CLSI (Clinical and Laboratory Standards Institute) Order of Draw 1. Blood culture tube or bottles 2. Sodium citrate tube(e.g., light blue-top coagulation tube) 3. Serum tube with or without clot activator, with or without gel(e.g., red, red/gray mottled, or gold stopper) 4. Heparin tube with or without gel (e.g., light or dark green top, green/gray mottled) 5. EDTA tube with or without gel separator (e.g., lavender/purple, pink, or white/pearl top) 6. Sodium fluoride/potassium oxalate glycolytic inhibitor (e.g., gray top) Order of Draw Blood cultures (sterile collections) Tube Stopper Color Yellow SPS Sterile media bottles Coagulation tubes Light blue Glass non-additive tubes Red Plastic clot activator tubes Red Serum-separator tubes (SSTs) Heparin tubes with gel/plasmaseparator Heparin tubes Red and gray rubber Gold plastic Green and gray rubber Light-green plastic Green Rationale for Collection Order Minimizes chance of microbial contamination The first additive tube in the order because all other additive tubes affect coagulation tests Prevents contamination by additives in other tubes Filled after coagulation tests because silica particles activate clotting and affect coagulation tests (carryover of silica into subsequent tubes can be overridden by anticoagulant in them) Heparin affects coagulation tests and interferes in collection of serum specimens; it causes the least interference in tests other than coagulation tests Heparin affects coagulation tests and interferes in collection of serum specimens; it EDTA tubes with Lavender, pink, purple Pearl/white top Oxalate/fluoride tubes Gray causes the least interference in tests other than coagulation tests Responsible for more carryover problems than any other additive: Elevates Na and K levels, chelates and decreases calcium and iron levels, elevates PT and PTT results Sodium fluoride and potassium oxalate affect sodium and potassium levels, respectively. Filled after hematology tubes because oxalate damages cell membranes and causes abnormal RBC morphology. Oxalate interferes in enzyme reactions Carryover/Cross-Contamination- is the transfer of additive from one tube to the next. It can occur when blood in an additive tube touches the needle during ETS blood collection or when blood is transferred from a syringe into ETS tubes. KEYPOINT: EDTA in tubes has been the source of more carryover problems than any other additive. Heparin causes the least interference in tests other than coagulation tests because it also occurs in blood naturally. Tissue Thromboplastin Contamination- Tissue thromboplastin, a substance present in tissue fluid, activates the extrinsic coagulation pathway and can interfere with coagulation tests. Although tissue thromboplastin is no longer thought to pose a clinically significant problem for prothrombin time (PT/INR), partial thromboplastin time (PTT or aPTT), and some special coagulation tests unless the draw is difficult and involves a lot of needle manipulation, it may compromise results of other coagulation tests. Therefore, unless there is documented evidence to show the test is unaffected by tissue thromboplastin any time a coagulation test other than a PT/INR or PTT/aPTT is the first or only tube collected, a few milliliters of blood should be drawn into a non-additive tube or another coagulation tube before it is collected. The extra tube is called a clear or discard tube because it is used to remove (or clear) tissue fluid from the needle and is then thrown away. Microbial Contamination- Blood cultures detect microorganisms in the blood and require special sitecleaning measures prior to collection to prevent contamination of the specimen by microorganisms that are normally found on the skin collected first in the order of draw to ensure that they are collected when sterility of the site is optimal and to prevent microbial contamination of the needle from the unsterile tops of tubes used to collect other tests. Blood cultures do not often factor into the sequence of collection because they are typically drawn separately. KEYPOINT: Contamination of blood culture bottles can lead to false-positive results and inappropriate or delayed care for the patient. Blood Collection Equipment Blood-Drawing Station- A blood-drawing station is a dedicated area of a medical laboratory or clinic equipped for performing phlebotomy procedures on patients, primarily outpatients sent by their physicians for laboratory testing, special chair where the patient sits during the blood collection procedure, and a bed or reclining chair for patients with a history of fainting, persons donating blood, and other special situations. Phlebotomy Chairs- Patients who have their blood drawn while in a seated position must be seated in a commercial phlebotomy chair, or at a minimum, a comfortable chair with arm rests to provide support for the arm and prevent falls. Caution: In the absence of a commercial phlebotomy chair, precautions must be taken to prevent falls and ensure client safety. Equipment Carriers- Equipment carriers make blood collection equipment portable. This is especially important in a hospital setting and other instances in which the patient cannot come to the laboratory precautions and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen standard require the wearing of gloves when performing phlebotomy. Nonsterile, disposable nitrile, neoprene, polyethylene, and vinyl examination gloves are acceptable for most phlebotomy procedures. A good fit is essential, latex gloves are not recommended. Antiseptics- (from Greek anti, “against” and septikos, “putrefactive”) are substances used to prevent sepsis, which is the presence of microorganisms or their toxic products within the bloodstream. Antiseptics prevent or inhibit the growth and development of microorganisms but do not necessarily kill them. The antiseptic most commonly used for routine blood collection is 70% isopropyl alcohol (isopropanol) in individually wrapped prep pads. Examples of Antiseptics Used in Blood Collection 70% ethyl alcohol 70% isopropyl alcohol (isopropanol) Benzalkonium chloride (e.g., Zephiran chloride) Chlorhexidine gluconate Hydrogen peroxide Povidone-iodine (0.1% to 1% available iodine) Tincture of iodine Disinfectants- are chemical substances or solutions regulated by the Environmental Protection Agency (EPA) that are used to remove or kill microorganisms on surfaces and instruments. They are stronger, more toxic, and typically more corrosive than antiseptics and are not safe to use on human skin. Hand Sanitizers- alcohol-based hand sanitizers for routine decontamination of hands as a substitute for handwashing provided that the hands are not visibly soiled Gauze Pads- used to hold pressure over the site following blood collection procedures.available to help prevent contamination of gloves from blood at the site Handheld Carriers- variety of styles and sizes designed to be easily carried by the phlebotomist and to contain enough equipment for numerous blood draws. They are convenient for STAT or emergency, situations or when relatively few patients need blood work. Bandages- Adhesive bandages are used to cover a blood collection site after the bleeding has stopped.It is also used to form a pressure bandage following arterial puncture or venipuncture in patients with bleeding problems. Phlebotomy Carts- They normally have several shelves to carry adequate supplies for obtaining blood specimens from many patients. Carts are commonly used for early-morning hospital phlebotomy rounds, when many patients need lab work, and for scheduled “sweeps” Carts are bulky and a potential source of nosocomial infection; they are not normally brought into patients’ rooms. Instead, they are parked outside in the hallway. A tray of supplies to be taken into the room is often carried on the cart. Needle and Sharps Disposal Containers- Used needles, lancets, and other sharp objects must be disposed of immediately in special containers referred to as sharps containers Gloves and Glove Liners- The Centers for Disease Control and Prevention-Healthcare Infection Control Practices Advisory Committee (CDC/HICPAC) standard Slides- glass microscope slides are used to make blood films for hematology determinations Pen- A phlebotomist should always carry a pen with permanent, nonsmear ink to label tubes and record other patient information. Watch- A watch, preferably with a sweep second hand or timer, is needed to accurately determine specimen collection times and time certain tests. Patient Identification Equipment- Many healthcare facilities use barcode technology to identify patients. The barcode is on the ID band and phlebotomists carry barcode readers to identify patients and generate labels for the specimen tubes. Venipuncture Equipment: Tourniquet- A tourniquet is a device that is applied or tied around a patient’s arm prior to venipuncture to compress the veins and restrict blood flow. Non-additive Tubes- Very few tubes are additive free. Even serum tubes need an additive to promote clotting if they are plastic. The few non-additive plastic tubes available are used for clearing or discarding purposes and limited other uses. Stoppers- Tube stoppers are typically made of a type of rubber that is easily penetrated with a needle but seals itself when the needle is removed. Some tubes have a rubber stopper covered by a plastic shield. Color Coding- Tube stoppers are color coded. For most tubes, the stopper color identifies a type of additive placed in the tube by the manufacturer for a specific purpose Needles- Phlebotomy needles are sterile, disposable, and designed for a single use only. Multisample needles: (Evacuated Tube System)- hypodermic needles (butterfly)- Syringe system Evacuated Tube System- It is a closed system in which the patient’s blood flows through a needle inserted into a vein directly into a collection tube without exposure to air or outside contaminants. The system allows numerous tubes to be collected with a single venipuncture. Multisample Needles-ETS needles are called multisample needles because they allow multiple tubes of blood to be collected during a single venipuncture. Tube Holders-A tube holder is a clear, plastic, disposable cylinder with a small threaded opening at one end (often also called a hub) where the needle is screwed into it and a large opening at the other end where the collection tube is placed. Needle and Holder Units-Needle and tube-holder devices are available permanently attached as a single unit or as both devices preassembled. Preassembled devices are often sealed in sterile packaging for use in sterile applications. Evacuated Tubes- are used with both the ETS and the syringe method of obtaining blood specimens. Additive Tubes- Most ETS tubes contain some type of additive.An additive is any substance placed within a tube other than the tube stopper or if the tube is glass, the silicone coating. Tube additives have one or more specific functions, such as preventing clotting or preserving certain blood components. Arterial Puncture The three main sites where arteries are accessed for specimen collection in order of selection are the wrist, the antecubital area of the arm, and the groin. The arteries accessed in these areas are as follo ws: Radial Artery- The first choice and most commonly used site for arterial puncture is the radial artery, located on the thumb side of the wrist. Although smaller than arteries at other sites, it is easily accessible in most patients. The biggest advantage of using the radial artery is the presence of good collateral circulation. Under normal circumstances, both the radial artery and the ulnar artery (see Fig. 14-2) supply the hand with blood. If the radial artery were accidentally damaged as a result of an arterial puncture, the ulnar artery would still supply the hand with blood. Consequently, the ulnar artery is normally off-limits for arterial specimen collection. Brachial Artery- is the second choice for arterial puncture. It is located in the medial anterior aspect of the antecubital fossa near the attachment of the biceps muscle. Femoral Artery- is the largest artery used for arterial puncture. It is located superficially in the groin, lateral to the pubic bone, femoral puncture is performed primarily by physicians and specially trained. Arterial Blood Gases: the main reason for performing arterial puncture is to obtain blood specimens for ABGs, which are collected to evaluate respiratory function. Arterial blood is the best specimen for evaluating respiratory function because of its normally high oxygen content and consistency of composition. Patient Preparation and Assessment: -The patient must be relaxed and in a comfortable position. He or she should be lying in bed or seated comfortably in a chair for a minimum of five minutes or until breathing has stabilized. Steady State- Current body temperature, breathing pattern, and the concentration of oxygen inhaled affect the amount of oxygen and carbon dioxide in the blood. Consequently, a patient should have been in a stable or steady state (i.e., no exercise, suctioning, or respirator changes) for at least 20 to 30 minutes before the blood gas specimen is obtained. Modified Allen Test- It must be determined that the patient has collateral circulation before arterial puncture is performed. The modified Allen test is an easy way to assess collateral circulation before collecting a blood specimen from the radial artery. Radial ABG Procedure: Puncture of the radial artery can be performed only if it is determined that there is collateral circulation provided by the ulnar artery and the site meets other selection criteria previously described. The major points of radial ABG procedure are explained as follows: Position the Arm: Position the patient’s arm out to the side, away from the body (abducted) with the palm facing up and the wrist supported. (A rolled towel placed under the wrist is typically used to provide support.) Ask the patient to extend the wrist at approximately a 30-degree angle to stretch and fix the tissue over the ligaments and bone of the wrist. Locate the Artery: Use the index finger of your non-dominant hand to locate the radial artery pulse proximal to the skin crease on the thumb side of the wrist. Palpate the artery to determine its size, direction, and depth. Take your time palpating the artery to verify the optimal point of entry. Clean the Site: Prepare the site by cleaning it with alcohol or another suitable antiseptic. Allow the site to air-dry, being careful not to touch it with any unsterile object. Prepare Equipment: Attach the safety needle to the syringe if not preassembled, and set the syringe plunger to the proper fill level if applicable. Put on gloves if they were not previously put on and clean the gloved non-dominant finger so that it does not contaminate the site when relocating the pulse before needle entry. Insert the Needle: Pick up and hold the syringe or collection device in your dominant hand as if you were holding a dart. Uncap and inspect the needle for defects. Advance the Needle Into the Artery: Slowly advance the needle, directing it toward the pulse beneath the index finger. When the artery is pierced, a “flash” of blood will appear in the needle hub. Withdraw the Needle and Apply Pressure: With draw the needle, immediately place a folded clean and dry gauze square over the site with one hand, and simultaneously activate the needle safety device with the other hand or place the needle in an approved needle removal safety device. Apply firm pressure to the puncture site for a minimum of three to five minutes. Check the Site Wrap-Up Procedures Hazards and Complications of Arterial Puncture: - There are hazards and complications associated with arterial puncture, as with any invasive procedure. Most can be avoided with proper technique, while some cannot be avoided. Arteriospasm: - Pain or irritation caused by needle penetration of the artery muscle and even patient anxiety can cause a reflex (involuntary) contraction of the artery referred to as an arteriospasm. Artery Damage: - Repeated punctures at the same site can damage the vessel, resulting in swelling, which can lead to partial or complete occlusion (blockage or obstruction) of the vessel. Discomfort: -Usually this is minor and temporary. Extreme pain during arterial puncture may indicate nerve involvement, in which case the procedure should be terminated. INFECTION: - Careful site selection, proper antiseptic preparation of the site, and avoiding activities that can contaminate the site prior to specimen collection minimize the chance of infection. Hematoma: -Multiple punctures to a single site also increase the chance of hematoma formation and should be avoided. Proper site selection, precise needle insertion, and adequate pressure applied by the phlebotomist following needle withdrawal are essential to minimize the risk of hematoma formation. Thrombus Formation: -Injury to the intima or inner wall of the artery can lead to thrombus (blood clot) formation. A thrombus may grow until it blocks the entire lumen of the artery, obstructing blood flow and impairing circulation Infection Control Infection Infection is a condition that results when a microbe (microorganism) invades the body, multiplies, and causes injury or disease. Microbes include bacteria, fungi, protozoa, and viruses. Most microbes are nonpathogenic, meaning that they do not cause disease under normal conditions. Microbes that are pathogenic (causing or capable of causing disease) are called pathogens. We normally have many nonpathogenic microbes on our skin and in other areas such as the gastrointestinal (GI) tract. These microbes are referred to as normal flora, though they can become pathogens if they enter and multiply in areas of the body where they do not normally exist. Communicable Infections: Some pathogenic microbes cause infections that are communicable (able to spread from person to person), and the infections they cause are called communicable diseases. Nosocomial Infections: and Healthcare-Associated Nosocomial Infection is the tradition term applied to patient infections acquired in hospitals. CDC List of Diseases and Organisms Found in Healthcare Settings Acinetobacter Burkholderia cepacia Candida auris Clostridium difficile Clostridium sordellii Carbapenem-resistant Enterobacteriaceae Gram-negative bacteria Hepatitis Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) Influenza Klebsiella Methicillin-resistant Staphylococcus aureus (MRSA) Mycobacterium abscessus Norovirus Pseudomonas aeruginosa Staphylococcus aureus Tuberculosis (TB) Vancomycin-intermediate Staphylococcus aureus (VISA) Vancomycin-resistant Staphylococcus aureus (VRSA) Vancomycin-resistant enterococci (VRE) Antibiotic-Resistant Infections: - Antibiotic resistance leads to much suffering and increases a patient’s risk of dying from once easily treatable infections. Well-Established Antibiotic-Resistant Bacteria: - The three of the most common HAI (healthcareassociated infections) pathogens, Clostridium difficile (C. difficile, C. diff), methicillin-resistant Staphylococcus (staph) aureus (MRSA), and Enterococcus. C. diff, a type of intestinal bacteria that multiplies when patients are treated with antibiotics, is responsible for mild to very severe GI infections and is the most commonly identified cause of diarrhea in healthcare settings MRSA is responsible for many types of HAIs from skin, wound, and surgical site infections, to pneumonia and bloodstream infections that can be fatal. Gram-Negative Bacteria: The newest challenge in antibiotic resistance in the healthcare setting comes from multidrug-resistant gram-negative bacteria these bacteria are resistant to almost all available treatments carbapenem-resistant Enterobacteriaceae (CRE), a family of gram-negative bacteria that are resistant to a class of drugs called carbapenems because they produce an enzyme that breaks down the drugs. Some CRE bacteria are also resistant to most currently available antibiotics. Carbapenems have traditionally been considered the “last resort” for treating bacterial infections such as Escherichia coli (E. coli), which causes most urinary tract infections, and Klebsiella pneumonia, which causes many types of HAIs. Both E. coli and Klebsiella bacteria can become resistant to carbapenem and can share or even transfer the genetic trait to other Enterobacteriaceae Infectious Agent: -The infectious agent, also called the causative agent, is the pathogenic microbe responsible for causing an infection. Reservoir: -The source of an infectious agent is called a reservoir. -a place where the microbe can survive, grow, or multiply. Reservoirs include humans, animals, food, water, soil, and contaminated articles and equipment. An individual or animal infected with a pathogenic microbe is called a reservoir host. - the viability or ability of the microbe to survive or live on the object. -the virulence or degree to which the microbe is capable of causing disease, and the amount of time that has passed since the item was contaminated. Contact Transmission: -Contact transmission is the most common means of transmitting infection. There are two types of contact transmission: direct and indirect. Direct contact transmission is the physical transfer of an infectious agent to a susceptible host through close or intimate contact such as touching or kissing. Indirect contact transmission can occur when a susceptible host touches contaminated objects such as patient bed linens, clothing, dressings, and eating utensils. It includes contact with phlebotomy equipment such as gloves, needles, specimen tubes, testing equipment, and trays. It also includes less obvious contaminated objects such as countertops, computer keyboards, phones, pens, pencils, doorknobs, and faucet handles. -Inanimate objects like these that can harbor material containing infectious agents are called fomites Droplet Transmission: -by coughing, sneezing, or talking as well as through procedures such as suctioning or throat swab collection. Vector Transmission: -is the transfer of an infectious agent carried by an insect, arthropod, or animal. Examples of vector transmission include the transmission of West Nile virus by mosquitoes and bubonic plague (Yersinia pestis) by rodent fleas. Vehicle Transmission: -is the transmission of an infectious agent through contaminated food, water, or drugs. Entry Pathway: -is a way for an infectious agent to enter a susceptible host. Entry pathways include body orifices (openings); the mucous membranes of the eyes, nose, or mouth; and breaks in the skin -can be exposed during invasive procedures such as catheterization, venipuncture, finger puncture, and heel puncture -healthcare personnel can be exposed during spills and splashes of infectious specimens or created by needlesticks and injuries from other sharp objects -The specialized application of information technology, such as the development, maintenance, and use of computers, computer systems and networks, to store, retrieve, and send information to optimize laboratory operations is called laboratory informatics. Laboratory Information System: -A laboratory information system (LIS) is a major part of laboratory informatics. It is a customized computer software package designed to record, process, manage, and store data from a variety of workflow processes in the laboratory. Icons and Mnemonic Codes: -Some lab systems use icons or images to request the appropriate program or function necessary to enter data. Others may use a menu of mnemonic (memory-aiding) codes or an abbreviation for selecting a function. Barcodes: -A barcode is a visual depiction of data in the form of a code that can be read by an electronic device. Barcodes can exist as linear onedimensional (1D) codes, or as two-dimensional (2D or matrix) barcodes. Radio Frequency ID: -RFID is a unique identifier that can be scanned to retrieve identifying information and wirelessly track a product or person. Specimen Handling and Processing: - someone with a decreased ability to resist infection. Factors that affect susceptibility include age, health, and immune status. -the preexamination (prior to testing) or preanalytical (prior to analysis) phase, the examination (during testing) or analytical (during analysis) phase, and postexamination (after testing) or postanalytical (after analysis) phase. Computers and Specimen Handling and Processing: Susceptible Host: Computers: -Our daily lives are enhanced by the improved efficiency and productivity that computers provide. Consequently, they have become an essential tool in many industries, including healthcare. Computerization in Healthcare: -Computers are used in healthcare to manage data (information collected for analysis or computation) -identify and monitor patients, automate analyzers, and even aid in diagnosis -computer literacy is a required skill in all areas of healthcare. - A special type of applications software called middleware is especially important to the use of POCT instruments. Middleware is sometimes called “plumbing” because it connects two sides of an application and passes data between them. Computer Networks: -A computer network is a group of computers that are all linked so that they can share resources. Laboratory Informatics: The terms “preanalytical,” “analytical,” and “postanalytical” have traditionally been used to describe the phases of the testing process. The CLSI Quality Management Systems (QMS) documents use the term “examination” instead of “analytical” when referring to the process of testing clinical samples. As laboratories and hospital systems become more quality focused, you will likely see the terms “preexamination,” “examination,” and “postexamination” replacing “preanalytical,” “analytical,” and “postanalytical.” Specimen Handling: -It is not always easy to tell when a specimen has been handled improperly. Therefore, to ensure delivery of a quality specimen for analysis, it is imperative that all phlebotomists be adequately instructed in this area so that established policies and procedures are followed. Transporting Specimens: -It is important to handle and transport blood specimens carefully and deliver them as quickly as possible to the laboratory for processing. A delay in separating the blood cells from the plasma or serum can result in metabolic changes in the sample. Rough handling and agitation can hemolyze specimens, activate platelets, and affect coagulation tests as well as break collection tubes ANTICOAGULANTS: Automated Transportation Systems: -One of the most common means of transporting specimens to the laboratory from other areas of a hospital is a pneumatic tube system (PTS or P-tube). -All specimens transported through a PTS or other type of automated transport system within the facility should be considered biohazards and require strict protocol to prevent potential contamination issues prevent clotting by inhibiting the formation of thrombin necessary to convert fibrinogen to fibrin HEPARIN- chemistry tests, STAT tests for electrolytes and in rapid response situations Major Anticoagulants: EDTA - used primarily when performing blood cell counts. SODIUM CITRATE - coagulation studies - prothrombin time HEPARIN - Na Heparin (viable lymphocytes -HLA test), Li Heparin (chemistry) PHELOBOTMY -Process referred to as “breathing vein” -from Greek word PHLEBOS -veins , I TOME0-incision 2 TYPES OF PHLEBOTMY Venipuncture Capillary puncture EQUIPMENTS: SYRINGE VACUTAINER/blood collection tube Needles(butterfly, vacutainer needle Lancets( cap, needle , body) ETS(EVACUATED TUBE SYSTEM) - Multiple usage of tubes for multiple test requests TEST TUBE ADDITIVES: Functions optimally when the tube is filled to its stated volume. Have one or more functions - preventing clotting or preserving certain blood components Anticogoulants EDTA (Ethylenediamine Tetraacetic Acid ) Sodium Citrate Heparin ( Na or Li) Flouride oxalate Prevents clotting by inhibiting the formation of thrombin necessary to convert fibronogen to fibrin Used in blood cell counts. is for collecting blood for performing coagulation studies. Inhibits clotting to produce plasma for biochem testing. Glucose Dtermination FLUORIDE OXALATE - glucose determination SPECIAL USED ANTICOAGULANTS: ACID CITRATE DEXTROSE (ACD)- RBC nutrient & preservative, yellow tops, 8 inversions. CITRATE PHOSPHATE DEXTROSE – • for blood transfusion • chelating calcium, • PO4 stabilizes pH, • dextrose provides cells • with energy and keeps • them alive SODIUM POLYANETHOL SULFONATE (SPS) binds to calcium, blood culture, slows down phagocytosis and reduces activity of certain antibiotics CLOT ACTIVATORS: collects serum more surface for platelet activation, ex. glass, silica particles (15-30 minutes) - SST serum separator tubes RST - rapid serum tube - 5 minutes clotting (orange top), 10 inversions ANTIGLYCOLYTIC: Prevent glycolysis (10mg/dl) Na flouride - most common antiglycolytic agent preserves glucose up to 3 days inhibits bacterial growth used to collect ethanol - prevent the increase in alcohol due to fermentation by bacteria THIXOTROPIC GEL SEPARATOR: TYPES OF ADDITIVES: ANTICOAGULANT SPECIAL USE ANTICOAGULANT CLOT ACTIVATOR ANTIGLYCOLYTIC AGENT THIXOTROPIC GEL density of gel is between cells and serum or plasma. VENIPUNCTURE: Identify any obstacles that might prevent access to the patient or prevent proper arm positioning. Patient Registration-A patient must be registered with the healthcare facility or specimen collection center before specimen collection can take place. Registration is a routine process during which data are collected that creates a patient record for the specific individual who is being admitted to the facility, or has arrived for testing at the specimen collection center. The patient’s identity (ID), which includes full name, date of birth, sex, address, and proof of ID, is established and entered into the facility database or verified if the patient is already in the database. The process typically involves assignment of a patients pecific identifier which will appear on all test requests and specimen labels for that patienT. Encountering Physicians and Clergy- If a physician or a member of the clergy is with the patient, don’t interrupt. The patient’s time with these individuals is private and limited. If the draw is not STAT, timed, or other urgent priority, go draw another patient and check back after that. If that is the only patient, wait outside the room for a few minutes or go back to the lab and draw the specimen on the next sweep. If the request is STAT, timed, or other urgent priority, excuse yourself, explain why you are there, and ask permission to proceed. Requests for Testing- a physician or other qualified healthcare professional requests laboratory testing; the exceptions are certain rapid tests that can be purchased and performed at home by consumers and blood specimens requested by law enforcement officials that are used for evidence. The Test Requisition- The form on which test orders are entered is called a requisition. Test requisitions become part of a patient’s medical record and require specific information to ensure that the right patient is tested, the physician’s orders are met, the correct tests are performed at the proper time under the required conditions, and the patient is billed properly. Manual Requisitions- Manual requisitions come in different styles and types as simple as a test request written on a prescription pad by a physician, or a special form issued by a reference laboratory. With increased use of computer systems, the use of manual requisitions is declining. However, they are typically used as a backup when computer systems fail. Venipuncture Steps: Step 1: Receive, Review, and Accession Test RequestBlood collection procedures legally begin with the test request. This is the first step for the laboratory in the preexamination or preanalytical (before analysis) phase of the testing process Receipt of the Test Request- Computer requisitions for inpatients usually print out at a special computer terminal at the phlebotomist station in the laboratory. Step 2: Approach, Greet, and Identify the Patient- Being organized and efficient plays a role in a positive and productive collection experience. Try to clear your mind of distractions and focus on the task at hand before calling an outpatient into the drawing area or proceeding to an inpatient room. Entering a Patient’s Room- Doors to inpatients’ rooms are usually open. If the door is closed, knock lightly, open the door slowly, and say something like “good morning” before proceeding into the room Scanning the Room- Upon entering the patient’s room, make a quick scan of the area. Note the availability and location of sharps containers and hand hygiene facilities. Handling Family and Visitors- It is best to ask them to step outside the room until you are finished. Most will prefer to do so; however, some family members will insist on staying in the room. It is generally acceptable to let a willing family member help steady the arm or hold pressure over the site. Finding the Patient Unavailable- If the patient cannot be located, is unavailable, or you are unable to obtain the specimen for any other reason, it is the policy of most laboratories that you enter this information into the computer system or fill out a form stating that you were unable to obtain the specimen at the requested time and the reason why. Bedside Manner- The behavior of a healthcare provider toward or as perceived by a patient is called bedside manner. Approaching a patient is more than simply calling an outpatient into the blood-drawing room or finding an inpatient’s room and proceeding to collect the specimen. The way you approach and interact with the patient sets the stage for whether the patient perceives you as a professional. Gaining the patient’s trust and confidence and putting the patient at ease are important aspects of a successful encounter and an important part of professional bedside manner. You will more easily gain a patient’s trust and confidence if you have a professional appearance and act in a way that shows respect for the patient and displays confidence. If you display confidence, you will most likely convey that confidence to patients and help them feel at ease. Greeting the Patient and Identifying Yourself- Greet the patient in a cheerful, friendly manner and identify yourself by stating your name, your title, and why you are there (e.g., “Good morning. I am Joe Smith, from the lab. I’m here to collect a blood specimen if it is alright with you.”). If you are a student, let the patient know this, and ask permission to do the blood draw.This is a part of informed consent and patient rights. The patient has the right to refuse to have blood drawn by a student or anyone else. Follow facility policy on whether to use your full name when identifying yourself. Stasis- If a tourniquet was applied during vein selection, release it and ask the patient to open the fist. This allows the vein to return to normal and minimizes the effects of stasis 70% isopropyl alcohol- The recommended antiseptic for cleaning a routine venipuncture site.
