Using sterile technique, a needle attached to a syringe, butterfly or a vacuum tube system is inserted through the skin into a vein, to obtain a blood sample for laboratory analysis.
II. Clinical Significance: N.A.
Venous blood is obtained by using proper venipuncture technique.
1. Vacuum collection tubes (Greiner brand)
2. Tourniquet, single use (Trinity Sterile #TR1-10001)
3. 2 x 2 gauze pads (Fisher #22362178)
A. Eclipse brand vacuum tube needles of 21 or 22 gauge (CardinalHealth #368607 or 368608)
B. Eclipse brand syringe needles:
22 gauge (CardinalHealth #BF305763)
23 gauge (CardinalHealth #BF305762)
C. Butterfly needle set-ups:
23 gauge Single Sample (Smiths Medical #972312)
23 gauge Multiple Sample (Smiths Medical #982312)
21 gauge Multiple Sample (Smiths Medical #982112)
5. BD One-Use Holder for vacuum tubes (CardinalHealth #BD364815)
6. 5 ml or 10 ml plastic syringes (CardinalHealth #SY35005LL or Sy35010LL)
7. Blood Transfer Device, BD (CardinalHealth #364880)
8. Paper Tape (CardinalHealth #M1535-1)
9. Kendall Conform Stretch Bandage (Kendall #2245)
10. Betadine swabs (CardinalHealth #40000-020)
11. Alcohol wipes (CardinalHealth #40000-090)
13. Hospital-approved hand gel (provided by the hospital)
V. Reagents: N.A.
VI. Standardization: N.A.
1. Consult the current edition of the Clinical Laboratory Testing Manual before performing the venipuncture. It is used to obtain information concerning the type and volume of specimen necessary, patient preparation, and other special information pertinent to the specimen and specimen handling. If the phlebotomist already knows this information for the test(s) ordered; this step is omitted.
2. Initial Client/Patient Contact: Proper initial contact with the client/patient is extremely important. Phlebotomists must awaken sleeping patients before drawing blood. The phlebotomist must have professional attributes in skill, attitude, and appearance. (Refer to the “Client Contact; Guidelines” and the “Dress and Appearance” guidelines in the UCL Personnel Policy Handbook.)
3. Identify the client/patient:
It is most important the client/patient be properly identified. Incorrect identification of a client/patient may cause a life-threatening situation. Refer to the “Patient Identification” policy.
4. Verify any patient diet restrictions; time and diet restrictions vary according to the test.
5. Select the appropriate system for blood collection:
A. Greiner tubes and BD Eclipse blood collection needles are used for routine venipunctures.
B. Plastic syringes are used for clients/patients with fragile, rolling, or threadlike veins, with children who have small veins, with people who bruise easily, or have difficult veins to find.
6. Check the test requisition(s) for correct date and time, and determine which collection tubes are necessary for the requested test(s).
7. Assemble the following items: appropriate collection tubes, alcohol, gauze pads, needle, blood tube holder (or syringe and blood transfer device), tourniquet and gloves. Inspect all supplies for defects and applicable expiration dates. Outdated supplies are not used.
Note: Phlebotomy trays/carts and equipment are placed out of the reach of children and psychiatric clients/patients, and are never left unattended in a client/patient room.
8. Make sure the client/patient is either sitting down comfortably or lying down. A venipuncture is not performed while the client/patient is standing. Chairs without arms are not acceptable.
9. The minimum PPE required to perform this procedure is designated labcoat, gloves and safety glasses. Put a fresh pair of gloves on in view of the patient. Hands are washed after removing gloves and between each patient during all blood collection procedures. See 25.I. of this procedure. If gloves have not been visibly contaminated with blood and/or body fluids, hands may be washed using hospital approved hand gel. If during the blood collection procedure gloves have become visibly contaminated with blood or body fluids, hands are washed using soap and water. (Refer to “Blood Specimen Acquisition” within the ”Engineering Work Practice Controls“ section of the UCL Exposure Control Plan.)
10. Choose the appropriate venipuncture site:
A. The median cubital and cephalic veins in the antecubital fosa area are preferred. The basilic vein may be used only when the safer median and cephalic vein cannot be found. (Refer to Diagram I at the end of this procedure.) Veins on top of the hand or wrist are used only after veins in the antecubital area have been determined unsuitable. Hand veins have a greater tendency to move or roll as the needle is inserted. Needle puncture in the hand and wrist area is more uncomfortable to the patient/client. Ankle and foot veins are used with verbal permission of the attending physician. Write the name of the approving physician on the requisition.
B. Factors to consider in venipuncture site selection
a. Scarred/burned skin:
Areas of extensive scarring or healed burned areas are avoided.
If the client/patient or signage indicates a previous mastectomy, use the arm on the opposite side. The arm on the same side as the mastectomy may be used with verbal permission from the attending physician and the client/patient. Write the name of the approving physician on the requisition.
Avoid collecting blood from an arm with a hematoma when possible. If another vein site is not available, apply the tourniquet below the hematoma and collect the blood. Make a notation to this effect on the test requisition.
d. I.V. therapy:
The venipuncture should be performed on the opposite arm of the I.V. therapy. If this is not possible, the I.V. is turned off and the blood is drawn below the I.V. site. Collection above the I.V. site is not recommended and should only be attempted when other alternatives have been exhausted. If the decision is made to turn off an I.V. line, the attending nurse must be consulted. Only a nurse familiar with the client/patient may turn off the I.V. It must be turned off for 2 full minutes before the tourniquet is applied; if possible have the arm elevated above the level of the heart during the two minutes. Select a vein other than the one receiving the I.V. Inform nursing personnel as soon as the venipuncture is finished. Only nursing personnel may restart an I.V. The individual performing the venipuncture must make a notation on the test requisition indicating an I.V. arm was used. (Refer to the Venipuncture Identification Code in this procedure.) If the I.V. is being infused into a jugular vein, subclavian, or an extremity that is not being used for venipuncture, no precautions need be taken or comments made on the requisition. No phlebotomy is to be performed on a lower extremity unless ordered by an attending M.D. and then only to be done using a small vein of the foot or ankle. No large artery or vein puncture (i.e., femoral) is used.
Note: Blood should not be collected from edematous (swollen) tissue due to an infiltrated I.V., even if the I.V. has been turned off or removed. Results of coagulation studies drawn above or below a heparin I.V. should be reported with the following disclaimer: "Disclaimer: drawn above/below I.V. containing heparin". A Pathologist does not need to be notified unless a problem or question arises that needs his/her input.
e. Fistula or vascular graft:
A fistula graft is a device surgically placed into a client/patient’s arm as an access for dialysis procedures. The fistula graft is usually placed in the wrist area but also may be in the antecubital fosa area. When the phlebotomist sees an area that looks bulging or when the veins seem very large for the area, he/she should suspect that the client/patient might have a fistula graft. Watch for signage, ask the client/patient directly, or ask the nursing staff if a fistula graft is suspected. Blood is not drawn from an arm with a fistula graft unless there is absolutely no other area that can be used. If blood must be collected from this arm, the tourniquet should not be used, or should be used very loosely and no longer than absolutely necessary. Only an experienced phlebotomist may collect blood under these circumstances. A notation is made on the requisition.
f. Blood transfusion:
If a client/patient is in the process of receiving a blood transfusion, it is appropriate to wait until the blood is fully infused before drawing any blood for testing purposes. If the physician has specifically ordered blood to be drawn while the client/patient is receiving a transfusion, make a notation on the requisition and use the arm opposite of the one in which the blood is being transfused.
g. Ankle, foot and other lower extremity sites may not be used without verbal permission of the physician.
h. Arterial punctures are not considered an alternative to venipuncture for difficult draws.
i. Veins on the underside of the wrist must not be used.
j. Phlebotomists do not draw blood from vascular access devices (VADs). If blood is collected for the lab, by nursing staff, from a vascular access device, the IV line is turned off for 2 minutes before collecting the specimen. A discard draw of 5 ml is obtained, followed by a collection of the required amount of blood for testing. The type of fluid being infused (for example TPN) must be written on the requisition along with the initials of the nurse drawing the blood specimen from the line. Collection of blood through lines that have been flushed with heparin should be avoided, if possible. If blood must be drawn, the line should be flushed with 5 ml of saline, followed by 5 ml discard draw. If the physician requires blood to be obtained without turning off the line as described above, a notation of the physician and the circumstances is made on the requisition and a disclaimer is made with the test result.
11. Apply a tourniquet. The tourniquet should not be applied until all the necessary equipment is assembled.
A. Use a tourniquet to increase venous filling. This makes veins more prominent and easier to enter.
B. Wrap the tourniquet around the area midway between the shoulder and elbow. Tuck the end under so that the tourniquet can easily be removed using one hand. The tourniquet may be placed over clothing.
C. The tourniquet should not be left on for longer than one minute. To do so may result in hemoconcentration. This may result in erroneously high values for all protein-based analytes, packed cell volume, and other cellular elements. When vein selection, cleaning and access take longer than one minute, the tourniquet must be released and reapplied after 2 minutes to minimize the effect of hemo-concentration.
D. If the client/patient has thin, papery skin, or other skin condition, place the tourniquet over clothing, or place a washcloth or piece of gauze around the area first, to avoid pinching the skin.
E. Refer to “Blood Specimen Acquisition” within the ”Engineering Work Practice Controls“ section of the “UCL Exposure Control Plan” for use of tourniquets.
Note: Ask the client/patient to make a fist only if it is necessary to find a vein. Pumping of the hand is avoided as it may alter test values. If a fist is made, it should be relaxed just before inserting the needle.
F. If a blood pressure cuff is used as a tourniquet, inflate it to no more than 40 mmHg.
12. Find a vein:
A. Have the patient extend his/her arm to form a straight line from the shoulder to the wrist.
B. A vein is palpated (felt). Trace the path of the vein several times with the index finger. Gloves are normally worn when palpating for a vein. If the patient/client has veins that are difficult to find, the veins may be palpated with ungloved fingertips.
C. An appropriate vein should feel resilient or “bouncy” to the touch. Arteries pulsate and are more elastic. The median cubital vein is usually bigger, anchored better, bruises less and is the vein of choice whenever possible. (Refer to Diagram I.)
D. Veins may be located deep within the arm of persons with fatty tissue and may take longer to locate than veins on the surface of the arm.
E. Care is taken to distinguish veins from tendons or other non-venous tissue in the area. These areas may feel cord-like or hard.
F. A warm washcloth or heel warmer may also be applied to the site to help locate a suitable vein. Lowering the extremity allows the veins to fill to capacity.
G. Massaging the arm from wrist to elbow helps promote blood flow to the area.
13. Cleanse the area of the venipuncture:
A. The venipuncture site is routinely cleansed to prevent chemical or microbiological contamination to both the client/patient and the specimen.
B. Use an alcohol prep from its sterile package to cleanse the site with a circular motion starting from the center and working outward. If the site appears unusually dirty, two wipes may be needed.
C. Allow the site to air-dry to prevent hemolysis and a burning sensation to the client/patient when the venipuncture is performed.
D. It is preferred that the venipuncture site not be touched again after it is cleansed until after the venipuncture is finished. If the venipuncture proves difficult and the vein must be touched again in order to draw blood, the gloved finger used to feel the site again must be thoroughly cleansed and allowed to dry before touching the site.
E. Refer to special cleansing precautions for blood alcohol in the “Alcohol, Legal Blood; Documentation Acquisition and Handling” protocol and for blood culture in the current edition of the “CLTM“ or the “Blood Culture, Collection & Setup; BacT-Alert” procedure.
Note: Alcohol must not be used as a cleansing agent when a blood alcohol is ordered on the specimen. Povidone-iodine prep pads are used as the cleansing agent in blood alcohol specimen collection.
14. Perform the Venipuncture:
Note: No food, liquid, chewing gum or thermometer should be in the patient’s mouth at the time the specimen is drawn.
A. Vacuum Tube Method:
a. Break the seal on a new, sterile needle. Holding both colored shields, twist and remove the white shield. Discard it in the proper waste container as non-contaminated waste.
b. Thread the needle onto the blood tube holder until it is secure.
c. Rotate the safety shield back.
d. Pull the needle shield straight off.
e. At this point, the first collection tube may be inserted into the adapter if desired. To prevent loss of vacuum, push the tube stopper only up to the recessed guideline on the adapter.
f. If possible, place the client/patient’s arm in a downward position to prevent reflux or back-flow from the collection tube into the client/patient’s vein.
g. Turn the adapter until the needle bevel is upward. Align it in the same direction as the vein. Visually inspect the needle for bends, hooks or defects.
h. Hold the needle/adapter assembly in the hand that will insert the needle. Stabilize the vein, holding the skin taunt. The thumb should be 1-2 inches below the venipuncture site. Ensure that the patient’s hand is open. The patient must not be allowed to pump his/her fist.
i. Reassure the client/patient using a calm, pleasant voice. It often helps to tell clients/patients exactly when to expect the needle stick so they are prepared and do not suddenly move his/her arm or jerk when the needle is inserted.
Note: From this point on, be prepared to react to sudden and unexpected loss of consciousness.
j. Insert the needle smoothly into the lumen (cavity) of the vein. The needle should align in the same direction as the vein and should be inserted at approximately a 15° angle to the skin. A sense of resistance is felt as the skin is punctured, followed by an ease of penetration as the needle enters the vein. See Diagram 2.
k. Using the widened base of the adapter to push against and steady the unit, insert the evacuated tube all the way into the adapter. This will push the rubber tip forward and expose the full lumen of the needle, allowing the blood to enter the tube.
l. Allow the tube to fill until the vacuum is exhausted and blood flow ceases. In tubes with an anticoagulant additive, this will ensure that there is a correct ratio of anticoagulant to blood. (Refer to specimen integrity requirements written in the “Specimen Integrity, Hematology” protocol.)
m. Remove the tube from the adapter. Keep the needle/adapter unit steady by pushing against the widened base of the adapter.
n. If the tube contains an anticoagulant, clot activator or ST gel, mix it immediately by gently inverting it 5 to 8 times. Gentle mixing is required to prevent hemolysis.
o. Obtain additional blood by choosing the next tube and proceed again with steps k through n, as described above.
Note: It is important to take the last tube filled out of the adapter assembly before removing the needle. This prevents blood from dripping out the bevel of the needle when it is withdrawn from the puncture site. If only one tube is collected, it must be removed prior to withdrawing the needle from the vein.
B. Syringe Method:
a. Peel open the needle package and remove the needle.
b. Attach the needle securely to the syringe.
c. Place the client/patient’s arm in a downward position to prevent reflux or back-flow into the client/patient’s vein.
d. Select the vacuum tubes that the blood will be transferred into and place the tubes and blood transfer device within easy reach.
e. Move the plunger of the syringe up and down within the barrel of the syringe several times to demonstrate that the plunger will freely move. Push the plunger in as far as it will go and expel all air from the syringe.
f. Rotate the needle safety shield back. Pull the needle shield straight off.
g. Turn the syringe until the needle bevel is upward and in the same direction as the vein. Visually inspect the needle for bends, hooks, or defects.
h. Hold the syringe assembly in the hand that will insert the needle. Stabilize the vein by placing the index and thumb of the opposite hand above and below the site, respectively, and holding the skin taunt. The thumb should be 1-2 inches below the venipuncture site.
i. Align the needle in the same direction as the vein and insert the needle at approximately a 15° angle to the skin. A sense of resistance is felt as the skin is punctured, followed by an ease of penetration as the needle enters the vein. Insert the needle smoothly into the lumen (cavity) of the vein.
j. Withdraw the desired amount of blood by gently pulling back on the plunger of the syringe.
k. Activate the safety feature on the needle and discard it into a sharps container. Transfer the blood from the syringe into a blood collection tube using a safety transfer device. Use the same “order of draw” as for the venipuncture with the vacuum tube system.
l. If the tube contains an anticoagulant, clot activator or ST gel, mix it immediately by gently inverting it 5 to 8 times. Gentle mixing is required to prevent hemolysis.
C. Winged Collection Set (Butterfly) Method:
a. Peel apart the package and remove the butterfly set.
1. If using the multisample luer adapter butterly (for use with evacuated tubes), thread the luer adapter securely into the holder adapter.
2. If using a single sample butterfly (for use with syringe), move the plunger of the syringe up and down within the barrel of the syringe several times to demonstrate that the plunger will freely move. Push the plunger in as far as it will go and expel all air from the syringe, then attach the butterfly unit securely to the syringe.
b. Select the vacuum tubes that the blood will be transferred into and place them within easy reach.
c. Remove the needle sheath and turn the unit until the needle bevel is upward and in the same direction as the vein. Visually inspect the needle for bends, hooks or defects.
d. Hold the butterfly assembly in the hand that will insert the needle. Stabilize the vein, holding the skin taunt. The thumb should be 1 - 2 inches below the venipuncture site.
e. Insert the needle smoothly into the lumen (cavity) of the vein. The needle should align in the same direction as the vein and should be inserted at approximately a 15° angle to the skin. A sense of resistance is felt as the skin is punctured, followed by an ease of penetration as the needle enters the vein.
f. If using a butterfly and syringe, withdraw the required amount of blood by very gently pulling back on the plunger of the syringe.
1. Activate the safety feature on the needle and discard it into a sharps container. Transfer the blood from the syringe into a blood collection tube using a safety transfer device. Use the same “order of draw” as for the venipuncture with the vacuum tube system.
2. If the tube contains an anticoagulant, clot activator or ST gel, mix it immediately by gently inverting it 5 to 8 times. Gentle mixing is required to prevent hemolysis.
g. If using the butterfly with multisample adapter:
1. Using the widened base of the adapter to push against and steady the unit, insert the evacuated tube all the way into the adapter. This will push the rubber tip forward and expose the full lumen of the needle, allowing blood to enter the tube.
2. Allow the tube to fill until the vacuum is exhausted and blood flow ceases. In tubes with an anticoagulant additive, this will ensure that there is a correct ratio of anticoagulant to blood. (Refer to specimen integrity requirements written in the “Specimen Integrity, Hematology” protocol.)
3. Remove the tube from the adapter. Keep the needle/adapter unit steady by pushing against the widened base of the adapter.
4. If the tube contains an anticoagulant, clot activator or ST gel, mix it immediately by gently inverting it 5 to 8 times.
5. To obtain additional blood, choose the next tube to be filled and proceed from step 1 through 4 above.
6. It is important to take the last tube filled out of the adapter assembly before removing the needle. This prevents blood from dripping out the bevel of the needle when it is withdrawn from the puncture site.
15. Release the tourniquet as blood begins to flow into the last tube, or when sufficient blood is in the syringe. This allows blood circulation to return to normal and reduces bleeding from the site after the needle is withdrawn.
16. Remove the needle from the arm carefully while keeping the bevel of the needle in an upward position. Do not apply pressure as the needle is withdrawn. Lightly place a clean gauze pad over the venipuncture site. Care is taken not to scratch the client/patient as the needle is withdrawn.
17. Needle Safety: The needle safety feature is activated immediately after specimen collection.
A. When using Eclipse blood collection needles:
Immediately after the needle is removed, and with the needle still in a downward position, use the thumb of the hand holding the adapter or syringe to firmly push forward on the safety shield. (The other hand is applying pressure to the site, as in step 17.) An audible click is heard when the shield is engaged. Visually inspect the needle to be sure the shield is locked in place.
B. Butterfly assembly needles are not recapped. Place the index finger behind the finger stop on top of the safety device. With the other hand, grasp the tubing with thumb and index finger and gently pull back until a “click” is heard or felt to ensure the needle is fully retracted and locked into the body of the collection set.
18. Apply mild pressure to the site with the gauze immediately after the needle is removed and until bleeding has stopped. Observe for hematoma.
19. If blood was collected in a syringe, transfer the blood to the evacuated tubes using a BD Blood Transfer Device.
20. Dispose of the contaminated and non-contaminated items. Items are discarded without disassembly.
Place the contaminated needle and the syringe transfer device assembly into a sharps container.
B. Vacuum tube needles:
Dispose of the needle/blood tube holder, as a single unit, into a sharps container.
The entire butterfly unit is disposed of in a sharps container.
D. Gloves and single-use tourniquet:
When the blood collection procedure is completed, hold the used tourniquet in the palm of a gloved hand and remove gloves in the approved way. The tourniquet will be wrapped inside the gloves. The glove/tourniquet unit is considered non-contaminated waste and is disposed of as such in the patient/outpatient waste container. The glove/tourniquet unit is disposed of in the waste container at the nursing station for any patient in behavioral health (Mercy Turning Point and Finley Summit Unit), pediatrics, or a nursing home.
21. The phlebotomist must ensure the hemostasis is complete before any bandage is applied. After the bleeding has stopped, use paper tape and gauze to apply a pressure bandage on the site. Tell the client/patient to leave the bandage on for 15 minutes. Do not allow the client/patient to bend his/her elbow to put pressure on a venipuncture site. Band-Aids are not used on the venipuncture site. (Refer to the phlebotomy section of the general policy “Client Contact; Guidelines”.)
A gauze wrap is used on the arms of patients with skin that is easily compromised, e.g. elderly patients with thin, papery skin; patients with skin problems or conditions, such as burns, hives, eczema, etc.; patients who bruise easily or have told us about bruising problems in the past, etc. The “wad” of gauze is still placed over the venipuncture site for direct pressure, and the gauze is not applied until the arm is checked and bleeding has stopped. The entire roll of gauze is used. Wrap the stretch bandage around the arm, holding the wad of gauze in place. It is wrapped firmly but not pulled tightly around the arm. The last two inches of the gauze wrap is tucked securely under the wrap.
Note: Clients/Patients who are known to have a low platelet count or are on anticoagulant therapy may tend to bleed more and for a longer period of time than normal after a venipuncture. It is important to keep direct pressure on the venipuncture site until there is no sign of bleeding. If a client/patient has unusual bleeding from a venipuncture site, 5 minutes or longer, make a notation on the test requisition, inform nursing staff asking them to check the venipuncture site again in 5 minutes.
22. All specimen labeling and accompanying paperwork are completed at the bedside or in the drawing area before the blood is brought into any laboratory department. (Refer to the “Specimen Handling: Identification, Integrity and Rejection” policy in the Quality Assurance Manual.)
23. Venipuncture Identification Code:
A notation is made on at least one of the test requisitions, by the phlebotomist, as to the site of blood collection and a notation if any unusual circumstances were encountered. If a client/patient receives more than one needle stick to collect a proper specimen for the requested tests, each needle stick is recorded in the following manner. The first location described is the unsuccessful needle stick site. The last location described is the successful needle stick site.
A. Describe the location of the venipuncture. Abbreviations to be used are:
• R denotes Right
• L denotes Left
• A denotes Arm
• W denotes Wrist
• H denotes Hand
• AK denotes Ankle
• FT denotes Foot
If a routine venipuncture is performed on the left arm, "LA" is written on at least one of the requisitions.
B. When a venipuncture is performed from an extremity with an I.V. denote as follows:
• I.V. denotes venipuncture above (proximal to) an I.V. site.
• I.V. denotes venipuncture below (distal to) an I.V. site.
If the phlebotomist draws a blood sample below an I.V. site from the left hand, the notation is: "LH IV".
Note: All I.V.s must be off 2 minutes prior to applying the tourniquet. If possible, have the I.V. arm raised above the level of the heart. Results of coagulation studies drawn above or below a heparin I.V. should be reported with a disclaimer (refer to Note: page 3). A pathologist does not need to be notified unless a problem or question arises that needs his/her input.
C. If the sample must be drawn from a hematoma or bruised area, make a notation such as: "drawn through hematoma" or note "prior hematoma" if a different vein is used.
D. If the venipuncture was difficult, the blood came back slowly or a syringe or butterfly was required to draw the blood, the notation “difficult draw” abbreviated “DD” is made on the requisition. (When a butterfly is used for routine blood cultures this notation is not necessary.)
24. At the hospital sites, the time the specimen arrives in the laboratory is documented by punching the requisition(s) into the time clock in the laboratory, or by specimen registering in CLICS.
25. Special Considerations:
A. Fasting clients/patients:
When drawing blood for a test that requires the client/patient to be fasting, it may be appropriate to ask the client/patient when he/she last had anything to either eat or drink, before performing the venipuncture. If the client/patient is not fasting or has not fasted long enough, ask an appropriate technical staff person if the blood can still be drawn.
B. Unsuccessful venipuncture:
a. If there is not a blood return in the tube or syringe:
1. Change the needle position slightly. Either advance the needle a slight amount or withdraw the needle a slight amount. This may bring the bevel of the needle into the lumen of the vein.
2. Try another tube. The first tube may not have contained sufficient vacuum.
3. Loosen the tourniquet. It may be too tight and cause blood flow to cease.
4. A very slight move of the needle can be made (to the right, left, up or down) to reposition a needle that has hit the wall of a vein rather than the lumen of the vein. The needle may also be rotated half a turn. Lateral needle relocation is never attempted in an effort to access the basilic vein, since nerves and the brachial artery are in close proximity. If the vein has rolled, the needle may be slightly redirected. A deep probe or extended probe with the needle is never allowed. It is painful to the client/patient and most times unsuccessful. An alternate site should be attempted.
b. A phlebotomist is allowed two attempts at successful venipuncture. If after two tries he/she has not obtained a proper specimen, another phlebotomist should attempt the venipuncture. (Refer to the general policy “Client Contact; Guidelines”.)
C. If, during the venipuncture, a bluish bump forms under the skin near the puncture site, a hematoma is probably forming. Release the tourniquet immediately and withdraw the needle. Apply firm pressure to the site for at least 3 minutes and until all bleeding has stopped.
D. Bruise or hematoma prevention:
a. Puncture only the uppermost wall of the vein, and make sure the needle penetrates the wall. Partial penetration may allow blood to leak out the bevel of the needle into the tissue surrounding the vein.
b. Remove the tourniquet before withdrawing the needle.
c. Apply pressure to the area immediately after withdrawing the needle and provide a means to keep pressure on the area for at least 5 minutes if direct pressure is used and 15 minutes if a bandage is used. It is recommended that unless there is an extenuating circumstance that prevents the site from being bandaged (hives, burned skin, etc.) all venipuncture sites should be bandaged using gauze and a hypoallergenic adhesive (e.g., paper tape), or gauze wrap as discussed in VII.21.
d. Use major veins, not superficial ones. Small veins are more easily damaged than major ones.
E. If the blood filling the syringe or tubes is bright red rather than a dark red, and fills the tube with a jerky or pulsating movement, this indicates an artery has been punctured. Upon completion of the phlebotomy, apply firm, direct pressure for 5 minutes to the site, inform nursing personnel and ask them to check the site again in 5 minutes. Make a notation on the requisition.
F. Precautions notices:
Information concerning special precautions about a client/patient, or information pertinent to the phlebotomist may be written in the text section of the test requisition, or may be posted at the bedside. The phlebotomist must look for such information and follow it closely. Examples are isolation precautions, nursing requests, restricted venipuncture sites, fasting instructions, or personal information about the client/patient, e.g., “Patient is deaf.”
G. Preventing hemolysis of the specimen:
a. Use an appropriate gauge needle. 21 gauge needles are used for routine venipunctures. 22 gauge needles are used for small veins. 23 gauge butterfly units are used in unusual circumstances when very fine and delicate veins are used. The smaller the needle, the greater the trauma placed on the red blood cells as they are drawn through the bevel of the needle.
b. Transfer blood from syringes into tubes using the BD Blood Transfer Device.
c. If the tube contains anticoagulant, clot activator or ST gel; mix it immediately by gently inverting 5 to 8 times.
d. Do not draw blood from a bruised area or hematoma.
e. If using a syringe, pull back gently on the plunger.
f. Centrifuge non-anticoagulated samples only when completely clotted.
H. Multiple sample; order of draw:
a. Blood culture tubes are drawn first if they are needed.
b. Coagulation tubes (blue stopper) are drawn second.
Note: When using a butterfly set with vacuum tubes, and a coagulation tube is the first tube to be drawn, a discard tube should be drawn first. The purpose is to fill the plastic tubing “dead space” with blood. The discard tube does not need to be completely filled. The discard tube should be a non-additive or coagulation tube.
c. Gel separator tubes (SST) and plastic non-anticoagulated (clot activator) tubes are drawn 3rd.
d. Heparin (green stopper) tubes are next.
e. EDTA (purple stopper) tubes are drawn last.
a. Before having direct contact with patients/clients.
b. Before entering the nursery.
c. After removing gloves.
d. Anytime hands are contaminated with blood and/or body fluids, or have touched client/patient’s skin.
J. Clients in isolation:
a. Hospital client/patients in isolation have signage on his/her door stating the type of isolation and special precautions that must be taken before entering the room.
b. The phlebotomist leaves his/her phlebotomy tray/cart just inside the patient’s doorway, and takes only the necessary items for performing the venipuncture into the room for all isolation types except airborn isolation. The tray/cart is left attended at/behind the nursing station for airborn isolation.
Note: Never leave a phlebotomy tray/cart unattended in the hallway.
d. Consult the nursing staff to answer any questions about a client/patient in isolation before entering the room.
K. Contamination with blood:
Collection tubes or reusable phlebotomy equipment that have been contaminated with blood or body fluid are disinfected with 1:10 bleach solution, available in the laboratory, before the equipment is used again and before tubes are sent to any laboratory department.
L. Blood cultures:
Refer to the “Blood Culture, Collection & Setup; BacT-Alert” procedure for instructions on drawing blood cultures.
M. Specimens for Blood Bank/Transfusion Testing:
The American Association of Blood Banks (AABB) states, “the intended recipient and the blood sample shall be identified positively at the time of collection.” This policy is followed for all blood sample collections, but is most important when obtaining specimens for blood or blood product transfusion.
N. Accidental needle-sticks:
An accidental needlestick (or other direct blood exposure), must be reported to the immediate supervisor before the end of the working shift and an Incident Investigation Report form must be completed before the end of the working shift.
a. Remove gloves and dispose of them properly.
b. Wash the area well with soap and water.
c. Make a notation of the client/patient’s name and identification number.
d. Refer to the “Occupational Exposure and Follow-up” section of the “UCL Exposure Control Plan”.
O. Client/Patient complications or reactions:
Hospital phlebotomy drawing rooms and patient rooms are equipped with a call light to summon for help. It is used any time there are client/patient complications. If no call light is available, verbally call for help. Protect the client/patient from injury. Stay with the client/patient until help arrives and the phlebotomist’s help is no longer needed. (Refer to “Initial treatment for Various Injuries” in the “Laboratory Safety Measures” section of the “UCL Safety Manual”.) The phlebotomist must anticipate reactions or complications and respond quickly and appropriately.
A small amount of pain is normally associated with a routine venipuncture. Anytime the patient complains of sharp, acute pain at the venipuncture site, the needle should be withdrawn immediately and an alternate site used.
b. Syncope (fainting):
If the person has a history of fainting or shows signs of anxiety or apprehension, have him/her lie down for the blood collection procedure. Watch for signs of increased perspiration, pale skin color, and shallow, slow breathing. If the person feels faint, remove the needle and try to prevent injury, (especially from falling). Have the person lower his/her head to supply the brain with extra blood and oxygen. If the patient has fainted, stay with him/her and use the call light or verbally call for help. Complete an “Incident Investigation Report” form.
Make the person feel as comfortable as possible and instruct him/her to take slow deep breaths. Have an emesis basin or wastebasket ready in case of vomiting.
d. Insulin shock:
Watch for signs of insulin shock in diabetic patients who have been fasting; cold sweat, pale face color, signs of weakness, being shaky or confused.
e. Nerve damage:
Any of the following symptoms may indicate nerve injury:
sensations of pain that fluctuate in severity according to needle position,
a description of “pins and needles” sensation or an “electric shock” sensation in the arm of the venipuncture,
pain that radiates (moves) up or down the arm during or immediately after venipuncture,
pain or tingling discomfort in the hand or fingertips,
acute pain, a scream of pain, or a nonverbal communication of pain during needle entry.
If any of the above symptoms are noted, remove the needle immediately and make a notation on the requisition and also an entry in the Phlebotomy Incidence Log.
P. If the client/patient cannot hold still or it is apparent he/she is extremely apprehensive about having blood drawn, ask the nursing staff or other laboratory staff to help before performing the venipuncture.
Q. Client refusal for blood collection: Refer to the general policy “Client Contact; Guidelines”.
R. A “Caution-Required” client list is kept at the reception desk at each UCL site. This list contains the names of individuals in which a witness had to be used while performing a blood collection or other laboratory procedure because of aggressive, rude, or violent behavior. The list includes patient names from all UCL sites. (Refer to “Client, Handling Abusive/Threatening” protocol.)
S. No sign of life:
If the client/patient appears deceased, do not attempt a venipuncture. Inform nursing personnel.
T. Phlebotomy Incidence Log:
Record all unusual circumstances in the Phlebotomy Incidence Log, following the “Incidence Recording” protocol in the Quality Assurance Manual.
VIII. Limitations: N.A.
IX. Results Derivation: N.A.
X. Expected Results and/or Critical Values: N.A.
XI. Quality Control: N.A.
1. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture. National Committee for Clinical Laboratory Standards (NCCLS), Second Edition, 1984.
2. Collection, Transport, and Preparation of Blood Specimens for Coagulation Testing and Performance of Coagulation Assays. National Committee for Clinical Laboratory Standards (NCCLS), December 1986.
3. Garland E. Pendergraph, Handbook of Phlebotomy, Lea & Fabiger, Philadelphia, 1988.
4. Diana Garza, Kathleen Becan-McBride, Phlebotomy Handbook, 2nd edition, Appleton & Lang, Norwalk, CT/San Mateo, California, 1989.
5. Jean M. Slockbower, Thomas A. Blumenfeld, Collection and Handling of Laboratory Specimens: A Practical Guide, J.B. Lippincott Company, 1983.
6. MAYO Clinic Laboratory, Phlebotomy Handbook, 1990
7. Deanna Klosinski, Claudia Miller, Virginia Narlock, Blood Collection: The Routine Venipuncture, ASCP Press, Chicago, 1989.
8. UCL Exposure Control Plan, 1992, 1997 and 2002
9. UCL Safety Manual, 1993, 1999 and 2002
10. Laboratory Notes; Volume 7, No. 2, Winter/Spring, 1997
7. BD Order of Draw for Multiple Tube Collections; April 2002.
8. Morbidity and Mortality Weekly Report, Vol:51, No. RR-16, pp 1-44, October 25, 2002.
9. McCall, Ruth E., and Cathee M. Tankersley, Phlebotomy Essentials, 3rd Ed., Lippincott, Williams & Wilkins, 2003.
10. Advance for Medical Laboratory Professionals, V15:9, pp 25-26; April 21, 2003.
11. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard; 5th Ed., V18:7.
12. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard; 6th Ed., V27:26.
13. Ernst, Dennis, “Blood Specimen Collection FAQs-Answers to Hundreds of the Most Frequently Asked Questions on Specimen Collection”. pp 237-242; 2008.
14. Personal correspondence with Dennis Ernst, June 2009.
i. February 1991 R. Schaefer
ii. September 1993 J.A. Schmitz (Revised: VII.8.B.d.and note; 12.B.a.; 21.A.&B.)
iii. June 1997 J.A. Schmitz (Revised: p. 3 & 9 drawing from limbs with I.V.'s.)
iv. March 1999 L. McGovern (Revised: VII.18. added note; VII.24.added T.a-d.)
v. March 2000 R. Schaefer/S. Raymond (Revised: IV.6&7., VII. 4., 9., 10., 11.B., E.Note, 12. F., 14.c., 16, 17; 19., 24.E., H.d, J.e., O.1-4, T.; XI.10.; Diagram I)
vi. January 2002 R. Schaefer (Revised: IV.; VII.5.A.,7.,9.,12., 14.,17.,20.,23.,25.R.)
vii. April 2002 R. Schaefer (Revised: VII.14.A.n., B.a., C.g.4., h.removed, 19., 25.G.b-c., H.b&d.; XII.)
viii. March 2005 R. Schaefer (Revised: IV.3.,4.,12.; VII.7.,9.,10.B.g-i.,14.Note,A.j.diagram,17.,20.D.,21.,25.B.a.4.,D.c.,G.c.,H.b.,d.Note,K.O.a.,b.,e.; XII.13-15.)
ix. August 2008 R. Schaefer (Revised: IV.2, 12.; VII.4.omit; VII.8-10.B., 11.C.&F., 12.A., 13.A.a.&e., 13.A.i.note, 13.A.n., 13.B.k.&l., 14.C.f.1-2., 16.A-B., 19.C-D., 20., 24.H.b., d-e., 24.J.; XII.12.added)
x. June 2009 R. Schaefer (Revised: II.4., 10.B.j., 12.B., 14.A.h., o., 18., 21., 23.D.note; XII.13-14.)
xi. June 2010 R. Schaefer (Revised: for Greiner tubes and Kendall wrap IV.1., 9.; VII.5.A., 21., 25.D.c.)
September 2010 T. Pfeiler (Revise: IV.9.,12.; VII.7.note,12.F.,20.D.,21.note,24.,25.J.b.; Vacutainer to vacuum tube)
December 2011 T. Gee (no changes)