Phlebotomy Lecture

By: JANETTE V. QUIRINO,RMT

Phlebotomy in the Philippines

 Person who has a degree of medical technology and has a license

 Medical laboratory technicians
 Nurses
 Medical technologist interns- as part of their training and
lab.exposure
 Doctors- for HTE (arterial)
Important Notes:
1. Phlebotomist must have a thorough knowledge of collection
tubes and other sample collection materials.
2. Phlebotomy will always be a manual procedure.
3. The Phlebotomist is RESPONSIBLE for obtaining the highest
quality specimen.
4. No amount of sophisticated machines or expert personnel can
produce a rightful result from IMPROPERLY collected specimens.
5. Phlebotomy is an invasive procedure with serious consequences
when improperly performed.
6. There is nothing a phlebotomist can do on a compromised
specimen.
Introduction
 Doctors depend on the test results to be accurately
timely.
 All sources of error must be identified and monitored.
 Pre-analytical errors can affect the quality of the
specimen and the validity of test result. Many of these
factors are under the responsibility of a phlebotomist.
 To ensure quality specimen collection and handling
policies and procedures should be based on specific
guidelines. It fall under an overall process called Quality
Assurance.
 Essential to
accurate
Laboratory
diagnosis

Influences Influences
Good Sample
Laboratory Management
therapeutic
efficiency decisions

Directly
affects
patient
care and
outcome
Quality Assurance

 Refers to processes used to create standardization for quality

service or product and prevention of problem.
 A QA program strives to guarantee quality service through
scheduled reviews that look at the appropriateness, applicability
and timeliness of patient care.
Quality Control

 QC is a component of Quality Assurance program and form a

procedural control. It refers to the specific activities and
techniques that are performed to fulfill the requirements for
quality service or product.
 Phlebotomy quality control involves using all available QC
checks on every operational procedure of process to make certain
is is performed correctly.
Patient preparation procedures

 Quality assessment in the laboratory testing actually starts before

the specimen is collected in the pre-analytical stage.
 To obtain a quality specimen, the patient must be prepared
properly.
 Prior to blood collection, the patient must be given correct
instructions on how to prepare for each laboratory tests.
 Utmost care must be observed to minimize factors that may
influence laboratory results.
CLSI 2011 STANDARDS
Clinical Laboratory Standards Institute
What is CLSI?
• Formally NCCLS
• International, interdisciplinary, non-profit,
standards-developing, educational
organization
• World-wide standards
• Way to improve patient testing and
healthcare services
UNIVERSAL PRECAUTIONS
Apply to transmission of blood borne
pathogens.
STANDARD PRECAUTIONS
Cover transmission of all known
infection agents; more comprehensive.
PROTECTIVE CLOTHING
Personal Protection in the Laboratory:
•Wear long-sleeved gowns with closed fronts or long-sleeved
laboratory coats that are buttoned closed while in the
laboratory.
•Wear laboratory coats or gowns inside the
laboratory only.
•Reusable cloth or disposable gowns/coats may be used.
PROTECTIVE CLOTHING
Occlusive Dressing
•Cover all non-intact skin located on parts of the body
exposed to blood or body fluid with a water-
impermeable occlusive bandage.
• NOTE:
REMOVE ALL PERSONAL PROTECTIVE
EQUIPMENT BEFORE LEAVING THE LABORATORY
WORK AREA
 HAND PROTECTION
Gloves of proper size and material must be
provided for your protection.
• Use aseptic techniques when both putting on and
removing gloves.
• Wear gloves at specimen receiving and set-up
areas.
• Do not contaminate clean areas by contact with
contaminated gloves.
• Change gloves after contact with each patient.
• Removes gloves before handling telephones,
uncontaminated laboratory equipment, doorknobs,
etc.
HAND HYGIENE
• Decontaminate hands after touching all potentially
infectious material, whether or not gloves are worn.
• Use an alcohol-based hand rub or soap and water
if hands are not visibly soiled.
• Removes gloves promptly after the completion of all
tasks.
HAND HYGIENE
• Decontaminate hands immediately after gloves are
removed and when otherwise indicated to avoid transfer
of microorganisms to other surfaces and environments.

• Change gloves between patients when performing

phlebotomy. Decontaminate the hands after glove
removal and before donning new gloves.
HAND HYGIENE
• Decontaminate hands:
• After the completion of work and before leaving
the laboratory:
•Before eating, drinking, smoking, applying make- up,
changing contact lenses, and before and after using
lavatory facilities; and
•Before all other activities which entail hand contact
with mucous membranes, eyes, or breaks in the skin
 HAND HYGIENE
• Avoid soap products that may disrupt skin integrity.
A moisturizing hand cream may reduce skin irritation
caused by frequent hand washing; but some
nonpetroleum-based hand creams may affect glove
integrity.

•Avoid wearing artificial fingernails or extenders when in

direct contact with patients at high risk for infections, such
as those in intensive care units or operating rooms.
FACIAL PROTECTION
• Use facial barrier protection if there is a reasonably
anticipated potential for spattering or splashing blood
or body substances.
• Full-face shields made of lightweight transparent
plastic are the preferred means of facial protection.
• Splashguards may serve as an acceptable alternative
to plastic face shields.
• Use a fluid-resistant mask and eye protection if face
shields are not available.
• Ordinary prescription glasses are not adequate eye
protection. Use plastic wrap around safety glasses that
fit over regular glasses.
Phlebotomy
 Diagnostic testing
 Treatment monitoring
 For transfusions at a donor center
 Therapeutic purposes:
Polycythemia (overproduction of RBC’s)
Hemochromatosis (excess iron deposits)
Phlebotomy

Two main types:

1. Venipuncture – puncturing a vein with a needle

2. Skin/ Capillary Puncture – puncturing the skin
with a lancet
Venipuncture Equipment

 Collection tray

 A well organized tray instills patient confidence.

STEPS IN DOING A VENIPUNCTURE

Assemble Supplies
• Inspect all supplies
• Remember to use the same (manufacturer)
needle, holder and tube
• Inspect all tubes
STEPS IN DOING A VENIPUNCTURE
Identification
 Patient identification is the most important aspect of
specimen collection.
 Methods are continually improved to ensure correct patient
ID.
(e.g. barcodes on requests and specimen labels)

Phlebotomist must actively involve patients in their

identification prior to specimen collection.
STEPS IN DOING A VENIPUNCTURE
Identify yourself
• Who you are
• Where you are from
• What you are going to do
STEPS IN DOING A VENIPUNCTURE
• VERIFY fasting states:
• Have you had anything to eat or drink?
• When was the last time you had anything to eat
or drink?
 STEPS IN DOING A VENIPUNCTURE
Verify Diet Restrictions
• Some tests require diet restrictions
• Fasting
• Eliminating certain foods

**Each facility should have a policy manual

Factors affecting Lab. results

 Posture
 Exercise
 Stress
Patient Basal State

 A patient who is at rest and has been fasting for

at least 12 hours.
 Specimen collected at this state, can provide the
most accurate assessment of some blood
parameters like electrolytes,glucose,lipids and
proteins.
Diurnal Variations

 Also called diurnal rhythm is a variation in an analyte at different

time throughout the day.
 Some hormones, like testosterone, decrease during the afternoon
while TSH increases in the evening.
 Levels of some type of white blood cells may rise during the day.
Timing for drug levels
 Therapeutic Drug Monitoring (TDM)- drawing of specimen at a
specific time
 TDM is monitoring of the amount of therapeutic drug in the
blood
 A peak level is a specimen collected when the drug level is at its
highest
( e.g. Cya C2 )
 Trough level is collected when the drug level is at its lowest.
( e.g. Tacrolimus, Everolimus, Sirolimus, CyA trough level)
Medications as Interfering Substances

 Interfering substances are substances that can alter

laboratory results
 Substances the phlebotomist has no control over include
medications or other drugs the patient is taking
 Interfering substances that are under control of the
phlebotomist are those contained in collection
tubes(additives).
Equipment

 Ensuring the quality and sterility of every needle

or lancet is essential for patient safety.

 Manufacturing defects in needles can be avoided

before use by quickly inspecting the needle after
unsheathing.
STEPS IN DOING A VENIPUNCTURE
• Check Latex Sensitivity:
• Gloves
• Tourniquets
• Bandages
• Check for Allergies:
• Seafood
• Other
STEPS IN DOING A VENIPUNCTURE
• Sanitize hands
• Put gloves on
• Recommended:
DO NOT touch patient without gloves on.
 STEPS IN DOING A VENIPUNCTURE
Request Form Should Include:
• Patient’s:
• Full name
• Date of birth
• Identification number
• Date, time it is drawn
• Name or initial of phlebotomist
• Department/tube color
STEPS IN DOING A VENIPUNCTURE
Position the Patient
• Make them comfortable
• Foreign objects out of mouth
• Gum
• Mints
• Food
• Thermometer
STEPS IN DOING A VENIPUNCTURE
• CLSI states—NEVER combine:
• Tubes
• Holders
• Needles
• From different manufactures
STEPS IN DOING A VENIPUNCTURE
Could cause:

• Hemolysis
• Needle/holder disengagement
• Inadequate filling of a tube
STEPS IN DOING A VENIPUNCTURE
TUBES:
• Check for expiration dates.
• Must have a clear view of the contents unless
test must be shielded from light.
• No sharp edges
• No surface roughness (capable of cutting skin)
• Should be used to collect blood straight into
the tube
• Must retain vacuum
STEPS IN DOING A VENIPUNCTURE

Apply tourniquet

•Tourniquet is used to increase intravascular pressure

• (*Tourniquet should be latex-free; single use only.)
• Helps with the palpitation of vein
• Helps with filling of the tube
• Within 20 seconds, the analytes begin to change
• Suggested time=1 minute
• Retying a tourniquet: must wait two (2) minutes
STEPS IN DOING A VENIPUNCTURE
Tourniquet Location
• 2-4 inches above or
• 3 fingers

Blood Pressure Cuff

• Inflate no more than 40 mmHg
• Pump hand one to two times
• NO vigorous hand pumping
(change certain analytes)
STEPS IN DOING A VENIPUNCTURE
DO NOT USE the following veins!!!
• Underside wrist
• Lower extremities
• Feet
• Ankles
• On the side of a mastectomy arm
STEPS IN DOING A VENIPUNCTURE
Problems that can occur
• Phlebitis
• Thrombophlebitis
• Tissue Necrosis (death of tissue and cells)
• Accidental Arterial Puncture
• Nerve Damage
SITES IN PHLEBOTOMY
STEPS IN DOING A VENIPUNCTURE
Cleanse Venipuncture Site
• Concentric motion from center to peripheral
• Allow area to DRY at least 30 seconds
• Do not wipe dry
• Prevents:
• Hemolysis
• Prevent burn in sensation on patient
• Allow antiseptic to work
• Difficult Veins
If you MUST re-touch, then you
MUST re-CLEAN!
• Perform the Venipuncture
• Hold arm below the venipuncture site.
**NO “window” method!
• Puncture at a 30 degree angle.
• Use correct order of draw.

• See the ORDER OF DRAW NEXT SLIDE

ORDER OF DRAW
• YELLOW SPS (Blood Cultures)
• LT. BLUE Sodium Citrate
• PLAIN RED No Additive
• PLASTIC RED Clot Activator
• GOLD, RED/GRAY SST/Gel w/ Clot Activator
• GREEN Heparin-Lithium or Sodium
• LAVENDER, TALL PINK EDTA
PURPLE EDTA
• GRAY Sodium Fluoride, Potassium Oxalate
NOTE:
Other tubes will be added into the Order of Draw by their additives.
Invert tubes IMMEDIATELY:
• CA 5 times
• Na Citrate 3-4 times
• Heparin 8 times
• EDTA 8 times
• Na Fluoride 8 times
TEST TUBE ADDITIVES
STEPS IN DOING A VENIPUNCTURE

Perform the Venipuncture

• Release tourniquet.
• Place gauze over the site. (NO cotton balls!)
• Gauze should be pre-packaged; 2X2.
• Remove needle and dispose IMMEDIATELY.
NOTE:
• A clearing tube must be used if using a
butterfly for coagulation studies
•A non-additive tube may be drawn before
coagulation studies when using a multi-draw
needle
• NO clot activator or additive tube should be
drawn before coagulation studies
NOTE:
• Check the venipuncture site (after 3-5 minutes).
• Bandage for 15 minutes to one (1) hour.
• Patients should NOT bend the arm up.
• Healthcare professional should notify nurse or supervisor
if bleeding lasts more than five (5) minutes.
STEPS IN DOING A VENIPUNCTURE

Labeling:
• Patient’s last and first name.
• ID #
• Date, time, and initials of person collecting sample.
• Time when TDMs are being collected.
STEPS IN DOING A VENIPUNCTURE

Labeling:
 Useat least two (2) unique identifiers to ensure
proper labeling of specimen.
1. full name of the patient
2. date of birth
NEVER leave a patient before
labeling tubes!
NEVER walk into a lab without a
specimen being labeled!
•NEVER DRAW IF THERE
IS A
DISCREPANCY!
Specimen transport and processing

 Laboratory test results can be greatly affected by the

way the specimens are handled.
 Thus, the phlebotomists’ role is crucial, as he is
responsible for ensuring that every specimen is handles
properly
 Specimens must be transported to the laboratory in a
timely manner and under test-specific conditions.
SPECIAL HANDLING
Examples of tests requiring specimen
chilling are:
• Gastrin
• Ammonia
• Lactic acid
• Catecholamines
• Pyruvate
• Parathyroid hormone (PTH)
SPECIAL HANDLING
Examples of tests requiring specimen
protection from light:
• Bilirubin
• All Vitamin levels
• Beta Carotene
• Porphyrins
 SPECIAL HANDLING
Serum:
• Specimens should be clotted before centrifugation.
• Spontaneous and complete clotting normally occurs within
30 to 60 minutes at room temperature (20 to 25 °C).
• NOTE: The use of a wooden applicator stick or similar device
for the release of a clot attached to the tube closure or the sides
of the tube (i.e., “rimming”) is not recommended because it is a
potential source for the laboratory-induced hemolysis.
• The time to clot will be prolonged if the patient is on
anticoagulant therapy or if the specimen is chilled.
SPECIAL HANDLING
Plasma:
• Use a collection device containing an
anticoagulant when plasma is required
• Centrifuge anti-coagulated specimens
immediately after collection.
SPECIAL HANDLING
Chilled Specimens
• To chill a specimen, place it immediately in a
mixture of ice and water. Good contact between
the cooling medium and the specimen is essential.
•Adequate cooling is essential; however, avoid
direct contact between the specimen and ice (or
other cooling materials such as dry ice), because
the temperature extreme may cause hemolysis.
• NOTE: Chilling whole blood beyond two hours
is contraindicated for a specimen intended for
potassium.
SPECIAL HANDLING
Preservatives:
• Use sodium fluoride to stabilize glucose in the
presence of blood cells for up to 24 hours at
25 °C or 48 hours at 4 to 8 °C.
• Use micro collection devices containing a
suitable anti-glycolytic agent for pediatric blood
glucose collection.
CRITERIA FOR REJECTION OF SPECIMEN
 Hemolysis
 Clotted specimen
 Incomplete collection (QNS)
 Incorrect tube
 Incorrect order of draw
 Icteric or lipemic specimen
 Documentation error
 Mislabeled
 Contamination
 Hemoconcentration
SPECIMEN TRANSPORT
Time and Temperature:
•
Transport specimens in the appropriate
biohazard bags or containers to the laboratory
in as short a time as possible.
• Unless chilling of the specimen is required
(i.e., lactic acid, ammonia), transport all
specimens at room temperature.
• Prompt removal of specimens from the
collections area is especially important if the
area temperature is above 22 °C, which may
cause some measurands to deteriorate.
SPECIMEN TRANSPORT
Tube Orientation:
• Place tubes of blood in a vertical position.
•Non-anti-coagulated tubes that contain gel
should always be stored in an upright position
as soon as the mixing is completed.
• NOTE:
• Evaluate automated transport systems,
pneumatic or otherwise, for any effect
on laboratory results.
SPECIMEN TRANSPORT
Tube Closure:
• Keep tubes of blood closed at all times.
Keeping the tube in a closed position eliminated
possible exogenous contamination
of the specimen and prevents evaporation and
the possibility of spills and aerosols.
SPECIMEN TRANSPORT
Agitation:
• Gentle handling of collected specimens helps
to minimize erythrocyte damage leading to
hemolysis of specimens.
SPECIMEN TRANSPORT
Exposure to Light:
•Avoid exposing blood specimens for
photosensitive measurands (i.e., bilirubin) to
artificial light or sunlight (ultraviolet) for any
length of time.
• Protect these specimens with an aluminum foil
wrap, an amber specimen container, or the
equivalent.
Thank you! ☺