LABORATORY ADMINISTRATION Policy Number Memorial Health University Medical Center, Inc. II:1

Statement of Policy Effective Date 9/2003 LABORATORY SPECIMEN COLLECTION AND HANDLING Last Revision GUIDELINES July 2010

POLICY STATEMENT

The quality and accuracy of laboratory tests results are highly dependent on proper patient preparation and proper specimen collection, handling, and transportation.

ENTITIES TO WHICH THIS POLICY APPLIES

Memorial Health University Medical Center- Laboratory and Patient Care givers

DEFINITION OF TERMS

A. Venipuncture-The collection of a patient’s blood sample using venous access. B. Capillary Collection-The collection of a patient’s sample by using capillary access, usually the finger. C. Healstick- The collection of an infant’s blood by using the baby’s heel area.

PURPOSE OF POLICY

The following guidelines will serve as instructions to correctly obtain laboratory blood and other specimens. This will ensure the integrity of each specimen collected and forwarded to Memorial Health University Medical Center Laboratory Services for testing.

PROCEDURE

A. General Information 1. The correct specimen requirements are listed in the Laboratory Services Test Directory. Please refer to the test listing prior collection of the specimens. 2. Fasting specimens require a minimum of a 12 hour fast. 3. Draw the patient’s blood in the appropriate order in the proper tube indicated in the specimen requirement section of the alphabetical section of the directory. It is very important to submit sufficient specimen required for each test ordered. In general, the amount of whole blood draw should equal at least two and a half times the amount of serum or plasma required for the test i.e., to obtain 4 ml serum, draw 10-15 ml of whole blood. Laboratory Specimen Collection and Handling Guidelines Page 2 of 8

4. Coagulation specimens should be collected directly into an evacuated tube from a peripheral vein using a 20 or 21 gauge needle. Line draws are not recommended. Syringe draws are more likely to be clotted or hemolyzed and should be avoided if possible. If a winged blood collection set (Butterfly) must be used, a 5ml discard tube must be drawn first. Do not collect any tube, other than the white tube that has no preservative, prior to filling coagulation tubes. If there is no other option and the specimen must be collected from a vascular access device, the line should be flushed with 5 ml of saline and six times the dead space volume of the line (no less than 5 ml) should be discarded. Lines that have previously been flushed with heparin should never be used. Incompletely filled tubes and specimens with a hematocrit greater than 55% will be rejected. They affect the anticoagulant ratio and may cause incorrect results. 5. Positive Patient Identification is of VITAL importance. 6. Following the Memorial Health University Medical Center Global Red Rules and additional references in Memorial Patient Care Policy PC-2000, Patient Identification, verify patient identification prior to drawing the blood. After each specimen is collected, label each specimen in the presence of the patient using the positive patient identification steps listed below.

B. POSITIVE PATIENT IDENTIFICATION OF INPATIENTS 1. The Lab Assistant (phlebotomist) will greet the patient in a pleasant professional manner. This includes introducing themselves, telling the patient they are from the Laboratory and they are there to draw blood. 2. Ask the patient to verbally (when possible) give their name and date of birth. 3. With the Lab Assistants’ Mobile Care Phlebotomy Monitor verify the Medical Record Number on the patient’s armband. 4. Scan the patient’s armband with the Mobile Care Phlebotomy Monitor. 5. The monitor may give the Lab Assistant a message saying “Check Patient and Label Identification. Unknown scanned information”. The Lab Assistant will then have the patient’s nurse apply a new armband and rescan. 6. Print the labels for patient’s test to be drawn at bedside. 7. Draw blood. 8. Label patient’s blood at bedside, adding collectors ID and time of collection. If a blood bank specimen, both the collectors ID and a witness to the collection must sign the tube. 9. Scan each label’s barcode at bedside with the Mobile Care Phlebotomy Monitor and hit the “submit”button to place the patient’s specimen on the “Transport Monitor” in the laboratory. 10. When it is a nurse or PCT drawing a patient, they will also greet their patient in a professional manner. If their floor has a label printer they will match the information on the label by asking the patient to verbally (when possible) give them their name and date of birth. They will then match the patient’s Medical Record number on the armband with the label. 11. When it is a nurse or PCT drawing a patient and their floor does not have a label printer, they will be required to match the Nurse Requisition order to the chart label and armband. 12. Place in pneumatic tube system and send to laboratory via station #15. Be sure the tube leaves before continuing other duties. 13. Should the patient be unable to verbally identify themselves it is acceptable to use the patient’s armband as identification. 14. TRAUMA PROTOCOL patients in the ED will be identified by a unique number on the RED ARMBAND. This number will also appear in the last 4 digits of the patient’s encounter number. Refer to Trauma Protocol policy. Laboratory Specimen Collection and Handling Guidelines Page 3 of 8

C. VENIPUNCTURE BLOOD COLLECTION

NOTE: OSHA requirements dictate that all hospital personnel must use Personal Protective Equipment and collection and transfer safety devices when blood collection is performed.

Preliminary/General Guidelines 1. Positively identify the patient using the methods above. 2. The patient’s arm should be placed in a comfortable position that would not cause any danger of falling should they lose consciousness. 3. NEVER DRAW BLOOD FROM A STANDING PATIENT. 4. You may raise the bed to take pressure from your back but, … Remember to lower the bed before leaving the room! 5. The tourniquet should be placed 3 to 4 inches above the venipuncture site prior to selecting the vein. This slows the blood flow and enlarges the vein. The tourniquet should be snug but not so tight as to be uncomfortable or pinch the patient. 6. After finding the vein you are going to use, release the tourniquet and prepare everything you will need for the draw. 7. When selecting a vein be careful not to palpate the vein with your thumb. Your thumb has your heartbeat and you may believe you are feeling an artery when indeed it is vein. 8. Never draw where you feel a heartbeat because that IS an artery. 9. After applying the tourniquet, palpate anticubital area with index/or middle finger. Palpate for the medial and/or cephalic vein. The vein will feel like an elastic tube under the skin. When you press down on a vein slowly let the vein push your finger up. This will give you some idea of the depth and width of the vein. 10. If you are unable to find a vein in one arm, check the other. 11. Should you only be able to find the vein in the back of a hand, remember never to use a vacutainer system. Always use a butterfly and needle holder or butterfly and syringe. 12. Never leave the tourniquet on longer than one minute! The tourniquet can be released as soon as the blood starts to flow into the tubes. Leaving the tourniquet on for too long may cause chemical changes in the blood resulting in erroneous test results. The tourniquet is also uncomfortable for the patient. 13. Cleanse the venipuncture area with an alcohol prep pad and then dry with gauze. Do not contaminate the site by palpating the vein again, otherwise you must repeat these two steps. 14. Order of draw is extremely important when it comes to delivering a viable specimen to the laboratory. 15. The use of the white discard tube is to be used when drawing coag specimens in the blue top tubes with a vacutainer system. 16. The order of draw when using the vacutainer system is white-blue-gold-red-green with gel- lavender- pink-green-gray. 17. The order of draw when using a syringe and safety transfer devise is blue-lavender-gold-green with gel–red-pink-green- gray. 18. ALL TUBES NEED TO BE MIXED 4 OR 5 TIMES AS SOON AS THEY ARE FILLED TO PREVENT CLOTTING IN SOME TUBES AND TO SPEED UP CLOTTING IN OTHER TUBES. 19. BLOOD CULTURES ARE ALWAYS DRAWN FIRST! Laboratory Specimen Collection and Handling Guidelines Page 4 of 8

D. VACUTAINER SYSTEM 1. Memorial Health University uses the Greiner needle holders. They are clear plastic with a green flip over safety needle cover. 2. When using the green 21 gauge Greiner needle, first unscrew the gray bottom cap. 3. You will see a black dot on the needle. Place the bottom of the needle into the needle holder with the black dot facing you. When you screw the needle into the holder the back dot should come back to face you. This indicates that the bevel is up. 4. When using the black 22 gauge Greiner needle follow the above procedure. However this time the dot will be white. 5. Place the tube into the gray rubber piercer AFTER you have entered the vein. Otherwise you will lose the vacuum in the tube and it will not draw from the vein. 6. When the tube is full, firmly grab the tube and push off the gray piercer but hold the needle holder firmly so as not to pull out of the vein. 7. Should you pop in your next tube and do not get a blood return, you have probably pushed the needle in further. Back out slowly until blood flow returns. 8. Holding the needle steady while transferring tubes is the best way for a successful vacutainer draw. 9. When you remove the needle click the safety shield over the needle 10. BE SURE THE TOURNIQUET IS OFF BEFORE THE NEEDLE IS OUT OF THE ARM! 11. DISPOSE OF ALL NEEDLES AND COLLECTION DEVICES IN APPROPRIATE BIOHAZARD CONTAINERS. Remove gloves and wash or foam your hands between patients. 12. Make sure bleeding has stopped before leaving the room.

E. SYRINGE METHOD 1. Remove syringe from its protective wrapper. Should there be an 18 gauge needle with red cover attached, remove and discard in biohazard container. 2. Replace needle with a syringe needle with safety guard or with a butterfly needle. 3. Push the barrel of the syringe up and down a few times to loosen the plunger. Then put barrel of syringe all the way down to expel all air. 4. The bevel of the needle should be facing up. The needle should be pointing in the direction parallel to the vein. The vein should be anchored during the draw by placing the thumb about one inch below the puncture site and pressing down while stretching the skin of the arm toward the hand. 5. Enter the vein at about a 15 degree angle to the arm. It can be helpful to puncture the skin slightly below the area where you envision the needle entering the vein. 6. Pull back gently on the plunger without altering the position of the needle in the vein. Do not forcefully pull back on the plunger as cell damage may occur. 7. When the desired amount of blood has been obtained, release the tourniquet (unless you have already done so). Withdraw the needle from the vein and activate the safety needle cover or close butterfly at vein site. Apply gauze and tape. 8. Quickly discard the needle or butterfly (hold the bottom of the butterfly up to prevent blood leaking from tubing) and discard in biohazard container. 9. Quickly attach the safety transfer device to bottom of syringe and adhere to the order of draw for syringe, blue, lavender, gold etc. Mix each tube well after filling. Blue tubes must be filled, however as little as 1 ml can be sufficient for a CBC or H&H. 10. NEVER force blood into the test tube by pushing down on the barrel. This can cause the cap of the tube to pop off splattering blood everywhere. Let the vacuum in the test tube pull the plunger down. Laboratory Specimen Collection and Handling Guidelines Page 5 of 8

11. When blood cultures are being collected, remove needle or butterfly and replace with sterile needle before injecting blood culture bottle. Remove needle and replace with another sterile needle for the second blood culture bottle. 12. If only a small amount of blood is obtained from the syringe draw, it may be transferred into a microtainer. 13. BE CERTAIN TO MARK THE MICROTAINER “VEIN” TO ALERT THE TESTING PERSONNEL 14. Inspect the site again before leaving. Add additional pressure until bleeding stops.

F. WINGED DRAWING DEVICE (BUTTERFLY) WITH LUER ADAPTER AND SAFETY NEEDLE COVER ATTACHED 1. The winged “butterfly” can be used with both vacutainer needle holder and syringe. When using a syringe simply remove the lower gray rubber piercing needle. The butterfly will then fit snuggly on the end of a syringe. 2. Place the wings of the butterfly between your thumb and middle finger. You will feel a rough bottom to the butterfly. That let’s you know that the bevel is up and ready to draw blood. 3. SUCCESSFULLY CLOSE BUTTERFLY AT VEIN SITE…TO PROTECT YOU…TO PROTECT YOUR PATIENT! 4. Place gauze over puncture site. Place middle finger of left hand (or right if you are left handed). Do not push down on the gauze as that causes pain from the needle underneath. 5. Firmly grab the left wing of the butterfly with your left thumb and index finger while middle finger is on the gauze. Reverse hands if you are left handed. 6. Pinch the butterfly wing to hold the butterfly securely in place. 7. Use your right thumb and right index finger and place at the very end of the butterfly. 8. Pinch the gripper in to release the safety sleeve. 9. With your left middle finger still on the gauze, pull back on the safety sleeve until you hear or feel it “click” 10. The butterfly is securely locked at this time and you may place tape over the gauze.

G. REACTION TO VENIPUNCTURE 1. Should the patient complain of feeling light headed, begins sweating, and complexion pale, lower their head between their knees. Support them with your arm while in this position. 2. Have the patient take slow deep breaths from their mouth. 3. As the patient recovers apply a cool wet cloth to forehead and back of neck. 4. The patient may feel nauseated so provide an emesis basin or waste basket. 5. Should the patient vomit have tissues ready as well as water to rinse their mouth. 6. Report and document as appropriate. 1. Bed patients rarely have a reaction.

H. CAPILLARY BLOOD COLLECTION Specimens can usually be obtained by finger stick on children over 6 months. Infants, however, will need a heel stick. 1. Assemble equipment needed:  Microlancet (needle depth appropriate to age of patient).  Gauze (Sterile if patient less than 6 months old). Laboratory Specimen Collection and Handling Guidelines Page 6 of 8

 Alcohol pad.  Microtainers appropriate for tests ordered.  Bandage. 2. Identify the patient. Refer to section II of this policy. 3. Choose a finger that is not cold, cyanotic (blue) or swollen. If the patient’s finger is cold, they may be warmed with a heel warmer, wet warm paper towel, or a by inserting them into a cup of warm water. 4. Massage finger 5-6 times by milking the finger from the proximal toward the distal end. This will increase blood flow. 5. Cleanse the finger with an alcohol prep pad to remove surface bacteria. Wipe the fingertip dry with clean dry gauze. Be certain that the finger tip is thoroughly dry as blood will not well up into a drop if the finger is moist. 6. Hold the lancet between the thumb and forefinger preparing to make a puncture lateral to the ball of the finger. Remove the bottom needle guard. 7. Press down perpendicularly to the lines in the fingertip so that blood will form into a drop. Punctures made parallel to the fingertip lines will allow blood to run down the finger. Dispose of microlancet in biohazard discard containers. 8. Using the hand supporting the finger, squeeze lightly to stimulate the flow of blood. Squeezing too hard inhibits blood flow and introduces fibrin into the sample. Gently massaging finger from the proximal toward the distal end will also be effective in getting a good blood flow. 9. Take a piece of gauze and wipe off the first drop of blood. This drop is contaminated with tissue fluid. 10. Still holding the finger fill the microtainer to the amount required for testing indicated by the top line of the microtainer. 11. Draw the lavender microtainer first. The container is lined with EDTA anticoagulant to prevent clotting but tapping the container lightly on a hard surface, getting the blood to the bottom of the container will further prevent clotting. Mix well after filling. 12. When sufficient blood has been obtained, place a clean dry gauze pad over the site and have the patient press down with thumb to apply pressure until bleeding has stopped. A bandage may be required with persistent bleeding. The use of a bandage on the finger of a child under the age of two should be held by a parent or nurse. A child in the 3 to 5 year range should have a bandage and the parent or nurse asked to remove in 30 minutes. 13. Label all specimens with the same information as you would for a venipuncture following hospital specimen labeling policy. 14 Dispose of lancet in biohazard container and place gloves and trash in waste basket. 15. CMP, Hepatic functions, and Cardiac draws cannot be obtained from a fingerstick 16. Coagulation studies can be performed by fingerstick but require a special tube obtained directly form the Hematology department.

I. HEELSTICK REQUIRED FOR INFANTS AND NEONATES 1. The selection of the site for a heelstick is very important. Care should be taken to avoid site of previous punctures. The puncture should be made on the flat, bottom surface of the foot. Do not draw on the posterior curvature of the heel (The area between the ankle and the bottom of the foot on the back of the heel). The heel bone (calcaneus) is very close to the skin surface at the back of the heal and could be damaged by a puncture in this area. 2. Assemble equipment:  Gloves Laboratory Specimen Collection and Handling Guidelines Page 7 of 8

 Microlancet with needle length appropriate for the stick.  Gauze  Alcohol  Needle disposal container  Bandage  Heel warmer 3. Identify the patient. It is the same as for venipuncture. Refer to Section II of this policy. 4. Apply gloves. 5. Warming the heel for 3 minutes prior to puncture with a heel warmer will help increase blood flow by as much as seven fold. 6. Position the infant so that you have access to the heel. Hold the foot with the heel sticking out of the hand between the index finger and thumb. 7. High risk newborns can be especially prone to infection. 8. Wipe site with alcohol for at least one minute. 9. Dry with gauze. 10. Puncture heel at a 45 to 60 degree angle. 11. Wipe away first drop of blood to remove tissue contaminants. 12. Gently massage the baby’s heel so that you do not cause hemolysis or bruising. 13. Fill lavender tube first, tapping blood to the bottom of the container and mixing well after filling. Continue with other microtainers for tests ordered. 14. When finished apply bandage and clean up the area, disposing of lancet in biohazard container, and trash and gloves in waste basket.

J. REFERENCE GUIDE TO OTHER LABORATORY SAMPLES

1. Urine for routine urinalysis should be collected in appropriate leak-proof containers and returned to t he laboratory within 1 hour properly labeled and with appropriate requisitions. In general a first morning specimen is preferred. The collection may be random voided, clean catch, or catherized depending on physician orders. Refer to the Laboratory Test Directory for specific gui delines. For urine chemistry tests also refer to the test directory.

2. Urine Culture specimens for culturing must be collected by the mid-stream technique in sterile containers or by catherization. Follow instructions included in the urine collection kit for clean catch specimens and for transferring urine into the proper container. Any urine culture add-on order > 2 hours beyond collection will have to be in the gray top urine container; therefore this tube is highly recommended.

3. 24 Hour Urine Collection specimens should be timed to insure specimen is delivered to the laboratory within one day after completion of the 24- hour urine collection. The beginning and end time should be recorded on the container and requisition.

4. Fluids must be submitted in sterile containers without a clot activator (plain red or “fluid set”) and immediately hand delivered to the laboratory along with the nurse collect requisition or down time requisition for each test ordered. They are to be signed in at the fluid sign-in book in the Hematology department after proper collection, labeling, and orders based upon laboratory policy. Laboratory Specimen Collection and Handling Guidelines Page 8 of 8

They may not be transported in the pneumatic tube system or in any other transport system. Delays in specimen receipt may affect test results.

5. Stool and fecal specimens for all laboratory testing need to be submitted in a clean leak-proof container and submitted properly labeled with proper orders. Some tests require submission in collection kits such as parasite studies. Refer to the Laboratory Test directory for specific test requirements.

K. TRANSPORT OF SPECIMENS TO THE LAB

1. Laboratory specimens are on a routine pick-up schedule from all in-patient and out-patient patient care areas during the hours of 10am until 6:30pm. STAT, ASAP and Timed specimens should be transported by pneumatic tube to the laboratory or hand delivered. Urines other than those in vacuum sealed tubes, all stools and all fluids may not be sent via pneumatic tube. 2. Refer to Memorial Health University Medical Center Infection Control policy P-2 Guidelines for Pneumatic Tube Transport of Blood Specimens to the Laboratory. 3. Specimens may also be hand carried to the Laboratory (required for fluids). Refer to the Laboratory Test Directory Guidelines for specific information by test name in alphabetical order located on the Laboratory’s department web site.

APPROVED BY:

______Bill Seignious, MS, ASCP, (MT) Date William E. Check, MD Date Laboratory Director Laboratory Medical Director

Original: October 2003 Revised: September 2005 December 2008 July 2010