Why Is It Important For Health Care Workers To Follow The Correct Order Of Draw During Venipuncture?

This chapter covers all the steps recommended for safe phlebotomy and reiterates the accepted principles for blood cartoon and claret drove (31). The chapter includes background information (Department 2.1), practical guidance (Section 2.ii) and illustrations (Section 2.3) relevant to best practices in phlebotomy.

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

Institutions tin can apply these guidelines to constitute standard operating procedures. Such procedures should clearly state the risks to patients and health workers, likewise equally the means to reduce those risks – discussed below in Sections two.ane.4 and 2.2.

ii.i. Background information on all-time practices in phlebotomy

Best practices in phlebotomy involve the following factors:

planning ahead;
using an appropriate location;
standards for quality care 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 grooming in phlebotomy;

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

2.1.1. Planning ahead

This is the most important function of carrying out any procedure, and is usually washed at the start of a phlebotomy session.

2.1.two. Using an appropriate location

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

two.1.three. Quality control

Quality balls is an essential part of all-time exercise in infection prevention and control (i). In phlebotomy, it helps to minimize the run a risk of a mishap. Table ii.1 lists the main components of quality balls, and explains why they are important.

Tabular array 2.ane

Elements of quality balls in phlebotomy.

ii.ane.4. Quality treat patients and health workers

Several factors can improve safety standards and quality of care for both patients and wellness 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 up phlebotomy services. Management should:

provide paw-hygiene materials (lather and water or alcohol rub), well-fitting non-sterile gloves, single-use 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 foreclose dangerous practices (east.1000. decanting blood to recycle laboratory tubes).

Several safety-engineered devices are bachelor on the market; such devices reduce exposure to blood and injuries. However, the use of such devices should be accompanied by other infection prevention and command practices, and grooming in their employ. Not all condom devices are applicable to phlebotomy. Before selecting a safety-engineered device, users should thoroughly investigate available devices to decide their advisable use, compatibility with existing phlebotomy practices, and efficacy in protecting staff and patients (12, 33). Annex B provides further information on infection prevention and control, safe equipment and all-time practise; Annex C provides a comprehensive guide to devices available for drawing blood, including safety-engineered equipment.

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

Where safety-engineered devices are non bachelor, skilled use of a needle and syringe is adequate.

Availability of post-exposure prophylaxis

Adventitious exposure and specific information almost an incident should exist recorded in a annals.

Support services should exist promoted for those who undergo accidental exposure. PEP can help to avert HIV and hepatitis B infections (13, 27). Hepatitis B immunization should be provided to all wellness workers (including cleaners and waste product handlers), either upon entry into health-care services or as function 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 upwardly to 25% of tourniquets contaminated through lack of hand hygiene on the role of the phlebotomist or reuse of contaminated tourniquets (35). In improver, reusable finger-prick devices and related point-of-care testing devices (e.g. glucometers) contaminated with blood have been implicated in outbreaks of hepatitis B (four, 5, 36).

To avoid contamination, any common-use items, such as glucometers, should be visibly make clean earlier use on a patient, and unmarried-employ items should not exist reused.

Training in phlebotomy

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

Groups of health workers who historically are not formally trained in phlebotomy should exist encouraged to have up such training; lax infection prevention and control practices consequence in poor safety for staff and chance to patients (xx, 37).
The length and depth of training will depend on local conditions; all the same, the training should at least encompass the essentials (see Annex Due east) (38).
Supervision by experienced staff and structured preparation is necessary for all wellness workers, including physicians, who undertake blood sampling.

Patient cooperation

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

Clear data – either written or verbal – should be bachelor to each patient who undergoes phlebotomy. Annex F provides sample text for explaining the blood-sampling process to a patient.

2.i.5. Quality of laboratory sampling

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

knowledge of staff involved in blood collection;
utilise of the correct estimate of hypodermic needle (see Table 3.1 in Chapter 3) to forbid haemolysis or abnormal results;
the anatomical insertion site for venepuncture;
the use of recommended laboratory collection tubes;
patient–sample matching (i.east. labelling);
transportation weather;
interpretation of results for clinical direction.

2.2. Practical guidance on all-time practices in phlebotomy

two.two.1. Provision of an advisable location

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

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

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

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

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at the patient's bedside, close the bed drape to offer privacy

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

2.two.two. Provision of clear instructions

Ensure that the indications for blood sampling are clearly defined, either in a written protocol or in documented instructions (east.1000. in a laboratory class).

ii.2.3. Procedure for cartoon claret

At all times, follow the strategies for infection prevention and command listed in Table two.ii.

Tabular array 2.2

Infection prevention and control practices.

Step ane. Assemble equipment

Collect all the equipment needed for the procedure and identify it inside safe and like shooting fish in a barrel reach on a tray or trolley, ensuring that all the items are conspicuously visible. The equipment required includes:

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

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

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vacuum-extraction claret tubes; or

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drinking glass tubes with screw caps;
a sterile glass or bleeding pack (collapsible) if large quantities of blood are to be nerveless;
well-fitting, non-sterile gloves;
an assortment of blood-sampling devices (prophylactic-engineered devices or needles and syringes, see beneath), of dissimilar sizes;
a tourniquet;
booze hand 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, but away from the patient, to avoid it being accidentally tipped over.

Step 2. Identify and prepare the patient

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

Introduce yourself to the patient, and enquire the patient to state their full name.
Check that the laboratory form matches the patient's identity (i.east. match the patient's details with the laboratory form, to ensure accurate identification).
Ask whether the patent has allergies, phobias or has ever fainted during previous injections or blood draws.
If the patient is anxious or afraid, reassure the person and enquire what would make them more comfortable.
Make the patient comfy in a supine position (if possible).
Place a clean paper or towel under the patient's arm.
Discuss the exam to be performed (run into Annex F) and obtain exact consent. The patient has a right to pass up a examination at whatsoever time before the claret sampling, so it is important to ensure that the patient has understood the procedure.

For paediatric or neonatal patients, come across Chapter half-dozen.

Footstep 3. Select the site

General

Extend the patient's arm and audit the antecubital fossa or forearm.
Locate a vein of a good size that is visible, straight and articulate. The diagram in Section 2.iii, shows mutual positions of the vessels, only many variations are possible. The median cubital vein lies between muscles and is usually the virtually easy to puncture. Under the basilic vein runs an artery and a nerve, and then puncturing here runs the risk of damaging the nervus or artery and is ordinarily more painful. DO Non insert the needle where veins are diverting, because this increases the take a chance of a haematoma.
The vein should be visible without applying the tourniquet. Locating the vein will help in determining the correct size of needle.
Apply the tourniquet about 4–v finger widths above the venepuncture site and re-examine the vein.

Hospitalized patients

In hospitalized patients, practice not have blood from an existing peripheral venous access site considering this may give false results. Haemolysis, contagion and presence of intravenous fluid and medication can all alter the results (39). Nursing staff and physicians may access central venous lines for specimens following protocols. However, specimens from central lines acquit a chance of contamination or erroneous laboratory test results.

It is adequate, but not ideal, to draw blood specimens when first introducing an in-dwelling venous device, before 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 easily are not visibly contaminated, clean with booze rub – use iii ml of alcohol rub on the palm of the paw, and rub it into fingertips, back of hands and all over the hands until dry.

Step v. Disinfect the entry site

Unless drawing claret cultures, or prepping for a claret collection, clean the site with a lxx% alcohol swab for 30 seconds and allow to dry completely (thirty seconds) (xl–42).

Note: booze is preferable to povidone iodine, because blood contaminated with povidone iodine may falsely increase levels of potassium, phosphorus or uric acrid in laboratory examination results (6, 7).
Apply firm merely gentle force per unit area. Start from the centre of the venepuncture site and work down and outwards to encompass an area of 2 cm or more.
Allow the area to dry out. Failure to permit enough contact time increases the run a risk of contamination.
Do Not touch the cleaned site; in detail, Practise Non place a finger over the vein to guide the shaft of the exposed needle. It the site is touched, repeat the disinfection.

Stride 6. Have blood

Venepuncture

Perform venepuncture as follows.

Anchor the vein by holding the patient's arm and placing a thumb BELOW the venepuncture site.
Enquire the patient to form a fist then the veins are more prominent.
Enter the vein swiftly at a thirty caste angle or less, and continue to introduce the needle along the vein at the easiest bending of entry.
One time sufficient blood has been collected, release the tourniquet BEFORE withdrawing the needle. Some guidelines advise removing the tourniquet as soon as blood flow is established, and ever earlier information technology has been in identify for ii minutes or more.
Withdraw the needle gently and utilize gentle pressure to the site with a clean gauze or dry cotton-wool ball. Ask the patient to hold the gauze or cotton wool in place, with the arm extended and raised. Ask the patient NOT to curve the arm, because doing and then causes a haematoma.

Step 7. Fill the laboratory sample tubes

When obtaining multiple tubes of claret, apply evacuated tubes with a needle and tube holder. This organization allows the tubes to exist filled direct. If this system is not bachelor, apply a syringe or winged needle set up instead.
If a syringe or winged needle prepare is used, best exercise is to place the tube into a rack earlier filling the tube. To forestall needle-sticks, utilise one hand to fill the tube or use a needle shield between the needle and the paw belongings the tube.
Pierce the stopper on the tube with the needle directly above the tube using boring, steady pressure. Do not press the syringe plunger considering boosted pressure increases the hazard of haemolysis.
Where possible, go along the tubes in a rack and move the rack towards you. Inject downwards into the advisable coloured stopper. Practise NOT remove the stopper considering it will release the vacuum.
If the sample tube does not take a rubber stopper, inject extremely slowly into the tube as minimizing the pressure and velocity used to transfer the specimen reduces the chance of haemolysis. Do Non epitomize and remove the needle.
Before dispatch, invert the tubes containing additives for the required number of times (as specified by the local laboratory).

Pace 8. Draw samples in the correct guild

Describe blood collection tubes in the correct society, to avoid cross-contamination of additives between tubes. As color coding and tube additives may vary, verify recommendations with local laboratories. For analogy purposes, Tabular array ii.3 shows the revised, simplified recommended order of draw for vacuum tubes or syringe and needle, based on United States National Committee Clinical Laboratory Standards consensus in 2003 (43).

Table 2.iii

Recommended order of draw for plastic vacuum tubes.

Step 9. Make clean contaminated surfaces and complete patient procedure

Discard the used needle and syringe or blood sampling device into a puncture-resistant sharps container.
Cheque the label and forms for accuracy. The characterization should be clearly written with the data required by the laboratory, which is typically the patient'due south start and terminal names, file number, appointment of birth, and the date and fourth dimension when the blood was taken.
Discard used items into the appropriate category of waste matter. Items used for phlebotomy that would non release a driblet of blood if squeezed (e.g. gloves) may exist discarded in the general waste, unless local regulations land otherwise.
Recheck the labels on the tubes and the forms earlier acceleration.
Inform the patient when the procedure is over.
Inquire the patient or donor how they are feeling. Check the insertion site to verify that it is non bleeding, and so thank the patient and say something reassuring and encouraging before the person leaves.

Step 10. Prepare samples for transportation

Pack laboratory samples safely in a plastic leak-proof bag with an outside compartment for the laboratory request course. Placing the requisition on the outside helps avoid contamination.
If in that location are multiple tubes, identify 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.1000. considering of a laboratory sample breaking in the phlebotomy area or during transportation, or excessive bleeding during the procedure), clean it upwards. An example of a safe procedure is given below.

Put on gloves and a gown or frock if contamination or bleaching of a compatible is probable in a big spill.
Mop up liquid from big spills using paper towels, and place them into the infectious waste.
Remove as much blood as possible with wet cloths before disinfecting.
Assess the surface to see whether it will be damaged by a bleach and h2o solution.
For cement, metal and other surfaces that can tolerate a stronger bleach solution, food the area with an approximately 5000 parts per 1000000 (ppm) solution of sodium hypochlorite (i:x dilution of a v.25% chlorine bleach to water). This is the preferred concentration for large spills (44). Leave the area wet for 10 minutes.
For surfaces that may exist corroded or discoloured by a strong bleach, clean carefully to remove all visible stains. Make a weaker solution and get out it in contact for a longer period of time. For instance, an approximately 525 ppm solution (1:100 dilution of v.25% bleach) is constructive.
Set up bleach solution fresh daily and go along it in a closed container because it degrades over fourth dimension 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 written report, as described in WHO all-time practices for injections and related procedures toolkit. For transportation of blood samples outside a infirmary, equip the transportation vehicle with a blood spillage kit. Annex H has farther data on dealing with a blood spillage.

2.3. Illustrations for best practices in phlebotomy

Figure ii.2 Filling tubes

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

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