I wonder if the "could be prevented" is efefctively a point. How can it be assured.?

Besides, air/solution interface is a place of  plasma membrane stress and cells do lyse on a clean air/solution surface.

Furthermore, resistance to stress-induced haemolysis follows a population distribution. ¿Is it been reached the inevitable behaviour of a percentage of the population that is not endogenously haemolytic but prone to haemolysis by "normal handling" of blood samples?

Just some thoughts about your question

Hi Juan,

Thanks for your point and questions.

The 'could be prevented' is based on evidence that's already out there regards pre-analytical blood sample haemolysis not in vitro. My question is based on the processes in blood sample collection (venepuncture/phlebotomy) be it the equipment, collection methods and blood sample handling that puts stress on the cell membrane leading to its rupture.

The venepuncture training does highlight ways in minimisisng this from happening. In addition, there is a lot of literature (systematic, critical reviews, expert advice) that could be used to highlight measures that can be implemented to reduce the rate.

With all this evidence available, where are we failing to spread this message? What is the best way to minimise high haemolysis rates caused by the above stated? Is there a proven method out there that has been used?

How are you drawing the blood, with a syringe or a vacutainer?  The causes of hemolysis are different for each method.  We have reduced hemolysis rate below 1% in many departments.

Hi David,

Thanks for your contribution and well done for the great achievement in reducing the haemolysis to this exceptional rate. The advocated methods are the evacuated system (vacuette / vacutainer).

The laboratory rate have historically been much lower then overall hospital rates.  Emergency department has been historically higher then the overall rate. 

We spent a lot of time looking at individuals with the highest rates instead of concentrating on the overall rate.  Once those people were identified each month we performed remedial training and really stressed the benefits to the patient and the workflow along with the technical aspects.  The largest factor in decreasing rates was reducing the use of syringe draws.  We stressed the use of large bore needles and vacutainers.  When I spoke to the employees I started by asking what they did during the blood collecting process and then added suggestions along the way.  I did not start by saying what you are doing is wrong.  We posted the rates on a public bulletin board, hoping peer pressure and personal integrity would inspire people to not want to be on this list.  When all else failed we sent experienced phlebotomist with the lowest contamination rates out with the ones with the highest rates.  We saw improvement the next month.  Continued follow-up was very important in creating long term benefits.

We used this same education method for blood cultures and had very good results. Again Blood culture collection rates were below 1% for laboratory phlebotomist many months. 

 If I can offer any more information please let me know.

David

Hi David,

This is great thanks. I am sure there will many of us that will benefit from your response and experience.

One further question regards posting staff names and rates on a bulletin board;

• What was the overall reaction from the responsible staff?

Hi Everyone,

Are there any of you out there who have used different interevention(s) to the one mentioned above that has equally been effective? More example or eveidence is welcome.

Thanks, Nellie.

Nellie,

I am glad I can help.  The employees that had higher rates posted publicly were uncomfortable with the posting but understood it is not an attack towards them personally but only reflects the data from the previous month. We did spend some time explaining our intentions to provide feedback in an open transparent forum.  The employees that had the most problems with posting results were the one that consistently had high rates and were typically problematic employees in other ways.

Hi David,

This is great, thanks again.

Regards, Nellie.

Quite interesting discussing this. Pre-analytical blood sample haemolysis will continue to be a problem in Africa despite the fact that it is preventable. Why? This is so because the main issue is in aspects of specimen collection, handling and transportation. Who is the phlebotomist? Who transports the specimen? In our environment most hospitals do not have standard guidelines for specimen collection. Interns with poor skills do the collection most time, while the patient, a novice transports it to the lab with poor handling techniques because he/she is ignorant. This problem will be resolved if all hospitals have standing rules that all blood specimen should be collected in the lab preferably except for those on admission on the ward and by trained phlebotomist. This minimises transportation too.

Thanks Ochuwa for your contribution.

It's interesting to learn how phlebotomy is performed in Africa, Legos in particular. I have some questions regards what you have written above.

1. What discipline are the interns from ie doctors, nurses etc

2. Are they the only ones who perform phlebotomy/venepuncture?

3. What type of phlebotomy training do they undergo, if any?

4. What blood collection methods do you use?

5. What's the pre-analytical blood sample haemolysis rate?

6. If the rates are high, have any measures been implemented to reduce the rate?

What is the best approach in the delivery of phlebotomy training to staff working in busy departments with high patient turnover like the Emergency Department, where haemolysis rate is usually high?

Cockill (2012) talks about the educational toilet posters; Ong et al (2014) talks about a mixture of web-based for theory and assessment, and classroom sessions for practical. David Pauff above talks about remedial one-to-one training with phlebotomists reporting high rate of haemolysis. A successful approach reported by McGrath et al (2012) after trying different approaches.

Could we say these are the best and sustainable approaches?

This is a very interesting discussion.... I'm interested to see what other people contribute...

Nellie: thanks for asking the questions!

Thanks Elia for your interest in the subject,

It'll be nice to learn different approaches out there and their effect. Anybody out there with same or different approach to the above and its effect on pre-analytical blood sample haemolysis, please share. Thanks in advance.

Hi David,

Just one other thing I forgot to ask about this subject ... are the tubes you use low vacuum? Some research is showing low haemolysis rate when blood samples are collected in low vacuum tubes and was wondering if the low rates you have is a combination of the training and the tubes you use.