D.12 Specimen Collection, 36C25522R0052.pdf

Pathology & Laboratory Medicine Service Department: POC VA Medical Center, Columbia, MO

POC.10 Patient Identification and Specimen Collection

The Pathology and Laboratory Medicine Policy for patient identification and specimen labeling applies to any specimen brought to the laboratory for testing. Due to the uniqueness of ancillary (Point-of-Care) testing, adjustments are made to this policy solely for use in ancillary testing.

1. The patient is to be identified using two sources. The patient ID bracelet provides a full name and SSN. The employee collecting the specimen will ask the patient to state their name and social security number. In the operating room, the patient will be identified by hospital policy using the "time out" policy in lieu of asking the patient to respond. Refer to Pathology and Hospital policies on patient identification.

2. There is to be one patient tested by one authorized instrument operator within the same room as the patient.

A. Cardiac Catheterization Laboratory – (ACT+ and Co-Ox) The specimen is to be tested in the same room where the patient procedure is taking place.

If for any reason a specimen is taken to an alternate procedure room, the specimen must be labeled with the patient name and full SSN before leaving the original room of collection.

B. Anesthesiology – (ACT+ and CG8+) The specimen is to be tested in the same room where the patient procedure is taking place. If for any reason a specimen is taken to an alternate procedure room, the specimen must be labeled with the patient name and full SSN before leaving the original room of collection.

C. All Accu-Check (Whole Blood Glucose) sites – The specimen is to be collected and tested at bedside. In the event that the specimen is venous or arterial blood in a syringe the person collecting the specimen must complete the testing at the bedside. Any time the specimen is collected by one person and another person will complete the testing, the specimen must be labeled with the patient name and SS#. If for any reason the specimen is taken to an alternate site, the specimen must be labeled with the patient name and full SSN.

D. Urine specimens – (Dipstick and hCG) The container will be labeled with the patient full name and full SSN before being given to the patient. The label on the specimen will be used to enter the patient ID into the Clinitek and for urine hCG testing.

D.12 Specimen Collection, 36C25522R0052

E. Body fluid pH – All body fluid pH will be tested at the patient bedside with the result recorded at the bedside on the sheet provided with the pH test kit. The sheet must be labeled with the patient's full name and full SSN at the bedside using the ID band for identification.

F. Skin Scrapings – Skin scrapings for KOH Prep or Mineral Oil testing will be tested on one patient at a time with the specimen and/or slide labeled with a minimum of the patient last name and "last-4". Results will be recorded using the full name and SSN.

G. Influenza and Strep testing will take place with one patient at a time. The operator will ask the full name and SSN. The SSN will be entered into the instrument.

H. The i-STAT1 will be tested at the patient bedside/chair. The full SSN will be entered into the i-STAT. If the specimen is taken to another area for testing, the tube of blood must be labeled with the patient full name and full SSN.

I. BinaxNOW COVID Ag will be tested at the patient bedside/chair. The full name and full SSN will be recorded on the log . If the specimen is taken to another area for testing, the swab must be labeled with the patient full name and full SSN.

3. Specific information pertaining to patient preparation, specimen preservation, and integrity of a specimen and resulting will be listed with the individual test procedures.

REFERENCES

• College of American Pathologists o Point of Care Testing Checklist o Laboratory General Checklist o All Common Checklist

• The Joint Commission

• HPM-390

• HPM-312

• McPherson MD MSc, R; Pincus MD PhD, M. 2017. Henry’s Clinical Diagnosis and Management of by Laboratory Methods 23rd Edition. Pages 481-508. St Louis, MO: Elsevier Inc.

Digital Copy link: https://www.clinicalkey.com/#!/browse/book/3-s2.0- C20130143425 https://www.clinicalkey.com/#!/browse/book/3-s2.0-C20130143425 https://www.clinicalkey.com/#!/browse/book/3-s2.0-C20130143425

BLOOD SPECIMEN COLLECTION

SOP PCS-11

Truman VA Medical Center Columbia, MO 65201

Signatory Authority:

Truman VA Medical Center Director

Responsible Owner:

Patient Care Services

Service Line(s):

Patient Care Services

Effective Date:

February 25, 2022

Recertification Date:

April 30, 2025

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures for the collection of blood specimens from peripheral sites and intravascular catheters.

b. There is no governing document.

2. PROCEDURES

a. Initial Assessment.

(1) Verify order for lab work to be drawn.

(2) Obtain all supplies prior to entering the patient environment.

(3) Introduce yourself to the patient.

(4) Verify the correct patient using two identifiers.

(5) Assess patient for allergies or sensitivity to antiseptic.

(6) Assess the patient for contraindications for venipuncture such as previous infiltration or phlebitis, mastectomy or other lymphatic system compromise, site affected by radiation, tissue injury or infection, site on affected side of cerebral vascular accident or current or planned hemodialysis access site.

(7) Ensure that all work surfaces used to hold blood drawing equipment have been disinfected to protect patient and specimens from contamination.

(8) Visually examine blood tubes and culture bottles for tube expiration dates and that blood specimen containers are not compromised.

b. Rules of Practice for Drawing Blood Cultures.

February 25, 2022 SOP PCS-11

(1) Although drawing blood cultures before or during the fever spike is optimal for recovery, volume is more important than timing in the detection of agents of septicemia.

When acute sepsis or another condition (osteomyelitis, meningitis, pneumonia, or pyelonephritis) requires immediate institution of antimicrobial agent therapy, draw two blood cultures of maximum volume consecutively from different anatomic sites before starting therapy.

(2) Two blood cultures of maximum volume should be drawn from two different sites.

Drawing at least two culture specimens from two different sites helps to distinguish between contamination and a true blood stream infection.

(3) Ensure that specimens are delivered to the laboratory promptly to detect infectious organisms in a timely fashion.

(4) Overfilling of the blood culture bottles can give a false positive result.

(5) Under filling blood culture bottles can diminish the yield of pathogens.

(6) For fever of unknown origin, subacute bacterial endocarditis, or other continuous bacteremia, or fungemia, draw a maximum of three blood cultures with maximum volume.

(7) Cultures should be obtained by a central venous access device only when a Central Line Associated Blood Stream Infection (CLABSI) is suspected and then a blood culture from a peripheral site should also be drawn.

(8) Beware of environmental contaminates including fans and aerosolizing trach's as these can contaminate the blood draw site after disinfection has occurred.

(9) If at all possible, blood cultures should be drawn prior to administering antibiotics.

(10) Do not use blood culture bottles that have cracks, contamination (indicated by a yellow sensor on the bottom), excessive cloudiness and bulging or indented bottle septums.

(11) If drawing multiple types of blood specimens, blood cultures should be obtained first.

(12) Keep blood culture bottles upright and below the level of the arm to avoid backflow of broth into the patient's vein when the butterfly is connected directly to blood culture bottles via the vacutainer adaptor.

(13) Disinfect blood culture bottle tops with 70% isopropyl alcohol and allow to dry.

(14) Palpate possible venipuncture site and pre-cleanse with alcohol prior to skin preparation and allow to dry.

(15) Prepare the insertion site with Chloraprep with a back and forth motion for 30 seconds, then, allow to dry.

(16) Do not wave the air with your hand to increase drying speed as this will increase the risk of recontamination of venipuncture site.

(17) Do NOT re-palpate venipuncture site once it has been cleansed.

(18) Using butterfly needle with vacutainer, obtain blood samples- remembering to hold the bottles in the upright position below the level of the arm to avoid back flow of broth into patient’s vein.

(19) Fill the blood culture bottles to the 10-ml mark made on the culture bottle. (The blood will not automatically stop flowing into the bottles).

(20) If using a butterfly needle with Vacutainer attachment, fill the aerobic bottle first as there may be air in the butterfly tubing. If using a syringe to draw the specimen, place a sterile transfer device on the syringe and fill the anaerobic tube first to minimize the chance of air going in the bottle.

c. When Drawing a Blood Culture From a Central Line.

(1) Replace the needleless connector prior to obtaining blood cultures to decrease the risk of contamination.

(2) Disinfect the new needleless connector with a vigorous mechanical scrub using a Chlorhexidine pad for 10-15 seconds and allow to dry. This step will be done before every access of the connector hub.

(3) After assessing the central venous catheter for patency, withdraw 10cc of blood from central line as waste.

(4) Clamp the central line and remove the waste syringe.

(5) Apply a sterile syringe to the needleless adaptor and withdraw the required volume of blood.

(6) Clamp central venous access device and remove syringe filled with blood.

(7) Attach blood filled syringes to a sterile transfer device and fill blood culture tubes to the 10ml mark (anaerobic bottle first if using a syringe).

(8) Attach sterile syringe with the appropriate flush solution and flush line with 10-20 ml.

(9) Resume ordered infusion or saline lock the central line and replace disinfecting port protector (Curos cap).

(10) Gently mix the culture broth and blood in the bottles.

(11) If Fungal and AFB blood cultures are needed, please contact the Micro department for the appropriate tubes.

d. Collection of Fungal Culture.

(1) Requires 10 ml of blood in Isolator tube (Fungal Culture).

(2) Invert the tube 4-5 times.

(3) Only submit this specimen between 5:00am-3:30pm.

(4) Prompt processing is needed when the patient is on antibiotics.

(5) Collection of AFB Blood Culture.

(6) Add 1-5 ml of blood into Myco/Lytic bottle and invert.

e. Peripheral Blood Draw Procedure.

(1) Explain the procedure to the patient.

(2) Perform Hand Hygiene.

(3) Don clean gloves.

(4) Palpate possible venipuncture site prior to skin preparation.

(5) For obtaining blood for blood cultures, see above 3b and 3c. For all other specimens, the skin can be prepared with a 70% alcohol.

(6) Cleanse the insertion site with appropriate disinfectant by a back and forth motion for 30 seconds.

(7) Allow the disinfectant to dry on the skin.

(8) Do not touch the venipuncture site once it has been cleansed.

(9) Obtain blood via venipuncture.

(10) See Appendix A for the order in which blood tubes should be filled.

(11) If a tourniquet is used, a new tourniquet should be obtained for each patient.

(12) A new vacutainer adaptor or collection barrel should be used for each patient.

(13) Discard the used needle, collection barrel and or transfer device in a designated sharps disposal container.

(14) Label all blood specimen containers at the bedside with the patient's name, full SSN, time, site of blood draw and initials of staff drawing the blood specimens. Do not cover the barcode label on the blood culture bottle if used.

(15) Immediately apply pressure over the venipuncture site with gauze until bleeding stops. Observe the site for hematoma or bleeding.

(16) Remove gloves.

(17) Perform hand hygiene.

(18) Transport blood specimens in a biohazard bag or as directed by the laboratory staff.

f. Peripheral Blood Draw Supplies.

(1) Alcohol swabs

(2) Chlorhexidine pads or sponges

(3) Tourniquet

(4) Band aide

(5) Clean gloves

(6) Butterfly catheter

(7) Vacutainer safety device

(8) Blood tubes and or Culture bottles

(9) Biohazard bags for transport to lab

(10) Ice slurry if needed for transport of specimens

(11) Laboratory forms/patient identification labels

g. Central Venous Line Blood Draw Procedure.

(1) Explain procedure to the patient.

(2) Perform hand hygiene.

(3) Don clean gloves.

(4) It the tubing must be detached, place a sterile cap on it.

(5) If drawing blood cultures or if visible debris or contamination is suspected, use aseptic technique and change the needleless connector before drawing the blood sample.

(6) Disinfect needleless connector with a vigorous mechanical scrub using the appropriate disinfectant and allow it to dry. (Chlorhexidine should be used when drawing blood cultures).

(7) After assessing the central venous catheter for patency by attaching a 10 ml normal saline flush or appropriate compatible flush solution and gently aspirating blood into the central line, then slowly inject flush solution into the central line.

(8) Withdraw 10cc of blood from central line and as waste to clear flush solution from the catheter.

(9) Clamp the central line and remove the waste syringe.

(10) Discard wasted blood specimen in appropriate biohazard container.

(11) Disinfect the needleless connector with a vigorous mechanical scrub with the appropriate disinfectant and allow to dry.

(12) Apply a sterile syringe to needleless adaptor and withdraw the required volume of blood.

(13) Clamp central venous access device and remove syringe.

(14) Repeat steps 11 and 12 if more blood is needed.

(15) Attach blood filled syringe(s) to a transfer device and fill blood specimen collection receptacles.

(16) Blood cultures should be obtained first and then tubes should be filled as per Appendix A.

(17) Aseptic technique should be maintained throughout procedure.

(18) Disinfect the needleless connector with a vigorous mechanical scrub with the appropriate disinfectant.

(19) Attach sterile syringe with the appropriate flush solution and flush line with 10-20 ml.

(20) Disinfect the needleless connector with a vigorous mechanical scrub with the appropriate disinfectant.

(21) Resume ordered infusion or saline lock the central line.

(22) Discard the supplies in the appropriate waste receptacles. Syringes used to draw blood should be discarded in the infectious waste receptacles.

(23) Label all specimens at the patient bedside with the patient's name, full SSN, time, site of blood draw and initials of staff drawing the blood specimens.

(24) If used, do not cover the barcode label on the blood culture bottles.

(25) Place the specimen(s) in a biohazard bag (Place bag in additional bag with ice if required).

(26) Remove gloves.

(27) Perform hand hygiene.

(28) Immediately transport the specimen to the laboratory.

h. Central Venous Line Blood Draw Supplies.

(1) Alcohol swabs

(2) Chlorhexidine swabs

(3) Clean gloves

(4) Sterile Syringes (Size and count determined by volume of blood needed)

(5) Blood transfer device

(6) Sterile needless connector

(7) Normal Saline flushes or appropriate flush solution

(8) Biohazard bags

(9) Blood tubes or culture bottles

(10) Ice slurry if needed for transport of specimens

(11) Laboratory forms/patient identification labels

i. Rules of Practice for Drawing Blood from a Central Line.

(1) Plan to obtain the blood samples at one time to minimize entry into the system and decrease the risk of CLABSI.

(2) Temporary double lumen dialysis lines and tunneled dialysis lines should only be accessed by nurses competent in hemodialysis.

(3) The third lumen in the Mahurkar temporary dialysis line can be accessed by nurses to draw blood specimens.

(4) Care should be taken when obtaining specimens for coagulation values from a heparinized central venous access device.

(5) Stop any running fluids for 3-5 minutes prior to drawing blood specimens.

(6) Blood should be drawn from an alternate site if stopping any intravenous infusion will cause instability for the patient.

(7) If tubing must be detached from the central venous catheter, a sterile cap should be placed on the end to prevent contamination.

(8) The needleless connector should be changed prior to obtaining the blood sample.

(9) All syringes used to draw blood from the central line should be free of air to prevent an air bolus to the patient.

(10) Only sterile syringes should be used to draw blood from a central line.

3. ASSIGNMENT OF RESPONSIBILITIES

N/A

4. DEFINITIONS

a. Additional Policy Information. Meticulous attention to aseptic and other proper procedural techniques in the collection of blood specimens from peripheral and intravascular catheter sites. This hospital policy memorandum (HPM) includes guidelines for drawing blood from a peripheral site and central venous catheters including dialysis catheters and is applicable to all services whose employees draw patient blood specimens from peripheral and or intravascular sites. Medical staff who collect blood cultures will be trained and signed off with the Blood Culture Competency Check Off (Appendix B).

5. REFERENCES

a. Centers for Disease Control and Prevention. (2011). Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines2011.pdf

b. Garcia, L. S. (2007). Clinical Microbiology Procedures Handbook. ASM Press.

c. Tile, P. (2017). Bailey and Scott's Diagnostic Microbiology. St. Louis Missouri:

Elsevier.

d. Valnet. (2017). Clinical Key for Nursing: Central Venous Catheter: Blood Sampling. Retrieved from Clinical Key for Nursing:

https://www.clinicalkey.com/nursing/#!/content/nursing_skills/63-s2.0CC_061?scrollTo=%23quicksheet

e. Valnet. (2017). Clinical Key for Nursing: Blood Specimen Collection: Blood Cultures. Retrieved from Clinical Key for Nursing:https://www.clinicalkey.com/nursing/#!/content/nursing_skills/63-s2.0-

GN_43_11C

6. REVIEW

This SOP must be reviewed at minimum at recertification.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of April 2025.

In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

Stephanie Absher, RN, MSN Associate Director of Patient Care Services Date Approved: February 25, 2022

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: SOPs are available at: http://dvagov.sharepoint.com/sites/vhacmo/pnp http://dvagov.sharepoint.com/sites/vhacmo/pnp

Appendix A

Laboratory tubes are color coded. The Clinical Laboratory Standards Institute (CLSI) recommends using tubes in the order shown.

• BLOOD CULTURE BOTTLES

• LT. BLUE Coagulation tube- Sodium Citrate

• RED, GOLD, RED/BLACK Serum tube: with or without clot activator/ gel

• GREEN Heparin-Lithium or Sodium

• LAVENDER, PURPLE, PINK EDTA

• GRAY Sodium Fluoride, Potassium Oxalate

Reference: Clinical and Laboratory Standards Institute (CLSI). Collection of Diagnostic Venous Blood Specimens; Approved Standard. 7th ed. CLSI document GP41. Wayne, PA: CLSI; 2017.

Appendix B

BLOOD CULTURE COMPETENCY CHECK OFF

Blood Culture Collection Education Points: Employee Initial

Contaminated blood cultures create false positive results for patients that may result in:

• Unnecessary antibiotics (potentially contributing to antibiotic resistant “super bugs”, C. diff infection, and prolonged hospitalization)

• PICC lines pulled or inserted as response to false positive

• Estimated cost of $4,385 to $8,720 on average for cost of inpatient stay stemming from contaminated culture. (1)

Blood culture sets (10ml volume each) should be drawn:

• From two different anatomical sites.

• Optimally, before starting antibiotic therapy.

• As the first fills in a series of blood specimen tubes.

Overfilling blood culture bottles can give a false positive result.

Underfilling blood culture bottles can diminish the yield of pathogens and give a false negative.

Cultures should ONLY be obtained from a central venous access device when a Central Line Associated Blood Stream Infection (CLABSI) is suspected. In this situation, one set of blood cultures should be drawn from a peripheral site for comparison.

Be aware of environmental contaminates including fans and aerosolizing trachs as these can contaminate the blood draw site after disinfection has occurred.

Collected specimens should be gently mixed, labeled per policy (with the site that it was drawn from), and sent immediately to the laboratory.

Rules of Practice for Drawing from Peripheral Site: Employee

Collect supplies and ensure blood culture bottles are not outdated or damaged.

Wash hands, introduce self, and verify the patient using two identifiers.

Disinfect blood culture bottles with 70% isopropyl alcohol and allow to dry.

Palpate possible venipuncture site and pre-cleanse with alcohol prior to skin preparation.

Prepare the insertion site with ChloraPrep with a back and forth motion for 30 seconds, then, allow to dry.

Do not wave the air with your hand to increase drying speed as this will increase the risk of recontamination of venipuncture site.

Do NOT re-palpate venipuncture site once it has been cleansed.

Using butterfly needle with Vacutainer, obtain blood samples remembering to hold the bottles in the upright position below the level of the arm to avoid back flow of broth into the patient’s vein.

Fill the blood culture tubes to the 10ml mark.

If using a butterfly needle with Vacutainer attachment, fill the aerobic bottle first as there may be air in the butterfly tubing.

If using a syringe to draw the specimen, place a sterile transfer device on the syringe and fill the anaerobic tube first to minimize the chance of air going in the bottle.

Rules of Practice for Drawing from Central Line: Employee

Collect supplies and ensure blood culture bottles are not outdated or damaged.

Wash hands, introduce self, and verify the patient using two identifiers.

Disinfect blood culture bottles with 70% isopropyl alcohol and allow to dry.

Replace the needleless connector prior to obtaining blood cultures to decrease the risk of contamination.

Disinfect the needleless connector with a vigorous mechanical scrub using a Chlorhexidine pad for 10-15 seconds and allow to dry. (2)

After assessing the central venous catheter for patency, withdraw 10cc of blood from central line as waste.

Clamp the central line and remove the waste syringe.

Chlorhexidine pad for 10-15 seconds and allow to dry.

Apply a sterile syringe to the needleless adaptor and withdraw the required volume of blood.

Clamp central venous access device and remove syringe filled with blood.

Attach blood filled syringes to a sterile transfer device and fill blood culture tubes to the 10ml mark. (anaerobic bottle first if using syringe)

Disinfect the new needleless connector with a vigorous mechanical scrub using a Chlorhexidine pad and allow to dry.

Attach sterile syringe with the appropriate flush solution and flush line with 10-20 ml.

Chlorhexidine pad and allow to dry.

Resume ordered infusion or saline lock the central line and replace disinfecting port protector (Curos cap).

BacT-Alert Manufacturer Videos of Procedure:

Peripheral Site- https://www.biomerieuxuniversity.com/bact-alert-direct-draw.html

Central Line- https://www.biomerieuxuniversity.com/bact-alert-central-line-draw.html

Clinical Skills Video Video of Procedure for Blood Culture Via Venipuncture:

https://mns.elsevierperformancemanager.com/NursingSkills/AnimationPlayer/Player.aspx?path=GN_43 _11C/GN_43_11C_20170622&animationID=GN_43_11C_20170622&mediaType=4

These videos are informational and have some differences from the above procedure. Please refer to procedure for detailed blood culture guidelines specific to Harry S Truman VA Hospital.

EMPLOYEE NAME: ___________________________________

EMPLOYEE SIGNATURE: ________________________________________ DATE: ______________

SUPERVISOR (OR SUPER-USER) SIGNATURE: _________________________ DATE: ______________

1. Zimmerman, F., Assous, M., Yinnon, A., & Wiener-Well, Y. (2018). Reducing blood culture contamination using a departmental report card. Journal of Hospital Infection [Online]. Retrieved from:

https://www.clinicalkey.com/#!/content/journal/1-s2.0-S0195670118301166

2. The Joint Commission (2013). Scrub the hub! The Joint Commission [Online]. Retrieved from:

https://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-21_Scrub_the_Hub.pdf https://www.biomerieuxuniversity.com/bact-alert-direct-draw.html https://www.biomerieuxuniversity.com/bact-alert-central-line-draw.html https://mns.elsevierperformancemanager.com/NursingSkills/AnimationPlayer/Player.aspx?path=GN_43_11C/GN_43_11C_20170622&animationID=GN_43_11C_20170622&mediaType=4 https://mns.elsevierperformancemanager.com/NursingSkills/AnimationPlayer/Player.aspx?path=GN_43_11C/GN_43_11C_20170622&animationID=GN_43_11C_20170622&mediaType=4 https://www.clinicalkey.com/#!/content/journal/1-s2.0-S0195670118301166 https://www.jointcommission.org/assets/1/6/CLABSI_Toolkit_Tool_3-21_Scrub_the_Hub.pdf