Annotated Bibliography; Hemolysis in the Clinical Laboratory
| APA REFERENCE CITATION
| Ong, M. E. H., Chan, Y. H. & Lim, C. S. (2009). Reducing blood sample hemolysis at a tertiary hospital emergency department. The American journal of medicine, 122(11), 1054-e1. |
| PROBLEM/ISSUE ADDRESSED IN THE STUDY
| In this article, Ong, Chan and Lim (2009) base their research on the argument that sample hemolysis which is the common problem encountered in medical practice leads unnecessarily retaking of the specimen. As a result, there are unacceptable delays in the clinical laboratories, delayed physician decisions, erroneous conclusions, increased costs of treatment and unnecessary pain to patients. |
| PURPOSE OF STUDY
| Ong, Chan and Lim (2009) anticipated determining factors that lead to high rates of blood sample hemolysis and to measure the effect of introducing an intervention to reduce specimen hemolysis in the Emergency Department of extensive health care facilities. |
| STUDY METHODOLOGY
| To achieve their objective, Ong, Chan and Lim (2009) conducted a phased study in at the Emergency Department of Singapore Tertiary Hospital from January 2006 to November 2006. In the first phase, the researchers studied factors associated with urea and electrolyte sample lysis. They then carried a literature review based on the results which led to the implementation of a 15-minute presentation educational program. In phase 2, doctors and medical students conducting blood sampling collected questionnaires, and sample processing led to data collection. |
| PARTICIPANTS/SAMPLING PROCEDURE USED
| Random sampling was used to determine sample sizes. In phase 1, patients who presented to the Emergency Department requiring electrolyte and blood urea analysis were suitable for the study regardless of submitting complaint or demographics. Doctors and medical students carrying out blood sampling were trained for the survey (Ong, Chan & Lim, 2009). |
| VARIABLES AND RELIABILITY AND VALIDITY OF MEASURES
| The variables included; the size of the needle from syringe or IV cannulation, method (IV Cannulation and venipuncture), system (vacutainer, arterial blood gas sampling, syringe), source (arterial or venous), time consumed in taking the sample and the time used to process each sample. |
| FINDINGS/RESULTS
| In the first phase (n=227), highest rates of hemolysis were associated with the use of vacutainer. The lysis rate with the use of vacutainer was 35.8% and 11% without use (Ong, Chan & Lim, 2009).). In the second phase (n=204), some changes were found: there was increased use of syringes (64.3%-98.5%) rather than vacutainer, blood sampling using venipuncture increased (26%-36.8%), sample volume increased (4.5 mL to 5.2 mL) and time is taken from sampling to analysis reduced (60.4 to 48.4 minutes) (Ong, Chan & Lim, 2009). Blood sample hemolysis was decreased from 19.8% to 4.9% which to save $556.30 in ED daily and $203,037 yearly (Ong, Chan & Lim, 2009). |
| CONCLUSIONS BY RESEARCHER
| The rates of sample hemolysis were significantly reduced by the introduction of an education program in the emergency department. |
| STRENGTHS AND WEAKNESSES
| The limiting factors in the study lack of standard objective to assess the gauge blood flow and the difficulty of phlebotomy as well as the (before-after) study design used to determine if the changes of the results were the outcome of the educational intervention. However, identifying the factors increasing the rates of hemolysis realized the strength of the study. |
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| APA REFERENCE CITATION
| Phelan, M. P., Reineks, E. Z., Schold, J. D., Hustey, F. M., Chamberlin, J., & Procop, G. W. (2017). Pre- analytic factors associated with hemolysis in emergency department blood samples. Archives of pathology & laboratory medicine, 142(2), 229- 235. |
| PROBLEM/ISSUE ADDRESSED IN THE STUDY
| In this article, Phelan, Reineks, Schold, Hustey, Chamberlin, and Procop (2017), addressed the negative impacts of sample hemolysis occurring in Emergency Departments on health care delivery. Hemolysis call for repeat testing, which results in increased patient discomfort, delayed and erroneous results and increased ED costs. |
| PURPOSE OF STUDY
| The core objective of the study was to determine the effects of pre-analytic factors (needle gauge, straight stick, intravenous IV line, needle gauge, band time, blood draw location, syringe versus vacuum tube use) on blood samples hemolysis in the Emergency Department. |
| STUDY METHODOLOGY
| Phelan, Reineks, Schold, Hustey, Chamberlin, and Procop (2017), achieved their objective by conducting a study in an urban tertiary centre with an allied ED residency program and annual census of about 65000 visits. The electronic health record was used to obtain potassium results, and blood draws technique. The 54531 potassium resulted, and the hemolysis index measured potassium hemolysis. Hemolysis by sampling techniques was compared by conducting tests of x2. |
| PARTICIPANTS/SAMPLING PROCEDURE USED
| Systematic sampling was used to determine sample sizes. The electronic health record was queried to potassium results which the blood draw techniques were determined from the data in the documentation flow sheet in the collection module in the Emergency Department nursing narrator of Epic. |
| VARIABLES AND RELIABILITY AND VALIDITY OF MEASURES
| The variables included the method of sample collection and the time used to process samples. |
| FINDINGS/RESULTS
| Out of 54531samples only 5439 (10%) were underwent hemolysis. Hemolysis was less among samples obtained with the stick (5.4%) 33 of 615 than those obtained with IV line (10.2%) 4821 of 44266 (Phelan et al., 2017). The antecubital location for IV-placed blood draws had statistically significant hemolysis of (7.4%) 2117 of 28786 compared to other sites with (14.6 %) 2622 of 17960 (Phelan et al., 2017). The blood drawn with syringes recorded 92 0f 705 (13.0%) rate of hemolysis more than that depicted with a vacuum which was 1820 of 16590 (11.0%) (Phelan et al., 2017). Lower hemolysis was observed between blood draws with larger gauge IV lines and smaller gauge IV lines: 3882 of 4157 (9.3%)and 939 of 5633 (16.7%) respectively (Phelan et al., 2017). |
| CONCLUSIONS BY RESEARCHER
| The study confirmed the previous findings that straight stick and antecubital locations were associated with significantly reduced hemolysis while shorter tourniquet time and larger IV gauges were significantly associated with lower hemolysis. |
| STRENGTHS AND WEAKNESSES
| The strength of the study includes collection of large number of samples which allowed comparison of the factors identified to be tied to hemolysis while the limitations include: deriving data from a single institution which resulted to systematic sampling rather than random sampling and other factors such as patient characteristics and equipment type associated with hemolysis was not identified for the analysis. |
| APA REFERENCE CITATION
| Ong, M. E., Chan, Y. H. & Lim, C. S. (2008). Observational study to determine factors associated with blood sample hemolysis in the emergency department. Ann Acad Med Singapore, 37(9), 745- 748.
|
| PROBLEM/ISSUE ADDRESSED IN THE STUDY
| Ong, Chan & Lim, (2008) suggest that hemolysis of blood samples a common problem encountered in the Emergency department leads retaking of a specimen that results in inaccurate blood results and high treatment costs. |
| PURPOSE OF STUDY
| The primary objective of the study includes determining the factors associated with higher rates of hemolysis. |
| STUDY METHODOLOGY
| The study was carried out in Ann Acad Med Singapore, between January 2008 to November 2008. Patients presenting to the ED requiring blood urea and electrolyte analysis were eligible for the study (Ong, Chan & Lim, 2008). The method used was determined by distributing questionnaires to doctors and nurses involved in blood sampling, and the outcome data were recorded after sample processing. |
| PARTICIPANTS/SAMPLING PROCEDURE USED
| An observational convenience sample of patients presenting to the ED requiring blood urea and electrolyte analysis was used in the study. The doctors and nurses carrying out sampling in ED residency were relevant in the study. |
| VARIABLES AND RELIABILITY AND VALIDITY OF MEASURES
| The variables include: method/ system used to draw blood, size of the needle, operator, plod flow, source, sample volume, the difficulty of cannulation and time taken to draw and process sample. |
| FINDINGS/RESULTS
| Out of the 227 electrolytes analyzed, only 49 (19.8%)underwent hemolysis (Ong, Chan & Lim, 2008). The variables including method, system, operator, rate of blood flow and difficulty in cannulation were analyzed, but their effects to hemolysis were not statistically significant. The use of vacutainer was associated with the highest levels of hemolysis. |
| CONCLUSIONS BY RESEARCHER
| The researchers found that drawing blood with vacutainer was associated with higher levels of hemolysis which could change the attitude towards the equipment used for blood sampling in ED. |
| STRENGTHS AND WEAKNESSES
| A limiting factor in the study includes the difficulty of phlebotomy and the subjective assessment of the blood flow rate. However, the recommendations were found helpful in reducing sample hemolysis in the ED. |
| APA REFERENCE CITATION
| McCaughey, E. J., Vecellio, E., Lake, R., Li, L., Burnett, L., Chesher, D., … & Westbrook, J. (2017). Key factors influencing the incidence of hemolysis: A critical appraisal of current evidence. Critical reviews in clinical laboratory sciences, 54(1), 59-72.
|
| PROBLEM/ISSUE ADDRESSED IN THE STUDY
| McCaughey et al., (2017) suggest the identify hemolysis as the leading cause of pre-analytical errors. |
| PURPOSE OF STUDY
| The purpose of the study is to identify factors contributing to hemolysis as a way of developing effective practices reducing hemolysis. |
| STUDY METHODOLOGY
| Factors influencing in vitro hemolysis were determined by reviewing Embase, PUBMED, Medline and CINAHL articles published between January 2000 and August 2016. |
| PARTICIPANTS/SAMPLING PROCEDURE USED
| The articles used for literature review were included if; they were published between January 2000 to August 2016, presented primary data from general population, provided the overall rate of hemolysis and analyzed a factor increasing hemolysis prevalence. |
| VARIABLES AND RELIABILITY AND VALIDITY OF MEASURES
| The variables of the study included: methods of drawing and transporting samples, the operator, size of specimen tubes, tube filling and tourniquet time. |
| FINDINGS/RESULTS
| The 40 studies reviewed provided excellent evidence that hemolysis rates are higher in Emergency Departments, for samples drawn using intravenous catheter compared to venipuncture, for non-antecubital draws and samples transported by pneumatic tube compared by hand. Also, rates of hemolysis increased when samples are collected by non-phlebotomist, larger volume specimen tubes are used, containers are filled less than halfway and when tourniquet time is more than one McCaughey et al., (2017). |
| CONCLUSIONS BY RESEARCHER
| The researchers conclude that clinical laboratories and hospitals consider deploying phlebotomists in EDs, collect blood through the antecubital region, draw blood through venipuncture and transporting blood by the laboratory personnel to reduce sample hemolysis. |
| STRENGTHS AND WEAKNESSES
| As the data used in the study were from the literature review, seven articles lacked statistical analysis which made it challenging to identify findings’ significance. However, most reports provided information about factors associated with hemolysis and the effect of the intervention. |
References
McCaughey, E. J., Vecellio, E., Lake, R., Li, L., Burnett, L., Chesher, D., … & Westbrook, J. (2017). Key factors influencing the incidence of hemolysis: A critical appraisal of current evidence. Critical reviews in clinical laboratory sciences, 54(1), 59-72.
Ong, M. E. H., Chan, Y. H. & Lim, C. S. (2009). Reducing blood sample hemolysis at a tertiary hospital emergency department. The American journal of medicine, 122(11), 1054-e1.
Ong, M. E., Chan, Y. H. & Lim, C. S. (2008). Observational study to determine factors associated with blood sample haemolysis in the emergency department. Ann Acad Med Singapore, 37(9), 745-748.
Phelan, M. P., Reineks, E. Z., Schold, J. D., Hustey, F. M., Chamberlin, J., & Procop, G. W. (2017). Preanalytic factors associated with hemolysis in emergency department blood samples. Archives of pathology & laboratory medicine, 142(2), 229-235.