What Should A Health Care Worker Do First If The Patient Faints During A Blood Draw?

This chapter covers all the steps recommended for safe phlebotomy and reiterates the accepted principles for claret drawing and claret collection (31). The chapter includes background information (Department ii.1), practical guidance (Section two.2) and illustrations (Section ii.3) relevant to all-time practices in phlebotomy.

The information given in this section underpins that given in the remainder of Role Ii for specific situations. Affiliate 4 also provides information relevant to the procedure for drawing blood given below in Section two.ii, but focuses on blood collection from donors.

Institutions can employ these guidelines to establish 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.ane.iv and ii.2.

2.1. Background information on best practices in phlebotomy

Best practices in phlebotomy involve the post-obit factors:

planning ahead;
using an advisable location;
standards for quality treat patients and health workers, including

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availability of appropriate supplies and protective equipment;

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availability of postal service-exposure prophylaxis (PEP);

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abstention of contaminated phlebotomy equipment;

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advisable training in phlebotomy;

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cooperation on the part of patients;
quality of laboratory sampling.

2.i.1. Planning alee

This is the nigh important part of carrying out any procedure, and is usually done at the first of a phlebotomy session.

2.1.2. Using an appropriate location

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

two.1.3. Quality control

Quality balls is an essential office of best practice in infection prevention and control (i). In phlebotomy, it helps to minimize the take a chance of a mishap. Table 2.ane lists the primary components of quality assurance, and explains why they are important.

Table 2.i

Elements of quality assurance in phlebotomy.

2.i.iv. Quality intendance for patients and wellness workers

Several factors can improve safety standards and quality of care for both patients and health workers, and laboratory tests. These factors, discussed below, include:

Availability of appropriate supplies and protective equipment

Procurement of supplies is the direct responsibility of the administrative (management) structures responsible for setting upwards phlebotomy services. Management should:

provide paw-hygiene materials (soap and h2o or booze rub), well-fitting non-sterile gloves, single-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 blood sampling;
brand available sufficient laboratory sample tubes to preclude dangerous practices (e.g. decanting claret to recycle laboratory tubes).

Several safety-engineered devices are available on the market; such devices reduce exposure to blood and injuries. Still, the use of such devices should be accompanied by other infection prevention and control practices, and grooming in their use. Not all safety devices are applicative to phlebotomy. Before selecting a safe-engineered device, users should thoroughly investigate available devices to determine 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, safety equipment and best exercise; Annex C provides a comprehensive guide to devices available for drawing blood, including safe-engineered equipment.

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

Where rubber-engineered devices are not available, skilled use of a needle and syringe is acceptable.

Availability of post-exposure prophylaxis

Adventitious exposure and specific data near an incident should be recorded in a register.

Support services should be promoted for those who undergo accidental exposure. PEP can aid to avert HIV and hepatitis B infections (13, 27). Hepatitis B immunization should exist provided to all health workers (including cleaners and waste handlers), either upon entry into health-care services or equally part of PEP (34). Annex D has details of PEP for hepatitis B and HIV.

Avoidance of contaminated phlebotomy equipment

Tourniquets are a potential source of methicillin-resistant Staphylococcus aureus (MRSA), with upwards to 25% of tourniquets contaminated through lack of mitt hygiene on the part of the phlebotomist or reuse of contaminated tourniquets (35). In addition, reusable finger-prick devices and related indicate-of-care testing devices (east.grand. glucometers) contaminated with claret have been implicated in outbreaks of hepatitis B (four, 5, 36).

To avoid contamination, any common-use items, such equally glucometers, should be visibly clean before use on a patient, and single-use items should not be reused.

Training in phlebotomy

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

Groups of health workers who historically are not formally trained in phlebotomy should be encouraged to take upwards such training; lax infection prevention and command practices issue in poor safety for staff and risk to patients (20, 37).
The length and depth of training will depend on local conditions; however, the preparation should at to the lowest degree cover the essentials (see Annex East) (38).
Supervision by experienced staff and structured training is necessary for all wellness workers, including physicians, who undertake blood sampling.

Patient cooperation

Ane of the essential markers of quality of care in phlebotomy is the interest and cooperation of the patient; this is mutually beneficial to both the health worker and the patient.

Clear information – either written or verbal – should be available to each patient who undergoes phlebotomy. Annex F provides sample text for explaining the claret-sampling procedure to a patient.

2.1.five. Quality of laboratory sampling

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

cognition of staff involved in blood collection;
use of the correct gauge of hypodermic needle (see Table three.1 in Chapter iii) to prevent haemolysis or abnormal results;
the anatomical insertion site for venepuncture;
the utilise of recommended laboratory collection tubes;
patient–sample matching (i.e. labelling);
transportation conditions;
interpretation of results for clinical management.

two.ii. Practical guidance on best practices in phlebotomy

2.2.1. Provision of an appropriate location

In an outpatient department or clinic, provide a dedicated phlebotomy cubicle containing:

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a clean surface with two chairs (one for the phlebotomist and the other for the patient);

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a hand wash basin with soap, running water and paper towels;

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booze hand rub.
In the claret-sampling room for an outpatient department or clinic, provide a comfortable reclining couch with an arm rest.
In inpatient areas and wards:

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at the patient'due south bedside, close the bed pall to offer privacy

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ensure that blood sampling is done in a individual and clean mode.

2.2.2. Provision of articulate instructions

Ensure that the indications for blood sampling are clearly defined, either in a written protocol or in documented instructions (due east.g. in a laboratory form).

2.2.3. Process for drawing claret

At all times, follow the strategies for infection prevention and control listed in Table ii.2.

Table 2.2

Infection prevention and control practices.

Step ane. Assemble equipment

Collect all the equipment needed for the procedure and place it within condom and easy reach on a tray or trolley, ensuring that all the items are clearly visible. The equipment required includes:

a supply of laboratory sample tubes, which should be stored dry and upright in a rack; blood tin can be collected in

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sterile glass or plastic tubes with safety caps (the choice of tube will depend on what is agreed with the laboratory);

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vacuum-extraction claret tubes; or

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drinking glass tubes with spiral caps;
a sterile drinking glass or bleeding pack (collapsible) if large quantities of blood are to be collected;
well-plumbing fixtures, not-sterile gloves;
an assortment of claret-sampling devices (rubber-engineered devices or needles and syringes, see below), of different sizes;
a tourniquet;
alcohol manus rub;
gauze or cotton fiber-wool ball to exist practical 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, the health worker, but away from the patient, to avert it existence accidentally tipped over.

Step two. Place and prepare the patient

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

Introduce yourself to the patient, and ask the patient to state their full proper name.
Check that the laboratory grade matches the patient'southward identity (i.e. match the patient's details with the laboratory class, to ensure accurate identification).
Ask whether the patent has allergies, phobias or has e'er fainted during previous injections or claret draws.
If the patient is anxious or afraid, reassure the person and inquire what would make them more comfy.
Make the patient comfortable in a supine position (if possible).
Place a make clean paper or towel under the patient's arm.
Discuss the test to be performed (see Annex F) and obtain exact consent. The patient has a right to refuse a test at any time before the blood sampling, and then it is of import to ensure that the patient has understood the process.

For paediatric or neonatal patients, see Chapter 6.

Pace three. Select the site

Full general

Extend the patient's arm and inspect the antecubital fossa or forearm.
Locate a vein of a adept size that is visible, straight and clear. The diagram in Section 2.three, shows common positions of the vessels, but many variations are possible. The median cubital vein lies betwixt muscles and is unremarkably the nigh like shooting fish in a barrel to puncture. Under the basilic vein runs an artery and a nerve, so puncturing here runs the risk of damaging the nervus or artery and is ordinarily more painful. DO Not insert the needle where veins are diverting, because this increases the risk of a haematoma.
The vein should be visible without applying the tourniquet. Locating the vein volition help in determining the correct size of needle.
Apply the tourniquet well-nigh 4–5 finger widths higher up the venepuncture site and re-examine the vein.

Hospitalized patients

In hospitalized patients, exercise not take blood from an existing peripheral venous access site considering this may requite faux results. Haemolysis, contamination and presence of intravenous fluid and medication can all alter the results (39). Nursing staff and physicians may access central venous lines for specimens following protocols. Nevertheless, specimens from primal lines bear a risk of contamination or erroneous laboratory test results.

Information technology is adequate, but not ideal, to depict blood specimens when first introducing an in-dwelling venous device, before connecting the cannula to the intravenous fluids.

Step 4. Perform paw hygiene and put on gloves

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

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if hands are not visibly contaminated, clean with alcohol rub – employ iii ml of alcohol rub on the palm of the hand, and rub it into fingertips, back 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, clean the site with a 70% alcohol swab for 30 seconds and permit to dry out completely (xxx seconds) (40–42).

Note: booze is preferable to povidone iodine, considering claret contaminated with povidone iodine may falsely increase levels of potassium, phosphorus or uric acid in laboratory exam results (6, 7).
Apply firm but gentle pressure. Start from the centre of the venepuncture site and piece of work downwards and outwards to cover an area of ii cm or more than.
Permit the expanse to dry out. Failure to allow enough contact time increases the risk of contagion.
Practise Non touch the cleaned site; in particular, Practise NOT identify a finger over the vein to guide the shaft of the exposed needle. It the site is touched, repeat the disinfection.

Step six. Have blood

Venepuncture

Perform venepuncture as follows.

Ballast the vein past holding the patient's arm and placing a pollex Below the venepuncture site.
Ask the patient to form a fist then the veins are more prominent.
Enter the vein swiftly at a 30 degree angle or less, and continue to introduce the needle along the vein at the easiest bending of entry.
Once sufficient blood has been nerveless, release the tourniquet BEFORE withdrawing the needle. Some guidelines propose removing the tourniquet as presently as blood period is established, and ever before it has been in place for 2 minutes or more than.
Withdraw the needle gently and apply gentle pressure to the site with a clean gauze or dry out cotton fiber-wool ball. Ask the patient to hold the gauze or cotton wool wool in place, with the arm extended and raised. Ask the patient NOT to bend the arm, considering doing so causes a haematoma.

Pace vii. Fill the laboratory sample tubes

When obtaining multiple tubes of blood, use evacuated tubes with a needle and tube holder. This system allows the tubes to be filled direct. If this system is not available, apply a syringe or winged needle ready instead.
If a syringe or winged needle set is used, best practice is to place the tube into a rack before filling the tube. To prevent needle-sticks, use one hand to make full the tube or use a needle shield betwixt the needle and the hand property the tube.
Pierce the stopper on the tube with the needle directly above the tube using wearisome, steady force per unit area. Practice not printing the syringe plunger considering boosted pressure increases the chance of haemolysis.
Where possible, go on the tubes in a rack and move the rack towards you. Inject down into the appropriate coloured stopper. Do NOT remove the stopper considering it volition release the vacuum.
If the sample tube does not have a prophylactic stopper, inject extremely slowly into the tube equally minimizing the pressure level and velocity used to transfer the specimen reduces the risk of haemolysis. DO Not recap and remove the needle.
Before dispatch, invert the tubes containing additives for the required number of times (as specified by the local laboratory).

Step viii. Depict samples in the correct gild

Draw claret collection tubes in the correct gild, to avoid cross-contamination of additives between tubes. As colour coding and tube additives may vary, verify recommendations with local laboratories. For analogy purposes, Table two.iii shows the revised, simplified recommended lodge of draw for vacuum tubes or syringe and needle, based on United States National Commission Clinical Laboratory Standards consensus in 2003 (43).

Tabular array 2.3

Recommended social club 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 label and forms for accurateness. The label should be clearly written with the data required by the laboratory, which is typically the patient's first and final names, file number, date of birth, and the date and time when the blood was taken.
Discard used items into the advisable category of waste. Items used for phlebotomy that would not release a drop of blood if squeezed (eastward.g. gloves) may be discarded in the general waste matter, 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, then give thanks the patient and say something reassuring and encouraging before the person leaves.

Step ten. Prepare samples for transportation

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

Pace eleven. Clean upwardly spills of blood or body fluids

If blood spillage has occurred (e.yard. because of a laboratory sample breaking in the phlebotomy expanse or during transportation, or excessive bleeding during the process), clean it up. An case of a prophylactic procedure is given beneath.

Put on gloves and a gown or apron if contamination or bleaching of a compatible is probable in a large spill.
Mop upwards liquid from large spills using newspaper towels, and place them into the infectious waste matter.
Remove equally much blood as possible with wet cloths before disinfecting.
Appraise the surface to see whether information technology will be damaged by a bleach and water solution.
For cement, metal and other surfaces that can tolerate a stronger bleach solution, food the area with an approximately 5000 parts per million (ppm) solution of sodium hypochlorite (ane:10 dilution of a 5.25% chlorine bleach to water). This is the preferred concentration for large spills (44). Leave the surface area wet for x minutes.
For surfaces that may be corroded or discoloured by a strong bleach, make clean carefully to remove all visible stains. Brand a weaker solution and get out it in contact for a longer catamenia of time. For example, an approximately 525 ppm solution (1:100 dilution of 5.25% bleach) is effective.
Set up bleach solution fresh daily and keep it in a closed container because it degrades over time and in contact with the sun.

If a person was exposed to claret through nonintact skin, mucous membranes or a puncture wound, complete an incident report, every bit described in WHO all-time 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 data on dealing with a claret spillage.

two.iii. Illustrations for all-time practices in phlebotomy

Effigy two.ii Filling tubes

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

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