Ministry of Health
Safe Phlebotomy Training
for Health Care Workers in Kenya
Participant’s Manual
2013
Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Copyright © 2013, Ministry of Health, Government of Kenya
The Safe Phlebotomy Training Curriculum is a comprehensive approach to the training of health
care workers. The other components in this package are:
• Trainers’ Manual
• Curriculum Outline
Enquiries regarding these Safe Phlebotomy Documents should be addressed to:
Head
National AIDS and STI Control Programme (NASCOP)
Ministry of Health
P.O. Box 19361 - 00202
Nairobi, Kenya
Telephone: +254 20 2729502/2729549
Fax: +254 20 271 0518 or 272 9502
Email: head@nascop.or.ke
Website: www.nascop.or.ke
Recommended Citation
National AIDS & STDs STI Control Programme (NASCOP), Ministry of Health Kenya. 2013.
Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual.
This publication was supported by Cooperative Agreement Number 1U2GPS001862 from the Centers for Disease Control and
Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the
Centers for Disease Control and Prevention.
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
CONTENTS
Acronyms and Abbreviations.............................................................4
Acknowledgements..........................................................................5
Introduction....................................................................................6
Background....................................................................................7
Understanding the Training Manuals..................................................8
Course Syllabus...............................................................................8
Broad Objectives.............................................................................9
Course Content...............................................................................9
Training Methodology.......................................................................10
Target Group...................................................................................10
Duration of Training.........................................................................10
Certification....................................................................................11
Training Schedule............................................................................13
Module 1........................................................................................13
Module 2.......................................................................................18
Module 3.......................................................................................30
Module 4.......................................................................................48
Module 5.......................................................................................59
Module 6.......................................................................................70
Module 7.......................................................................................83
Module 8.......................................................................................92
Module 9.......................................................................................97
Additional Resources.......................................................................102
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
ACRONYMS AND ABBREVIATIONS
AIDS
BD
CDC
DBS
DH
EDTA
FEFO
FIFO
HAI
HBV
HCV
HCW
HIV
IDSR
IV KAIS
KEMRI
KMTC
LCD
MOH
MOU
MSH
NASCOP
NEMA
NSI
OGAC
PEP
PEPFAR
PGH
PPE PPP
SOPs
TOT
UON
WHO
Acquired Immune Deficiency Syndrome
Becton Dickinson
Centres for Disease Prevention and Control
Dried Blood Spot
District Hospital
Ethylene Diamine Tetra Acetic Acid
First Expiry First Out
First In First Out
Hospital Acquired Infections
Hepatitis B Virus
Hepatitis C Virus
Health Care Workers
Human Immunodeficiency Virus
Integrated Disease Surveillance And Response
Intravenous
Kenya AIDS Indicator Survey
Kenya Medical Research Institute
Kenya Medical Training College
Liquid Crystal Display
Ministry of Health
Memorandum of Understanding
Management Sciences for Health
National AIDS & STDs Control Program
National Environmental Management Authority
Needle Stick Injuries
Office of Global AIDs Coordinator
Post Exposure Prophylaxis
President’s Emergency Plan for AIDS Relief
Provincial General Hospital
Personal Protective Equipment
Public-Private Partnership
Standard Operating Procedures
Training of Trainers
University of Nairobi
World Health Organization
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
ACKNOWLEDGEMENTS
The following institutions are acknowledged for their contribution in the development of the
Safe Phlebotomy Training Curriculum:
•
•
•
•
•
National AIDS & STI Control Programme
Becton, Dickinson Company
US Office of the Global AIDS Coordinator (OGAC-PEPFAR)
US Centers for Disease Control and Prevention
Management Sciences for Health
The following individuals dedicated their time and tirelessly contributed towards the development of this manual.
Abdille Ali
Beatrice Kipesha
Beatrice Njoki
Carren Ogutu
Catherine Gichimu
Clement Kalesingor
Dr Kelvin Okoth
Dr. Gabriel Mngola
Dr. Patrick Mwangi
Dr. Paul Njanwe
Dr. Robbinson Nduati
Fridah Sirima
Jacob Okello Japheth Gituku Jayne Munyao
Joseph Mwangi Martin Mudogo
Nancy Bowen Paul Okumu Peter Kariuki Peter Mbugua Rachel Chege Stephen Maina
Winnie Migwi Zacharia Abukutsa
Garissa Provincial General Hospital
Coast Provincial General Hospital
Embu Provincial General Hospital
Siaya District Hospital
Management Sciences for Health
Kapenguria District Hospital
Migori District Hospital
Coast Provincial General Hospital
University of Nairobi
Kitale District Hospital
Thika District Hospital
Busia District Hospital
Management Sciences for Health
National AIDS & STI Control Programme
Kakamega Provincial General Hospital
Kenya Medical Research Institute
Butere District Hospital
National AIDS & STI Control Programme
Nyanza Provincial General Hospital
Nakuru Provincial General Hospital
Kenya Medical Training College
Nyeri Provincial General Hospital
Becton Dickinson Company
Nakuru Provincial General Hospital
Kakamega Provincial General Hospital
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
INTRODUCTION
Phlebotomy practices pose a risk of infection to health care workers, patients, and the community. The risk of exposure is related to service delivery as well as handling of medical waste. As
a result, the Ministries of Health through the National HIV/AIDS and STI Control Programme
(NASCOP) has developed a programme to address safe phlebotomy practices.
Phlebotomy is a complex procedure, requiring both knowledge and skills. The phlebotomist
must be knowledgeable in anatomy and physiology, be trained in all aspects of blood collection,
and possess sufficient skill to perform the procedure safely. The importance of obtaining a good
blood specimen cannot be overemphasised. Blood specimens are used in diagnosis of medical
conditions, and to measure the level of medications in the patient’s blood to determine the effectiveness of patient management. Therefore, the integrity of the blood specimen is vital.
The majority of laboratory errors occur during the pre-analytical phase. Several factors impact
specimen quality: patient preparation, specimen collection equipment, collection technique,
safety concerns, specimen handling, specimen transport, specimen processing, and specimen
storage. Maintaining specimen quality therefore requires institutions and health care workers to
be committed to acquiring knowledge and skills in order to reduce the errors.
Institutions should implement an occupational exposure control plan that specifically addresses health care worker safety. Technology has evolved over time to address these concerns by
providing a variety of safe equipment, including safety-engineered blood collection devices.
Manufacturers respond to market forces and continue to work with the health care community
to innovate and develop even safer devices. It is the responsibility of the health care community
to advocate for safer medical devices so that procedures such as blood collection are no longer
considered high risk.
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
BACKGROUND
The risk of hospital-acquired infection (HAI) is universal and pervades every health care facility
and system around the world. There are an estimated 35 million health care workers in the
world and an estimated 2 million needle stick injuries (NSIs) annually, potentially exposing
those workers to hepatitis B (HBV), hepatitis C (HCV), HIV, and other infections. In fact, this
estimate is probably low, because of the lack of surveillance systems and the under-reporting
of injuries. Research reported by the Global Occupational Health Network has shown 40-75%
under-reporting of NSIs.1 The World Health Organization (WHO) estimates that the global burden of disease from occupational exposure to HBV and HCV is approximately 40% for each, and
4.4% of the HIV infections among health care workers.2
By 2007, 3 million Kenyans were being tested for HIV annually. At the time, 1.4 million Kenyans were living with HIV, of whom 750,000 were receiving care and treatment, thereby requiring regular blood tests.3 Since then, there has been a programmatic scale-up of HIV and AIDS
interventions.
The KAIS 2012 preliminary report estimate that, slightly more than 100,000 children aged
between 18months to 14 years and approximately1,200,000 adults aged between 15- 64
years are living with HIV of these, 58% of the PLWHA require ARVs and subsequently blood
draws in their management.
With expansion of HIV testing, care, and treatment, there has been a rapid increase in blood
collection. NASCOP initiated the Safe Phlebotomy project under the Injection Safety programme
in 2006, with the aim of reducing the occupational risks from blood-borne pathogens. This
culminated in the signing of a memorandum of understanding between Becton, Dickinson (BD)
and the Office of the Global AIDS Coordinator (OGAC-PEPFAR) in 2009 as a public-private
partnership activity based on a common agenda of strengthening health worker and patient
safety through appropriate blood-drawing practices and laboratory services in countries severely
affected by the HIV and AIDS pandemic.
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Understanding the Training Manuals
The National Safe Phlebotomy Curriculum for Health Care Workers in Kenya is comprised of a
package of four key components. These are the Curriculum Outline, Trainer’s Manual, Participant’s Manual, and the nine teaching modules (presentation slides).
Course Syllabus
Participant’s Manual Description
The profession of phlebotomy is taught through didactic, student laboratory, and clinical experiences. The participant will be trained to perform a variety of blood collection methods using proper techniques and equipment—including vacuum collection devices, syringes, capillary
skin puncture, butterfly needles, and blood culture specimen collection in adults, children, and
infants. Emphasis will be placed on infection prevention, including safety and post-exposure
prophylaxis (PEP), proper patient identification, proper labelling of specimens, and specimen
handling, with emphasis on specimen quality, a component of quality assurance.
Participants will also learn how to perform proper and safe blood draws using manikins—a
skills-based approach—before performing further blood draws on patients in their institutions to
enhance the skills learned during training. A teach-back methodology will be used to assess the
trainee’s capacity to deliver the course to their colleagues. This Participant’s Manual therefore
acts as a road map to guide the trainee through the course. It offers information on the following
aspects pertinent to effective course delivery:
•
•
•
•
•
Course syllabus
Course schedule
Pre- and post-test
Health care worker survey
End of course evaluation
Course Goal
The overall goal of the Safe Phlebotomy Training is to improve the safety of health care workers, patients, and the community, as well as to improve the quality of specimens and other
blood-drawing procedures critical to patient management.
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Broad Objectives
The objectives of the course are to:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Explain the importance of safety and quality as core concepts in phlebotomy
Describe phlebotomy equipment and supplies
Equip participants with the skills for successful specimen collection by venipuncture
Provide participants with knowledge and skills on equipment and techniques used in special
conditions
Provide participants with knowledge on complications arising from venipuncture and skills
for their management
Equip participants with knowledge and skills in capillary blood collection
Furnish participants with knowledge, skills, and attitudes on biosafety practices
Equip participants with the knowledge to manage occupational exposure to blood and body
fluids
Equip participants with knowledge and skills in inventory management
Course Content
The course covers the following nine modules:
•
•
•
•
•
•
•
•
•
Module
Module
Module
Module
Module
Module
Module
Module
Module
1:
2:
3:
4:
5:
6:
7:
8:
9:
Importance of Safe Phlebotomy in Patient Care
Phlebotomy Equipment and Supplies
Successful Specimen Collection by Venipuncture
Special Techniques in Specimen Collection by Venipuncture
Complications during Specimen Collection by Venipuncture
Capillary Blood Collection
Safety and Infection Control
Occupational Exposure
Inventory Management
Training Methodology
This course uses a skills-based learning approach. The approach presupposes that all participants will acquire the knowledge, skills, and attitudes to perform safe phlebotomy. To determine
participants’ level of knowledge, skill, and attitude acquisition, a pre-course assessment is given before training and a post-course test after training. The approach further appreciates that
people not only learn best in different ways but also vary in their abilities to absorb new information. A variety of training methods and techniques suitable for adult learners have therefore
been carefully selected to address individual differences as well as provide an enjoyable way of
learning. These include lectures, quizzes, group discussions, demonstrations, role plays, video/
slide shows, practicals, teach back, and evaluation (pre- and post-test and course evaluation).
The course takes very practical and participatory approaches, moving away from the traditional
teacher-student model in which the teacher is held to be the expert. The approach assumes that
participants are:
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
• Bringing with them a wealth of experience
• Willing to be actively involved in training activities in order to acquire new skills or sharpen
those they already have and gain competency in safe phlebotomy
• Interested in helping to improve phlebotomy practices in their health facilities and having a
positive impact on patient management
Target Group
Participants should be students from medical institutions and health care workers involved in
blood drawing.
Duration of Training
The duration is two days training (theory and practical) and one day of teach back and work
plan development. The participants will be assigned topics for teach back in the second day
by the trainers.
Certification
Upon successful completion of the course, participants will be certified by NASCOP and the
collaborating institution.
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
TRAINING SCHEDULE
Day 1
Time
Title
8:00–8:30
Registration 8:30–9:00
Introductions and Climate Setting
• Expectations
• Group norms
• Administrative issues
9:00–9:15
Agenda
• Opening remarks
9:15–9:45
Healthcare Worker Survey
9:45–10:15
Pre-training Phlebotomy Quiz
Tea/coffee break
10:45–11:45
Module 1: Importance of Safe Phlebotomy in Patient Care
11:45–13:00
Module 2: Phlebotomy Equipment and Supplies
Lunch break
14:00–16:00
Module 3: Successful Specimen Collection by Venipuncture
16:00–16:45
Module 4: Special Techniques in Specimen Collection by
Venipuncture
16:45–17:00 Memory Jogger and Close
Each participant notes down what changes he/she would
make in procedure after learning from the day.
Facilitators’ review meeting
11
Facilitator
Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Day 2
Time
8:00–8:15
8:15–9:00
Title
Review of previous day and questions
Module 5: Complications During Blood Collection by
Venipuncture
9:00–10.00
Module 6: Capillary Blood Collection
10:00–10:15
Tea/coffee break
10:15–11:00
Module 7: Safety and Infection Control
11:00–11:45
Module 8: Post-exposure Prophylaxis
11:45–12:30
Module 9: Inventory Management
12:30–13:30
Lunch break
13:30–14:30
Hands-on with Training Arm
• Hand washing demo
• Venous blood draws
• Special venous collection
14:30–15:30
Hands-on
• Finger prick
• Heel prick
15:30–17:00
Post-test
Evaluation
Closing remarks
17:00
Tea/coffee break
17:00–17:30
Facilitators’ review/planning meeting
Facilitator
Day 3
Coaching of participants in clinical setting
Perform four successful venipunture and four capillary blood draws (two heel pricks and two
finger pricks)
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Module 1
Importance of Safe Phlebotomy in Patient Care
Aim
To introduce the importance of safety and quality as core concept in phlebotomy
Prerequisite Modules
None
Objectives
At the end of this module you will be able to:
1. Describe the significance of safety in phlebotomy
2. Describe the importance of specimen quality
3. Describe the chain of infection and preventive measures
Content Outline
• Introduction; definition of phlebotomy and the importance of phlebotomy in patient care
• Safety of patients, HCWs, and the community
• Quality of specimen in patient care and clinical decisions
• Mode of transmission, port of entry, port of exit, reservoir host, susceptible host, breaking
the chain of infection
Notes on Customisation 13
Module 1
Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Introduction and Definition
What is phlebotomy?
The term phlebotomy is from the Greek phlebo, meaning related to veins, and tomy, meaning
related to cutting. Phlebotomy is therefore opening a vein to collect blood: it is the practice of
drawing blood.
What is the importance of phlebotomy?
Phlebotomy is important in diagnostic testing of diseases, therapeutic assessment, and monitoring of the patient’s condition.
Safety
In phlebotomy, the safety of the patient, HCWs, and the community is the overall goal. The
sample collected should be a true representation of the patient’s condition.
The need for safety in phlebotomy is supported by the following facts documented by WHO and
the Kenya AIDS Indicator Survey (KAIS):
There are an estimated 35 million HCWs in the world and an estimated 2 million needle stick
injuries (NSIs) annually, potentially exposing those workers to HBV, HCV, HIV, and other infections.
This estimate is probably low, because of the lack of surveillance systems and the under-reporting of injuries. Research has shown 40–75% under-reporting of NSIs.
WHO estimates that the global burden of disease from occupational exposure to HBV and HBC
is approximately 40% for each, and 4.4% for HIV infections among HCWs (Prüss-Ustün). In
Kenya, over 1.4 million people are living with HIV, of whom 750,000 are receiving care and
require regular blood tests. Three million Kenyans are tested for HIV status annually. Besides
HIV, other infections can be contracted thorough NSIs, as shown in the chart below.
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Diseases
That
CanbeBe
Contracted
List
of diseases
that can
contracted
through
Needle-stick
injuries
through NSIs
Module 1
Viral Infections
Bacterial Infections
Fungal Infections
Hepatitis B
Brucella abortus
Blastomyces dermatidis
Hepatitis C
Corynebacterium diptheriae
Cryptococcus neoformans
Hepatitis G
Neisseria gonorrheae
Sporotrichum schenkii
Human immunodeficiency virus
Leptospira
Icterohaemorrhagiae
Simian immunodeficiency virus
Mycobacterium marinum
Protozoal infections
Herpes simiae
Mycoplasma caviae
Plasmodium falciparum
Herpes simplex
Orientia tsutsugamushi
Toxoplasma gondii
Herpes zoster
Rickettsia rickettsii
Ebola/Marburg
Staphylococcus aureus
Dengue
Streptococcus pyogenes
Creutzfeldt-Jakob disease
Treponema pallidum
Mycobacterium tuberculosis
Modes of Transmission
Chain of Infection
The chain of infection can be broken by effective hand hygiene procedures, immunisation against
HBV, proper decontamination of surfaces and instruments, proper disposal of sharps and infectious waste, use of gloves, gowns, mask respirators, and other personal protective equipment
(PPE), and safer and proper use of equipment.
Infectious Agent
Susceptible Host
Reservoir
Chain of Infection
Portal of Entry
Portal of Exit
Mode of Transmission
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Module 1
Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Specimen Quality
A specimen is not just a tube but a true representation of the patient’s condition. Only when a
quality sample is produced can the laboratory produce valid results, which will enable the clinician to make an informed judgement based on the best possible data. Large numbers of clinical
decisions are based on laboratory tests results. Poor sample quality affects the reliability of the
results, which, in turn impacts doctors’ ability to provide quality patient care. Laboratory errors
therefore affect the patient, clinician, laboratory, and the entire hospital.
Some research has indicated that laboratory errors occur more frequently than expected. One
study (Plebani and Carraro 1997) showed that one error occurs for every 214 laboratory results.
Laboratory errors may occur either in the pre-analytical, analytical, or post-analytical phase of
sample analysis.
Up to 68% of laboratory errors occur in the pre-analytical phase, where most of the blood draws
are done; 13% in analytical; and 19% in the post-analytical phase of sample analysis. Factors that impact specimen quality include patient preparation as well as specimen collection
equipment and technique, handling, transportation, processing, and storage. Therefore, observation of the factors to the right contributes to the delicate link between the clinician, patient,
and the hospital. Improvement in sample quality leads to increased reliability of test results,
reduced errors, and better patient care and safety.
Steps in Patient Sample Testing
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Module 1
Sample Rejection
A blood sample will not be accepted for analysis if it does not meet the standard of quality. Recommended rejection criteria include haemolysis, insufficient sample, wrong sample container,
leaking sample, etc. A rejection stamp is a tool used to ensure smooth communication. Sample
rejection should also be documented in the laboratory.
Key Messages
1. Safety for patients, HCWs, and the community is the ultimate goal in sample collection.
2. Phlebotomy also plays a key role in the intervention of transmission of blood-borne
diseases.
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Module 2
Phlebotomy Equipment and Supplies
Aim
To introduce you to phlebotomy equipment and supplies
Prerequisite Modules
Module 1: Importance of Safe Phlebotomy in Patient Care
Objectives
By the end of this module you will be able to:
1. Identify equipment and supplies used in venous blood collection
2. Describe the purpose and importance of equipment
3. Differentiate between open and closed systems of phlebotomy
Content Outline
• Equipment and supplies
• Application of equipment: different colour-coded tubes, tourniquet, etc.
• Open system; syringe and needle
• Closed system; evacuated system.
Notes on Customisation
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Module 2
Types of Equipment
There are various types of equipment and supplies used in venous blood collection. These include the following:
•
•
•
•
•
•
•
•
•
Tourniquet
Gloves
Antiseptic and disinfectant
Needle
Syringe or needle holder
Specimen container
Gauze
Tape or bandage (strapping)
Sharps container
Tourniquets
This is a stretchable strip of material 35–45 cm (15–18 inches) in length, and may be single
use or re-usable.
There are different types of tourniquets: latex, vinyl, elastic bands, etc.
•
•
•
Latex is the most commonly used because it is easily available and cheap.
Vinyl is useful where the HCW or patient is allergic to latex.
Elastic bands with Velcro® or buckle closure may also be used.
Tourniquets should be discarded after use or cleaned with alcohol at the end of the procedure
on each patient.
Tourniquet application time = maximum 1 minute.
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Module 2
Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Use and Application of Tourniquets
•
•
•
Tourniquets make the veins easier to locate and feel.
They also slow down venous blood flow and enlarge the veins.
The tourniquet should not restrict arterial blood flow into the limb.
Wrap 7.5–10.0 cm (3–4 inches) above the intended venipuncture site and tie so that it is releasable with one hand..
Gloves
Gloves are sterile or clean coverings for the hands, usually with a separate sheath for each finger
and thumb. They are part of personal protective equipment (PPE) against contact with blood
during phlebotomy. They provide a barrier between the user and the patient, and hence prevent
the spread of infection.
A new pair should be worn for each patient and for each procedure to avoid infection crossover.
A good fit is essential for effective infection prevention.
Washing or reuse of gloves can compromise integrity of the material to serve as a barrier without
showing any visible changes.
Types of Gloves
Three types of gloves are commonly used: latex, nitrile, and vinyl.
Latex: Powdered latex gloves have cornstarch added to them to help the user who is donning
them (putting them on) to slide their hands in more easily and more quickly. Latex gloves are
comfortable, fit well, provide good barrier protection, and have tactile sensitivity. They are the
most commonly used of the three common types.
Nitrile: Nitrile is made from a synthetic polymer in the form of a latex or emulsion and can be
used or processed very much like natural rubber latex. They fit well and provide good protection.
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Module 2
Vinyl: Research has shown that vinyl gloves are not as strong as latex or nitrile gloves in terms
of their puncture resistance. They fit loosely to the hands due to their limited ability to stretch.
They are mostly used for non-medical purposes. Vinyl gloves are too loose fitting and do not
provide an adequate barrier to viruses.
Antiseptics and Disinfectants
Antiseptics inhibit or prevent the growth of bacteria, are approved for use on the skin, and are
recommended for cleaning the venipuncture site. The most commonly used antiseptic is 70%
isopropyl alcohol. Disinfectants kill bacteria and inhibit some viruses. Disinfectants are used on
surfaces and instruments, but are not recommended for use on the skin. They are used to clean
up all blood spills. The commonly used disinfectant is 1:10 hypochlorite solution (bleach).
Antiseptics versus Disinfectants
Antiseptics
•
•
•
•
•
Inhibit growth of bacteria
Are used on the skin
Evaporate in open air
Are recommended for venipuncture
Example: 70% isopropyl alcohol
Disinfectants
•
•
•
•
•
Kill bacteria and some viruses
Are used to clean surfaces and instruments, but not skin
Do not evaporate
Are recommended for cleaning spills
Example: 1:10 hypochlorite solution (bleach)
Isopropyl alcohol as an antiseptic
Isopropyl alcohol is used in an optimal concentration of 70% as an antiseptic.
Directions for use
It is stored in a closed container to prevent the evaporation of the active ingredient. The active
ingredient will evaporate from an open container, leaving water behind and causing the antiseptic properties to diminish. This renders pre-soaked cotton balls ineffective.
Bacteria from hands and the container can multiply and cause infection in the patient if alcohol from an open container is used to “clean” the intended puncture site, and in addition the
“cleaned” site may not dry quickly.
NB: Never pre-soak cotton balls.
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Module 2
Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Needles
A needle is a hollow stainless-steel shaft with lumen (the interior dimension) and bevel (the
slant at the end). It is sterile, disposable, and for single use.
Needles sizes
Needles vary in sizes according to gauge.
Gauge (G) refers to the diameter: The larger the number, the smaller the diameter of the needle.
Different colour codes are used for different gauges, as shown.
Length varies from 0.5–1.15 inches.
Selection of the needle is based on:
•
Size of the vein
•
Location of the vein
•
Volume of the blood to be collected
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Module 2
Syringes
The syringe is an instrument used to inject fluids into the body or draw them from it. It is made
of three components, namely:
1. Plunger: Used to pull the blood fluid into the barrel
2. Barrel: Used to hold the syringe in place and contains the blood fluid
3. Needle hub: Attaches the barrel to the needle
Sizes of Syringes
There are different sizes of syringes: they range from 2 ml–20 ml
Selection of size depends on:
•
Patient (e.g. geriatric, paediatric)
•
Volume of blood needed
•
Strength of vacuum expected
Advantages
•
•
Blood flash can be seen on entering vein
User controls the amount of blood drawn
Disadvantages
•
•
Specimen can clot
Specimen must be transferred
Never exert pressure on the plunger in transfer to vacuum tube.
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Module 2
Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Systems of Blood Collection
There are two systems of blood collection:
1.
2.
Open system: Blood is collected using a syringe and needle.
Closed system: Blood is collected using the evacuated system.
Open System
Open system: syringe and needle blood collection
The vacuum to draw blood from the vein through the needle and into the syringe is created as
the plunger is withdrawn. The vacuum is controlled by the user, as shown below.
Reused prevention syringes
should not be used for blood collection.
Closed System
Closed system: evacuation blood collection system
The vacuum in the tube allows blood to be drawn directly from the vein into the evacuated tube,
hence, there is no need to transfer blood. The vacuum in the tube controls the amount of blood
to be drawn.
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Closed System Components
Multiple-Specimen Collection Needles
The multiple-specimen collection needle has two ends:
1. Patient end
•
Longer needle
•
Determines the gauge
•
Longer bevel to pierce patient skin and enter the vein
2. Non-patient end
•
Shorter needle
•
20 G to minimise haemolysis
•
Penetrates rubber top of collection tube
•
Enclosed by a flexible rubber sheath to prevent blood leak between specimens
25
Module 2
Module 2
Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Other Equipment
Needle Holder
The needle holder is a clear plastic device with two ends: a narrow end and a wider end.
The needle is attached to the holder at the narrow end while the collection tube is inserted to
the wider end.
The needle holder has wings or extensions which act as a lever to exert pressure when inserting
or removing tubes while keeping the needle steady.
Use needles and holders from the same manufacturer to ensure compatibility.
Gauze Pads and Bandages
Gauze pads are used to apply pressure to the site after needle removal and they should be clean.
Adhesive bandages or tape are used to secure gauze and should not be applied directly to the
site without gauze pads.
Cotton is not recommended, as fibres can stick to the site and initiate bleeding when removed.
Do not use alcohol swabs on the site, because they cause irritation.
Sharps Disposal Containers and Safety Devices
These are containers designed for the safe disposal of sharps waste.
Needles and holders or needles and syringes should be disposed of as a unit immediately after
use.
Needles should not be recapped, bent, or cut, to avoid accidental pricks.
The sharps container should have a biohazard label affixed to it.
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There are different types of sharps disposal containers, as shown.
Engineered Safety Devices/ Mechanisms
These are devices which are incorporated into the needle for the safety of the user.
The sheathing device is on the non-patient end of the needle and the needle retraction device
is on the patient end.
Evacuated TuAbes
These are specimen containers used for venous blood draw and have a sterile interior. They are
for single use, draw a predetermined volume of blood based on a measured vacuum, and have
a predetermined quantity of additive which enables the correct blood/additive ratio. These are
some of the evacuated tubes.
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Evacuated Tube Attributes
•
•
•
•
•
•
•
Colour coded according to additive contained in the tube
Additive will either promote or inhibit clotting
Tube sizes vary from 2–10 ml
Tube selected varies by:
Tests to be performed
Volume of blood to be collected
Tubes have expiration dates;
Do not use a tube after its expiry date because it loses its predetermined vacuum
Serum Tube – Red Top
The red top evacuated tube has the following:
•
•
•
•
•
Additive: silicone coat
Mode of action: it has a silica clot activator to accelerate clotting
Clotting time: 60 minutes
Closure colour: red
Principal application: serum extraction for routine procedures
Purple/Lavender Top Tube
The purple top evacuated tube has the following:
•
•
•
•
•
Additive: EDTA anticoagulant
Mode of action: it removes calcium (chelates) from the blood
Clotting time: 30 minutes
Closure colour: purple/lavender
Principal application: whole blood for haematology testing, HbA1C,
red cell folate, haemoglobin electrophoresis, etc.
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Gold Top – Serum Gel Tube
The gold top evacuated tube has the following:
•
•
•
•
•
Additive: silica clot activator to accelerate clotting
Mode of action: contains a “gel” material between the cellular
components of the specimen and the serum/plasma
Clotting time: 30 minutes
Closure colour: gold
Principal application: serum extraction for routine procedures
Green Top
The green top evacuated tube has the following:
•
•
•
•
Additive: heparin
Mode of action: it blocks the action of thrombin and thus
prevents conversation of soluble fibrinogen to insoluble fibrin
Closure colour: green
Principal application: plasma for clinical chemistry testing
Grey Top
The grey top evacuated tube has the following:
•
•
•
•
Additives: anticoagulant additives fluoride oxalate and fluoride
EDTA
Mode of action: fluoride acts as a glycolytic inhibitor, hence
stabilising glucose concentration in the blood
Closure colour: grey
Principal application: glucose testing, also used for lactose testing
Light-Blue Top
The light-blue top evacuated tube has the following:
•
Additives: anticoagulant additives—tri-sodium citrate
•
Mode of action: acts by removing calcium from the blood (reversible
action if calcium is replenished)
•
Closure colour: light blue
•
Principal application: plasma for coagulation testing
Key message
It is important to understand the purpose and function of every piece of equipment before
using it!
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Module 3
Successful Specimen Collection by Venipuncture
Aim
To equip you with skills for successful specimen collection by venipuncture
Prerequisite Modules
Module 1: Importance of Safe Phlebotomy in Patient Care; Module 2: Phlebotomy Equipment
and Supplies
Objectives
By the end of this module you will be able to:
1.
2.
3.
4.
Outline the steps of patient identification
Describe standard precautions during venous blood collection
Identify recommended venipuncture sites
Perform successful venous blood collection
Content Outline
•
•
•
•
Patient requisition, introduction, reassurance, identification; and handling of difficult and
special situations
Safety precautions: hand washing, gloves, gowns, masks, sharps containers
Site selection: antecubital fossa
Venous procedure: Steps involved in venous blood collection
Notes on Customisation
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What Defines Successful Blood Collection?
Successful venous blood collection ensures:
•
•
•
Patient safety
HCW safety
Quality of the specimen
Steps in Blood Collection
Blood collection involves several steps, including patient requisition, patient interaction, safety
precaution, selecting equipment, positioning the patient, site selection, tourniquet application,
site cleansings, blood withdrawal, sharps disposal, sample mixing and handling, and sample
transportation.
Steps in Venous Blood Collection
Patient
requisition
Patient
interaction
Standard
precautions
Selacting
equipment
Site
cleansing
Tourniquet
application
Site selaction
Positioning
the patient
Perform
venipuncture
Sharps
disposal
Sample
handling/mixing
Sample
transport
The above steps are important during venous blood draw; hence all steps should be taken
seriously. They are discussed in detail below.
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Step 1
Patient Requisition
The clinician initiates the diagnostic process by requesting laboratory tests. Information contained on a requisition form includes:
•
•
•
•
•
•
•
•
•
•
Patient’s name*
Patient’s date of birth (DOB)*
Medical record number* – this number is unique for each patient
Date requested
Residence
Specimen destination
Patient’s ward, bed, and room location
Name or code of the physician making the request
Type of tests requested
Information about patient status (e.g. potential bleeding disorders or puncture sites to
be avoided)
Step 2
Patient Interaction
Approach the patient calmly but confidently with a soothing and reassuring tone of voice. Introduce yourself to the patient. If a child or infant, ask parents to assist. If an inpatient, state where
you are from and the purpose of your visit. Also look for special notices in the room regarding
the patient.
Patient reassurance
Explain the procedure to be performed, providing reassurance to the patient. Gain the patient’s
confidence by assuring the patient that the puncture may be slightly painful and will take a short
time.
Patient identification
Identify the patient by asking him/her to state full names and date of birth. Verify with the information provided on the requisition form.
Obtaining a specimen from the wrong patient can have serious, even fatal consequences, as in
the case of specimens for typing and cross-match before transfusion.
Where there is an identification discrepancy, the specimen must not be obtained until the discrepancy is resolved and the patient identification is verified.
In the ward, ask patient name, verify name and medical record number on identification band,
and match with the requisition form.
Also verify patient with ward staff if an identification band is not available. In case of a young,
mentally incompetent, or unconscious patient, you may ask the nurse, attendant, or relative to
identify the patient. Also look for special notices in the room regarding the patient.
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Patient preparation
Be aware of specific dietary requirements for the requested test. Verify that special diet instructions have been followed. Fasting means refraining from eating for a preset time, as indicated
by the clinician. Ask the patient the last time he/she took meals, and also inquire if the patient
is hypersensitive to latex.
Handling patient in special conditions
In case the patient is asleep, gently wake by nudging the bed. Startling can cause a change
in tests results. Anxiety and stress cause increased secretion of hormones (aldosterone, angiotensin, catecholamines, cortisol, prolactin, somatotropin, TSH, vasopressin) and increased
concentrations of albumin, fibrinogen, glucose, insulin, and lactate in the patient.
Step 3. Standard precautionAll specimens should be handled as if they were potentially infectious. Wash hands before and after patient care, wear protective gear such as gloves, dust coat,
and mask, and avoid needle recapping.
Step 3
Standard precautionAll specimens should be handled as if they were potentially infectious.
Wash hands before and after patient care, wear protective gear such as gloves, dust coat, and
mask, and avoid needle recapping.
Hand Washing
Hand washing helps to reduce the transmission of microbes acquired through contact. It also removes dirt and debris from the hands and protects the self and others. Hands should be washed
in between patients, and after exposure to blood and other body fluids.
1. Wet hands with water
2. Apply enough soap to cover all hand
surfaces.
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3. Rub hands palm to palm.
4. Right palm over left dorsum with interlaced
fingers and vice versa.
5. Palm to palm with fingers interlaced.
6. Backs of fingers to opposing
palms with fingers interlocked.
7. Rotational rubbing, with left thumb clasped
in right palm and vice versa.
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8. Rotational rubbing, backwards and forwards with clasped fingers of right hand
in left palm and vice versa.
9. Rinse hands with water.
10. Dry thoroughly with a single-use towel.
11. Use towel to turn off faucet.
12. Your hands are safe.
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Hand Sanitisers
When soap and water are not available, hand sanitisers can complement infection control practices,
but nothing can replace water and soap in achieving effective hand hygiene.
How to Sanitise the Hands
1. Apply a palmful of the product in a cupped hand and cover
all surfaces.
2. Rub hands palm to palm.
3. Right palm over left dorsum with interlaced fingers and vice versa.
4. Palm to palm with fingers interlaced.
5. Backs of fingers to opposing palms with fingers interlocked.
6. Rotational rubbing of left thumb clasped in right palm and
vice versa.
7. Rotational rubbing, backwards and forwards with clasped
fingers of right hand in left palm and vice versa.
8. Once dry, your hands are safe.
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Wearing Gloves
Since it may not be immediately evident that a specimen is infectious, all patient blood specimens should be treated as potentially infectious and handled according to standard precautions, which require the wearing of gloves during procedures involving blood/body fluids. Gloves
provide a barrier to exposure to blood and fluids.
A new pair of gloves should be worn for each procedure, and a good fit is essential.
Step 4
Equipment Selection The appropriate equipment selected will be based on the patient, the procedure, and the test
ordered. Assemble the eclipse needle and holder or needle and syringe. Remove needle sheath
just before insertion into the vein.
Step 5
Positioning the Patient
The patient should be seated or lying down, but never standing or sitting on a high stool. For
patients with a history of fainting, the appropriate positioning is lying down. The arm should be
firmly supported and extended downwards, ensuring that it is kept straight from the shoulder to
the wrist. The hand should be closed to make the veins prominent, but pumping of the fist must
be avoided to prevent haemolysis.
Positioning Paediatric Patients
A child could have fear of unknown origin, and hence turn very aggressive. This could pose a
risk to both self and the health care worker. Therefore, it is critical to restrict the movement of
the child before the venipuncture procedure is initiated.
Restrain the child by having them sit either beside the parent in a special chair or on the parent’s
lap. The parent should wrap their arm around the child and over the arm that is not being used.
The parent could also restrain the child by lying down, as shown above.
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Step 6
Site Selection
Blood is one of the most commonly analysed body fluids for diagnostic purposes. It is important
to keep in mind that all veins are not suitable for venipuncture. The selected veins must meet
some preset attributes that would help in making the specimen collection process least inconvenient to the patient whilst ensuring appropriate specimen quality.
Attributes of Preferred Veins
•
•
•
•
•
Large enough to support good flow
Easily visible
Close to the skin surface
Elastic – should not be hard to feel.
Well anchored in surrounding tissue
Vein Selection
The major veins commonly used for venipuncture are located in the antecubital area. Veins of
choice, in order of preference for venipuncture are:
1.
2.
3.
Median cubital vein
Cephalic vein
Basilic vein
Median cubital vein
This is the first choice of vein because it is large, well anchored, least painful, and least likely
to bruise.
Cephalic vein
This is the second choice of vein because it is large, not as well anchored, and may be more
painful than the median cubital vein.
Basilic vein
This is the third choice because it is generally large and easy to palpate, but often not well anchored. It involves greatest risk because it lies near the brachial artery and median nerve, either
of which could be accidentally punctured.
• Piercing a nerve with a needle may cause ongoing pain and/or paralysis of the arm.
• Scratching the brachial artery with a needle may cause hidden bleeding, leading to
haematoma.
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Palpating the Vein
After vein selection, palpation of the vein is a necessary so as to identify whether the vein is
suitable for puncture. This is achieved by pressing and releasing the vein several times. A thrombosed vein lacks resilience and should not be used. Rotating the arm slightly can help find a vein
or differentiate a vein from other structures in the arm.
Probing for a vein is never recommended.
Inappropriate Sites for Venipuncture
For safe blood collection and quality of blood sample, there are areas which are unsuitable for
blood collection.
These
•
•
•
•
•
•
•
include the following:
Burns
Edematous areas
Scarred areas
Haematomas
Damaged veins (e.g thrombosed, non-elastic)
Arm on side of mastectomy
Sites downstream proximal from an IV line – these are sites which are closer to the heart
and are above the IV line
• Tattoo areas
Step 7
Tourniquet Application
A tourniquet makes the veins easier to locate and feel. It also slows down the venous flow, hence
enlarging the veins. It should not restrict arterial blood flow into the limb.
Wrap the tourniquet 7.5–10 cm (3–4 inches) above the intended puncture site. It should be tied
to be releasable with one hand, and application time should not exceed one minute.
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Tourniquet application procedure
1. Position the tourniquet 7.5–10 cm (3–4 inches) above the
venipuncture site.
2. Cross the tourniquet over the patient arm.
3. Tuck a portion of one end under the opposite end to form a
loop.
4. A properly applied tourniquet for easy release.
Why the Maximum Time for Tourniquet Application is One Minute
The recommended time of one minute ensures that the patient’s comfort is taken care of and
there is slowed venous blood flow in and out of limb.
Leaving the tourniquet in place for greater than one minute changes the concentration of blood
components within the vein due to a biological process called haemo-concentration – small
molecules (e.g. electrolytes and water) move from capillaries to interstitial space and the concentration of macromolecules (e.g. proteins, enzymes) left in the blood appears falsely elevated.
Prolonged tourniquet application can also impact on other test values – e.g. platelet activation,
which may lead to coagulation test errors. For example, a PTT (activated prothrombin time test)
on patients receiving IV heparin because it leads to increase in the coagulation time.
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Note: In case of unsuccessful blood draw, the tourniquet should be re-applied after two minutes.
Step 8
Cleaning the Venipuncture Site
This is a process which enables the phlebotomist to achieve the required cleanliness of the site.
Start from the centre of the site and move outwards in ever-widening concentric circles. Failure
to follow this procedure may reintroduce dirt and bacteria. Use sufficient pressure to remove
surface dirt and debris. If the site remains dirty, repeat with a new swab. Allow to air-dry. Do not
wipe, blow on, or fan, as these actions may reintroduce contaminant micro-organisms. Follow
institutional procedure for blood cultures.
Note: The site should not be touched after it is cleaned.
Step 9
Needle Insertion Technique
Angle of Insertion
This technique involves two procedures; attaining the correct angle of needle insertion and correct needle insertion technique, as explained below.
•
•
•
√ Top: Bevel of needle fully inserted at the recommended 15–30-degree angle.
× Middle: Angle too steep. Potential for needle to completely penetrate the vein, possibly
resulting in formation of a haematoma.
× Lower: Angle too shallow, bevel occluded by wall or partially in the vein/partially in
tissue, possibly resulting in formation of a haematoma.
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Insertion Technique
•
•
•
•
•
With needle cover removed, use dominant hand to grip holder/syringe (index and middle
fingers below, thumb on top).
Grasp patient’s arm (using non-dominant hand) with thumb on top, fingers wrapped to
the back. Pull skin taut below the intended site with thumb, anchoring the vein to keep
it from moving or rolling.
Align with the vein (bevel up), in the same direction as venous flow.
Use a smooth motion to quickly insert the needle.
Stop needle advancement when slight decrease in resistance is felt, signalling entry into
the vein.
Areas of caution
•
•
•
•
Needle contact with a nerve can cause pain and may induce involuntary reflex
(pulling arm away from needle).
Arteries, which can be detected by a pulse, should be avoided.
To avoid accidental puncture, do not select a vein that overlies or is close to an artery. Excessive or blind probing can lead to permanent injury of the nerve or artery, which
may result in permanent damage.
Blood Collection
There are two systems of blood collection:
A.
Evacuated / closed system
B.
Open system
A.
Evacuated / closed system
In the closed system, the blood specimen is collected directly from the vein through the needle
to the evacuated tube. After needle insertion, the procedure continues as explained below.
The blood flows into the tube as shown below.
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Tube Filling
To ensure the continuous flow of blood into the tube, a downwards positioning of the tube
should be maintained so that the blood and additive do not touch the non-patient end of the
multi-sample needle. This will help prevent reflux of the anticoagulant.
Allow the tube to fill until the vacuum is exhausted and the blood flow stops.
Remove the tube from the holder by applying pressure against the wings of the Vacutainer
holder with the thumb and the index finger. Application of pressure assists in holding the needle
steady as tubes are removed and inserted.
Invert the tube gently several times after removal to mix blood and additive. Additional mixing
per tube type can be performed while the next tubes are filling. Continue to draw blood following
the correct order of draw.
Needle Removal
• The tourniquet must be fully released and the patient’s hand open and relaxed before the
needle is removed.
• Hold clean a gauze pad in position over the site. Gently and quickly remove needle from arm.
• Pressure must be applied to the site, to prevent leakage of blood and possible haematoma
formation, as soon as the needle is fully withdrawn, but not before. Pressure is applied firmly
to the puncture site using the gauze pad. Assistance from the patient may be sought when
possible.
• When using a safety-engineered blood collection needle, the safety device is activated at this
time.
• The patient’s arm should be extended and preferably raised; do not bend the arm, as this
increases the risk of haematoma formation.
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Step 10
Sharps Disposal
After successful blood collection, it is important to dispose of the used materials appropriately.
The complete assembly should be discarded into a safety box. Remember never to cut, bend,
break, burn, or recap needles.
Step 11
Mixing of Blood Samples
Mixing of the blood sample in the tubes is paramount in maintaining the integrity of the sample
quality. The sample is mixed by inversion, as illustrated bel
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Why?
All tubes contain additive that needs to be mixed with the blood samples. Tubes with an anticoagulant, e.g. EDTA, need to be mixed to ensure the specimen does not clot.
How?
Holding the tube upright, gently invert 180 degrees and then back.
When?
This should be done immediately after drawing.
Note: There are consequences of failing to mix the samples with the additives in the tube. The
samples in tubes with anticoagulant will clot. As a result, the specimen will often need to be
redrawn.
Order of Draw
The order of draw is significant in the prevention of contamination of red top tubes with the
EDTA in the analysis of electrolytes. Therefore, the collection of blood should start with the red
top Vacutainer followed by the purple top Vacutainer.
Order of draw
•
•
Red top tube first to be drawn
Purple / lavender top tube second to be drawn
Number of inversions
Specific specimen tubes have a recommended number of inversions to be done so as to achieve
the complete mixing of the sample and additive, as indicated below:
•
Red: 5X
•
Purple / lavender: 8X
Proper mixing of the samples and the additive ensures that the sample will be fit for analysis.
B. Open system
In this system, the venipuncture procedure involves the use of needle and syringe. After the
needle is in the vein, slowly pull the plunger back to start filling the syringe, and while blood
flows into the syringe release the tourniquet.
After blood collection, the sample is transferred into the tube by piercing the tube top and vacuum allowed to suck the blood.
To ensure that the whole procedure of blood drawing is safe, removal of the needle from the vein
should be given attention. This is illustrated below.
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Transfer of Blood from a Syringe to a Tube
•
•
•
•
Do not remove the rubber stopper when using evacuated tubes.
Place the tube upright in a rack.
Slowly pierce the stopper of the evacuated tube with the needle.
Allow the tube to fill (without applying pressure to the plunger) until blood flow into the tube
ceases. This technique helps to maintain the correct ratio of blood to additive.
• Follow the same order for filling tubes as the order of draw for an evacuated system.
When transferring blood from a syringe to a tube, do not hold the tube in hand while inserting
the needle. Do not recap or bend the needle before disposal.
Specimen Labelling
This is a very important step after specimen collection. It is done to reduce the risk of specimen
misidentification. Label the container after blood is drawn and mix the specimen while the patient is still present.
Verify information on the tube labels against the requisition form to ensure all identifiers are
accurate.
Tubes must not be labelled prior to venipuncture and the patient must not be released before
labelling is completed.
Post-Venipuncture
After specimen collection, the venipuncture site must be taken care of by examining the patient’s arm to see if bleeding has stopped. An adhesive bandage should be applied on the site to
fix the gauze pad if the bleeding fails to stop. Instruct the patient to leave the bandage on for a
minimum of 15 minutes. For outpatients, advise them not to carry heavy objects with that arm
for one hour.
Thank the patient for his or her cooperation, as this leaves the patient with a positive feeling.
Use gauze instead of cotton. Cotton has fibres that will stick to the venipuncture site, and when
removed leads to more bleeding.
Dispose of used supplies in a safety box before attending to the next patient.
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Removal of Gloves
Gloves should be removed without touching the contaminated areas with the hand.
• Grasp the wrist of one glove with the opposite
gloved hand.
• Pull the glove inside out and off the hand.
• With the first glove held in the gloved hand, slip
the fingers of the non-gloved hand under the
wrist of the remaining glove without touching the
exterior surfaces.
• Pull the glove inside out over the hand so that the
first glove ends up inside of the second glove; no
exterior glove surfaces are exposed.
• Then drop the contaminated gloves into the appropriate waste receptacle.
Key Messages
1. Success in blood collection is greatly determined by attention to the safety of the patient,
the HCW, and the community.
2. The quality of the specimen is key to proper diagnosis, management of the patient, and
the reputation of the facility.
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Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
Module 4
Special Techniques in Specimen Collection by
Venipuncture
Aim
To equip you with knowledge and skills on equipment and techniques used in special conditions
in venipuncture
Prerequisite Modules
Module 1: Importance of Safe Phlebotomy in Patient Care
Module 2: Phlebotomy Equipment and Supplies
Module 3: Successful Specimen Collection by Venipuncture
Objectives
By the end of this module you will be able to:
1.
2.
3.
4.
Identify equipment used for small and fragile venous access for blood collection
List special conditions in venipuncture
Identify alternative sites for venous blood collection in special conditions
Perform venipuncture using a winged blood collection set
Content Outline
•
Special draw equipment; winged blood collection set; venipuncture in special conditions
(paediatrics and geriatrics; burns and thrombosed veins)
•
Alternative sites; dorsum of the hand and the foot
•
Use of winged blood collection set: handling and manipulation, needle withdrawal,
safety feature activation, disposal, and specimen transfer
Notes on Customisation
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Module 4
Special Draw Equipment
Introduction
This module enables you to discuss those conditions where there are difficulties in blood draw
and special care is required while drawing venous blood. Such difficult conditions occur in paediatrics, geriatrics (the elderly), and cancer patients, who may have small and fragile veins for
performing venipunture. In this module, the types of equipment used, how to use them, and
alternative sites for venous blood collection are discussed.
Phlebotomy equipment – special draw
While accessing small / fragile veins (paediatric / geriatric patients), use of alternate equipment
is recommended.
Alternate equipment includes:
•
Gauge 22/23 needles
OR
•
Winged blood collection set
Alternative equipment is required for easing manipulation and reducing the stress exerted on
veins (venous collapse).
Winged Blood Collection Set with Luer Adapter This figure shows the various parts of a
winged blood collection set.
Winged Blood Collection Set with Luer Adapter
This figure shows the various parts of a winged blood collection set.
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Needle Sizes and Colour Coding
Winged blood collection sets may have different needle sizes and colour coding. The coding is
on the wings and is the same as for other needles. The selection of the gauge number depends
on the condition or size of the selected vein for venipuncture. The higher the gauge number, the
smaller the size of the needle.
Green, 21G
Blue, 23G
Dark blue, 25G
Holders
When using a winged blood collection set for an evacuated closed collection system, a holder is
attached to the luer adapter. Holders are clear and moulded to a standard shape, with wings, or extensions, at the tube end
of the holder, which act as a lever against which fingers or thumb can exert pressure to insert or
remove the tube while continuing to hold needle steady within the patient’s vein.
Advantage: This design prevents the risk of accidental needle stick injury by protecting phlebotomis from the non-patient end of the needle.
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Disposal
Dispose of holder with the attached needle as one unit.
Larger sharps containers may be required to accommodate disposable holders.
Winged Blood Collection Set with Syringe
A winged blood collection set can also be fitted to the nozzle of a hypodermic syringe attached
to other end of the luer slip of the winged set. Remove the luer adapter to fix a syringe to the
luer slip (see figure below). The combination is useful while accessing very fragile veins, when
the user would like to control the vacuum applied in order to prevent the vein from collapsing.
Ensure that the connection is tight, to prevent leakage of vacuum from a loose connection and
also formation of froth, which might result in haemolysis.
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Winged Blood Collection Set with Safety Shield
The winged set has a safety shield attached to the needle, so that after use the patient end of
the needle is easily and completely retracted into the shield and locked in place.
This helps reduce the chance of needle stick injury after use.
Other Equipment Needed for Venipuncture
Let’s review other equipment needed for performing venipuncture in special conditions.
Equipment and Supplies
•
Tourniquet
•
Gloves
•
Antiseptic and cotton
•
Winged set
•
Specimen container
•
Gauze
•
Adhesive bandage
•
Safety box
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Module 4
Special Conditions for Venipuncture
In addition to paediatric, geriatric, and cancer patients, as mentioned earlier, the following conditions may lead to use of a winged set.
•
Intravenous lines in both arms
•
Burned or scarred areas
•
Cast(s) on arm(s)
•
Partial or radical mastectomy on one or both sides
•
Thrombosed veins
•
Edematous arms
In such conditions, blood may need to be drawn from veins in the dorsum of the hand, hence
necessitating a special blood draw procedure.
Site Selection
•
•
If an IV line is present, blood should be obtained from the opposite arm.
In cases where an IV line is in both arms, the following should be done:
•
Draw from a vein distal to (below) the IV site.
•
Ask the physician / nurse to turn off the IV for at least 2 minutes.
•
Place tourniquet between the IV and venipuncture sites.
•
Perform venipuncture, discarding the first 5 ml of blood.
•
Indicate the IV solution, arm used, and “drawn below IV”.
Alternative Sites
Site selection in hand
•
•
•
Veins on hands have a narrow diameter; hence it is advantageous to use a
small-gauge needle.
Use of a winged blood collection set with luer adapter may enhance success and make the procedure less painful.
Extra care must be used to anchor these veins to prevent them from rolling.
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In case the veins are not visible, wrapping a warm, wet towel around the hand for a few minutes
may be considered. This is said to increase blood flow sevenfold, and helps make the veins
easier to feel. In case of uncertainty about a vein, tapping the site gently for a few minutes may
assist in dilating the veins and making them more prominent.
Wrist veins tend to move or roll aside as the needle is inserted, and therefore it is critical to hold
the hand such that veins are well anchored. It is preferable to use a winged blood collection set
to perform venipuncture on the wrist.
Blood Draw from the Foot
Foot veins, shown in the figure below, are the last resort for blood collection after the arm veins
have been determined to be unsuitable.
Due to the risk of complications in some patients (e.g. those with diabetes or coagulopathies),
blood collection from foot veins can result in gangrene and thrombosis.
Steps in Blood Collection
Let’s review the procedure involved in venous blood collection.
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Patient
requisition
Patient
interaction
Standard
precautions
Selacting
equipment
Site
cleansing
Tourniquet
application
Site selaction
Positioning
the patient
Perform
venipuncture
Sharps
disposal
Sample
handling/mixing
Sample
transport
The purpose of this is to help you recall the common steps between routine evacuated blood
collection and special collection with a winged set. It is important to note the difference in the
site of venipuncture.
Venipuncture Procedure Using a Winged Blood Collection Set
Preparatory Steps
1)
2)
3)
4)
5)
6)
7)
Identify and communicate with patient
Perform hand hygiene
Put on gloves
Assemble and arrange required equipment and supplies
Position the patient
Select a vein
Sterilise the area
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How to Use a Winged Blood Collection Set
• Grasp both wings of the blood collection set using the index finger and
thumb of the dominant hand.
• Hold the winged blood collection set
as shown below, with holder or syringe attached to the non-patient end.
While anchoring the veins and keeping skin
taut with the thumb of the non-dominant
hand, enter the vein at a 10–15° angle.
Using non-dominant hand:
a)
If using evacuated collection, push the
tube into the holder using thumb while
index and middle fingers grasp wings
of the tube holder.
b)
If using syringe, slowly withdraw the
syringe plunger.
Blood will now begin to flow.
Release the tourniquet.
Note: When using evacuated collection method, follow the same order of draw as discussed in
the previous module (Module 3).
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Withdraw the Needle
•
•
Once the last tube has filled and been
withdrawn or the required amount of blood has been withdrawn in the syringe, put a clean
gauze pad on the site and apply light pressure
using three fingers, as shown.
Gently and quickly withdraw the needle and
continue applying pressure to the site.
Withdraw the needle while grasping the safety shield
area with thumb and index finger.
With opposite hand, grasp tubing between thumb and
index finger.
Push the safety shield forwards until the shield locks
in place. Discard the complete assembly into an approved safety box.
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Discarding the Blood Collection Set
•
•
Discard the complete assembly without removing the
holder, into an approved safety box.
Be aware that tubing attached to sharps can recoil
and lead to injury – maintain control of both tubing
and the device during disposal
Transfer of Blood from Syringe into Specimen Container
•
Remove the cap of the container and gently transfer the specimen into it by pushing the
plunger.
•
Ensure there is no froth formation during blood flow into the container.
•
Do not overfill.
•
Replace the container cap.
•
When evacuated tubes are not used, the phlebotomist needs to remove the cap of the vacuum tube and allow blood to flow on the sides of the walls of the tube while ensuring
no froth formation. Avoid pushing the plunger to avoid froth or haemolysis and risk of aerosol formation.
Sample Transport
•
Ensure that the outside of the specimen container is clean and uncontaminated.
•
Containers should be tightly closed so that the contents do not leak during
transportation.
•
Label and date the container appropriately and complete the requisition form.
•
Arrange for immediate transportation of the specimen to the laboratory.
•
During transportation, samples should be placed upright in appropriate racks and placed
in appropriate carriers.
•
Arrange for immediate transportation of the specimen to the laboratory.
Notes:
•
•
Delay in sample transportation affects a number of analytes (e.g bilirubin).
Criteria should be developed by the laboratory specifying the circumstances under which
the processing of a specimen may not be done by the laboratory.
Key Message
Be aware that tubing attached to sharps can recoil and lead to injury; maintain control of
both tubing and device during disposal.
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Module 5
Complications During Specimen Collection by Venipuncture
Aim
To equip you with knowledge and skills on the management of complications arising from venipuncture
Prerequisite Modules
Module 3: Successful Specimen Collection by Venipuncture;
Module 4: Special Techniques in Specimen Collection by Venipunture
Objectives
By the end of this module you will be able to:
1)
2)
3)
4)
Identify causes of failed venipuncture
Outline the corrective actions for failed venipuncture
Identify potential patient-related complications arising from venipuncture
Describe the management of venipuncture complications
Content Outline
•
•
•
•
Causes of failed venipuncture: improper positioning, rolling of vein, puncture through the
vein, needle obstruction
Corrective actions for failed venipuncture: troubleshooting failed venipuncture
Potential patient complications arising from venipuncture: vomiting, convulsions,
excessive bleeding
Venipuncture complications management: patient comfort, notification, first aid,
following guidelines
Notes on Customisation 59
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Causes of Failed Venipuncture
Failed venipuncture is a condition whereby the blood collection fails. It can also lead to direct
complications for the patient.
These
a)
b)
complications can be classified into two types:
Procedure-related: A problem or situation that makes phlebotomy more difficult and
affects the process of drawing blood
Patient-related: A problem or situation that happens to the patient during the process
of phlebotomy
Procedure-Related Complications
•
•
•
•
•
•
•
•
•
•
Improper positioning of tube
Rolling of vein
Puncture through vein
Needle bevel obstruction
Collapsed vein
Partially inserted needle
Tube pop-off
Anticoagulant reflux
Accidental arterial puncture
Tourniquet not removed
Patient-Related Complications
•
•
•
•
•
•
Excessive bleeding
Petechiae
Nausea
Vomiting
Fainting
Convulsions / seizures
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Procedure-Related Complications and Their Management
Improper Positioning of the Tube
This is when the tube is wrongly positioned in the holder, either angulated or with the needle
partially piercing the rubber stopper. In a well-positioned tube, the non-patient end of the eclipse
needle must penetrate the rubber stopper completely.
Tube 1 is correctly / properly inserted into the tube and into the holder. This makes sample
collection possible.
Tube 2 is incorrectly / improperly inserted, resulting in an incompletely punctured stopper and
angulation of the needle in the stopper. This can lead to insufficient quantity collection, underfilling of tubes, and haemolysis of red cells.
Tube 3 is incorrectly inserted, since the stopper is partially punctured and therefore cannot obtain the blood sample as desired.
Corrective measure:
Avoid angulated insertion of the tube or incomplete insertion / puncture through the stopper
when inserting the Vacutainer into the holder.
Corrective measure:
Avoid angulated insertion of the tube or incomplete insertion / puncture through the stopper
when inserting the Vacutainer into the holder.
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Rolling of the Vein
This is a condition where the vein moves sideways on attempting to puncture it during phlebotomy.
This happens when a vein is not well anchored prior to puncture; it may change position (roll)
after or during the process of needle insertion. When a vein rolls, the needle may slip to the side
of the vein without penetrating it.
When this happens, no sample can be collected since the needle is not in the vein, as shown
in this diagram.
Corrective measure:
•
Remove tube from needle holder to preserve vacuum.
•
Withdraw needle until bevel is just under the skin, anchor vein, and redirect needle into
vein.
•
Reinsert the same tube into the holder.
•
If there is still no blood flow, remove tourniquet and ensure patient’s hand is open.
•
Withdraw tube and remove needle from patient’s arm and consider an alternative site,
preferably on the opposite arm.
Puncture Through Vein
This is when the needle penetrates through both walls of the vein. This may happen either
when the needle is inserted too fast, or when the holder is not kept steady when tubes are
pushed into and removed from the needle.
This image shows a needle going through the two walls of the vein.
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Corrective measure:
•
•
•
•
•
•
•
•
•
Withdraw needle slightly to establish blood flow.
If blood flow is restored, take care when removing tube and when inserting and
removing subsequent tubes to ensure holder and needle assembly is well anchored
(use the wings). Continue but be alert for haematoma. If haematoma begins to form,
cease procedure immediately.
If blood flow is not restored, then:
Remove tourniquet.
Ensure patient’s hand is open.
Withdraw tube.
Remove needle from patient’s arm and apply pressure to the site.
Keep arm straight and elevated if possible.
Consider alternative site on opposite arm.
Remember: Application of pressure to the site at the end of the procedure is key.
Needle Bevel Obstruction
This is blockage of a needle, and happens occasionally when the bevel of the needle lies
against the wall of the vein, preventing free blood flow.
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A needle obstructed by the vascular wall (left)
needle obstruction leads to difficulties in the flow of blood into the Vacutainer (right)
Corrective measure:
•
•
•
Pull the needle back slightly.
If there is still no blood flow, remove tourniquet and ensure patient’s hand is open.
Withdraw tube, and remove needle from patient’s arm.
Avoid:
•
Rotating needle, because this may damage the vessel wall. If you must rotate, do it
with care up to a one-quarter turn.
•
Changing the angle of the needle, because redirection may lead to significant tissue
damage. If done, it should be in moderation and with care. It’s good to remove tube while the
needle is repositioned, and the same tube can be reinserted in the holder when the vein is
accessed.
A needle bevel free from the wall of the vein (left)
A reestablished blood flow into the tube (right)
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Module 5
Collapsed Vein
The vacuum draw of the tube or pressure created by pulling the plunger of a syringe may
cause a vein to collapse. Blood flow slows and then stops as the vein collapses.
When the vein collapses after the first tube, it may be due to insufficient tourniquet pressure.
This can also occur when the tourniquet is applied too close to the puncture site.
A vein collapse (left)
Blood has already stopped flowing into the tube due to vein collapse (right)
Corrective measure:
•
Ensure needle is in the vein (and that the problem is due to vein collapse).
•
Experiment with tourniquet pressure (increase or decrease as appropriate).
•
Try use of a partial-draw tube, since it has a relatively small volume of vacuum compared with the standard Vacutainer.
•
If blood flow does not resume, remove tube from needle holder, wait a few seconds for
blood flow to reestablish, and reinsert tube.
If there is still no blood flow, remove tourniquet and ensure the patient’s hand is open before
withdrawing tube and needle.
Partial-draw tubes are useful in “softening” the draw with small and fragile veins susceptible to collapse.
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Partially Inserted Needle
This is when the bevel of the needle is not totally within the lumen of vein. Blood may leak into
the surrounding tissue, causing a haematoma and reduced blood flow into the tube.
Haematoma
Partially inserted bevel of needle
Poor blood flow
Corrective measure:
•
•
•
•
•
Remove tube.
Release tourniquet and withdraw needle immediately.
Apply firm pressure to the site for several minutes and request patient to maintain
pressure for a prolonged period if possible, or request assistance from nursing staff or a
relative as appropriate.
Consider an alternative site on the opposite arm.
For haematoma, apply pressure and reassure patient since it will resolve on its own.
Tube Pop-Off
This is when the tube is ejected, and occurs occasionally during venipuncture where a needle
sleeve pushes the tube off the needle slightly and as a result blood flow stops.
(left) No blood flows when the tube pops off. (right) Tube (stopper) pushed away by the sleeve
of the needle.
Corrective measure:
Re-advance the tube and hold it in place to reestablish blood flow until the tube is filled.
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Module 5
Reflux of Anticoagulant
This is flow of the anticoagulant from the Vacutainer into the vein.
If the tube is not properly oriented and the tourniquet is suddenly released, pressure inside the
tube may momentarily exceed that in the vein. Blood might then flow back into the patient’s
vein (reflux) from the collection tube.
This picture shows anticoagulant in the vein (from Vacutainer).
Corrective measure:
To prevent reflux, the patient’s arm should be maintained in a downwards position to ensure
the tube remains below the site and fills from bottom upwards.
Tourniquet Not Removed
This is when a phlebotomist accidentally forgets to remove the tourniquet after blood starts
flowing into the tube.
Failure to remove the tourniquet before withdrawing the needle maintains pressure inside vein.
Blood can spill out of the vessel once the needle is removed, creating:
•
Biohazard risk, such as spillage of blood that can lead to contamination
•
Patient anxiety
•
Haematoma
This image shows a tourniquet forgotten when drawing blood.
Always check for any residual tourniquet tension before removing needle.
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Corrective measures:
Tourniquet tension should be reduced or removed when blood begins to flow into the first tube. If
not yet removed, make sure it’s loosened or removed completely. Remember that the tourniquet
should not be in place for more than one minute during the procedure, since it also compromises quality of the specimen.
In case of spillage:
•
•
•
Apply pressure to the puncture site after the procedure to reduce risks of bleeding or
haematoma formation.
Reassure patient and explain that this complication may occur.
Decontaminate the surfaces.
Patient-Related Complications and Their Management
Accidental Arterial Puncture
This is accidental puncture to the artery instead of the vein. Arterial blood has a bright red colour
and the tube fills very quickly.
Management:
•
•
•
Remove needle.
Apply pressure for at least five minutes.
Note on the requisition sheet that the specimen is arterial blood, and inform the lab,
since specimen values may be different from those expected.
Excessive Patient Bleeding
This is when bleeding occurs for longer than five minutes. It can be due to poor procedure, like
a tourniquet left in place, or to a bleeding disorder.
Management:
•
Give first aid by applying pressure. If the bleeding does not stop, alert a nurse or any
clinician.
•
Continue applying pressure on the site as long as necessary to stop the bleeding.
•
Wrap bandage securely around arm over gauze pad.
•
Leave bandage on the site for at least 15 minutes or until bleeding stops.
Petechiae
This is the presence of red spots under the skin, usually due to microtrauma or fragile
blood vessels below the skin. They may be due to a tourniquet left in place or may represent
excessive capillary fragility in some patients.
Management:
Observe the complication and manage appropriately. You can also investigate for bleeding disorders.
Nausea
This is an unpleasant feeling preceding vomiting.
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Module 5
Management:
•
•
•
•
Make patient as comfortable as possible.
Instruct patient to breathe deeply and slowly in and out.
Apply cold compresses on patient’s forehead.
Notify personnel trained in first aid.
Vomiting
Emesis, or what is known informally as “throwing up.”
Management:
•
Same steps as in nausea.
•
Give patient an emesis basin, carton, or any other container to vomit in to act as a
receptacle.
•
Give patient water to rinse out mouth.
Fainting
This is transient loss of consciousness, and can be induced or inflicted by pain.
Management:
•
•
•
•
Notify personnel trained in first aid.
If patient is sitting, lay him/her flat or lower his/her head and arms.
Loosen tight clothing.
Cease procedure.
Convulsions / seizures
These are abnormal electrical discharges in the brain characterised by involuntary movement
of the limbs.
Management:
•
•
•
•
•
•
Cease procedure immediately.
Call for help.
Have someone hold pressure to the site.
Lower patient to the floor and clear space to prevent injury.
Do not restrain patient’s extremities.
Notify personnel trained in first aid.
Key Message
Great care should be taken during and after venipuncture because of patient- and procedure-related complications that may result.
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Module 6
Capillary Blood Collection
Aim
To equip you with knowledge and skills on capillary blood collection
Prerequisite Modules
Module 1: Importance of Safe Phlebotomy in Patient Care;
Module 2: Phlebotomy Equipment and Supplies
Objectives
By the end of this module you should be able to:
1.
Identify equipment used in capillary blood collection
2.
Identify sites for capillary blood collection
3.
Perform capillary blood collection
Content Outline
•
•
•
Equipment: lancets, micro collection tubes, capillary tubes, quick heel safety lancet
Sites for capillary blood collection: finger and heel
Recommended practices: procedure, complications in capillary blood collection, safety,
order of draw
Notes on Customisation
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Module 6
Introduction
Collection of blood from capillaries is a procedure that involves penetrating the dermis of the
skin with a lancet or other sharp device in order to collect a blood specimen. It is also called
dermal puncture or skin puncture.
Tests
•
•
•
commonly performed on capillary blood include:
Blood smear
-
Microscopic assessment of cell morphology
-
Preparation for malarial parasites
HIV
-
Rapid test
-
Dried blood spot (DBS) for early infant diagnosis
Blood glucose monitoring
Key dimensions of successful capillary blood collection are:
•
Health care worker safety – this can be compromised by blood exposure, sharps injury
during the procedure, and injuries due to improper waste disposal
•
Patient safety and comfort – injuries may occur during a procedure
•
Specimen quality – the integrity of the specimen can only be maintained by obtaining
a specimen that is truly representative of the in vivo status of the patient. The integrity
of the specimen can be compromised by poor specimen quality, leading to a wrong
result.
•
Device selection – based on patient’s age and safe penetration depth
•
Required blood volume: This is determined according to test type.
Collection from Children
In paediatrics, capillary blood collection is a common practice since children’s veins are small
and fragile, unless large volumes of blood are required.
Depth of heel and finger sticks:
•
•
•
Heel stick should be less than 2.0 mm.
Finger stick on children over 12 months should be less than 1.5 mm.
Finger stick on children over 8 years should be less than 2.0 mm.
Contact with the heel bone (calcaneus) may cause osteomyelitis, which could go undetected
for a long period, resulting in serious complications in children.
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Collection from Adults
Skin puncture may be a procedure of choice for blood collection for adults under the following
conditions:
•
•
•
•
•
•
•
•
Severe burns – these may result in lack of availability of suitable venipuncture sites
Extreme obesity – this makes it difficult to locate / palpate veins
Hypercoagulability (thrombotic tendency) – venipuncture could result in serious conse
quences for these patients, leading to conditions such as deep vein thrombosis
Geriatric or fragile veins – it can be difficult to access / find suitable veins
Need to preserve veins for therapy – some patients, such as those on chemotherapy,
have superficial, delicate veins that need to be preserved for their therapy
Home testing – e.g. glucose testing
Apprehensive patients – patients who refuse venous access
Point of care testing – within wards (e.g. glucose)
Depth of heel and finger sticks:
•
Heel stick should be less than 2.0 mm.
•
Finger stick on adults should be less than 2.4 mm.
Equipment Used in Capillary Blood Collection
In this section you will identify the types of equipment and supplies needed and their applications for successful capillary blood collection. All the equipment and supplies will be reviewed,
with emphasis on those that were not discussed in Module 2: Phlebotomy Equipment and
Supplies.
Equipment used:
•
Gloves
•
Lancets
•
Antiseptic and cotton
•
Gauze (clean)
•
Sharps containers
•
Adhesive bandages
•
Specimen collection equipment
•
Micro collection tubes
•
Slides
•
Filter paper (for DBS)
•
Rapid test kits
•
Capillary tubes
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Module 6
Gloves (see Module 2 for review)
Gloves are key supplies in standard infection control. They provide a barrier to the spread of
infection. For each patient and procedure, a new pair of gloves should be worn. Gloves are part
of personal protective equipment (PPE) against contact with blood during phlebotomy. A good
fit is essential; hence one should select the right size.
Gloves may not be completely defect-free, and any micropores in the gloves could let contaminants in and hence pose a risk of infection to the health care worker.
Gloves should therefore not be washed and reused.
Antiseptics (see Module 2 for review)
Antiseptics are chemical substances that inhibit or prevent the growth of bacteria. An antiseptic
is recommended for use in cleaning the skin prior to drawing blood. The most commonly used
antiseptic is 70% isopropyl alcohol.
Rapid Test Kits
The devices are supplied with defined sample application sites. They are simple to use and require minimum time for test results.
Slides
These are frequently used for preparation of blood smears. They are made of clear glass.
Capillary Tubes
These are either plastic- or glass-clad. Plastic-clad capillary tubes are non-sharp, and hence
safer for use. Capillary tubes may be with or without anticoagulant.
Capillary tubes can be used in blood collection for DBS preparation.
73
Capillaries
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• Glass- or plastic-clad
capillaries.
• Plastic-clad capillaries
are safer (non-sharp).
• With or without
anticoagulant.
Micro Collection Tubes
These tubes are designed for collection, transportation, and processing of capillary blood from
infants, children, and adults with inaccessible veins, and from geriatric and critical care patients. They are colour-coded, similar to evacuated tubes. They do not have vacuum, and hence
the caps need to be removed in order to collect the sample. Tubes with anticoagulant require
simultaneous mixing to avoid clotting. Tests done using micro collection tubes are similar to
those done using evacuated tubes.
ection Tubes
tubes are designed
ansport, and
pillary blood.
coded similarly to
.
ollection from:
en, adults with
eins, andNote:
geriatric
Micro collection tubes do not have vacuum.
e patients.
Filter Papers
Filter papers are useful devices for sample collection since they provide ease of transport and
sample handling. They are used for HIV testing (early infant diagnosis), etc.
um.
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Module 6
Cotton
This may be supplied as pre-packed swabs or made into cotton balls moistened with 70% isopropyl alcohol just before use.
Pre-soaked cotton is not suitable since the active ingredient (alcohol) evaporates, leaving water behind, and the antiseptic property diminishes.
Manual Lancets
These are for single-use, used for skin punctures, and they are of different shapes and sizes.
Their puncture depth depends primarily on the operator and length of needle / blade.
Safety Lancets
These are single-use devices for skin punctures. They are of different sizes for different depths.
The depth should never exceed 2.4 mm. Safety lancets only activate when positioned and
pressed against the skin. They facilitate a consistent puncture depth and are permanently retractable.
ger Puncture
Finger puncture manual lancets
punctures.
and sizes.
epends
perator
the
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Finger puncture safety lancets
Heel Puncture Safety Lancets
These are single-use devices supplied in different sizes. They are automatic and permanently
retractable. The blade is used to make a shallow but longer cut, which helps in faster healing as
well as better blood flow, since capillaries are concentrated in the top 1 millimetre of the skin. A
shallow cut is also less painful, since the top layer of the skin has fewer nerve endings.
Use of these devices minimises chances of contact with the bone during the procedure.
Heel puncture safety lancets
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Module 6
Sites for Capillary Blood Collection
Capillary blood collection is performed from two sites; the heel and the finger.
In the case of infants, skin puncture is performed on the heel. For children who have started
walking and for adults, it is usually performed on the finger.
Heel
The heel is the recommended site for capillary blood collection for neonates and infants. The
plantar surface of the heel (medial to a line drawn posteriorly from the large toe to the heel or
lateral to a line drawn posteriorly from between the fourth and fifth toes to the heel) is the site
of choice.
Finger
The palmar surface on the tip of the third and fourth fingers is the site of choice for capillary
blood collection for infants older than one year, as well as for older children and adults.
Recommended sites are as indicated in the picture above, because blood capillaries are concentrated on the side of the finger.
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Capillary Blood Collection Procedure
The below graphic shows the steps involved in capillary blood collection.
The steps are the same as for venous blood collection with the exception of the tourniquet
application step.
Patient
requisition
Patient
interaction
Standard
precautions
Selacting
equipment
Perform
venipuncture
Site
cleansing
Site selaction
Positioning
the patient
Sharps
disposal
Sample
handling/mixing
Patient Requisition, Patient Interaction, and Standard Precautions
(Steps 1–3) Steps 1–3 are important in blood collection procedure. However, these steps have
been adequately covered in Module 3: Successful Specimen Collection by Venipuncture.
In capillary blood collection procedure, therefore, we shall only deal with the equipment selection step through the sample transport step.
Step 4: Selecting Equipment
After verifying the information on the requisition form, it is important to select micro collection
devices and assemble them according to the test to be done before starting the procedure.
Step 5: Positioning the Patient
Adults and older children should sit with their arm flat on a surface. Children can be restrained
by either having them sit beside a parent or on the parent’s lap. The parent should wrap their
arm around the child and over the arm that is not being used. The parent could also restrain the
child by lying down on a couch/bed as shown.
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Module 6
Positioning for the heel prick
Step 6: Site Selection
After site selection, it may be necessary to warm the puncture site to increase the blood flow.
Warming is known to increase blood flow sevenfold. This can be done with a warm, moist towel
or warming device for 3 to 5 minutes.
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Step 7: Site Cleansing The skin puncture site must be cleaned with 70% isopropyl alcohol as pre-packed swabs or
cotton moistened with the antiseptic at the time of use. Allow the area to air-dry so that the
antiseptic action of the alcohol can take effect. Residual alcohol causes rapid haemolysis and
can adversely effect some test results (e.g. blood glucose determination).
Betadine (povidine iodine) must not be used to clean and disinfect skin puncture sites: blood
contaminated with betadine may have falsely elevated levels of potassium, phosphorus, or uric
acid. Clean the area starting from the intended puncture site and work outwards to prevent
contaminating the area.
Step 8: Perform Skin Puncture – Finger
When carrying out this procedure, it is appropriate to inform adult patients about imminent
pain. Hold the finger and firmly place a new sterile lancet at the selected site, and then orient
the lancet across the fingerprint groves to help in drop formation.
If using a self-retracting safety lancet, activate it; or if using a manual lancet, perform a single
puncture in one smooth motion.
across
X parallel
Skin Puncture – Heel
During heel puncture, hold the foot in a firm grip with the thumb placed below the puncture site
and index finger placed over the arch. Hold and orient the lancet on the intended puncture site
at a 90-degree angle / perpendicular to the length of the foot. Firmly and completely depress
the trigger of the safety lancet or perform a single puncture with one smooth motion if using a
manual lancet.
The following precautions should be observed during heel puncture procedure:
•
Do not puncture deeper than 2.0 mm to avoid contact with the bone.
•
Do not puncture through previous punctures.
•
Do not puncture outside the medial and lateral aspects of the heel, as previously
described.
•
Do not puncture the posterior curvature or the arch of the heel.
•
Do not puncture areas of the foot other than the heel.
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Module 6
Blood Collection from Finger or Heel
After successful puncture, wipe out the first drop of blood with a clean, dry gauze pad, as it
contains an excess of tissue fluid which would dilute the sample, thereby affecting the analyte
results.
Collect the sample beginning with the second drop, using the appropriate device according to
the test being performed (e.g. slides, capillary tubes, rapid test, micro collection tubes, filter
papers).
Holding the puncture site downwards, gently apply intermittent pressure to the surrounding
tissue to enhance blood flow. Avoid “milking” or scraping since this can cause sample dilution
with tissue fluids. Continue until the desired volume of blood has been collected.
Note: Before starting the sample collection procedure, ensure the waste containers are within
reach.
Blood Collection on Filter Papers (DBS Preparation)
Dried blood spots (DBS) are prepared by collecting whole blood on designated filter papers positioned in a drying rack. Label the filter paper appropriately before using. Using a capillary tube,
, collect sample from the puncture site and put two drops on each circle.
NAME:
DATE:
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When preparing DBS, avoid the following:
•
•
•
•
•
Oversaturated spots
Scratches on spots
Scattered spots
More than one layer
Touching or smearing the blood spot
Drying
After preparation, allow the specimen to fully air-dry horizontally overnight at room temperature.
This ensures complete drying, as demonstrated by a chocolate-brown colour.
While
•
•
•
•
drying avoid the following:
Direct sunlight Dust
Heat
Stacking or touching other surfaces
Post–Skin Puncture Procedure
When blood collection is complete, it is the role of the phlebotomist to ensure bleeding from the
site of puncture is stopped. This is achieved by applying clean, dry gauze at the bleeding point
and asking the patient to apply pressure for a short time.
Do not apply an adhesive bandage on children below two years, since this may irritate infant
skin, or the infant may remove it, put the bandage in the mouth, or swallow it.
Ensure all specimens are labelled immediately after the draw.
Ensure proper disposal of all waste.
Key Messages
1)
2)
3)
4)
5)
The first drop of blood must be discarded to avoid specimen dilution by tissue fluid.
Never “milk” or scrape the puncture site.
Mix anticoagulated micro collection tubes continuously during collection.
Never exceed the specified puncture depth to avoid osteomyelitis.
Follow recommended order of draw for micro collection tubes.
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Module 7
Safety and Infection Control
Aim To equip you with knowledge, skills, and attitudes on infection prevention and control practices
Prerequisite Modules
Module 3: Successful Specimen Collection by Venipuncture
Module 4: Special Techniques in Specimen Collection by Venipuncture
Module 6: Capillary Blood Collection
Objectives
By the end of this module you will be able to:
1.
2.
3.
4.
List infectious agents potentially transmissible during blood collection
Describe risk factors of blood-borne pathogens during blood specimen collection
Outline standard precautions in the workplace
Describe the waste management process
Content •
Infectious agents: viral, bacterial, fungal, and protozoan
•
Risk factors: non-intact skin, needle stick and sharps injuries, splashes on mucous
membrane
•
Appropriate use of PPE and safe work practices
•
Waste management: proper waste segregation, containment, handling, storage,
transport, treatment or destruction and disposal of sharps
Notes on Customisation
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Infectious Agents
These are pathogenic microorganisms that when present in human blood can cause diseases.
HCWs are at a higher risk due to occupational exposure to blood-borne pathogens.
Exposure can occur through various types of contact:
•
Needle stick injuries (NSIs)
•
Mucous membrane
•
Non-intact skin
HCWs must therefore take precautions while collecting or handling blood and other body fluids
to avoid coming into contact with infectious agents.
These infectious agents are classified into the following categories: viral, bacterial, fungal, and
protozoan.
Diseases That Can Be Contracted
through NSI
The table below gives a breakdown of the pathogens which can be contracted through NSIs.
Viral Infections
Bacterial Infections
Fungal Infections
Hepatitis B
Brucella abortus
Blastomyces dermatidis
Hepatitis C
Corynebacterium diptheriae
Cryptococcus neoformans
Hepatitis G
Neisseria gonorrheae
Sporotrichum schenkii
Human immunodeficiency virus
Leptospira icterohaemorrhagiae
Simian immunodeficiency virus
Mycobacterium marinum
Protozoal infections
Herpes simiae
Mycoplasma caviae
Plasmodium falciparum
Herpes simplex
Orientia tsutsugamushi
Toxoplasma gondii
Herpes zoster
Rickettsia rickettsii
Ebola/Marburg
Staphylococcus aureus
Dengue
Streptococcus pyogenes
Creutzfeldt-Jakob disease
Treponema pallidum
Mycobacterium tuberculosis
Risk Factors
Risk of infection due to sharps injury
The data below showan estimated risk burden attributed to contaminated sharps injuries among
health workers. The data emphasise that not only HIV poses a high risk with exposure to contaminated sharps but also HBV and HCV, the incidence of which are both much higher.
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Virus
HBV
HCV
HIV
Module 7
NSI risk burden
23–62%
0–7%
0.3–0.5%
Risk Factors for HIV/HCV/ HBV Transmission after Percutaneous Exposure
Several factors increase one’s susceptibility to infection from an NSI.
•
Deep injury
•
Injury with device visibly contaminated with blood
•
Procedures involving placement of device in patient’s artery or vein
•
Hollow-bore needles
•
High viral load in source patient
•
Failure to take or complete post-exposure prophylaxis for HIV
•
Failure to get vaccination against HBV
Appropriate Use of PPE and Safe Work Practices
These are procedures/practiceswhich prevent thetransfer of pathogenic microorganisms from
the source to the HCW, general population, and environment.
Standard precautions
•
Safe and proper use of equipment
•
Effective hand hygiene procedures
•
Immunisations, e.g. hepatitis B
•
Proper decontamination of surfaces and instruments
•
Keeping safety boxes at arm’s length
•
Labelling of all biohazard materials
•
Use of gloves during blood drawing
•
Use of gowns, masks, respirators, and other PPE wherever indicated
•
Use of closed-toe shoes or boots
Note: All samples should be considered potentially infectious.
Hand Hygiene
This is the act of keeping hands free from contamination by washing/sanitising them frequently to prevent the spread of infection.
Situations when hand washing/sanitising is required:
•
Before and after each patient contact
•
Between unrelated procedures (e.g. wound care, blood draw)
•
Before putting on gloves and after taking them off
•
Before and after going to the washroom
•
Whenever hands become visibly or knowingly contaminated
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Hand hygiene can be performed by:
•
Hand washing using soap and water
•
Using hand gel / sanitiser
Hand washing with soap and water is the most important means of preventing and controlling
the spread of infection.
Sharps Safety Practices
These
•
•
•
•
•
•
•
practices help ensure proper handling of sharps to prevent NSIs.
Be prepared before beginning a procedure.
Organise equipment at the point of use.
Make sure the workplace has adequate lighting.
Keep sharps pointed away from the user.
Keep safety boxes within arm’s length.
Assess a patient’s ability to cooperate and get help if necessary.
Ask patient to avoid sudden movement.
Be Aware During a Procedure
•
•
•
•
•
•
•
•
Maintain visual contact with sharps.
Be aware of sharps nearby.
Control location of sharps to avoid injury to yourself and others.
Do not pass exposed sharps from one person to another.
Use predetermined “neutral zones” for placing / retrieving sharps.
If using devices with safety features:
Activate as soon as procedure is completed.
Observe audible or visual cues that confirm the feature is locked in place.
Failure to follow the above precautions exposes the patient as well as other HCWs to accidental
needle stick injury.
The safety box should be kept at arm’s length so that sharps can be disposed of immediately
after use; do not leave them “laying around” as pictured below.
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Module 7
Dispose with Care
•
Be accountable for the sharps you use.
•
Check procedure trays, waste materials, and bedding for exposed sharps before
handling.
•
Look for sharps / equipment left behind inadvertently.
•
Inspect safety box visually (do not overfill).
•
Always keep hands behind sharps.
•
Never put hands or fingers into the sharps container.
•
Use mechanical device if you cannot safely pick up sharps by hand.
•
If disposing of sharps with attached tubing:
•
Be aware that tubing attached to sharps can recoil and lead to injury.
•
Maintain control of both tubing and the device.
Proper Use of Safety Boxes
An overfilled safety box (below) with protruding sharps poses a risk of sharps injury, especially to
the next person depositing sharps in the container, even when closing it before disposal. Usually,
the safety boxes have a fill line beyond which it should not be filled. If using a safety box that
is not transparent, the user should check the fill level through the opening of the box with great
care while maintaining a safe distance.
Note: Replace safety boxes before they become overfilled.
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Handling Broken Samples
The picture below illustrates how the health care worker can most safely handle broken sample
containers on the floor.
Disposal
It is important that proper segregation of waste is maintained in the department. This prevents
exposing the person responsible for collecting waste (non-sharps) to possible sharps injury, as
shown below.
Sharps in a non-sharps waste bin could pose a serious risk of needle stick injury to workers
responsible for handling waste. This form of sharps injury could be even more serious, because
of lack of awareness in personnel handling waste as well as the difficulty in linking the sharp to
the patient on which it was used.
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Waste Management
Waste management is the proper handling, treatment, and disposal of medical wastes.
Purpose of waste management:
•
To protect people who handle waste items from accidental injury
•
To prevent the spread of infection to HCWs who handle waste
•
To prevent the spread of infection to the local community
•
To safely dispose of hazardous material
Measures to Reduce the Risk of Infection from Medical Waste
•
•
•
•
•
•
•
Segregate waste at the source.
Use PPE when handling medical wastes.
Handle sharps with care.
Do not sort through waste.
Keep facility clean inside and outside.
Have knowledge in first aid.
Get fully immunised against tetanus and hepatitis B.
In case of injury, go for immediate evaluation for PEP.
Key Steps in Waste Management
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Waste Segregation
This is the process of separating generated medical wastes into their appropriate bins before
disposal. It should be done at the point of generation by type and category, as follows:
•
•
•
•
Non-infectious – disposed in the black waste bin (e.g. papers, food remains)
Infectious – disposed in the yellow bin (e.g. used gloves, cotton, gauze)
Highly infectious – disposed in the red bin (e.g. body fluids, such as blood, aspirates, used culture media)
Sharps (highly infectious) – disposed in safety boxes
Containment This is the safe method of managing segregated waste in an orderly manner to prevent cluttering. The purpose is to reduce or eliminate exposure of HCWs and the environment to potentially
hazardous agents.
Handling and Storage
This is the safe method of ensuring waste is kept in safe and designated rooms awaiting collection to the disposal site. Labelling should be done according to type and category.
Transportation
This is the transporting of medical waste to disposal sites by appropriate means. There are two
types of disposal sites:
•
•
On-site: within the facility by using a wheelbarrow, waste trolley, or hand cart
Off-site: outside the facility by using a dedicated waste collection vehicle; a licence
must be obtained from the relevant authority (e.g. NEMA or local authority).
Each waste category should be transported separately.
Precautions to follow during transport:
•
Keep boxes upright.
•
Keep safety boxes dry.
•
Avoid direct contact of safety boxes with other medical wastes or medical supplies in
the same vehicle.
•
After transport, clean vehicle surfaces with disinfectant.
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Treatment
Medical waste treatment is a process that renders medical waste harmless to the health care
worker, general population, and the environment. The commonly used methods are:
•
•
•
Burning and burying
Incineration
Autoclave (limited to laboratory specimens)
Waste Disposal
Incinerator
(top and bottom) Waste shredders
Open disposal and burning
Key Message
It is not just about numbers
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Module 8
Occupational Exposure
Aim
To equip you with knowledge and skills to manage occupational exposure to blood and body
fluids
Prerequisite Modules
Module
Module
Module
Module
3:
4:
6:
7:
Successful Specimen Collection by Venipuncture
Special Techniques in Specimen Collection by Venipuncture
Capillary Blood Collection
Safety and Infection Control
Objectives
By the end of this module you should be able to:
1.
2.
3.
4.
5.
Define terminologies in occupational exposure
Describe the risk of transmission of HIV and hepatitis after occupational exposure
Identify the devices causing percutaneous injuries
Outline PEP management
Outline institutional policy in relation to occupational exposure
Content
•
Terminologies: occupational exposure and PEP
•
Risk of transmission of different viruses following accidental needle stick injury
•
Devices involved in percutaneous injuries or exposure: hypodermic needles, sutures,
scalpels, etc.
•
PEP management procedures: goals, immediate measures, first aid, evaluation for PEP,
PEP regimens, administering PEP, monitoring drug interactions, side effects, and
follow-up
•
Institutional policies such as having a PEP plan, appropriate use of the PEP register,
and advocating for hepatitis B vaccination for all health care workers
Notes on Customisation
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Module 8
Terminology
1.
2.
3.
Occupational exposure to HIV refers to an accidental exposure to blood or body fluids
with a potential risk of transmitting HIV to HCWs during performance of their duties.
Post-exposure prophylaxis (PEP) refers to the preventive management given to
minimise the risk of infection following potential exposure to HIV.
Non-occupational exposure refers to exposure to potential blood-borne infections (HIV,
HBV, HCV) outside the work setting, e.g. sexual assault / rape / sodomy.
Risk of Transmission
Although the main focus is HIV, it is also important to note that hepatitis B and C have a
higher risk of transmission than HIV.
It is important to note that the consequences of viral infections are expensive and associated
with many complications and that there is no effective management for viral hepatitis.
Risk of transmission of different viruses following accidental NSI
Hepatitis B 6–30%
Hepatitis C 1.8%
HIV0.3%
Exposure Risk for HIV
This table shows the comparative risk of acquiring HIV through different portals of entry. The
risk is highest for percutaneous exposure and lowest for non-intact skin.
Percutaneous0.3%
Mucous membrane0.1%
Non-intact skin< 0.1%
Devices that May Cause Percutaneous Injuries
Devices that are associated with percutaneous injuries are:
•
•
•
•
•
Hypodermic needles
Blood collection needles
Suture needles
Needles used in IV delivery systems Scalpels
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Factors Increasing the Risk of Sharps Injuries
Past studies have shown that sharps injuries are often associated with the activities outlined
below.
•
The risk of sharps injuries is highest when sharps are not handled and disposed of
correctly.
•
Injuries can also occur when recapping needles or other devices.
•
Injuries can occur when transferring a body fluid between containers.
•
Injury can be caused by failing to dispose of used needles or other devices properly in
puncture-resistant sharps containers.
Goal of Post-Exposure Prophylaxis
The ultimate goal of PEP is to maximally suppress viral replication that may occur, and to shift
the biological advantage to the host cellular immune system to prevent or stop early infection.
First Aid
•
•
•
•
•
•
For percutaneous exposure, wash needle stick injuries and cuts with soap and copious
amount of free-flowing water.
For non-intact skin exposure, wash with soap and water as explained above.
For mucous membrane exposure, irrigate the nose, mouth, or skin with water. Avoid
use of soap since it can cause irritation and increase risks of contracting HIV infection.
Irrigate eyes with copious amount of clean water or sterile saline.
Report exposure to the immediate supervisor.
Ensure initiation of the first dose of PEP as soon as possible.
PEP should be initiated preferably within 2 hours and not later than 72 hours
post-exposure to optimise its benefit.
Evaluation of Exposure and Source of Exposure •
Evaluate the type of body substance (e.g. blood, urine, pus) involved.
•
Evaluate the severity of exposure.
•
Establish baseline / initial HIV and HBV status of the source of exposure (patient).
•
Establish baseline / initial HIV and HBV status of the exposed HCW.
•
Determine appropriate PEP regimen depending on the severity of exposure.
Management and Follow-Up
The principles of PEP management are:
•
•
•
Counselling and provision of PEP drugs
Monitoring and managing PEP toxicity 2 weeks after starting PEP
HIV testing at 6 weeks, 3 months, and 6 months
Note: Efavirenz is teratogenic; hence, test to rule out pregnancy in women.
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Module 8
The tolerability of HIV PEP in HCWs is affected by the side effects listed in the graph below.
Incidence of common side effects
Duration of PEP Therapy
•
A four-week course of therapy equivalent to 28 days
•
Adherence is taking medicines as prescribed, taking into consideration the timing and
the actual dosages.
Access to Therapy
Access to the full course of PEP drugs must be ensured for all HCWs.
•
A 3-day supply should be available
•
24 hour/7-day availability of services must be ensured
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Institutional Policies
Different institutions have different strategies on the provision of post-exposure management.
The following are recommended guidelines:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Have a plan for immediate provision of PEP.
Have a plan for counselling HCWs:
Protect HCW’s confidentiality about exposure, treatment, and test results.
Acknowledge and be prepared to address fears.
Review the HCW in 2–3 days to answer questions and clarify issues.
Review medication frequently for:
Possible toxicities
Interactions Adherence
Arrange for referral to an HIV comprehensive care clinic.
Provide contacts for questions.
Provide counselling about:
Sexual and reproductive issues Breastfeeding Avoid donation of blood, plasma, organs, tissue, or semen.
Recommendations for Hepatitis
•
•
•
•
•
All HCWs should be immunised against HBV
For unimmunised HCWs, give prophylactic HBIG (hepatitis B immunoglobulin) and
initiate the vaccine series.
There is no effective prophylaxis against hepatitis C, and administration of immuno
globulin and antiviral agents is NOT recommended.
Determine status of source and establish baseline serology of employee and repeat
testing at 4–6 months post-exposure.
Early treatment is advised if infection occurs.
Key Messages
1)
2)
3)
More and more patients with HIV infection continue to seek treatment and a
greater number of NSIs are likely to occur.
The risk of HIV transmission is low.
The availability of PEP should not preclude taking standard precautions
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Module 9
Inventory Management
Aim
To equip you with knowledge and skills on inventory management
Prerequisite Module Module 2: Phlebotomy Equipment and Supplies
Objectives
By the end of this module you will be able to:
1)
2)
3)
Define terms used in inventory management
Identify tools used in inventory management
Outline steps in inventory management
Content
•
Definition of terms: inventory, inventory management
•
Inventory tools (S11, S12, stock card)
•
Inventory process: requesting, receiving, storage, issuing/distribution, use, and
reporting
•
Storage: general guidelines for storage practices
Notes on Customisation
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Definitions and Tools
Inventory: refers to a list of goods / materials held in stock in an institution at a given time.
Inventory management: refers to the process of ordering, receiving, storing, distributing, and
issuing of items and reporting on consumption.
The goal of efficient inventory management is to maintain a steady supply of stock to the
operating units (e.g. benches, wards) while minimising costs associated with overstocking and
understocking.
S11 Form
This form is used to order supplies from the main store to the departmental store (e.g. laboratory
store).
FORM
S11
Serial
No..........................................
REPUBLIC OF KENYA
COUNTER REQUISITION AND ISSUE VOUCHER
Ministry
..................................................................
Dept Branch................................................
Unit..........................................................
To (Issue
Point)...........................................................................................................................................................................................................................................................
Please issue the store linked below to (Point of use)...............................................................................................................................................
Code No.
Item Description
Account No:
.........................................................
Requisitioning officer
..........................................
Issued by:
............................................................
Received by:..............................................
Unit of Issue
Quantity
Required
Quantity
Issued
Designation:
.........................................................
Signature:
............................................................
Designation:
............................................................
98
Value
Remarks/Perpose
Date:
..................................................................
Sign:
..................................................................
Date:
..................................................................
Sign:
..................................................................
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Stock and Bin Card
This card is used to enter all supplies ordered from the main store to the departmental store.
MINISTRY OF HEALTH
Serial No..........................
Laboratory Stock Card
District................................................................
Commodity name and Description
Name of Facility.......................................................
Unit of issue
Item Code
Average Monthly Consumption
Date
Received
From
RECEIPTS
Doc. Quant.
No.
Storage requirements
Minimum Level
Batch
No.
Expiry Loc.
Name
Maximum Level
DISBURSEMENTS/ISSUES
Doc.
Name
No. Quant. Dest.
Doc. No. - Document Number, Quant. - Quantity, Loc. - Location, Dest. - Destination
STOCK
Unit
Balance Value
Total
Value
Balance C/F.......................... to Card No. .................
Top-Up Form
This is used to order from the departmental store to the point of use.
MINISTRY OF HEALTH
Serial No..........................
NATIONAL PUBLIC HEALTH LABORATORY SERVICES
LABORATORY TOP-UP FORM
Name of Facility..........................................................
Date
Commodity
Department/Section..................................................................
Current Tests done Order
Issue
UnityofIssue Balance
Quantity Quantity
99
Issued by
Name
Received by
Sign
Name
Sign
Remarks
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S12 Form
This is used to order supplies between facilities.
Steps in Inventory Management
Requesting /
Reporting/
using data
reordering
supplies
Use, tracking/
monitoring
Receiving
supplies
Storage bulk/
point of use
General Guidelines for Good Storage Practices
•
•
•
•
•
•
•
•
•
•
•
Provide appropriate space and security for stored stock.
Provide safe and orderly arrangement of stock in the store.
Maintain correct storage conditions to safeguard quality.
Good stock control and rotation: practice first expiry, first out (FEFO) and first in, first
out (FIFO).
Label clearly all reagents and chemicals with their name, date of preparation, and
hazard symbol.
Store chemicals, reagents, and other supplies correctly zoned, making sure
incompatible chemicals are not stored together.
Secure storage areas, e.g. for expensive or dangerous items.
Maintain the correct temperature conditions for items, especially reagents.
Conduct regular physical stock counts and record them.
Develop and implement standard operating procedures (SOPs) for storage of supplies.
Maintain updated stock cards and track expiry dates of supplies using the expiry
tracking chart.
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Expiry Tracking Chart
Serial No..........................
MINISTRY OF HEALTH
Expiry Tracking Chart for Laboratory Reagents and Consumables
Commodity
Batch No.
Ecpiry Date
Year:
Year:
Year:
Stock Count
This is physically counting each item in the store. It is done at the beginning of each month by
a designated person.
Note: All items must be accounted for. Everything that comes in and goes out must be recorded.
Key Messages
1)
2)
3)
4)
5)
Order supplies that you can use before their expiry.
Always inspect a new shipment before accepting it.
Maintain an adequate inventory at all times to ensure uninterrupted supply.
Ensure that the inventory is tracked at all times by ensuring that the tools are well
filled in / used and reported in a timely manner.
Ensure that all items in the inventory are accounted for and recorded.
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Module 9
Safe Phlebotomy Training for Health Care Workers in Kenya: Participant’s Manual, 2013
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