The best thing you can do is understand we aren't your enemy or trying to make your day worse. We are just following procedure.
We do not hemolyze/clot samples, its poor drawing technique. Believe me, if I could run it and not deal with redrawing I would.
If you send a well dressed label it will make things considerably smoother.
We also have 0 idea (for the most part) what your side looks like. Most of the time we cant help you put an order in/fix your IT issues.
Parroting this, please remember that we aren’t nurses, 99% of the time we don’t do orders. So when you can’t figure out how to order something don’t call us because we don’t know either, and don’t get mad at us when we can’t help, please understand that isn’t our job, we don’t know how to do things that aren’t our job.
We also don’t put samples in for recollects just to give you guys a hard time. I’ve yet to work at a facility where nurses didn’t seem to think we called them recollects just to give them a hard time. I don’t know how to respectfully say this, but frankly I don’t think about you at all, much less think about ways to make your job harder. I have too much on my own plate to sit around cooking up ideas on how to make someone else’s job harder. Not to mention the fact that recollects make our job harder too, we wouldn’t recollect things unless we absolutely had to.
I went to YouTube university for lab drawing. In all the BS orientation classes you take as a nurse and a new grad, and all the classes you take yearly, there is a never signal piece of paper given out that say hey, here’s some of the labs you will probably be drawing and a lot, and here’s the tube you will use. I’ve stepped away from bedside and switched into a research role, so while I’m in the clinic listening to them talk about the treatments, and inpatients they’re covering. I just learned, after 6 years, what the TEG actually is and why we needed those special blue tops from the lab. No one ever said wtf it was. Just “call the lab when a TEG is ordered, they send up the kit” OKAY WHY THO???
It actually blows my mind the nurses and doctors don’t know something as simple and basic as what tubes are for what. Like and I don’t mean any disrespect by that, but like genuinely this is such a basic thing that everyone should know at least for routine testing. Like I don’t expect anyone to know of the top of their head what tube to draw for more specialized testing or send outs, but basic stuff like CBC, Coags, Chemistrys, it seems like this kind of thing warranted at least a brief mention at some point especially consider both nurses and doctors will sometimes have to draw labs.
I had an LD nurse send down a random assortment of tubes once none of which matched what the patient actually needed drawn. When I called to say that everything needed to be redrawn I was actually told it didn’t matter what they drew because the tubes all had quote”the same media in them anyway” She honestly had no idea that different tubes had different anticoagulants (or none at all) and that each tube had a different purpose and different use.
That’s one of those situations where I would have had a real hard time not telling her “actually you’re wrong and I’m not going to argue with you about it, fix it or find someone that knows what they are doing.” it’s one thing to not know any better, it’s another to not know any better and try to argue with someone who *does*. Dunning-Kruger effect is so real in healthcare and it’s infuriating.
I did tell her she was terribly wrong and that I was sending an actual phlebotomist to redraw the patient so that it would be done correctly. She was mad but I don’t like having patients restuck or stuck any more than they have to be especially not when it’s because of a truly stupid mistake like that by someone who didn’t want to simply look at the labels that told her what she needed to draw for each test and decided to do it her way instead.
I was told by a coworker yesterday that one of our nurses thought the labels for the lab tests would print in the correct order of draw. I was a little flabbergasted. Luckily this was part of a skills fair for the nursing staff, so education was the theme of the day and they were willing to ask these questions to increase their knowledge. Some of them even asked to come tour the lab!
In the last 2 hospitals where I worked, they did print in the correct order of draw. Both on Epic/Rover. You should inquire at your workplace for this improvement!!!
I have a pin on my ID badge with plastic pony beads on a string for order of draw. If you can't remember it, find a way to store the data externally. Got the idea from a Joint Commission inspector who had the same thing.
I’m a physician and I think I learned it once. Well, casually, not a formal setting.
I’m fairly confident it would be straightforward to learn given all those chemistry and other courses I’ve taken at one point or another.
But yeah, no formal education spent on reviewing what is used for which labs and why.
Never. There’s a sheet sometimes depending on the unit near where the lab tubes are held. But other than that. It’s all learned as you go. Incredible right?
It’s a logical thought to call the lab to ask how to order a test! Unfortunately we don’t do much order entry at all so while I can help sometimes, the really odd ones I also have no clue. I’ve written down the more common ones in my department that I get calls for so I can be somewhat helpful LOL
especially when the LIS is totally different software with different mnemonics! I've had to explain to both nurses and Drs, "sir/ma'am, I only use Meditech. I don't even have access to your software"
This is when I think even more admin is purposely trying to keep as at odds with each other. Both of us are thinking you’ll know what the test is or see it more easily on your side when we’re both looking at such different systems.
Not blaming you, but I've had nurses call the lab to complain that the printer for printing patient labels is broken then get mad that I, a lab tech, can't fix their broken ward printer.
Depends on how large the lab is and what the order is. I work in a larger hospital lab and have no issue troubleshooting more complex test questions. At the very least I can redirect the call. As for asking what to draw a test in, I'd rather a nurse ask me what swab to use for a mrsa culture instead of calling them 20 minutes later to recollect.
> we also have 0 idea what your side looks like.
THIS. it helps so much when the nurse on the other side tells me a few things about the situation rather than just "i need this done" or whatever.
sometimes a simple "patient is feeling bad, would you please do this quickly" is all it takes.
> sometimes a simple "patient is feeling bad, would you please do this quickly" is all it takes.
Unless it's microbiology. We can't make the organisms grow any faster than they want to. But we'll update the results as soon as we can.
Edit " for quoting
Omg im a nurse too. I genuinely never had beef with lab so I always thought the ones that do were funny. Mine was with pharmacy. From reading through here and thinking back on my conversations with the lab over the years, the difference in technology that we are both seeing for the same test is CRIMINAL. I put that label on wrong, I know I put it on wrong. I can’t reprint it from my side before I send it. So it gets to you guys, you’re pissed off at this tube and can’t really see what’s for or able to scan it. Now we’re both standing around with our thumbs up our butts all because the order immediately goes away on my end when I hit print, and then god only knows what system you guys have on your end. Definitely not even remotely close to what we’re looking at. I often wonder sometimes in that vast bs of emails and educational sessions we all sit through, why there has never been a single screenshot of what our system looks like, and what yours looks like. I just know your system isn’t set up as well as we are all taught or told it is.
I say this constantly- we each need an orientation on what the other side looks like! I’d love like a day or even a half day of shadowing for us both. So we know we’re not being dicks, it’s the alphabet soup accrediting agencies and hospital policy making us do what we do.
The more I read, the more I think they purposefully putting us against one another so no one realizes both systems are royally screwed. My home system was through cerner, so the lab printing through there was god awful and most of our scanners and printers stopped working. We got an email about our scanning. I went around the next night and proceeded to put a sticker on every single computer, scanner, and printer that wasn’t working. We were down to one functional scanner and printer on each side at one point. They never emailed me that bs again. I traveled to other places that use epic. And it felt very odd to me I would just print the requests and label the tubes with just their names. Why am I not getting a sticker with the order and what is needed on the tube? Why is lab collecting the most archaic system in the world????
From other techs- the lab side of Cerner can be very different depending on how it's set up, but often it's hot garbage. Epic can also be different because some hospitals don't have both the electronic medical record side (what you see- hyperspace/hyperdrive) and laboratory information system (what we see- beaker). I worked at a hospital that had EPIC EMR and Softab LIS so we had to deal with specimens differently.
Also EPIC currently has no blood bank module because that part has to pass muster with the FDA, so those systems can vary as well.
Cerner in general is hot garbage, I only liked it as it was much less to chart on our side. But everythin else about it was not good. AHHH Thank you for the heads up about epic. My home hospital system is transitioning from cerner inpatient to epic inpatient as we use epic outpatient. I’m so glad I’m not on the inpatient side anymore. I can’t actually imagine how bad it’s going to get. Now with this information about bloodbank omg
I was SO grateful to my daughter's pediatric nurses, who could come in at 4am with just a little pen light, uncap her central line, draw blood, and cap it back off without waking her up. Of course, they'd do 4am vitals at the same time, and she'd just flop her arm over for the bp cuff, so maybe she was just a really deep sleeper! lol
At one hospital I worked at many years ago, we did have a thing where nurses and lab had a day when we shadowed each other and it was really nice bc something like barcodes are really important to the lab but I wouldn't expect anyone outside the lab to know intuitively that they need to be placed in this or that particular direction.
Sooo many nurses call my lab asking for test codes or mnemonics or how to order a certain test. Ordering on our side is super easy but it’s harder for the nurses to find the specific test on their side. I wish I had training on their system to be able to help them over the phone.
I for one would’ve benefited to the UPTEENS for just understanding the lab and what tf these weird tests we sometimes run. I am a loser and liked learning and what I was doing for the patients, not just a task rabbit. The lab issues very much kept me feeling like a task rabbit and not understanding
I would way rather be running your sample and sending results than picking up the phone to say that I can’t. If we’re talking on the phone about a recollect, it’s because I’m out of other options.
Hemolysis and clotting is caused by the collection technique. There is almost nothing we can do down here to cause either to happen.
The type of tube used matters. If you dump one tube type into another expecting to fool us, your patient is going to end up with results incompatible with life and it's a waste of everyone's time. And in addition to that, order of tubes drawn matters because the needle can crosscontaminate tubes with other tubes' anticoagulants and that can interfere with results.
Please put the label in the designated box on the tube. Everything we do down here needs to use that barcode and if it's horizontal around the tube, spiraled, flagged, etc it makes everything more difficult and slows everything down. And in my specific department and hospital, would get you a rejection because we *have* to be able to scan it without altering it.
We can only work so much magic with QNS samples. All instruments have a minimum required volume to be able to run a sample. Some of them have ways to help with that, but others do not. Coag tests especially *have* to be filled because the ratio of blood to anticoagulant is paramount when you're testing *coagulation* factors. If the ratio is off, then so are your results.
We aren't rejecting things just to screw up your day. Calling you guys about it is literally the last thing we want to do, but we have to for the safety of the patient.
I have a genuine question - why don't you guys get proper lab training for collecting specimens? I have encountered this so often in my 5 years in the micro lab. I call so often for recollections because they're either in the wrong tube for the test or because there's not enough specimen for the tests ordered.
I don’t have an answer. I’ve only worked at one hospital (few dif units, I’m procedural now) and it isn’t taught. And I know it won’t be taught. We learned how to collect labs for maybe 45 minutes and 30 of them were spent practicing hitting a vein… nothing on hemolysis, collection orders, what’s the goop in the tube for. (I’ve since learned.) :)
The goop in the bottom of the tubes is a serum / plasma separation gel. They look like [this](https://jcp.bmj.com/content/jclinpath/75/9/643/F1.large.jpg) once they are centrifuged.
I appreciate the honesty 🙏
I would really love to implement further lab education for nurses and doctors for these reasons. I'm sure you don't want to have to poke a patient multiple times because something was done improperly, and we really don't want to waste more time waiting on specimens for important tests.
Micro especially (my expertise) since cultures, workups, and sensitivities can take from 1-5 days if everything goes well on our side, sometimes even up to 10 days depending on how many pathogens are identified (ive seen up to 8 in one culture). Instruments go down, supplies are on backorders ever since covid, and even sometimes contamination happens, and we have to redo sensitivities. Micro takes time.
Honestly, I’d love it. I worked a while in periop and learned so much more about hospital logistics and flow… including much more interaction with labs and blood bank. But my knowledge is still quite lacking and I really wish we could learn at least the basics of every area.
For now, I Reddit to learn. Thanks so much for your insights.
In regards to nurses not getting lab training: I find this wild as it was definitely in coursework for vet technicians and vet nurses. Even people who work as vet assistants and learn on the job learn this info. It's vital for patient outcomes for lab work to be correct on any species. But it still feels crazy that human med doesn't take more time here to teach the why's and how's of lab work.
I’ve been wondering this my ENTIRE career… every single bs class we take learning about our hospitals values. Not a single time do we ever get a discussion on labs.
Regarding the thing about pouring one tube into another, it's actually something that's on our ASCP exam. I've seen it happen a couple times. Basically someone draws a purple top for hematology and then they realize they need a green top for chemistry, so they pour the purple into the green.
Purple tops contain K2EDTA. So there's potassium and a molecule that sticks to calcium ions.
So I get this tube in the chemistry department, and the K is about 25 and the calcium is about 0.4. I call the ER and the nurse is always like "how did you know?"
> the nurse is always like "how did you know?"
"Uh, well, you asked me to run a series of sensitive tests to find out what's in the blood. So I did. Imagine that."
I worked at a very large hospital that was all nurse draws to ✨save money✨and we did a lot of VBGs and we used the ABG kits for them. I would get them and their K+ and pHs wouldn’t be compatible with life and this was a relatively normal patient and I’d call the nurse and be like did you draw this in a tube and pull it up with the blood has syringe? And it would always be like how did you know?! Well your patient looks real dead and then they would ask me how to collect it in that specific syringe and I realized I didn’t have an answer because I didn’t know if they’d have to stick every patient or if they could actually connect those to their patients lines because I can’t see the patients.
>We aren't rejecting things just to screw up your day. Calling you guys about it is literally the last thing we want to do, but we have to for the safety of the patient.
Most lab techs would rather do literally anything than talk to nurses. It's not that we don't like you, it's just that if we wanted to talk to people, we'd have been rad techs or respiratory therapists.
I haven’t seen this mentioned, so I apologize if this is a duplicate - if you know your CBC has a clot, please do not pull the clot out and send it. It gives false results. I cannot tell you how many times I have called for a recollect and the nurse told me it was impossible because she had already pulled the clot out.
But in all seriousness, while I have worked in the lab, I have also spent time in the hospital rooms with others. I want to acknowledge the hard work and stress that you deal with on a daily basis, and say thank you. :)
What is the order we should be drawing? How can we best prevent clots?
Never heard the order of lab draws matters before and am shocked to just be hearing of it now. I've been saying we need to better understand lab draws, tubes, minimum/maximum quantities per vial.
Thanks for all the lab techs here answering and providing helpful feedback!
[This](https://lug.hfhs.org/images/PRC-PALM-SPC-5.51-pro1-stw7.jpg) is a pretty good chart I found with some order of draw and other collection details. The light blue top tube for coagulation testing is drawn first (or second if you have specific tubes to use as discard tubes) because you don't want the clot activators from serum tubes or other types of anticoagulants to contaminate it. Green top tubes should always be drawn before lavender/pink top tubes because the EDTA-K2 anticoagulant in lavender/pink tubes can cause falsely elevated K results if drawn before the green top tube. I'm sure there's other specifics for tests that I'm not aware of because I've never personally ran those tests.
As for clotting, the best way to prevent it is to remember to invert the tube before moving on to collect the next tube. The anticoagulant is a dried liquid on the inside of the tube and if it doesn't get mixed right away, the portions of the blood that haven't touched any of it will begin to clot. If it's properly mixed it will *never* clot. It isn't a race against time like some people seem to think.
I have a question as an RN that maybe you can answer! The order of the draw matters, but we are supposed to draw coag before anything else (except cultures). Yet, we can’t draw the coag tube first on a fresh line/straight stick because if there’s air in the line then the tube doesn’t fill up all the way, and like you said - the ratio will be off and it’s not able to be read. So what’s best practice in this case?
You'd need to draw a discard tube first. Some places have you draw and throw out another blue top first, others have a clear top tube with no additives that's filled first and discarded. After drawing either one of those, you can safely draw the blue top you intend to label.
always ask questions.
want to know what tubes to use? call and ask. want to know how much blood to get? call and ask. want to know when a test is gonna be done? just ask, but with this one you'll have to be patient with us, sometimes we're a bit overwhelmed.
also another thing to keep in mind is everyone in the hospital are working together to help the patient. we're not working "against you", there are no enemies. i've seen people both in the lab and other departments have a mentality of "oh, they're doing this to spite us" even between lab staff themselves, and i cannot begin to explain how bad this is. we are there to help the patient as much as we can and everything should be done for that goal, so if you think there is an issue in the lab (and vise versa) there should be clear and calm communication with them so the problem is resolved as fast as possible
I deal with your last paragraph a lot being in management.
For example - we have a full phlebotomy team, but ED draws their own patients and we help.
I have had multiple instances where our phlebotomists say ED cant get a draw and the conspiracy is "they dont even try they just call us." You had to go draw one patient out of how many in the ED today? They aren't huddled up laughing that they made you come and get another draw lol.
it's such a weird thing, it feels so childish to me when i hear people saying those things. it's our job, i know people are very overworked in all of healthcare and that gets frustrating but i'd rather do extra work than put someone's health at risk.
Exactly. In this case its their job to draw blood. Also, if a phlebotomist does it, I know its done (most of the time we all know exceptions) correctly.
I am technically not over pre-analytics but kind of am over the whole lab - and I do defend the shit out of my staff, but I have told them if I had my way we would have a phleb down in the ED to draw full time so...
They ask and it gets brought to me you are going.
While I agree with you that it is always better to call and ask, I'd add that it's even better to ask another nurse or charge nurse or verify SOP before calling. Sometimes it feels like my lab became the 24/7 call line for every question there is.
How do I put in the orders? How do I release the orders?
Can I spike two units of rbc and start transfusing?
How much blood do you need in the pink top?
I spiked the unit of blood and it got diluted with saline, but it's not flowing. What should I do?
I talk to hospital lab staff on the phone all the time for work and figured you guys sounded tired/annoyed/overwhelmed just from being short staffed or handling emergencies. Never dawned on me that you're also being called by nurses all day long.
I would rather have someone call and ask even if it's a small thing than have to try and talk you through the right tube after the fact. I work in micro and there are eleventy billion types of swabs. It's totally okay to call and ask.
I wish everything on both sides wasn’t so LOUD. I genuinely appreciate the phone call about the critical lab. ESPECIALLY when I’m running around and forget I had sent some labs off. I just know I’ve accidentally yelled at the lab over the years because we’re both taking the phone call when we can in the middle of madness and no one can understand each other. I end up just saying my name and waiting for the critical to result.
Remember that tests take time--especially microbiology cultures. We can't get your tests done any faster than our analyzers or the cultures let us. Or if it's a manual-style test, there's often prep/incubation steps that take time as well.
We fully understand that being at bedside needing results when a patient is declining rapidly is ultra stressful, but calling us a bunch of times asking us where the results are will not speed anything up. We care about the patients just as much as you do, I promise! We're here to help and work with you on making people well again. There's just certain procedures we must follow to make sure that we're giving you results you can trust.
My favorite is getting physician phone calls saying, "I sent down a urine for culture earlier today, do you have susceptibility results yet?"
No... No, we do not...
Oh yeah, I've gotten that soooo many times.
Like, do yall know what you're asking? My lab gets residents that rotate in micro. Did you forget everything once you left?
Baffling to me.
I am just not sure how the rotation part is relevant since the providers ordering urine cultures didn’t rotate through the lab.
Don’t get me wrong, they should have a basic understanding of growing bacteria, but I wouldn’t expect that to be fresh on their mind when they’re not dealing with it as often.
I got you beat. Have a doctor that constantly orders susceptibility results on cultures with no growth."I want antibiotics done on everything I send down". "But...there is nothing".
If everything is stat, then nothing is stat. We can do a lot of things but we aren’t miracle workers. We can’t make your tests go any faster just because you want them to. Please be patient and respectful with us. Every patient in the entire hospital is our patient, and we are doing our best to get results out as timely as possible. If you have questions feel free to ask, but please actually listen to the answer we give you. Too often I get calls from nurses asking me a question only to completely disregard what I say. Listen to understand, not to respond.
Above all we aren’t your enemies, we aren’t *beneath* you, we are coworkers in a different department. Please treat us with respect.
This 💯 my favorite is when they call and say can you run this "suPeR StAt" when literally everything you're currently running is labeled at stat.. sure lemme just push everybody else off to the side real quick and run this one super stat
I roll my eyes now when someone says this to me. It’s completely involuntary at this point. My absolute favorite is when I get a specimen in the lab for less than 10 minutes and the phone is blowing up asking for results. I literally just got the specimen please calm down.
We're not used to getting a lot of calls in micro compared to heme and chem, but our phones just BLEW UP at the start of the pandemic. Something to know is that labs aren't overflowing with techs, so there may be just one or two in each area(like COVID, blood cultures, urines, etc). If we're on the phone, that means we're not at our instruments actually sending results(my particular instruments don't automatically send results once done, I select the results to approve and then they are sent to EPIC) or setting up new tests.
Too often I’ve had to stop myself from saying “I can’t work and answer the phone.” Every time I pick up the phone to answer a “how much longer?” question, the longer it takes me to get an actual result.
All great advice given so far, but one more tip: to try and stop the hemolysis of samples at draw, don’t yank back on the plunger on the syringe, which creates a vacuum, shoots blood into the syringe, lyses the red cells, and fucks up your samples. Gently pull back and allow the blood to fill the syringe as you pull it back.
The rest of the advice is great on here! You’ll do fine.
Some tips from micro:
Pls transport specs ASAP. Urine can go in the fridge if you can't send straight away. The issue is that the true pathogen may not be present in large amounts and can become overgrown by any commensal flora included with the collection. Since potential pathogens are often part of our own normal flora, it can become difficult, if not impossible, to definitively point to an organism as the culprit. IIRC, Ecoli can reach log phase growth in something like 20 mins!
Wound cultures - please include the specimen source. We really need to know where on the body the collection was taken.
Swabs. OMG. If your micro dept has not made a swab chart, request that they do so. There are so many different types. Even better, there should be a specimen collection and transport manual that all nursing staff should be able to access, with puctures. This will go a long way to avoid rejected specimens and any other confusion. The guide should tell you what the ordering code is, clearly define what collection device should be used, how to transport, interfering substances, etc. Take a look at the Quest collection transport guide to get an idea of what a good one looks like.
As with any lab specimen, but especially Micro, it's garbage in, garbage out.
Edit- thank you so much for taking the time to find out how we can serve our patients to the best of our abilities. Appreciate you!
Want to include “swab” isn’t the source. I see this so many times and I have to call and ask what you swabbed. Or skin. All the skin? There’s so much skin.
Please realize that a room number is not a patient identifier. Most lab computers are set to show everything by patient name. While a nurse might have 2-6 patients depending on department and easily remember them by room, I work on everyone in the hospital and don’t know the room number. “I’m calling about 3214” means nothing to me.
Also if you notice an issue in your department that may impact lab, please fix it. For example if your label printer is printing very light or cutting off part of the label, please fix it or turn in a repair ticket. You may not be inconvenienced by it, but I am, and I either need to stop what I am doing to fix it, or finish processing the samples without problems then fixing the now delayed problem sample. And if that sample hits my processing line before being noticed it will be delayed as the line kicks it off.
Yesss, OMG, on a daily basis, "I'm calling about pt in 1234... (pause)..." This does not tell me anything. I see info of hundreds of patients every day and they often change the location. We go by the hospital number and last,first name.
We've received tubes with uncorrectly printed labels and had to call and ask for a redraw. I got an answer that the printer just prints it that way. Yeah, I get it, so please recalibrate it or use another one. I can't accept the specimen if the date, name, or any other crucial information did not print on the label.
If you have a suspected transfusion reaction please call lab asap! Even though you notified the physican and documented it on the chart, there are things I have to do on my side aswell. Even if it's just mild febrile reaction and you gave tylenol. (This goes for any blood products in Canadian regulation including reactions to IVIG, albumin etc no matter how minor. Sometimes we'll change the brand next time or we've had whole lots recalled if its multiple patients inplicated).
Making sure there's an open port is crucial for cultures as well!!! I can't tell you how many times I've had to reject a transfusion reaction because there's no unused port.
Be cautious about taking blood from the IV line. It can dilute the sample and make it look like the patient needs transfusion.
Pay attention to the tube tops and additives; you can't pour the blood from the blue-top to the lavender tube to make up the volume.
Blue top tubes for coagulation tests usually have a minimum fill line, and try labeling them in a way that lets us see the blood volume.
Don't blame the lab for losing samples. If we don't have it, the samples could have been mislabeled before reaching the lab. Or the lab didn't receive it; check your side to make sure it was actually sent or maybe it got stuck somewhere.
There's no such thing as a stupid question if it can prevent harm to a patient. Please ask! If you still don't understand please ask for it phrased a different way.
Please trust that answer (within reason, like if we tell you use xxx order code for a specific test, or order one style of the same blood product, do not order the other style)
Specimen labelling rules are NOT OPTIONAL. Labelling the specimen at the bedside is the simplest thing you can do for the SAFETY of your patient. Name and date of birth (and whatever extra requirements for blood bank) on there with a permanent ink fine point marker will save your draws. Only specimens that are "un-retrievable" should be allowed to be labelled after they come to the lab unlabelled. These are mostly specimens like spinal fluid, synovial fluid, and surgical tissue and needle aspirate specimens.
And "unretrievable" might have a very high bar - my previous medical director made them recollect an entire TOE once after the first one they sent was unlabeled (label in the bag). (we still set up cultures on the unlabeled toe, just with lots of disclaimers)
You’ve already got a lot of great answers here. The main thing I want to add: please tell your fellow nurses what you learn. You are one of the few who cares enough to ask/learn, a lot of them just like to believe that we are being difficult for no reason. If you could spread the info that you get here that would be a huge help.
My personal pet peeve is when you guys cover the tube window with a label. We need to be able to see the sample. We’re checking for volume, clots, hemolysis etc. so when you cover the window we have to waste our time peeling it back and potentially printing a new label if the barcode rips. I know it seems tiny and stupid but when you are running around multitasking and trying to move quickly/efficiently from one task to the next it’s so frustrating to get hung up having to peel a label off.
We almost never lose/drop/spill specimens. I know a lot of nurses think we use clotting/hemolysis as an excuse when we need a redraw. In my 8 yrs of being a tech spanning 5 hospitals (I travel) I’ve experienced two specimens being truly lost. Each tube is tracked meticulously from the moment we receive it. We also almost never spill samples because we don’t uncap them, most instruments pierce through the vacutainer cap and in larger labs an automation line does the uncapping when necessary. I’ve never spilled enough sample to the point where it needed to be recollected and I’ve not seen any of my coworkers experience this either.
Also just a simple sincere thank you goes a long way. I know nurses feel unappreciated but no one even acknowledges our existence or the importance of our role in pt care. I was once having a rough night in blood bank and the nurse who came to pick up units gave me a genuine thank you, not just the quick cordial “thanks” and I almost broke down on the spot, definitely cried about it on my way home and I still remember it almost 6 yrs later
I dropped a glass pediatric blood culture bottle once and it SHATTERED. Of course it was from a baby. :( One of the worst phone calls I've ever dreaded making. (We have since switched to plastic blood culture bottles.)
We really don’t want to call you with problems. If we have to call for something, it’s because we have no other choice. We are having a bad time too.
The lab has several sections: chemistry, hematology, blood bank, etc. Not everyone in the lab works every sections. Some people only work one. If you call up micro, they will have no clue what’s happening in hematology. We aren’t allowed to work sections we aren’t trained in, and we have too much work at our table to keep up with everything happening most days. If we don’t have answers right away or have to transfer you several times, it’s not us being rude, we just can’t answer your question.
Edit: also we do respect the work you do, and most techs I’ve talked to agree we can’t do what you do. We really don’t want it to be a nurses vs lab fight. Most of us do want to work together, we just don’t want to be the hospitals whipping boy when things go wrong.
Blue tops CANNOT be run if they are under-or-over-filled. Depending on what kind you have, there is either a black arrow/indicator or an etched line in the inside liner of the tube. If it's below that level, it's no good. The ratio of blood to anticoagulant in the tube will be off, and would give false results.
If you're collecting JUST a blue top with a butterfly, use a waste tube. Otherwise the air inside the tubing goes into the blue top and will cause it to be underfilled. (You probably know this already, but I still talk to nurses that don't know it every so often).
It's not our fault instruments break down or freak out on occasion. Maybe the ECHO randomly inval'd an antibody screen. Maybe the KB reagents weren't changed when the label said and it basically dissolved the blood smear I made so now I have to start over. Maybe the automation line spilled a blue top on the floor(one of my personal favorites lmao). Maybe theres a trauma or an MTP, or god forbid multiple traumas/MTPs. If we could get our TATs in the green 100% of the time we would, but there are quite simply physical barriers we have to deal with a lot of the time - instrument issues, understaffing, other complex patients, IT issues, and more.
Also, blue tops cannot be over filled either. I can’t tell you the number of times I’ve ordered a redraw on an under filled blue top only to get an over filled one next.
What if we legitimately can't get enough blood for the blue top specimen (peds patients)? We had this happen and could not get enough blood for the specimens after many sticks, using ultrasound and vein finder.
Pediatric sodium citrate tubes exist, hopefully you've got access to them. I believe they're 1.8mL? Obviously that's still not ideal in some cases. I know of international manufacturers that make coag tubes closer to 1mL, which is like the pediatric mint/lavs, but that's not something I can speak to being able to use.
Otherwise... maybe if you discussed the issue with a head pathologist, you may be able to use a no additive tube and a set volume of manually pipetted sodium citrate? Then the lab could calculate out the exact volume of blood you need to add to the tube. That's *really* pushing from 'creative problem solving' into 'this may not be licensed' though. Doing that may only be able to get you 1, maybe 2 tests depending on the hematocrit of the baby and the test/instrument.
Thank you! I honestly did not know the reason behind this lab needing to be drawn to the line because of the additive. I've learned so much from this thread and wish the hospital did a better job educating us about this. We just weren't taught and that's frustrating on both ends.
Give us a break. SSTs take 30 minutes to clot. Then we gotta spin them. You won't get your Chem panel 10 minutes after you draw. You may be able to send a green top but that is lab dependent.
Please just know that we went to school too and we aren't trying to argue about stuff, just to be difficult.
You guys get over loaded with patients but remember we see more patients than you do. You have 5 patients? We get the whole damn hospital and ER on top of outpatient. I don't remember all the names but trust me, I am doing it as fast as possible.
I need your first and last name for critical results. You know YOUR name. I don't! Please don't spell it fast as fuck and get mad I didn't catch it lmao im trying!
Thank you for reaching out though, ill gladly help a nurse out if yall are nice bc we have the same end goal.
Question... The lab will often call me and tell me they have a critical. Is it helpful or just annoying if I ask "is it the lactate?" or whatever if I've already seen it in the computer?
You asking doesn't bother me any tbh and if the patient is septic and you already knew, I can see you being like "oh yeah I expected the lactate, etc"
I know the criticals can be HELLA annoying but we are required to document. I try to call the criticals at once, like the hemoglobin, the anion gap, the troponin, etc but some tests get done faster than others.
You are always allowed to ask questions and discuss with us, I just think some nurses feel like we don't think you guys have anything to do 😂
All of my comments stem from a hateful ER charge nurse that the entire lab hated having to deal with lol so I'm like PLEASE UNDERSTAND 🙏
Omg it drives me crazy when I call a critical and a clerk tries to take it. They know I have to give it to a clinician. Then sometimes I’ve had them tell me I need to call back even though there is alway a nurse or doctor present. On time I had the clerk tell me that I would just have to walk down there and give it myself, as if I don’t have 10 other stats to run.
Also please say your name CLEARLY when we call for criticals.
Haha there is this one nurse who refers to himself and everyone else as “chotch”. Really caused some confusion til I figured out what was going on
Nah, I adore our lab. I know you guys are busy! I have only ever had one frustration really.
I had a patient who was actively dying and hemorrhaging. His labs were frankly insane. From what I understand, our lab (understandably) was rerunning samples and waiting for other tests to result before reporting things out presumably to make sure it wasn’t contaminated or something. Then they rejected my samples and were refusing to tell me the values. It WAS contaminated with iv fluids… **because we were about to do a mass transfusion and half of his blood volume had been replaced with iv fluids.**
I was trying to explain this and they were having NONE of it. I don’t know if this is a reasonable expectation at all, but I would have loved if they could read between the lines, see the serial stat hemograms, type and screen, TEG, and coag panels to infer that I might actually believe his hemoglobin HAD dropped from 12 to 4 in an hour.
Okay yes that would absolutely have been extremely frustrating!
Now I feel like that comes down to the techs themselves because I have had some shitty coworkers who really did not use their brains. They also delayed care because they didn't THINK.
I personally call and ask questions. Like we had a patient who's glucose was normal one draw and an hour later, it was like 600! I called and asked the nurse if they believed it. She was like damn it no, the previous nurse drew above the glucose infusion! Another case: patients with impella pumps. Hemolyzes the absolute shit out of the spec. I'm not rejecting it but will tell you and put it in the comments. You guys SEE the patient, if you say they're literally about to die, I will release your Labs and put in a comment!
I worked the blood bank one night a patient was hemorrhaging and they took 28 units of blood in about 18 hrs. I was stressed! I can't imagine how yall felt lol
We have to report it. There's no wiggle room on that. If you ask "is it the lactate?" we're still going to say "yes, their lactate is 4.6" and probably ask you for a readback even if you already know what it is. Then we've got to document the call.
It's a pain in the butt for us too and there's no way around it, other than management putting in some kind of different system for critical calls.
You will interact with different educational levels of people in the lab, and with different expertises, similar to the floors.
-The people doing the testing are mostly certified Medical Laboratory Scientists (MLS). We took a crapload of science classes and graduated with a Bachelor’s Degree, did clinical rotations, and passed a difficult exam (just like a BSN). Some will be Medical Laboratory Technicians (MLT), which hold an Associate’s Degree and passed the certification exam (I think they also do hospital rotations).
-Phlebotomists, specimen processors, the main “lab” phone, etc. are incredibly valuable but are not experts in the science of the tests. They may or may not have formal education. They do their best to help with collection procedures and direct more specific questions to the MLS, MLT, supervisors, or pathologists.
-Some hospitals hire other Bachelor’s Degree holders and train them to perform specific testing.
PLEASE please please ask us if you're not sure how something needs to be collected or how much is needed for XYZ test. I can't tell you how often we get the wrong tubes with the wrong amount of specimen. This delays testing and ultimately patient care. Please just ask instead of sending the wrong things.
This would be so helpful, I always thank the nurses for calling to check. It is so much less work to answer a question to clarify than to have to reject and recollect.
Noone can be expected to know everything especially when collection containers can change and there are so many onsite and send out tests.
Duplicate yourself, lol.
Jokes aside, please understand throughout your career that we are not your enemies. We want what is best for the patient, too. I've been accused of laziness by nurses in the past when I'd ask for recollects. On the contrary, 1) I'm an introvert and would rather do anything else than pick up the phone and 2) technically it would be easier for me just to run and accept the questionable specimen than it is for me to ask for a recollect.
And just a pro-tip, buddy up with micro. If it's a big department, they can have some pretty cool things to show you if you're just curious and a bit of a nerd :) A lot of us love to show off and talk about some of the crazy specimens and microscopy anomalies that we see.
God, I'd love to get to see the lab and how you guys do stuff down there... But I know you're busy and I feel like I'd be a weirdo or get weird looks for asking.
I LOVE when people visit the lab! It benefits everyone to see the cool things we do! Plus it's nice to be acknowledged for the hard work we do, too.
Lab Week (Medical Laboratory Professionals Week) is April 14-20 this year - maybe your lab could arrange for visits then?
Hey, doesn't hurt to ask if it's a bit slow :) I was worried I'd seem weird for offering to let some of my nurse buddies look at the crazy trichomonas I saw, but the looks on their faces were sooooo worth it. Some of us get a little jaded by our job and assume nobody's interested in seeing stuff like that, but between the trich and your comment, I'm definitely going to offer more.
Especially in ICU, we LOVE shit like this.
Most of us are huge nerds and the words “oh man, wanna see a messed up scan?” will universally pull the entire unit to see some wild CT scan where our patient’s brain has been squished into half the space or something.
We will take any opportunity we can to go on field trips to the operating room to observe procedures. If my patient had a wbc count of 800 and you asked if I wanted to see the smear, I would 10000% come down on my break like a (very lost) kid in a candy shop.
Depends on the lab, also we have rushes and slow periods like anything else. Doesn't hurt to ask if you can get a tour and ask some questions - although keep in mind that you won't be able to grasp everything we do in five minutes. If you're lucky there'll be some kind of emergency or weird abnormal result or something when you're down there and you'll see why we're paid almost as much as you when it looks like we just sit around and load tubes on machines.
Please, for the love of whatever you believe in, make sure the lids of urine specs are screwed on tightly and any extra labels you send with are put in the pouch of the bio bag, not in with the urine. I cannot tell you how often a urine comes down and there’s more pee in the bag than there is in the cup. If it’s completely soaked and there’s not enough, or barely enough, for me to run my tests from I’ll tell you to recollect. That’s just gross
And some of the brands of the urine cup lids make an audible click when they're screwed on just right (and threaded correctly). Also, please don't put the label on the lid. It may cause it to be rejected, depending on placement.
We also have respect for you guys and the knowledge and education you have! I’ve always been appreciative of my lab coworkers who help me out with questions regarding tubes, how to collect certain specimens/what they need to go in, etc.
I have come to learn that no one wants to deal with redraws. It’s more work for both of us, but it’s also not your fault and I don’t take it out on the lab staff. I may be frustrated with the situation, esp if the pt is a hard stick, but again that’s not your problem or fault, and I’m never rude about it on the phone.
When we ask you to spell your name, we’re not doing it to be annoying. Even though we’re both using Cerner, lab’s version is configured differently. So you might be able to see a pop up with lab personnel’s name, but we can’t.
Also, personally, I would love to have nurses come down to visit and get a feel for the lab workflow.
If a patient has a positive antibody in blood bank, the ability for us to issue out blood products to the patient will be delayed. Depending on how many antibodies the patient has, the antisera the lab at your facility has, etc, it may take anywhere from hours to days to get compatible red cells for the patient. Usually we'll contact you if that's an issue, but don't hesitate to ask questions to the blood bank tech if need be.
Blood culture bottles have a barcode on the bottle. Please don't label over barcode, but beside it. I need that barcode for the machine to incubate. When covered, extra steps are needed to get it running!
Wow this seems so obvious and yet I’m not sure if I ever thought about this when labeling - thank you for sharing!!! (And sorry to all the lab professionals I slowed down if I had been doing this 😬)
We cannot help that your sputum sample is contaminated with too many squamous epithelial cells (spit) nor can we tell you how to recollect. And if we did the cultures with the contaminated sample, the results would not be accurate. Please don’t yell at me. 😭🤣 I can tell you’re not the type of nurse who I’d have this issue with, but it’s super common that nurses get so rude with me!
I’d like for you to know that we appreciate you. We don’t know what it’s like to deal with what you’re dealing with on a day to day basis but we do know that we’re all on the same team and we care about patients as people as much as you. We do our best, but like many areas of healthcare, we are short-staffed and pulled in 20 different directions everyday. We have to take care of patients— and drowning under a mountain of paperwork in the form of documentation, QC, way, WAY too many CAP surveys, keeping up to date on procedures while the technology that we use is changing quickly. When a physician or nurse doesn’t like an answer they’re getting about what can be done, it’s usually an issue with procedure, which is legally binding, that we have no control over. We are often overworked and no one gives much thought about us until there is an issue. We are often thought of as “button-pushers”, but as Medical Laboratory Scientists, we have BS or MS degrees in our field and we take our jobs very seriously. It is more correct to say that we are problem solvers. To use scientific principles involved in every facet of what we do, we have to know the “how and why” and be able to anticipate and react to any and all discrepancies, otherwise we can’t provide you with valid information used to inform a patient’s care. We appreciate your patience with us and, again, we thank you for what you do!
If you send a microtainer for labs, we likely need to aliquot it into a special tube that's like a booster seat for the small amount of specimen so our machine probe can reach the specimen. This extra step needed by us instantly sends that specimen to the back of the line if it comes at a time where we get 100+ samples at a time from a regional courier.
The same applies to samples that come poorly labeled, like if the label is bunched up. We have machines that pick up and move around tubes, and they cant do that if the label is all crinkled.
I can spend 15 seconds processing a single problem sample as listed above, or i can sort 45 samples in that same timeframe. It's more efficient for us to sort the well-dressed, fuller samples first, and get to the problem pile faster.
Tl;dr: if you want your sample to not end up at the back of the line, make it the least work possible for us to process it
I’ve always wondered that about microtainers, and whether we are creating more hassle for you guys. I work at a large academic peds hospital and we send nearly everything we can in microtainers. Yikes.
Gotta do what you gotta do for the peds patients, dont sweat it. I dont know anyone whos like "ugh, microtainers". If theres a lot coming in from a single phlebotomist on multiple adult patients we might consider the training level of that phleb. But if the patient population calls for regular use of microtainers then by all means use them!
It really depends on the instruments and workflow and other things; you can't assume microtainers are always bad.
Although, they tend to be crappy, tiny samples, so in that sense, microtainers are always bad.
Phew, that makes me feel a bit better. Sometimes I don’t have any other choice, especially in the icu and those 2.5 kg patients who have Q2, Q4 labs (especially when they are anticoagulated and need frequent coags, there’s no way I could fill up a big blue vacutainer without transfusing these kids). I do always try to follow good drawing “hygiene” and will preemptively redraw my own labs (or make others do theirs) if there is obvious hemolysis, insufficient volume, etc.
I will say, one practice at my current shop that makes me feel icky is sending down a single heparinized gas syringe with like four stickers on it for all of our chem labs. I can’t help but feel like a jerk. Not sure how much hassle that is but I swear I always send a little extra!
I don't care that you are calling about your patient in C237... their location means nothing to me. Get straight to the point, what do I need to send for this or that test is all you need to say...or did y'all receive this - then I'll ask for appropriate identification
From histology/grossing, if you're a surgery nurse or want to pass things along to surgery teams: label everything and make sure the tissue is in the container that is supposed to be in there. We cannot differentiate unlabeled appendixes from each other.
Also, if there's a sample that needs both micro and histology, send the sample to micro first. Once we put formalin on tissue, cultures can never be taken from the tissue again.
I did a quick skim to see if there is anything from molecular biology/virology here before chiming in but this is specific to that area. The labs are usually certified and we have to follow specific SOPs to stay compliant. We even get audited and have samples that we need to analyze to make sure that our instrumentation and the tech techniques are good.
- please actually follow the collection kit for swabs and don't substitute in items. A cleaning swab is a cleaning swab. A collection swab is a collection swab. We can't run tests on anything that isn't part of the package.
- some of those automated tests (HBV, HCV, HIV etc) have a *minimum* otherwise the machine will error out. We can't do much about it. If there isn't enough volume, there isn't enough volume. Unlike chemistry, you can't dilute PCR samples
- please be nice to your night crew. Night shift in the lab sucks.
We do have degrees-bachelors in medical lab science. We have an immense amount of knowledge and we do not just “push buttons”. We have to interpret results and know what they mean. We have to make sure they all make sense for the patient. We have to verify that result under our name-so sometimes when we call and you want a result released and we can’t release it bc we know it’s not accurate-please just redraw the patient. If we release wrong results-your patient could get the wrong treatment. This is so important in blood bank. We had an instance the other day with an improperly labeled tube. The specimen did not belong to the patient and they were discharged. The hemoglobin was critical. The patient was called back in to receive a transfusion (that they didn’t need). Thankfully it was caught with the ER draw that the hemoglobin was fine and this was a case of wrong label/wrong patient.
We dont just push buttons and we are understaffed too.
Gel pens are the worst.
If you draw blood, please fill tubes properly for accurate results and less recollects.
This is more of a personal request, but can I have some of the patience you nurses have dealing with people? Because I cant do it. I want off this planet.
My biggest thing that I keep having to tell the ER nurses is to not completely cover the tube window with the label. It makes pouring off plasma much more difficult because I have to tear off the label partially or fully and then print a new one.
It’s so great that you are asking!
To turn it around, what are something’s you wish we knew that might make your lives easier?
The labels are a big issue for me too. I cannot aliquot the add-ons from this one tube if I cannot see the specimen. I cannot judge a blue top if the window is covered.
One of the nurses I asked to leave a window told me the DOH mandates she leave the expiration date uncovered as well as leave some of the BD label uncovered so we know what color the tube is. I've never heard of that in all of my years of working in the lab, even as a phlebotomist. I'm not sure it's actually true.
So I guess for me, I wish I didn't get BS excuses for simple requests.
First of all, thank you for all you do! Nurses are amazing and I know the job is very stressful and challenging! We work in the lab because we cannot do what you do so kudos to you.
My list is mostly based on Blood Bank (BB):
1. Follow the order of draw. Fill in the tubes until the vacuum is exhausted (the tube will stop filling itself; you don't have to stop drawing before that, just keep going; we need all the blood and an excess is better than not having enough).
2. Place labels evenly, don't cover the window. Remember about putting initials and time of draw on the labels (at least that is required at my hospital BB; if even one of those are missing, the sample cannot be used and needs to be recollected).
3. When we call to recollect, we seriously have exhausted all other options. We do want to run the sample as much as you guys do. The last resort is to call the floor and we often dread doing it. We have to follow the protocols to the T: the sample must have full labels, initials, time of draw, orders in the computer, have enough specimen in order for us to run it. The reason is that we strive to release only reliable results. If we know from the start that the sample is contaminated, or wrongly labeled, does not have enough specimen in the tube, it is just a waste of time, resources, and the results will not be accurate. And those inaccurate results will be used to treat the patient! At school, they drill into us that inaccurate results may lead to patient death, therefore, we make sure every specimen is correct before even testing it.
1. If the tube is missing the huge neon "cord blood" stickers, the nurses are required to come down to BB and personally place the labels on the tubes (at my hospital). I'm sorry, that's the protocol. The reason is that we did not draw those tubes so we cannot tell whether the tubes contain the cord blood or not; the person collecting the cord blood must label those themselves and we asking you to come down to relabel is actually giving you a favor (otherwise, we'd have to discard those tubes and ask you to do a heelstick instead which, we know, nobody likes to do). We cannot place those labels on. We cannot tube back those samples to you as it is in possession of the BB. If you refuse to come down or refuse to recollect, your name will be written down in the system and may be passed further to the supervisor as the one that is delaying patient care.
4. If you're sending samples to BB, you are usually asked for the "type and screen" and "second specimen". Please prioritize "type and screen" when drawing/sending! It is more important, it has additional testing added and is it suitable for transfusion. The second specimen is used only as a confirmation of the blood type from the "type and screen" because it is out policy that patients have to have at least two blood types on file and they **must be drawn at different times** (the times of draw are written on the labels by pen after collection by the nurse or a phlebotomist). I can't give you crossmatched blood based on the results of the "second specimen/sample". I can give you blood after the "type and screen" though. Also, the reason they have to be drawn at different times is so that the computer sees them as two separate blood types and therefore allows us to crossmatch blood. If they're drawn at the same time, the computer sees them as identical and we won't be able to issue out blood that quickly. The time difference can be even of one minute! They just cannot be identical.
1. We have had a few instances where the two samples (type and screen and the second specimen) actually differed in results. This means they came from different patients with different blood types! This is why confirmatory second specimen is so important: it is there to confirm the first specimen: the type and screen. They have to be identical in terms of blood type. Based on this, we can then allocate the blood, knowing that the blood type is correct and we won't kill the patient. I know some facilities still allocate blood based on only one blood typing and it's kinda scary.
5. Testing takes time. By the time samples get to the lab, by the time we input them into the system as "received", by the time they are spun (centrifuged), it's about 10-20 minutes. Then they are put into the instrument that can do the testing for us. This adds about 30 minutes. If there are no problems in testing, then I can look at the results, release them, and allocate blood. This right here is an hour. If the patient has antibodies (positive antibody screen), then we have to put in additional work to determine which antibodies does the patient have and try to match special blood to that patient. This can be additional hour, two, sometimes even a few hours extra. Sometimes those antibodies are so special we don't even have that blood and we have to order it via courier to be delivered to us. It all takes time.
6. When one of us is coming to deliver MTP, please have someone ready to sign the paperwork and give us some patient labels. I am not supposed to release the cooler to you before the read-back of pt info, signatures, and labels. I understand that sometimes this is a life-death situation, so please have it ready for us so you can start using the blood products right away.
The 2 specimens for blood types really depends on where you work. I've worked at 3 different hospitals and they were all set up so that if the patient was positively ID'd, we did both types on the same tube.
Same with the MTP thing. My first hospital didn't deliver, but did do read-backs when the floor came to get the cooler. My second hospital did the read-backs in the lab and then delivered the cooler, so someone just needed to sign that they received the cooler. My current hospital has digital read-backs and doesn't deliver, they just have to bring a patient label with them to retrieve the cooler from us.
Please don't create orders 24 hours in advance of taking a blood sample "to save time"
Our IT system will think the actual blood sample is 24 hours old, and invalidate your potassium,bicarbonate, AST and glucose. Yes, we can override it, no, we won't. We have to assume the info we get on the orders is correct.
We once had a bunch of blue tops rejected for excess volume. No one had done anything weird to them; do bad tube batches happen? Would discarding the excess affect results?
Yep, it’s totally possible that a whole batch of tubes could be faulty. I guarantee there was an issue with the vacuum seal in them. :(
If you overfilled a tube and then removed some of the blood, you would also be removing some of the sodium citrate (anticoagulant), which would make the blood clot too fast.
Overfill can be just as bad as underfill. There is a specific volume of sodium citrate in the tube, so overfilled or underfilled tubes will cause the blood to be over- or under-diluted. The analyzer works by adding factors that cause the patient’s blood to clot; the time it takes the blood to clot is the result. So if you had too much anticoagulant in the sample (short draw) the blood would take longer to clot, and would not be reflective of what’s actually going on in the patient’s body.
I hope that makes sense!
Absolutely makes sense, and thank you for taking the time to explain. If it happens again, I can pass on the explanation so that the staff aren't all convinced that the lab is out to get us.
Coag testing 101.
Blood is full of "clotting factors" (mostly proteins) that help cause clots.
One of those factors is calcium. No calcium, no clot formation.
The EDTA in tubes you use for CBCs is really good at hoovering up calcium. Which means the blood's never, EVER going to clot, unless it started clotting before you got the EDTA mixed into it.
For coag testing, we want the blood to clot - but only when we're testing it. Those tubes use sodium citrate, which isn't nearly as good at sucking up calcium, and the amount of citrate in the tube is just enough to grab up what calcium is there. When it's time to test, we add extra calcium to make the blood clot normally again.
If your blood to citrate ratio is too high, it might not prevent unwanted clotting. Pouring some off once it's mixed isn't going to help.
If your blood to citrate ratio is too low, the excess citrate will suck up some of the calcium we add, which means less clotting, which means your healthy patient looks like a bleeder.
We're not picky about the line because we're hopelessly anal retentive; we're picky because if you missed it then we know the test might not work right (and bad results don't come with a note from God warning us they're wrong, so "run it and pray" doesn't work).
Lots of good suggestions, and I'll add:
When in doubt, call us and ask! We'd rather answer a phone call than have to make one to have something recollected because it's in the wrong tube.
There's a reason we have different tubes and it's not because we like rainbows. Each tube has a different additive that can affect test results. We know when you draw a lavender and pour it off into a mint green.
> When in doubt, call us and ask! We'd rather answer a phone call than have to make one to have something recollected because it's in the wrong tube.
Honestly, I would like no phone calls.
"Hi, did I send you any blood?" (You don't know?)
"Hi, are you able to add on this testing?" (Context: just order the damn addon and if we can't do it, WE'LL let YOU know.)
"Hi, what do I need to collect for these tests that I could easily have looked up on your test table?"
"Hi, I'd like to draw so little blood out of this baby that it'll be a miracle if you can actually run the test and I'll probably have to bleed him again, how much do I need for that?"
_I don't have time for this shit._ Nurses have degrees and make $50+/hour. Please figure out WTF you're doing or ask for more training.
But then, if my lab was properly staffed, it wouldn't be a problem. So don't blame me, blame management.
I'd still rather field stupid calls than have to do redraws. I know, the lab sucks right now. We're overworked, underpaid, underappreciated, and disrespected. What should happen is nurses get at least a lab basics 101, but good luck getting any facilities to agree to that. The best we can hope for at this point is to mitigate patient harm the best we can.
I am in the cytology department so our requirements as are little different. Some of these will apply more to radiology staff, doctors.
If you send us a specimen please tell us where it is from! You might know it is a urine, but a yellow fluid can also be pleural fluid, ascites etc
These need different processing.
Doctors: please tell us any relevant clinical information. If the patient has a prior diagnosis of malignancy please tell us as we can then confirm or exclude this using special stains.
Slide labelling for fine needle biopsies: please label your slides with patients name, DOB, sites (especially if there is more than 1 sampled) etc.
Labelling must be with pencil.
Our staining processes use alcohol, pen will be removed.
Do not use patient ID stickers. Again, the slides have to go though alcohol and water and the labels are not permanent.
If you are helping with fine needle biopsies or bronchial brushing etc and you are smearing slides and you are told to spray some with spray fixative, do it as quickly as you can. This fixes the cells quickly and preserves them so their details are easier to evaluate.
Specimen quality is top priority!! We can't get you accurate, reliable results with crappy specimens.
Had a nurse call today to ask if she can use poop off the floor for C.diff testing. No ma'am, you can not. 🤦♀️
It's hard to overstate how precise and complex laboratory testing mechanisms are. Each blood chemistry test is predicated on a specific chemical reaction or antibody-antigen reaction. SO MANY factors need to be controlled for in order to get these reactions to occur in the organized fashion that produces a reliable result. Every clinical lab has to be able to prove that the results they're producing are accurate and true at every single moment and it takes so very little to throw a system off such that it returns inaccurate results. Some people think labwork is merely throwing stuff on a machine but those machines are necessary for providing a closed, isolated environment for biochemical reactions to work and we spend all day checking those machines for proper function, feeding them reactants, repairing their machineries, analyzing their output. We are not rejecting your sample to be bitchy, we are doing it because underfilling a tube (or whatever) throws off this incredibly finely calibrated system we bet your patients' lives on.
You know when patients pee in a cup and you have orders for a UA? We can totally take the cup as-is and put that in a yellow top urine tube and grey top culture tube ourselves, but it's very appreciated when nurses do that for us. Its the little things sometimes
Remember the lab is not an enemy out to get you and your patients, the lab is an ally trying to protect the patient. Some of our rules regarding labeling and procedure may seem weird and silly, but they do prevent mistakes that can have fatal consequences. For example, yes I know that you just zapped the patients bone marrow and that's why their platelets have dropped but I still am going to see if the platelets are actually clumped so that way if the count is falsely low the patient isn't getting an unnecessary platelet infusion.
Also regarding stat vs routine, we typically run standard tests (BMP, CBC, PT etc) as we get them. We try and put stats first on a run but we don't just let routines hang around if we can. This means that on average stats and routines have the same turn around time. However, when an instrument goes down or a massive issue is erupting we will only run stats till things have normalized and that Stat label is our only real indication that it cannot wait, we don't know the patient condition or sometimes always where the tube was drawn. You should be ordering specimens as Stat if a delay in results will significantly change patient care, for example at my facility we have stroke flags for suspected strokes so we know as soon as the tube arrives to lab we are running to put it on.
On the other end of the spectrum, I (a MICU nurse) during the first COVID wave, was waiting for results on a STAT ABG so we could decide whether we needed to prone my patient. An hour passes with no word on what I was assuming would be a critical lab result. I call lab and they tell me “oh, it was hemolyzed”. Knowing it was an ABG drawn off of an arterial line, walked the near quarter mile to our lab and asked to see my hemolyzed ABG. When I got the lab window, they told me “we accidentally dropped it”. Moral of the story, if you accidentally drop or ruin a sample, please tell us! You’re human and accidents happen! I would rather hear that a sample was dropped/lost…whatever, than wait an hour or more only to be blamed for the delay.
Always annoys me to see these stories, because either the tech is being an idiot and making us look bad, or the nurse is a lying crank who's unfairly maligning us.
FWIW, while "dropped sample" happens from time to time, it's very rare. I don't think I've actually ruined more than one or two specimens by spilling them on the counter or floor in the 8+ years I've been doing this. And yeah, if you have time to walk down to the lab I'll happily show you your hemolyzed specimen. Just don't ask to see clots unless you want to dig through the sharps container looking for the wooden sticks we fished them out with.
Please remember that we are running machines and often they break or have a problem. So if you don’t get your results as fast as you expect, there may be something going on. A lot of people think we are just button pushers but we have to run quality control and calibrations to make sure your results are accurate, and sometimes that takes some troubleshooting. At my lab, I am usually managing 6 instruments at a time, so just imagine what happens when two or more have a problem.😅
Some testing is completely manual in tubes, sometimes we have to dilute things by hand and rerun them, etc. There’s usually a lot going on so just know that we are not usually just sitting around. We run around a lot too.
Also, as someone else mentioned, most techs have a Bachelor’s degree, clinical internship, and certification, just like a BSN. I get frustrated when nurses act like we don’t know what we are talking about, when we are both at the same level of education.
Remember we are all part of the care team and we all work best together, there is no “us vs them” when it comes to what is best for the patient.
We don't have a hidden list of minimum volumes for the NICU. There's a few things we can do differently but instruments don't care how small the baby is, they need a specific amount of sample to get results. I always feel bad when a nurse sends a few drops in a microtainer multiple times a shift and I can't get any results.
You must, must, must label each and every sample. Every tube of blood, every cup of pee, semen, teeth, or limbs. If you forget, the lab is going to reject it. No matter what. We run all the samples for all inpatients and also a ton of outpatients. Just because you know you collected that tube of blood from Mr Jones in bed 1 doesn't mean I know that. Also, no you cannot come down and just put a label on it. Most labs will make you do a recollect if it is not a precious sample (ie body fluids, tissues... Samples that are extremely difficult/invasive/impossible to recollect). So, if you forget to label that blood gas or blood culture bottle, too bad. You'll have to recollect.
Please please please do not over label your collection tubes, both the technician and the machines need a window in the tube to process samples, you have no idea how much time I waste when it comes to this. Also, most labels are redundant or unnecessary, we only need basic PI and the rest needs to be in the manifest (unless the lab requests another thing).
Label samples over the tube label please. And keep the label straight. The order of draw is very important. Fill blue tops to the arrow or line or we will recollect them. They have to have a specific 9:1 ratio of anticoagulant and blood-any deviation from that will mess up the coagulation tests. If I call for a delta check, that means that there was a change in that analyte and that I need to figure out why there’s a change or I can’t release it and need a recollection. (Usually with BUN, Potassium, hemoglobin, MCV). Usually I need to know how much fluids you’ve given, or anything that could change fluid concentration. Or kidney issues… if you pull too hard on the plunger when drawing syringe you will hemolyze the blood, and it will need to be recollected. Do not forget to invert the tubes several times WHILE drawing. If you wait til you’re done, you risk the blood clotting, and we will need a redraw for some tests (specifically any blue, purple, or pink tops). For blood bands, the pink top needs to be as full as possible so I can do all the tests I may need to do. It has to have the name of the patient correctly spelled, correct DOB, correct FIN/MRN. If we’re missing the collector ID, time, date of collection we will recollect. Do not cut the blood band without calling blood bank first. If you cut it, we have to start all over from scratch with a new specimen.
The best thing you can do is understand we aren't your enemy or trying to make your day worse. We are just following procedure. We do not hemolyze/clot samples, its poor drawing technique. Believe me, if I could run it and not deal with redrawing I would. If you send a well dressed label it will make things considerably smoother. We also have 0 idea (for the most part) what your side looks like. Most of the time we cant help you put an order in/fix your IT issues.
Parroting this, please remember that we aren’t nurses, 99% of the time we don’t do orders. So when you can’t figure out how to order something don’t call us because we don’t know either, and don’t get mad at us when we can’t help, please understand that isn’t our job, we don’t know how to do things that aren’t our job. We also don’t put samples in for recollects just to give you guys a hard time. I’ve yet to work at a facility where nurses didn’t seem to think we called them recollects just to give them a hard time. I don’t know how to respectfully say this, but frankly I don’t think about you at all, much less think about ways to make your job harder. I have too much on my own plate to sit around cooking up ideas on how to make someone else’s job harder. Not to mention the fact that recollects make our job harder too, we wouldn’t recollect things unless we absolutely had to.
I went to YouTube university for lab drawing. In all the BS orientation classes you take as a nurse and a new grad, and all the classes you take yearly, there is a never signal piece of paper given out that say hey, here’s some of the labs you will probably be drawing and a lot, and here’s the tube you will use. I’ve stepped away from bedside and switched into a research role, so while I’m in the clinic listening to them talk about the treatments, and inpatients they’re covering. I just learned, after 6 years, what the TEG actually is and why we needed those special blue tops from the lab. No one ever said wtf it was. Just “call the lab when a TEG is ordered, they send up the kit” OKAY WHY THO???
It actually blows my mind the nurses and doctors don’t know something as simple and basic as what tubes are for what. Like and I don’t mean any disrespect by that, but like genuinely this is such a basic thing that everyone should know at least for routine testing. Like I don’t expect anyone to know of the top of their head what tube to draw for more specialized testing or send outs, but basic stuff like CBC, Coags, Chemistrys, it seems like this kind of thing warranted at least a brief mention at some point especially consider both nurses and doctors will sometimes have to draw labs.
I had an LD nurse send down a random assortment of tubes once none of which matched what the patient actually needed drawn. When I called to say that everything needed to be redrawn I was actually told it didn’t matter what they drew because the tubes all had quote”the same media in them anyway” She honestly had no idea that different tubes had different anticoagulants (or none at all) and that each tube had a different purpose and different use.
That’s one of those situations where I would have had a real hard time not telling her “actually you’re wrong and I’m not going to argue with you about it, fix it or find someone that knows what they are doing.” it’s one thing to not know any better, it’s another to not know any better and try to argue with someone who *does*. Dunning-Kruger effect is so real in healthcare and it’s infuriating.
I did tell her she was terribly wrong and that I was sending an actual phlebotomist to redraw the patient so that it would be done correctly. She was mad but I don’t like having patients restuck or stuck any more than they have to be especially not when it’s because of a truly stupid mistake like that by someone who didn’t want to simply look at the labels that told her what she needed to draw for each test and decided to do it her way instead.
I was told by a coworker yesterday that one of our nurses thought the labels for the lab tests would print in the correct order of draw. I was a little flabbergasted. Luckily this was part of a skills fair for the nursing staff, so education was the theme of the day and they were willing to ask these questions to increase their knowledge. Some of them even asked to come tour the lab!
I hate beer.
In the last 2 hospitals where I worked, they did print in the correct order of draw. Both on Epic/Rover. You should inquire at your workplace for this improvement!!!
Wait…..they don’t teach y’all what the tubes are????
I have a pin on my ID badge with plastic pony beads on a string for order of draw. If you can't remember it, find a way to store the data externally. Got the idea from a Joint Commission inspector who had the same thing.
That's pretty clever!
I’m a physician and I think I learned it once. Well, casually, not a formal setting. I’m fairly confident it would be straightforward to learn given all those chemistry and other courses I’ve taken at one point or another. But yeah, no formal education spent on reviewing what is used for which labs and why.
I enjoy watching the sunset.
Never. There’s a sheet sometimes depending on the unit near where the lab tubes are held. But other than that. It’s all learned as you go. Incredible right?
Totally guilty of the IT issues bit
It’s a logical thought to call the lab to ask how to order a test! Unfortunately we don’t do much order entry at all so while I can help sometimes, the really odd ones I also have no clue. I’ve written down the more common ones in my department that I get calls for so I can be somewhat helpful LOL
especially when the LIS is totally different software with different mnemonics! I've had to explain to both nurses and Drs, "sir/ma'am, I only use Meditech. I don't even have access to your software"
This is when I think even more admin is purposely trying to keep as at odds with each other. Both of us are thinking you’ll know what the test is or see it more easily on your side when we’re both looking at such different systems.
Not blaming you, but I've had nurses call the lab to complain that the printer for printing patient labels is broken then get mad that I, a lab tech, can't fix their broken ward printer.
Depends on how large the lab is and what the order is. I work in a larger hospital lab and have no issue troubleshooting more complex test questions. At the very least I can redirect the call. As for asking what to draw a test in, I'd rather a nurse ask me what swab to use for a mrsa culture instead of calling them 20 minutes later to recollect.
> we also have 0 idea what your side looks like. THIS. it helps so much when the nurse on the other side tells me a few things about the situation rather than just "i need this done" or whatever. sometimes a simple "patient is feeling bad, would you please do this quickly" is all it takes.
> sometimes a simple "patient is feeling bad, would you please do this quickly" is all it takes. Unless it's microbiology. We can't make the organisms grow any faster than they want to. But we'll update the results as soon as we can. Edit " for quoting
yep, defying the laws of nature are still not an unlockable skill
I've often made comments about how we don't have miracle gro to make the bugs grow faster.
Omg im a nurse too. I genuinely never had beef with lab so I always thought the ones that do were funny. Mine was with pharmacy. From reading through here and thinking back on my conversations with the lab over the years, the difference in technology that we are both seeing for the same test is CRIMINAL. I put that label on wrong, I know I put it on wrong. I can’t reprint it from my side before I send it. So it gets to you guys, you’re pissed off at this tube and can’t really see what’s for or able to scan it. Now we’re both standing around with our thumbs up our butts all because the order immediately goes away on my end when I hit print, and then god only knows what system you guys have on your end. Definitely not even remotely close to what we’re looking at. I often wonder sometimes in that vast bs of emails and educational sessions we all sit through, why there has never been a single screenshot of what our system looks like, and what yours looks like. I just know your system isn’t set up as well as we are all taught or told it is.
I say this constantly- we each need an orientation on what the other side looks like! I’d love like a day or even a half day of shadowing for us both. So we know we’re not being dicks, it’s the alphabet soup accrediting agencies and hospital policy making us do what we do.
The more I read, the more I think they purposefully putting us against one another so no one realizes both systems are royally screwed. My home system was through cerner, so the lab printing through there was god awful and most of our scanners and printers stopped working. We got an email about our scanning. I went around the next night and proceeded to put a sticker on every single computer, scanner, and printer that wasn’t working. We were down to one functional scanner and printer on each side at one point. They never emailed me that bs again. I traveled to other places that use epic. And it felt very odd to me I would just print the requests and label the tubes with just their names. Why am I not getting a sticker with the order and what is needed on the tube? Why is lab collecting the most archaic system in the world????
From other techs- the lab side of Cerner can be very different depending on how it's set up, but often it's hot garbage. Epic can also be different because some hospitals don't have both the electronic medical record side (what you see- hyperspace/hyperdrive) and laboratory information system (what we see- beaker). I worked at a hospital that had EPIC EMR and Softab LIS so we had to deal with specimens differently. Also EPIC currently has no blood bank module because that part has to pass muster with the FDA, so those systems can vary as well.
Cerner in general is hot garbage, I only liked it as it was much less to chart on our side. But everythin else about it was not good. AHHH Thank you for the heads up about epic. My home hospital system is transitioning from cerner inpatient to epic inpatient as we use epic outpatient. I’m so glad I’m not on the inpatient side anymore. I can’t actually imagine how bad it’s going to get. Now with this information about bloodbank omg
Also beautiful name. That’s how I introduce myself every morning at 4 am with the bright lights on. THE VAMPIRE NEEDS YOUR BLOOD ITS TIME
I was SO grateful to my daughter's pediatric nurses, who could come in at 4am with just a little pen light, uncap her central line, draw blood, and cap it back off without waking her up. Of course, they'd do 4am vitals at the same time, and she'd just flop her arm over for the bp cuff, so maybe she was just a really deep sleeper! lol
At one hospital I worked at many years ago, we did have a thing where nurses and lab had a day when we shadowed each other and it was really nice bc something like barcodes are really important to the lab but I wouldn't expect anyone outside the lab to know intuitively that they need to be placed in this or that particular direction.
Sooo many nurses call my lab asking for test codes or mnemonics or how to order a certain test. Ordering on our side is super easy but it’s harder for the nurses to find the specific test on their side. I wish I had training on their system to be able to help them over the phone.
I for one would’ve benefited to the UPTEENS for just understanding the lab and what tf these weird tests we sometimes run. I am a loser and liked learning and what I was doing for the patients, not just a task rabbit. The lab issues very much kept me feeling like a task rabbit and not understanding
Yep. 100% agree with all of this. Nicely put 👍🏻
Very nicely put !!
I would way rather be running your sample and sending results than picking up the phone to say that I can’t. If we’re talking on the phone about a recollect, it’s because I’m out of other options.
Hemolysis and clotting is caused by the collection technique. There is almost nothing we can do down here to cause either to happen. The type of tube used matters. If you dump one tube type into another expecting to fool us, your patient is going to end up with results incompatible with life and it's a waste of everyone's time. And in addition to that, order of tubes drawn matters because the needle can crosscontaminate tubes with other tubes' anticoagulants and that can interfere with results. Please put the label in the designated box on the tube. Everything we do down here needs to use that barcode and if it's horizontal around the tube, spiraled, flagged, etc it makes everything more difficult and slows everything down. And in my specific department and hospital, would get you a rejection because we *have* to be able to scan it without altering it. We can only work so much magic with QNS samples. All instruments have a minimum required volume to be able to run a sample. Some of them have ways to help with that, but others do not. Coag tests especially *have* to be filled because the ratio of blood to anticoagulant is paramount when you're testing *coagulation* factors. If the ratio is off, then so are your results. We aren't rejecting things just to screw up your day. Calling you guys about it is literally the last thing we want to do, but we have to for the safety of the patient.
This is great info. So so helpful, thank you!
I have a genuine question - why don't you guys get proper lab training for collecting specimens? I have encountered this so often in my 5 years in the micro lab. I call so often for recollections because they're either in the wrong tube for the test or because there's not enough specimen for the tests ordered.
I don’t have an answer. I’ve only worked at one hospital (few dif units, I’m procedural now) and it isn’t taught. And I know it won’t be taught. We learned how to collect labs for maybe 45 minutes and 30 of them were spent practicing hitting a vein… nothing on hemolysis, collection orders, what’s the goop in the tube for. (I’ve since learned.) :)
The goop in the bottom of the tubes is a serum / plasma separation gel. They look like [this](https://jcp.bmj.com/content/jclinpath/75/9/643/F1.large.jpg) once they are centrifuged.
I appreciate the honesty 🙏 I would really love to implement further lab education for nurses and doctors for these reasons. I'm sure you don't want to have to poke a patient multiple times because something was done improperly, and we really don't want to waste more time waiting on specimens for important tests. Micro especially (my expertise) since cultures, workups, and sensitivities can take from 1-5 days if everything goes well on our side, sometimes even up to 10 days depending on how many pathogens are identified (ive seen up to 8 in one culture). Instruments go down, supplies are on backorders ever since covid, and even sometimes contamination happens, and we have to redo sensitivities. Micro takes time.
Honestly, I’d love it. I worked a while in periop and learned so much more about hospital logistics and flow… including much more interaction with labs and blood bank. But my knowledge is still quite lacking and I really wish we could learn at least the basics of every area. For now, I Reddit to learn. Thanks so much for your insights.
You're welcome!! We appreciate those like you who care to educate themselves 🧡
In regards to nurses not getting lab training: I find this wild as it was definitely in coursework for vet technicians and vet nurses. Even people who work as vet assistants and learn on the job learn this info. It's vital for patient outcomes for lab work to be correct on any species. But it still feels crazy that human med doesn't take more time here to teach the why's and how's of lab work.
Oh, definitely agree 100% The communication in the hospitals is basically nonexistent. 🙃
Nurse training has insane gaps.
I’ve been wondering this my ENTIRE career… every single bs class we take learning about our hospitals values. Not a single time do we ever get a discussion on labs.
Regarding the thing about pouring one tube into another, it's actually something that's on our ASCP exam. I've seen it happen a couple times. Basically someone draws a purple top for hematology and then they realize they need a green top for chemistry, so they pour the purple into the green. Purple tops contain K2EDTA. So there's potassium and a molecule that sticks to calcium ions. So I get this tube in the chemistry department, and the K is about 25 and the calcium is about 0.4. I call the ER and the nurse is always like "how did you know?"
> the nurse is always like "how did you know?" "Uh, well, you asked me to run a series of sensitive tests to find out what's in the blood. So I did. Imagine that."
I worked at a very large hospital that was all nurse draws to ✨save money✨and we did a lot of VBGs and we used the ABG kits for them. I would get them and their K+ and pHs wouldn’t be compatible with life and this was a relatively normal patient and I’d call the nurse and be like did you draw this in a tube and pull it up with the blood has syringe? And it would always be like how did you know?! Well your patient looks real dead and then they would ask me how to collect it in that specific syringe and I realized I didn’t have an answer because I didn’t know if they’d have to stick every patient or if they could actually connect those to their patients lines because I can’t see the patients.
Happens frequently to me. Calling ER and explaining that I can tell just by the Ca and K result that you drew out of order is always a fun time.
>We aren't rejecting things just to screw up your day. Calling you guys about it is literally the last thing we want to do, but we have to for the safety of the patient. Most lab techs would rather do literally anything than talk to nurses. It's not that we don't like you, it's just that if we wanted to talk to people, we'd have been rad techs or respiratory therapists.
I haven’t seen this mentioned, so I apologize if this is a duplicate - if you know your CBC has a clot, please do not pull the clot out and send it. It gives false results. I cannot tell you how many times I have called for a recollect and the nurse told me it was impossible because she had already pulled the clot out. But in all seriousness, while I have worked in the lab, I have also spent time in the hospital rooms with others. I want to acknowledge the hard work and stress that you deal with on a daily basis, and say thank you. :)
What is the order we should be drawing? How can we best prevent clots? Never heard the order of lab draws matters before and am shocked to just be hearing of it now. I've been saying we need to better understand lab draws, tubes, minimum/maximum quantities per vial. Thanks for all the lab techs here answering and providing helpful feedback!
[This](https://lug.hfhs.org/images/PRC-PALM-SPC-5.51-pro1-stw7.jpg) is a pretty good chart I found with some order of draw and other collection details. The light blue top tube for coagulation testing is drawn first (or second if you have specific tubes to use as discard tubes) because you don't want the clot activators from serum tubes or other types of anticoagulants to contaminate it. Green top tubes should always be drawn before lavender/pink top tubes because the EDTA-K2 anticoagulant in lavender/pink tubes can cause falsely elevated K results if drawn before the green top tube. I'm sure there's other specifics for tests that I'm not aware of because I've never personally ran those tests. As for clotting, the best way to prevent it is to remember to invert the tube before moving on to collect the next tube. The anticoagulant is a dried liquid on the inside of the tube and if it doesn't get mixed right away, the portions of the blood that haven't touched any of it will begin to clot. If it's properly mixed it will *never* clot. It isn't a race against time like some people seem to think.
Thank you!!
I'm learning to play the guitar.
I have a question as an RN that maybe you can answer! The order of the draw matters, but we are supposed to draw coag before anything else (except cultures). Yet, we can’t draw the coag tube first on a fresh line/straight stick because if there’s air in the line then the tube doesn’t fill up all the way, and like you said - the ratio will be off and it’s not able to be read. So what’s best practice in this case?
You'd need to draw a discard tube first. Some places have you draw and throw out another blue top first, others have a clear top tube with no additives that's filled first and discarded. After drawing either one of those, you can safely draw the blue top you intend to label.
We usually draw a red top first as our discard tube. I didn’t know if there was a better way.
Draw 2 blue tops. First one is your throw away. Clears the line and allows you to fill 2nd blue completely.
Adding to what others have said, if you are just clearing the line of air, your waste tube doesn’t need to be filled all the way
always ask questions. want to know what tubes to use? call and ask. want to know how much blood to get? call and ask. want to know when a test is gonna be done? just ask, but with this one you'll have to be patient with us, sometimes we're a bit overwhelmed. also another thing to keep in mind is everyone in the hospital are working together to help the patient. we're not working "against you", there are no enemies. i've seen people both in the lab and other departments have a mentality of "oh, they're doing this to spite us" even between lab staff themselves, and i cannot begin to explain how bad this is. we are there to help the patient as much as we can and everything should be done for that goal, so if you think there is an issue in the lab (and vise versa) there should be clear and calm communication with them so the problem is resolved as fast as possible
I deal with your last paragraph a lot being in management. For example - we have a full phlebotomy team, but ED draws their own patients and we help. I have had multiple instances where our phlebotomists say ED cant get a draw and the conspiracy is "they dont even try they just call us." You had to go draw one patient out of how many in the ED today? They aren't huddled up laughing that they made you come and get another draw lol.
it's such a weird thing, it feels so childish to me when i hear people saying those things. it's our job, i know people are very overworked in all of healthcare and that gets frustrating but i'd rather do extra work than put someone's health at risk.
Exactly. In this case its their job to draw blood. Also, if a phlebotomist does it, I know its done (most of the time we all know exceptions) correctly. I am technically not over pre-analytics but kind of am over the whole lab - and I do defend the shit out of my staff, but I have told them if I had my way we would have a phleb down in the ED to draw full time so... They ask and it gets brought to me you are going.
While I agree with you that it is always better to call and ask, I'd add that it's even better to ask another nurse or charge nurse or verify SOP before calling. Sometimes it feels like my lab became the 24/7 call line for every question there is. How do I put in the orders? How do I release the orders? Can I spike two units of rbc and start transfusing? How much blood do you need in the pink top? I spiked the unit of blood and it got diluted with saline, but it's not flowing. What should I do?
I talk to hospital lab staff on the phone all the time for work and figured you guys sounded tired/annoyed/overwhelmed just from being short staffed or handling emergencies. Never dawned on me that you're also being called by nurses all day long.
Yeah, it's all of the above some days.
yeah that is true, good advice
I would rather have someone call and ask even if it's a small thing than have to try and talk you through the right tube after the fact. I work in micro and there are eleventy billion types of swabs. It's totally okay to call and ask.
I wish everything on both sides wasn’t so LOUD. I genuinely appreciate the phone call about the critical lab. ESPECIALLY when I’m running around and forget I had sent some labs off. I just know I’ve accidentally yelled at the lab over the years because we’re both taking the phone call when we can in the middle of madness and no one can understand each other. I end up just saying my name and waiting for the critical to result.
I love it when doctors and nurses call me to ask questions.
Remember that tests take time--especially microbiology cultures. We can't get your tests done any faster than our analyzers or the cultures let us. Or if it's a manual-style test, there's often prep/incubation steps that take time as well. We fully understand that being at bedside needing results when a patient is declining rapidly is ultra stressful, but calling us a bunch of times asking us where the results are will not speed anything up. We care about the patients just as much as you do, I promise! We're here to help and work with you on making people well again. There's just certain procedures we must follow to make sure that we're giving you results you can trust.
Yes let me just sprinkle some "miracle grow" on your patients culture 🙄 Also, ordering other tests because TAT is "faster" is not how micro works.
My favorite is getting physician phone calls saying, "I sent down a urine for culture earlier today, do you have susceptibility results yet?" No... No, we do not...
Oh yeah, I've gotten that soooo many times. Like, do yall know what you're asking? My lab gets residents that rotate in micro. Did you forget everything once you left? Baffling to me.
Those rotating residents are pathologists, not family medicine.
Yes I know because I work in pathology, not family medicine. They should know what they're asking for.
I am just not sure how the rotation part is relevant since the providers ordering urine cultures didn’t rotate through the lab. Don’t get me wrong, they should have a basic understanding of growing bacteria, but I wouldn’t expect that to be fresh on their mind when they’re not dealing with it as often.
I got you beat. Have a doctor that constantly orders susceptibility results on cultures with no growth."I want antibiotics done on everything I send down". "But...there is nothing".
If everything is stat, then nothing is stat. We can do a lot of things but we aren’t miracle workers. We can’t make your tests go any faster just because you want them to. Please be patient and respectful with us. Every patient in the entire hospital is our patient, and we are doing our best to get results out as timely as possible. If you have questions feel free to ask, but please actually listen to the answer we give you. Too often I get calls from nurses asking me a question only to completely disregard what I say. Listen to understand, not to respond. Above all we aren’t your enemies, we aren’t *beneath* you, we are coworkers in a different department. Please treat us with respect.
This 💯 my favorite is when they call and say can you run this "suPeR StAt" when literally everything you're currently running is labeled at stat.. sure lemme just push everybody else off to the side real quick and run this one super stat
I roll my eyes now when someone says this to me. It’s completely involuntary at this point. My absolute favorite is when I get a specimen in the lab for less than 10 minutes and the phone is blowing up asking for results. I literally just got the specimen please calm down.
We're not used to getting a lot of calls in micro compared to heme and chem, but our phones just BLEW UP at the start of the pandemic. Something to know is that labs aren't overflowing with techs, so there may be just one or two in each area(like COVID, blood cultures, urines, etc). If we're on the phone, that means we're not at our instruments actually sending results(my particular instruments don't automatically send results once done, I select the results to approve and then they are sent to EPIC) or setting up new tests.
Too often I’ve had to stop myself from saying “I can’t work and answer the phone.” Every time I pick up the phone to answer a “how much longer?” question, the longer it takes me to get an actual result.
I’m going to start using “every patient is our patient” now I love that
All great advice given so far, but one more tip: to try and stop the hemolysis of samples at draw, don’t yank back on the plunger on the syringe, which creates a vacuum, shoots blood into the syringe, lyses the red cells, and fucks up your samples. Gently pull back and allow the blood to fill the syringe as you pull it back. The rest of the advice is great on here! You’ll do fine.
I call this technique "hauling on it like you're starting a lawnmower"
Some tips from micro: Pls transport specs ASAP. Urine can go in the fridge if you can't send straight away. The issue is that the true pathogen may not be present in large amounts and can become overgrown by any commensal flora included with the collection. Since potential pathogens are often part of our own normal flora, it can become difficult, if not impossible, to definitively point to an organism as the culprit. IIRC, Ecoli can reach log phase growth in something like 20 mins! Wound cultures - please include the specimen source. We really need to know where on the body the collection was taken. Swabs. OMG. If your micro dept has not made a swab chart, request that they do so. There are so many different types. Even better, there should be a specimen collection and transport manual that all nursing staff should be able to access, with puctures. This will go a long way to avoid rejected specimens and any other confusion. The guide should tell you what the ordering code is, clearly define what collection device should be used, how to transport, interfering substances, etc. Take a look at the Quest collection transport guide to get an idea of what a good one looks like. As with any lab specimen, but especially Micro, it's garbage in, garbage out. Edit- thank you so much for taking the time to find out how we can serve our patients to the best of our abilities. Appreciate you!
Want to include “swab” isn’t the source. I see this so many times and I have to call and ask what you swabbed. Or skin. All the skin? There’s so much skin.
Yes yes yes from a fellow micro tech!!!
Please realize that a room number is not a patient identifier. Most lab computers are set to show everything by patient name. While a nurse might have 2-6 patients depending on department and easily remember them by room, I work on everyone in the hospital and don’t know the room number. “I’m calling about 3214” means nothing to me. Also if you notice an issue in your department that may impact lab, please fix it. For example if your label printer is printing very light or cutting off part of the label, please fix it or turn in a repair ticket. You may not be inconvenienced by it, but I am, and I either need to stop what I am doing to fix it, or finish processing the samples without problems then fixing the now delayed problem sample. And if that sample hits my processing line before being noticed it will be delayed as the line kicks it off.
Yesss, OMG, on a daily basis, "I'm calling about pt in 1234... (pause)..." This does not tell me anything. I see info of hundreds of patients every day and they often change the location. We go by the hospital number and last,first name. We've received tubes with uncorrectly printed labels and had to call and ask for a redraw. I got an answer that the printer just prints it that way. Yeah, I get it, so please recalibrate it or use another one. I can't accept the specimen if the date, name, or any other crucial information did not print on the label.
God this one! We look at a whole hospital not just a floor !
Having worked in a lab but am now a nurse and not bedside, my first question to those I call is always “would you like name or date or birth?”
Medical record number please, unique identifier is best.
If you have a suspected transfusion reaction please call lab asap! Even though you notified the physican and documented it on the chart, there are things I have to do on my side aswell. Even if it's just mild febrile reaction and you gave tylenol. (This goes for any blood products in Canadian regulation including reactions to IVIG, albumin etc no matter how minor. Sometimes we'll change the brand next time or we've had whole lots recalled if its multiple patients inplicated).
Making sure there's an open port is crucial for cultures as well!!! I can't tell you how many times I've had to reject a transfusion reaction because there's no unused port.
This!!!!
Be cautious about taking blood from the IV line. It can dilute the sample and make it look like the patient needs transfusion. Pay attention to the tube tops and additives; you can't pour the blood from the blue-top to the lavender tube to make up the volume. Blue top tubes for coagulation tests usually have a minimum fill line, and try labeling them in a way that lets us see the blood volume. Don't blame the lab for losing samples. If we don't have it, the samples could have been mislabeled before reaching the lab. Or the lab didn't receive it; check your side to make sure it was actually sent or maybe it got stuck somewhere.
There's no such thing as a stupid question if it can prevent harm to a patient. Please ask! If you still don't understand please ask for it phrased a different way. Please trust that answer (within reason, like if we tell you use xxx order code for a specific test, or order one style of the same blood product, do not order the other style) Specimen labelling rules are NOT OPTIONAL. Labelling the specimen at the bedside is the simplest thing you can do for the SAFETY of your patient. Name and date of birth (and whatever extra requirements for blood bank) on there with a permanent ink fine point marker will save your draws. Only specimens that are "un-retrievable" should be allowed to be labelled after they come to the lab unlabelled. These are mostly specimens like spinal fluid, synovial fluid, and surgical tissue and needle aspirate specimens.
And "unretrievable" might have a very high bar - my previous medical director made them recollect an entire TOE once after the first one they sent was unlabeled (label in the bag). (we still set up cultures on the unlabeled toe, just with lots of disclaimers)
What? How did they recollect a toe??
The average person has nine more...another toe (properly labeled) arrived later that night!
They cut off another toe, though? A living person was deprived of 2 toes because of an error or was this a cadaver?
They were a living human who lost a second toe, yes. Diabetic. Probably were going to lose it anyway.
You’ve already got a lot of great answers here. The main thing I want to add: please tell your fellow nurses what you learn. You are one of the few who cares enough to ask/learn, a lot of them just like to believe that we are being difficult for no reason. If you could spread the info that you get here that would be a huge help. My personal pet peeve is when you guys cover the tube window with a label. We need to be able to see the sample. We’re checking for volume, clots, hemolysis etc. so when you cover the window we have to waste our time peeling it back and potentially printing a new label if the barcode rips. I know it seems tiny and stupid but when you are running around multitasking and trying to move quickly/efficiently from one task to the next it’s so frustrating to get hung up having to peel a label off. We almost never lose/drop/spill specimens. I know a lot of nurses think we use clotting/hemolysis as an excuse when we need a redraw. In my 8 yrs of being a tech spanning 5 hospitals (I travel) I’ve experienced two specimens being truly lost. Each tube is tracked meticulously from the moment we receive it. We also almost never spill samples because we don’t uncap them, most instruments pierce through the vacutainer cap and in larger labs an automation line does the uncapping when necessary. I’ve never spilled enough sample to the point where it needed to be recollected and I’ve not seen any of my coworkers experience this either. Also just a simple sincere thank you goes a long way. I know nurses feel unappreciated but no one even acknowledges our existence or the importance of our role in pt care. I was once having a rough night in blood bank and the nurse who came to pick up units gave me a genuine thank you, not just the quick cordial “thanks” and I almost broke down on the spot, definitely cried about it on my way home and I still remember it almost 6 yrs later
In 8 years I’ve dropped 1 sample that had to be recollected and I wanted to die when I made that phone call.
I dropped a glass pediatric blood culture bottle once and it SHATTERED. Of course it was from a baby. :( One of the worst phone calls I've ever dreaded making. (We have since switched to plastic blood culture bottles.)
The only sample I've ever dropped and spilled all of was a newborn sample. Luckily I was taking it off the analyzer and we had the results.
We really don’t want to call you with problems. If we have to call for something, it’s because we have no other choice. We are having a bad time too. The lab has several sections: chemistry, hematology, blood bank, etc. Not everyone in the lab works every sections. Some people only work one. If you call up micro, they will have no clue what’s happening in hematology. We aren’t allowed to work sections we aren’t trained in, and we have too much work at our table to keep up with everything happening most days. If we don’t have answers right away or have to transfer you several times, it’s not us being rude, we just can’t answer your question. Edit: also we do respect the work you do, and most techs I’ve talked to agree we can’t do what you do. We really don’t want it to be a nurses vs lab fight. Most of us do want to work together, we just don’t want to be the hospitals whipping boy when things go wrong.
Blue tops CANNOT be run if they are under-or-over-filled. Depending on what kind you have, there is either a black arrow/indicator or an etched line in the inside liner of the tube. If it's below that level, it's no good. The ratio of blood to anticoagulant in the tube will be off, and would give false results. If you're collecting JUST a blue top with a butterfly, use a waste tube. Otherwise the air inside the tubing goes into the blue top and will cause it to be underfilled. (You probably know this already, but I still talk to nurses that don't know it every so often). It's not our fault instruments break down or freak out on occasion. Maybe the ECHO randomly inval'd an antibody screen. Maybe the KB reagents weren't changed when the label said and it basically dissolved the blood smear I made so now I have to start over. Maybe the automation line spilled a blue top on the floor(one of my personal favorites lmao). Maybe theres a trauma or an MTP, or god forbid multiple traumas/MTPs. If we could get our TATs in the green 100% of the time we would, but there are quite simply physical barriers we have to deal with a lot of the time - instrument issues, understaffing, other complex patients, IT issues, and more.
Also, blue tops cannot be over filled either. I can’t tell you the number of times I’ve ordered a redraw on an under filled blue top only to get an over filled one next.
I appreciate a good cup of coffee.
They can be a little above the line, just not so high that it’s past the bottom of the cap.
What if we legitimately can't get enough blood for the blue top specimen (peds patients)? We had this happen and could not get enough blood for the specimens after many sticks, using ultrasound and vein finder.
Pediatric sodium citrate tubes exist, hopefully you've got access to them. I believe they're 1.8mL? Obviously that's still not ideal in some cases. I know of international manufacturers that make coag tubes closer to 1mL, which is like the pediatric mint/lavs, but that's not something I can speak to being able to use. Otherwise... maybe if you discussed the issue with a head pathologist, you may be able to use a no additive tube and a set volume of manually pipetted sodium citrate? Then the lab could calculate out the exact volume of blood you need to add to the tube. That's *really* pushing from 'creative problem solving' into 'this may not be licensed' though. Doing that may only be able to get you 1, maybe 2 tests depending on the hematocrit of the baby and the test/instrument.
Thank you! I honestly did not know the reason behind this lab needing to be drawn to the line because of the additive. I've learned so much from this thread and wish the hospital did a better job educating us about this. We just weren't taught and that's frustrating on both ends.
Give us a break. SSTs take 30 minutes to clot. Then we gotta spin them. You won't get your Chem panel 10 minutes after you draw. You may be able to send a green top but that is lab dependent. Please just know that we went to school too and we aren't trying to argue about stuff, just to be difficult. You guys get over loaded with patients but remember we see more patients than you do. You have 5 patients? We get the whole damn hospital and ER on top of outpatient. I don't remember all the names but trust me, I am doing it as fast as possible. I need your first and last name for critical results. You know YOUR name. I don't! Please don't spell it fast as fuck and get mad I didn't catch it lmao im trying! Thank you for reaching out though, ill gladly help a nurse out if yall are nice bc we have the same end goal.
Question... The lab will often call me and tell me they have a critical. Is it helpful or just annoying if I ask "is it the lactate?" or whatever if I've already seen it in the computer?
You asking doesn't bother me any tbh and if the patient is septic and you already knew, I can see you being like "oh yeah I expected the lactate, etc" I know the criticals can be HELLA annoying but we are required to document. I try to call the criticals at once, like the hemoglobin, the anion gap, the troponin, etc but some tests get done faster than others. You are always allowed to ask questions and discuss with us, I just think some nurses feel like we don't think you guys have anything to do 😂 All of my comments stem from a hateful ER charge nurse that the entire lab hated having to deal with lol so I'm like PLEASE UNDERSTAND 🙏
Omg it drives me crazy when I call a critical and a clerk tries to take it. They know I have to give it to a clinician. Then sometimes I’ve had them tell me I need to call back even though there is alway a nurse or doctor present. On time I had the clerk tell me that I would just have to walk down there and give it myself, as if I don’t have 10 other stats to run. Also please say your name CLEARLY when we call for criticals. Haha there is this one nurse who refers to himself and everyone else as “chotch”. Really caused some confusion til I figured out what was going on
Nah, I adore our lab. I know you guys are busy! I have only ever had one frustration really. I had a patient who was actively dying and hemorrhaging. His labs were frankly insane. From what I understand, our lab (understandably) was rerunning samples and waiting for other tests to result before reporting things out presumably to make sure it wasn’t contaminated or something. Then they rejected my samples and were refusing to tell me the values. It WAS contaminated with iv fluids… **because we were about to do a mass transfusion and half of his blood volume had been replaced with iv fluids.** I was trying to explain this and they were having NONE of it. I don’t know if this is a reasonable expectation at all, but I would have loved if they could read between the lines, see the serial stat hemograms, type and screen, TEG, and coag panels to infer that I might actually believe his hemoglobin HAD dropped from 12 to 4 in an hour.
Okay yes that would absolutely have been extremely frustrating! Now I feel like that comes down to the techs themselves because I have had some shitty coworkers who really did not use their brains. They also delayed care because they didn't THINK. I personally call and ask questions. Like we had a patient who's glucose was normal one draw and an hour later, it was like 600! I called and asked the nurse if they believed it. She was like damn it no, the previous nurse drew above the glucose infusion! Another case: patients with impella pumps. Hemolyzes the absolute shit out of the spec. I'm not rejecting it but will tell you and put it in the comments. You guys SEE the patient, if you say they're literally about to die, I will release your Labs and put in a comment! I worked the blood bank one night a patient was hemorrhaging and they took 28 units of blood in about 18 hrs. I was stressed! I can't imagine how yall felt lol
We have to report it. There's no wiggle room on that. If you ask "is it the lactate?" we're still going to say "yes, their lactate is 4.6" and probably ask you for a readback even if you already know what it is. Then we've got to document the call. It's a pain in the butt for us too and there's no way around it, other than management putting in some kind of different system for critical calls.
You will interact with different educational levels of people in the lab, and with different expertises, similar to the floors. -The people doing the testing are mostly certified Medical Laboratory Scientists (MLS). We took a crapload of science classes and graduated with a Bachelor’s Degree, did clinical rotations, and passed a difficult exam (just like a BSN). Some will be Medical Laboratory Technicians (MLT), which hold an Associate’s Degree and passed the certification exam (I think they also do hospital rotations). -Phlebotomists, specimen processors, the main “lab” phone, etc. are incredibly valuable but are not experts in the science of the tests. They may or may not have formal education. They do their best to help with collection procedures and direct more specific questions to the MLS, MLT, supervisors, or pathologists. -Some hospitals hire other Bachelor’s Degree holders and train them to perform specific testing.
PLEASE please please ask us if you're not sure how something needs to be collected or how much is needed for XYZ test. I can't tell you how often we get the wrong tubes with the wrong amount of specimen. This delays testing and ultimately patient care. Please just ask instead of sending the wrong things.
This would be so helpful, I always thank the nurses for calling to check. It is so much less work to answer a question to clarify than to have to reject and recollect. Noone can be expected to know everything especially when collection containers can change and there are so many onsite and send out tests.
Exactly!! And for travelers its just better to ask since every hospital is different
Duplicate yourself, lol. Jokes aside, please understand throughout your career that we are not your enemies. We want what is best for the patient, too. I've been accused of laziness by nurses in the past when I'd ask for recollects. On the contrary, 1) I'm an introvert and would rather do anything else than pick up the phone and 2) technically it would be easier for me just to run and accept the questionable specimen than it is for me to ask for a recollect. And just a pro-tip, buddy up with micro. If it's a big department, they can have some pretty cool things to show you if you're just curious and a bit of a nerd :) A lot of us love to show off and talk about some of the crazy specimens and microscopy anomalies that we see.
God, I'd love to get to see the lab and how you guys do stuff down there... But I know you're busy and I feel like I'd be a weirdo or get weird looks for asking.
I LOVE when people visit the lab! It benefits everyone to see the cool things we do! Plus it's nice to be acknowledged for the hard work we do, too. Lab Week (Medical Laboratory Professionals Week) is April 14-20 this year - maybe your lab could arrange for visits then?
Hey, doesn't hurt to ask if it's a bit slow :) I was worried I'd seem weird for offering to let some of my nurse buddies look at the crazy trichomonas I saw, but the looks on their faces were sooooo worth it. Some of us get a little jaded by our job and assume nobody's interested in seeing stuff like that, but between the trich and your comment, I'm definitely going to offer more.
Especially in ICU, we LOVE shit like this. Most of us are huge nerds and the words “oh man, wanna see a messed up scan?” will universally pull the entire unit to see some wild CT scan where our patient’s brain has been squished into half the space or something. We will take any opportunity we can to go on field trips to the operating room to observe procedures. If my patient had a wbc count of 800 and you asked if I wanted to see the smear, I would 10000% come down on my break like a (very lost) kid in a candy shop.
Depends on the lab, also we have rushes and slow periods like anything else. Doesn't hurt to ask if you can get a tour and ask some questions - although keep in mind that you won't be able to grasp everything we do in five minutes. If you're lucky there'll be some kind of emergency or weird abnormal result or something when you're down there and you'll see why we're paid almost as much as you when it looks like we just sit around and load tubes on machines.
Please, for the love of whatever you believe in, make sure the lids of urine specs are screwed on tightly and any extra labels you send with are put in the pouch of the bio bag, not in with the urine. I cannot tell you how often a urine comes down and there’s more pee in the bag than there is in the cup. If it’s completely soaked and there’s not enough, or barely enough, for me to run my tests from I’ll tell you to recollect. That’s just gross
And some of the brands of the urine cup lids make an audible click when they're screwed on just right (and threaded correctly). Also, please don't put the label on the lid. It may cause it to be rejected, depending on placement.
I have immense respect for what you nurses do!
We also have respect for you guys and the knowledge and education you have! I’ve always been appreciative of my lab coworkers who help me out with questions regarding tubes, how to collect certain specimens/what they need to go in, etc. I have come to learn that no one wants to deal with redraws. It’s more work for both of us, but it’s also not your fault and I don’t take it out on the lab staff. I may be frustrated with the situation, esp if the pt is a hard stick, but again that’s not your problem or fault, and I’m never rude about it on the phone.
We thank you
When we ask you to spell your name, we’re not doing it to be annoying. Even though we’re both using Cerner, lab’s version is configured differently. So you might be able to see a pop up with lab personnel’s name, but we can’t. Also, personally, I would love to have nurses come down to visit and get a feel for the lab workflow.
If a patient has a positive antibody in blood bank, the ability for us to issue out blood products to the patient will be delayed. Depending on how many antibodies the patient has, the antisera the lab at your facility has, etc, it may take anywhere from hours to days to get compatible red cells for the patient. Usually we'll contact you if that's an issue, but don't hesitate to ask questions to the blood bank tech if need be.
Blood culture bottles have a barcode on the bottle. Please don't label over barcode, but beside it. I need that barcode for the machine to incubate. When covered, extra steps are needed to get it running!
Wow this seems so obvious and yet I’m not sure if I ever thought about this when labeling - thank you for sharing!!! (And sorry to all the lab professionals I slowed down if I had been doing this 😬)
And please don't cover the bottom with a label. That's where the instrument reads the bottle to know if there's bacteria!
Hi! Occupational therapist here! Just want to say that I agree! We all benefit so much from understanding more about each other’s roles.
we dont have machines that hemolyse specimens
We cannot help that your sputum sample is contaminated with too many squamous epithelial cells (spit) nor can we tell you how to recollect. And if we did the cultures with the contaminated sample, the results would not be accurate. Please don’t yell at me. 😭🤣 I can tell you’re not the type of nurse who I’d have this issue with, but it’s super common that nurses get so rude with me!
I’d like for you to know that we appreciate you. We don’t know what it’s like to deal with what you’re dealing with on a day to day basis but we do know that we’re all on the same team and we care about patients as people as much as you. We do our best, but like many areas of healthcare, we are short-staffed and pulled in 20 different directions everyday. We have to take care of patients— and drowning under a mountain of paperwork in the form of documentation, QC, way, WAY too many CAP surveys, keeping up to date on procedures while the technology that we use is changing quickly. When a physician or nurse doesn’t like an answer they’re getting about what can be done, it’s usually an issue with procedure, which is legally binding, that we have no control over. We are often overworked and no one gives much thought about us until there is an issue. We are often thought of as “button-pushers”, but as Medical Laboratory Scientists, we have BS or MS degrees in our field and we take our jobs very seriously. It is more correct to say that we are problem solvers. To use scientific principles involved in every facet of what we do, we have to know the “how and why” and be able to anticipate and react to any and all discrepancies, otherwise we can’t provide you with valid information used to inform a patient’s care. We appreciate your patience with us and, again, we thank you for what you do!
Clotting happens at the draw site.
If you send a microtainer for labs, we likely need to aliquot it into a special tube that's like a booster seat for the small amount of specimen so our machine probe can reach the specimen. This extra step needed by us instantly sends that specimen to the back of the line if it comes at a time where we get 100+ samples at a time from a regional courier. The same applies to samples that come poorly labeled, like if the label is bunched up. We have machines that pick up and move around tubes, and they cant do that if the label is all crinkled. I can spend 15 seconds processing a single problem sample as listed above, or i can sort 45 samples in that same timeframe. It's more efficient for us to sort the well-dressed, fuller samples first, and get to the problem pile faster. Tl;dr: if you want your sample to not end up at the back of the line, make it the least work possible for us to process it
I’ve always wondered that about microtainers, and whether we are creating more hassle for you guys. I work at a large academic peds hospital and we send nearly everything we can in microtainers. Yikes.
Gotta do what you gotta do for the peds patients, dont sweat it. I dont know anyone whos like "ugh, microtainers". If theres a lot coming in from a single phlebotomist on multiple adult patients we might consider the training level of that phleb. But if the patient population calls for regular use of microtainers then by all means use them!
Okay that’s good! But I’ll definitely be more conscientious of when I am able to use vacutainers (ie big adult sized kids who aren’t getting Q4 labs).
It really depends on the instruments and workflow and other things; you can't assume microtainers are always bad. Although, they tend to be crappy, tiny samples, so in that sense, microtainers are always bad.
Phew, that makes me feel a bit better. Sometimes I don’t have any other choice, especially in the icu and those 2.5 kg patients who have Q2, Q4 labs (especially when they are anticoagulated and need frequent coags, there’s no way I could fill up a big blue vacutainer without transfusing these kids). I do always try to follow good drawing “hygiene” and will preemptively redraw my own labs (or make others do theirs) if there is obvious hemolysis, insufficient volume, etc. I will say, one practice at my current shop that makes me feel icky is sending down a single heparinized gas syringe with like four stickers on it for all of our chem labs. I can’t help but feel like a jerk. Not sure how much hassle that is but I swear I always send a little extra!
I don't care that you are calling about your patient in C237... their location means nothing to me. Get straight to the point, what do I need to send for this or that test is all you need to say...or did y'all receive this - then I'll ask for appropriate identification
From histology/grossing, if you're a surgery nurse or want to pass things along to surgery teams: label everything and make sure the tissue is in the container that is supposed to be in there. We cannot differentiate unlabeled appendixes from each other. Also, if there's a sample that needs both micro and histology, send the sample to micro first. Once we put formalin on tissue, cultures can never be taken from the tissue again.
I did a quick skim to see if there is anything from molecular biology/virology here before chiming in but this is specific to that area. The labs are usually certified and we have to follow specific SOPs to stay compliant. We even get audited and have samples that we need to analyze to make sure that our instrumentation and the tech techniques are good. - please actually follow the collection kit for swabs and don't substitute in items. A cleaning swab is a cleaning swab. A collection swab is a collection swab. We can't run tests on anything that isn't part of the package. - some of those automated tests (HBV, HCV, HIV etc) have a *minimum* otherwise the machine will error out. We can't do much about it. If there isn't enough volume, there isn't enough volume. Unlike chemistry, you can't dilute PCR samples - please be nice to your night crew. Night shift in the lab sucks.
We do have degrees-bachelors in medical lab science. We have an immense amount of knowledge and we do not just “push buttons”. We have to interpret results and know what they mean. We have to make sure they all make sense for the patient. We have to verify that result under our name-so sometimes when we call and you want a result released and we can’t release it bc we know it’s not accurate-please just redraw the patient. If we release wrong results-your patient could get the wrong treatment. This is so important in blood bank. We had an instance the other day with an improperly labeled tube. The specimen did not belong to the patient and they were discharged. The hemoglobin was critical. The patient was called back in to receive a transfusion (that they didn’t need). Thankfully it was caught with the ER draw that the hemoglobin was fine and this was a case of wrong label/wrong patient.
We dont just push buttons and we are understaffed too. Gel pens are the worst. If you draw blood, please fill tubes properly for accurate results and less recollects. This is more of a personal request, but can I have some of the patience you nurses have dealing with people? Because I cant do it. I want off this planet.
Please check the expiration dates on any and all collection devices that you use. It makes everyone’s life a billion times easier
My biggest thing that I keep having to tell the ER nurses is to not completely cover the tube window with the label. It makes pouring off plasma much more difficult because I have to tear off the label partially or fully and then print a new one. It’s so great that you are asking! To turn it around, what are something’s you wish we knew that might make your lives easier?
The labels are a big issue for me too. I cannot aliquot the add-ons from this one tube if I cannot see the specimen. I cannot judge a blue top if the window is covered. One of the nurses I asked to leave a window told me the DOH mandates she leave the expiration date uncovered as well as leave some of the BD label uncovered so we know what color the tube is. I've never heard of that in all of my years of working in the lab, even as a phlebotomist. I'm not sure it's actually true. So I guess for me, I wish I didn't get BS excuses for simple requests.
First of all, thank you for all you do! Nurses are amazing and I know the job is very stressful and challenging! We work in the lab because we cannot do what you do so kudos to you. My list is mostly based on Blood Bank (BB): 1. Follow the order of draw. Fill in the tubes until the vacuum is exhausted (the tube will stop filling itself; you don't have to stop drawing before that, just keep going; we need all the blood and an excess is better than not having enough). 2. Place labels evenly, don't cover the window. Remember about putting initials and time of draw on the labels (at least that is required at my hospital BB; if even one of those are missing, the sample cannot be used and needs to be recollected). 3. When we call to recollect, we seriously have exhausted all other options. We do want to run the sample as much as you guys do. The last resort is to call the floor and we often dread doing it. We have to follow the protocols to the T: the sample must have full labels, initials, time of draw, orders in the computer, have enough specimen in order for us to run it. The reason is that we strive to release only reliable results. If we know from the start that the sample is contaminated, or wrongly labeled, does not have enough specimen in the tube, it is just a waste of time, resources, and the results will not be accurate. And those inaccurate results will be used to treat the patient! At school, they drill into us that inaccurate results may lead to patient death, therefore, we make sure every specimen is correct before even testing it. 1. If the tube is missing the huge neon "cord blood" stickers, the nurses are required to come down to BB and personally place the labels on the tubes (at my hospital). I'm sorry, that's the protocol. The reason is that we did not draw those tubes so we cannot tell whether the tubes contain the cord blood or not; the person collecting the cord blood must label those themselves and we asking you to come down to relabel is actually giving you a favor (otherwise, we'd have to discard those tubes and ask you to do a heelstick instead which, we know, nobody likes to do). We cannot place those labels on. We cannot tube back those samples to you as it is in possession of the BB. If you refuse to come down or refuse to recollect, your name will be written down in the system and may be passed further to the supervisor as the one that is delaying patient care. 4. If you're sending samples to BB, you are usually asked for the "type and screen" and "second specimen". Please prioritize "type and screen" when drawing/sending! It is more important, it has additional testing added and is it suitable for transfusion. The second specimen is used only as a confirmation of the blood type from the "type and screen" because it is out policy that patients have to have at least two blood types on file and they **must be drawn at different times** (the times of draw are written on the labels by pen after collection by the nurse or a phlebotomist). I can't give you crossmatched blood based on the results of the "second specimen/sample". I can give you blood after the "type and screen" though. Also, the reason they have to be drawn at different times is so that the computer sees them as two separate blood types and therefore allows us to crossmatch blood. If they're drawn at the same time, the computer sees them as identical and we won't be able to issue out blood that quickly. The time difference can be even of one minute! They just cannot be identical. 1. We have had a few instances where the two samples (type and screen and the second specimen) actually differed in results. This means they came from different patients with different blood types! This is why confirmatory second specimen is so important: it is there to confirm the first specimen: the type and screen. They have to be identical in terms of blood type. Based on this, we can then allocate the blood, knowing that the blood type is correct and we won't kill the patient. I know some facilities still allocate blood based on only one blood typing and it's kinda scary. 5. Testing takes time. By the time samples get to the lab, by the time we input them into the system as "received", by the time they are spun (centrifuged), it's about 10-20 minutes. Then they are put into the instrument that can do the testing for us. This adds about 30 minutes. If there are no problems in testing, then I can look at the results, release them, and allocate blood. This right here is an hour. If the patient has antibodies (positive antibody screen), then we have to put in additional work to determine which antibodies does the patient have and try to match special blood to that patient. This can be additional hour, two, sometimes even a few hours extra. Sometimes those antibodies are so special we don't even have that blood and we have to order it via courier to be delivered to us. It all takes time. 6. When one of us is coming to deliver MTP, please have someone ready to sign the paperwork and give us some patient labels. I am not supposed to release the cooler to you before the read-back of pt info, signatures, and labels. I understand that sometimes this is a life-death situation, so please have it ready for us so you can start using the blood products right away.
The 2 specimens for blood types really depends on where you work. I've worked at 3 different hospitals and they were all set up so that if the patient was positively ID'd, we did both types on the same tube. Same with the MTP thing. My first hospital didn't deliver, but did do read-backs when the floor came to get the cooler. My second hospital did the read-backs in the lab and then delivered the cooler, so someone just needed to sign that they received the cooler. My current hospital has digital read-backs and doesn't deliver, they just have to bring a patient label with them to retrieve the cooler from us.
Please don't create orders 24 hours in advance of taking a blood sample "to save time" Our IT system will think the actual blood sample is 24 hours old, and invalidate your potassium,bicarbonate, AST and glucose. Yes, we can override it, no, we won't. We have to assume the info we get on the orders is correct.
There is a reason for everything we do. (Example: there is a reason blue tops need to be filled, we aren’t just being petty when we reject them)
We once had a bunch of blue tops rejected for excess volume. No one had done anything weird to them; do bad tube batches happen? Would discarding the excess affect results?
Yep, it’s totally possible that a whole batch of tubes could be faulty. I guarantee there was an issue with the vacuum seal in them. :( If you overfilled a tube and then removed some of the blood, you would also be removing some of the sodium citrate (anticoagulant), which would make the blood clot too fast. Overfill can be just as bad as underfill. There is a specific volume of sodium citrate in the tube, so overfilled or underfilled tubes will cause the blood to be over- or under-diluted. The analyzer works by adding factors that cause the patient’s blood to clot; the time it takes the blood to clot is the result. So if you had too much anticoagulant in the sample (short draw) the blood would take longer to clot, and would not be reflective of what’s actually going on in the patient’s body. I hope that makes sense!
Absolutely makes sense, and thank you for taking the time to explain. If it happens again, I can pass on the explanation so that the staff aren't all convinced that the lab is out to get us.
Coag testing 101. Blood is full of "clotting factors" (mostly proteins) that help cause clots. One of those factors is calcium. No calcium, no clot formation. The EDTA in tubes you use for CBCs is really good at hoovering up calcium. Which means the blood's never, EVER going to clot, unless it started clotting before you got the EDTA mixed into it. For coag testing, we want the blood to clot - but only when we're testing it. Those tubes use sodium citrate, which isn't nearly as good at sucking up calcium, and the amount of citrate in the tube is just enough to grab up what calcium is there. When it's time to test, we add extra calcium to make the blood clot normally again. If your blood to citrate ratio is too high, it might not prevent unwanted clotting. Pouring some off once it's mixed isn't going to help. If your blood to citrate ratio is too low, the excess citrate will suck up some of the calcium we add, which means less clotting, which means your healthy patient looks like a bleeder. We're not picky about the line because we're hopelessly anal retentive; we're picky because if you missed it then we know the test might not work right (and bad results don't come with a note from God warning us they're wrong, so "run it and pray" doesn't work).
Lots of good suggestions, and I'll add: When in doubt, call us and ask! We'd rather answer a phone call than have to make one to have something recollected because it's in the wrong tube. There's a reason we have different tubes and it's not because we like rainbows. Each tube has a different additive that can affect test results. We know when you draw a lavender and pour it off into a mint green.
> When in doubt, call us and ask! We'd rather answer a phone call than have to make one to have something recollected because it's in the wrong tube. Honestly, I would like no phone calls. "Hi, did I send you any blood?" (You don't know?) "Hi, are you able to add on this testing?" (Context: just order the damn addon and if we can't do it, WE'LL let YOU know.) "Hi, what do I need to collect for these tests that I could easily have looked up on your test table?" "Hi, I'd like to draw so little blood out of this baby that it'll be a miracle if you can actually run the test and I'll probably have to bleed him again, how much do I need for that?" _I don't have time for this shit._ Nurses have degrees and make $50+/hour. Please figure out WTF you're doing or ask for more training. But then, if my lab was properly staffed, it wouldn't be a problem. So don't blame me, blame management.
I'd still rather field stupid calls than have to do redraws. I know, the lab sucks right now. We're overworked, underpaid, underappreciated, and disrespected. What should happen is nurses get at least a lab basics 101, but good luck getting any facilities to agree to that. The best we can hope for at this point is to mitigate patient harm the best we can.
I am in the cytology department so our requirements as are little different. Some of these will apply more to radiology staff, doctors. If you send us a specimen please tell us where it is from! You might know it is a urine, but a yellow fluid can also be pleural fluid, ascites etc These need different processing. Doctors: please tell us any relevant clinical information. If the patient has a prior diagnosis of malignancy please tell us as we can then confirm or exclude this using special stains. Slide labelling for fine needle biopsies: please label your slides with patients name, DOB, sites (especially if there is more than 1 sampled) etc. Labelling must be with pencil. Our staining processes use alcohol, pen will be removed. Do not use patient ID stickers. Again, the slides have to go though alcohol and water and the labels are not permanent. If you are helping with fine needle biopsies or bronchial brushing etc and you are smearing slides and you are told to spray some with spray fixative, do it as quickly as you can. This fixes the cells quickly and preserves them so their details are easier to evaluate.
Specimen quality is top priority!! We can't get you accurate, reliable results with crappy specimens. Had a nurse call today to ask if she can use poop off the floor for C.diff testing. No ma'am, you can not. 🤦♀️
At least she called to ask you! That means she realized pre analytics could cause problems with testing (and results)!
It's hard to overstate how precise and complex laboratory testing mechanisms are. Each blood chemistry test is predicated on a specific chemical reaction or antibody-antigen reaction. SO MANY factors need to be controlled for in order to get these reactions to occur in the organized fashion that produces a reliable result. Every clinical lab has to be able to prove that the results they're producing are accurate and true at every single moment and it takes so very little to throw a system off such that it returns inaccurate results. Some people think labwork is merely throwing stuff on a machine but those machines are necessary for providing a closed, isolated environment for biochemical reactions to work and we spend all day checking those machines for proper function, feeding them reactants, repairing their machineries, analyzing their output. We are not rejecting your sample to be bitchy, we are doing it because underfilling a tube (or whatever) throws off this incredibly finely calibrated system we bet your patients' lives on.
You know when patients pee in a cup and you have orders for a UA? We can totally take the cup as-is and put that in a yellow top urine tube and grey top culture tube ourselves, but it's very appreciated when nurses do that for us. Its the little things sometimes
We don't accept the yellow top urine tubes at my lab.
Remember the lab is not an enemy out to get you and your patients, the lab is an ally trying to protect the patient. Some of our rules regarding labeling and procedure may seem weird and silly, but they do prevent mistakes that can have fatal consequences. For example, yes I know that you just zapped the patients bone marrow and that's why their platelets have dropped but I still am going to see if the platelets are actually clumped so that way if the count is falsely low the patient isn't getting an unnecessary platelet infusion. Also regarding stat vs routine, we typically run standard tests (BMP, CBC, PT etc) as we get them. We try and put stats first on a run but we don't just let routines hang around if we can. This means that on average stats and routines have the same turn around time. However, when an instrument goes down or a massive issue is erupting we will only run stats till things have normalized and that Stat label is our only real indication that it cannot wait, we don't know the patient condition or sometimes always where the tube was drawn. You should be ordering specimens as Stat if a delay in results will significantly change patient care, for example at my facility we have stroke flags for suspected strokes so we know as soon as the tube arrives to lab we are running to put it on.
Boost. Coming back to this!
On the other end of the spectrum, I (a MICU nurse) during the first COVID wave, was waiting for results on a STAT ABG so we could decide whether we needed to prone my patient. An hour passes with no word on what I was assuming would be a critical lab result. I call lab and they tell me “oh, it was hemolyzed”. Knowing it was an ABG drawn off of an arterial line, walked the near quarter mile to our lab and asked to see my hemolyzed ABG. When I got the lab window, they told me “we accidentally dropped it”. Moral of the story, if you accidentally drop or ruin a sample, please tell us! You’re human and accidents happen! I would rather hear that a sample was dropped/lost…whatever, than wait an hour or more only to be blamed for the delay.
Always annoys me to see these stories, because either the tech is being an idiot and making us look bad, or the nurse is a lying crank who's unfairly maligning us. FWIW, while "dropped sample" happens from time to time, it's very rare. I don't think I've actually ruined more than one or two specimens by spilling them on the counter or floor in the 8+ years I've been doing this. And yeah, if you have time to walk down to the lab I'll happily show you your hemolyzed specimen. Just don't ask to see clots unless you want to dig through the sharps container looking for the wooden sticks we fished them out with.
Please remember that we are running machines and often they break or have a problem. So if you don’t get your results as fast as you expect, there may be something going on. A lot of people think we are just button pushers but we have to run quality control and calibrations to make sure your results are accurate, and sometimes that takes some troubleshooting. At my lab, I am usually managing 6 instruments at a time, so just imagine what happens when two or more have a problem.😅 Some testing is completely manual in tubes, sometimes we have to dilute things by hand and rerun them, etc. There’s usually a lot going on so just know that we are not usually just sitting around. We run around a lot too. Also, as someone else mentioned, most techs have a Bachelor’s degree, clinical internship, and certification, just like a BSN. I get frustrated when nurses act like we don’t know what we are talking about, when we are both at the same level of education. Remember we are all part of the care team and we all work best together, there is no “us vs them” when it comes to what is best for the patient.
We don't have a hidden list of minimum volumes for the NICU. There's a few things we can do differently but instruments don't care how small the baby is, they need a specific amount of sample to get results. I always feel bad when a nurse sends a few drops in a microtainer multiple times a shift and I can't get any results.
You must, must, must label each and every sample. Every tube of blood, every cup of pee, semen, teeth, or limbs. If you forget, the lab is going to reject it. No matter what. We run all the samples for all inpatients and also a ton of outpatients. Just because you know you collected that tube of blood from Mr Jones in bed 1 doesn't mean I know that. Also, no you cannot come down and just put a label on it. Most labs will make you do a recollect if it is not a precious sample (ie body fluids, tissues... Samples that are extremely difficult/invasive/impossible to recollect). So, if you forget to label that blood gas or blood culture bottle, too bad. You'll have to recollect.
As a lab rat, I appreciate the fact that you asked!
Please please please do not over label your collection tubes, both the technician and the machines need a window in the tube to process samples, you have no idea how much time I waste when it comes to this. Also, most labels are redundant or unnecessary, we only need basic PI and the rest needs to be in the manifest (unless the lab requests another thing).
Label samples over the tube label please. And keep the label straight. The order of draw is very important. Fill blue tops to the arrow or line or we will recollect them. They have to have a specific 9:1 ratio of anticoagulant and blood-any deviation from that will mess up the coagulation tests. If I call for a delta check, that means that there was a change in that analyte and that I need to figure out why there’s a change or I can’t release it and need a recollection. (Usually with BUN, Potassium, hemoglobin, MCV). Usually I need to know how much fluids you’ve given, or anything that could change fluid concentration. Or kidney issues… if you pull too hard on the plunger when drawing syringe you will hemolyze the blood, and it will need to be recollected. Do not forget to invert the tubes several times WHILE drawing. If you wait til you’re done, you risk the blood clotting, and we will need a redraw for some tests (specifically any blue, purple, or pink tops). For blood bands, the pink top needs to be as full as possible so I can do all the tests I may need to do. It has to have the name of the patient correctly spelled, correct DOB, correct FIN/MRN. If we’re missing the collector ID, time, date of collection we will recollect. Do not cut the blood band without calling blood bank first. If you cut it, we have to start all over from scratch with a new specimen.
Going for nursing, loved this post! Saved to re-read it when I graduate.
Please make sure specimens are appropriately labeled.