Phlebotomy

1. Phlebotomy For Health Care Workers

2. Phlebotomy Phlebos is Greek for “Vein” Tome means to “cut” Phlebotomy means to cut a vein Phlebotomy is a term used to describe the specialized technique of blood collection by a venipuncture “Veni” is a prefix which means vein Puncture refers to the penetration of the vein for any reason, including the administration of IV’s and other medications. (Venipuncture) Phlebotomy is an invasive procedure that invades the body through cutting or puncture, and is performed by professionals known as a: Phlebotomists

3. History of Phlebotomy First documented in Egypt around 1000 BC Removing blood from the veins dates back as far as 1400 BC Leeches: Were used in 1800s Venesection: Vein was pierced with a sharp object to drain blood Cupping: Produced a vacuum effect by pulling blood to the capillaries under a heated glass cup Phlebotomy profession emerged as a result of technology and expansion of lab function in the late 1980s and 1900s

4. Bloodletting as a profession is believed to have originated with Barber Surgeons in the 12th Century , in Italy. The Barber Surgeon carried a red and white staff or cane crowned with a ball as a symbol of his skills in bloodletting and his role in the health care of the day. The red stripe of his staff or cane stood for the blood of the patient The white stripe was for the bandages of the procedure The ball on the top was for the cup which was used to catch the blood flow The Barber Surgeon could perform surgeries, administer enemas, let blood, pull teeth, and even cut hair. A blue and white staff signified patriotism

5. Following developments in the history of phlebotomy in chronological order • Hippocrates’ theory on the relationship between excess body fluids • and disease • Appearance of the barber pole symbol • Collection of blood for diagnostic testing • Development of structured phlebotomy training programs • Certification of phlebotomists

6. Two behaviors that represent negative body • language: • Shuffling into the room • Avoiding eye contact • Demonstrate good telephone communication skills • By making sure the call is not an emergency before • placing them on hold • Providing instructions to a patient • Explain you are going to transfer their call

7. Why is the appearance and personal hygiene • of the phlebotomists important to the patient? • Patients feel that the quality of care they receive is reflected by the appearance and cleanliness of the caregiver • Five barriers to effective verbal communication and means to overcome each: • Hearing Impairment: Speak slowly and look directly at the person • Emotions: Use a calm tone of voice and demonstrate confidence & • concern • Age: Use age-appropriate phrases and words • Educational Level: Use terminology appropriate to the educational • level • Language Proficiency: Attempt to locate a translator; use basic • words and sign language

8. Clinical and Laboratory Standards Institute (CLSI) Established the techniques and principals for the phlebotomy profession. Primary roleof the phlebotomist is: To obtain blood specimens and transport specimens for diagnostic testing. Representative of the laboratory to the patient and the health care staff of the institution. Requires a professional, courteous, and understanding manner in all contacts with the patient. Two methods for collecting blood is: Venipuncture Microtechnique (dermal/capillary puncture) Sometimes arterial blood is collected by phlebotomists.

9. Functions of a phlebotomist To obtain venous blood specimens for diagnostic testing To remove blood from donors for blood transfusions Collect and properly package urine specimens Accept incoming specimens Route specimen to the proper departments to be tested and analyzed

10. Phlebotomist is a valuable member of the health care team Responsible for: Collection Processing Transportation of specimens

11. Duties of the phlebotomist • Demonstrate professional attire, attitude • and communications • Know facility’s policies and procedures • Properly identify patients • Collect both venous and capillary blood specimens • Select the appropriate and accurate specimen container for the specified tests

12. Cont’d • Properly label, handle, and transport • specimens following department policies • Sort specimens received and process • specimens for delivery to laboratory departments • Perform computer operations and/or • update log sheets where required • Perform point-of-care testing • Perform quality control checks • Observe all safety regulations

13. Phlebotomy Programs • Require high school diploma or GED • Offered in hospitals, technical and private schools and community colleges • Clinical training is from 120/200 hours • Courses vary from a few weeks to months

14. Phlebotomy Organizations ASCP: American Society of Clinical Pathologist PBT (ASCP) ASPT: American Society of Phlebotomy Technicians CPT (ASPT) AMT: American Medical Technologist RPT (AMT) NPA: National Phlebotomy Association CPT (NPA)

15. Entering the Room Should greet the patient and identify themselves and the procedures that will take place. Put the patient at ease. Effective communication is essential. Both verbal and nonverbal. Inpatient Proper identification of the patient is mandatory. Ask for full name, and check armband. Hospital identification number is the primary means for identifying the patient. Outpatient (OPD) Use the requisition as a reference. Birthday and social security Number is a source of information about the patient and a method of communication between the phlebotomist and the laboratory staff. Today OPD patients also are given an armband.

16. Post Venipuncture • Thank the patient after the procedure and excuse yourself • courteously, leaving the patient with a positive impression of • you and the laboratory you represent. (Clean up work areas) • Equipment and Supplies for Venipuncture • Collection Tray with Test Tube Racks • Evacuated Tubes • Needles • Holders • Tourniquets • Safety Disposal Unit (biohazard with symbol) • Alcohol Wipes (70 % isopropyl alcohol) • 2” X 2” Gauze Sponges • Bandages • Ammonia • Gloves • Requisition Forms

17. Common Errors • Identification of patient • Not labeling the tubes • Wrong name of the patient on tubes • Improper selection of tubes • Improper site cleansing • Improper specimen collection • Not properly mixing the tubes • Improper transportation of specimens

18. Problem Patients Fainting Refusal Nausea or Vomiting Convulsions Excessive Bleeding Cessation of Breathing Unconsciousness Obesity Tremors Disruptive Behavior Deaf or Hearing Impaired Communication Barriers Special Precautions Special Instructions at the Bedside Blind or visually Impaired Hematoma

19. Laboratory Departments • Hematology • Coagulation • Urinalysis • Immunohematology/Blood Bank • Immunology/Serology • Chemistry • Toxicology • Biochemistry • Microbiology • Bacteriology • Virology • Parasitology • Mycology • Rickettsiology • OPD/Collection & Transportation

20. Hematology Department Tube: Lavender/purple Anticoagulant: K3 Ethylenediaminetetraacetic Acid (EDTA) Invert: 8 Times This anticoagulant binds calcium Tests: CBC= Complete Blood Count WBC= White Blood Cell RBC=Red Blood Cell Plt=Platelet Count HGB=Hemoglobin HCT=Hematocrit Diff=Differential Cell Count (Identify 100 WBCs, RBC Morphology, Platelet estimation) Red Cell Indicies=MCV, MCH, MCHC RDW= Red Cell Distribution Width MPV=Mean Platelet Volume Other Test performed in this department are: Reti= Reticulocyte Sed Rate, or ESR= Erythrocyte Sedimentation Rate

21. Coagulation Department Tube:Light Blue Anticoagulant: Sodium Citrate Invert: 8 Times Anticoagulant binds calcium Tests: PT =(Prothrombin Time) PTT= (Partial Prothrombin Time) APTT= (Activated Partial thromboplastin Time) D-Dimer Fibrinogen TT=(Thrombin Time) Coagulation Factors FDP= (Fibrin Degradation Products) FSP=(Fibrin Split Products)

22. Blood Bank/Immunohematology • Tube: Plain Red (Glass) other tube: Pink/Lavender • Anticoagulant: None EDTA • Invert: None • Tests: • Type & RH • Crossmatch (x-match) • Antibody Screen (ABS) • Direct Coombs (DAT) • Antibody Identification Panel • RhoGam • Cold Agglutins • Blood Unit Components: • Packed Cells, Platelets, Fresh Frozen Plasma, Cryoprecipitate

23. Urinalysis Department • Collection Containers: • (urine)Plastic; Paper; or Metal • (stool) Plasic • (sperm) Plastic tube • Tests: Urinalysis • Physical (color, appearance, volume, odor) • Chemical (Sp.Gr., pH, Protein, Glucose, Ketones, Blood, Bilirubin, Urobilinogen, • Nitrite, Leukocyte esterase WBC) • Microscopic (WBCs, RBCs, Epithelial Cells, Casts, Crystals, Bacteria, etc.) • Stool (Feces) • WBC • Observe for Parasites (O & P) • Occult Blood • Spermatozoa • Sperm count • Motility • Types and Collection: • Random, First Morning, Timed, Midstream Clean-Catch, Catheterized

24. Serology/Immunology Department Tube: SST/Gold Plain RED Evacuated Tubes: (SST/Gold): Gel & Clot Activator Plain Red: None Invert: SST/Gold mix 5 Times Tests: Mono RA/RF Lupus ASO TITER CRP (C-Reactive Protein) ANA (antinuclear Antibody) HCG (Human Chorionic Gonadotropin) Pregnancy Tests Anti-HIV Hepatitis B Surface Antigen (HBsAG) Rapid Plasma Reagin (RPR) VDRL (Venereal Disease Research Laboratory)

25. Chemistry Department Tubes: Gold/SST Red Green/Mint Green Gray Lavender Royal Blue Clot Activator/Plain tunes: Gold/SST: Gel & Clot Activator Red: None Anticoagulant tubes: Green: Heparin (Sodium, Lithium, Ammonia) Mint Green: Gel & Plasma Activator Gray: Sodium Fluoride & Potassium Oxlate Lavender: EDTA Royal Blue: Red: None; Lavender: EDTA; Green: Heparin Invert: 5-8 Times except for the Red which is none

26. Chemistry Cont’d Tests: Electrolytes: Cardiac: Sodium CK- MB (Creatine Kinase) Potassium SGOT/AST Chloride LDH/LD (Lactic Dehydrase) Carbon Dioxide ALT/SGPT Tropin Kidney: BUN Liver: Creatinine SGOT/AST (Aspartate Aminotransferase) Creatinine Clearance ALT (Alanine Aminotransferase) ALP (Alkaline Phosphatase) Bone: Bilirubin (Total & Direct) Calcium GGT (Gamma Glutamyl Transferase) Phosphous Amylase Lipase Lipids: Vitamin B12 Cholesterol (HDL, LDL, VLDL) Lactic Acid Triglycerides Folate Ammonia Glucose (2 Hr PC, GTT, Fasting)

27. Microbiology Department Proceduresin this department are: Cultures, Stains, Microscopic examinations Biochemical Reactions Specimens are: Blood Urine Feces Sputum Genitourinary Tract Vaginal Eye Ears Nose Throat Wounds (Anaerobic, aerobic)

28. Special Handling Requirements Chilled Specimens Warmed Specimens Acetone Cold Agglutinin Test Ammonia Blood Gases Catecholamine Corticotropin Fibrinogen Ketones Lactic Acid Serum Gastrin (Chilled specimens are cooled immediately following collection to slow down metabolic processes that may alter some chemical values.) Light-Sensitive Specimens Bilirubin Carotene Erythrocyte Protoporphyrin Vitamine B12 Folate To protect from light wrap the collection containers in aluminum foil., or place in a dark container.

29. Special Procedures GTT: Glucose Tolerance Test (Diabetes Mellitus) A multiple-timed glucose test that evaluates the metabolism of carbohydrates over time 2 hour PC/PP:A type of glucose specimen collected 2 hours after the ingestion of food Fasting: Nothing to eat or drink for 8-14 hours Forensic or Chain of Custody Specimens Forensic specimens, which may be required for law enforcement agencies or litigation, must follow a special protocol called chain of custody. Chain of Custody: is a process of in-depth documentation that accounts for every personnel contact with the specimen from time of collection through Recording of the final results Blood Alcohol: Must carefully follow institutional procedure when collecting these specimens. Use a non alcohol antiseptic or soap and water for cleansing . Use a vacuum tube with sodium fluoride

30. Toxicology Specimens evaluated for the presence of drugs Therapeutic Drug Monitoring (TDM): Collection and testing of blood to evaluate and manage medication therapy effectively and safely Important to the diagnosis and safe management of drug treatment of the client Peak Level: A drug level in the blood collected 15 to 30 minutes after the dosage has been administered or when the highest serum concentration is expected Trough Level: A drug level in the blood collected when the lowest serum concentration is expected, which is usually immediately before administering the next dosage

31. Coagulation • Primary Hemostasis • 1. Vascular Platelet Phase • 2. Platelet Plug • 3. Bleeding time • Secondary Hemostasis • 1. Stable fibrin clot • a. Extrinsic System • b. Intrinsic System • c. Common Pathway • 2. Laboratory Assessment • a. Prothrombin Time • b. Activated Partial Thromboplastin Time • Fibrinolysis • 1. Breakdown of clot • 2. Fibrin degradation Products of D-dimers

32. Blood • Plasma • Formed Elements • 1. Red Blood Cells (Erythrocytes) • a. Function (Transports O2 and CO2) • b. Production • c. Destruction • d. ABO Blood Type Groups • e. Rh Blood Type (positive or negative) • 2. White Blood Cells (Leukocytes) Body Defense • a. Neutrophils (most numerous of WBC’s) • b. Lymphocyts • c. Monocytes • d. Eosinophils • e. Basophils • 3. Platelets(Thrombocytes) Blood Clotting

33. Three Major Types of Blood Vessels Arteries:(Oxygenated Blood) Are muscular and carry blood awayfrom the heart Veins: (Deoxygenated Blood) Have valves and carry blood to the heart Capillaries:(Resembles more Oxygenated Blood) Have walls only one cell thick for exchange of substances between the blood and tissues

34. Flow of Blood through the heart Vena cava Right Atrium Right Ventricle Pulmonary Artery Lung Pulmonary Vein Left Atrium Left Ventricle Aorta

35. Types of Needles 1. Multi-sample (evacuated method) Hypodermic (syringe) Parts of Needles 1. Hub Shaft Beveled Point Size of Needles 16-Gauge (Blood Donor Collection) 21- Gauge (Routine Venipuncture) 23-Gauge (Patient with small veins, butterfly)

36. Order of Draw • Blood Cultures (Sterile) SPS/Yellow • Coagulation Tubes (Sodium Citrate) Light Blue • SST/Gold , Plain Red • Green (Heparin)/(PST)Mint Green • Lavender (EDTA) • Gray (Sodium Fluoride, Potassium Oxalate) • Yellow (ACD)

37. Information that must be on a patient’s ID band • Patient’s Name • Patient’s ID Number • Date of Birth • Requesting Physician • Tests requested • Date and Time • Where to look for ID Band on the patient • Wrist • Ankle

38. 3 Reasons for requiring a requisition • Authorization to perform the procedure • Collection of appropriate equipment • Patient location and identification

39. Three Major Veins • Median Cubital (middle) • Cephalic (outer side) • Basilic (Inside)

40. Tourniquet Length of time to leave on the arm is: One Minute Why use a tourniquet? To permit arterial flow and to block venous flow Placement of tourniquet 3 to 4 inches above the bend of elbow Four test results that are affected by prolonged tourniquet application are: Proteins, Lipids, Enzymes, and Potassium

41. 3 Reasons for vein palpation 1. Determining the direction of the vein Determining the depth of the vein Determining the size of the vein

42. Reasons to allow the alcohol to dry on the patient’s arm before venipuncture Maximum bacteriostatic action Preventing a stinging sensation for the patient Prevention of hemolysis Alcohol + Blood = Hemolysis Two tests seriously affected by hemolysis are: Potassium LD Hemolysis: Red Cell destruction (Pink) Lipemic: Fats in Blood (Milky) Jaundice: Yellow Color of plasma or serum (eyes, skin)

43. Reasons why blood may not be obtained Collapsed vein Occluded vein Bevel of the needle resting on the wall of the vein Defective evacuated tube Causes of hematomas Removing the needle before removing the tourniquet Enadequate pressure or bending the arm Excessive probing Needle not fully inserted through the vein Needle inserted through the vein

44. Specimen Rejection 1. Unlabeled specimen Mislabeled specimen Inadequate Volume Wrong Tube Hemolysis Clotted Anticoagulated Tube Improper Transport Missing Requisition Form Contaminated Specimen Container

45. What is a professional? A person having great skill or experience in a particular field What is the definition of phlebotomy? To cut into a vein for the purpose of withdrawing a blood specimen What is the definition of venipuncture? To cut into a vein for any purpose Communication skills consist of : Speaking in a pleasant tone, making eye contact, being patient Who is considered the “father” of modern medicine? Hippocrates What is a “barber-surgeon”? A person who would cut hair, give an enema, let blood and pull teeth

46. What does OSHA stand for? Occupational Safety and Health Administration What does OSHA do? Sets standards for a safe and healthy workplace What is the best way for a health care professional to avoid infection? Hand washing between each patient and to wear gloves If an infection is airborne, it means? It is spread through droplets An infectious organism is an organism which is? Capable of spreading disease What is a susceptible host? Someone who lacks an effective resistance to a disease

47. An infection would cause the release of: White Blood Cells What equipment is needed to clean up a blood spill? Gloves, Bio-Hazard Bag, Paper Towel, and 1:10 dilution of bleach What is the number-one cause of exposure to disease in health care workers? Needle-stick injuries What is the CDC? Center of Disease Control What type of antiseptic is used to cleanse the skin of pathogenic bacteria fora normal blood specimen? 70% Isopropyl Alchol What infection is more easily spread through accidental needlestick injury? Hepatitis What is PPE? Personal Protective Equipment

48. How should a blood tube be opened to aliquot a sample? The tube top should be covered and “popped” away from the phlebotomist Where should lab coats be worn? In the work place setting The department responsible for analyzing a “Type/Crossmatch” is? Blood Bank Other tests in this department are? Direct Coombs, and Indirect Coombs The color of tube used primarily in this department is? Plain Red (May use Lavender or Pink) The department that analyzes an H & H, CBC, Reti, SedRate, Platelet Count, Diff,RBC, WBC, Platelet count is? Hematology The color of tube for this department is? Lavender/Purple Anticoagulant in this tube is? EDTA (Ethylenediaminetetraacetic Acid)

49. What department within a laboratory would handle a PTT/APTT specimen? Coagulation/Special Hematology What is the color of tube? Light Blue What is the anticoagulant? Sodium Citrate Other tests in this department are: PT, Fibrinogen, D-Dimer, Coagulation factors APTT must be tested within 4 hours What department within a laboratory would handle a specimen for a Culture and Sensitivity? Microbiology In what department of the hospital would you see a patient having radioactive isotopes injected into his/her arm? Nuclear Medicine

50. What kind of specimens are sent to the anatomical pathology laboratory? Biopsy Tissue, Cytology Specimens, Autopsy Specimens Blood collected in a Red Tube Yields: Serum What are the 3 main veins that are used for venipuncture? Basilic, Median Cubital, Cephalic The most common vein used for venipuncture is? Median Cubital Whenever drawing blood some of the considerations used for deciding which vein to draw blood from is? Bounce, Depth, Size also does it move, is it visible, does it looked bruised and red, Does it have a pulse and is it too hard and cord-like to puncture Veins are located in Skeletal Muscle and Collagen Veins have valves