 Best Practices in Phlebotomy

 WHO Guidelines on Drawing

Blood
 Safe and Unsafe Phlebotomy
 Issues in Phlebotomy

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April 2008 – WHO Injection Program, Geneva
( part of the Department of Essential Health
Technologies (EHT)
 consultation for phlebotomy and blood
collection

2010- WHO published guidelines

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MAIN OBJECTIVE OF THE GUIDELINES

To improve the quality of blood specimens

and the safety of phlebotomy for health workers and
patients by promoting best practices in phlebotomy

• Current Situation in Local Setting

 Few MT are available to perform phlebotomy

 Nurses are being trained and hired to do the
function
 Some Schools offer short course in Phlebotomy
 PCQACL offers seminars/trainings
 PAP was formed by group from DOH

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• Current Situation in Local Setting

 CHED is pushing for the inclusion in ladderized

program
 PAMET has designed a training module for MT
graduates
 PAMET has submitted proposal in congress (Med Tech
Law)

• Current Situation in Global Setting

According to WHO:

Phlebotomy practice varies considerably between

countries and between institutions and individuals within
the same country, even though perceptions of risks are
similar
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CHECKLIST AGREEMENT (WHO)

 Medical treatment is intended to save life

& improve health
 All health workers have responsibility to
prevent transmission of health care
associated infections
 Phlebotomy is one of the most common
invasive procedures in healthcare
 Adherence to safe injection practices and
related infection control is part of that
responsibility- it protects patients and
health workers
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 Does not harm the recipient
 Does not expose the provider to any
avoidable risk
 Does not result in any waste that is
dangerous for other people

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 Unsterile Equipment
 Improper Equipment
 Improper Technique

21 million HBV infections (32% new HBV infections)

2 million HCV infections (40% of new HCV infection)
260 000 HIV infections (5 % new HIV infections)

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 Blood Collection Equipment,
Additives & Order of Draw
 Venipuncture Procedure
 Pre-analytical Considerations
 Capillary Puncture Equipment
and Procedures

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 A laboratory requisition form is needed
before beginning any blood draw.
 Each facility has their own form, which
may be hand written or computer
generated.
 Lab requisition forms will normally
include the patient’s information, test
ordered, and the doctor who ordered it.
 Phlebotomists must be able to figure out
what color tubes to draw and which type
of technique to use.
 Phlebotomists must have a pen to write
patient information on tubes after their
blood draw.
 They also need a watch, enabling them to
record the time of draw.
 BLOOD DRAWING STATION - a dedicated area of
medical laboratory or clinic equipped for performing
phlebotomy procedures on patients, primarily
outpatients sent by their physicians for laboratory
testing.

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 PHLEBOTOMY CHAIRS

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 EQUIPMENT CARRIERS

Hand Held Carriers

Phlebotomy Carts

 GLOVES AND GLOVES LINERS

 ANTISEPTIC – substance used to prevent sepsis(

presence of microorganism or their toxic product in
the blood stream)
70% Isopropyl Alcohol, 70% Ethyl Alcohol,
Benzalkonium chloride, Chlorhexidine gluconate,
Hydrogen Peroxide, Povidone Iodine, Tincture of
Iodine
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 The CDC and OSHA require the use of
gloves when performing a blood draw
using the venipuncture, capillary, or
arterial methods.
 Gloves provide a protective barrier
between the phlebotomist and the
patient.
 They can help prevent the spread of
infectious agents but cannot help protect
from an accidental needle stick.
 A new pair of gloves must be applied for
each patient and removed after the
procedure is completed.
 The following gloves are recommended.
 Nitrile
 Latex
 Neoprene
 Polyethylene
 Vinyl

 A good fit is necessary.

 Hand washing is required between each
removal and donning of new gloves.
 Liners are available for those with
dermatitis or allergies when gloves are
worn.
 Barrier hand creams are also available to
help hands with repeat glove use.
 Antiseptics are used to prevent or
inhibit the growth and development of
microorganisms.
 Antiseptics are used to clean the site
prior to the blood collection.
 The most commonly used antiseptic is
70% isopropyl alcohol.
 They come individually wrapped.
 If a collection requires a more potent
antiseptic, providone-iodine is used.
 If a patient is allergic to iodine,
chlorhexidine gluconate is used
instead.
 Disinfectants are chemicals regulated
by the EPA that are used to kill or
remove microorganisms on surfaces and
laboratory instruments.

 Disinfectants are not used on human

skin!

 Solutions of sodium hypochlorite

(bleach) can be used.

 If there is a large spill of blood a 1:10

dilution of bleach is used and must
spend 10 minutes on the surface for the
disinfectant to be effective.
 Alcohol hand sanitizers can be
used for routine hand cleaning.
 Hand sanitizers can replace hand
washing only when the hands are
not visibly soiled.
 Ifthe hands are soiled with
organic material (blood, feces,
urine) hand washing is a must.
 Alcohol-based hand sanitizers can
come in liquid, foam, or gel
forms.
 GAUZE PADS/ COTTON BALLS- used to hold
pressure over the site following blood
collection procedures

 BANDAGES/MICROPORE

 NEEDLE & SHARPS DISPOSAL CONTAINERS

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 Gauze pads are used to hold pressure on the
venipuncture site.
 A common size is a 2 X 2 inch pad.
 Sterile gauze should be kept in its wrapper
until it is ready for use.
 The gauze is placed on the arm right after the
needle is removed.
 Apply pressure until the bleeding has stopped.
 The gauze can be folded into quarters to help
increase pressure.
 A bandage or piece of tape can be applied to the
gauze.
 Bandages are used to cover the
venipuncture site after the bleeding has
stopped.
 Surgical tape, paper tape, a band aid,
or self adhesive gauze wraps can be
used to cover the venipuncture site.
 Be careful of latex allergies!
 There are latex-free bandages.
 Self-adhesive wraps are good for
patients with bleeding disorders or
patients on anticoagulant therapies.
 SLIDES- for making blood films for hematology
determination
 PEN- indelible, permanent non smear ink to
label the tubes
 WATCH- to determine special collection time
 VEIN LOCATING DEVICES (VENOSCOPE)

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 TOURNIQUET- a device that is applied or
tied around a patient’s arm prior to
venipuncture to restrict blood flow

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 The most common tourniquets used today
are strips made of latex, nitrile, or vinyl.
 Modern tourniquets are meant to be
disposed of and are not made to be reused
by multiple patients.
 If necessary, a blood pressure cuff can be
used as a tourniquet.
 If the tourniquet is left on for longer than 1
minute, the makeup of the blood
components can change, resulting in
erroneous (incorrect) laboratory results.
 A tourniquet must be applied so that it can
be easily removed by the phlebotomist
during the venipuncture.
 NEEDLES – sterile, disposable, designed for single
use only
Types:
• Multisample Needles
• Hypodermic Needles
• Winged(butterfly) Needles

Needle Gauge- number that relates to the diameter of

the lumen
needle diameter is inversely proportional
to the gauge number

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• Developed due to the large number
of needlestick injuries
• Requires needles to have special
safety features to protect from
accidental puncture
• Safety feature should be activated
as soon as the procedure is
complete

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• If you or a co-worker sustain a
needlestick injury, you must
report it
to a supervisor!

• You are obligated to report

hazards from needles you
observe in the workplace!

28 Chapter 3
  Bevel- end that
pierces the vein
 Shaft- long
cylindrical portion
 Hub- the end that
attaches to the blood
collection device
 Lumen- internal
space of the needle

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 EVACUATED TUBES/BLOOD COLLECTION- are
glass or plastic tubes sealed with a partial
vacuum inside by rubber stoppers

• Adult tubes has volumes of 5,7,10,15 ml

• Pediatric Tubes has volumes of 2,3 and 4 ml

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 LIGHT BLUE

Additive: Sodium Citrate

Usage: Coagulation
Studies, PT,PTT and
Fibrinogen

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 RED

No Additive
No Anticoagulant Present

Usage: Test using serum

which include most blood
chemistries, Serology Test,
Blood Bank Testing

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LAVENDER

Additive: EDTA
( Ethylenediaminetetraacetic)

Usage: Hematology studies,

CBC, Reticulocyte Count

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GREEN

Additive: Sodium heparin,

Lithium heparin or Ammonium
heparin

Usage: STAT blood chemistries

utilizing plasma

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GRAY

Additives: Potassium
Oxalate, Sodium Flouride or
Lithium Iodacetate & Heparin

Usage: Glucose, Blood

Alcohol levels, Lactic Acids

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 ROYAL BLUE

Additive: Color of the

tubes indicates additives
if any:
Purple: EDTA
Green: Heparin
Red: None

Usage: Trace metal

analysis, nutrients, and
toxicology studies
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BLACK

Additive: Buffered Sodium Citrate

Usage: Westergren Sedimentation

Rate Determination

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 RED AND BLACK
MOTTLED

No Additive
Silicone ( Serum
Separating Material)

Usage: All test using

serum except Blood
Bank

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 BROWN

Additive: Sodium Heparin

or EDTA

Usage: Lead Levels

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PINK

Additive: K3 EDTA

Usage: Blood Bank Testing

Using Gel System

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 Yellow-Topped

• Available with two different additives:

- Sodium polyanethol sulfonate (SPS),
which is used for blood culture
collections
- Acid citrate dextrose (ACD) which
maintains red cell viability

NOTE: It is very important that the correct yellow-topped

tube be used because they look alike but have different
additives!

42 Chapter 3
- Closed system in which the patient’s blood flows
through a needle inserted into a vein, directly into a
collection tube without being exposed to the air or
outside contaminants

Equipments:

 DOUBLE POINTED NEEDLE(MULTISAMPLE NEEDLE)

 PLASTIC HOLDER/ ADAPTER- clear plastic cylinder
with a small threaded opening at one end where
collection tubes is placed
 EVACUATED TUBES/ VACCUM TUBES
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Used for patients with small or difficult veins

Equipments

 Hypodermic Needle ( Sterile syringe needle)

 Sterile Plastic Syringe with a Luer lock (
special tip that allows the needle to attach
more securely than a slip tip)

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  Barrel- a cylinder
with graduated
markings in either
milliliters or cubic
centimeters
 Plunger- a rodlike
device that fits
tightly into barrel

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Collecting Blood from small or difficult veins
such as hands veins and veins of elderly and
pediatric patients

Equipments:

Winged infusion set/Butterlfy set

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Complete system for blood collection in which the
blood collection tube and collection apparatus are
combined in a single unit

Equipments:

S-Monovette Blood Collection System

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MULTI DRAW- fills several vacuum collection tubes
each with a different color stopper appropriate for
each test ordered
IMPORTANCE:
• Necessary to avoid contaminating the blood in one
tube with traces of chemical from a previous tube
that might alter the test results

• CRITICAL due to potential for carryover of

additive in the tube to the next tube which will
adversely affects the result of laboratory testing

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CLINICAL LABORATORY STANDARD INSTITUTES (CLSI)
provides national standards for clinical laboratories

1. Sterile/Blood cultures(yellow top or bottles)

2. Light Blue Coagulation Tube
3. Red-Non-Additive
4. Gel Separator (Speckled or “Tiger” Top
5. Green (Heparin)
6. Plasma Separator Tube (PST) with heparin (green-
gray mottled top)
7. Lavender/purple top (EDTA)
8. Gray top( Oxalate/Flouride tube)

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• Blood collection procedure begin with the test
request

• REQUISITION- form on which test orders are entered

TYPES:
• Manual Requisition
• Computer Requisition- contain the actual labels that
are placed on the specimen tubes
• Bar code Requisition- contains bar codes

• ACCESSION- to record in the order received

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APPROACHING THE PATIENT

 When entering the patient’s room, knock lightly,

open the door slowly
 If a physician is with the patient, don’t interrupt. If
the request is stat or timed specimen, excuse
yourself, why you are there and ask permission to
proceed.
 If the patient cannot be located, informed the
nurses
 Identify yourself to the patient by stating your
name, your title and why you are there
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 PATIENT IDENTIFICATION

The process of verifying a patient’s identity

Most important step in specimen collection

 Verifying Name and Date of Birth

Ask his or her full name
 Checking Identification Bracelets
 3 Way ID
Patient’s Verbal ID Statement, Check of the ID
Band,Visual Comparison of the Labelled Specimen
w/ the patient’s ID Band before leaving the
bedside
 ID Discrepancies
Nurses should be notified

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 Sleeping Patients
Wake the person gently, try not to startle the
patient, as this can affect the result
 Unconscious Patients
Ask a relative or the nurse to identify the
patient

 Identification of Young, Mentally Incompetent or

Non English Speaking Patients
Ask the patients relative, attendant or friend to
identify by name, address and identification number or
birthdate
 Outpatient ID
Receptionist verifies the patient’s identity and
fills out the proper lab requisition or generates one via
computer
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 PREPARING THE PATIENT

 Explaining the Procedure

 Addressing Patients Inquiries
 Handling Patient Objections
 Handling Difficult Patients
 Addressing Needle Phobia
 Addressing Objects in the Patient’s Mouth

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DIET RESTRICTIONS
 Important to verify that any special diet instructions
or restrictions have been followed
 If the patient was not be able to follow diet
instruction the patient’s physician or nurse must be
notified so that a decision can be made as to whether
or not to proceed with the test
LATEX SENSITIVITY
 Verify all equipment that will be used for patients

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 Proper hand hygiene plays a major role in
preventing the spread of infection and is an
important step in the venipuncture procedure that
should not be forgotten or performed poorly

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 POSITIONING THE PATIENT

 Patient should be seated in one that is sturdy

and comfortable and has armrest
 When venipuncture is performed on hand or
wrist vein, the patients hand must be well
supported on a bed, rolled towel or armrest
 For venipuncture in the antecubital area,
patient’s arm should be extended downward in
a straight line from the shoulder to wrist and
not bent at the elbow

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 TOURNIQUET APPLICATION AND FIST CLENCHING

 Tourniquet is applied 3-4 inches above the intended

venipuncture site to restrict venous blood flow and
make the veins prominent
 If tourniquet is applied closer to the site, the vein
may collapse as blood is removed
 If tourniquet is applied too far from the site, it
may be ineffective
 When drawing blood from a hand vein the
tourniquet is applied proximal to the wrist bone
 If a patient has sensitive skin or dermatitis, apply
the tourniquet over a dry washcloth or gauze
wrapped around the arm

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Preferred venipuncture site is the
antecubital area

VEINS IN ANTECUBITAL AREA

 Median Cubital- M pattern
- Normally closer to
surface
- Less movable
- Nerve Injury is less
 Cephalic Vein
 Basilic Vein – last choice vein
because it is near the brachial
artery
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 Patient have the most prominent veins in the
dominant arm
 To locate a vein, palpate (examine by touch or
feel) the area by pushing down on the skin with
the tip of the index finger

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 Determine the patency ( state of being freely open),
size and depth and the direction they follow
 When you found a vein, roll your finger from one side
to the either while pressing against it to help judge
its size
 Trace its path to determine a proper entry point
 A patent vein is turgid ( distended from being filled
with blood), giving it a bounce or resilience and has a
tubelike feel
 Do not select vein that feels hard and cordlike or
lack resilence ( SCLEROSED OR THROMBOSED VEIN),
because such vein are hard to penetrate or may not
have adequate blood flow

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 70% Isopropyl Alcohol
 Clean the site with a circular motion, starting to
the point where you expect to insert the needle
and moving outward in ever-widening concentric
circles (circles with a common center)

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 Choose the collection system, needle size, and
tube volume according to the age of the patient,
size and location of the vein, and amount of
blood to be collected
 Select the tube according to the test that have
been ordered

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 Reapply the tourniquet, being careful not to
touch the cleaned the area
 Be aware that there are a few test that must be
collected without using a tourniquet
e.g. Lactic Acid Test

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The non-dominant hand is used to anchor the vein
while the collection equipment is held and the
needle inserted using the dominant hand

ANCHORING
 Grasp patient’s arm with free hand, using your
fingers to support the back of the arm just below
the elbow
 Place your thumb a minimum of 1-2 inches below
and slightly to the side of the intended
venipuncture site, and pull the skin toward the
wrist
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NEEDLE INSERTION

 Insert the needle into the skin 15-30 degrees angle

depending on the depth of the vein
Shallow Vein – angle closer to 15 degrees
Deeper Vein- angle closer to 30 degrees
Using butterfly needle- 10-15 degrees

 When the needle enters the vein, you will feel slight
“give” or decrease in resistance

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 Do not leave the tourniquet on for more that 1
min or test results may be affected

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 If the tube contains an additive, mix it by
gently inverting it to 3-8 times

 Inadequate mixing can lead to clot formation

and necessitate recollection of the specimen

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 Withdraw the needle from the vein in one smooth
motion
 Apply pressure to the site 3-5 minutes or until
bleeding stops
 Failure to apply pressure can result in leakage of
blood and hematoma formation
 Do not bend the arm up

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 A needle should be discarded in a sharps
conatainer

 OSHA regulations prohibit cutting, bending,

breaking or recapping blood collection
needles

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 Tubes must be labeled immediately after
blood collection

 All handwritten labeling must be done with

permanent ink

 Informations:
Patient’s first and last names
Patient’s identification number(if applicable) or
date of birth
Date and time of collection
Phlebotomist Initials

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 Ammonia- place specimens to be cooled in a
crushed ice slurry
 Cold Agglutinin – specimen must be kept at
body temperature
 Bilirubin- wrap specimens that require
protection from light, in aluminum foil or other
light blocking material or light blocking
container

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 Dispose of contaminated materials in the proper
biohazard containers

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 Being courteous is a creating also a good rapport
between you and your patient

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  Capillary Puncture
 Dealing with
parents/guardians
 Dealing with the
child
 Pain interventions
 Selecting a method
of restraint
 Equipment selection

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  Skin changes
 Hearing Impairment
 Visual Impairment
 Mental Impairment
 Effects of Disease

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COMPOSITION OF CAPILLARY SPECIMENS

Mixture of arterial, venous and capillary blood

along with interstitial fluid( fluid in the tissue
spaces between the cells) and intracellular
fluid (fluid within the cells)

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 For infants
 There are no accessible veins
 Available veins are fragile or must be saved for
other procedures
 The patient has thrombotic or clot forming
tendencies
 Glucose Monitoring

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 Capillaryblood gases
 Blood smears
 EDTA tubes
 Other anticoagulated tubes
 Serum tubes
LANCET/INCISION DEVICE

A sterile, disposable, sharp-pointed or

bladed instruments that either punctures or make
an incision in the skin to obtain capillary blood
specimens for testing.

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 Width: No longer than 2.5 mm
 Depths
 Maximum depth: 2.0 mm for heelsticks
 Safety features: Retractable blades
 Color-coded
 Patient age and collection site
 Depth and width
 Amount of blood needed
COLLECTION TUBES

MICROTAINER/MICROCOLLECTION CONTAINERS

 Special small plastic tubes used to as “to

collect the tiny amounts of blood obtained
from capillary punctures
 Often referred to as “ bullets” because of
their size and shape
 250 ul or 500 ul, 600ul

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MICROHEMATOCRIT TUBES AND SEALANTS

 disposable, narrow-bore plastic clad glass

capillary tubes that fill by capillary action and
typically hold 50-75ul of blood

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 Increased blood
flow
 Seven-fold
 Commercial heel
warmer
 Warm cloths
 Maximum 42°C
 FINGER PUNCTURE

-for adults and > 1 year old children

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Puncture site should be in the central, fleshy
portion of the finger, slightly to the side of
center and perpendicular to the grooves in the
whorls

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 Do not collect blood from fingers on the same
side without consultation with the patient’s
physician
 Do not puncture fingers of infants and children
under the age of 1 year
 Do not puncture the side or very tip of the
finger
 Do not puncture the index finger.
 Do not puncture the fifth o little finger
 Do not puncture the thumb.
 Do not puncture parallel grooves or line of the
fingerprint

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 HEEL STICK/ HEEL PUNCTURE

 Recommended site for

collection of capillary
specimens on infants less than
1 year old
 done on the plantar surface of
the heel, medial to an
imaginary line extending from
the middle of the great toe to
the heel or lateral to an
imaginary line extending
from between the fourth and
fifth toes to the heel.

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 Do not puncture earlobes
 Do not puncture deeper than 2.0 mm.
 Do not puncture through previous sites
 Do not puncture the area between the
imaginary boundaries
 Do not puncture the posterior curvature of the
heel, as the bone can be as little as 1 mm deep
in this area
 Do not puncture in the area of the arch and
other areas of the foot other than the heel, as
arteries, nerves, tendons and cartilage may be
injured
 Do not puncture severely bruised areas
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