Laboratory Tube Collection

Issues of Concern

Issues inherent to the application of laboratory tube collection include, but are not limited, to the following:

• Problems with the evacuated tube system (ETS): Multiple blood collection will be difficult, especially when the vacutainer used is already damaged or malfunctioning. 

• Problems with the collection tube: The tubes may also be damaged. For instance, the vacuum inside the tube could be lost when it is uncapped. On the other hand, an anticoagulant may not be present in some tubes during packaging, which will mean incorrectly using serum instead of plasma for testing.

• Inadequately trained personnel: The laboratory staff should have training in laboratory tube collection. The order of draw is made easy with color-coding, but it can still lead to an incorrect collection if the phlebotomist does not follow the order of draw because of inadequate training.

• Contamination: If the tubes become contaminated from the beginning, during, or after the collection, these will yield incorrect and unreliable results. For example, the sterility of the cap of blood culture tubes must be ensured and should not be in contact with any potential source of contamination. Another way of contamination is when the anticoagulant from a tube can be transferred to another tube when it sticks with the needle of the vacutainer. 

• Lack of research studies on laboratory tube collection: While the CLSI made the recommendations for the proper sequence of tubes, additional studies are needed to reveal the actual amount of variability if improper order of collection occurs. Future studies can reveal underlying concepts to the laboratory tube collection process itself, which can help develop future standards on laboratory science practice in healthcare. Medical laboratory scientists working not only in the clinical laboratories but also in research and the academe should give adequate attention to laboratory tube collection as it is given less priority nowadays despite its clinical implications.

Clinical Significance

The correct application of the "order of draw" principle in multiple blood tube collection is an essential aspect of ensuring quality laboratory test results.[8] Falsely increased and false decreased values may result in specific analytes in biochemistry, hematology, serology, and clinical microbiology, to name a few.[9] These inaccurate and unreliable results can never be used in clinical correlation as they will alter the diagnosis and management of the patient's disease. 

When the laboratory medicine department does not address these problems, incorrect results may reach the clinicians, nurses, and other clinical personnel without being noticed.[10] This situation is even worse in the wards and emergency departments. However, additional studies concerning the role of laboratory-related errors on laboratory tube collection and its impact in clinical settings may still be necessary to strengthen these claims, and thus, their clinical relevance.

Nursing, Allied Health, and Interprofessional Team Interventions

Even though laboratory tube collection is mainly the responsibility of the clinical laboratory and its staff, team interventions in the clinic and hospital settings can still help in the total quality implementation of such laboratory practices. For instance, non-laboratory personnel such as nurses and clinicians should at least become oriented or aware of the order of draw so that when they get to see laboratory staff or phlebotomists at the bedside engaging in improper procedures, they can immediately call attention to it before there is an adverse clinical impact to the patient. Assisting a colleague at work can have a significant effect on patient care. 

Moreover, during conferences or department meetings, the laboratory manager (or pathologist) can discuss the importance of proper laboratory tube collection with the administration, clinical staff, purchasing department, and human resources. Aside from non-laboratory health personnel, non-clinical personnel must be included in the team to increase the scope of knowledge. While interprofessional teams' goal is to improve overall patient care, it should be emphasized that helping other colleagues should not be intended to blame a health professional but rather to lift everyone in the team and provide corrective action.

Nursing, Allied Health, and Interprofessional Team Monitoring

Team monitoring is not standard practice because of the departmentalized system in healthcare. On the other hand, interprofessional teams require collaboration among different healthcare professionals and should solely rely upon the clinicians, specialists, and other providers. Nursing, allied health (laboratory, pharmacy, etc.), and non-health (administration staff) can create teams with clinicians and specialists and conduct team monitoring via regular "peer review" (as a recommendation) so that each member of the team will get to realize the interconnectedness of the work they do in healthcare and its collective impact to patients. The specific steps in conducting a peer review of the interprofessional team, in the case of laboratory tube collection, for example, must be further studied.