BLOOD COLLECTION **
The safety of both the patient and the phlebotomist must be considered during the process of blood collection. The objective is to obtain the best possible sample for the test to be performed. Only trained certified and licensed personnel working under the direction of a qualified, licensed physician may procure blood. The phlebotomist must adhere to the policies set forth by the facility, because those policies were developed to protect both the patient and the phlebotomist.
SPECIMEN
The laboratory staff is permitted to collect blood from two sources only: capillary (peripheral) and venous blood. Arterial blood may be used in certain testing situations, but such blood must be collected only by physicians or by staff with documented training in the collection of arterial blood specimens. The laboratory staff should not withdraw blood from a Hickman catheter (or other central line), as this requires the introduction of drugs, saline, or heparin; this procedure can only be performed by licensed personnel such as physicians or registered nurses. The phlebotomist must be suitably familiar with the laboratory tests so that the proper amount of blood is collected, is placed in the correct test tubes, and is processed according to the protocol of the specific test methodology.
REAGENTS AND MATERIALS
70% isopropyl alcohol (pre-packaged alcohol wipes)
Gauze sponges or cotton balls
Assorted needles, sterile, single use: 18-23 gauge, 3/4″ to 1/2” length
Multi-draw needles for use with evacuated collection tubes
Or Hypodermic for use with a syringe
Or Butterfly tubing for use with a syringe and/ or evacuated tubes
Or Lancets, sterile, single use for collection of capillary blood
Multi-draw needle holder
Disposable gloves
Disposable (one time use) tourniquets
Sharps disposal container for contaminated needles, lancets, syringes, test tubes
Appropriate selection of evacuated collection tubes for blood processing
Adhesive bandages
Soap, water, paper towels or antimicrobial foams or gels for hand cleansing
Procedure:
(Universal Precautions must be maintained at all times: See Exposure Control Plan for Blood-Borne Pathogens)
It is imperative that the patient, whether sitting or reclining, be made as comfortable as possible. Psychological comfort may also be required, so take time to explain the procedure to the patient.
Always wear gloves, throughout the entire procedure, when obtaining blood specimens.
VENOUS COLLECTION
Securely fasten a tourniquet around the patient’s arm, just above the elbow. Instruct the patient to keep his arm as straight as possible and to make a fist (if possible). Gently palpate the antecubital area in search of a suitable vein. It may be necessary to examine the other arm, wrists, or hands.
When a vein has been located, thoroughly cleanse the site with disinfectant. Allow to dry.
Assemble the vacuum collection set of syringe and needle. Remove the needle cap or sheath.
Grasp the patient’s arm (or hand) with your free hand to hold the skin and underlying tissue taut.
Insert the needle into the vein by using a quick, deliberate motion. Begin to withdraw the blood by (a.) inserting the vacuum tube(s) onto the sheathed end of the multi-draw needle, or by pulling back on the syringe plunger. If blood does not return, it may be necessary to make small adjustments to the position of the needle to penetrate the vein.
NOTE: Do not or try to make large adjustments; this action will only cause discomfort to the patient and may even bruise the area. If you are unsuccessful in obtaining a good blood flow, retract the needle, and apply a gauze sponge or cotton ball to the area with pressure until bleeding stops. It may be necessary to select a second area to try again. If after two tries, you are unsuccessful, ask a co-worker to make an attempt.
When sufficient blood has been withdrawn, release the tourniquet. Place the clean gauze sponge or cotton ball over the puncture site. Simultaneously withdraw the needle while using the sponge to apply pressure to the site.
Instruct the patient to apply pressure to the puncture site with the other hand. If the patient is unable, you should continue to apply pressure to the site until bleeding has stopped.
Failure to apply adequate pressure can result in a hematoma, or bruise, to the draw site.
Tourniquets are discarded immediately after use.
Order of Draw:
If you are using a Multi—draw needle for multiple tube collections, insert the tubes into the needle holder in this order:
Blood Culture (or “Sterile tubes”)
Citrate tube (light blue top)
Serum tube (“red top”), or Gel separator (brown “tiger top”)
Heparin tube (“green top”) or Gel separator with Heparin (green “tiger top”)
EDTA tube (“purple or lavender top”)
Fluoride tube (“gray top”)
If using a syringe, dispense blood into appropriate tubes as soon as possible after drawing, by inserting the needle through each tube’s stopper.
Take care not to stick yourself.
After blood has been dispensed into the tubes dispose of the needle apparatus into appropriate Sharps biohazard waste containers.
All tubes except plain “red top” tubes must be mixed immediately by gently inverting 8 to IO times. ALL tubes must be properly labeled immediately AFTER filling them. Take care that you have matched the specimens to the correct patient and label them:
Patient’s first and last names
Patient’s secondary identifier (Patient ID or medical record number)
Date and time of collection
Initials of phlebotomist
When the puncture site has stopped bleeding, apply an adhesive bandage, gauze or other suitable material.
Clean any blood spills with disinfectant. Remove and discard gloves. Thoroughly wash your hands with soap and water, or use an appropriate antimicrobial foam or gel for hand cleansing.
Precautions:
1. Place extra evacuated collection tubes for the procedure in a convenient place near the draw area. If the tube you are using has lost vacuum, a fresh tube may be inserted in the holder and onto the needle.
2. Use a flat rubber tourniquet rather than round tubing. Round tubing bites into the skin and causes the patient discomfort.
3. Make certain evacuated collection tube stoppers are not loosened or punctured before use. Partial or complete vacuum loss will result. If this occurs, immediately discard tube.
4. Evacuated collection tubes containing anticoagulant should be filled to capacity. It is important the blood to anticoagulant ratio be correct to avoid a greater than allowable dilution of the blood.
ANTICOAGULANTS
Most anticoagulants prevent blood clotting by removing ionic calcium from the blood with the formation of a unionized calcium salt. Heparin prevents coagulation by removing one of the clotting factors – thrombin. The anticoagulant effect of Heparin lasts approximately 24 hours.
Most chemical analyses are performed on serum. To obtain serum, the blood is allowed to clot in the absence of anticoagulant.
In the analysis of carbon dioxide or glucose, special precautions are necessary to achieve value results. The carbon dioxide determination requires that the blood remain in an anaerobic state until analysis. An anaerobic state is obtained by never allowing the blood to be exposed to air by not opening the tube until immediately before testing. Glucose is vulnerable to enzyme action resulting in a marked decerase of glucose, a process called glycolysis. Because the enzymes that cause glycolysis are in the red blood cells, separation of the red cells from the plasma or serum will reduce glycolysis. These enzymes can be inhibited by using sodium fluoride as the anti-coagulant.
Serum or plasma may be stored at room temperature, under refrigeration, or in the freezer, depending on the determination to be run. With few exceptions, the lower the temperature, the greater the stability of the constituents.
Plasma is blood minus the cellular elements (white and red blood cells and platelets); serum is plasma that has been allowed to clot; most of the coagulation factors have been activated to form the fibrin clot.
NOTES
1. lf venipuncture is not successful, another site should be chosen. Under normal circumstances, if blood cannot be obtained after two attempts, capillary collection should be considered or another staff member should attempt venipuncture.
2. Never recap needles except for special procedures, such as for blood gas collection. Refer to your facility Safety Manual for further information on the recapping of needles.
3. Use a new collection set for each attempt at venipuncture (or capillary puncture). The skin is to be cleansed with alcohol again, even if the puncture is in the same area as the first attempt. Never re-use a needle or lancet.
4. Wash your hands before touching the patient and after each collection procedure.
5. Syncope, or lightheadedness, is a common complication of blood collection. If the patient states that this often happens adjust the phlebotomy chair to have him/her in a semi-supine position before the procedure. If a patient becomes lightheaded or dizzy, or begins to faint, terminate the procedure immediately and adjust the phlebotomy chair to the full supine position. Call for assistance before moving the patient; never let the patient leave without fully recovering.
6. If any injuries occur, such as accidental needle sticks to staff or patient, or patient falls, always fill out an Incident Report and give it to the appropriate person for follow-up.
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ROUTINE CAPILLARY PUNCTURE BLOOD COLLECTION GUIDELINES
CAPILLARY PUNCTURE
Capillary puncture may be used for obtaining specimens in infants or in adults where
venipuncture is difficult.
Specimens from infants under the age of 6 months are typically collected by heelstick.
Patients over the age of 6 months should have capillary specimens collected by
fingerstick.
Capillary specimens are collected in microtainers with colored caps that are used to
indentify the microtainers additive.
NOTE
Capillary punctures are not suitable for blood culture testing and most coagulation tests.
Capillary Specimens may be collected on filter paper and sent to lab for testing for
specific tests only. Refer to online test directory for each tests collection requirements.
Capillary Specimens may be used immediately for point-of-care testing.
MATERIALS
1. Lancets
2. Microtainer Blood Collection Tubes.
Tubes with different additives are used for collecting blood specimens for specific types
of tests.
3. Recommended order of collection for microtainer specimens:
Lavender EDTA microtainers
Green –Lithium Heparin
Mint green-Lithium heparin PST
Grey
Gold –SST
Red-No additive
4. Filter paper ( if required)
5. Gloves-latex free
6. Warming device
7. Antiseptic. Individually packaged 70% isopropyl alcohol wipes.
8. 2×2 Gauze
9. Sharps Disposal Container. An OSHA acceptable, puncture proof container marked
“Biohazardous”.
10. Bandages or tape
SAFETY
1. Observe universal (standard) safety precautions. Observe all applicable isolation
procedures.
2. PPE’s will be worn at all time.
3. Wash hands in warm, running water with an appropriate hand washing product, or if not
visibly contaminated, with a commercial foaming hand wash product before and after
each patient collection.
4. Gloves are to be worn during all blood collection procedures, and changed between
patient collections.
5. A lab coat or gown must be worn during blood collection procedures.
6. Lancets are disposed of in an appropriate ‘sharps’ container as one unit.
7. Gloves are to be discarded in the appropriate container immediately after the blood
collection procedure.
8. All other items used for the procedure must be disposed of according to proper
biohazardous waste disposal policy.
9. Contaminated surfaces must be cleaned with freshly prepared 10% bleach solution. All
surfaces are cleaned daily with bleach.
10. In the case of an accidental stick, immediately wash the area with an antibacterial soap,
express blood from the wound, and contact your supervisor.
PROCEDURE
1. Identify the patient. Two forms of active identification are required. Ask the patient or
caregiver to state the patient’s name and date of birth. This information must match the
requisition.
2. Reassure the patient that the minimum amount of blood required for testing will be drawn.
3. Select the appropriate microtainers for the specimens to be collected. Any microtainers
containing additives should be tapped to dislodge additives from the walls and top.
4. Wash hands and put on gloves.
5. Position the patient with the arm extended to form a straight-line form shoulder to wrist.
6. Do not attempt a capillary puncture more than twice. Notify your supervisor or patient’s
physician if unsuccessful.
HEEL STICK
1. Position the infant with the head slightly elevated.
2. Warm the heel from which blood is to be obtained. A commercial heel warmer may be used.
3. Cleanse the heel with alcohol prep, then dry with a sterile 2×2 as alcohol can influence test
results.
4. Using a sterile lancet, puncture the most medial or lateral portion of the plantar surface of the
heel, medial to a line drawn posteriorly from the mid great toe to the heel.
Heel Stick Example
5. Puncture no deeper than 2.4mm (approximately 0.1 inches).
6. Punctures to the posterior curvature of the heel cab cause damage to the bones.
7. Previous puncture sites should be avoided. Avoid bruising the infant’s heel when obtaining
blood.
8. Wipe away the first drop of blood with sterile 2×2 gauze.
9. Allow another large drop of blood to form. Lightly touch the microtainer capillary collection
device (or filter paper) to the LARGE drop of blood. Collect drops of blood into the collection
device by gently massaging the heel. Avoid excessive pressure that may squeeze tissue fluid
into the drop of blood. Fill the microtainer tube(s) as needed, adhering to the order of draw.
10. Cap, rotate and invert the microtainer to mix the blood collected.
11. When finished, clean the site and apply pressure with clean gauze to stop the bleeding. Apply an adhesive bandage.
12. Label all specimens per accepted guidelines.
13. Place labeled specimens in zip lock bag and deliver to the laboratory as soon as possible.
FINGER STICK
1. Position the patient so that the hand is easily accessible.
2. Cleanse the fingertip of the 3rd (middle) or 4th (ring) finger with an alcohol prep. Allow the
finger to dry or wipe dry with a sterile 2×2 gauze.
3. Using a sterile lancet, puncture the fingertip in the fleshy part of the finger, slightly to the side
of the center and across (perpendicular to) the grooves of the fingertip. This enables the blood
to form as a drop on the fingertip. If the puncture is parallel to the lines of the fingerprint, the
blood will not form as a drop but will run down the finger making collection difficult.
4. Wipe away the first drop of blood with a sterile 2×2 gauze.
5. Allow another large drop of blood to form. Lightly touch the microtainer capillary collection
device (or filter paper) to the LARGE drop of blood. Collect drops of blood into the collection
device by gently massaging the finger. Avoid excessive pressure that may squeeze tissue fluid
into the drop of blood. Fill the microtainer tube(s) as needed.
6. Cap, rotate and invert the microtainer to mix the blood collected.
7. When finished, clean the site and apply pressure with a clean gauze to stop the bleeding. Apply
an adhesive bandage.
8. Label all specimens per accepted guidelines.
9. Place labeled specimens in zip lock bag and deliver to the laboratory as soon as possible.
FILTER PAPER SPECIMEN COLLECTION
1. Allow the blood to soak through and completely fill the pre-printed circle on the filter paper.
2. Filter paper should touch only the blood and not the heel or finger.
3. Apply only ONE drop of blood per circle. Do not add blood to a circle already filled or
partially filled with blood.
4. Apply blood to the printed side of the filter paper.
5. Make certain that the blood completely saturates all four (4) circles and is visible from both
sides.
6. If the blood flow is diminished, repeat the capillary PUNCTURE to complete the collection.
7. Allow filter paper to air dry for two (2) hours at room temperature. Avoid placing sample on
hot surfaces such as bili-lights or monitors.
8. Forward completed/dry collections to the laboratory as soon as possible.
Capillary blood sampling is becoming a common way to minimize the amount of blood drawn from a patient. The 10 or 20 microliters can be used to look for anemia, check blood sugar or even to evaluate thyroid function. The procedure is easier and less painful than traditional venipuncture which draws blood from a vein.
In order to collect blood with a capillary tube, the appropriate site must be cleaned and punctured with a lancet so that a drop of blood can be gently expressed.
But what is an appropriate site?
take a capillary blood sample from the fingerFinger – Usually the third or fourth finger is preferred in adults and children. The thumb has a pulse and is likely to bleed excessively. The index finger can be calloused or sensitive and the little finger does not have enough tissue to prevent hitting the bone with the lancet. The puncture is done to the left or right of the midline of the palmar surface of the fingertip, staying away from the fingernail.
take a capillary blood sample from baby heelHeel – This site is used for infants, less than one year old, whose fingers are too tiny. The puncture is done on the farthest lateral or medial aspect of the plantar surface of the heel, not on the bottom. Punctures done on the plantar surface can damage cartilage or bone.
take a capillary blood sample from ear lobeEar lobe – The ear lobe has been used for capillary blood sampling, but is no longer recommended. Studies have shown that the blood flow in the ear lobe is less than that in either the finger tip or the heel. The ear lobe can still be used if no other site is available.
take a capillary blood sample from big toeGreat toe – The big toe can be used if necessary in infants who are not yet walking. Callous formation after a child starts walking can interfere with blood collection and is a contraindication. The site should be lateral to the midline of the plantar surface of the toe. Only the great toe has the amount of tissue necessary to protect the bone from injury.
Take a capillary blood sample from PalmPalm – There are two areas on the palm that can be used if necessary. Especially in diabetics who test their own blood sugars frequently, alternate sites give some relief from reusing the same sites over and over. The thenar and hypothenar eminences have capillary circulation equivalent to the f
