WHO guidelines on drawing blood - World Health Organization

1 WHO guidelines on drawing blood : best practices in phlebotomyWHO Library Cataloguing-in-Publication DataWHO guidelines on drawing blood : best practices in standards. standards. injuries prevention and control. Health Organization . ISBN 978 92 4 159922 1 (NLM classification: WB 381) World Health Organization 2010 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization , 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.))

2 Dotted lines on maps represent approximate border lines for which there may not yet be full mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its by the WHO Document Production Services, Geneva, Switzerland iiiContentsAcknowledgements ..viiAcronyms.

3 XiExecutive summary ..xiiiPART I BACKGROUND ..11 Introduction .. Overview .. Issues in phlebotomy .. The need for guidelines .. Definitions .. Purpose and scope .. Objectives .. Target audience .. Indications for blood sampling and blood collection .. Structure of document ..6 PART II ASPECTS OF PHLEBOTOMY ..72 Best practices in phlebotomy .. Background information on best practices in phlebotomy .. Planning ahead .. Using an appropriate location .. Quality control .. Quality care for patients and Health workers .. Quality of laboratory sampling .. Practical guidance on best practices in phlebotomy .. Provision of an appropriate location .. Provision of clear instructions .. Procedure for drawing blood .. Illustrations for best practices in phlebotomy ..183 blood -sampling systems .. Background information on blood -sampling systems .. Closed systems.

4 Open systems .. Practical guidance on blood -sampling systems .. Needle and syringe .. Choice of gauge .. Illustrations for blood -sampling systems ..234 Venepuncture for blood donation .. Background information on venepuncture for blood donation .. Minimum requirements for venepuncture for blood donation .. Before a blood donation .. Practical guidance on venepuncture for blood donation .. Collecting blood .. After a blood donation .. Adverse events in blood donation ..295 Arterial blood sampling .. Background information on arterial blood sampling .. Choice of Complications related to arterial blood sampling .. Sampling errors .. Practical guidance on arterial blood sampling .. Equipment and supplies .. Procedure for arterial blood sampling using radial artery .. Illustrations for arterial blood sampling ..33iv WHO guidelines on drawing blood : best practices in phlebotomy6 Paediatric and neonatal blood sampling.

5 Background information on paediatric and neonatal blood sampling .. Choice of procedure and site .. Practical guidance on paediatric and neonatal blood sampling .. Patient identification .. Venepuncture .. Finger and heel- prick .. Illustrations for paediatric and neonatal blood sampling ..377 Capillary sampling .. Background information on capillary sampling .. Choice of site .. Selecting the length of lancet .. Order of draw .. Complications .. Practical guidance on capillary sampling .. Selection of site and lancet .. Procedure for capillary sampling .. Illustrations for capillary sampling ..45 PART III IMPLEMENTATION, EVALUATION AND MONITORING ..478 Implementing best phlebotomy Setting policies and standard operating procedures .. Procurement .. blood -sampling equipment .. Protection .. Phlebotomy training .. Safe waste and sharps disposal .. Prevention and management of incidents and adverse events.

6 Patient related .. Health -worker related .. Risk assessment and risk reduction strategies ..549 Monitoring and evaluation ..55 PART IV REFERENCES ..57 PART V ANNEXES ..63 Annex A: Methods and evidence base ..65 Annex B: Infection prevention and control, safety equipment and best practice ..69 Annex C: Devices available for drawing blood ..71 Annex D: Managing occupational exposure to hepatitis B, hepatitis C and HIV ..73 Annex E: Training course content for phlebotomists ..77 Annex F: Explaining the procedure to a patient ..79 Annex G: Disassembly of needle from syringe or other devices ..81 Annex H: blood spillage ..83 Annex I: Modified Allen test ..85 Annex J: Cochrane review ..87 Annex references ..103 Glossary ..105 vTablesTable Elements of quality assurance in phlebotomy ..10 Table Infection prevention and control practices ..12 Table Recommended order of draw for plastic vacuum tubes.

7 16 Table Recommended needle gauge, length and device for routine injection and phlebotomy procedures for different age groups ..22 Table Adverse events in blood donation ..29 Table Conditions influencing the choice of heel or finger- prick ..41 Table Summary of risks and risk-reduction strategies ..54 Table Recommendations for infection prevention and control, safety equipment and best practice ..69 Table Devices for drawing blood ..71 Table Recommendations for HBV post-exposure prophylaxis, according to immune status ..74 Table Recommended two and three-drug post-exposure prophylaxis regimens ..75 Acknowledgements viiAcknowledgementsThe World Health Organization (WHO) Injection Safety and Related Infection Control programme and the Safe Injection Global Network (SIGN) Secretariat in the WHO Department of Essential Health Technologies (EHT) wish to express their thanks to the people listed below for their contribution to the development of these phlebotomy guidelines .

8 The authors and reviewers are experts in the field of injection safety and related infection control. Particular thanks go to Shaheen Mehtar of Stellenbosch University, South Africa, who prepared background documents for the consultation, and wrote the initial and final of this publication was supported by Cooperative Agreement CDC-RFA-CI09-903 from: the Department of Health and Human Services/Centers for Disease Control and Prevention (CDC), Atlanta, United States of America (USA); the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Global AIDS Program (GAP). Technical authors and main reviewers Internal authors and reviewers (WHO)Dr Neelam DhingraCoordinator blood Transfusion Safety (BTS) WHO Headquarters (WHO/HQ), Health Systems and Services, Department of Essential Health Technologies (HSS/EHT)Dr Micheline DiepartAntiretroviral Treatment and HIV Care WHO/HQ, Department of HIV/AIDS (WHO/HQ/HTM/HIV)Dr Gerald DziekanProgram Manager WHO Patient Safety Program (PSP) WHO/HQ, Department of Information, Evidence and Research (IER)Dr Selma Khamassi, MD, MScInjection Safety and Related Infection Control SIGN Secretariat WHO/HQ/HSS/EHT/Diagnostic Imaging and Medical Devices (DIM) Dr Fernando Otaiza, MD, MSc, Infection Prevention and Control in Health CareBiorisk Reduction for Dangerous Pathogens WHO Department of Epidemic and Pandemic Alert and Response Mrs Susan WilburnWHO, Department of Occupational and Environmental Health (OEH)viii WHO guidelines on drawing blood .

9 Best practices in phlebotomyExternal authors and reviewersDr Rana Al-AbdulrazzakHead of Donation Department & Hospital Liaison Department Kuwait Central blood Bank KuwaitMs Patricia K BertscheManager, Global Occupational Health Services Abbott Laboratories USADr Nizam DamaniInternational Federation of Infection Control Northern IrelandDr Che-Kit Lin Hospital Chief Executive Hong Kong Red Cross blood Transfusion Service Hong KongDr Lawrence Marum Team Leader Medical Transmission Global AIDS Program, HIV Prevention Branch CDC, Atlanta, USAP rofessor Shaheen MehtarHead of Academic Unit for Infection Prevention and Control Tygerberg Hospital and Stellenbosch University, Cape Town South AfricaDr Joseph PerzActing Team Leader, Research and Field Investigations Epidemiology and Surveillance Branch Division of Healthcare Quality Promotion (DHQP) CDC, Atlanta, USADr Ruby PieterszManager of Department of Research and Education Plesmanlaan 125, 1066 CX Amsterdam The NetherlandsDr Christie ReedHIV Prevention Branch Global AIDS Program CDC, Atlanta, USADr Dejana SelenicHIV Prevention Branch Global AIDS Program CDC, Atlanta, USADr Steven WiersmaDivision of Viral Hepatitis CDC, Atlanta, USAA cknowledgements ixExperts who contributed to the development of the recommendation on skin disinfection before blood collection for transfusion purposesDr Michael Bell Associate Director for Infection Control, Division of Healthcare Quality Promotion, NCPDCID CDC, Atlanta, USADr Barry Cookson Director, Laboratory of HealthCare Associated Infection, Centre for Infections, Health Protection Agency, London, United Kingdom (UK)

10 Dr Peter HoffmanConsultant Clinical Scientist, Central Public Health Laboratory Laboratory of HealthCare Associated Infection, Centre for Infections, Health Protection Agency, London, UKDr Carl McDonaldHead of Bacteriology, National Bacteriology Laboratory National Health Service blood and Transplant, London, UKDr Ziad MemishDirector, Gulf Cooperation Council States Center for Infection Control Head, Adult Infectious Diseases Section Dept of Medicine and Infection Prevention and Control Program National Guard Health Affairs King Fahad National Guard Hospital, Saudi ArabiaAdjunct Professor Department of Medicine Division of Infectious Diseases, University of Ottawa, CanadaDr Shirley Paton MN, RNSenior Advisor, Health Care Associated Infections Centre for Communicable Diseases and Infection Control Public Health Agency of CanadaPeer review Dr Michael BorgChair, International Federation of Infection Control Infection Control Unit Mater Dei Hospital Msida MSD2090 Malta Dr Mary Catlin BSN, BA, MPH4210 Midvale Ave N.