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Hanne Rylaarsdam
Phlebotomists are considered to have occupational exposure to blood borne pathogens. The performance of routine vascular access procedures by skilled phlebotomists requires, at a minimum, the use of gloves to prevent contact with blood. Airborne precautions may be considered to provide a level of safety against infectious diseases such as tuberculosis, influenza, and COVID-19. Precautions include a medical grade face mask. With risk for blood spatter a face shield provides protection. A face mask reduces risk for blood culture specimen contamination.
Laboratory coats or work smocks are not typically needed as personal protective equipment during routine venipuncture, but an employer must assess the workplace to determine whether certain tasks, workplace situations, or employee skill levels may result in an employee's need for laboratory coats or other personal protective equipment to prevent contact with blood. It is an employer's responsibility to provide, clean, repair, replace, and/or dispose of personal protective equipment/clothing. As part of presenting a professional appearance, an institutional dress code may include wearing of a laboratory coat or smock.
Patient identification is critical for safety. At least two patient identifiers, such as name and date of birth, are needed. Label collection tubes after identification of the patient. Interruptions and distractions during medical encounters and procedures should be avoided.
A requisition form must accompany each sample submitted to the laboratory. This requisition form must contain the proper information in order to process the specimen. The essential elements of the requisition form are:
Evacuated Collection Tubes - The tubes are designed to fill with a predetermined volume of blood by vacuum. The rubber stoppers are color coded according to the additive that the tube contains. Various sizes are available. Blood should NEVER be poured from one tube to another since the tubes can have different additives or coatings (see illustrations at end).
Needles - The gauge number indicates the bore size: the larger the gauge number, the smaller the needle bore. Needles are available for evacuated systems and for use with a syringe, single draw or butterfly system.
Second - coagulation tube (light blue top). If just a routine coagulation assay is the only test ordered, then a single light blue top tube may be drawn. If there is a concern regarding contamination by tissue fluids or thromboplastins, then one may draw a non-additive tube first, and then the light blue top tube.
NOTE:Tubes with additives must be thoroughly mixed. Erroneous test results may be obtained when the blood is not thoroughly mixed with the additive. Transferring a sample from one collection tube to another or mixing blood from different collection tubes must be avoided.
The phlebotomist's role requires a professional, courteous, and understanding manner in all contacts with the patient. Greet the patient and identify yourself and indicate the procedure that will take place. Effective communication - both verbal and nonverbal - is essential.
Proper patient identification MANDATORY. If an inpatient is able torespond, ask for a full name and always check the armband or bracelet for confirmation. For an inpatient DO NOT DRAW BLOOD IF THE ARMBAND OR BRACELET IS MISSING. For an inpatient the nursing staff can be contacted to aid in identification prior to proceeding.
An outpatient must provide identification other than the verbal statement of a name. Using the requisition for reference, ask a patient to provide additional information such as a birthdate. A government issued photo identification card such as a driver's license can aid in resolving identification issues.
The Patient's Bill of Rights has been adopted by many hospitals as declared by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The basic patient rights endorsed by the JCAHO follow in condensed form are given below.
Expect that any discussion or consultation involving the patient's case will be conducted discretely and that individuals not directly involved in the case will not be present without patient permission.
Reasonable informed participation in decisions involving the patient'shealth care. The patient shall be informed if the hospital proposes to engagein or perform human experimentation or other research/educational profits affecting his or her care or treatment. The patient has the right to refuseparticipation in such activity.
Although the larger and fuller median cubital and cephalic veins of the arm are used most frequently, the basilic vein on the dorsum of the arm or dorsal hand veins are also acceptable for venipuncture. Foot veins are a last resort because of the higher probability of complications.
Intravenous therapy (IV) / blood transfusions - fluid may dilute the specimen, so collect from the opposite arm if possible. Otherwise, satisfactory samples may be drawn below the IV by following these procedures:
Lines - Drawing from an intravenous line may avoid a difficult venipuncture, but introduces problems. The line must be flushed first. When using a syringe inserted into the line, blood must be withdrawn slowly to avoid hemolysis.
Cannula/fistula/heparin lock - hospitals have special policies regardingthese devices. In general, blood should not be drawn from an arm with a fistulaor cannula without consulting the attending physician.
If superficial veins are not readily apparent, you can force blood intothe vein by massaging the arm from wrist to elbow, tap the site with index andsecond finger, apply a warm, damp washcloth to the site for 5 minutes, or lowerthe extremity over the bedside to allow the veins to fill.
Apply the tourniquet 3-4 inches above the selected puncture site. Do not place too tightly or leave on more than 2 minutes (and no more than a minute to avoid increasing risk for hemoconcentration). Wait 2 minutes before reapplying the tourniquet.
Grasp the patient's arm firmly using your thumb to draw the skin taut and anchor the vein. The needle should form a 15 to 30 degree angle with the surface of the arm. Swiftly insert the needle through the skin and into the lumen of the vein. Avoid trauma and excessive probing.
Patient identification
- Filling out the requisition
- Equipment
- Apply tourniquet and palpate for vein
- Sterilize the site
- Insert needle
- Drawing the specimen
- Drawing the specimen
- Releasing the tourniquet
- Applying pressure over the vein
- Applying bandage
- Disposing needle into sharps
- labeling the specimens
PERFORMANCE OF A FINGERSTICK:
The best locations for fingersticks are the 3rd (middle) and 4th (ring) fingers of the non-dominant hand. Do not use the tip of the finger or the center of the finger. Avoid the side of the finger where there is less soft tissue, where vessels and nerves are located, and where the bone is closer to the surface. The 2nd (index) finger tends to have thicker, callused skin. The fifth finger tends to have less soft tissue overlying the bone. Avoid puncturing a finger that is cold or cyanotic, swollen, scarred, or covered with a rash.
Using a sterile lancet, make a skin puncture just off the center of the finger pad. The puncture should be made perpendicular to the ridges of the fingerprint so that the drop of blood does not run down the ridges.
Therapeutic Drug Monitoring: different pharmacologic agents have patterns of administration, body distribution, metabolism, and elimination that affect the drug concentration as measured in the blood. Many drugs will have "peak" and "trough" levels that vary according to dosage levels and intervals. Check for timing instructions for drawing the appropriate samples.
Effects of Exercise: Muscular activity has both transient andlonger lasting effects. The creatine kinase (CK), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), and platelet count may increase.
Stress: May cause transient elevation in white blood cells (WBC's)and elevated adrenal hormone values (cortisol and catecholamines). Anxiety that results in hyperventilation may cause acid-base imbalances, and increased lactate.
Diurnal Rhythms: Diurnal rhythms are body fluid and analyte fluctuations during the day. For example, serum cortisol levels are highest in early morning but are decreased in the afternoon. Serum iron levels tend to drop during the day. You must check the timing of these variations for the desired collection point.
Posture: Postural changes (supine to sitting etc.) are known to vary lab results of some analytes. Certain larger molecules are not filterable into the tissue, therefore they are more concentrated in the blood. Enzymes, proteins, lipids, iron, and calcium are significantly increased with changes in position.
Prewarming the infant's heel (42 C for 3 to 5 minutes) is important to obtain capillary blood gas samples and warming also greatly increases the flow of blood for collection of other specimens. However, do not use too high a temperature warmer, because baby's skin is thin and susceptible to thermal injury.
Using a sterile blood lancet, puncture the side of the heel in the appropriate regions shown above in green. Do not use the central portion of the heel because you might injure the underlying bone, which is close to the skin surface. Do not use a previous puncture site. Make the cut across the heelprint lines so that a drop of blood can well up and not run down along the lines.
Wipe away the first drop of blood with a piece of clean, dry cotton. Since newborns do not often bleed immediately, use gentle pressure to produce a rounded drop of blood. Do not use excessive pressure or heavy massaging because the blood may become diluted with tissue fluid.
A variety of techniques can be employed to reduce pain and anxiety. Effective methods use distraction. These may include listening to music or a story, watching a video, playing with a toy, having a parent provide distraction with talk or touch, using flash cards, and squeezing a rubber ball. (Uman et al, 2013)
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