Vein Pattern Locating Technology for Cannulation: A Review of the Low-Cost Vein Finder Prototypes Utilizing near Infrared (NIR) Light to Improve Peripheral Subcutaneous Vein Selection for Phlebotomy.

One of the most common means for diagnosis is through medical laboratory testing, which primarily uses venous blood as a sample. This requires an invasive method by cannulation that needs proper vein selection. The use of a vein finder would help the phlebotomist to easily locate the vein, preventing possible pre-analytical error in the specimen collection and even more discomfort and pain to the patient. This paper is a review of the scientific publications on the different developed low-cost vein finder prototypes utilizing camera assisted near infrared (NIR) light technology. Methods: Electronic databases were searched online, these included PubMed (PMC), MEDLINE, Science Direct, ResearchGate, and Institute of Electrical and Electronics Engineers (IEEE) Xplore digital library. Specifically, publications with the terms vein finder prototype, NIR technology, vein detection, and infrared imaging were screened. In addition, reference lists were used to further review related publications. Results: Cannulation challenges medical practitioners because of the different factors that can be reduced by the utilization of a vein finder. A limited number of publications regarding the assessment of personnel performing cannulation were observed. Moreover, variations in methodology, number of patients, type of patients according to their demographics and materials used in the assessment of the developed prototypes were noted. Some studies were limited with regard to the actual human testing of the prototype. Conclusions: The development of a low-cost effective near infrared (NIR) vein finder remains in the phase of improvement. Since, it is being challenged by different human factors, increasing the number of parameters and participants/human for actual testing of the prototypes must also be taken into consideration for possible commercialization. Finally, it was noted that publications regarding the assessment of the performance of phlebotomists using vein finders were limited.

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.

ASSESSMENT OF A LANCET-AND-SWAB BLOOD SAMPLING TECHNIQUE FOR SURVEILLANCE OF ELEPHANT ENDOTHELIOTROPIC HERPESVIRUS INFECTION.

Lancing a finger elicits minimal pain in humans and is applied routinely to obtain small volumes of blood for clinical diagnostics. A modified lancet bleeding method and several blood sampling matrices were evaluated in this study for the purpose of routine elephant endotheliotropic herpesvirus (EEHV) surveillance in Asian elephants (Elephas maximus). The procedure enabled weekly sampling from elephants as young as 9 mo of age. The blood sampling matrices were evaluated for their sensitivity measuring ß-actin, tumor necrosis factor α, and/or EEHV-1 by quantitative polymerase chain reaction assays. Foam and flocked swabs produced significantly (P < 0.05) lower quantitation cycles, ie, increased analytical sensitivity, than filter papers, Whatman® FTA cards, or conventional cotton-tipped swabs. The two swab types also demonstrated comparable analytical sensitivity to that of a similar volume of EDTA whole blood for the detection of EEHV-1 DNA. This lancet-and-swab technique proved satisfactory for the detection of EEHV-1 viremia in two Asian elephant calves, and in one instance viremia could be detected 5 days prior to the development of clinical signs. Low blood yield from the lancet application may reduce sensitivity and compromise early detection of viremia. Therefore, standard venipuncture remains the recommended blood sampling method, and training for consistent and regular vein access should continue to be the priority for collections holding elephants. However, if appropriate measures are taken to collect an optimum blood volume, this lancet-and-swab technique offers a suitable alternative for EEHV surveillance in situations where venipuncture may not be practical.

Reduction in Blood Culture Contamination Through Use of Initial Specimen Diversion Device.

BACKGROUND: Blood culture contamination is a clinically significant problem that results in patient harm and excess cost. METHODS: In a prospective, controlled trial at an academic center Emergency Department, a device that diverts and sequesters the initial 1.5-2 mL portion of blood (which presumably carries contaminating skin cells and microbes) was tested against standard phlebotomy procedures in patients requiring blood cultures due to clinical suspicion of serious infection. RESULTS: In sum, 971 subjects granted informed consent and were enrolled resulting in 904 nonduplicative subjects with 1808 blood cultures. Blood culture contamination was significantly reduced through use of the initial specimen diversion device™ (ISDD) compared to standard procedure: (2/904 [0.22%] ISDD vs 16/904 [1.78%] standard practice, P = .001). Sensitivity was not compromised: true bacteremia was noted in 65/904 (7.2%) ISDD vs 69/904 (7.6%) standard procedure, P = .41. No needlestick injuries or potential bloodborne pathogen exposures were reported. The monthly rate of blood culture contamination for all nurse-drawn and phlebotomist-drawn blood cultures was modeled using Poisson regression to compare the 12-month intervention period to the 6 month before and after periods. Phlebotomists (used the ISDD) experienced a significant decrease in blood culture contamination while the nurses (did not use the ISDD) did not. In sum, 73% of phlebotomists completed a post-study anonymous survey and widespread user satisfaction was noted. CONCLUSIONS: Use of the ISDD was associated with a significant decrease in blood culture contamination in patients undergoing blood cultures in an Emergency Department setting. CLINICAL TRIALS REGISTRATION: NCT02102087.

Preanalytical external quality assessment of the Croatian Society of Medical Biochemistry and Laboratory Medicine and CROQALM: finding undetected weak spots.

INTRODUCTION: The aim of this paper is to present results of first two years of preanalytical external quality assessment (EQA) in Croatia. MATERIALS AND METHODS: This paper summarizes results from 6 rounds of preanalytical EQA during 2014-2016 in 161-175 Croatian laboratories (number ranged between cycles). EQA was designed as an online survey of the compliance with National recommendations for phlebotomy (NRP). Forty-seven questions in 5 categories are analyzed (materials and equipment, patient identification, patient preparation, sampling and storage). Additionally, preanalytical cases are presented. Overall performance scores (Question score (Qscore) for compliance with NRP and Case score (Cscore) for preanalytical cases) are calculated for each question/case as a proportion of laboratories with satisfactory procedure (x 100). Qscores and Cscores ≥ 70 were classified as acceptable (maximal score = 100). RESULTS: In investigation of compliance with NRP, acceptable Qscores were obtained for 34/47 questions. The lowest scores were observed for the availability of sterile disposable tourniquets (Qscore = 15) and safe-sharp needles (Qscore = 34), obtaining patients address as an identifier (Qscore = 21), using glycolysis inhibitor tubes for glucose concentration measurement (Qscore = 21) and verification of manufacturers declarations on temperature and time of storage (Qscore = 31). There was no statistically significant difference in overall Qscore according to different categories of phlebotomy procedures (P = 0.284). The results of preanalytical cases showed acceptable Cscore values for all cases (89-96). CONCLUSION: First two years of preanalytical EQA showed good compliance with the NRP and excellent expertise in resolving complex preanalytical issues. Major critical spots are lack of availability of safe-sharp needles, disposable tourniquets and glucose inhibitor tubes.

Cost-Effectiveness Analysis of Safety-Engineered Devices.

OBJECTIVE To estimate the cost-effectiveness of safety-engineered devices (SEDs) relative to non-SEDs for winged steel needles, intravenous catheter stylets, suture needles, and insulin pen needles. DESIGN Decision analysis modeling. PARTICIPANTS Hypothetical cohort of healthcare workers who utilized needle devices. METHODS We developed a decision-analytic model to estimate and compare the life-cycle costs and benefits for SED and non-SED needle devices. For this cost-effectiveness analysis, we quantified the total direct medical cost per needlestick injury, number of needlestick injuries avoided, and incremental cost-effectiveness ratio. Sensitivity analyses were performed to examine the robustness of the base-case analysis. RESULTS In the base-case analysis, we calculated the incremental cost-effectiveness ratios of SED winged steel needles, intravenous catheter stylets, suture needles, and insulin pen needles to be $2,633, $13,943, $1,792, and $1,269 per needlestick injury avoided, respectively. Sensitivity analyses showed that the calculated incremental cost-effectiveness ratio values for using SEDs did not fall below zero even after adjusting the values of each parameter. CONCLUSION The use of SED needle devices would not produce cost savings for hospitals. Government intervention may be needed to systematically protect healthcare workers in Japan from the risk of bloodborne pathogen infections. Infect Control Hosp Epidemiol 2016;37:1012-1021.

Towards a low-cost mobile subcutaneous vein detection solution using near-infrared spectroscopy.

Excessive venipunctures are both time- and resource-consuming events, which cause anxiety, pain, and distress in patients, or can lead to severe harmful injuries. We propose a low-cost mobile health solution for subcutaneous vein detection using near-infrared spectroscopy, along with an assessment of the current state of the art in this field. The first objective of this study was to get a deeper overview of the research topic, through the initial team discussions and a detailed literature review (using both academic and grey literature). The second objective, that is, identifying the commercial systems employing near-infrared spectroscopy, was conducted using the PubMed database. The goal of the third objective was to identify and evaluate (using the IEEE Xplore database) the research efforts in the field of low-cost near-infrared imaging in general, as a basis for the conceptual model of the upcoming prototype. Although the reviewed commercial devices have demonstrated usefulness and value for peripheral veins visualization, other evaluated clinical outcomes are less conclusive. Previous studies regarding low-cost near-infrared systems demonstrated the general feasibility of developing cost-effective vein detection systems; however, their limitations are restricting their applicability to clinical practice. Finally, based on the current findings, we outline the future research direction.

Venous International Assessment, VIA scale, validated classification procedure for the peripheral venous system.

PURPOSE: VIA scale is a dynamic performance status tool of the peripheral venous system that is divided into five different grades, composed of three parameters: number of observable puncture points; optimal catheter size for cannulation and ease of performing venipuncture and risk of extravasation. METHODS: Prospective single-center, observational, open, non-randomized study divided into two phases. In the first longitudinal phase, we studied the clinical characteristics and the changes in their peripheral venous systems during intravenous chemotherapy for 16 patients (n=16) for an average period of 24 months. In the second transverse phase, we measured the vein's diameter at the selected puncture points with a high-resolution ultrasound and paired this figure with VIA scale. We selected a group of oncology patients (n=52) and a control group (n=56). RESULTS: In the first phase, the level of agreement between the three reviewers was excellent. The second step was to assess the relationship between the measurements obtained with ultrasound and the VIA scale. The vein diameter measurements show a decrease directly related to the assessment of observers in the VIA scale. CONCLUSIONS: The VIA scale is a simple, easy and practical method for classification of the peripheral venous system in terms of vascular access. The practical application of our VIA scale significantly increases the quality of life of patients by increasing the chances of successful venipuncture and cannulation and thus reducing the risk of extravasation and material costs, allowing both an economical and a safe venous assessment tool.

Getting the basics right: delays in phlebotomy and intravenous cannulation: a survey of foundation year 1 doctors.

Junior doctors frequently experience delays in routine ward-based procedures. There is little published data on this subject, but it is clear that such delays can have implications in terms of costs, efficiency, length of patient stay, team working and patient safety and experience. We formulated an anonymous online survey to quantify the experiences of foundation year 1 (FY1) doctors with respect to phlebotomy services and intravenous (IV) cannulation. We gathered data on equipment availability, time taken to carry out these tasks and the factors thought to contribute to delays. The results were compared to clinically relevant standards. Between April and August 2012, 199 responses were received. For IV cannulation, 21% of doctors reported equipment availability as 'very good', but only 3% said that they were able to find all of the pieces of equipment they needed close to each other ('essentially in the same place'). Similar results were obtained for phlebotomy. Nevertheless, there appears to be significant room for improvement and we offer recommendations to address delays.

Jugular vascular access port implantation for frequent, long-term blood sampling in cats: methodology, assessment, and comparison with jugular catheters.

Long-term, frequent venous access for diagnostic, therapeutic, or research purposes in cats is problematic. Frequent blood sampling over extended periods is necessary for some therapeutic regimes and often required for clinical research in veterinary science. In this paper, we describe the implantation of vascular access ports (VAPs) and assess their use for repeated blood sampling over 16 weeks and 38 weeks, as well as the use of jugular catheters for one week. The VAP placement procedure was well-tolerated with few minor complications (minor swelling, contusion, or superficial dermatitis from self-trauma), which were not observed when neck bandages were applied immediately after surgery. Thromboembolism occurred in two cats, but did not occur after switching to a smaller catheter with a rounded tip and taurolidine-citrate locking solution. Although duration of access was much longer with VAPs compared to jugular catheters, patency rates were similar (89% (n=28) to 92% (n=12) after 16 weeks and 75% (n=12) after 38 weeks for VAPs; 88% (n=49) after one week for jugular catheters). Behavioural reactions to blood collection from 30 cats-assessed over 16 weeks and comprising 378 collections-were absent or minor in 99% of collections. These findings indicate that VAPs offer a viable alternative to jugular catheters for studies requiring frequent blood sampling and lasting more than 2 weeks.

VACUETTE(®) for burn depth assessment--a simple and novel alternative use for a ubiquitous phlebotomy device.

The depth of any burn wound is an important determinant of its management and outcome. It also governs the outcome of wound healing and scarring making initial depth assessment extremely vital. Various methods both invasive and non-invasive have been described in literature for burn depth estimation. We describe a useful adjunct to clinical burn depth assessment, a VACUETTE(®) venous blood sampling device. This single cheap, ubiquitous and sterile device usually used for phlebotomy allows subjective assessment of the most useful parameters in the assessment of burn wounds, including, capillary refill, evaluation of sensation to blunt and sharp stimuli including pain.

A retractable winged steel (butterfly) needle performance improvement project.

A performance improvement project used an interdisciplinary, systematic approach, including frontline staff input, in identifying, selecting, and evaluating a safer needle device. Following adoption of a retractable needle, needlesticks of health care workers decreased from 3.19 to zero incidents per 100,000 needles.

Fainting and hemolysis during blood sampling in youngsters: prevalence study.

OBJECTIVE: To assess the incidence of fainting and hemolysis in taking blood samples from adolescents in a school setting. DESIGN: A cross-sectional school-based survey. All blood samples and data were collected during September and October 2005. SUBJECTS: A community sample of 869 youngsters attending third grade secondary education in 14 secondary schools in the Flemish province of Antwerp, Belgium (mean age: 17.3 years, +/-1.2 years). MEASUREMENTS: Fasting blood samples were obtained on-site for measurement of levels of glucose, high density lipoprotein cholesterol and triglycerides. The incidence of fainting and hemolysis was assessed. RESULTS: In 60% of the total sample a blood sample was taken, 15% refused. In the remaining 25%, taking a blood sample was not possible due to problems in drawing blood from the vein (4%) or not fasting (21%). The incidence of fainting was 2.5%. Hemolysis occurred in 2.4% of the blood samples. CONCLUSION: When taking blood samples in this age group, there seems to be a great willingness to participate. Precaution should be taken though when taking blood samples in youngsters. In this study, about 1 in 40 students fainted. When blood samples are taken on-site and transported to a laboratory, an incidence of hemolysis of 2.4% should be taken into account.

Innovations in central vascular access device insertion.

The new millennium has brought with it many technological advances that have affected every industry, especially healthcare and nursing. The key to success will be the ability of nurses to acclimate to these changes. To accomplish this, nurses need to advance their individual practice and skills, and to pursue and maintain an education in their respective fields. At no other time in healthcare history have so many changes taken place in such a short time, and nurses must remain abreast of changes to ensure career securement, advancement, and the safety of their patients. This article focuses on peripherally inserted central catheters and the changing technology for their insertion, maintenance, and training requirements.

A comprehensive approach to percutaneous injury prevention during phlebotomy: results of a multicenter study, 1993-1995.

OBJECTIVE: To examine a comprehensive approach for preventing percutaneous injuries associated with phlebotomy procedures. DESIGN AND SETTING: From 1993 through 1995, personnel at 10 university-affiliated hospitals enhanced surveillance and assessed underreporting of percutaneous injuries; selected, implemented, and evaluated the efficacy of phlebotomy devices with safety features (ie, engineered sharps injury prevention devices [ESIPDs]); and assessed healthcare worker satisfaction with ESIPDs. Investigators also evaluated the preventability of a subset of percutaneous injuries and conducted an audit of sharps disposal containers to quantify activation rates for devices with safety features. RESULTS: The three selected phlebotomy devices with safety features reduced percutaneous injury rates compared with conventional devices. Activation rates varied according to ease of use, healthcare worker preference for ESIPDs, perceived "patient adverse events," and device-specific training. CONCLUSIONS: Device-specific features and healthcare worker training and involvement in the selection of ESIPDs affect the activation rates for ESIPDs and therefore their efficacy. The implementation of ESIPDs is a useful measure in a comprehensive program to reduce percutaneous injuries associated with phlebotomy procedures.

Incidence and management of catheter occlusion in implantable arm ports: results in 391 patients.

PURPOSE: To evaluate the incidence and management of catheter occlusion in implantable arm ports. MATERIALS AND METHODS: Findings were prospectively examined in 391 patients in whom 393 arm ports were placed. The indications for port placement included chemotherapy (n = 347), antibiotic administration (n = 35), combination chemotherapy/antibiotic use (n = 7), transfusion (n = 3), and phlebotomy (n = 1). Of the total catheters, 323 (82.2%) underwent tip modification prior to placement. Malfunctioning catheters were usually treated with urokinase instillation. RESULTS: Three hundred ninety-three devices were implanted with 247 mean days of catheter use (total, 97,256 days; range, 1-694 days). The overall incidence of catheter occlusion was 0.14 per 100 catheter days. A single catheter occlusion occurred in 90 (22.9%) catheters, with a mean of 90.1 days before the event. A second occlusion occurred in 36 (9.2%) of the above catheters, with a mean of 60.1 catheter days before the second event. Eighty-five (24.0%) of the 347 cancer patients had at least one occlusive event, yielding a complication rate of 0.098 per 100 catheter days at risk (95% confidence interval [CI]; 0.079-0.114). Of the 35 patients receiving antibiotics, three (8.6%) had at least one occlusive event. This represented a complication rate of 0.032 per 100 catheter days at risk (95% CI; 0.010-0.061). Seventeen (24.3%) of the nonmodified catheters developed an occlusion versus 72 (22.3%) of the modified (P > .05; Fisher exact test). Of the catheters with a first occlusive event, 75 (98.7%) were treated successfully with urokinase instillation. Four (1.0%) patients developed symptomatic subclavian vein thrombosis. No bleeding complications occurred. CONCLUSION: Catheter occlusion is a common complication of long-term arm port placement, with a significantly higher incidence in the cancer patients in our series (P <. 05, Fisher exact test). Catheter tip modification, however, does not considerably affect the incidence of occlusion. Low-dose urokinase therapy is a safe and efficacious treatment of catheter occlusion, obviating the need for catheter removal.