Fundamentals of Phlebotomy
May 2012
Historical Origins: Superstition
Phlebotomy Today: Diagnostic tool
CP1154634-9
Potential Exposure from
Needle Stick Injuries
• 1 in 6 - Hepatitis B
• 1 in 20 - Hepatitis C
• 1 in 300 - HIV
CP1154634-9
1
Tracking at Mayo Clinic Rochester
1983-1996
Decline from 1.5 Exposures/10,000 to
0.2 Exposures/10,000
1985
1-handed recapping blocks
1987
Disposal of evacuated holders
1988
CDC Universal Precautions
1989
CDC HIV and Hepatitis B
prevention guidelines
1991
OSHA occupational exposure to
bloodborne pathogens final rule
CP1154634-27
Tracking at Mayo Clinic Rochester (cont)
1983-1996
Decline from 1.5 Exposures/10,000 to
0.2 Exposures/10,000
1992
Resheathing needles and
retractable lancets
1992
Biohazard container improvement
initiative
1994
“Clean” needle stick removed
from database
1995
Discontinued changing needles
for blood cultures
CP1154634-28
Tracking at Mayo Clinic Rochester
1983-1996
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
Frequency Rate per 10,000 punctures
CP1154634-29
2
2010 Blood/Body-Fluid Exposures
• 592 Needlestick and Blood/Body-Fluid Exposures
occurred to Mayo staff during 2010 (161 “hollow
core punctures” – or needles)
Order Entry,
Phlebotomy Supplies and
Safety
New Device / Equipment Evaluation
Device / Equipment Name_________________
Evaluation Site_______________Date of Evaluation_____________
Rating Scale
Strongly Agree (please circle)- Strongly Disagree
Is the Device Safe?
5
4
3
2
1
User Friendly?
5
4
3
2
1
Easily Adapted to
the Work Environment?
5
4
3
2
1
Better than existing
device?
5
4
3
2
1
Comments
3
Research from Center for
Disease Control (CDC)
“Research from CDC … indicates that
selecting safer medical devices could
prevent 62-88% of sharps injuries in the
hospital setting…”
Szabo J: MLO 33(3):18, 2001
CP1154634-17
Orders for Collection &
Preparing the Accession Order
• Ordering the
collection
•Physician
•Designated
healthcare
professional
• Preparing the order
for collection
•The phlebotomist
Phlebotomy Safety: Hand
Cleansing
• Soap & Water
• Waterless Hand Sanitizer
CP1154634-12
4
Safety: Latex Allergy
• Studies indicate that 5-17% of
healthcare workers show latex
sensitivity, compared to 1-6% of the
general population
• Exposure can be reduced by
switching to lower allergen
products, or by using non-latex
substitutes
CP1154634-41
Phlebotomy Supplies: Needles
5
Phlebotomy Supplies:
Evacuated / Syringe / Winged Infusion
Phlebotomy Supplies:
Skin Preparations
• 70% Isopropyl Alcohol
• Tincture of Iodine
Phlebotomy Supplies:
Gauze and Pad & Gauze Roll
6
Phlebotomy Supplies:
Capillary Collection Devices
Capillary Collection
Phlebotomy Supplies:
Needle Gauge*
* Determined by the size & condition of the vein
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Considerations
Prior to the Collection
• Thorough patient history
• Patient condition
• Time of collection
• Basal state
• Fasting
• Age
• Gender
• Diurnal or daily variations
Additional Considerations
•
•
•
•
Age
Growth
Development
Safety
Considerations
• Communication
Physical Conditions of a Patient
Affecting Blood Collections
• Stress
• Dehydration
• Strenuous exercise
• Pregnancy
• Smoking habits
• Weight, age and other
factors
8
Mayo Clinic Patient Identifiers
• Patient must state and spell their first and
last name
• Patient must state their date of birth
Patient Identification
2
1
4
3
3
3
Additional Variables to
Patient Identification
• Language or cultural barriers
• Pediatric patients
• Unidentified patients
• Unconscious patients
• Dementia, Intubated patients
and other possibilities
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NOTE:
• It is the responsibility of the phlebotomist
to perform PATIENT IDENTIFICATION
with each and every patient interaction
regardless of how many times in a work
shift the phlebotomist may see the same
patient for additional collections.
Patient Identification,
Arm Anatomy,
&
Collection Materials
Approach & Identify the Patient
•
•
•
•
Identifying yourself
Observe surroundings
Considerations
Patient to spell first &
last name
• Patient to give date of
birth
• Tech code or initial all
collection labels
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Vein Assessment
• Site selection process and anatomical
structure.
Arm Anatomy:
Preferred Sites/Veins
Cephalic Vein
Median Cubital Vein
Basilic Vein
Three Phlebotomy Methods
• Evacuated
• Syringe
• Winged Infusion (Butterfly)
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Joint Commission Recommended
Guideline
for Age Groups
•
•
•
•
•
•
•
Infant and toddlers: 0 to 3 years
Young children: 4 to 6 years
Older children: 7 to 12 years
Adolescence: 13 to 20 years
Young adults: 21 to 39 years
Middle adults: 40 to 64 years
Adults: 65+ years
Site Selection Process:
Considerations
• Burn and/or Scars
• Skin Integrity
• Edema
• Hematoma
• Mastectomy
The Venipuncture Procedure
12
Evacuated Tubes
• Color Codes
• Anticoagulated Tubes
• Citrate – light blue
• Heparin - green
• EDTA – Purple, pink, or lavender
• Oxalate/Fluoride (antiglycolytic) - gray
• Serum tubes
• Gel Separator - gold or red/black
• Non- gel separator - red
CLSI (NCCLS) H3-A5 Order of Draw
• Culture tubes (not illustrated)
• Coagulation tubes
• Serum tubes
• with or without clot activator
• with or without gel
• Heparin tubes
• with or without gel
• EDTA tubes
• Oxalate/fluoride tubes
Mayo Clinic Order of Draw
• Serum Gel Separator
• Serum (Red)
• Anticoagulant Tubes
• Citrate
• Heparin
• EDTA
• Oxalate/Fluoride
13
Evacuated Tube Considerations
• Mixing* by gentle inversion
• Fill volumes of the of tubes
* Follow manufacture's guidelines for the
number of inversions
Patient and Sample Identification
• The consequences of an incorrectly
labeled tube are the same as an
incorrectly identified patient.
Tips for Phlebotomists
• Remain calm, professional and polite
• Place no blame
• Look at all possible sites for second
collection
• Apply heat
• Consider reduced amounts
• Consult a more experienced
phlebotomist
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Specimen Transport
Specimen Processing
Hematoma forming
15
Conditions That Cause a Hematoma
• Needle placement
• Failure to remove the tourniquet before
removing the needle
• Not applying adequate pressure on the
site after the needle is removed
Needle Placement Conditions
That Cause a Hematoma
• Accessing the vein too slowly
• Needle is too deep and has gone
completely through the vein
Ways to Prevent a Hematoma
• Penetrate only the upper most vein wall
• Remove the tourniquet before removing
the needle
• Use major veins, not superficial veins
• Apply gentle pressure to the site with
gauze after needle removal and while
bandaging
16
1
2 3 4
1- Hemolyzed
2-“Normal”
3- Icteric
4- Lipemic
Acute Hemolysis
Elliott K, et al. Transfusion 43:297, 2003
Common Complications
of Phlebotomy
• Fainting
• Nausea
WHAT TO DO?
•
•
•
•
Safety of the patient is the first concern
Immediately stop procedure
Do not leave patient unattended
Call for assistance if needed
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The Venipuncture Process:
Evacuated Method
•
•
•
•
•
•
•
•
Patient Identification
Tourniquet application
Site selection & cleansing
Phlebotomy collection
Removal of the tourniquet
Remove needle and apply pressure
Wrap and secure site
Label tubes
The Venipuncture Process:
Winged Infusion with a Syringe
•
•
•
•
•
•
•
•
•
Patient Identification
Tourniquet application
Site selection & cleansing
Phlebotomy collection
Removal of the tourniquet
Remove needle and apply pressure
Wrap and secure site
Dispense blood
Label tubes
The Venipuncture Process:
Syringe Method
•
•
•
•
•
•
Patient Identification
Tourniquet application
Site selection & cleansing
Phlebotomy collection
Removal of the tourniquet
Remove needle and apply
pressure
• Wrap and secure site
• Dispense blood
• Label tubes
18
The Venipuncture Process:
Winged Infusion /Evacuated Method
•
•
•
•
•
•
Patient Identification
Tourniquet application
Site selection & cleansing
Phlebotomy collection
Removal of the tourniquet
Remove needle and apply
pressure
• Wrap and secure site
• Label tubes
References
Accuracy in Patient and Sample Identification. GP33-P. (2009). CLSI. 29(13)
Dale, J. C., Hermansen, J., McConnell, Nielsen, J. (1998). Accidental needlesticks in the phlebotomy
service of the department of laboratory medicine and pathology at Mayo Clinic Rochester.
COMMUNIQUÉ – A Mayo Medical Laboratories Publication. 23(5).
Dale, J. C., Pruett, S. K., and Maker, M. D. (1998). Accidental needlesticks in the phlebotomy service of
the department of laboratory medicine and pathology at Mayo clinic Rochester. Mayo Clinic Proceedings.
73(7). 611-613.
Procedures and Devices for the Collection of Diagnostic Blood Specimens by Skin Puncture, 5th ed. H4A6. (2004). NCCLS. 24(21).
Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens, 6th ed. H4-A6.
(2008). CLSI. 28(25).
Procedure for the Collection of Diagnostic Blood Specimens by Venipuncture, 4th ed. (1991). H3-A3.
NCCLS. 11(10).
Procedure for the Collection of Diagnostic Blood Specimens by Venipuncture, 5th ed. (2003). H3-A5.
CSLI. 23(32).
Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture, 6th Ed. (2007). H3-A6.
CLSI. 27(26)
Szabo, J. (2001). MLO. New OSHA bloodborne pathogen standard clarifies need for employers to select
safer needle devices. 33(3). 18.
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