Dr Piyush Tailor

Procedure for receiving request

• Each indoor and outdoor patient of NCHS has unique ID. It must be mentioned on the request form and sample container.
• Erroneous request filling leading to rejection of examination request at Hematology Section of NCHSLS

1. Ask patient to sit comfortably on a chair
2. Ask family member to sit on a chair and hold the child
3. For weak and disabled, use supine position for sample collection
4. Reassure anxious patients.
5. When in doubt as to reaction of a patient to venipuncture, ask for a clinician’s help before venipuncture.
6. Hands must be washed prior to and after all phlebotomy procedures. Use soap and work up a generous lather, scrub vigorously for 10 to 15 seconds, rinse well. A hand sanitizer product can be used.
7. Examine the patient’s arms and obtain information from the patient as to phlebotomy restrictions (i.e., patient’s choice of arms, limitations due to surgeries, nerve damage, mastectomies, etc.)

• In case of BMA, clear explanation of the procedure is given to the patient and written consent is taken. In case of patient’s age is less than 18 years guardian consent is mandatory.
• The procedure is carried out in left/right lateral position on the examination table under strict aseptic precaution

• Each indoor and outdoor patient of NCHS has unique ID.
• It must be mentioned on both the request form and sample container.
  • Following Errors of positive identification may be cause for rejection of examination request

1. Positive identification not mentioned on Sample tube.
2. Positive identification not mentioned on Request Form.
3. Discrepancy in Positive identification between Sample tube and Request Form
4. In selected cases like pediatric samples, irreplaceable sample or if critical, examination is performed, however reports are dispatched only after unambiguous identity of the sample is documented on report.

Blood (Phlebotomy)

• PRINCIPLE:

Laboratory test results are only as good as the specimen, and the specimen is only as good as the method by which it is collected, handled, and processed. The procedures listed below are designed to provide minimum instruction on obtaining a quality blood sample. Consideratio n is placed on comfort to the patient, safety to patient and phlebotomist, and the integrity of the sample.

• MATERIALS:

Venipuncture Tourniquet, Vacutainer safety needles, winged collection (butterfly) safety needles, Syringe, Needle holder, Vacutainer collection tube

Capillary collection Sterile blood lancets, Heel warmer (or moist compress) for heel

General collection supplies

• 70% isopropyl alcohol, denatured spirit, sterile water (for infant collections)
• Gauze squares
• Adhesive bandages – Gauze or paper tape preferred. Should never be applied to patients under two years of age unless the patient is under close observation until the bandage is removed. Small children may choke on bandages.
• Disposable gloves – Proper fit is important for safety. If too small, the gloves may tear. If too large, items may be more easily dropped. Replace gloves immediately when ripped, torn, or contaminated (soiled or wet). Do not wash or disinfect gloves for reuse.
• Needle is discarded in white container and syringe is discarded in red bag.

• PROCEDURES:

Venipuncture

• Receive patient to collection room. The phlebotomist should first check the patient's identity, making sure that it corresponds to the details on the request form, and also ensure that the phlebotomy tray contains all the required specimen containers.
• Person collecting the primary sample should compulsory write own initials on vial or vacutainers with time of collection.
• Select prominent vein mainly in anticubital fossa for blood collection.
• Apply the tourniquet three to four inches above the venipuncture site with enough tension to compress the vein, but not the artery. A blood pressure cuff maintained below diastolic pressure (<40) may be used.
• Palpate or feel for the vein even when it can be seen.
• If a vein is difficult to find, it may become easier to see after massaging the arm from the wrist to elbow which forces blood into the vein. A warm moist towel (warm to the touch but not hot) can also be used. You may need to examine the patient’s other arm if you are having difficulty finding a vein. You may select a dorsal hand or wrist vein and collect with a smaller gauge needle (22g or 23g).
• Hemoconcentration will occur after one minute. If a tourniquet has been applied for longer than 1 minute while you searched for a vein, release it for at least 2 minutes, reapply the tourniquet and relocate the vein.
• Cleanse the area for venipuncture in a circular motion from the center outward with a 70% isopropyl alcohol pad or denatured spirit. Allow to air dry.
• Anchor the vein by placing your free thumb below the venipuncture site where the needle is to enter and pull skin taught.

Blood collection with ordinary Vacutainer needles

• Introduce the Vacutainer needle apparatus with the bevel up at a 15°-30° angle to the skin and parallel to the vein.
• Once the needle is properly positioned in the vein, anchor the needle by grasping the holder with thumb on top and other fingers under the holder, resting securely on the patient’s arm. Push the appropriate Vacutainer tube into the holder with gentle pressure in order to puncture the cap. The tube will automatically fill with blood.
• Watch the blood as it flows into the Vacutainer tube until collection is complete.
• For multiple draws, the order of tubes is as follows:
  1. Blood culture vials (sterile)
  2. Coagulation tube-Sodium Citrate (light blue top) – tube must be full
  3. Serum tube with or without clot activator or gel (red top)
  4. Heparin (e.g. green top)
  5. EDTA (e.g. lavender top)
  6. Fluoride (e.g. gray top)
  7. Other tubes with additives
• Gently invert all tubes 5-10 times after filling.
• Release tourniquet within one minute.
• When all tubes are filled, withdraw the last tube, place cotton or gauze square over the site and withdraw the needle.
• Apply pressure to the site until bleeding has stopped.
• The phlebotomist should again check the patient's identity and ensure that it corresponds to the details on the request form. In addition to the request form being labeled.
• Never re-cap the needle.
• Needle is discarded in white container and syringe is discarded in red bag.
• Inspect the puncture wound. When bleeding has stopped, apply a cotton swab.
• If bleeding continues, apply pressure for an additional 3-5 minutes.
• Prolonged bleeding may be related to the patient’s disease.

Blood collection with Winged Collection (Butterfly) with evacuated tubes or syringe

• Note: This method is used primarily for difficult draws, hand draws, infant draws and blood culture collections.
• Holding the wings of the butterfly with your dominant hand and smoothly insert the needle with the bevel up, parallel to the vein, at approximately a 10°-15° angle.
• Once the needle is properly positioned in the vein, hold one wing of the winged collection set and insert evacuated tubes using the Vacutainer holder according to the order of draw. For syringe draws, gently pull on the plunger to allow blood to flow into syringe. Pulling on the plunger too fast may cause possible collapse of the vein and restrict blood flow into the syringe and/or hemolyze the sample.
• When sufficient blood has been collected, release tourniquet. Place gauze/cotton over the site, and apply pressure to the site until bleeding has stopped.
• Butterfly device shoud be discarded in white container.

Blood collection by Skin Puncture for Collection of Blood Specimens Finger Puncture

• This method is appropriate for pediatric patients who are not walking and for adults. This method is not used on the fingers of infants who are small for their age, premature, or < 3 months of age.
• Wash hands. Put on properly fitting gloves.
• Choose a finger that is not cold or swollen. The ring or middle finger is preferred. Cover the site with a warm, moist towel at a temperature no higher than 42 degrees Centigrade (warm but not hot to the touch) for 3-5 minutes. Never use a microwave to heat warming device.
• With non-dominant hand apply a light massaging motion to the fleshy portion of the finger. The ring or middle finger is preferred.
• Cleanse the ball or pad of the finger with an alcohol wipe and allow to air dry.
• With your non-dominant hand, firmly grasp the patient’s finger and firmly place the sterile lancet against the site. The cut should be across the fingerprint. Cutting along the lines of the fingerprint will cause the blood to stream down the finger.
• Discard the lancet into sharps container
• Wipe away the first drop of blood with gauze. If blood does not flow freely, hold the puncture site downward and gently apply continuous pressure to the surrounding tissue to enhance blood flow. Strong, repetitive pressure (milking) should not be applied as it may cause contamination with tissue fluid or hemolysis.
• Bring the tip of the specimen collection tube (or capillary) into contact with the drop. Do not scrape the skin tissue with the tip of the capillary collection tube as specimen hemolysis may occur.
• Inspect the puncture wound. When the bleeding has stopped completely, apply a bandage. If bleeding continues, apply pressure for an additional 3-5 minutes. Prolonged bleeding may be related to the patient’s disease.
• Exception: A bandage should never be applied to patients under two years of age unless the patient is under close observation by an adult until the bandage is removed. Small children may choke on bandages. If a bandage is applied, instruct the adult to remove it within 2 hours.

Heel Stick

• Note: This method is used for infants less than 1 year old who are not weight-bearing (not walking yet).
• Warm the heel with warm, moist heat no greater than 42’C (not hot to the touch), for 3-5 minutes.
• Wash hands. Put on properly fitting gloves.
• Cleanse the heel with an alcohol wipe and allow to air dry.
• Grasp the infant’s heel with a moderately firm grip, with your forefinger at the arch of the foot and your thumb placed at the ankle.
• Open a sterile blood lancet without touching the tip.
• Make a puncture in one continuous motion. The puncture should be less than 2.0 mm deep on top of heel (meaty area only).
• Discard the lancet into sharps container.
• Wipe away the first drop of blood with gauze. Blood flow is enhanced if the puncture site is held downward and continuous pressure is applied to the surrounding tissue.
• Bring the tip of the specimen collection tube (or capillary) into contact with the drop. Do not scrape the skin tissue with the tip of the capillary collection tube as specimen hemolysis may occur.
• Inspect the puncture wound. When the bleeding has stopped completely, apply a bandage. If bleeding continues, apply pressure for an additional 3-5 minutes. Prolonged bleeding may be related to the patient’s disease.
• Exception: A bandage should never be applied to patients under two years of age unless the patient is under close observation by an adult until the bandage is removed. Small children may choke on bandages. If a bandage is applied, instruct the adult to remove it within 2 hours.

Blood collection by ordinary syringe and needles:

• All steps are same as that of vacuum tube collection except as follows
• Introduce the syringe needle with the bevel up at a 15°-30° angle to the skin and parallel to the vein. Once the needle is properly positioned in the vein, anchor the needle by grasping it with thumb on top and other fingers under, resting securely on the patient’s arm, and pull the plunger slowly to aspirate blood. Remove syringe after appropriate volume is collected.
• Remove vacuum of the tube and add blood from the syringe slowly. Discard needle in white puncture proof container. Dispose syringe in Red container.

• Mention following on the primary sample container legibly

1. Patient Name
2. Patient ID
3. Department /ward/ Unit

• Sample ID given by laboratory (as soon as it is generated)

• At lower left corner of request form identity of person collecting sample must be mentioned. In the absence of this detail, sample request will be rejected.