Best practices in phlebotomy

This guidelines covers all the steps recommended for safe phlebotomy and reiterates the accepted
principles for blood drawing and blood collection. The chapter includes background information, practical
guidance and illustrations relevant to best practices in phlebotomy.

It also provides information relevant to the procedure for drawing blood given below.

Background information on best practices in phlebotomy

Best practices in phlebotomy involve the following factors:
• planning ahead;
• using an appropriate location;
• quality control;
• standards for quality care for patients and health workers, including
– availability of appropriate supplies and protective equipment;
– availability of post-exposure prophylaxis (PEP);
– avoidance of contaminated phlebotomy equipment;
– appropriate training in phlebotomy;
– cooperation on the part of patients;
• quality of laboratory sampling.

 Planning ahead
This is the most important part of carrying out any procedure, and is usually done at the start of
a phlebotomy session.

 Using an appropriate location

The phlebotomist should work in a quiet, clean, well-lit area, whether working with outpatients
or inpatients.

 Quality control
Quality assurance is an essential part of best practice in infection prevention and control (1). In
phlebotomy, it helps to minimize the chance of a mishap. Table1.1 lists the main components of
quality assurance, and explains why they are important.

Table 1.1 Elements of quality assurance in phlebotomy

Element Notes
Education and training Education and training is necessary for all staff carrying out phlebotomy. It
should include an understanding of anatomy, awareness of the risks from
blood exposure, and the consequences of poor infection prevention and
control.

Standard operating SOPs are required for each step or procedure. They should be written and be
procedures (SOPs) readily available to health workers.

Correct identification of Identification should be through matching to the laboratory request form.
the patient • For blood donation, the identity of the donor should be accurately matched to
the results of screening tests.
• For blood sampling, after samples have been taken from a patient or donor, a
system of identification and tracking is essential to ensure that the sample is
 correctly matched with the result and with the patient or donor.

The condition of the The condition of the sample should be such that the quality of the results is
sample satisfactory.

Safe transportation Making safe transportation of blood or blood products part of best practices
will improve the quality of results from laboratory testing
An incident reporting A system is required for reporting all adverse events. A log book or register
system should be established with accurate details of the incident, possible causes and
management of adverse events

Quality care for patients and health workers

Several factors can improve safety standards and quality of care for both patients and health
workers, and laboratory tests. These factors, discussed below, include:

Availability of appropriate supplies and protective equipment

Procurement of supplies is the direct responsibility of the administrative (management) structures
responsible for setting up phlebotomy services. Management should:
 provide hand-hygiene materials (soap and water or alcohol rub), well-fitting non-sterile gloves, single-
use disposable needles, and syringes or lancing devices in sufficient numbers to ensure that each patient
has a sterile needle and syringe or equivalent for each blood sampling;
 make available sufficient laboratory sample tubes to prevent dangerous practices (e.g. decanting blood
to recycle laboratory tubes).

Several safety-engineered devices are available on the market; such devices reduce exposure to blood
and injuries. However, the use of such devices should be accompanied by other infection prevention and control
practices, and training in their use. Not all safety devices are applicable to phlebotomy. Before selecting a
safety-engineered device, users should thoroughly investigate available devices to determine their appropriate
use, compatibility with existing phlebotomy practices, and efficacy in protecting staff and patients.
For settings with low resources, cost is a driving factor in procurement of safety-engineered
devices.
Where safety-engineered devices are not available, skilled use of a needle and syringe is
acceptable.

Availability of post-exposure prophylaxis

Accidental exposure and specific information about an incident should be recorded in a register. Support
services should be promoted for those who undergo accidental exposure. PEP can help to avert HIV and
hepatitis B infections. Hepatitis B immunization should be provided to all health workers (including cleaners
and waste handlers), either upon entry into health-care services or as part of PEP.

Avoidance of contaminated phlebotomy equipment

Tourniquets are a potential source of methicillin-resistant Staphylococcus aureus (MRSA), with up to
25% of tourniquets contaminated through lack of hand hygiene on the part of the phlebotomist or reuse of
contaminated tourniquets. In addition, reusable finger-prick devices and related point-of-care testing devices
(e.g. glucometers) contaminated with blood have been implicated in outbreaks of hepatitis B. To avoid
contamination, any common-use items, such as glucometers, should be visibly clean before use on a patient, and
single-use items should not be reused.
Training in phlebotomy
All staff should be trained in phlebotomy, to prevent unnecessary risk of exposure to blood and to
reduce adverse events for patients.
 Groups of health workers who historically are not formally trained in phlebotomy should be encouraged
to take up such training; lax infection prevention and control practices result in poor safety for staff and
risk to patients.
 The length and depth of training will depend on local conditions; however, the training should at least
cover the essentials.
 Supervision by experienced staff and structured training is necessary for all health workers, including
physicians, who undertake blood sampling.

Patient cooperation
One of the essential markers of quality of care in phlebotomy is the involvement and cooperation of the
patient; this is mutually beneficial to both the health worker and the patient.
Clear information – either written or verbal – should be available to each patient who undergoes
phlebotomy.

Quality of laboratory sampling

Factors that influence the outcome of laboratory results during collection and transportation
include:
knowledge of staff involved in blood collection;
use of the correct gauge of hypodermic needle to prevent haemolysis or abnormal results;
the anatomical insertion site for venepuncture;
the use of recommended laboratory collection tubes;
patient–sample matching (i.e. labelling);
transportation conditions;
interpretation of results for clinical management.

Practical guidance on best practices in phlebotomy

Provision of an appropriate location

 In an outpatient department or clinic, provide a dedicated phlebotomy cubicle containing:
– a clean surface with two chairs (one for the phlebotomist and the other for the patient);
– a hand wash basin with soap, running water and paper towels;
– alcohol hand rub.
 In the blood-sampling room for an outpatient department or clinic, provide a comfortable reclining
couch with an arm rest.
 In inpatient areas and wards:
– at the patient’s bedside, close the bed curtain to offer privacy
– ensure that blood sampling is done in a private and clean manner.

Provision of clear instructions

Ensure that the indications for blood sampling are clearly defined, either in a written protocol or
in documented instructions (e.g. in a laboratory form).

Procedure for drawing blood

At all times, follow the strategies for infection prevention and control listed in Table 1.2
Table 1.2 Infection prevention and control practices

Do Do not

DO carry out hand hygiene (use soap and water or DO NOT forget to clean your hands
alcohol rub), and wash carefully, including wrists and
spaces between the fingers for at least 30 seconds
(follow WHO’s ‘My 5 moments for hand hygiene ‘a)

DO use one pair of non-sterile gloves per procedure DO NOT use the same pair of gloves for more than
or patient one patient
DO NOT wash gloves for reuse

DO use a single-use device for blood sampling and DO NOT use a syringe, needle or lancet for more
drawing than one patient

DO disinfect the skin at the venipuncture site DO NOT touch the puncture site after disinfecting it

DO discard the used device (a needle and syringe DO NOT leave an unprotected needle lying outside
is a single unit) immediately into a robust sharps the sharps container
container
Where recapping of a needle is unavoidable, DO use DO NOT recap a needle using both hands
the one-hand scoop technique
DO seal the sharps container with a tamper-proof lid DO NOT overfill or decant a sharps container

DO place laboratory sample tubes in a sturdy rack DO NOT inject into a laboratory tube while holding
before injecting into the rubber stopper it
with the other hand

DO immediately report any incident or accident DO NOT delay PEP after exposure to potentially
linked to a needle or sharp injury, and seek contaminated material; beyond 72 hours, PEP is NOT
assistance; start PEP as soon as possible, following effective
protocols

Step 1 – Assemble equipment

Collect all the equipment needed for the procedure and place it within safe and easy reach on a
tray or trolley, ensuring that all the items are clearly visible. The equipment required includes:
 a supply of laboratory sample tubes, which should be stored dry and upright in a rack; blood can be
collected in
– sterile glass or plastic tubes with rubber caps (the choice of tube will depend on what is agreed with
the laboratory);
– vacuum-extraction blood tubes; or
– glass tubes with screw caps;
 a sterile glass or bleeding pack (collapsible) if large quantities of blood are to be collected;
 well-fitting, non-sterile gloves;
 an assortment of blood-sampling devices (safety-engineered devices or needles and syringes, see below),
of different sizes;
 a tourniquet;
 alcohol hand rub;
  70% alcohol swabs for skin disinfection.
 gauze or cotton-wool ball to be applied over puncture site;
 laboratory specimen labels;
 writing equipment;
 laboratory forms;
 leak-proof transportation bags and containers;
 a puncture-resistant sharps container.

Ensure that the rack containing the sample tubes is close to you, the health worker, but away from the
patient, to avoid it being accidentally tipped over.

Step 2 – Identify and prepare the patient

Where the patient is adult and conscious, follow the steps outlined below.
 Introduce yourself to the patient, and ask the patient to state their full name.
 Check that the laboratory form matches the patient’s identity (i.e. match the patient’s details with the
laboratory form, to ensure accurate identification).
 Ask whether the patent has allergies, phobias or has ever fainted during previous injections or blood
draws.
 If the patient is anxious or afraid, reassure the person and ask what would make them more comfortable.
 Make the patient comfortable in a supine position (if possible).
 Place a clean paper or towel under the patient’s arm.
 Discuss the test to be performed and obtain verbal consent. The patient has a right to refuse a test at any
time before the blood sampling, so it is important to ensure that the patient has understood the
procedure.

Step 3 – Select the site

General
 Extend the patient’s arm and inspect the antecubital fossa or forearm.
 Locate a vein of a good size that is visible, straight and clear. The median cubital vein lies between
muscles and is usually the easiest to puncture. Under the basilic vein runs an artery and a nerve, so
puncturing here runs the risk of damaging the nerve or artery and is usually more painful. DO NOT
insert the needle where veins are diverting, because this increases the chance of a haematoma.
 The vein should be visible without applying the tourniquet. Locating the vein will help in determining
the correct size of needle.
 Apply the tourniquet about 4–5 finger widths above the venipuncture site and re-examine the vein.

Hospitalized patients
In hospitalized patients, do not take blood from an existing peripheral venous access site because this
may give false results. Haemolysis, contamination and presence of intravenous fluid and medication can all
alter the results. Nursing staff and physicians may access central venous lines for specimens following
protocols. However, specimens from central lines carry a risk of contamination or erroneous laboratory test
results.
It is acceptable, but not ideal, to draw blood specimens when first introducing an in-dwelling venous
device, before connecting the cannula to the intravenous fluids.

Step 4 – Perform hand hygiene and put on gloves

 Perform hand hygiene; that is
– wash hands with soap and water, and dry with single-use towels; or
 – if hands are not visibly contaminated, clean with alcohol rub – use 3 ml of alcohol rub on the palm of
the hand, and rub it into fingertips, back of hands and all over the hands until dry.
 After performing hand hygiene, put on well-fitting, non-sterile gloves.

Step 5 – Disinfect the entry site

 Unless drawing blood cultures, or prepping for a blood collection, clean the site with a 70% alcohol
swab for 30 seconds and allow to dry completely (30 seconds).
Note: alcohol is preferable to povidone iodine, because blood contaminated with povidone iodine may
falsely increase levels of potassium, phosphorus or uric acid in laboratory test results.
 Apply firm but gentle pressure. Start from the centre of the venepuncture site and work downward and
outwards to cover an area of 2 cm or more.
 Allow the area to dry. Failure to allow enough contact time increases the risk of contamination.
 DO NOT touch the cleaned site; in particular, DO NOT place a finger over the vein to guide the shaft of
the exposed needle. It the site is touched, repeat the disinfection.

Step 6 – Take blood

Venepuncture
Perform venepuncture as follows.
 Anchor the vein by holding the patient’s arm and placing a thumb BELOW the venepuncture site.
 Ask the patient to form a fist so the veins are more prominent.
 Enter the vein swiftly at a 30 degree angle or less, and continue to introduce the needle along the vein at
the easiest angle of entry.
 Once sufficient blood has been collected, release the tourniquet BEFORE withdrawing the needle. Some
guidelines suggest removing the tourniquet as soon as blood flow is established, and always before it has
been in place for two minutes or more.
 Withdraw the needle gently and apply gentle pressure to the site with a clean gauze or dry cotton-wool
ball. Ask the patient to hold the gauze or cotton wool in place, with the arm extended and raised. Ask the
patient NOT to bend the arm, because doing so causes a haematoma.

Step 7 – Fill the laboratory sample tubes

 When obtaining multiple tubes of blood, use evacuated tubes with a needle and tube holder. This system
allows the tubes to be filled directly. If this system is not available, use a syringe or winged needle set
instead.
 If a syringe or winged needle set is used, best practice is to place the tube into a rack before filling the
tube. To prevent needle-sticks, use one hand to fill the tube or use a needle shield between the needle
and the hand holding the tube.
 Pierce the stopper on the tube with the needle directly above the tube using slow, steady pressure. Do
not press the syringe plunger because additional pressure increases the risk of haemolysis.
 Where possible, keep the tubes in a rack and move the rack towards you. Inject downwards into the
appropriate coloured stopper. DO NOT remove the stopper because it will release the vacuum.
 If the sample tube does not have a rubber stopper, inject extremely slowly into the tube as minimizing
the pressure and velocity used to transfer the specimen reduces the risk of haemolysis. DO NOT recap
and remove the needle.
 Before dispatch, invert the tubes containing additives for the required number of times (as specified by
the local laboratory).
Step 8 – Draw samples in the correct order

Draw blood collection tubes in the correct order, to avoid cross-contamination of additives between
tubes. As colour coding and tube additives may vary, verify recommendations with local laboratories. For
illustration purposes, Table 2.3 shows the revised, simplified recommended order of draw for vacuum tubes or
syringe and needle, based on United States National Committee Clinical Laboratory Standards consensus in
2003

Table 1.3 Recommended order of draw for plastic vacuum tubes

Order Type of tube/usual Additive Mode of action Uses

of usea colour

1 Blood culture bottle Broth mixture Preserves viability of Microbiology –

(yellow-black striped microorganisms aerobes, anaerobes,
tubes) fungi

Non-additive tube

Coagulation tubed Sodium citrate Forms calcium salts to Coagulation tests

(light blue top) remove calcium (protime and prothrombin
time),
requires full draw
Clot activator (red Clot activator Blood clots, and the Chemistries,
top) serum is separated by immunology and
centrifugation serology, blood bank
(cross-match)
Serum separator tube None Contains a gel at the Chemistries,
(red-grey tiger top or bottom to separate immunology and
gold) blood from serum on serology
centrifugation
Sodium heparin (dark Sodium Inactivates thrombin and For lithium level use
green top) heparin or thromboplastin sodium heparin, for
lithium heparin ammonia level use
either

PST (light green top) Lithium Anticoagulants with Chemistries

heparin lithium, separates
anticoagulant plasma with PST gel at
and a bottom of tube
gel separator

EDTA (purple top) EDTA Forms calcium salts to Haematology, Blood

remove calcium Bank (cross-match)
requires full draw

Blood tube (pale Acid-citrate- Complement inactivation DNA studies

yellow dextrose HLA tissue typing,
top) (ACD, ACDA paternity testing,
or ACDB)
 Oxalate/fluoride Sodium Antiglycolytic agent Glucoses, requires
(light grey top) fluoride and preserves glucose up to full draw (may cause
potassium five days haemolysis if short
oxalate draw)

ACD, acid-citrate-dextrose; DNA, deoxyribonucleic acid; EDTA, ethylenediaminetetraacetic acid; HLA, human leucocyte antigen; PST, plasma
separating tube.
“1” indicates draw first, and “10” draw last (if used).

Verify with local laboratory in case local colour codes differ.

Gently invert tubes with additives to mix thoroughly; erroneous test results may be obtained when the blood is not thoroughly mixed with the
additive.

If a routine coagulation assay is the only test ordered, then a single light blue top tube may be drawn. If there is a concern about
contamination by tissue fluids or thromboplastins, then a non-additive tube can be drawn before the additive tube. The PST tube contains
lithium heparin anticoagulant and a gel separator; if used, draw in the order shown.