S02 - SOLICITATION ATTACHMENT - D.19 20-03 Ordering Laboratory Tests Phlebotomy and Specimen Collection.pdf

The master document is controlled electronically on the D&T drive. Printed copies of this document are not controlled and users are responsible for ensuring printed copies are valid prior to use.

Department of Memorandum Veterans Affairs

Date: March 10, 2020 LABORATORY PROTOCOL

20-03

From: Chief Pathologist, P&LMS 113

Subj: Ordering Laboratory tests, Phlebotomy, and Specimen Collection;

• Test request

• Patient identification

• Specimen collection and labeling

• Minimizing of Blood Volumes taken

• Inpatient and Outpatient Phlebotomy issues

To: P&LMS Staff

PURPOSE:

The purpose of this policy is:

1. To meet and exceed all appropriate regulations

2. To define acceptable practice for ordering tests, patient identification prior to phlebotomy, and acceptable specimen labeling

3. To address issues and concerns related to inpatient phlebotomy, to include:

• Provision of additional protective clothing and devices to be used as required for isolation patients.

• Provision of notice to P&LMS staff of AFB patients on the morning collection.

• Phlebotomy of patients receiving blood/blood product transfusion.

• Handling of patients with an IV or heplock.

• Safety related issues and practices.

• Phlebotomy in Dining rooms.

4. To define policy and address issues specific to the outpatient phlebotomy process

5. To minimize volume of blood collected for test requests

6. To ensure at least 2 sources of patient identification are used to identify patient prior to phlebotomy, and to label specimen containers.

ATTACHMENT D.19 20-03

The master document is controlled electronically on the D&T drive. Printed copies of this document are not controlled and users are responsible for ensuring printed copies are valid prior to use.

PROTOCOL: (refer to Clinical Laboratory Manual for detail procedure and notes)

• Ordering Lab tests:

1. Lab orders should be placed in the computer. A lab slip may be used in an unusual circumstance.

2. Lab orders must include the patient's name, social security number, patient location, ordering physician, and tests requested.

3. In the case of Blood Bank requests, a complete Laboratory Requisition form or the downtime form are required. Please refer to the Clinical Laboratory Manual or Medical Center Professional Memorandum for details.

4. STAT or PRIORITY requests must be indicated as such. Unless specified otherwise, all orders will be processed as ROUTINE.

5. The information must be correct and legible.

6. In the case of an Order Entry request (OE):

a. The label with the order number on it is to be placed on the specimen in such a way as not to interfere with opening the specimen. The specimen should be delivered to the Laboratory promptly.

b. Laboratory staff will promptly accession all specimens. For regulatory purposes, the accession time is to be considered the time of receipt, as the difference is clinically insignificant.

c. Once a Lab order has been collected and sent to the Laboratory for processing that lab order number cannot be used again later when collecting a new specimen. New orders are required for future specimens.

7. In the event that there is a discrepancy between the patient identification information on the test request, on the specimen, or in the computer, (or that this information is absent/illegible), the Laboratory staff will request a new specimen.

*NOTE: ALL SPECIMENS SUBMITTED TO THE LABORATORY MUST BE PROPERLY

LABELED WITH THE PATIENT’S FULL NAME AND FULL SOCIAL SECURITY NUMBER.*

• Inpatient Identification – by lab staff on morning rounds:

1. The patient is found by matching ward, room, and bed numbers on the request. If this information is not recorded on the collection list, then ask at the nursing station.

2. Greet the patient and ask the patient to recite his/her name and social, if able. Do not state the patient’s name, and then ask the patient for confirmation of his/her name to determine if this is the correct patient. Patients have agreed to incorrect names, especially if hard of hearing.

3. If there is no ID band affixed to the patient, wait until a proper wristband is affixed to the patient. Never draw a patient without a wristband on their person (not on table or bed).

4. Verify the patient’s name and social security number from the patient's wristband. The information on the

The master document is controlled electronically on the D&T drive. Printed copies of this document are not controlled and users are responsible for ensuring printed wristband should match the name and social security number on the request and/or labels.

5. Ask the patient to recite his/her social security number as a second verification of identity. If he/she is unable, then refer to the patient's bedside chart, labeled IV/medication bag, or the patient directory board at the nursing station as a secondary source of identity. Verbal identification from a nurse is acceptable only as a secondary source of identity.

6. If there appears to be a discrepancy in the name or the social security number, check with the nursing station for possible error.

7. If the patient does not want his/her blood drawn, explain that the test was ordered by a doctor and that it is in his/her benefit to have it drawn. At all times be courteous. If the patient still does not want his blood drawn, do not argue. Thank the patient, and do not draw the blood.

8. In the case of patients with a large number of tests ordered, all efforts will be made to minimize the blood volume taken. The volumes needed are noted on the collection list, and any questions can be directed to more experienced staff in the appropriate lab sections.

9. Laboratory staff should discontinue phlebotomy efforts on a patient after two unsuccessful attempts and refer the test order to a troubleshooter.

10. The tubes should be labeled at the bedside immediately after the blood is drawn and the patients puncture site is tended to. Staff should never pre-label tubes.

11. Proper labeling of all non-blood bank specimens must include the patient’s full first and last name and the entire social security number. The phlebotomist’s initials must be written on the lab collection list. Each individual patient drawn should be initialed on the collection list, not just one set of initials for the entire list. The date and time of collection should be noted on all specimens, not just blood bank tubes. When date and time of specimen collection are not available on the specimen, the receipt time in the laboratory will be used as the collection time. Unknown collection time (T@U) will not be used.

12. Blood Bank specimens must include the phlebotomist’s initials, date, and time of draw on the label. They must be accompanied with the Lab Requisition form or the downtime form, which must include the date and time of draw, the patient’s full name and social security number, and the phlebotomist’s signature and DUZ number. Blood Bank specimens should only be drawn after a provider has entered an order.

• A second phlebotomist or nurse must be present as a witness to the patient identification and the collection of a Blood Bank specimen. The witness must confirm the correct patient identification and correct labeling of the specimen. After collection is complete, they are required to sign the requisition form as the witness at the Signature of Witness area and provide their DUZ#.

They must also record the date and time of the draw.

• It is the phlebotomist’s responsibility to locate a witness for the specimen collection. The patient’s bedside nurse or another medical technologist would be an appropriate witness.

13. If the phlebotomy on a patient is not successful, the Charge Nurse should be notified before leaving the ward. If the reason the patient was not drawn is that he/she is a difficult stick, this would apply after the trouble shooter makes an attempt. The patient information, tests/specimens needed, the reason the patient was not drawn, and the name of the Charge Nurse informed should be left as a communication on the ward. The reason the patient

The master document is controlled electronically on the D&T drive. Printed copies of this document are not controlled and users are responsible for ensuring printed was not drawn and the name of the Charge Nurse should also be documented on the collection list and entered into the computer when the tests are canceled by the laboratory staff. If the Charge Nurse is unavailable, note this on the collection list and enter the name of alternate Nurse who was informed on the collection list and in the computer. (Please refer to separate lab protocol on “Morning Bloods Not Collected” for additional details.

• Additional Inpatient Phlebotomy Issues:

1. Phlebotomists will follow hospital policy and which protective garments must be worn for patients in various forms of isolation. If these garments are not provided outside the patient’s room, P&LMS staff will not enter the isolation room.

*Note that the CLC on the 8th floor uses “Lady Bug” signs to indicate precautions to maintain a home-like environment. Check with a floor nurse before entering any patient room with a Lady Bug sign to confirm what precautions are necessary before entering the room.

2. It is the responsibility of Infection Control to ensure adequate notification of patients on AFB isolation is provided. The “Airborne Transmission Precaution” sign must be placed prominently at the entrance of the patient room and must specify what precautions must be taken in order to enter the room. The only exception to the requirement of this sign is when the patient must be transported outside of the negative pressure room. In this case, verbal communication would be used with all involved in the transport of the patient. In the rare event that a nurse informs a phlebotomist that the patient is under AFB isolation precautions and there is no sign posted on the patient’s door, the phlebotomist should use proper precautions to draw the patient and then notify Infection Control that the sign was not posted on the door.

a. The notification of patients on AFB isolation is required to ensure that the personnel use the required proper respiratory mask. Phlebotomists should have these masks available in their cart if they are not supplied by the floor. Phlebotomists should be FIT tested to identify the correct style and size mask. It is each individual employee’s responsibility to ensure FIT testing is up to date. If FIT testing is expired, a Powered Air Purifying Respirator (PAPR) shall be used and is provided on each floor.

3. Patients that are in the process of being transfused blood or blood products will not be phlebotomized by the lab during the transfusion.

4. When a patient has an IV or heplock, the other arm should be used for phlebotomy. If this is not possible, then a site BELOW the IV or heplock can be used. For example, a patient with a heplock in their forearm/wrist area must only be drawn in the hand on that arm (if the opposite arm is not able to be drawn), and not in the antecubital area. If there is not an adequate site below the IV/heplock, the patient will not be drawn.

5. All staff will utilize the appropriate personal protective equipment while performing phlebotomy, as defined in the standard operating procedures. The following practices will be required:

a. Gloves will be changed between all patients, and hands washed/decontaminated.

b. Recapping of needles will not be allowed.

c. Tourniquets will be discarded between patients.

6. Phlebotomy will not be allowed in dining rooms.

The master document is controlled electronically on the D&T drive. Printed copies of this document are not controlled and users are responsible for ensuring printed

• Outpatient Phlebotomy

1. All patients must fill out a sign-in slip with their name and the last four digits of their social security number, or alternate ID and give the slip to facilitator through the window. The phlebotomist/technologist will locate lab orders and print out specimen labels after patient arrival. (Labels will not be pre-printed). If there is an incorrect order location, the phlebotomist should correct the order or central accessioning should be contacted to correct the order and/or suggest the appropriate tubes to draw.

2. All patients should be greeted promptly and courteously; addressing them by title (Mr./Ms./Mrs.) followed by their last name.

3. Once the patient is in the phlebotomy chair the patient should be asked to recite their full social security number as one form of identification. Additional or alternate forms of identification can be the patient's

Veteran’s Identification Card (VIC) or driver’s license for a positive patient identification.

4. Proper labeling of all specimens will include the patient’s name, the entire social security number, date and time collected. Staff will initial the sign-in slips for each patient drawn and document time drawn. The sign-in slips will be saved for the entire shift. Initialing the (non-Blood Bank) tubes on outpatients drawn is strongly recommended.

Blood Bank draws

a. Prior to accessioning a Blood Bank order, requisitions are to be printed from

Outpatient Phlebotomy through CPRS. Blood Bank specimens should only be drawn after a provider has entered an order.

1. During computer downtime, a downtime form must be used.

2. If the order was entered as Lab Collect, a downtime form must be used.

b. Once phlebotomist receives a patient who requires blood to be drawn for BB testing the phlebotomist will follow the directions as outlined in the ATTACHMENT: How to Print a Blood Bank Request for Outpatient Phlebotomy.

c. The phlebotomist will compare the name on the requisition and specimen labels.

Another unique form of patient identification is mandatory prior to drawing blood bank specimens.

d. Unique patient identification may include, but are not limited to:

1. Driver’s License

2. Veteran’s Identification Card (VIC)

3. Armband (if available, can be used for patient ID)

4. VISTA Imaging (photo ID)

5. Recitation of Full Social Security number

e. The phlebotomist that verified patient identity should be the phlebotomist that draws the specimen (there are no exceptions to this rule).

1. If the phlebotomist that verified the patient identification has trouble collecting the specimen and requires the help of another phlebotomist, then the subsequent

The master document is controlled electronically on the D&T drive. Printed copies of this document are not controlled and users are responsible for ensuring printed phlebotomist is required to re-verify the patient’s identification before phlebotomizing the patient. This subsequent phlebotomist is also required to start the phlebotomy process from the beginning.

2. Absolutely no pre-labeling of tubes should occur.

f. A second phlebotomist must be present as a witness to the patient identification and the blood draw of a type and screen specimen (see part i.).

1. In the event that there are no other phlebotomists available to witness the specimen collection, the phlebotomist must immediately contact the Blood

Bank to request for a medical technologist to report to Outpatient Phlebotomy to witness the collection. The medical technologist will designate another appropriate technologist to witness the collection if they are unable to report to

Outpatient Phlebotomy at the time of the request.

g. Once the specimen has been collected the phlebotomist who performed the phlebotomy (verifier) is required to sign, date, and provide their DUZ# at the

Signature of Verifier area of the Lab Requisition form (or a downtime form if during computer downtime). Upon signing the requisition, the phlebotomist will attest the following:

I have performed positive identification of this patient. I compared the full name and social security number on the sample label and verified that they exactly match the identifiers on this form, and the patient’s armband or VIC card/Driver’s license. I labeled the sample before leaving the patient’s side.

h. The witness must confirm the correct patient identification and correct labeling of the specimen. After collection is complete, they are required to sign the requisition form as the witness at the Signature of Witness area and provide their DUZ#. They must also record the date and time of the draw. By signing as the witness, they attest to the following:

I witnessed the person above collect this blood sample. I have read the full name and social security number on the sample and verified that they exactly match the identifiers on this form and the patient’s armband or VIC card/Driver’s License before leaving the patient’s side.

i. The specimen and requisition must be placed in an appropriate bag and brought immediately to the Blood Bank laboratory. The phlebotomist must call Escort and verify that immediate pick-up is available. If Escort is unavailable, it is the phlebotomist’s responsibility to bring the specimen immediately to Blood Bank.

j. Any specimen collection concerns or questions should be directed to the personnel in Blood Bank at x53325 or x53326.

The master document is controlled electronically on the D&T drive. Printed copies of this document are not controlled and users are responsible for ensuring printed

5. In the case of patients with a large number of tests ordered all efforts will be made to minimize the blood volume taken. The volumes needed are noted in the computer, and any questions can be directed to the appropriate lab sections.

6. If a urine specimen is required, the urine cup should be labeled prior to giving it to the patient, and the patient directed to the rest room within Outpatient Phlebotomy. If that restroom is already occupied, then the patient should be directed to the next nearest restroom. The patient should also be instructed where to drop off the specimen when they are through.

7. If patients are to report to additional departments, instruct them as to the proper location.

8. The following tools will be posted and available in phlebotomy for handling problem requests and ensuring coverage:

a. List of clinics, phone extensions, hours of operation

b. Schedule for departmental coverage and phone extensions

c. Facilitator schedule and phone extensions

9. Efforts will be made to keep the patients waiting period under 20 minutes. In the event of heavy workload, if the waiting period exceeds 20 minutes, a call for departmental assistance will be made.

10. Phlebotomists will utilize the appropriate personal protective equipment while performing phlebotomy, as defined in the standard operating procedures. The following practices will be required:

a. Gloves will be changed between all patients, and hands washed/decontaminated.

b. Recapping of needles will not be allowed.

c. Visibly contaminated tourniquets or blood drawing equipment will be disposed.

• Truncated Patient Names on Specimen Labels

On occasion, patient names have too many characters to fit onto a specimen label and are truncated.

They may only be accepted under certain circumstances:

1. When drawing blood:

a. These labels may be used for specimen labeling after phlebotomy if the full social security number is visible on the specimen label and it matches the verbally recited full social security number (when applicable) and the printed number on the patient’s wristband.

2. When receiving labeled specimens:

a. These labels may be accepted in the laboratory for specimen testing if the full social security number is visible on the specimen label and it matches the patient’s full social security number that is listed with the lab order number.

b. These labels may be accepted in the Blood Bank for testing if the full social security number is visible on the specimen label and it matches the patient’s full social security number that is listed with the lab order number and it matches the patient’s full social security number that is on the requisition form. The visible characters of the patient’s name on the specimen label must also be compared to the full name listed on the requisition form.

The master document is controlled electronically on the D&T drive. Printed copies of this document are not controlled and users are responsible for ensuring printed

• Specimen Identification in the Laboratory

1. After properly labeled specimens have been received in the lab, the lab will maintain adequate identification on specimen containers throughout all phases of testing. This includes, but is not limited to, aliquots, dilutions, tubes, slides, blocks, culture plates, and other secondary specimens created during specimen processing and/or testing and will be defined by section procedures.

RESCISSIONS: 07-01, 08-01, 11-01, 12-02, 13-10, 16-10, 17-03, 18-02, 19-06

RESPONSIBILITY: The responsibility of ensuring compliance with this policy is delegated to the technical staff performing the phlebotomy, and the Section Supervisors. Overall responsibility resides with the

Chief Pathologist, P&LMS.

REVIEW & REVISION SCHEDULE:

• Annual review by Lead Pathologist (date and initials below)

• Revision every 3 years: Due 2023

Yiran Dai, MD

Chief Pathologist, Pathology and Laboratory Medicine 113

Henry D. Friedman, MD

Blood Bank Medical Director Pathology and Laboratory Medicine 113

20-03: Ordering Laboratory Test, Phlebotomy, and Specimen Collection

Date Annual Review Complete: Initials of Reviewer (Lead Pathologist)

Review Due 2021 __________

Review Due 2022 ________________

REVISION DUE 2023