What is the best practice for emergency room blood draws?

Best Practices for Emergency Room Blood Draws

Blood draws in the emergency department should follow a standardized protocol that includes proper sterile technique, use of blood conservation devices, appropriate diversion methods, and specialized phlebotomy teams to minimize contamination rates and prevent iatrogenic anemia.

Sterile Technique and Contamination Prevention

Blood Culture Collection

• Use sterile technique for all blood cultures - Studies show sterile procedures reduce blood culture contamination (BCC) rates by up to 90% 1
• Collect blood cultures before starting antimicrobial therapy if possible without delaying treatment beyond 45 minutes 1
• Obtain at least two sets of blood cultures (aerobic and anaerobic) from separate peripheral sites 1
• Target BCC rates should be <3% (ideally <2%) through proper technique 1
• For suspected catheter-related infections, draw one set from the catheter and simultaneous peripheral cultures 1

Specific Sterile Technique Components

• Use sterile gloves when drawing blood cultures
• Perform thorough skin antisepsis
• Allow antiseptic to dry completely before venipuncture
• Avoid touching the venipuncture site after antisepsis

Blood Conservation Strategies

Reducing Iatrogenic Anemia

• Use blood conservation devices that return blood from flushing lines to patients - These reduce blood loss by approximately 25% in ICU patients 1
• Implement small volume tubes which may reduce the risk of anemia 1
• Avoid "rainbow draws" (collecting multiple tubes regardless of need) as they contribute to unnecessary blood loss and waste 2
• For arterial lines, use sodium chloride 0.9% as the flush solution to prevent sample contamination errors 1

Optimizing Blood Collection

• Discard minimal volumes (1-2 mL) when using diversion techniques to prevent contributing to iatrogenic anemia 1
• Consider bundled interventions that include blood conservation devices, which can reduce blood loss by at least 25% 1
• For patients requiring frequent blood draws, track cumulative blood loss to monitor risk for iatrogenic anemia

Specialized Personnel and Training

Phlebotomy Teams

• Utilize dedicated phlebotomy teams for blood draws when possible, as they achieve lower contamination rates than other providers 1
• Implement comprehensive training programs for all staff involved in blood collection 1
• High-intensity training programs show greater reduction in BCC rates compared to low-intensity programs 1

Education and Quality Improvement

• Provide regular feedback on contamination rates to staff
• Use multidisciplinary teams to develop blood draw protocols
• Implement regular competency assessments for all staff performing blood draws

Special Considerations for Transfusion Support

Blood Type Selection

• Use Group O RhD negative blood for women of childbearing potential (<50 years) in emergency situations 1, 3
• Use Group O RhD positive blood for adults without childbearing potential to conserve O negative supplies 1, 3
• Group-specific blood should be available within 15-20 minutes of receiving properly labeled samples 1

Major Hemorrhage Protocol

• Hospitals must have a major hemorrhage protocol that includes clinical, laboratory, and logistic responses 1
• Implement clear communication protocols between clinical areas and laboratory services 1
• Designate clear roles including team leader (senior anesthetist) and coordinator 1

Common Pitfalls and How to Avoid Them

1. Blood culture contamination - Avoid by using proper sterile technique and dedicated phlebotomy teams
2. Iatrogenic anemia - Prevent by using blood conservation devices and minimizing unnecessary draws
3. Sample contamination from arterial lines - Always use sodium chloride 0.9% as flush solution, never glucose-containing solutions 1
4. Delayed transfusion in emergencies - Have clear protocols for emergency release of blood products
5. Unnecessary blood draws - Avoid "rainbow draws" and coordinate lab tests to minimize blood volume requirements

By implementing these evidence-based practices, emergency departments can optimize blood draw procedures to improve patient outcomes, reduce complications, and enhance resource utilization.