Blood collection failures from a blood establishment perspective.

OBJECTIVES: The objective of this study was to show experience of the Croatian Institute of Transfusion Medicine in monitoring and analysing collection failures caused by the venepuncture technique or occurred as a result of adverse reactions and complications experienced by donors during donation. BACKGROUND: Collection failures represent one of the leading nonconformities in blood establishments. Apart from being a negative motivating factor for blood donors, they also affect the blood components supply and have a negative financial impact. METHODS: Nonconformity records referring to collection failures were analysed retrospectively over a 6-year period (2013-2018) with regard to their frequency, causes, donor characteristics (age, gender, number of donations), place of occurrence (blood establishment, mobile sessions) and trends during the analysed period. RESULTS: A total of 5166 collection failures out of 618 251 donations (0.84%) were recorded during the analysed period. The leading cause was haematoma at puncture site (1676, i.e., 32.4%). Collection failures which are primarily attributed to the venepuncture technique or vein selection accounted for 91% of all cases, whereas collection failures which occurred as a result of discontinued punctures due to adverse reactions in donors accounted for 9% of all cases. A much higher frequency of all collection failure types was recorded in female donors, whereas younger donors experienced adverse reactions more frequently (median age of 24). CONCLUSION: The analysis and monitoring frequency of collection failures play an important role in planning of staff training activities, work organisation and timely implementation of corrective actions.

Validation of phlebotomy performance metrics developed as part of a proficiency-based progression initiative to mitigate wrong blood in tube.

AIMS: The purpose of this study was to (1) characterise the procedure of phlebotomy, deconstruct it into its constituent parts and develop a performance metric for the purpose of training healthcare professionals in a large teaching hospital and to (2) evaluate the construct validity of the phlebotomy metric and establish a proficiency benchmark. METHOD: By engaging with a multidisciplinary team with a wide range of experience of preanalytical errors in phlebotomy and observing video recordings of the procedure performed in the actual working environment, we defined a performance metric. This was brought to a modified Delphi meeting, where consensus was reached by an expert panel. To demonstrate construct validity, we used the metric to objectively assess the performance of novices and expert practitioners. RESULTS: A phlebotomy metric consisting of 11 phases and 77 steps was developed. The mean inter-rater reliability was 0.91 (min 0.83, max 0.95). The expert group completed more steps of the procedure (72 vs 69), made fewer errors (19 vs 13, p=0.014) and fewer critical errors (1 Vs 4, p=0.002) than the novice group. CONCLUSIONS: The metrics demonstrated construct validity and the proficiency benchmark was established with a minimum observation of 69 steps, with no critical errors and no more than 13 errors in total.

Is placental blood a reliable source for the evaluation of neonatal hemostasis at birth?

BACKGROUND: Phlebotomy is among the main determinants of anemia of prematurity. Blood sparing policies endorsed umbilical cord blood (here called placental) as an alternative source for laboratory testing. Little is known on the suitability of placental blood to evaluate neonatal hemostasis of newborn infants. We aimed to compare the hemostatic profile of paired placental and infant venous blood, by means of prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen, antithrombin, protein C, thromboelastography (TEG) and thrombin generation assay (TGA). STUDY DESIGN: This was an observational single-center study. METHODS: We collected at birth venous citrated blood from both placental and infant venous source and performed PT, APTT, fibrinogen, antithrombin, protein C, TEG (reaction time-R; kinetics-K alpha angle-α, maximum amplitude-MA and lysis at 30 minutes-LY30), and TGA (endogenous thrombin potential-ETP). RESULTS: We enrolled 60 neonates with a median gestational age (range) of 37 weeks (28+1 -41) and birth-weight 2417 g (950-4170). Based on TEG and TGA, placental blood showed a procoagulant imbalance as indicated by lower median R (4.0 vs. 6.1 min; p < 0.001) and K (1.3 vs. 2.2 min; p < 0.001); higher α-angle (69.7 vs. 57.4°; p < 0.001) and ETP (1260 vs. 1078; p = 0.002) than those observed for infant venous blood. PT and APTT did not differ significantly between the two groups. CONCLUSIONS: While placental and neonatal blood samples are equally suitable to measure the standard coagulation tests PT and APTT, placental blood leads to a procoagulant imbalance when testing is performed with TEG or TGA. These effects should be considered when interpreting results stemming from investigation of neonatal hemostasis.

Reduced risk of vasovagal reactions in Australian whole blood donors after national implementation of applied muscle tension and water loading.

BACKGROUND: A new national donor safety initiative was introduced in Australia in 2018, which aimed to encourage all whole blood donors to water load and to use applied muscle tension. This study evaluated the effect of this initiative on the rate of vasovagal reactions (VVR). STUDY DESIGN AND METHODS: Routinely collected data were used to identify whole blood donations and any associated VVRs before (n = 167,056 donations) and after implementation (n = 215,572 donations). Multivariate logistic regression analyses were performed to evaluate the differences in VVR rates. RESULTS: The total rate of VVRs declined from 22.5 per 1000 donations to 20.6 per 1000 donations after implementation, a reduction of 8% (p < 0.001). The rate of presyncopal reactions decreased by 8% in new donors and 12% in repeat donors. No impact was observed on the rate of syncope in any of the groups. The multivariate logistic regression analysis demonstrated the odds of experiencing a presyncopal reaction was reduced by 13% following implementation, with no significant effects on syncope. CONCLUSION: The findings of this study support the use of water loading and applied muscle tension in routine whole blood collection to reduce the incidence of VVRs.

Ensuring donor safety: is venesecting therapeutic donors to haemoglobin levels below Blood Service guidelines safe?

Therapeutic phlebotomy is the cornerstone of treatment for HFE haemochromatosis (HH). Current Australian Red Cross LifeBlood Service guidelines mandate measuring haemoglobin (Hb) levels prior to phlebotomy and if below 130 g/l in men or 120 g/l in women, donors are deferred from donating whole blood. Therapeutic donation below these levels may take place where both the treating doctor and a blood service medical officer approve. The aim of the current study was to determine whether adverse events are more frequent in those who undergo therapeutic phlebotomy below current Hb thresholds applied to volunteer therapeutic donors. A retrospective review of all therapeutic donations was undertaken for the financial year 2016-2017. The data were obtained through the Australian Red Cross Blood Service. Inclusion criteria were any donor between 16 and 70 years of age, weighing more than 50 kg and meeting blood service guidelines for donation. All adverse events recorded in an electronic quality system were obtained and associated with donor haemoglobin level. Statistical analyses were performed using analysis of variance or Fisher's exact test (GraphPad Prism). About 34 886 therapeutic phlebotomy donations occurred during 2016-2017, of whom the majority were referred for HH (34 089). In total, 365 of 34 886 donations (0·0105%) were complicated by an adverse event. A total of 305 (0·0087%) therapeutic donations occurred while below the lower limit of blood service Hb threshold for their respective genders. Of the donations that occurred below the blood service threshold, 3 of 305 (0·0098%) had an adverse event compared with 362 of 34 581 donations above the lower limit threshold (0·0105%, P = 0·99). The incidence of adverse events was not increased in the group which underwent therapeutic phlebotomy below the current Australian Red Cross Blood Service Hb threshold compared with those above threshold, indicating safety of treatment at Hb levels lower than currently recommended.

Underfilling of vacuum blood collection tubes leads to increased lactate dehydrogenase activity in serum and heparin plasma samples.

Background Lactate dehydrogenase (LD) activity is routinely monitored for therapeutic risk stratification of malignant diseases, but is also prone to preanalytical influences. Methods We systematically analyzed the impact of defined preanalytical conditions on the hemolysis-susceptible parameters LD, potassium (K) and hemolysis index in vacuum blood collection tubes (serum [SE], heparin plasma [HP]). Blood was collected by venipuncture from healthy volunteers. Tubes were either filled or underfilled to approximately 50%, then processed directly or stored at room temperature for 4 h. Potassium (K), sodium (Na), chloride (Cl), LD, creatine kinase (CK), total cholesterol, and indices for hemolysis, icterus, and lipemia were analyzed. Filling velocity was determined in a subset of tubes. Findings in healthy volunteers were reconfirmed in an in-patient cohort (n = 74,751) that was analyzed for plasma yield and LD data distribution. Results LD activity was higher in HP compared to SE. Underfilling led to higher LD values (SE: +21.6%; HP: +28.3%), K (SE: +4.2%; HP: +5.3%), and hemolysis index (SE: +260.8%; HP: +210.0%), while other analytes remained largely unchanged. Filling velocity of tubes was approximately 3-fold higher in the first half compared to the second half in both HP and SE collection tubes. Importantly, plasma yield also inversely correlated with LD in routine patients. By calculating reference limits, the lowest plasma yield quartile of the patient cohort displayed LD values clearly exceeding current reference recommendations. Conclusions Underfilling of tubes leads to a higher proportion of blood aspirated with high velocity and relevant elevations in LD. This finding should be considered in cases of clinically implausible elevated LD activities.

Efforts to improve diagnosis of bacteraemia by reducing blood culture contamination in an emergency department: strategies and outcome.

OBJECTIVE: To assess the strategies and outcome for reducing blood culture contamination in order to improve the diagnosis of bacteraemia. METHODS: The interventional study was conducted at a tertiary care hospital in Karachi from January 1, 2013, to December 31, 2016. The blood culture contamination data related to the first year of the study was taken as the baseline pre-intervention data. Strategies were planned as intervention for improvement by consolidating training and education in the form of dedicated lectures, practising on mannequins and developing in-house video, replacing povidone with 2% chlorhexidine preparation spray plus 70% isopropyl alcohol swabs and inducting dedicated phlebotomy team whose only responsibility was blood sample collection and minimising the probability of error. RESULTS: In 2013, there were 8868 samples; 7402 in 2014; 6897 in 2015; and 9756 samples in 2016. The contamination rate in 2013 was 8% which went down to 7.75% in 2014, 4.25% in 2015 and 3.9% in 2016. The decline became statistically significant (p<0.001) after implementing a dedicated phlebotomy team in the emergency department. CONCLUSIONS: Apart from teaching and training, the concept of blood culture collection kit with checklist and dedicated blood collection team was found to be vital in reducing blood culture contamination.

The Effect of Acupressure on Acute Pain During Venipuncture in Children: Implications for Evidence-Based Practice.

AIMS: The study was conducted as a randomized controlled trial in order to determine the effects of acupressure on acute pain during venipuncture in children. METHODS: The population of the study consisted of children, aged between 9 and 12 years, who received venipuncture between September 2015 and June 2016 at a university hospital in Istanbul. The sample consisted of a total of 90 children, including 45 children in the acupressure group and 45 children in the control group, who met the sample inclusion criteria. The results of the study were obtained by using an information form, the State Anxiety Inventory for Children (STAIC), the visual analog scale (VAS), and the Faces Pain Scale-Revised (FPS-R). Acupressure was applied to the children in the acupressure group for 10 min before the venipuncture procedure. Pain, heart rate, and oxygen saturation levels of the children in the acupressure and control groups were evaluated both before and after the venipuncture procedure. RESULTS: The children in the acupressure and control groups were found to be similar in terms of age, gender, parents' educational levels and working status, number of venipuncture procedures, and mean anxiety scores. In the evaluation that was conducted before the venipuncture procedure, no statistically significant differences were observed between the heat rates, oxygen saturation levels, and expected pain scores from the venipuncture procedure in the children in the acupressure and control groups. On the other hand, it was observed that the children in the acupressure group (VAS: 19.51 ± 4.98; FPS-R: 2.08 ± 0.41) experienced less pain than the children in the control group (VAS: 47.37 ± 9.89; FPS-R: 4.84 ± 1.08), and there was a significant difference between the two groups (p< .000). LINKING EVIDENCE TO ACTION: Acupressure administration is effective in reducing the pain that is experienced by children during a venipuncture procedure.

Detailed Analysis of the Characteristics of Sample Volume in Blood Culture Bottles.

Blood volume is the most important variable for the detection of microorganisms in blood cultures (BCs). Most standards recommend 40 to 60 ml blood, collected in several BC bottles filled up to 10 ml. We measured blood volume in individual BC bottles and analyzed the associations of hospital, bottle type, day of the week, daily sampling time, and age and sex of the patient with sampling volume and BC result. The variation in blood volume per BC bottle was analyzed in a mixed linear model using hospital, bottle type, weekday, sampling time, age, and sex as fixed factors and patient identification (ID) and episode as random factors to control for repetitive sampling of individual patients. Only 18% of all bottles were filled with the recommended 8 to 10 ml, and 47% were filled with less than 8 ml. The mean (± standard error) volume was larger in positive bottles (9.09 ± 0.15) than in negative bottles (8.47 ± 0.07) (P < 0.001). Blood volume was larger in BacT/Alert-FA Plus bottles than in -FN Plus BC bottles (P < 0.001). There were significantly lower volumes collected during the night (P < 0.001). The volume of blood collected decreased significantly with increasing patient age (P < 0.001). Larger volumes were collected from male patients than from female patients: 8.78 (± 0.06) versus 8.36 (± 0.06) ml (mean ± standard error [SE]), respectively (P < 0.001). The odds of detecting a positive patient increases by 13% for each additional milliliter of blood drawn. Our results show that we need to work actively with the development of blood sampling routines to overcome age and sex effects and to optimize blood sampling volumes.

Improvement of blood culture contamination rate, blood volume, and true positive rate after introducing a dedicated phlebotomy team.

The introduction of dedicated phlebotomy teams certified for blood collection has been reported to be highly cost-effective by reducing contamination rates. However, data on their effects on blood volume and true positive rate are limited. Therefore, we investigated the effect of replacing interns with a phlebotomy team on blood culture results. We performed a 24-month retrospective, quasi-experimental study before and after the introduction of a phlebotomy team dedicated to collecting blood cultures in a 2700-bed tertiary-care hospital. The microbiology laboratory database was used to identify adult patients with positive blood culture results. During the study period, there were no changes in blood collection method, blood culture tubes, and the application of antiseptic measures. Blood volume was measured by the BACTEC™ FX system based on red blood cell metabolism. A total of 162,207 blood cultures from 23,563 patients were analyzed, comprising 78,673 blood cultures during the intern period and 83,534 during the phlebotomy team period. Blood volume increased from a mean of 2.1 ml in the intern period to a mean of 5.6 ml in the phlebotomy team period (p < 0.001). Introduction of the phlebotomy team also reduced contamination rate (0.27% vs. 0.45%, p < 0.001) and led to a higher true positive rate (5.87% vs. 5.01%, p < 0.05). The increased true positive rate associated with the phlebotomy team involved both gram-positive and gram-negative bacteria. The introduction of a dedicated phlebotomy team can increase blood volumes, reduce blood culture contamination rate, and increase true positive rate.

Heparin and citrate additive carryover during blood collection.

Background Published evidence on the risk of additive carryover during phlebotomy remains elusive. We aimed to assess potential carryover of citrated and heparinized blood and the relative volume needed to bias clinical chemistry and coagulation tests. Methods We simulated standardized phlebotomies to quantify the risk of carryover of citrate and heparin additives in distilled water, using sodium and lithium as surrogates. We also investigated the effects of contamination of heparinized blood samples with increasing volumes of citrated blood and pure citrate on measurements of sodium, potassium, chloride, magnesium, total and ionized calcium and phosphate. Likewise, we studied the effects of contamination of citrated blood samples with increasing volumes of heparinized blood on heparin (anti-Xa) activity, lithium, activated partial thromboplastin time (APTT), prothrombin time (PT) and thrombin time (TT). We interpreted these results based on measurement deviations beyond analytical, biological and clinical significance. Results Standardized phlebotomy simulations revealed no significant differences in concentration of surrogate markers. Clinically significant alterations were observed after contamination of heparinized blood samples with volumes of citrated blood beyond 5-50 µL for ionized calcium and beyond 100-1000 µL for sodium, chloride and total calcium. Investigations of pure citrate carryover revealed similar results at somewhat lower volumes. Heparinized blood carryover showed clinically significant interference of coagulation testing at volumes beyond 5-100 µL. Conclusions Our results suggest that during a standardized phlebotomy, heparin or citrate contamination is highly unlikely. However, smaller volumes are sufficient to severely alter test results when deviating from phlebotomy guidelines.

Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic review.

BACKGROUND: As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia. METHODS: We conducted a systematic review and meta-analysis using the Laboratory Medicine Best Practices (LMBP) systematic review methods for rating study quality and assessing the body of evidence. Searches of PubMed, Embase, Cochrane, Web of Science, PsychINFO, and CINAHL identified 2564 published references. We included studies of the impact of interventions to reduce phlebotomy-related blood loss on blood loss, hemoglobin levels, transfusions, or anemia among hospital inpatients. We excluded studies not published in English and studies that did not have a comparison group, did not report an outcome of interest, or were rated as poor quality. Twenty-one studies met these criteria. We conducted a meta-analysis if > 2 homogenous studies reported sufficient information for analysis. RESULTS: We found moderate, consistent evidence that devices that return blood from flushing venous or arterial lines to the patient reduced blood loss by approximately 25% in both neonatal ICU (NICU) and adult ICU patients [pooled estimate in adults, 24.7 (95% CI = 12.1-37.3)]. Bundled interventions that included blood conservation devices appeared to reduce blood loss by at least 25% (suggestive evidence). The evidence was insufficient to determine if these devices reduced hemoglobin decline or risk of anemia. The evidence suggested that small volume tubes reduced the risk of anemia, but was insufficient to determine if they affected the volume of blood loss or the rate of hemoglobin decline. CONCLUSIONS: Moderate, consistent evidence indicated that devices that return blood from testing or flushing lines to the patient reduce the volume of blood loss by approximately 25% among ICU patients. The results of this systematic review support the use of blood conservation systems with arterial or venous catheters to eliminate blood waste when drawing blood for testing. The evidence was insufficient to conclude the devices impacted hemoglobin levels or transfusion rates. The use of small volume tubes may reduce the risk of anemia.

Assessment and Management of Procedural Pain During the Entire Neonatal Intensive Care Unit Hospitalization.

BACKGROUND: Despite strong evidence that repeated pain exposure in neonates is associated with adverse outcomes, pain assessment and management continues to be less than optimal in most neonatal intensive care units (NICUs). AIMS: To evaluate current pain assessment and management practices, and identify factors associated with optimal treatment throughout a cohort of preterm neonates over the entire hospital stay. DESIGN: A secondary analysis of study data collected from 2012 to 2016 as part of a larger clinical trial and supplemental chart review. SETTINGS: Tertiary level neonatal intensive care unit. PARTICIPANTS/SUBJECTS: 242 stable preterm neonates born at less than 37 weeks gestational age. METHODS: Data were analyzed quantitatively using R for statistics. RESULTS: The 242 neonates underwent a total of 10,469 painful procedures (4,801 tissue breaking and 5,667 non-tissue breaking, with only 56.6% and 12.2% having a documented pain score using the Premature Infant Pain Profile, respectively). Average pain exposure was 43 with a median of 32(10-576) per entire hospital stay. Documented pain score and greater postnatal age were associated with higher use of a pain reducing intervention and lower gestational age, first day, first week, higher illness severity, non tissue breaking and night time procedures were associated with lower. Use of a pain relieving intervention was documented in 58.5% of procedures. Sucrose was most commonly used pharmacologic and non nutritive sucking the most common non pharmacologic interventions. CONCLUSIONS: Increased efforts are needed to promote consistent pain assessment and management to ensure optimal outcomes for vulnerable at risk neonates.

The impact of venepuncture training on the reduction of pre-analytical blood sample haemolysis rates: A systematic review.

BACKGROUND: Venepuncture involves the introduction of a needle into a vein to collect a representative blood sample for laboratory testing. In the pre-analytical phase, haemolysis (the rupturing of erythrocytes and release of their contents into the extracellular compartment) has safety, quality and cost implications. Training in correct venepuncture practice has the potential to reduce in vitro haemolysis rates, but the evidence for this notion has yet to be synthesised. DESIGN: Systematic review (PRISMA Checklist). METHODS: Published studies on the effectiveness of venepuncture training on haemolysis rates were searched in relevant databases. The McMaster critical appraisal tool was used to assess methodological quality. The GRADE tool was used to evaluate the body of evidence in relation to the research questions. Implementation fidelity was also scrutinised in each study. RESULTS: Eight out of 437 retrieved studies met the inclusion criteria. None were randomised controlled trials (RCT). Between-study heterogeneity in design, intervention characteristics and the biochemical threshold for haemolysis precluded a meta-analysis. Post-training reductions in haemolysis rates of between 0.4%-19.8% were reported in four of the studies, which developed their intervention according to a clear evidence base and included mentoring in the intervention. Rises in haemolysis rates of between 1.3%-1.9% were reported in two studies, while the intervention effect was inconsistent within two other studies. CONCLUSION: There are no RCTS on the effectiveness of venepuncture training for reducing haemolysis rates, and findings from the existing uncontrolled studies are unclear. For a more robust evidence base, we recommend more RCTs with standardisation of haemolysis thresholds and training-related factors. RELEVANCE TO CLINICAL PRACTICE: While venepuncture training is an important factor influencing quality of blood sample in clinical practice, more robust evidence is needed to make specific recommendations about training content for reduction of haemolysis rates. Standardisation of haemolysis thresholds would also enable future meta-analyses.

Evaluation of the clinical implementation of a large-scale online e-learning program on venous blood specimen collection guideline practices.

BACKGROUND: When performed erroneously, the venous blood specimen collection (VBSC) practice steps patient identification, test request management and test tube labeling are at high risk to jeopardize patient safety. VBSC educational programs with the intention to minimize risk of harm to patients are therefore needed. In this study, we evaluate the efficiency of a large-scale online e-learning program on personnel's adherence to VBSC practices and their experience of the e-learning program. METHODS: An interprofessional team transformed an implemented traditional VBSC education program to an online e-learning program developed to stimulate reflection with focus on the high-risk practice steps. We used questionnaires to evaluate the effect of the e-learning program on personnel's self-reported adherence to VBSC practices compared to questionnaire surveys before and after introduction of the traditional education program. We used content analysis to evaluate the participants free text experience of the VBSC e-learning program. RESULTS: Adherence to the VBSC guideline high-risk practice steps generally increased following the implementation of a traditional educational program followed by an e-learning program. We however found a negative trend over years regarding participation rates and the practice to always send/sign the request form following the introduction of an electronic request system. The participants were in general content with the VBSC e-learning program. CONCLUSIONS: Properly designed e-learning programs on VBSC practices supersedes traditional educational programs in usefulness and functionality. Inclusion of questionnaires in the e-learning program is necessary for follow-up of VBSC participant's practices and educational program efficiency.

What everybody should know about postural changes.

Posture changes have been known for a long time to influence the concentration of many analytes in blood especially macromolecules. It is very clear that when someone switches from supine to sitting or standing or from sitting to standing a hemoconcentration is induced. Similarly, when someone switches from standing to sitting or lying a hemodilution occurs. In the context of clinical chemistry, rules have been issued to buffer the impact of postural changes close to the blood specimen collection (e.g. 15 min of seated rest before the blood puncture). A big work has then been performed to educate the personnel concerned by blood specimen collection (medical doctors, nurses, phlebotomists, pharmacists, clinical researchers, scientists, etc.) through professional training to standardize the puncture and the collection procedures. Official procedures and guidelines have been published. Nevertheless, there is still a long way to go and too often standardization of posture before the blood collection is not properly performed. Maybe, this relative failure could be overcome by using new strategies in forwarding the message on the impact of posture changes in the outcome of blood tests and the importance of controlling this factor when blood specimens are taken. Some possible actions are presented concerning the improvement of the education of medical and paramedical personnel especially during their primary training, and also to educate the patients and the whole population in general.

Patient and Health Care Provider Responses from a Prospective, Double-Blind, Randomized Controlled Trial Comparing Vapocoolant Spray versus Placebo Spray in Adults Undergoing Venipuncture in the Emergency Department.

BACKGROUND: Painful medical procedures are common. Topical anesthetics are easily applied, rapid onset, inexpensive, and avoid injection pain and needlestick injury. The aims of this study, using patient and health care provider questionnaires, were to answer the following questions: (1) Does vapocoolant spray decrease venipuncture pain? (2) Would patients be satisfied with and use a vapocoolant spray in the future? (3) Would providers be satisfied with and use a vapocoolant spray in the future? DESIGN: Adults (18-80 years) in a hospital emergency department (ED) were randomly assigned to sterile water placebo spray (S) (N = 50) or vapocoolant spray (V) (N = 50) before venipuncture. Questionnaires were completed by patients undergoing venipuncture (N = 100) and the health care providers (N = 100) who performed the venipuncture (total questionnaires = 200) as part of a prospective, double-blind, randomized controlled trial comparing the efficacy and safety of vapocoolant spray compared with placebo spray in patients undergoing venipuncture in the ED. RESULTS: Patient and venipuncture variables were not significantly different for the two groups (S vs. V). Responses to the questionnaires were significantly different for the S versus V groups for both the patients and the health care providers. Patient questionnaires: Did you have less pain with spray? S 14%, V 76% (p < .001). Compared with previous blood draws, the spray was much more painful/more painful: S 10%, V 6%; same: S 76%, V 16%; less painful/much less painful: S 14%, V 78% (p < .001). How satisfied were you with the spray? Satisfied/very satisfied: S 20%, V 74% (p < .001). Would you use this spray in future? Yes S 20%, V 80% (p < .001). Provider results: The patient had less pain with the use of the spray: S 14%, V 78% (p < .001). How satisfied were you with the use of the spray? Satisfied/very satisfied: S 12%, V 82% (p < .001). Would you use this spray in the future? Yes S 24%, V 84% (p < .001). CONCLUSIONS: The use of a vapocoolant spray in adult ED patients undergoing venipuncture significantly decreased venipuncture pain, was associated with high patient and provider satisfaction, and both patients and providers would use a vapocoolant spray in the future for venipuncture and other painful procedures.

Effect of peripheral IV based blood collection on catheter dwell time, blood collection, and patient response.

AIM: To evaluate the effect of daily PIV-based phlebotomy using the PIVO device on PIVC dwell times and replacement rates, as well as the reliability of blood sample collection, and patient response to this method of blood collection. BACKGROUND: Blood draws which are also known as phlebotomy for laboratory analyses are one of the most common experiences for hospitalized patients. When performed by venipuncture, they are often associated with pain and anxiety for patients. Most hospitals avoid phlebotomy from peripheral IV catheters due to sample hemolysis, sample dilution by fluids in PIVC line or infused medications, PIVC dislodgement or infiltration, and increased rates of phlebitis. METHODS: A prospective, randomized- controlled study of 160 GI surgery patients was enrolled. Patients were randomized to either control evaluation of PIVC dwell or to receive daily PIVO blood collections in addition to evaluation of PIVC dwell. RESULTS: Daily PIVO blood collections did not negatively affect PIVC dwell or replacement rates. Overall 81% of blood collection attempts were successful and the likelihood of success was strongly associated with PIVC condition. Patients reported 0.7/10 pain for PIVO blood collection on a 0-10 pain scale and a 9.1/10 preference for PIVO on a 0 (strongly prefer needle) to 10 (strongly prefer PIVO) preference scale. Results suggest that use of a PIV based blood collection was a reliable and valid approach and was superior to routine phlebotomy in self-reported responses from patients.

[Reducing Blood Culture Contamination Rates in the Emergency Department].

BACKGROUND: Rate of contamination is a well-known indicator of quality of care in the emergency department. Blood-culture results may affect clinical decision making. From January 1, 2015 to December 31, 2015, the contamination rate of blood culture in our emergency department was 5.63%, which exceeded the maximum of 3% suggested by the American Society for Microbiology and the clinical laboratory at our hospital. PURPOSE: Using a quality improvement strategy, this project aimed to (1) identify potential factors contributing to the high blood culture contamination rate and (2) achieve a blood culture contamination rate below 3%. RESOLUTION: The factors that were identified as potentially contributing to the high blood culture contamination rate were: (a) Nursing staff: lack of related education and training and ignorance of related clinical guidelines; (b) The system: inconsistent and non-evidence-based clinical guidelines (e.g., no requirement to use sterile gloves when obtaining blood cultures and changing disinfectants); (c) The patient: older patients, residents of long-term care facility, and patients whose blood culture were in the first set were associated with higher blood culture contamination rates. Our quality improvement strategy included: design a new bedside working plate, develop slogans and posters illustrating the proper blood-drawing procedure, make a video introducing current standard technology, provide continuing education, monitor contamination rates, and provide individual feedback and retraining for those with higher contamination rates. RESULTS: The strategy was implemented from October 1, 2016 to December 31, 2016, during which period the blood culture contamination rate reduced from 5.63% to 1.51%. CONCLUSIONS: Conclusion: Improving equipment, using multiple teaching methods, and providing regular feedback not only significantly reduced the blood culture contamination rate but also enhanced the knowledge and skills of nursing staff in terms of blood culture sampling. We hope that our results are referenced by other nursing departments and used to improve the blood culture contamination rates in other clinical settings.

Medical practice assessment during the phlebotomy: clinical audit of blood sampling.

INTRODUCTION: Phlebotomy is taking a venous blood sample for a medical biology analysis .If the taking of a sample is poorly executed, the results for this sample may be inaccurate and mislead the clinician, or the inconvenience of the patient having to undergo a new levy. The three main problems associated with errors in the collection are: hemolysis, contamination and mislabelling. We conduct clinical audit to evaluate compliance of activities in relation to the recommendations. Our objective was to determine the compliance rate of the different steps of the phlebotomy procedure and propose corrective actions. METHODS: it is an observational study which follows a forward-looking approach based on direct observation of blood collection procedures in 2015. RESULTS: 330 acts of phlebotomy were audited in 11 services. The overall compliance rate phlebotomy was 57.7%. The overall compliance rate ''patient prescribing and preparation "was 94.4%; "equipment preparation" was 85.3%. There was a lack of tourniquets, holders and hydro-alcoholic solutions. The overall compliance rate "collection procedure" was 45.1%, the overall compliance rate for hand hygiene is low (28%), wearing gloves (20%) and the use of antiseptics (44.4%). The overall compliance rate "sample identification"quot; was 61.3% (tube labeling (45.7%) and compliance of the laboratory worksheet (76.9%). the overall compliance rate "Transport" was 49.4%. There was a lack of bag or holders for transport. CONCLUSION: The results obtained allowed to propose an improvement plan to improve this practice. In fact, the ultimate purpuse of medical practice assessment is to improve the quality of care.