Phlebotomy – the drawing of blood – has been practiced for centuries and is still one of the most common invasive procedures in health care. However, practice varies considerably between countries, and between institutions and individuals within the same country. These differences include variations in blood-sampling technique, training (both formal and “on-the job”), use of safety devices, disposal methods, reuse of devices and availability of hepatitis B vaccine.
The term ‘Phlebotomy’ suggests the taking of Blood only. This subject is not only concerned with “bloodletting”, but rather the whole range of skills and knowledge necessary for the collection of viable specimens for later analysis in a laboratory.
Phlebotomy – the act of drawing or removing blood from the circulatory system through a puncture to obtain a specimen for analysis and diagnosis.
Venipuncture– the puncture of a vein for surgical or therapeutic purposes, or for collecting blood specimens for analysis.
Vascular Access Devices (VAD)-a device inserted temporarily or permanently into a vein and /or artery to allow access to the circulatory system for the administration of fluids or medications, or for various procedures.
By its nature, phlebotomy has the potential to expose health workers and patients to blood from other people, putting them at risk from blood borne pathogens. These pathogens include human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and those causing viral haemorrhagic fevers (Crimean Congo haemorrhagic fever, Ebola, Lassa and Marburg) and dengue. For example, outbreaks of hepatitis B have been reported with the use of glucometers (devices used to determine blood glucose concentration). Diseases such as malaria and syphilis may also be transmitted via contaminated blood, and poor infection control practices may lead to bacterial infection where the needle is inserted and contamination of specimens.
If a blood sample is poorly collected, the results may be inaccurate and misleading to the clinician, and the patient may have to undergo the inconvenience of repeat testing. The three major issues resulting from errors in collection are haemolysis, contamination and inaccurate labelling.
Best practices in phlebotomy involve the following factors
• planning ahead;
• using an appropriate location;
• Quality control;
• Standards for quality care for patients and health workers, including –– availability of appropriate supplies and protective equipment; –– availability of post-exposure prophylaxis (PEP); –– avoidance of contaminated phlebotomy equipment; –– appropriate training in phlebotomy; –– cooperation on the part of patients;
• Quality of laboratory sampling.
Be prepared to deal with a reaction every time you do a venipuncture, There is no way to predict how a patient will react to a needle puncture. The collector must immediately report to the supervisor all complications and incident occurring during the draw and document it according to clinical laboratory policy, including exposure to blood and other infectious materials.
Hematoma is caused by blood leaking into the tissue during tissues during or following venipuncture and is identified by rapid swelling at or near the venipuncture site. If a hematoma begin to form during the venipuncture, the collector must remove the needle immediately and apply pressure. The collector must apply a pressure over the puncture site for at least 2 minutes. A cold or compress or an ice pack must also be applied to relieve pain and reduce swelling.
Situations that can trigger hematoma formation are as follows:
I. The vein is fragile or too small for the needle size.
II. The needle penetrates all the way through the vein.
III. The needle is only partly inserted into the vain.
IV. The needle is removed while the tourniquet is still on.
V. Excessive or blind probing is used to locate.
VI. Reassure is not adequately applied following venipuncture.
Accidental Arterial Puncture
If the blood pulses into the collection system or fills collection tubes rapidly and is bright red, an artery has been punctured. The collector must remove the needle immediately and apply direct forceful pressure to the puncture site for a minimum five minutes and until active bleeding has ceased. Inform the supervisor, or nurse –in-charge /physician; and document the incident.
Fainting or Syncope refers to the state of loss of consciousness and postural tone resulting from insufficient blood flow to the brain. The collector must watch the patient for signs of fainting like pallor (paleness), hyperventilation, vertigo, dizziness and light-headedness. When an incidence of fainting occurs, the collector must discontinue immediately the procedure by releasing the tourniquet and discarding the needle to protect the patient and discarding the needle to protect the patient and himself from injury.
The collector must have the patient to lay the patient flat or lower his/her head and arms .Recline chair is recommended for blood collection procedure. Loosen tight clothing; ask assistance form relative if available. A glass of water or orange juice may be provided. Maintain the patient in recumbent position until fully recovered, and continue monitoring.
The collector must call any nearby attending nurse or physician if the patient did not respond. Ammonia inhalants may be associated with adverse reaction and must not be used. Never draw blood from a patient who is standing. A standing patient is more likely to faint than one who is sitting or lying down.
Nausea and Vomiting
If patient feels nausea and vomits during venipuncture, the process must be terminated straight away. The patient should be reassured and made as comfortable as possible. The blood collector must ask the patient to breathe deeply and slowly. The blood collector must apply a cold compress to the patient’s forehead and provides him with an emesis basin (kidney dish) or bag. Give patient water to rinse out his/her mouth.
Anxiety / Fear
Patients, especially children under the age of 12 or mentally disabled persons, may show anxiety or fear when they present for blood collection. The collector must start by relieving the patients by explaining exactly what will happen and tries to calm him down as much as possible. The collector must communicate with the patient on each step he is doing to keep on reassuring him.
Normally, a patient will stop bleeding from the venipuncture site within few minutes. However, some patients are on anticoagulant therapy like aspirin, may take longer to stop bleeding. If bleeding endures, the collector must apply a firm pressure on the puncture site until the bleeding visibly ceases. The collector can also advise the patient to hold his hand elevated above the level of his/ her heart. If by any means, the bleeding didn’t stop for more than 5 minutes, the collection must notify his or her treating physician.
Wash wounds and skin sites that have been in contact with blood or body fluids with soap and water. Apply a sterile dressing as necessary and apply pressure through the dressing if bleeding is still occurring. Encourage bleeding before washing well with soap and water. If blood gets on the skin, irrespective of whether there are cuts or abrasions, wash well with soap and water. If blood or body fluids get in the mouth, spit them out and then rinse the mouth with water several times. If clothing is contaminated, remove clothing and shower if necessary. Inform your Immediate Supervisor and/or Head of the Department immediately after the exposure