An Expand Role for Nurses in Laboratory Utilization

Introduction: The majority of testing errors occur in the pre-analytical stage, including specimen collection. Children provide challenges including small blood volumes, small veins, and inability to cooperate. We describe... [ view full abstract ]

Introduction: The majority of testing errors occur in the pre-analytical stage, including specimen collection. Children provide challenges including small blood volumes, small veins, and inability to cooperate. We describe collaboration between laboratorians and nursing staff to improve specimen collection and reliability of test results.  

Methods: We identified three areas for specimen collection improvement: (1) Volume of blood for culture (2) Urine collection, and (3) Appropriate blood collection through a line. Base line data was established. Guidelines for specimen collection were updated. Nurse members of the Laboratory Utilization Committee developed educational tools.

Results:

Adequate blood volume for a meaningful culture: Standardized desired blood volumes based on patient weight were established. Nursing education increased the adequacy of volume collected from 63% to 81% for inpatients and 37% to 62% for outpatients.

Clean catch urine collection for culture from outpatients: Contamination rates of cultures of midstream, clean catch urines in females were >50%. Efforts focused on improved collection failed. Outpatients with a positive UA had a contamination rate of 2-3%, while those patients with negative UA had a contamination rate of 67-76%. An algorithm for urine culture based on UA results has been proposed.

IV Fluid Contamination: To avoid needle sticks, blood specimens from hospitalized children are drawn through lines when present. D5 dextrose in IV fluid has a glucose of 5000 mg/dl.  Using glucose > 300 mg/dl with CO2 > 12 mol/L as an indicator of contamination ~ 1% of line collected  blood specimens and ~ 4% of blood gas specimens were contaminated. Intense efforts including bedside reminder cards were effective on selected units. But improvement has been difficult to sustain. Finger stick testing may be an alternative.

Discussion: The majority of the lab errors are preanalytical. Nursing participation in laboratory utilization efforts provides an opportunity to address these issues.