Dr Piyush Tailor

(REGISTRATION WINDOW)

• Patient at the Common Collection Center registration window are having their case file & request form. Request forms will be filled up by respective treating doctors. Patient should submit their request form at registration window & form will be examined, if any of the required information is lacking, and then ask correction from referring doctor.
• Request form should have following details:
  • Full name of patient
  • Age & SeX
  • MRD number ( Unique ID number)
  • Registration Number
  • Referral OPD & Unit
  • List of investigation
  • Short clinical history
  • Signature of requester
  • Date and time of sample collection

• On registration counter, each case is assigned a specific lab number and entered into info.diagnostica software/register with patient’s name, age, sex, Referral OPD, MRD no and investigations.
• Same details are also entered in HMIS Lab Module for facilitating segregation of samples and record keeping.
• Note down the lab registration number on patient’s request form with date of registration
• Send patient to next window for payment under rogikalyan samiti.

• After registration patient comes to the next window for the fees payment under rogi kalyan samiti.
• Fees (Rs 10) is collected per patient for all the investigation, which is applicable for the patients who have monthly income Rs 3000 or more.
• Patient is given receipt for the same.
• Followings are exempted from these charge:
  • BPL card holder.
  • Medico legal cases
  • Freedom fighters
  • Senior citizen(Age >60 years)
  • Thalassemia patients
• After the payment patient is asked to go to the next window to collect the container for sample collection.

• After fees payment patient comes to the next window where sample containers are provided.
• After checking the receipt of payment, according to the list of investigation in patient request form, sample containers are provided to the patient.
• Vacuette for the collection of blood and disposable containers for collection of urine are provided as per the primary sample collection manual of respective section.

*Not in scope

• Sample container are properly labeled with the following details
  • Patient name
  • Lab. Registration number.
  • List of investigation
  • Referring OPD/Unit
• Then patient is asked to enter the laboratory waiting and wait till he/she is called by the technician in the blood collection room for sample collection.
• For urine samples patient collect the urine in the given container as per the instruction (ref- primary sample collection manual- clinical pathology section) and make it available at the clinical pathology processing room.

Instruction for patient:-

Pre analytical variable and patient preparation-

• In preparing a patient for phlebotomy, all care should be taken to minimize factors related to activities that might influence laboratory determinations. So phlebotomist should be aware of most critical variables.
• Factors are- fasting, posture, exercise, stress, alcohol, smoking, diurnal variations, drug ingestion, etc.

1. Fasting – ask about fasting conditions for fasting blood glucose levels, lipid profile, etc..
2. Alcohol- ask about any alcohol ingestion, because it affects results of plasma lactate, urates and triglyceride concentration.
3. Drugs- ask for any anticoagulation therapy for tests of PT, apTT.
4. Torniquet application- Prolonged application- increases serum enzyme proteins, cholesterol, calcium and triglycerides. It has been standardized and must not exceed 60 seconds in a single application.

• 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.
• Select prominent vein mainly in anticubital fossa for blood collection.
• Prepare local part with applying 70% ethanol with cotton swab and allowed to dry spontaneously before being punctured.
• After cleaning and drying the site and applying a tourniquet (not more than 1 minute), ask the patient to make a fist a few times. The tourniquet should be applied just above the venepuncture site and released as soon as the blood begins to flow into the syringe or evacuated tube
• With help of vacutainer needle, puncture the skin and withdraw required amount of blood in corresponding Vacuttee.
• If a syringe is used for blood collection, the piston of the syringe should be withdrawn slowly and no attempt should be made to withdraw blood faster than the vein is filling.
• Specimens must be mixed with anticoagulant by inverting the vacuttee 8-10 times.
• After obtaining the blood and releasing the tourniquet, remove the needle and then press a sterile swab over the puncture site, applying pressure on the swab. The arm should be elevated after withdrawal of the needle, and pressure should continue to be applied to the swab with the arm elevated for a few minutes before checking that bleeding has completely ceased. Then cover the puncture site with a small adhesive dressing.

Order of draw for blood collection:

1. Culture container
2. Coagulation tube-Sodium Citrate (light blue top) – tube must be fill up to the mark
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. Oxalate/fluoride (e.g. gray top)

( REF- BD vacutainer chart of order of draw)

• After completion of collection procedure, collecting person should write their name & initials with date & time of collection.
• Acknowledgement should be handed over to patient and patient is asked to come with that acknowledgement for collection of report.

Post phlebotomy Procedure

• 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.
• Needle should be burned in electric needle cutter and nozzle of syringe should be cut by needle cutter.
• Remaining part of burned needle and syringe are kept in puncture proof container with 1% sodium hypochlorite solution at least for 30 minute.
• Specimens will be collected in rack by main laboratory. The specimen tubes must be set upright in a holder or rack and placed in a carrier together with the request forms for transport to the laboratory.

• Patient is provided sample container for urine collection with proper labeling
• Patient should be instructed to void directly into the container. During collection the initial portion of the urine stream is allowed to escape while the midstream portion is collected.
• After collection patient is asked to keep the sample with its form at clinical pathology processing room window for examination

The specific instruction for collection of random urine sample for urine analysis- Mid stream / clean catch- For urine samples patient collect the urine in the given container as per the instruction (ref- primary sample collection manual- clinical pathology section) and it is available at the clinical pathology processing room.

A. Syncope/ fainting/ vasovagal syndrome: Some or all of the following signs and symptoms may occur in a patient. Sweating Dizziness Weakness Loss of consciousness Convulsions Cold skin Involuntary passage of urine or faeces Slow pulse Hypotension

MANAGEMENT:

1. Place the patient on his or her back and raise the legs above the level of head.
2. Loosen tight clothing
3. An adequate airway should be ensured.
4. Apply cold compresses to patient’s forehead if needed.
5. Administer aromatic spirit of ammonia by inhalation of sufficient strength.
6. Check B.P., pulse and respiration periodically.

NOTE: If patient feels comfortable and B.P., pulse, respiration rate comes in normal limits allow the patient to go. If the above treatment fails, call medical officer immediately.

B) Nausea or/and vomiting.

MANAGEMENT:

1. Turn the head of the patient to a side to avoid aspiration of vomit.
2. Ask the donor who is nauseated to breathe slowly and deeply.
3. Apply cold compresses to the forehead of the patient.
4. If patient vomits, provide proper receptacle and tissue paper to clean his mouth.
5. Give water to rinse mouth.
6. Call medical officer if above treatment fails.

(C). Haematoma

MANAGEMENT:

1. Deflate the pressure cuff and withdraw the needle from the arm.
2. Place 4 to 5 dry sterile gauze pieces or cotton swabs over the haematoma and apply firm digital pressure for 8 to 10 minutes with patient arm held above the heart level.
3. If desired, apply ice for 5 minutes to the area.

(D). Convulsions - True convulsions are very rare but if occur

MANAGEMENT:

1. Call someone to help you immediately because some patients show great muscular power during severe seizures and difficult to restrain.
2. If possible, hold the donor on bed or chair or floor.
3. Ensure an adequate airway.
4. If possible, place a tongue blade between the teeth of patient to prevent him from biting the tongue.
5. Call physician immediately if donor does not recover.

(E). Puncture of artery - An unusually rapid flow of bright red blood when the needle is withdrawn. There may be severe leakage of blood followed by extensive bruising.

MANAGEMENT:

1. If arterial puncture is suspected, the needle should be withdrawn immediately and firm pressure applied for at least 10minutes followed by a pressure dressing.

List of emergency Drugs in common collection center  

An “exposure” that may place a Health Care Provider (HCP) at risk of blood borne infection is defined as a percutaneous injury (e.g. needle-stick or cut with a sharp instrument), contact with the mucous membranes of the eye or mouth, contact with non-intact skin (particularly when the exposed skin is chapped, abraded, or afflicted with dermatitis), or contact with intact skin when the duration of contact is prolonged (e.g. several minutes or more) with blood or other potentially infectious body fluids.

Management of Exposure:

• In case of any accident or occupational exposure, lab Incharge is informed immediately and treated as emergency.
• If there is cut then hands are washed running water with soap.
• If there is splash of blood or any other fluid, then area is washed properly with water. Inform the lab in-charge and document in accident register.
• Lab in charge should inform the Medical officer, In-Charge, ART centre for appropriate actions.
• Risk of infection & transmission is evaluated by clinician and if necessary, prophylaxis is initiated by him.

DONTS:

• Do not panic
• Do not reflexively place pricked finger into mouth
• Do not squeeze blood from wound, this causes trauma and inflammation, increasing risk of transmission
• Do not use bleach, alcohol, betadine, or iodine, which may be caustic, also causing trauma

DOS:

Following any needle stick / sharp injury:-

• Wash off splashes on skin with soap and running water, but without scrubbing. Gently encourage bleeding if the skin has been broken, but without sucking the wound.
• Record the source of the exposure (patient’s name, unit number etc), type of body fluid, and type of injury on the incident/accident form.
• Incident Forms must be completed as soon as possible.

Following eye/ mucus membrane exposure:

• Exposed mucous membranes, including conjunctivae, should be irrigated copiously with water / NS.

Record the source of the exposure (patient’s name, unit number etc), type of body fluid, and type of injury on the incident/accident form.

Incident Forms must be completed as soon as possible.

• All samples are appropriately labeled with the patient’s name, laboratory registration ID no, investigation etc which facilitates its proper identification.
• All collected samples are stored in leak proof containers and are placed in respective repository.
• Proper precautions are taken for handling of samples and care is taken for maintenance of aseptic conditions. It is mandatory for the staff members to wear appropriate personal protective equipments while handling the samples.
• All the samples are received at sample receiving window with their request forms.
• Samples of biochemistry, microbiology, hematology & clinical pathology sections are segregated with request forms
• Details of samples ( sample ID, Investigation) which are collected are entered with the respective sections in Sample dispatch register

• Samples are segregated according to the various sections.
• Transportation of samples with their request forms from the collection centre to various laboratory areas of the hospital is done in appropriate leak proof containers so as to prevent any form of spillage. It is mandatory for the staff members to wear appropriate personal protective equipments while handling the samples.
• Transportation is being carried out as per the guidelines of Primary sample collection manual.
• Proper precautions are taken to avoid any delay for sample transport and to maintain the temperature.
• Person receiving the samples in various sections has to sign in the sample dispatch register with his name.

• After processing ,online report is generated at the laboratory site, the print out of which is taken and dispatched at common collection center.
• Patient with his/her case paper is required to wait in a que at Report window.
• Patient will come with his/her case paper & acknowledgement which has Lab No.
• Now patient is asked to take the reports and consult his/ her clinicians.
• See lab registration number and find out list of investigations from request form.
• Find out the reports by his/her registration number and date.
• Dispatch all the reports to patient & write down “report dispatched” on patient’s request form for confirmation as reports are dispatched.