Comparison of Clinical, Economic, and Humanistic Outcomes Between Blood Collection Approaches: A Systematic Literature Review

Supplemental Digital Content is Available in the Text.

ABSTRACT

Background:

A systematic literature review was performed to understand the prevalence, advantages, and disadvantages of blood collection using different approaches (direct venipuncture or vascular access devices), and interventions used to mitigate the disadvantages.

Methods:

The review included a broad range of study designs and outcomes. Database searches (Embase, MEDLINE, Cochrane library, and Centre for Reviews and Dissemination) were conducted in March 2021 and supplemented by hand searching.

Results:

One hundred forty-one publications were included. The data indicate that blood sampling from vascular access devices is common in emergency departments, trauma centers, and intensive care units. Studies showed that hemolysis and sample contamination place a considerable economic burden on hospitals. Significant cost savings could be made through enforcing strict aseptic technique, or using the initial specimen diversion technique.

Conclusions:

Hemolysis and sample contamination are far from inevitable in vascular access device-collected or venipuncture samples; both can be reduced through adherence to strict blood sampling protocols and utilization of the initial specimen diversion technique. Needle-free blood collection devices offer further hope for reducing hemolysis. No publication focused on the difficult venous access population; insertion success rates are likely to be lower (and the benefits of vascular access devices higher) in these patients.

Introduction

Blood testing is essential for diagnosis, treatment, and monitoring. Almost 500 million inpatient blood collections are performed in United States (US) hospitals each year,¹ informing 60–70% of clinical decisions.²

Although blood collection via direct venipuncture is considered standard of care,³ there are several potential advantages of collecting blood from indwelling vascular access devices (VADs), which can affect the quality of care. These include reducing the stress and discomfort associated with needle punctures,^4,5 and minimizing the number of venipunctures for patients requiring repeated blood sampling. This is particularly important in patients with difficult venous access (DIVA),⁶ who represent more than one-third of all venipuncture patients⁷ and often require several attempts to successfully collect blood.^8-10

Recent innovations include initial specimen diversion devices (ISDDs) that automatically divert and sequester the initial 1–2 ml of blood from blood culture samples and are intended to reduce contamination rates.¹¹ Others include needle-free blood collection systems, which are intended to reduce hemolysis rates and increase blood collection success rates from peripheral intravenous catheters (PIVCs) in place for several days.¹²

A systematic literature review (SLR) was performed to gather contemporary evidence on blood collection and compare clinical, economic, and humanistic outcomes across different approaches. The objective was to gain a better understanding of the prevalence, advantages, and disadvantages of blood collection using different approaches, and any interventions/innovations that can been used to mitigate the disadvantages.

Methods

Electronic database searches were conducted on 5^th and 8^th March 2021 and were date-limited from 2010 to the present day, to only capture contemporary data. The review was not registered, and a protocol is available upon request. Embase, MEDLINE, Cochrane Library databases, and Centre for Reviews and Dissemination databases were searched via the Ovid platform. The full electronic search strategy is presented in Supplemental Digital Content 1 (see Tables S1–S3, http://links.lww.com/JHQ/A195). Hand-searching was also performed by screening bibliographic reference lists of included studies and relevant SLRs/meta-analyses. The population of interest was patients requiring blood collection for diagnostic, prognostic, or treatment monitoring purposes, regardless of disease/indication. Relevant interventions included blood collection by a range of approaches, such as direct venipuncture, PIVCs, midline catheters, and central lines (encompassing peripherally inserted central catheters [PICCs], centrally inserted central catheters [CICCs], and implanted ports). The focus of this SLR was venous blood collection, so studies on arterial catheters were not eligible for inclusion. The full population, intervention, comparator(s), outcomes, and study design (PICOS) elements used to assess study eligibility are presented in Supplemental Digital Content 1 (see Table S4, http://links.lww.com/JHQ/A195).

Two independent reviewers screened citations by title/abstract, with any conflicts regarding eligibility resolved by discussion. Full-texts were also evaluated by two independent reviewers, with any disputes regarding eligibility resolved by dialogue. Arbitration was provided by a third, more senior reviewer if required.

Results

Seven thousand three hundred thirty-five publications were identified through electronic database searches. Overall, 141 publications were included in the final review, comprising 132 publications identified via database searches, and nine publications identified via hand-searching. The flow of publications through the SLR is shown in Figure 1.

Figure 1.

PRISMA diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

The included publications reported on studies performed across geographical locations spanning six continents, and a diverse range of study designs, including cross-sectional surveys and questionnaires, randomized and nonrandomized trials, and prospective and retrospective observational studies.

Proportion of Blood Samples Collected by Device Type

Sixteen publications reported the proportion of total blood samples in a particular hospital or ward/department using specific device types (Table 1). As anticipated, blood sampling through VADs was most common in emergency departments (EDs), trauma centers, intensive care units (ICUs), and hematology-oncology units. A survey spanning multiple sites across the US, Puerto Rico, and Canada determined that in ICU patients with existing central lines, blood culture samples were drawn through these existing lines in 52% of adult and 96% of pediatric practices. For hematology–oncology and bone marrow transplant patients, the respective figures were 64% and 98%.²⁹

Table 1.

Proportion of Blood Samples Collected by Device Type in the Hospital Setting

Reason for collecting blood	Setting	Author, year	Country	Proportion of blood samples collected by device type
				Direct VP	PIVC	Central linea	Otherb
Blood culture	ED	Self et al, 201213	US	—	23.1%	—	76.9%
	ICU	Alahmadi et al, 201514	Northern Ireland	41.0%	—	33.3%	25.7%
	ICU + wider hospital	Boyce et al, 2013c,15	US	89.1%	—	10.9%	—
	NICU	McLaughlin et al, 201316	Australia	5.0%	62.2%	—	32.8%
	PICU	Woods-Hill et al, 2017c,17	US	26.9%	—	73.1%	—
Routine testing	Clinical laboratory of level 1 pediatric trauma center	Bush et al, 201018	US	30%	70%	—	—
	ED	Barnard et al, 201619	UK	30.5%	69.5%	—	—
		Berg et al, 201120	UK	20%	80%	—	—
		Dietrich et al, 201421	US	36.9%	63.1%	—	—
		Guihard et al, 201822	France	—	80%	—	20%
		Lippi et al, 201423	Italy	22%	78%	—	—
		Ramakers et al, 201824	The Netherlands	—	80%	—	20%
	ICU	Bodley et al, 202125	Canada	—	—	17.4%	82.6%
		Kuriakose et al, 2020c,26	US	10%	—	70%	20%
	NICU	Tolan et al, 201627	US	29%	33%	—	38%
	PICU	Valentine et al, 201228	US	4%	6%	33%	57%

CICC, centrally inserted central catheter; ED, emergency department; ICU, intensive care unit; IV, intravenous; NICU, neonatal intensive care unit; PICC, peripherally inserted central catheter; PICU, pediatric intensive care unit; PIVC, peripheral intravenous catheter; UK, United Kingdom; US, United States; VP, venipuncture.

^aPICCs, ports and CICCs.

^bIncluding arterial and dialysis lines.

^cProportions reported are preintervention. After interventions, the proportions were: direct VP 99.6%, central line 0.4% (Boyce), direct VP 60.5%, central line 39.5% (Woods-Hill), and CICC 3% (Kuriakose).

The studies in Table 1 are categorized based on the purpose of blood collection (blood culture or routine), because many publications reported that healthcare professionals (HCPs) in their institution were explicitly advised not to collect blood culture samples from VADs to minimize the risk of bloodstream infection and sample contamination. A 2018 survey of over 80 hospitals in the US revealed that 90% of hospitals advise staff to collect culture samples via direct venipuncture rather than from central VADs wherever possible.³⁰

Placement and Blood Collection Success by Device Type

Overall, 28 publications reported placement and blood collection success outcomes such as first attempt insertion success rate, number of attempts required to access the vein, blood collection success after venous access, or an overall success rate encompassing insertion and blood collection success.

Summary statistics were challenging to derive because of the variation in measuring and reporting. Nevertheless, the accumulated data indicate that in most patients, even if multiple attempts are sometimes required, blood collection via direct venipuncture is ultimately successful in obtaining a sample.

Importantly, it is not always possible to obtain complete blood samples from indwelling catheters. Across three pediatric studies, overall success rates for obtaining useable blood samples from existing PIVCs were 91.3%, 76%, and 85.1%.^31-33 In addition, the ability to obtain a specimen from a PIVC may decrease as the catheter ages. In one of the three studies, the rate of successful PIVC blood collection decreased from 85% in PIVCs aged <24 hours to just 63% in PIVCs aged >24 hours (p = .010).³³ The size of the PIVC was not significantly associated with the ability to obtain a specimen; however, results revealed a trend indicating that larger gauge PIVCs were more successful in providing a complete specimen, whereas the smallest gauge PIVC was less successful.³³

Only one study reported on the ease of blood sampling from PIVCs using the needle-free PIVO device, which is designed for PIVC blood collection. The blood collection success rate was 81% across 126 blood collections in 62 hospitalized patients performed over 4 days.³⁴

Hemolysis of Blood Samples by Device Type

Of the 36 publications that reported hemolysis rates, 18 compared rates between two devices, and 18 reported rates for a single device category. Hemolysis rates were numerically higher in catheter-collected samples in 14/17 publications comparing direct venipuncture and PIVC blood collection (Table 2). Of these, the difference was statistically significant in all five publications that presented a p-value.

Table 2.

Studies Comparing Hemolysis Rates Between Blood Samples Collected by Direct Venipuncture and PIVCs

Author, year	Country	Setting	Hemolysis rate numerically higher with PIVC or direct VP?	Hemolysis rate in PIVC samples	Hemolysis rate in direct VP samples	p
Barnaby et al, 201635	US	ED	PIVC	6,225/55,082 (11.3%)	1,468/33,881 (4.3%)	NR
Barnard, 201619	UK	ED	PIVC	14.3%	2.7%	p < .001
Berg et al, 201120	UK	Emergency medicine, hospital inpatients	PIVC	10/40 (25%)	2/10 (20%)	NR
Berger-Achituv et al, 201031	Israel	Pediatric surgery and pediatrics	Direct VP	0/34	1/34	NR
Bush et al, 201018	US	Clinical laboratory of level 1 pediatric trauma center	PIVC	25/155 (16%)	4/66 (6%)	p = .04
Giavarina et al, 201036	Italy	ED	PIVC	BD Insyte Autoguard: 22.9% B Braun Vasofix Safety: 18.2% Terumo Surflo-w: 23% Neo Delta Ven T: 16.1%	3%	NR
Hambleton et al, 201437	Spain	ED	NR	“No significant differences between the percentage of hemolysis in samples extracted from the PIVC and those from venipuncture”		p = .4
Heiligers-Duckers et al, 201338	The Netherlands	ED Reference group: Internal medicine ward and outpatient clinic	PIVC	Syringe tube samples: 16% Vacuum tube samples: 24%	3%	p ≤ .02
Lippi et al, 201423	Italy	Large urban ED	PIVC	29%	1%	NR
Mattila et al, 201739	Finland	Ambulance (samples takenbefore hospital admission) and ER (samples taken upon hospital admission)	PIVC	EDTA plasma samples: 9.3% Serum samples: 6.5%	EDTA plasma samples: 1.6% Serum plasma: 0.7%	NR
Munnix et al, 201140	The Netherlands	ED and an internal medicine outpatient clinic	PIVC	Retrospective review: 574/8,710 Prospective study: 16/100 (16%)	Retrospective review: 105/9,754 Prospective study: 0/50 (0%)	NR
Ortells-Abuye et al, 201441	Spain	Inpatient ward or emergency services short stay unit	PIVC	3.7%	0%	NR
Phelan et al, 201842	US	ED	PIVC	Hemolyzed: 8.2% Gross hemolysis: 2.0% Hemolyzed or gross hemolysis: 10.2%	Hemolyzed: 4.2% Gross hemolysis: 1.1% Hemolyzed or gross hemolysis: 5.4%	p < .001 p = .12 p < .001
Straszewski et al, 201143	US	ED	PIVC	Samples collected by PIVC or direct VP: 23%	Samples collected by direct VP only: 6.6%	NR
Tolan et al, 201627	US	NICU	Direct VP	13%	15%	NR
Twibell et al, 201944	US	Pediatric unit	PIVC	15%	4%	p = .002
Wollowitz et al, 201345	US	ED	PIVC	14.6%	2.7%	NR

BD, Becton, Dickinson and Company; ED, emergency department; EDTA, ethylenediaminetetraacetic acid; ER, emergency room; NICU, neonatal intensive care unit; NR, not reported; PIVC, peripheral intravenous catheter; UK, United Kingdom; US, United States; VP, venipuncture.

Although hemolysis rates were generally higher in PIVC than direct venipuncture blood samples, the accumulated data suggest that the risk of hemolysis is lowered when specific sampling procedures are followed, such as collecting blood from the antecubital fossa,^19,42,45 using larger gauge needles,^42,45 ensuring not to underfill collection tubes,⁴⁵ keeping tourniquet time to under a minute,^42,45 and discarding the initial portion of blood.⁴⁰

Two studies reported on the use of the PIVO device to collect blood samples from patients with PIVCs.^12,34 The first reported significantly lower hemolysis rates in blood samples collected from PIVCs using the PIVO device (1.8%) relative to those collected more conventionally, by direct venipuncture or from central lines (3.3%).¹² The other reported a hemolysis rate of 0% in an intervention group that underwent daily blood sampling from a PIVC using the PIVO device.³⁴

Sample Contamination/False Positives in Blood Cultures by Device Type

Thirty-one publications reported sample contamination rates. Of these, 10 compared two devices, whereas the other 21 reported rates for a single device, or data pooled across two devices.

In studies comparing direct venipuncture and VAD-collected blood samples, contamination rates were numerically higher among VAD-collected samples in 7/10 publications, but lower in 2/10 publications (Table 3). In both latter studies, blood was collected from PIVCs at insertion rather than over dwell, and samples were collected following strict sterile protocols.^16,47

Table 3.

Studies Comparing Contamination rates Between Blood Samples Collected by Direct Venipuncture and VADs

Author, year	Country	Setting	Comparison	Contamination rate numerically higher with VAD or direct VP?	Contamination rate in VAD-collected samples	Contamination rate in direct VP samples	p
Alahmadi et al, 201514	Northern Ireland	ICU	Direct VP versus CICC	VAD	9.5%	4.8%	NR
Boyce et al, 201315	US	ICU and wider hospital	Direct VP versus unspecified central lines	VADa	All wards except ED and ICU in 2010a: 44/921 (4.8%) ICUs only in 2010a: 21/422 (5%)	All wards except ED and ICU in 2010a: 40/4,353 (0.9%) ICUs only in 2010a: 7/869 (0.8%)	NR
Jones et al, 201746	US	NR	Direct VP versus CICC	Neither	1.4%	1.4%	NR
Kelly et al, 201347	Australia	ED	Direct VP versus PIVC	Direct VP	3.2%	3.6%	p = .52
McLaughlin et al, 201316	Australia	NICU	Direct VP versus PIVC	Direct VP	2.2%	13.7%	NR
Ramirez et al, 201548	Spain	ICU	Direct VP versus unspecified IV catheters	VAD	17%	7%	p = .028
Santos et al, 201849	US	NR	Direct VP versus unspecified central lines	VAD	Contaminated samples/1,000 samples with samples collected by central lines or direct VP: 3.8	Contaminated samples/1,000 samples with blood collected almost exclusively by direct VP: 3.4	p = .569
Self et al, 201213	US	ED	Direct VP versus PIVC	VAD	6.53%	3.56%	NR
Stohl et al, 201150	Israel	ICU	Direct VP versus CICC	VAD	8%	4%	p < .001
Weddle et al, 201151	US	ED	Direct VP versus PIVC	VAD	Samples collected by PIVC or direct VP: 6.7%	Samples collected by direct VP only: 2.3%	p = .001

CICC, centrally inserted central catheter; ED, emergency department; ICU, intensive care unit; IV, intravenous; NICU, neonatal intensive care unit; NR, not reported; PIVC, peripherally inserted central catheter; US, United States; VAD, vascular access device; VP, venipuncture.

^aContamination rate was higher in VAD-collected samples than direct venipuncture samples at the beginning of the study in 2010, but this trend was reversed by the end of the study after an intervention to reduce contamination rates.

Interventions to reduce contamination rates in VAD collections have been shown to be effective; in a US hospital, training in aseptic technique contributed to a reduction in contamination rates from 4.8% to 0% (p = .005) for central lines.¹⁵ Another study reported a significant reduction in contamination rates among PIVC-collected samples, from 3.9% to 1.6% (p < .0001), following enforcement of a strict sterile technique for PIVC insertion and blood collection.⁵² This implies that sample contamination is not inevitable during VAD blood sampling, and if applied strictly, aseptic protocols can virtually eradicate contamination risk.

There is also room for improvement in blood culture contamination rates for direct venipuncture. Kai et al.⁵³ demonstrated a drop in contamination rates from 6.3% to 1.1% (p < .001) in a Japanese ED after implementation of a six-element intervention “bundle” that included alcohol wiping, improved hand hygiene, and the use of sterile gloves during venipuncture.

Impact of the Initial Specimen Diversion Technique on Sample Quality

Multiple publications evaluated the impact of the initial specimen diversion technique (ISDT) on sample contamination or hemolysis rates. In the earliest of these studies, Patton et al. discovered that discarding the first 1 ml of blood sample collected by direct venipuncture significantly reduced false-positive blood cultures.⁵⁴ The authors concluded that venipuncture needles can soil blood culture specimens with unsterilized skin fragments, and thus the ISDT is effective in reducing contamination. Two subsequent studies involving direct venipuncture sampling reported similar results; blood culture contamination rates dropped from 3.4% to 2.4% after the ISDT was adopted at a Canadian institution,⁵⁵ whereas a randomized trial in an Israeli medical center documented a 1.7% contamination rate in an ISDT group relative to 5% in a control group (p = .015).⁵⁶

The SLR identified two publications that testify to the effectiveness of bespoke ISDDs. In a US ED and trauma center, contamination rate was only 0.22% in cultures prepared with an ISDD, compared with 1.78% without one (p = .001).⁵⁷ In an Israeli hospital, an ISDD was used with an integrated needle or by attaching it to a newly-placed intravenous (IV) catheter; contamination rate was 1.0% with the ISDD and 5.2% without it (p = .008).¹¹

Other Sample Quality Issues

Seven publications documented the number of blood samples rendered unsuitable for analysis because of clotting, coagulation, or underfilled tubes, although only two enabled direct comparison between different device types (Table 4).

Table 4.

Studies Documenting Sample Quality Issues

Author, year	Country	Setting	Blood collection method	Proportion of samples unsuitable for analysis and reasons
Lancé et al, 201358	The Netherlands	Operating theater	Direct VP	9.1% because of coagulation
			Venous line	0%
			Large bore central venous line	0%
Ortells-Abuye et al, 201441	Spain	Inpatient ward or emergency services short stay unit	Direct VP	0.7% because of clotting
			PIVC	0.4% because of clotting
Atay et al, 201459	Turkey	Laboratory serving inpatients, outpatients and ED	Direct VP	0.65%; of these, 24% rejected because of clotting and 34% because of insufficient sample volume
Bhushan, and Sen, 201760	India	Coagulation laboratory	Direct VP	0.11% because of clotting 0.39% because of underfilled vacutainer tubes
Goswami et al, 201061	India	Tertiary hospital	Direct VP	1.4%; of these, 7.5% rejected because of insufficient sample volume
Braniff et al, 201432	US	Pediatric unit or pediatric ICU	PIVC	0.67% because of clotting 0% because of insufficient sample volume
Berger-Achituv et al, 201031	Israel	Pediatric surgery and pediatrics	PIVC	4.26% because of coagulation 4.26% because of insufficient sample volume

ED, emergency department; ICU, intensive care unit; PIVC, peripheral intravenous catheter; US, United States; VP, venipuncture.

Anxiety, Fear, and Stress by Device Type

Eleven studies presented self-reported measures of patient anxiety, fear, or stress aroused by blood collection via direct venipuncture, and one via IV catheters, but none compared these across device types.

Healthcare Costs, Resource Utilization, and Economic Burdens by Device Type

Thirty-six publications reported data regarding healthcare resource utilization, and 13 publications on specific costs or economic burdens. Of note, two studies showed blood culture contamination to be associated with a longer length of stay and increased costs^56,62; in another study, each contaminated blood culture resulted in an additional $2,800 of hospital charges.⁵² In all three studies, the additional spending was principally attributable to patients' increased length of stay. In an Italian ED, the economic burden attributable to sample rejection because of hemolysis was €19,535 ($22,551) in 2012 (€17,484 [$20,183] for materials and €2,051 [$2,368] for personnel), accounting for 22.8% of the department's annual expenditure on blood sample collection.Currency converted from Euros to United States Dollars on 14th October, 2021 using exchange rates from Google Finance (https://www.google.com/intl/en/googlefinance/disclaimer/).²³

Logically, interventions that reduce blood culture contamination rates should also decrease healthcare resource use and hospital spending. In the study by Hall et al.,⁵² enforcement of a strict sterile technique for PIVC insertion and blood draw decreased blood culture contamination rates, saving the hospital approximately $250,000 annually. Another publication presented a cost-benefit analysis evaluating use of the SteriPath ISDD for ED blood culture collection, compared with direct venipuncture.⁶² Use of the ISDD was associated with cost savings of $272 (3%) per blood culture in overall hospital costs, and $28 (5.4%) in direct-only costs. The main drivers of these cost savings were decreased contamination rates and reduced duration of antibiotic administration. In a Canadian institution, adoption of a manual ISDT was forecasted to yield savings of between $143,000 and $1,246,960 per year.⁵⁵

Time Saved or Lost during the Blood Collection Pipeline

Nineteen publications reported data on the time spent waiting for an HCP to arrive to collect blood, the duration of the blood collection procedure, or the waiting time for recollection in the event of sample rejection. The only study to directly compare the duration of sampling between relevant devices revealed that blood collection by direct venipuncture took longer than from an existing PIVC (175.8 ± 229.6 vs. 104.5 ± 53.4 seconds; p = .053).³¹

Risk of Anemia

Another concern expressed in multiple studies was that repeated blood sampling in hospitalized patients can lead to anemia, and greater efforts should be made to minimize blood wastage during blood collection to safeguard patients' wellbeing.^25,28 A study performed in a Canadian ICU established that on average, 5.5 ml of blood is wasted during each draw from a central venous line, compared with 6.3 ml from a PICC.²⁵ In a US-based pediatric ICU, the mean volume of blood drawn in excess of laboratory requirements was 1.9 ml for centrally inserted central catheters, but only 1.2 ml for PIVCs, and 0.8 ml for direct venipuncture.²⁸

Needlestick Injuries

Seven publications reported data on needlestick injuries (NSIs), with none comparing NSI rates between device types. Reported NSI rates varied widely; they were lower in studies involving HCPs from developed countries,^54,56,57,63 but higher in less developed countries.^64-66

Limitations

The SLR was associated with some limitations because of data availability or ambiguous results. For example, because VADs used for blood collection are almost always used for other purposes (e.g., the infusion of medicines/fluids), it is difficult to establish a causal relationship between blood sampling and specific complications observed in patients. Further research is required to quantify the isolated risks associated with collecting blood from VADs.

No studies directly compared the occurrence of NSIs between VAD and direct venipuncture blood sampling; research is required to quantify the number of NSIs that could be avoided by collecting blood from indwelling VADs. In addition, no quantitative self-reported data were identified on anxiety, fear, or stress during VAD blood sampling. Further research is required to confirm the impact of collecting blood from indwelling VADs on patient (and potentially also HCP) anxiety, fear, or stress, compared with direct venipuncture. It is expected that collecting blood through an existing VAD would be less stressful for patients; Twibell et al.⁶⁷ have reported significantly lower distress scores (p < .001) for PIVC relative to direct venipuncture blood collection, although their study was not eligible for the present SLR because distress scores were not self-reported. In fact, observer-rated distress (particularly needlestick distress in babies) is a well-researched topic that could warrant a future SLR in itself. Another interesting topic for a future SLR would be the reliability of different blood collection techniques for determining drug concentrations in plasma.

Finally, many of the identified publications offered limited description of the devices used. Where no further details were provided, the term “venipuncture” was assumed to be synonymous with direct venipuncture, but the term “phlebotomy” was not. It is possible that some of the included publications were misclassified as reporting on direct venipuncture alone, when in fact multiple devices were used and data were pooled across device types.

Discussion

This review involved a comprehensive search of the literature drawing on over a decade of published research, six major electronic databases, a broad range of study designs and prespecified outcomes, and no geographical limitations. For the purposes of this review, PIVCs and midline catheters were treated as distinct devices, but only 3/141 publications explicitly mentioned the use of midline catheters, relative to 53/141 for PIVCs, highlighting the lack of published data on midline catheters. Similarly, very few publications were identified on implanted ports (5/141 publications).

The data indicate that blood sampling from VADs is common in EDs, trauma centers, and ICUs; in these departments, the number of blood samples drawn from VADs often exceeds that from direct venipuncture, sometimes with a ratio as high as 4:1.^22-24 However, where blood is to be collected specifically for culture, blood draw from indwelling VADs is widely discouraged, because of fears over sample contamination.^15,17,30 These recommendations are important for the quality of care and based on historic data suggesting that contamination rates are higher in blood culture samples drawn from VADs compared with direct venipuncture.

Several studies showed that hemolysis and sample contamination place a considerable economic burden on hospitals, because patients may be required to stay in hospital longer, awaiting repeat test results. According to the data gathered in this review, both can be reduced through adherence to strict blood sampling protocols and use of the ISDT. According to a 2018 survey, 40% of US hospitals did not practice the ISDT for peripheral draws or central line draws,³⁰ so regional/national interventions may be required to encourage its uptake.

Limited evidence was available on novel, needle-free blood collection devices, but the two publications included suggest that hemolysis rates may be lower in PIVO-collected blood samples than in samples collected by more established techniques.^12,34 Educational programs are also known to decrease contamination of blood cultures and hemolysis rates.⁶⁸

Conclusions

Blood is already collected from VADs in everyday clinical practice; this approach is most common in EDs, trauma centers, and ICUs, where patients are more likely to have had VADs inserted for other purposes such as the administration of fluids and medicines. Hemolysis and sample contamination are far from inevitable in VAD-collected or venipuncture samples; both can be reduced through adherence to strict blood sampling protocols and utilization of the ISDT. Needle-free blood collection devices offer further hope for reducing hemolysis, although few studies have been published to date. No publications focused specifically on the DIVA population; the benefits of VADs are likely to be higher in these patients.

Implications

Selecting the most optimal approach for blood sample collection is essential for ensuring high-quality healthcare. Healthcare quality professionals and organizational leaders should prioritize the implementation of safe and effective blood collection practices by considering various quality-related factors, including patient experience, provider safety, and delivery of prompt/appropriate care.

Our findings will be useful to hospital administrators, clinicians, and researchers striving for improved patient experience and health outcomes. Adherence to appropriate blood sampling protocols and utilization of the ISDT can reduce hemolysis and sample contamination, which may enable timely medical interventions.

Where blood sampling through VADs is indicated, this approach could offer multiple advantages, including fewer NSIs for providers and reduced anxiety for patients (and potentially HCPs), although these benefits remain to be objectively quantified by empirical research. Novel needle-free technologies may present further improvements in provider safety and patient experience. These benefits of VADs and needleless solutions (i.e., PIVO) will likely be greater in patients with DIVA.

Authors' Biographies

Cathy Perry DNP, is a nurse practitioner at Tennessee Oncology, Clarksville, TN.

Kimberly Alsbrooks BSN, is Sr. Director Medical Affairs at BD, Franklin Lakes, NJ.

Alicia Mares BSN, is Associate Director Medical Affairs at BD, Franklin Lakes, NJ.

Klaus Hoerauf MD, is professor of Anesthesiology and Intensive Care at the Medical University of Vienna, Vienna, Austria and VP Global Medical Affairs at BD, Franklin Lakes, NJ.