fundamentals of phlebotomy - cdn.prod-carehubs.net · 1 fundamentals of phlebotomy may 2012...

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Fundamentals of Phlebotomy

May 2012

Historical Origins: Superstition

Phlebotomy Today: Diagnostic tool

Historical Origins: Superstition

Phlebotomy Today: Diagnostic tool

CP1154634-9

Potential Exposure from Needle Stick Injuries

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 Rochester1983-1996


1985 1-handed recapping blocks

1987 Disposal of evacuated holders

1988 CDC Universal Precautions

1989 CDC HIV and Hepatitis Bprevention guidelines

1991 OSHA occupational exposure to bloodborne pathogens final rule

1985 1-handed recapping blocks

1987 Disposal of evacuated holders

1988 CDC Universal Precautions

1989 CDC HIV and Hepatitis Bprevention guidelines

1991 OSHA occupational exposure to bloodborne pathogens final rule

Decline from 1.5 Exposures/10,000 to0.2 Exposures/10,000


CP1154634-27

Tracking at Mayo Clinic Rochester (cont)1983-1996

Tracking at Mayo Clinic Rochester (cont)1983-1996

1992 Resheathing needles andretractable lancets

1992 Biohazard container improvementinitiative

1994 “Clean” needle stick removedfrom database

1995 Discontinued changing needlesfor blood cultures

1992 Resheathing needles andretractable lancets

1992 Biohazard container improvementinitiative

1994 “Clean” needle stick removedfrom database

1995 Discontinued changing needlesfor blood cultures



CP1154634-28

1983198319841984198519851986198619871987198819881989198919901990199119911992199219931993199419941995199519961996



Frequency Rate per 10,000 puncturesFrequency Rate per 10,000 puncturesCP1154634-29

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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)

Order Entry, Phlebotomy Supplies and

Safety

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

Research from Center for Disease Control (CDC)

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…”

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

CP1154634-17

Orders for Collection & Preparing the Accession Order

• Ordering the collection•Physician•Designated healthcare professional

• Preparing the order for collection•The phlebotomist

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

• 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 AllergySafety: Latex Allergy

CP1154634-41

Phlebotomy Supplies: Needles

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Phlebotomy Supplies:Evacuated / Syringe / Winged Infusion

Phlebotomy Supplies: Skin Preparations

• 70% Isopropyl Alcohol

• Tincture of Iodine

Phlebotomy Supplies: Gauze and Pad & Gauze Roll

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Phlebotomy Supplies:Capillary Collection Devices

Capillary Collection

Phlebotomy Supplies: Needle Gauge*

* Determined by the size & condition of the vein

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ConsiderationsPrior to the Collection

• Thorough patient history

• Patient condition

• Time of collection• Basal state

• Fasting• Age• Gender• Diurnal or daily variations

Additional Considerations

• Age

• Growth

• Development

• Safety Considerations

• Communication

Physical Conditions of a PatientAffecting 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

Patient Identification

1 2

34

33

Additional Variables toPatient 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.

Patient Identification, Arm Anatomy,

& Collection Materials

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.

Arm Anatomy: Preferred Sites/Veins

Median Cubital Vein

Basilic Vein

Cephalic Vein

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

Site Selection Process: Considerations

• Burn and/or Scars

• Skin Integrity

• Edema

• Hematoma

• Mastectomy

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

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

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

Patient and Sample Identification

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

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

Specimen Processing

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

Needle Placement ConditionsThat Cause a Hematoma

• Accessing the vein too slowly

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

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- Hemolyzed2-“Normal”3- Icteric4- Lipemic

1 2 3 4

Acute Hemolysis

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

Common Complicationsof 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

The Venipuncture Process: Winged Infusion with a Syringe








• Dispense blood

• Label tubes

The Venipuncture Process:Syringe Method








• Dispense blood

• Label tubes

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The Venipuncture Process: Winged Infusion /Evacuated Method








• Label tubes

ReferencesAccuracy 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.

fundamentals of phlebotomy - cdn.prod-carehubs.net · 1 fundamentals of phlebotomy may 2012...

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