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Key factors influencing the incidence of hemolysis: A critical appraisal of

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 Critical Reviews in Clinical Laboratory Sciences

ISSN: 1040-8363 (Print) 1549-781X (Online) Journal homepage: http://www.tandfonline.com/loi/ilab20

Key factors influencing the incidence of hemolysis:

A critical appraisal of current evidence

Euan James McCaughey, Elia Vecellio, Rebecca Lake, Ling Li, Leslie Burnett,
Douglas Chesher, Stephen Braye, Mark Mackay, Stephanie Gay, Tony
Badrick, Johanna Westbrook & Andrew Georgiou

To cite this article: Euan James McCaughey, Elia Vecellio, Rebecca Lake, Ling Li, Leslie Burnett,
Douglas Chesher, Stephen Braye, Mark Mackay, Stephanie Gay, Tony Badrick, Johanna
Westbrook & Andrew Georgiou (2017) Key factors influencing the incidence of hemolysis: A
critical appraisal of current evidence, Critical Reviews in Clinical Laboratory Sciences, 54:1,
59-72, DOI: 10.1080/10408363.2016.1250247

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Crit Rev Clin Lab Sci, 2017; 54(1): 59–72

! 2016 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/10408363.2016.1250247

REVIEW ARTICLE

Key factors influencing the incidence of hemolysis: A critical appraisal of

current evidence
Euan James McCaughey1, Elia Vecellio1,2, Rebecca Lake1, Ling Li1, Leslie Burnett2,3,4, Douglas Chesher3,4,
Stephen Braye3,5, Mark Mackay6, Stephanie Gay6, Tony Badrick6, Johanna Westbrook1, and Andrew Georgiou1
1
Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia,
2
South Eastern Area Laboratory Services, NSW Health Pathology, Prince of Wales Hospital, Randwick, NSW, Australia, 3Pathology North, NSW
Health Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia, 4Northern Clinical School, Sydney Medical School, University of Sydney,
NSW, Australia, 5Pathology North, NSW Health Pathology, Newcastle, NSW, Australia, and 6Royal College of Pathologists Australasia Quality
Assurance Program, St Leonards, NSW, Australia

Abstract Keywords
Hemolysis is a leading cause of pre-analytical laboratory errors. The identification of Blood, hemolysis, laboratory, pathology,
contributing factors is an important step towards the development of effective practices to specimen, preanalytical error
reduce and prevent hemolysis. We performed a review of PUBMED, Embase, Medline and
CINAHL to identify articles published between January 2000 and August 2016 that identified History
factors influencing in vitro hemolysis rates. The 40 studies included in this review provide
excellent evidence that hemolysis rates are higher in Emergency Departments (EDs), for non- Received 21 July 2016
antecubital draws, for specimens drawn using an intravenous catheter compared to Revised 6 October 2016
venipuncture and for samples transported by pneumatic tube compared to by hand. There Accepted 16 October 2016
is also good evidence that hemolysis rates are higher when specimens are not collected by Published online 21 December 2016
professional phlebotomists, larger volume specimen tubes are used, specimen tubes are filled
less than halfway and tourniquet time is greater than one minute. The results of this review
suggest that hospitals and clinical laboratories should consider deploying phlebotomists in
EDs, drawing all blood through a venipuncture, using the antecubital region as the optimum
blood collection site and transporting specimens by laboratory assistant/other personnel, or if
this in not practical, ensuring that pneumatic transport systems are validated, maintained and
monitored. Studies also recommend making hemolysis a hospital-wide issue and ensuring
high-quality staff training and adherence to standard operating procedures to reduce
hemolysis rates. Awareness of the factors that influence hemolysis rates, and adoption of
strategies to mitigate these risk factors, is an important step towards creating quality practices
to reduce hemolysis rates and improve the quality of patient care.

Abbreviations: CI: confidence intervals; ED: Emergency Department; IV: intravenous; OR: odds
ratio; RCT: randomized control trial

Introduction
Hemolysis refers to the rupturing of erythrocytes (red blood
cells), resulting in the release of the oxygen-carrying pigment
Address for correspondence: Dr Euan J. McCaughey, Centre for Health
Systems and Safety Research, Australian Institute of Health Innovation,
Level 6, 75 Talavera Road, North Ryde, NSW 2109, Australia.
E-mail:euan.mccaughey@mq.edu.au
Referees: Dr. Ana-Maria Simundic, Department of Medical Laboratory
Diagnostics, University Hospital Sveti Duh, Zagreb, Croatia; Dr. Chris
Florkowski, Molecular Pathology Laboratory, Canterbury Health
Laboratories, Canterbury District Health Board, Christchurch, New
Zealand; Dr. Glenn Edwards, School of Animal and Veterinary Sciences,
Charles Sturt University, Boorooma Street, Wagga Wagga, New South
Wales, Australia.
hemoglobin into the surrounding fluid1. This release of
hemoglobin can have a significant impact on the efficiency
and effectiveness of diagnostic testing as it has the potential to
lead to incorrect measurements of some analytes, dilution
effects, spectral interference and/or chemical elevations, all of
which can cause erroneous laboratory results2. While Carraro
and Plebani3 reported a significant decrease in the number of
errors observed in a clinical laboratory between 1996 and
2006, the proportion of pre-analytical errors remained rela-
tively unchanged. As one of the leading causes of pre-
analytical laboratory errors2,4 reported to account for 40–70%
of all specimen rejections2, hemolysis constitutes an area of
major importance for clinical laboratories. The existence of
hemolysis requires a replacement specimen to be sought to
60 E. J. McCaughey et al.
Figure 1. PRISMA flow diagram of search
protocol. Duplicate studies refer to studies
that were returned from more than one of the
four search databases.
enable the requested tests to be performed; this impacts
resources, delays the availability of test results5 and poten-
tially subjects the patient to a repeat blood draw, and with it
an increased risk of iatrogenic injury and infection6. This need
for a replacement specimen also contributes to a delayed time
to diagnosis, longer episodes of hospital care and increased
laboratory costs5. Therefore, as well as having a major
bearing on the quality and efficiency of the laboratory
process7, hemolysis also has major implications for the safety
and quality of patient care8,9.
Although hemolysis may be present through hemolytic
anemia, which is termed in vivo hemolysis, it is more
commonly caused by incorrect procedures relating to the
collection, handling, transportation or storage of the speci-
men, which is termed in vitro hemolysis10. Therefore,
understanding and addressing the sources of in vitro hemoly-
sis is an area of major importance for clinical laboratories.
Despite individual studies identifying specific factors asso-
ciated with hemolysis, there has been no previous review
which has sought to synthesize this evidence. This narrative
review aimed to investigate factors influencing the incidence
of in vitro hemolysis, as a step towards creating quality
practices to monitor and reduce this leading cause of
pre-analytical laboratory errors.
Materials and methods
Search strategy
A search of PUBMED, Embase, Medline and CINAHL,
performed in September 2016, was used to identify studies
that investigated pre-analytical errors, rejected specimens or
in vitro hemolysis. Peer reviewed studies were included if
they: (i) were published between January 2000 and August
2016; (ii) presented primary data from the general population
(i.e. were not disease specific, due to the possibility of higher
Crit Rev Clin Lab Sci, 2017; 54(1): 59–72
hemolysis rates for specific conditions11); (iii) provided an
overall rate of hemolysis (or sufficient information to
calculate this); and (iv) analyzed at least one factor that
influenced hemolysis rates. Articles that were not available in
English, letters, reviews and conference abstracts were
excluded.
The following search terms were used individually and in
combination, including both British and American English
variants of spelling: h(a)emolysis, pre(-)analytical error(s),
rate/frequency/prevalence, error(s), retrospective analysis/
audit, rejection rate, h(a)emolysed/h(a)emolyzed and blood
specimen/sample collection. The titles and abstract of all
returned articles were independently reviewed (EV, RL) and
sorted based on the predefined inclusion criteria, with each
reviewer evaluating all articles. The full text of the studies
that matched these criteria were then independently reviewed
(EV, RL) and once again sorted based on the predefined
inclusion criteria, with each reviewer evaluating all articles.
Any disagreements relating to the inclusion or exclusion of
articles were resolved via discussion between the two
reviewers until a consensus was reached. Reference lists of
studies that met the inclusion criteria were hand-searched for
relevant studies that were not returned in the initial search.
The search protocol is summarized in Figure 1.
Analysis
Studies were grouped based on four categories relating to
whether they investigated differences in hemolysis rates due
to hospital/laboratory, patient, equipment or phlebotomy/draw
method characteristics. Hospital/laboratory characteristics
relate to patient location; whether the phlebotomy was
performed by laboratory or clinical staff; and time of day or
day of the week of draw. Patient characteristics relate to
patient age, gender and diagnosis. Equipment characteristics
DOI: 10.1080/10408363.2016.1250247
Table 1. Evidence classification structure.
Strength of evidence Quantity Risk of bias
Poor Low (1 study) High (no statistical analysis or
confounding factors not considered)
Satisfactory Low Low (statistical analysis and confounding
factors considered)
Moderate (2 or more studies) High
Good Moderate Low
High (3 or more studies) Low
Excellent High Low
No consensus Moderate or high Low
relate to the draw equipment used for intravenous (IV) access
and aspiration, needle or catheter thickness, size and type of
the specimen tube and whether extension tubing was used.
Phlebotomy/draw method characteristics relate to the methods
used for the phlebotomy including the draw site, site
preparation (including tourniquet time), specimen tube full-
ness, difficulties or complications during the phlebotomy and
method of specimen transport.
Results are presented as the proportion (and absolute
number) of specimens that were hemolyzed. All reported
statistical analyses were extracted directly from each study,
with a p value50.05 being regarded as significant. In cases
where statistical significance was presented as an odds ratio
(OR), the 95% confidence intervals (CI) are reported.
Critical appraisal of the bodies of evidence
Due to the heterogeneous nature of the studies included in this
narrative review, the quality of individual studies was not
assessed. Instead, studies were grouped according to factors
potentially influencing hemolysis rates and a pragmatic
approach was adopted to assess the overall strength of the
evidence base relating to how each factor impacts hemolysis
rates, based on the FORM framework for grading evidence
quality12. This framework was developed for, and endorsed by,
the Australian National Medical and Health Research Council
and provides a structured process for considering the whole
body of evidence relevant to a particular clinical question in the
context of the setting in which it is to be applied. It focuses on
the quantity and quality (by assessing risk of bias) of the studies
forming the evidence base and the consistency, impact,
generalizability and applicability of study findings. To maxi-
mize the generalizability and applicability of the study
findings, only studies that presented primary data from the
general population were included in this review. Furthermore,
due to the low numbers of Randomized Control Trials (RCTs)
in the area of hemolysis, it was decided not to consider
individual study designs when assessing the risk of bias.
Instead, risk of bias was assessed by considering whether the
studies forming the evidence base conducted appropriate
statistical analysis and considered potential confounding
factors. By considering the quantity and risk of bias of the
studies addressing each factor that may influence hemolysis
rates, and the consistency of the findings across these studies,
the evidence base for each factor was classified as: (i) Poor -
Key factors influencing the incidence of hemolysis 61
Contributing factors
Consistency
N/A
N/A
High (both studies in agreement)
High
Moderate (one study in disagreement)
High
No agreement
low quantity (i.e. only one study) and high risk of bias (i.e. no
statistical analysis or confounding factors were not con-
sidered); (ii) Satisfactory - low quantity but low risk of bias
(i.e. statistical analysis and confounding factors were con-
sidered), or moderate quantity (i.e. two or more studies) and
high risk of bias; (iii) Good - moderate quantity, low risk of bias
and high consistency (i.e. all studies in agreement), or high
quantity (i.e. three or more studies), low risk of bias and
moderate consistency (i.e. one study in disagreement); and (iv)
Excellent - high quantity and consistency and low risk of bias.
In instances where the findings consistently disagreed,
evidence was classified as having no consensus. This classi-
fication structure is shown in Table 1.
Results
Forty studies met the inclusion criteria (Table 2). Eight
(20.0%) were RCTs13–20 and 32 (80.0%) were observational
studies, including 12 (30.0%) prospective cohort studies21–32,
seven (17.5%) prospective case control studies11,33–38, six
(15.0%) retrospective case control studies39–44, five (12.5%)
retrospective cohort studies45–49, and one (2.5%) prospect-
ive50 and one retrospective (2.5%)51 observational longitu-
dinal study. Eighteen (45.0%) studies were from
Europe13,14,20,21,26,28–31,33,35,39,41,43,45,47,49,50, 14 (35.0%)
were from the USA11,15,16,18,22–24,27,32,37,44,46,48,51, six
(15.0%) from Asia19,25,34,36,40,42, and one each (2.5%) from
both Australia17 and New Zealand.38 Twenty-four (60.0%)
were published between 2010 and 201613–15,19–25,28–31,33,38–
42,45,47–49
, with the remaining 16 (40.0%) published between
2000 and 200911,16–18,26,27,32,34–37,43,44,46,50,51, possibly
reflecting a growing interest in hemolysis research. Thirty
studies (75.0%) included specimens collected in an
ED11,13,15–24,26,27,29–31,33,34,36–38,41,43,44,46–49,51, 14 (35.0%)
in an inpatient ward14,28,29,32,35,36,40–44,46,50,51, five (12.5%)
in an outpatient setting29,33,40,42,44,45, two (5.0%) in primary
care26,39, and one (2.5%) in a pediatric inpatient ward25, labor
ward27 and nursing home26. Fourteen studies (35.0%)
examined the impact of hospital/laboratory characteristics
on hemolysis rates11,26,28,34,35,40–46,50,51, three (7.5%) patient
characteristics11,26,36, 25 (62.5%) equipment characteris-
tics11,14–20,22–25,27,30–39,46,47 and 16 (42.1%) phlebotomy/
draw characteristics11,13,14,17,21,23,29,33–37,46,48–50. A Venn dia-
gram of the comparisons made by these studies is shown in
Figure 2, with the results of these comparisons presented here.
 62

Table 2. Characteristics and key findings of included studies.

Comparison Statistical
Study authors Year Country Study design Setting Detection method categories Comparisons Key findings analysis
Cadamuro 2016 Austria Observational Inpatient Hemolysis index Hospital Collector staff Higher hemolysis rate when Yes
et al.28 (Cohort) specimens collected by
doctors without professional
phlebotomy training com-
E. J. McCaughey et al.

pared to nurses trained in

phlebotomy
Phelan et al.48 2016 USA Retrospective ED Hemolysis index Phlebotomy Transport No significant difference in Yes
observational method hemolysis rates between
(Cohort) specimens transported by
pneumatic tube compared to
those transported by hand.
Pasqualetti 2016 Italy Retrospective ED Hemolysis index Phlebotomy Transport Higher rates of hemolysis in Yes
et al.49 observational method samples transported by
(Cohort) pneumatic tube compared to
by hand
Ryan et al.38 2015 New Zealand Observational ED Hemolysis index Equipment Tube type No significant difference in Yes
(Cohort) hemolysis rates when speci-
mens were collected in rapid
serum tubes compared to
plasma serum tubes and
non-gel plasma tubes
Ibrahim et al.19 2015 Singapore RCT (Crossover) ED Hemolysis index Equipment Needle gauge Higher hemolysis rate when Yes
size specimens were drawn using
an insulin needle compared
to a standard needle
Lippi et al.31 2015 Italy Observational ED Hemolysis index Equipment Tube type Higher rates of hemolysis when Yes
(Cohort) using BD Vacutainer Plus
serum tubes compared to
Sarstedt S-Monovette serum
tubes
Bockel- 2014 Germany Observational ED, inpatient and Hemolysis index Phlebotomy Transport Higher hemolysis rate when No
Frohnhofer (Cohort) outpatient method specimens were transported
et al.29 by pneumatic tube com-
pared to by hand
Davidson45 2014 UK Retrospective Outpatient Hemolysis index Hospital Collector staff & Higher hemolysis rate when No
observational location in specimens collected by
(Cohort) hospital clinical staff in ED than by
laboratory phlebotomists in
outpatient department
Fernandez 2014 Spain Retrospective Primary care Hemolysis index Equipment Blood aspiration Higher hemolysis rate when Yes
et al.39 observational methods, tube syringes used to aspirate
(Case-control) size specimen than evacuated
tube systems, higher rate of
hemolysis for 8-9 mL tubes
than 3.5-4 mL tubes
Crit Rev Clin Lab Sci, 2017; 54(1): 59–72

(continued )
 Comparison Statistical
Study authors Year Country Study design Setting Detection method categories Comparisons Key findings analysis
Kara et al.13 2014 Turkey RCT (Parallel ED Hemolysis index Phlebotomy Transport Higher hemolysis rate for spe- Yes
group) method cimens transported by
pneumatic tube than by hand
Lippi et al.47 2014 Italy Retrospective ED Hemolysis index Equipment Tube size Higher hemolysis rates for Yes
observational 5 mL tubes than 3.5 mL
(Cohort) tubes.
Lippi et al.21 2014 Italy Observational ED Hemolysis index Phlebotomy Draw site Specimens drawn from median Yes
DOI: 10.1080/10408363.2016.1250247

(Cohort) cephalic & basilic veins had

lower hemolysis rates than
metacarpal plexus, basilic
vein & cephalic vein.
Ortells-Abuye 2014 Spain RCT (Crossover) Inpatient Undefined Equipment, Draw equipment Higher hemolysis rate for IV Yes
et al.14 Phlebotomy catheter than venipuncture
Lippi et al.20 2013 Italy RCT (Parallel ED Hemolysis index Equipment Draw equipment, Higher rate of hemolysis when Yes
group) tube type using an evacuated tube
system compared to a syr-
inge and when using BD
Vacutainer Plus serum tubes
compared to Sarstedt S-
Monovette serum tubes
Lippi et al.30 2013 Italy Observational ED Hemolysis index Equipment Draw equipment No difference in hemolysis Yes
(Cohort) rates when samples were
collected using a BD
Vacutainer One Use Holder
compared to Greiner Holdex
Dietrich22 2013 USA Observational ED Hemolysis index Equipment Draw equipment Higher hemolysis rate for new No
(Cohort) compared to existing IV
catheters
Upreti et al.40 2013 India Retrospective Inpatient & Undefined Hospital Location in Higher hemolysis rate in inpa- No
observational outpatient hospital tients than outpatients
(Case-control)
Wollowitz 2013 USA Observational ED Hemolysis index Equipment, Draw equipment, Higher hemolysis rate when Yes
et al.23 (Cohort) Phlebotomy tube fullness, using IV catheter than
tourniquet butterfly needle, when spe-
time cimen tube was less than
half full, when tourniquet
time was 41 minute
Stauss et al.15 2012 USA RCT (Parallel ED Visual Equipment Extension tube No difference in hemolysis rate Yes
group) when extension tube used
Berg et al.41 2011 UK Retrospective ED & inpatient Hemolysis index Hospital Location in Higher hemolysis rate in ED Yes
observational hospital than inpatients
(Case-control)
Straszewski 2011 USA Observational ED Visual Equipment Draw equipment Higher hemolysis rate when Yes
et al.24 (Cohort) using butterfly needles or IV
catheters than only butterfly
needles
Berger-Achituv 2010 Israel Observational Pediatric Hemolysis index Equipment Draw equipment No difference in hemolysis Yes
Key factors influencing the incidence of hemolysis

et al.25 (Cohort) inpatient rates for specimens col-

lected using an IV catheter
63

compared to venipuncture

(continued )
 64

Table 2. Continued

Comparison Statistical
Study authors Year Country Study design Setting Detection method categories Comparisons Key findings analysis
Chawla et al.42 2010 India Retrospective Inpatient & Visual Hospital Location in Higher hemolysis rate in No
observational outpatient hospital inpatients than outpatients
(Case-control)
Munnix et al.33 2010 Netherlands Observational ED & outpatient Hemolysis index Equipment, Draw site, Lowest hemolysis rate in No
(Case-control) Phlebotomy number of specimens drawn from
draws antecubital fossa, first
E. J. McCaughey et al.

specimen was most likely to

be hemolyzed
Ellis50 2009 UK Observational Inpatient Hemolysis index Hospital, Transport Higher hemolysis rate for Yes
(Longitudinal) Phlebotomy method specimens transported by
pneumatic tube than by hand
Ong et al.34 2009 Singapore Observational ED Undefined Equipment, Collector staff, Higher hemolysis rate when Yes
(Case-control) Hospital, draw equip- specimens drawn through IV
Phlebotomy ment, aspir- catheters than venipunc-
ation method, tures, when evacuated tube
draw diffi- systems were used to aspir-
culty, blood ate specimen than syringes,
flow rate, for moderate or easy draws,
needle gauge when blood flow was slow
size, draw site or moderate. No difference
for gauge sizes less or
greater than 21G, for venous
compared to arterial draw
sites, for moderate or easy
draws, when blood flow was
slow or moderate
Saleem et al.35 2009 UK Observational Inpatient Hemolysis index Equipment, Collector staff, Higher hemolysis rate when Yes
(Case-control) Hospital, tourniquet specimens drawn by nurses
Phlebotomy time, transport & medical staff than allied
method health professionals, for a
tourniquet time of 41 min-
ute, borderline higher rate
for specimens transported
by pneumatic tube
compared to by hand
Söderberg et al.26 2009 Sweden Observational ED, primary Hemolysis index Hospital, Patient Location in Higher hemolysis rate in ED Yes
(Cohort) care, nursing hospital, compared to nursing home
home patient & local primary healthcare
gender, center, in males, in patients
patient age 463 years of age
Salvagno et al.43 2008 Italy Retrospective ED & inpatient Visual Hospital Location in Higher hemolysis rate in ED Yes
observational hospital than intensive care unit,
(Case-control) pediatric, surgical & clinical
department
Fang et al.36 2008 Taiwan Observational ED & Inpatient Visual Equipment, Patient gender, Higher hemolysis rate for Yes
(Case-control) Patient, draw equip- specimens drawn through IV
Phlebotomy ment, tube catheters than venipunc-
type, draw tures, serum tubes,
non-antecubital draws,
Crit Rev Clin Lab Sci, 2017; 54(1): 59–72

(continued )
 Comparison Statistical
Study authors Year Country Study design Setting Detection method categories Comparisons Key findings analysis
location, specimens transported by
transport type ward assistants than labora-
tory staff. No difference
between males & females.
Lowe et al.16 2008 USA RCT (Crossover) ED Visual Equipment Draw equipment Higher hemolysis rate for Yes
specimens drawn through IV
catheters than straight
DOI: 10.1080/10408363.2016.1250247

needle venipunctures
Pretlow et al.51 2008 USA Retrospective ED & inpatient Undefined Hospital Location in Higher hemolysis rate in ED No
observational hospital than non-ED wards
(Longitudinal)
Stark et al.44 2007 USA Retrospective ED, inpatient & Undefined Hospital Location in Higher hemolysis rate in ED Yes
observational outpatient hospital than both inpatient &
(Case-control) outpatient settings
Dwyer et al.17 2006 Australia RCT (Parallel ED Hemolysis index Equipment, Aspiration No difference in hemolysis rate Yes
group) Phlebotomy method between specimens drawn
using a syringe directly
through IV cannula hub &
those drawn using a syringe
through a device connected
to IV cannula cap
Dugan et al.11 2005 USA Observational ED Visual Equipment, Collector staff Higher hemolysis rate in Yes
(Case-control) Hospital, type, time of respiratory or reproductive
Patient, day, aspiration system illness, for larger
Phlebotomy method, tube tube sizes, when IV catheter
type, dis- placement was regarded as
charge cat- difficult. Lower hemolysis
egory, tube rate in specimens drawn
size, difficulty from right antecubital. No
of catheter difference in specimens
placement, collected by patient care
draw location technicians compared to
registered nurses, at
different times of day, for
evacuated tube systems than
syringes when using
different tube types.
Cox et al.18 2004 USA RCT (Parallel ED Hemolysis index & Equipment Tube size Higher hemolysis rate in 10 mL Yes
group) visual tubes than 5 mL tubes
Grant37 2003 USA Observational ED Visual Equipment, Draw equipment, Higher hemolysis rate when Yes
(Case-control) Phlebotomy aspiration using new and existing IV
method catheters compared to
venipuncture, when using an
evacuated tube system than
a syringe (when specimen
drawn through a new IV
catheter)
Key factors influencing the incidence of hemolysis

(continued )
65
66 E. J. McCaughey et al. Crit Rev Clin Lab Sci, 2017; 54(1): 59–72

Statistical
Hospital/laboratory characteristics

analysis
Yes

Yes

Yes
Location
Three observational studies reported higher rates of hemolysis

was filled less than halfway.

rather than metal, when tube
antecubital fossa compared

than ‘medical floor’, when

Higher hemolysis rate in ED
from specimens collected in an ED compared to another
Higher hemolysis rate when

Lower hemolysis rate for

No difference in hemolysis
using IV catheters than

IV cannula was plastic

specimens drawn from
location. Two studies found significantly higher hemolysis

catheters compared to
to hand and forearm.
venipuncture. Lower

rates when using IV

rates in an ED than an inpatient ward [10.7% (n ¼ 50) versus
hemolysis rate for

antecubital draws.
2.9% (n ¼ 30), p50.000141 and 12.4% (n ¼ 372) versus 1.6%

venipuncture
(n ¼ 16), p50.000146], while a third reported higher rates of
Key findings

hemolysis in the ED compared to non-ED wards [18.1%

(n ¼ 195) versus 0.7% (n ¼ 69)]; however, no statistical
analysis was performed51.
The finding that hemolysis is higher in the ED is consistent
with two observational studies that compared hemolysis rates
Draw equipment,

fullness, draw
material, tube
Location in hos-

Draw equipment
pital, cannula

across multiple locations; one found a significantly higher

Comparisons

draw site

hemolysis rate in an ED (3.9%, n ¼ 194, p50.001) compared

location

to an intensive care unit (0.9%, n ¼ 67) and a pediatric (0.8%,

n ¼ 16), surgical (0.7%, n ¼ 222) and clinical ward (0.1%,
n ¼ 207)43, and the other found a significantly higher
hemolysis rate in the ED (31.1%, n ¼ 139, p50.001)
Phlebotomy

compared to a nursing home (12.5%, n ¼ 26) and a local

Comparison

Hospital,
Equipment,

primary healthcare center (10.4%, n ¼ 920)26. Stark et al.44

Equipment

Equipment
categories

also reported a higher rate of hemolysis in the ED compared

to inpatient and outpatient settings [1.8% (n ¼ 2578) versus
0.8% (n ¼ 3773) and 0.3% (n ¼ 2063)]; however, no statistical
analysis was performed. Thus, due to the high quantity and
Detection method

consistency of results, evidence of higher hemolysis rates in

the ED compared to other locations was classified as
excellent.
Visual

Visual

Visual

Two observational studies also reported a higher rate of

hemolysis in specimens collected from inpatients compared to
outpatients [1.1% (n ¼ 607) versus 0.2% (n ¼ 105) and 0.2%
ED & labor ward

ED & inpatient

(n ¼ 95) versus 0.1% (n ¼ 39), respectively]40,42. However,

due to the poor overall quality of these studies, this evidence
Inpatient

was classified as satisfactory.

Setting

Collector staff type

An observational study by Saleem et al.35 found significantly
observational
Observational

Observational
Retrospective

higher hemolysis rates among specimens drawn by nurses and

Study design

(Cohort)

(Cohort)

(Cohort)

medical staff [14.1% (n ¼ 10) and 9.8% (n ¼ 5), respectively]

compared to allied health professionals including laboratory
phlebotomists (3.6%, n ¼ 8, p ¼ 0.006). This is consistent with
the findings of an observational study by Davidson45, who
reported that specimens collected by clinical staff in two EDs
had a higher rate of hemolysis [11.2% (n ¼ 745) and 9.4%
(n ¼ 889)] than those collected in two outpatient departments
Country

by laboratory phlebotomists [1.6% (n ¼ 63 and 82)]. However,

USA

USA

USA

it should be noted that this study may be weakened by the fact

that it did not account for the two different locations from
which specimens were drawn. Thus, due to the consistent
findings of these two studies, evidence that specimens
2003

2002

2000
Year

collected by phlebotomists have lower hemolysis rates was

classified as of good strength.
In an observational study, Ong et al.34 found no significant
Table 2. Continued

difference in hemolysis rates for specimens collected by

Yoshikawa46

students/nurses (31.5%, n ¼ 17, OR 2.3 [95% CI: 0.4–12.7]),

Tanabe et al.27

Reinhardt32
Study authors

Seemann and

senior doctors/consultants (22.2%, n ¼ 4, OR 2.8 [95% CI:

Burns and

0.5–14.8]) and residents/medical officers (16.1%, n ¼ 22, OR

1.9 [95% CI: 0.3–14.9]) compared to junior doctors/registrars
DOI: 10.1080/10408363.2016.1250247
Figure 2. Venn diagram of article classification according to the nature
of hemolysis rate comparisons (n ¼ 30). H ¼ Hospital/laboratory char-
acteristics, Pa ¼ Patient characteristics, Ph ¼ Phlebotomy/draw method
characteristics and E ¼ Equipment characteristics.
(11.1%, n ¼ 2). This is consistent with results from an
observational study by Dugan et al.11, which found no
significant difference in hemolysis rates between specimens
collected by patient care technicians and registered nurses
(14.1% (n ¼ 29) versus 11.3% (n ¼ 20), OR 3.0 [95% CI: 0.5–
16.5]). Thus, due to the consistent findings of these two
studies, evidence that the clinical role of collector staff (e.g.
doctors or nurses) does not affect hemolysis rates was
classified as of good strength. In contrast, an observational
study by Cadamuro et al.28 found a statistically higher rate of
hemolysis in specimens collected by doctors without profes-
sional phlebotomy training compared to nurses trained in
phlebotomy and specimen preparation techniques [1.8%
(n ¼ 387) versus 1.6% (n ¼ 358), p ¼ 0.021]. However, this
difference may have been caused by the effect of the training
rather than the collector staff type.
Day of week and time of day
An observational study found no significant difference in
hemolysis rates for specimens collected between 2400 h and
0600 h [19% (n ¼ 15)], 0600 h and 1200 h [8.3% (n ¼ 6)],
1200 h and 1800 h [11.6% (n ¼ 10)] and 1800 h and 2400 h
[12.4% (n ¼ 18)]11, while another reported higher hemolysis
rates for specimens drawn on weekends compared to week-
days (7.3% versus 2.9%)45. However, the latter provided no
absolute numbers. As such, evidence that time of day does not
affect hemolysis rates was classified as satisfactory and
evidence of higher hemolysis rates at weekends was classified
as poor.
Patient characteristics
Gender
Two observational studies considered the effect of patient
gender on hemolysis rates, with one finding a significantly
higher rate of hemolysis in specimens drawn from males than
females [13.1% (n ¼ 532) versus 10.1% (n ¼ 550),
p50.001]26 and the other finding no significant difference
between these groups [21.2% (n ¼ 39) versus 16.7% (n ¼ 15),
Key factors influencing the incidence of hemolysis 67
p ¼ 0.47]36. However, it should be noted that the later study
analysed 35 times fewer specimens (n ¼ 274) than the former
(n ¼ 9504). Therefore, due to the far larger sample size in the
first study, evidence that hemolysis is more common in males
was classified as satisfactory.
Age
One study, which examined hemolysis in relation to patient
age, found a significantly higher rate of hemolysis in
specimens from patients over 63 years of age compared to
younger patients [12.4% (n ¼ 566) versus 10.5% (n ¼ 520),
p50.004]26. Due to this low quantity of specimens, evidence
that hemolysis is more likely in older patients was classified
as satisfactory.
Diagnosis
One observational study found that patients with a respiratory
(52.9%, n ¼ 9) or reproductive system illness (31.0%, n ¼ 13)
had significantly higher rates of hemolysis than patients with
other diagnoses11, providing satisfactory evidence of higher
hemolysis rates in these patients.
Equipment characteristics
Draw equipment
When comparing hemolysis rates in specimens drawn using
IV catheters and straight needle venipunctures, an RCT16 and
three observational studies27,34,36 all reported significantly
higher rates of hemolysis for specimens drawn through IV
catheters compared to straight needle venipunctures (24.4%
(n ¼ 41) versus 6.8% (n ¼ 4), OR 4.4 [95% CI: 1.5–13.0])24,
18.5% (n ¼ 10) versus 4.5% (n ¼ 10), p50.0126, 5.6%
(n ¼ 28) versus 0.3% (n ¼ 1), p50.00116 and 10% (n ¼ 41)
versus 1.5% (n ¼ 3), p50.00127). An RCT by Ortells-Abuye
et al.14 also reported a higher rate of hemolysis for IV
catheters compared to venipuncture [3.7% (n ¼ 10) versus
0%]; however, no statistical analysis was performed. In
contrast, two small observational studies (4025 and 1932
specimens in each group, respectively) found no significant
difference in hemolysis rates between specimens collected
using an IV catheter or venipuncture [0% versus 2.5% (n ¼ 1),
p ¼ 0.6425 and 23.5% (n ¼ 4) versus 0%, p ¼ 0.0932], but this
may be due to the small sample sizes in both studies.
Therefore, due to the large quantity of consistent supporting
evidence, evidence of higher hemolysis rates when specimens
are drawn using an IV catheter compared to venipuncture was
classified as excellent.
Two observational studies compared hemolysis rates for
specimens drawn using IV catheters compared to butterfly
needles. Both studies found significantly higher rates of
hemolysis for specimens drawn using IV catheters compared
to butterfly needles (14.6% (n ¼ 544) versus 2.7% (n ¼ 21),
OR 7.7 [95% CI: 4.9–12.0])23 or when using butterfly needles
or IV catheters compared to only butterfly needles [23.0%
(n ¼ 72) versus 6.6% (n ¼ 169), p50.0001]24, respectively.
Therefore, due to the consistency of these findings, there was
deemed to be good evidence of higher hemolysis rates for
specimens drawn using IV catheters compared to butterfly
needles.
68 E. J. McCaughey et al.
Grant37 found significantly higher (p50.001) rates of
hemolysis that led to test cancelation when using new IV
catheters compared to venipuncture [20% (n ¼ 50) versus
0.9% (n ¼ 1)] and no significant difference when using
existing IV catheters compared to venipuncture [10%
(n ¼ 10) versus 0.9% (n ¼ 1)]. Dietrich22 also reported
higher hemolysis rates when using newly inserted IV catheters
compared to existing IV catheters [1.1% (n ¼ 41) versus 0.8%
(n ¼ 14)]. However, the IV access method was confounded
with different collector staff type and no statistical analysis
was performed. Therefore, evidence of higher hemolysis rates
when using new compared to existing IV catheters was
classified as poor.
One RCT and five observational studies compared differ-
ent aspiration methods. The RCT and one observational study
found a significantly higher hemolysis rate when evacuated
tube systems were used compared to syringes [30.8% (n ¼ 16)
versus 2.0% (n ¼ 51), p50.0120 and 35.8% (n ¼ 29) versus
11.0% (n ¼ 16), OR 6.0 [95% CI: 2.3–15.2]34], while another
observational study found no significant difference between
these aspiration methods [12.6% (n ¼ 35) versus 13.5%
(n ¼ 14), p40.05]11. Grant37 found specimens drawn through
a newly inserted IV catheter had significantly higher
hemolysis rates when aspirated with an evacuated tube
system compared to a syringe [77.4% (n ¼ 195) versus
28.3% (n ¼ 17), p ¼ 0.02], but when the specimen was
drawn through a straight needle, there was no significant
difference in hemolysis rates between the aforementioned
aspiration methods [2.9% (n ¼ 3) versus 9.1% (n ¼ 1),
p40.05]. In contrast, Fernandez et al.39 found significantly
higher hemolysis rates when syringes were used to aspirate
specimens compared to evacuated tube systems [5.3%
(n ¼ 22) versus 2.4% (n ¼ 1543), OR 2.2 [95% CI: 1.5–
3.3]]. However, this study was weakened by the authors not
reporting the draw equipment that was used. Finally, Saleem
et al.35 compared the hemolysis rates for different IV access
and aspiration methods but did not explicitly specify how they
were combined; they reported a hemolysis rate of 16.7%
(n ¼ 10) for blood drawn using an IV catheter, 4.7% (n ¼ 10)
for an evacuated tube system, 4.3% (n ¼ 2) for butterfly
needles and 3.2% (n ¼ 1) for syringes. These results suggest
no consensus about how different aspiration methods affect
hemolysis rates.
There was also deemed to be satisfactory evidence of
higher hemolysis rates when using a plastic IV cannula
compared to metal [13.5% (n ¼ 22) versus 0%, p ¼ 0.02]46,
and satisfactory evidence of no significant difference in
hemolysis rates when an extension tube is used [31.7%
(n ¼ 19) versus 30% (n ¼ 18), p ¼ 0.84]15, when specimens
are drawn directly through an IV cannula hub or through a
needleless device connected to the IV cannula cap [6.5%
(n ¼ 45) versus 7.2% (n ¼ 50), p40.05]17 or when samples
are collected using a BD Vacutainer One Use Holder
compared to Greiner Holdex [28.3% (n ¼ 17) versus 28.3%
(n ¼ 17), p ¼ 1.00]30. However, it should be noted that in the
final study the concentrations of cell-free hemoglobin (0.42 g/
L versus 0.22 g/L, p ¼ 0.042) and the frequency of gross
hemolysis (cell-free hemoglobin43.0 g/L) were higher when
using the BD Vacutainer One Use Holder compared to the
Greiner Holdex [6.7% (n ¼ 4) versus 0%, p ¼ 0.042]30.
Crit Rev Clin Lab Sci, 2017; 54(1): 59–72
Needle/catheter gauge sizes
An observational study by Tanabe et al.27 found that while
increased IV catheter gauge (i.e. narrower) led to a significant
increase in hemolysis rates [16G: 4% (n ¼ 4); 18G: 10.2%
(n ¼ 26), p ¼ 0.05 versus 16G; 20G: 20.5% (n ¼ 9), p ¼ 0.001
versus 16G; 22G: 50% (n ¼ 2), p50.001 versus 16G], there
was no relationship between steel needle gauge size and
hemolysis rates [19G: 6.2% (n ¼ 1); 21G: 1.1% (n ¼ 1),
p ¼ 0.17 versus 19G; 23G: 3% (n ¼ 1), p ¼ 0.59 versus
19G]. Ong et al.34 also found no significant difference in
hemolysis rates for gauge sizes of less than 21G compared
to their narrower counterparts (21.3% (n ¼ 30) versus 17.4%
(n ¼ 15), OR 1.4 [95% CI: 0.6–3.1]). Finally, Ibrahim
et al.19 reported higher hemolysis rates when using 29G
insulin needles compared to 23G standard needles [31.3%
(n ¼ 15) versus 11.6% (n ¼ 5), p ¼ 0.035]. However, this
study confounded the needle gauge size with different
syringes and needle lengths. Therefore, evidence that there
is no effect of steel needle gauge size on hemolysis rates
was classified as good due to these consistent findings,
while evidence that a higher IV catheter gauge (or narrower
IV catheter) leads to increased hemolysis rates was classi-
fied as satisfactory due to the low quantity of supporting
evidence.
Tube size
Cox et al.18 performed an RCT and found significantly higher
hemolysis rates for specimens collected in 10 mL tubes
compared to 5 mL tubes (0.6 standard deviations units in
Hitachi readings, p50.0001). This agrees with the findings of
observational studies by Fernandez et al.39, who found a
significantly higher rate of hemolysis for 8–9 mL tubes
compared to 3.5–4 mL tubes (2.9% (n ¼ 464) versus 2.3%
(n ¼ 1109), OR 1.26 [95% CI: 1.13–1.40]), and Dugan et al.11,
who found that 1.8 mL tubes had a significantly lower rate of
hemolysis compared to all larger tube sizes [1.8 mL: 0%,
3.0 mL: 9.3% (n ¼ 15), 3.5 mL: 10% (n ¼ 7), 4.5 mL: 19.3%
(n ¼ 11), 5.0 mL: 15.5% (n ¼ 11), 6.0 mL: 26.3% (n ¼ 5)]. In
contrast, Lippi et al.47 found that hemolysis rates were
significantly higher when using 3.5 mL tubes compared to
5 mL tubes [5.2% (n ¼ 836) versus 3.5% (n ¼ 549), p50.001].
Due to this slight lack of consistency, evidence of higher
hemolysis rates for larger volume specimen tubes was
classified as good.
Tube type
One observational study found significantly higher hemoly-
sis rates in serum tubes compared to non-serum tubes
[23.8% (n ¼ 45) versus 16.7% (n ¼ 9), p ¼ 0.013]36. In
contrast, Ryan et al.38 found no significant difference in
the rates of hemolysis when specimens are collected in rapid
serum tubes compared to plasma serum tubes and non-gel
plasma tubes [13.3% (n ¼ 46) versus 9.2% (n ¼ 32) and
11.0% (n ¼ 38), no p values provided]. Two studies also
found higher rates of hemolysis when using BD Vacutainer
Plus serum tubes compared to Sarstedt S-Monovette serum
tubes [4.4% (n ¼ 624) versus 2.6% (n ¼ 342), p50.00131 and
28.8% (n ¼ 15) versus 2.0% (n ¼ 1), p50.0120]. A fifth
DOI: 10.1080/10408363.2016.1250247
study found no significant difference in hemolysis rates
between sodium citrate tubes (17.4%, n ¼ 12), and sodium or
lithium heparin (13.7%, n ¼ 19), K2EDTA (di-potassium,
12.7%, n ¼ 14) and polymer gel tubes (6.3%, n ¼ 4)11.
Therefore, there was no consensus on the effect of tube type
on hemolysis rates.
Phlebotomy/draw method characteristics
Draw site
A number of observational studies investigated the effect of
draw sites on hemolysis rates, with two finding significantly
higher rates for non-antecubital draws compared to antecubital
draws [33.7% (n ¼ 31) versus 12.6% (n ¼ 23), p ¼ 0.00]36 and
draws from the distal arm compared to antecubital draws
[18.0% (n ¼ 18) versus 4.2% (n ¼ 4), p ¼ 0.005]46, respect-
ively. Tanabe et al.27 found significantly lower hemolysis rates
for specimens drawn from the antecubital fossa compared to
the hand and the forearm [4.9% (n ¼ 17) versus 15.5% (n ¼ 9),
p ¼ 0.002 and 10.7% (n ¼ 13), p ¼ 0.02, respectively], no
instances of hemolysis in two specimens drawn from the feet
(0%, n ¼ 2), and no significant difference between the
antecubital fossa and the wrist or all other remaining sites
[4.9% (n ¼ 17) versus 5.9% (n ¼ 4), p ¼ 0.73 and 2.3% (n ¼ 2),
p ¼ 0.92, respectively]. This agrees with the findings of Dugan
et al.11, who found significantly higher hemolysis rates in
specimens drawn from the right hand (40.9%, n ¼ 9) and the
right forearm (30.3%, n ¼ 10), and significantly lower rates in
specimens drawn from the right antecubital (5.5%, n ¼ 9),
compared to the left hand (25.0%, n ¼ 3), left antecubital
(13.0%, n ¼ 17) and left forearm (5.3%, n ¼ 1). Another found
that specimens drawn from the median cephalic and basilic
veins (17.4%, n ¼ 4) had significantly lower hemolysis rates
compared to specimens drawn from the metacarpal plexus
(75.0%, n ¼ 6, p50.01), the basilic vein (33.3%, n ¼ 2,
p50.01) and the cephalic vein (28.6%, n ¼ 4, p ¼ 0.01)21.
Finally, Munnix et al.33 also found lower hemolysis rates for
specimens drawn from the antecubital fossa [13% left (n ¼ 4)
and 4% (n ¼ 1) right] than the hand [67% left (n ¼ 2) and 60%
right (n ¼ 3)] and forearm [20% left (n ¼ 4) and 12% (n ¼ 2)
right]; however, sample sizes were small. Therefore, due to the
quantity and consistency of findings, evidence of lower
hemolysis rates for antecubital draws than non-antecubital
draws was classified as excellent.
There was also found to be satisfactory evidence of no
significant difference in hemolysis rates for venous compared
to arterial draw sites (20.1% (n ¼ 44) versus 14.3% (n ¼ 1),
OR 5.0 [95% CI: 0.5–10.0])34.
Transport method
An RCT and two observational studies all found significantly
higher hemolysis rates for specimens transported by pneu-
matic tube compared to by hand [100% (n ¼ 53) versus 16.3%
(n ¼ 8), p50.000113; 10.9% versus 3.3%, p50.000150; and
9.4% (n ¼ 908) versus 6.6% (n ¼ 655), p50.00149], while an
observational study found a borderline significant increase in
hemolysis rates for specimens transported by these two
methods [7.4% (n ¼ 22) versus 0%, p ¼ 0.055]35. Böckel-
Frohnhofer et al.29 also found a higher hemolysis rate when
Key factors influencing the incidence of hemolysis 69
specimens collected in lithium heparin tubes were transported
by pneumatic tube compared to by hand [17.5% (n ¼ 239)
versus 2.6% (n ¼ 23)]; however, no statistical analysis of this
difference was performed. Phelan et al.48 found no statistical
difference in hemolysis rates for specimens transported by
pneumatic tube system compared to those transported by hand
[13.6% (n ¼ 2156) versus 13.1% (n ¼ 12), p ¼ 0.9]. However,
only 92 specimens were hand-delivered and they do not
provide information as to the role, training or equipment of
the foot-courier. Therefore, due to the quantity and consist-
ency of evidence in the other studies, evidence of higher
hemolysis rates in specimens transported by pneumatic tube
compared was classified as excellent.
Fang et al.36 also found significantly higher rates of
hemolysis in specimens transported by hand by ward assist-
ants compared to laboratory staff [51.9% (n ¼ 27) versus
12.2% (n ¼ 27), p50.01], but the low quantity of specimens
meant that this evidence was classified as satisfactory.
Tube fullness
Two observational studies both observed significantly higher
rates of hemolysis when the specimen tubes were filled less
than halfway compared to when the tube was filled over
halfway [3.0% (n ¼ 147) versus 10.8% (n ¼ 418), OR 1.9
[95% CI: 1.5 to 2.2]23 and 18.6% (n ¼ 13) versus 6.2% (n ¼ 8),
p ¼ 0.02,46 respectively]; these provided what was deemed to
be good evidence of higher hemolysis rates when specimen
tubes are filled less than halfway.
Tourniquet time
Two observational studies both found that a tourniquet time of
greater than one minute led to a significantly higher rate of
hemolysis [20.2% (n ¼ 20) versus 1.3% (n ¼ 3), p50.00125
and 17.5% (n ¼ 214) versus 10.7% (n ¼ 352), OR 1.3 [95% CI:
1.0–1.6],23 respectively]; these provided what was deemed to
be good evidence of this effect.
Draw difficulty and resistance
Three observational studies investigated the effect of draw
difficulty and resistance on hemolysis rates. While one
found significantly higher hemolysis rates when IV catheter
placement was perceived as ‘‘difficult’’ compared to ‘‘not
difficult’’ (39.4% (n ¼ 13) versus 10.3% (n ¼ 36), p50.05)11,
another found no significant difference in hemolysis rates for
draws rated as ‘‘moderately’’ difficult (26.9%, n ¼ 14, OR 3.0
[95% CI: 0.7–12.4]) or ‘‘easy’’ (18.5%, n ¼ 27, OR 1.6 [95%
CI: 0.4–6.1]) compared to ‘‘hard’’ (13.8%, n ¼ 4)34 and when
the blood flow was ‘‘slow’’ (24.2%, n ¼ 8, OR 2.0 [95% CI:
0.6–6.9]) or ‘‘moderate’’ (22.5%, n ¼ 23, OR 2.3 [95% CI:
0.9–5.7]) compared to ‘‘fast’’ (15.2%, n ¼ 14)34. Munnix
et al.33 observed that when four blood specimens were drawn
from the same IV catheter, the first specimen was most likely
to be hemolyzed (Median Hemolysis Index indices of 719,
270, 156 and 67, respectively); however, the proportion of
hemolyzed samples was not reported. Therefore, there was
deemed to be satisfactory evidence that flow speed does not
affect hemolysis rates, poor evidence that the first specimen is
most likely to be hemolyzed and no consensus over the effect
of draw difficulty on hemolysis rates.
70 E. J. McCaughey et al. Crit Rev Clin Lab Sci, 2017; 54(1): 59–72

Discussion this review. While there was excellent evidence of higher

hemolysis rates for specimens transported by pneumatic tube
This review identified a number of factors that influence
compared to by hand, the resource implications of hand-
hemolysis rates, including where and by whom a specimen is
delivering all specimens to the laboratory may mean that this
drawn, patient characteristics, phlebotomy methods and
is not always practical. Therefore, when opting for a
phlebotomy equipment. As a leading cause of pre-analytical
pneumatic tube system, Kara et al.13 recommended
laboratory errors2,4, awareness of the factors that influence
that laboratories consider the speed, pressure and changes
hemolysis rates is an important step towards creating quality
of direction of the system during design and installa-
practices to reduce the prevalence of hemolysis and thereby
tion, and regularly maintain and monitor systems after
both increase laboratory efficiency and improve the safety and
installation.
quality of patient care.
Due to the large number of influencing factors identified
When considering the effect of hospital and patient
in this review, hemolysis can be regarded as a systemic
characteristics on hemolysis rates, there is excellent evidence
problem. To this end, Dietrich22 recommends that hemolysis
that specimens collected in the ED, and good evidence that
be made a hospital-wide issue, with all departments
specimens collected by non-phlebotomy staff, have higher
receiving education and training and being involved in
hemolysis rates. As such, Berg et al.41 suggested that small
improvement efforts. This is supported by the findings of
groups of dedicated laboratory phlebotomist staff could be
Cadamuro et al.28, which suggested that effective staff
deployed in EDs, and that this extra expenditure could be cost
training in phlebotomy and specimen preparation techniques
beneficial for the healthcare system overall. There is also
can reduce hemolysis rates. Lippi et al.21 also recommended
good evidence to suggest that whether a sample is collected
that each hospital or laboratory should analyze their own
by a doctor or a nurse does not affect hemolysis rates,
circumstances, and devise targeted solutions. The import-
indicating that interventions designed to reduce hemolysis
ance of this is demonstrated in another study by Lippi
rate cannot focus on any one group of clinical staff.
et al.47, where despite three studies to the contrary, they
The most influential equipment effect on hemolysis rates
concluded that there were higher rates of hemolysis in one
was the draw equipment, with excellent evidence that
ED for lower volume specimen tubes. While the authors do
specimens drawn through IV catheters display higher hem-
not provide a specific explanation for this conclusion, it
olysis rates compared with those drawn using straight needle
demonstrates the need to consider local circumstances.
venipunctures, and good evidence that they have higher
Damato and Rickard54 demonstrated that Lean Six Sigma
hemolysis rates than those drawn using butterfly needles. As
methodology can be used to reduce hemolysis rates both
such, a number of authors have recommended that specimens
within the ED and hospital wide. Milutinovic et al.55 found
be drawn through a venipuncture rather than an IV
that healthcare professionals generally had poor knowledge
catheter34,36,37. There is also good evidence that steel needle
of some of the factors affecting hemolysis rates described in
gauge size has limited effects on hemolysis rates.
this review, with particularly poor knowledge of the effect of
When examining the aspiration method, there was no
draw method and needle size. Therefore, a number of
consensus between studies about the effect of using either a
governance, education and training interventions may also
syringe or evacuated tube systems to aspirate the specimen on
assist in reducing rates of hemolysis. Specifically, the
hemolysis rates. However, needle-and-syringe phlebotomy
development of clinical guidelines or protocols for phlebot-
methods present an increased risk of needle-stick injury and
omy56,57; adherence to standard operating procedures11,41,46;
phlebotomist exposure to blood-borne pathogens52.
improved or more frequent staff training11,28,34,36,41,51,52,57
Therefore, safety-engineered blood collection needles, such
and proficiency training or competency testing for staff
as evacuated tube systems, may be preferable over syringes
performing phlebotomies11,40,51, are all suggested as poten-
for practical reasons53.
tial solutions to reduce hemolysis rates. However, the
When considering the effect of draw site on hemolysis rates,
influence of these factors on hemolysis rates has not been
there is excellent evidence that specimens drawn from the
directly examined.
antecubital region have lower hemolysis rates than those drawn
A number of limitations of this review were identified.
from other areas. As such, a number of authors recommend the
Firstly, seven articles performed no statistical ana-
antecubital fossa as the optimum blood collection site11,36,46.
lyses22,29,33,40,42,45,51, making it difficult to ascertain the
There is good evidence of higher hemolysis rates when
significance of the findings. In future, all studies investigat-
using larger volume specimen tubes. Therefore, Cox et al.18
ing factors influencing hemolysis should strive to perform
recommended that the smallest specimen tube possible be
rigorous statistical analysis. Secondly, some articles failed to
employed. There is also good evidence of higher rates of
control for confounding variables, making it difficult to
hemolysis when the specimen tubes were filled less than
establish causality and the effect of the intervention. One
halfway and when the tourniquet time was greater than one
such example is that while there is evidence to suggest that
minute. As such, Burns and Yoshikawa46 recommended that
not all specimen tube types are equally sensitive to
the specimen tube is filled as fully as possible, while Saleem
hemolysis during transportion29, none of the four studies
et al.35 recommended that the tourniquet time be kept to under
that investigated the impact of transport method on
one minute (which may require placing the tourniquet more
hemolysis rate explicitly stated or controlled for the tube
than once during the blood collection process).
type used13,29,35,50. Consideration of such confounding
The effect of tube transport method on hemolysis rates
variables at the study conception stage would improve the
may be more complex than some other factors addressed in
quality of evidence relating to factors influencing hemolysis
DOI: 10.1080/10408363.2016.1250247
rates. The heterogeneous nature of the papers included in
this review meant that pragmatic judgment had to be applied
when classifying the level of evidence for each factor.
However, this approach should help to inform clinical
decision making and to provide a framework for future
studies. Some of the aforementioned heterogeneity stemmed
from the different methods used to detect hemolysis (Table
1). A move towards harmonization of hemolysis detection
methods would reduce this heterogeneity and is worthy of
further investigation. There was also found to be satisfactory
or poor evidence of the influence of a number of factors.
Further research is necessary to fully understand the impact
of these factors, their interactions and the overall complexity
of hemolysis. Finally, due to the relative immaturity of the
field, the broad aims of the included studies, and the wide
range of potential influencing factors, a systematic review
was not performed. While this is a scoping search, the
search strategy was broad and included a search for gray
literature58 from a variety of sources in order to minimize
the risk of publication bias. The high consistency of results
demonstrates a sufficient lack of publication bias, with this
article laying an important platform for future rigorous
evidence reviews.
Conclusions
As a leading source of pre-analytical laboratory errors,
hemolysis is of major importance for laboratories and patient
safety. This review demonstrates that there are a range of
factors that can negatively impact hemolysis rates, such as
where, when and by whom a blood specimen is drawn, patient
characteristics, the phlebotomy method and the phlebotomy
equipment. The results of this review suggest that as well as
making hemolysis a hospital-wide issue and ensuring high-
quality staff training and widespread adherence to standard
operating procedures, hospitals and clinical laboratories
should consider implementing the following strategies to
mitigate the risk of hemolysis: deploying phlebotomists in
EDs; drawing blood through a venipuncture; adopting the
antecubital fossa as the optimum blood collection site, and
transporting specimens by laboratory assistant/other person-
nel, or if this in not practical, ensuring that pneumatic
transport systems are validated and regularly maintained and
monitored. There is also good evidence to suggest that
hospitals and clinical laboratories may also want to consider:
deploying small groups of dedicated laboratory phlebotomist
staff; using the smallest volume specimen tube practical;
filling the specimen tube as fully as possible, and keeping the
tourniquet time under one minute. Awareness of the factors
that influence the incidence of hemolysis, and implementation
of strategies to reduce hemolysis rates, is an important step
towards creating quality practices to improve the quality of
patient care.
Declaration of interest
The authors report no conflicts of interest.
This project was funded by the Royal College of
Pathologists Australasia Quality Assurance Program
Key factors influencing the incidence of hemolysis 71
(RCPAQAP), an Australian Government Department of
Health: Quality Use of Pathology Program (QUPP) grant
and a National Health and Medical Research Council
(NHMRC) Program Grant.
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