Venipuncture, Inpatient

PRINCIPLE

Proper collection of blood specimens is of the utmost importance in producing valid laboratory results. Following proper venipuncture standards will produce biologically representative specimens for analysis as well as minimal discomfort for the patient.

PATIENT PREPARATION

1. Patient Greeting. Greet the patient using the “AIDET” technique which includes: Acknowledge, Introduce, Duration, Explanation, and Thank You.  This will help put the patient and ease during the procedure. Other notes:
   1. Inpatients:      If physician is in room or if a procedure is in progress, excuse yourself and return at another time.
   2. Children:        Be friendly, calm and confident reassuring the child and parent to limit the anxiety and in obtaining their cooperation. Prepare equipment prior to draw and out of sight to prevent any additional anxiety.  At CRMC, coordinate with RN to see if topical anesthetic will be applied on inpatient pediatric patients.

2. Patient Identification:
   1. Inpatients must be positively identified via their hospital Identification band attached to the patient.
      1. If patient is coherent, ask the patient to state his or her first and last name.  The collector must verify name and Medical Record on the armband with the request for laboratory work.
      2.  Verify visually or by Positive Identification Device (PID) procedure#16968.
      3. The request may be in the form of a laboratory requisition or computer generated labels.
   2. Outpatients must be positively identified verbally.
      1. Ask the patient or companion to say the patient’s name and birth date or social security number.
      2. Verify this information with the outpatient requisition presented with the patient.
      3. Enter on requisition any requested clinical data, e.g. height, weight.
      4. Verify that all requested tests have been ordered appropriately.

3. Order Verification:
   1. If fasting or other diet restrictions are required for requested tests, verify that these conditions have been met.
   2. Verify any special timing requirements for collection, e.g., peak or trough drug levels, cardiac enzymes, timed glucose levels, stimulation tests.
   3. Follow appropriate age specific criteria as indicated in resource manual for Community Medical Centers Laboratories Age Specific Criteria for Specimen Collection.
       

EQUIPMENT and MATERIALS

1. Gloves- disposable, single use, nitrile (Use of special Hypersensitive gloves if approved by Employee Health.)
2. Tourniquet, non-latex
3. 70% isopropyl alcohol pads.
4. 2X2 gauze pads
5. Paper tape.
6. Sterile evacuated tubes, e.g., Vacutainers.
7. Biohazard bag for transport.  Rack for Outpatients.
8. Ice in cup or biohazard bag, if applicable for test.
9. Venipuncture Supplies (specific to collection method):

Direct draw method with Vacutainer holder	Sterile multi-sample needles 21 or 22 gauge
	Holder Device with safety mechanism
For Direct Draw method with Butterfly and vacutainer holder	21g or 23g Saf-T Wing Blood Collection Set with Holder 25g may be used on very small veins
For Direct Draw method with Butterfly, syringe and Transfer device	21g or 23g Saf-T Wing Blood Collection Set with syringe 25g may be used on very small veins

PROCEDURE - STEPWISE

1. Complete patient preparation and order review steps as indicated in Patient Preparation above.
2. Wash hands or use Gelsan™ alcohol based hand cleaner.
3. Put on Gloves.  Clean gloves must be worn when performing venipuncture. If veins are difficult to palpate and skin is intact, initial site selection may be performed before gloves are donned. Gloves must be changed after each patient and when visibly contaminated.
4. Venipuncture Site Selection.
   1. The antecubital fossa is generally the most accessible site and causes less pain to the patient. The median cubital vein should be considered first as this is usually stable and not in close proximity of nerves. The cephalic and basilic veins should be secondary sites since they normally are closer to surrounding nerves. Care must be taken to avoid the brachial artery when using the basilic vein. Dorsal wrist and hand veins are acceptable for venipuncture when the antecubital area is unavailable. See procedure note #2.
   2. Position patient. Have patient extend arm to form a straight line from shoulder to wrist.
   3. Apply a tourniquet 3-4 inches above venipuncture site with enough pressure to restrict the vein but not an artery. If adequate pressure is used, a radial pulse can still be felt. Do not leave the tourniquet in place for more than one minute as hemoconcentration may occur resulting in falsely elevated values for protein based analytes and packed cell volume.  Reapply tourniquet just prior to puncture.
   4. Have patient close fist to make veins more prominent and easier access. Do not pump. Palpate the vein for depth and direction. Veins should have a spongy or elastic feel vs. tendons that have a hard and ropelike feel. Avoid thrombosed veins that lack resilience, feel hard and roll easily. If veins are not readily apparent, tapping gently at the site with index fingers may help dilate the vein. Warming the site may also be useful in making a vein more prominent. Blood can also be forced into the vein by massaging the arm from wrist to elbow.
   5. Alternative sites – Dorsal wrist or hand veins are acceptable. Ankles or lower extremities may be used with physician approval. Documentation of approval is to be placed in specimen comment in LIS system (SOFT).
5. Draw Method selection.  Choose one of these methods as appropriate for patient type and status.
   1. Direct draw with straight multi-sample needle and holder.  Appropriate for routine draws in the antecubital area.
   2. Direct draw with a winged collection set with multi-sample vacutainer tube holder.  Appropriate for small veins and the wrist/hand area where veins are close to the surface of the skin.
   3. Direct draw with a winged collection set with a syringe.  May be used for extremely fragile veins where collapse is likely for blood culture collection.
6. Venipuncture Site preparation:  Clean the site using 70% isopropanol in a circular motion from center to periphery. Dry the area with 2x2 gauze or allow to air dry while preparing equipment. This prevents pain and hemolysis. Do not retouch. If vein must be touched it must be cleansed again.

Venipuncture Procedure:  Select one method

1. Apply pressure to Venipuncture site.  A bandage of gauze and paper tape may be applied. Always ensure that bleeding has ceased before leaving patient. Tell patient to leave on bandage for at least 15 minutes.
8. Dispose of all contaminated material into appropriate biohazard containers
9. LABEL ALL TUBES AT THE BEDSIDE. Use barcode labels for samples or hand label.  Label must contain:
   1. Patient First and Last Name
   2. Medical record Number
   3. Date and time of specimen collection
   4. Initials of collector (if using the PID system, this may be done electronically).

PROCEDURE NOTES

1. Vacutainer Tube Draw order- Proper order of filling evacuated tubes must be followed to avoid possible contamination of samples. Fill in the following order:
   1. Blood culture bottles
   2. Blue (citrate):  Note: When using a butterfly and a blue coagulation tube is the first to be drawn, first use a discard tube (use either a CLEAR RED tube with no additives or a second blue top tube). The first tube is used to displace the air in the butterfly tubing.  Once blood reaches the discard tube, it can be replaced with the blue collection tube for testing. This ensures that the specimen tube can be filled to the FILL LINE and that the proper anticoagulant/blood ratio is maintained.
   3. Red- Serum
   4. Gold- Serum with separator gel (SST)
   5. Orange - Rapid Serum Tube (RST)
   6. Dark Green for whole blood or Light green with separator gel (PST)- heparin
   7. Lavender –EDTA (LAV)
   8. Pink – EDTA
   9. Gray -oxalate/fluoride
2.  Non-routine draw site selection and notes:
   1. Avoid sites containing shunts, vascular grafts, and fistula/cannulas.
   2. Avoid healed burn areas, extensive scarring areas, and existing hematomas.
   3. Avoid sclerosed or hardened veins as these do not allow blood to flow through them easily.
   4. Mastectomy guidance:  Physician approval must be obtained before drawing blood from the same side as where mastectomy has been performed.
   5. IV Therapy - Blood should not be taken from above an active IV site as hemodilution will occur. If no other site is available, the IV flow must be stopped for at least 5 minutes before drawing blood above the site (IV stops and restarts must be performed by the patient’s Nurse).  Document in the Soft system under specimen comment.
   6. When the antecubital fossa is not an accessible site, dorsal wrist or hand veins may be used. Veins on the inside of the wrist should be avoided, if possible, as nerves, tendons and the radial artery are all in close proximity.
   7. Never draw from a heparin lock or line. Never allow a parent to draw from their own child.
   8. Foot and Ankle veins – Physician approval must be sought before proceeding to draw foot and ankle veins. Approval must be documented in SOFT system under specimen comment.
   9. Phlebotomists are not licensed to draw from a heparin lock or line.
   10. Never allow a parent to draw from their own child.
3. Preventing hemolyzed samples
   1. Invert tubes gently, do not shake.
   2. Never apply pressure to syringe plunger when filling evacuated tubes.
   3. Avoid using a small gauge needle. 21 gauge is recommended for standard venipuncture. Blood should not routinely be collected with a needle smaller than 23 gauge.
   4. Do not choose a site where a hematoma is present. If no other site available, draw just below the hematoma.
   5. Avoid excessive force when pulling back on syringe plunger.
   6. Allow alcohol(isopropanol) from wipe to dry thoroughly before puncture is made.
   7. Allow blood to flow down the side of the tube when filling with a syringe.
4. When the specimen cannot be obtained –
   1. Slightly change the position of the needle.  Varying the angle may increase blood flow. Small re-positioning movements are acceptable, do not probe. If penetrated to far, pull needle back slightly. If needle is not in far enough, advance slightly further into vein.
   2. Try another tube, occasionally tubes have lost vacuum.
   3. Loosen the tourniquet, it may have been tied too tightly and restricting blood flow.
   4. After two unsuccessful venipuncture attempts, seek another person to draw the specimen.
   5. Needles are single use and may be used only once. A needle must be discarded if it has pierced the skin, whether or not the venipuncture was successful.
   6. If after multiple sticks and at least 2 different phlebotomists have tried, contact the patient’s nurse who will contact the ordering physician to determine the next course of action. For outpatients, reschedule or try on another day. Notify physician.
5. Blood Culture Collection Notes:
   1. Blood cultures may be collected using one of the following methods:
      1. Direct draw method consisting of a Saf-T Wing Blood collection set and Blood Collection male Adapter Cap.
      2. Direct draw method consisting of a Saf-T Wing Blood Collection set and syringe.  Use a Female Adapter to safely transfer blood from the syringe to the blood culture bottles.

SPECIAL SAFETY PRECAUTIONS

Follow all CMC safety and infection control procedures.

SPECIMEN HANDLING REQUIREMENTS

1. Mix all tubes with anticoagulant by gentle inversion at least 8-10x times.
2. Place samples in biohazard bag for delivery to Lab.
3. Samples can be sent to the laboratory through the Pneumatic Tube System (PTS) if available.

SPECIMEN STORAGE REQUIREMENTS

General guidance:

• Inpatients:  Deliver specimens to Lab within 30 minutes of collection.
• Outpatients:  Deliver processed specimens hourly according to main laboratory. Stat specimens as needed.

VENIPUNCTURE OR PATIENT PROBLEMS