What Happens if I Use a Too Small of a Guage Needle When Drawing Blood for a Blue Top Vacurtainer

Venipuncture, Inpatient

Message

PRINCIPLE

Proper collection of blood specimens is of the utmost importance in producing valid laboratory results. Following proper venipuncture standards will produce biologically representative specimens for analysis as well as minimal discomfort for the patient.

PATIENT PREPARATION

1. Patient Greeting. Greet the patient using the "AIDET" technique which includes: Acknowledge, Introduce, Duration, Explanation, and Thank You.  This will help put the patient and ease during the procedure. Other notes:
   1. Inpatients:      If physician is in room or if a procedure is in progress, excuse yourself and return at another time.
   2. Children:       Be friendly, calm and confident reassuring the child and parent to limit the anxiety and in obtaining their cooperation. Prepare equipment prior to draw and out of sight to prevent any additional anxiety.  At CRMC, coordinate with RN to see if topical anesthetic will be applied on inpatient pediatric patients.

2. Patient Identification:
   1. Inpatients must be positively identified via their hospital Identification band attached to the patient.
      1. If patient is coherent, ask the patient to state his or her first and last name.  The collector must verify name and Medical Record on the armband with the request for laboratory work.
      2.  Verify visually or by Positive Identification Device (PID) procedure#16968.
      3. The request may be in the form of a laboratory requisition or computer generated labels.
   2. Outpatients must be positively identified verbally.
      1. Ask the patient or companion to say the patient's name and birth date or social security number.
      2. Verify this information with the outpatient requisition presented with the patient.
      3. Enter on requisition any requested clinical data, e.g. height, weight.
      4. Verify that all requested tests have been ordered appropriately.

3. Order Verification:
   1. If fasting or other diet restrictions are required for requested tests, verify that these conditions have been met.
   2. Verify any special timing requirements for collection, e.g., peak or trough drug levels, cardiac enzymes, timed glucose levels, stimulation tests.
   3. Follow appropriate age specific criteria as indicated in resource manual for Community Medical Centers Laboratories Age Specific Criteria for Specimen Collection.
      

EQUIPMENT and MATERIALS

1. Gloves- disposable, single use, nitrile (Use of special Hypersensitive gloves if approved by Employee Health.)
2. Tourniquet, non-latex
3. 70% isopropyl alcohol pads.
4. 2X2 gauze pads
5. Paper tape.
6. Sterile evacuated tubes, e.g., Vacutainers.
7. Biohazard bag for transport.  Rack for Outpatients.
8. Ice in cup or biohazard bag, if applicable for test.
9. Venipuncture Supplies (specific to collection method):

Direct draw method with Vacutainer holder	Sterile multi-sample needles 21 or 22 gauge
	Holder Device with safety mechanism
For Direct Draw method with Butterfly and vacutainer holder	21g or 23g Saf-T Wing Blood Collection Set with Holder 25g may be used on very small veins
For Direct Draw method with Butterfly, syringe and Transfer device	21g or 23g Saf-T Wing Blood Collection Set with syringe 25g may be used on very small veins

PROCEDURE - STEPWISE

1. Complete patient preparation and order review steps as indicated in Patient Preparation above.
2. Wash hands or use Gelsan™ alcohol based hand cleaner.
3. Put on Gloves. Clean gloves must be worn when performing venipuncture. If veins are difficult to palpate and skin is intact, initial site selection may be performed before gloves are donned. Gloves must be changed after each patient and when visibly contaminated.
4. Venipuncture Site Selection.
   1. The antecubital fossa is generally the most accessible site and causes less pain to the patient. The median cubital vein should be considered first as this is usually stable and not in close proximity of nerves. The cephalic and basilic veins should be secondary sites since they normally are closer to surrounding nerves. Care must be taken to avoid the brachial artery when using the basilic vein. Dorsal wrist and hand veins are acceptable for venipuncture when the antecubital area is unavailable. See procedure note #2.
   2. Position patient. Have patient extend arm to form a straight line from shoulder to wrist.
   3. Apply a tourniquet 3-4 inches above venipuncture site with enough pressure to restrict the vein but not an artery. If adequate pressure is used, a radial pulse can still be felt. Do not leave the tourniquet in place for more than one minute as hemoconcentration may occur resulting in falsely elevated values for protein based analytes and packed cell volume.  Reapply tourniquet just prior to puncture.
   4. Have patient close fist to make veins more prominent and easier access.Do not pump. Palpate the vein for depth and direction. Veins should have a spongy or elastic feel vs. tendons that have a hard and ropelike feel. Avoid thrombosed veins that lack resilience, feel hard and roll easily. If veins are not readily apparent, tapping gently at the site with index fingers may help dilate the vein. Warming the site may also be useful in making a vein more prominent. Blood can also be forced into the vein by massaging the arm from wrist to elbow.
   5. Alternative sites – Dorsal wrist or hand veins are acceptable. Ankles or lower extremities may be used with physician approval. Documentation of approval is to be placed in specimen comment in LIS system (SOFT).
5. Draw Method selection.  Choose one of these methods as appropriate for patient type and status.
   1. Direct draw with straight multi-sample needle and holder.  Appropriate for routine draws in the antecubital area.
   2. Direct draw with a winged collection set with multi-sample vacutainer tube holder.  Appropriate for small veins and the wrist/hand area where veins are close to the surface of the skin.
   3. Direct draw with a winged collection set with a syringe.  May be used for extremely fragile veins where collapse is likely for blood culture collection.
6. Venipuncture Site preparation: Clean the site using 70% isopropanol in a circular motion from center to periphery. Dry the area with 2x2 gauze or allow to air dry while preparing equipment. This prevents pain and hemolysis. Do not retouch. If vein must be touched it must be cleansed again.

Venipuncture Procedure:  Select one method

Direct draw method:  Saf-T-Holder and multi-sample  Blood Collection needle:	Twist and remove white needle cap from selected gauge multi-sample needle. Screw needle securely into the Saf-T Holder. Twist and pull colored needle cap straight off Have patient make a fist.  Anchor the vein by drawing the skin taut with thumb 1-2 inches below puncture site With needle bevel up, align the needle with the vein and puncture the vein using a quick smooth motion. The needle should be at a 15-30° angle with the skin. Once the vein has been entered, remove the anchoring finger and use that hand to grasp the flange of the needle holder and push the first tube forward.  Turn label of tube underneath to have a visual of blood flow in the tube At this position blood should begin entering the tube. The needle assembly must be held securely to prevent movement of the needle. Do not change position of the needle once blood flow is established.  Once vacutainer tube is full, remove and mix tube by inverting it 8-10 times. Insert additional vacutainer tubes, if applicable.  Follow correct order of draw as indicated in procedure note #1 Disengage the last tube from the needle before withdrawing from vein. Release tourniquet and have the patient open hand.  Position gauze pad over needle, withdraw needle and apply pressure with gauze keeping arm straight. Immediately after removing needle from vein, activate safety by positioning thumb squarely on orange safety shield or push orange shield against hard surface forward to cover needle.  An audible click may be heard. Discard immediately the needle and holder as one unit into nearest sharps container. Do not replace caps on needles A bandage of gauze and paper tape may be applied. Always ensure that bleeding has ceased before leaving patient. Tell patient to leave on bandage for at least 15 minutes.
Direct Draw method using Saf-T Wing Blood Collection Set and vacutainer tube holder:	Remove butterfly from wrapper and connect tubing to hub. Remove sheath from needle. Insert needle into vein by holding butterfly wings or housing. Ensure proper anchoring of butterfly for specimen collection.  Note:  For controlled patients with good veins, the device may not require ongoing anchoring.  For combative/moving patients, the phlebotomist may have to provide ongoing anchoring for needle. Insert vacutainer tube into the HUB/HOLDER and allow blood to flow into tube using correct order of draw. Once vacutainer tube is full, remove and mix tube by inverting it 8-10 times. Insert additional vacutainer tubes, if applicable.  Follow correct order of draw as indicated in procedure note #1. Disengage the last tube from the hub before withdrawing the butterfly needle from vein. Release tourniquet and have the patient open hand.  Position gauze pad over needle, withdraw needle and activate the safety mechanism in one of these three ways: Underhand Activation - best practice: Place gauze over the needle to absorb any blood that comes just after activation. Hold butterfly housing with thumb on top and fingers beneath with one hand. Pull tubing quickly from base close to housing.  There must be an audible click or visual confirmation of full activation. Overhand Activation Place gauze over the needle to absorb any blood that comes just after activation Hold butterfly housing with fingers on top and thumb is beneath with one hand Pull tubing quickly from base close to housing.  There must be an audible click or visual confirmation of full activation. Out of Vein activation for actively moving patients.  Keep control of needle at all times. Place gauze on top of butterfly needle Remove the needle from patient arm with needle pointing away from the patient and yourself. Quickly activate the needle by pulling tubing from base close to housing with other hand. There must be the audible click or visual confirmation of full activation.
Direct Draw method using Saf-T Wing Blood Collection Set and Syringe:	Remove butterfly from wrapper and connect tubing to syringe. Remove sheath from needle. Insert needle into vein by holding butterfly wings or housing. Ensure proper anchoring of butterfly for specimen collection. Note:  For controlled patients with good veins, the device may not require ongoing anchoring.  For combative/moving patients, the phlebotomist may have to provide ongoing anchoring for needle. Pull syringe plunger back slowly to control the amount of pressure placed on vein. Release tourniquet and have the patient open hand.  Position gauze pad over needle, withdraw needle and activate the safety mechanism in one of these three ways: Underhand Activation - best practice: Place gauze over the needle to absorb any blood that comes just after activation Hold butterfly housing with thumb on top and fingers beneath with one hand. Pull tubing quickly from base close to housing. There must be an audible click or visual confirmation of full activation. Overhand Activation - best practice: Place gauze over the needle to absorb any blood that comes just after activation When specimen is obtained, disconnect syringe and immediately discard butterfly. Immediately thereafter, attach syringe to transfer device and begin filling tubes in the correct order of draw as indicated in procedure note #1. Once vacutainer tube is full, remove and mix tube by inverting it 8-10 times Out of Vein Activation: When specimen is obtained, disengage syringe from butterfly. Place gauze on top of butterfly needle. Remove the needle from the patient arm with needle pointing away from the patient and yourself. Quickly activate the needle by pulling tubing from base close to housing with other hand.  There must be the audible click or visual confirmation of full activation. Discard butterfly. Attach  transer device to syringe and obtain specimens using correct order of draw as indicated in procedure note #1. Once vacutainer tube is full, remove and mix tube by inverting it 8-10 times. Discard transfer device and syringe assembly.

1. Apply pressure to Venipuncture site.  A bandage of gauze and paper tape may be applied. Always ensure that bleeding has ceased before leaving patient. Tell patient to leave on bandage for at least 15 minutes.
8. Dispose of all contaminated material into appropriate biohazard containers
9. LABEL ALL TUBES AT THE BEDSIDE . Use barcode labels for samples or hand label.  Label must contain:
   1. Patient First and Last Name
   2. Medical record Number
   3. Date and time of specimen collection
   4. Initials of collector (if using the PID system, this may be done electronically).

PROCEDURE NOTES

1. Vacutainer Tube Draw order- Proper order of filling evacuated tubes must be followed to avoid possible contamination of samples. Fill in the following order:
   1. Blood culture bottles
   2. Blue (citrate): Note: When using a butterfly and a blue coagulation tube is the first to be drawn, first use a discard tube (use either a CLEAR RED tube with no additives or a second blue top tube).The first tube is used to displace the air in the butterfly tubing.  Once blood reaches the discard tube, it can be replaced with the blue collection tube for testing. This ensures that the specimen tube can be filled to the FILL LINE and that the proper anticoagulant/blood ratio is maintained.
   3. Red- Serum
   4. Gold- Serum with separator gel (SST)
   5. Orange - Rapid Serum Tube (RST)
   6. Dark Green for whole blood or Light green with separator gel (PST)- heparin
   7. Lavender –EDTA (LAV)
   8. Pink – EDTA
   9. Gray -oxalate/fluoride
2. Non-routine draw site selection and notes:
   1. Avoid sites containing shunts, vascular grafts, and fistula/cannulas.
   2. Avoid healed burn areas, extensive scarring areas, and existing hematomas.
   3. Avoid sclerosed or hardened veins as these do not allow blood to flow through them easily.
   4. Mastectomy guidance:  Physician approval must be obtained before drawing blood from the same side as where mastectomy has been performed.
   5. IV Therapy - Blood should not be taken from above an active IV site as hemodilution will occur. If no other site is available, the IV flow must be stopped for at least 5 minutes before drawing blood above the site (IV stops and restarts must be performed by the patient's Nurse) .  Document in the Soft system under specimen comment.
   6. When the antecubital fossa is not an accessible site, dorsal wrist or hand veins may be used. Veins on the inside of the wrist should be avoided, if possible, as nerves, tendons and the radial artery are all in close proximity.
   7. Never draw from a heparin lock or line. Never allow a parent to draw from their own child.
   8. Foot and Ankle veins – Physician approval must be sought before proceeding to draw foot and ankle veins. Approval must be documented in SOFT system under specimen comment.
   9. Phlebotomists are not licensed to draw from a heparin lock or line.
   10. Never allow a parent to draw from their own child.
3. Preventing hemolyzed samples
   1. Invert tubes gently, do not shake.
   2. Never apply pressure to syringe plunger when filling evacuated tubes.
   3. Avoid using a small gauge needle. 21 gauge is recommended for standard venipuncture. Blood should not routinely be collected with a needle smaller than 23 gauge.
   4. Do not choose a site where a hematoma is present. If no other site available, draw just below the hematoma.
   5. Avoid excessive force when pulling back on syringe plunger.
   6. Allow alcohol(isopropanol) from wipe to dry thoroughly before puncture is made.
   7. Allow blood to flow down the side of the tube when filling with a syringe.
4. When the specimen cannot be obtained –
   1. Slightly change the position of the needle.  Varying the angle may increase blood flow. Small re-positioning movements are acceptable, do not probe. If penetrated to far, pull needle back slightly. If needle is not in far enough, advance slightly further into vein.
   2. Try another tube, occasionally tubes have lost vacuum.
   3. Loosen the tourniquet, it may have been tied too tightly and restricting blood flow.
   4. After two unsuccessful venipuncture attempts, seek another person to draw the specimen.
   5. Needles are single use and may be used only once. A needle must be discarded if it has pierced the skin, whether or not the venipuncture was successful.
   6. If after multiple sticks and at least 2 different phlebotomists have tried, contact the patient's nurse who will contact the ordering physician to determine the next course of action. For outpatients, reschedule or try on another day. Notify physician.
5. Blood Culture Collection Notes:
   1. Blood cultures may be collected using one of the following methods:
      1. Direct draw method consisting of a Saf-T Wing Blood collection set and Blood Collection male Adapter Cap.
      2. Direct draw method consisting of a Saf-T Wing Blood Collection set and syringe.  Use a Female Adapter to safely transfer blood from the syringe to the blood culture bottles.

SPECIAL SAFETY PRECAUTIONS

Follow all CMC safety and infection control procedures.

SPECIMEN HANDLING REQUIREMENTS

1. Mix all tubes with anticoagulant by gentle inversion at least 8-10x times.
2. Place samples in biohazard bag for delivery to Lab.
3. Samples can be sent to the laboratory through the Pneumatic Tube System (PTS) if available.

SPECIMEN STORAGE REQUIREMENTS

General guidance:

• Inpatients:  Deliver specimens to Lab within 30 minutes of collection.
• Outpatients:  Deliver processed specimens hourly according to main laboratory. Stat specimens as needed.

VENIPUNCTURE OR PATIENT PROBLEMS

Problem	Action/Corrective Action
Patient refusal	If a patient refuses a draw, do not draw against patient's wishes. Report objections to the patient's nurse. Document in order comment in SOFT if test is canceled due to patient refusal.  Clovis documents all refusals, even if test is not canceled but collection is merely postponed.
Syncope(Fainting) or Unexpected Responsiveness	For Inpatients, immediately get help from the patient's nurse.  Press call button or loudly call for help.  RN may initiate Rapid Response call. Outpatient:  If practical, lay the patient flat. If the patient is sitting and cannot be laid flat, then lower their head and arms below the level of their heart. Loosen tight clothing. Apply a cool wet towel to the forehead. If the patient does not immediately improve or is non-responsive to the above steps, then Dial 13 to request EMS service from Security dispatch. Report incident in IRIS reporting system.
Seizures or Convulsions	Inpatients: Immediately get help from patient's nurse. Press call button or loudly call for help.  RN may initiate Rapid Response call. Outpatient:  Dial 13 to request EMS service from Security dispatch for non-responsive patients. Call Pathologist immediately. The patient may lose consciousness and will usually have involuntary movement of extremities. Prevent injury to the patient by moving furniture or other objects away from them. Do not attempt to restrain the patient. Report incident in IRIS reporting system.
Nausea or Vomiting	For Inpatients, immediately get help from the patient's nurse.  Press call button or briefly leave room to get nurse help. Instruct patient to breathe deeply and slowly. Apply cold compresses to the patient's forehead Give the patient an emesis basin and have tissue available in case of vomiting.  If vomiting occurs, give patient water to rinse his/her mouth. Outpatient:  Contact Pathologist for serious vomiting especially if accompanied by feeling faint. Notify patient's physician for direction to continue with tests or return at a later date.
Continued bleeding  at venipuncture site	Ask patient if they are on aspirin or anticoagulant therapy.   Patients on therapy may bleed longer. Apply pressure to site with sterile gauze until bleeding stops. Wrap a Coflex™ bandage around the site over pad. Tell patient to leave bandage on the site for at least 15 minutes. Coflex is not carried on Clovis inpatient phlebotomist carts. In this circumstance, inpatient phlebotomist would either apply pressure until bleeding stops or contact the RN. If bleeding is excessive, contact nurse or pathologist. Continue to apply pressure.
Excessive pain at venipuncture site	The patient may encounter minimal pain during venipuncture.  Occasionally, the phlebotomist may accidentally hit a nerve due to inserting needle all the way through the vein, selecting wrong vein or in re-positioning the needle.  The patient will most likely have experience a sharp, electric tingling, painful sensation that radiates down to the hand. Release the tourniquet immediately and apply pressure over the site. Contact RN for inpatients or pathologist for outpatients.  A cold pack may be applied to the site. Report incident in IRIS reporting system.

Test Code

VENIP

Performing Laboratory
CRMC Laboratory
CCMC Laboratory
FHSH Laboratory
CCI Laboratory

The CPT Codes provided in this document are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payor being billed. Any Profile/panel component may be ordered separately. Reflex tests are performed at an additional charge.

wrightfroople.blogspot.com

Source: https://jdos.nicholsinstitute.com/dos/cmclab/test/370447

Share this post