Clinical Laboratory Services


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  • Routine Venipuncture

    Department of Pathology

    Division of Clinical Laboratory Medicine

    University of Mississippi Medical Center

       

    Prepared
    and written
    by:
    Marilyn B. Bray, BS MT (ASCP) Director of Laboratory Services
    Effective Date:January 1, 2013
    Approved:Bradley Brimhall, MD, MPH, Director of Clinical Pathology
    I.Purpose
      The Routine Venipuncture procedure outlines the steps for collection of specimens submitted for testing to the University of Mississippi Medical Center Laboratory System by venipuncture.
    II.Scope/Responsibility
     This procedure will apply to all University of Mississippi personnel deemed competent to perform phlebotomy procedures or collect specimens to be submitted for testing.
    III.Procedure
     Proper identification of the patient is a necessity.
     1.All patients must be identified using two (2) unique identifiers prior to the collection of any sample. Standard identifiers used in the University of Mississippi Medical Center system are: Name and UMMC Medical Record Number. The date of birth is a third form that may be used for clarification of ID.
     2.All patients will have a Positive Patient Identifier or wristband that will include the patient's full name, Medical Record Number, Date of Birth and gender. All Identifiers will be checked when blood is collected, before collection process is performed.
     3.If an inpatient does not have a properly attached hospital identification wristband, the phlebotomist must ask a nurse or physician to verify the identity of the patient. An armband must be placed on the inpatient by nursing personnel before blood can be drawn.
     4.If the armband is unreadable, or if the information is incomplete or does not match the LIS computer generated label, the differences must be resolved and a new wristband generated before the collection procedure is initiated.
     5.Do not ask the patient, “are you.....?”. Patients may have affirmative answers to any question or may not understand, therefore incorrect information may be given.
     6.WHEN POSSIBLE, active patient ID is preferred. Ask the patient to state their full name and date of birth.
     Outpatients
     Outpatients will not have an armband.
     1.If an outpatient is unresponsive or unable to respond to verbal questions, a competent individual familiar with the outpatient must confirm the patient's identity and respond to verbal questions before blood collection.
     Safety
     1.Observe universal/standard safety precautions. Observe all applicable isolation procedures.
     2.Personal Protective Equipment will be worn during all phlebotomy procedures.
     3.Wash hands according to approved Hand-Washing Procedure.
     4.Gloves must be worn during all phlebotomies and changed between patient collections.
     5.In-patients should be lying in a comfortable position that will allow easy access to the patients antecubital fossa by collection personnel.
     6.Out-patients should be seated in a designated Phlebotomy draw chair with a lockable arm rest unless concerns for fainting or other reactions are possible.
     7.Reassure the patient. Gain the patient’s confidence by approaching the patient in a confident manner; tell the patient that there may be a minimal amount of pain. The actions of the collection personnel leading up to the venipuncture can determine the success of the procedure. Continued assurances are especially helpful with children and patients who are nervous and apprehensive.
     8.Check to ensure ordered collection time is valid and diet restrictions have been followed. If not, contact the physician or ordering healthcare personnel.
     Precautions:
      Drawing below the IV site is permissible providing a tourniquet can be used below the IV site.
     1.Do not perform a venipuncture in any site that contains a cannula, vascular graft, fistula or arterial line. At no time may a phlebotomist perform a venipuncture on an artery.
     2.Extensive scarring or healed burn areas should be avoided.
     3.Avoid areas of hematoma.
     4.Mastectomy sides should be avoided.
     5.Pedal venipuncture should be performed ONLY after consultation with the patient's physician.
     6.Consult with the patient's physician if no area is available for a venipuncture draw.
     7.Infant draw allowance (mL) = 1.7 x child's weight in kg. Maximum volume should not exceed 5.0% total blood volume within a 30 day period, unless deemed medically necessary by physician.
     Equipment:
     A.Vacutainer System:
      Vacutainer needle holder
      Double-ended Vacutainer needle or butterfly
      Specimen transport bag (zip-lock)
      70% alcohol pad for routine tests
      Chloroprep for blood cultures and Betadine for blood Alcohol specimens.
      Gauze
      Adhesive bandage or Coban
      Gloves
      Tourniquet
      Vacutainer tubes
     B.For Venipuncture performed with a syringe:
      Appropriately sized plastic syringe
      Usually 23 gauge winged infusion set is proper for draw but needle should be changed to larger gauge, preferably 12 gauge, before transferring blood to the vacutainer tubes.
      70% alcohol pad for routine test
      Chloroprep for blood cultures
     
     
    Betadine for blood alcohol specimens
     
     
    Gauze
     
     
    Adhesive tape or Coban
     
     
    Gloves
     
     
    Tourniquet
     
     
    Puncture resistant disposal container
     
    C.Additional supplies should be prepared as needed:
     
     
    Ice
     
     
    Heel warmers
     
     
    Needle selection will be based on the patient's needs and physical characteristics. The gauge of the needle for venipuncture should be 21 or 23 depending on the patient. Butterfly selection may also be beneficial. All needles will be inspected for burrs or rough edges prior to use.
     
     
    Gloves will be worn for all phlebotomy procedures and changed between collections.
    IV.Performing Venipuncture
     
    1.Apply a tourniquet to the patients arm 3 to 4 inches above the antecubital fossa. Ask the patient to clench his/her fist (to allow veins to become more apparent). Identify the intended venipuncture site. If a vein cannot be palpated, possible solutions:
     
     
    Lightly tap the area to be used - DO NOT THUMP
     
     
    Massage the arm from the wrist up to the elbow
     
     
    Apply a warm, wet cloth to the area
     
     
    Select an alternate site. Preferred sites are the median cubital, the cephalic vein and the basilica vein
     
    2.Remove the tourniquet while assembling the supplies.
     
    3.Assemble the Vacutainer system with the holder and needle. Thread the needle or butterfly apparatus into the Vacutainer adapter.
     
    4.Assemble the tubes in the proper order of draw.
     
    The correct Order of Draw is important to avoid possible test result error and interference due to cross contamination from tube additives. The order of draw applies to all blood collection draws.
     
     
    a.Blood Cultures
     
     
    b.Coagulation: LIGHT BLUE STOPPER
     
     
    c.Non-additive Tubes: RED, GOLD SST
     
     
    d.Green top Heparin tubes
     
     
    e.Lavender Tube
     
     
    f.Gray Top
     
     
    g.If Blood Cultures are not requested-draw 5 ccs in a red-top tube BEFORE collecting Coagulation Tests.
     
    5.Reapply the tourniquet and palpate the draw site
     
    6.Cleanse the venipuncture site with 70% isopropyl alcohol. Allow the alcohol to air dry. Residual alcohol may affect the integrity of the sample. Chloroprep must be used to cleanse the site when a blood culture is included in the draw. Only Betadine should be used to cleanse the site when blood alcohol and drug screen specimens are obtained.
     
    7.Grasp the patients arm. Using your thumb, pull the patients skin taut below the venipuncture site. This will anchor the vein and prevent the vein from rolling.
     
    8.With the bevel of the needle at a 15-30 degree angle, firmly insert the needle with a quick, small thrust into the vein in one smooth motion. Grasp the vacutainer system assembly and push the tube forward until the inner needle pierces the stopper of the tube. Blood flow should be established. Fill the tube, remove and replace successive tubes to complete the tests request. Make sure all tubes are filled to recommended levels.
     
    9.Gently invert all tubes 6-8 times. DO NOT SHAKE OR MIX VIGOROUSLY.
     
    10.If a syringe has been used, draw slowly back on the plunger until correct amount of blood has been drawn then transfer to correct collection tubes only after the needle has been changed to a larger bore needle, preferably a 12 or 16 gauge. Never force the blood through the stopper. Allow the vacuum to gently pull the blood into the tube or remove the stopper and allow the blood to flow down the side of the collection tube. If the latter is chosen, place the stopper back onto the tube and puncture with 23 or 21 gauge needle to ensure the stopper will not pop off the tube. This procedure should ensure that HEMOLYSIS will not occur.
     
    11.Remove the last tube from the Vacutainer assembly. Request the patient relax his/her hand and release the tourniquet. The tourniquet should never be left tied for more than one (1) minute.
     
    12.Position a clean gauze pad over the venipuncture site as you draw the needle from the vein. Apply slight pressure to the draw site as the needle is withdrawn.
     
    13.Engage the safety shield over the needle during this step,
     
    14.Apply firm pressure to the site and hold for 1 full minute. Finally, apply a pressure bandage to the draw site. If applicable, the patient may apply pressure for an additional 2 minutes.
     
    15.The entire vacutainer assembly must be discarded in a puncture proof container. The phlebotomist or other specimen collector must never resheath a needle.
     
    16.The collector will apply the label at the patients bedside, including their own initials and the date and time of collection. All tubes must be labeled or risk being discarded by the laboratory.
     
    17.Check the venipuncture site for any continuous bleeding or other complications before leaving the area. Additional pressure may be required. Do not leave the patient if bleeding does not cease. A physician should be contacted.
     
    18.Remove gloves and throw away according to the hospital's safety policy.
     
    19.Wash hands according to the Hand Washing Policy before leaving the patient's room.
     
    20.Hands must be washed before each patient encounter. New gloves must also be donned.
     
    21.All accidental needle sticks must be reported to the supervisor or designee as soon as possible after the occurrence. The employee will be directed to Employee Health, or the Emergency Room if after hours.
     
    22.All phlebotomy equipment taken into any isolation room must remain in that room after the venipuncture is completed.
     
    23.The phlebotomist may not perform venipuncture on any patient who is being transfused with blood products.
     24.If a patient has an alert for Radiation therapy, blood will be collected according to procedure but will be labeled as having received Radiation Therapy.
    V.Troubleshooting for Blood Collection
     
    If a blood sample is not attainable:
     
    Reposition the needle
     
    Ensure that the collection tube is completely pushed onto the back of the needle in the hub.
     
    Try another tube as the vacuum may have been lost.
     
    Loosen or re-tie the tourniquet.
     
    At no time will a phlebotomists or collector probe. Another collection site should be selected.
     
    After 2 unsuccessful attempts, a phlebotomist or the specimen collector should call a supervisor or other healthcare personnel to assess the patient.
    References:
    Clinical and Laboratory standards Institute: Procedure for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard 5th Edition CLSI Document 2009
    College of American Pathologist Publications Committee, Phlebotomy Editorial Group. So Youre Going to Collect a Blood Specimen: An Introduction to Phlebotomy. 11th ed. Northfield, IL; College of American Pathologists, 2009.