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201711331

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Policies,Clinical,UW Health Clinical,General Care and Procedures,Labs/Specimens

Drawing Venous Blood Specimens on Inpatients (2.5.7)

Drawing Venous Blood Specimens on Inpatients (2.5.7) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Labs/Specimens

2.5.7


UW HEALTH CLINICAL POLICY 1
Policy Title: Drawing Venous Blood Specimens on Inpatients
Policy Number: 2.5.7
Category: UW Health
Type: Inpatient
Effective Date: November 21, 2017

I. PURPOSE

To provide clarification of hospital inpatient department responsibilities for drawing venous blood specimens.

II. POLICY ELEMENTS
A. The UW Health Clinical Laboratory is responsible for providing a phlebotomy service.
i. The Phlebotomy staff provides routine and special phlebotomy service in a variety of inpatient and
outpatient settings. Services provided include routine adult and pediatric venipuncture or capillary
collections, blood culture collection and blood bank specimen collection. Special services include
collection of the H. pylori breath test.
ii. The phlebotomists collect specimens in the majority of the patient care units. Note: Phlebotomy
does not collect from ICU patients, serve TLC, ED, Post Anesthesia Care areas, nor The American
Center (TAC). Early AM draw (Phlebotomy AM Rounds) occur between 0430 and 0900. Electronic
orders can be added for the 0430-0900 draw before 0800. Orders placed after 0800 will be
collected during the 0900 sweep by phlebotomy. The Phlebotomy Department provides “continuous
sweeps” for covered Inpatient units between 0900 and 2300. These sweeps occur every 60-90
minutes. Health Link orders with the status Lab Collect will cross into the Phlebotomy handheld
system at or after 0900. The phlebotomist will collect lab sample requested by the arrival of each
sweep of the unit. If an order is placed shortly after the phlebotomist has visited the unit, it will be
saved and collected on the next sweep. For that reason, it is important that timed draws or Stat
collections be set up for Unit collect (Collect Now) in Health Link.
iii. If phlebotomists are unable to obtain a specimen from certain patients, they are required to inform
the nurse, or alternately, the Care Team Leader or Charge Nurse, before they leave the unit. The
phlebotomist will document cancellation and rescheduling actions in the Communication Log inside
the Phlebotomy Unit Binder located at the unit work station. The phlebotomist can reschedule
collection for a future sweep (up to two hours ahead, if rescheduled more than two hours, labs will
be cancelled with cancellation description “to be collected by unit”) at the request of the unit staff. If
the unit chooses to cancel the phlebotomy collection prior to the two hour timeframe, the
phlebotomist will cancel the orders in the lab system promptly and provide cancellation labels to the
unit. If the nurse later completes the collection, use the cancellation labels provided by the
phlebotomist for labeling of the specimens. The cancellation labels:
a. List the names of the tests that were cancelled and the tube type needed for collection.
b. Provide notice to the Core laboratory that the testing was cancelled in the lab system and
must be reordered.
iv. When phlebotomy staff is not available (2300-0430), or tests are ordered for a specific time or Stat,
the lab orders will be set up as Unit Collect. In emergencies and/or routine situations medical staff,
interns, residents, registered nurses, other personnel, and persons in training under appropriate
supervision will draw the specimens.
B. All disciplines that have responsibility for drawing blood will be competent to do so, and are aware of related
policies. See Section III, References.
C. When the specimen of blood is drawn, it must be collected and submitted in the appropriate tube/container
and accompanied by an appropriate request form.
i. The tube/container must be labeled in the presence of the patient, comparing the patient labels and
the Workstation order form to the patient ID band.
ii. The labels must be legible with at least the patient's full name, date of birth, MR number, date and
time of specimen collection and collector identification.
iii. If collecting specimens for Transfusion Service, write employee ID number and date and time
collected on the label. Endorsing the label on a pink tube with employee ID number indicates you
have verified the patient identification AND that the patient has a proper wristband in place.
iv. The Workstation order must be printed (unless cancelation labels have been provided) and sent
with all non-lab collected specimens. This ensures that the laboratory knows the correct tests to
release for the specimen type, date and collection time from all of the tests that are available to be



UW HEALTH CLINICAL POLICY 2
Policy Title: Drawing Venous Blood Specimens on Inpatients
Policy Number: 2.5.7

released. This ensures we act on the intent of the provider that ordered the test and the intent of
the person that collected the specimen.
v. The Workstation order form must be legible with the required information including patient's full
name, MR number, date of birth, ordering physician, date of service, diagnosis/signs and
symptoms, collector information and the test(s) requested. If the collector differs from that listed on
the Workstation order form, this information must be changed on the form before submitting the
specimens to the lab.
vi. For instances where orders have been released from Health Link into the lab system and the unit
wishes to collect the specimens, use Phlebotomy Collect Orders that are Drawn by Unit form. Send
properly labeled samples with this form to Core laboratory.
vii. The labeled tube/containers and matching Workstation order (or Phlebotomy Collect Orders that
are Drawn by Unit) form must be individually bagged together and sent to the laboratory in a
biohazard bag. The tubes are sealed inside the bag and the form is placed in the outside pouch.
When the pneumatic tube system is used for transport, the biohazard bag is sealed in a red
pneumatic tube pouch (CS item #1202065) for delivery.
viii. Use of laboratory Inpatient request forms (form name: IPDOWNTIME) are limited to use for Health
Link Downtime or hospital departments not active on CPOE. Forms are available on u-connect.
ix. For Code Blue, use Code Blue Cart forms. Forms are kept in Central Services for stocking the
carts.
D. To reduce the risk of needlestick injury, phlebotomy equipment with sharp safety shields will be used
routinely:
i. To draw blood and transfer blood specimens.
ii. Activating sharps safety shields immediately after use.
iii. Discard used/blunted sharps into a sharps disposal container.
iv. Use butterfly needle only when absolutely necessary (not routinely) and only if you can safely
activate the sharps safety device properly.
III. FORMS

Physicians Order Sheets, UWHC #1280071
Inpatient Downtime, UWH #IPDOWNTIME
Microbiology Lab Req, UWH #1280625
Transfusion Lab Req, UWH #1280411

IV. COORDINATION

Author: Director, Clinical Lab
Senior Management Sponsor: SVP/COO, University Hospital
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: November 20, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


VI. REFERENCES




UW HEALTH CLINICAL POLICY 3
Policy Title: Drawing Venous Blood Specimens on Inpatients
Policy Number: 2.5.7

Nursing Departmental Policy #1.11, Arterial Catheter: Insertion, Maintenance, Blood Drawing and
Discontinuation
Nursing Departmental Policy #1.14A, Invasive and Non-invasive Hemodynamic Monitoring (Adult)
Nursing Departmental Policy 1.20AP-Venous Access Device Phlebotomy Procedure
Nursing Departmental Policy #11.11, Arterial Blood Specimen Drawing via Direct Radial Artery Puncture
Phlebotomy Procedure #1507.P009, Venipuncture Technique
Phlebotomy Procedure #1507.P014, Blood Culture Collection
Phlebotomy Policy #1507.BD.3.11, Labeling Laboratory Specimens
Phlebotomy Procedure #1507.P010, Skin Puncture Blood Collection
Clinical Laboratories Policy #1502.5.07, Specimen Rejection
UW Administrative Policy #4.12, Drawing of Blood at Police Request

VII. REVIEW DETAILS
Version: Revision
Last Full Review: November 21, 2017
Next Revision Due: November 2020
Formerly Known as: UWHC policy #8.19