The document provides information about the roles and responsibilities of phlebotomists in a biochemistry laboratory. It discusses key duties like ensuring proper patient identification, sample handling and transport procedures. It also outlines various preanalytical and analytical considerations for sample collection and testing, including different anticoagulants, test types, quality standards and transport methods. The document emphasizes the importance of adherence to protocols and informing the laboratory of any issues that could impact test results.

1. Phlebotomy and the Biochemistry Dept Felicity Dempsey Senior Medical Scientist Biochemistry Laboratory St James’s Hospital

2. 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

3. 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

4. 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

5. 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.

6. Sampling Procedures Venepuncture Finger prick Heel prick Capillary

7. Sample types Plasma (anticoagulated) Serum (clotted) Whole blood

8. Laboratory Process Preanalytical – Major Advances Primary Sampling, Analysers Analytical – Instrumentation/Analyses Postanalytical – Final result

9. Preanalytical issues Diet Diurnal variations Drug Therapy Pregnancy Dehydration Patient’s current condition

10. Viruses Bacteria Foods Sunlight Stress Drugs Genes Menopause Pregnancy Post-pregnancy Preanalytical Gender

11. Preanalytical issues Haemolysis Lipaemia Icterus Partially filled tubes Cross contamination Incorrect sample type Incorrect/inadequate labelling/unlabelled

12. Problems with vacuutainers Loss of vacuum Improper storage Incorrect sampling technique Incorrect blood/additive ratio Expired tubes

13. Blood containers Evacuated or syringe Gel separators Viscosity changes on centrifugation Inhibits cell metabolism Change of tube system validated by lab

15. Additives Liquid, spray dried or powder Anticoagulants Antiglycolytic Clot activators Trace element

16. Order of draw Blood Cultures Citrate Serum Heparin EDTA Oxalate

17. Essential precautions Invert gently to mix Vigorous mixing - haemolysis Cross contamination Never transfer between tubes

18. NCCLS H3-H5, Vol 23, No 23, 8.10.2

19. Anticoagulants Chelates/ precipitates calcium Ca unavailable coagulation process Inhibits thrombin formation Prevents Fibrinogen to Fibrin process

20. Commonly used in Biochemistry Colour coded tubes Lithium Heparin (green/orange) Fluoride Oxalate (grey) Clotted (red) Trace metal (royal blue) System to system variation

21. Test requisition Electronic Patient Register (EPR) Phlebotomy lists Bar coded labels Hospital Forms GP multidisciplinary forms

22. Minimum Acceptance Criteria Form / EPR label Patients Name MRN Hospital /Ward DOB Referring Consultant Date/Time collected (desirable) Clinical Details (noted if not supplied)

23. Transport to Laboratory Pneumatic transport tube system Hospital porter Internal Couriers External Couriers Train Post

24. Considerations for Phlebotomists Transport on ice Transport frozen Light protected Requires immediate separation Refridgerated centrifuge Inform lab of impending arrival

25. Analytical issues Routine biochemistry (daily) Routine biochemistry (1-3 times weekly) STAT biochemistry Endocrinology POCT Discipline specific specialities Neonatal/Paediatric Biochemistry

26. 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

27. Renal profile Urea Creatinine Sodium/Potassium (Na/K) Bicarbonate

28. Bone Profile Calcium (Ca) Inorganic Phosphate (In P) Alkaline Phosphate (ALP) Albumin

29. Liver profile Total Protein/Albumin Total Bilirubin Enzymes – GGT, ALP, Transaminases - AST, ALT

30. Cardiac Profiles/Markers Enzymes LDH, AST, CK Markers CKMBM (mass measurement) Troponin T or I Pro BNP

31. Routine Biochemistry Lipid profiles Therapeutic Drug Monitoring (TDM) anti epileptic, anti asthmatic, lithium, digoxin Diabetes monitoring HbA1c, urinary microalbumen Toxicology Non blood biochemistry

32. Endocrinology Thyroid function tests Infertility testing Adrenal testing Growth & Development DM & Obesity

34. Specialities Porphyria Haemochromotosis typing Tumour Markers Bone Markers DNA analysis Metabolic disorders Neonatal screening

35. Irish Neonatal Metabolic Screening Programme Phenylketonuria (PKU) Maple Syrup Urine Disease (MSUD) Congenital Hypothyroidism (CHT) Galactosaemia Homocystinuria

36. Guthrie Cards Preanalytical Considerations Adequate sample application Air dry elevated / horizontal No stacking - Cross Contamination Other Contaminants: Powder / Lotions Alcohol wipes Urine, Faeces & Sweat

37. 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

38. Timing of samples Fasting samples TDM requirements Digoxin - +6 hrs Stimulation tests

39. TDM requirements Efficacy Dose Avoid Toxicity Compliance Lithium – serum required

40. Chain of Custody Protocols Samples unsuitable medico-legal purposes Legal samples Coroner’s requests Industry Work related injury Employee insurance schemes Drug screening

41. Glucose Testing Random Fasting 2hr PP GTT Incorrect Timing - misinterpretation

42. Take home message Reference ranges not consensus Method/ Instrument variation Possible sample type variation Protocols may differ Contact lab if unsure

43. Therapeutic Phlebotomy Haemochromatosis (Fe) Porphyria Cutanea Tarda (Fe) Polycytaemia (RBC)

44. 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

45. Post analytical Data Review Delta checking Phone urgent results Additional testing Gender based reference ranges

46. Post analytical Electronic reports - Wards Healthlink, Medibridge Computer generated results OPD / Clinic lists Follow up letters/phonecalls

47. 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

48. Changing face of Pathology Preanalytical analysers Blood Sciences Combined Biochemistry, Haematology, Immunology analysers Increased POCT

51. Why Don’t You…… Visit your hospital laboratory Befriend the Lab Staff