CENTRAL VENOUS CATHETER (CVC) BLOOD COLLECTION Learning Module Revised Feb. 5, 2013 By: Denise Steele Last revised January 2011 November 2003 Prepared by: Carolyn Doroshuk & Denise Steele Parenteral Nurse Clinicians
Central Venous Catheter Blood Collection - 1 - TABLE OF CONTENTS 1.0 Objectives... page 2 2.0 Criteria for Successful Completion... page 2 3.0 Who May Draw Blood Samples... page 3 4.0 Procedure page 3 5.0 Exam... pages 4&5 6.0 Performance Criteria Checklist 6.1 CVC with an Intermittent Injection Cap.. page 6 6.2 CVC with a Continuous Infusion... page 7
Central Venous Catheter Blood Collection - 2 - This learning module is to be used in conjunction with corporate policy #VII-B-300, Central Venous Catheter - Blood Collection. 1.0 OBJECTIVES Upon completion of this learning module, the qualified staff member will be able to: 1. Describe how to clinically assess whether a CVC is suitable for blood sampling. 2. Select appropriate supplies and equipment. 3. Demonstrate use of routine practices or additional precautions as appropriate during the procedure. 4. Demonstrate how to prepare a patient for drawing blood samples from a CVC. 5. Perform blood sampling from a CVC using either a syringe or a vacutainer. 6. Demonstrate troubleshooting techniques for blood sampling. 2.0 CRITERIA FOR SUCCESSFUL COMPLETION 1. Review site and/or corporate policies/protocols or resource materials relative to: CVC Blood Collection (Corporate Policy and Procedure #VII-C-300) Central Venous Catheter (Tunnelled, Non-tunnelled Short Term, Peripherally Inserted Central Catheter, and Implanted Vascular Access Device) Review troubleshooting hemolysis issues. Review proper use of Vacutainer Luer-Lok access Device and Vacutainer Blood Transfer Device. 2. Receive a demonstration on blood sampling using an artificial model and/or a patient in the clinical setting. 3. Complete Performance Checklist and Exam.
Central Venous Catheter Blood Collection - 3-3.0 WHO MAY DRAW BLOOD SAMPLE Qualified staff successfully completing the criteria (see 2.0), and demonstrating competency, may withdraw blood samples from both short term and long term CVCs. To maintain competency, see requirements outlined in corporate policy #VII-B-300, Central Venous Catheter - Blood Collection. NOTE: The staff member is always constrained by their own level of expertise. A risk vs. benefit evaluation should always be done prior to obtaining blood samples via central venous access devices (CVAD). Risks of CVC blood sampling: Increased risk of central line-associated blood stream infection (CLABSI) Increased risk of catheter occlusion Inaccurate specimen results of coagulation studies/drug levels/electrolytes if these substances have been in contact within the CVC lumen. Anemia associates with frequent sampling due to the discard amount of blood required Benefits of CVC sampling: Avoidance of venipuncture pain and anxiety Reliable blood sampling for patients with difficult venous access. 4.0 PROCEDURE Review and be able to demonstrate the procedure outlined in corporate policy #VII-B-300, Central Venous Catheter - Blood Collection.
Central Venous Catheter Blood Collection - 4-5.0 EXAM 1. When drawing blood from a CVC, you would first draw off and discard a minimum of: a) 1 ml b) 3 ml c) 5 ml d) 10 ml 2. You drew the specimen with a 60 ml syringe and transferred the blood into the tube using a transfer device by injecting into the tube. What quality problem can result? a) hemolysis b) under and over filled tubes c) Inaccurate results d) all of the above 3. The procedure for drawing blood from CVC includes: a) scrubbing the hub of the injection cap with chlorhexidine/alcohol swabs and allowing the solution to dry b) turning off infusates for 10 minutes prior to drawing samples c) withdrawing initial 5 ml of blood and saving same d) selecting the distal lumen as the sampling port 4. Indications a lumen is occluded include: a) frequently ringing occlusion alarm on infusion pump b) inability to gently flush lumen c) inability to withdraw blood from lumen d) all of the above 5. The first sample of blood drawn from a CVC is: a) sent for testing b) saved for future use c) discarded d) none of the above 6. After drawing blood from a central line how much saline is used to flush line. a) 3ml b) 5ml c) 10ml d) 20ml
Central Venous Catheter Blood Collection - 5-7. Which type of central line would you lock with 10 Units/mL of heparin? (may be more than one answer) a) closed ended Groshong PICC b) open ended short term triple lumen with slide clamps c) open ended PICC with clamps d) tunnelled Catheter 8. Name 3 risks to the patient of CVC blood sampling. 1) 2) 3) 9) How long do you cleanse injection cap with chlorhexidine/alcohol swab before accessing? a) 5 seconds b) 10 seconds c) 15 seconds d) 30 seconds 10) Before obtaining blood drug levels, how much normal saline must you flush into the CVC? A) 5 ml b) 10 ml c) 20 ml d) 30 ml 11. Blood cultures are taken from a CVC: A) Within 15 minutes of blood culture collection from a peripheral vein B) From one CVC lumen only C) From all CVC lumens D) Regardless of the suspected source of infection. E) A and C above 12. Prior to obtaining blood cultures the following changes to the usual procedure must occur. Circle all that apply. A) Withdraw a larger discard sample. B) Attach new injection cap. C) Do not draw a discard sample. D) Do not flush. 13. Explain time to positivity.
Central Venous Catheter Blood Collection - 6-6.0 PERFORMANCE CRITERIA CHECKLISTS Demonstration Checklist Preparation for all care: (Accessing, flushing, needle removal and/or blood collection) Two patient identifiers, Patient teaching and procedure explanation Clean your work area (eg.virox) Hand hygiene at 4 times as identified by IP&C Each time the injection cap is entered it must be scrubbed with an alcohol or chlorhexidine/alcohol wipe for 15 seconds and the solution allowed to dry. We call this Scrub the hub. Hand hygiene happens at all 4 of these opportunities throughout the procedure: Before touching the patient and/or objects in the patient s environment Before any new procedure or when going from one procedure to another on same patient. After glove removal After touching the patient and /or the patients environment Assess site for redness, drainage, swelling, pain; also palpate along CVC On cleaned area Prepare needed supplies; Have client look away from site to prevent contamination Questions that may be asked: 1. What would you do if you are not able to aspirate blood? 2. How many minutes are infusions stopped prior to taking blood specimens? 3. Which lumen(s) do we flush after taking blood? 4. How can hemolysis be prevented? 5. What type of test results should we maintain a high level of suspicion if the reported values appear unlikely?
Central Venous Catheter Blood Collection - 7 - Name: Date: Blood Sample Collection CVC with or without an Infusion Using a Vacutainer Confirms patient care order for blood collection. Confirms order of draw, special handling requirements if applicable and number of times to invert each tube. Performs hand hygiene and assembles and prepares equipment on clean surface. Identifies and teaches patient. Performs hand hygiene. Dons personal protective equipment. Scrubs hub of injection cap before entering cap at each opportunity. Stops infusion (if appropriate) for 1-3 minutes. Flushes lumen with NS. Withdraws discard amount in same syringe or collection tube and ensures it is discarded. If vacutainer used, discard tube is the same color as 1 st draw tube. Collects blood specimen using a luer lock vacutainer access device, maintaining correct order of draw, and inverting collection tube the number of times outlined by the lab. Ensures injection cap on lumen remains tight. Flushes lumen with at least 20 ml NS. Ensures injection cap is free of visible blood or attaches new sterile cap. Flushes each lumen with normal saline and Heparin lock each lumen as appropriate. Labels blood tubes correctly. Attaches line draw sticker. Completes lab requisitions. Transfers collection tube into biohazard bag and places at lab pick up area on unit. Documents blood collection Demonstrated Correctly Yes No Requires Prompting May perform skill independently Please repeat Observer Name: December 2010
Central Venous Catheter Blood Collection - 8 - Name: Date: Blood Sample Collection CVC with or without infusion Using Syringe Confirms patient care order for blood collection. Confirms order of draw, special handling requirements if applicable and number of times to invert each tube. Performs hand hygiene and assembles and prepares equipment on clean surface. Identifies and teaches patient. Performs hand hygiene. Dons personal protective equipment. Scrubs hub of injection cap before entering cap at each opportunity. Stops infusion (if appropriate) for 1-3 minutes. Flushes lumen with NS. Withdraws discard amount in same syringe and ensures it is discarded. Collects blood specimen using syringe method and vacutainer luer lock access device, maintaining correct order of draw, and inverting collection tube the number of times outlined by the lab. Safely transfers blood to specimen tube using transfer device. Allows tubes to fill without injecting. Flushes lumen with at least 20 ml NS. Ensures injection cap is free of visible blood or attaches new sterile cap. Flushes each lumen with normal saline and Heparin lock each lumen as appropriate. Labels blood tubes correctly. Attaches line draw sticker. Completes lab requisitions. Transfers collection tube into biohazard bag and places at lab pick up area on unit. Documents blood collection Demonstrated Correctly Yes No Requires Prompting May perform skill independently Please repeat Observer Name:
Central Venous Catheter Blood Collection - 9 - Name: Date: Blood specimen Collection From IVAD Confirms patient care order for blood collection. Confirms order of draw, special handling requirements if applicable and number of times to invert each tube. Performs hand hygiene and assembles and prepares equipment on clean surface. Identifies and teaches patient. Performs hand hygiene. Dons personal protective equipment. Scrubs hub of injection cap on non-coring needle before entering cap at each opportunity. Stops infusion (if appropriate) for 1-3 minutes. Flushes extension tubing with NS. Withdraws discard amount in syringe or collection tube. If vacutainer used, it is the same color as 1 st draw tube. Collects blood specimen using vacutainer or syringe method, maintaining correct order of draw, and inverting collection tube the number of times outlined by the lab. Flushes extension with at least 20 ml NS. Ensures injection cap is free of visible blood or attaches new sterile cap. Locks IVAD with appropriate solution or attaches continuous infusion ensuring sterile connector is used. Labels blood tubes correctly. Applies line draw sticker. Completes lab requisitions. Transfers collection tube into biohazard bag and places at lab pick up area on unit. Documents blood collection Demonstrated Correctly Yes No Requires Prompting May perform skill independently Please repeat Observer Name:
Central Venous Catheter Blood Collection - 10 - Name: Date: Blood Culture Collection from CVC with Syringe Method. Note: Obtain blood culture prior to administration of antibiotic if possible Confirms patient care order for blood collection. Coordinates peripheral blood culture collection with CVC blood culture collection. Performs hand hygiene and assembles and prepares equipment on clean surface. Identifies and teaches patient. Performs hand hygiene. Dons personal protective equipment. Stops infusion (if appropriate) for 1-3 minutes. Scrubs injection cap/hub connection with chlorhexidine/alcohol wipe for 15 seconds and allows solution to dry. Replaces injection cap on each lumen with new, sterile injection cap. Scrubs aerobic and anaerobic collection bottles with chlorhexidine/alcohol wipes for 15 seconds and allows solution to dry. Does not flush lumen. Does not withdraw discard amount unless lumen locked with antibiotic solution. Ensures peripheral blood cultures are drawn at the same time or within 15 minutes of CVC collection. Collects a minimum of 10 ml of blood for each specimen bottle using syringe method. All CVC lumens cultured for aerobic and anaerobic testing. Hands blood filled syringes to second person so that specimen can be aseptically and safely transferred to specimen bottle using transfer device. Second person ensures 10 ml volume enters each specimen bottle. Flushes lumen with at least 20 ml NS. Ensures injection cap is free of visible blood or attaches new sterile cap. Flushes each lumen with normal saline and Heparin/citrate locks each lumen as appropriate. Ensures that blood tubes are labeled correctly with name, which lumen was used and date/time of draw so that time to positivity can be analyzed. Completes lab requisitions. Transfers collection bottles into biohazard bag and places at lab pick up area on unit. Documents blood culture collection Demonstrated Correctly Yes No Requires Prompting May perform skill independently Please repeat Observer Name: