Dec 2017 1

Up to 85% of decisions about diagnosis and treatment

are based on laboratory results.

NOTE: The information contained in this booklet is aimed to give a better understanding of the need for quality

specimen collection.

A good quality patient specimen ensures accurate laboratory test results and supports quality patient

care.

QHC Laboratory Medicine

Pre-Analytical Specimen Collection

Dec 2017 2

QHC LABORATORY SERVICES

Point of Care Charge Technologist: Contact: Kelly Richmond ext. 2404

Prince Edward – Point of Care testing on site

Contact: Julie Craig ext. 4506

Trenton Memorial – Point of Care testing on site

Contact: Nancy Osborne ext. 5425

North Hastings – Point of Care testing on site

Contact: Julie Craig ext. 4506

Courier Deliveries:

1 Courier run per day Monday – Friday

1 Courier run on weekends

Taxi runs as required

North Hastings: 2 courier runs per day on weekdays and 1 courier run on weekends.

Dec 2017 3

Laboratory Department Contacts

Laboratory

E2 (above Emerg)

Microbiology

x2599

Operates daily 7 a.m. to 5 p.m.

Histology

x2370

Operates Monday to Friday

7 a.m. to 4 p.m.

Core Lab

Ext 2396

Full Service Lab

Operates 24 hours/day

Blood bank

x2363

Hematology

x2362

Chemistry

x2316

Dec 2017 4

Belleville Laboratory Departments

Full Service Core Lab:

Blood Bank:

test samples for transfusion and issue blood

products

Hematology:

test samples for CBC and morphology review,

as well as coagulation studies

Chemistry:

all chemistry tests including drug screens,

blood gases, urinalysis, pregnancy tests, etc.

Microbiology:

interprets urines, stools, swabs etc for

bacterial, fungal or viral infections

responsible for public health specimens

Histopathology:

prepares tissues to aid in patient diagnosis

Dec 2017 5

Order Entry

Dec 2017 6

Entering orders into the LIS system (OE, EDOC, and EDIS) will generate

labels.

Always Remember Labels do not print in the correct order of draw, labels

print as to how tests were ordered in MediTech!

• Labels provide all the information required. – Type(s) of vacutainer(s) to collect – Patient information (DOB, Unique Identifier, and

patient location) – All barcode labels that print must be collected. – Barcodes have specimen numbers on them that

correlate with the tests ordered. Some are tested on site, some are sent out for testing. ex.

• 2311:H4 LAV3 • 2311:H5 BLUE r Hematology (Coagulation) • 2311:C3 SST (gold)/RST (orange) • 2311:U7 14mL Red Top sterile container

Urinalysis • • 2311:BB3 LAV7 • 2311:SO2 SST (gold) • 2311:M3516 SST (gold) • 2311:XM4516 SST (gold)

Dec 2017 7

Before performing the venipuncture, gather all the supplies needed including labels and bring to bedside. Place the required tubes in the correct order of draw Standard Needle Gauges: 21g (green cap straight needle) – most common and needle of choice 21g (green butterfly) 22g (black cap straight needle)

23g (light blue butterfly) and 25g (dark blue butterfly)

Prepare Supplies

Dec 2017 8

The Patient

Dec 2017 9

**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

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.

Always use two patient identifiers when identifying your patient. Patient First and Last Name Patient Health Card Number Patient Unique Hospital Number

(ANY OF THE ABOVE TWO INDENTIFERS)

Dec 2017 10

Specimen Collection

Wash Hands or use Alcohol based hand rub.

Wear gloves

Position the patient

Tie tourniquet

Venipuncture site selection

Clean the site Needle Insertion: 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.

�(Do Not “thread” the needle in the vein)

Insert the first tube into the tube holder.

NOTE: Butterfly Collections: 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. Use a discard tube. To avoid carryover, a discard tube must be an additive tube matching your first draw tube if specific discard tubes are not available

(100257) Discard Vacutainer

TUBE VAC HEMO 13x100 6ml NO ADDTIVES

Dec 2017 11

Specimen Collection Cont’d

Coagulation orders must always collect a discard.

Once the flow of blood begins, the tourniquet should be released, no longer than 2 min of being on the patients arm.

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

Note: If you are not able to draw an adequate volume of blood on the second attempt, you should stop the procedure and have another staff attempt collection, if unsuccessful then notify your supervisor.

Tubes must also be thoroughly mixed. Improper mixing allows micro clots in the whole blood &/or fibrin to form in the serum; which causes erroneous results and analyzer issues. Vacutainers must be mixed at least 8 to 10 times.

Dec 2017 12

Safety As soon as the needle is removed from the patient, the safety device should be activated. Discard all sharps into approved sharps container. Before applying the bandage, check to make sure that the bleeding has stopped. Bleeding that last longer than five minutes needs to be brought to the attention of a doctor or nurse.

Dec 2017 13

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 and microbiology

specimen containers.

Labeling technique and required information

Dec 2017 14

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)

Labeling Tubes

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 phlebotomist's mnemonic (ex. RNSMIJOA1), include RN, RPN, GN, SN,

etc) **The date and time of collection **Any relevant patient information regarding

collection (eg. PICC, IV Arm)

**NOTE: specimen samples missing key or illegible

information will be *returned to patient care area to be completed correctly or a call made to request correct information.

Laboratory staff will call and let the patient care area know that the specimen has been sent back.

RATIONALE: Providing correct information improves patient care, tracking and turnaround time. No need to call and get information causing delay in processing.

Dec 2017 15

Transportation

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

Confirm all specimens are labeled. (never on lid)

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

Place specimens into a bio-hazard bag for transportation to the laboratory.

Multiple urine specimens should be separated into individual bio-hazard bags to eliminate leaking specimens.

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

Send all extra barcode labels.

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.

Remove and discard gloves.

Wash hands or use alcohol based hand rub.

Dec 2017 16

BLUE. Sodium Citrate. Plasma

Blood Cultures: Blood cultures are collected from patients with suspected sepsis or bacteremia. Virtually any organism may cause bacteremia. An order for blood cultures includes TWO SETS of blood culture bottles. Due to the large neck of the blood culture bottles a butterfly needle is required for this type of blood collection. Adults = one green bottle (aerobic) and one orange bottle (anaerobic) constitutes a set. Collect Aerobic: Green first, then Anaerobic: Orange second (GO)

Behind the Scenes (Laboratory)

All vacutainers have a specific job Proper collection techniques and labeling ensures a good sample for the laboratory

to process.

Dec 2017 17

Paediatric = one yellow aerobic bottle constitute a set. For infants, a single aerobic Paed’s blood culture (Yellow) bottle is required. Each SET of blood cultures must be from separate venipuncture collections. Ideally 2 different sites, 1 set from each arm IF two separate venipuncture sites cannot be used, draw the second set from same arm waiting a minimum of 5 minutes. Under filling blood culture bottles decreases the possibility of bacterial recovery. Volume in each blood culture bottle Adult = 5 to10 mls Paediatric = 2-4 mls 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. After, cleanse the tops of each bottle after caps have been removed TWICE with two alcohol preps. ifugation time.

Dec 2017 18

Plasma is usr Coagion studies.

NOTE: Prior to ALL blue top tubes a discard tube must be

taken 6mL Non-Additive Sodium Citrate (BLUE) * No clotting required. 7 minute centrifugation time. * Plasma is used for Coagulation studies. * Must be a full draw to avoid anti- coagulated/blood ratio incompatibilities. (actual small amount of anticoagulant in the tube 0.3 mL.)

ifugation time.

Dec 2017 19

RST (orange): requires 5 minute clotting time from time of collection & 10 min Centrifugation time Improves turnaround time for STAT testing (cost good for critical care areas. i.e. Emerg and ICU)

SST (gold): requires ½ hour 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.

LAV3: EDTA Whole Blood. No clotting or centrifuging required. Used for CBC and ESR

LAV7: EDTA Plasma No clotting. Centrifuge for 7 mins. Used for Type & Screen and crossmatches. Must have both patient identification and T#

SST

RST

Dec 2017 20

ABG Syringe:

.

SENDING SWABS IN THE PNEUMATIC TUBE SYSTEM Please orientate the swab in the carrier as shown when sending swab specimens to Microbiology through the pneumatic tube system.

The bottom of the swab (media) should be pointed up in the direction the carrier is travelling. Otherwise, even if the cap of the swab is tight, the material within may be pulled out by the vacuum. Staff and the pneumatic tube system could be unnecessarily exposed to a biohazard

Bottoms Up

Cap End

Venous blood gas/lactate collection Follow order of draw, collect last A butterfly is required for this type of collection. Mix thoroughly after collection to mix heparin Gently remove any air within the syringe Place on a slurry of ice in outer pocket of a bio-hazard bag and deliver to lab, to be analyzed within 30 minutes. DO NOT PUT SAMPLES DIRECTLY IN ICE SLURRY.

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

Dec 2017 21

Histology and Cytology

You do not need to order anything for these specimens. Simply fill out the requisition and label the specimen.

On the requisition include the following information

◦ Name and DOB

◦ Health card number

◦ Ordering physician and physician to copy to

◦ Specimen collected by

◦ Specimen collection date

◦ Specimen collection time

◦ Specimen type

Dec 2017 22

LAB TIPS

ALWAYS LABEL tubes at the bedside!!

Drug Monitoring:

Be aware of dosage times. Some drug levels require testing at specific times.

Blood Gas/Lactates:

Must be delivered to the lab in the outer pocket of an ice slurry to be analyzed within 30 minutes

Tourniquet should be released before collection of Blood Gas/Lactate sample

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. Never cut off a Blood Bank Identification Band armband unless

armband becomes illegible, then contact Blood Bank.

Affix patient header label or addressograph label to Blood Bank Ident-A-Blood Identification card (T# sheet)

When ordering any tests for Public Health (XM#), please fill out appropriate form.

Use “myQHC INTRANET” > Departments & Programs > Laboratory Services > Specimen Procurement Manual.

If you would like additional practice with phlebotomy, call Gina

Hendrick ext 2558.

Dec 2017 23

Order of Draw for Regular Venipuncture

NOTE: No discard required if order of draw includes Blood Cultures. IF Blood Cultures are not being drawn and a blue top is required you MUST collect a non additive discard tube prior.

** HEPARIN Blood Gas/Lactate Syringe to be COLLECTED LAST

Dec 2017 24

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 to ensure adequate volume and accurate hematology test results.

Dec 2017 25

Rejected specimens (Exceptions: irretrievable specimens)

Wrong Patient **HIGHEST PRIORITY** Unlabeled specimens Mislabeled specimens Wrong container Hemolysis (hemolysis cannot 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

Dec 2017 26

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Dec 2017 28

Hemolysis:

In vitro hemolysis: DEFINITION

- Visually, hemolysis is defined as free hemoglobin

concentration > 30 - 50 mg/dL, conferring detectable pink/red

hue to serum or plasma.

In vitro hemolysis: CAUSES

- In vitro hemolysis can occur beginning at the patient’s bedside

and continue through sample handling, processing and storage.

- Factors vary depending upon the patient’s condition (fragile

veins), the skill of the person collecting the sample (training),

and the local environment (temperature, length of transport).

In vitro hemolysis: ROOT CAUSES

Dec 2017 29

Hemolytic specimens are a frequent occurrence in

laboratory practice.

- The prevalence is described as being as high as 3.3% of all

routine samples afferent to a clinical laboratory.

- They account for 40%–70% of all unsuitable specimens.

- They are the primary cause of unsuitable specimens, nearly

five times the rate of the second.

- In vitro hemolysis remains the leading cause of unsuitable

specimens for both outpatient and inpatient samples, for

routine and stat specimens.

1In vitro hemolysis: PREVALENCE (Routine)

The total number of hemolysed specimens recorded was 8440

(5.6%)

Reference: In Vitro Hemolysis: Causes, Prevalence, Effects, Measurements & Solutions. Euromedlab 2009 Innsbruck, ISW # 20.

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NOTES:

Thank You

References: QHC Nursing Resource Manual – Blood and blood Products

Administration

QHC Specimen Procurement Manual (On Infonet)

Clinical and Laboratory Standards Institute Manuals