Clinical practice guideline: prevention of blood specimen hemolysis in peripherally-collected venous specimens

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

An implementation strategy was not provided.

Appropriate prevention of blood specimen hemolysis in peripherally-collected venous specimens

Not stated

All articles relevant to the topic were identified via a comprehensive literature search. The following databases were searched: PubMed, Google Scholar, Cumulative Index to Nursing and Allied Health (CINAHL), eTBlast, Ovid, Cochrane Library, Agency for Healthcare Research and Quality (AHRQ; www.ahrq.gov), Specimen Care (www.specimencare.com), and the National Guideline Clearinghouse (www.guideline.gov). Searches were conducted using various combinations of key words including hemolysis, phlebotomy technique, and blood samples. Initial searches were limited to English language articles from January 2002 to October 2012. This search limit was found to be inadequate and, therefore, the time frame was extended to begin with January 1990. In addition, the reference lists in the selected articles were scanned for pertinent research articles. Research articles from emergency department settings, non-emergency department settings, position statements and guidelines from other sources were also reviewed.

Articles that met the following criteria were chosen to formulate the clinical practice guideline (CPG): research studies, meta-analyses, systematic reviews, and existing guidelines relevant to the topic of blood specimen hemolysis. Articles included in meta-analyses or systematic reviews were not considered independently unless there were factors not addressed in the meta-analysis/systematic review. Other types of reference articles and textbooks were also reviewed and used to provide additional information.

28 documents were included in the evidence tables.

Grading the Levels of Evidence*

1. Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of RCTs
2. Evidence obtained from at least one properly designed RCT
3. Evidence obtained from well-designed controlled trials without randomization
4. Evidence obtained from well-designed case control and cohort studies
5. Evidence from systematic reviews of descriptive and qualitative studies
6. Evidence from a single descriptive or qualitative study
7. Evidence from opinion of authorities and/or reports of expert committees

Grading the Quality of the Evidence

1. Acceptable Quality: No concerns
2. Limitations in Quality: Minor flaws or inconsistencies in the evidence
3. Major Limitations in Quality: Many flaws and inconsistencies in the evidence
4. Not Acceptable: Major flaws in the evidence

*Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, & Wilkins.

The clinical practice guideline (CPG) authors used a standardized reference table to collect information and assist with preparation of tables of evidence ranking each article in terms of the level of evidence, quality of evidence, and relevance and applicability to practice. Clinical findings and levels of recommendations regarding patient management were then made by the Emergency Nurses Association (ENA) 2012 Emergency Nursing Resources Development Committee according to ENA's classification of levels of recommendation for practice, which include: Level A High, Level B Moderate, Level C Weak or Not recommended for practice (see the "Rating Scheme for the Strength of the Recommendations" field).

This clinical practice guideline (CPG) was created based on a thorough review and critical analysis of the literature following Emergency Nurses Association (ENA)'s Guidelines for the Development of Clinical Practice Guidelines (see the "Availability of Companion Documents" field).

Conference calls with Subcommittee members and staff are held as necessary to discuss progress and facilitate the Subcommittee's work. All members of the Subcommittee independently complete an exhaustive review of all identified literature, complete a separate evidence table for each topic (if possible), and then reconvene to reach consensus. Each Subcommittee prepares a description of the topic, definition, background, significance, and evidence table. The Subcommittee identifies and assigns preliminary scores for quality and strength of evidence, and describes conclusions based on the review of the body of evidence. Each Subcommittee also serves as "second readers" for another topic; this assures an in-depth look at the literature by two Subcommittees. The entire Committee reads the articles and reviews the evidence-appraisal tables for each topic and then finalizes implications for practice and the level of recommendation.

A formal cost analysis was not performed and published cost analyses were not reviewed.

The Institute for Emergency Nursing Research (IENR) Advisory Council reviews the final document for overall validity and provides feedback as appropriate using the Clinical Practice Guidelines (CPGs) Evaluation Worksheet. Reviews and feedback are sent to the Subcommittee to evaluate and incorporate, as appropriate. Emergency Nurses Association (ENA) staff creates the final products for publication with input from the Committee.

Not applicable: The guideline was not adapted from another source.

Emergency Nurses Association

2012 ENA Emergency Nursing Resources Development Committee

Committee Members: Jean A. Proehl, MN, RN, CEN, CPEN, FAEN; Judith Young Bradford, DNS, RN, FAEN; Sherry Leviner, MSN, RN, CEN; Andrew Storer, DNP, RN, ACNP, CRNP, FNP; Susan Barnason, PhD, RN, APRN-CNS, CEN, CCRN, FAAN; Carla Brim, MN, RN, CEN, CNS; Judith Halpern, MS, RN, APRN; Cathleen Lindauer, MSN, RN, CEN; Vicki C. Patrick, MS, RN, SRPN, ACNP, CEN, FAEN; Jennifer Williams, MSN, RN, CEN, CCRN, CNS

Not stated

This is the current release of the guideline.

Electronic copies: Available in Portable Document Format (PDF) from the Emergency Nurses Association Web site.

The following are available:

• Requirements for the development of: clinical practice guidelines, clinical practice guidelines synopsis, and translation into practice (TIP) recommendations. Des Plaines (IL): Emergency Nurses Association; 2013 Dec. 40 p. Electronic copies: Available in Portable Document Format (PDF) from the Emergency Nurses Association Web site.
• Clinical practice guideline: prevention of blood specimen hemolysis in peripherally-collected venous specimens. Synopsis. Des Plaines (IL): Emergency Nurses Association; 2012 Dec. 1 p. Electronic copies: Available in PDF from the Emergency Nurses Association Web site.
• CPG evidence table: prevention of blood specimen hemolysis in peripherally-collected venous specimens. Des Plaines (IL): Emergency Nurses Association; 2012 Dec. 16 p. Electronic copies: Available in PDF from the Emergency Nurses Association Web site.
• CPG other resources table: prevention of blood specimen hemolysis in peripherally-collected venous specimens. Des Plaines (IL): Emergency Nurses Association; 2012 Dec. 1 p. Electronic copies: Available in PDF from the Emergency Nurses Association Web site.

None available

This NGC summary was completed by ECRI Institute on February 13, 2014. The information was verified by the guideline developer on March 27, 2014.

This summary is based on the original guideline, which is subject to the guideline developer's restrictions.

Any disease or condition requiring a blood draw

To evaluate which pre-analytic variables related to peripheral venous specimen collection and transportation decrease blood culture hemolysis

Patients requiring a blood draw

The grades of recommendations (A–C, Not Recommended, I/E), levels of evidence (I–VII), and quality of evidence (I–IV) are defined at the end of the "Major Recommendations" field.

Description of Decision Options/Interventions and the Level of Recommendation

Please note that the references listed after each recommendation represent the evidence considered when making the recommendation. This does not mean that the evidence in each individual reference supports the recommendation.

1. Education of the staff performing phlebotomy may decrease hemolysis. Level C – Weak (Halm & Gleaves, 2009; Ong, Chan, & Lim, 2009; Corkill, 2012)
2. The type of personnel performing phlebotomy does not influence hemolysis. Level C – Weak (Halm & Gleaves, 2009; Bush et al., 2010; Harrison et al., 2010; Saleem et al., 2009; Ong, Chan, & Lim, 2008)
3. Hemolysis is less likely when blood is drawn from the antecubital fossa. Level B – Moderate (Tanabe, Kyriacou, & Garland, 2003; Fang et al., 2008; Heyer et al., 2012)
4. Minimize tourniquet time by removing the tourniquet after identifying the venipuncture site while preparing equipment and as soon as good blood flow is established. Level C – Weak (Saleem et al., 2009)
5. There is insufficient evidence to determine if the number of venipuncture attempts affects hemolysis. Level – I/E (Saleem et al., 2009)
6. There is insufficient evidence as to whether intravenous catheter insertion perceived to be difficult is associated with an increased risk of hemolysis. Level – I/E (Stauss et al., 2012; Ong, Chan, & Lim, 2008)
7. Direct venipuncture with straight needles is less likely to cause hemolysis than blood collection through intravenous catheters. Level B – Moderate (Tanabe, Kyriacou, & Garland, 2003; Ong, Chan, & Lim, 2009; Bush et al., 2010; Berger-Achituv et al., 2010; Heyer et al., 2012; Saleem et al., 2009)
8. Stainless steel needles are less likely to cause hemolysis than intravenous catheters; teflon catheters are less likely to cause hemolysis than Vialon™ catheters. Level C – Weak (Raisky et al., 1994; Sharp & Mohammad, 1998)
9. There is conflicting evidence regarding the influence of needle or catheter gauge on hemolysis. Level – I/E (Sharp & Mohammad, 1998; Sharp & Mohammed, 2003; Tanabe, Kyriacou, & Garland, 2003; Sequin, McEachrin, & Murphy, 2004; Heyer et al., 2012)
10. There is conflicting evidence regarding hemolysis with syringes versus vacuum tubes. Level – I/E (Sharp & Mohammad, 2003; Halm & Gleaves, 2009; Ong, Chan, & Lim, 2009; Bush et al., 2010; Saleem et al., 2009; Sequin, McEachrin, & Murphy, 2004)
11. Drawing blood through an extension tubing attached to an intravenous catheter does not increase hemolysis in adults. Level C – Weak (Stauss et al., 2012)
12. Drawing blood through needleless connectors does not increase hemolysis. Level B – Moderate (Dwyer et al., 2006; Sharp & Mohammad, 2003)
13. There is insufficient evidence regarding the impact of the rate of blood flow into a vacuum tube on hemolysis. Level – I/E (Ong, Chan, & Lim, 2008)
14. Low (partial) vacuum tubes result in less hemolysis. Level B – Moderate (Heyer et al., 2012; Schwartzer et al., 2001)
15. Filling vacuum tubes to their recommended volume decreases hemolysis. Level C – Weak (Unger, Filippi, & Patsch, 2007; Tamechika et al., 2006)
16. Properly functioning pneumatic tube systems do not increase hemolysis. Level C – Weak (Stair et al., 1995; Fang et al., 2008; Ellis, 2009; Saleem et al., 2009; Streichert et al., 2011; Evliyaoglu et al., 2012)
17. There is insufficient evidence to determine if the volume of venipunctures performed influences hemolysis. Level – I/E (Hawkins, 2010)
18. There is insufficient evidence to determine if monitoring hemolysis rates and providing feedback to the staff performing phlebotomy decreases the incidence of hemolysis. Level – I/E (McGrath, Rankin, & Schendel, 2012)

Definitions:

Levels of Recommendation for Practice

Grading the Levels of Evidence*

1. Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of RCTs
2. Evidence obtained from at least one properly designed RCT
3. Evidence obtained from well-designed controlled trials without randomization
4. Evidence obtained from well-designed case control and cohort studies
5. Evidence from systematic reviews of descriptive and qualitative studies
6. Evidence from a single descriptive or qualitative study
7. Evidence from opinion of authorities and/or reports of expert committees

Grading the Quality of the Evidence

1. Acceptable Quality: No concerns
2. Limitations in Quality: Minor flaws or inconsistencies in the evidence
3. Major Limitations in Quality: Many flaws and inconsistencies in the evidence
4. Not Acceptable: Major flaws in the evidence

*Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, & Wilkins.

None provided