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Venipuncture Technique (1507.P009)

Venipuncture Technique (1507.P009) - Policies, Clinical, UWHC Clinical, Department Specific, Clinical Laboratories

1507.P009

UWHC Clinical Laboratories Original Date: 2/18/2000
Phlebotomy Current Version Date: 2/25/2016
Document Title: Venipuncture Technique
Document ID: 1507.P009 Page 1 of 6

Medical Director and Date: Teresa Darcy, MD 4/25/13, 1/7/2014 & 3/7/2016; David Yang, MD 5/24/17

Effective Date: 1/28/2015
Technical Reviewer Date Manager Date Faculty Director Date
Karin Ravet 4/25/13 Kimberly Corrado 4/25/13 Teresa Darcy, MD 4/25/13
Melissa Hahn 1/7/14 Kimberly Corrado 1/7/14 Teresa Darcy, MD 1/7/14
Melissa Hahn 1/15/15 Kimberly Lueptow 1/15/15 Teresa Darcy, MD 1/15/15
Melissa Hahn 2/29/16 Kimberly Lueptow 2/29/16 Teresa Darcy, MD 3/7/16
Melissa Hahn 5/25/17 Kimberly Lueptow 6/7/17 David Yang, MD 5/24/17




I. Purpose
A. Provide phlebotomy service for patients of all ages and obtain quality venipuncture
specimens for laboratory testing.
B. Maintain patient comfort and satisfaction - be sure to K.N.O.D. whenever interacting
with patients and families
1. Knock or AcKnowledge
2. Name
3. Occupation
4. Duty
C. Use SPOT method for patient safety
1. Scan barcode labels whenever possible
2. Print labels immediately before use at patient side
3. Observe proper identifiers and scan for signs in patient rooms
4. Toss unused labels immediately
D. Ensure phlebotomists’ safety
II. Procedure
A. The equipment listed below is needed to perform a routine venipuncture:
1. Gloves
2. Tourniquet
3. 2 X 2 gauze
4. Alcohol wipes
5. Blood collection tubes – pediatric fill as needed
6. 21 or 22 gauge needle assembly (i.e., Eclipse™) or 21 or 23 gauge winged
infusion set (butterfly needle with leur adaptor and needleless connector as
needed)
7. Heel warmer, or instant heat pack for pediatric or hard to draw patients
8. Syringe and transfer device
9. Tape
B. Venipuncture technique
1. Wash hands or clean with alcohol hand gel.
2. Identify patients using at least two (2) patient identifiers.
a. For outpatients, ask them to spell their first and last name and state their
date of birth.

UWHC Clinical Laboratories Original Date: 2/18/2000
Phlebotomy Current Version Date: 2/25/2016
Document Title: Venipuncture Technique
Document ID: 1507.P009 Page 2 of 6

b. For inpatients, ask them their name. Verify their name (including spelling)
and date of birth by scanning their barcoded wristband with wireless
handheld. Scan the barcoded patient labels to verify labels and patient
identification match.
3. Attach the needle to the needle holder and assemble supplies. Place gauze to be
used after needle is withdrawn on a clean surface. If after assembly, it is
determined that the venipuncture cannot be done, the needle assembly should
be disposed of in the sharps container.
4. Put on gloves. Note: It is also acceptable to put on gloves after applying the
tourniquet and locating the venipuncture site if the patient is not in isolation.
5. Tie tourniquet around the arm 3-4 inches above the venipuncture site. Tie the
tourniquet tight enough to restrict venous return, but not too tight to restrict
arterial flow. Tourniquet application should not exceed one minute as localized
stasis with hemoconcentration and infiltration of blood into tissue can occur. If the
tourniquet has been in place for longer than one minute it should be released and
reapplied after two minutes.
6. Following CLSI procedure for selection of blood collection site and precautions.
Locate a suitable site in the antecubital fossa area (the area of either arm that is
in front of and below the bend of the elbow). Veins on the back of the hand are
also acceptable for venipuncture. Locate by finger palpation and trace the path of
the vein with your finger. Do not collect from:
a. sites where a pulse is detected
b. areas of extensive scarring such as healed burns
c. limb on same side of body on which a mastectomy or lymphadenectomy
was performed
d. avoid a site of a hematoma or edema if possible
e. limbs with intravenous fluids running. If there are no other options, you
may draw below the IV after fluids have been paused for 2 minutes or you
may draw above the IV after drawing a waste tube.
f. active fistulas/grafts
g. any site with restriction noted by care team (i.e., do not use left arm)
7. Cleanse site with alcohol prep using a circular motion from center to periphery.
Site should be re-cleansed if contaminated by re-palpation. Allow the area to dry.
8. Hold the patient’s arm firmly. Immobilize the intended puncture site before
inserting the needle. To immobilize, place the phlebotomist’s thumb below the
intended puncture site and draw the skin taut. Do not place other fingers in front
of the draw site.
9. Insert the needle bevel up at a 15 to 30 degree angle. Use a smooth, steady
advance until the bevel tip enters the vein. Hold the needle firmly in place.
10. While keeping the assembly firmly in place, use the flange of the tube holder to
gently push tube forward until it is engaged.
11. After tube is filled, smoothly disengage it using tube holder for leverage.
Withdraw the tube from holder. Mix the blood gently and thoroughly by inverting
the tube 6-10 times. Repeat until all specimens are collected. Follow correct
order of draw:
a. Blood culture (with proper skin preparation with Chlorahexadine)
b. Light blue
c. Red or royal blue (non-additive); SST
d. Green, PST

UWHC Clinical Laboratories Original Date: 2/18/2000
Phlebotomy Current Version Date: 2/25/2016
Document Title: Venipuncture Technique
Document ID: 1507.P009 Page 3 of 6

e. Lavender, pink or royal blue EDTA
f. Pico syringe
g. Research kits
12. As the last tube is filling, release tourniquet and remove the last tube from the
holder.
a. IP setting: use tourniquet available in patient room. Tourniquet will be
removed by Environmental Services when room is turned over. If not
available, use disposable tourniquet. Do NOT leave tourniquets in rooms
with a sitter, Department of Corrections patient or B6/5.
b. OP setting: tourniquet is to be disposed of after single use. Only during an
emergency shortage can the tourniquet be wiped down with Cavi wipe
between patients for an additional use.
13. Withdraw the needle. Activate the safety device with one hand by using your
thumb to push forward until an audible click is heard.
14. Throw disposable holder and needle with engaged safety shield in sharps
container. Do not remove needle from holder prior to disposal. Do not stick finger
in the holder assembly, as it contains a contaminated needle under the rubber
sleeve.
15. Place clean side of gauze against the venipuncture site and apply gentle
pressure to stop bleeding. If able, patient may assist by holding gauze in place.
16. Assess site for bleeding prior to placing bandage over venipuncture site. If
patient is still bleeding, apply pressure to site until bleeding stops. Apply tape or
bandage to puncture site. Do not use CoFlex or Coban on patients.
17. Correctly label all tubes at the patient’s bedside or before the patient leaves.
18. Wash hands or gel out using alcohol hand gel before leaving the patient room or
finishing process (for OP). Inpatients hand held devices need to be wiped down
with a Caviwipe between patients, or place in a plastic bag or wipe with a Clorox
wipe (bleach based wipe required) for patients in isolation setting (includes C.
difficile infection).
19. Winged infusion set (butterfly) draw:
a. Use with peripheral veins and blood cultures.
b. Insert butterfly needle after proper site preparation as detailed above.
c. Collect blood into blood collection tubes with a leur adaptor and
disposable needle holder or use a syringe with needleless connector
valve.
d. Upon completion withdraw needle and apply light pressure to site.
e. Immediately activate the safety device on the butterfly. It will click when
the shield is locked in place. Discard in a sharps container.
f. If sample collected with a syringe, using a transfer device, transfer blood
into collection tubes following proper order of draw.
20. If necessary to perform the venipuncture from the same extremity as an existing
IV (unable to find another suitable location), do the following:
a. Phlebotomists are required to call patient’s nurse to pause any IV. Wait
two minutes after IV is stopped then apply tourniquet.
b. Draw sample (preferably below IV site). If necessary to draw above the
IV, take a five (5) mL waste before collecting samples.
c. Remove tourniquet.
d. Indicate on the label specimen was obtained either above or below
existing IV site.

UWHC Clinical Laboratories Original Date: 2/18/2000
Phlebotomy Current Version Date: 2/25/2016
Document Title: Venipuncture Technique
Document ID: 1507.P009 Page 4 of 6

e. Call nurse to resume IV flow.
21. Alternate site collections should only be considered if unable to obtain blood from
the antecubital area or the back of the hand. An alternate site collection is only
allowed in the foot or ankle. If there is a need to perform an alternate site
collection proceed as follows:
a. Inpatient - Check with nursing before proceeding with the alternate site
collection. Ask the nurse if the patient is diabetic. If the patient is diabetic
inform the nurse you cannot perform the collection on the foot or ankle.
Nursing will need to decide how to proceed with the collection and
phlebotomist will cancel the order as “to be drawn by unit”.
b. Outpatient – Review “Snap Shot” in Health Link to determine patient’s
diabetic status. If unable to determine diabetic status, contact the
patient’s provider or clinic nurse to ask if the patient is diabetic. If patient
is diabetic, inform ordering provider you cannot perform the collection on
the foot or ankle and phlebotomist will cancel the order as “unable to
collect”.
c. Patient may be drawn from the foot with note in chart from MD and if the
patient is not diabetic.
22. Important Points:
a. When locating a suitable vein, the tourniquet should be released after one
minute to avoid localized stasis.
b. The selected vein should be soft, large, with good tone and no pulse.
c. When doing venipuncture on an arm with a venous access device (VAD),
the tourniquet placement and venipuncture site must be below the VAD.
d. You may draw from a limb with a non-working fistula or graft, but only
below the fistula or graft and without using a tourniquet.
e. Avoid placing your hand and fingers in front of the needle’s pathway.
f. Maintain constant needle position while changing tubes.
g. Discontinue immediately if the site begins to swell (hematoma) or the
patient experiences pain.
h. If the vein is missed on the first attempt, only attempt a second time if
confident of obtaining blood and has been signed off for 2nd sticks, or get
a more experienced phlebotomist to take over the blood collection.
i. Hard to draw and low blood return:
i. Change the position of the needle. If the needle has penetrated
too far into the vein, pull it back a bit. If not in far enough, advance
it farther into the vein.
ii. Try another tube to ensure the tube selected is not defective. DO
NOT PROBE OR MOVE NEEDLE LATERALY.
iii. Avoid damaged, sclerosed, or occluded veins as they do not allow
blood to flow through them.
iv. Follow the 2 Stick Rule 1507.P009.A3. If phlebotomist is within
his/her first six months of employment and is unsuccessful after
one attempt, request assistance from another phlebotomist.
v. Warming the area will help dilate the veins. Warming should be
performed with a manufactured warming pack.
23. Transplant patients will have 2 ABO/Rh tests ordered for collection within 24
hours. Collecting the specimens on two different occasions and by two different

UWHC Clinical Laboratories Original Date: 2/18/2000
Phlebotomy Current Version Date: 2/25/2016
Document Title: Venipuncture Technique
Document ID: 1507.P009 Page 5 of 6

collectors is a requirement by definition 3.1.4.2 of the Organ Procurement and
Transplantation Network.
a. Heart, abdominal or lung transplant
i. Reception staff will contact the Order Organizer (OO) and place
a note on the Arrival Notice to indicate one order has been
released and patient needs two ABO’s collected.
ii. First Phlebotomist will complete patient identification and collect
all labs to include one ABO. After completing collect verify, notify
the OO.
iii. The OO will release the second ABO test from Health Link, print
label and arrange for a second Phlebotomist to collect the
second ABO. If person at OO does not have releasing rights,
contact lab receptionist to release the second test.
iv. Second Phlebotomist completes patient identification and
collects the second ABO.
24. Special considerations and guidelines for pediatric collections are outlined in
1507.P009.A1 Venipuncture Technique, Pediatric Collection.
25. Inpatient pediatric collections require phlebotomist to speak with nursing before
proceeding with blood collection (see 1507.P009.A2 Phlebotomy Pediatric
Workflow).
a. The blood collection must be approved by the nurse, and the
phlebotomist must check for any additional notes in phlebotomy unit
binder.
b. The phlebotomist must verify patient weight and determine if blood
volume to be drawn exceeds maximum blood draw guidelines for
pediatric patients for prior 24 hours. Refer to Maximum Blood Draw
Guideline for Pediatric Patients (UWHC/AFCH). Please note, even if
drawing minimum volumes, the maximum allowable blood draw volume
could be exceeded
c. If the blood volume exceeds allowable volume, the phlebotomist will
receive approval for an over draw volume and obtain an order of priority
of collection for the volume of blood authorized (document this
information on the lime green PRIORITY OF DRAW Card). Approval must
come from the ordering physician, which must be annotated on the
bottom of the lime green PRIORITY OF DRAW Card.
Note: Phlebotomists should always draw minimum volumes on pediatric
patients weighing volume tubes (white ring) for patients weighing over 40kg. If there
is a clinical reason for using minimum volumes on patients >40kg,
this should be communicated to the phlebotomists by nursing.
d. If the patient is not available for the collection, the phlebotomist will speak
to the patient’s nurse and determine if the nurse will draw the blood
i. If the nurse will be able to collect the blood within 30 minutes, the
phlebotomist will leave the orders in the hand held, make a
notation in the phlebotomy unit binder, and ask nurse to submit
specimens with the Phlebotomy Collect Orders that are Drawn by
Unit form. Noting the tubes needed on this form is helpful to
nursing staff.

UWHC Clinical Laboratories Original Date: 2/18/2000
Phlebotomy Current Version Date: 2/25/2016
Document Title: Venipuncture Technique
Document ID: 1507.P009 Page 6 of 6

ii. If nurse is planning to collect the blood but is unable to collect the
blood within 30 minutes, the phlebotomist will cancel the order and
leave the cancel labels with the nurse for the later collection. The
phlebotomist will make a notation in the phlebotomy unit binder.
iii. If the phlebotomist will be collecting the blood, the phlebotomist
will reschedule the order in the hand held for a later phlebotomy
collection and note this action in the phlebotomy unit binder.
e. After blood collection the blood volume taken must be recorded in Health
Link. The phlebotomist will record the volume taken in the phlebotomy
unit binder and this volume will be transferred into Health Link by unit
staff.
f. Blood collected must be immediately sent to the lab for processing.

III. Safety
A. Employee safety
1. Activate the safety device to shield needles.
2. Wear buttoned laboratory coat and wear gloves.
3. For a needle stick, refer to UWHC Clinical Laboratories Safety Manual, Section 3
Emergency Procedures.
B. Patient safety
1. Use single use tourniquet for outpatients and designated tourniquet in room for
inpatients.
IV. Alternate and/or Down Time Procedure – N/A
V. References
A. CLSI: Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture;
Approved Standard - Sixth Edition, H3-A6 Vol.27, No. 26
B. UWHC Administrative Policy 13.08, Hand Hygiene, September 1, 2011.
C. CLSI: Procedures and Devices for the Collection of Diagnostic Capillary Blood
Specimens; Approved Standard - Sixth Edition, H04-A6 Vol. 28, No. 25
VI. Attachments
A. 1507.P009.A1 Routine Venipuncture Technique, Pediatric Collection (January 2015)
B. 1507.P009.A2 Phlebotomy Pediatric Workflow (January 2015)
C. 1507.P009.A3 2 Stick Rule (January 2015)
VII. Author and/or Revised By
Phlebotomy Manager and/or Supervisor