Investigation of the preanalytical process practices in primary care in Istanbul regarding the newborn screening tests

Objectives

This descriptive study was conducted to evaluate the practices and knowledge levels of midwives and nurses regarding dried blood spot samples in the preanalytical phase.

The questions expected to be answered in the research are;

1. What preparations do midwives and nurses make for neonatal heel prick blood sampling?

2. How are the midwives’ and nurses’ heel prick blood sampling practices?

3. How do midwives and nurses practice drying and transport in the heel prick blood sampling process?

4. Do the heel prick blood sampling practices of midwives and nurses differ according to their characteristics?

Population and sampling

The study population consisted of 360 midwives and nurses working in Family Health Centers in three districts on the European side of Istanbul, Turkey. The total number of family health centers in the districts included in the study was 90, and an average of four midwives or nurses work in each center. The sample of the study consisted of 233 participants (midwives and nurses) who were on duty on the days of data collection and submitted written consent forms about their willingness to participate in the study. Of the 127 people not included in the study, only 12 did not agree to participate. The entire population could not be reached since the study coincided with the summer period and with the annual leave periods, and each family health center was visited once. The participation rate in the study was 64.7%.

Data collection tools

The research data were collected using the “information form” prepared by the researchers and the “Preanalytical Phase Evaluation Form (PPEF)” prepared for dried blood spot sampling. The information form was a tool consisting of six questions (gender, age, professional education status) that evaluated the socio-demographic characteristics of the midwives and nurses participating in the study.

PPEF was prepared in accordance with the literature [7, 12], [13], [14], [15], [16], [17], [18], [19], [20] and consisted of 21 dichotomous items (yes/no questions) to evaluate the preanalytical phase practices of dried blood spot sampling of midwives and nurses. The correct answer for seven of the 21 items was “no”, while the correct answer for 14 of them was “yes”. The items with the correct answer “yes” (items; 1, 2, 4, 5, 6, 7, 8, 9, 12, 15, 17, 18, 20, 21) included taking comfort measures for the newborn before blood sampling, wearing gloves, drying the heel, warming the heel, cleaning the heel with 70% alcohol, waiting to dry, pricking and wiping the first blood, using the side of the heel, soaking the blood evenly on the circles, filling all the circles, applying pressure on the incision site with a compress, drying cards (4 h) sending the cards to the laboratory on the same day or within 3 days and storing them in the fridge. On the other hand, the items with the correct answer “no” (items; 3, 10, 11, 13, 14, 16, 19) included keeping the heel above the heart level, squeezing the heel and applying blood drops to the same circle more than once, using both sides of the card, applying blood by using a tool (syringe or hematocrit tube) keeping the heel below the heart level after taking the blood, and keeping the dried cards unaffected by heat (Table 1).

In the PPEF evaluation, each item with a correct answer was scored as 1, and each item with an incorrect answer was scored as 0. The lowest score that could be obtained from the items was zero, and the highest score was 21. The increase in the score shows that the preanalytical phase applications of dried blood spot sampling were suitable (Table 1).

Implementation of data collection tools

The researcher visited each family health center within the scope of the study. After giving information about the research topic, midwives and nurses were requested to fill in the forms in their working environment. Participants often filled in the forms in their leisure time (at lunch breaks) when they felt comfortable, and the same researcher collected the forms during working hours. The questionnaires took about 10–15 minute to complete. Each family health center was visited only once, and no repeat visits were made to meet employees who were not in the institution that day.

Statistical analysis

SPSS 22.0 [Statistical Package for the Social Sciences] software was used for data analysis. The participants’ socio-demographic characteristics and responses to each item in PPEF were assessed using frequency, percentage, total score, mean and standard deviation. Shapiro-Wilk verified the conformity of data with normal distribution. Since the data were not normally distributed, the Mann Whitney-U test was used to analyze the differences in PPEF scores according to the participant’s age and status of being a midwife or nurse, while the Kruskal Wallis chi-square test was used to examine the differences according to years of work experience and educational level. The significance level was determined as p<0.05.

Ethical aspect of the research

The research was carried out by considering scientific and universal ethical principles. The study was explained to each midwife and nurse invited to participate. They were told that they could freely participate in the study and terminate it whenever they wanted, and their written informed consent was obtained. Before the research started, approval was obtained from the clinical research ethics committee (Istanbul University-Cerrahpaşa Ethical Board Approval No: 88508) and each institution where the study was conducted.

What preparations do midwives and nurses make for neonatal heel prick blood sampling?

Good practices stated by the majority of the participants in the preparation phase of the blood collection technique: wearing gloves before taking blood (92.7%), ensuring that the heel is completely dry before taking blood (79.4%), 70% isopropyl alcohol should be used as an antiseptic to clean the heel before taking blood (75.1%) (Table 1). At this stage, only 61.8% of the participants reported that they warmed the heel before taking blood, and 43.3% of them informed the mother about different methods for the comfort of the baby and to support the baby (Table 1).

How are the midwives and nurses’ heel prick blood sampling practices?

The practices determined to be correct by the majority of the participants during the blood sample collection process were taking blood from the lateral region of the heel (90.6%), not using any tools for absorption (85.8–84.5%), applying blood dripping from the heel directly to the paper (80.7%) and wiping the first blood flow with sterile gauze (73.8%). The most common practices determined to be performed incorrectly by the participants during the blood collection process were squeezing the heel for a while and keeping it filling the same circle (56.2%) and keeping the heel above the heart level during blood collection (53.6%) (Table 1).

How do midwives and nurses practice drying and transport in the heel prick blood sampling process?

In the process of drying and sending dried blood spot samples, the practices determined to be performed correctly by the majority of midwives and nurses were that 90.6% of them dried their filter cards at room temperature for at least 4 hours and 70% of them sent their dried blood spot cards to the laboratory within the same day or three days at the latest (Table 1). The most common practice determined to be performed incorrectly was that 46.4% of them did not keep dried blood spot samples, which were not sent to the laboratory on the same day, in the fridge (Table 1).

Do the heel prick blood sampling practices of midwives and nurses differ according to their characteristics?

The mean total PPEF score of the participants was 14.64 ± 3.40 (min–max = 6–20; Table 1). When the difference between the PPEF mean scores of the participants according to their age groups was examined, it was seen that there was a statistically significant difference. It was found that the mean PPEF scores of those aged between 31 and 56 (16.22 ± 2.46) were higher than those in the age range of 18–30 (13.29 ± 3.51) (Table 2).

Mean PPEF scores of the participants with a working period of 16 years or more (17.03 ± 1.87) were significantly higher than the ones with a working period of 1–5 years (13.30 ± 3.73), of 6–10 years (14.19 ± 3.22) and 11–15 years (15.97 ± 2.21) (Table 2).

There was a significant difference between the mean PPEF scores of the midwives and nurses who were graduates of undergraduate studies (15.96 ± 2.75), graduate studies (15.89 ± 2.93), associate degree studies (14.98 ± 2.79) and health vocational high school studies (12.88 ± 3.67). The scores of health vocational high school graduates were significantly lower (Table 2). In the study, the PPEF scores of midwife participants (15.71 ± 2.96) were significantly higher than nurse participants (13.57 ± 3.54) (Table 2). A statistically significant difference was found between the PPEF scores of the participating midwives and nurses according to their training status on the heel prick technique. The scores of those who did not receive training (16.61 ± 1.79) were found to be significantly higher than those who received training (14.27 ± 3.50) (Table 2).

What preparations do midwives and nurses make for neonatal heel prick blood sampling?

One thing which is ignored by the majority of midwives and nurses regarding the preparation phase of blood sampling is pain management which is critical for mothers and babies. Piercing the heel with a lancet is a painful, invasive procedure for the newborn. Therefore, to reduce/prevent pain before blood is drawn, the mother/caregiver should be supported and informed about comfort measures such as loose swaddling, skin contact, therapeutic touch [23, 24], encouraging the mother to breastfeed or administering a dose of sucrose [19, 24, 25]. It is essential to raise the awareness of midwives and nurses regarding pain management during dry blood spot sampling.

The second practice ignored by midwives and nurses during the blood sampling process is warming the heel from which blood will be drawn. It is recommended that the newborn’s heel be warmed with a warm and moist towel (max: 42 °C) by hand or using booties before blood is drawn [7, 16, 24]. Since poor circulation in a cold heel causes inaccurate sampling [7, 16, 24]. It can be argued that this malpractice stems from the fact that the participants did not have sufficient knowledge of the topic, their workload or their disbelief in the necessity of this practice.

The research revealed that the third error midwives and nurses made during the preparation phase were not paying attention to the dryness of the area, which may affect the quality of the analyte in the blood sample, and not cleaning the skin with 70% alcohol. Especially, after the skin is cleaned, taking samples before the area dries up may disrupt the concentration of the analyte on the card, resulting in erroneous results. The guidelines recommend that the heel of the newborn should be dry to prevent infection and contamination [8, 10, 12, 24, 26], and the area from which blood will be collected should be cleaned with 70% isopropyl alcohol [24].

In accordance with this result, it can be argued that the health staff responsible for the dry blood spot sampling lacked skin preparation knowledge, hence making errors.

How are the midwives and nurses’ heel prick blood sampling practices?

It was determined that 36.1–56.2% of midwives and nurses performed practices that could lead to deterioration of analyte concentration during heel blood sampling (items 10, 11).

A significant percentage of midwives and nurses do not pay attention to the fact that the blood is spread symmetrically and evenly on both sides of the filter paper (item 9) and that the printed circles are suitably filled with blood (item 12) during the heel blood sampling process. However, since insufficient blood samples can lead to erroneous results [10], the blood sample should be soaked into all the circles (5 circles) so that it covers the entire printed circle on the filter card and an equal size blood spot is observed on both sides of the card [7, 17].

Among the blood sampling errors made by the midwives and nurses participating in the research are squeezing the heel and using the blood to fill the same circle, and soaking both sides of the card. These practices may result in the hemolysis of blood samples (item 10), double layering (items 10, 11) multi-spotted samples (items 10), and the deterioration of analyte concentration [6, 9].

In the research, it was determined that a great majority of the midwives and nurses used the sides of the heel to draw blood, they allowed the blood specimen to be absorbed by the card equally on both sides, and they filled the printed circles with the blood specimen. These results are consistent with the blood sampling practices recommended in the literature [7, 12, 14], [15], [16], [17, 26].

How do midwives and nurses practice drying and transport in the heel prick blood sampling process?

The study determined that almost all participants (90.6%) dried the cards they used for at least 4 hours and sent them to the laboratory on the same day or within three days at the latest. These results are consistent with the practices recommended in the literature [20, 26], [27], [28], [29]. However, they stated that approximately half of the midwives and nurses (46.4%) did not store the dried blood spot samples collected in their units in the fridge (item 20), instead pinned them on the panel in the unit or stored them in the box on the counter (data not shown). However, dried blood spot samples should be stored in a dry and cool place after drying [30] (Table 1).

Do the heel prick blood sampling practices of midwives and nurses differ according to their characteristics?

The mean PPEF score of the participants was found to be 14.64. Considering that a minimum score of 6 and a maximum score of 20 could be achieved on the form, it may be argued that the practices of midwives and nurses in collecting dry blood spot samples are above the medium level but insufficient. To achieve accurate results in newborn screening tests, which are vital, the blood sample must be collected correctly.

In the study, participants aged 31–56, midwives, those with longer work experience, and those who reported that they did not receive training performed significantly better practices for dry blood spot sampling. This finding could be related to experience resulting from working years and the fact that midwives are more experienced with newborns (Table 2).

Most of the midwives and nurses participating in the study (84.5%) stated that they received in-service training on the heel blood collection technique. However, it is noteworthy that the PPEF scores of those who did not receive training were higher, although the percentage of those who received training was quite high compared to those who did not. Similar results were obtained in a study, and the training provided was reported to be short-term, unsystematic, confusing, lacked theoretical information about the cause, and was only practice-based [31]. These results suggest that the content of education given to health professionals has not changed much over the years [31].