To the Editor:I am a MT who is now in nursing school. Last night, I saw a nurse recollect a specimen for CBC and Chem 8 on a pediatric patient. The collection was difficult, and as she was pushing the blood into the tubes, I saw her pull 2 large clots out and discard them. I called her on it, but she was very defensive and said she has been doing this for 10 years, and I might know the laboratory side but I don’t have a clue about the pediatric side. She guaranteed me it would work. I told her it might work, but the results would be wrong. I can’t find anything to document this on the Web. Have there been any studies showing the difference in a specimen with a clot pulled off before testing? Show
Response From the Editor:2009 Many questions come to mind after reading this letter to the editor describing the manual removal of clots from tubes collected by venipuncture and the possibility of impact on the quality of laboratory test results and subsequent patient outcome.
We need to take a look at why and how blood clots. We know that the blood circulating in the body is composed of 55% plasma (liquid) and 45% cells (formed elements) allowing the blood to appear as a fluid and to flow freely through the arteries, veins, and capillary vessels (circulatory system). When we need whole blood or plasma as a sample for testing, we collect it into tubes containing anticoagulants such as acid citrate dextrose (ACD), Citrate, EDTA, fluoride, heparin, oxylate, or thrombin. Clotting of blood is prevented by one of the following methods:
When we need serum for our testing sample we collect the patient’s blood into tubes that do not contain an anticoagulant. During the clotting process the liquid separates from the blood clot, and this fluid is called serum. Clots may form in any tube, including anticoagulated tubes, if they are not properly inverted immediately following collection. Once clots have formed in an evacuated tube, it must not be used for testing as results will be erroneous. It is never appropriate to physically remove the clots from a tube of blood. The tube must be discarded, and the specimen must be recollected. The person collecting the blood whether a phlebotomist, tech, or nurse is responsible for ensuring the quality of each specimen collected. The test results provided by the laboratory are an integral part of diagnosis and monitoring of the patients in our hospitals. Every specimen must be collected and handled following the guideline put forth by the laboratory in the Phlebotomy Specimen Collection Manual. When we focus on quality assurance in phlebotomy we are helping to assure quality patient care by checking on patient outcomes. It is important to remember that the quality of the test results is completely dependent on the quality of the specimen provided to the laboratory for testing. Compromise is never an option! © American Society of Clinical Pathologists © American Society of Clinical Pathologists Venipuncture Procedure ROUTINE VENIPUNCTURE GUIDELINES MATERIALS 1. Safety Needles, 22g or less 2. Butterfly needles. 21g or less 3. Syringes 4. Vacutainer tube holder 5. Transfer Device 6. Blood Collection Tubes. 7. Tourniquets. Single use, disposable, latex-free tourniquets 8. Antiseptic. Individually packaged 70% isopropyl alcohol wipes. 9. 2×2 Gauze 10. Sharps Disposal Container. An OSHA acceptable, puncture proof container 11. Bandages or tape SAFETY 1. Observe universal (standard) safety precautions. 2. Observe all applicable isolation procedures. 3. PPE’s will be worn at all times. 4. Wash hands in warm, running water with a appropriate hand washing product, 5. If hands are not visibly contaminated a commercial foaming hand wash product may be used before and after each patient collection. 6. Gloves are to be worn during all
phlebotomies, and changed between patient collections. 7. Palpation of phlebotomy site may be performed without gloves providing the skin is not broken. 8. A lab coat or gown must be worn during blood collection procedures. 9. Needles and hubs are single use and are disposed of in an appropriate ‘sharps’ container as one unit. 10. Needles are never recapped, removed, broken, or bent after phlebotomy procedure. 11. Gloves are to be discarded in the appropriate container immediately after the phlebotomy procedure. 12. All other items used for the procedure must be disposed of according to proper biohazardous waste disposal policy. 13. Contaminated surfaces must be cleaned with freshly prepared 10% bleach solution. All surfaces are cleaned daily with bleach. 14. In the case of an accidental needlestick, immediately wash the area with an antibacterial soap, express blood from the wound, and contact your supervisor. PROCEDURE 1. Identify the patient, two forms of active identification are required.
2. Reassure the patient that the minimum amount of blood required for testing will be drawn. 3. Verify that any diet or time restrictions have been met. 4. Order of Draw
1. Blood Culture 2. Light Blue Top (plasma): 3.2% sodium citrate. These tubes are used for coagulation tests and need to be completely filled to ensure the proper ratio of blood to anticoagulant. 3. Red Top (serum): Plain and gel. Used for chemistry and reference tests. 4. Green Top (plasma): With and without gel, contains lithium heparin. These tubes are used primarily for chemistry tests. 5. Lavender or Pink Top (plasma): Contains EDTA. Used primarily for hematology and blood bank testing. 6. Gray Top (plasma): Contains sodium fluoride/potassium oxalate. Used by chemistry for glucose testing. 7. Yellow Top (plasma and cells): Contains ACD solution A or B. Used for Genetics testing. NOTE: When using a winged blood collection set for venipuncture and a coagulation tube is the first tube needed, first draw a discard tube (plain red top or light blue top). The discard tube does not need to be filled completely. 1. Assemble the necessary equipment appropriate to the patient’s physical characteristics. 2. Wash hands and put on gloves. 3. Position the patient with the arm extended to form a straight-line form shoulder to wrist. 4. Do not attempt a venipuncture more than twice. Notify your supervisor or patient’s physician if unsuccessful. 5. Select the appropriate vein for venipuncture.
6. Apply the tourniquet 3-4 inches above the collection site.
7. Clean the puncture site by making a smooth circular pass over the site with the 70%
8. Perform the venipuncture 1. Attach the appropriate needle to the hub by removing the plastic cap over the small end of the needle and inserting into the hub, twisting it tight. 2. Remove plastic cap over needle and hold bevel up. 3. Pull the skin tight with your thumb or index finger just below the puncture site. 4. Holding the needle in line with the vein, use a quick, small thrust to penetrate the skin and enter the vein in one smooth motion. 5. Holding the hub securely, insert the first vacutainer tube following proper order of draw into the large end of the hub penetrating the stopper. Blood should flow into the evacuated tube. 6. After blood starts to flow, release the tourniquet and ask the patient to open his or her hand. 7. When blood flow stops, remove the tube by holding the hub securely and pulling the tube off the needle. 8. Gently invert each tube
9. DO NOT SHAKE OR MIX VIGOROUSLY. If multiple tubes are needed, follow the proper order of draw 9. Place a gauze pad over the puncture site and remove the needle. 10. Activate the safety device and properly dispose of the vacutainer holder with needle attached into a sharps container. 11. Immediately apply slight pressure to the gauxe pad over the venipuncture site..
12. Tubes must be positively identified after filling with a firmly attached patient label.
13. Observe special handling requirements
VENIPUNCTURE PROCEDURE USING A SYRINGE: 1. Place a sheathed needle or butterfly on the syringe. 2. Remove the cap and turn the bevel up. 3. Pull the skin tight with your thumb or index finger just below the puncture site. 4. Holding the needle in line with the vein, use a quick, small thrust to penetrate the skin and vein in one motion. 5. Draw the desired amount of blood by pulling back slowly on the syringe stopper. Release the tourniquet. 6. Place a gauze pad over the puncture site and quickly remove the needle. 7. Immediately apply pressure. Ask the patient to apply pressure to the gauze for at least 2 minutes. 8. When bleeding stops, apply a fresh bandage, gauze or tape. 9. Transfer blood drawn into the appropriate tubes as soon as possible using a Blood Transfer Device, as a delay could cause improper coagulation. 10. Gently invert tubes containing an additive 5-8 times. 11. Dispose of the syringe and needle as a unit into an appropriate sharps container. INFANT/CHILD PHLEBOTOMY 1. Confirm the patient’s identification 2. Secure patient to Papoose apparatus for stabilization if child is unable to sit upright on their own. 3. Assemble the required supplies 4. Select the collection site and proceed as routine phlebotomy. If the child is old enough, collect blood as in an adult. TROUBLESHOOTING HINTS FOR BLOOD COLLECTION If a blood sample is not attainable: 1. Reposition the needle. 2. Ensure that the collection tube is completely pushed onto the back of the needle in the hub. 3. Use another tube as vacuum may have been lost. 4. Loosen the tourniquet. 5. Probing is not recommended. In most cases, another puncture in a site below the first site is advised. 6. A patient should never be stuck more than twice unsuccessfully by a phlebotomist. The Supervisor should be called to assess the patient. Why is it important to use a discard to when collecting blood with a winged infusion set directly into evacuated tubes?A discard tube is recommended when using a wing infusion set and evacuated tubes to remove the air from the tubing. Which allows subsequent tubes to fill adequately.
What is the importance of using a discard tube?Discard tubes have traditionally been obtained when drawing samples for coagulation testing to avoid potential tissue factor activation of coagulation in the first tube that may lead to inaccurate results.
Why is it necessary to collect a discard tube before filling the coagulation tube?Most often used for coagulation studies. Must be drawn prior to collection of serum tubes to prevent contamination with clot activator and interference with coagulation cascade.
Why do we use a discard tube when drawing an anticoagulant draw?In most laboratories, it is standard practice to draw a discard tube, or red-stoppered tube, before filling a coagulation (blue-stoppered) tube to minimize contamination of the coagulation specimen by tissue factor.
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Why is it important to use a discard tube when collecting blood with a winged infusion set directly into evacuated tubes?
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