Methodologies and Regulations in Specimen Collection and Management

Methodologies and Regulations in Specimen Collection and Management Module 1: Phlebotomy Equipment

Objectives At the conclusion of this module you will be able to: • Define Phlebotomy • List types of phlebotomy and identify the equipment used in each type • Venipuncture • Dermal Puncture • Identify the various types of anti-coagulants, additives, tube colors, and order of draw used in the evacuated tube method of blood collection.

Objectives At the conclusion of this module you will be able to: • Discuss other blood drawing equipment • Identify arm veins used in venipuncture • Demonstrate the ability to organize all equipment and supplies necessary to perform a venipuncture and dermal puncture • Demonstrate proper procedure for collection and transport of Dried Blood Spots (DBS)

Today’s Agenda • Define Phlebotomy • List types of phlebotomy and identify the equipment used in each type • Venipuncture • Dermal Puncture • Identify the various types of anti-coagulants, additives, tube colors, and order of draw used in the evacuated tube method of blood collection. • Identify and correctly use other types of blood drawing equipment

Definition of Phlebotomy Comes from the Greek word: • Phlebo-: meaning vein • -Tome: meaning incision Phlebotomy is the process of collecting blood from a client by puncturing a vein

Types of Phlebotomy • Venipuncture: • Involves collecting blood by penetrating a vein with a needle and collection apparatus • Includes the use of the evacuated tube system, syringe, and winged infusion systems

Types of Phlebotomy • Dermal (Skin) Puncture: • Collecting blood after an incision is made to the skin with a lancet • Includes finger puncture and heel puncture • Maximum depth should never exceed 2.0 mm

Equipment and Supplies • Band Aid • Sharps Container • Tourniquet • Gloves • Needle • Holder • Tubes • Gauze • Alcohol Pad

Gloves • Standard Precautions require the wearing of gloves • Gloves provide protection from infection • A new pair of gloves must be worn for each client and for each new procedure • Types: “A good fit is essential” • Nitrile • Vinyl • Latex

Tourniquet • Slow down venous flow without affecting arterial flow • Enlarge the vein for easier location and easier penetration • Assess the width, direction and depth of veins • Should be left on for no longer than one minute

Tourniquet Application Position the tourniquet 7.5 – 10 cm above the venipuncture site with strip equal on both sides Pull left side over the right side and make an X

Tourniquet Application With X in place, tuck a loop Have both ends of strip facing up End that is facing up is used for one hand and easy removal

Needles • Sterile, Disposal and for Single use only • Color coded for size or gauge • Hollow stainless steel shafts • Bevel or slant at the end

Needle Features • Bevel or slant: • Must face up • Shaft: • Cylindrical portion, length ranges from .65 to 3.80 cm • Hub: • Attaches the needle to the holder • Gauge: • The size of the needle, refers to the diameter of the needle

Needle Size Needle Size or Gauge • Gauge is the diameter of the needle • Routine: 21 gauge • Children: 23 gauge • The larger the number the smaller the needle • Colored coded for size • Range from 16 – 25 • Most common size used is 21g by 3.80 cm

Multi Sample Needle • Used for multiple samples during a single venipuncture • Composed of a double pointed needle • The hub screws into the needle holder • Open with a twist motion

Safety Needles • Allows the user’s hand to remain behind the needle • Always use a safety needle when available • Minimizes exposure to blood borne pathogens

Holder or Barrel (Bulldog) • A plastic tube like device • Feet extensions: • Used for placement and removal of the evacuated tube • Many different kinds: • Retract the needle • Draw the needle into the barrel

Needle Holder & Adapter • The second pointed needle with rubber sleeve resides in the holder • Push the tube directly into the middle of the holder for proper collection • Second needle will penetrate top of tube

Antiseptics & Disinfectants • Antiseptic: to prevent sepsis, to inhibit or prevent the growth of bacteria • 70% isopropyl alcohol • Methylated spirits • Iodine • Chlorohexidine sulfonate • Disinfectant: will kill bacteria, used on surfaces and instruments, not skin • Household Bleach 1:10 • Jik or Biosite (product labs/clinics use in some countries) • Clean up all blood spills on countertops / floors, phlebotomy chairs

Gauze Pads • Called a 2 X 2 • Should be sterile • Used for drying the site after cleaning with alcohol • Placed on the site after needle removal • Cotton balls are not recommended – they can stick to the site and initiate bleeding

Bandages Adhesive Band-Aids or Plastics Be careful of latex allergies Should be placed over site after venipuncture Two Point Check Always make sure patient is not bleeding before applying the bandage Be careful when using a plastic or adhesive bandage on children

Sharps Containers • Marked Biohazard • Used for the disposal of used needles, lancets or other sharp objects • Needles are not to be recapped, bent or cut • All needles and holders are disposed of immediately after use • Do not detach needle from holder

Any questions?

Knowledge Check 1 • What is the purpose of the tourniquet? • What is the maximum time a tourniquet should be on a client’s arm?

Evacuated Tube System • A closed system which allows blood to go directly from the vein into a stopper tube without blood being exposed to air • Allows multiple tubes to be drawn with a single venipuncture • Tubes contain a vacuum which is premeasured and guaranteed by the manufacturer until the expiration date stamped on each tube

Evacuated Tube System • Collection Tubes • Types of Specimens • Anticoagulants • Additives • Tube Stoppers • Order of Tubes During Blood Draw • Inverting and Mixing Tubes

Collection Tubes • Size varies from 2 mL to 15 mL • May or may not contain an additive • An additive is a substance that has been added to the tube • Types of additives: • Anticoagulants • Gel separators • Clot activators

Types of Specimens • Whole Blood • Cells + Plasma • Anticoagulant prevents clotting • Mix specimen well • Haematology / Full Blood Count • CD4 Testing

Types of Specimens • Plasma • Plasma contains fibrinogen • Centrifuge whole blood, separate plasma from cells

Types of Specimens • Serum • Allow blood to clot for 20 - 30 minutes • Centrifuge 10 – 15 minutes, separate cells from serum • Serum does not contain fibrinogen • Chemistry Testing

Any questions?

Knowledge Check 2 • What is the difference between serum and plasma?

Anticoagulants • A substance that prevents blood from clotting. Yields a whole blood specimen or when spun a plasma specimen • Types: • EDTA ethylenediaminetetraacetic acid in a tripotassium or disodium base (Purple) • Sodium Citrate (Light Blue) • Heparin (Green) • Sodium Fluoride/Potassium Oxalate (Gray)

Anticoagulants • EDTA • Ethylenediaminetetraacetic acid in a tripotassium or disodium base • (Purple): prevents clotting by binding calcium • Used in Hematology for CBC and CD4

Anticoagulants • Sodium Citrate (Light Blue): prevents clotting by binding the calcium. Used for coagulation workup (PT and APTT) • Ratio of 1 part anticoagulant to 9 parts blood is critical for quality specimen and quality test result • Must be filled with exact amount of blood – NOT UNDERFILLED or OVERFILLED

Anticoagulants • Heparin (Green): Three types: ammonium, lithium, and sodium. Prevents clotting by inhibiting thrombin. Used for plasma chemistry testing • Use appropriate type of heparin

Anticoagulants • Potassium or ammonium oxalate (Gray): prevents clotting by binding the calcium. Used in glucose testing • Sodium Fluoride (Gray): inhibits the metabolism of glucose by the cells. Used for glucose tolerance testing

Additives • Clot activator: • initiate or enhance coagulation. Can be thrombin, glass or silica particles • Gel Separator: • forms a barrier between the cells and the serum portion after the blood has been spun • Used for Chemistry Testing

Tube Stoppers • Red/Glass: no additives • Red/Plastic: clot activator • Red/Gray or marbled: gel separator • Green: Heparin (three types) • Mint Green: Heparin with gel separator • Lavender: EDTA • Light Blue: Sodium citrate • Gray: potassium oxalate and sodium fluoride • Hemogard: plastic stopper with rubber inside. • Used for safety

Colors of Tubes

Order of Draw with the Evacuated Tube System • Blood Cultures: sterile specimen • Light Blue: sodium citrate for coagulation. Tube should be full and well mixed • Gel Separator with or without clot activator • Glass or Plastic Tubes • Green: heparin or plasma chemistry • Purple: EDTA for Hematology, CBC, CD4 • Gray: oxalate/fluoride, glucose testing

Inverting and Mixing the Tubes • Tubes with additives must be gently mixed • Gently invert several times for proper mixing

Any questions?

Knowledge Check 3 • What color tube is used to draw the laboratory test CD4? • What color tube is used to draw a CBC?

Other Blood Drawing Equipment • Syringe • Winged Infusion or Butterfly • Lancet • Micro-collection • Warming Devices

Other Blood Drawing Equipment • Syringe • used for fragile veins, you determine the pressure and pull • Winged Infusion or Butterfly • used for difficult veins, small veins and hand veins. Usually used for elderly clients and children

Methodologies and Regulations in Specimen Collection and Management