Skill IIIA: Routine ETS Venipuncture Extensive Study Notes

Skill Identification: Skill IIIA: Routine ETS (Evacuated Tube System) Venipuncture.
Temporal Constraint: The total time allowed for this procedure is $10$ minutes.

Step 1: Requisition Review: The practitioner must review the test request or requisition provided via the competition scenario.
Step 2: Introduction: Approach and greet the patient, and explicitly identify oneself to the patient.
Step 3: Verification of Identity: Ask the patient to state their full name and date of birth. Explicitly require the patient to spell both their first and last names.
Step 4: Correspondence Check: Verbally match the identification provided by the patient to the information listed on the requisition.
Step 5: Consent and Explanation: Explain the venipuncture procedure to the patient and obtain consent to proceed.
Step 6: Collection Requirements: Verify any specific collection requirements and identify potential sensitivities or problems the patient may have.
Step 7: Preliminary Hand Hygiene: Wash hands or use an alcohol-based hand rub for hand hygiene, followed by putting on gloves.

Step 8: Positioning: Position the phlebotomy arm (or the venipuncture arm used in the simulation) for the procedure.
Step 9: Initial Tourniquet Application: Apply the tourniquet $3$ to $4$ inches above the intended venipuncture site. The tourniquet should feel slightly tight but must not be rolled or twisted.
Step 10: Fist Clenching: Verbally ask the patient to clench their fist.
Step 11: Vein Selection: Select the appropriate vein in the antecubital area. This is done by palpating the area using the tip of the index finger.
Step 12: Tourniquet Release: Release the tourniquet after the vein has been selected.
Step 13: Mental Landmarks: Visualize the exact location of the vein and note its position in reference to surrounding features such as hair, skin creases, scars, or moles.
Step 14: Site Cleansing: Clean the selected puncture site using back-and-forth friction with adequate pressure.
Step 15: Drying: Allow the cleansed site to air dry completely.

Step 16: Equipment Setup: Prepare the equipment by selecting appropriate items and attaching the needle to an ETS (Evacuated Tube System) holder.
Step 17: Tourniquet Reapplication: Reapply the tourniquet to the arm.
Step 18: Needle Inspection: Uncap the needle and inspect it for any defects.
Step 19: Fist Remaking: Verbally ask the patient to remake a fist.
Step 20: Anchoring the Skin: Use the thumb to draw the skin taut by placing it $1$ to $2$ inches below the intended puncture site.
Step 21: Warning: Warn the patient of the impending needlestick.
Step 22: Needle Insertion: Line the needle up with the vein and insert it with the bevel facing up. Use a smooth forward motion at an angle of $15-30$ degrees.

Step 23: Needle Depth: Stop advancing the needle when a decrease in resistance is felt. At this point, verbally ask the patient to release their fist.
Step 24: Tube Holder Grip: Grasp the short wings of the tube holder using the index and middle fingers.
Step 25: Pushing the Tube: Use the thumb to push the evacuated tube into the multi-draw needle.
Step 26: Steadying the Device: Prevent the collection device from moving throughout the duration of the venipuncture.
Step 27: Blood Flow Establishment: Establish blood flow and fill the tube until the vacuum is completely exhausted and blood flow stops.
Step 28: Order of Draw (Total Points: $8$ ): Complete the draw in the correct order as dictated by the scenario (which will include all colored tubes):
- a. Light Blue: Typically used for coagulation tests.
- b. Red, Red/Gray Mottled, or Gold Stopper: Serum tubes with or without clot activator/gel.
- c. Light or Dark Green Top, or Green/Gray Mottled: Heparin tubes.
- d. Lavender/Purple, Pink, or White/Pearl Top: EDTA or molecular diagnostic tubes.
Step 29: Final Tourniquet Release: Remove the tourniquet as the last tube begins to fill.

Step 30: Needle Removal: Remove the needle in a smooth motion and immediately activate the needle's safety feature.
Step 31: Site Pressure and Mixing: Place a clean, folded gauze pad over the puncture site with the free hand, apply pressure, and mix the collected tubes according to the manufacturer's instructions.
Step 32: Patient Instruction (Immediate): Instruct the patient to maintain pressure on the venipuncture site until the bleeding stops.
Step 33: Bandaging: Check the patient's arm to ensure there is no additional bleeding and then apply a bandage.
Step 34: Biohazard Disposal: Discard the used blood collection unit in a designated biohazard Sharps container.
Step 35: Specimen Handling: Label the tubes and prepare them for handling and transport in the appropriate specimen bag.
Step 36: Patient Instruction (Long-term): Instruct the patient to maintain pressure for a minimum of $15$ minutes and to protect that arm from any physical exertion.
Step 37: Clean Up: Dispose of all used materials appropriately and clean the workspace.
Step 38: Courtesy: Thank the patient.
Step 39: Final Hand Hygiene: Remove and dispose of gloves, then wash hands or use alcohol-based hand rub.

Step 40: Communication Skills: Use appropriate verbal and nonverbal communication with the patient and other healthcare personnel throughout the process.
Step 41: Procedural Consistency: Ensure that standard precautions are practiced during every phase of the skill.