NITO BIOINGENIØRFAGLIG INSTITUTT
Challenges in Organising Preanalytical Work in Hospitals
Marie Nora Roald, Consultant, NITO The Norwegian Institute of Biomedical Science (BFI), Norway. E-mail marie.nora.roald@nito.no
Introduction
In Norwegian hospitals, phlebotomy has traditionally
been taken care of by biomedical laboratory scientists,
and then to a large extent by biomedical laboratory
scientists employed in the clinical chemistry labora-
tory or its equivalent. However, a shortage of
biomedical laboratory scientists, increased production
of laboratory analyses and demands for increased
productivity have led to the testing of several models
for rationalising the work involved in collecting blood
samples. It is a matter of concern for medical
laboratories if taking blood samples becomes a low
priority task in hospitals resulting in reduced
preanalytical quality. In November 2002 BFI presented
a policy document on Phlebotomy in hospitals (1). This
document is currently being revised and an updated
policy will be presented in 2009.
Preanalytical
Conditions
Preanalytical conditions are the sum of all of those
conditions in effect from the time when the analysis is
ordered to the time when the specimen is ready to be
analysed. If an error is made when the sample is
drawn which is of significance for the analytical
method to be used, the resulting error will without
exception be transferred to the result of the analysis.
This type of error will seldom or never be detected
with the help of the laboratories’ ordinary analytical
control routines. In such a case laboratory analysis,
that is itself of high quality and correctly carried out,
is of little help.
When taking blood samples, each individual
phlebotomist is responsible for knowing and following
the right procedures. Phlebotomy is a craft, and
expert guidance and practice over time is therefore
essential for acquiring the knowledge and skills
required to take blood samples in a considerate,
correct and efficient way.
It is of great importance that all those who take blood
samples receive proper training, in order to
understand the significance of following procedures
and, not least, the importance of reporting deviations.
Uncertainty concerning preanalytical conditions will
always leave a question mark on the final results of
the analysis. (1, 2, 3, 4)
Centralised versus Decentralised
Phlebotomy Services
Centralised phlebotomy services means that biomedi-
cal laboratory scientists and other qualified personnel
employed in the medical laboratories take the blood
samples in hospitals. In a decentralised service,
personnel from each hospital ward take blood samp-
les, with guidance and training from the medical
laboratories.
Advantages of centralised phlebotomy
Biomedical laboratory scientists have phlebotomy and
preanalytical factors as an important part of their edu-
cation. This means that through their education, biomedi-
cal laboratory scientists acquire theoretical knowledge
of the significance preanalytical sources of error have
for the results of various laboratory analyses.
Biomedical laboratory scientists are trained and
qualified to understand the significance of preanalyti-
cal factors in the total analysis process, and a defined
pool of phlebotomists, with many sample drawings per
person, makes it easy to maintain competence and
quality. It is also easier to maintain training, updating
and to implement changes in a defined group of
personnel.
Also, phlebotomy is an important contact point
between the biomedical laboratory scientist, patients and
other health care professionals in the hospital. (1, 2)
Disadvantages of decentralised phlebotomy
In large hospitals, the laboratory staff might have to
walk long distances in order to take blood samples.
When ward personnel take blood samples, the time for
collecting blood samples can be adapted to the
patient’s rhythm and to other ward routines, and the
patient will have fewer health professionals to relate
to during the days.
There are however, many disadvantages. The ward
personnel have little or no theoretical background on
the significance of preanalytical factors in the total
analysis process, and there will be a continuing need
for large resources for training and continuing
updating. The ward personnel have many important
tasks and the quality assurance of phlebotomy
becomes a low priority task. High turn-over and a
large pool of ward personnel carrying out phlebotomy
makes it difficult for the personnel to maintain their
competence, and to update and to implement changes.
All these factors further increase the risk of
preanalytical errors. A less trained staff will also
increase the need for renewed sample collection,
leading to more pain for the patients and higher
equipment costs. (1, 2, 5)
Quality and costs
Several studies have documented a higher error rate
with a decentralised phlebotomy service.
Studies from the US shows that when converting from
decentralised to centralised phlebotomy services
Sarah Bush Lincoln Health Center, Illinois, reduced the
number of accidental needle sticks by 83 percent,
hemolysis rate by 18 percent, labelling errors by 40
percent and blood culture contamination by 71
percent. Ingalls Hospital, Illinois, have documented
cost savings to the amount of 400 000 US$ per year
by converting from decentralised to centralised
phlebotomy services. (5)
Organisation of phlebotomy
in Norwegian hospitals
Since the first biomedical laboratory scientist educa-
tion programmes began in Norway in the 1950s, phle-
botomy has been an important part of the education.
Phlebotomy in hospitals has traditionally been taken
care of by biomedical laboratory scientists and then,
to a large extent, by biomedical laboratory scientists
employed in the medical biochemistry departments or
its equivalent. In recent years four large Norwegian
hospitals have decentralised some phlebotomy
services from medical laboratories to hospital wards.
Conclusion
How should challenges in organising preanalytical
work in hospitals be addressed?
Centralised phlebotomy services are cost effective
and give better quality than decentralised phlebotomy
services.
Biomedical laboratory scientists are responsible for
analysis of blood samples and the technical validation
of the results of the analysis. They have the
competency required to evaluate preanalytical
sources of error and their significance.
Biomedical laboratory scientist’s education and
professional experience makes biomedical laboratory
scientists the professional group best qualified to
handle phlebotomy in hospitals.
The managers of medical laboratories must
acknowledge their responsibility for phlebotomy in
hospitals and actively influence models for organising
phlebotomy to secure the overall quality of the total
analysis process.
References
1. Blodprøvetaking i sykehus, NITO Bioingeniørfaglig
institutt, november 2002. English version;
Phlebotomy in hospitals, November 2003.
2. Wallin O: Preanalytical errors in hospitals.
Department of Medical Biosciences, Umeå
University, Sweden, 2008
3. Guder, Narayanan, Wisse, Zawta: Samples: From
the Patient to the Laboratory - The impact of
preanalytical variables on the quality of laboratory
results. 3rd edition. John Wiley and Sons. New
York, 2003
4. Husøy AM (red): Blodprøvetaking i praksis. 1.
utgave, 1. opplag, Akribe forlag, 2005
5. Dennis J. Ernst: Organising phlebotomy services.
Oral lecture at conference, March 2009.
http://www.nito.no/dm/public/204889.PDF
6. NOKLUS www.noklus.no
Quality assurance of phlebotomy outside
Norwegian Hospitals
Quality assurance of phlebotomy outside hospitals is
handled by the Norwegian Quality Improvement of
Laboratory Services in Primary Care (NOKLUS), which
was established in 1992. NOKLUS has developed infor-
mation folders which are distributed to all doctors’
surgeries and nursing homes affiliated to the arrange-
ment (99 percent of doctors’ surgeries in Norway are
affiliated). The folders contain a broad spectrum of
information on laboratory activities, including informa-
tion on phlebotomy. NOKLUS has advisory biomedical
laboratory scientists covering all Norwegian counties.
The advisory biomedical laboratory scientists are
responsible for promoting quality assurance of all
laboratory services in primary health care. This
includes securing that the quality of blood samples
being taken is satisfactory. (6)
Photos: Finger – Jens Vinsrygg. Arm – Svein Arild Sletteng