Phlebotomy is the process of drawing blood samples by injecting a needle into a vein. Draw blood in the colour coded Vacutainer tube. For serum or plasma draw about 2–2.5 times the requested volume. For serum, allow the blood to clot for at least 30 mins. and separate by centrifugation. For plasma, mix the blood with the anticoagulant by gently inverting the tube 8–10 times and separate by centrifugation.

• Identification of Patient’s Sample
• Patient Preparation
• Specimen Collection
• Universal Precautions

Identification of Patient’s Sample

• Each patient is assigned an identification number during registration at the reception counter.
• This ID code generated by the computer following the coding given below
  AA / BB / CCCCCC
  AA Centre Code
  BB Financial year code starting from 1st April of each year
  CCCCCC Patient ID number which is a continuous series starting from 1st April to 31st March every year.
• The computer generates the above ID number which is mentioned in the patient booking slip, patient receipt and the stickers which are pasted on the patient sample containers
• The bar code printer prints these patient ID stickers at the sample collection location.
• Check the vials to be used for each patient & special instructions if any (Refer Directory of Services).
• Each sample has to be labeled with patient’s number along with the date
• Time of collection of sample and the types of sample collected should also be entered in the given format immediately & should be signed by the sister on duty collecting the sample.
• Any additional test on the same sample is given same identification number and should be communicated to the TM & the Department I/c immediately.
• Samples received from IPD / Outside Collection
  Samples should be checked immediately for:
  • Name, Age, Sex
  • Tests
  • Volume
  • Container
  • Any damage
• Where required or relevant for the test check the availability of patient’s additional information / history.
• Note receiving time.
• If any discrepancy is found, enter the details in sample Rejection Record.
• Also inform the reception / ward in-charge about the sample being rejected so that the source of
• sample is informed to send the fresh sample.

Patient Preparation:

• If fasting sample is required, make sure the patient is fasting ( overnight fasting ) water is permitted.
• Patient should not undergo rigorous exercise just prior to the test. He must rest for at least 15 minutes before blood collection.

Body posture can influence the concentration of various analytes in blood. The redistribution of the fluids takes place when the person changes from supine to upright position resulting in increase of analytes concentration by approx 5-15% compare to supine position. The values of Hb, PCV, RBC, WBC & Platelets increase with the change in body position from recumbent to sitting and to erect and the differences are statistically significant.

The changes in concentration of analytes as a result of exercise are largely due to shift of fluid between intravascular and interstitial compartments, changes in hormone concentration stimulated by change in activity and by loss of fluid due to sweating, ALT, AST, Creatinine & Phosphate increases significantly after strenuous exercise.

• It is necessary to find out whether the patient is under special medication e.g. Acitrom (when PT/ APTT is asked).
• For PP sugar collection patient must report to the collection area 15 minutes prior to scheduled time.

Specimen Collection

• Ensure patient's correct identity- Lab No., Name, Age, Sex, etc.
• Sampling done only after patient has rested for ten minutes.
• Refer to the Alphabetical List of Tests in Reference Guide for detailed instructions on specimen collection.
• Label & barcode the blood collection tubes prior to sampling.
• Select & prepare proper phlebotomy site.
• Puncture the vein when spirit has evaporated completely.
• Avoid sites of I/V infusion, hematoma, oedema & thrombosis.
• Do not apply tourniquet for more than one minute.
• Draw blood sample with minimum trauma using correct order of draw (Blood culture, SST/Red Top, Citrate, Heparin, EDTA, Flouride) and needle size (preferred 19-21G).
• Ensure correct volume draw for additive tubes.
• Mix the blood with the anticoagulant by gently inverting 8-10 times for additive tubes and 3-4 times for SST.
• Press the puncture site keeping the arm horizontal till blood stops flowing; apply Band - aid'.

Universal Precautions

• Technicians/phlebotomists should wear gloves and apron for their safety.
• Destroy the needle in needle cutter after drawing blood.
• Discard sharps and other biological waste in proper bins containing disinfectant (1% sodium hypochlorite).

• Use a ‘Zip lock bag' for packaging specimens .
• Place the specimen(s) wrapped in absorbent paper,
• Seal the Zip Lock bag. This will prevent the sample from contaminating.
• Transport the specimen bag at specified temperatures as per the lab’s guideline.

• The OPD / IPD requisition slip received from ref clinician mentions URGENT.
• Alternatively the patient while collection for sample may request for URGENT report.
• The phlebotomist / technician put the ORANGE sticker on the sample container and marks URGENT in the requisition slip along with the time of report.
• The phlebotomist ensures that urgent samples are immediately transported to processing / working area
• On receipt of such samples, the receiving technicians verified the quality / quantity of sample immediately and starts processing / testing activity
• Results are immediately communicated to ref doctor over phone by department in-charge.
• Some examinations have some special clinical significance attached to them and are given priority in processing irrespective of the URGENT request made by the patient / doctor. Results if conveyed quickly may help the clinician in timely diagnosis and the treatment in grave situations.

Laboratory has a procedure defined in Sample Collection Manual (SP – SCM) for safe

transportation of the patient samples in-house and from outside locations

All lab staff collecting samples from outside has been adequately instructed on proper packing of patient samples and biomedical waste items before transportation of the same to lab to ensure general safety during transportation.

Dedicated sample collection bag have been provided to all collection staff to ensure that the sample is transported

1. Within a time frame appropriate to the nature of the requested examinations and the laboratory discipline concerned
2. Within a temperature interval specified for sample collection and handling and with the designated preservatives to ensure the integrity of samples. Ice packs are provided in the sample collection bag for compliance; The sample receiving team verifies and records the temperature in which the sample was received.
3. In a manner that ensures safety for the carrier, the general public and the laboratory, in compliance with biomedical waste management guidelines. All sample collection bag carry biohazard logo for the same purpose.

In case of noncompliance due to time, spill or temperature resulting in compromising the integrity of the patient sample, the patient, hospital is informed of the same and fresh sample requested.

Reduction in errors. Bar code systems reduce the number of data entry errors. This has been proven in studies showing the typical error rate for manual data entry to be one error in 300 characters. Savings in Time. Beside being more accurate than manual data entry, the entry of data using bar codes is much faster. Whereas routine manual data entry for a particular customer order may take a few minutes, transferring this information via bar code can take just a few seconds. Bar coding tubes prior to sample draw is a good laboratory practice.

• Use appropriate barcode stickers.
• Numbers should be on the right hand side.

Precautions:

• Do not change the numbers on the barcode by hand
• Do not use ink or write on the barcode label by hand
• Do not soil the barcode

Specimen Handling For Routine Submission

• Check if sample received is in formal saline. If suspected otherwise, get specimen checked by Pathologist before accepting
• Very small specimen must be checked by Pathologist before accepting.
• Use a separate container for each separately identified specimen.
• Do not crush the specimen with forceps.
• Do not force a large specimen into small container. Formal saline volume to specimen ratio of 10:1 is to be maintained.
• Sampling Technician should collect prepared formal saline from Histopath Technician (if required).
• Label each container.
• Complete requisition form with patient’s age, sex, clinical information and anatomic site of the specimen should accompany the specimen.
• Do not accept any specimen without the operation notes and reference slips
• Bone biopsy should be accompanied with the X-Ray.

PAP/LBC Smear

• Ask the patient to pass urine.
• Explain about the procedure, if she is getting it done for the first time.
• Patient is asked to lie down in the examination couch in a lithotomy position.
• Pap jar is labeled with the name and ID number of the patient.
• Wear sterile gloves, use sterilized speculum according to the size required.

FNAC

• Get Consent Form No. ADMN / FR / 14 filled.
• Inform Doctor by phone as soon as FNAC arrives.
• Prepare the following collection material before calling the doctor:
  • Needle holder
  • Slides
  • Syringe
  • 24 G needles in case of thyroid FNACs
• Check the patients booking slip and referral slip
• Position the patient
• Call the doctors
• The skin above the area to be aspirated is swabbed with anti septic solution.
• The rules of universal precautions must be observed, the mass to be aspirated should be palpated.
• A special needle of required diameter is passed
• Immediate examination of aspirate to be done under microscope
• In addition “quick read” cases to be identified