r/medlabprofessionals • u/Visual_Revenue6554 • 12d ago
Discusson Labs in my area will no longer draw a citrate tube to prevent platelet clumping, how to fix this?
Background : 59 yr old female with 30+ year history of RA, Felty's syndrome and platelet clumping (EDTA reaction).
I have clumped so aggressively that, for a period around 20-25 years ago when I had monthly draws due to methotrexate prescription, I was drawn sitting next to the centrifuge in the lab annex of the clinic to make sure the sample was readable.
Subsequent to that, I now get occasional draws 4-6 times a year. I have made a practice of letting the phlebotomist know that I clump and they need to draw a citrate (blue top) tube. Occasionally they would ignore the request and I would get the call that the platelet count clumped and needed to be redrawn. To avoid extra pokes (and because I am not an easy draw : rolling/ducking veins, butterfly needles needed, even ultra sound to set an IV for a procedure a few years ago), I tried to self advocate and insist on the blue top draw.
Around 3 years ago I started to get not just push back but utter refusal by the tech to draw the tube if it was not on the orders (and it NEVER was). My doctors couldn't find a code to even order it. Once incidence involved a call from a new doctor receiving the CBC results to tell me that my platelet count was dangerously low and I should go to the ER for a transfusion. After several hours there and 2 more draws by the ER staff (the second one with citrate tube) I was sent home with my perfectly normal range platelet count.
I have tried Quest and LabCorp.. neither will draw a blue top tube on request if it's not indicated on the orders nor do the phlebotomists seem to have any awareness of a specific protocol for EDTA clumping. The most recent visit(today) at LabCorp involved my PCP's nurse walking over with the order while I waited at the lab (they are in the same business complex) but there wasn't a code to order it and neither the lab nor the doctor can find one so the lab will not draw the test. I declined to get drawn if they couldn't run all the tests and the nurse went back to her office to see what she could find out.
She called me about 30 minutes later and they have found the test but are not allowed to order it. It seems it can only be ordered by certain entities for studies or special permissions with the lab. So basically my PCP can't order a test for me to be performed to get accurate results for BASIC bloodwork.
We are going to try another lab in the area that doesn't seem to restrict access to ordering a blue top citrate tube, so hopefully we have found a solution.
My reason for posting this is to find out if anyone in the profession has any insight on why this is happening, was there some post-covid shift in lab protocols (timing wise that's the only possible correlation I can find) and whether there is a procedure we should be following to get the care I need.
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u/Indole_pos MLS-Microbiology 12d ago
I really hope you find a solution. The doctors here put a note in the CBC orders in reference to the extra citrate tube drawn. Central receiving will order it as an extra tube for storage if any extra tubes are received unless there is a note. We also see it for patients whose blood easily hemolyzes. Maybe they can just place an order for an extra citrate tube draw when you go for labs. As a hard stick (ultrasound guided IV only here) and a laboratory technologist, this situation strikes a nerve.
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u/ISawThatFirst 12d ago
My (hospital based) lab recently got new analyzers. They are fantastic analyzers but when the medical directors tried to get citrated platelet counts added to the test menu it was discovered that these VERY popular analyzers are not validated for them and will not do any validations. (It was discovered that our previous analyzers were also not validated but no one knows why we ran them). ONE site did a self validation (out of 8 hospital sites), and they will analyze them for outpatients but only if it is drawn at their location and ordered STAT.
Long story short, call the Quests and Labcorps that are located INSIDE of hospitals and ask if they draw citrated platelet counts. Most likely your best bet.
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u/cdipas68 12d ago
This is the right answer. Very few labs validate CBC for citrate.
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u/LegitPancak3 MLS-Generalist 12d ago
My lab uses Beckman Coulter Dxh and we do citrated platelets. We just have to multiply the PLT count by 1.1.
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u/Practical-Reveal-787 12d ago
Same with sysmex XN
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u/deloniejenkins 12d ago
I've used both Dxh and sysmex and have ran blue tops. I never even wondered if they were validated. I assumed they were but now im questioning if it was ever done.
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u/cdipas68 12d ago
Sysmex XN 10 is not validated by manufacturer for citrate unless he IFU i am looking at is out of date.
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u/a-cure-for-optimism 12d ago
Let me guess, Sysmex? We just ran into the same issue. We're going to have to build it as an LDT if we want to run it at all
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u/Tarianor UK BMS 12d ago
First off, really sorry to hear that and you have all my sympathy.
But hearing about issues like this makes me glad I am where I am, as we have specific orders ready for doctors to use freely for stuff like this, we even have patient specific comments in the lab system that pings if patients are clumpers or if they need ultrasound for phlebotomy. I wish you all the best ❤️
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u/AnusOfTroy 12d ago
Non-haem AP/incoming FY1 here - could you explain what's happening with the platelets here and why the blue top for my own curiosity/learning please
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u/Reasonable-Bike1036 12d ago
Sometimes plts clump as a reaction to the EDTA anticoagulant. So drawing a NaCitrate tube (and being ran and multiplied by 1.1 [due to the 1:9 coagulation factor]) ensures accurate results. However—— the test is not fda/ lab developed.
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u/AnusOfTroy 12d ago
And is it just platelets you're wanting if you're having to use a blue top? Or could you get a full FBC off a blue top
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u/bdg006 12d ago
These patients have platelets that literally clump on contact with EDTA (additive in a lavender top tube).
When we analyze the CBC on these patients, they usually appear to have critically low platelet counts with a flag on the results from the analyzer stating “platelet clumps.” This triggers a review of the peripheral blood smear manually at the microscope. We often observe that the entire slide is covered with platelet clumps which are as large as WBCs. These clumps cannot be accurately measured by the automated method. We can do an “estimate” at the microscope and report out a comment that the count is adequate or increased/decreased.
In the past a citrate tube was an alternative as the other commenter mentioned. It required only a simple calculation to compensate for the variation in dilution between the different tube types. In many labs this is no longer an option because accreditation agencies are cracking down and can ask for proof that this method has been validated in the lab. Most of these labs cannot provide proof because the test has just always been done this way (for decades) and was never formally validated.
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u/Resident_Talk7106 Lab Assistant 12d ago
The issue is that the majority of manufacturers of hematology instruments have never validated them for use with sodium citrate, the anticoagulent in blue top tubes. Very few labs have done their own validation studies for using blue top tunes. Doing so becomes a LDT, a lab developed test. This opens up a whole lot of regulations from accreding agencies. I do not know if manual platelet counts are being done anymore. I know a lab that has written in it's procedures, to draw a blue top on platelet crumpets. Then do an 'estimate'. We all know how estimate is performed. (Also include manual smear)
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u/Visual_Revenue6554 12d ago
I do think the correlation between moving to increased automation and newer technology that can't actually perform/ hasn't been rated to perform this particular test has been a factor in this situation.
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u/mystir 12d ago
Doing validations isn't exactly the most difficult thing though. Larger medical centers do stuff like this all the time. The problem with organizations like LabCorp and Quest is that they are profit-driven, and so they don't want to slow down their workflows with relatively rare edge cases if they don't have to. Combined with the under- and unqualified people that those places like to hire (cheap labor), people may not even catch that this is something that needs to be addressed.
Your physician likely will need to talk to the technical supervisor of wherever your test is going to ensure they can properly do the job. If not, many medical centers will accept external requisitions, but not all.
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u/DookiePootie 12d ago
It's really not a difficult test to do or validate when you have the patient population to run it on. It sounds like Lapcorp and Quest just got rid of the test altogether sometime last year for whatever reason (likely just about $$$). It's one of those in between tests that your particular patient population may or may not demand enough to need to spend the resources. It really sucks that patients like you get left behind in these decisions with no obvious alternative.
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u/Rj924 12d ago
This used to be a practice at my lab. The comment to draw a citrate was attached to the patient's MRN. We no longer have this validated at our site. So even if you asked, we would refuse. We make a slide look at the platelets under microscope, and comment that they are decreased, adequate or increased. Which is all that is medically necesarry for most people. We would never report out a critical because of clumping.
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u/Tankdawg0057 12d ago
Just a suggestion, but have you tried your local hospital laboratory? Labcorp and Quest are the Walmart and Target of laboratories. Their labs are literal Amazon warehouse sized places with hundreds of employees in them. You couldn't find a worse place for personalized service. Giant corporations aren't your friends.
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u/LawfulnessRemote7121 12d ago
I work in a smaller private lab and we have a list of known platelet clumpers and have a prompt written into their record to always draw a citrate.
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u/Unusual-Courage-6228 MLS 12d ago
Blame the FDA and the regulations placed on LDTs
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u/Visual_Revenue6554 12d ago
I finally saw a post referring to that but it said the courts overturned the rule. Of course the CYA measures that were put in place in the meantime aren't being rolled back it seems
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u/Unusual-Courage-6228 MLS 12d ago
I believe it was struck down in 2024 for them to regulate LDTs as “medical devices”. To my knowledge, that situation is what ended up bringing a lot of attention to using citrate tubes for clumpers. CAP (accrediting agency) has been cracking down on it during inspections since. My lab got cited for it last year. Many labs ended up making the decision to just not run them at all
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u/Ramin11 MLS 12d ago
Im a tech that does phlebotomy as part of my job every day. No one will draw a specific tube on request from the patient. That needs to be either communicated to the draw site from the doctor or put on the order by the doctor (most orders have comment sections), or both even. Talk to your doctor and ask them if they could notify the lab ahead of time of the requirement and/or see about putting it on the order (even a handwritten note by the doctor is fine, though they might call to verify if youre not a regular there as it is unusual). Do NOT write on the order yourself. That camould get you into a lot of trouble. Just talk to your doctor about it.
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u/Visual_Revenue6554 12d ago
I understand your perspective, but for literally years I did just that :"Hey I'm a clumper, you'll need a citrate tube" and voila! correct numbers. I am sure regulations tightened up and I get why that would no longer be the case. The issue is that there is no code or way to add it to the orders. The nurse literally walked the orders over this morning with it notated and they still would not do it without a code that the lab didn't even know what one is needed.
I have multiple providers that have dealt with this issue in the last 2-3 years PCP, rheumatologist, gastroenterologist (both of the last 2 are in the same local clinic that I've been a patient of since 1993, the same one where they used to run me in the annex and throw it on the machine) The only one who could just run it was my oncologist whose office has an in house lab.
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u/DookiePootie 12d ago
Like others have mentioned, not a lot of labs will have citrated platelet validated to be able to report it out. I think your care team, if they really needed the value, needs to find a lab that offers the test. In our hospital lab, we will get the orders but we are only validated to run them within an hour of draw, meaning they must be drawn at our medical center - not at the doctor's office. However this might also mean you would pay out of pocket for it. This is something to discuss with your doctor(s).
That one lab that reported out critically low platelets when it wasn't... I hope you complained and had them written up.
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u/AigataTakeshita 12d ago
not a lot of labs will have citrated platelet validated to be able to report it out
I haven't come across this before as I haven't been in the game very long. Do they have an alternative like thrombexact?
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u/DookiePootie 12d ago
Never heard of it. Sounds esoteric enough that if you don't have blue tops validated for platelet counts, you're not doing that in house either.
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u/AigataTakeshita 11d ago
Ok. I thought a commercial product might make navigating red tape easier somehow.
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u/Visual_Revenue6554 12d ago
My providers and I should get points for creativity. I had an endoscopy procedure last year to stretch constrictive striations in my esophagus and the gastroenterologist wanted an accurate platelet count for preop work. The lab at his clinic couldn't draw/run a blue top so he ended up calling my oncologist (separate facility, they have an in house lab) and they drew and ran it for him as I am still their patient while in post treatment monitoring until 2028.
While I am very lucky and appreciative of the lengths my providers have been willing to go to for my health, it should not be this hard or this much work for any of us. I can only think about patients with less resources, less involved practitioners or those that are unable or uncomfortable with self advocacy and how they are falling through the cracks and may not even know it.
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u/velvetcrow5 Lab Director 12d ago
Can I ask, when you get your CBC results with clumping, is the platelet count in normal range?
Because if it is, it's fairly common to not reflex to citrate. With the rationale that your platelets are inaccurate but it's not clinically important. (That is to say in my experience the practice is 50/50 across the labs ive worked with)
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u/Visual_Revenue6554 12d ago
The results are usually not available due to "excessive specimen clumping" or come back abnormally low. I was sent to the ER for a transfusion after one such reading on Valentine's Day of 2023 and spent hours there waiting while they (rightfully) triaged more emergent cases only to have them run a citrate tube (on the 2nd draw there when the first one clumped as I told them it would) , get normal results and send me home with no additional treatment (because there never was a need at all).
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u/AtomicFreeze MLS-Blood Bank 12d ago
Does the hospital associated with that ER offer outpatient lab draws? The ER samples and outpatients would be run on the same instruments and with the same procedures, so they're at least capable of doing it
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u/Ksan_of_Tongass MLS 🇺🇸 Generalist 12d ago
Find a hospital with an outpatient lab. Quest and LabCorp draw stations arent known for their high level of patient care.
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u/Mcnugget84 12d ago
The EMR needs to have a blue top platelet count test mapped to the lab, interface with the correct CPT code. This is an IT issue. With the rise of efficiency draws count the tubes used. If it’s not mapped the provider needs to contact the EMR rep and specifically ask for this.
That’s why certain providers can order it and some can’t. Many provider to lab interfaces are silo’s and restrict this.
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u/Suspicious_Spite5781 12d ago
Looks like, if you’re stuck with LabCorp, that your doc has to order a platelet count collect in citrate tube. The phleb will then collect a purple and blue top tube. The purple goes the normal route for your standard cbc results and your platelet count gets done on the blue top.
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u/Visual_Revenue6554 12d ago
Well that's what we tried but the provider didn't have the code that LabCorp requires and LabCorp couldn't tell them what code it was.
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u/Visual_Revenue6554 12d ago
The additional fly in the ointment is that I have historically had ONE incident of spontaneous thrombocytopenia. Six months after a pre eclampsia and HELLP syndrome induced C section at 28 4/7th weeks (1 lb 11 oz preemie that is now a 25 year old college graduate :)); I was admitted to ICU with internal bleeding and basically non existent platelet count. They never found a source for the bleeding beyond I just wasn't clotting; but could see a gradually lowering platelet count on the previous months' bloodwork that had gone unremarked as, traditionally with the Felty syndrome, my chronic low white count got all the attention.
So while I don't expect to have a reoccurrence of THAT, it still needs to be monitored as part of my continuing care.
I swear I can't make this stuff up. I sound like a medical soap opera. A melodramatic one.
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u/DookiePootie 12d ago
This makes sense why you would want your platelet count monitored properly. Like I mentioned in another comment, you might be stuck going out of network for this specific test if your providers can't order it with their contracted labs. But you should discuss with your doctors on if and when you should be concerned about your platelet counts. It might be that they only really care enough if you're having symptoms to really need to know the values, and if your CBC has platelet clumps but you feel fine, then it's not really a concern to them. Your doctors would know your condition the best to tell you what they think and to find you a lab that will do a citrated platelet out of pocket.
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u/cellophanesheeps 12d ago
We don't have a way to place an order specifically to draw an extra tube where I work, but we have ways of notifying staff that it's necessary. We add comments to orders for inpatients and document on the department communications board, and for outpatients the ordering provider can add instructions to the orders. If we have a patient that tells us they have special requirements but we don't have any instructions telling us, we either would go ahead and just draw the extra tube, or call the Drs office for verification. There's really no reason for them to make this so difficult. I know the outreach labs for both Quest and LabCorp are very peculiar, so the only suggestion I can think of would be to see if there's a lab you can be drawn at that does the testing on site. At least that way it wouldn't have to pass through as many hands.
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u/soupy-c 12d ago
Hmm it’s odd that it’s not an order. Where I work there’s an order for a citrated platelet count, so an EDTA and sodium citrate tube must be collected at the same time. The CBC, including the platelet count, is reported from the EDTA tube and then there’s a citrated platelet count from the sodium citrate tube. That being said, we can’t draw something that isn’t ordered so I do understand why they can’t just draw one at your request. Idk how things work in the US but where I work, the doctor can contact the lab’s hematologist directly for things like this. Maybe your doctor can escalate it and get an answer as to why they can’t run it or for how to order it
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u/Chi-Town-Pearls 12d ago
I understand how exhausting it is advocating for yourself and your health. That being said, I’m pretty sure it’s a requirement at every lab that the patient has either; orders in the system from their provider, or a physical prescription, “outside order” including a diagnosis code for the bloodwork being performed. Your issue should not be with labs that are following protocol. We can’t draw blood for tests without an order. If it were me, I would seek out a better Hematologist/Oncologist that would give you a physical prescription “outside order”that you could take to whatever hospital/healthcare provider lab in your area that will run a citrated plasma test for pseudothrombocytopenia. If you haven’t officially been diagnosed with pseudothrombocytopenia that is likely why you’re experiencing the roadblocks you are.
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u/OnlyHere4Football 12d ago
We recently switched to Epic and we have an option to order a rainbow, basically an extra tube. Maybe see if the doctor can order a “rainbow blue.” That would be your sodium citrate, and then the lab will have it and you won’t have to come in for redraws. Alternatively, they can order a “citrated platelet count” at Quest or LabCorp, along with the CBC. That way they have the lavender and the blue top.
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u/Tricky_Ad_5332 12d ago
My smallish town community hospital did it no problem. If a patient told us they are a clumped it’s automatic. Results released with a comment on platelet count that it was performed on a sodium citrate tube. Our pathologist and the oncology docs would cover us. It was literally part of the written CBC procedure.
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u/glitterfae1 Lead 12d ago edited 12d ago
For 19 out of the 20 years I’ve been a lab tech my hospital did not have an order for citrated platelet count. We just reported it under the normal platelet count with a comment that it was from the blue top. We didn’t do any validation study as far as I know. I wasn’t the one who validated our analyzers, so I don’t know that for sure - but I’m assuming so since we don’t even use a SOP for it, there’s just a couple of lines about it in our Sysmex SOP. Finally we did get the order built in the LIS because it was such a problem trying to get the redraw to be drawn in a blue top.
You’ll definitely have better luck at a hospital lab. Your doctor could try to speak to the hematology tech, lab manager, or head pathologist and get it pushed through, reported under the platelet count like we had to do before the test was built. Oh one other thing, you could ask your doctor to fill out a paper order (write it on a prescription pad or blank space on a paper requisition.) Labs can order “miscellaneous test” for unorderable tests.
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u/bdg006 12d ago
CAP can ask to see your validation studies for this. They have cited other labs for this very thing. That’s why so many labs with Sysmex analyzers have stopped running citrate tubes for platelet clumpers, including ours.
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u/glitterfae1 Lead 12d ago
Oh I’m sure. Someone higher up than me can worry about that. We just got a new supervisor AND a new director - and we’re getting a new analyzer in a few months. So maybe this time around it’ll get done.
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u/superduperzz 12d ago
I am surprised that if you frequently visited any lab, that they did not put any notes in your chart about needing a blue top drawn due to a platelet clumping disorder. I know we do this and will gladly look it up if a patient says they need special requirements. I would ask to speak to management, as this is such an easy fix to just draw 1 additional tube. If it is noted in the chart it should be a no-brainer.
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u/Loud-Lab-3001 12d ago
The test order from both Quest and LabCorp should be Citrated platelet count. The provider should be able to order this at the same time as a CBC.
I’m sure it’s frustrating as a patient when you know this is an issues and you cannot get cooperation. I have always believed the patient when they tell me they have this. As a tech, I tell my phlebotomists to leave my blue tops alone until my CBC is done , just in case this is an issue.
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u/unique_perfectionist 12d ago
I wish more nurses drew citrated tubes for platelets and order it that way if they really want to just know the platelets (like when they say the only thing they cared about was the platelets but order a cbc with diff) and or there is a history of clumps being seen repeatedly.
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u/LabNerd13 MLS 12d ago
At my hospital it is orderable as a citrated platelet. Are they looking for the right name for the order?
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u/Freyja_of_the_North 11d ago
I've drawn several of those in the past it just needs to be mentioned on the req and we will sort out the code/whatever
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u/TiltedIn2016lul 11d ago
Sunrise Medical (part of the larger Sonic Healthcare) I know draws blue. You may get a cranky phlebotomist but it’s at least part of their testing repertoire. Every lab tech should be familiar with your case, it sounds like it’s a matter of how much healthcare has become corporate and someone somewhere doesn’t know how to charge you for your wellbeing 🙄
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u/TiltedIn2016lul 11d ago
At least for the tri state area https://www.sunriselab.com/clinicians/regions/new-yorktri-state/new-york-test-directory/
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u/Actual-Anteater2815 9d ago
a citrated tube is not FDA approved on a lot of analyzers for cbc testing
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u/notagoddess22 12d ago
It sounds like you are doing everything you can. Perhaps ask for managers if they refuse to draw it?
This is kind of crazy to me, as at my facility we built a test specific for platelet clumpers that has the tubes / specimen type listed as both a lavender and blue top. I think at this point I would be trying to escalate up the management chain, as it’s bad patient care and potentially a waste of a blood transfusion (that has its own risks) if they continue to test improperly.
Best of luck!