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 laboratory 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.

Centralised versus Decentralised Phlebotomy Services
Centralised phlebotomy services means that biomedical 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 samples, 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 education. This means that through their education, biomedical 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 preanalytical 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)

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)

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 information folders which are distributed to all doctors’ surgeries and nursing homes affiliated to the arrangement (99 percent of doctors’ surgeries in Norway are affiliated). The folders contain a broad spectrum of information on laboratory activities, including information 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

Organisation of phlebotomy in Norwegian hospitals
Since the first biomedical laboratory scientist education programmes began in Norway in the 1950s, phlebotomy 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.