The Art and Science of Sample Collection

The Art and Science of Sample Collection
Ana K. Stankovic, MD, PHD, MSPH
WW VP, Medical Affairs
BD Diagnostics – Preanalytical Systems
Karen Scraba, MLT, BSc(MLS), MT(ASCP)
Clinical Market Manager
BD Diagnostics - Preanalytical Systems
October 18, 2013
THE ART:
History of
Blood Collection
It Started With Blood-Letting …
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Phlebotomy is the practice of opening a vein by incision or puncture to
remove blood as therapeutic treatment or for diagnosis.
The ancient art of phlebotomy dates back three thousand years as the
practice began with the Egyptians in 1000 B.C.
Egyptian history records blood-letting as a treatment for variety of
ailments. Blood-letting was believed to drive out evil spirits; therefore,
the procedure was performed by a priest, who was also a physician.
In Greece, Hypocrites was responsible for early medical theory, which
believed illness was caused by an “imbalance” in the body. The
removal of this “excess” by plugging, starving, vomiting, or bloodletting was thought to restore this balance.
Blood-letting continued as a practice in the middle ages where it began
to fall into the duties of – strangely enough – barbers.
The main process of blood-letting in 19th century medicine included
the use of leeches to drain blood from a patient. During the 1830s,
France imported approximately 40 million leeches for the purpose of
blood-letting up to as late as the early 19th century as preventive
medicine.
It wasn't until the 19th century that members of the medical
community seriously questioned the merits of this practice. In the
1830s, Pierre Charles Alexandre Louis convincingly argued against the
perceived effectiveness of phlebotomy for the treatment of pneumonia
and fever.
… And Continued with Transfusion …
 The first historical attempt at blood transfusion
was described by the 15th-century chronicler
Stefano Infessura. Infessura relates that, in 1492,
as Pope Innocent VIII sank into a coma, the blood
of three 10-year-old boys was infused into the
dying pontiff (through the mouth, as the concept
of circulation and methods for intravenous access
did not exist at that time) at the suggestion of a
physician. However, not only did the pope die,
but so did the three children.
 The first fully documented human blood
transfusion was administered by Dr. Jean-Baptiste
Denys, eminent physician to King Louis XIV of
France, on June 15, 1667. He transfused the blood
of a sheep into a 15-year old boy, who survived
the transfusion.
... To Specimen Collection
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It is open to debate when blood first began to be examined for
diagnostic purposes. It is known that other body fluids have
been examined since medieval times.
The invention of the microscope in the 17th century, coupled
with advances in physiologic chemistry and cellular
physiology in the 19th century, paved the way for the
examination of blood as a diagnostic tool.
In 1908, James C. Todd, professor of clinical pathology at the
University of Colorado School of Medicine, published the first
Manual of Clinical Diagnosis.
The 1912 edition of the book has a chapter titled "The Blood."
One passage reads: "For most clinical examinations only one
drop of blood is required“. The Manual, in addition to
describing general techniques and anatomical points for
blood-letting, discusses the method of obtaining a blood
culture from a skin puncture in the lobe of the ear "...by gently
milking, 20 to 40 drops can usually be obtained."
Between the two World Wars, specimens were collected with
needles and glass syringes.
In 1949, Joseph Kleiner patented the “Evacuator”, and the
modern concept of evacuated blood collection was born.
Blood Collection/Acquisition Devices: Timeline of
Innovation
Safety in Blood Collection for
Laboratory Testing
 In recent years, major improvements have been made
in the area of healthcare worker (HCW) safety.
 New and innovative safety devices, combined with
effective HCW training, adoption of best practices,
and elimination of sharps use, have ensured continued
reduction of occupational exposure to pathogens and
percutaneous injuries, thus successfully lowering rates
of HCW acquired infections.
 Voluntary adoption of a culture of safety, as well as
legislative mandates (US Needlestick Safety and
Protection Act – NSPA) are external factors that will
further facilitate safety adoption.
Injury Rates From Conventional Devices vs.
SEDs for Blood Collection Procedures
16 Italian hospitals, 1997-2009
[ total conventional devices = 9,860,855 , total safety-engineered devices (SEDs) = 13,288,640]
Injuries per 100,000 devices used
12
conventional
10
safety year 1
safety year 2+
8
6
-45%
-60%
4
-74%
-54%
2
-65%
-69%
-85%
-94%
-84%
-98%
0
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J.Jaeger, personal communication
Percutaneous Injuries Before and After NSPA
 The annual rates of percutaneous
injuries per 100 full-time–equivalent
hospital employees were calculated.
 There was a trend toward increasing
rates of injuries before the legislation
was enacted, which was followed by a
drop of about 38% (95% confidence
interval, 35 to 41) in 2001when the
NSPA took effect. Subsequent injury
rates, through 2005, remained well
below pre-NSPA rates.
 Two factors directly linked to the
legislation were:
– shift from conventional to safetyengineered devices and
– an increase in the number of OSHA
citations for violation of the revised
standard for handling bloodborne
pathogens.
Philips E.K. et al. NEJM 366:670-1, 2012
To see the on-line
version
http://www.canadianhe
althcarenetwork.ca/heal
thcaremanagers/
Click on “Management”
then on “Patient Safety”
Lastly, Click on:
Second-generation
collection set reduces
needlestick injuries
Open Collections are Still Common
Developed markets: 6.3%
Globally Emerging markets: 30%
THE SCIENCE:
Development of New Specimen
Collection Devices
IVD Product Life Cycle Management
Laboratories are Faced with Constant Pressures
to Improve Testing Turnaround Time
 This is particularly important in the Emergency Department (ED),
where prolonged patient waiting time can result in ED “crowding”,
which in turn can lead to:
– Reduced patient satisfaction and diversion (to another facility)
– Compromised patient care
– Loss of revenue opportunity
 When trying to maximize the turnaround time (TAT) in the ED, plasma
offers time savings as compared to serum; however, quality and
stability issues, as well as potentially limited assay choices, are a
concern.
 Serum, on the other hand, is often considered superior regarding
specimen quality, but it can negatively impact the TAT.
 There is a need for a blood collection tube with an additive that will
assure the speed of plasma and the quality of serum.
General Flow Down Structure for
Critical Parameter Management
VOC:
Needs…
Flow down of the Voice of the Customer…
Requirements to be fulfilled through the
measurement of Critical Functional Responses
(CFRs) & Critical to Function Specs (CTFs) …
System Level:
Requirements
System Level:
CFRs…
Subsystem Level:
Requirements
Cp
Cp =
Subsystem Level:
CFRs…
VOC
VOP
Roll-up of the Voice of the Design &
RollMfg. Critical Parameters…through the
actual measurement of CFRs & CTFs
Copyright PDSS Inc. 2003
Subassembly
Subassembly:
CFRs…
Cp
6s
>1.33 = standard
~ 2.00 = 6 s
Subassembly
Subassembly:
Requirements
Cp
=
USL--LSL
USL
Components:
CTF Reqs.
Components:
CTF Specs…
Cp
Mfg. Process:
Process
Requirements
Mfg.
Process:
Process
CTF
Specs…
Effect of Manufacturing Variability on
Additive to Blood Ratio
Variability
reduced
by 50%
Maximal
Allowable
variability
Additive to Blood Ratio (mg/mL)
Potential Advantages of BD Vacutainer®
Rapid Serum Tubes (BD RST)
5 min Clotting Time
Clean Serum
↓Fibrin ↓Hemolysis
Less Instrument Downtime
Fewer Redraws
Faster Results
BD RST Can Reduce Serum STAT Testing TAT
BD RST: Ready to analyze in 8 min*
TAT savings = 32 min**
*Centrifuged at 4000 g for 3 minutes
**Compared to standard serum separator control tubes, 30 min. clot time, 10 min centrifuge time
Impact of BD RST on Preanalytical TAT
70
Tub e Ty p e
60
BD RS T
Control Serum Separator Tube
Minutes
50
40
30
Centrifugation:
High Speed Centrifuge
20
10
0
Collection to clot
Clot to centrifuge
Centrifuge to Load
30.5 min gain
38.5 min gain
Preanalytical intervals
Prusa R, Douppvcova J, Stankovic AK, and Warunek D. Improving laboratory efficiencies through significant time reduction in
preanalytical phase. Clin Chem Lab Med 2010; 48:293-6.
BD RST - Clinical Evaluation
 Evaluations were conducted using multiple instrument testing
platforms to compare the performance of the BD RST with the
BD Vacutainer® SST™ Blood Collection Tube (BD SST™) for selected
analytes in clinical chemistry, immunology and serology.
 For each analyte, between-tube comparisons at initial time were
performed using a Deming Regression in order to obtain the BD RST
vs. BD SST™ mean bias (with confidence intervals) at predetermined medical decision levels and at the average of the control
tube. The tube comparisons were evaluated relative to the assigned
clinical acceptance limit (CAL) for each analyte.
 Stability testing was performed for selected analytes by calculating
the mean bias (with confidence intervals) for the 24 hrs vs. initial time
comparison for each tube type.
 For Troponin I, the percentage of concordant and discordant results
above or below medically important decision levels or lower limits of
reportable ranges was determined.
 Overall, BD RST showed clinically equivalent or clinically
acceptable performance for tested analytes when compared to the
BD SST™.
Instrument Platforms and Number of Tested
Analytes: BD RST Comparison with BD SST™
Instruments
Number of
analytes/per
instrument
Beckman Coulter Access®/Access® 2
6
Beckman Coulter UniCel® DxC 800
17
Beckman Coulter UniCel® DxI 800
15
Biomerieux VIDAS®
2
Dynex DS2®/Wampole Laboratories
2
Ortho Clinical Diagnostics VITROS® 5,1 FS
10
Roche COBAS Integra® 800
27
Roche COBAS MODULAR ANALYTICS
25
Siemens Dimension® RxL
19
Siemens ADVIA Centaur®/Centaur® XP
15
Total number of analytes tested: 55
BD RST vs. BD SST™ Comparison of Clinical
Chemistry, Immunology and Serology Analytes
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Albumin (ALB)
Alkaline Phosphatase (ALKP)
Alanine Aminotransferase (ALT)
Amylase (Amy)
Aspartate Aminotransferase (AST)
Bilirubin, Direct (DBIL)
Bilirubin, Total (TBIL)
Blood Urea Nitrogen (BUN)
Calcium (Ca)
Carbon Dioxide (CO2)
Chloride (Cl)
Cholesterol (Chol)
Complement C3 (C3)
Complement C4 (C4)
Cortisol (Cortisol)
Creatine Kinase (CK)
Creatine Kinase-MB fraction (CKMB)
C-reactive Protein (CRP)
Creatinine (Creat)
Cytomegalovirus Antibodies, IgG
(anti-CMV IgG)
Cytomegalovirus Antibodies, IgM
(anti-CMV IgM)
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Estradiol (E2)
Ferritin (Ferritin)
Folate (Folate)
Follicle Stimulating Hormone (FSH)
Free Triiodothyronine (FT3
Free Thyroxine (FT4)
Gamma-glutamyl transferase (GGT)
Glucose (Glu)
Human Chorionic Gonadotropin (hCG)
High Density Lipoprotein (HDL)
Immunoglobulin G (IgG)
Immunoglobulin M (IgM)
Iron (Fe)
Lactate Dehydrogenase (LDH)
Lipase (Lip)
Low Density Lipoprotein (LDL)
Luteinizing Hormone (LH)
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Magnesium (Mg)
Myoglobin (Myo)
Phosphorus (Phos)
Potassium (K)
Progesterone (Prog)
Rheumatoid Factor (RF)
Sodium (Na)
Testosterone (Testosterone)
Thyroid Stimulating Hormone
(TSH)
Total Protein (TP)
Total Triiodothyronine (TT3)
Total Thyroxine (TT4)
Transferrin (Transferrin)
Triglycerides (Trig)
Troponin I (TnI)
Uric Acid (UA)
Vitamin B12 (Vitamin B12)
BD Rapid Serum Tube demonstrated clinically equivalent or clinically acceptable
performance compared to the BD SSTTM for all analytes on each platform evaluated
BD data on file
Troponin I (TnI): Beckman Coulter Access®
Bias and confidence limits for BD RST vs. BD SST™
CAL
Medical
decision level
or average
Type
BD RST vs. BD SST™
Systematic bias
(Two one-sided 95% confidence
limits)
TnI
>0.04 ng/mL
20%
2.31 ng/mL
AV
3.1% (-4.1, 10.9)
TnI
>0.06 ng/mL
20%
2.575 ng/mL
AV
3.4% (-4.8, 12.3)
0.5 ng/mL
CV
0.9% (-2.9, 4.9)
Analyte
Values listed are either the average of the analyte group or analyte-specific medical decision levels
CV – Critical Value, AV – Derived Average From Control Group
*White paper – VS8129 – data on file at BD.
Concordance Table: Troponin I (Initial Time)
(Beckman Coulter Access®)
All
BD RST
BD
SST™
Negative
(<0.5 ng/mL)
Positive
(≥0.5 ng/mL)
Negative
(<0.5 ng/mL)
101
0
101
Positive
(≥0.5 ng/mL)
0
4
4
101
4
105
All
The observed percent concordance is 105/105 = 100% (with exact 95% lower confidence
limit = 97.2%).
There is no significant difference in the distribution of results per tube (McNemar's
chi-square test with continuity correction, p-value = 1).
*Whit e paper VS8129 – data on file at BD.
The BD RST Demonstrated 59% Reduction in Hemolysis
and Fibrin Strands Relative to a Comparator Serum Tube
Hemolysis
Rating Scale: 0-3
0=none, 1=trace, 2=moderate, 3=gross
0
1
2
3
Study
Tube Type
N
%
N
%
N
%
N
%
BD RST HG
Comparator
Serum Tube
1103
98.84
12
1.08
1
0.09
-
-
Total
724
97.18
16
2.15
3
0.40
2
0.27
59% relative
decrease in
hemolysis
Fibrin Strand
0=none, 1=small, thin strand, 2=large, thick strand
0
1
2
Study
Tube Type
N
%
N
%
N
%
BD RST HG
Comparator Serum
Tube
1080
96.77
36
3.23
-
-
Total
687
92.21
54
7.25
4
0.54
*White paper VS8133 - Data on file
59% relative
decrease in
fibrin strands
BD RST Improves Average Turnaround
Time
90
80
70
60
Minutes
50
Creatinine
Beta-hCG
40
30
20
10
0
June
(Initial state)
September
(Analyzer change)
November
(Tube change)
Improvements in Laboratory Turnaround Time Metrics. Poster Presented By Dr. J. Wesenberg
at the AACC 2010.
Breakdown of Average TAT Improvement
Analyte
TAT Improvement
Total System
New Analyzer
BD RST
Creatinine
24%
6%
18%
b-hCG
43%
27%
16%
* Improvements in Laboratory Turnaround Time Metrics. Poster Presented By Dr. J. Wesenberg at the
AACC 2010.
BD RST Decreases False-Positive
Immunoassay Results
 BD RST tubes were investigated to reduce undetermined interferences contributing
to false-positive immunoassay results in heparin plasma samples.
 Patients being evaluated for suspected myocardial infarction had specimens drawn
into an RST in addition to a standard lithium-heparin plasma separator tube (PST).
 28 separate analytes were measured in both specimens using immunoassay,
electrochemical, and spectrophotometric methods.
 Higher results were observed in some PST specimens tested for troponin I,
creatine kinase-MB isoenzyme, human chorionic gonadotropin, and thyroidstimulating hormone.
 These discrepancies were investigated by repeating analyses after recentrifugation
of both specimens. Reanalysis showed results for the PST specimens that were
lower and agreed well with initial results from RSTs, suggesting false-positive rates
of 10.8% for troponin I and about 2% for each of the other 3 analytes.
 Overall, specimens collected in RSTs had fewer false-positive immunoassay results
than specimens collected in plasma separator tubes.
Strathman FG et al., AJCP, 136:325-9, 2011.
Summary
 Development of new blood collection
devices is a complex process. It requires
thorough market needs assessment,
good product requirement
determination, optimal product design,
determination of device safety and
efficacy and successful product launch.
?...
ana_stankovic@bd.com
karen_scraba@bd.com