How To Perform A Blood Draw

This chapter covers all the steps recommended for rubber phlebotomy and reiterates the accepted principles for blood drawing and blood drove (31). The chapter includes groundwork information (Section 2.1), practical guidance (Department 2.2) and illustrations (Department 2.3) relevant to all-time practices in phlebotomy.

The data given in this section underpins that given in the remainder of Part II for specific situations. Chapter 4 also provides information relevant to the procedure for cartoon claret given below in Section ii.2, but focuses on blood drove from donors.

Institutions can use these guidelines to plant standard operating procedures. Such procedures should conspicuously state the risks to patients and health workers, every bit well as the ways to reduce those risks – discussed beneath in Sections 2.1.4 and ii.2.

2.1. Background data on best practices in phlebotomy

Best practices in phlebotomy involve the following factors:

planning alee;
using an appropriate location;
standards for quality intendance for patients and health workers, including

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availability of appropriate supplies and protective equipment;

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availability of post-exposure prophylaxis (PEP);

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avoidance of contaminated phlebotomy equipment;

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appropriate preparation in phlebotomy;

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cooperation on the part of patients;
quality of laboratory sampling.

ii.1.i. Planning ahead

This is the most of import part of carrying out any process, and is usually done at the start of a phlebotomy session.

ii.1.2. Using an appropriate location

The phlebotomist should work in a quiet, make clean, well-lit expanse, whether working with outpatients or inpatients.

2.1.3. Quality control

Quality assurance is an essential role of best practice in infection prevention and command (1). In phlebotomy, it helps to minimize the take a chance of a mishap. Table ii.1 lists the master components of quality assurance, and explains why they are important.

Table 2.ane

Elements of quality assurance in phlebotomy.

2.1.4. Quality care for patients and health workers

Several factors can improve safety standards and quality of intendance for both patients and health workers, and laboratory tests. These factors, discussed beneath, include:

Availability of appropriate supplies and protective equipment

Procurement of supplies is the direct responsibility of the administrative (management) structures responsible for setting upwards phlebotomy services. Management should:

provide mitt-hygiene materials (soap and water or alcohol rub), well-plumbing equipment non-sterile gloves, single-employ disposable needles, and syringes or lancing devices in sufficient numbers to ensure that each patient has a sterile needle and syringe or equivalent for each blood sampling;
make bachelor sufficient laboratory sample tubes to prevent dangerous practices (e.g. decanting blood to recycle laboratory tubes).

Several prophylactic-engineered devices are available on the market; such devices reduce exposure to blood and injuries. Notwithstanding, the use of such devices should be accompanied by other infection prevention and control practices, and grooming in their employ. Non all safety devices are applicable to phlebotomy. Before selecting a safety-engineered device, users should thoroughly investigate available devices to determine their advisable utilize, compatibility with existing phlebotomy practices, and efficacy in protecting staff and patients (12, 33). Annex B provides further information on infection prevention and control, condom equipment and best practice; Annex C provides a comprehensive guide to devices available for cartoon blood, including rubber-engineered equipment.

For settings with low resources, toll is a driving cistron in procurement of safety-engineered devices.

Where rubber-engineered devices are not available, skilled use of a needle and syringe is acceptable.

Availability of post-exposure prophylaxis

Accidental exposure and specific information about an incident should be recorded in a register.

Support services should be promoted for those who undergo accidental exposure. PEP can assist to avert HIV and hepatitis B infections (thirteen, 27). Hepatitis B immunization should be provided to all health workers (including cleaners and waste material handlers), either upon entry into health-intendance services or as part of PEP (34). Addendum D has details of PEP for hepatitis B and HIV.

Avoidance of contaminated phlebotomy equipment

Tourniquets are a potential source of methicillin-resistant Staphylococcus aureus (MRSA), with up to 25% of tourniquets contaminated through lack of hand hygiene on the function of the phlebotomist or reuse of contaminated tourniquets (35). In addition, reusable finger-prick devices and related point-of-care testing devices (due east.g. glucometers) contaminated with blood have been implicated in outbreaks of hepatitis B (iv, 5, 36).

To avoid contamination, any common-use items, such every bit glucometers, should be visibly clean before use on a patient, and unmarried-use items should not be reused.

Training in phlebotomy

All staff should be trained in phlebotomy, to prevent unnecessary risk of exposure to claret and to reduce adverse events for patients.

Groups of health workers who historically are not formally trained in phlebotomy should be encouraged to have upwardly such preparation; lax infection prevention and command practices result in poor safety for staff and risk to patients (twenty, 37).
The length and depth of training will depend on local conditions; however, the training should at to the lowest degree cover the essentials (run across Annex Eastward) (38).
Supervision by experienced staff and structured training is necessary for all wellness workers, including physicians, who undertake claret sampling.

Patient cooperation

One of the essential markers of quality of care in phlebotomy is the interest and cooperation of the patient; this is mutually beneficial to both the health worker and the patient.

Clear information – either written or exact – should exist available to each patient who undergoes phlebotomy. Annex F provides sample text for explaining the blood-sampling procedure to a patient.

2.1.5. Quality of laboratory sampling

Factors that influence the outcome of laboratory results during collection and transportation include:

knowledge of staff involved in blood collection;
use of the correct gauge of hypodermic needle (see Tabular array 3.one in Chapter three) to prevent haemolysis or abnormal results;
the anatomical insertion site for venepuncture;
the use of recommended laboratory collection tubes;
patient–sample matching (i.e. labelling);
transportation conditions;
estimation of results for clinical management.

2.2. Applied guidance on best practices in phlebotomy

2.2.1. Provision of an appropriate location

In an outpatient department or dispensary, provide a defended phlebotomy cubicle containing:

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a make clean surface with two chairs (i for the phlebotomist and the other for the patient);

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a hand wash basin with lather, running water and paper towels;

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alcohol hand rub.
In the blood-sampling room for an outpatient department or dispensary, provide a comfortable reclining burrow with an arm residuum.
In inpatient areas and wards:

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at the patient's bedside, close the bed mantle to offering privacy

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ensure that blood sampling is done in a private and clean manner.

2.ii.2. Provision of clear instructions

Ensure that the indications for claret sampling are clearly defined, either in a written protocol or in documented instructions (due east.k. in a laboratory form).

2.2.3. Process for drawing blood

At all times, follow the strategies for infection prevention and control listed in Table 2.2.

Table two.2

Infection prevention and control practices.

Footstep 1. Gather equipment

Collect all the equipment needed for the procedure and place it within rubber and easy reach on a tray or trolley, ensuring that all the items are clearly visible. The equipment required includes:

a supply of laboratory sample tubes, which should be stored dry out and upright in a rack; blood can be collected in

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sterile glass or plastic tubes with safe caps (the choice of tube volition depend on what is agreed with the laboratory);

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vacuum-extraction blood tubes; or

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drinking glass tubes with screw caps;
a sterile drinking glass or bleeding pack (collapsible) if large quantities of claret are to be nerveless;
well-plumbing fixtures, non-sterile gloves;
an array of blood-sampling devices (rubber-engineered devices or needles and syringes, run across below), of unlike sizes;
a tourniquet;
alcohol mitt rub;
gauze or cotton-wool ball to be applied over puncture site;
laboratory specimen labels;
writing equipment;
laboratory forms;
leak-proof transportation bags and containers;

Ensure that the rack containing the sample tubes is close to you, the health worker, simply away from the patient, to avoid it beingness accidentally tipped over.

Step ii. Identify and prepare the patient

Where the patient is adult and conscious, follow the steps outlined beneath.

Introduce yourself to the patient, and inquire the patient to state their full name.
Check that the laboratory form matches the patient's identity (i.e. match the patient's details with the laboratory class, to ensure accurate identification).
Inquire whether the patent has allergies, phobias or has ever fainted during previous injections or blood draws.
If the patient is anxious or agape, reassure the person and ask what would make them more comfortable.
Make the patient comfortable in a supine position (if possible).
Place a clean paper or towel nether the patient's arm.
Discuss the test to be performed (run across Annex F) and obtain verbal consent. The patient has a correct to refuse a test at any time before the claret sampling, so it is important to ensure that the patient has understood the process.

For paediatric or neonatal patients, come across Chapter 6.

Pace 3. Select the site

General

Extend the patient's arm and inspect the antecubital fossa or forearm.
Locate a vein of a good size that is visible, straight and clear. The diagram in Section 2.3, shows mutual positions of the vessels, but many variations are possible. The median cubital vein lies betwixt muscles and is usually the about easy to puncture. Under the basilic vein runs an artery and a nerve, so puncturing hither runs the run a risk of dissentious the nervus or artery and is normally more than painful. Do NOT insert the needle where veins are diverting, because this increases the chance of a haematoma.
The vein should be visible without applying the tourniquet. Locating the vein volition help in determining the correct size of needle.
Apply the tourniquet nearly 4–5 finger widths above the venepuncture site and re-examine the vein.

Hospitalized patients

In hospitalized patients, do non have blood from an existing peripheral venous access site because this may give faux results. Haemolysis, contamination and presence of intravenous fluid and medication can all alter the results (39). Nursing staff and physicians may access primal venous lines for specimens following protocols. However, specimens from central lines carry a take a chance of contagion or erroneous laboratory exam results.

It is acceptable, but not platonic, to draw blood specimens when offset introducing an in-domicile venous device, earlier connecting the cannula to the intravenous fluids.

Step 4. Perform hand hygiene and put on gloves

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wash hands with soap and h2o, and dry with single-use towels; or

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if hands are non visibly contaminated, clean with booze rub – apply 3 ml of booze rub on the palm of the hand, and rub it into fingertips, back of hands and all over the easily until dry.

Pace 5. Disinfect the entry site

Unless drawing blood cultures, or prepping for a blood collection, clean the site with a 70% alcohol swab for thirty seconds and permit to dry out completely (30 seconds) (40–42).

Annotation: booze is preferable to povidone iodine, because claret contaminated with povidone iodine may falsely increase levels of potassium, phosphorus or uric acrid in laboratory test results (half-dozen, 7).
Apply firm just gentle pressure. Start from the center of the venepuncture site and work downward and outwards to cover an surface area of 2 cm or more than.
Permit the surface area to dry. Failure to permit enough contact time increases the take chances of contamination.
Do NOT touch the cleaned site; in particular, DO Not place a finger over the vein to guide the shaft of the exposed needle. It the site is touched, echo the disinfection.

Stride 6. Accept blood

Venepuncture

Perform venepuncture equally follows.

Anchor the vein by holding the patient'due south arm and placing a thumb Beneath the venepuncture site.
Ask the patient to grade a fist then the veins are more prominent.
Enter the vein swiftly at a 30 degree angle or less, and continue to innovate the needle forth the vein at the easiest angle of entry.
In one case sufficient blood has been collected, release the tourniquet BEFORE withdrawing the needle. Some guidelines suggest removing the tourniquet as soon equally claret menstruum is established, and always earlier information technology has been in place for two minutes or more.
Withdraw the needle gently and utilize gentle pressure to the site with a clean gauze or dry out cotton-wool brawl. Inquire the patient to concur the gauze or cotton wool wool in identify, with the arm extended and raised. Ask the patient Non to curve the arm, because doing so causes a haematoma.

Step 7. Make full the laboratory sample tubes

When obtaining multiple tubes of blood, use evacuated tubes with a needle and tube holder. This system allows the tubes to be filled directly. If this organization is not available, use a syringe or winged needle fix instead.
If a syringe or winged needle set is used, all-time practice is to place the tube into a rack earlier filling the tube. To prevent needle-sticks, utilize one mitt to fill the tube or employ a needle shield between the needle and the hand holding the tube.
Pierce the stopper on the tube with the needle directly higher up the tube using slow, steady pressure. Do not printing the syringe plunger because additional force per unit area increases the risk of haemolysis.
Where possible, go along the tubes in a rack and motion the rack towards y'all. Inject downwardly into the appropriate coloured stopper. Practice Not remove the stopper because it will release the vacuum.
If the sample tube does not take a safety stopper, inject extremely slowly into the tube every bit minimizing the pressure and velocity used to transfer the specimen reduces the gamble of haemolysis. DO NOT recap and remove the needle.
Earlier dispatch, capsize the tubes containing additives for the required number of times (as specified past the local laboratory).

Step 8. Draw samples in the correct club

Draw claret collection tubes in the correct society, to avoid cross-contamination of additives between tubes. Equally color coding and tube additives may vary, verify recommendations with local laboratories. For illustration purposes, Table 2.iii shows the revised, simplified recommended society of depict for vacuum tubes or syringe and needle, based on United States National Commission Clinical Laboratory Standards consensus in 2003 (43).

Table 2.three

Recommended society of draw for plastic vacuum tubes.

Pace 9. Clean contaminated surfaces and consummate patient process

Discard the used needle and syringe or blood sampling device into a puncture-resistant sharps container.
Check the label and forms for accuracy. The label should be clearly written with the data required past the laboratory, which is typically the patient's starting time and last names, file number, date of birth, and the appointment and time when the blood was taken.
Discard used items into the appropriate category of waste matter. Items used for phlebotomy that would not release a driblet of blood if squeezed (e.grand. gloves) may be discarded in the general waste, unless local regulations state otherwise.
Recheck the labels on the tubes and the forms before dispatch.
Inform the patient when the procedure is over.
Enquire the patient or donor how they are feeling. Cheque the insertion site to verify that it is not bleeding, then thank the patient and say something reassuring and encouraging before the person leaves.

Stride 10. Set samples for transportation

Pack laboratory samples safely in a plastic leak-proof bag with an exterior compartment for the laboratory asking course. Placing the requisition on the outside helps avoid contamination.
If there are multiple tubes, place them in a rack or padded holder to avoid breakage during transportation.

Step 11. Clean upwards spills of blood or body fluids

If blood spillage has occurred (e.thou. considering of a laboratory sample breaking in the phlebotomy area or during transportation, or excessive haemorrhage during the procedure), clean information technology up. An example of a safe procedure is given beneath.

Put on gloves and a gown or frock if contamination or bleaching of a uniform is likely in a big spill.
Mop up liquid from large spills using newspaper towels, and identify them into the infectious waste matter.
Remove as much blood as possible with wet cloths before disinfecting.
Appraise the surface to see whether it will exist damaged by a bleach and water solution.
For cement, metal and other surfaces that can tolerate a stronger bleach solution, food the area with an approximately 5000 parts per million (ppm) solution of sodium hypochlorite (1:10 dilution of a 5.25% chlorine bleach to water). This is the preferred concentration for large spills (44). Go out the area wet for 10 minutes.
For surfaces that may be corroded or discoloured by a potent bleach, make clean advisedly to remove all visible stains. Brand a weaker solution and get out it in contact for a longer period of fourth dimension. For example, an approximately 525 ppm solution (one:100 dilution of 5.25% bleach) is effective.
Prepare bleach solution fresh daily and go on information technology in a airtight container because it degrades over time and in contact with the sun.

If a person was exposed to blood through nonintact skin, mucous membranes or a puncture wound, complete an incident report, as described in WHO best practices for injections and related procedures toolkit. For transportation of blood samples exterior a hospital, equip the transportation vehicle with a blood spillage kit. Addendum H has further information on dealing with a blood spillage.

two.three. Illustrations for all-time practices in phlebotomy

Figure two.2 Filling tubes

Source: https://www.ncbi.nlm.nih.gov/books/NBK138665/

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