General Laboratory

Document Title: Specimen Collection1

IngallsMemorialHospital
Laboratory / Section / General / Policy
Reviewed By / Marilyn Nelson, Director, Laboratory and Cardiac Services
Drusilla Brewer, Supervisor, Support Services
Lori Jones, Supervisor, Pathology
Suzan Al Rafati, Supervisor, Microbiology / 1/17
Revised By / Marilyn Nelson, Director, Laboratory and Cardiac Services
Drusilla Brewer, Supervisor, Support Services
Lori Jones, Supervisor, Pathology
Suzan Al Rafati, Supervisor, Microbiology / 1/17
Approved By / Enric Solans, M.D., Chairman, Pathology and Laboratory Services / 1/17
Title / Specimen Collection / Pages / 20

COLLECTION OF SPECIMENS: This policy applies to all Ingalls Hospital staff and Ingalls FCC Staff who perform and/or evaluate or have demonstrated competency for specimen collection.

  1. Early AM specimens will be collected seven days a week.
  1. Clinical Laboratory Associates(CLA’s), ED Techs, OB Techs and RN’s (Nurse draw) will be responsible for primary collection of specimens.
  1. Patient's identification armband must be checked before drawing specimen to confirm name, MR# and date of birth. (a handheld device may be used to confirm this information) Patient should be asked to verbally state their name if at all possible. A visual assessment of the patient must be made to confirm that information on band is correct. If the patient has no armband, an armband must be placed on patient prior to specimen collection.

A. For LTC Outreach patients: Patient’s identification armband must be checked before drawing specimen to confirm name, and date of birth. Patient should be asked to verbally state their name and date of birth if at all possible. A visual assessment of the patient must be made to confirm that information on band and requisition is correct. If the patient has no armband or cannot verbally or clearly identify themselves, a caregiver employed by the facility must identify the patient. Documentation, including a signature of the caregiver identifying the patient, must be recorded on the requisition prior to specimen collection.

  1. All specimens must be labeled with the computer label, chart label, handheld label or manually written, after the specimen is drawn and before leaving the bedside. Labeled specimen must be rechecked against patient armband prior to leaving bedside. Label must include collection date, time and initials of phlebotomist, along with name, MR# and date of birth of patient.
  1. Make no more than two attempts to obtain specimen. A finger stick may also be performed to collect specimens when minimum volumes can be used for testing purposes. If it is determined that there are no acceptable sites for draw in a patient’s arm or hand, specimens may be drawn from their foot or ankle if physician permits and order is documented.
  1. Notify the nursing station when collections are unable to be completed.
  1. Use "alcohol-wipe" and sterile gauze to prepare the venipuncture site, except for alcohol and blood culture specimens.
  1. STANDARD PRECAUTIONS are to be used with ALL patients.
  1. Observe proper technique with isolation patients.
  2. Use PVP Iodine solution for alcohol specimens in lieu of "alcohol-wipe”. Do not use a ChloraPrep One-Step Frepp Applicator kit for alcohol, as this cleanser contains alcohol.
  1. Use ChloraPrep One-Step Frepp Applicator kit for Blood culture specimens in lieu of “alcohol-wipe”. See below for full Blood Culture collection procedure.
  1. Minimum specimen requirements are placed on collection labels to minimize unnecessary blood draw volumes. Please consult Policy on Hospital Intranet under General Laboratory (Blood Collection Vacutainer Tubes) if unsure of what volume of blood or type of tube to draw for specimen collection.
  1. To perform the venipuncture: Secure tourniquet around the patients arm. Do NOT leave tourniquet secured for longer than one minute. If the tourniquet is removed and to be reapplied, two minutes must pass before reapplying the tourniquet. This will help to prevent hemoconcentration.
  1. Select the appropriate vein by palpating. Veins will be elastic and have a spongy or bouncy feel.
  1. Cleanse the site you have chosen with alcohol using a circular motion. Look at the pad and re-cleanse if the pad has become visibly soiled during the first cleaning.
  1. The area must be allowed to AIR DRY. Do not blow, wave or wipe the area dry. It must air dry. Air drying of the alcohol on the skin is essential in cleansing the site. Prematurely drying the site will inhibit the cleansing action of the alcohol. NOTE: Leaving area moist can cause hemolysis of specimen.

General Laboratory

Document Title: Specimen Collection1

  1. Secure the needle into needle holder. Rotate until firmly seated. Insert tube into the holder. Advance no further than the guideline on the holder. Remove needle sheath and rotate orange needle protection device away from needle bevel to desired position prior to stick.
  1. Using opposite thumb, anchor vein and insert needle at a 15-30 degree angle. The vein is entered with the bevel of the needle upward. Anchor the vein with the thumb, wrapping fingers around the back of the patient’s arm in an “L” hold.
  1. The collection tube will be loose within the needle holder. Push the tube in as far as it will go keeping the needle holder as still as possible. The tube should be held in the needle holder with gentle pressure to keep the tube fully engaged to ensure correct fill. The tube should be filled until the vacuum is exhausted and the blood flow ceases, to ensure a correct fill. Do not overfill.
  1. Recommended order of draw:
  1. Blood Culture tube (Yellow SPS tubes)
  2. Blue top Citrate tubes
  3. Non-additive tube (Red top without gel separator)
  4. SST Gel separator (gold or red clot activator tube)
  5. Green top Heparin plain and plasma separator tubes
  6. EDTA Lavender and Pink Blood Bank tubes
  7. NOTE: If only a Blue top tube is needed, please draw anadditional blue tube if drawing the patient with a winged infusion set (butterfly). This discard tube is needed to avoid air space in the tubing entering the Blue top tube. This will ensure correct fill. No discard tube is needed if using a needle and holder.
  1. After each tube is drawn, gently invert the tube at least 8-10 times. After tube(s) have filled, release the tourniquet. Tourniquets should not be left on for more than one minute. Hemoconcentration may occur if the tourniquet is left on for more than one minute.
  1. Do not exit site before removing last tube from needle holder assembly. The tube must be disengaged and the tourniquet removed before removing the needle from the patient’s arm. This will prevent hematoma formation.
  1. Engage safety device over needle, using one-handed technique, by pressing the sheath against a flat surface.
  1. Place a clean gauze sponge over the venipuncture site and apply pressure until bleeding has stopped. After the bleeding has fully stopped, apply a bandage to the site appropriate to the patient’s needs.
  1. Label tubes before leaving patients bedside with: *
  • Full name of patient
  • Date
  • Date of birth
  • Time
  • 8 digit MR#
  • Initials of person who drew specimen

*Note: For Nursing Home and Outreach patients, the minimum is first and last name and Date of Birth.

  1. Labeled specimens must be rechecked against patient armband prior to leaving bedside.
  1. Barcode labels should be placed over the manufacturer’s label, vertically on the tube so as not to obscure view of specimen.
  1. Transport tubes to the Laboratory as soon as possible using appropriate biohazard transport bags. Dispose of used needle/safety device in Sharps Container and contaminated materials and supplies in designated biohazard containers. See hospital policy "Transport of Patient Specimens to Laboratory by Patient Care Services Personnel".
  1. **Note: It is strictly prohibited to recap, bend or break needles, or remove needles from disposable syringes**
  1. If phlebotomy is interrupted at anytime prior to completion of Step #19, specimen must be discarded. Restart procedure at Step #3.

COLLECTION INSTRUCTIONS FOR BLOOD CULTURES

Blood should be collected as soon as possible after the onset of fever or chills or whenever serious infection is suspected. Sets of blood cultures should be drawn at intervals at least 15 minutes apart due to the intermittent nature of most bacteremia. However, the ideal time interval between blood cultures has not been established. Blood cultures should be drawn before antibiotic therapy whenever possible. Each peripheral blood culture specimen should be obtained by a separate venipuncture stick using sterile technique.

Blood Volume recommendations:

1. Adults and Children ≥ 13 years old:15-20 ml per blood culture venipuncture

2.Children 12 years and younger: 1-10 ml per blood culture venipuncture

Blood Collection:

Blood should be collected by venipuncture of peripheral veins or intravascular access devices, such as ports or catheters. Strict aseptic technique should be used and Standard Precautions observed.

A.Blood Culture Collection (Direct Inoculation of bottles via venipuncture)

  1. Identify patient
  2. Choose appropriate vein
  3. Assemble equipment
  1. Chloraprepp One-Step FREPP Applicator
  2. Butterfly collection system
  3. Phlebotomy supplies
  4. Blood Culture Bottle(s)
  5. Adults and children 13 years and older
  1. Each blood culture order should include:
  2. Once aerobic bottle (blue top)
  3. One anaerobic (purple top)
  4. Each bottle is inoculated with 8-10 ml. of blood
  5. If < than 10 ml. is collected, inoculate aerobic bottle only.
  6. Children 12 years and younger
  1. Each blood culture order should include:
  2. One aerobic bottle (blue top) only

3.Special Care Nursery

a. Blood volume drawn determined by physician/nurse collecting specimen.

b. Inoculate 1 pediatric (PF-yellow top) bottle

  1. Disinfection of Skin
  1. Remove chloraprepp One-Step FREPP Applicator from kit and hold by center handle.
  2. Holding the foam surface down, pinch the handle to break ampule
  3. DO NOT CONTINUE TO SQUEEZE HANDLE
  4. Apply foam surface to the area to be cleansed. Depress against surface to saturate foam.
  5. Clean area thoroughly for one minute and allow to completely air dry. Do not blow, wave air or wipe the area.
  6. Remove plastic flip-top from blood culture bottle(s) and clean the tops with alcohol prep pads.

5.Perform venipuncture as described in step 13 of Collection of Specimens section of this policy.

6.Allow the cleanser to dry and then insert needle end of the device into vein. Insert other end into blood culture bottle.

7.Hold the blood culture bottle at a position below the patient’s arm with the bottle in an upright position.

  1. Note: Monitor the direct draw process closely at all times during collection to assure proper flow is obtained and to avoid flow of the bottle contents into adapter tubing.
  2. Note: Do not allow the blood culture bottle contents to touch the stopper or the end of the needle during the collection procedure.

8.Inoculate bottles as follows:

a.Adults and children 13 years and older

1.Collect 8-10 ml of blood in the aerobic bottle

2.Collect 8-10 ml of blood in the anaerobic bottle

b.Children 12 years and younger

1.Collect 1-10 ml of blood in the aerobic bottle only

9.If other tubes are being drawn at the same time for additional tests, draw the blood cultures first. Always draw the aerobic bottle of each blood culture order first in the event additional blood for the anaerobic bottle cannot be obtained and to ensure any oxygen trapped in the tubing will not be transferred to the anaerobic bottle.

10.Release the tourniquet as soon as blood starts to flow into the blood culture bottle or within 2 minutes of application.

11.Withdraw the needle from the patient’s arm, cover venipuncture site with sterile gauze pad and raise arm.

12.Dispose of used needle in sharps container, place gloves in the appropriate receptacle, and wash hands before leaving patient room.

13.Label blood culture bottles appropriately and transport to laboratory immediately.

B.Blood Culture Collection (Yellow top SPS tube(s) via Vascular Access Device)

1.Collect the following volume of blood in Yellow top SPS tubes for each culture order:

a.Adults and children 13 years and older: 2 yellow top SPS tubes (total volume of 15-20 ml)

b.Children 12 years and younger: 1 Yellow top SPS tube (total volume 1-10 ml)

  1. Refer to the Blood Sampling section of the Nursing Vascular Access Device Policy and Procedure.

MICROBIOLOGY(For all specimens not listed below, please contact Microbiology at ext. 6767 for specific requirements)

All culture specimens should be transported to the lab immediately for processing

1.Routine bacterial culture (specimens other than stool)

  1. Sterile container
  2. Swab culturettes with liquid Amies or Stuart’s media

2.Anaerobic bacterial culture

  1. Sterile Container
  2. Specimens should be submitted in anaerobic transport media when possible

3.Stool Culture

  1. Clean container
  2. Transportation vial with Cary-Blair media

4.Fungal Cultures

  1. Sterile container
  2. Swabs

5.Mycobacteria Cultures (AFB)

  1. Sterile Container

6.Viral Cultures

  1. Sterile container
  2. Sterile container with viral transport media
  3. Swab in viral transport media

7.Genital Specimen for chlamydia and / or gonorrhea by amplified probe

  1. Aptima Unisex Collection Swab

8.Urine Specimen for Chlamydia and / or gonorrhea by amplified probe

  1. Sterile container with no preservatives
  2. Aptima Urine Collection Tube

9.Specialized Microbiology Specimen

  1. Contact Microbiology for specimen requirements

10.Genital specimens for HPV testing

  1. Endocervical specimen in ThinPrep

11.Factor II and Factor V

  1. Vacutainer with EDTA (purple top)

FASTING PROCEDURES

PLEASE NOTE: Fasting patients should be allowed a tumbler (6-8 oz.) of drinking water prior to any test if they desire it. Test results will NOT be affected. Fasting is 8-16 hours of no eating, drinking, or gum chewing. The patient may drink water or black coffee or black tea only.

Patients should fast for the following tests:

Cholesterol / 8 hours
Glucose (except post-prandial) / 8 hours
High Density Lipoprotien (HDL) / 8 hours
Lipid Profile / 12 hours
Lipoprotien Phenotype / 12 hours
Basic Metabolic Panel (BMP) / 8 hours
Comprehensive Metabolic Panel (CMP) / 8 hours
Tolerances (all, including D-Xylose) / 8 hours

CLINICAL DATA

Accurate clinical information must be obtained and documented when indicated. (e.g., maternal AFP, GFR, creatinine clearance, etc.).

PATIENT PREPARATION FOR SPECIAL TESTS

Homovanillic Acid

Aspirin may produce interfering fluorescence

Serotonin (5-Hydroxy-Indol-Acetic Acid)

Dietary restriction:

Falsely elevated values are caused by avocados, bananas, tomatoes, plums, walnuts, pineapples, eggplant, acetaminophen, and phenacetin.

Decreased values are caused by corticotropin, ethanol, imipramine, isoniazid, levodopa and methyldopa.

Vanillylmandelic Acid (VMA)

Dietary restriction: Coffee, tea, chocolate, banana, citrus fruit, vanilla containing foods and drugs (especially anti-hypertensive agents) should be restricted for three days prior to collection and during

collection.

CRITERIA FOR REJECTING SPECIMENS

  1. Unlabeled specimens will be discarded. (See “special consideration for specimens from invasive procedures”).
  1. Patient identification wristlet (name and number) must be checked before drawing specimen. If the patient has no armband, an armband must be placed on patient by the nursing staff following correct patient identification procedures prior to specimen collection.
  1. Back-up labels may be placed on specimen, but patient name and MR# MUST also appear on the specimen.
  1. All specimens must be labeled with the computer label or back-up requisition label, or hand written if a label is not available, after the specimen is drawn, and before leaving the bedside including patient name, unique identifying number i.e. MR# or date of birth(other than room number), phlebotomist’s initials and date and time of collection.
  1. All specimens that are to be used in the Blood Bank must have a Secure link armband applied.
  1. Grossly hemolyzed or incompletely filled evacuated tubes will not be accepted for analysis.
  1. Improperly labeled specimens will be refused until corrected. (see category #1 below). Phlebotomist/nurse may make corrections and document and sign on Specimen Correction Form
  1. All lab staff has authority to reject an improper specimen and request that a new one be obtained.
  1. Lab will examine incoming specimen to determine if acceptable. If specimen is unsatisfactory, notify the nursing station or Clintech immediately.

Reason for Improper Specimen

Category 1:

  • Specimen not properly labeled (position of label)
  • Minor clerical error on specimen of requisition

Action To Be Taken: Nurse/phlebotomist must come to the laboratory to correct problem and document on Specimen Correction Form.

Category 2:

a.Quantity not sufficient (QNS)

Action To Be Taken: If quantity is not sufficient for multiple requests, i.e., fungal culture, AFB, smear and bacterial culture, call doctor and determine which type of culture has priority and request additional specimen.

Category 3:

a.Specimen in wrong container

b.Container damaged or contaminated

c.No specimen with requisition.

d.Specimen contaminated.

e.No label on specimen

f.Any reason to believe that it did not come from indicated patient

Action To Be Taken: Inform the nurse/phlebotomist that specimen cannot be processed and will be discarded. Arrange to have specimen recollected.

NOTE: All AFB specimens must be submitted in approved leak-proof containers, placed in a water tight plastic bag.

Guidelines for Testing Sub-Optimal Specimens

  1. Sub-optimal specimens include, but are not limited to hemolysis, lipemia, icterus and hard-stick short draws.
  1. Occasionally physicians will request testing of sub-optimal specimens. When a physician requests such testing, the following steps should be followed:
  1. Explain to physician/R.N. that results may be affected by the condition of the sample and recommend collecting a new sample.
  1. If the physician/R.N. insists on running a sub-optimal specimen:
  1. Add a comment to the result explaining possible inaccuracy of the result due to the condition of the sample. Use Comment Code XIS.
  1. Explain which condition of the sample was objectionable (e.g., hemolyzed, icteric, or lipemic specimen, etc.) and record the dialog which was held with physician/R.N. including physician’s name, date, time and notation limiting test result interpretation, such as:
  1. (condition of sample) specimen. Called to physician/R.N. (name) at (time) on (date) by (tech). Possibly inaccurate result. Interpret result with caution. Suggest repeat testing if clinically indicated.

Special considerations for specimens from invasive procedures: