Volume 36 Number 4 | August 2022

Laura R. Link, MS, MLS(ASCP)CM, ASCLS Diversity Advocacy Council Councilor

Laura LinkThe patient had been feeling “blah” for a few days, with a slight fever (or was it just the June heat?), joint pain (or was it just arthritis?), and a rash (or was it something from weeding the flower bed?). But now she’s starting to gasp when talking and is winded after walking short distances. Could this be COVID-19?

Phlebotomy may be the most important and least understood part of a patient’s experience. Many patients don’t know there is a distinction between the nursing team and phlebotomy, leading to an assumption that “a nurse drew my blood.” Some states do not require phlebotomists to be certified or licensed, and many employers conduct on-the-job training to prepare phlebotomists for collecting samples from patients, without oversight from an accrediting body or any curricular requirements.

All week long, the patient’s daughter-in-law tried to convince her to see her doctor. The patient is elderly and has type 2 diabetes. She also takes medication for high blood pressure. She complained that she didn’t have any energy and said her skin felt like it was on fire. Was it COVID-19? In the summer of 2020, this thought was frightening. Finally, early Saturday morning, the patient consented to see a doctor. Since her regular physician did not have Saturday hours, and the patient was clearly getting worse, the decision was made to seek help at an urgent care facility.

“Where does the responsibility of the laboratory begin and end?”

Laboratory scientists are charged with meeting quality standards as established by Clinical Laboratory Improvement Amendments (CLIA), College of American Pathologists (CAP), and the Joint Commission, to name a few. Laboratory teams must communicate with other healthcare professionals to ensure optimal patient care. When someone performs phlebotomy and sends samples to the lab, the laboratory professional does not have any control over that phase of testing.

The patient was clearly uncomfortable, with a fever that was increasing, and she continued to complain that her skin felt like it was burning. The daughter-in-law, after pleading her case and being screened for COVID-19 symptoms, was able to stay with the patient and assist her as needed. Once the patient was evaluated and the attending physician consulted, an IV drip of normal saline was ordered. The patient was told this would then assist with intravenous antibiotics if needed and that when the IV was started, blood would be drawn.

Laboratory scientists do not insert IV catheters or other indwelling devices, so when blood is collected for testing during these procedures, it will likely be another healthcare provider who does this. Many patients and their family members see this as a win-win: only one stick is needed for multiple purposes. If the blood is drawn before the IV fluids are hooked up and running, there is no chance of contamination, and especially during the COVID-19 pandemic, if one healthcare provider can perform more than one function, possible exposures are limited.

The patient consented to having an IV inserted and agreed that blood could be drawn during this procedure. The tourniquet was applied approximately halfway between the elbow and wrist. The patient’s arm was cleansed with what appeared to be an iodine-containing solution, but she was not questioned to see if she had allergies or sensitivity to iodine. While the cleansing solution dripped onto the floor, the daughter-in-law began to watch the clock. A full two minutes elapsed before the IV catheter was inserted and another minute passed before the catheter was seated and blood tubes were attached. A green top tube was filled and placed on the table, a lavender top tube was filled and placed on the table, then a light blue top tube was filled. The daughter-in-law questioned the order of draw and threw the light blue top tube into the biohazard container. She then mixed the tubes of blood herself. This was annoying to others in the room. The daughter-in-law stood her ground, quoting statistics that made her case:

Venous stasis of no more than one to three minutes is documented to have an adverse effect on CBC results, leading to increases in hemoglobin and hematocrit measurements, as well as red blood cell count (De la Salle, 2019).

If EDTA from the lavender top tube contaminates tubes drawn after it, the chelation of calcium can interfere with coagulation testing, biasing both the PT and PTT values (Lima-Oliveira, 2014).

A tube that is insufficiently or never mixed may not maintain the appropriate anticoagulant-to-blood ratio or may contain microclots (Narayanan, 2005).

Where does the responsibility of the laboratory begin and end? How can we maintain our standards of quality if other healthcare providers do not have the appropriate education and training to properly collect the samples we will assess? The answers to these questions are neither clear-cut nor easy. It is our responsibility—all of us—to work for better interprofessional communication and take every opportunity to ensure that optimal patient care is delivered to all our patients. I hope this short article gets you thinking about this, and I would love to hear from you.

What about this patient? She was admitted with a diagnosis of cellulitis and mild dehydration, suffered no ill effects from her experience, and went home after two days as an in-patient. We’re very thankful!

  1. De la Salle, B. (2019). Pre- and postanalytical errors in hematology. International Journal of Laboratory Hematology. doi: 10.1111/ijlh.13007
  2. Lima-Oliveira, G., Salvagno, G. L., Danese, E., Favaloro, E. J., Guidi, C. G., & Lippi, G. (2014). Sodium citrate blood contamination by K2-ethylenediaminetetraacetic acid (EDTA): Impact on routine coagulation testing. International Journal of Laboratory Hematology. doi: 10.1111/ijlh.12301
  3. Narayanan, S. (2005). Preanalytical issues related to blood sample mixing. Acute Care Testing. https://acutecaretesting.org/-/media/acutecaretesting/files/pdf/preanalytical-issuesrelated-to-blood-sample-mixing.pdf

Laura R. Link is the Medical Laboratory Science Program Director, Assistant Professor at Radford University Carilion in Roanoke, Virginia.