Lab Requisition Review

Requisition Review

• Physicians, physician assistants, and nurse practitioners can order lab tests
• Chiropractors can also order lab tests in some states
• A laboratory order (requisition) form includes:
  • The tests the provider wants
  • The provider's information
  • Patient's full name, date of birth, sex
  • Specific identification numbers
• Social Security numbers are not as commonly used anymore on registration forms due to identity theft concerns
• Requisition forms may list precautions like latex allergies, fainting tendencies, bleeding issues, or sites to avoid
• Forms document collection date/time, billing, and diagnostic coding
• Examine requisition forms to verify tests comply with testing times, and to check for discrepancies
• Note preparations or restrictions, like fasting (basal state)
• Confirm blood collection priorities
  • "Stat," "medical emergency," and "ASAP" mean tests must be completed and relayed immediately
  • Routine collections determine diagnosis or baseline values and do not have urgency
• Contact the provider if information is missing
• Understand which tubes to use and the correct order of draw
• Not doing so could lead to preanalytic errors, skewed results, and unnecessary venipunctures
• Consult the lab manual or ask a colleague/supervisor if unsure
• Specimen labels are printed at the lab reception area and accompany the requisition
• Labels contain patient information for placement on blood samples
• Some labels may have bar codes
• If no labels are available, include the date/time of collection, initials, patient's name, date of birth, and other specifics
• Perform this immediately after collection, before the patient leaves
• Paper requisitions are now less common due to electronic records
• Understand requirements for paper requisitions, as some facilities still use them
• Paper requisitions usually have multiple parts and require handwritten documentation with perforations
• Use a handwritten blood collection log to record the blood collection, which may be a backup in case of computer failure, power outages, or emergencies

Patient Identification

• Phlebotomists are often the first clinical person a patient interacts with at a healthcare facility
• Treat patients with care, respect, and professionalism, using therapeutic communication
• Greet the patient warmly, introduce yourself as a phlebotomist, and explain you are collecting a blood sample
• Professional identification badges should be visible
• Phlebotomy students should inform the patient they are students
• Knock before entering inpatient rooms and be mindful of room lights and sleeping patients
• Hospitalized patients are especially vulnerable
• The Joint Commission requires two identifiers to verify a patient's identity
• This ensures that blood is collected from the correct patient for the correct tests
• Ask patients to state two identifiers: full name, date of birth, home address, telephone number, or Social Security number
• Compare identifiers with the requisition form
• Patients can use photo ID, which can be compared with the requisition form
• Comply with HIPAA guidelines, maintaining patient privacy
• HIPAA Privacy Rule makes patient information confidential and gives patients control over their information
• HIPAA now requires notification of privacy policy and reasonable effort to obtain acknowledgment, instead of written consent for disclosure
• Exercise discretion to prevent anyone not involved in the patient's care from overhearing protected health information (PHI)
• Only call the patient's name, avoiding clinical information like "Lester Moore for a hepatitis B test"
• Double-check patient information with the hospital wristband and requisition form in inpatient settings
• Barcode scanners can confirm matches between wristbands and forms or labels
• Compare facility identification numbers since two patients can have similar names
• Never use the patient's room and bed number as an identifier
• Ask patients to state personal information whenever possible
• If asking for confirmation, patients might nod without processing
• Confirm identity by viewing the wristband and asking a family member, acquaintance, or hospital staff in cases of diminished consciousness, cognitive deficits, sedating medications, psychological conditions, or inability to speak
• Use a medical interpreter if there are language barriers
• Follow facility protocols if unsure how to identify patients, including children
• Preliminary steps include inability to identify the patient, discrepancies on the form or wristband, or the information a patient shares verbally
• Report discrepancies to the supervisor immediately
• Do not conduct procedures in inpatient settings, surgery centers, or rehabilitation facilities if the patient lacks an identification band

Obtaining Consent

• Obtaining patient consent is essential before collecting blood
• Touching a patient without consent may be battery, a criminal offence
• Types of consent:
  • Informed consent: patient received procedure information in understandable language, which is often required for high risk, invasive, and surgical procedures
  • Expressed consent: patient gives explicit consent to procedure orally or in writing on a consent form
  • Implied consent: patient's actions demonstrate consent for the procedure and is the most common type of consent for phlebotomy, vital signs, or blood collection, and may be needed in emergencies with the understanding that full information will be provided later
  • Consent for minors: usually, a child's parent/guardian must grant consent
• Teenagers who are married, in the military, emancipated, or self-supporting are some exceptions
• Patients can refuse consent for personal, cultural, or religious reasons without explanation
• Obtain written proof of refusal to protect yourself and the patient when a patient refuses
• Inform the provider of the refusal
• A patient may not understand what is being done so more investigation to solve the issue is required

Patient Interview: Adherence

• Some tests have pre-collection requirements
  • Fasting
  • Medication administration
  • Avoiding specific foods/beverages
  • Specific time of blood collection
• Explain testing requirements in terms patients understands
• Discussing tests with patients ensures you all have the same understanding
• Consult with the provider if a patient has not adhered to the requirements prior to arriving
• Consult with the provider to determine if tests need to be rescheduled
• De-escalate the situation should the patient become upset/angry
• Verify understanding by reviewing the testing requirements/directions in understandable terms
• Facilitate understanding by encouraging questions and by having the patient repeat the directions
• Common pre-testing preparations:
  • Fasting: no intake other than water 8-12 hours before collection
    • Encourage the patient to drink water to facilitate hydration and find viable venipuncture sites, unless condition/procedure prohibits it
    • Black coffee or tea may be permissible
  • Medication:
    • Tests may determine effectiveness of medication
    • The patient should take medication at a predetermined time, noting when they take the medication
    • Prescribers rely on accurate timing when making treatment decisions, so it is important to collect the specimen at the correct time
  • Basal state:
    • Based on the patient's lifestyle and overall condition, specimens are usually collected first thing in the morning, after refraining from eating or exercising for 12 hours
    • Necessary preparation when the provider wants to establish reference ranges because exercise/food can affect the results
    • Determine what a fasting basal state means for each patient and adjust collection times appropriately
    • For example, "first thing in the morning" may correspond to the end of a night shift
    • Clarification of work habits is needed to schedule appointments appropriately

Patient Interview: Alert Bracelets

• After pre-testing requirements have been discussed, prevent and manage complications by asking about allergies
• Due to common allergies to latex/adhesives, facilities commonly use hypoallergenic options
• If your facility still uses products containing latex, it is vital that you assess allergies and ask the patient about it, even though they may be anxious/forgetful to state it
• Inquire about patients who have fainted during blood collections as syncope can occur
• Be aware that patients who are fasting are prone to low blood sugar levels, which can lead to fainting
• Utilize the routine phlebotomy chair because it makes the procedure easier and has a locking arm to prevent falls
• Be aware that nausea and vomiting are potential reactions, and that you provide facial tissues, washcloths, wipes, and a trash receptacle always
• You can be proactive by asking questions in these areas
• Engage the patient in conversation for distraction to avert fainting/complications
• Should a patient feel faint:
  • Stop the procedure
  • Have the patient lower their head and breathe deeply
  • Loosen clothes around the neck and apply cold compress
  • Allow/observe the patient for a minimum of 15 minutes following the episode before determining whether to discharge
  • Document complete details of the incident
• Patients who lose consciousness and do not respond need immediate intervention from a rapid response team
• Maximize safety by asking which arm the patient prefers or if some procedures have failed/succeeded in using the other arm
• You require current medication information to alert you to additional concerns that require specific precautions
• Classify common medications, like anticoagulants to prevent excessive bleeding
• Note how other factors (alcohol use, cigarette smoking, exercise) affect test results and document these for the provider to review
• For example, alcohol can affect coagulation activation/platelet reactivity, and smoking elevated coagulation factors

Patient Education

• Patient education is simple and easy to incorporate
• Describing what will happen reduces patient anxiety
• When reviewing the specific order and tests, be sure to ensure any errors that need to be corrected can be made quickly and any questions that patients may have can be answered prior to administering any treatment
• Discuss possible complications that can occur based on risk factors
• If this is their first venipuncture, expect that extra nervousness could be present and provide information for these reactions which can involve answering any questions that the patient has
• Key discussion points include:
  • They will feel a slight prick when the needle is inserted/while the tubes fill but never promise that it will not hurt at all because pain is subjective
  • Immediately state severe pain/sickness
  • Complications, such as hematoma, infection, prolonged bleeding, serious pain will be discussed

Patient Preparation: Possible Complications

• These are some complications, though considered uncommon:
  • Excessive bleeding/bruising:
    • A little light bleeding can happen, so you should apply firm pressure to the venipuncture site or have the patient do so until no evidence of additional bleeding
    • Light bruising is also to be expected, though a widening bruise that expands to about 2x2 indicates a continuance of bleeding under the skin with the need to apply pressure and ice until the provider is contacted
  • Severe pain/lack of sensation:
    • Evaluate further for severe pain, or any numbness or tingling
    • If there is nerve damage, you must remove the tourniquet/needle, with the added possibility of icing depending on facility policy
    • It is worth noting that the risk of nerve involvement intensifies when drawing from the basilic vein because it lies close to the median nerve
  • Infection:
    • Redness, swelling, and pain could signify an infection
    • Hematomas may evolve into infections
    • Infections do not occur immediately
    • You must alert patients to look for these signs and contact their provider if they appear

Patients should be given time to ask questions before advising they seek medical advice should any odd symptoms occur afterward

Patient Preparation: Positioning

• The goals are to prioritize patient safety, and to supply comfortability for efficiency in order to obtain necessarily collected specimens
• Good positioning can assist goals
• Perform the procedure in a comfortable position in bed for inpatient settings because this safety net can reduce chances of fainting
• Utilize a venipuncture chair with comfortable, adjustable armrests and a padded locking to prevent any falls
  • These chairs also adjust to a high height and recline for additional comfort
  • Never perform the procedure standing unless for extra-wide venipuncture chairs/wheelchair stations

You can achieve proper positioning in each patient by extending the arm with palm facing upwards and rotating the harm. Other comfortability measures are using pillows/armrest devices or having the patient support their arm under the elbow using their free hand

Patient Preparation: Selection of Sites

• Medical conditions can pose contraindications for venipuncture, such as cellulitis, hematoma, vascular shunt, or graft
• Use dermal punctures for laboratory tests that only need small amounts of blood, which obtains blood through capillaries rather than veins
• Middle or ring fingers work best for capillary punctures on an adult
• Avoid little fingers as they are too small
• Index and thumb fingers are likely to be sensitive or have calluses
• Side of the finger is the preferable puncture site, and if the patient still feels tender afterward, continue to use because fingertips are tender
• Avoid doing tests on fingers that are cold, blue, scarred, swollen, or have rashes
• If something goes wrong, speak to a supervisor/provider for the proper steps to keep the patient comfortable

Selected Sites: Veins

• The lab must be contacted so you can know whether to perform which specimen collection, such as a capillary in the case of infants
• Choose proper veins by knowing where blood can be collected, which involves making sure the patient's arm is extended with palm facing upward since the main region is the antecubital fossa
• There are some other times the antecubital veins may not work for the patient
  • Hand veins: Next best choice outside antecubital veins, and have some downsides: The veins are fragile, roll, and small which makes it more painful, and a good angle for puncture is difficult alongside increased risk of piercing through completely with the butterfly needle being easiest to guide
  • The wrist cannot be accessed (palm facing upright) because there are tendons/nerves near the surface of the skin
  • Ankle/foot veins: Last resort due to being so difficult to access since there is an increase of injury/pain. The use of a butterfly needle makes the procedure much easier. Diabetes or issues with lower extremities are also worth noting as they increase risks of infection, phlebitis, or htemoatoma
• Always check your facility’s protocol before attempting to collect otherwise

Vein Selection

• First inspect, then palpate in order to choose the proper vein. Palpating needs to find areas that will make the vein unsuitable for the patients, which are based on the following:
  • The feeling of soft, flexible, spongy/bouncy
    • The artery will bounce because it is not a vein, and will not be used
• Trace with your finger in order to know the vessel, so you can then palpate to find the depth/direction, as they will help with angles required for the insertion point

Sites That Require Extra Care/Should Generally be Avoided

• These places require a warm compress/need gravity to get the veins filled. Here are those veins:
  • One you cannot visually identify or those that are very deep because there many other veins with equal visibility and palpability
    • Never force it, or slap the area, both of which can cause a sign of threatening/abuse
  • The following veins below should never be used:
    • An IV insertion site on an arm near mix with blood during the sample/and also alter the results
    • An arm that compromises the circulation of its arteriovenous fistula/shunt for dialysis by damaging the shunt
    • An arm with a central venous access device, since using will likely to damage the device
    • An arm or that the antecubital fossa with a recent mastectomy because it has potential to swell/cause injury/infection
    • A site that might provide test result alterations while causing potential pain because it has to deal with excess fluid around the area that causes edema
    • A site with scarring because drawing there might cause long-term pain/scarring
    • A site where blood collection might increase pain (like the enlargement from nerve damage of hematoma) while altering test results

Vein Conditions That Make Them Unsuitable

Vein size does not always determine what veins are best to perform venipuncture on. The following are the veins that are a vascular/neurological damage risk: - Sclerotic veins: veins tend to become more hard, inflexible, and narrow as one age, causing these veins to be more likely to cause pain - Tortuous veins: More well known as “varicose veins” because of how easy to make the angle push through the vein’s wall do to the twisty/lack of elasticity - Thrombotic veins: veins that are touch to feel that have thrombus or clots which are unbending - Phlebitic veins: Tenderness with warmth in the vein, a red are, and clots

Influences of Procedure, Assessment, and Questions

• As can be said if age and mental capabilities could reduce the ease of ability to perform venupucture, assess patients ability objectively.
  • Can be performed in under less than 1 minute by way of observation/listening:
    • Ask of past syncope, as if they were to faint, the nurse should ask about pain levels, amount of bruising, bleeding, if there was chest pains/dizzyiness/etc
    • Also, see if they’re anxious, nervous, the body language/tone of voice, then ask them why they feel the way they do
    • Evaluate which is the best course of action for children as based on the site/type, never the deeper than 2mm heel skin to have heel blood drawn from on them, and don’t dermal finger puncture for kids, since it can cause injury
• Exmaine/palpate the veins of those in older adulthood, though do not make assumptions. Some patients have had many blood collections already

Tourniquet Application and Palpation

• Check for contamination, cracks, or wear on the type of tourniquet
• 3-4 inches should be left above the antecubital
• Not enough tension due to distance or even too much tension, which results in collapsing vein
• Too-high tourniquets slow the flow
• Apply the tourniquet to make the removal easy later and be sure to do so within one minute, or the results may become inaccurate due to hemoconcentration of blood cells
• When palpating, start at the antecubital and reach toward the arm’s outside with the tip of index finger that is sensitive. (This process needs to happen without thumb for the ease)
  • Use sponge tests/tendons as reference points for the depth/direction and see if the area can make the vein pop out (by squeezing, applying gravity by going further below heart,) and don’t beat on the palpated vein
• Utilize sterile technique with alcohol pad around center (where the vein goes) in circles that stretch the area/Do at minimum three cleaning areas
• Only those whom are being tested that have allergies to the previous technique would need chlorihexidine gluconate or Povidone-iodine applied

Phlebotomy Procedures

• In order to prevent rolling and bleeding, proper vein site anchoring is needed right at the quick insertion area
• Place your thumb 2 inches from that area so you can tug slightly - you shouldn’t press hard against it/onto the skin or else it will cause potential discomfort/bruising or disrupt the steady holding. It is advisable to stay clear of such incidents
• There should be beveled placement through needle insertion within in range of 15-30 degrees that corresponds to the deepness, as it could cause nerve injury/damage
• It should be pointed out, there is less deep penetration since the angle might cause problems
• Dorsal hands will be shallow and is about 10 degrees of angle for a blood colleciton

Correct Order

• Steps follow all previous cleansing/safety
• 1 - Introduction
• 2 - Identifiers
• 3 - Seizure safe zone
• 4 - Clean
• 5 - Setup
• 6 - Straight position
• 7 - Tourniquet
• 8 - Feel the point
• 9 - Choose carefully
• 10 - Sanitize
• 11 - Inspect
• 12 - Stabilize
• 13 - Alert
• 14 - Angle (range is 15-30 or dorsal at 10)
• 15 - Position and draw (below point)
• 16 - Check point flow
• 17 - Remove tour - 60s or before fainting
• 18 - Change tubes (invert immidiately)
• 19 - Swift angle out - same as 14
• 20 - Safety enable immediately.
• 21 - Safe device - go into sharp box straight away
• 22 - Check point for blood presence
• 23 - Check for leaks - bandage right
• 24 - Clean before leaving!
• 25 - Thank you
• 26 - Observe/ask/leave for new face

Collection Types

• Collection with winged infusion must be boxed separately and those needles are never to be reused again after putting in hub. One should note if pre-collection for safety is enabled beforehand for each new set-up
• For syringe, a few steps are:
  • 6 - Pull the plunger through, making sure everything functions as it should
  • Push everything forward and leave no air in it - must calculate the necessary tubes for tests to make everything work correctly