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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
2
Tracking at Mayo Clinic Rochester1983-1996
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
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
Decline from 1.5 Exposures/10,000 to0.2 Exposures/10,000
Decline from 1.5 Exposures/10,000 to0.2 Exposures/10,000
CP1154634-28
1983198319841984198519851986198619871987198819881989198919901990199119911992199219931993199419941995199519961996
Tracking at Mayo Clinic Rochester1983-1996
Tracking at Mayo Clinic Rochester1983-1996
Frequency Rate per 10,000 puncturesFrequency Rate per 10,000 puncturesCP1154634-29
3
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
4
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
5
• 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
6
Phlebotomy Supplies:Evacuated / Syringe / Winged Infusion
Phlebotomy Supplies: Skin Preparations
• 70% Isopropyl Alcohol
• Tincture of Iodine
Phlebotomy Supplies: Gauze and Pad & Gauze Roll
7
Phlebotomy Supplies:Capillary Collection Devices
Capillary Collection
Phlebotomy Supplies: Needle Gauge*
* Determined by the size & condition of the vein
8
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
9
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
10
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
11
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)
12
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
13
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
14
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
16
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
17
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
18
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
• Patient Identification
• Tourniquet application
• Site selection & cleansing
• Phlebotomy collection
• Removal of the tourniquet
• Remove needle and apply pressure
• Wrap and secure site
• Dispense blood
• Label tubes
The Venipuncture Process:Syringe Method
• Patient Identification
• Tourniquet application
• Site selection & cleansing
• Phlebotomy collection
• Removal of the tourniquet
• Remove needle and apply pressure
• Wrap and secure site
• Dispense blood
• Label tubes
19
The Venipuncture Process: Winged Infusion /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
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.