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A quality control procedure for central venous blood sampling based on potassium concentrations

  • Lingli Wang ORCID logo , Xiaomei Zhang , Yi Qin EMAIL logo , Feng Wang , Ming Cui , Yingjuan Shi and Yu Chen
Published/Copyright: December 21, 2023
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Journal of Laboratory Medicine
From the journal Journal of Laboratory Medicine Volume 48 Issue 1

Abstract

Objectives

To evaluate the extent of agreement between two blood collection methods for electrolytes, central venous blood sampling by the push-pull technique versus venipuncture, and to mitigate errors in blood sampling by a potassium-based quality control procedure.

Methods

A comparative within-subject study was carried out for adult patients in the intensive care unit. Intraclass correlation coefficients (ICCs) were used to estimate concordance, and Bland–Altman analysis and clinically acceptable limits were used to compare the equivalence of the two methods. An in-house checklist was designed to identify errors made by nurses throughout central venous blood sampling by the push-pull technique, the corrective training and quality control procedure were conducted, and the rate of errors, incidence of hemolysis and distribution of potassium concentrations were comparatively analyzed for the quality of central venous blood sampling before and after the quality control procedure.

Results

All the ICCs of 220 paired blood samples displayed excellent reliability, except for potassium. Most of the electrolyte variables were within the clinically acceptable limits, and the results showed that the potassium concentrations did not seem to sufficiently affect clinical decision-making. A total of 30 nurses accepted 90 observations before and after the quality control procedure, and the results showed that blood exposure and repeated disconnections of the line in the push-pull technique were always the main problems throughout the process of central venous blood sampling. In addition, after improvement, the number of patients with hypokalemia or hyperkalemia tended to decrease, but the difference was not statistically significant. For all of the blood samples, only three push-pull paired samples received hemolysis notice.

Conclusions

Central venous blood sampling by the push-pull technique could be an acceptable substitute for most electrolytes via venipuncture, but caution should be exercised for potassium-based quality control procedures.

Keywords: push-pull technique; central venous blood sampling; potassium concentrations; quality improvement

Introduction

In the intensive care unit, a central venous catheter (CVC) allows for painless and convenient access for blood collection, and blood collection via a CVC has been considered an acceptable procedure in the clinic.

According to the existing reports, the technique for blood sampling from a CVC mainly included the reinfusion technique, discard technique and push–pull technique. As expected, every method has its own advantages and disadvantages, and the best strategy for blood sampling has not been confirmed. The reinfusion technique has been deprecated due to the risk of pollution and thrombosis. The discard technique is currently a recognized technique to withdraw blood samples from a CVC [1, 2]; it usually requires a volume of blood to be discarded, which is obviously inconsistent with the view of “reducing blood loss during blood collection” advocated in most literature [3]. Unlike the discard technique, the push-pull technique is a “zero blood loss” technique, which aspirates and returns 4–6 mL blood and repeats it for 3 to 5 cycles [4, 5]. A study conducted by Byrne compared the feasibility of the discard blood sampling method for central vascular access devices with the push-pull technique in 21 measurement laboratories. The results of this study showed that either technique was within clinically acceptable ranges, and no hemolysis was noted in 61 paired samples [6]. Some studies have demonstrated that the push-pull technique has more advantages in reducing blood wastage, but there are still many inconsistencies in details. It is more important to establish a standardized blood sampling procedure to further mine the role and potential benefits of the push-pull technique.

In our previous research, we refined the specific steps and details of the push-pull technique for central venous blood sampling from a CVC [7]. This protocol clarified a 6-mL withdrawal and return volume and four push-pull cycles, and the speed and duration of each cycle were also refined. In addition, according to nursing practice in China, we developed the push-pull technique using a needle-free connector. The results of this study demonstrated that blood samples collected from a CVC by the push-pull technique were acceptable for coagulation and hematologic laboratory tests. In other words, although the details of the push-pull technique vary by study, the applicability of each procedure for obtaining blood samples from a CVC is widely confirmed.

Electrolyte detection is an important clinical test to evaluate changes in patient conditions, assist in clinical diagnosis, and monitor treatment effects, especially for ICU patients. Previous results showed that the push-pull technique could be a better alternative method to discard technique or venipuncture for central venous blood collection, but these results were still limited in terms of both the number of references and sample size. Moreover, a study found that the potassium concentration in electrolytes could reflect the quality of phlebotomy technique services [8]. A continuous phlebotomy quality monitoring program based on potassium concentrations improved patient safety and decreased cost and critical value alerts [9]. However, few studies have focused on continuous quality monitoring of the central venous blood collection process, so whether the potassium concentration could be applied to evaluate the quality of central venous blood collection is worth exploring.

Objectives

In this study, we attempted to create a quality control procedure for the previous protocol. The study was conducted in three phases: (1) a comparative within-subject study was designed to demonstrate the equivalence of the push-pull technique and venipuncture for electrolytes; (2) an observation study was conducted to identify the errors made by nurses in the central venous blood sampling procedure; and (3) a comparative study on pre- and post-quality improvement was conducted to evaluate the quality of central venous blood sampling based on potassium concentrations.

Patients and methods

Phase 1: a comparative within-subject study

In Phase 1, our hypothesis was that the push-pull technique is a suitable method for electrolyte testing via central venous blood sampling, and its results are equivalent to those of venous blood sampling.

The patients were enrolled from ICUs in the Affiliated Hospital of Nantong University. We included adult patients with a CVC (14/18-gauge double lumen or 16-gauge single lumen). Exclusion criteria: (1) less than 18 years old, (2) patients with a malfunctioning catheter, (3) suspected central venous catheter-related bloodstream infection, (4) continuous infusion of drugs that cannot be interrupted, and (5) patients who refused to participate. All patients or their families signed informed consent.

Blood collection

In this study, the previously published scheme was used to obtain blood samples from a CVC through the push-pull technique [7]. Samples were obtained from the 16-gauge single lumen CVC or the proximal lumen (18-gauge) of the double-lumen CVC after stopping the infusion solutions for 2 min. Prepare a prefilled 20-mL 0.9 % sodium chloride syringe, an empty syringe and a blood transfer device, and connect them together with a 3-way stopcock (BD Connecta). A volume of 10 mL 0.9 % sodium chloride was used to flush the lumen according to the protocol. Then, a 6 mL blood volume was aspirated and returned using the empty 20-mL syringe, a push-pull cycle lasted for 15 s and performed 4 cycles. Finally, blood samples were transferred to the lab tube using the blood transfer device, and then the catheter was flushed or locked based on need or reconnected infusion. Notably, the needleless connector needed to be removed before blood collection and finally replaced with a new connector according to the local recommendation in China.

After the implementation of the above protocol, paired blood samples were collected by direct venous puncture using a 0.7*25 mm needle (WEGO, China). Blood sampling via venipuncture was still performed according to the regular procedure of our hospital. The first step was to choose an appropriate vein, which was usually a superficial vein located on the body surface and not in the infusion state, then disinfected around the puncture point and waited for drying. The second step was to tie a tourniquet approximately 6 cm above the puncture site and disinfect again. The last step was to puncture for blood collection, then loosen the tourniquet, and press the puncturing spot after needle withdrawal for 5–10 min.

We established a project team, including a director of the nursing department, who was responsible for overall quality control, a chief nurse who was responsible for the training for the implementation of the project, and a chief physician of the laboratory department who was responsible for technical guidance and support.

In January 2022, 30 nurses from five ICUs received training about the blood collection protocol and were appraised by a trained specialist (corresponding author). From February 2022 to April 2022, the protocol was carried out by trained nurses in shifts, and a total of 220 paired blood samples were obtained from 182 patients.

Phase 2: an observation study

We designed a checklist for our protocol by drawing lessons from the guidelines for venous specimens and combining them with observations made in our hospital. The observation checklist consisted of 26 observation items and was divided into 3 parts: pre-sampling phase, sampling phase and post-sampling.

From May 2022 to July 2022, a three-month observation period was carried out by two trained staff members using the checklist (first and corresponding author of this paper). The observation was unannounced and occurred actively in the field, and each nurse was observed monthly at least three times within the period. The nurses involved in the first phase were observed 90 times altogether.

Phase 3: a comparative study on pre-and post-quality improvement

In Phase 3, our hypothesis was that the degree of deviation in potassium values could function as the quality evaluation index of central venous blood sampling by the push-pull technique.

Based on the results of the checklist in phase 2, corrective training was implemented, and a quality control procedure was conducted. From August 2022 to October 2022, the push-pull technique protocol was performed again. In this phase, we used the same exclusion and inclusion standards as the first phase. Blood samples were only collected via CVCs by the push-pull technique and analyzed for potassium concentration. If the patient had potassium values >5.1 mmol/L but no apparent clinical justification, the doctor needed to evaluate the patient further on whether to redraw venous blood samples. A total of 196 blood samples for electrolyte analysis were obtained from 156 patients, and the same nurses were observed for a total of 90 observations.

In this study, electrolytes tested included potassium, sodium, chlorine, calcium, phosphorus and magnesium, and blood was stored in a separating gel vacuum tube (Suzhou Lingyan medical technology Co., Ltd, China). The blood samples were transported by dedicated personnel and tested in the same laboratory by the Beckman Coulter AU5800 analyzer (Beckman Coulter, Inc, USA). Beckman Coulter AU5800 analyzer determines serum indices spectrophotometrically to obtain the approximate concentration of hemoglobin, thereby labeling the hemolytic index level of the serum. The results express as qualitative data in six categories (from normal to 5+), the cut-off value for classification of the sample as hemolyzed (1+) is 500 mg/L Hb. If it is necessary to collect blood samples again, the nurse will be informed.

Statistical analysis

Statistical analysis was performed using SPSS 25.0 and MedCalc software version 20.1.15. The Kolmogorov‒Smirnov test was used to assess the normality of distribution. Measurement data were expressed as the mean with standard deviation (SD) or median with range, and enumeration data were expressed as frequency and percentages. The ICCs were used to estimate the concordance of the two methods. Bland‒Altman analysis was used to analyze the differences in electrolytes between the two methods in blood samples. T tests and chi-square tests were used to compare the differences among groups. Differences for which p<0.05 were considered significant.

In our study, the clinically acceptable limit (CAL) of blood indices was defined by the Quality Evaluation Standards for Clinical Laboratory Centers of the National Health Commission by the in China (2021). The normal value range of each indicator was defined by the institution; for example, the normal range of potassium concentration was defined as 3.5–5.1 mmol/L, over 5.1 mmol/L as hyperkalemia and below 3.5 mmol/L as hypokalemia. Significantly, test results via venipuncture were the gold standard in this study; if the diagnosis from central venous blood sampling was consistent with venous blood sampling, it can be considered that central venous blood sampling would not affect clinical decision making.

Ethical considerations

The study was approved by the Ethics Committee of the hospital.

Results

A total of 30 nurses participated in this study; 182 patients were enrolled in phase one and 156 in phase three. The demographic characteristics of the patients are presented in Table 1. In these two phases, in both sexes, the ratios of 14/18-gauge double lumen were both more than 80 percent, and there was no difference in age, sex, department or CVC type.

Table 1:

The demographic data of the patients in phase 1 and phase 3.

Variables Phase 1 (n=182) Phase 3 (n=156) p-Value
Age (Mean ± SD, year) 65.93 ± 14.64 65.09 ± 16.28 0.621a
Sex, n (%)
 Male 122 (67.0) 100 (64.1) 0.572b
 Female 60 (33.0) 56 (35.9)
Department, n (%)
 ICU 55 (30.2) 49 (31.4) 0.263b
 EICU 42 (23.1) 45 (28.8)
 NICU 35 (19.2) 17 (10.9)
 RICU 24 (13.2) 24 (15.4)
 CCU 26 (14.3) 21 (13.5)
CVC types, n (%)
 14/18-gauge double lumen 157 (86.3) 138 (88.5) 0.546b
 16-gauge single lumen 25 (13.7) 18 (11.5)

  1. at-test; bChi-square test.

In phase 1, three push-pull samples from a CVC were informed of hemolysis, and 220 paired blood samples were obtained from 182 patients for electrolyte testing. The difference between two sets of data showed a nonnormal distribution in the Kolmogorov‒Smirnov test. Table 2 shows the result of the ICCs and Bland‒Altman analysis of 220 paired blood samples. All the ICCs were above 0.90, indicating excellent reliability between the techniques. The Bland‒Altman plots showed that the upper and lower limits of the 95 % LOAs were within the clinically acceptable limits of most of the variables of electrolytes except potassium, confirming that the push-pull technique was clinically acceptable during central venous blood sampling for electrolytes, with good agreement compared to venipuncture (Figure 1). In addition, although the potassium concentration was not within the clinically acceptable limit, there was no statistical significance in clinical decision-making (p=0.332).

Table 2:

Summary of ICC and Bland‒Altman Analysis for 220 paired blood samples.

Variables ICC Ratio means Lower 95 % LoA (95 % CI) Upper 95 % LoA (95 % CI) Clinically acceptable limit (CAL)
Potassium 0.951 1.014 0.936 (0.927–0.945) 1.098 (1.088–1.108) ±6 %
Sodium 0.962 0.999 0.978 (0.976–0.981) 1.020 (1.017–1.022) ±4 %
Chlorine 0.981 1.000 0.981 (0.978–0.983) 1.020 (1.018–1.022) ±4 %
Calcium 0.973 1.004 0.971 (0.967–0.975) 1.039 (1.035–1.043) ±5 %
Phosphorus 0.993 1.002 0.935(0.927–0.942) 1.074 (1.066–1.083) ±10 %
Magnesium 0.969 1.008 0.941 (0.934–0.949) 1.080 (1.071–1.088) ±15 %
Figure 1: The Bland‒Altman plots of electrolyte.
Figure 1:

The Bland‒Altman plots of electrolyte.

Table 3 showed the compliance with the checklist. Only when the blood collection behavior meets the standards needed in the checklist is the results recorded as “Yes”; otherwise, they are recorded as “No”. In all items, whether before or after quality improvement, the proportions of item 19 “was a blood transfer device used to avoid blood exposure?” and item 11 “was a 3-way stopcock used to avoid multiple disconnection of the line?” were low. These results also meant that blood exposure and repeated disconnections of the line have been the main problems in central venous blood sampling.

Table 3:

The results of observation checklist for push-pull technique in phase 1 and phase 3 (n=90).

Phase 1 Phase 3
Yes, % No, % Yes, % No, %
Pre-sampling 1. Was the patient identity confirmed? 96.7 3.3 100 0.0
2. Was the patient fully prepared? 94.4 5.6 93.3 6.7
3. Was the catheter preliminarily assessed? 77.8 22.2 83.3 16.7
4. Whether the infusion solutions have been stopped for 2 min? 93.3 6.7 95.6 4.4
5. Was the correct hand hygiene performed? 91.1 8.9 91.1 8.9
6. Were sterile gloves put on timely? 80.0 20.0 82.2 17.8
7. Was a treatment towel used? 65.6 34.4 68.9 31.1
Sampling 8. Did the removed infusion tube remain sterile? 90.0 10.0 94.4 5.6
9. Was the needleless connector removed? 78.9 21.1 88.9 11.1
10. Were the steps of disinfection correctly? 84.4 15.6 85.6 14.4
11. Was a 3-way stopcock used to avoid multiple disconnection of the line? 6.7 93.3 27.8 72.2
12. Was the lumen flushed with 10 mL of saline? 92.2 7.8 93.3 6.7
13. Was the of patency of catheter confirmed effectively? 61.1 38.9 61.1 38.9
14. Was a volume of withdraw and return at least 6 mL 68.9 31.1 78.9 21.1
15. Was the intensity of each push-pull cycle performed properly? 78.9 21.1 84.4 15.6
16. Was the speed of each push-pull cycle performed properly? 73.3 26.7 83.3 16.7
17. Was the time of each push-pull cycle performed properly? 65.6 34.4 80.0 20.0
18. Was the push-pull cycle repeated at least 4 times? 91.1 8.9 83.3 16.7
19. Was a blood transfer device used to avoid blood exposure? 3.3 96.7 20.0 80.0
20. Were the blood tubes filled properly? 91.1 8.9 91.1 8.9
21. Were the blood tubes mixed immediately after sampling? 86.7 13.3 90.0 10.0
Post-sampling 22. Was the lumen flushed or locked correctly after sampling? 88.9 11.1 90.0 10.0
23. Was the tube connection disinfected again properly after sampling? 83.3 16.7 85.6 14.4
24. Was a new needleless connector attached? 55.6 44.4 62.2 37.8
25. Was the correct hand hygiene performed after sampling? 91.1 8.9 90.0 10.0
26. Was the medical waste disposed correctly? 95.6 4.4 97.8 2.2

  1. The item #1 the patient identity must be correct, once mistakes are found, they must be corrected, and the procedure must restart. Only the blood collection behavior reached the required standard in the checklist, results were recorded as “Yes”, otherwise recorded as “No”.

After the implementation of quality improvement, the number of patients with hypokalemia or hyperkalemia had a decreasing trend, but the difference was not statistically significant. The incidence of hemolysis also tended to decrease, no hemolysis observed in the blood samples in phase 3 (Table 4).

Table 4:

The distribution of potassium concentration in phase 1 and phase 3.

Variables Phase 1 p-Value Phase 3 p-Value
Venous blood sampling Central venous blood sampling Central venous blood sampling
Hemolysis, n 0 3 0

0.923b
Hyperkalemia, n (%) 3 (1.4) 3 (1.4) 0.332a 2 (1.0)
Hypokalemia, n (%) 34 (15.5) 46(20.9) 43 (21.9)
Normal value, n (%) 183 (83.2) 171 (77.7) 151 (77.0)

  1. aRepresented venous blood sampling vs. central venous blood sampling in the phase 1. bRepresented central venous blood sampling in the phase 3 vs. central venous blood sampling in phase 1.

Discussions

Critically ill patients often require repeated blood sample collection throughout disease treatment. At present, the venipuncture method is the conventional technology used to draw blood samples in China [10]; however, it may damage blood vessels and surrounding tissues and cause subcutaneous hematoma and other complications. For elderly individuals, obese individuals, those with anemia, those with poor vascular conditions and those with poor cooperation ability, the risk of blood collection through peripheral puncture may be greater [11]. If the test results of blood samples collected by CVCs are consistent with those obtained by peripheral vein puncture, it represents a good choice for the patients.

The results of our study confirmed that the push-pull technique was clinically acceptable for most values of electrolytes except potassium in samples obtained from CVCs, which was inconsistent with some reported results. Currently, most studies take the discard method as the gold standard. Compared to standard samples, the push-pull technique can be used for the determination of potassium concentration [4, 5, 12]. Only one study reported that the pull-push technique could replace venipuncture for potassium concentration from central venous blood sampling [13]. The results of our study also showed that central venous blood sampling had no significant effect on clinical decision-making based on the potassium concentration. From another perspective, although differences showed in in the details of the push-pull technique, study population and statistical method in the reported literature, the conclusions drawn from these studies are of great benefit to future research, and we need to try to improve it and seek the best strategy for central venous blood sampling.

To date, blood exposure and repeated disconnections of the line are still serious problems in central venous blood collection in our institution, which is related to many factors. First, nurses’ professional knowledge is not comprehensive enough. Second, taking into account the cost, some nurses stubbornly refused to use the 3-way stopcock and blood transfer device. Third, the lack of a local guidance document is also a key problem. Therefore, it is important to establish a local standardized policy for central venous blood sampling. More importantly, central venous blood sampling should not be advocated blindly in clinical practice, and health professionals should decide whether CVC blood specimen collection is needed and beneficial to the patients according to professional judgment and personal capability and even the economic cost and cost regarding time.

Potassium was an important monitoring index of ICU patients, which was considered to relate to the draw technique of phlebotomists in previous studies [8]. Based on this, our study initially tried to construct an improved scheme of the push-pull technique procedure of central venous blood sampling based on potassium concentration. After the implementation of corrective training and quality control procedures, there was no significant difference in potassium concentration (3.80 vs. 3.85, p=0.493), same to the distribution of potassium concentrations and hemolysis. In a similar study, a potassium-based quality of service was carried out for the phlebotomy technique, the study found that potassium concentrations tended to be normal, and the percentage of hyperkalemia and hemolyzed samples decreased [9].

Therefore, although we are still trying to figure out how to evaluate the quality of blood samples through objective data, the result seemed not optimistic, which may be related to several limitations of the study. At the level of preanalysis, transport, centrifugation and storage prior to analysis have not been considered [14, 15]. At the nurse level, the neglected time covariant factor disrupted the confirmation of the training effect. At the statistical level, the lack of an estimated study size based on potassium may also be a factor.

Limitations and recommendations for further research

First, our study subjects were only ICU patients, and whether the results of this study can be extended to other patients should be further studied. Second, due to a lack of standardized documentation or procedures of the push-pull technique for central venous blood sampling, this protocol was only implemented in our institution, and the results need to be followed up with a multicenter study for verification. Third, there were still many defects in this study, and the occurrence of hemolysis was only based on laboratory notice; the hemolytic indices have not been fully utilized. In addition, other preanalytical factors have not been considered, which led to the need for careful interpretation of the results.

Conclusions

This study revealed that the push-pull technique could be used for most electrolyte tests via central venous blood sampling, but whether the quality of improvement of central venous blood sampling should be based on potassium concentration is worth further research and exploration. In addition, future research can improve and perfect improvement projects from all angles, such as transport, centrifugation, storage, etc.

Corresponding author: Yi Qin, Department of Nursing, Affiliated Hospital of Nantong University, Nantong, Jiangsu, P.R. China, E-mail:
Lingli Wang and Xiaomei Zhang contributed equally to this work and should be regarded as co-first authors.

Funding source: Affiliated Hospital of Nantong University

Award Identifier / Grant number: Tfh2201

Funding source: Nantong Basic Research and People’s Livelihood Science and Technology Program Mandatory Project in 2022

Award Identifier / Grant number: JC22022092

Acknowledgments

We would like to express gratitude to all the staff for the preparation of this research.

  1. Research ethics: The project was approved by the Human Research Ethics Committee, and informed consent was obtained from each patient (2021-K070-01).

  2. Informed consent: Informed consent was obtained from all patients and their families.

  3. Author contributions: All authors confirmed the significant contributions to the design, analysis and interpretation of data, draft and revise the article.

  4. Competing interests: The authors state no conflict of interest.

  5. Research funding: This work was supported by the Nantong Basic Research and People’s Livelihood Science and Technology Program Mandatory Project in 2022 (No JC22022092), and also supported by a grant form Affiliated Hospital of Nantong University (No Tfh2201).

  6. Data availability: Data available on request from the authors.

References

1. Dalton, KA, Aucoin, J, Meyer, B. Obtaining coagulation blood samples from central venous access devices: a review of the literature. Clin J Oncol Nurs 2015;19:418–23. https://doi.org/10.1188/15.cjon.19-04ap.Search in Google Scholar

2. Winokur, EJ, Pai, D, Rutledge, DN, Vogel, K, Al-Majid, S, Marshall, C, et al.. Blood culture accuracy: discards from central venous catheters in pediatric oncology patients in the emergency department. J Emerg Nurs 2014;40:323–9. https://doi.org/10.1016/j.jen.2013.04.007.Search in Google Scholar PubMed

3. Matzek, LJ, LeMahieu, AM, Madde, NR, Johanns, DP, Karon, B, Kor, DJ, et al.. A contemporary analysis of phlebotomy and iatrogenic anemia development throughout hospitalization in critically ill adults. Anesth Analg 2022;135:501–10. https://doi.org/10.1213/ane.0000000000006127.Search in Google Scholar PubMed PubMed Central

4. Hess, S, Decker, M. Comparison of the single-syringe push-pull technique with the discard technique for obtaining blood samples from pediatric central venous access devices. J Pediatr Oncol Nurs 2017;34:381–6. https://doi.org/10.1177/1043454217713453.Search in Google Scholar PubMed

5. McBride, C, Miller-Hoover, S, Proudfoot, JA. A standard push-pull protocol for waste-free sampling in the pediatric intensive care unit. J Infusion Nurs 2018;41:189–97. https://doi.org/10.1097/nan.0000000000000279.Search in Google Scholar

6. Byrne, D. Comparing the push-pull versus discard blood sample method from adult central vascular access devices. J Infusion Nurs 2016;39:130–5. https://doi.org/10.1097/nan.0000000000000167.Search in Google Scholar

7. Wang, L, Zhang, X, Qin, Y, Wang, F, Cui, M, Shi, Y, et al.. A comparative study on coagulation and hematologic laboratory techniques for blood sampling using the push-pull method from a CVC versus venipuncture. J Vasc Access 2022;929314070. https://doi.org/10.1177/11297298221118742.Search in Google Scholar PubMed

8. Greenblatt, MB, Torre, M, Means, J, Tanasijevic, M, Vitale, PL, Bunnell, CA, et al.. Use of potassium concentrations as a quality-of-service metric for phlebotomists detects systematic preanalytical biases and facilitates their correction. Clin Chem 2014;60:1453–5. https://doi.org/10.1373/clinchem.2014.227686.Search in Google Scholar PubMed

9. Lucas, F, Mata, DA, Greenblatt, MB, Means, J, Jarolim, P. A potassium-based quality-of-service metric reduces phlebotomy errors, resulting in improved patient safety and decreased cost. Am J Clin Pathol 2022;157:789–98. https://doi.org/10.1093/ajcp/aqab194.Search in Google Scholar PubMed

10. Cai, Q, Zhou, Y, Yang, D. Nurses’ knowledge on phlebotomy in tertiary hospitals in China: a cross-sectional multicentric survey. Biochem Med 2018;28:10703. https://doi.org/10.11613/bm.2018.010703.Search in Google Scholar PubMed PubMed Central

11. Xiong, X, Xiong, Y, Liu, G. Systematic review and meta-analysis: safety of ultrasound-guided peripheral venipuncture and catheterization. Ann Palliat Med 2021;10:11721–32. https://doi.org/10.21037/apm-21-3163.Search in Google Scholar PubMed

12. Adlard, K. Examining the push-pull method of blood sampling from central venous access devices. J Pediatr Oncol Nurs 2008;25:200–7. https://doi.org/10.1177/1043454208320975.Search in Google Scholar PubMed

13. Lokeskrawee, T, Muengtaweepongsa, S, Patumanond, J, Sawaengrat, C. Accuracy of laboratory tests drawn by pull-push method from central venous catheterization after routine flushing with 10 ml normal saline in patients with sepsis at the emergency department. Heliyon 2021;7:e7355. https://doi.org/10.1016/j.heliyon.2021.e07355.Search in Google Scholar PubMed PubMed Central

14. Sciacovelli, L, Panteghini, M, Lippi, G, Sumarac, Z, Cadamuro, J, Galoro, C, et al.. Defining a roadmap for harmonizing quality indicators in laboratory medicine: a consensus statement on behalf of the IFCC Working Group “laboratory error and patient safety” and EFLM Task and Finish Group “performance specifications for the extra-analytical phases”. Clin Chem Lab Med 2017;55:1478–88. https://doi.org/10.1515/cclm-2017-0412.Search in Google Scholar PubMed

15. Mrazek, C, Lippi, G, Keppel, MH, Felder, TK, Oberkofler, H, Haschke-Becher, E, et al.. Errors within the total laboratory testing process, from test selection to medical decision-making – a review of causes, consequences, surveillance and solutions. Biochem Med 2020;30:20502. https://doi.org/10.11613/BM.2020.020502.Search in Google Scholar PubMed PubMed Central

Received: 2023-07-14
Accepted: 2023-11-21
Published Online: 2023-12-21
Published in Print: 2024-02-26

© 2023 the author(s), published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. Editorial to: German Society for Clinical Chemistry and Laboratory Medicine – areas of expertise – division reports from the German Congress of Laboratory Medicine 2022 in Mannheim, 13–14 October 2022
  4. Report
  5. German Society for Clinical Chemistry and Laboratory Medicine – areas of expertise: Division reports from the German Congress of Laboratory Medicine 2022 in Mannheim, 13–14 October 2022
  6. Original Articles
  7. Impact and frequency of IV fluid contamination on basic metabolic panel results using quality metrics
  8. A quality control procedure for central venous blood sampling based on potassium concentrations
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https://doi.org/10.1515/labmed-2023-0084
Keywords for this article
push-pull technique; central venous blood sampling; potassium concentrations; quality improvement
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Articles in the same Issue

  1. Frontmatter
  2. Editorial
  3. Editorial to: German Society for Clinical Chemistry and Laboratory Medicine – areas of expertise – division reports from the German Congress of Laboratory Medicine 2022 in Mannheim, 13–14 October 2022
  4. Report
  5. German Society for Clinical Chemistry and Laboratory Medicine – areas of expertise: Division reports from the German Congress of Laboratory Medicine 2022 in Mannheim, 13–14 October 2022
  6. Original Articles
  7. Impact and frequency of IV fluid contamination on basic metabolic panel results using quality metrics
  8. A quality control procedure for central venous blood sampling based on potassium concentrations
  9. Establishment of high-sensitivity cardiac troponin I reference interval for a hospitalized paediatric population under improved selection criteria in the Shandong area
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