fundamentals of phlebotomy...5 tracking at mayo clinic rochester (cont) 1983-1996 1992 resheathing...

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Fundamentals of Phlebotomy

May 2012

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Historical Origins: Superstition

Phlebotomy Today: Diagnostic tool

CP1154634-9

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Potential Exposure from

Needle Stick Injuries

CP1154634-9

• 1 in 6 - Hepatitis B

• 1 in 20 - Hepatitis C

• 1 in 300 - HIV

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Tracking at Mayo Clinic Rochester 1983-1996

1985 1-handed recapping blocks

1987 Disposal of evacuated holders

1988 CDC Universal Precautions

1989 CDC HIV and Hepatitis B prevention guidelines

1991 OSHA occupational exposure to bloodborne pathogens final rule

Decline from 1.5 Exposures/10,000 to 0.2 Exposures/10,000

CP1154634-27

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Tracking at Mayo Clinic Rochester (cont) 1983-1996

1992 Resheathing needles and retractable lancets

1992 Biohazard container improvement initiative

1994 “Clean” needle stick removed from database

1995 Discontinued changing needles for blood cultures

Decline from 1.5 Exposures/10,000 to 0.2 Exposures/10,000

CP1154634-28

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0.2

0.2

0.2

0.4

0.5

0.8

0.5

0.6

0.7

1

1.3

1.5

1.31.3

0 0.5 1 1.5 2

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996

Tracking at Mayo Clinic Rochester 1983-1996

Frequency Rate per 10,000 punctures CP1154634-29

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2010 Blood/Body-Fluid Exposures

• 592 Needlestick and Blood/Body-Fluid Exposures occurred to Mayo staff during 2010 (161 “hollow core punctures” – or needles)

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Order Entry, Phlebotomy Supplies and

Safety

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New Device / Equipment Evaluation

Device / Equipment Name_________________ Evaluation Site_______________Date of Evaluation_____________

Rating Scale Strongly Agree (please circle)- Strongly Disagree Is the Device Safe? 5 4 3 2 1 User Friendly? 5 4 3 2 1 Easily Adapted to the Work Environment? 5 4 3 2 1 Better than existing device? 5 4 3 2 1 Comments

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Szabo J: MLO 33(3):18, 2001

Research from Center for Disease Control (CDC)

“Research from CDC … indicates that selecting safer medical devices could prevent 62-88% of sharps injuries in the hospital setting…”

CP1154634-17

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Orders for Collection & Preparing the Accession Order

• Ordering the collection

•Physician

•Designated healthcare professional

• Preparing the order for collection

•The phlebotomist

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CP1154634-12

Phlebotomy Safety: Hand Cleansing

• Soap & Water

• Waterless Hand Sanitizer

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•Studies indicate that 5-17% of healthcare workers show latex sensitivity, compared to 1-6% of the general population

•Exposure can be reduced by switching to lower allergen products, or by using non-latex substitutes

Safety: Latex Allergy

CP1154634-41

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Phlebotomy Supplies: Needles

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Phlebotomy Supplies: Evacuated / Syringe / Winged Infusion

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Phlebotomy Supplies: Skin Preparations

• 70% Isopropyl Alcohol

• Tincture of Iodine

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Phlebotomy Supplies: Gauze and Pad & Gauze Roll

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Phlebotomy Supplies: Capillary Collection Devices

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Capillary Collection

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Phlebotomy Supplies: Needle Gauge*

* Determined by the size & condition of the vein

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Considerations Prior to the Collection

• Thorough patient history

• Patient condition

• Time of collection

• Basal state

• Fasting

• Age

• Gender

• Diurnal or daily variations

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Additional Considerations

• Age

• Growth

• Development

• Safety Considerations

• Communication

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Physical Conditions of a Patient Affecting Blood Collections

• Stress

• Dehydration

• Strenuous exercise

• Pregnancy

• Smoking habits

• Weight, age and other factors

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Mayo Clinic Patient Identifiers

• Patient must state and spell their first and last name

• Patient must state their date of birth

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Patient Identification

1 2

3 4

3

3

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Additional Variables to Patient Identification

• Language or cultural barriers

• Pediatric patients

• Unidentified patients

• Unconscious patients

• Dementia, Intubated patients and other possibilities

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NOTE:

• It is the responsibility of the phlebotomist to perform PATIENT IDENTIFICATION with each and every patient interaction regardless of how many times in a work shift the phlebotomist may see the same patient for additional collections.

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Patient Identification, Arm Anatomy,

& Collection Materials

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Approach & Identify the Patient

• Identifying yourself

• Observe surroundings

• Considerations

• Patient to spell first & last name

• Patient to give date of birth

• Tech code or initial all collection labels

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Vein Assessment

• Site selection process and anatomical structure.

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Arm Anatomy: Preferred Sites/Veins

Median Cubital Vein

Basilic Vein

Cephalic Vein

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Three Phlebotomy Methods

• Evacuated

• Syringe

• Winged Infusion (Butterfly)

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Joint Commission Recommended Guideline

for Age Groups

• Infant and toddlers: 0 to 3 years

• Young children: 4 to 6 years

• Older children: 7 to 12 years

• Adolescence: 13 to 20 years

• Young adults: 21 to 39 years

• Middle adults: 40 to 64 years

• Adults: 65+ years

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Site Selection Process: Considerations

• Burn and/or Scars

• Skin Integrity

• Edema

• Hematoma

• Mastectomy

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The Venipuncture Procedure

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Evacuated Tubes

• Color Codes

• Anticoagulated Tubes

• Citrate – light blue

• Heparin - green

• EDTA – Purple, pink, or lavender

• Oxalate/Fluoride (antiglycolytic) - gray

• Serum tubes

• Gel Separator - gold or red/black

• Non- gel separator - red

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CLSI (NCCLS) H3-A5 Order of Draw

• Culture tubes (not illustrated)

• Coagulation tubes

• Serum tubes • with or without clot activator

• with or without gel

• Heparin tubes • with or without gel

• EDTA tubes

• Oxalate/fluoride tubes

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Mayo Clinic Order of Draw

• Serum Gel Separator

• Serum (Red)

• Anticoagulant Tubes

• Citrate

• Heparin

• EDTA

• Oxalate/Fluoride

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Evacuated Tube Considerations

• Mixing* by gentle inversion

• Fill volumes of the of tubes

* Follow manufacture's guidelines for the number of inversions

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Patient and Sample Identification

• The consequences of an incorrectly labeled tube are the same as an incorrectly identified patient.

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Tips for Phlebotomists

• Remain calm, professional and polite

• Place no blame

• Look at all possible sites for second collection

• Apply heat

• Consider reduced amounts

• Consult a more experienced phlebotomist

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Specimen Transport

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Specimen Processing

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Hematoma forming

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Conditions That Cause a Hematoma

• Needle placement

• Failure to remove the tourniquet before removing the needle

• Not applying adequate pressure on the site after the needle is removed

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Needle Placement Conditions

That Cause a Hematoma

• Accessing the vein too slowly

• Needle is too deep and has gone completely through the vein

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Ways to Prevent a Hematoma

• Penetrate only the upper most vein wall

• Remove the tourniquet before removing the needle

• Use major veins, not superficial veins

• Apply gentle pressure to the site with gauze after needle removal and while bandaging

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1- Hemolyzed

2-“Normal”

3- Icteric

4- Lipemic

1 2 3 4

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Acute Hemolysis

Elliott K, et al. Transfusion 43:297, 2003

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Common Complications of Phlebotomy

• Fainting

• Nausea

WHAT TO DO?

• Safety of the patient is the first concern

• Immediately stop procedure

• Do not leave patient unattended

• Call for assistance if needed

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The Venipuncture Process: Evacuated Method

• Patient Identification

• Tourniquet application

• Site selection & cleansing

• Phlebotomy collection

• Removal of the tourniquet

• Remove needle and apply pressure

• Wrap and secure site

• Label tubes

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The Venipuncture Process: Winged Infusion with a Syringe

• Patient Identification

• Tourniquet application

• Site selection & cleansing

• Phlebotomy collection

• Removal of the tourniquet

• Remove needle and apply pressure

• Wrap and secure site

• Dispense blood

• Label tubes

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The Venipuncture Process: Syringe Method

• Patient Identification

• Tourniquet application

• Site selection & cleansing

• Phlebotomy collection

• Removal of the tourniquet

• Remove needle and apply pressure

• Wrap and secure site

• Dispense blood

• Label tubes

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The Venipuncture Process: Winged Infusion /Evacuated Method

• Patient Identification

• Tourniquet application

• Site selection & cleansing

• Phlebotomy collection

• Removal of the tourniquet

• Remove needle and apply pressure

• Wrap and secure site

• Label tubes

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References

Accuracy in Patient and Sample Identification. GP33-P. (2009). CLSI. 29(13)

Dale, J. C., Hermansen, J., McConnell, Nielsen, J. (1998). Accidental needlesticks in the phlebotomy service of the department of laboratory medicine and pathology at Mayo Clinic Rochester. COMMUNIQUÉ – A Mayo Medical Laboratories Publication. 23(5).

Dale, J. C., Pruett, S. K., and Maker, M. D. (1998). Accidental needlesticks in the phlebotomy service of the department of laboratory medicine and pathology at Mayo clinic Rochester. Mayo Clinic Proceedings. 73(7). 611-613.

Procedures and Devices for the Collection of Diagnostic Blood Specimens by Skin Puncture, 5th ed. H4-A6. (2004). NCCLS. 24(21).

Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens, 6th ed. H4-A6. (2008). CLSI. 28(25).

Procedure for the Collection of Diagnostic Blood Specimens by Venipuncture, 4th ed. (1991). H3-A3. NCCLS. 11(10).

Procedure for the Collection of Diagnostic Blood Specimens by Venipuncture, 5th ed. (2003). H3-A5. CSLI. 23(32).

Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture, 6th Ed. (2007). H3-A6. CLSI. 27(26)

Szabo, J. (2001). MLO. New OSHA bloodborne pathogen standard clarifies need for employers to select safer needle devices. 33(3). 18.