Early vs. Late Tourniquet Release and Phlebotomy-Induced Hemolysis in the Emergency Department: The TOURNI-ED Randomized Trial (TOURNI-ED)

BACKGROUND AND RATIONALE:

Hemolysis is recognized as the leading preanalytical source of error in clinical laboratories, with emergency department settings reporting particularly high rates (range: 12-26%) due to specimen collection under time pressure, use of small-bore intravenous catheters, and challenging venous access. Hemolyzed specimens affect measurements of potassium, lactate dehydrogenase, bilirubin, and other analytes, resulting in clinical misinterpretation, repeated laboratory requests, and procedural delays in a time-sensitive environment.

Venous stasis created by tourniquet application is a physiological perturbation that promotes erythrocyte deformation and lysis through hemoconcentration and shear stress. Clinical guidelines (Clinical and Laboratory Standards Institute, CLSI H03-A6; Turkish Biochemistry Society Phlebotomy Guidelines 2015) recommend that the tourniquet should be released as soon as blood flow is established, ideally within 60 seconds, and not later than the completion of the first collection tube. However, in routine emergency nursing practice, the tourniquet is frequently maintained throughout the entire multi-tube collection sequence to maintain venous distension and reduce the likelihood of failed collection attempts.

This pragmatic trial directly tests whether adherence to guideline-recommended early tourniquet release translates into a clinically meaningful reduction in hemolysis rates compared to the commonly observed late release practice, in a controlled setting using standardized sphygmomanometer-applied venous stasis at 60 mmHg.

INTERVENTION DELIVERY:

Both interventions use a standard aneroid sphygmomanometer (not a conventional tourniquet rubber strap) inflated to 60 mmHg to standardize venous stasis pressure across all participants. This represents a methodological innovation that eliminates inter-practitioner variability in tourniquet application pressure.

Tube collection order (identical for both groups, per CLSI H03-A6):

1. Sodium citrate (blue cap, 2.7 mL) - coagulation studies
2. SST/gel separator (yellow cap, 5 mL) - serum biochemistry [PRIMARY OUTCOME TUBE]
3. K2-EDTA (purple cap, 3 mL) - complete blood count

Group A - Early Release Protocol: After confirming blood flow and completing the first tube (sodium citrate), the sphygmomanometer is deflated to 0 mmHg and removed. Subsequent tubes are collected without venous stasis.

Group B - Late Release Protocol: The sphygmomanometer remains inflated at 60 mmHg throughout all three tubes. It is deflated and removed only after the third tube (K2-EDTA) completes filling.

DIFFICULTY ASSESSMENT - A-DIVA Scale: All participants are assessed for venous access difficulty using the A-DIVA (Amsterdam Difficult Intravenous Access) Scale (van Loon et al., 2016) prior to blood collection. The A-DIVA scale assigns 0-1 points for each of five items: (1) history of difficult venous access, (2) no palpable vein, (3) no visible vein, (4) vein diameter <3 mm, (5) unplanned/emergency procedure. Total score ≥2 is classified as high-difficulty. The A-DIVA score is recorded as a covariate in statistical analysis.

HEMOLYSIS ASSESSMENT:

The Hemolysis Index (HI) is measured on all SST/yellow cap tube specimens by the clinical chemistry laboratory analyzer, reported on a six-category ordinal scale corresponding to free hemoglobin concentrations: (-) <50 mg/dL, (1+) 50-99 mg/dL, (2+) 100-199 mg/dL, (3+) 200-299 mg/dL, (4+) 300-500 mg/dL, (5+) >500 mg/dL. Laboratory technicians performing HI analysis are blinded to group assignment throughout the study.

BLINDING:

Participants and healthcare providers administering the intervention cannot be blinded due to the procedural nature of the intervention. Outcome assessors (laboratory technicians performing hemolysis index measurement) are blinded to group assignment. Statistical analysis is performed on de-identified data.

PATIENT AND PUBLIC INVOLVEMENT (CONSORT 2025 Item 8):

Patients and the public were not formally involved in the design of this trial due to the pragmatic, low-risk, procedure-modification nature of the study. Findings will be disseminated through open-access publication and presented to nursing and laboratory staff at the participating institution.

DATA SHARING (CONSORT 2025 Item 4):

De-identified individual participant data and the data dictionary will be made available to qualified researchers upon reasonable written request to the principal investigator, following publication of the primary manuscript and approval by the institutional ethics committee, in accordance with applicable data protection regulations.