PHLEBOTOMY SERVICES

The use of laboratory phlebotomy services for the procurement of blood specimens is strongly encouraged in order to provide patients with the most efficient laboratory services.

INPATIENT

Pediatric Services

Rounds for routine morning blood work are scheduled from 7-10 AM on all inpatient care units. At all other times, contact the phlebotomist through beeper 4209 to request service.

Adult Services

Rounds for routine morning blood work are scheduled from 5-10 AM on all inpatient care units. At all other times, contact the department to request service according to the following schedule.

Emergency Management Coverage

For the weekend and holiday "on call" schedule, please contact Laboratory Client Service at 212-305- 8600.

OUTPATIENT

Outpatient phlebotomy services are available at several convenient locations for patients of physicians on staff at New York Presbyterian Hospital.

Outpatient Phlebotomy Stations

COLLECTION CONTAINERS

• Vacutainer® Tube Use

  The following table lists the most common types of collection tubes required for blood specimen analysis. Additional collection tube types may be required for selected tests. Refer to the Alphabetical Listing of Tests. Invalid results, as well as rejection of the specimen, may occur if improper collection techniques and/or collection tubes are used. Always allow the Vacutainer® tube to fill completely for correct blood:anticoagulant ratios.

Tube Top Color	Additive	Draw Volume
Light blue	Sodium citrate	1.8 mL or 2.7 mL
Lavender (purple)	EDTA	2 mL
Gold	Plain with gel separator and clot activator	5 mL
Red	Plain	4 mL
Tan	Sodium heparin	5 mL
Pale green	Lithium heparin	3 mL
Gray	Sodium fluoride/oxalate	4 mL
Yellow	ACD	6 mL
Black	Sodium citrate	2.4 mL For ESR only
Royal blue	Metal free	7 mL
Royal blue	EDTA	7 mL For Blood Bank only
Yellow/black speckled	IsolatorTM tube	3 or 5 mL For AFB and fungal blood cultures only

• Urine or Fluid Collection Containers

  The following containers are acceptable for collection/transport of body fluids for routine analysis. ALWAYS secure top/lid tightly to prevent possible specimen leakage. Label each specimen with the patient's name, date of collection, and medical record number.

  • Uri-tek tube for routine urinalysis

  • Sterile black top 16 mm x 125 mm clear screw-top tube for miscellaneous fluids

  • 200 mL sterile wide-mouth cup with green screw-top lid for small volume fluids

  • 3000 mL opaque plastic container with lid for timed specimen collections -preservative may be required for certain tests - see the Alphabetical Listing of Tests or contact the laboratory at 212-305-8600

  • CSF Collection Kit Tubes: Use the sterile tubes provided in the Spinal Tap Kit. Label each tube with the patient's name and medical record number. Clearly indicate the tube sequence.

PEDIATRIC GUIDELINES

Pediatric Phlebotomy Specimen Volume Requirements

The volume of blood drawn during pediatric venipunctures must be minimized due to the size and total blood volume of the infant/child. Small infants may become anemic if too much blood is taken in the course of a day. A 10 mL sample taken from a premature or newborn infant is equivalent to 5% to 10% of the infant's total blood volume. Calculation of blood volume is based on weight. The total blood volume of a person can be calculated by multiplying weight (kg) by the following blood volumes:

Guidelines for the maximum allowable amount of blood which can be drawn at one time have been established for patients younger than 14 years of age, based on calculated blood volume.

In order to follow these guidelines, only the following types of collection tubes may be used at New York Presbyterian Hospital, Columbia Presbyterian Campus for infants.

BD MicrotainerTM, lavender top	(500 L)	EDTA
BD MicrotainerTM, green top	(600 L)	Heparin
BD MicrotainerTM, gold top	(600 L)	Plain/serum
BD MicrotainerTM, red top - amber tube	(600 L)	Plain/serum - use for tests requiring light protection

Pediatric Collection Devices

To minimize trauma to the pediatric patient, a 23-gauge safety winged infusion set (butterfly needle) with a Vacutainer® tube adaptor should be used. Smaller gauge needles tend to hemolyze the blood. If the use of a 5 mL syringe is required, aspirate the blood gently. Prolonged delay will increase the chance of clotting. Remove the syringe from the infusion set and transfer the required amount of blood to the appropriate collection tube/Microtainer^TM using standard precautions. Heelsticks are performed only for PKUs/metabolic screens or upon specific request.

Pediatric Minimum Specimen Requirements

Listed in the table below are the minimum specimen requirements for commonly ordered tests.

If the number of tests ordered on any individual patient necessitates drawing more than the maximum allowable phlebotomy as determined by the patient's weight, consult the attending physician to prioritize the most critical tests.

Test	Minimum Specimen Requirements	Equivalent/Approx Volume
Ammonia/Lactate	One full green top MicrotainerTMon ice	600 L
Bilirubin	One red top/amber tube MicrotainerTM	600 L
CBC/Retic	One lavender top MicrotainerTM	500 L
Basic Metabolic Panel	One full green top MicrotainerTM	600 L
Cyclosporine	One tan Vacutainer® tube	5 mL (2 mL minimum)
Dilantin®	One green top MicrotainerTM	600 L
ESR	One 2.4 mL black top Vacutainer® tube -full	2.4 mL
FK506	One lavender top MicrotainerTM	500 L
Hepatic Function Panel	One full green top MicrotainerTM	600 L
Lead	One tan top Vacutainer® tube	5 mL (2 mL minimum)
Other Chemistries (excluding CM7), maximum of 5 tests/full MicrotainerTM	One full green top MicrotainerTM	600 L
Phenobarbital	One green top MicrotainerTM	600 L
PT/PTT/Fibrinogen	One 1.8 mL blue top Vacutainer® tube	1.8 mL
Serologies (eg, RPR, Hepatitis Antibodies, etc)	One full gold top MicrotainerTM for every 2 tests	600 L
Type and Crossmatch	Two lavender top MicrotainersTM	500 L
Vitamin A/E	One 4 mL red top Vacutainer® tube	4 mL (2 mL minimum)
Vitamin D	One 5 mL gold top Vacutainer® tube	5 mL (2 mL minimum)

BLOOD COLLECTION PROCEDURES

Patient Preparation

The ordering physician should provide the patient with information on fasting, diet, and medication restrictions prior to requesting testing. See the Alphabetic Listing of Tests for any specific requirements relating to the test(s) you have ordered. A correctly completed request for laboratory testing must be submitted by the healthcare provider. Please see the section on "Requesting Laboratory Services and Tests" in this manual.

Venipuncture Technique

Considerations:

• Draw specimens from veins without an I.V.

• Use a large enough needle to permit adequate flow of blood.

• Avoid drawing from a vein associated with a hematoma.

• If a patient has had a mastectomy, do not draw blood from that side.

• Always use Standard Precautions when drawing or handling blood specimens or blood specimen collection equipment.

Procedure:

• Confirm the identity of the patient. Check armbands of all inpatients for name and medical record number. Ask outpatients for their name and date of birth.

• The name and medical record number on the laboratory requisition must match the information on the armband and/or information provided by the patient.

• Wash hands.

• Glove.

• Inspect the patient's arm and select an appropriate venipuncture site.

• Place the tourniquet approximately 3" to 5" above the vein site. Instruct the patient to extend his/her arm and open and close the fist a few times to engorge the veins for easier identification.

• Palpate the selected vein if necessary, than cleanse with alcohol or povidone-iodine prep pads. Allow the area to dry completely. Never leave the tourniquet on the arm for more than 2 minutes without releasing.

• Prepare the Vacutainer® holder by aseptically screwing in the multisample needle into the holder. Use only holders that are equipped with a needle safety device.

• Firmly grasping the Vacutainer® holder with the dominant hand, puncture the vein at a 35° to 45° angle. As the needle enters the skin, lower the angle so that only the anterior wall of the vein is pierced. Push the Vacutainer® tube onto the needle in the holder. Maintain stability of the needle in the vein. Blood should immediately begin to fill the tube due to the vacuum action. Fill all tubes completely. When drawing multiple blood tests, it is important to draw the blood in a specific order to prevent contamination of subsequently drawn tubes by anticoagulants. The required order of draw is:

  Blood culture Red top tube Gold top tube Light blue top tube Black top tube Green or tan top tube Royal blue EDTA Blood Bank tube (lavender band on tube) Lavender/purple top tube Gray top tube Yellow top ACD tube Yellow/black top IsolatorTM tube

• Remove the tube and replace it with a new tube as needed, keeping the needle steady and in the vein. Gently invert the collected tube of blood several times. DO NOT SHAKE.

• After all tubes have been collected, release the tourniquet. Remove the Vacutainer® tube from the holder before removing the needle from the vein.

• Press a sterile gauze pad over the venipuncture site and remove the needle. Hold the pad in place for 1-3 minutes until bleeding has stopped.

• Place a bandage over the site to prevent blood leakage.

• Immediately label all specimens with the patient's name and medical record number. Be sure that the name on the requisition and corresponding tube are spelled correctly.

• Indicate the number and type of tubes drawn and the time of collection on the requisition. Sign the requisition with your name or phlebotomy identification code. Initial all Blood Bank tubes. (See specific instructions for collection of samples for Blood Bank at the end of this section.)

• Place all tubes in the approved specimen transport bag with the requisition and transport to the laboratory as soon as possible.

• Special care must be taken to handle all specimens optimally. Check the Alphabetical Listing of Tests for any special handling requirements (warm, iced, etc).

Time of Sampling

Analysis of drug concentration is useful in assessing therapeutic efficacy and potential drug toxicity. Many factors may affect drug bioavailability, including but not limited to, age, disease state, metabolism, and route of administration. Trough levels should be drawn immediately before the next dose. Peak levels are usually drawn 1-2 hours after dose (this is drug dependent). Clearly mark the laboratory test requisition and specimen to indicate if the sample is a peak or trough sample. Bag the specimens separately. Do not order both peak and trough drug levels on the same requisition (or same sample).

Glucose Tolerance Tests

Many variables affect the carbohydrate tolerance of an individual, and thus also impact the interpretation of glucose tolerance test results for that patient. Glucose tolerance tests may only be scheduled for patients at the Irving Pavilion (212-305-5540), Allen Pavilion (212-932-4220), or Columbia-Presbyterian/Eastside (212-326-8444).

Patient Preparation:

• The patient must be ambulatory.

• No surgery, trauma, or illness within 2 weeks.

• Unrestricted carbohydrate diet (at least 150 g of carbohydrate per day) for at least 3 days.

• Fasting for at least 8 hours but no more than 16 hours prior to testing.

• The patient may not smoke, drink coffee, or exercise during the test (other than to walk around). If autonomic nervous system responses develop during the test (pallor, sweating, nausea, fainting, etc), the test will be discontinued after a sample is obtained.

BLOOD BANK SPECIMEN COLLECTION REQUIREMENTS

Tests: Type and Screen, DAT, Antibody Identification, Antibody Titer

Test: Fetal Screen Testing for Postpartum Women

Note:All samples must be labeled with the full first name and last name of the patient, plus the medical record number, signature of the person collecting the sample, and the date collected. The Blood Bank requisition must contain the identical information.

If all the required pieces of identification are not present and correct, the specimen will be rejected. THERE ARE NO EXCEPTIONS TO THIS REQUIREMENT.

URINE COLLECTION PROCEDURES

Clean Catch Midstream Urine Collection

• Wash hands thoroughly with soap and water; rinse and dry well with a paper towel.

• Female: Separate the skin folds around the urinary opening. Wash the area with a soap pad or towelette using a front to back motion. Repeat twice.

  Male: Wash the head of the penis with a soap pad or towelette.

• Begin urinating into the toilet with the skin folds held apart with the fingers.

• Insert collection container into the urine stream without allowing the container to touch the skin area.

• Fill half of the container and remove from the urine stream.

• Replace the container lid and seal completely, being careful not to touch the rim of the container. Attach a label to the outside of the container with your name and medical record.

• Record the date and time of collection of the specimen on the test requisition.

• Place the specimen in the approved specimen transport bag with the requisition and transport to the laboratory as soon as possible.

• Refrigerate the specimen if transport to the laboratory is delayed.

Routine 24-Hour Urine Collection

The 24-hour urine specimen should be submitted in a wide-mouth, chemically clean, properly labeled urine container. These containers are available through materials management and at the outpatient service centers. If a preservative is required, the collection container may be picked up from the Core Laboratory, PH 3-355. Refer to the Alphabetical Listing of Tests section for specific preservative requirements. Nonapproved alternate collection containers are not acceptable.

Give the patient instructions for collecting a 24-hour urine specimen.

Follow these instructions when collecting your 24-hour urine specimen.

Do not add anything but urine to the bottle. Do not pour out any liquid or powder that may already be in the collection bottle (the preservative). Keep the collection bottle refrigerated throughout the collection period. Label the container with your complete name and medical record number. Add the date and time of collection as described below.

• Upon arising in the morning, urinate into the toilet, emptying your bladder completely. Do not collect this sample. Note the exact time and write it down on the container label and test request form.

• After this time, collect all urine voided for 24 hours in the container provided. All urine passed during the 24-hour time period (day and night) must be collected.

• Refrigerate the collected urine between all voiding or keep in a cool place.

• At exactly the same time the following morning, void completely again (first time after awakening), and add this sample to the collection container. Note the exact time and write it down on the container label and test request form. This completes your 24-hour collection.

• Take the 24-hour specimen to the laboratory as soon as possible.

MICROBIOLOGY SPECIMEN COLLECTION

Specimen Quality and Transport Media

The Clinical Microbiology Service utilizes tests that are largely growth dependent, therefore, the quality of results are directly dependent on the quality and appropriate handling of the submitted specimens. Pay careful attention to specific specimen collection and transport media requirements delineated for each specimen type in order to adequately recover pathogens. The appropriate specimen transport devices are summarized below.

Any questions regarding the collection procedures for a specific organism, please contact the laboratory.

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