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The preanalytical process in the emergency department, a European survey

  • Luis Garcia-Castrillo Riesgo EMAIL logo , Door Lauwaert , Janne Cadamuro ORCID logo , Alexander von Meyer and Christoph Dodt
Published/Copyright: October 31, 2022
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Clinical Chemistry and Laboratory Medicine (CCLM)
From the journal Clinical Chemistry and Laboratory Medicine (CCLM) Volume 61 Issue 1

Abstract

Objectives

Clinical decision-making in emergency medicine is under constant pressure from demand and performance requirements, with blood tests being a fundamental part of this. However, the preanalytical process has received little attention. Therefore, this study aimed to investigate the quality of preanalytical phase processes in European emergency departments (EDs) from the perspectives of the three main providers: clinicians, nurses, and laboratory specialists.

Methods

This online survey, distributed among European EDs and laboratories, was supported by the European Society for Emergency Nursing (EUSEN), European Society for Emergency Medicine (EuSEM), and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM). The size of the centres, the European region, the responder’s profession and the country’s economic condition were used as co-variables.

Results

We included 376 responses from all ED-related professions from 306 European centres. In 66.9% of all ED visits, at least one blood test was performed. Tests were requested mostly by nurses (44.6%) using electronic Order/Entry systems (65.4%). Only a minority (19%) reported not using laboratory quality indicators (QIs). Most responders defined the TAT starting point “when the laboratory receives the sample” (66.1%), defining the goal to be “less than 60 min” (69.9%), but only 42.4% of the centres estimated achieving this goal.

Conclusions

Our survey illustrates the current situation on preanalytical blood sample processing in European EDs from the clinical and laboratory perspectives. The results emphasise the importance of the IT infrastructure and QI usage in this process and highlight some differences between European regions.

Keywords: blood sampling; blood specimen collection; emergency departments; emergency nursing; haemolysis; hematologic tests; key performance indicators; preanalytical phase; quality assurance; quality indicators
Corresponding author: Dr. Luis Garcia Castrillo, Mies de Puerto 1A, Oruña de Pielagos 39477, Cantabria, Spain; and Emergency Department, Hospital Marqués de Valdecilla, Santander, Spain, Phone: + 34 629468845, E-mail:

Funding source: Becton Dickinson

Acknowledgments

For distribution of the survey, we are especially thankful to members of the EFLM research network, members of the EUSEM research network, and the member associations of EuSEN. We are especially thankful to all staff and board members from the participating scientific societies for their priceless support.

  1. Research funding: This study was supported by Becton Dickinson via an unrestricted grant.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Not applicable.

  5. Ethical approval: The project and survey were evaluated and supported by the EUSEM Ethical and Research Committees and the Boards of the EuSEN and EFLM.

References

1. Lehtonen, H, Lukkarinen, T, Kämäräinen, V, Rautava, VP. Improving emergency department capacity efficiency. Signa Vitae 2016;12:52–7.10.22514/SV121.102016.9Search in Google Scholar

2. Mason, S, Mountain, G, Turner, J, Arain, M, Revue, E, Weber, EJ. Innovations to reduce demand and crowding in emergency care; a review study. Scand J Trauma Resuscitation Emerg Med 2014;22:55. https://doi.org/10.1186/s13049-014-0055-1.Search in Google Scholar PubMed PubMed Central

3. Carrus, B, Corbett, S, Khandelwal, D. A hospital-wide strategy for fixing emergency-department overcrowding. McKinsey, Health Int 2009;9:6–17.Search in Google Scholar

4. Pines, JM, Hilton, JA, Weber, EJ, Alkemade, AJ, Al Shabanah, H, Anderson, PD, et al.. International perspectives on emergency department crowding. Acad Emerg Med 2011;18:1358–70. https://doi.org/10.1111/j.1553-2712.2011.01235.x.Search in Google Scholar PubMed

5. Jayaprakash, N, O’Sullivan, R, Bey, T, Ahmed, SS, Lotfipour, S. Crowding and delivery of healthcare in emergency departments: the European perspective. West J Emerg Med 2009;10:233–9.Search in Google Scholar

6. Di Somma, S, Paladino, L, Vaughan, L, Lalle, I, Magrini, L, Magnanti, M. Overcrowding in emergency department: an international issue. Int Emerg Med 2015;10:171–5. https://doi.org/10.1007/s11739-014-1154-8.Search in Google Scholar PubMed

7. Ngo, A, Gandhi, P, Miller, WG. Frequency that laboratory tests influence medical decisions. J Appl Lab Med 2017;1:410–4. https://doi.org/10.1373/jalm.2016.021634.Search in Google Scholar PubMed

8. Lippi, G. The irreplaceable value of laboratory diagnostics: four recent tests that have revolutionized clinical practice. eJIFCC 2019;30:7–13.Search in Google Scholar

9. Jordan, B, Mitchell, C, Anderson, A, Farkas, N, Batrla, R. The clinical and health economic value of clinical laboratory diagnostics. eJIFCC 2015;26:47–62.Search in Google Scholar

10. Howanitz, JH, Howanitz, PJ. Laboratory results. Timeliness as a quality attribute and strategy. Am J Clin Pathol 2001;116:311–5. https://doi.org/10.1309/H0DY-6VTW-NB36-U3L6.Search in Google Scholar PubMed

11. Badiou, S, Vuillot, O, Bargnoux, AS, Kuster, N, Lefebvre, S, Sebbane, M, et al.. Improved quality of samples and laboratory turnaround time using 3.5 mL low vacuum BD Vacutainer® Barricor tubes in the emergency department. Pract Lab Med 2019;16:e00128. https://doi.org/10.1016/j.plabm.2019.e00128.Search in Google Scholar PubMed PubMed Central

12. Kaushik, N, Khangulov, VS, O’Hara, M, Arnaout, R. Reduction in laboratory turnaround time decreases emergency room length of stay. Open Access Emerg Med 2018;10:37–45. https://doi.org/10.2147/OAEM.S155988.Search in Google Scholar PubMed PubMed Central

13. Carraro, P, Plebani, M. Errors in a stat laboratory: types and frequencies 10 years later. Clin Chem 2007;53:1338–42. https://doi.org/10.1373/clinchem.2007.088344.Search in Google Scholar PubMed

14. Petersmann, A, Odbaatar, EA, Krause, F, Schlueter, K, Nauck, M. A systematic approach to optimize the preanalytical phase over the last 6 years. Clin Chem Lab Med 2015;53:eA76.Search in Google Scholar

15. Heireman, L, Van Geel, P, Musger, L, Heylen, E, Uyttenbroeck, W, Mahieu, B. Causes, consequences and management of sample hemolysis in the clinical laboratory. Clin Biochem 2017;50:1317–22. https://doi.org/10.1016/j.clinbiochem.2017.09.013.Search in Google Scholar PubMed

16. Goswami, B, Singh, B, Chawla, R, Gupta, VK, Mallika, V. Turn around time (TAT) as a benchmark of laboratory performance. Indian J Clin Biochem 2010;25:376–9. https://doi.org/10.1007/s12291-010-0056-4.Search in Google Scholar PubMed PubMed Central

17. Saxena, S, Wong, ET. Does the emergency department need a dedicated stat laboratory? continuous quality improvement as a management tool for the clinical laboratory. Am J Clin Pathol 1993;6:606–10. https://doi.org/10.1093/ajcp/100.6.606.Search in Google Scholar PubMed

18. Sørup, CM, Jacobsen, P, Forberg, JL. Evaluation of emergency department performance – a systematic review on recommended performance and quality-in-care measures. Scand J Trauma Resuscitation Emerg Med 2013;21:62. https://doi.org/10.1186/1757-7241-21-62.Search in Google Scholar PubMed PubMed Central

19. Rhee, KJ, Donabedian, A, Burney, RE. Assessing the quality of care in a hospital emergency unit: a framework and its application. QRB Qual Rev Bull 1987;13:4–16. https://doi.org/10.1016/s0097-5990(16)30097-5.Search in Google Scholar PubMed

20. Cadamuro, J, Lippi, G, von Meyer, A, Ibarz, M, van Dongen, E, Cornes, M, et al.. European survey on preanalytical sample handling – Part 1: how do European laboratories monitor the preanalytical phase? On behalf of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase (WG-PRE). Biochem Med (Zagreb) 2019;29:020704. https://doi.org/10.11613/BM.2019.020704.Search in Google Scholar PubMed PubMed Central

21. Cadamuro, J, Lippi, G, von Meyer, A, Ibarz, M, van Dongen-Lases, E, Cornes, M, et al.. European survey on preanalytical sample handling - Part 2: practices of European laboratories on monitoring and processing haemolytic, icteric and lipemic samples. On behalf of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase (WG-PRE). Biochem Med (Zagreb) 2019;29:020705. https://doi.org/10.11613/BM.2019.020705.Search in Google Scholar PubMed PubMed Central

22. World Health Organisation. General hospitals, per 100 000. https://gateway.euro.who.int/en/indicators/hlthres_65-general-hospitals-per-100-000/ [Accessed May 2021].Search in Google Scholar

23. Pati, HP, Singh, G. Turnaround time (TAT): difference in concept for laboratory and clinician. Indian J Hematol Blood Transfus 2014;30:81–4. https://doi.org/10.1007/s12288-012-0214-3.Search in Google Scholar PubMed PubMed Central

24. National Center for Health Statistics (NCHS). National hospital ambulatory medical care survey. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2018-ed-web-tables-508.pdf [Accessed 25 June 2021].Search in Google Scholar

25. Kocher, KE, Meurer, WJ, Desmond, JS, Nallamothu, BK. Effect of testing and treatment on emergency department length of stay using a national database. Acad Emerg Med 2012;19:525–34. https://doi.org/10.1111/j.1553-2712.2012.01353.x.Search in Google Scholar PubMed

26. Athey, S, Scott, S. The impact of information technology on emergency health care outcomes. Rand J Econ 2002;33:399–432. https://doi.org/10.2307/3087465.Search in Google Scholar

27. European Commission. European hospital survey - benchmarking deployment of eHealth services (2012–2013). https://digital-strategy.ec.europa.eu/en/library/european-hospital-survey-benchmarking-deployment-ehealth-services-2012-2013 [Accessed May 2021].Search in Google Scholar

28. Zaboli, A, Pfeifer, N, Solazzo, P, Marsoner, T, Scola, G, Malloth, M, et al.. Blood sampling during nurse triage reduces patient length of stay in the emergency department: a propensity score-weighted, population-based study. Int Emerg Nurs 2020;49:100826. https://doi.org/10.1016/j.ienj.2019.100826.Search in Google Scholar PubMed

29. Hansen, K, Boyle, A, Holroyd, B, Phillips, G, Benger, I, Chartier, LB, et al., On behalf of the ITEM Quality and Safety Special Interest Group. Updated framework on quality and safety in emergency medicine. Emerg Med J 2020;37:437–42. https://doi.org/10.1136/emermed-2019-209290.Search in Google Scholar PubMed PubMed Central

30. Khalifa, M, Zabani, I. Developing emergency room key performance indicators: what to measure and why should we measure it? Stud Health Technol Inform 2016;226:179–82.Search in Google Scholar

31. Madsen, M, Kiuru, S, Castrèn, M, Kurland, L. The level of evidence for emergency department performance indicators: systematic review. Eur J Emerg Med 2015;22:298–305. https://doi.org/10.1097/MEJ.0000000000000279.Search in Google Scholar PubMed

32. Lagrosen, S. Quality management in Europe: a cultural perspective. TQM Mag 2002;14:275–83. https://doi.org/10.1108/09544780210439707.Search in Google Scholar

33. von Meyer, A, Lippi, G, Simundic, AM, Cadamuro, J. Exact time of venous blood sample collection – an unresolved issue, on behalf of the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE). Clin Chem Lab Med 2020;58:1655–62. https://doi.org/10.1515/cclm-2020-0273.Search in Google Scholar PubMed

34. Breil, B, Fritz, F, Thiemann, V, Dugas, M. Mapping turnaround times (TAT) to a generic timeline: a systematic review of TAT definitions in clinical domains. BMC Med Inf Decis Making 2011;11:34. https://doi.org/10.1186/1472-6947-11-34.Search in Google Scholar PubMed PubMed Central

35. Plebani, M, Astion, ML, Barth, JH, Chen, W, de Oliveira Galoro, CA, Escuer, MI, et al.. Harmonization of quality indicators in laboratory medicine. A preliminary consensus. Clin Chem Lab Med 2014;52:951–8. https://doi.org/10.1515/cclm-2014-0142.Search in Google Scholar PubMed

36. Steindel, SJ, Howanitz, PJ. Physician satisfaction and emergency department laboratory test turnaround time. Arch Pathol Lab Med 2001;125:863–71. https://doi.org/10.5858/2001-125-0863-PSAEDL.Search in Google Scholar PubMed

37. Howanitz, PJ, Cembrowski, GS, Steindel, SJ, Long, TA. Physician goals and laboratory test turnaround times. A College of American Pathologists Q-Probes study of 2763 clinicians and 722 institutions. Arch Pathol Lab Med 1993;117:22–8.Search in Google Scholar

38. Holland, LL, Smith, LL, Blick, KE. Reducing laboratory turnaround time outliers can reduce emergency department patient length of stay: an 11-hospital study. Am J Clin Pathol 2005;124:672–4. https://doi.org/10.1309/E9QP-VQ6G-2FBV-MJ3B.Search in Google Scholar PubMed

39. Guss, DA, Chan, TC, Killeen, JP. The impact of a pneumatic tube and computerized physician order management on laboratory turnaround time. Ann Emerg Med 2008;51:181–5. https://doi.org/10.1016/j.annemergmed.2007.03.010.Search in Google Scholar PubMed

40. Stark, A, Jones, BA, Chapman, D, Well, K, Krajenta, R, Meier, FA, et al.. Clinical laboratory specimen rejection association with the site of patient care and patients’ characteristics: findings from a single health care organization. Arch Pathol Lab Med 2007;131:588–92. https://doi.org/10.5858/2007-131-588-CLSRWT.Search in Google Scholar PubMed

41. Rooper, L, Carter, J, Hargrove, J, Hoffmann, S, Riedel, S. Targeting rejection: analysis of specimen acceptability and rejection, and framework for identifying interventions in a single tertiary healthcare facility. J Clin Lab Anal 2017;31:e22060. https://doi.org/10.1002/jcla.22060.Search in Google Scholar PubMed PubMed Central

42. Dikmen, ZG, Pinar, A, Akbiyik, F. Specimen rejection in laboratory medicine: necessary for patient safety? Biochem Med (Zagreb) 2015;25:377–85. https://doi.org/10.11613/bm.2015.037.Search in Google Scholar

43. Lippi, G, Blanckaert, N, Bonini, P, Green, S, Kitchen, S, Palicka, V, et al.. Haemolysis: an overview of the leading cause of unsuitable specimens in clinical laboratories. Clin Chem Lab Med 2008;46:764–72. https://doi.org/10.1515/CCLM.2008.170.Search in Google Scholar PubMed

44. Phelan, MP, Reineks, EZ, Schold, JD, Hustey, FM, Chamberlin, J, Procop, GW. Preanalytic factors associated with haemolysis in emergency department blood samples. Arch Pathol Lab Med 2018;142:229–35. https://doi.org/10.5858/arpa.2016-0400-OA.Search in Google Scholar PubMed

45. Lippi, G, Cervellin, G, Mattiuzzi, C. Critical review and meta-analysis of spurious hemolysis in blood samples collected from intravenous catheters. Biochem Med (Zagreb) 2013;23:193–200. https://doi.org/10.11613/bm.2013.022.Search in Google Scholar PubMed PubMed Central

46. Mrazek, C, Simundic, AM, Wiedemann, H, Krahmer, F, Felder, TK, Kipman, U, et al.. The relationship between vacuum and hemolysis during catheter blood collection: a retrospective analysis of six large cohorts. Clin Chem Lab Med 2017;55:1129–34. https://doi.org/10.1515/cclm-2016-0940.Search in Google Scholar PubMed

Supplementary Material

The online version of this article offers supplementary material (https://doi.org/10.1515/cclm-2022-0581).

Received: 2022-04-23
Accepted: 2022-09-30
Published Online: 2022-10-31
Published in Print: 2023-01-27

© 2022 Walter de Gruyter GmbH, Berlin/Boston

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  33. Acknowledgment
  34. Letters to the Editor
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  36. Response to “About the estimation of albuminuria based on proteinuria results”
  37. Reply to Abildgaard et al.: lot variation and inter-device differences contribute to poor analytical performance of the DCA vantage™ HbA1c POCT instrument in a true clinical setting
  38. Reply to letter from Mayfield et al. regarding “Lot variation and inter-device differences contribute to poor analytical performance of the DCA Vantage™ HbA1c POCT instrument in a true clinical setting”
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https://doi.org/10.1515/cclm-2022-0581
Keywords for this article
blood sampling; blood specimen collection; emergency departments; emergency nursing; haemolysis; hematologic tests; key performance indicators; preanalytical phase; quality assurance; quality indicators

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. A new milestone on the road to global standardization of apolipoprotein measurements
  4. Review
  5. Saliva – a new opportunity for fluid biopsy
  6. Opinion Papers
  7. Emerging technology: a definition for laboratory medicine
  8. The next wave of innovation in laboratory automation: systems for auto-verification, quality control and specimen quality assurance
  9. EFLM Paper
  10. The new, race-free, Chronic Kidney Disease Epidemiology Consortium (CKD-EPI) equation to estimate glomerular filtration rate: is it applicable in Europe? A position statement by the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM)
  11. Guidelines and Recommendations
  12. Overcoming challenges regarding reference materials and regulations that influence global standardization of medical laboratory testing results
  13. General Clinical Chemistry and Laboratory Medicine
  14. Quantitative protein mass-spectrometry requires a standardized pre-analytical phase
  15. Report from the HarmoSter study: inter-laboratory comparison of LC-MS/MS measurements of corticosterone, 11-deoxycortisol and cortisone
  16. The influence of proteoforms: assessing the accuracy of total vitamin D-binding protein quantification by proteolysis and LC-MS/MS
  17. Total serum vitamin B12 (cobalamin) LC-MS/MS assay as an arbiter of clinically discordant immunoassay results
  18. The preanalytical process in the emergency department, a European survey
  19. Proenkephalin A as a marker for glomerular filtration rate in critically ill children: validation against gold standard iohexol GFR measurements
  20. Umbilical cord blood gases: probability of arterial or venous source in acidemia
  21. Reference Values and Biological Variations
  22. Pediatric reference interval verification for 17 specialized immunoassays and cancer markers on the Abbott Alinity i system in the CALIPER cohort of healthy children and adolescents
  23. Hematology and Coagulation
  24. Performance of digital morphology analyzer CellaVision DC-1
  25. Cancer Diagnostics
  26. Managing the impact of inter-method bias of prostate specific antigen assays on biopsy referral: the key to move towards precision health in prostate cancer management
  27. Cardiovascular Diseases
  28. Quantitation of cardiac troponin I in cancer patients treated with immune checkpoint inhibitors: a case-control study
  29. Infectious Diseases
  30. A novel scoring system combining Modified Early Warning Score with biomarkers of monocyte distribution width, white blood cell counts, and neutrophil-to-lymphocyte ratio to improve early sepsis prediction in older adults
  31. Technical and health governance aspects of the External Quality Assessment Scheme for the SARS-CoV-2 molecular tests: institutional experience performed in all clinical laboratories of a Regional Health Service
  32. Acknowledgment
  33. Acknowledgment
  34. Letters to the Editor
  35. About the estimation of albuminuria based on proteinuria results
  36. Response to “About the estimation of albuminuria based on proteinuria results”
  37. Reply to Abildgaard et al.: lot variation and inter-device differences contribute to poor analytical performance of the DCA vantage™ HbA1c POCT instrument in a true clinical setting
  38. Reply to letter from Mayfield et al. regarding “Lot variation and inter-device differences contribute to poor analytical performance of the DCA Vantage™ HbA1c POCT instrument in a true clinical setting”
  39. High-sensitive cardiac troponin T: are turbulences coming?
  40. Analytical performance evaluation of bioactive adrenomedullin on point-of-care platform
  41. Increased PD-L1 surface expression on peripheral blood granulocytes and monocytes after vaccination with SARS-CoV2 mRNA or vector vaccine
  42. Neopterin level can be measured by intraocular liquid biopsy
  43. The stability of pleural fluid pH under slushed ice and room temperature conditions
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