Phlebotomy Practices Research Articles

Observational Study on Adherence to modified Clinical and Laboratory Standard Institute H3-A6 Guidelines on Blood Sampling Procedures

Background: The accuracy of clinical laboratory results is paramount for effective patient diagnosis and treatment. However, errors in the pre-analytical phase, particularly during phlebotomy, significantly impact the reliability of laboratory data. With the Clinical and Laboratory Standards Institute (CLSI) guidelines serving as a benchmark for best practices in blood collection, adherence to these standards is crucial for minimizing errors. Objective: This study aimed to assess compliance with modified CLSI guidelines in phlebotomy procedures within a healthcare setting and identify the most prevalent errors in the pre-analytical phase that could compromise patient safety and the integrity of laboratory results. Methods: Conducted at the Combined Military Hospital Lahore from January to March 2023, this observational study scrutinized phlebotomy practices across three distinct healthcare settings: emergency department, outpatient department, and clinical wards. A structured checklist, adapted from the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) guidelines and aligned with local modifications, was employed to evaluate compliance in 20 specific areas of phlebotomy practice. A total of 285 phlebotomies were observed by specialized staff, with data analyzed using SPSS version 25 to compare error frequencies and compliance rates across different settings and among various healthcare professionals. Results: The study revealed an overall compliance rate of 88% for identified request forms, 76% for patient identification according to local guidelines, and 66% for proper hand sanitization. However, significant errors were identified in checking for potential complications of venipuncture (34% compliance), with tubes being clearly under or overfilled (46% compliance), and in verifying that patients were prepared for phlebotomy (46% compliance). The error frequency varied across settings, with the highest discrepancies observed in the emergency department. Differences in compliance rates between laboratory staff and nurses were statistically significant in key areas, including patient identification (p<0.001) and tube labeling (p=0.081). Conclusion: The study highlights a critical need for improving adherence to CLSI guidelines within phlebotomy practices to enhance patient safety and the accuracy of laboratory results. Targeted educational and training interventions are essential for addressing the identified gaps in compliance, particularly in patient identification, sample volume control, and verification of patient preparation for phlebotomy.

Observational Assessment of Pre-Analytical Errors in Request Format and Phlebotomy Practice in Hematology Tests at Hawassa University Comprehensive Specialized Hospital in Sidama Zone, Southern Ethiopia

Observational Assessment of Pre-Analytical Errors in Request Format and Phlebotomy Practice in Hematology Tests at Hawassa University Comprehensive Specialized Hospital in Sidama Zone, Southern Ethiopia

A novel multimodal approach for the assessment of phlebotomy performance in nurses

Abstract Objectives Phlebotomy is presumably the most challenging preanalytical aspect in laboratory medicine. In Europe, inpatient phlebotomy is performed by nurses in 45–60 % of cases. We aimed to develop and test a novel phlebotomy assessment tool for nurses. Methods A group of 24 nurses working in a surgical ward was investigated. A three-pronged approach was devised: (1) a standardized knowledge test, (2) three blinded phlebotomy audits, and (3) prospective monitoring of samples sent from the investigated surgical ward for the calculation of preanalytical quality indicators. Results The average knowledge test score was 22.7/31 points (12–31, interquartile range 20.5–25). The average audit score was 14.5/18 points (13.7–14.7, interquartile range 14–15). No statistically significant correlations were found between phlebotomy knowledge (or lack of) and corresponding phlebotomy practices (or errors, respectively). Moreover, there was no statistically significant correlation between individual knowledge scores and audit scores. Several misconceptions about the preanalytical phase were identified, along with common phlebotomy errors. Conclusions Sometimes, nurses do not follow guidelines due to lack of theoretical knowledge. Other times, nurses fail to follow procedures despite having the prerequisite theoretical knowledge. We observed a discordance between theory and practice regarding certain aspects of phlebotomy. The novel multimodal methodology presented here describes an improved assessment tool and a superior alternative to the popular survey studies. This tool may be used to identify specific and recurrent phlebotomy issues and to improve institutional continuing education programs for nurses through targeted training programs.

Effect of automated feedback laboratory comments promoting good phlebotomy practice on the frequency of ethylenediaminetetraacetic acid (EDTA) contamination of serum samples.

Ethylenediaminetetraacetic acid (EDTA) contamination of serum samples is common but under-recognized unless EDTA is measured. Incorrect order of draw with closed phlebotomy (vacutainer) does not cause EDTA contamination. EDTA contamination occurs largely or solely during open phlebotomy due to syringe tip or needle-tip contamination when delivering blood into EDTA sample tubes before other sample tubes or direct transfer of blood from EDTA containing tubes to other tubes. Therefore, preference for closed phlebotomy or following the order of tube fill when open phlebotomy is used may reduce EDTA contamination. The laboratory's comments for EDTA-contaminated serum samples were amended to encourage closed phlebotomy and with open phlebotomy filling of serum tubes before EDTA and fluoride-EDTA tubes. The weekly frequency of EDTA sample contamination, normalized for weekly urea and electrolyte (U&E) requests, was studied 52 weeks before and 43 weeks after amending the comments. Median (IQR) frequency of EDTA-contaminated samples per week per 10,000 U&Es decreased by 58% [5.6 (3.1-9.2) versus 2.3 (1.1-4.4); P < 0.001] after the introduction of the new comment. Explicit automated laboratory feedback comments promoting closed phlebotomy and order of tube fill with open phlebotomy were associated with a 58% reduction in EDTA-contaminated samples and thus may play a role in improving phlebotomy practise.

A Contemporary Analysis of Phlebotomy and Iatrogenic Anemia Development Throughout Hospitalization in Critically Ill Adults.

Anemia is common in critically ill patients and may be exacerbated through phlebotomy-associated iatrogenic blood loss. Differences in phlebotomy practice across patient demographic characteristics, clinical features, and practice environments are unclear. This investigation provides a comprehensive description of contemporary phlebotomy practices for critically ill adults. This is an observational cohort study of adults ≥18 years of age requiring intensive care unit (ICU) admission between January 1, 2019, and December 31, 2019, at a large academic medical center. Descriptive statistics were utilized to summarize all phlebotomy episodes throughout hospitalization, with each phlebotomy episode defined by unique peripheral venous, central venous, or arterial accesses for laboratory draws, exclusive of finger sticks. Secondarily, financial costs of phlebotomy and the relationships between phlebotomy practices, hemoglobin concentrations, and red blood cell (RBC) transfusions were evaluated. A total of 6194 patients were included: 59% were men with a median (interquartile range) age of 66 (54-76) years and median ICU and hospital durations of 2.1 (1.4-3.9) and 7.1 (4.3-11.8) days, respectively. The median number of unique laboratory draws was 41 (18-88) throughout hospitalization, with a median volume of 232 (121-442) mL, corresponding to 5.2 (2.6-8.8) draws and 29 (19-43) mL per day. Waste (ie, discard) volume was responsible for 10.8% of total phlebotomy volume. Surgical patients had a higher number of phlebotomy episodes and greater total phlebotomy volumes compared to nonsurgical patients. Phlebotomy practices differed across ICU types, with the greatest frequency of laboratory draws in the cardiac surgical ICU and the greatest daily phlebotomy volume in the medical ICU. Across hospitalization, ICU environments had the greatest frequency and volumes of laboratory draws, with the least intensive phlebotomy practice observed in the general hospital wards. Patients in the highest quartile of cumulative blood drawn experienced the longest hospitalizations, lowest nadir hemoglobin concentrations, and greatest RBC transfusion utilization. Differences in phlebotomy practice were limited across patient age, gender, and race. Hemoglobin concentrations declined during hospitalization, congruent with intensity of phlebotomy practice. Each 100 mL of phlebotomy volume during hospitalization was associated with a 1.15 (95% confidence interval [CI], 1.14-1.17; P < .001) multiplicative increase in RBC units transfused in adjusted analyses. Estimated annual phlebotomy costs exceeded $15 million (approximately $2500 per patient admission). Phlebotomy continues to be a major source of blood loss in hospitalized patients with critical illness, and more intensive phlebotomy practices are associated with lower hemoglobin concentrations and greater transfusion utilization.

Proteomic Analysis of Whole Blood Using Volumetric Absorptive Microsampling for Precision Medicine Biomarker Studies.

Microsampling of patient blood promises several benefits over conventional phlebotomy practices to facilitate precision medicine studies. These include at-home patient blood collection, supporting telehealth monitoring, minimal postcollection processing, and compatibility with nonrefrigerated transport and storage. However, for proteomic biomarker studies, mass spectrometry of whole blood has generally been avoided in favor of using plasma or serum obtained from venepuncture. We evaluated the use of a volumetric absorptive microsampling (VAMS) device as a sample preparation matrix to enable LC-MS proteomic analyses of dried whole blood. We demonstrated the detection and robust quantitation of up to 1600 proteins from single-shot shotgun-LC-MS analysis of dried whole blood, greatly enhancing proteome depth compared with conventional single-shot LC-MS analyses of undepleted plasma. Some proteins not previously reported in blood were detected using this approach. Various washing reagents were used to demonstrate that proteins can be preferentially removed from VAMS devices prior to downstream analyses. We provide a demonstration that archival frozen blood cell pellets housed under long-term storage (exceeding 5 years) are compatible with VAMS to enable quantitation of potential biomarker proteins from biobank repositories. These demonstrations are important steps in establishing viable analysis workflows to underpin large-scale precision medicine studies. Data are available via ProteomeXchange with the identifier PXD028605.

Phlebotomy Staffing.

Laboratory directors are tasked with staffing laboratories in a manner that provides adequate services and maintains economic sustainability. To determine the national normative rates of phlebotomy staffing and the types of laboratory operational characteristics that may be associated with the magnitude of those staffing levels. Study participants provided data on inpatient and outpatient phlebotomy sites, including the numbers of patients receiving phlebotomy services, phlebotomy staff, and billable tests. From these data, we calculated performance indicators including the numbers of phlebotomies/phlebotomy full-time equivalent staff, outpatient phlebotomy visits/full-time equivalent staff, and average outpatient phlebotomy wait times. Participants also completed a survey of their laboratory phlebotomy practices. This study was conducted during the third quarter of 2017. Forty-two institutions participated in this study, providing eligible results for 40 selected inpatient sites and 70 selected outpatient sites. The ratios for all performance indicators spanned between 3.3- and 142-fold. The median average outpatient phlebotomy wait time was 8 minutes. None of the performance indicators were associated with the practice variables that we chose to test. The distribution of phlebotomy staffing performance indicators among the laboratories participating in this study varied widely, even among those groups performing similar volumes of tests.

Framework Design of Patient Phlebotomy Identification System (PPIS) Mobile Applications for RFID Blood Test Tube

Phlebotomy procedures is the venepuncture, it's an important tool for diagnosing many medical conditions. However, there are a lot of human error and sample rejection during the phlebotomy procedures due to sample and patient identification. Currently, there are various advance production of medical computing system which able to provide significant benefits to medical staff and society. With this explosion of Smart mobile medical computing systems, a Patient Phlebotomy Identification System (PPIS) is designed to minimize the human error in phlebotomy practice that can caused blood specimen being rejected. The key of PISS is the continuous exchange and transfer of information between doctors and lab technologists. The conceptual framework of PPIS is designed in mobile application that can connect to RFID technology on the blood tube. The patient and blood sample identification data are stored in MySQL databases and real-time access by medical staff thru the PPIS mobile application. This mobile application able to perform data search and identification for work efficiency. This system is user-friendly and eco-friendly.

Utilisation of remote capillary blood testing in an outpatient clinic setting to improve shared decision making and patient and clinician experience: a validation and pilot study

BackgroundIn a tertiary respiratory centre, large cohorts of patients are managed in an outpatient setting and require blood tests to monitor disease activity and organ toxicity. This requires either visits...

Review of coagulation preanalytical variables with update on the effect of direct oral anticoagulants.

There are many preanalytical variables (PAV) that are known to affect coagulation testing. The more commonly acknowledged PAV addressed by the clinical laboratory tend to start with their influence on blood collection, but realistically coagulation PAV starts with the patient, where the laboratory has less influence or control. Patient selection and appropriate timing for blood collection may be integral for assuring proper diagnosis and management. Laboratory control and assurance for ideal phlebotomy practice would mitigate most PAVs related to blood collection to minimize suboptimal sample collection. Laboratory oversight of sample transportation, processing and storage will assure sample integrity until testing can be facilitated. The purpose of this document is to review common PAV that should be taken into consideration when ordering, performing and interpreting a coagulation test result, with additional attention to the effect of direct oral anticoagulants (DOACs).

Emergency Nurses’ Knowledge, Attitudes, and Practices Related to Blood Sample Hemolysis Prevention: An Exploratory Descriptive Study

IntroductionThe aim of the study was to identify emergency nurses’ knowledge, attitudes, and practices related to blood sample hemolysis prevention and explore associations between these factors and demographic characteristics. The current state is unknown. Understanding baseline knowledge, attitudes, and practices addresses a gap in the literature. MethodAn exploratory, descriptive design with cross-sectional survey methodology employing a study-specific instrument was used. ResultsRequest for participation email was sent to a random sample of 5000 Emergency Nurses Association members, and 427 usable surveys were returned (response rate = 8.5%). Mean years in nursing was 13.85 (standard deviation = 10.78), and 226 (52.9%) were certified emergency nurses. Only 85 participants (19.9%) answered all 3 knowledge questions correctly. Answering the 3 knowledge questions correctly was significantly associated with being a certified emergency nurse (χ2 = 7.15, P < .01). Participant responses to attitude items about the sequelae of blood sample hemolysis were skewed toward agreement, and most attitude items were associated with whom participants reported as being primarily responsible for phlebotomy. Emergency nurses remain primarily responsible for phlebotomy as well as addressing hemolyzed samples, but few reported that blood sample hemolysis was addressed at a departmental level. DiscussionFindings suggest that emergency nurses lack some knowledge related to blood sample hemolysis prevention best practices. Attitudes toward phlebotomy practices may be 1 reason practice has not changed. Every effort should be made to prevent hemolyzed blood samples to decrease delays and costs in emergency care.

Patient harm associated with serial phlebotomy and blood waste in the intensive care unit: A retrospective cohort study.

BackgroundIntensive care unit (ICU) patients are at high risk of anemia, and phlebotomy is a potentially modifiable source of blood loss. Our objective was to quantify daily phlebotomy volume for ICU patients, including blood discarded as waste during vascular access, and evaluate the impact of phlebotomy volume on patient outcomes.MethodsThis was a retrospective observational cohort study between September 2014 and August 2015 at a tertiary care academic medical-surgical ICU. A prospective audit of phlebotomy practices in March 2018 was used to estimate blood waste during vascular access. Multivariable logistic regression was used to evaluate phlebotomy volume as a predictor of ICU nadir hemoglobin < 80 g/L, and red blood cell transfusion.ResultsThere were 428 index ICU admissions, median age 64.4 yr, 41% female. Forty-four patients (10%) with major bleeding events were excluded. Mean bedside waste per blood draw (144 draws) was: 3.9 mL from arterial lines, 5.5 mL central venous lines, and 6.3 mL from peripherally inserted central catheters. Mean phlebotomy volume per patient day was 48.1 ± 22.2 mL; 33.1 ± 15.0 mL received by the lab and 15.0 ± 8.1 mL discarded as bedside waste. Multivariable regression, including age, sex, admission hemoglobin, sequential organ failure assessment score, and ICU length of stay, showed total daily phlebotomy volume was predictive of hemoglobin <80 g/L (p = 0.002), red blood cell transfusion (p<0.001), and inpatient mortality (p = 0.002). For every 5 mL increase in average daily phlebotomy the odds ratio for nadir hemoglobin <80 g/L was 1.18 (95% CI 1.07–1.31) and for red blood cell transfusion was 1.17 (95% CI 1.07–1.28).ConclusionA substantial portion of daily ICU phlebotomy is waste discarded during vascular access. Average ICU phlebotomy volume is independently associated with ICU acquired anemia and red blood cell transfusion which supports the need for phlebotomy stewardship programs.

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

IntroductionPoor 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 methodsThe 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.ResultsClotted 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.ConclusionClotted 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.

SUN-199 PHLEBOTOMY PRACTICE IN A TERTIARY CARE PEDIATRIC HOSPITAL - AUDIT FOR IMPLEMENTING "SAVE YOUR VEINS" INITIATIVE

Venipuncture is often done indiscriminately in hospitals leading to phlebitis and stenosis of veins. Patients with chronic diseases have difficult venous access and it is catastrophic in pediatric patients, more specifically those with chronic kidney diseases, hematological disease and cancers. Due to long life expectancy for paediatric chronic kidney patients, now all efforts must be focused on vein preservation for future use. Campaigns to preserve veins in kidney patients have been conducted worldwide, but not in developing countries. No paediatric specific data or campaigns are available. Hence, we reviewed the current practice of venipuncture in our pediatric department with special focus on nephrology patients. We aimed to assess the knowledge about vein preservation among our phlebotomists, nurses and junior doctors and review the current phlebotomy practice in pediatric patients in our center. A survey designed to test the knowledge among phlebotomists, nurses and junior doctors regarding vein preservation, assess current practice and willingness to get training was conducted and data was collected. Simultaneously we noted all venipunctures performed at the emergency department(ED), paediatric ward (PW) and paediatric outpatient department (OPD) in our hospital for 30 days. Data on admitting department, diagnosis, type of venipuncture (needle stick or cannula), purpose (sample collection or drug instillation), number of pricks and site preferred were collected. Outcomes like percentage of phlebotomies done by each group of health care personnel, preferred site and department or diagnosis associated with difficult venous access (2 or more attempts) were analysed. Out of 320 venipunctures recorded, 203 were considered for analysis (117 - insufficient data). The mean age of patients was 4.7 years. 85 (41.9%), 85(41.9%) and 33(16.2%) procedures were done in OPD, ED and PW respectively. General paediatrics department (n=116, 57.1%) had most patients, followed by nephrology (n= 34, 16.7%) and hematooncology (n= 33, 16.2%). 84/203 (41.3%) children were suffering from chronic disease. Nurses performed 103(50.7%), followed by phlebotomists (90 (44.3%)) and junior doctors (10(4.9%)). Only 17.2% requests had physician instruction regarding vascular access. 124 patients (61.1%) had needle stick and 79 patients (38.9%) had cannula placed. The preferred site used for needle stick method was cubital fossa (n=62, 50%) followed by dorsum of hand (n= 60, 48.3%). For cannula placement, 77/79 venipuncture attempts were made in dorsum of hand. 7% of patients required more than 1 attempt to obtain sufficient blood samples. Of 203 patients, 46 had difficult access and all these patients (100%) who had this difficult venous access were chronic disease patients (Kidney 50%, hematology 37.5%, endocrine 12.5% ). Only 60% of doctors and 33.3% of phlebotomists preferred dorsum of hand as first site. Vein preservation education is lacking and should be implemented in all hospitals. This strategy benefits children with chronic disease most, especially kidney disease. Interventions like flagging patients with chronic disease, use of wrist bands and bracelets, educating parents/children on vein preservation can help these patients.

Blood collection guidelines for inpatients and outpatients, home-based care and long-term care facilities

The World Health Organization (WHO) guidelines on drawing blood: best practices in phlebotomy [1] were developed in 2010. They incorporated two hand hygiene moments, 1 and 4, from ‘My five moments for hand hygiene’ [2,3] highlighted in the WHO guidelines on hand hygiene in health care [4]. An observational study of phlebotomy practices identified patient safety concerns due to inappropriate glove use and reduced hand hygiene compliance by phlebotomists. Therefore, the WHO guidelines for phlebotomy [1] were revisited to incorporate Moments 2 and 3.

Patient Harm from Repetitive Blood Draws and Blood Waste in the ICU: A Retrospective Cohort Study

Introduction: Frequent blood testing in the intensive care unit (ICU) is instrumental to patient diagnosis, monitoring, and titration of invasive therapies. However, there is a growing appreciation that a significant proportion of ICU blood tests are reflexive and unnecessary.1,2 Serial phlebotomy is associated with extended hospital length of stay and acquired anemia in the general hospital population.3 Since patients in the ICU are prone to developing anemia,4,5 they are likely at increased risk of harm from serial phlebotomy. In response, multiple recent campaigns advocate for physician restraint in laboratory test ordering.6,7 However, relatively little is known about the effect of excessive phlebotomy on outcomes in critically ill patients. Better understanding of ICU phlebotomy practices, and harms associated with serial testing, is important in planning, implementing, and evaluating phlebotomy reduction interventions. Objectives: 1) Quantify average daily phlebotomy volume for ICU patients including blood discarded as waste when accessing vascular devices. 2) Identify if average daily phlebotomy volume is an independent risk factor for ICU acquired anemia (hemoglobin &amp;lt; 80 g/L) or the need for red blood cell transfusion. 3) Explore the relationship between daily phlebotomy volume and hospital mortality. Methods: This was a retrospective cohort study at an academic tertiary care center in Toronto, Ontario, utilizing hospital administrative data, laboratory data, and select chart review. Index Medical Surgical ICU admissions between September 2014 and August 2015 with an ICU stay of three days or greater were included. Major bleeding events were defined as a hemoglobin drop of 30 g/L within a 24 hour period. Average daily phlebotomy volumes were calculated using the number of samples received by the lab multiplied by standard blood volumes required for each sample type. A bedside prospective audit was conducted in March 2018 to quantify average blood volume discarded as waste during phlebotomy. Blood discard/waste data were summarized with descriptive statistics, but not included in further analysis. Multivariable logistic regression was used to study the association between average daily phlebotomy volume and each of: nadir hemoglobin (&amp;lt; 80 g/L), the need for red blood cell transfusion, and hospital mortality. Patients with a major bleeding event were excluded from the regression. Control variables included sex, age, ICU length of stay, admission hemoglobin, and admission Sequential Organ Failure Assessment (SOFA) score. Results: There were a total of 525 index patient admissions, mean age 62.1 yr, 41% female (Table 1). Fifty-two (52) patients had a major bleeding event in the ICU. Mean phlebotomy volume per patient day was 28.3 mL (95% CI 27.4 - 29.1 mL, stdev 10.1 mL). Mean bedside waste during the phlebotomy audit (total of 144 blood draws) varied by vascular access: 3.9 mL for arterial, 5.5 mL for central venous, and 6.25 mL for peripherally inserted catheters. The mean estimated daily bedside waste for phlebotomy was 14.8 mL per patient day. Outcomes of logistical regression, excluding patients with major bleeding events, are summarized in Table 2. Average daily phlebotomy volume (mL) was predictive of nadir hemoglobin &amp;lt; 80 g/L (parameter estimate 0.091, p &amp;lt;0.001), the need for red blood cell transfusion (0.092, p&amp;lt;0.001), and inpatient mortality (0.053, &amp;lt;0.001). For every 5 mL increase in average daily phlebotomy, the odds ratio (OR) for nadir hemoglobin &amp;lt; 80 g/L was 1.58 (95% CI 1.31 - 1.90) and the OR for a red cell transfusion was 1.58 (95% CI 1.33 - 1.87). Conclusion: Daily ICU phlebotomy volume is associated with ICU acquired anemia and the need for red blood cell transfusion, including in a multivariable model with patient demographics, major bleeding events, and severity of illness as estimated by day 1 SOFA score. However, the ICU admission SOFA score was only weakly predictive of mortality, and the unexpected association between average daily phlebotomy and mortality needs to be further explored. It is possible that in this data set day 1 SOFA score did not completely control for severity of illness. Our findings support the need for ongoing phlebotomy stewardship interventions in the ICU. We suggest ICU acquired anemia and the need for red blood cell transfusion are appropriate patient outcome measures to evaluate stewardship interventions. Disclosures No relevant conflicts of interest to declare.

SAT-310 ‘R.O.A.R’ TO PROTECT THE VEINS (AND SAVE THE LIVES) OF CHILDREN WITH CHRONIC KIDNEY DISEASE

Vessel preservation for adult patients with chronic kidney disease (CKD) is the gold standard of care and multiple education programs worldwide actively promote this. Ideally, it should begin before dialysis access is required and should continue post transplantation. Paediatric CKD patients form a unique cohort as they are likely to require multiple episodes of dialysis and several transplants throughout their lifetime. Yet the majority of paediatric nephrology centres around the world do not routinely promote vessel preservation for their patients. We performed an audit of the current phlebotomy practices in the outpatient setting of a large quaternary paediatric nephrology centre over a three-month period. In response to the results of this audit, we created ‘Be a Lion and R.O.A.R.’ - the first vessel preservation education campaign specifically designed for a paediatric population. Data was collected retrospectively from outpatient nephrology clinics (transplant, dialysis, general nephrology, tubular and nephrotic clinics) between 1st April 2017 and 30th June 2017 using the phlebotomy department’s mandatory logbook. All bloods collected via the outpatient phlebotomy service were of a routine nature in otherwise stable patients. Statistical analysis was performed using descriptive statistics. A total of 686 outpatient phlebotomy episodes were recorded for 472 nephrology patients over the 3-month period from 1st April 2017 to 30th June 2017. The mean age of patients attending outpatient phlebotomy was 10 years, with a range from 1 month to 18.3 years. Overall, 89.1% of these patients had bloods taken from the antecubital fossa (ACF) only. Hand veins were used in 9.7% of patients and as the first attempt in only 7.6% of patients. Foot veins were rarely utilised. More than one attempt was required in 9.9% of patients with 62.7% of these patients having all attempts taken from the ACF only. These trends were echoed across all nephrology patient subgroups, regardless of the clinic they attended. The results of this audit highlight the need for a formal vessel preservation strategy and education awareness program in children with CKD. ‘Be a Lion and R.O.A.R.– Respectfully Object And Re-evaluate’ is a child friendly motto specifically designed to promote vessel preservation in all renal patients. Using quality improvement (QI) methodologies we designed a Driver Diagram plan for vessel preservation. Using a multitier approach, we identified the need for interventions at three key levels: leadership and staff engagement, the creation of a formal hospital policy and most importantly, active promotion of patient and parent education. Implementation and review of these health interventions will occur in stages over the coming months and years. Vessel preservation is not actively practised for paediatric nephrology patients in the outpatient phlebotomy setting. The 'R.O.A.R.' QI template for vessel preservation in children provides a strategic approach for the implementation of this important health intervention. This model is currently in the pilot phase at our quaternary paediatric hospital and if successful, would be applicable to other paediatric nephrology centres worldwide.

Factors Contributing to Hospital Acquired Anemia among Critical Ill Patients

Background: Hospital acquired anemia (HAA) is one of the most common intensive care unit (ICU) acquired complications that associated with poor outcomes, increase morbidity and mortality for critically ill patients. Factors contribute to its development include profound loss of RBCs or insufficient RBCs production. Aim of the study: to assess factors contributing to HAA among critical ill patients. Design: A descriptive exploratory design was utilized. Setting: The study was carried in Beni –Suief university hospital inside the critical care units which include; general ICU, cardio care unit (CCU) and chest ICU. Study subjects: purposive sample of 75newly admitted adult critically ill patients to the above mentioned sitting was included in the study. Data collection tools: Data were obtained through patients assessment tool, factors contributing to HAA and indicators of HAA tool. Results: reveals that, nearly one third of studied patients their age were more than or equal fifty years. As regard to gender, the results revealed that, more than half of them were males, nearly one third of anemic patients had HAA in the 5th day from admission to hospital. As well more than three quarter of anemic patients were under feeding and more than one third of them had sepsis, in addition to mean amount of blood loss for anemic patients exceed amount of blood loss for non anemic patients. Conclusion: More than half of studied patients developed HAA during their ICU stay. Even, non-anemic patients were subjected to a decline in their Hb level. As well as, there were statistically significant relation between nutrition deficiency, sepsis, blood loss in ICU and drugs increase RBCs loss factors and occurrence of HAA. Also there were insignificant relation between demographic characteristic of studied patients, their diagnosis on admission to hospital, hemodilution, drugs affect RBCs production and occurrence of HAA. Recommendations: Designing in-service training and educational program for nurses about blood conversation strategies especially prevention of blood loss associated invasive procedure and phlebotomy practice.

Are we getting better at the preanalytical phase or just better at measuring it?

There is now consolidated evidence that the vast majority of laboratory errors occur in the extra-analytical phases of the total testing process, and especially in the preanalytical phase. Although development and dissemination of best practice recommendations for this crucial area of diagnostic testing have greatly contributed to reinforce error identification and reporting strategies, it is also undeniable that the combination of greater consciousness about preanalytical issues and technological advancements have helped decreasing the inherent vulnerability of many preanalytical activities, thus finally making the preanalytical phase less vulnerable to errors, slips and lapses. Many potential strategies can be adopted for reducing preanalytical errors, including education and training of healthcare staff on phlebotomy practice and preanalytical errors, greater observance of available phlebotomy guidelines, dissemination of specimen collection modules or phlebotomist check-lists, certification of phlebotomists, transmission of periodic preanalytical quality reports to phlebotomists, establishment of direct feed-back between laboratory professionals and phlebotomists, use of quality and validated blood collection systems for drawing blood, along with introduction of harmonized means for recording preanalytical errors.

Nurses' knowledge on phlebotomy in tertiary hospitals in China: a cross-sectional multicentric survey.

IntroductionIn China, phlebotomy practice is mostly executed by nurses instead of phlebotomists. Our hypothesis was that these nurses may lack of knowledge on phlebotomy, especially factors influencing quality of blood samples. This study aims to assess the overall nurses’ knowledge on phlebotomy to provide reference for improving blood sampling practice in China.Materials and methodsA survey was conducted involving nurses from 4 regions and 13 hospitals in China. A phlebotomy knowledge questionnaire was designed based on the Clinical and Laboratory Standards Institute H3-A6 guidelines, combining with the situations in China. Descriptive analysis and binary logistic regression analysis were used to analyze the knowledge level and its influencing factors.ResultsA total of 3400 questionnaires were distributed and 3077 valid questionnaires were returned, with an effective return rate of 90.5%. The correct rates of patient identification, hand sanitization, patient assessment, tube mixing time, needle disposing location and tube labelling were greater than 90%. However, the correct rates of order of draw (15.5%), definition of an inversion (22.5%), time to release tourniquet (18.5%) and time to change tube (28.5%) were relatively low. Binary logistic regression analysis showed that the correct rates of the aforementioned four questions were mainly related to the regional distribution of the hospitals (P < 0.001).ConclusionsThe knowledge level on phlebotomy among Chinese nurses was found unsatisfactory in some areas. An education program on phlebotomy should be developed for Chinese nurses to improve the consistency among different regions and to enhance nurse’s knowledge level on phlebotomy.