ROUTINE VENIPUNCTURE GUIDELINES

MATERIALS

1.    Safety Needles, 22g or less
2.    Butterfly needles. 21g or less
3.    Syringes
4.    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. 
       See Selecting the Appropriate Collection Tube  and Specimen Container Types.
5.    Tourniquets.  Latex-free tourniquets are available
6.    Antiseptic.  Individually packaged 70% isopropyl alcohol wipes.
7.    2x2 Gauze or cotton balls. 
8.    Sharps Disposal Container.  An OSHA acceptable, puncture proof container marked "Biohazardous".
9.    Bandages or tape

 

SAFETY

1.    Observe universal (standard) safety precautions.  Observe all applicable isolation procedures.
2.    PPE's will be worn at all time.
3.    Wash hands in warm, running water with the chlorhexidine gluconate hand washing product (approved
       by the Infection Control Committee), or if not visibly contaminated with a commercial foaming
       hand wash product before and after each patient collection.
4.    Gloves are to be worn during all phlebotomies, and changed between patient collections. 
       Palpation of phlebotomy site may be performed without gloves providing the skin is not broken.
5.    A lab coat or gown must be worn during blood collection procedures.
6.    Needles and hubs are single use and are disposed of in an appropriate 'sharps' container as one unit.
       Needles are never recapped, removed, broken, or bent after phlebotomy procedure.
7.    Gloves are to be discarded in the appropriate container immediately after the phlebotomy procedure.
       All other items used for the procedure must be disposed of according to proper biohazardous
       waste disposal policy.
8.    Contaminated surfaces must be cleaned with freshly prepared 10% bleach solution.  All surfaces
       are cleaned daily with bleach.
9.    In the case of an accidental needlestick, immediately wash the area with an antibacterial soap, express blood
       from the wound, and contact your supervisor.


PROCEDURE

1.    Identify the patient.  Outpatients are called into the phlebotomy area and asked their name and date of
       birth.  This information must match the requisition.    Inpatients are identified by their arm band.
       If it has been removed, a nurse must install a new one before the patient can be drawn.

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

3.    Assemble the necessary equipment appropriate to the patient's physical characteristics.
     
4.    Wash hands and put on gloves.

5.    Position the patient with the arm extended to form a straight-line form shoulder to wrist.

6.    Do not attempt a venipuncture more than twice.  Notify your supervisor or patient's physician if
        unsuccessful.

7.    Select the appropriate vein for venipuncture. 
       The larger median cubital, basilic and cephalic veins are most frequently used, but other may be necessary
       and will become more prominent if the patient closes his fist tightly.  At no time may phlebotomists
        perform venipuncture on an artery.  At no time will blood be drawn from the feet unless there is a specific order in the computer.

       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.
            * If an IV is in place, samples may be obtained below but NEVER above the IV site. 
            * Do not obtain specimens from an arm having a cannula, fistula, or vascular graft.
            * Allow 10-15 minutes after a transfusion is completed before obtaining a blood sample.

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

9.   Clean the puncture site by making a smooth circular pass over the site with the 70% 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.

10.    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 patient to open his or her 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 of draw to avoid cross
                contamination and erroneous results 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 over the puncture site and remove the needle. 
                Immediately apply slight pressure.  Ask the patient to apply pressure for at least 2 minutes. 
                When bleeding stops, apply a fresh bandage, gauze or tape.
        J.     Properly dispose of hub with needle attached  into a sharps container.  Label all tubes with
                patient labels, initials, date and time.

11.    Venipuncture procedure using a syringe:
        A.    Place a sheathed needle or butterfly on the syringe. 
        B.    Remove the cap and turn the 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
               vein in one motion.
        E.    Draw the desired amount of blood by pulling back slowly on the syringe stopper.
        F.    Release the tourniquet.
        G.    Place a gauze pad over the puncture site and quickly remove the needle. 
               Immediately apply pressure.  Ask the patient to apply pressure to the gauze for at least 2 minutes. 
               When bleeding stops, apply a fresh bandage, gauze or tape.
        H.    Transfer blood drawn into the appropriate tubes as soon as possible using a needleless BD
               Vacutainer Blood Transfer Device, as a delay could cause improper coagulation.
               Gently invert tubes containing an additive 5-8 times.
        I.    Dispose of the syringe and needle as a unit into an appropriate sharps container.

 

12.    Infant/Child Phlebotomy
        A.    Confirm the patient's identification
        B.    Secure patient to Papoose apparatus for stabilization if child is unable to sit upright
               on their own.
        C.    Assemble the required supplies
        D.    Select the collection site and proceed as routine phlebotomy.  If the child is old enough,
               collect blood as in an adult. 

SPECIAL NOTE WHEN USING BUTTERFLY COLLECTION DEVICE: When coagulation  tube (light blue top)
 will be the first tube collected, it is MANDATORY to collect a DISCARD light blue top first to remove
 the air from the tubing.  A second light blue top can then be collected appropriately.  Failure to
collect the discard tube may result in specimen being rejected due to inappropriate volume.

 

UAMS CLINICAL LABORATORY BLOOD DRAW MINIMIZATION

 1.      Increasing the number of point of care glucose and electrolyte testing devices which use a
         fingerstick sample to perform test instead of drawing a whole tube of blood to send to the lab.

2.       Doing a thorough search in our LIS to see if blood can be used from an earlier draw whenever
there is an add-on test requested to prevent patient from being drawn again.

3.       The Clinical Lab coordinated an intradisciplinary committee to reduce mislabeled and unlabeled
specimens to prevent patient redraws . The lab audits and sends out notification for corrective
action in cases of non-compliance.

4.       Designing our LIS system to identify minimum volumes of blood to be drawn for all tests and
print out the appropriate number of labels to match the different types of blood tubes to be drawn.

5.       Purchasing testing equipment in the nursery laboratory which uses a lesser volume of blood than
previous equipment.

6.       Participating in Nursery quality control meetings weekly which address methods of improvement
for reducing the volume of blood collection.

7.       Participating in the IRB to have a voice in encouraging research studies to be conservative in blood
collection.

8.       Communicating with nurse managers and staff education to improve blood draw techniques to
minimize hemolyzed, clotted  and unsatisfactory specimens to prevent redraws.

9.       Assuring the competence and accuracy of phlebotomists by prompt communications when
specimen collection problems occur and providing solutions and corrective action when needed.

10.      Saving blood specimens in the proper environment for the maximum usage time span  to increase
opportunities for not having to redraw a specimen.

 

TROUBLESHOOTING HINTS FOR BLOOD COLLECTION

If a blood sample is not attainable:   


REFERENCES

NCCLS: Procedure for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved
Standard,
Sixth Edition, Vol 27, No 26 (H3-A6), 2007

Neonatal Procedures: SpecColProc2003.doc

Nursing Procedure Manual.  Lippincott Online with addenda, 2004.

OSHA Safety and Health Bulletin SHIB 03-10-15: Disposal of Contaminated Needles and Blood
Tube Holders Used for Phlebotomy.

 

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