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WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy. Geneva: World Health Organization; 2010.
This chapter covers all the steps recommended for safe phlebotomy and reiterates the accepted principles for blood drawing and blood collection (31). The chapter includes background information (Section 2.1), practical guidance (Section 2.2) and illustrations (Section 2.3) relevant to best practices in phlebotomy.
The information given in this section underpins that given in the remainder of Part II for specific situations. Chapter 4 also provides information relevant to the procedure for drawing blood given below in Section 2.2, but focuses on blood collection from donors.
Institutions can use these guidelines to establish standard operating procedures. Such procedures should clearly state the risks to patients and health workers, as well as the means to reduce those risks – discussed below in Sections 2.1.4 and 2.2.
Best practices in phlebotomy involve the following factors:
planning ahead; using an appropriate location; quality control; standards for quality care for patients and health workers, including quality of laboratory sampling.This is the most important part of carrying out any procedure, and is usually done at the start of a phlebotomy session.
The phlebotomist should work in a quiet, clean, well-lit area, whether working with outpatients or inpatients.
Quality assurance is an essential part of best practice in infection prevention and control (1). In phlebotomy, it helps to minimize the chance of a mishap. Table 2.1 lists the main components of quality assurance, and explains why they are important.
Elements of quality assurance in phlebotomy.
Several factors can improve safety standards and quality of care for both patients and health workers, and laboratory tests. These factors, discussed below, include:
Procurement of supplies is the direct responsibility of the administrative (management) structures responsible for setting up phlebotomy services. Management should:
provide hand-hygiene materials (soap and water or alcohol rub), well-fitting non-sterile gloves, single-use disposable needles, and syringes or lancing devices in sufficient numbers to ensure that each patient has a sterile needle and syringe or equivalent for each blood sampling;
make available sufficient laboratory sample tubes to prevent dangerous practices (e.g. decanting blood to recycle laboratory tubes).
Several safety-engineered devices are available on the market; such devices reduce exposure to blood and injuries. However, the use of such devices should be accompanied by other infection prevention and control practices, and training in their use. Not all safety devices are applicable to phlebotomy. Before selecting a safety-engineered device, users should thoroughly investigate available devices to determine their appropriate use, compatibility with existing phlebotomy practices, and efficacy in protecting staff and patients (12, 33). Annex B provides further information on infection prevention and control, safety equipment and best practice; Annex C provides a comprehensive guide to devices available for drawing blood, including safety-engineered equipment.
For settings with low resources, cost is a driving factor in procurement of safety-engineered devices.
Where safety-engineered devices are not available, skilled use of a needle and syringe is acceptable.
Accidental exposure and specific information about an incident should be recorded in a register.
Support services should be promoted for those who undergo accidental exposure. PEP can help to avert HIV and hepatitis B infections (13, 27). Hepatitis B immunization should be provided to all health workers (including cleaners and waste handlers), either upon entry into health-care services or as part of PEP (34). Annex D has details of PEP for hepatitis B and HIV.
Tourniquets are a potential source of methicillin-resistant Staphylococcus aureus (MRSA), with up to 25% of tourniquets contaminated through lack of hand hygiene on the part of the phlebotomist or reuse of contaminated tourniquets (35). In addition, reusable finger-prick devices and related point-of-care testing devices (e.g. glucometers) contaminated with blood have been implicated in outbreaks of hepatitis B (4, 5, 36).
To avoid contamination, any common-use items, such as glucometers, should be visibly clean before use on a patient, and single-use items should not be reused.
All staff should be trained in phlebotomy, to prevent unnecessary risk of exposure to blood and to reduce adverse events for patients.
Groups of health workers who historically are not formally trained in phlebotomy should be encouraged to take up such training; lax infection prevention and control practices result in poor safety for staff and risk to patients (20, 37).
The length and depth of training will depend on local conditions; however, the training should at least cover the essentials (see Annex E) (38).
Supervision by experienced staff and structured training is necessary for all health workers, including physicians, who undertake blood sampling.
One of the essential markers of quality of care in phlebotomy is the involvement and cooperation of the patient; this is mutually beneficial to both the health worker and the patient.
Clear information – either written or verbal – should be available to each patient who undergoes phlebotomy. Annex F provides sample text for explaining the blood-sampling procedure to a patient.
Factors that influence the outcome of laboratory results during collection and transportation include:
knowledge of staff involved in blood collection;use of the correct gauge of hypodermic needle (see Table 3.1 in Chapter 3) to prevent haemolysis or abnormal results;
