PhlebotomyProcedure.html

PHLEBOTOMY PROCEDURE 

Principle:

Phlebotomy will be performed in accordance with specific guidelines to ensure that the samples obtained are of the highest quality.  These guidelines will emphasize patient comfort, safety, confidentiality and sample acceptability.

Specimen: 

The University of Virginia Medical Laboratory Handbook (also available on the web at http://www.healthsystem.virginia.edu/internet/medlabs/   provides information on specimen type(s), amount (s) and special handling instructions.  The Medical Laboratory computer system (Misys) also provides this information under function MIQ.  If additional information is required call the Medical Laboratory Customer Service department at 1-434-924-LABS.

Safety:

Phlebotomy is an invasive procedure and Standard Precautions must be followed at all times.  Gloves and a buttoned fluid resistant lab coat or scrubs must be worn.  If there is a potential of splashing or spraying blood a face shield must also be worn.  Lab coats must be removed when leaving the work area.  Proper handwashing must be performed between each patient.  If handwashing is not possible, then use a hospital approved waterless hand sanitizer must be used until proper handwashing can be done.

Blood spill cleanup shall be done according to the procedure in the Exposure Control and the Infection Control Manual.

For inpatients on isolation follow procedures as listed on the isolation card located on the patient’s room door and in the Infection Control Manual.

Outpatients who are free from active infections can be drawn in the phlebotomy area.  Patients with active infections are to remain in the examination room in the clinic and the Phlebotomist will report to the clinic for blood collection.   Consult the isolation procedures outlined in the Infection Control Manual for specific instructions.

Material and Equipment:

2 x 2 gauze pads

70% Isopropyl alcohol prep pads

Multisample needles (21G and 22G)

Safety Syringe needles (19G and 20G)

Syringes (5cc and 10cc)

Safety “butterfly” infusion sets (21G, 23G and 25G)

Safety Lock Needle holder

Luer adapters

 

Vacutainer tubes:

·        Red top tubes (no anticoagulant) 7 ml

·        Lavender top tubes (K3EDTA additive) 3 ml

·        Pink top tubes (K2EDTA additive) 6 ml

·        Blue top tubes (Sodium Citrate additive) 4.5 ml and 1.8 ml

·        Gray top tubes (Sodium fluoride additive) 4 ml

·        Dark Green top tubes (Sodium heparin) 10 ml 

·        Lime Green top tubes (Lithium heparin) 3 ml

·        Yellow top tubes (ACD) 10 ml

·        Gold top tubes (gel and serum separator)

 

Microtainers:

·        Lime green – (Lithium heparin)

·        Lavender – (K3EDTA)

·        Red (no additive)

·        Red (gel and serum separator)

·        Yellow (gel and serum separator)

·        Gray (sodium fluoride and potassium oxalate)

 

Gloves

Sharps container

Contaminated Waste Container (CMC)

Band-aid

Surgical tape (vinyl and paper)

Hospital approved waterless hand sanitizer

Fluid resistant lab coats or scrubs

 

Specimen collection will be performed on patients only at the written or electronic request of a physician or authorized individual.  Oral requests for collection of laboratory tests cannot be honored unless accompanied by a written (FAX copy is acceptable) or electronic request.  If a patient presents at a collection site without the proper paperwork or if the order is not clear as to what the physician requested, the staff will contact the physician and/or clinic to retrieve an order.    A phlebotomist can not cancel or reschedule a test without notification of a caregiver.  Any cancellation or rescheduling of a lab test must be documented in the computer (and on the collection list or lab request form) with the reason and the complete name (first and last) of the person who was notified. 

All out-patients must be registered in billing computer A2K3 for the current date of service (unless the charges are covered by a wholesale or grant account).   If the patient is not registered, have them present to the nearest registration hub to be registered.  The registration hubs are located in the West Complex, Primary Care and Northridge.

The phlebotomist cannot perform blood collection without the patient or guardian’s consent.   If the patient or guardian refuses to have blood drawn, notify the requesting physician.

Check for isolation signs on the in-patient door before entering the room.  If the patient is on isolation, follow instructions on the posted sign or refer to the Infection Control Manual.   Outpatients who are assessed by the clinic to be free of active infection, may report to the laboratory area to have their blood drawn.  Long-term isolation patients who are assessed to have an active infection must remain in the clinic to have their blood drawn.  Consult the Infection Control Manual for room cleaning specifications.

 

PROCEDURE:

A.                 Proper patient identification is essential.  It is the phlebotomist’s responsibility to follow the steps below to ensure that each patient is properly identified and that all paperwork and samples are labeled accordingly.

 

For Inpatients:

1.      Clearly state your name.

2.      State the reason you are there (I need to draw a blood sample from your arm).

3.      Ask the patient to state his/her full name.

4.      ALSO - verify that the name, medical record number and/or birthdate on the collection list or the PPID matches the patient hospital identification armband.  If all information matches continue with the collection.  If the collection list or PPID and the arm band information DO NOT MATCH:

·        DO NOT DRAW THE BLOOD SAMPLES

·        Inform the Health Unit Coordinator (HUC) of the discrepancy.

·        When the problem has been corrected, draw the blood samples.

·        Fill out a Quality Report (QR)

 

For Outpatients:

 When patients present in the outpatient phlebotomy area with lab request forms:

1.      Prior to venipuncture, the phlebotomist must verify that the name and date of birth matches the test request form or the computer information.

***Proper patient identification is the responsibility of the phlebotomist.  Ask the patient to state their name and date of birth.   

2.      If the request form(s) or the electronic order and the patient information do not agree:

·        DO NOT DRAW THE BLOOD SAMPLES

·        Contact the appropriate outpatient resource for corrective action.

·        After the corrections have been made, draw the blood samples.

·        Fill out a Quality Report (QR)

A phlebotomist should never untie a patient in restraints. A nurse or otherwise qualified person with specific skill documentation must be utilized to perform this function.  If it is necessary to untie a patient to draw blood, contact the patient’s caregiver who has this specific skill documented.

B.                 For Inpatients, examine the collection list, transmittals or the PPID system to determine the type and number of tubes to draw.  It is important to combine tests and check form minimal test volumes so blood taken from patients can be kept to a minimum.

For Outpatients, examine the test request forms and/or bar coded labels.  It is the phlebotomist’s responsibility to verify that all tests have been ordered correctly by the order entry person.  Determine the type and number of tubes to draw it is important to combine tests and check for minimal test volumes so blood taken from patients can be kept to a minimum.

C.                  Ask the patient if he/she has a preference as to which arm should be used for phlebotomy.  For inpatients, look for signs above the bed for instructions about which arm can be used.  If the patient does not have a preference, examine either arm.   (Patient’s must have a written physician’s order for feet or ankle veins to be used for phlebotomy.  Check with the patient’s caregiver to be certain proper documentation is in order before using feet or ankle veins). 

The following sites should not be used for phlebotomy:

Burned or scarred veins

Sclerosed veins

Edematous areas

Site of Mastectomy (in case of a double mastectomy, the site associated with the older surgery should be used.  Normal flow of lymph fluid usually returns in approximately 6 months)

Arms with IV fluids (if the arm containing an IV must be used, the blood must be drawn below the IV….NEVER ABOVE)

Palm side of the wrist

Areas of skin abrasions or lesions

Sites with fistulas or shunts

Extensive scarring

Hematomas 

D.                Place the tourniquet around the arm 3 - 4 inches above the antecubital area.  The tourniquet should be tight but not tight enough to restrict blood flow.  The tourniquet must not be left on the arm for longer than 1 minute.  Once the tourniquet has been released, it must remain off for 2 minutes before it is reapplied. 

E.                 Ask the patient to make a fist, but do not pump or squeeze hard. 

F.                  Palpate for a vein using the index finger.  The median cubital and cephalic veins located in the antecubital area are the veins used most frequently.  The veins on the back of the hand are also acceptable.  In extreme circumstances veins in other locations may be used.  Once a vein has been located, palpate to determine the size, depth and direction.  Untie the tourniquet to assemble the equipment.

G.                Once the site has been determined, prepare the appropriate equipment.  The size and location of the vein should be used to determine the equipment to be used: 

·        Medium to large veins in the antecubital area, use a Vacuette Quickshield 21G (green cap)

·        Small veins in the antecubital area or hand use a Vacuatiner holder with a luer adapter and a butterfly infusion set 23G

·        Extremely fragile veins (Geriatric) or extremely small veins (Pediatric) may require the use of a syringe and butterfly infusion set 23G or smaller.  After the blood has been collected into the syringe, a vacutainer safety transfer device must be used to fill the collection tubes. This system, which allows the phlebotomist to control the amount of pull on the vein, may be used in the antecubital area, hand or wrist.

H.                Cleanse the venipuncture site with an alcohol pad (70% isopropyl alcohol).  Cleanse the area in a circular motion starting at the inside of the venipuncture site and working outward.  For maximum bacteriostatic action to occur, the alcohol must be allowed to dry on the patient’s arm rather then being wiped off.  It is very important to allow the alcohol to dry before performing the venipuncture.  Do not touch the intended site as this will cause contamination of the phlebotomy area.  While the alcohol is drying, make a final survey of the tubes to be sure everything required for the procedure is at hand. 

I.                   Retie the tourniquet. 

J.                  Anchor the intended vein by slightly pulling back on the skin below the venipuncture site. 

K.                Uncap the sterile needle and check for noticeable defects.  Do not use the needle if any defects are detected or if the seal in broken in any way.  NEVER REUSE NEEDLES FOR ANY REASON.

L.                 With the bevel of the needle facing up enter skin at a 15 – 30o angle (depending on the depth of the vein).  The skin must be entered with a swift, smooth motion to minimize discomfort to the patient.  The phlebotomist will feel a lessening of resistance once the lumen of the vein has been entered. 

M.              While holding the needle firmly in place, ease the tube onto the vacutainer holder.  This will allow the stopper to be punctured and blood to enter the tube.  Placing the tube onto the holder label down allows the phlebotomist to monitor blood flow in the tube.

N.                Once the blood flow is established release the tourniquet and instruct the patient to relax his/her fist.

Note:  If blood is not obtained it may be necessary to change the position of the needle.  If the needle has not penetrated the vein far enough, advance the needle slightly.  If the needle has penetrated too far, pull back slightly.  Probing is not acceptable and is painful for the patient.  Try another tube to make sure the tube is not defective.  A phlebotomist should only attempt the venipuncture twice before asking a co-worker to look at the patient. 

O.                When the tube has completely filled, remove it by grasping the end of the tube and gently pulling.  It is imperative that the needle not be moved during this process.  If another tube is to be drawn, insert the next tube.  The order that the tubes are drawn is extremely important to avoid cross contamination of anticoagulants. Chance of carryover can be minimized by making certain that specimen tubes fill from the bottom up from collection. Tubes must be drawn in the following order:

·        Blood Cultures

·        Coagulation tube (Blue-sodium citrate)

·        Serum tube with or with clot activator, with or without gel  (Red or gold)

·        Heparin tube with or without gel plasma separator (green)

·        Lavender/Pink (EDTA)

·        Gray (Sodium fluoride)

·        Other anticoagulants

Note:  If a coagulation tube (blue top) is the first tube drawn and a winged infusion (butterfly) is used, a red top discard tube should be drawn first.  The discard tube can be removed once blood flow into the tube has been established; it is not necessary to completely fill the discard tube.

P.                  The last tube must be removed from the holder before the needle is removed from the venipuncture site.  Place several clean gauge pads lightly over the venipuncture site.

Q.                If using the push button device, activate the button while the needle is still in the vein.  If not using the push button device, remove the needle from the vein and immediately apply direct pressure to the venipuncture site.  Ask the patient to press down on the site with the arm still in an extended position.  (Bending the arm may cause a hematoma by not applying pressure directly to the site.)

R.                Engage safety lock (if NOT using the push button device) to cover contaminated needle.  NEVER RECAP NEEDLES!!  Discard all needles in an appropriate sharps container.  

S.                  Mix anticoagulated tubes 8 – 10 times by gently inverting the tubes.  If a syringe has been used to obtain the blood remove the needle and apply a blood transfer device.  Then transfer blood into the appropriate tubes using this order, 

Blue top (Sodium citrate)

Lavender (EDTA)

Green (Lithium heparin)

Other anticoagulants

Red

Allow the tubes to fill; DO NOT FORCE BLOOD into tubes.  This will cause the blood cells to hemolyze and the pressure may cause the top to blow off resulting in an exposure.

T.                 Label all tubes with the computer barcode in the patient’s presence, verifying again that all information matches.  If possible have the patient verify that the name printed on the barcode label is correct.  If the patient cannot read the label, the phlebotomist should read the name out loud to the patient and have the patient verbally agree that the label is correct.  If this is not possible the phlebotomist should verify the barcode label with the patient’s armband label, paperwork or registration label.  Samples drawn for Blood Bank must be labeled according to the Typenex procedure (Addendum I).  If labels are not available the following information must be on the tube:  Patient’s full name, medical record number, date and time of collection. 

U.                 Indicate on the request form(s), collection list or the in the PPID system, the time of collection, the number and type of tubes drawn and the initials of the person performing the venipuncture.

V.                 Examine the venipuncture site to make sure the bleeding has stopped.  Ask the patient if they are allergic to the bandaid or tape.  (If a patient is on “blood thinners” hold the site for a longer period of time and apply a pressure bandage.)  Apply either a bandaid or clean gauze and tape.  Do not use bandaids on children under 2 years of age.  Ask parent or guardian permission before applying bandaids to children over two.  Instruct the patient not to remove the bandage for 15 minutes.

Note:  The phlebotomist should check for continued bleeding.  If a hematoma develops or bleeding continues for longer than five minutes, a nurse or caregiver must be notified. 

W.               Before the patient leaves an outpatient area, make sure the patient is feeling no ill effects from the procedure.  DO NOT allow a patient who is feeling dizzy or sick to leave.  For inpatients, make sure the patient is comfortable and the room is returned to the original position (bed railings up, lights off and all items removed from the bed). 

X.                 Discard all contaminated materials in the proper locations as indicated in the Infection Control Manual.   For out-patients, clean the phlebotomy chair (arm and seat) with a disposable germicidal cloth (Asepti-Wipe II).  If the outpatient is on isolation follow the cleaning procedure in the Infection Control Manual.  Remove and discard gloves.  Perform proper handwashing.

Y.                 Observe any special handling criteria for samples (on ice, protect from light, STAT, etc.)   Tube samples and request forms to the laboratory.

Z.                  Phlebotomy baskets and carts used on the inpatient units, are to be clean once a week with a disposable germicidal cloth (Asepti-Wipe II) or Cavicide.  If there is visible blood contamination the basket should be cleaned with a 1:10 dilution of sodium hypochlorite (household bleach) prepared weekly.  The bleach should be allowed to air dry on the contaminated surface before removal.

NOTES: 

1.      If several anticoagulated tubes are to be drawn, mix the filled tube while the next tube is filling.  This will keep the tube from clotting.

2.      NEVER pour blood from an anticoagulated tube into a non-additive tube.

3.      If a hematoma begins to appear at the venipuncture site, DO NOT continue to try to obtain the blood.  Remove the needle and apply direct pressure to the site.  It is common courtesy to inform the patient that he/she may notice a bruise at the venipuncture site.  The bruise is nothing to be alarmed about and will disappear in a few days.  Attempt to obtain blood from another site. 

4.      DO NOT perform venipuncture more than 2 times.  If you are unable to obtain a sample in two venipunctures, request that another phlebotomist examine the patient.  DO NOT perform venipuncture on a difficult patient more that 4 times in a 24 hour period.

5.      If unsure of a suitable venipuncture site, ask another phlebotomist to examine the patient. 

6.      If a patient complains of feeling faint, immediately remove the needle from the vein and apply pressure to the venipuncture site.  Make sure the patient does not fall (if the patient has previously had blood drawn and has had symptoms of fainting, it is advisable to start with him/her in a reclining chair).  Request help from another phlebotomist.  Have the patient place his/her head between their knees.  Cold compresses applied to the forehead and back of the neck may help.  For outpatients immediately call Medic 5 at 2-2000.  For inpatients, use the patient’s call bell and ask to have a nurse sent to the room immediately.  NEVER release or leave a patient who is feeling dizzy or faint.

7.      For pediatric patients requiring only small amounts of blood for testing, blood can be obtained by capillary puncture (see Collection of Diagnostic Blood Specimens by Skin Puncture Procedure).  If a large amount of blood is needed, it is advisable to obtain blood by the venipuncture method, collecting the minimum amounts required.

8.      In rare cases, when no other sites are available, the phlebotomist should contact the patient’s nurse to evaluate interrupting the IV fluid so the sample can be obtained.  This can only be done by the nurse (never the phlebotomist).  The IV fluid should remain off for at least 10 minutes.  The first tube must be a 10 ml discard tube, then collect the ordered specimens.  When venipuncture is completed on this patient contact the nurse to have IV fluid restarted.  Mark the collection list or request form with the comment “Samples were drawn above an off IV”. 

9.      It is acceptable to obtain blood from the opposite arm while the patient is receiving a blood transfusion. 

REFERENCES:

1.      Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture,  Publication by the National Committee for Clinical Laboratory Standards, 2003, Fifth edition.

2.      Garza, D and Becan-McBride, K., Phlebotomy Handbook,  Appleton & Lange A Simon & Schuster Company, 1996

3.      Strasinger, S. and Di Lorenzo, M., Phlebotomy Workbook for the Multiskilled Healthcare Professional,  F. A. Davis Company, 1996

 

Addendum I

 

IDENTIFICATION PROCEDURE FOR BLOOD BANK SPECIMEN COLLECTION

(From Phlebotomy Venipuncture Manual)

Purpose: Specimens submitted to the Blood Bank for Type and Hold and intended for compatibility testing must be labeled using a Blood Recipient Identification System.

Materials:

Typenex Armbands (available in patient care areas)

6 ml EDTA (pink top) tubes 

Procedure:

1.                   Verify the patient’s identity by asking him/her to state their name. Match the patient name and history number that appear on the hospital armband and the MIS transmittal. The middle name is not required, but Jr., III, etc. are required. All information must agree before proceeding.

2.                   If patient is wearing an existing Blood Recipient Identification band, check to see if the corresponding sample is still available for use before proceeding. If the dating has exceeded its 3 day limitation, cut the band off and proceed.

3.                   Collect the patient blood specimen into a 6 ml EDTA (pink top) tube according to appropriate procedure.

4.                   Using a ballpoint pen, legibly write the patient’s full name, including suffix (Jr., Sr., etc), history number, date of specimen collection, and the phlebotomist’s first initial and last name on the long label.

5.                   Detach the strip of extra numbers from the band.

6.                   Remove the label from the arm band, attach the strip of extra numbers to the label and label the patient sample tube with the alpha-numeric number positioned at the top of the tube.

7.                   Wrap the band once around the patient’s wrist, so that the numbered side is out and the clear white area lies between the front and rear guides of the bracelet clip.

8.                   Firmly close the bracelet clasp.

9.                   Remove the coded self sticking number from the armband and attach it to the MIS transmittal to accompany the sample.

Sample Retention:

1.                   Specimens submitted for Type and Hold are eligible for use in compatibility testing for 3 days. For example, samples received after 0000 of DAY ONE may be used to provide compatibility blood units until 0700 of DAY FOUR.

2.                   Pre-operative patients who have not been transfused or pregnant in the last three months may be drawn under the Preadmission Assessment Specimen (PAS) Protocol. The Blood Recipient Identification band for this protocol is YELLOW. The samples may be drawn a maximum of 14 days before the date of surgery but expire one-day post surgery regardless of date drawn.

3.                   Infants less than four months of age may qualify for the Neonatal Protocol. For those infants that qualify, no additional crossmatch sample need be submitted during the first four months, UNLESS, the original band is cut off or the child is discharged and readmitted.

Reference: 

Typenex Blood Recipient Identification Bands Direction, Baxter Healthcare Corporation, Fenwal Division, Deerfield, IL 60015

 

dated:October 2011

uploaded:January 2012 KAS