Phoenix Children's HospitalOPC-SP-1.00

Outpatient Laboratory - Specimen Processing
BLOOD COLLECTION PROCEDURE (PHLEBOTOMY)
Effective Date: June 20, 2007

Related Policies/Procedures

Specimen Labeling Requirements

Positive Patient Identification (for Blood Bank specimens)

Bactec Blood Culture

Reason for Policy

To establish guidelines for safe and effective collection of blood specimens.

Scope

Outpatient Clinic Laboratory

PRINCIPLE

Valid laboratory results are dependent upon proper specimen collection and handling. The venipuncture procedure is complex, requiring both knowledge and skill to perform. Several essential steps are required for every successful collection procedure:

  • Identify the patient with two patient identifiers (patient name and medical record number)
  • Assess the patient’s physical disposition
  • Check the requisition form or collection labels for requested tests, patient information, and any special requirements
  • Select a suitable site for blood collection
  • Prepare the equipment, the patient and the puncture site
  • Perform the blood collection
  • Collect the sample(s) in the appropriate container(s)
  • Recognize complications associated with the phlebotomy procedure
  • Assess the need for sample recollection and/or rejection
  • Label the tubes at the bedside or drawing area
  • Promptly send the specimen(s) to the laboratory

equipment/supplies

  1. Sterile syringe and transfer safety device
  2. Vacutainer supplies
  3. Needles with needle safety caps
  4. Holders
  5. Evacuated tubes
  6. Butterfly needles
  7. Lancet or other approved device for capillary collection
  8. Tourniquet
  9. Antiseptics
  10. Isopropyl alcohol preps
  11. PCH approved blood culture prep
  12. Gauze pads
  13. Cotton balls
  14. Band-aids/tape (non-latex)
  15. Sharps container for used needles
  16. Exam gloves
  17. Patient labels

venipuncture PROCEDURE

  1. Wash hands thoroughly before beginning any phlebotomy procedure.
  2. Check collection labels or requisition for tests ordered and specimen requirements.
  3. Assemble supplies necessary for the tests requested, including appropriate tube types and quantities. If any special handling is required (specimen on ice, protection from light) make sure you have those items as well.

NOTES:

If specimens for BLOOD BANK are being collected, refer to Blood Bank Identification and Labeling policy.

If a BLOOD CULTURE is being collected, refer to Blood Culture collection procedure.

  1. Reassure the patient, explaining who you are.
  2. Identify the patient. This step is crucial and failure to do so can result in serious consequences.
  3. Compare patient name and Medical Record number which appears on the collection label, or patient order, with the patient’s ID band. In the outpatient setting, if an armband is not available, a patient label (sticker) may be placed on the patient. An alternative is to have the parent/guardian assist in identification, stating name and date of birth.
  4. If outpatient, ask the patient to spell his/her last name, or ask the parent to do so.
  5. If any of the information appears incorrect, do not proceed until the patient is appropriately identified.
  6. Select venipuncture site.
  7. Put on exam gloves.
  8. Apply tourniquet. Do not leave on longer than 1 minute.
  9. Cleanse area with alcohol swab and allow to air dry.
  10. Have patient close fist.
  11. Perform venipuncture using needle and syringe or vacutainer system, depending on site chosen and condition of the patient’s veins. Use of gloves during venipuncture is required.
  12. Keep patient’s arm in downward position.
  13. Anchor the vein with finger or thumb, pulling the skin taut.
  14. Insert needle with bevel up.
  15. If using vacutainer, allow tubes to fill until vacuum is exhausted.
  16. All tubes with additives should be gently inverted 5-10 times.
  17. If collecting a specimen for coagulation, refer to Order of the Draw for special instructions. Coagulation tubes not filled properly will not be acceptable for testing.
  18. Release the tourniquet as soon as possible, after filling all necessary tubes.
  1. Remove the needle, close protective cap over needle. DO NOT RECAP NEEDLE WITHOUT A PROTECTIVE HOLDER THAT HELPS PREVENT NEEDLE STICKS. Place needle in sharps container.

NOTE: If syringe is used, blood must be transferred to tubes as soon as possible, using a safety transfer device. Any delay may result in a clotted specimen.

  1. Apply a dry gauze pad or cotton ball over the puncture site. Keep pressure on the site for a few moments and apply adhesive tape or Coban to hold the gauze in place. If age appropriate, the patient may have a non-latexband aid instead (Outpatient).
  2. Instruct patient (or parent), if appropriate, to leave tape in place for 10-15 minutes, then discard.
  3. Check arm before leaving to make sure bleeding has stopped. If not, apply pressure until bleeding stops.
  4. Always label patient specimens AT THE BEDSIDE OR DRAWING STATION, while next to the patient.
  5. Label all tubes to include patient name and medical record number. Write date and time of collection and employee ID number on the tube label. Avoid writing on any barcodes. Labels should be placed straight along the length of the tube. Do not wrap label around the tube or make a ‘flag’.
  6. Dispose of used supplies appropriately.
  7. Remove and dispose of gloves and wash hands thoroughly.
  8. Deliver specimen(s) to the laboratory ASAP.

capillary collection PROCEDURE

The ideal specimen laboratory is drawn by venipuncture method. When that isn’t possible, a fingerstick or heelstick may also be performed. NOTE: The capillary method should never be used for collecting specimens for coagulation testing.

  1. Select the puncture site. Warm if necessary using a heel warmer or warm washcloth for three minutes.

Finger: Use the central fleshy area of the third or fourth fingers (palmar surface of the distal phalanx of the finger).

Heel: Use the fleshy area at the side curvature of the heel (the most medial or lateral portion of the plantar surface).

  1. Clean the puncture site with 70% isopropyl alcohol and let the area air dry.
  2. Place the puncture device firmly on the puncture site.

Finger: The blade should be aligned to cut across the grooves of the fingerprint.

Heel: Place the blade spot of the lancet against the heel so its center point is vertically aligned with the desired incision site.

  1. Puncture the skin with the disposable lancet.
  2. Wipe away the first drop of blood with a sterile dry gauze or cotton ball.
  3. Collect the specimen in the chosen container. Touch only the tip of the collection tube to the drop of blood. Blood flow is encouraged if the puncture site is held in a downward angle and a gentle pressure applied to the finger or heel. Refer to correct order of draw below. All tubes with additives must be inverted gently (5-10 times) immediately after blood is added
  4. Apply pressure to the puncture site with a gauze square or cotton ball.

special circumstances

  1. IV’s – If the patient has IV’s in one arm only, use the opposite arm for venipuncture. If both arms have IV’s, apply the tourniquet 6 inches below the IV and collect sample below the tourniquet. If no such site exists, consult with an RN or physician.
  1. Indwelling lines (PIC lines) – only RN’s or physicians may draw from an indwelling line.
  1. Vascular Access Device – only RN’s or physicians may draw from such devices.
  1. If the blood does not immediately flow into the tube/syringe, try:
  2. Changing the position of the needle; pull back a bit or gently advance further into the vein.
  3. Try another tube; the tube may not have any vacuum.
  4. Loosen the tourniquet.
  1. Uncooperative patients – Every reasonable attempt will be made to obtain the required specimens from patients. However, when a patient resists the phlebotomist’s attempts to obtain a specimen, the parents/guardian will be requested to hold the patient or permit laboratory or other PCH employees to do so. If the parent gives permission for PCH employees to hold the patient, the following items must be explained:
  1. the method of holding the child
  2. that employee will hold the patient’s arms and legs to keep the child from kicking and scratching
  3. there is a possibility that such may bruise the child.

Assure the parent that PCH employees will do all that is possible to ensure the child’s safety. If the patient cannot be safely held, or the parents will not assist or give permission to hold the patient, then the PCH employee should make no further attempt to obtain the specimen. The RN or phlebotomist will contact the physician immediately to inform him/her of the situation and to obtain further instructions.

  1. Difficult draws – If, after two attempts, you can’t draw the specimen, or the required amount, let the RN or ordering physician know. They may want to attempt to draw the labs.
  1. Sites to avoid:
  1. Scarred or burned areas
  2. Hematoma area
  3. IV sites, as explained above
  4. Arm which has indwelling cannula, fistula or vascular graft. Consult with RN or physician before using an arm with one of these.
  5. Vessels with a pulse (arteries)
  6. Thrombosed or cord-like veins
  1. If at any time, the parent/guardian questions whether their child should be having a certain procedure performed, or are questioning what tests have been ordered, the question should not be taken lightly. An RN or physician should be contacted to answer the parent’s questions/concerns.
  1. Adverse Reaction – All phlebotomy procedures are performed within or in a room adjacent to the Hematology-Oncology department. If the patient experiences an adverse reaction, such as fainting, seizures, injuries, etc., call for immediate assistance from the Hematology-Oncology department. The RN or physician will assess and provide appropriate medical care.

collection tubes and order of draw

The following is a list of the most commonly used specimen collection tubes. Some of these are available in various sizes, including microtainers.

  • ‘Tiger’ Top or Gold Top – contains a clot activator with serum separator (SST) in bottom, for collection of serum samples.
  • Red Top – contains no anticoagulant, for collection of serum samples
  • Purple Top – contains EDTA for collection of hematology, blood bank
  • Light Green Top – contains lithium heparin for chemistry (plasma)
  • Dark Green Top - contains sodium heparin for flow cytometry, some chemistry
  • Gray Top – contains sodium fluoride and potassium oxalate, for glucose
  • Light Blue Top – contains sodium citrate for coagulation samples. Full blood draw required.
  • Dark Blue Top – many contain sodium heparin or EDTA, for trace metal studies
  • Light Yellow Top – contains acid citrate dextrose, HLA tissue typing, DNA studies
  • Blood Culture bottles – for blood cultures, aerobic and anaerobic

Blood collection tubes must be drawn in a specific order to avoid cross-contamination of additives between tubes. The recommended order of draw for tubes is:

  1. Blood culture bottle
  2. Coagulation tube (light blue)*
  3. Non-additive tube (red top)
  4. Additive tubes in this order:
  5. SST (Tiger or Gold)
  6. Sodium Heparin (dark green)
  7. Lithium Heparin (light green)
  8. EDTA (lavender top)
  9. Light yellow top
  10. Light gray top

*NOTE: If a coagulation test is the only test ordered, then a single light blue top tube may be drawn. It is recommended, though, that a non-additive “discard” tube be drawn first, to avoid any possibility of contamination by tissue fluids.

*NOTE: When a butterfly is used and the blue-top tube is the first one to be filled, a tube with no additive or another blue-top tube must be filled first as a discard tube. If this is not done, the air in the tubing will affect the volume of blood in the blue-top tube, possibly affecting results.

additional notes:

TIPS FOR PREVENTING HEMOLYSIS

  1. Do not draw from a hematoma or bruised area
  2. Avoid using a needle that is too small.
  3. Avoid drawing back the plunger of a syringe too forcefully.
  4. Avoid foaming or frothing of the blood as it enters the syringe.
  5. Let the alcohol on the puncture site air dry before inserting the needle.
  6. Avoid squeezing finger or heel too hard when performing capillary collections.
  7. When performing capillary collections, allow blood to flow into microtainer; do not scrape blood off the skin surface

TIPS FOR PREVENTING CLOTTING

  1. Fill tubes containing anticoagulant as soon as possible.
  2. Gently invert tubes containing anticoagulant 5-10 times immediately after blood is added.

SPECIMEN QUALITY ISSUES

Preanalytical variables are crucial in providing accurate, valid results. The accuracy of results depends on the initial quality of the specimen. If clotted samples, or other issues related to poor phlebotomy technique are traced back to a laboratory employee, the employee will be counseled. Re-training and competency reassessment will also be a consideration.

absolute blood draw minimums and maximums

  1. When collecting blood samples from pediatric patients, it is essential for the phlebotomist to know the absolute minimums required for the tests being performed. Drawing too much blood at one time from a pediatric patient can pose a health risk. Drawing not enough may result in the patient having to be redrawn if the laboratory can’t perform the test.
  2. Should a physician order several tests requiring a significant amount of blood to be drawn, it may be necessary to contact the patient’s physician to notify of the total blood volumes required, and follow their instructions. The physician can then decide whether the blood will be drawn all at once or spread out over a period of time. For requests greater than the maximum draw, physician approval must be obtained prior to the blood draw.
  3. Check with the laboratory to verify absolute minimum volumes if necessary. If the test ordered is to be sent to a reference laboratory, you may need them to request that information from that laboratory as well.
  4. Use the following guidelines to determine pediatric maximum blood volumes permitted to be drawn from patients based on weight:

Patient Weight
(pounds) / Patient Weight
(Kilograms) / Maximum drawn volume (mls) in one blood draw / Maximum drawn in a 30-day period (mls)
2.2 / 1.0 / 2.5 / 23
4.4 / 2.0 / 4.5 / 23
6.6 / 3.0 / 6 / 23
8.8 / 4.0 / 8 / 30
11 / 5.0 / 10 / 40
13.2 / 6.0 / 12 / 40
15.4 / 7.0 / 14 / 40
17.6 / 8.0 / 16 / 60
19.8 / 9.0 / 18 / 60
22 / 10.0 / 20 / 70
24 - 33 / 10.9 – 15.0 / 22 - 30 / 70 - 100
35 – 44 / 15.9 – 20.0 / 32 - 40 / 130 - 140
46 - 55 / 20.9 – 25.0 / 42 – 50 / 160 - 180
57 - 66 / 25.9 – 30.0 / 52 – 60 / 200 - 220
68 – 77 / 30.9 – 35.0 / 62 – 70 / 240 - 250
79 – 88 / 35.9 – 40.0 / 72 – 80 / 270 - 290
90 – 99 / 40.9 – 45.0 / 82 – 90 / 290 - 330
101 – 110 / 45.9 – 50.0 / 92 – 100 / 330 - 350
111 & up / 50.5 & up / 100 / 350

references

  1. Phlebotomy website:
  1. Children’s Hospital, St. Louis, Phlebotomy Procedure Manual, Proc #0041, 7/23/07.
  1. Children’s Hospital and Regional Medical Center Laboratory, Seattle, Washington, 2001.
  1. Children’s Hospital Central California, PO30, Specimen Procurement, 4/20/05.
  1. Driscoll Children’s Hospital, Department of Pathology and Laboratory Medicine, Maximum Blood Collection procedure, 3/15/07.
  1. CLSI “Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard – 6th Edition”, 2007.
  1. CLSI “Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens; Approved Standard – 6th Edition”, 2008.
  1. Hoeltke, Lynn B, “Phlebotomy Procedures & Practices,” Thomson Delmar Learning, 2006.

Policy Information/History:
Manual: / Laboratory
Hematology / Section: / Start Page:
Author: Ruth Spates, MT, SH(ASCP) / June 20, 2007REV: 2/01/10;REV 2/14/12
Reviewed by:
Technical Supervisor:. / Date
Administrative Director: / Date
Medical Director: / Date
Section Chief: / Date
Date
2/02/10 – Procedure revised to include special circumstances and minimum blood draw volumes.
Revised 2/14/12 to include adverse reactions and providing feedback to the collector
Annual Review (To be signed and dated annually)
Medical Director or Designee / Administrative Director / Technical Supervisor

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