QHC Laboratory Medicine

Pre-Analytical

Specimen Collection

Where is the lab located?

■ At BGH we’re located on Level E2

❑Down the hall from cafeteria

❑Above the new emerg

❑Must be a registered MLT or MLA

❑MLT’s are accountable to the CMLTO and certified by

the CSMLS

❑MLA’s are certified through the CSMLS or OSMT

QHC LABORATORY SERVICES

■ Belleville General – Full service Core Lab,

Microbiology and Histopathology services

■ North Hastings – Point of Care testing on site

■ Prince Edward – Point of Care testing on site

■ Trenton Memorial – Point of Care testing on site❑ 1 courier run per day Monday – Friday

❑ 1 courier run on weekends

❑ Taxi runs as required

❑ North Hastings: 2 courier runs during the week and 1 courier run on

weekends

POC Contacts

■ Belleville – Kelly Richmond x 2404

■ Trenton – Nancy Osborne x 5425

■ Picton and North Hastings

– Julie Craig x 4506

■ For more information visit:❑myQHC Intranet > Departments & Programs

> Laboratory Services > Point of Care

Lab Departments

x2396 x2599 x2370

x2316 x2362 x2363

Lab Departments

■ Core Lab – operates 24/7

❑ Blood Bank – tests samples prior to transfusion and issues

blood products

❑ Hematology – performs coagulation studies, CBCs, and

reviews cell morphology

❑ Chemistry – all chemistry tests including drug screens,

blood gases, pregnancy tests, urinalysis etc.

■ Microbiology – operates daily 7am – 5pm

❑ Interpret urines, stools, swabs etc for bacteria, fungal or

viral infection, and specimens for public health

■ Histopathology – operates Mon–Fri 7am-4pm

❑ Prepare tissues to aid in patient diagnosis

“Garbage In, Garbage Out”

Up to 85% of decisions about diagnosis and

treatment are based on laboratory results.

BUT…

Good results depend on good collection

practices.

Specimen Collection

Specimen Collection

Perform

Venipuncture

Label

SpecimensSign labels

Send

Specimens to

the lab

Entering orders into the LIS SystemOE, EDOC, & EDIS will generate Labels

■ Labels provide all the information required.

❑ Type(s) of vacutainer(s) to collect

❑ Patient information (DOB, Unique Identifier, and patient location)

■ Barcoded labels have specimen numbers on them that correlate with the tests ordered. Some are tested on site, some are sent out for testing. Ex.

❑ 2311:H00004 LAV3 → for Hematology

❑ 2311:H00005 BLUE → for Hematology (Coagulation)

❑ 2311:C00003 SST(gold)/RST(orange) → for Chemistry

❑ 2311:BB0003 LAV7 → for Blood Bank

❑ 2311:SO0002 SST (gold) → Sent Out for Testing

❑ 2012:XM0013 SST (gold) → Sent Out for Micro

❑ 2012:M0005 Sterile container → for Microbiology (urine/stool)

Note: The barcode labels do not print in the order of draw.

■ All barcode labels that print must be collected.

Order Entry

Prepare Supplies

■Before performing the venipuncture, gather all the supplies needed.

■Bring everything you need including your labels to the patient’s bedside. This will ensure you have the right specimen and the right patient.

**IMPORTANT**

IF Blood Bank Ident-A-Blood band wristband is needed for your patient, fill out prior and must be affixed to the

patients wrist prior to phlebotomy after patient identification. (Example: Type and Screen and/or Crossmatch)

Format on wristband: T##### LAST NAME, FIRST NAME MIDDLE NAME Date and Initials

VacutainersAll vacutainers have a specific job.

Proper collection techniques and labeling ensures a good sample for the

laboratory to process.

■ Blood Cultures

■ Blood cultures are collected from patients with suspected sepsis or bacteremia. These should be collected prior to the initiation of antimicrobial therapy.

■ Draw first when other tests are also ordered.

■ At least 2 separate collections should be drawn resulting in 2 sets of blood cultures ideally from 2 different sites

■ If two separate venipuncture sites can not be used, draw the second set from the same site after waiting a minimum of 5 minutes.

NOTE: When preparing the blood cultures bottles for

collection after removing the lid clean the tops with

2 separate alcohol wipes.

DO NOT TOUCH THE LIDS AFTER CLEANING

Vacutainers

■ For Adults

❑ 1 set of blood cultures consists of 2 culture

bottles, one for aerobic bacteria (Green)

and the other for anaerobic bacteria

(Orange).

❑ 5-10mL should be collected per bottle.

❑ Because there is air in the butterfly line you

should collect the Green (GO) bottle first.

❑ One green and one orange = 1 set drawn

from a single venipuncture site.

❑ 2 sets = 4 bottles (ideally one set from each arm)

Adult

For Infants and Young Children1 set includes a single aerobic Paed’s blood

culture (Yellow) bottle.

Draw 2-4mL per bottle.

2 sets = 2 bottles

Vacutainers

Paed’s

Vacutainers

Sodium Citrate (BLUE): Haematalogy■ No clotting required. 7 minute centrifugation time.

■ Plasma is used for Coagulation studies.

■ Must be a full draw to avoid anticoagulated/blood ratio incompatibilities. (actual small amount of anticoagulant in the tube 0.3 mL.)

RST (Orange): Chemistry■ requires 5 minute clotting time from time of collection

■ 10 minute centrifugation time and then analyzer processing time.

■ (↑cost→ good for critical care areas. ie. Emerg and ICU)

■ Cannot be used for send out testing

SST (Gold): Chemistry / Send out Testing■ Requires 30 minute clotting time from time of collection.

■ 10 minute centrifugation time and then analyzer processing time. Used for majority of Chemistry testing. Ex. Glu, UREA, ELE, Troponin, etc. Laboratory can only test the serum portion of an SST tube and require a full draw whenever possible. Each test ordered has a different processing time on the analyzer.

RST

SST

VacutainersEDTA (anticoagulant in the tube, coats the inside of the tube)

LAV3 (Haematalogy)

■ No clotting or centrifuging required.

■ Whole Blood is used for CBC and ESR

LAV7 (Transfusion Medicine)

■ No clotting but requires centrifugation of 7 min.

■ Used for Type & Screen and Crossmatches

■ Must have both patient identification and T#

■ Never cut off an existing Blood Bank armband

Vacutainers

▪ ABG Syringe Chemistry

▪ Venous blood gas/lactate collection▪ Follow order of draw collected last▪ Required – butterfly needle for this collection▪ Mix thoroughly after collection to mix heparin▪ Gently remove any air within the syringe▪ Place on ice slurry and deliver to lab immediately, to be analyzed within 30

mins.

Have your ice in a biohazard bag at bedside so tubes and syringe can be placed in it after they have been labelled

DO NOT place sample directly on ice, put in front sleeve of biohazard bag

Selecting a Needle

■ Select a needle gauge appropriate for the vein size, vein

location and patient’s condition.

■ The ideal gauge is 21G (green cap).

❑A lower gauge of needle (18G and lower) causes

blood to enter tube faster/forcefully and may cause

hemolysis. (larger bore needle)

❑A higher gauge of needle (23G and up, blue cap) can

also cause hemolysis. Blood traveling through an

extremely small opening, under a great force can

cause rupturing of the RBCs. (smaller bore needle)

The Patient

■ Identifying the patient is the most important step in any phlebotomy

procedure. Blood test results from a misidentified patient may be linked to

the wrong patient, and can put the health of two patients at risk.

■ To identify an inpatient, match the requisition/label to their identification

bracelet. If the patient is not wearing an identification bracelet, do not

perform the venipuncture until patient is properly identified and banded.

■ Position the patient in a comfortable position that will allow you to perform

venipuncture easily.

NOTE: Sample labels should ALWAYS come to the bedside before performing

sample collection and the samples should be labeled at the bedside.

What Are the Identifiers?

✓Patient Full Name

✓Hospital Unique Number

✓Health Card Number

as per Accreditation Canada

Do Not Use:

Patient Room Number

Patient Bed Tag

1. Tie the Tourniquet ■ The tourniquet should be tied above the

venipuncture site.

■ Remember there is a 2 minute time limit

before the tourniquet must be removed.(If tied for a prolonged time, hemoconcentration can result in

osmotic pressure which affects the red blood cells, causing

them to rupture).

■ Remember that your site has been cleaned!❑ If you need to feel for the vein again, remember to untie the

tourniquet and clean the site again before inserting the

needle

PERFORM THE VENIPUNCTURE

2. Selecting a Venipuncture Site■ Vein of choice: Anticubital Vein

In the presence of a hematoma, collect as far away as

possible from the hematoma

■ Specimens collected from a hematoma may cause erroneous results.

❑ If a hand vein is used, it is recommended to use a smaller gauge needle (ie 22G or 23G)

❑ Ideally do not collect from the IV arm.

■ If no other option, ensure IV is turned off at least 2 minutes prior to collection to avoid sample dilution.

■ Collect below the IV site and discard the tube first tube drawn.

Palpitate the arm with firm pressure to find the appropriate vein.

3. Clean the Site

■ Aseptic technique should always be used

when performing venipuncture.

■ Allow Alcohol to dry before venipuncture.

❑Performing venipuncture before alcohol is allowed

to dry thoroughly may cause RBC’s to rupture.

4. Insert the Needle

Hold the needle with the bevel up and insert it into the vein with one quick smooth motion.

A "pop" or sudden decrease in resistance will signal entry into the vein. (firm resistance followed by entering into a hollow space)

Traumatic Draws

❑Do Not Probe or reposition the needle several

times forward or backward. Try another site.

❑ If not successful after 2 attempts ask for another

person to perform venipuncture.

5. Load the Vacutainer

■ Insert the first tube into the tube holder.

■ Coagulation orders must always have a discard tube collected first. ❑ This is done to avoid the risk of activating coagulation factors

when the vein is first punctured.

■ If using a Butterfly collect a discard tube first. ❑ Because of the length of tubing between the needle and the

tube, the first tube will be under filled by 0.5 mL.

❑ Under filling a tube with an additive will affect the additive to blood ratio for that tube and can cause erroneous results.

Order of Draw

■ After the vacuum is exhausted, remove the first tube from the holder and insert the second tube.

■ Mix the first tube while the next tube is filling.

■ Continue in this manner until all tubes have been collected.

■ Note: If you are not able to draw an adequate volume of blood on the second attempt, seek assistance.

6. Release the Tourniquet

■ Release the tourniquet within 2 minutes after

initial placement of the tourniquet on the arm.

■ Tourniquet can be removed after the flow of

blood has been established with the first tube

collected

❑Prolonged tourniquet time can result in

hemoconcentration.

❑Osmotic pressure can effect the RBC’s leading to

rupture of cells thus causing hemolysis.

❑ Tourniquet should be released before collection of

Venous Gas / Lactate sample. (Heparin Syringe)

7. Mixing

■ Invert all the tubes at least 8-10

times for a final mixing after the

collection is complete.❑ Improper mixing allows microclots in the whole

blood &/or fibrin to form in the serum. This will causes erroneous results and analyzer issues.

❑ Not mixing blood tubes with additives may

cause excessive concentrations of these

additives leading to rupture of the RBC

membrane and can affect the function of the

additive.

❑ Vigorous mixing may cause RBC’s to rupture.

8. Removing the Needle

Safely■ As soon as the needle is removed from the

patient, the safety device should be activated.

■ Discard all sharps into approved sharps

container.

■ Press a fresh cotton ball to the site to stop the

bleeding minimum 2 minutes.

■ Before applying the bandage, check to make

sure that the bleeding has stopped. Bleeding

that lasts longer than 5 minutes needs to be

brought to the attention of a physician.

Labeling Technique and Required

Information■ Patient name next to the lid.

Label so blood is visible, and the lab can see blood volume, hemolysis, etc.

■ Do not wrap label so blood volume is hidden.

■ Do not wrap label around the tube like a flag or double wrap

■ Do not apply the label with the tube lid on the right side.

■ Do not place label on lid of histology or microbiology specimen containers.

Signing Labels

■ To minimize error, all specimens must be labeled at the patient’s bedside.

Labels must include:

■ The patient's first and last name

■ The patient's ID number

■ The specimen ID

■ The phlebotomist's mnemonic

(ex. RNDOEJAN1)

■ Any important comments (ex. Drawn from

PICC, IV Arm, etc)

■ The date and time of collection

RATIONALE:

■ Providing correct information improves patient care, tracking and turn around time. When done properly there will be no need to call and get information causing delay in processing.

REMEMBER Only use a smudge proof pen

when filling out your collection labels and

Ident-A-Blood Band for Blood Bank !!!

(Ident-A-Pens can be ordered from stores)

Specimen Transport

■ Confirm all specimens are secured tightly (ex. histology, urine specimens) to avoid spills and leaks, and possible loss of specimen.

Do Not put Urinalysis and Urine Culture samples in same bag

■ Confirm all specimens are labeled on the tube or container. (never on lid)

■ Confirm date/time of collection and name of person is documented.

■ Place specimens into the main opening of a bio-hazard bag.

■ Place header labels/requisitions in the pouch of the biohazard bag.

■ Specimen(s) are sent to lab via porter or pneumatic tube.

■ Laboratory should be notified when STAT’s or time sensitive tests are being dropped off or sent.

Specimen Rejection Criteria

■ Wrong Patient **HIGHEST PRIORITY**■ Unlabeled specimens

■ Mislabeled specimens

■ Wrong container

■ Hemolysis (hemolysis can not be detected before centrifugation)

■ Insufficient blood volume (NSQ)

■ Incorrect blood volume/anticoagulant (ex. half filled coagulation vacutainer)

■ Clotted specimens.

■ No T# on a Blood Bank collection.

■ Leaking specimens

In BG core lab, ≤100 samples are rejected monthly for any of the above reasons.

(The above do not apply to irretrievable samples ex: histology)

What is Hemolysis?

■ The rupturing of RBCs allowing the cells contents to spill into the serum/plasma. ❑ Can cause false results ex: lactate

and potassium

❑ Can interfere with the test itself

■ Hemolytic specimens are a frequent occurrence and account for 40%–70% of all unsuitable specimens.

QHC Most common specimen

collection error

Causes of InVitro Hemolysis

■ Needle Gauge too small or too large

■ Collecting before antiseptic has had time to

dry

■ Tourniquet left on too long

■ Inaccurate needle placement within the vein

■ Collecting from IV catheter (frothing)

■ Under filling tubes containing additives (LAV)

■ Failing to mix tubes

In Vivo Hemolysis

■ Check the patient’s history.

■ Hemolysis can also be due to;o Chemical agents (medication)

o Physical agents (heart valve)

o Infectious agents (bacteria)

o DIC

o Burns

o Blood Substitutes

o Hemolytic Anemia (sickle cell)

NOTE: If lab receives multiple hemolysed samples in succession patient

care area is called to review patient’s clinical condition

Tips for Capillary Collections

■ Continuous mixing during collection is essential to prevent clotting of sample.❑ Excessive squeezing or pressure while “milking”

the finger or heel can cause hemolysis.

❑ Manual lancets do allow you to control the depth

of incision and can also cause hemolysis.

❑ Do Not Scoop up blood which has smeared or

dribbled away from puncture site since partially

coagulated blood may cause hemolysis and/or

erroneous results.

Remember order of draw is different LAV tube

is always first.

Special Considerations – Blood Culture Collections

2% Chlorohexidine Swipe

Skin Preparation: If dirty clean with soap & water Solu IV swab 2% chlorhexidine without any alcohol Always ensure an aseptic technique during collection is followed. Vigorously scrub the skin over venipuncture site in a circular motion approximately 3 inches in

diameter with a sterile 2% chlorhexidine swab. Then clean over the same area with a sterile 70% isopropyl alcohol wipe and allow to air dry

completely. Continue with blood sample collection as before.

NOTE: When preparing the blood culture bottles for collection after removing the lid clean the tops with 2 separate alcohol wipes.

DO NOT TOUCH THE LIDS AFTER CLEANING

Special Considerations – Blood Culture Collections

Blood Culture Collection Bottle Labeling:

Example: Improper

labelling on blood culture

bottles

Blood culture bottles now have an indication where the sample label should be placed.

Finger indicates where

the sample label should

be placed.Sample label is placed

over the barcode area.

Ensures the bottle

barcode is not hidden.

Special Considerations – Transfusion Medicine

Ident-A-band T# tabs that identify samples and unit/s to the patient Only one Ident-A-band # per patient This Ident-A-band system is required for ALL Type and Screens when there is potential to transfuse: Packed Cells, Frozen Plasma and Platelets

If the patient has an existing Ident-A-band #:

Write the T# on the blank tab, and place on patients labelled tube

Write on only the tab(s) necessary and please remove any marked tabs you are not using

to avoid potential mislabelling.

DO NOT send blank tab sheets to the lab with specimen,

keep on the floor for later use.

Special Considerations – Transfusion Medicine

Histology and Cytology

■ You don’t need to order anything just fill out a requisition and label the specimen.

■ On the requisition you must fill out;❑Name and DOB

❑Health Card #

❑Ordering Physician and Physician Copy To

❑Specimen Collected By

❑Specimen Collection Date

❑Specimen Collection Location

❑Specimen Type

Cytology Specimens

■ Cytology specimens must be sent to the lab

in Cytolyt which is available through SPD.

❑Fluids: Add directly to Cytolyt tube up until volume

reads 50mL.

❑Brushes: Cut brush leaving 3” of wire and place

brush into 15mL of Cytolyt

■ Ensure tubes are labeled with the patient’s

address-o-graph label and that the lid is

secured tightly.

More Lab Tips

■ ALWAYS LABEL tubes at the bedside!!■ Drug Monitoring : Be aware of dosage times. Some drug

levels require testing at specific times.■ Mix samples well during and after collection. Never

remove a clot from any tube.■ Draw a sample for every label. Send all labels to the lab

with the specimens.■ When ordering any tests for Public Health (XM#), please

fill out appropriate forms■ T# sticker must be on all Blood Bank tubes for Type and

Screen(s) and/or Crossmatch■ Attach patient header label to Ident-A-Blood Identification

card (T# sheet)

■ Call the lab (x 2396)

❑ When unsure of the test to order or unable to find it in

Meditech.

❑ When labels do not print. Do not reorder multiple times.

❑ We do not have secretarial staff to answer phones,

therefore please be patient if the phone is not answered

right away.

■ Use “myQHC INTRANET” > Departments &

Programs > Laboratory Services

■ If you would like additional practice with phlebotomy,

call Kim Stephenson ext. 2237

More Lab Tips