PHLEBOTOMY PRACTICES DEPARTMENT OF BIOCHEMISTRY, LABORATORY PROCESS PRE-ANALYTICAL - PHLEBOTOMY ANALYTICAL – PROCESSING OF SAMPLES POST-ANALYTICAL – REPORTING/RELEASE ERRORS IN LABORATORY PROCESS PRE-ANALYTICAL – UPTO 70 % ANALYTICAL – UPTO 20 % POST-ANALYTICAL – UPTO 10 % PRE-ANALYTICAL – MOST IMPORTANT DEPARTMENT IN LABORATORY PRACTICE VACUTAINER ADDITIVE MODE OF ACTION USES Red top None Blood clots, and the serum is separated by centrifugation Chemistries, Immunology and Serology, Blood Bank (Crossmatch) Purple top EDTA Forms calcium salts to remove calcium Hematology (CBC) and Blood Bank (Cross match); requires full draw - invert 8 times to prevent clotting and platelet clumping Light blue top Sodium citrate Forms calcium salts to remove calcium Coagulation tests , full draw required Green top Sodium heparin or lithium heparin Inactivates thrombin and thromboplastin For lithium level, use sodium heparin For ammonia level, use sodium or lithium heparin Light gray top Sodium fluoride and potassium oxalate Anti-glycolytic agent preserves glucose up to 5 days Glucose, requires full draw (may cause hemolysis if short draw) Black top Sodium citrate (buffered) Forms calcium salts to remove calcium Wintergreen Sedimentation Rate; requires full draw ORDER OF FLOW FOR BLOOD COLLECTION TUBES • BLOOD CULTURE BOTTLES: • LIGHT BLUE TOP: Sodium citrate. Mix by inverting 8 - 10 times • RED TOP: Additive none. Mix by inverting 5 times. • GOLD TOP(GEL SEPERATOR TUBE) : by inverting 5 times • GREEN TOP: Additive heparin. Mix by inverting 8 - 10 times • PURPLE TOP: Potassium EDTA:Mix by inverting 8-10 times • LIGHT GRAY TOP: Sodium fluoride EDTA: 8-10 times • Blood should NEVER be poured from one tube to another . ORDER OF DRAW STEPS OF SAMPLE COLLECTION Step 1. Assemble equipment Step 2. Identify and prepare the patient Step 3. Select the site Step 4. Perform hand hygiene and put on gloves Step 5. Disinfect the entry site Step 6. Take blood Step 7. Fill the laboratory sample tubes in correct order Step 8. Clean contaminated surfaces and complete patient procedure REQUIREMENTS FOR PRIMARY SAMPLE COLLECTION • Hand washing facility • 70% alcohol and cotton swabs for skin sterilization • Tourniquet, Needles & Syringes • Vacutainers • Universal safety precautions PPE • Biomedical waste disposal bins PATIENT PREPARATION • Make the patient comfortable. • Guide the patient before blood collection in terms of diet , exercise, drugs intake & time. • Patient identification . Ask name, age , etc. • Check MR number • Ensure the fasting status of the patient . • A fasting specimen of 10-12 hrs is preferred for some tests. PROPER LABELING OF SPECIMENS • The vacutainers must be labeled with the patient’s name (barcode) written exactly as it appears on the test request form. • Label each specimen with the patient’s name, MR no, IP no. and lab no,etc. • Fix all labels on the sample containers. • Note date, time of drawn, identity of phlebotomist. • Fill the TRF properly & completely CORRECT TRF FORM The time of specimen collection and the identity of the phlebotomist collecting the Primary sample is recorded. PHLEBOTOMY PROCEDURE • Ensure and confirm the tests in tests requisition form. • Phlebotomist must wear sterile gloves, and apron (PPE)before collecting the blood samples from the patient/subject. • Identify the patient correctly by verifying his/her identity. • Ensure that the patient is seated comfortably. • Check for the availability of vein, apply the tourniquet app 3-5 inches above the antecubital fossa, and clean the area with alcohol swab. • Ask the patient/subject to hold his fist tightly then insert the needle into a prominent vein and collect the required amount of blood into the relevant vacutainer tube. VEINS USED FOR DRAWING BLOOD • MEDIAN CUBITAL VEIN – First choice, well supported, least apt to roll • CEPHALIC VEIN – Second choice • BASILIC VEIN – Third choice, often the most prominent vein, but it tends to roll easily and makes vein puncture difficult. • VEIN SELECTION • Choose the veins that are large and accessible. • Avoid bruised and scarred areas. • CAN’T FEEL THE VEIN? • Have the Patient “pump” the hand 3 times. • Don’t overdue it because over-pumping can create heam concentration. • Have the patient dangle arm below the heart level for 1-3 minutes. • Warm the area with a hot pack or warm, moist cloth heated to approximately 42oC • If all else fails, consult another technician for their opinion and/or intervention. VENIPUNCTURE SITE SELECTION AREAS TO BE AVOIDED : • Extensive scars from burns and surgery • Hematoma • Intravenous therapy (IV) / blood transfusions • Cannula/fistula • Edematous extremities CLEANING THE SITE • Clean the puncture site with 70% Isopropyl alcohol or alcohol swabs. • Rub the alcohol swab in a circular motion moving outward from the site; use enough pressure to remove all perspiration and dirt from the puncture site. • After cleansing do not touch the site, if the vein must be repalpated, the area must be cleansed again. PIERCING THE SKIN • Hold the prepared holder with the bevel up. • Use the thumb of the nondominant hand below the puncture site to anchor the vein and pull the skin taut. • The needle entering the site should not touch the thumb of the phlebotomist. • Position the needle in the same direction as the vein, enter the skin and penetrate the vein at a 30 degree angle in one swift, smooth motion to decrease the patient discomfort. REMOVING THE NEEDLE • Gently release the tourniquet , not more than one minute. • Remove the last tube from the needle • Withdraw the needle in a single quick movement • Quickly place clean gauze over the site, and apply pressure. • You may ask the patient to continue applying pressure until bleeding stops. • Never ask patient to bend the arm. NEEDLE DISPOSAL • Remove the needle from the holder if appropriate, and properly discard it in an approved sharps disposal container. • Discard all waste and gloves in the appropriate bio hazard waste container. • Wash hands and apply sterilizer lotion. IF AN INCOMPLETE COLLECTION,THEN... • Try another tube. Use a smaller tube with less vacuum. There may be no vacuum in the tube being used. • Re-anchor the vein. Veins sometimes roll away from the point of the needle and puncture site. • Pre-warm the region of the vein to reduce vasoconstriction and increase blood flow. • Have the patient drink fluids if dehydrated. UNWANTED EFFECTS OF FAULTY SAMPLE COLLECTION Poor venepuncture practice may result in: • Bruising, haematoma and injury to anatomical structures in the vicinity of the needle entry: Apply anti-coagulant ointment on the sample collection site. • Fainting : Call doctor THE INTEGRITY OF THE SPECIMEN • The right patient. • The right container. • The right time. • Use correct technique/site. • Label correctly and completely. • Avoid hemolysis. COMMON ERRORS IN SPECIMEN COLLECTION……… • Non fasting specimen when test requires fasting • Hemo-concentration from prolonged tourniquet tying • Unsterile container for culture • Exposure to light / extreme temperatures [vitamins] • Improperly timed specimens / Delayed delivery to laboratory COMMON ERRORS IN SPECIMEN COLLECTION:REJECTION OF SAMPLES • Mis-identification of patient • Discrepancies between requisition & specimen label • Unlabeled or mislabeled specimen • Short draws / wrong anticoagulant to blood ratio • Mixing problems / clots • Wrong tubes / wrong anticoagulant • Hemolysis HAEMOLYSIS: Means lysis of RBC which affects certain test results like Potassium, Magnesium, Iron, LDH, Phosphorus, Ammonia & Total protein. The serum/plasma will appear red instead of straw colored Causes of haemolysis : • Needle gauge too thin • Syringe plunger pulled back too fast • Expelling blood vigorously in the tubes • Mixing tubes vigorously • Collecting blood before alcohol has dried at venipuncture site IMPROPER MIXING AND OVER/UNDER FILLING • Clots in anticoagulated specimen • Failure to mix or inadequate mixing of samples collected into additive tubes. • There is clumping of red cells • Over or under filling of anticoagulant tubes. • Incorrect blood to additive ratio will adversely affect the laboratory test results. • Use pediatric vacutainers for children. • INSUFFICIENT SAMPLE (QNS):When many tests are ordered on the same patient, be sure to know the amount of sample needed for each test. • WRONG TUBE: Sample collected in wrong vacutainer for test ordered. • IMPROPER STORAGE & TRANSPORT: Certain tests must be collected and placed on ice, protected from light, or be kept warm after collection. CRITICAL ALERT RESULTS • Some laboratory results are life-threatening to patients unless something is done promptly. Such results/reports are termed as critical /alert results. • Critical /alert results once received in the nursing station must be communicated/informed urgently to the corresponding doctor without fail. • List of critical results is available in all nursing stations. MAKE USE OF DOS & PSCM • The entire list of laboratory tests is available in soft copy format on your desktop systems named as DIRECTORY OF SERVICES-DOS. • The details of sample collection is given in the primary sample collection manual, available as PSCM file on the system. PRIMARY SAMPLE COLLECTION MANUAL : PSCM DIRECTORY OF SERVICES:DOS DIRECTORY OF SERVICES:DOS DIRECTORY OF SERVICES:DOS THANK YOU !
