size because hemolysis is caused by blood cells traveling from a large vein into and through a small needle
- use straight stick rather than butterfly needles because hemolysis can be caused by blood cells traveling through the butterfly tubing.
Other strategies included:
- ensure correct order of draw to avoid erroneous results or clots from cross-contamination of additives
- inverting the collected specimen rather than shaking it, which can cause hemolysis.
Sources: Garza & Becan-McBride, 2018; WHO, 2010
Outcomes
Among members of the sample group, personal hemolysis rates decreased during the 6-month initiative. One member’s blood draw techniques before the project resulted in nine hemolyzed samples; during the project, that member’s hemolysis rate dropped to zero. Another sample group member’s hemolysis rate decreased by half. Data collected from all volunteers who participated in the full 12 months of the project showed a collective hemolysis rate of 36 in the 6 months before initiating the new technique and 20 during the 6 months of new technique use.
Unit-wide, the mean number of hemolyzed samples for the 6 months before new technique initiation was 123.3; during new technique use, the mean was 71.3. The average mean number of hemolyzed ED samples from May 2017 to October 2017 was 112.2; for the 6 months of the new technique implementation (May 2018 to October 2018), the average mean was 71.3.
The project had some limitations. The sample size was small, and data were collected from only one ED. In addition, some members of the participating group left the hospital during the CQI, and new nurses who joined the department were taught the best practice during orientation, altering the sample size. Other factors that may have affected hemolysis rates include lack of padding in the tube system used to send blood specimens to the lab and the installation of new analyzers in the hospital’s lab.
Future research
Our literature review and project outcomes indicate that hemolysis rates are minimized when blood isn’t pulled from existing I.V. catheters. Instead, initial blood samples should be drawn when catheters are first inserted. For additional blood studies, venipuncture should be performed. We also concluded that hemolysis rates are reduced when needle size is chosen based on vein size and accessibility, and that straight needles should be used when possible because a butterfly-style needle in a larger vein may cause hemolysis.
We believe further study is warranted. Hemolysis rates also can be affected by tourniquet time and vein location choice; these factors weren’t included in this CQI project. Analyzers and their influence on hemolysis improvement rates also should be considered.
At the time of this project, Kelly Williams was a staff nurse in the emergency department at Sinai Hospital at LifeBridge Health in Baltimore, Maryland. She currently is the clinical instructor at a pediatric emergency department in Washington, DC.
References
Garza D, Becan-McBride K. Phlebotomy Handbook. 10th ed. Upper Saddle River, NJ: Pearson Education; 2018.
Heyer NJ, Derzon JH, Winges L, et al. Effectiveness of practices to reduce blood sample hemolysis in EDs: A laboratory medicine best practices systematic review and meta-analysis. Clin Biochem. 2012;45(0):1012-32.
Phelan MP, Reineks EZ, Schold JD, Hustey FM, Chamberlin J, Procop GW. Preanalytic factors associated with hemolysis in emergency department blood samples. Arch Pathol Lab Med. 2018;142(2):229-35.
Seemann TL, Nybo M. Continuous quality control of the blood sampling procedure using structured observation scheme. Biochem Med. 2016;26(3):337-45.
World Health Organization. WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy. Geneva: World Health Organization; 2010. ncbi.nlm.nih.gov/books/NBK138665/
