Blood Specimen Collection: Venipuncture Vacuum-Extraction Method (Home Health Care) - CE

ALERT

Strictly adhere to guidelines for hand hygiene, standard precautions, and site preparation to minimize the risk for a health care–associated infection.^{undefined#ref15">15}

Signs of nerve injury include severe, unusual or shooting pain, tingling or numbness, or a tremor in the arm. If the patient complains of any of these symptoms during venipuncture, withdraw the needle immediately.²

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

OVERVIEW

Infection control standards must be followed when obtaining a blood specimen. Appropriate safety devices should always be used and standards should be followed to minimize the risk of exposure blood-borne pathogens.¹⁶ The use of safer needleless devices such as those with a reliable integrated safety feature is recommended.¹⁶ Venipuncture requires an aseptic no-touch technique and sterile gloves if contact with the skin is required after the skin preparation with an antiseptic.⁸ Veins used for venipuncture should be repeatedly assessed for infiltration, extravasation, infection, or phlebitis using standardized scales.^11,12,13 Pain, burning, stinging, erythema, warmth, and subcutaneous swelling should be reported to the practitioner.

A vacuum-extraction blood specimen collection system uses vacuum force to draw blood into vacuum-sealed test tubes. Venipuncture with these systems involves inserting a hollow-bore needle into the lumen of a vein to obtain a specimen. A hollow-bore straight needle or winged-butterfly needle with a short length of tubing is connected to a collection barrel housing a rubber-sheathed needle with a Luer lock. The rubber-sheathed needle housed in the collection barrel is used to puncture the rubber top of a vacuum test tube after the connecting hollow-bore needle rests in the vein’s lumen. Once the rubber top is punctured, the vacuum is initiated within the tube, and a set volume of blood is extracted from the patient’s vein.

The correct amount of blood required by the laboratory must be drawn into each blood collection tube to ensure accurate laboratory test results and decrease the patient’s risk of anemia.¹⁰ Some blood collection tubes contain fixative agents that require an exact amount of blood in the collection tube. Blood collection tubes without fixative agents allow variable amounts of blood. Some laboratory tests require less blood than others; the minimum amount of blood needed for a required test should be confirmed with the organization’s laboratory.¹⁰ Some fixatives are more likely to contaminate other blood specimens when blood collection tubes are sequentially engaged in the rubber-sheathed needle. Knowing the prescribed laboratory order of the blood specimens to be obtained into the blood collection tubes is essential.¹⁷ The sequence of collecting blood specimens is different when using a syringe and transfer device than when using a vacuum-extraction blood collection system. Blood specimens should be delivered to the laboratory immediately after collection per the organization’s practice.¹⁷ Some blood specimens may require special storage or handling, such as being placed on ice, refrigerated, or frozen.¹⁷

Because limited venous access may be a life-threatening complication of venipuncture, maintaining the patient’s vein’s integrity is essential. A patient with veins that may collapse or become injured from the vacuum pressure may require an alternative method of blood specimen collection. In addition, a patient whose veins may be difficult to locate because of unusual anatomy, trauma from repeated phlebotomy, or edema may also require an alternative method of blood specimen collection.

Tourniquets should be used with caution. If a tourniquet is deemed necessary, the nurse should not apply the tourniquet for longer than 1 minute.¹⁰ Prolonged tourniquet application may cause stasis and hemoconcentration.¹⁰ Infection-control standards require that the tourniquets be single-use.⁷ Contamination from Staphylococcus aureus from reused tourniquets is a common finding.¹⁸

When preparing a specimen label, the patient’s identifying information should be confirmed per the organization’s practice. A laboratory cannot process a mislabeled blood specimen or one that does not arrive in a timely manner. Errors in any aspect of blood specimen collection may require repeat specimens, placing the patient at risk for blood loss and venous injury. Accuracy in obtaining, labeling, and handling blood specimens reduces the need for redrawing specimens.

Venipuncture can be painful, and the patient may experience anxiety or fear before the procedure. A calm approach and skilled technique may help limit a patient’s aversion to venipuncture. Anxiety may be assuaged by communicating with the patient about how to help relieve the patient’s concerns.

Appropriate laboratory tubes should be obtained before the home visit. If needed, the laboratory should be called so that the proper tubes and the volume required to process the specimens can be confirmed.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the purpose of collecting the blood specimen and the method to be used.
• Explain how a tourniquet, antiseptic swab, and venipuncture may feel.
• Explain that pressure is applied to the venipuncture site briefly after the needle is withdrawn, without bending the patient’s arm.
• Explain that the patient may apply pressure if able.
• For a patient who has a bleeding disorder or is undergoing anticoagulant therapy, explain that pressure may have to be applied for a longer period of time to achieve clotting.
• Teach the patient on the signs and symptoms of a vasovagal response (e.g., pale skin, lightheadedness, tunnel vision, nausea) and provide instructions on when to seek additional care.
• Teach the patient on the signs and symptoms of venipuncture complications (e.g., hematoma, nerve pain, extravasation, excessive bleeding, arterial puncture, infection, phlebitis) and provide instructions on when to seek additional care.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient, family, and caregivers.
3. Verify the correct patient using two identifiers.
4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
5. Verify the practitioner’s order and assess the patient for pain.
6. Prepare an area in a clean, convenient location and assemble the necessary supplies.
7. Consult with the practitioner to minimize venipuncture and conserve blood by substituting point-of-care testing for venipuncture, using low-volume collection tubes, performing all daily tests during one venipuncture, and eliminating routine testing.¹⁰
8. Assess the patient’s history for risks associated with venipuncture, such as anemia, anticoagulant therapy, low platelet count, bleeding disorder, venous collapse, traumatic venipuncture, or phlebitis.
9. Review the patient’s history for adverse reactions to previous venipuncture, including a vagal response.
10. Determine the patient’s ability to cooperate with the procedure and the patient’s experience with blood specimen collection (e.g., anxiety or fear related to venipuncture).
11. Review the patient’s history for an allergy or sensitivity to antiseptic solutions,⁷ adhesives, and dressings.¹⁴
12. Review the patient’s anatomy for sites contraindicated for venipuncture, such as IV access sites; a site with signs of a hematoma or signs of phlebitis or previous infiltration; potential site on the arm on the side of a mastectomy or other lymphatic system compromise; a site affected by radiation, tissue injury or infection; a site on the arm on the side affected by a stroke; or current or planned hemodialysis shunt.¹⁰

    Rationale: Drawing blood specimens from contraindicated sites can result in false test results or may injure the patient.

13. Determine the patient’s hydration and perfusion status.
14. Assess for the need to apply a local anesthetic to reduce pain from the venipuncture per the organization’s practice.
15. Review the anatomy of the venous system and the organization’s practice for the preferred veins for venipuncture.
16. Review the manufacturer’s instructions for using blood collection tubes and transfer devices.
17. Identify whether cautions or preconditions must be met before the specimen can be collected. Specimen timing can be related to medication administration, nutritional intake, procedures, or diagnostic testing.
18. Identify the appropriate laboratory blood collection tubes and validate the order in which the specimens are to be transferred into the collection tubes (if multiple specimens are required) and the volume required for each test with the laboratory.
19. Review the laboratory’s requirements for labeling and handling the blood specimens.
20. Gather supplies and equipment, including specimen labels, blood collection tubes, and vascular visualization devices, if required, and bring them to the patient’s side. Replace latex equipment with nonlatex equipment if the patient has a latex allergy.
    1. Ensure that all equipment has been cleaned and disinfected using an Environmental Protection Agency (EPA)-registered disinfectant per the organization’s practice.
    2. Ensure that all work surfaces used to hold blood specimen collection equipment, including chair arm extensions and tables, have been disinfected to protect the patient and the blood specimen from contamination.¹⁸
    3. Ensure that the blood collection tubes’ expiration dates have not passed and that all equipment and tubes are intact and free from defects or compromises.¹
    4. Ensure that the blood collection tubes have been stored upright and at the correct temperature (e.g., tubes with some fixative agents require refrigeration).¹⁷
    5. Do not preassemble devices before patient identification.¹
    6. Ensure that devices for the blood specimen collection process are from the same manufacturer.⁴
21. Provide privacy for the patient.
22. Ensure proper lighting to aid observation of vein contours and colors.
23. Assist the patient to a comfortable position and have the patient remove food as well as gum and mints from the mouth.

Rationale: A low, supported position and an empty mouth¹ reduce the risk of injury if the patient experiences lightheadedness or a seizure or faints from vagal stimulation.

Be prepared to manage venipuncture-associated vasovagal or seizure reactions for a patient who is at risk.¹⁸

24. Perform hand hygiene and don gloves.
25. Support the patient’s selected arm and extend it to form a straight line from the shoulder to the wrist. Place a small pillow or towel under the upper arm or place the patient’s arm on the arm of the chair or on a table.

    Rationale: Correct patient positioning helps stabilize the patient’s arm.

26. Place a clean cloth or paper drape under the patient’s arm.¹⁸
27. Identify the best sites for venipuncture per the organization’s practice, avoiding contraindicated sites.⁶
1. Choose a vein that is easily visible without applying a tourniquet.
   1. If IV fluid is being administered in one arm, choose a site on the opposite arm for blood specimen collection.³ If unable to locate a site in the arm opposite an IV infusion site, look for a venipuncture site distal to the IV infusion site.³

      Consult with the practitioner about stopping the IV infusion before obtaining blood specimen, as applicable.^3,10

      Rationale: Stopping any infusions allows the catheter to clear any IV solutions or medications that may interfere with laboratory analysis of the specimen. Research has not established an ideal wait time for blood sampling.⁹

   2. Choose a vein that is straight and does not divert into another branch;¹⁸ that has no swelling, hematoma, phlebitis, infection, or infiltration; and that has not had recent venous access or venipuncture. Typically, the median cubital vein is the easiest to puncture because it lies between the muscles (Figure 1).¹⁸

      Obtain a blood specimen below a peripheral access device, if applicable.¹⁸ Obtaining a blood specimen from an arm with a peripheral access device already in place may cause blood specimen contamination or hemolysis.

      To reduce the risk of a hematoma, avoid venipuncture in locations where a vein branches. Puncturing the basilica vein is associated with damage to the underlying artery or nerve and is typically more painful.¹⁸

2. If needed, apply a single-use tourniquet proximal to and four to five finger widths from the insertion site.¹⁸ If the venipuncture site will be on the same arm as an IV infusion site, place the tourniquet between the IV infusion site and the intended venipuncture site.³

   Rationale: A tourniquet blocks venous return to the heart from the arm, causing the veins to dilate for easier access.

   1. Encircle the arm and pull one end of the tourniquet tightly over the other, looping one end under the other (Figure 2) (Figure 3).

      Avoid using a tourniquet for a patient who has a history of bleeding, is easily bruised, has fragile skin, or has diminished circulation; however, if a tourniquet must be used, apply it loosely.

   2. Apply the tourniquet so it can be removed by pulling one end with a single motion.

      Do not keep the tourniquet on the patient longer than 1 minute¹⁰ before the procedure is performed. Prolonged tourniquet application causes stasis, hemolysis, and hemoconcentration because of changes in the vascular epithelium from increased venous pressure and hypoxia.¹⁰

3. Palpate the selected vein for firmness and rebound (Figure 4).

Rationale: A patent, healthy vein is elastic and rebounds on palpation. A thrombosed vein is rigid, rolls easily, and is difficult to puncture.¹⁸

Do not use a vein that feels rigid or cordlike or one that rolls when palpated.

4. If the selected vein cannot be palpated or viewed easily, apply a warm compress over the arm for several minutes per the organization’s practice. If a tourniquet was deemed necessary, remove it and apply a warm compress for several minutes and then reapply the tourniquet.

Rationale: Warming increases arterial blood flow, making veins more prominent.

5. Quickly inspect the vein distal to the tourniquet to confirm the selected venipuncture site.
6. Release the tourniquet.
28. Apply a topical anesthetic as prescribed or per the organization’s practice to reduce pain, as needed. Remove the anesthetic completely from the skin after the prescribed dwell time.
29. Remove gloves, perform hand hygiene, and don clean gloves.
30. Prepare the blood collection equipment using blood collection tubes, holders, and needles from the same system and manufacturer to prevent equipment incompatibility.⁴

Rationale: Combining systems may injure the patient or yield incorrect laboratory test results. Incompatibility of components may cause failure of the process.⁴

1. Choose an appropriate-size needle that is small enough to fit in the vein but will accommodate the prescribed therapy and the patient’s need.⁵

   1. Adults: 20 G to 24 G⁵
   2. Older adults or patients with limited venous access options: 22 G to 26 G⁵

      Rationale: Needles that are 22 G or smaller minimizes insertion-related trauma to the vein.⁵

2. Ensure that a double-ended straight or winged-butterfly venipuncture with tubing and a safety device is securely attached to the vacuum-extraction system collection barrel.¹⁸ Alternatively, and if required, remove the sterile cap from the rubber sheathed end of the double-ended straight or winged-butterfly needle and attach the needle to the collection barrel (Figure 5). If a single-ended straight or winged-butterfly needle is used, attach the needle securely to a collection barrel housing a sheathed needle.

Rationale: Safety devices can decrease the risk of needlestick injury by 75%.¹⁸

Vacuum-extraction system sheathed needles are considered sharps that are associated with needlestick injuries, and they must be disposed of in a sharps container that is within arm’s reach and is large enough to allow disposal of the entire device without detaching the needle.¹⁸ The sheathed needle’s flexible cover prevents blood from flowing when the needle is not engaged in a vacuum tube; however, the sheath does not prevent a needlestick injury if a finger inadvertently enters the collection barrel.

Use a new collection barrel for each patient. Do not detach the needle from the collection barrel for disposal after use.¹⁸

Keep the needle hub and the connection sites sterile.

3. Place the correct blood collection tube inside the collection barrel. Wait to puncture the rubber stopper with the sheathed needle.

Rationale: Puncturing the stopper before the needle is in the vein causes the blood collection tube to lose its vacuum.

31. Relocate the selected venipuncture site.
32. Prepare the venipuncture site.
1. Cleanse the site with friction using a gauze pad and 70% isopropyl alcohol solution.¹
2. Allow the area to air-dry.

   If the specimen is being collected for a blood alcohol level, use a nonalcohol based cleanser.¹

   Do not touch the site after preparation unless sterile gloves are worn.¹

33. Obtain the blood sample.
1. Reapply the tourniquet and relocate the vein.
2. Remove the cap from the venipuncture needle, maintaining the needle’s sterility. Warn the patient to expect to feel a stick.

If contamination occurs, discard the needle and the collection barrel in a sharps container and prepare a new venipuncture set.

3. Place the thumb or forefinger of the nondominant hand distal to the venipuncture site and gently pull and stretch the patient’s skin until it is taut and the vein is stabilized.

Rationale: Gently pulling and stretching the patient’s skin helps stabilize the vein and prevent rolling during needle insertion.

4. Hold a butterfly needle (if used) by its wings; hold a straight needle (if used) at the hub. Insert the needle at a 30-degree angle¹⁸ from the patient’s arm with the bevel facing upward, just distal to the exact site selected for vein penetration.¹

Rationale: The smallest and sharpest point of the needle should puncture the skin first to reduce the chance of penetrating the sides of the vein during insertion. Keeping the bevel up causes less trauma to the vein. Entering the skin distal to the vein prevents unanticipated vein puncture, which may result in inadequate blood specimen retrieval and hematoma.

5. Slowly insert the needle into the vein (Figure 6). If using a butterfly needle, look for blood return in the tubing of the butterfly setup.

Rationale: Inserting the needle slowly prevents puncture through the opposite side of the vein.

6. Hold the collection barrel securely and advance the first blood collection tube into the sheathed needle inside the barrel so that the needle pierces the rubber top of the blood collection tube. Do not to advance the needle farther into the patient’s vein.

Rationale: Pushing the sheathed needle through the rubber top breaks the vacuum, pulling blood into the tube. If the needle advances too far, it may transverse the vein through the opposite wall into the subcutaneous tissue.

Collect blood specimens for coagulation studies before collecting other blood specimens that require a blood collection tube containing a clot activator or other additive. If using a butterfly needle with tubing, use a nonadditive blood collection tube to collect the air from the tubing before engaging a coagulation tube.¹

7. Observe for the rapid flow of blood into the blood collection tube (Figure 7).

Rationale: If blood does not appear, the vacuum is lost or that the needle is not in the vein.

8. Obtain the required amount of blood for all the ordered laboratory tests, keeping the needle stabilized.
9. After the blood collection tube is filled to the correct level for the ordered test(s) (indicated by the marking on the tube or per the laboratory’s practice), grasp the collection barrel firmly and remove the blood collection tube, using caution not to disrupt the venipuncture needle’s location in the patient’s vein.

   Rationale: Grasping the collection barrel prevents the venipuncture needle from advancing or dislodging. The blood collection tubes should be filled to the correct level because additives in certain tubes are measured in proportion to the filled tube.

10. Insert and remove additional specimen tubes in the laboratory-directed order into the collection barrel, engaging the sheathed needle, as needed.
11. If the blood collection tubes contain additives, gently invert them back and forth immediately after they are filled with blood. Follow the manufacturer’s instructions for the number of inversions.¹

Rationale: Inverting the tube gently ensures the additives are properly mixed to prevent erroneous test results.

Do not shake the blood collection tube.

Rationale: Shaking the blood collection tube may cause lysis of the blood cells, resulting in inaccurate test results.

12. If the blood is flowing sufficiently into the blood collection tubes and a tourniquet was used, release the tourniquet just before filling the last blood collection tube. If blood flow is slow, wait to release the tourniquet until the last tube is almost full. Fill the last tube and remove it from the collection barrel.

Rationale: Releasing the tourniquet before filling the last specimen tube reduces bleeding at the site when the needle is withdrawn.

13. Apply a 2 × 2-inch sterile gauze pad over the venipuncture site without applying pressure. Disconnect the collection tube to break the vacuum and quickly but carefully withdraw the needle from the vein, activating the safety mechanism to prevent an accidental needlestick injury.⁴

Rationale: Applying pressure over the needle can cause discomfort and injury to the patient. Carefully removing the needle minimizes discomfort and vein trauma.

14. Immediately apply pressure over the venipuncture site with the gauze pad until the bleeding stops (Figure 8). Observe the site for hematoma or bleeding. Instruct the patient to help apply pressure if the patient is able.

    Rationale: Direct pressure minimizes bleeding and prevents hematoma formation. A hematoma may cause compression and nerve injury.

    A patient who has a bleeding disorder or who is undergoing anticoagulant therapy may require holding pressure for several minutes until the bleeding stops.

    Do not use a cotton ball or a rayon ball when applying pressure because of the potential for dislodging the platelet plug at the venipuncture site.¹

15. Observe the venipuncture site for bleeding for 5 to 10 seconds before applying tape or a bandage.¹ Use tape or a bandage to secure the gauze pad and allow it to remain in place for at least 15 minutes.¹

    Rationale: Applying gauze with tape or an adhesive bandage keeps the venipuncture site clean and controls any final oozing.

    Instruct the patient not to bend the arm of the venipuncture site.

34. Immediately discard the collection barrel, needle, and tubing in a sharps container.¹ Do not recap needles or attempt to remove the needle from the collection barrel.¹⁶

Rationale: Transfer devices and sheathed needles are considered sharps that are associated with needlestick injuries, and they must be disposed of in a sharps container. The sheathed needle’s flexible cover prevents blood from flowing when the needle is not engaged in a vacuum tube; however, the sheath does not prevent a needlestick injury if a finger inadvertently enters the collection barrel.¹⁶

35. Check the blood collection tubes for any sign of external contamination with blood. Decontaminate the blood collection tubes, if necessary, per the laboratory’s practice.

Rationale: Decontamination prevents cross-contamination and reduces the risk of exposure to pathogens present in the blood specimen.

36. Assist the patient to a comfortable position for several minutes.
37. In the presence of the patient, label the specimen per the organization’s practice.¹⁵
38. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
39. Reassess the venipuncture site to determine whether bleeding has stopped or a hematoma has formed.
40. Assess the patient for tolerance of the venipuncture, including signs of anxiety or fear.

Rationale: A patient may require more venipunctures in the future. Addressing concerns and letting the patient express emotions may reduce any aversion to future venipunctures. Documenting the patient’s response allows for improved care planning for future venipunctures.

41. Assess the patient for infection or phlebitis using standardized scales. Report pain, burning, stinging, erythema, warmth, or subcutaneous swelling to the practitioner.^11,12,13
42. Report adverse events in an organization-approved occurrence reporting system.¹⁸
43. Assess pain, treat if necessary, and reassess.
44. Discard supplies, remove PPE, and perform hand hygiene.
45. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• Vein is accessed successfully without nerve or adjacent tissue injury.
• Aseptic technique is maintained.
• Venipuncture site shows no evidence of continued bleeding or hematoma after specimen collection.
• Blood specimen is appropriately labeled and transported immediately after home visit.
• Patient tolerates procedure with minimal anxiety, fear, or discomfort.
• All required laboratory blood specimens are collected accurately.

UNEXPECTED OUTCOMES

• Hematoma forms at venipuncture site.
• Needle is inserted through the vein.
• Patient has vasovagal response, including dizziness, fainting, or loss of consciousness.
• Infection or phlebitis develops at the venipuncture site.
• Nerve or adjacent tissue injury occurs.
• Hemostasis is not achieved.
• Laboratory specimen is inadequate for testing or hemolyzed and cannot be processed.
• Aseptic technique is not maintained.
• Blood specimen is not obtained.
• Needlestick injury occurs.

DOCUMENTATION

• Date and time of venipuncture, number and location of attempts, and name and credentials of person performing procedure
• Blood specimens obtained and disposition of specimens
• Location and description of venipuncture site
• Volume of blood drawn for a patient undergoing frequent blood specimens or a patient with anemia
• Laboratory to which the specimen was delivered and any information required by the laboratory
• Inability to obtain sample, if unsuccessful
• Patient’s tolerance of venipuncture
• Education
• Patient’s progress toward goals
• Unexpected outcomes and related interventions
• Assessment of pain, treatment if necessary, and reassessment

OLDER ADULT CONSIDERATIONS

• Older adults have fragile veins that are easily traumatized during venipuncture. Applying a warm compress may help with obtaining a blood sample. Using a small-gauge needle may also be beneficial.

REFERENCES

1. Ernst, D.J. and others. (2017). Chapter 2: Blood specimen collection process. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 5-30). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
2. Ernst, D.J. and others. (2017). Chapter 4: Complications. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 35-41). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
3. Ernst, D.J. and others. (2017). Chapter 5: Special situations. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 41-48). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
4. Ernst, D.J. and others. (2017). Chapter 6: Quality management system elements. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 49-60). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
5. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 26: Vascular access device planning. Journal of Infusion Nursing, 44(Suppl. 1), S74-S81. (Level I)
6. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 27: Site selection. Journal of Infusion Nursing, 44(Suppl. 1), S81-S86. (Level I)
7. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 33: Vascular access site preparation and device placement. Journal of Infusion Nursing, 44(Suppl. 1), S96. (Level I)
8. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 34: Vascular access device placement. Journal of Infusion Nursing, 44(Suppl. 1), S97-S101. (Level I)
9. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 41: Flushing and locking. Journal of Infusion Nursing, 44(Suppl. 1), S113-S118. (Level I)
10. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 44: Blood sampling. Journal of Infusion Nursing, 44(Suppl. 1), S125-S133. (Level I)
11. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 46: Phlebitis. Journal of Infusion Nursing, 44(Suppl. 1), S138-S141. (Level I)
12. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 47: Infiltration and extravasation. Journal of Infusion Nursing, 44(Suppl. 1), S142-S147. (Level I)
13. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 50: Infection. Journal of Infusion Nursing, 44(Suppl. 1), S153-S157. (Level I)
14. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 55: Catheter-associated skin injury. Journal of Infusion Nursing, 44(Suppl. 1), S168-S170. (Level I)
15. Joint Commission, The. (2021). National Patient Safety Goals^® for the home care program. Retrieved June 28, 2021, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/npsg_chapter_ome_jan2021.pdf (Level VII)
16. Occupational Safety and Health Administration (OSHA^®). (n.d.). Healthcare wide hazards: Needlesticks/sharps injuries. Retrieved June 28, 2021, from https://www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html (Level VII)
17. Pagana, K.D., Pagana, T.J. (2018). Chapter 2. Blood Studies. In Mosby’s manual of diagnostic and laboratory tests (6th ed., pp. 10-476). St. Louis: Elsevier.
18. World Health Organization (WHO). (2010). WHO guidelines on drawing blood: Best practices in phlebotomy. Retrieved June 28, 2021, from http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf (classic reference)* (Level VII)

ADDITIONAL READINGS

O’Grady, N.P. and others. (2011, updated 2017). Guidelines for the prevention of intravascular catheter-related infections, 2011. Centers for Disease Control and Prevention. Retrieved June 28, 2021, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports