How To Tie A Tourniquet For Blood Draw

This chapter covers all the steps recommended for condom phlebotomy and reiterates the accustomed principles for blood drawing and blood collection (31). The chapter includes background information (Section ii.1), practical guidance (Section 2.2) and illustrations (Section 2.3) relevant to best practices in phlebotomy.

The information given in this section underpins that given in the remainder of Part Ii for specific situations. Chapter four also provides data relevant to the procedure for drawing blood given below in Section 2.two, merely focuses on claret collection from donors.

Institutions tin use these guidelines to found standard operating procedures. Such procedures should clearly state the risks to patients and health workers, as well as the means to reduce those risks – discussed below in Sections 2.1.4 and 2.two.

ii.1. Groundwork data on all-time practices in phlebotomy

Best practices in phlebotomy involve the following 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 mail service-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 part of patients;
quality of laboratory sampling.

2.one.1. Planning ahead

This is the most important part of carrying out any procedure, and is ordinarily done at the start of a phlebotomy session.

2.1.2. Using an advisable location

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

2.1.3. Quality control

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

Table 2.one

Elements of quality assurance in phlebotomy.

2.1.4. Quality care for patients and health workers

Several factors tin can ameliorate safety standards and quality of treat both patients and health workers, and laboratory tests. These factors, discussed beneath, include:

Availability of appropriate supplies and protective equipment

Procurement of supplies is the directly responsibleness of the administrative (management) structures responsible for setting upward phlebotomy services. Management should:

provide hand-hygiene materials (soap and water or booze rub), well-fitting non-sterile gloves, unmarried-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 unsafe practices (e.g. decanting claret to recycle laboratory tubes).

Several safe-engineered devices are available on the market; such devices reduce exposure to blood and injuries. However, the use of such devices should exist accompanied by other infection prevention and control practices, and training in their use. Non all safety devices are applicable to phlebotomy. Before selecting a safety-engineered device, users should thoroughly investigate available devices to decide their appropriate use, compatibility with existing phlebotomy practices, and efficacy in protecting staff and patients (12, 33). Annex B provides further information on infection prevention and control, safe equipment and best practice; Annex C provides a comprehensive guide to devices available for drawing blood, including prophylactic-engineered equipment.

For settings with depression resources, cost is a driving gene in procurement of safety-engineered devices.

Where safety-engineered devices are not bachelor, skilled utilise of a needle and syringe is acceptable.

Availability of mail service-exposure prophylaxis

Accidental exposure and specific information nigh an incident should exist recorded in a register.

Support services should be promoted for those who undergo adventitious exposure. PEP can aid to avert HIV and hepatitis B infections (thirteen, 27). Hepatitis B immunization should be provided to all health workers (including cleaners and waste handlers), either upon entry into health-care services or equally office of PEP (34). Annex D has details of PEP for hepatitis B and HIV.

Abstention 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 betoken-of-care testing devices (due east.k. glucometers) contaminated with claret have been implicated in outbreaks of hepatitis B (four, 5, 36).

To avert contamination, any common-use items, such as glucometers, should exist visibly make clean before use on a patient, and single-utilise items should not be reused.

Grooming in phlebotomy

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

Groups of health workers who historically are not formally trained in phlebotomy should exist encouraged to take up such training; lax infection prevention and control practices event in poor safe for staff and adventure to patients (twenty, 37).
The length and depth of training will depend on local weather condition; however, the training should at least cover the essentials (see Addendum E) (38).
Supervision by experienced staff and structured training is necessary for all health workers, including physicians, who undertake blood sampling.

Patient cooperation

1 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 data – either written or verbal – should exist bachelor to each patient who undergoes phlebotomy. Annex F provides sample text for explaining the blood-sampling process to a patient.

2.ane.5. Quality of laboratory sampling

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

knowledge of staff involved in claret collection;
employ of the correct gauge of hypodermic needle (meet Tabular array 3.1 in Chapter 3) to prevent haemolysis or aberrant results;
the anatomical insertion site for venepuncture;
the apply of recommended laboratory collection tubes;
patient–sample matching (i.e. labelling);
transportation conditions;
estimation of results for clinical management.

2.2. Practical guidance on all-time practices in phlebotomy

ii.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 (1 for the phlebotomist and the other for the patient);

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a hand launder basin with lather, running water and paper towels;

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booze manus rub.
In the blood-sampling room for an outpatient section or clinic, provide a comfortable reclining couch with an arm residual.
In inpatient areas and wards:

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at the patient'south bedside, shut the bed curtain to offer privacy

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

2.two.two. Provision of clear instructions

Ensure that the indications for blood sampling are conspicuously defined, either in a written protocol or in documented instructions (e.g. in a laboratory course).

two.2.3. Procedure for drawing claret

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

Table two.two

Infection prevention and command practices.

Step i. Assemble equipment

Collect all the equipment needed for the procedure and place it within prophylactic and easy accomplish on a tray or trolley, ensuring that all the items are conspicuously 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 volition depend on what is agreed with the laboratory);

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vacuum-extraction blood tubes; or

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glass tubes with screw caps;
a sterile drinking glass or bleeding pack (collapsible) if big quantities of claret are to be collected;
well-plumbing equipment, non-sterile gloves;
an assortment of claret-sampling devices (safety-engineered devices or needles and syringes, see below), of dissimilar sizes;
a tourniquet;
alcohol manus 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 lot, the health worker, merely away from the patient, to avoid it being accidentally tipped over.

Step two. Place and prepare the patient

Where the patient is developed and conscious, follow the steps outlined beneath.

Introduce yourself to the patient, and ask the patient to country their total name.
Check that the laboratory course matches the patient'due south identity (i.e. friction match the patient's details with the laboratory form, to ensure accurate identification).
Ask whether the patent has allergies, phobias or has e'er fainted during previous injections or blood draws.
If the patient is broken-hearted or afraid, reassure the person and enquire what would brand them more than comfortable.
Make the patient comfortable in a supine position (if possible).
Identify a clean newspaper or towel under the patient's arm.
Talk over the test to exist performed (run into Annex F) and obtain verbal consent. The patient has a right to refuse a test at whatsoever time earlier the blood sampling, so it is important to ensure that the patient has understood the process.

For paediatric or neonatal patients, run across Affiliate 6.

Stride 3. Select the site

General

Extend the patient's arm and audit the antecubital fossa or forearm.
Locate a vein of a skillful size that is visible, directly and clear. The diagram in Section 2.iii, shows common positions of the vessels, but many variations are possible. The median cubital vein lies between muscles and is commonly the near easy to puncture. Under the basilic vein runs an artery and a nerve, so puncturing here runs the take chances of dissentious the nerve or artery and is usually more than painful. DO Non insert the needle where veins are diverting, because this increases the take chances of a haematoma.
The vein should exist visible without applying the tourniquet. Locating the vein volition assist in determining the correct size of needle.
Apply the tourniquet almost 4–5 finger widths above the venepuncture site and re-examine the vein.

Hospitalized patients

In hospitalized patients, practice not accept claret from an existing peripheral venous admission site because this may give false results. Haemolysis, contamination and presence of intravenous fluid and medication can all alter the results (39). Nursing staff and physicians may access key venous lines for specimens following protocols. However, specimens from key lines carry a take a chance of contamination or erroneous laboratory test results.

It is acceptable, but not ideal, to draw claret specimens when first introducing an in-dwelling house venous device, earlier connecting the cannula to the intravenous fluids.

Footstep iv. Perform hand hygiene and put on gloves

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wash hands with soap and h2o, and dry with single-utilize towels; or

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if hands 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, dorsum of hands and all over the hands until dry.

Step v. Disinfect the entry site

Unless drawing blood cultures, or prepping for a blood collection, make clean the site with a 70% alcohol swab for 30 seconds and let to dry completely (30 seconds) (40–42).

Note: booze is preferable to povidone iodine, because blood contaminated with povidone iodine may falsely increase levels of potassium, phosphorus or uric acid in laboratory examination results (6, 7).
Utilise house but gentle pressure. Offset from the centre of the venepuncture site and piece of work downward and outwards to cover an area of 2 cm or more.
Permit the area to dry. Failure to allow plenty contact time increases the run a risk of contamination.
DO Not touch the cleaned site; in item, DO Not place a finger over the vein to guide the shaft of the exposed needle. It the site is touched, repeat the disinfection.

Footstep 6. Take blood

Venepuncture

Perform venepuncture as follows.

Anchor the vein by holding the patient'due south arm and placing a thumb BELOW the venepuncture site.
Ask the patient to form a fist so the veins are more prominent.
Enter the vein swiftly at a 30 degree angle or less, and keep to introduce the needle along the vein at the easiest angle of entry.
Once sufficient claret has been collected, release the tourniquet Before withdrawing the needle. Some guidelines suggest removing the tourniquet as before long as blood menstruum is established, and always earlier information technology has been in place for two minutes or more.
Withdraw the needle gently and apply gentle pressure to the site with a clean gauze or dry cotton fiber-wool ball. Inquire the patient to agree the gauze or cotton wool wool in identify, with the arm extended and raised. Enquire the patient Not to curve the arm, because doing so causes a haematoma.

Step 7. Fill up the laboratory sample tubes

When obtaining multiple tubes of blood, use evacuated tubes with a needle and tube holder. This organization allows the tubes to exist filled directly. If this organisation is not available, employ a syringe or winged needle set instead.
If a syringe or winged needle gear up is used, best practice is to identify the tube into a rack earlier filling the tube. To prevent needle-sticks, use ane hand to fill the tube or apply a needle shield betwixt the needle and the hand holding the tube.
Pierce the stopper on the tube with the needle directly above the tube using slow, steady pressure. Practice non printing the syringe plunger because additional pressure increases the risk of haemolysis.
Where possible, keep the tubes in a rack and movement the rack towards you. Inject downwards into the appropriate coloured stopper. DO Not remove the stopper because it will release the vacuum.
If the sample tube does not have a rubber stopper, inject extremely slowly into the tube as minimizing the pressure level and velocity used to transfer the specimen reduces the risk of haemolysis. DO Not recap and remove the needle.
Before acceleration, invert the tubes containing additives for the required number of times (as specified past the local laboratory).

Step viii. Draw samples in the correct society

Draw blood drove tubes in the correct order, to avoid cross-contamination of additives betwixt tubes. Every bit colour coding and tube additives may vary, verify recommendations with local laboratories. For illustration purposes, Tabular array 2.3 shows the revised, simplified recommended order of draw for vacuum tubes or syringe and needle, based on United States National Committee Clinical Laboratory Standards consensus in 2003 (43).

Tabular array 2.3

Recommended order of draw for plastic vacuum tubes.

Step nine. Clean contaminated surfaces and complete patient procedure

Discard the used needle and syringe or blood sampling device into a puncture-resistant sharps container.
Bank check the characterization and forms for accuracy. The characterization should be conspicuously written with the information required past the laboratory, which is typically the patient's commencement and last names, file number, date of nativity, and the engagement and fourth dimension when the blood was taken.
Discard used items into the appropriate category of waste. Items used for phlebotomy that would not release a drop of blood if squeezed (east.yard. gloves) may be discarded in the general waste, unless local regulations state otherwise.
Recheck the labels on the tubes and the forms before dispatch.
Inform the patient when the procedure is over.
Enquire the patient or donor how they are feeling. Check the insertion site to verify that information technology is not bleeding, and so give thanks the patient and say something reassuring and encouraging before the person leaves.

Step 10. Prepare samples for transportation

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

Pace 11. Clean up spills of claret or torso fluids

If blood spillage has occurred (e.g. because of a laboratory sample breaking in the phlebotomy area or during transportation, or excessive haemorrhage during the procedure), clean it up. An example of a condom process is given beneath.

Put on gloves and a gown or apron if contamination or bleaching of a compatible is likely in a large spill.
Mop up liquid from big spills using paper towels, and place them into the infectious waste product.
Remove as much claret equally possible with wet cloths before disinfecting.
Assess the surface to see whether it will be damaged by a bleach and water solution.
For cement, metal and other surfaces that tin tolerate a stronger bleach solution, food the area with an approximately 5000 parts per million (ppm) solution of sodium hypochlorite (1:10 dilution of a five.25% chlorine bleach to h2o). This is the preferred concentration for large spills (44). Leave the expanse moisture for 10 minutes.
For surfaces that may be corroded or discoloured past a strong bleach, clean carefully to remove all visible stains. Make a weaker solution and exit it in contact for a longer period of time. For example, an approximately 525 ppm solution (one:100 dilution of 5.25% bleach) is effective.
Prepare bleach solution fresh daily and keep information technology in a closed container because it degrades over fourth dimension and in contact with the sunday.

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

2.3. Illustrations for best practices in phlebotomy

Figure two.2 Filling tubes

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

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