SOP #:P Page 1 of 9

Transcription

1 SOP #:P Page 1 of 9 PURPOSE: Several essential steps go into successful specimen collection. This procedure describes the sequential manner in which one would progress through the collection process. RESPONSIBILITY: All hospital personnel responsible for the collection and labeling of patient specimens. PROCEDURE: I. Specimen Collection Blood A. General Phlebotomy Considerations 1. Since prolonged stasis due to the application of a tourniquet can result in alteration of some chemical values, a tourniquet should be removed from the patient within 1 minute of application. 2. Venipuncture should not be performed while IV solutions are being administered when possible. 3. A syringe that was used to inject IV solutions should not be used for blood collection. 4. Blood samples should be collected in appropriate tube for the test requested. See the Lab Service Manual for details. 5. If a patient has received radioisotope material just before having blood drawn for any radioassay, the test results may not be valid. 6. Phlebotomy trays and supply sources should be replenished and restocked at the end of each shift in preparation for the next shift. 7. Do not place the phlebotomy trays on the patient's bedside table. 8. Avoid discussion concerning the medical condition of the patient or answering any questions regarding what the tests are for. Notify the patient that these types of questions are better answered by his/her physician. B. Safety Precautions 1. All Edward employees responsible for collecting patient specimens are trained on the proper protocol for handling blood and body fluids. 2. Employee hands are washed between each patient by either using a hospital approved hand sanitizer or washing in a sink per hospital policy. 3. Clean gloves are put on prior to blood collection in the presence of the patient. 4. In the event of clothing or skin contamination with blood, the garment or skin must be decontaminated prior to proceeding to the next patient. C. Blood Volume Considerations

2 SOP #:P Page 2 of 9 II. Patient Identification 1. It is Edward Hospital practice to minimize the amount of blood collected from a patient for laboratory testing. This is accomplished in the following ways: a) The HIS is programmed with rules for combining blood tubes to be collected from each patient when possible. b) When possible, the smallest vacutainer tube available is used in collecting blood (ex: pediatric/neonate patient s will be drawn using pediatric tubes instead of 7ml adult tubes). c) Extra vacutainer tubes are not collected on a routine basis. d) See Attachment A - Minimum Blood Draw Requirements for Neonates. A. Patient Armbands B. Inpatient 1. All patients admitted to Edward Hospital are required to have a Patient Armband. 2. Each armband contains information that is used by Edward employees to positively identify the patient. The information Edward employees use on the armband to positively identify the patient is the patient s full name, the medical record number, the billing number and the date of birth. 3. Information found on the patient s armband such as the room number may NOT be used to identify the patient. 1. Knock prior to entering the patient s room. 2. Identify yourself and inform the patient of your purpose. 3. Ask the patient to state their name and date of birth. 4. Confirm the patient s name and date of birth by looking at the patient s armband and comparing the information against the PDA, LIS test label or HIS chart label. 5. Two unique patient identifiers must be used every time a patient sample is obtained and labeled. 6. DO NOT draw any patient that is not wearing an Edward Hospital Patient Armband. 7. When using a handheld phlebotomy device, patient identification is confirmed through the scan of the patient s armband. C. Outpatient (including Home Care Patient s) 1. Ask the patient to state their name and date of birth. If the patient is a child or infant, the parent or adult with the child must provide the child's name and

3 SOP #:P Page 3 of 9 date of birth. 2. Confirm the name and date of birth provided by the patient against the test requisition and/or LIS test label. 3. Two unique patient identifiers must be used every time a patient sample is obtained and labeled. D. Linden Oaks 1. Call the patient into the blood collection room. 2. Ask the patient to state their name and date of birth. 3. Confirm the patient s name and date of birth by looking at the patient s armband and comparing the information against the LIS test label or HIS chart label. 4. Due to the nature of some LOH patient s, the patient may not be wearing a patient armband. In these cases, the nurse responsible for the patient should identify the patient by use of the patient s photo in the chart and confirming the patient s identity for the phlebotomist. 5. Confirm the name and date of birth provided by the patient or nurse against the LIS test label or HIS chart label. 6. Two unique patient identifiers must be used every time a patient sample is obtained and labeled. III. Blood Collection - Venipuncture A. Tourniquet Application and Vein Identification 1. Examine both arms for adequate veins. 2. Avoid using areas with heavy bruising. 3. Tie the tourniquet tightly around the patient's arm, but not so tightly as to cause pain. 4. Do not leave the tourniquet on the patient s arm for more than 1 minute. 5. If a vein becomes evident about the time the tourniquet should be removed, remove the tourniquet and allow the patient to dangle their arm for several minutes before reapplying the tourniquet and re-palpitating for a vein. 6. Patient s may be asked to clench their fist several times. Excessive fist clenching can also cause hemoconcentration and should be avoided. B. Decontamination of the Venipuncture Site 1. Clean gloves are put on prior to blood collection in the presence of the patient. 2. Alcohol swabs or Betadine must be used for cleansing the venipuncture site. 3. Scrub the site somewhat vigorously and allow the area to dry completely before proceeding with the venipuncture. 4. Do not re-palpitate the area once it is cleansed.

4 SOP #:P Page 4 of 9 5. Site preparation for collecting blood cultures is critical and can be found in the Blood Culture Collection procedure found in the Lab Services Manual. C. Venipuncture 1. Hold the patient s arm below the venipuncture site with one hand and pull the skin tightly with the thumb to stabilize the vein. 2. Insert the needle quickly and smoothly at approximately a 15-degree angle with skin into the vein. The needle should run in the same direction as the vein and should be inserted with the bevel facing up. 3. As the blood begins to flow instruct the patient to open their fist if it was clenched. 4. Remove the tourniquet upon obtaining venous access or after the blood collection is complete, but prior to withdrawing the needle from the vein. 5. Allow blood to flow into the vacutainer tubes until they are filled completely. 6. If blood flows into the tube, then stops, the needle should be moved slightly forward or backward to re-secure venous access. Probing is not recommended since it is painful to the patient. If this slight movement does not result in the free flow of blood again, remove the tourniquet and look for an alternate site. 7. Upon completion of specimen collection, place a gauze pad over the venipuncture site and remove the needle from the patient s arm. Using the needle safety device, cover the needle. 8. Apply pressure to the patient s arm until there are no signs of bleeding from the site. 9. Apply a bandage or gauze with tape to the venipuncture site. D. Blood Collection Using an Arm containing an Intravenous Line 1. Request that a nurse stop the IV flow. 2. Wait 15 minutes after the IV is shut off before performing a venipuncture on that arm. Follow the procedure outlined above. 3. After gaining venous access, collect one waste tube to minimize the possibility of contamination with IV fluid. 4. Indicate on the tube label that the sample was drawn above or below the IV line. IV. Blood Collection - Finger Puncture A. Choose a finger that is not cold or swollen; the best choice is the 4th, or ring finger of the non-dominant hand. B. Gently massage the finger 5-6 times from the base to the tip to aid blood flow. C. Cleanse the finger with alcohol and allow to air dry. D. Remove the protective cover from the lancet tip and without touching the tip, make a puncture halfway between the center of the ball of the finger and the side. The cut

5 SOP #:P Page 5 of 9 should be across the fingerprints to produce a large drop of blood. E. Wipe the first drop of blood away with gauze. F. Fill the appropriate microcontainers or filter paper cards as necessary. Care should be taken to avoid clotting of specimens requiring whole blood samples. G. Apply pressure to the puncture and observe that the site is no longer bleeding. Apply a bandage to the site if needed. V. Blood Collection - Heelstick A. Pre-warm the heel of the infant for at least 5 minutes using a heel warmer. B. Cleanse the site with alcohol and allow to air dry. C. The site of the puncture should be the lateral or medial portion of the planter surface of the heel. D. Using the lancet device, make an incision on the heel then wipe away the first drop of blood. E. Fill appropriate microcontainers or filter paper cards as necessary. Care should be taken to avoid clotting of specimens requiring whole blood samples. F. Apply pressure to the puncture and observe that the site is no longer bleeding. Apply a bandage to the site if needed. VI. Blood Collection - Butterfly Draws for Coagulation Testing A. When using a winged blood collection set for venipuncture and a coagulation tube is the first tube to be drawn, a discard tube should be drawn first. B. The discard tube must be used to fill the blood collection tubing dead space and to assure maintenance of the proper anticoagulant/blood ratio. C. The discard tube cannot be a red top and must be a blue top because of the additives in the red top. VII. Vacutainer Tube Draw Order A. The order in which the vacutainer tubes are drawn is an important consideration due to the different additives contained within the vacutainer. B. Vacutainer tubes should be collected in the following order: 1. blood culture vials 2. blue top Sodium Citrate 3. gold top or red top/serum separator 4. green top - heparin or gel separator tube with heparin 5. purple top EDTA 6. gray top C. Specimen Label Crosswalk

6 SOP #:P Page 6 of 9 VACUTAINER BLOOD COLLECTION Code Stopper Color Additive ATXPINK Pink EDTA BLUE Blue Sodium Citrate DKGRN Dark Green Sodium Heparin GOLD Gold Clot Activator GREY Gray Sodium Oxalate LAV Lavender EDTA LTGRN Light Green Lithium Heparin PINK Pink EDTA RED Red None VIII. Specimen Handling A. Blood Specimens Plasma 1. Draw a sufficient amount of blood with the indicated anticoagulant to yield the necessary plasma volume. 2. Gently mix the blood collection tube by inverting 8 to 10 times immediately after collection. 3. If required, separate plasma from cells by centrifugation within minutes of collection B. Blood Specimens Serum 1. Draw a sufficient amount of blood to yield the necessary serum volume. 2. Invert the tube 8 to 10 times to activate clotting. 3. Allow blood to clot at room temperature for minutes. 4. Serum specimens should be centrifuged within an hour of collection. C. Blood Specimens Whole Blood 1. Draw a sufficient amount of blood into the appropriate tube. 2. Gently mix the blood collection tube by inverting 8 to 10 times immediately after collection. 3. Tubes intended for whole blood analysis are not to be centrifuged and separated. D. Fasting Specimens 1. Overnight fasting is required for most fasting specimens. 2. Some tests, particularly lipids, triglycerides, and lipoproteins, required further dietary restrictions. For these tests, a 14 hour fasting is required prior to specimen collection. 3. The meal eaten the evening before the specimen is drawn should contain no fatty foods or alcohol and it should be completed prior to 6:00 p.m.

7 SOP #:P Page 7 of 9 4. Drinking water, black coffee or tea does not alter fasting specimen acceptability. E. Centrifugation 1. Centrifugation should be performed at g for 10 minutes. 2. Tubes of blood, serum, and plasma are to be kept closed at all times to prevent possible exogenous contamination, evaporation, concentration changes, or possible spillage or aerosols. IX. Specimen Labeling A. Label all specimens at the patient s bedside NEVER leave the patient s bedside with an unlabeled specimen. B. Follow the Laboratory Specimen Collection, Labeling, Acceptability and Rejection policy for details of specimen labeling requirements. C. All inpatient specimens submitted to the Laboratory for testing must contain a HIS generated patient label. D. All specimens must contain the following information: 1. Patient first and last name 2. Patient Medical Record Number and/or date of birth 3. Date and time of specimen collection 4. HIS employee code of employee responsible for collecting/labeling the specimen. 5. Blood Bank specimen labels must include the patient s ATX number and Blood Loc code. X. Specimen Transport A. All specimens must be placed into a secondary container or specimen bag and sealed tightly prior to transport. B. If a requisition is required for the sample, place the requisition in the outer pocket of the biohazard specimen bag. Requisitions are required for all Pathology specimens. C. Deliver all specimens to the lab as soon after collection as possible, preferably within an hour. See the Laboratory Services Manual for details regarding specimen age requirements. D. Never use the pneumatic tube system for any specimen that cannot be replaced or recollected (i.e. Pathology specimens, tissue, spinal fluid, semen, surgical specimens, amniotic fluid etc). These specimens must be hand delivered directly to the lab. E. All specimens submitted for Microbiology testing should be delivered to the laboratory within an hour of collection unless preserved. (exception - CSF and any fluid for anaerobic culture (that is not in anaerobic transport) must be delivered to the laboratory within 15 minutes). F. Microbiology specimens that cannot be processed immediately must be refrigerated at 2-8 C, with the exception of CSF, genital specimens, and anaerobic specimens which

8 SOP #:P Page 8 of 9 should be held at room temperature. G. Most specimens may be transported to the Laboratory via the pneumatic tube system. H. Blood specimens collected by Laboratory personnel will be sent to the lab after every 3 patient collections or every 15 minutes to facilitate turnaround time. I. When tubing specimens to the lab observe the tube leaving the station to ensure timely delivery. XI. Procedural Notes A. There is a maximum limit of two venipuncture attempts per phlebotomist per patient per order. Notify the patient s nurse of the unsuccessful draw and add a comment to the patient s order that the patient is a difficult draw. B. Request assistance from the nursing staff or a co-worker to help with pediatric or geriatric patients if needed. C. Never use alcohol to cleanse the venipuncture site for a blood alcohol test. Betadine prep must be used for blood alcohol tests. D. Blood collections from patients with central lines are obtained by the nursing personnel only. E. Be aware of isolation signs on doors. Follow the appropriate precautions. F. Do not argue with a patient refusing to have blood drawn. Report the refusal to the patient s nurse and wait for directives as to whether the test is cancelled or rescheduled. Reference:

9 SOP #:P Page 9 of 9 Date Author Approval 11/30/05 Caroline Yacko, MT(ASCP) Mary Cluver MT(ASCP) Review Revision Date Approval Comments / Reason for Removal L.Patel L.Patel /02/06 Draw blue top as a waste before actual blue top for testing (except when using butterfly) is removed since it is not necessary. L.Patel /08/06 Added paragraph about Minimum amount of blood draw. C. Goldberg 11/06 New Medical Director L.Patel 02/05/07 Deleted name (Tenderfoot) of lancet device. J. Fonseca 10/13/08 P1.0.4 Coordination of information contained in G B.Lopez 10/5/09 Sodium heparin listed for dark green. Lithium heparin listed for light green