CRITTENTON HOSPITAL MEDICAL CENTER
ASCENSION PROVIDENCE ROCHESTER HOSPITALPATHOLOGY DEPARTMENT POLICIES AND PROCEDURESManualSPECIMEN COLLECTIONProcedureSC.02 Standard Blood Drawing ProcedureIntroductionThe collection, handling and processing of a patient’s specimen comes between the physician’s order and the testing or examination of the specimen. Proper patient preparation, specimen collection, and specimen handling (transport, processing, and storage) are absolutely essential prior to optimal testing or examining any specimen. The possibility and magnitude of errors from these aspects of laboratory services are much greater than the error occurring in the testing or examination of the specimen.Confirming the identity of the patient, and then labeling the specimen in the presence of the patient (name, birth date, medical record number, etc.) is mandatory to avoid obtaining a specimen on the wrong patient or mislabeling a specimen.Before performing a laboratory study, the proper specimen to be collected, the amount, the manner of collection, handling, and processing should all be known. The proper preparation of the patient, e.g., fasting state, avoidance of drug interference, and proper dietary preparation, is a prerequisite for the collection of a satisfactory specimen.Once the correct specimen has been obtained, it must be properly handled to maintain specimen integrity until the time of testing or examination.Draw sheetObtain a letter-size piece of paper (8.5 x 11 inches). Print your name/initials and current date. This becomes the draw sheet for the day and is a daily requirement.SuppliesLaboratory utility carts are taken up with morning draws and aid in morning blood specimen procurement. The carts are stocked with the venipuncture and micro puncture equipment/supplies.Always check stock on cart for expirations dates before going to the floors. Discard all expired supplies and re-stock.Blood collecting trays may be used by lab personnel who have a limited number of venipunctures to perform.Tray or cart should contain:Needles – sterile, safetySyringe(s) – sterileMultidraw needlesButterfly(ies)Vacutainer holders for Vacutainer tubes and needlesVacutainer tubes – see Order of Draw and Minimum Volume of Draw procedureTourniquets70% isopropyl alcohol swabsChloraPrep? swab sticksTape/bandagesCotton balls/gauzeBD Microtainer? Blood Collection TubesCardinal Health GentleHeel? Lancet for infant heel puncturesBD Microtainer? Contact-Activated LancetsBlood bank armbandsTransport bagsSupply ExpirationAs noted above, stock on trays and carts must be checked for expiration dates before going to the floor. Expired supplies must not be used or stored on trays or carts. Discard expired supplies.Laboratory Manager or designee will monitor phlebotomy supply expirations monthly in stock room and outpatient phlebotomy area (including all drawers potentially containing stray phlebotomy supplies). This will be documented in the Phlebotomy Supplies Expiration Checks log located in the CLA/Specimen Collection manual in the outpatient phlebotomy area. All pertinent information, including upcoming expiration dates, will be noted in the comment section.hand hygieneHand hygiene referred to in the procedures below includes two options:Wet, lather/wash with hospital-provided soap for 15 seconds, rinse, and then towel dry.Hospital-provided hand hygiene alcohol sanitizer product may be used when hands are not visibly soiled or contaminated with blood. Apply product (golf ball size) and rub hands for 15 seconds or longer until product dries. Do not towel dry hands.ProcedureIdentify patient in accordance with Specimen Collection procedure Patient Identification, Specimen Labeling and Order-to-Collect Turnaround Time Standards.Close bedside curtain or room door. Bring equipment to bedside.Raise or lower bed to comfortable working height.Assist patient to supine or semi-Fowlers position with arms extended to form a straight line from shoulders to wrist. Place pillow or towel under upper arm if needed.Don disposable gloves and other appropriate PPE, as indicated. New unused gloves must be used with each patient. If gloves become contaminated with blood, replace with a clean pair after proper disposal of contaminated gloves and PPE.Verify all phlebotomy supplies to be used, e.g., blood collection tubes, blood culture bottles, needles, and syringes, are within expiration dates. Discard any outdated item.Apply tourniquet 5–10 cm (2–4 inches) above potential venipuncture site (antecubital fossa site is most often used). Encircle extremity and pull one end of the tourniquet tightly over the other, looping one end under other. Apply tourniquet so it can be removed by pulling end with single motion. A new tourniquet must be used with each patient.Keep tourniquet on patient no longer than one minute.Quickly inspect extremity for best venipuncture site, looking for straight, prominent vein without swelling or hematoma.Palpate selected vein with fingers. Note: If vein is firm and rebounds when palpated proceed. If vein feels rigid and cordlike and rolls when palpated, be prepared to anchor vein more securely during phlebotomy.Select venipuncture site. In case of blood cultures, two different sites are selected. If tourniquet has been in place longer then one minute, remove and assess other extremity, or wait 60 seconds before reapplying. If vein cannot be palpated or viewed easily, remove tourniquet and apply warm, wet compress over extremity for 10 minutes.Obtaining blood sampleSyringe methodHave syringe with appropriate needle securely attached.Cleanse venipuncture site with antiseptic swabs, moving in circular motion from site outward for about 5 cm (2 inches). Allow to air dry.Remove needle cover and inform patient the “stick” will last only a few seconds.Place thumb or forefinger of nondominant hand 2.5 cm (1 inch) below site, and gently pull skin down until vein is stabilized. Hold syringe and needle at 15 to 30 degree angle from patient’s arm with bevel up.Slowly insert needle into vein. With experience you will feel “pop” as needle enters vein.Hold syringe securely and pull back gently on plunger.Note: If plunger is pulled back too quickly, negative pressure may cause vein to collapse.Look for blood return.Obtain desired amount of blood, keeping needle stabilized.After specimen is obtained, release tourniquet.Apply cotton ball/gauze over puncture site without applying pressure. Quickly but carefully withdraw needle from vein, and apply pressure following removal of needle.Activate needle safety cover. Do not recap.For blood obtained by syringe, transfer specimen to tubes using the blood transfer device.For blood tubes containing additives, gently rotate back and forth 5–10 times.Tape cotton ball over site after bleeding has stopped.Check tubes for signs of external contamination by blood; decontaminate with alcohol swab if necessary.At patient’s bed/chair side, write draw time and collector’s initials on properly identified Cerner computer-generated specimen label(s).While still at patient’s bed/chair side, securely apply specimen label to each tube.Dispose of needles and syringes in the sharps container.Dispose of tourniquet and gloves in regular trash if not soiled with blood. Place items in a biohazard container if soiled with blood.Vacutainer method (vacuum tube system method)Attach double-ended needle to Vacutainer holder.Have proper blood specimen tube(s) resting inside Vacutainer holder/bedside, but do not puncture rubber stopper.Cleanse venipuncture site with antiseptic swab, moving in circular motion from site outward for about 5 cm (2 inches). Allow to air dry.Remove needle cover and inform patient the “stick” will last only a few seconds.Place thumb or forefinger of nondominant hand 2.5 cm (1 inch) below site, and pull skin taut. Stretch skin down until vein is stabilized. Hold Vacutainer needle at a 15 to 30 degree angle from arm with bevel up.Slowly insert needle into vein. Grasp Vacutainer holder securely and advance specimen tube into needle of holder; do not advance needle in vein.After specimen tube is filled, grasp Vacutainer firmly and remove tube, insert additional specimen tubes if needed.After the last tube is filled and removed from Vacutainer holder, release tourniquet.Apply cotton ball/gauze over venipuncture site without applying pressure and quickly, but carefully, withdraw needle from vein. Activate safety device.Immediately apply pressure over venipuncture site with cotton ball.For blood tubes containing additives, gently rotate back and forth 5–10 times.Tape cotton ball securely over site after bleeding has completed.Check tubes for signs of external contamination by blood; decontaminate with alcohol swab if necessary.At patient’s bed/chair side, write draw time and collector’s initials on properly identified Cerner computer-generated specimen label(s).While still at patient’s bed/chair side, securely apply specimen label to each tube.Dispose of Vacutainer holder in sharps container.Dispose of tourniquet and gloves in regular trash if not soiled with blood. Place them in a biohazard container if soiled with blood.Place specimen/labels in the biohazard bag that is sent to the laboratory via the pneumatic tube system.Perform hand hygiene after procedure.Place a patient aliquot label on the draw sheet. Write patient room number and time of draw next to the label.Send specimen to laboratory via pneumatic tube system.Blood culturesCarefully prepare proposed sites.First use alcohol swab, moving in a circular motion outward from site for about 5 cm (2 inches). Allow to air dry.Remove ChloraPrep? applicator from pouch. Place foam flat side down on arm. Repeat back-and-forth strokes of the applicator for about 30 seconds. Completely wet the treatment area. Allow to air dry for 30 seconds. Do not blot or wipe away.For children <2 years old, do not use ChloraPrep? swab, but swab twice with alcohol. Allow to air dry.Clean tops of culture bottles with alcohol swab. Allow to air dry.Collect required amount of blood by age of patient.Adults: Aerobic (gray) bottle minimum 8 mL to 10 mL maximum. Anaerobic (yellow) bottle minimum 5 mL to 7 mL maximum. If difficult draw, you may use one Peds Plus? (pink) bottle with 1 mL minimum.Children (<13 years old): Peds Plus? (pink) bottle minimum 1 mL to 3 mL maximum.If both aerobic and anaerobic cultures are needed, inoculate Aerobic (gray bottle) first.Mix gently after inoculation.Immediately apply pressure over venipuncture site with cotton ball/gauze until bleeding stops. Apply tape cotton ball/gauze dressing securely.Check bottles for signs of external contamination by blood; decontaminate with alcohol swab if necessary.At patient’s bed/chair side, write draw time and collector’s initials on properly identified Cerner computer-generated specimen label(s).While still at patient’s bed/chair side, securely apply specimen label to each tube. Place the bottles in proper cones/bags for transfer.Dispose of Vacutainer holder/needle/transfer device in sharps container.Place a patient aliquot label on the draw sheet. Write patient room number and time of draw next to label.Perform hand hygiene after procedure.Send to laboratory immediately via pneumatic tube system.Micro finger stickChoose a finger that is not cold, cyanotic (blue), or swollen.With your left thumb and index finger, grasp the patient’s ring finger about 3 inches above the tip of the finger.With your right hand, hold the sides of the patient’s ring finger. With your left hand toward the tip of the patient’s finger, apply a massaging motion to the fleshy portion of the finger. Repeat this massaging process 5 or 6 times.Cleanse the ball or pad of the finger with alcohol swab.Dry finger with cotton ball.Prepare a BD Microtainer? Contact-Activated Lancet. Adhere to universal precautions.Grasp patient’s prepared finger. Position lancet on selected puncture site, which should be on the side of the ball of the finger, across the fingerprint.Activate lancet by pressing it firmly against the puncture site. Do not remove lancet device from site until an audible click is heard.Wipe away first drop of blood and proceed with blood collection.Never squeeze or rub the finger hard. Use only a gentle massaging action well below the cut if the blood does not flow freely.When finished collecting sample, place cotton ball on puncture site and hold it firmly until bleeding stops; apply bandage.Check tubes for signs of external contamination by blood; decontaminate with alcohol swab if necessary.At patient’s bed/chair side, write time of draw and collector’s initials on properly identified Cerner computer-generated specimen label(s).While still at patient’s bed/chair side, securely apply specimen label to each tube.Dispose of BD Microtainer? Contact-Activated Lancet in sharps container.Dispose of gloves in regular trash if not soiled with blood. Place them in a biohazard container if soiled with blood.Place a patient aliquot label on the draw sheet. Write the patient room number and time of draw next to the label.Perform hand hygiene after procedure.Send to lab immediately via pneumatic tube system.Heel punctureApply heel warmer to increase blood flow. Leave warmer on for approximately 5 minutes.The heel is generally used for children less than 1 year old. The incision site must be on the plantar surface in an area visually marked by a straight line drawn from the middle of the great toe to the heel, or a visual line drawn from between the fourth and fifth toes to the heel, both lines to be parallel to the sides of the foot. With the infant in a supine position, clean the site with an alcohol swab. Allow to air dry.Remove the GentleHeel? Heel Incision Device from package. Adhere to universal precautions.Remove the trigger lock. Once the lock is removed, do not depress the trigger or place anything in front of the opening at the base of the device.Firmly grasp foot/heel lateral portion of the plantar surface of the heel.The GentleHeel? Heel Incision Device should be placed against the cleansed site and triggered. Care must be taken to prevent the device from penetrating the bone. Wipe away the first drop of blood using a dry sterile gauze pad. Collect the blood sample.Blood flow is enhanced if the puncture site is held downward and a gentle continuous pressure is applied to the surrounding tissue. Strong repetitive pressure should not be used as it may result in contamination. A second puncture is preferable to squeezing the puncture site.When finished collecting sample, elevate the infant’s foot above the body and press a clean cotton ball against the incision site until the bleeding stops. Apply bandage.Check tubes for signs of external contamination by blood; decontaminate with alcohol swab if necessary.At patient’s bed/chair side, write time of draw and collector’s initials on properly identified Cerner computer-generated specimen label(s).While still at patient’s bed/chair side, securely apply specimen label to each tube.Dispose of GentleHeel? Heel Incision Device in sharps container.Dispose of gloves in regular trash if not soiled with blood. Place them in a biohazard container if soiled with blood.Place a patient aliquot label on the draw sheet. Write the patient room number and time of draw next to the label.Perform hand hygiene after procedure.Send to lab immediately via pneumatic tube system.sites to avoid and special instructionsDo not draw the underside of the wrist due to possibility of hitting the radial or ulnar nerve or artery. Hitting the nerve on the underside of the wrist can cause nerve damage with the patient possibly losing the ability to open and close her/his hand.Do not draw from side of mastectomy or injury.Do not draw above (proximal to) an IV site.Foot draws may be performed with RN clearance only.Do not puncture skin at greater than a 30 degree angle due to the risk of passing through the vein.NOTEThe AccuVein AV400 is available for use if a vein is difficult to find. Refer to Specimen Collection procedure AccuVein AV400 for instructions.REFERENCESBD Microtainer? Contact-Activated Lancet Quick Guide. Franklin Lakes NJ: Becton, Dickinson and Company; 9/2007 (VS7536-2). PDF.GentleHeel? Incision Device Instructions for Use [package insert]. Waukegan IL: Cardinal Health; 3/2011. ................
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