Docstoc

Allina Hospitals and Clinics plunger

Document Sample
Allina Hospitals and Clinics plunger Powered By Docstoc
					Allina Hospitals and Clinics                                               Venipuncture Procedure
Laboratory Services
Support Procedure


                                  VENIPUNCTURE PROCEDURE

PURPOSE
This procedure provides instructions for collecting venous blood samples for laboratory testing
while ensuring the following:
1. Patient Safety
2. Employee Safety
3. Correct (color) tubes are collected for tests ordered.
4. Collection is performed in a timely manner.
5. Test types and times are consolidated when appropriate to minimize unnecessarily large
    blood volumes
6. All specimens are uniquely identified and labeled as per CLSI standard.
NOTE: Click Here to access Appendixes and Shortcuts to specific procedure details.
PROCEDURE
Equipment:
1. Vacutainer safety needles with pre-attached holder
    a. 21G (green)
    b. 22G (black)
2. 23G push button blood collection set (butterfly)
3. 21G & 22G hypodermic syringe needles
4. Single use Vacutainer holder
5. 3ml, 6ml, 12ml & 20ml syringes
6. Non-latex tourniquet
7. 70% isopropyl alcohol wipes- Alternative antiseptics may be used: povidone iodine &
    chlorahexadine (see Exceptions)
8. Gauze
9. Paper tape or bandages
10. Blood collection tubes- See Standardization of Blood Collection Tubes
11. Non-latex gloves
12. Marker or pen

Safety Precautions:
1. Wash hands or use Quick-Care Foam and change gloves between each patient.
2. Use Standard Precautions. All patient blood specimens are to be treated as infectious.
3. Engage safety device and dispose of used needle in sharps container.
4. Follow established Blood Drawing Procedure for Patients in Isolation.
5. Phlebotomy carts and trays and sharps containers must be locked or attended at all times in
   accordance with Joint Commission regulations.

Quality Assurance:
1. Make no more than two attempts to collect a specimen.
2. A new, sterile needle must be used for each phlebotomy attempt.
3. Inspect gloves to assure there are no rips or tears.
4. Inspect needle tip for burrs or irregularities.
5. Take note of patient’s age and observe guidelines for Age Specific Concerns.




Date Printed: 5/14/2011 2:10 PM                                                      Page 1 of 19
Allina Hospitals and Clinics                                                  Venipuncture Procedure
Laboratory Services
Support Procedure



Procedure:
1. Locate Patient
   a. All inpatient locations are listed on the tube label or requisition. Their location consists of
      both a room number and a bed number.

2. Evaluate Labels and Orders
   a. Review all tests requested. Check for duplicate orders.
   b. Check with nursing before combining TIMED and ROUTINE orders.
   c. Note any patient restrictions or special drawing and handling instructions. Some tests
      may require special handling prior to or during collection. Please refer to specific
      test in department procedure for detailed instructions. Clarify unclear or ambiguous
      orders to ensure proper collection.
   d. In order to minimize the collection of unnecessarily large blood volumes, refer to the
      following tables:
      1) Volumes for Neonatal Testing
      2) Maximum Draw Volumes for Pediatrics
      3) Guidelines for Minimal Blood Draw Volumes

3. Greet the Patient
   a. Identify yourself and the department which you represent. Explain why you are there.
   b. You must obtain patient approval before drawing a sample. Consent, while it need not
      be documented, may be either verbal or nonverbal communication. The patient has the
      right to refuse the phlebotomy procedure.
   c. Do not attempt to answer medical questions about the tests being drawn. You must
      refer the patient to their physician or nurse.

4. Identify the Patient
      Prior to collecting a blood specimen, a minimum of two patient identifiers must be used
      to verify the patient’s identity. Acceptable patient identifiers (stated by patient and / or
      printed on wristband) include name, medical record number, and date of birth. Patient
      identifiers must be compared with printed information on the specimen labels or
      requisition and the patient wristband.

         If a patient is unable to state the requested identifiers, a family member or caregiver may
         be asked to provide the information, or the wristband may be used as the sole means of
         identification.

    a. Inpatients
       1) Always ask the patient’s name.
       2) Check the patient’s wristband.
       3) Match collection labels or requisition to the wristband, checking both the patient
          name and a second unique identifier specific to your hospital Patient Identification
          Policy.

    b. Outpatients
       1) Use patient’s full name when addressing them.
       2) Ask patient to state their first and last name as well as another unique identifier such
          as date of birth prior to collection of sample.


Date Printed: 5/14/2011 2:10 PM                                                         Page 2 of 19
Allina Hospitals and Clinics                                                 Venipuncture Procedure
Laboratory Services
Support Procedure
         3) Match the stated information to the collection labels or requisition, checking both
            patient identifiers.

    c. Patient Without Wristband
       1) If a patient is not wearing an identification wristband, and is a registered hospital
           inpatient or outpatient, notify the patient’s nurse and have the patient banded prior to
           collection of the sample.
       2) For patients unable to state their name and an additional identifier (unconscious,
           confused, young children, non-English speaking patients), refer to individual hospital
           policy.
       3) In a critical / emergency situation the patient may be identified by a physician or a
           member of the nursing staff that is present in the patient’s room. A family member or
           significant other may also identify the patient.
       4) For emergency Blood Bank specimens, follow the Specimen Acceptability Criteria
           Hospital Inpatient and Outpatient Policy

         5) Emergency armbands

         See Individual Institutional Policies or contact laboratory.

5. Assemble Necessary Supplies
   a. Evacuated Tube System
      1) Remove Vacutainer needle with pre-attached holder from packaging.
      2) Pull back safety device on needle to provide an unobstructed view of the puncture
         site.
      3) Inspect the tip of the needle to determine that it is free of hooks or burrs at the point
         and that the bevel is free of any small particles that could obstruct the flow of blood.

    b. Venipuncture Using Hypodermic Needle and Syringe
       1) Remove needle from packaging.
       2) Choose appropriate size syringe to match volume of blood required.
       3) Thread needle onto syringe maintaining sterility of the needle.
       4) The plunger must be moved within the barrel of the syringe to show syringe and
          needle patency and freedom of plunger movement.
       5) Inspect the tip of the needle to determine that it is free of hooks or burrs at the point
          and that the bevel is free of any small particles that could obstruct the flow of blood.

    c. Venipuncture with Push-Button Butterfly and Syringe
       1) Select largest size syringe that vein can handle.
       2) The plunger must be moved within the barrel of the syringe to show syringe and
          needle patency and freedom of plunger movement.
       3) Inspect the tip of the needle to determine that it is free of hooks or burrs at the point
          and that the bevel is free of any small particles that could obstruct the flow of blood.
       4) Remove luer adapter and maintaining sterility, attach a clean syringe to the open end
          of the butterfly.

    d. 6.3 Venipuncture with Push-Button Butterfly and Evacuated Tube System
       1) Thread single-use holder onto needle end of the luer adaptor until it is secure. Take
           care not to turn holder forcefully as threads are easily stripped.
       2) Inspect the tip of the needle to determine that it is free of hooks or burrs at the point
           and that the bevel is free of any small particles that could obstruct the flow of blood.

Date Printed: 5/14/2011 2:10 PM                                                        Page 3 of 19
Allina Hospitals and Clinics                                                    Venipuncture Procedure
Laboratory Services
Support Procedure



6. Properly position patient.
   a. Seated patients- When seated, a patient’s arm should be supported firmly and extended
      downward in a straight line from the shoulder to the wrist. Make sure to observe patients
      for any signs of dizziness or fainting.
   b. Bedded patients- When lying down, the patient’s arm should be extended in a straight
      line from shoulder to wrist. Support arm if necessary.

    c. Be aware of employee ergonomic issues when positioning patient. Lowering bed rails or
       raising the height of the patient’s bed may help the employee to perform the
       venipuncture in a more ergonomically correct position.

7. Application of Tourniquet or Blood Pressure Cuff
   a. Use of Tourniquet
      1) Apply the tourniquet at least 3-4 inches above the venipuncture site. The tourniquet
         should remain “flat” around the patient’s arm to avoid any discomfort. You may place
         the tourniquet over the patient’s clothing or place a tissue between the skin and
         tourniquet if they are sensitive to the tourniquet (excessive hair on arm or any
         epidermal condition). The tourniquet should not be so tight as to restrict arterial flow.
      2) After applying the tourniquet the patient may be requested to make and hold a fist.
         However, the patient must not be allowed to pump hand.
      3) The tourniquet should be left on the site for no longer than 1 minute due to the
         possibility of hemoconcentration and / or the variation of test values.

    b. Use of Blood Pressure Cuff.
       1) The blood pressure cuff is applied to the patient’s arm and inflated to 40 mm Hg.
       2) After applying the blood pressure cuff the patient may be asked to make and hold a
          fist. However, the patient must not be allowed to pump hand.
       3) The blood pressure cuff should not be left on the site for longer than 1 minute due to
          the possibility of hemoconcentration and / or the variation of test values.

8. Select the Vein Site
      Diagram: Anatomy of the Anticubital

                 Both arms should be assessed to determine if the median cubital or
                  cephalic vein are viable options before collecting a sample from a basilic or
                  hand vein.
                 To locate veins it is necessary to palpate and trace the path of veins several
                  times with the index finger. It is often best to use the index finger of the hand that
                  is opposite from the hand you will draw with.
                 If superficial veins are not readily apparent, blood can be forced into the vein by
                  massaging the arm from the wrist to elbow.
                 Warming the site by applying a warm blanket or a commercial warming device
                  (following manufacturer’s directions) for five minutes may dilate the vein.
                 Lowering the extremity over the bedside will allow the veins to fill to capacity.

    a. Median Cubital Vein- This is the first choice to draw from. It is usually larger and
       anchored best. It also tends to bruise less and is the least painful.



Date Printed: 5/14/2011 2:10 PM                                                            Page 4 of 19
Allina Hospitals and Clinics                                                   Venipuncture Procedure
Laboratory Services
Support Procedure
    b. Cephalic Vein (thumb side)- This is the second choice for a draw site. It does tend to
       roll and can bruise easily.
    c. Basilic Vein (little finger side)- This is the third choice for a draw site. This vein tends to
       be painful when drawn and is very close to the brachial artery. It also bruises easily.
    d. Hand / Wrist- Veins of the hands and wrist are more delicate and smaller in diameter.
       They bruise extremely easily. Veins of the anterior (palm side) wrist should never be
       considered for a venipuncture.
    e. Feet / Ankle- This site is drawn only with physician’s order. Ask with the patient’s nurse
       to get a physician’s order for a foot draw if there are no available sites on the arms or
       hands. It is recommended that these veins be drawn with a butterfly and syringe. Upon
       completion of draw, apply pressure until bleeding stops. This is to prevent clots in
       patients who are prone to thrombosis.

    f.   Other Considerations

         1) Blood Draws from Peripheral IVs: Follow individual Allina institutional policies and
            procedures for sample collection from peripheral IVs. It has been noted that a
            decrease in sample quality may occur utilizing this collection methodology.

         2) Below an IV: Current guidelines recommend that whenever possible the arm
            opposite an IV should be utilized unless there is no other alternative.

              a)   Have the RN turn off patient IV for 2 minutes.
              b)   Apply the tourniquet below the IV site.
              c)   Perform the venipuncture.
              d)   Indicate on the request / label that the sample was drawn from a site below an IV.
              e)   Ask the RN to turn the IV back on when the draw is complete.

         3) Above an IV: In general collection above an IV is not recommended and should
            only be attempted when other alternatives have been exhausted.

              a)   Have the RN turn off patient IV for 2 minutes.
              b)   Select a vein other than the one with the IV.
              c)   Perform the venipuncture.
              d)   Indicate on the request / label that the sample was drawn from a site above an IV.
              e)   Ask the RN to turn the IV back on when the draw is complete.
              f)   Note: a physician order is required to perform this procedure at United Hospital

         4) Indwelling Lines or Catheters: RNs are able to draw blood from lines or catheters
            after complete, thorough and documented training. Refer to institutional policies and
            procedures. Venipuncture should be avoided from an arm containing a PICC line.
            Blood cultures should not be collected from Lines or Catheters unless specifically
            ordered by a physician.

         5) Saline Lock: Lab tests may be drawn above or below a saline lock with the following
            protocol: Identify when lock was last flushed. Venipuncture should not be attempted
            if saline lock has been used within 5 minutes.

         6) Mastectomy with lymph node dissection: Do not draw from an arm on the side of
            an axillary node dissection because of lymphostasis. If there is no alternative site or


Date Printed: 5/14/2011 2:10 PM                                                          Page 5 of 19
Allina Hospitals and Clinics                                                    Venipuncture Procedure
Laboratory Services
Support Procedure
              if there has been a bilateral axillary node dissection, approval of the physician is
              required to draw from any site.

         7) Extensive Scarring: Burned or healing areas should be avoided.

         8) Hematoma: Specimens collected from a hematoma may cause erroneous results. If
            another site is not available the venipuncture should be performed below the
            hematoma.

         9) Cannula, Fistula, Shunt: These are venous access devices reserved for kidney
            dialysis. The arm which contains these devices should not be used for blood
            collection. Patients with a kidney dialysis access device that is no longer used or is
            not working may request that the venipuncture be performed on the arm. It is
            acceptable to do so with the physician’s approval. Place the tourniquet below the
            device and obtain the blood from this area.

         10) Casts, Slings and other unusual situations: Consult with patient’s nurse to obtain
             permission to draw patient.

9. Cleanse the Area
   The venipuncture site should be cleansed to prevent any chemical or microbial
   contamination of either the patient or the specimen.
   a. Use a gauze pad with a 70% isopropyl or a commercially prepared alcohol pad.
   b. Cleanse the site with a circular motion from the center to the periphery.
   c. Allow the area to air dry to prevent hemolysis of the specimen and to prevent the patient
      from experiencing a burning sensation when the venipuncture is performed.
   d. If the venipuncture proves difficult and the vein must be touched again to draw blood, the
      site should be cleansed again.
   e. Exceptions:
      1) Blood Cultures: use ChloraPrep SEPP applicator (2% Chlorhexidine Gluconate /
           70% isopropyl alcohol). Refer to the Blood Culture Collection Procedure
      2) Alcohol (ETOH) levels: use povidone Iodine swabs or soap and warm water.
      3) Allergies to alcohol: use povidone Iodine swabs or soap and warm water.
      4) Allergies to both alcohol and iodine: use soap and warm water and cleanse
           thoroughly.

10. Performing the Venipuncture
    a. Venipuncture with Evacuated Tube System: Equipment of choice for best quality
       specimen.
       1) Put on gloves. Gloves must remain intact with no visible rips or tears.
       2) Grasp the patient’s arm firmly. The phlebotomists thumb should be used to draw the
          skin taut. This anchors the vein. The thumb should be one or two inches below the
          venipuncture site.
       3) With the bevel up, line up the needle with the vein and using a forward motion guide
          the needle into the skin keeping the angle of the needle less than 30.
       4) After needle is in the vein, insert the blood collection tube into the holder. Engage
          the collection tube. Be sure to grasp the vacutainer assembly securely when
          engaging the tube to prevent the needle from advancing further into the vein.
       5) To obtain additional specimens, insert the next tube into the holder. Follow the
          correct order of draw listed below and all specimen-handling instructions.


Date Printed: 5/14/2011 2:10 PM                                                           Page 6 of 19
Allina Hospitals and Clinics                                                 Venipuncture Procedure
Laboratory Services
Support Procedure
              a) Blood culture (sterile) collection. First anaerobic and then aerobic
              b) Blue (Citrate)
              c) Red (clot activator)
              d) Gold (SST) / Marble Top
              e) Dark Green (PST, sodium heparin)
              f) Light Green (PST, lithium heparin)
              g) Lavender (EDTA)
              h) Gray
         6)   Fill the tube until the vacuum is exhausted and the blood flow ceases. This will
              ensure that there is a correct ratio of additive to blood.
         7)   Immediately after drawing, mix each tube that contains an additive by gently inverting
              the tube 8-10 times.
         8)   Release the tourniquet and remove the last tube from the holder prior to withdrawing
              the needle from the patient’s arm.
        9)    A clean gauze pad should be place lightly over the venipunture site.
       10)    Slight pressure should be applied to the pad. The needle should be removed slowly
               while keeping the bevel in an upward position. The phlebotomist must exercise care
               not to scratch the patient’s arm.
       11)    Engage the needle safety device.
       12)    Slip the gauze pad over the site, continuing mild pressure until bleeding has ceased.
               If bleeding continues longer than 5 minutes notify the patient’s nurse.
       13)    Apply an adhesive or gauze bandage over the venipuncture site. A bandage should
               never be placed over a site that is still bleeding.
       14)    Instruct the patient to leave the bandage on for at least 15 minutes.

    b. Venipuncture Hypodermic Needle and Syringe: Equipment of choice when blood
       transfers are required (i.e. Blood Culture Collection)

         1) Put on gloves. Gloves must remain intact with no visible rips or tears.
         2) Grasp the patient’s arm firmly. The phlebotomists thumb should be used to draw the
             skin taut. This anchors the vein. The thumb should be one or two inches below the
             venipuncture site.
         3) With the bevel up, line up the needle with the vein and using a forward motion guide
             the needle into the skin keeping the angle of the needle less than 30.
         4) Pull the plunger of the syringe back gently but firmly (blood will come rather slowly)
         5) Release the tourniquet.
         6) When enough blood is collected, place clean gauze lightly over the venipuncture site.
         7) Slight pressure should be applied to the pad. The needle should be removed slowly
             while keeping the bevel in an upward position. The phlebotomist must exercise care
             not to scratch the patient’s arm.
         8) Engage the needle safety device.
         9) Slip the gauze pad over the site, continuing mild pressure until bleeding has ceased.
             If bleeding continues longer than 5 minutes notify the patient’s nurse. A bandage
             should never be placed over a site that is still bleeding.
         10) Apply an adhesive or gauze bandage over the venipuncture site.
         11) Instruct the patient to leave the bandage on for at least 15 minutes.
         12) Carefully remove needle from syringe and discard needle in sharps container.
         13) Fill the tube(s) using the Blood Transfer Device.
         14) Blood Transfer Device
                Within 30 seconds of collection attach a needleless transfer device to the syringe.
                Gently invert the syringe 3-5 times to assure uniformity of the specimen. Fill your

Date Printed: 5/14/2011 2:10 PM                                                        Page 7 of 19
Allina Hospitals and Clinics                                                  Venipuncture Procedure
Laboratory Services
Support Procedure
                tubes following the prescribed order of draw also taking care to follow all special
                handling instructions.
                1) Blood culture (sterile) collection. First anaerobic and then aerobic.
                2) Blue (Citrate)
                3) Red (clot activator)
                4) Gold (SST) / Marble Top
                5) Dark Green (PST, sodium heparin)
                6) Light Green (PST, lithium heparin)
                7) Lavender (EDTA)
                8) Gray

         All transfers must be completed in an upright position. Use your thumb to slow the
         syringe plunger. This controls the speed of the fill and prevents hemolysis of the
         specimen. Do not push blood into the tubes; the vacuum in the tubes will draw in the
         correct amount. Mix each tube that contains an additive by gently inverting the tube 8-10
         times.

    c. Venipuncture with Push-Button Butterfly and Syringe: Equipment of choice for
       small fragile veins.

         1) Put on gloves. Gloves must remain intact with no visible rips or tears.
         2) Grasp the patient’s arm firmly. The phlebotomists thumb should be used to draw the
             skin taut. This anchors the vein. The thumb should be one or two inches below the
             venipuncture site.
         3) With the bevel up, line up the needle with the vein. Using a forward motion guide the
             needle into the skin with the wings, keeping the angle of the needle less than 30.
             Watch for a “flash" of blood to appear in the body of the butterfly.
         4) When the flash appears, pull the plunger of the syringe back gently but firmly
             (blood will come rather slowly, as the diameter of the needle is small.)
         5) Release the tourniquet.
         6) If multiple syringes are required, kink butterfly tubing to stop blood flow. Remove
             syringe and attach additional syringe.
         7) When enough blood is collected, place clean gauze lightly over the venipuncture site.
         8) The butterfly safety device is designed to be activated while the needle is still in the
             patient's vein. To operate the safety device correctly:
                   While the needle is still in the vein, grasp the body of the butterfly with the
                  thumb and middle finger.
                   Activate the button with the tip of the index finger.
                   The needle will safely retract into the body of the butterfly.
         9) Slip the gauze pad over the site, continuing mild pressure until bleeding has ceased.
             If bleeding continues longer than 5 minutes notify the patient’s nurse. A bandage
             should never be placed over a site that is still bleeding.
         10) Apply an adhesive or gauze bandage over the venipuncture site.
         11) Instruct the patient to leave the bandage on for at least 15 minutes.
         12) Fill the tube(s) using the Blood Transfer Device.
         13) Blood Transfer Device

                Within 30 seconds of collection attach a needleless transfer device to the syringe.
                Gently invert the syringe 3-5 times to assure uniformity of the specimen. Fill your



Date Printed: 5/14/2011 2:10 PM                                                         Page 8 of 19
Allina Hospitals and Clinics                                                  Venipuncture Procedure
Laboratory Services
Support Procedure
                tubes following the prescribed order of draw also taking care to follow all special
                handling instructions.
                9) Blood culture (sterile) collection. First anaerobic and then aerobic.
                10) Blue (Citrate)
                11) Red (clot activator)
                12) Gold (SST) / Marble Top
                13) Dark Green (PST, sodium heparin)
                14) Light Green (PST, lithium heparin)
                15) Lavender (EDTA)
                16) Gray

         All transfers must be completed in an upright position. Use your thumb to slow the
         syringe plunger. This controls the speed of the fill and prevents hemolysis of specimen.
         Do not push blood into the tubes; the vacuum in the tubes will draw in the correct
         amount. Mix each tube that contains an additive by gently inverting the tube 8-10 times.

    d. Venipuncture with Push Button Butterfly and Evacuated Tube system: Equipment
       of choice for small children, hand veins, combative patients.

        1) Put on gloves. Gloves must remain intact with no visible rips or tears.
        2) Grasp the patient’s arm firmly. The phlebotomists thumb should be used to draw the
            skin taut. This anchors the vein. The thumb should be one or two inches below the
            venipuncture site.
        3) With the bevel up, line up the needle with the vein and using a forward motion guide
            the needle into the skin keeping the angle of the needle less than 30. Watch for a
            “flash" of blood to appear in line.
        4) After needle is in the vein, insert the blood collection tube into the holder. Engage
            the collection tube.
        5) Release the tourniquet.
        6) To obtain additional specimens, insert the next tube into the holder. Follow the
            correct order of draw listed below and all specimen-handling instructions.
            a) Blood culture (sterile) collection. First anaerobic and then aerobic
            b) Blue (Citrate)
            c) Red (clot activator)
            d) Gold (SST) / Marble Top
            e) Dark Green (PST, sodium heparin)
            f) Light Green (PST, lithium heparin)
            g) Lavender (EDTA)
            h) Gray
        7) Fill the tube until the vacuum is exhausted and the blood flow ceases. This will
            ensure that there is a correct ratio of additive to blood.
        8) Immediately after drawing, mix each tube that contains an additive by gently inverting
            the tube 8-10 times.
        9) A clean gauze pad should be place lightly over the venipuncture site.
        10) The butterfly safety device is designed to be activated while the needle is still in the
            patient's vein. To operate the safety device correctly:
                While the needle is still in the vein, grasp the body of the butterfly with the
                thumb and middle finger.
                Activate the button with the tip of the index finger.
                The needle will safely retract into the body of the butterfly.
       11) Slip the gauze pad over the site, continuing mild pressure until bleeding has ceased.

Date Printed: 5/14/2011 2:10 PM                                                         Page 9 of 19
Allina Hospitals and Clinics                                                Venipuncture Procedure
Laboratory Services
Support Procedure
           If bleeding continues longer than 5 minutes notify the patient’s nurse.
       12) Apply an adhesive or gauze bandage over the venipuncture site. A bandage should
           never be placed over a site that is still bleeding.
       13) Instruct the patient to leave the bandage on for at least 15 minutes.

11. Disposal of Sharps and used Equipment
   a. Assure that all needle safety devices are engaged.
   b. Do not remove Vacutainer holder from needle. Discard the unit as a whole.
   c. If a blood transfer device has been used, do not remove the device from the syringe.
       Discard the unit as a whole.
   d. Dispose of all needles and syringes in a puncture resistant (Sharps) container.
   e. All other used equipment that is not saturated with blood may be disposed of in regular
       trash.
   f. Any equipment that is saturated with blood must be disposed of in a biohazard
       container.
   g. Note: Tourniquets must be discarded when contamination with blood or body fluids is
       obvious or suspected. Tourniquets used in an isolation room should either be left in the
       patient room or discarded.

12. Labeling Tubes
    a. Label the tubes at the bedside. Refer to the Specimen Acceptability Criteria Inpatient
       and Outpatient Policy.
    b. Place identification label over blank paper label on tube.
    c. Label must be lengthwise with the patient’s last name as close to tube stopper as
       possible.
    d. Barcode must be straight without creases or wrinkles
    e. Do not place labels on stopper.

13. Exiting Patient Room
    a. Leave the patient’s room as you found it. Make sure to lower the bed and raise the rails.
       Turn off or dim the lights if necessary.
    b. Ask the patient if they require further assistance. Thank them for their time.

14. Transport of specimens
    a. Return all specimens to the laboratory within 30 minutes of collection. STATs and
       TIMED specimens should be sent immediately. Samples may be hand carried or
       transported to the laboratory through the Pneumatic Tube System (PTS)
    b. Each patient should be bagged individually. For routine collections 3-5 bags may be
       placed in a carrier.
    c. Follow the established institutional policies for the transport of specimens as indicated at
       each site.
    d. All sites follow standardized guidelines for Restricted Specimens

APPENDIXES
1.   Order of Draw
2.   Standardization of Blood Collection Tubes
3.   Age Specific Concerns.
4.   Maximum Draw Volumes for Pediatrics
5.   Guidelines for Minimal Blood Draw Volumes
6.   Volumes for Neonatal Testing

Date Printed: 5/14/2011 2:10 PM                                                      Page 10 of 19
Allina Hospitals and Clinics                                                       Venipuncture Procedure
Laboratory Services
Support Procedure
7. Other Considerations (i.e. peripheral IVs, Indwelling lines or catheters, above and below IVs
   etc.)

RELATED DOCUMENTS
1. Blood Culture Collection Procedure
2. Specimen Acceptability Criteria Hospital Inpatients and Outpatients Policy
3. Blood Drawing Procedure for Patients in Isolation

REFERENCES
1. CLSI Procedures for the Collection of Diagnostic Blood Specimens by Skin Puncture,
   Publication H4A5, Vol. 24 No.21, Wayne, PA: National Committee for Clinical Laboratory
   Sciences; 2008
2. Ernst, Dennis and Ernst, Catherine, Phlebotomy for Nurses. 2001, Health Star Press
3. Garza, Diana and Becan-McBride, Kathleen, Phlebotomy Handbook. 1999, Appleton & Lange
4. CLSI Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture;
   Approved Standard- Sixth Edition, H3A6, Vol. 27 No. 26, USA 2008
5. Mayo Medical Laboratories, Mayo Guidelines for Pediatric Patients, August 2006
6. Children’s Hospitals and Clinics, Laboratory SOP#SCM5.02, June 2006

DOCUMENT HISTORY
Table of Document History

APPROVAL
Author:   Belinda Trudeau/Julie Singewald
Approver: Lauren Anthony, MD

KEY WORDS
Title: Venipuncture
Department: General Lab
Document Type: Support Procedure
Applicable Sites: ANW, BUF, CAM, COC, MCY, NEU, OWT, RFA, STF,UTD, UTY
Alternate Terms: Phlebotomy Procedure, Phlebotomy, Venipuncture, Blood Draws, Specimen
Collection
Date of Last Major Revision: 08/15/10
Document Owner: Heather Dawson

DOCUMENT HISTORY return

                OnBase
   Date                                                 Summary of Change
                Version
5/19/09             2          Addition of hypodermic needle draw. Minor update to match recent CLSI
                               changes.
11/12/09            3          Add an additional applicable site.
08/15/10            4          Separate isolation to support procedure
3/4/11               5         Updated links
3/24/11             6          Corrected clerical error in Above IV portion



Date Printed: 5/14/2011 2:10 PM                                                             Page 11 of 19
Allina Hospitals and Clinics                                               Venipuncture Procedure
Laboratory Services
Support Procedure


                               Standardization of Blood Collection Tubes
                                               Sept 2007
                                   Allina Standardization Committee


                                                                Type of
 Tube Color                    Collection tube                                BD Reorder #
                                                                tube

      Red            CLOT TUBES, NON GEL
                     4 ml Hemogard with clot activator          Plastic       367812
                     (13x75)
                     15 ml rubber stopper (16x125)              Glass         366432
                     10 ml rubber stopper (16x100)              Glass         366430
                     7 ml rubber stopper (13x100)               Glass         366431

      Gold           CLOT TUBES, GEL
                     3.5 ml (13x75 tube) SST with clot          Plastic       367983
                     activator

     Light           HEPARIN, Li, GEL
     Green           3 ml, PST Hemogard (13x75)                 Plastic       367960


     Green           HEPARIN, Li, NON GEL
                     6 ml, non-gel Hemogard (13x100)            Plastic       367886


  Lavender           EDTA, K2
                     3 ml Hemogard (13x75)                      Plastic       367856
                     4 ml Hemogard (13X75)                      Plastic       367861

      Blue           SODIUM CITRATE, 3.2%
                     2.7 ml Hemogard (13x75)                    Plastic       363083
                     4.5 Hemogard (13x75)                       Glass         369714

      Gray           Na FLOURIDE, K OXALATE
                     4 ml Hemogard (13x75)                      Plastic       367922

 Dark Green HEPARIN, Na (for cytogenetics and                   Plastic       367871
            special testing only.)
            4 ml Hemogard (13x75)




Date Printed: 5/14/2011 2:10 PM                                                     Page 12 of 19
Allina Hospitals and Clinics                                              Venipuncture Procedure
Laboratory Services
Support Procedure
                                                                                     APPENDIX I
        CONCERNS AND BEHAVIORS OF DIFFERENT PATIENT AGE
                           GROUPS
                                          (Page 1 of 2)
                     Very Young                                  6 to 13 Months

   Usually trust most adults                       Fear of strangers & separation contact
   Use very gentle approach                        Allow parents to be in close range of child
   Keep patient warm                               Use comfortable toys, pacifier, or blanket
   Introduce self to parents                       Introduce self to parents
   Explain procedure carefully before              Explain procedure carefully before
    beginning                                        beginning
   Allow parent to hold child                      Allow parent to hold child
   Keep supplies from within child’s reach         Keep supplies from within child’s reach
   Use pediatric sized supplies                    Use pediatric sized supplies
   Encourage parent to cuddle child during         Encourage parent to cuddle child during
    and after the procedure                          and after procedure
   Thank parents for their cooperation             Thank parents for their cooperation
                  1 to 3 Years                                     3 to 5 years

   Fear of injury, long separations                Enjoy role playing, playing doctor
   Parents nervous                                 Talk slowly to child, maintain eye contact
   Give child time they need to think              Fear injury, separation from parent
   Introduce self to child and parents             Child will understand simple commands
   Explain procedure carefully before               and understand your requests
    beginning                                       Introduce self to child and parents
   Allow parent to hold child                      Prepare child for brief “stick”.
   Allow child to touch supplies if safe           Encourage parents to offer praise for
   Use appropriate sized supplies                   cooperation and bravery
   Give lots of praise after procedure             Give lots of praise after procedure
   Offer stickers as reward                        Offer stickers as reward
   Thank parent & child for their cooperation      Thank parent & child for their cooperation




Date Printed: 5/14/2011 2:10 PM                                                    Page 13 of 19
Allina Hospitals and Clinics                                                  Venipuncture Procedure
Laboratory Services
Support Procedure

        CONCERNS AND BEHAVIORS OF DIFFERENT PATIENT AGE
                           GROUPS
                                            (Page 2 of 2)
                  6 to 12 Years                                      Teenagers
Fear of losing self control                         Embarrassed to show fear, need privacy
More willing to participate                         May act hostile to mask fear
Curious, explain/demonstrate procedures             Use adult language, don’t talk down to them
slowly                                               when explaining procedure
Let them express fears without                      Ask, have they done this before- ever fainted?
embarrassment                                       Remind them of “little hurt” but will be over
Remind them it hurts a little but will be over       quickly
quickly                                             Ask them what might make them more
Ask them what might make them more                   comfortable
comfortable                                         Allow time for questions, offer opportunity to
Do not leave items within reach of patient           recover if they have cried, assure them it is a
Have a parent nearby                                 normal reaction
If tearful, remind them it is a normal
                                                    Always thank them for their cooperation
reaction & how well they cooperated during
the procedure
Thank the child for cooperating with
                     Adult                                             Elderly
   Introduce self, explain procedure               Fear of being unable to read, hear, or
   Allow to verbalize fears and concerns            understand directions
   Ask them what might make them more              Fear pain of procedure, expense of visit
    comfortable                                     May be frail & have trouble moving about
   Remind them of a “little stick”                 May have tremors, have difficulty holding still
   With increased age, more response to             & worry about tech not being able to collect
    stress                                           specimen, causing more pain
   Allow as many choices as possible               Explain each step slowly
   More attention to health concerns               Frequently ask if they have any questions
   Emotional changes with chronic illness          Pause to make sure they understand you
   Foster image of self-esteem                     Offer reassurance about procedure, remind
   Thank patient for their cooperation              them of a “little stick”
                                                    Gentle approach helpful in calming fears
                                                    Comments like “I know this isn’t the most
                                                     comfortable position but I will be finished as
                                                     soon as possible” are invaluable in giving
                                                     patient’s a sense of control.
                                                    Always thank the patient for their cooperation.




Date Printed: 5/14/2011 2:10 PM                                                        Page 14 of 19
Allina Hospitals and Clinics                                       Venipuncture Procedure
Laboratory Services
Support Procedure

                                  Minimum Neonatal Volumes
             TEST                                TUBE            MINIMUM VOLUME

Coag
Protime / INR                     3.2% Citrate / Blue plastic       2.7 ml in 2.7 ml tube
Special Coag                      3.2% Citrate / Blue glass         4.5 ml in 4.5 ml tube

Hematology                        EDTA / Lavender (dark)              2.5 ml in 4 ml tube
(CBC, plt, diff)                  EDTA / Lavender (light)               1 ml in 3 ml tube
                                  EDTA Microtainer                                 0.5 ml

ESR                               EDTA / Lavender                                   2.0 ml
(sed rate)

         Panel 8 and / or         SST Tube / Gold                     2.5 ml in 5 ml tube
         Bilirubin                Red/ Peach Microtainer                  1 full container
                                  PST Tube / Green                       2.5 in 5 ml tube
                                  Green Microtainer                                 0.5 ml

         Electrolytes             SST Tube / Gold                     2.5 ml in 5 ml tube
                                  Red/ Peach Microtainer                  1 full container
                                  PST Tube / Green                       2.5 in 5 ml tube
                                  Green Microtainer                                 0.5 ml

         CRP                      SST Tube / Gold                     2.5 ml in 5 ml tube
                                  PST Tube / Green                       2.5 in 5 ml tube
                                  Green Microtainer                                0.5 ml

         Hepatic Panel            SST Tube / Gold                     2.5 ml in 5 ml tube
                                  Red/ Peach Microtainer                  1 full container
                                  PST Tube / Green                       2.5 in 5 ml tube
                                  Green Microtainer                       1 full container

         Hepatitis B or C         SST Tube / Gold                          1 full 5 ml tube
                                  Cannot be collected in
                                  Microtainers

        Blood Cultures            BD Bactec bottles
* Blood cultures can be            Pediatric (pink bottle)                        1-3 ml
collected in the Pediatric         Aerobic (gray/blue bottle)                    3-10 ml
bottle only, in both the           Anaerobic (purple bottle)                     3-10 ml
Aerobic and Anaerobic
bottles or only in the
Aerobic bottle.

Chromosomes                       NA Heparin Tube (dark green)                        3 ml
                                  Cannot be collected in
                                  Microtainers

Date Printed: 5/14/2011 2:10 PM                                             Page 15 of 19
Allina Hospitals and Clinics                                                  Venipuncture Procedure
Laboratory Services
Support Procedure
                                  Table IPediatric Blood Draw Volumes

                  Maximum amounts of blood to be drawn on pediatric patients



                         Pounds            Kilograms     (mLs.) Volume which can
                          (lbs.)               (kg.)       safely drawn per day
                           6-8               2.7 - 3.6             4.6-6.1
                          9 – 10            4.1 – 4.6             7.0 – 7.8
                         11 – 14            5.0 – 6.4            8.5 – 10.8
                         15 – 17            6.8 – 7.7           11.6 – 13.1
                         18 – 20            8.2 – 9.1           13.9 – 15.5
                         21 – 23            9.6 – 10.5          16.3 – 17.9
                         24 – 26           10.9 – 11.8          18.5 – 20.1
                         27 – 29           12.3 – 13.2          23.2 – 24.7
                         30 – 32           13.6 – 14.5          23.2 – 24.7
                         33 – 35           15.0 – 15.9          25.5 – 27.1
                         36 – 38           16.4 – 17.3          27.8 – 29.4
                         39 – 41           17.7 – 18.6          30.1 – 31.7
                         42 – 44            19.1 – 20           32.5 – 34.0
                         45 – 47           20.5 – 21.4          34.8 – 36.3
                         48 – 50           21.8 – 22.7          37.1 – 38.6

                           lbs./2.2 = kg                    kg. x 1.7 = mLs

Procedure Notes:
1. The laboratory has developed procedures to minimize specimen volume requirements
   whenever possible. The laboratory staff will do their best to work with the specimens that
   have been collected and will notify the patient’s caregiver if testing cannot be completed.
2. This procedure is a guideline for pediatric phlebotomy. If test requests require greater
   amounts of blood to be drawn than indicated in the guidelines, laboratory staff should call
   the ordering provider to determine if all tests are to be drawn or to prioritize testing.
3. General Information:
   a. Approximate blood volume1:
         Age                        Total Blood Volume
         Premature infants           90 – 105 ml/kg
         Term newborns               78 – 86 ml/kg
         >1-month                    78ml/kg
         > 1-year                    74 – 82 ml/kg
         Adult                       68 – 88 ml/kg
4. For phlebotomy, observe the patient for the risk of development of physiologic signs of rapid
   blood loss. Symptoms of excessive blood loss are tachycardia, decreased profusion,
   bradycardia, decrease in blood pressure, and shock. Symptoms are more severe with acute
   loss. If signs of acute blood loss are apparent or if the patient losses consciousness,
   immediately inform the nurse.



Date Printed: 5/14/2011 2:10 PM                                                        Page 16 of 19
Allina Hospitals and Clinics                                                                Venipuncture Procedure
Laboratory Services
Support Procedure
                                    Guidelines for Minimal Blood Draw Volumes
                                        Frequently Ordered Tests                                     TABLE III
       Test #                  Test Name                Tube Type & Special Instructions                 Min/Vol
        908           Alk Phos                                     Gold / Green                            1 ml
         17           Albumin                                      Gold / Green                            1ml
        254           ALT                                          Gold / Green                            1ml
         31           Amylase                                      Gold / Green                            1ml
        910           AST                                          Gold / Green                            1ml
        272           B 12 Vitamin                       Gold/ Green – protect from light                  1 ml
        690           BHCG, Qual                                    Gold ONLY                              1 ml
       6133           Blood Type                          4 ml Lavender- Verify MRN#                       4 ml
         46           Bilirubin. Total                   Gold / Green- protect from light                  1 ml
         47           Bilirubin, Direct                  Gold / Green- protect from light                  1ml
         52           BUN                                          Gold / Green                            1ml
        400           CBC /CBC Diff                               3 ml Lavender                            1ml
         56           Calcium                                      Gold / Green                            1ml
         67           Chloride                                     Gold / Green                            1ml
         71           Cholesterol                                  Gold / Green                            1ml
         80           CK total                                     Gold / Green                            1ml
        538           CK&CK-MB                                     Gold / Green                            1ml
         82           Creatinine                                   Gold / Green                            1ml
       6083           X-match & type                      4 ml Lavender-Verify MRN#                        4ml
         92           Digoxin                                Pl. Red / Gold / Green                        1 ml
         91           Dilantin / Phenytoin                    5 ml plain red ONLY                          1 ml
       6085           Direct Coombs                                  Lavender                             2.5 ml
        945           Serum Drug Screen                           5 ml Plain Red                           1 ml
         19           Ethanol                                  Grey / Gold / Green                         1 ml
        103           Folate                                       Gold / Green                            1 ml
        104           FSH                                          Gold / Green                            1 ml
        832           Gentamycin                             Pl. Red / Gold / Green                        1 ml
        114           GGT                                          Gold / Green                            1 ml
        109           Glucose                                      Gold / Green                            1 ml
       3631           HDL Cholesterol                              Gold / Green                            1 ml
        241           Hemoglobin A1C                                 Lavender                             2.5 ml
        450           Hemoglobin                                     Lavender                             2.5 ml
        230           Hemo w/o plt                                   Lavender                             2.5ml
        430           Hemo/plt                                       Lavender                             2.5 ml
        800           Hemo/diff/no plt                               Lavender                             2.5 ml
        400           Hemo./diff/plt                                 Lavender                             2.5 ml
       2283           Heparin                                          Blue                        Until vacuum exhausted
        100           Iron & IBC                                   Gold / Green                            1 ml
        101           Fibrinogen                                       Blue                        Until vacuum exhausted
        149           Lactate                                      Grey- on ice                            5 ml
        909           LD total                                     Gold / Green                            1ml
        169           Lithium                                     Pl. Red / Gold                           1ml
        175           Magnesium                                    Gold / Green                            1ml
        205           Phoshorus                                    Gold / Green                            1ml
        484           Platelet                                       Lavender                            2.5 ml
        PFT           Platelet Function Test                     Lavender & blue                       3ml & 4.5 ml
        211           Potassium                                    Gold / Green                            1ml
       2455           Prealbumin                                       Gold                                1ml
       7095           Pro-BNP                                         Green                                1ml
        215           Prolactin                                    Gold / Green                            1ml
        219           Protein-total                                Gold / Green                            1ml
        487           PT-INR                                           Blue                        Until vacuum exhausted
        490           APTT                                             Blue                        Until vacuum exhausted
       6035           Rh Immunglobulin / Rhogam             Lavender – verify MRN#                        2.5 ml
        503           Sed Rate                                       Lavender                             2.5 ml
        233           Sodium                                       Gold / Green                            1ml
        952           Tegretol / Carbamazepine               Pl. Red / Gold / Green                        1ml
        248           Theophylline                           Pl. Red / Gold / Green                        1ml
       5190           Troponin T                                  Green- ONLY                              1 ml
        258           TSH                                          Gold – ONLY                             1ml
       6083           Type & Screen                        4 ml lavender-Verify MRN#                       4 ml
        262           Uric Acid                                    Gold / Green                            1ml
        949           Valproic Acid / Depakote               Pl. Red / Gold / Green                        1ml
        697           Vancomycin                             Pl. Red / Gold / Green                        1ml
         7            Basic Metabolic Panel                       1 Gold / Green                           1 ml
         95           Comp Metabolic Panel                        1 Gold / Green                           2ml
         94           Electrolyte Panel                           1 Gold / Green                           1ml
        223           Hepatic Function Panel                      1 Gold / Green                           2ml
        694           Acute Hepatitis Panel               2 Gold – need 10 ml serum                       10ml
        160           Lipid Panel                                 1 Gold / Green                           2ml
        751           Obstetric Panel(s)                  2 Lav, 1 Gold -verify MRN#                      13ml
         15           Renal Function Panel                        1 Gold / Green                             2ml

Date Printed: 5/14/2011 2:10 PM                                                                      Page 17 of 19
Allina Hospitals and Clinics                                             Venipuncture Procedure
Laboratory Services
Support Procedure



       The following items MUST NEVER be transported through the
                         pneumatic tube system:
LABORATORY
   Empty blood product bags
   Alleged assault specimens
   Any surgical specimens (placenta, biopsies, etc.)
   Amniotic fluid
   Bone Marrow
   Cerebral spinal fluid
   Specimens for Cold agglutinins, Cryofibrinogens and Cryoglobulins
   Gastric bronchial aspirates or bronchial washings
   Plasma hemoglobin specimens
   Stones for analysis
   Stool
   Petri dishes
   24 hour urine containers
   Any irretrievable specimens
PHARMACY
   Chemotherapy agents
OTHER
   Any needles(needles MUST be removed from syringe specimens)
   Food or beverage
   Items over 10 pounds
   Original medical records / files
   Soiled instruments
   Mercury Thermometers
REMEMBER
   Ensure that container lids / covers are tightly secured and parafilm is wrapped tightly.
   Non-restricted liquids & items with the potential to leak must be in double re-sealable
    plastic bags
   Include a foam liner to prevent jarring or breakage (foam liners can be obtained from
    Pharmacy or Lab)
   Do not wrap any specimens in towels




Date Printed: 5/14/2011 2:10 PM                                                   Page 18 of 19
Allina Hospitals and Clinics      Venipuncture Procedure
Laboratory Services
Support Procedure




Date Printed: 5/14/2011 2:10 PM            Page 19 of 19

				
DOCUMENT INFO