Do You Draw Below Or Above An Iv Insertion?

This chapter covers all the steps recommended for safe phlebotomy and reiterates the accepted principles for blood drawing and claret collection (31). The affiliate includes background information (Section two.ane), practical guidance (Section 2.2) and illustrations (Section 2.3) relevant to best practices in phlebotomy.

The information given in this department underpins that given in the residuum of Part 2 for specific situations. Chapter iv also provides data relevant to the procedure for drawing blood given below in Section 2.2, only focuses on blood collection from donors.

Institutions can use these guidelines to establish standard operating procedures. Such procedures should clearly state the risks to patients and wellness workers, as well as the means to reduce those risks – discussed below in Sections 2.one.4 and 2.2.

2.1. Groundwork information on best practices in phlebotomy

Best practices in phlebotomy involve the following factors:

planning ahead;
using an appropriate location;
standards for quality care for patients and wellness workers, including

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availability of appropriate supplies and protective equipment;

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availability of postal service-exposure prophylaxis (PEP);

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avoidance of contaminated phlebotomy equipment;

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appropriate training in phlebotomy;

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cooperation on the office of patients;
quality of laboratory sampling.

2.1.i. Planning ahead

This is the most important part of conveying out any procedure, and is normally done at the start of a phlebotomy session.

2.1.2. Using an appropriate location

The phlebotomist should piece of work in a quiet, clean, well-lit area, whether working with outpatients or inpatients.

2.1.3. Quality command

Quality assurance is an essential part of all-time practice in infection prevention and control (1). In phlebotomy, it helps to minimize the chance of a mishap. Table 2.ane lists the master components of quality assurance, and explains why they are of import.

Table two.1

Elements of quality assurance in phlebotomy.

2.one.iv. Quality treat patients and health workers

Several factors can improve rubber standards and quality of care for both patients and wellness workers, and laboratory tests. These factors, discussed below, include:

Availability of appropriate supplies and protective equipment

Procurement of supplies is the straight responsibility of the administrative (management) structures responsible for setting up phlebotomy services. Management should:

provide paw-hygiene materials (lather and water or alcohol rub), well-fitting non-sterile gloves, unmarried-use dispensable needles, and syringes or lancing devices in sufficient numbers to ensure that each patient has a sterile needle and syringe or equivalent for each blood sampling;
make available sufficient laboratory sample tubes to prevent dangerous practices (e.chiliad. decanting blood to recycle laboratory tubes).

Several prophylactic-engineered devices are available on the market; such devices reduce exposure to blood and injuries. However, the apply of such devices should be accompanied by other infection prevention and control practices, and training in their use. Non all safety devices are applicable to phlebotomy. Before selecting a rubber-engineered device, users should thoroughly investigate available devices to determine their appropriate use, compatibility with existing phlebotomy practices, and efficacy in protecting staff and patients (12, 33). Annex B provides further information on infection prevention and control, safety equipment and best do; Annex C provides a comprehensive guide to devices available for drawing claret, including condom-engineered equipment.

For settings with low resource, price is a driving gene in procurement of safety-engineered devices.

Where safe-engineered devices are non bachelor, skilled use of a needle and syringe is acceptable.

Availability of post-exposure prophylaxis

Accidental exposure and specific information about an incident should be recorded in a annals.

Support services should be promoted for those who undergo adventitious exposure. PEP tin assist to avert HIV and hepatitis B infections (13, 27). Hepatitis B immunization should be provided to all wellness workers (including cleaners and waste material handlers), either upon entry into health-care services or as office of PEP (34). Annex D has details of PEP for hepatitis B and HIV.

Avoidance of contaminated phlebotomy equipment

Tourniquets are a potential source of methicillin-resistant Staphylococcus aureus (MRSA), with up to 25% of tourniquets contaminated through lack of manus hygiene on the function of the phlebotomist or reuse of contaminated tourniquets (35). In addition, reusable finger-prick devices and related point-of-care testing devices (e.m. glucometers) contaminated with blood accept been implicated in outbreaks of hepatitis B (iv, 5, 36).

To avoid contamination, whatever common-use items, such every bit glucometers, should be visibly clean before use on a patient, and single-use items should not be reused.

Preparation in phlebotomy

All staff should be trained in phlebotomy, to foreclose unnecessary risk of exposure to claret and to reduce adverse events for patients.

Groups of health workers who historically are non formally trained in phlebotomy should exist encouraged to have upwardly such training; lax infection prevention and control practices outcome in poor rubber for staff and risk to patients (20, 37).
The length and depth of grooming will depend on local atmospheric condition; yet, the training should at least comprehend the essentials (come across Addendum E) (38).
Supervision past experienced staff and structured training is necessary for all wellness workers, including physicians, who undertake claret sampling.

Patient cooperation

One of the essential markers of quality of care in phlebotomy is the involvement and cooperation of the patient; this is mutually beneficial to both the health worker and the patient.

Clear information – either written or verbal – should be available to each patient who undergoes phlebotomy. Annex F provides sample text for explaining the claret-sampling process to a patient.

ii.i.5. Quality of laboratory sampling

Factors that influence the upshot of laboratory results during collection and transportation include:

knowledge of staff involved in blood collection;
use of the right judge of hypodermic needle (meet Table 3.1 in Chapter 3) to prevent haemolysis or abnormal results;
the anatomical insertion site for venepuncture;
the use of recommended laboratory drove tubes;
patient–sample matching (i.e. labelling);
transportation weather condition;
interpretation of results for clinical management.

2.2. Practical guidance on all-time practices in phlebotomy

2.2.1. Provision of an appropriate location

In an outpatient department or dispensary, provide a dedicated phlebotomy cubicle containing:

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a clean surface with two chairs (one for the phlebotomist and the other for the patient);

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a mitt wash basin with soap, running h2o and paper towels;

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alcohol hand rub.
In the blood-sampling room for an outpatient section or clinic, provide a comfortable reclining burrow with an arm residue.
In inpatient areas and wards:

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at the patient's bedside, close the bed curtain to offer privacy

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ensure that blood sampling is done in a private and make clean fashion.

2.2.two. Provision of clear instructions

Ensure that the indications for blood sampling are clearly defined, either in a written protocol or in documented instructions (east.g. in a laboratory form).

2.2.3. Procedure for drawing claret

At all times, follow the strategies for infection prevention and command listed in Table 2.2.

Table 2.2

Infection prevention and control practices.

Step 1. Assemble equipment

Collect all the equipment needed for the procedure and place information technology inside safe and easy attain on a tray or trolley, ensuring that all the items are clearly visible. The equipment required includes:

a supply of laboratory sample tubes, which should be stored dry out and upright in a rack; blood tin exist collected in

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sterile glass or plastic tubes with rubber caps (the choice of tube will depend on what is agreed with the laboratory);

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vacuum-extraction blood tubes; or

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drinking glass tubes with screw caps;
a sterile glass or bleeding pack (collapsible) if large quantities of claret are to exist collected;
well-fitting, non-sterile gloves;
an assortment of blood-sampling devices (safety-engineered devices or needles and syringes, see beneath), of different sizes;
a tourniquet;
alcohol hand rub;
gauze or cotton wool-wool ball to exist practical over puncture site;
laboratory specimen labels;
writing equipment;
laboratory forms;
leak-proof transportation numberless and containers;

Ensure that the rack containing the sample tubes is close to you, the health worker, but abroad from the patient, to avert it being accidentally tipped over.

Step 2. Place and fix the patient

Where the patient is adult and conscious, follow the steps outlined below.

Introduce yourself to the patient, and inquire the patient to state their full proper noun.
Check that the laboratory class matches the patient's identity (i.e. match the patient's details with the laboratory course, to ensure accurate identification).
Ask whether the patent has allergies, phobias or has ever fainted during previous injections or blood draws.
If the patient is anxious or afraid, reassure the person and ask what would brand them more than comfy.
Brand the patient comfortable in a supine position (if possible).
Place a clean paper or towel under the patient's arm.
Discuss the test to be performed (see Annex F) and obtain verbal consent. The patient has a right to refuse a test at any fourth dimension before the blood sampling, then it is important to ensure that the patient has understood the process.

For paediatric or neonatal patients, see Chapter 6.

Step 3. Select the site

Full general

Extend the patient's arm and inspect the antecubital fossa or forearm.
Locate a vein of a adept size that is visible, straight and articulate. The diagram in Section 2.3, shows common positions of the vessels, but many variations are possible. The median cubital vein lies between muscles and is usually the nigh easy to puncture. Under the basilic vein runs an artery and a nerve, then puncturing here runs the risk of damaging the nerve or artery and is usually more painful. Do Non insert the needle where veins are diverting, considering this increases the risk of a haematoma.
The vein should be visible without applying the tourniquet. Locating the vein will help in determining the correct size of needle.
Utilise the tourniquet about iv–five finger widths above the venepuncture site and re-examine the vein.

Hospitalized patients

In hospitalized patients, do not take claret from an existing peripheral venous access site because this may give imitation results. Haemolysis, contamination and presence of intravenous fluid and medication can all change the results (39). Nursing staff and physicians may admission cardinal venous lines for specimens following protocols. Nonetheless, specimens from central lines acquit a run a risk of contamination or erroneous laboratory exam results.

It is acceptable, but not ideal, to depict blood specimens when first introducing an in-home venous device, before connecting the cannula to the intravenous fluids.

Pace 4. Perform hand hygiene and put on gloves

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launder hands with soap and h2o, and dry with single-use towels; or

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if hands are not visibly contaminated, clean with booze rub – use 3 ml of alcohol rub on the palm of the hand, and rub it into fingertips, back of hands and all over the hands until dry out.

Step 5. Disinfect the entry site

Unless drawing blood cultures, or prepping for a blood drove, clean the site with a 70% alcohol swab for 30 seconds and let to dry completely (xxx seconds) (forty–42).

Note: booze is preferable to povidone iodine, considering blood contaminated with povidone iodine may falsely increase levels of potassium, phosphorus or uric acid in laboratory test results (6, 7).
Use business firm just gentle pressure. Start from the eye of the venepuncture site and piece of work downward and outwards to cover an area of 2 cm or more.
Allow the area to dry. Failure to permit enough contact time increases the gamble of contagion.
DO NOT impact the cleaned site; in particular, Practice NOT place a finger over the vein to guide the shaft of the exposed needle. Information technology the site is touched, repeat the disinfection.

Step 6. Have blood

Venepuncture

Perform venepuncture as follows.

Anchor the vein by holding the patient's arm and placing a thumb Beneath the venepuncture site.
Ask the patient to class a fist then the veins are more prominent.
Enter the vein swiftly at a thirty degree angle or less, and go on to introduce the needle along the vein at the easiest angle of entry.
In one case sufficient blood has been collected, release the tourniquet BEFORE withdrawing the needle. Some guidelines suggest removing the tourniquet as soon as blood flow is established, and always before it has been in identify for two minutes or more.
Withdraw the needle gently and utilise gentle pressure to the site with a clean gauze or dry cotton wool-wool ball. Enquire the patient to hold the gauze or cotton fiber in place, with the arm extended and raised. Ask the patient NOT to bend the arm, because doing and then causes a haematoma.

Footstep 7. Fill up the laboratory sample tubes

When obtaining multiple tubes of claret, use evacuated tubes with a needle and tube holder. This organisation allows the tubes to be filled directly. If this system is not available, use a syringe or winged needle ready instead.
If a syringe or winged needle gear up is used, all-time practice is to place the tube into a rack before filling the tube. To prevent needle-sticks, use one hand to fill the tube or use a needle shield between the needle and the manus holding the tube.
Pierce the stopper on the tube with the needle directly in a higher place the tube using tedious, steady force per unit area. Do not press the syringe plunger because additional pressure increases the risk of haemolysis.
Where possible, keep the tubes in a rack and move the rack towards you. Inject downwards into the appropriate coloured stopper. Do NOT remove the stopper because information technology will release the vacuum.
If the sample tube does not have a rubber stopper, inject extremely slowly into the tube as minimizing the pressure and velocity used to transfer the specimen reduces the risk of haemolysis. DO NOT epitomize and remove the needle.
Before acceleration, capsize the tubes containing additives for the required number of times (as specified by the local laboratory).

Footstep 8. Describe samples in the right order

Draw blood collection tubes in the correct social club, to avert cross-contamination of additives between tubes. As colour coding and tube additives may vary, verify recommendations with local laboratories. For illustration purposes, Table ii.three shows the revised, simplified recommended lodge of draw for vacuum tubes or syringe and needle, based on United States National Committee Clinical Laboratory Standards consensus in 2003 (43).

Table ii.3

Recommended order of draw for plastic vacuum tubes.

Step 9. Clean contaminated surfaces and complete patient procedure

Discard the used needle and syringe or blood sampling device into a puncture-resistant sharps container.
Check the label and forms for accuracy. The characterization should be clearly written with the information required past the laboratory, which is typically the patient's showtime and last names, file number, date of birth, and the date and time when the claret was taken.
Discard used items into the appropriate category of waste. Items used for phlebotomy that would non release a drib of claret if squeezed (e.yard. gloves) may be discarded in the full general waste, unless local regulations state otherwise.
Recheck the labels on the tubes and the forms before dispatch.
Inform the patient when the procedure is over.
Ask the patient or donor how they are feeling. Check the insertion site to verify that it is not haemorrhage, then thank the patient and say something reassuring and encouraging before the person leaves.

Footstep 10. Prepare samples for transportation

Pack laboratory samples safely in a plastic leak-proof bag with an outside compartment for the laboratory request grade. Placing the requisition on the outside helps avoid contamination.
If there are multiple tubes, place them in a rack or padded holder to avoid breakage during transportation.

Footstep 11. Clean upward spills of blood or body fluids

If blood spillage has occurred (e.thou. considering of a laboratory sample breaking in the phlebotomy surface area or during transportation, or excessive bleeding during the procedure), clean it up. An example of a safe process is given beneath.

Put on gloves and a gown or frock if contagion or bleaching of a uniform is probable in a large spill.
Mop upwardly liquid from large spills using paper towels, and place them into the infectious waste.
Remove as much blood as possible with wet cloths earlier disinfecting.
Assess the surface to see whether it will exist damaged by a bleach and water solution.
For cement, metallic and other surfaces that can tolerate a stronger bleach solution, food the surface area with an approximately 5000 parts per million (ppm) solution of sodium hypochlorite (1:10 dilution of a five.25% chlorine bleach to water). This is the preferred concentration for big spills (44). Leave the surface area wet for ten minutes.
For surfaces that may exist corroded or discoloured past a strong bleach, clean carefully to remove all visible stains. Brand a weaker solution and go out it in contact for a longer period of fourth dimension. For instance, an approximately 525 ppm solution (1:100 dilution of v.25% bleach) is effective.
Prepare bleach solution fresh daily and keep information technology in a closed container because it degrades over time and in contact with the sun.

If a person was exposed to blood through nonintact pare, mucous membranes or a puncture wound, complete an incident report, as described in WHO best practices for injections and related procedures toolkit. For transportation of claret samples outside a hospital, equip the transportation vehicle with a blood spillage kit. Addendum H has further information on dealing with a claret spillage.

2.3. Illustrations for best practices in phlebotomy

Effigy ii.2 Filling tubes