Niels de Jonge, Robert Herpers, Myriam Roelofs and Edmée van Dongen

Blood sampling after COVID-19 − How to organize large scale phlebotomy services in the post SARS CoV-2 era

De Gruyter | 2020

To the Editor,

Regular healthcare has come to an abrupt standstill because of the SARS CoV-2 pandemic. As in some countries the enormous pressure of COVID-19 on critical care nowadays seems to diminish, regular care should be taken up again [1]. As a consequence clinical laboratory testing and blood sampling is increasing [2].

Safe phlebotomy activities on a large scale, however, cannot be done without additional measures. Triage of symptomatic COVID-19 patients and non-symptomatic patients is not enough, since a large proportion of infectious patients are asymptomatic [3−7].

The main challenge lies in spreading patients in time and place so that safety during blood sampling is guaranteed in accordance with infection prevention guidelines. Here we describe a number of measures based on best practices and recommendations from the Working Group Preanalytical Phase of the Dutch Society for Clinical Chemistry and Laboratory Medicine.

The measures are aimed at a restart of phlebotomy activities in a so-called “1.5 m society” with social distancing measures as obliged by the Dutch government and Dutch infections prevention standards. Measures differ from country to country [8]. In this paper we refer to the situation in The Netherlands [9].

The measures are preferably in concordance with best practices in other parts of society, like supermarkets or public transport. Some are based on concrete evidence, others are based on the precautionary principles and common sense. The list may not be complete, but is based on the authors’ best knowledge at the time of preparing this paper.

COVID-19 will probably last for a long time [10]. However, certain long-term measures, like the application of phlebotomy robots, are beyond the scope of this paper.

The practical measures described below are meant as an advice or suggestion to aid in adapting phlebotomy services after COVID-19. This paper is not an obligatory guideline. Local regulations should always be observed.

The authors are well aware that organisation of and responsibility for blood sampling facilities differ in different countries [11], but we believe that the practical measures in this paper apply to most settings.

Measures

Indication

  • 1.

    Ask physicians to critically judge the necessity and frequency of laboratory testing [12]

  • 2.

    Routine checks or protocols could be adjusted [12]

  • 3.

    Triage to split up patient stream: COVID-19 patients, non-COVID-19 patients and patients with symptoms possibly related to COVID-19

Requests

  • 4.

    Digital requests are preferred, to reduce physical contact with potentially contaminated paper request forms

  • Hospital information systems

  • Primary care order entry systems

  • 5.

    Application of Point-of-care testing

Crowd control

  • 6.

    Patients are requested to visit the phlebotomy service unattended if possible

  • 7.

    Spread outpatient phlebotomy services in space and time

  • 8.

    Increase opening hours; opening during evening and weekend

  • 9.

    Inform patients about peak and off times of outpatient phlebotomy services

  • 10.

    Blood sampling by appointment; special locations or opening hours for patients with (possible) SARS CoV-2 infection

  • 11.

    Necessity for fasting blood sampling (lipids, glucose) [13]

  • 12.

    Avoid any priority procedures for specific patient groups in order to optimize the flow of patients

  • 13.

    Blood sampling on parking lots, so that patients can wait in their car [12]

Social distancing [14], [15], [16]

  • 14.

    One way routing in phlebotomy services

  • 15.

    Refer the patient directly to the blood collection room (working without a counter, registering the application and performing the blood collection by the same person at the same place)

  • 16.

    Reception and waiting rooms:

  • Minimize the number of chairs and tables. Clearly mark fixed seats as out of use in case a minimum distance of 1.5 m cannot be met

  • Place chairs at a minimum distance of 1.5 m

  • Maximum number of patients allowed in facility

  • Grid on the floor (with instruction that only one person is allowed per square)

  • 17.

    Provide counters with screens if necessary

  • 18.

    Physical barriers, such as plexiglass, can also help in situations where a 1.5 m distance is not possible

Hygiene

  • 19.

    Disinfectant dispenser for patients and attendants at the entrance and exit of the blood collection site

  • 20.

    Instruction for applying hand hygiene

  • 21.

    Instruction for averting face during blood draw [15]

  • 22.

    Seats and tables are easy to clean (no fabric furniture) [17]

  • 23.

    Clean regularly all contact points in central areas and waiting areas (e. g. chairs, tables, counters) [17]

  • 24.

    No newspapers or magazines offered or allowed in waiting areas

  • 25.

    No food or drink offered or allowed in waiting areas

  • 26.

    Washable keyboards [17]

  • 27.

    Blood collection booths equipped with screens [15]

  • 28.

    Use disposable thrust belts and disposable blood collection sleeves

  • 29.

    Personal protective equipment for employees (mouth-nose mask, splash goggles, gloves, apron)[18]

  • 30.

    Possibly also a mouth-nose mask for the patient/attendant after triage

Communication

  • 31.

    Communicate to both physicians and patients about the limited capacity of phlebotomy services due to safety measures related to the COVID-19 situation

Acknowledgments

The authors thank Joyce Curvers, Marco Wouters and Adrian Kruit for their critical remarks.

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