What Vein Do They Draw Blood From

This chapter covers all the steps recommended for safety phlebotomy and reiterates the accepted principles for blood drawing and claret collection (31). The chapter includes background information (Section two.one), practical guidance (Section two.2) and illustrations (Section ii.iii) relevant to all-time practices in phlebotomy.

The data given in this section underpins that given in the residuum of Office 2 for specific situations. Chapter 4 also provides data relevant to the procedure for drawing blood given below in Section 2.two, merely focuses on blood collection from donors.

Institutions tin can employ these guidelines to establish standard operating procedures. Such procedures should clearly state the risks to patients and wellness workers, also as the means to reduce those risks – discussed below in Sections ii.1.4 and two.2.

two.i. Background data on best practices in phlebotomy

Best practices in phlebotomy involve the post-obit factors:

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

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availability of appropriate supplies and protective equipment;

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availability of post-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 role of patients;
quality of laboratory sampling.

2.1.1. Planning ahead

This is the most important role of carrying out any procedure, and is usually done at the get-go of a phlebotomy session.

ii.ane.two. Using an appropriate location

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

two.one.3. Quality control

Quality balls is an essential function of best practice in infection prevention and command (1). In phlebotomy, it helps to minimize the chance of a mishap. Table 2.1 lists the main components of quality assurance, and explains why they are important.

Tabular array ii.one

Elements of quality assurance in phlebotomy.

ii.1.4. Quality care for patients and health workers

Several factors can amend safety standards and quality of care for both patients and health workers, and laboratory tests. These factors, discussed below, include:

Availability of appropriate supplies and protective equipment

Procurement of supplies is the direct responsibility of the administrative (direction) structures responsible for setting upwards phlebotomy services. Management should:

provide paw-hygiene materials (soap and water or alcohol rub), well-fitting not-sterile gloves, single-use disposable needles, and syringes or lancing devices in sufficient numbers to ensure that each patient has a sterile needle and syringe or equivalent for each claret sampling;
make available sufficient laboratory sample tubes to prevent dangerous practices (eastward.1000. decanting blood to recycle laboratory tubes).

Several safety-engineered devices are available on the market; such devices reduce exposure to blood and injuries. Still, the use of such devices should be accompanied by other infection prevention and control practices, and training in their employ. Not all safety devices are applicable to phlebotomy. Before selecting a safe-engineered device, users should thoroughly investigate available devices to determine their appropriate apply, compatibility with existing phlebotomy practices, and efficacy in protecting staff and patients (12, 33). Annex B provides further information on infection prevention and control, prophylactic equipment and all-time do; Annex C provides a comprehensive guide to devices available for cartoon claret, including safety-engineered equipment.

For settings with depression resources, toll is a driving factor 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

Adventitious exposure and specific information about an incident should be recorded in a register.

Support services should be promoted for those who undergo accidental exposure. PEP tin can help to avert HIV and hepatitis B infections (13, 27). Hepatitis B immunization should be provided to all wellness workers (including cleaners and waste handlers), either upon entry into wellness-intendance services or as part of PEP (34). Addendum 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 hand hygiene on the part of the phlebotomist or reuse of contaminated tourniquets (35). In addition, reusable finger-prick devices and related indicate-of-care testing devices (e.k. glucometers) contaminated with blood accept been implicated in outbreaks of hepatitis B (4, 5, 36).

To avoid contamination, any common-utilise items, such equally glucometers, should be visibly clean before employ on a patient, and unmarried-use items should not exist reused.

Preparation in phlebotomy

All staff should be trained in phlebotomy, to prevent unnecessary risk of exposure to blood and to reduce agin events for patients.

Groups of health workers who historically are not formally trained in phlebotomy should be encouraged to have upwardly such training; lax infection prevention and control practices result in poor safe for staff and take chances to patients (20, 37).
The length and depth of training will depend on local conditions; still, the grooming should at least cover the essentials (see Addendum Due east) (38).
Supervision by experienced staff and structured training is necessary for all health 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 exact – should be available to each patient who undergoes phlebotomy. Annex F provides sample text for explaining the claret-sampling procedure to a patient.

2.1.5. Quality of laboratory sampling

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

knowledge of staff involved in blood collection;
apply of the correct gauge of hypodermic needle (run into Tabular array 3.one in Affiliate 3) to preclude haemolysis or aberrant results;
the anatomical insertion site for venepuncture;
the use of recommended laboratory collection tubes;
patient–sample matching (i.e. labelling);
transportation conditions;
interpretation of results for clinical management.

2.ii. Applied guidance on best practices in phlebotomy

2.2.1. Provision of an appropriate location

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

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

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a hand wash basin with soap, running water and paper towels;

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booze hand rub.
In the claret-sampling room for an outpatient department or dispensary, provide a comfortable reclining couch with an arm rest.
In inpatient areas and wards:

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at the patient's bedside, close the bed pall to offering privacy

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

2.2.2. Provision of clear instructions

Ensure that the indications for blood sampling are clearly defined, either in a written protocol or in documented instructions (e.1000. in a laboratory form).

two.2.3. Procedure for drawing blood

At all times, follow the strategies for infection prevention and control listed in Table two.2.

Table 2.2

Infection prevention and control practices.

Step 1. Assemble equipment

Collect all the equipment needed for the process and identify information technology within safety and easy reach 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 and upright in a rack; blood tin can 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 blood are to be collected;
well-plumbing fixtures, not-sterile gloves;
an assortment of blood-sampling devices (safety-engineered devices or needles and syringes, run across below), of different sizes;
a tourniquet;
booze hand rub;
gauze or cotton fiber-wool ball to be applied over puncture site;
laboratory specimen labels;
writing equipment;
laboratory forms;
leak-proof transportation bags and containers;

Ensure that the rack containing the sample tubes is close to you, the health worker, but away from the patient, to avert information technology beingness accidentally tipped over.

Step 2. Identify and prepare the patient

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

Introduce yourself to the patient, and ask the patient to land their full name.
Check that the laboratory course matches the patient's identity (i.eastward. match the patient'southward details with the laboratory form, to ensure authentic identification).
Ask whether the patent has allergies, phobias or has e'er fainted during previous injections or blood draws.
If the patient is anxious or agape, reassure the person and ask what would brand them more comfortable.
Make the patient comfortable in a supine position (if possible).
Identify a make clean newspaper or towel under the patient's arm.
Talk over the test to exist performed (encounter Annex F) and obtain verbal consent. The patient has a right to refuse a test at any fourth dimension before the blood sampling, so it is important to ensure that the patient has understood the procedure.

For paediatric or neonatal patients, see Chapter vi.

Step 3. Select the site

General

Extend the patient's arm and audit the antecubital fossa or forearm.
Locate a vein of a adept size that is visible, straight and clear. The diagram in Department two.3, shows mutual positions of the vessels, simply many variations are possible. The median cubital vein lies between muscles and is usually the most easy to puncture. Under the basilic vein runs an artery and a nerve, so puncturing here runs the chance of damaging the nervus or artery and is unremarkably more than painful. DO Not insert the needle where veins are diverting, because this increases the hazard of a haematoma.
The vein should be visible without applying the tourniquet. Locating the vein will help in determining the correct size of needle.
Apply the tourniquet about iv–5 finger widths above the venepuncture site and re-examine the vein.

Hospitalized patients

In hospitalized patients, do non take blood from an existing peripheral venous admission site because this may give false results. Haemolysis, contagion and presence of intravenous fluid and medication tin all change the results (39). Nursing staff and physicians may access central venous lines for specimens following protocols. Nonetheless, specimens from central lines carry a adventure of contamination or erroneous laboratory test results.

It is acceptable, but not platonic, to draw blood specimens when commencement introducing an in-abode venous device, before connecting the cannula to the intravenous fluids.

Footstep 4. Perform paw hygiene and put on gloves

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wash hands with soap and water, and dry with single-use towels; or

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

Footstep 5. Disinfect the entry site

Unless drawing claret cultures, or prepping for a claret collection, clean the site with a 70% booze swab for xxx seconds and allow to dry completely (30 seconds) (40–42).

Notation: alcohol is preferable to povidone iodine, because blood contaminated with povidone iodine may falsely increase levels of potassium, phosphorus or uric acid in laboratory test results (6, 7).
Apply house but gentle pressure. Start from the centre of the venepuncture site and work down and outwards to embrace an area of 2 cm or more.
Allow the expanse to dry. Failure to let enough contact time increases the risk of contagion.
DO NOT touch the cleaned site; in particular, DO 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 six. Have blood

Venepuncture

Perform venepuncture as follows.

Ballast the vein by holding the patient's arm and placing a pollex Beneath the venepuncture site.
Ask the patient to grade a fist so the veins are more prominent.
Enter the vein swiftly at a thirty degree angle or less, and continue to introduce the needle along the vein at the easiest angle of entry.
Once sufficient claret has been collected, release the tourniquet Earlier withdrawing the needle. Some guidelines suggest removing the tourniquet equally soon as blood menses is established, and always earlier information technology has been in place for 2 minutes or more.
Withdraw the needle gently and apply gentle force per unit area to the site with a clean gauze or dry out cotton-wool ball. Ask the patient to concord the gauze or cotton wool in place, with the arm extended and raised. Ask the patient NOT to bend the arm, considering doing so causes a haematoma.

Step 7. Fill the laboratory sample tubes

When obtaining multiple tubes of blood, use evacuated tubes with a needle and tube holder. This system allows the tubes to be filled straight. If this system is not available, use a syringe or winged needle fix instead.
If a syringe or winged needle set up is used, best practice is to place the tube into a rack before filling the tube. To prevent needle-sticks, use ane hand to fill up the tube or use a needle shield between the needle and the mitt holding the tube.
Pierce the stopper on the tube with the needle straight higher up the tube using slow, steady pressure. Do not press the syringe plunger because additional force per unit area increases the risk of haemolysis.
Where possible, continue the tubes in a rack and move the rack towards you. Inject downwards into the advisable coloured stopper. Practise NOT remove the stopper because information technology will release the vacuum.
If the sample tube does not have a condom stopper, inject extremely slowly into the tube as minimizing the pressure and velocity used to transfer the specimen reduces the run a risk of haemolysis. DO NOT epitomize and remove the needle.
Before acceleration, invert the tubes containing additives for the required number of times (as specified by the local laboratory).

Step viii. Draw samples in the correct order

Draw blood collection tubes in the correct lodge, to avoid cross-contamination of additives between tubes. As colour coding and tube additives may vary, verify recommendations with local laboratories. For analogy purposes, Table ii.3 shows the revised, simplified recommended order of draw for vacuum tubes or syringe and needle, based on United States National Commission Clinical Laboratory Standards consensus in 2003 (43).

Table 2.three

Recommended society of describe for plastic vacuum tubes.

Stride ix. Clean contaminated surfaces and complete patient process

Discard the used needle and syringe or blood sampling device into a puncture-resistant sharps container.
Check the label and forms for accuracy. The label should be clearly written with the information required by the laboratory, which is typically the patient'due south first and terminal 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 matter. Items used for phlebotomy that would not release a driblet of blood if squeezed (eastward.m. gloves) may be discarded in the general waste matter, unless local regulations state otherwise.
Recheck the labels on the tubes and the forms before dispatch.
Inform the patient when the process is over.
Enquire the patient or donor how they are feeling. Check the insertion site to verify that it is not bleeding, then give thanks the patient and say something reassuring and encouraging earlier the person leaves.

Footstep ten. Prepare samples for transportation

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

Step xi. Clean upward spills of blood or trunk fluids

If blood spillage has occurred (east.g. considering of a laboratory sample breaking in the phlebotomy area or during transportation, or excessive haemorrhage during the procedure), clean it up. An case of a safe procedure is given below.

Put on gloves and a gown or apron if contagion or bleaching of a uniform is probable in a large spill.
Mop up liquid from large spills using paper towels, and place them into the infectious waste.
Remove equally much blood as possible with moisture cloths before disinfecting.
Assess the surface to come across whether information technology will be damaged by a bleach and water solution.
For cement, metal and other surfaces that can tolerate a stronger bleach solution, food the area with an approximately 5000 parts per 1000000 (ppm) solution of sodium hypochlorite (one:10 dilution of a 5.25% chlorine bleach to water). This is the preferred concentration for large spills (44). Leave the expanse wet for 10 minutes.
For surfaces that may be corroded or discoloured by a stiff bleach, clean carefully to remove all visible stains. Brand a weaker solution and leave it in contact for a longer flow of fourth dimension. For case, an approximately 525 ppm solution (1:100 dilution of five.25% bleach) is effective.
Prepare bleach solution fresh daily and go on it in a closed container because it degrades over fourth dimension and in contact with the sunday.

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

2.3. Illustrations for best practices in phlebotomy

Figure 2.ii Filling tubes

Source: https://www.ncbi.nlm.nih.gov/books/NBK138665/

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