Module 2 - Infusion Safety

7/28/2019 Module 2 - Infusion Safety

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Protocol For Inserting A Peripheral Line

Only staff nurses/trained medical professionalswith assistance will insert a peripheral cannula.

All peripheral lines should be replaced in 72

hrs. (96 hrs if vialon material used)

Sterile dressing should be reinforced as and

when necessary.

Make a record of person inserting peripheral

line, including time and date of insertion.


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Cannulating staff nurses and head nurses should

know infusion therapy process model. Anatomy & Physiology of the part to be

cannulated should be known

Patient consideration (thin, fat, hydration status)

Therapy consideration Initiation of therapy

Dressing

After care of catheter

Managing complications

Protocol For Inserting A Peripheral Line


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1. Successful completion

of infusion therapy

2. Reduced catheter

related complications

3. Minimized number of

venipunctures per

patient

4. Reduced supplyrelated costs

5. Reduced labor related

costs

6. Patient satisfaction

7. Reduced needlestick

injuries

Outcomes

Patient

Considerations

Device

Selection

Site

Preparation

Site

Maintenance

Site Assessment

& EvaluationTherapy

Considerations

Clinician

ConsiderationsInsertion

Considerations

Purpose

Administration Rate

Duration

Nature of Fluids/Meds Insertion Difficulty

Access Limitations

Vein

Skin Status

Interventional Radiologist

Insertion Angle

Insertion Speed

Skin Traction

Vein Dilation

Safety Practices

Needle Disposal

Catheter Advancement

Infection Control Practices

Education Needs

Disease State

Orientation

Care Setting

MobilityAge

Therapy Considerations

Risk Assessment

Device Material

Safety Features

Cost-in-Use

Patient Preferences

Antimicrobial Awareness

Appropriate Application

Local AnestheticHair Removal Asepsis

Documentation

Flushing Protocols

Monitor/Assessment

Dressing Integrity

Administration Set Protocols

Maintenance Protocols

Catheter Stabilization

Delivery Equipment Requirements

Types

Allergies

Gauge & Length

Complication Prevention

BD DECISIV

Process Model-

for Safe InfusionSpecialized Areas

Generalist

Physician

IV Specialist

Copyright 1997

Updated: March


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1. Successful completion

of infusion therapy

2. Reduced catheter

related complications

3. Minimized number of

venipunctures per

patient

4. Reduced supplyrelated costs

5. Reduced labor related

costs

6. Patient satisfaction

7. Reduced needlestick

injuries

Outcomes

Patient

Considerations

Device

Selection

Site

Preparation

Site

Maintenance

Site Assessment

& EvaluationTherapy

Considerations

Clinician

ConsiderationsInsertion

Considerations

Purpose

Administration Rate

Duration

Nature of Fluids/Meds Insertion Difficulty

Access Limitations

Vein

Skin Status

Interventional Radiologist

Insertion Angle

Insertion Speed

Skin Traction

Vein Dilation

Safety Practices

Needle Disposal

Catheter Advancement

Infection Control Practices

Education Needs

Disease State

Orientation

Care Setting

MobilityAge

Therapy Considerations

Risk Assessment

Device Material

Safety Features

Cost-in-Use

Patient Preferences

Antimicrobial Awareness

Appropriate Application

Local AnestheticHair Removal Asepsis

Documentation

Flushing Protocols

Monitor/Assessment

Dressing Integrity

Administration Set Protocols

Maintenance Protocols

Catheter Stabilization

Delivery Equipment Requirements

Types

Allergies

Gauge & Length

Complication Prevention

BD DECISIV

Process Model-

for Safe InfusionSpecialized Areas

Generalist

Physician

IV Specialist

Copyright 1997

Updated: March


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Choose correct catheter

COLOUR COMMON APPLICATIONS SIZE/GAUGE CRYSTALLOID PLASMA BLOOD SANG

OrangeUsed in theatres or emergency for rapid

transfusion of blood or viscous fluids14G 16.2 13.5 10.3

GreyUsed in theatres or emergency for rapid

transfusion of blood or viscous fluids16G 10.8 9.4 7.1

GreenBlood transfusions, parenteral nutrition,stem cell harvesting and cell separation,

large volumes of fluids

18G 4.8 4.1 2.7

Pink Blood transfusions, large volumes of fluids 20G 3.2 2.9 1.9

Blue

Blood transfusions, most medications and

fluids 22G 1.9 1.7 1.1

YellowMedications, short term infusions, fragile

veins, children24G 0.8 0.7 0.5

Approximate Flow Rates (l/hr)

A uide to choosin the correct catheter for our atient


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Steps of the cannula Insertion procedure

Preparation of equipment (Tray)

Preparation of environment

Preparation of patient


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Tourniquet

Examination Gloves

Sterile Drapes Surgical Scissors

Cotton Swabs

Betadine Swabs

Spirit Swabs

5ml / 10ml Syringe Bivalve

Normal saline flush (10ml)

Safety cannulas

Gauze Squares

Sterile dressing Site label (to record time & date of insertion)

IV sets (as required)

IV bottles (as required)


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Preparation of environment

Provide privacy

Well lit room


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Inform the patient about the procedure

Site selection Vein should be visible, soft, elastic, straight, palpable

& without valve (metacarpal ,basilic ,cephalic)

Observe skin for abrasions, hematoma, local skin

infection etc. Vein visibility

a. Clip the selected site if required

b. Apply tourniquet 6-8 inches above the site

c. Palpate the selected veind. Instruct the patient to pump his fist 2-3 times


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Cleaning the site - Clean the chosen areacovering about 2-3 inches radius, with spirit /alcohol, and let it dry. Thereafter betadine solutionis used to clean the same area in circular motionand allow to dry. Do not repalpate or touch the

cleaned site

Safety Cannulas should be selected according tothe purpose, vein size and fluid / medication

requirement.


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Destroys bacteria by denaturingcell proteins

Alcohol is fast drying and provides

immediate kill

WHY ALCOHOL ALONE IS NOT

THE BEST PRACTICE

Residual Ac t iv i ty : None, so

has no long term

ant imicrob ial effect iveness

70% Alcohol

Combines with proteins of the cellcausing the organism to die

WHY IODOPHORS ALONE IS NOT

THE BEST PRACTICE

Does not provide immediate

k i l l of m icroorganisms

Requires minimum 2 minutes of

skin contact to begin anti-

microbial effect

10% Iodophor

Choosing the right skin preparation


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Use alcohol followed by application of main

disinfectant - 10% Povidone Iodine or 2%Chlorhexidine prep.

Provides immediate kill as well as residual activity

For Iodophor - 2-3 hrs

For Chlorhexidine prep. - 6 hrs

Process - 2 Steps

1. Apply alcohol in circular motion outwards, allow it todry

2. Apply Povidone Iodine or Chlorhexidine in circularmotion outwards, allow it to dry

Best practice for Site Preparation


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CLSI - Clinical and Laboratory Standards Institute, USA Cleansing the site first with 70% isopropyl alcohol, Allow it to air dry

Followed by application of the main disinfectant - Povidone Iodine or CHG

INS (1998, S53) - Infusion Nursing Society, USAAntimicrobial solution containers should be in a single-unit of use and that

they should be discarded after individual use

Excess hair over venipuncture site should be clipped instead of shaved

CDC - Centre for Disease Control and Prevention, USA 2% Chlorhexidine based antimicrobial preparation is preferred*

Palpation of catheter insertion site should not be performed after

application of antiseptic*

Allow the antiseptic to remain on the insertion site and to air dry beforecatheter insertion*

* CDC, Centre for Disease Control and Prevention, Guidelines for prevention of Intravascular catheter related Infections, MMWR, 2002: 51 (

No. RR 10 )

** Infusion Therapy in clinical practice Judy Hankins et al, 2nd Edition, The Infusion Nursing Society, INS


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No. RR 10 )



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No. RR 10 )



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Procedure

Assemble all articles at patient bedside. Thorough hand washing (Follow 6 steps)

Wear clean gloves.

Support the chosen limb.

Apply the tourniquet.

Assess and select the vein by gently tapping

the site.


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Insertion

Disinfect the injection site according to local hospital

policy Remove the catheter from the packaging and lower the

wings.

Adopt your preferred grip and remove the needle cover

Insert the catheter at 15-30 degree angle Upon primary flashback (back flow), lower the angle

almost parallel to the skin

Advance the catheter slightly, 2- 3 millimeters, to ensure

catheter tip is in vein You might consider stabilizing the catheter by holding one

of the wings


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Insertion

Ease the needle back 2- 3 millimeters. Secondary flashback between the needle &

catheter will confirm correct placement of the

catheter in the vein.

Advance the catheter completely into the vein. Remove the tourniquet.

Stabilize the catheter by holding one wing.

Occlude the vein just above catheter tip &withdraw the needle holding the needle grip or grip

plate.


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Recording

Upon Insertion of the catheter one should always

- Record the date of insertion.

- Record the site of insertion.

- Record the name of the person who has

inserted the catheter.- Record the Safety cannula Number

(Gauge)

- Signature of the person who has entered

the catheter.


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Line Management

Use aseptic technique at all times.

All IV ports should be closed. Verify patency of line by gently flushing with normal

saline.

Ensure that lines are labeled (date, time, signature)

Remove line on any sign of redness ,swelling orpain.

Change IV set after every 24- 48 hrs.

Cannula to be inspected after every 6- 8 hrs inadults. In Neonates it should be every 2- 4 hrs.

For giving antibiotics SAS (Saline followed byAntibiotic followed by Saline) must be followed.


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Line Management

Use aseptic technique at all times.

All IV ports should be closed. Verify patency of line by gently flushing with normal

saline.

Ensure that lines are labeled (date, time, signature)

Remove line on any sign of redness ,swelling orpain.

Change IV set after every 24- 48 hrs.

Cannula to be inspected after every 6- 8 hrs inadults. In Neonates it should be every 2- 4 hrs.

For giving antibiotics SAS (Saline followed byAntibiotic followed by Saline) must be followed.

P t P d


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Post Procedure

Remove all equipment and dispose in proper

manner. Document

Date and time

Gauge and length of catheter Site of placement

The patients response

Initials.

Inform the patient about signs and symptoms that

should be reported such as pain or swelling.


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Dressings

Replace dressing when dressing becomesdamp, loosened or visibly soiled.

Use clean gloves while changing dressing.

Document dressing changes with date, time.


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Dressing Guidelines

Use either sterile gauze or steriletransparent, semi permeabledressing to cover the catheter site

Replace catheter dressing if the

dressing becomes damp, loose, orvisibly soiled

Replace dressings at every 2 daysfor gauze dressing and 7 days fortransparent (TSM) dressing

CDC, Centre for Disease Control and Prevention, Guidelines for prevention of Intravascular catheter related Infections, MMWR,

2002: 51 ( No. RR 10 )

Sit C


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Site Care

Inspect through transparent dressing on each shift.

If transparent dressing is not used palpate insertion sitefor pain or tenderness.

Remove an opaque/ gauze dressing and inspect visually

if patient develops local tenderness or signs of infection.

Replace catheter as soon as possible or with in 48 hrs

when aseptic technique during insertion can not be

ensured.

Clean access port with antiseptic and access port only

with sterile device.

Cap stop cocks when not in use.

Si C


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Site Care

Document the status of IV access device and the site.

Flush IV cannula at least once in 8hrs with NormalSaline/heplock if not in use.

Restart peripheral IV sites every 72-96 hours inadults.

Peripheral catheter can be retained in pediatricpatients

until development of any complication.

If the patient is febrile without another obvious cause

remove the dressing to usually inspect the site.

Remove the IV catheter as soon as its use is over.

Si id


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Sites to avoid

Veins in the lower extremities

Points of flexion Veins close to arteries

Obvious valves

Median cubital veins

Small visible superficial veins Veins irritated from previous use

Sclerosed vein

Limbs affected by clinical condition

Infected sites

Broken skin

Ri k d ti th h C th t


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Risk reduction through Catheter

Flushing

C h Fl hi


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Catheter care - Flushing

All vascular access devices used should be flushed with 0.9% sodiumchloride (normal saline) or heparin to* Maintain catheter patency Prevent contact between incompatible fluids and medications

Appropriate Flushing helps to reduce catheter thrombosis and thus CR-BSIrisk** As thrombi or fibrin deposits could serve as a nidus for microbial colonization

When catheter flushing is to be performed Just after catheter insertion

Before and after each administration of medication

Blood sampling

Every 6-8 hours when catheter is not in use (Once a day - home care PICCs )

INS standards, 2006 Single use flushing systems to be used, that is, do not use multiple use vials

~ 8% Syringes prepared by nurses are contaminated - Syringe tip, Fluid*** Touch contamination

Multiple use vials or their inappropriate usage

* Infusion Therapy in clinical practice Judy Hankins et al, 2nd

Edition, The Infusion Nursing Society,page 394, ** CDC, Centre for Disease Control and Prevention, Guidelines for prevention of IV catheter related Infections,

MMWR, 2002: 51, Page 9 ( No. RR 10 ), ** APIC, Lynn Hadaway, Webinar series 2006

C h Fl hi


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Catheter care - Flushing Heparin lock usually not required in short peripheral catheters

Heparin, in lowest possible concentration, is the accepted solution for Centralvenous catheters

When using heparin, use smallest dose possible so that it does not alterpatients coagulation factors

Use saline flush between medication and heparin, to avoid any incompatibilitywith other IV medications

Volume for flushing

Minimum should be twice the internal volume of catheter system (Catheter +

add on devices ) Follow the hospital policy on volume and concentration

Maintain positive pressure techniques for flushing

Close the clamp on the ext. set before disconnecting syringe, Leave the clampclosed before until catheter is used again

As the last ml of fluid is flushed in, withdraw the syringe

Catheter should not be flushed to remove an occlusion

* Infusion Therapy in clinical practice Judy Hankins et al, 2nd Edition, The Infusion Nursing Society,page 394, ** CDC, Centre for Disease Control and Prevention, Guidelines for prevention of IV catheter related Infections,

MMWR, 2002: 51, Page 9 ( No. RR 10 )


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Appropriate Usage of

Equipments


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Appropriate use of equipmentIntravasular Access

Monitor and inspect catheter site regularly, the site should

be observed for any signs of inflammation, infection ormalfunction

Use vented IV sets with plastic non collapsible IV bags orglass bottles

Non vented IV set can only be used with collapsibleplastic bags**

Use single dose Vials for parenteral additives or anymedications

If multi-dose Vials are used, cleanse the accessdiaphragm of the multi-dose vial with 70% alcoholbefore inserting a device into the vial

CDC, Centre for Disease Control and Prevention, Guidelines for prevention of Intravascular catheter related Infections, MMWR, 2002: 51 ( No. RR 10 )

** Infusion Therapy in clinical practice Judy Hankins et al, 2nd Edition, The Infusion Nursing Society,

a e 394

Appropriate se of eq ipment


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Appropriate use of equipment

For any intravascular access

Replace IV tubing and add on devices no more frequently than72 hours

Replace tubing used to administer blood products or lipids within 24 hrs.

Clean injection ports with 70% alcohol or an iodophor beforeaccessing

IVD replacement

Peripheral Venous : 72-96 hrs. in adults / first signs of phlebitis,

In pediatric patients, Do not routinely replace peripheralvenous catheters unless clinically indicated

CVCs / PICC / Hemodialysis / PA / Peripheral Arterial : NOT

routinely*

CDC, Centre for Disease Control and Prevention, Guidelines for prevention of Intravascular catheter related Infections, MMWR, 2002: 51 ( No. RR 10 )


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Closed Port for infection

prevention

Open Ports


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Open Ports CDC - Centre for Disease Control and Prevention*

Stopcocks represent a potential portal of entry formicroorganisms into vascular access

Stopcock contamination is common, occurring in45-50% cases

INS - Infusion Nursing Society, USA**

Studies have shown stopcocks have often beencause of microorganisms entering the IV systemthrough

hands of personnel,

syringes used to flush or draw blood

residual blood that remains in the port afteruse, serving as breeding ground for bacteria

Failure to keep a sterile cap on when not inuse

* CDC, Centre for Disease Control and Prevention, Guidelines for prevention of Intravascular catheter related Infections, MMWR, 2002: 51 ( No. RR 10 )

** Infusion Therapy in Clinical Practice, Infusion Nurses Society, 2nd Edition, Judy Hankins, et al, chapter 24, Page 429, Pearson ML : Guidelines for prevention of IV device related

infections, Infect Control Hosp Epidemiol.17(7):438,1996


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Closed port


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Closed port


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Venipuncture &

Blood Collection

Where do the laboratory errors happen?


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Where do the laboratory errors happen?

St i Bl d C ll ti


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Steps in Blood Collection

Patient

interaction

Standard

precautions

Selecting

equipment

Positioning

the patient

Tourniquet

application

Site

selection

Site

cleansing

Perform

venipuncture

Sample

handling /

mixing

Sharps

disposalSample

transport

Patient

requisition

A Laboratory TEST is no better than the SPECIMEN, & the


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A Laboratory TEST is no better than the SPECIMEN, & the

specimen no better than the manner in which it was collected

Hemolysis Fibrin Mass

EDTA Under fillRed cells in

suspension

Fibrin

threads& poor

barrier

formation

Sample Quality is a challenge

e -


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e beyond the control of phlebotomists

Age

Race

Gender

Pregnancy

Diet

Exercise

Environment/Lifestyle

These are important variables but not of particular relevance

to phlebotomists and laboratory staff as physicians will

generally take these factors into account when interpreting

test result data

The PRE ANALYTICAL PHASE


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The PRE-ANALYTICAL PHASE

within control of phlebotomist / lab worker

Phlebotomy Related Causes

Patient and Specimen Identification

Dietary Status, Medications

Collection time (interval from last

meal, timing in context of drug

administration and other therapies -

eg dialysis, transfusion, surgery

Site of Phlebotomy

Tourniquet (placement, duration)

Cleansing of the site

Quality of Phlebotomy (trauma,

duration, needle gauge etc.)

Transport Related Causes

Improper handling

Temperature & Humidity

Time

Specimen Integrity

Exposure to LightProcessing Related Causes

Time

Centrifugation

Temperature Storage

re erre a r u es o ve ns or


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Large enough to support good flow

Easily visible

Close to the skin surface

Elastic do not feel too hard

Well anchored in surrounding tissue

re erre a r u es o ve ns or venipuncture

Site selection in Arm


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Site selection in Arm

1. Median cubital vein

This is the first choice because

It is large Well-anchored

Generally least painful

Least likely to bruise

2. Cephalic vein

This is the second choice

It is large

Not as well-anchored

May be more painful than the median cubital vein

3. Basilic vein

This is the third choice

It is generally large It is easy to palpate (elastic / feel)

Often not well anchored (slippery)

1. It lies near brachial artery and median nerve either of whichcould be accidentally punctured

Inappropriate Sites for Venipuncture


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Inappropriate Sites for Venipuncture

Arms on side of mastectomy

Edematous areas

Hematomas

Scarred areas

Burns

Tattoos

Damaged veins (e.g thrombosed, non-elastic veins)

Sites downstream (proximal) from an IV line*

* Note that whilst it is always preferable to draw blood from the opposite arm in this situation,phlebotomy may be performed upstream (distal) on the same arm when a suitable site is not

available on the opposite arm. Where there is no alternative to drawing downstream (on the same

arm), the line may be switched off** and the specimen collected after a minimum wait of 2minutes. These specimens must be labeled accordingly (e.g. intra-transfusion) (Ref: CLSI H03-

A6 Procedures for the Collection of Diagnostic Blood Specimens by venipuncture; Approved

Standard - Fifth Edition, p. 23, paragraph 11.5.1)

** with permission of the doctor in charge of the case!

E i t d S li


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Tourniquet

GlovesAntiseptic & Cotton

Needle

Syringe or Needle

holder

Specimen

Container

Gauze Tape or Bandage

Sharps Container

Equipment and Supplies

Patient Identification


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Patient IdentificationThis is the most important step in the venipunctureprocedure*

Out-patients:

Patient to be asked to state his/her fullname, spell the last name and date of birth

This is verified with the information on therequisition

In-Patients:

The patient's identification band to bechecked in order to verify the name andhospital identification number and match theorder.

The patients ID to be verified with ward staffif identification band is not available

Young or Mentally incompetent patient: May ask patients nurse, attendant, relative

to identify him / her

* patient ID error is the ultimate pre-analytical error!

Tourniquets


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Tourniquets

Stretchable strip of material 35 to 45

cm (15 to 18 inches) in length and maybe single-use or re-usable.

Different types of tourniquets are:

Latex

Vinyl usefulwhere the healthcare

workeror patient is allergic to latex

Elastic band with Velcro or buckleclosure

Use of a Tourniquet


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Use of a Tourniquet

Makes the veins easier to locate and feel

Slows down venous flow

Enlarges the veins

Should not restrict arterial blood flow into the limb

Wrap 7.5 to 10.0 cm ( 3 - 4 inches) above intended

venipuncture site

Tied to be releasable with one hand

Tourniquet time = maximum 1 minute

Gloves


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GlovesKey element of standard

infection control precautionsProvide a barrier to spread of

infection

Part of personal protectiveequipment (PPE) against contact

with blood during phlebotomy

Good fit is essential

Washing or reuse of gloves can compromise integrity of material to serve as barrierwithout visible changes.

Gauze Pads & Bandages


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Gauze Pads & Bandages

Gauze Pads

Should be clean

Used to apply pressure on site after

needle removal

Adhesive Bandages/Tape

Used to secure gauze

Do not apply directly on the site

Cotton not recommended as fibers can stick to site and initiate bleeding

when removed Do not use alcohol swab

Antiseptic and Disinfectant


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Antiseptic and DisinfectantAntiseptic

Inhibit or prevent the growth of bacteria

Approved for used on the skin

Used to clean venipuncture site

70% isopropyl alcoholmost commonly used

Disinfectant

Kills bacteria and inhibits some viruses

Check manufactures label

For use on surfaces and instruments, not on skin

Used to clean up all blood spills

1:10 hypochlorite (bleach) solution commonly used

Isopropyl alcohol


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70% optimal concentration asantiseptic

Store in closed container

Active ingredient evaporates fromopen container leaving water behind

Antiseptic properties diminished Bacteria from hands, container can

multiply and cause infection inpatient if used to clean intendedpuncture site

Cleaned site may not dry quickly

Isopropyl alcohol

Never pre-soak cotton balls

Cleaning the Site


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Cleaning the Site

Use pre-packaged swab or cotton ballthat has been moistened with antiseptic

at time of use on patient

Clean area in a spiral starting at theintended site of puncture moving

outward

Let air dry

Do not blow or fan site


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Clinical And Laboratory Standards Institute

Syringe and Needle Blood Collection


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Syringe

Variety of sizes:

2ml, 5ml,10ml, 20 ml Selection depends on

Patient

Volume of blood to collect

Strength of vacuum created

Advantage

Blood flash can be seen on

entering vein

Disadvantage

Specimen can clot

Specimen must be transferred

Never exert pressure on plunger in

transfer to vacuum tube

Vacuum to draw blood

from vein throughneedle and into syringe

created as plunger

withdrawn

User controls thevacuum

Syringe and Needle Blood Collection

Venipuncture Procedure Using Needle


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p gand Syringe

After needle is in the vein,slowly pull the plunger back

to start filling the syringe.

While blood flows into the

syringe, release the

tourniquet.

Transfer of Blood From Syringe into


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Remove the cap of the container

and gently transfer specimen

into it by pushing the plunger

Ensure there is no froth

formation during the blood flowinto the container

Do not overfill

Replace the container cap

y gSpecimen Container

Transfer of Blood from a Syringe into a


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Do not remove rubber stopper when using

evacuated tubes. Place the tube upright in a rack.

Slowly pierce the stopper of the evacuated tube

with the needle.

Allow the tube to fill (without applying pressure

to the plunger) until blood flow into the tube

ceases. This technique helps to maintain the

correct ratio of blood to additive.

Follow the same order for filling tubes as the

order of draw for an evacuated system.

y g

Evacuated Tube

1. WHO guidelines for drawing blood: best practices in phlebotomy, November 2009

Evacuated Closed Blood Collection


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Evacuated Closed Blood Collection

Vacuum in tube allowsblood to be drawn directly

from vein into evacuated

tube

No need to transfer blood

Tube Filling evacuated system


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g y Maintain downward position so blood and additive do not

touch non-patient end of multi-sample needle.

Allow to fill until vacuum is exhausted and flow stops. Remove from holder by applying pressure against wings*

of holder with thumb and index finger. This assists inholding needle steady as tubes are removed and inserted.

Invert gently several times after removal to mix blood andadditive. Additional mixing per tube type can be performedwhile next tubes are filling.

Continue to draw tubes following correct order of draw.

* As for tube placement above, this is critical to thesuccess of the procedure.

Order of Draw


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Order of Draw

(with clot activator)

1. Sterile samples (eg: Blood Cultures)

2. Citrate tubes*

3. Plain Serum tubes

4. Heparin tubes

5. EDTA tubes

6. Fluoride Oxalate (glucose tubes)

7. ACD tubes

* this tube is acceptable for routine coagulation testing (e.g. aPTT and PT/INR). For some special coagulation testing where low level activation of coagulation

factors may be of particular concern**, the use of a non-additive discard tube may be considered1. Because of dead space in the tubing of winged (butterfly)

sets, a discard tube should also be used where citrate tubes are the first drawn and a winged collection set is used. This is particulally important when 1.8mL and

2.7mL tubes are used.

** activation may be induced by tissue factor (tissue thromboplastin) introduced into the initial sample stream as the needle traverses the subcutaneous tissue.

Note regarding ESR: in accordance with CLSI1 recommendations, ESR tubes should be placed at position 2 above.

1. CLSI document H3-A6 Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture. 6th Edition, 2007

Mixing of Tubes


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Why

All tubes contain

additive that needs to be

mixed with the blood

sample.

Tubes withanticoagulants such as

EDTA need to be mixed

to ensure the specimen

does not clot.

How

Holding tube

upright, gently

invert 180 andback.

When Immediately after

drawing.

Consequences if not mixed:

Tubes with anticoagulants will clot

Specimen will often need to be redrawn

Mixing of Tubes

Needle Disposal


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Needle Disposal Ifa single-use holder is used, the complete assembly should

bediscarded into a puncture-proof sharps container.

Otherwise - The contaminated needles must be safely removed from the

holder and discarded in a suitable sharps container1,2

Nevercut, bend, break, burn, or re-cap needles.

A variety of containers is available. Most have a facility3to

provide safe removal of the needle from the (re-usable) holderwhen using an evacuated tube system.

1. Needles must not be removed with fingers. If needle doesnot separate from the holder, the entire assembly may bediscarded in the sharps container.

2. Place needle in the proper slot in the lid, and rotate anti-

clockwise until it unscrews from the holder. Allow theneedle to drop into the container

Sharpcontainers should not be overfilled


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Post venipuncture


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p

The patients arm is examined to see if bleeding hasstopped.

An adhesive bandage or tape is applied on the site(following institutional policies).

The patient is instructed to leave the bandage on for aminimum of 15 minutes.

Out patients should be advised not to carry a purse or otherheavy object or lift heavy objects with that arm for 1 hour.

The patient should be thanked for his or her cooperationthis helps leave the patient with a positive feeling.*

(Contaminated materials should be disposed of in approvedbiohazard containers following the institutional policiesbefore attending to the next patient.

*Reference: Ruth E McCall & Cathee M. Tankersley. "Phlebotomy Essentials" 3rd edition (2003) p 272.

Tube Transportation


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p Tubes transported through public hallways should be placed in a

secondary container to minimize the risk of leakage and spillage.

The secondary container shouldbe clearly labeled "BIOHAZARD.

Once the tubes are in the container, they should be sealed prior totransport.

Once primary containers are inside the externally uncontaminatedsecondary container, they can be handled without gloves2.

Personnel who transport specimens should be trained in safe handlingpractices and decontamination procedures2.

Paper requisition(s) and other documents (if present) mustbe attachedsecurely to the secondary transport container.

All necessary steps shouldbe taken to avoid exposure of tubes tomechanical trauma, temperature extremes and delays duringtransportation as these can introduce significant pre-analytical error1.

Once received in the laboratory, gloves should be worn while removingspecimens from the secondary container and for all manipulations ofprimary container2.

1. CLSI Document H18-A3. Procedures for the Handling and Processing of Blood Specimens; Approved Guideline, 3rdEdition, 2004

2. CLSI Document M29-A3 Protection of Laboratory workers from occupationally acquired infections; Approved Guidelines,3rd Edition, 2005

Special Collection Procedures


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p Use of winged collection set is recommended for all blood

culture collection procedures.

Thorough skin preparation is essential* The site should first be cleansed with 70% alcohol

The site should then be swabbed with 1-10% povidine-iodine solution or chlorhexidine gluconate (the latter isrecommended for infants greater than 2 months of ageand patients with iodine sensitivity) by circular motion,

starting in the middle. The site must then be allowed to dry. The iodine /

chlorhexidine can then be removed with an alcoholswab.

* institutional policies and procedures must befollowed

The culture bottle stopper should be disinfected followingmanufacturers instructions.

Summary


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y

Prepare the tray. Ensure all the logistic/equipment areavailable in the tray

Choose the correct site for cannulation.Avoidjoint/obliterated vein

Follow aseptic technique, wash hand,clean cannulationsite and wear clean gloves

Maintain record of cannulation

Watch for complication like phlebitis/haematoma etc.

Replace cannula every 72-96 hours

Dispose sharps and other materials appropriately as per

guideline(CPCP/SPCB)

Module 2 - Infusion Safety

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Transcript of Module 2 - Infusion Safety