Established criteria for the proper collection of venous blood specimens are necessary to maintain the biological integrity of patient samples for laboratory analyses. Blood samples should always be handled with care and treated as potentially infectious material. Criteria for specimen handling has been established and must be followed for the protection of the patient and phlebotomist.

PEDIATRIC VENIPUNCTURE

In order to optimize the amount of blood drawn from pediatric patients, a weight based chart has been established. The chart can be found at the end of this procedure.

EQUIPMENT

• Vacutainer tubes
• Needles
• Multisample - Portex 21G x 1", Portex 22G x 1"
• Butterflies with push button safety device - 21G x ¾", 23G x ¾", 25G x ¾"
• Portex Venipuncture Needle-Pro
• 3x3 gauze pad
• Alcohol preps
• Adhesive or expandable gauze bandage or coflex bandage
• Tourniquet (non-latex)
• Labels
• Gloves (non-latex)

PROCEDURE

Obtain request for laboratory services. The following information required:

• Patient's full name
• Ordering physician's full name
• Patient's identification number - medical record or financial number
• Laboratory tests ordered
• Date requested
• Time of collection
• Diagnosis code or reason for testing

Reassure the patient.

• Introduce yourself.
• Explain the procedure.
• Make casual conversation.

Identify the patient.

Outpatient

• Ask the patient to state his/her full name and date of birth.
• Verify with laboratory requisition and specimen labels.
• If the patient cannot respond, have a responsible person state the patient's full name. Document the name of the person identifying the patient.

Inpatient

• Ask the patient to state his/her full name and date of birth.

· Verify that information with the name and date of birth printed on the patient's hospital armband with the specimen label and/or requisition.

• If the patient cannot respond, have a responsible person (parent, guardian, nurse) identify the patient.
• If armband is missing, notify nursing service that an armband must be placed on the patient before drawing blood.

Cautions

• Patients having specimens collected for Transfusion Services/Blood Bank with the possibility of receiving a transfusion must be banded with a Blood Bank identification band that contains the patient's name and date of birth prior to specimen collection.
• If Blood Bank armband doesn't contain required information, call Transfusion Services/Blood Bank for instructions.
• If the patient is missing a hospital armband DO NOT draw a Blood Bank specimen until the hospital armband is placed on the patient by nursing service personnel.
• For YorkHospital, the only staff that may draw specimens for possible transfusion include YorkHospital personnel, Laboratory personnel and limited exceptions of others, by approval of Transfusion Service supervision.
• Blood drawn by a nurse on LTAC at YorkHospital must be witnessed by a lab phlebotomist.
• Verify Blood Bank arm band has required information and patient is wearing a LTAC identification bracelet.
• Initial the tube with Cerner identification and have nurse write his/her name and BB armband number on the tube label.
• When identifying a patient, do not ask a patient "Are you Mrs. Smith?" have the patient state his/her name and date of birth.
• When there are any discrepancies, DO NOT collect specimen until positive identification is made.
• Never use name cards or signs not attached to patient for identification.
• EMR and inpatients must have a YorkHospital or GettysburgHospital identification armband before putting on the Blood Bank armband.

Evaluate status of patient's diet restrictions and other factors.

• Fasting appropriate length of time.
• Avoidance of particular foods.

Special dietary requirements.

• Collection time requirements.
• Patient position - supine vs. erect

Position the patient.

Adult Venipuncture

• Patient seated in collection chair or wheelchair.
• Position yourself in front of the collection chair to protect the patient from falling forward if he/she faints and makes it easier to administer care if needed.
• Arm rest and wheelchair needs to be locked in place.
• Position patients' arm on the armrest, extending arm to form a straight line from the shoulder to the elbow.
• A pillow may be used for support if needed.
• Patient lying down.
• Position patients' arm, extending arm to form a straight line from the shoulder to the elbow.
• A pillow may be used for support if needed.
• Cautions
• Have patient remove food, gum or thermometer from mouth.
• Never perform a venipuncture while a patient is standing.

Pediatric Blood Draw

• Patient seated
• Collection of blood specimens from pediatric patients presents both technical and psychological challenges.
• Place equipment in a location that is readily accessible and out of reach of the patient.
• A 22g-23g butterfly or straight needle should be used on patients =6 years of age.
• Consult the table at the end of this procedure for volume limitations based on age and weight of the patient.
• A second phlebotomist or other staff person should be called to assist with a venipuncture on a patient =6 years of age.
• Immobilization of pediatric patients is necessary to ensure the safety of the patient and the phlebotomist.
• A parent or caregiver may also assist by holding the patient on their lap.
• Primary phlebotomist should position themselves in front of the collection chair.
• Arm rest should be locked in place if possible.
• Position the patients arm, extending arm to form a straight line from the shoulder to the elbow.
• A pillow may be used for support.

Patient lying down

• A second phlebotomist or other staff person should be called to assist with a venipuncture on a child =6 years of age.
• A 22g-23g butterfly or straight needle should be used on patients =6 years of age.
• Consult the table at the end of the procedure for volume limitations based on age and weight of the patient.
• Immobilization of pediatric patients is necessary to ensure the safety of the patient and the phlebotomist.
• A parent or caregiver may assist in holding the child.
• Position patients' arm, extending arm to form a straight line from the shoulder to the elbow.
• A pillow may be used for support if needed.

Assemble supplies.

• Place equipment in a location that is readily accessible and out of reach of the patient.
• Easy access to sharps container is critical.

Verify requisitions and tube selection.

• Compare information on the requisition, labels and/or clipboard.
• Verify appropriate number and types of collection containers.

Select the vein site.

• Apply tourniquet.
• Place tourniquet 3-4 inches above the venipuncture site and hold ends up.
• Cross left hand over the right.
• With the right hand, hold the left strap.
• With the left hand, stretch the right strap.
• Maintain the tension and tuck a loop of tourniquet, which is held in the left hand under the tourniquet which encircles the arm.
• Check tension.
• Purpose is to slow blood return to the heart but not constrict arterial flow.
• Blood should enter at a normal rate but leave more slowly.
• Blood will pool in the vein allowing easier access.
• Retie tourniquet if not applied properly.
• Precautions.
• If a patient has intravenous lines or other vascular access devices, refer to Support Services Policy SS-SP-25 for specific details.
• Post-mastectomy and lymph node dissection precautions, refer to Lab Policy A-SP-19 for details.
• Do not draw blood from an arm that has a fistula.
• Never leave the tourniquet on longer than 1 minute.
• Prolonged tourniquet use may lead to localized stasis, partial filtrate of blood and in to tissues, hemoconcentration or hematoma.
• If patient has skin problem, put tourniquet on over clothing.
• Discard the tourniquet when contaminated.
• Have patient make a fist.
• Patient should not repeatedly open and close fist.
• May result in contaminated specimen.
• Palpate and trace path of vein with index finger.
• Feel firmly.
• Lightly tapping or rubbing over skin will not allow you to feel deeper veins.
• Do not use the thumb.
• Acceptable veins in the antecubital fossa (Triangular region at the front of the elbow).
• Cephalic vein - lateral edge of fossa.
• Median cubital vein - also known as median basilic vein, from cephalic vein, runs below the elbow, upward and outward to join the basilic vein.
• Basilic vein - medial edge of fossa.
• Median cephalic vein.
• Median vein.
• Site selection for difficult patients.
• back of the arm
• back of the hand
• forearm
• dorsal wrist area only
• foot or leg (requires written physician order and is used as the last resort)
• Feel for the vein with the tip of finger.
• Massage arm from wrist to elbow.
• Apply heat.
• Lower arm.
• Differentiating veins, arteries and tendons.
• Veins
• Under less cardiac pressure.
• Thinner walls.
• Located close to body surface.
• Elastic consistency.
• Arteries
• Under greater cardiac pressure.
• Thick walls.
• Located deep within the body surface.
• Pulsate.
• Tendons
• Feel very hard.
• Not flexible.

Put on gloves

• Phlebotomist must put gloves on before venipuncture is performed.

Cleanse the venipuncture site.

• Cleansing agents - soap, iodine, alcohol, chloroprep.
• Procedure.
• Move in circular motion from the center of the site outward.
• Allow to air dry. Do not wipe, fan or blow area dry.
• Prevents hemolysis.
• Avoids burning sensation at site.
• Avoids contamination of the specimen.
• Increased bacteriostatic properties of cleansing agents.
• Do not touch after cleansing.
• Sterile vs. antiseptic puncture site
• Sterile - free from living microorganisms.
• Antiseptic - clean but not sterile.

Attach needle to Needle-Pro holder

Inspect the needle.

• Check tip of needle for hooks.
• Check bevel of needle for small particles.

Grasp the patient's arm and anchor vein.

• Place thumb one inch below the puncture site.
• Fingers should be around and underneath, grasping the arm.
• Press down on the arm with the thumb and at the same time pull the skin toward the hand.

Perform the venipuncture.

• Position the holder and needle in the direction of the vein and parallel to it.
• Needle bevel should be facing up with the needle at a 15-30 degree angle.
• Place the tube in the holder.
• Enter the vein in a smooth quick motion.
• Grasp wings of the holder with index finger and middle finger and push forward on the bottom of the tube with thumb until the needle punctures the stopper.
• When pushing tube on the needle, it is important to center the tube in the holder.
• Eliminates side wall penetration.
• Prevents potential loss of vacuum in tube.

Have patient open his/her fist when blood begins to flow.

Collect the specimen.

• Fill the tube until the vacuum is exhausted and blood flow ceases.
• Assures adequate specimen volume.
• Assures proper anticoagulant to specimen ratio.
• Remove tube
• Grasp holder tightly.
• Push wing with thumb and at the same time pull tube off with fingers.
• Invert gently 5-10 times.
• Do not shake tube - vigorous mixing will cause hemolysis.
• Do not handle tubes by the Hemoguard closure alone, because it could become unseated.
• Insert a new tube if required.
• Blood flow should begin immediately.
• If flow does not resume, move needle slightly forward or backward until blood flow begins.
• Release the tourniquet as soon as possible after the blood begins to flow.
• Order of draw prevents cross contamination and allows anti-coagulated tubes to be mixed as soon as possible after collection. The Clinical Laboratory Standards Institute (CLSI) recommends the following order:
• Blood Cultures - always draw first if ordered.
• Isolator (if needed)
• Aerobic bottle blue label
• Anaerobic bottle purple label
• Other Tubes
• Dark royal blue top (glass tube, no additive)
• Red top (glass tube, no additive)
• Light blue top (Sodium Citrate)
• FSP tube
• Red top (plastic tube with clot activator)
• Gold top gel SST or tiger top (serum separator with clot activator)
• Green top (Lithium Heparin or Sodium Heparin additives, with or without gel plasma separator)
• Lavender, Pink, Tan or Royal Blue top (EDTA additive)
• Gray top (Glycolityic inhibitors-Oxalate or Fluoride additives)
• Yellow top with ACD solution
• Whatever else.

NOTE: When using a winged blood collection set and the light blue top tube is the first tube to be drawn, a discard tube should be drawn first. Discard tube may be a glass red top tube or a light blue top tube. Amount of blood to be discarded should be at least 1mL.

• Precautions:
• Occasionally a faulty tube will have no vacuum, if a tube is not filling and the needle is in the vein, change to another tube.
• If a tube starts to fill and then stops, move the needle slightly forward or backward or rotate the needle slightly.
• If the tourniquet is on too tight, it may restrict all blood flow to the area, releasing the tourniquet may help re-establishing blood flow.
• Do not probe.

Withdraw the needle.

• Place gauze over the venipuncture site.
• For straight needles, withdraw the needle and activate the safety device.
• For butterfly needles, activate the safety device (push button on butterfly) while the needle is still in patient's arm.
• Apply pressure to site until bleeding stops.
• If necessary, have patient elevate his/her arm straight above his/her head.
• It is not recommended that the patient bend his/her arm.

Provide care to the venipuncture site.

• Apply non-latex adhesive, expandable or coflex gauze and leave in place at least 15 minutes.
• Apply pressure bandage if patient has bleeding problems or is on anticoagulant therapy.
• Don't leave the patient until the bleeding has stopped.

Label the specimen.

• Specimens must be labeled following collection.
• Do not dismiss the patient until the specimen has been properly labeled.
• Do not leave the bedside until the specimen has been labeled.
• Do not pre-label tubes.
• Required Information
• Patient's full first and last name.
• Date of birth
• Date and time of collection.
• Test(s) ordered.
• York Hospital Blood Bank specimens must also include the Blood Bank armband identification number and phlebotomist's identification.
• Gettysburg Hospital Blood Bank specimens and Hollister card must also include patient location at time of collection including bed number, patient MRN #, and phlebotomist's identification)
• Include any other pertinent information such as drawn from IV arm.

Dispose of used equipment.

Remove gloves and wash hands.

Dismiss or leave the patient.

• Determine that the patient is in no distress.
• Thank the patient.
• Replace any items that were relocated during the collection.
• Gather all equipment and supplies.

Distribute the specimens.

Deliver the specimens to the specimen receiving area of the laboratory according to the proper transport procotol or contact TransLab Services for laboratory courier service.