Journal Assignment Week 9

JANUARY 2017 MLO-ONLINE.COM 22 LAB MANAGEMENT SPECIMEN COLLECTION/HANDLING Proper patient preparation, specimen collection, and sample handling are critical to quality care By Anthony Kurec, MS, H(ASCP)DLM just over $1 million a year in quality assurance investigations, blood redraws, repeat testing, and management oversight. 7 One of the most common errors is ordering the wrong test. 5,8 With the ever-expanding clinical laboratory test menu, ensur- ing that the right test is ordered can be somewhat daunting.

Some examples: factor V and factor V Leiden; 25-hydroxyvi- tamin and 1,25-dihydroxyvitimin D; and thyroid tests. With a huge infl ux of information overload, the addition of new tests, the pressure to see more patients, and the expanding use of cutting-edge molecular diagnostics create numerous opportu- nities to make mistakes in laboratory test orders. Other pre-analytic variables One of the least invasive procedures a patient may endure is the phlebotomy, yet it may be a signifi cant source of poor patient care: 8-13  Proper patient identifi cation is mandatory. It is also useful to understand the patient’s health status, which may have an infl uence on test results.  Regulations require that at least two patient identifi ers be obtained, usually spelling of their name and their date of birth.

 In addition, proper labeling of the specimen is also critical (patient’s name, hospital number or date of birth, time and date of collection, phlebotomist’s name).

 Fasting status. Patient diagnosis. Correct test ordered.

 Physiologic factors  Fasting, especially prolonged fasting, may cause increas- es in amino acids, bilirubin, ketones, growth hormones, fatty acids, and triglycerides. Decreases may be observed in assays for glucose, high density lipoprotein (HDL), insulin, T3, and lactate dehydrogenase (LD). Fatty meals may increase potassium, triglycerides, alkaline phospha- tase, and 5-hydroxyindoleacetic acid (5-HIAA). Meat, fi sh, iron, horseradish, and some bismuth-based antacids may render a false positive in stool occult blood tests.

 Diets  Vegetarians, especially long-term vegetarians, may show decreased levels of low density lipoprotein (LDL), very low density lipoprotein (VLDL), phospholipids, cholesterol, triglycerides, and vitamin B12.

 High protein/meat diets show increased serum urea, ammonia, and urate levels.

 High protein/low carbohydrate diets (Atkins Diet) can result in increased urine ketones and serum blood urea nitrogen (BUN).

 Alcohol intake can increase triglycerides, lipoprotein, B12, lactate, and liver enzymes. Decreased levels of glucose, prolactin, and cortisol may also occur. Alcohol abuse can G arbage In, Garbage Out (GIGO), as the saying goes. This adage has been applied in a universal manner in address- ing human errors. It certainly applies to establishing laboratory procedures that ensure care in managing the pre- analytical phase of laboratory testing. Sixty years ago, many common laboratory tests were performed manually, and thus were prone to inaccuracy and analytical mistakes. Today’s ad- vanced technology places laboratory science in a highly auto- mated and quality-focused environment that ensures accurate testing processes. Total Testing Process (TTP)Medical errors are the third leading cause of death in the U.S.

The laboratory’s contribution to this major healthcare concern is only 0.33 percent. 1 While this number appears small, labora- tory errors do occur, not always resulting is death, but never- theless having an important impact on patient care. As clinical laboratory scientists, we must make every effort to produce accurate test results. One of the fi rst efforts (1947) in laboratory quality manage- ment involved the collection of survey results where six com- mon analyte samples were shared with a number of laborato- ries. The results pointed to wide and signifi cant variation. 2 In later years (1997) the concept of “brain-to-brain turnaround time” was introduced by George Lundberg and later modi- fi ed to “brain-to-brain loop." 3 This process included nine steps involving laboratory testing: 1) ordering, 2) collection, 3) iden- tifi cation, 4) transportation, 5) separation, 6) analysis, 7) report- ing, 8) interpretation, and 9) action. 1 This became the basis for the concept of the Total Testing Process (TTP), to include pre- analytic, analytic, and post-analytic phases of testing. Over the past decades, as a result of intense quality management pro- grams, laboratory errors have been reduced by as much as 75 percent. 1 While efforts were initially focused on the analytical part of laboratory testing, it became clear that the pre-analytical and post-analytical phases of testing were just as, if not more, impor- tant in providing quality services. A number of studies have been done that have looked at the accuracy of laboratory testing. In general, error rates for each phase range from 46 percent to 68 percent for pre-analytical, 7 percent to 13 percent for analytical, and 18 percent to 47 percent for post-analytical. 4 Since almost 70 percent of all laboratory errors reside within the pre-analytical phase, laboratories began to focus on preemptive practices that would minimize, and hopefully avoid, common errors. Pre-pre-analytic and pre-analytic phases The pre-pre-analytic phase has been has been added as part of the initial patient encounter process. 5,6 As noted, this is where most laboratory errors occur. Table 1 identifi es some areas of common errors. These errors may cost a moderate-sized hospital Pre-pre-analytical Pre-analytical Analytical Post-analyticalPost-post-analytical Wrong test ordered Error in order-entry Wrong patient identifi cation Collection error Improper handling and transportation Improper sorting, aliquoting, labeling, centrifugation Poor QC Instrument malfunction Interference (lipemia, hemolysis, etc.) Reporting errors Increased turnaround times Transcription errors Failure in critical value reporting Incorrect interpretation of lab results Delay in looking at results No follow-up testing No consultation Table 1: Examples of errors in each laboratory testing phase 6 continued on page 24 MLO201701_LabMgmt_MECH_AL.indd 22 MLO201701_LabMgmt_MECH_AL.indd 22 12/12/2016 4:23:45 PM 12/12/2016 4:23:45 PM JANUARY 2017 MLO-ONLINE.COM 24 LAB MANAGEMENT SPECIMEN COLLECTION/HANDLING Anthony Kurec, MS, H(ASCP)DLM, is Clinical Associate Professor, Emeritus, at SUNY Upstate Medical University in Syracuse, New York. He is also a member of the MLO Editorial Advisory Board. refl ect elevation of HDL,  -glutamyltransferase (GGT), urate, and mean corpuscular volume (MCV).

 Coffee/caffeine may increase glucose, plasma rennin, free fatty acids, and catecholamine concentrations.

Increased levels of non-esterifi ed fatty acids may in- terfere with albumin-bound drug and hormone mea- surements. Studies suggest that caffeine may decrease platelet aggregation and increase vitamin D levels. 14,15  Other factors: Bananas, pineapples, tomatoes, and avo- cadoes may elevate urine 5-HIAA. Cholesterol, triglyc- erides, and apoB lipoproteins may be altered in obese patients.  Herbal supplements: Herbal supplements are used glob- ally for a variety of ailments. Numerous studies have shown how some supplements can interfere with thera- peutic drugs as well as laboratory testing. Most, if not all herbal supplements are not regulated by the FDA; thus their co-activity with other agents may not be fully ap- preciated. Various Chinese herbs have been shown to af- fect some laboratory test values. In addition, heavy metal poisoning has been reported based on elevated lead and zinc protoporphyrin levels. Table 2 lists some common supplements. 11,12  Exercise: Exercise may increase free fatty acids, lac-tate, creatine phosphokinase (CK), creatinine, pyru- vate kinase, aspartate aminotransfrerase (AST), lactate dehydrogenase (LD), aldostrone, cortisol, HDL, prolac- tin, uric acid, bilirubin, platelets, WBC, and ammonia.

Cholesterol and triglycerides may decrease.

 Posture: Plasma rennin activity and calcium may be low-er when supine. Changing from supine to upright can alter hemoglobin, hematocrit, RBC, WBC, calcium, protein, and lipid levels.

 Stress: Hormones tend to increase with stress. Total cholesterol may increase, while HDL may decrease.

 Blood collection  Tourniquet: Prolonged tourniquet application (hemo- concentration > one minute) may affect potassium, magnesium, albumin, protein, serum enzymes, coagu- lation factors, iron, ammonia, calcium, cholesterol, and triglyceride levels.  Decontamination: Alcohol that has not dried ( it needs 30 to 60 seconds) can destroy red cells. Iodine may elevate phosphate, uric acid, and potassium.

 Order of draw: First to draw are blood cultures followed by light blue tubes (Na citrate), red (SST), green (hepa- rin), lavender (versene), yellow (ACD), and fi nally gray (K oxalate/Na fl uoride) tubes.

 Wrong tubes: Using the wrong anticoagulant in collection can alter test results.

 Improper mixing: Gentle mixing, using complete 180 o inversions, is critical. For serum separation tubes (SST), inverting fi ve times, allowing to sit 30 minutes, and then centrifuging (1,000-1,300 RCF) in a swing bucket for 10 minutes provides a proper specimen for analysis. 16  Interfering substances  Tobacco: Hemoglobin, carboxyhemoglobin, catechol- amines, glucose, lactate, growth hormone, cholesterol, triglycerides, LDL, cortisol, WBC, RBC, and MCV may be elevated. Decreased levels of vitamin B12, HDL, IgA, IgG, IgM, and sperm counts/motility are also seen.

 Hemolysis: As red cells break apart, potassium, phos-phorus, ALT, LD, CK, coagulation factors, magnesium, iron, sodium, HDL, triglycerides, and cholesterol levels may be altered.

 Lipemia: When triglycerides exceed 300 mg/dL, lipemia occurs, causing diffi culties in measuring hemoglobin, white blood cells, and platelets. Any assay using spectral analysis may be affected by the abnormal light scatter caused by lipemic particles. 16 Knowing the variablesProper preparation of the patient regarding fasting needs as well as careful phlebotomy procedures are essential to ensuring accurate laboratory testing results. General practice is to have the patient fast twelve hours prior to blood draw, especially when testing for a lipid profi le and glucose tests. There is also evidence that fasting for creatinine levels should be considered, especially when high protein/meat diets are consumed. 17 In ad- dition, patients should avoid alcohol, tobacco, physical stress, and caffeine. Having the patient sit for fi fteen minutes prior to the blood draw and performing it in the morning (7-11 AM) is ideal. 13 While all pre-analytic variables cannot be eliminated, phle- botomists and technical staff need to be made aware of the many variables that can impact laboratory testing accuracy.

Up-to-date blood collection procedures should provide guid- ance in addressing potential critical outcomes in the pre-ana- lytical phase of testing. Establishing quality assurance monitors for selected possible pre-analytic errors can help identify op- portunities that can be addressed, thus minimizing the risk of adverse outcomes. References available online. Possible Impact on Lab Tests Herbal Supplement Liver toxicity; may see altered liver enzyme tests (ALT, AST, Alkaline phosphatase, GGT, Bilirubin) Black Cohosh Chaparral Kava-kava Mistletoe Germander Comfrey Hypokalemia, CK, Aldosterone, Cortisol, Renin Activity Licorice Thyroid Tests Kelp Therapeutic Drug Interference Digoxin Chan Su Dan Shen Siberian Ginseng Digoxin, Theophylline, Cyclosporin St. John’s Wort Anticonvulsants Evening Primrose Borage Oil (Starfl ower) Shankhapushpi Warfarin Angelica Root Feverfew Garlic Ginko Devils Claw Licorice CoQ10 Cranberry Saw Palmetto Ginger Glucose Chromium Garlic Melatonin Antipsychotic Drugs Goldenseal Table 2. Effect on laboratory tests of a few herbal supplements 11,12,19 continued from page 22 MLO201701_LabMgmt_MECH_AL.indd 24 MLO201701_LabMgmt_MECH_AL.indd 24 12/12/2016 4:24:07 PM 12/12/2016 4:24:07 PM Copyright ofMLO: Medical Laboratory Observeristhe property ofNP Communications, LLC anditscontent maynotbecopied oremailed tomultiple sitesorposted toalistserv without thecopyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.