NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS



REVISIONS TO POLICY STATEMENT: YES NO OTHER REVISIONS: YES NO

APPLIES TO: All Northpointe staff who have had venipuncture training and have been assigned responsibility for providing lab draw services

POLICY: Northpointe will provide laboratory services to the individuals we serve.

PURPOSE: To provide standardized procedures to assure that lab services are provided safely, utilizing proper technique when performing venipuncture, that specimens and infectious waste are handled correctly.

DEFINITIONS:

Venipuncture: surgical puncture of a vein for the withdrawal of blood or administration of intravenous medications.

Phlebotomy: The letting of blood for transfusion, apheresis, diagnostic testing, or experimental procedures.

Hematoma: A semi-solid mass of blood in the tissues, caused by injury, disease, or a clotting disorder.

Hemolysis: the destruction of red blood cells and the release of the hemoglobin they contain.

Materials:

1. Safety Needles, 22g or less.

2. Blood Collection Tubes. The vacuum tubes are designed to draw a predetermined volume of blood.

Tubes with different additives are used for collecting blood specimens for specific types of tests.

The color of the rubber stopper is used to identify these additives.

3. Tourniquets. Latex-free tourniquets are available.

4. Alcohol prep pads.

5. Gauze or cotton balls.

6. Sharps Disposal Container. An OSHA acceptable, puncture proof biohazard container.

7. Bandages or tape

Safety:

1. All blood specimens are to be treated as infectious and handled using universal (standard) safety precautions. Dispose of all items used in the appropriate biohazard container.

2. Gloves are to be worn during venipuncture and changed between individual collections. Palpation of phlebotomy site may be performed without gloves providing the skin is not broken.

3. A lab coat or gown must be worn during blood collection procedures.

4. In the case of an accidental needle stick, immediately wash the area with an antibacterial soap, express blood from the wound, and contact your supervisor.

PROCEDURES

1. Identify the individual.

2. Reassure the patient that the minimum amount of blood required for testing will be drawn.

3. Ask the individual if they have followed the diet restrictions if the specimen requires fasting.

4. For therapeutic drug levels ask the individual when the last dose of medication was taken.

5. Assemble the necessary equipment.

6. Wash hands and put on gloves.

7. Position the individual with the arm extended to form a straight-line from shoulder to wrist.

8. Do not attempt a venipuncture more than twice. Notify the practitioner if unsuccessful.

9. Select the appropriate vein for venipuncture. The larger median cubital, basilic and cephalic veins are most frequently used, but others. Ask the individual to close their fist tightly.

At no time perform venipuncture on an artery.

Factors to consider in site selection:

* Extensive scarring or healed burn areas should be avoided

* Specimens should not be obtained from the arm on the same side as a mastectomy.

* Avoid areas of hematoma.

10. Apply the tourniquet 3-4 inches above the collection site. Never leave the tourniquet on for over 1minute. If a tourniquet is used for preliminary vein selection, release it and reapply after two minutes.

11. Clean the puncture site by making a smooth circular pass over the site with an alcohol pad, moving in an outward spiral from the zone of penetration. Allow the skin to dry before proceeding. Do not touch the puncture site after cleaning.

12. Perform the venipuncture:

A. Attach the appropriate needle to the hub by removing the plastic cap over the small end of the needle and inserting into the hub, twisting it tight.

B. Remove plastic cap over needle and hold bevel up.

C. Pull the skin tight with your thumb or index finger just below the puncture site.

D. Holding the needle in line with the vein, use a quick, small thrust to penetrate the skin and enter the vein in one smooth motion.

E. Holding the hub securely, insert the first vacutainer tube following proper order of draw into the large end of the hub penetrating the stopper. Blood should flow into the evacuated tube.

F. After blood starts to flow, release the tourniquet and ask the individual to open their hand.

G. When blood flow stops, remove the tube by holding the hub securely and pulling the tube off the needle. If multiple tubes are needed the proper order is as follows:

1) Blood culture vials or bottles, sterile tubes.

2) Coagulation tube (light blue top)(Routine PT/PTT may be performed if blue top is first tube collected. It may be desirable to collect a second tube for other coagulation assays.)

3) Serum tube with or without clot activator or silica gel (Red or Gold)

4) Heparin tube (Green top)

5) EDTA (Lavender top)

6) Glycolytic inhibitor (Gray top)

H. Each coagulation tube (light blue top) should be gently inverted 4 times after being removed from the hub. Red and gold tops should be inverted 5 times. All other tubes containing an additive should be gently inverted 8-10 times.

DO NOT SHAKE OR MIX VIGOROUSLY.

I. Place a gauze pad or cotton ball over the puncture site and remove the needle. Immediately apply slight pressure. Ask the individual to apply pressure for at least 2 minutes. When bleeding stops, apply a fresh bandage, gauze or tape ask the individual to leave the bandage on for at least 15 minutes.

J. Properly dispose of hub with needle attached into a sharps container. Label tubes with the individual’s name, time of collection and initials of the staff completing the venipuncture. Store the tubes in a biohazard container (bag) after collection and during transportation to the laboratory.

TROUBLESHOOTING HINTS 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.

• Use another tube as vacuum may have been lost.

• Loosen the tourniquet.

• Probing is not recommended. In most cases another puncture in a site below the first is advised.

Prevention of Hematoma:

a. Puncture only the uppermost wall of the vein.

b. Use only the major veins, avoiding the superficial veins.

c. Make sure the needle fully penetrates the uppermost wall of the vein; partial penetration may allow blood to leak into the soft tissue surrounding the vein by way of the needle bevel.

d. Remove the tourniquet before removing the needle.

e. Apply a small amount of pressure to the site by placing a cotton ball under the bandage and stretching it slightly when taping the arm.

Prevention of Hemolysis:

a. Avoid drawing blood from an area of hematoma

b. Select a vein of appropriate size and avoid probing for a vein with a needle.

c. Allow alcohol to dry completely prior to the venipuncture

d. If vein is fragile, do not use large volume tubes.

e. Fill tubes to capacity to ensure proper blood additive ration

CROSS REFERENCE:

NCCLS: Procedure for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard, Fifth Edition

CDC standard precaution guide to infection prevention in the out patient setting

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