phlebotomist & biochemistry
DESCRIPTION
TRANSCRIPT
Phlebotomy and the Biochemistry Dept
Felicity Dempsey
Senior Medical Scientist
Biochemistry Laboratory
St James’s Hospital
Role of Phlebotomist
• Inform patient of any test preparation
• Ensure correct sampling & handling
• Properly identify the patient
• Label sample with 2 unique identifiers
• Adherence Hospital Quality System
• Adherence Health & Safety Codes
• Minimise risk management
Role of Phlebotomist
• Knowledge of test requirements (user manual)• Universal Blood Precautions (CJD)• Ensure quality of sample• Ensure patient details stated correctly• Avoid haemolysis & microclotting• Prioritise STAT samples• Prompt dispatch• LIS/EPR operation
CPA STANDARDS
C3standard – The facilities for the patient should provide privacy during reception and sampling
C3.1 Waiting/Reception area with disabled access
Phlebotomy Area for privacy & recovery
Toilet facilities separate to staff
C3.2 Notices advising patients of Health & Safety precautions
E3 Specimen collection and handling
• E3.1 Lab management should establish procedures for specimen collection and handling
• E3.2 Procedures available to service users & those responsible for specimen collection and handling
• E3.3 Lab periodically reviews its sample volume requirements to ensure that neither insufficient nor excessive amounts are collected.
Sampling Procedures
• Venepuncture
• Finger prick
• Heel prick
• Capillary
Sample types
• Plasma (anticoagulated)
• Serum (clotted)
• Whole blood
Laboratory Process
• Preanalytical – Major Advances
Primary Sampling, Analysers
• Analytical – Instrumentation/Analyses
• Postanalytical – Final result
Preanalytical issues
• Diet
• Diurnal variations
• Drug Therapy
• Pregnancy
• Dehydration
• Patient’s current condition
Viruses
BacteriaFoods
Sunlight
Stress
Drugs
Genes
MenopausePregnancy
Post-pregnancy
Preanalytical
Gender
Preanalytical issues
• Haemolysis
• Lipaemia
• Icterus
• Partially filled tubes
• Cross contamination
• Incorrect sample type
• Incorrect/inadequate labelling/unlabelled
Problems with vacuutainers
• Loss of vacuum
• Improper storage
• Incorrect sampling technique
• Incorrect blood/additive ratio
• Expired tubes
Blood containers
• Evacuated or syringe
• Gel separators
• Viscosity changes on centrifugation
• Inhibits cell metabolism
• Change of tube system validated by lab
Additives
• Liquid, spray dried or powder
• Anticoagulants
• Antiglycolytic
• Clot activators
• Trace element
Order of draw
• Blood Cultures
• Citrate
• Serum
• Heparin
• EDTA
• Oxalate
Essential precautions
• Invert gently to mix
• Vigorous mixing - haemolysis
• Cross contamination
• Never transfer between tubes
NCCLS H3-H5, Vol 23, No 23, 8.10.2
Anticoagulants
• Chelates/ precipitates calcium
• Ca unavailable coagulation process
• Inhibits thrombin formation
• Prevents Fibrinogen to Fibrin process
Commonly used in Biochemistry
• Colour coded tubes
• Lithium Heparin (green/orange)
• Fluoride Oxalate (grey)
• Clotted (red)
• Trace metal (royal blue)
• System to system variation
Test requisition
• Electronic Patient Register (EPR)
• Phlebotomy lists
• Bar coded labels
• Hospital Forms
• GP multidisciplinary forms
Minimum Acceptance Criteria
• Form / EPR label• Patients Name• MRN• Hospital /Ward• DOB• Referring Consultant• Date/Time collected (desirable)• Clinical Details (noted if not supplied)
Transport to Laboratory
• Pneumatic transport tube system
• Hospital porter
• Internal Couriers
• External Couriers
• Train
• Post
Considerations for Phlebotomists
• Transport on ice
• Transport frozen
• Light protected
• Requires immediate separation
• Refridgerated centrifuge
• Inform lab of impending arrival
Analytical issues
• Routine biochemistry (daily)
• Routine biochemistry (1-3 times weekly)
• STAT biochemistry
• Endocrinology
• POCT
• Discipline specific specialities
• Neonatal/Paediatric Biochemistry
Routine – Organ Profiling
• Renal /Liver/Bone/Cardiac profiles
• ICU profiles – ICU, HDU, BU, Oncology
• Overlap in some tests
• Glucose – random, fasting, post prandial
• Amylase
• Magnesium
Renal profile
• Urea
• Creatinine
• Sodium/Potassium (Na/K)
• Bicarbonate
Bone Profile
• Calcium (Ca)
• Inorganic Phosphate (In P)
• Alkaline Phosphate (ALP)
• Albumin
Liver profile
• Total Protein/Albumin
• Total Bilirubin
• Enzymes – GGT, ALP,
• Transaminases - AST, ALT
Cardiac Profiles/Markers
Enzymes• LDH, AST, CK
Markers
• CKMBM (mass measurement)
• Troponin T or I
• Pro BNP
Routine Biochemistry
• Lipid profiles• Therapeutic Drug Monitoring (TDM)- anti epileptic, anti asthmatic, lithium, digoxin• Diabetes monitoring- HbA1c, urinary microalbumen- Toxicology• Non blood biochemistry
Endocrinology
• Thyroid function tests
• Infertility testing
• Adrenal testing
• Growth & Development
• DM & Obesity
Specialities
• Porphyria
• Haemochromotosis typing
• Tumour Markers
• Bone Markers
• DNA analysis
• Metabolic disorders
• Neonatal screening
Irish Neonatal Metabolic Screening Programme
• Phenylketonuria (PKU)
• Maple Syrup Urine Disease (MSUD)
• Congenital Hypothyroidism (CHT)
• Galactosaemia
• Homocystinuria
Guthrie Cards
• Preanalytical Considerations• Adequate sample application• Air dry elevated / horizontal• No stacking - Cross Contamination• Other Contaminants: Powder / Lotions Alcohol wipes Urine, Faeces & Sweat
Commonly encountered sample problems
• Delay in separation (GP)• Haemolysis• Incorrect sample type• Cross contamination• Drip arm sample• Incorrect patient• Lipaemia• Icterus• Alcohol/Trace Metal Contamination
Timing of samples
• Fasting samples
• TDM requirements
• Digoxin - +6 hrs
• Stimulation tests
TDM requirements
• Efficacy Dose
• Avoid Toxicity
• Compliance
• Lithium – serum required
Chain of Custody Protocols
• Samples unsuitable medico-legal purposes
• Legal samples
• Coroner’s requests
• IndustryWork related injuryEmployee insurance schemesDrug screening
Glucose Testing
• Random
• Fasting
• 2hr PP
• GTT
• Incorrect Timing - misinterpretation
Take home message
• Reference ranges not consensus
• Method/ Instrument variation
• Possible sample type variation
• Protocols may differ
• Contact lab if unsure
Therapeutic Phlebotomy
• Haemochromatosis (Fe)
• Porphyria Cutanea Tarda (Fe)
• Polycytaemia (RBC)
Common aims
• Know & Comply Hospital/Dept Quality Policy• Reduce Turnaround Time (TAT)• Inform lab if urgent• Efficient transport• Efficient Reporting• Prioritise wards
(ICU/CCU/BU/AE/HDU/Oncology• POCT
Post analytical
• Data Review
• Delta checking
• Phone urgent results
• Additional testing
• Gender based reference ranges
Post analytical
• Electronic reports - Wards Healthlink, Medibridge
• Computer generated results
• OPD / Clinic lists
• Follow up letters/phonecalls
Changing face of Pathology
• Pathology review – just published
• 3 cold labs (GP work) ??S,W,E
• 14 hot labs (i.e. 14 A/E)
• Reduced from 48
• Country wide/combine hospitals
• Smaller hospitals – community hospitals
• Tenders – public/private interests
Changing face of Pathology
• Preanalytical analysers
• Blood Sciences
• Combined Biochemistry, Haematology, Immunology analysers
• Increased POCT
Why Don’t You……
• Visit your hospital laboratory
• Befriend the Lab Staff