PHLEBOTOMY MANUAL

POLICIES AND PROCEDURES

ACULABS INC. 2 KENNEDY BLVD., EAST BRUNSWICK, NJ 08816

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1. Subject:
This SOP will provide guidance for the laboratory personnel about performing phlebotomy
according to the policy implemented by Aculabs.

2. Responsibility:
The laboratory director or his/her designee is responsible for the monitoring and evaluation of the
phlebotomy manual. The laboratory director must approve all phlebotomy policies and changes before
implementation.

3. Scope:
It is the policy of ACULABS to ensure that the laboratory phlebotomists meet defined
standards for quality and patient safety, are in compliance with acceptable regulations, and to ensure
that the phlebotomy part of the pre-analytical segment of the testing is monitored and evaluated. This
SOP is to guide the phlebotomists on basic phlebotomy technique and principles to protect them and
the patient from accidental needle sticks or injury. A phlebotomist must be trained properly and
practice safety to bring to Extended Care Facilities the quality of care that Aculabs has to offer.

4. Aculabs Quality Assurance Program:

1) Welcome to Aculabs:

The primary goal is to develop in our phlebotomist the highest degree possible of technical
and professional competence in a professional environment.

2) Skills:

Aculabs takes pride in giving the technical skill that you need to succeed in phlebotomy. These
include training associated with the following:

I. Proper patient Identification: 2 Active Identifiers required.

II. Venipuncture site selection.
III. Tube order of draw.
IV. Drawing adequate volume.
V. Hematoma: prevention and management.
VI. Phlebotomy techniques resulting in erroneous results.
VII. Leaving a tourniquet on a patients arm.
VIII. Prevention of needle sticks.
IX. Proper draw sites. (Facilities are responsible to draw from a Peripherally Inserted
Central Catheters (PICC) or shunt line.)
X. General specimens handling and transportation.
XI. Patient confidentiality.
XII. Respecting patient‘s privacy: do not draw patient in dining area, hallway or bathroom.
XIII. Legal Issues in phlebotomy.

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3) Dress-Code Policy:

Aculabs has dress requirements for personnel who work in the technical field. Always
remember you represent the Company as well as yourself and your skills. Therefore, it is imperative
that you dress accordingly.

The following is a list of the day to day dress code policies which you need to adhere to:

I. Uniforms are required while on duty (this consists of scrubs/or business casual and a
lab coat).
II. Shoes must be closed toe with appropriate traction. It is mandatory to wear a slip
resistant shoe for safety and injury prevention. Absolutely no heels, sandals, or clogs
are allowed.
III. Hair must be neat and well groomed. Long hair must be tied back.
IV. Employee personal hygiene is a must.
V. Nails are to be kept short, clean and trimmed.
VI. Identification tag: consisting of name, picture, position, and company.
VII. Proper equipment must be with you, this includes a sharps container.
VIII. Any employee found not meeting these standards is subject to disciplinary action.

4) Phlebotomist Code of Conduct:

This section is significant to your personal well-being. Your work environment is made up of
many people in distress, as well as many unhappy individuals. Although you work with them, day after
day, you must at all times maintain the highest code of professionalism and discipline when
confronted with unpleasant situations.

You must always follow these guidelines listed:

Remain warm and considerate to patient’s needs.

Treat all patients with dignity.
Do Not Ask, “How Are You? Stress the words” your doctor ordered these tests”. This
emphasizes the procedures importance and its necessity to the patient’s care.
Commit yourself to constant improvement.
Absolutely no foul language or vulgarities. Always remain respectful.
Do not engage in confrontational or combative behavior with anyone in the facilities.
No use of drugs or alcohol.
Do not practice theft.
Follow the dress code.
Practice Infection Control: demonstrate appropriate concern for the patients’ safety
and yourself by following the guidelines for universal precautions.
Remember patient’s Bill of Rights.
Implement Aculabs’ Policies and Procedures.
Report any suspicion of abuse or failures related to quality of care to direct
supervisor.
English should be the sole communicating language by the phlebotomists unless
specified by the facility.
Do not leave your phlebotomy kit unattended.
Be aware that phlebotomy is a talent you enjoy and what you do is worthy of your
time
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All Extended Care Facilities are to report any violations to the Laboratory and/or their customer
service representative at any time. All such reports will be thoroughly reviewed and corrective and
disciplinary action taken as appropriate up to and including termination.

5. Venipuncture Specimen Collection Procedure:

1) Infection Control: Every healthcare institution is required by The Joint (TCJ) to have
an infection control program to break the chain of infection. Such procedures are aimed
at protecting not only patients but also the employee, visitors, and any others. An
infection control program is also responsible for monitoring and collecting data on all
infections occurring within the healthcare institution and instituting special precautions
in the event of an outbreak of a particular infection.

2) Safety Rules:
I. Hand wash before and after each patient contact.
II. Hand wash before putting on gloves and taking them off.
III. Hand wash before leaving the facility.
IV. Hand wash before eating anything, drinking, smoking, and/or the
manipulation of contact lenses.
V. Hands should be washed immediately after accidental contact with blood,
bodily fluid, and contaminated materials.
VI. Hand wash before and after going to the restroom.
VII. Hand wash whenever hands become visibly or knowingly contaminated.
VIII. Be safe! All blood specimens are considered potentially infectious.
IX. Care must be taken not to spill or splash blood. Clean any blood spill with
10% bleach solution.
X. Laboratory Coats and gloves must be worn when collecting blood.
XI. Needles must not be recapped, reused, bent or broken.
XII. All needles must be disposed of in a biohazard container immediately after
use.
XIII. Be sure to take all supplies with you when leaving a residents room
XIV. Blood borne Pathogen is a term applied to any infectious
microorganism present in blood and other body fluids or tissue.

A) Proper Hand washing:

I. Wet hands with clean running water (warm or cold) and apply soap.
II. Rub hands together to make a lather and scrub them well; be sure to scrub
the backs of hands, between fingers, and under nails.
III. Continue rubbing hands for at least 20 seconds (sing the “Happy Birthday”
song twice)
IV. Dry hands using a clean towel or air dry.
V. Use towel to turn off faucet.

Washing hands with soap and water provides the best infection control. If soap and water are
not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol.
Alcohol-based hand sanitizers can quickly reduce the number of germs on hands in some
situations, but sanitizers do not eliminate all types of germs. The following steps are
recommended when using hand sanitizer:
I. Apply the product to the palm of one hand.
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II. Rub your hands together.

III. Rub the product over all surfaces of your hands and fingers until your hands
are dry.
If hands are visibly soiled, soap and water needs to be used for hand washing rather than
hand sanitizers.
Laboratory personnel should avoid wearing artificial nails and keep natural nails short.
Standard soap products available on the market are acceptable for use in the laboratory.

B) Glove-wearing: All laboratory personnel should wear gloves to prevent skin

and mucous membrane contamination while handling any of the following
materials that are considered potentially infectious by the Occupational Safety
and Health Administration (OSHA).

I. Blood, and any bodily fluids visibly contaminated by blood or unfixed tissues
and/or organs.
II. Touch items or surfaces soiled with blood or bodily fluids, e.g. vaginal
secretions
III. Performs venipuncture, finger sticks, and other vascular access procedures.
IV. Have any cuts, scratches, and/or breaks in your skin.
V. When cleaning surfaces
VI. For phlebotomy procedures, gloves must be changed between patients.

C) Other Precautions:

I. Disposable gloves should not be washed or reused.

II. Be safe! All blood specimens are considered potentially infectious.
III. Care must be taken not to spill or splash blood. Clean any blood spill with
10% bleach solution.
IV. Laboratory coats and gowns must be worn when collecting blood.
V. Phlebotomists must use non-slip shoes to avoid injuries.
VI. Do not attempt to draw combative patients alone, ask for assistance from
the charge nurse. Lastly, record the name of the nurse who provided
assistance on the requisition form. If help is not available, do not draw
patient.
VII. Upon approval from authorized health care giver in charge of the patient,
you may raise the bed at a comfortable level to prevent back strain.
Immediately after the blood is drawn have the care giver return the bed to
the original position.
VIII. Aculabs prohibits manual manipulation of the needle: Needles should not be
recapped, reused, bent, broken or other manipulation to the needle. All
needles should be disposed of in a biohazard sharp container immediately
after used.

3) Universal Precautions:
Maintain your personal protective equipment in good condition.
Wear your personal protective equipment when it is required (gloves, mask, and
gowns).
Maintain good housekeeping in your work area.
Obey safety labels (such as hazardous waste symbols).
Perform your task in a safe and proper manner.
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Report any incident regardless of injury to the extended care facility and ensure an
incident report is filled out. If they refuse, you must obtain the name of the person
with whom you spoke to.
Report any incident regardless of injury to your immediate supervisor. They will
instruct you on what to do next.
We encourage you to choose to receive the immunization against HBV for Hepatitis
when hired. THIS IS OFFERED TO YOU FREE OF CHARGE! It is extremely
important for health care workers to protect both themselves and their patients from
the spread of disease especially blood borne disease such as HBV, HBV or
Hepatitis. Since it is not possible to tell visually if any patient has these diseases, it is
necessary to treat all patients as if they were infected with HIV. Please note:
Any employee who elects to receive the immunization must receive their first
vaccine within ten (10) days from the date they are hired. Failure to do so will
result in suspension until they have completed the above.
Occupational Safety and Health Administration (OSHA) of the federal
government requires very strict guidelines to prevent such infections.

4) Patient in Isolation Room:

A patient with a contagious disease is placed in isolation. The patient stays in a
private room and anyone entering that room is required to wear a mask, gown,
shoe protectors and gloves. Only the phlebotomy equipment needed for that
patient is to be taken into the room. Place the needed equipment in a plastic bag.
The disposable equipment used to draw the patient, including the needle, gauze,
needle holder, and the tourniquet must be put in double bags and placed in the
designated sharp container. The only items to leave the room are the tubes that
contain the blood sample.
5) Test requisition:

I. Test requisition highlights:

The forms on which test orders are entered and sent to the lab are called test
requisition forms.
Blood collection procedures begin legally with the test request.
Test requisitions become part of the patient’s permanent medical record and they
require specific information to ensure that the right patient is tested and the physician
orders are met.
They should insure correct tests are performed at the proper time under the required
conditions.
They should provide all necessary data so the patient is billed properly.

II. Test Requisition Procedures:

Test requisitions must include the following information:
A) Patient information:
 Patient full name.
 Date of birth.
 SS number.
 Gender.
 Room number.
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 Requesting physician name

B) Facility information:
 Nursing home and client number.
 Address.
 Phone number.
C) Billing information:
 Medicare or insurance name and number
 Responsible party
 Diagnosis, ICD-10 code(s)
D) Test information:
 All tests requested.
 Nurse’s and/or doctor’s signature.
 Phlebotomist’s signature.
 Phlebotomist’s ID number
 Time and date of the blood collection by the Phlebotomist.
 Site of draw by the Phlebotomist.

III. Procedure for Handling Test Requisitions Lacking Required

Information:

In a case of incomplete test requisitions:

The phlebotomist shall ask for all required information from a nurse or other
authorized personnel in the Extended Care Facility.
 If this information is not provided by authorized personnel, the phlebotomist should
ask for the appropriate diagnostic code.
According to Highmark Medicare services, it requires each lab order to be justified
with a proper ICD-10 Code (Diagnosis Code).

6) Initiating Patient Contact:

When it is time to collect the specimens, check the requisition to see that all of the needed
equipment is in the blood collecting kit.

Arrange the test request according to priority.

Proceed to the patient’s room.

I. Entering the Patient’s Room:

Doors to patients’ rooms are usually open.

If the door is closed, knock lightly, open the door slowly, and say something like
“good morning” before proceeding into the room.
Even if the door is open, it is a good idea to knock to make occupants aware that you
are about to enter.
Curtains are often pulled when nurses are working with patients or when patients are
using bedpans.
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Make your presence known to patients before proceeding or opening the curtain to
protect their privacy and avoid embarrassing them.
Always, ask the patients “What is your full name?” never ask, “Are you Mr. Martin?”
The patient will often reply yes. Make sure that the full name that the patient gave you
matches the identification band and test requisition.
Always check the patient’s identification band.
If a patient identification band is missing have the nurse identify the patient and
document this on the test requisition form including the nurse’s name.
Never use the name that is on the door or foot of the bed to identify the patient.
Patients often are moved from one unit to another.
If the patient asks “Will this hurt?” Never Reply “NO.” Say, it may hurt a little, but it will
be over in a minute.
Never attempt to draw a patient when he/she is standing. The patient might suddenly
collapse.
Do not draw a patient in a hallway, bathroom, dining area or any open areas.
Remember the patient’s right of privacy. The patient should be drawn only in the room
where he/she resides.
Should the patient experience any of the following during phlebotomy, immediately
cease venipuncture, bandage the site and seek assistance from the nurse on the unit:
1. Fainting.
2. Seizure.
3. Any injury, including hematoma.

II. Professional appearance:

The phlebotomist must present a professional appearance to their patient:

Maintain a calm attitude.

Do not appear hurried.
Make the patient feel important.
Your appearance should mark you as “professional”.
Smile when you greet your patient.
Be clean, neat and dress conservatively.
Your laboratory coat should be buttoned.
Long hair should be tied back
Hands must be clean and nails well groomed.
Wear gloves that fit properly.

III. Watch for signs:

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It is important to look for a sign containing information concerning your patient.
Signs are typically posted on the door to the patient’s room or on the wall behind the
head of the patient’s bed.
Signs of particular importance to phlebotomists are signs that signify infection control
precautions on blood draws from a particular arm.

IV. Identify Yourself:

Identify yourself to the patient by stating your name that you are from the lab, and
why you are there.

The Laboratory performs analytical testing only upon receipt of a request form from
a physician or other authorized medical personnel.

V. Identify the patient:

In an effort to assure that the proper resident is drawn, and in keeping with The Joint
Commission, phlebotomists are instructed to seek and use two active identifiers before
beginning the phlebotomy procedure on each resident.

The phlebotomist is required to identify patients by having them (or a designee)

state their full name and at least one other active identifier such as:

Assigned identification number.

Patient’s birth date
Social Security number
Photo ID, etc.

 Do not draw if identity has not been established.

 A phlebotomist, who inadvertently draws blood from a patient who has

not been identified using two active identifiers, will be prohibited from
working in phlebotomy until they have completed an in-service retraining
session. They will also be issued a first and final warning. Any second
offense within a 36 month period from the time of the first and final will
result in immediate termination.

VI. How to Handle ID Discrepancies:

If there is a discrepancy with the patients name on the ID band and the information on
the test requisition:

The patient’s nurse should be notified.

The specimen should not be obtained until the discrepancy is addressed and
patient identity is verified.
If the patient’s nurse verifies the patient, the phlebotomist must document on
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the test requisition ‘patient identified by (who)’ following by a nurse’s signature.

If there is no ID band, check to see if it is on an ankle.
Never verify information from an ID band that is not attached to the patient.
Never use an article in the patient’s room for identification such as TV, water
pitcher, name on the door, and name on foot of the bed.

VII. Handling Special Situations:

1. The Patient is asleep:

If the patient is asleep, as is often on early morning rounds, wake him /her
gently.
Try not to startle the patient. (Startling can cause a change in test results.)
Speak softly but distinctly.
Never attempt to collect a blood specimen from a sleeping patient. Such an
attempt may startle the patient and cause injury to the patient or the
phlebotomist.
Drawing blood from a sleeping patient doesn’t allow proper identification to
take place.
It violates the patient’s right to informed consent and could result in a claim of
assault and battery.

2. The Patient is Unconscious:

If the patient is unconscious, continue to speak to the patient.

Identify yourself and inform the patient of your intent just as you would an
alert patient.
Unconscious patients can often hear what is going on around them even
though they are unresponsive.
3. A Physician is with the Patient:

If the patient’s physician is with the patient, don’t interrupt.

The patient’s time with the physician is private and limited.
Proceed to the next patient and come back to that patient later.
If the request is for a stat or timed test specimen, excuse yourself, explain
why you are there, and ask permission to proceed.

4. Family or Visitors are with Patient:

Often there are family members or visitors in the room when you arrive to
collect a specimen.
It is best to ask them to step outside the room until you are finished. Most will

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prefer to do so; however, some family members will insist on staying in the
room. Proceed with the draw.
Occasionally a family member, especially a spouse, is willing to assist you if
needed.
It is acceptable to let a willing family member help steady the arm or hold
pressure over the site while you label tubes.

5. The Patient is not in the Room:

If the patient is not in the room, check at the nurse’s station to find out where
the patient is.
If the patient has been taken to another unit, ask the nurse for the transfer
paper and attach it to the requisition form, then you may proceed to that unit.
If the patient is in the hallway inform the nurse that you need someone to
bring the patient back into his/her room.
Every attempt should be made to find the patient, especially if the test is
timed.
If the patient cannot be located, unavailable, or you are unable to obtain the
specimen for any reason, it is Aculabs policy to document that you were
unable to obtain the specimen and the reason why on the proper form
Obtain the nurse’s signature making her aware of any UTO’s, and refusals.
Inform your supervisor of the unable to obtain/refusal and submit the form
along with the other test requisition forms for the facility along with all
specimens to be sent to the lab
Leave a copy of the UTO/REFUSAL form in the lab book for the nursing staff
indicating the reason the patient was not drawn.

VIII. Handling Difficult Patients:

Hospitalization or illness is typically a stressful situation for a patient. A patient

may be lonely, scared, fearful or just plain disagreeable and may react in a
negative manner toward you.

It is important to remain calm and professional and treat the patient in a
caring manner under all circumstances.
A statement of your intent to perform a blood test is usually sufficient for
them to understand what is about to occur.
If a patient does not speak or understand English, check with the nurse in
charge of the patient and ask for help.
Speaking slowly and distinctly, using language, or writing down information
may be necessary for patients with hearing problems.
If a patient refuses to have his blood drawn, remind the patient that the

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doctor ordered the test. This sometimes convinces the patient to cooperate.
If not, the patients nurse may be able to convince the patient to cooperate.
Do not attempt to badger the patient into cooperating or restrain a conscious,
mentally alert adult patient to obtain a specimen.
Remember, the patient does have the right to refuse testing.
If the draw was unsuccessful after two attempts, it is the responsibility of the
facility to notify the ordering physician and place a new request form in the
lab book.
If a patient refuses to cooperate, fill out the UTO/REFUSAL form and notify
the patient’s nurse and your supervisor. Have the nurse sign the form.
Leave a copy of the UTO/REFUSAL form in the lab book for the nursing staff.

7) Routine Evacuated Tube System/Order of Draw/Venipuncture:

I. Evacuated Tube System Used:

Although the analytical instrumentation may only require 1.0mL of sample, collect
enough venous blood as required for the type of evacuated tube system used.

 Blue-top tubes are extremely volume-sensitive due to the requirements of

coagulation testing. The ratio of blood to anticoagulant must be 9:1.
 Tubes received with less than the optimum volume will be rejected.
 Phlebotomists shall make sure that the tube is filled until no vacuum
remains.
 If the evacuated tube cannot be filled to capacity, air is to be admitted into
the tube.
 When requested, a sodium citrate (blue top) tube may be drawn for Platelet
Count to offset the effect of EDTA –clumping. Mark the stopper so blood
does not get spun down. Appropriate correction calculations are included in
CBC procedures.
II. Blood Drawing Order:

When drawing more than one tube of blood from a single venipuncture using an
evacuated tube, the following order of draw is followed:
Blood culture tubes or vials.
Sodium citrate tubes (blue-stopper).
Serum tube with or without clot activator or gel separator (red-, or gold stopper,).
Heparin tubes (green-stopper).
EDTA tubes (lavender-stopper).
Glycolytic inhibitor (gray-stopper)
Please refer to the end of this Manual for additional tubes and requirements.

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Additive tubes must be gently inverted anywhere from 5 to 10 times. Never shake or
vigorously mix a specimen it can cause hemolysis.
When multiple tubes are drawn during a single venipuncture, tubes without additives
should be drawn first to avoid contamination.
The maximum amount of tubes that are permitted to be drawn during a 24 hour period
is seven (7). Under no circumstances will an allowance be made to draw more than
this limit. In the event that ordered blood work requires more than the above a nursing
supervisor must be notified that patient safety requirements allow only 7 tubes to be
drawn in one day. They may contact the General Lab Supervisor or Medical Director if
they take exception to this rule. THERE ARE NO EXCEPTIONS.
Source: CLSI Procedures for the Collection of Diagnostic Blood Specimens by
Venipuncture [H3-A6].

III. Positioning the Patient:

Patients are positioned so that
The vein you will use is readily accessible.
You are able to work in a comfortable position.
IV. If a patient is not in the bed:
Use the patient’s table. Place the patient’s table in a position where the arm
can be placed across the table.
If necessary, put a small pillow or towel under the patient’s arm to support
the extended arm.
Always remember to lock wheel chair when drawing blood.

V. Phlebotomy Kit:

Phlebotomy kit must be kept clean and neat at all times. The kit must be
cleaned with bleach a minimum of once a week and where there is
suspected contamination.
It should be check and replenished as needed
Phlebotomy kit should be decontaminated with 10 percent bleach
Specimen collection kit and processing areas should be decontaminated at
the end of each shift.
Gloves should be worn when cleaning.
All supplies must be within their expiration date and stored according to
manufacturer recommendations.
You are responsible to see that your equipment is in order. Aculabs will not
tolerate you borrowing supplies from nurses. You must come to your
designated office or the laboratory to pickup your supplies
 Alcohol prep pads
 Povidone-iodine swabs for blood culture
 Nonalcohol-based antiseptic for blood alcohol collection
 Gauze pads.
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 Adhesive bandage
 Gloves
 Tourniquet
 Blood collection tubes
 Single use safety needles
 Sharps container
 Pens

VI. Performing Venipuncture

Do not draw blood until identity has been established. If the patient’s identity
cannot be established with certainty, notify the nurse in charge to resolve the
discrepancy and have her sign the request form for approval of identification.
Always check for a sign (indicating a site of draw).
Patients should be either seated or lying down when having blood drawn.
Collect the needed supplies for draw. (Keeping in mind you may need an extra
one or two for tube replacement.)
Insert the first tube into needle with pre-attached holder ready to use right out of
the package, with no assembly required and pull back pink safety shield toward
the holder and twist and pull green needle cap straight off.
Place the tourniquet between the elbow and the shoulder. (About 2 to 4 inches
above the elbow). If more than 2 minute has past while looking for vein you
must release the tourniquet and reapply the tourniquet to try and find another
vein.
Scrub the area for venipuncture with an alcohol swab in a circular motion. If by
any circumstance, you touch the cleaned area, you must re-clean the area with
alcohol. Allow alcohol to dry.
Use the tip of the index finger to palpate or feel veins to determine their
suitability or to locate veins that cannot be seen. Do not select a vein that feels
hard.
The vein should be fixed or held taunt during the puncture (you may need a
pillow under the arm of a patient who is lying down to achieve proper
positioning).
The needle should be lined up with the vein. The needle should be about a 15
degree angle with the skin. When you introduce the needle, grip the needle
holder firmly and keep it steady.
Positioning the evacuated tube into tube holder holding it firmly and keep it
steady as the tube fills with blood.
Release the tourniquet just before the needle is removed from vein, to avoid a
HEMATOMA (bruise).
Place the gauze before needle is removed. Place pressure over the
venipuncture site making sure bleeding has stopped. Re-check the site to see if
bleeding has stopped then bandage the puncture site.
Dispose needle with safety shield into the sharp Biohazard Container, and
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dispose other contaminated material in the proper biohazard container.

Label specimen tube with patient’s last name and first name, and the numeric
label from matching requisition form and time and date of collection when
necessary.
Side rail may be lowered to perform phlebotomy. It must be returned to the
position in which it was found before you exit patient’s room. (A phlebotomist
who lowers a bed rail and forgets to raise it can be held liable if the
patient falls out of bed and is injured.)
Do not make any positional changes to the patient. If this is required, notify the
nurse in charge to help you.
Do not transport a wheelchair patient. If this is required, ask a nurse to assist.
Do not give patient water, food, cigarettes, or matches as the nursing staff may
not allow these privileges.
Do not discuss a blood test with patient.
Do not draw from a site other than a resident’s arm; this includes the hand if
needed. Any other site is prohibited.
Do not draw a site where an IV, Fistula, Shunt, Arterial lines, Heparin lock,
indwelling line, and implanted port is located. Use the other arm. Aculabs
phlebotomists are not permitted to do venipuncture on these sites.
When attempting to get blood and you are not successful, do not stick the
patient more than two times. After the first unsuccessful attempt; reevaluate
the veins and use a butterfly needle if needed. If you are not able to obtain
blood on the second attempt, STOP, and report this to the nurse in charge and
to your supervisor.
Aculabs policy requires 8-10 draws per hour minimum.
Check to see that you have your tourniquet and other equipment before exiting
the patient’s room.
Thank the patient for his or her cooperation.

VII. Collection of Blood Cultures:

Careful Technique is a Must, as you know bacteria enters the body and causes
diseases. At times, during a bacterial disease process, bacteria may enter the blood
stream and grow. Blood cultures are ordered by a physician when there is a fever of
unknown origin or suspect bacteria in the blood, or pathogenic bacteria in the blood. The
skin is covered with bacteria. If skin bacteria are picked up by the needle and put into a
culture bottle, they may grow there, and then neither the bacteriologist nor the physician
can determine whether this was simply a contaminated organism or whether it is growing
inside the patient and producing a severe disease.

Always wear properly fitted gloves.

Locate the vein before cleansing the skin. Special patient preparation is
required.

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After selecting the venipuncture site, release the tourniquet.

Scrub the site with 70% alcohol prep pad for 30 seconds. This is done to rid the
site of excess dirt and surface debris.
Next use a 1% to 2% tincture of iodine for 30 seconds or a Povidone-iodine
swab stick for 60 seconds to cleanse the site.
Beginning in the center and moving outward in concentric circles without going
over any area more than once. Cover an area about 3 to 4 inches.
Allow the site to air dry.
Touching or palpating the site after it has been prepared is not recommended.
Remove the protective flip-top covering the rubber septum and clean the tops of
the blood culture bottle with 70% alcohol or iodine.
Next use another 70% alcohol prep pad. Beginning in the center and moving
outward in concentric circles without going over any area more than once.
Cover an area about 3 to 4 inches
Prepare venipuncture equipment, being careful to handle all equipment in an
aseptic manner.
Reapply the tourniquet, taking care not to touch the prepared area in the
process.
Blood culture bottles have a vacuum, but it is not measured as in evacuated
tubes. Therefore it is important to collect 8-10 mL on the side of the bottle’ fill
lines to ensure enough, but not too much, blood enters the bottle.
Blood may be collected directly into blood culture media or with a butterfly
collection set.
Fill the aerobic vial first.
Avoid backflow by keeping the culture bottle or tube lower than the collection
site.
After filling both bottles, and collecting any other tests, remove the needle from
the patient’s arm and hold pressure over the site.
To perform a blood culture, you must have two bottles anaerobic and aerobic.
Each set must be numbered (set # 1 or set #2) with time of collection and
patient’s name.
If a physician orders a blood culture X2 different site the blood culture must
indicate the site of draw, time collected, patient’s name.

VIII. Labeling Blood Collection Tubes:

All blood tubes and non-blood specimens shall be labeled at the site of
phlebotomy (bedside) in full view of the patient who has been drawn with (at
least) patient’s full name and the numeric label from the requisition.
Date and time collected (if a timed draw), should be on the specimen as well.
At Aculabs, patient specific, unique bar-code labels are attached to the
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requisition form and to each specimen container to be tested afterward

Label blood tube with a pen using black or blue ink.
Print patient last name and first name.
Do not label tubes before venipuncture.
Never leave the room before labeling the tubes.
Do not label tubes with a pencil or marker
Do not write on the blood tubes in cursive.

IX. Disposal of used Blood Collection Supplies:

Used venipuncture needle(s) with plastic tube holder attached are to be

immediately disposed of in a sharps container at the patient’s bedside.
Never stick the needle into the patient’s mattress.
Do not cut, bend, or break needles.
These containers are to be transported to ACULABS for disposal when filled.
Employee ID numbers must be written on each sharps container.
Syringes may be received from ECF where nurses’ draw blood samples.
They should be disposed of as a unit in a sharps container.
Dispose of gloves and gauze in a red bag, and wash hands as often as
possible.
Follow all protocols as listed in ACULABS’ Exposure Control Plan.

X. Specimen Transport:

The analytic integrity of blood and non-blood specimens depends upon the timely
transport of theses specimens to the laboratory. The transport environment must be
monitored and evaluated to ensure that no significant changes in temperature occur
during the interval between the time the specimens leave the point of collection and the
time the specimens reach the laboratory.

XI. Phlebotomist Duties for Specimen Transport:

All blood specimens must be placed in plastic biohazard bags; all the
requisitions must be placed in separate biohazard bags and sealed to prevent
contamination. The blood specimen biohazard bag and the requisition
biohazard bag must be placed in large plastic bag and the bag must be labeled
with the facility name and date.
Each phlebotomist is responsible for transporting blood and non-blood
specimens from the point of collection to the laboratory in a timely manner. The
blood must be placed in the back seat of the car and not in the trunk.
Under certain circumstances the phlebotomist will transport their specimens to
a pick-up point or Aculabs Remote location. The phlebotomist is responsible to
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rack the blood and place it in the clear plastic bag, the bag must be labeled with
the facility name and date. The bag must be placed in an insulated holding box.
This box is designed to prevent the contents’ exposure to sudden temperature
changes. If the phlebotomist is dropping the specimens at drop-off points,
he/she must bring their specimens to the building in the closed insulated bag
and must check with the facility for the location of Aculabs refrigerator and/or
insulated dry box. The phlebotomist must transfer the content of their insulated
bag as is (do not open the large plastic bags) to the refrigerator and/or dry box.
The specimens not directly transported to the laboratory by a phlebotomist will
be transported by a delivery person.
He/she will pick-up the specimens at the designated pick-up points.
Specimens will be placed into an insulated and appropriately marked transport
container.
Transported to the laboratory without delay.
The pick-up and delivery times will be monitored and documented.
All blood and non-blood specimen transport containers must be labeled with an
appropriate BIOHAZARD label, large enough and placed as to be clearly
visible.

XII. Driver (courier) Duties:

The blood container must be placed in the back seat of the car and not in the
trunk.
All drivers are instructed to check in upon arriving at Aculabs with a designated
person in the Accessioning Department.
The arrival time is recorded, and a note of tardiness is taken if appropriate.
Drivers beginning their route at Aculabs are instructed of any route changes
made necessary by call-outs, etc.
All drivers who do not routinely report to the lab before beginning their route are
required to call their supervisor upon arrival at their first stop.
The above policy will enable monitoring chronic offenders in terms of tardiness so
that appropriate action may be taken.

5. Procedure At Extended Care Facilities:

The phlebotomist will proceed in the following order:

Report to nurse’s station to announce arrival.

Review all test requests found in the lab book, and organize the requisition by
room number.
Note: If a patient has been sent out to the hospital or has expired, the original
test requisition copy must be signed by the nurse and sent to the lab. The
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phlebotomist does not sign this form you only need to ensure that “Hospital” or
“Expired”, etc is written on the requisition form.
Proceed to the patient’s room, you must always knock and announce yourself
upon arrival and identify yourself with the patient.
Follow the laboratory protocol to draw all the patients
After finishing your rounds you must go back to the nurse’s station and re-file all
the yellow copies of all the venipunctures performed.
Sign and date the daily log sheet.
Notify the nurse of any UTO/REFUSALS and have them sign the
UTO/REFUSAL form, leave a copy of those forms as well.
Check specimen refrigerators and check test requisition for any discrepancies.
Check specimen to make sure proper documentation is on specimen. Don’t
forget to sign the test requisition. Remember checking the facility specimen
refrigerators is part of your job.
Once you have gathered all the requisitions including those for the non blood
specimens you must fax all the forms over to the lab for pre-accessioning. The
fax number will be given to you upon hire by your supervisor.
If you have been assigned more than one facility, you must place each facility’s
lab work and specimens in separate bags with the facility name on the outside
of the bag.

6. Standing Order Procedures:

It is the policy of Aculabs to print and issue the Standing Order forms on the 20th of
each month for the following month. These are kept in a Daily Lab Book at each
nursing unit of each Extended Care Facility. Each Standing Order is subject for
renewal after 30 days.

Renewal of a Standing Order shall include all of the following:

A Test Request is sent to the laboratory when the patient requires repeat
testing at regular intervals.
A Physician does not have to write a new order each time a patient needs
testing.
The Standing Order Department enters the test orders in a computer under the
direction of the patient’s nurse.
Computer request is transmitted through a special computer network and a
requisition prints in the laboratory.
The Standing Order Department verifies against the requesting physician’s
order.
Entering or confirming the correct (up-dated) ICD-10 code.
Signing the form to authorize blood draw.
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7. Stat Procedure and Protocol:

The following apply to all phlebotomists and it is a mandatory requirement; STATS are
a part of the phlebotomist’s responsibility and shall be handled in an efficient,
professional manner.

The various phone operators take the initial STAT request. All requests are
completed with: facility name, room number, unit and/or floor number, callers
name and the tests needed.
The request will be dispatched to your company phone with the above
information.
You must accept the order once you have viewed it on your phone.
When a phlebotomist is dispatched to a facility for a STAT he/she should
promptly arrive to the facility.
Once the stat is assigned to the phlebotomist the time will be noted on the
request. The stat arrival time at the lab will be noted by the person receiving the
stat; accessioning time will be noted in the computer.
The turn around time for stat specimens depend greatly on the phlebotomist
promptness.
Report to the nurse’s station upon arrival, and review stat request in the lab
book. Follow the lab protocol for drawing patient.
Place the stat in a separate bag along with the requisition form. Make sure that
STAT is marked off on the requisition form by the nursing staff. The test
requisition must be placed in the outer pocket of the specimen bag.
When Performing a STAT during morning rounds, you must place the STAT in a
separate STAT bag along with the requisition form. This bag must be placed
along with all other lab work performed during morning rounds.
You must complete the steps of an assignment on your phone. (Please refer to
the phone manual for the protocol) Follow-up with a phone call and notify your
supervisor of the outcome.
Peaks and troughs (along with all other tests ordered for that patient) are
handled and bagged as a Stat. Peaks and troughs monitoring helps the
physician establish drug dosage, maintain dosages at beneficial levels, and
avoid drug toxicity. Timing of specimen collection in regard to dosage
administration is critical for safe and beneficial treatment and must therefore be
consistent.
If a phlebotomist performing morning rounds has an order for a Trough and Peak
the requisition form must have a confirmation number on it which serves as
verification that it was properly ordered. If the proper procedure was not followed
then the nurse must be notified that a random level can be performed instead or
they must reschedule the request for a different day allowing Aculabs 24 hours
notice. (Please refer to the end of this manual for specific instructions regarding
TROUGHS/PEAKS)
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8. Procedure for blood collection in an isolation room:

For the protection of the patient and the phlebotomist from the transmission of disease causing
organisms, the following must be followed:

I. Prepare to take only essential items in the room. Do not take your kit (make sure to
leave it by the door and where you can see it) into the isolation room. Any supplies
taken into the room must be left there or discarded.
II. Check the isolation sign on the door for isolation instruction if available or ask the
nurse for isolation precautions.
III. Wash hands and put on gloves.
IV. Place paper towels on the table and place equipment on one or two towels.
V. Obtain specimens in the usual manner, avoiding any unnecessary contact with the
patient and bed.
VI. After mixing place the filled tubes on clean paper towel.
VII. Dispose of blood collection assembly into an easily accessible approved puncture
resistant disposal container.
VIII. Dispose of the tourniquet in the paper container for biohazard materials.
IX. Pick up the tubes from the paper towel, place the tubes in a biohazard bag then
double bag it.
X. Remove gown and gloves and dispose of them in the proper paper container for
biohazard materials
XI. Wash Hands
XII. Turn off the faucet with a clean paper so hands are not contaminated.

9. Blood Collection Complications and Procedural Errors

Each blood collection situation is unique. A competent phlebotomist must not only
posses the technical skills necessary to collect a quality specimen, but must also
understand the numerous patient variables, complications, and procedural errors that
can affect the integrity of the specimen or the health and safety of the patient to avoid
or reduce any negative impact

1. Procedure Errors:

Patient Identification.
Selecting Edematous area (should be avoided as blood collection sites)
Order of Draw
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Fasting Test
Tourniquet too tight
Wrong size of needle used
Mixing additive tubes too vigorously or using rough handling during transport.
Short draw
Needle position
Temperature
No name
Blood with no test requisition
Test requisition with no blood
No phlebotomy supplies
Late drop off of blood
Specimen Bagging
Starting late

10. Procedure for inability to obtain a Specimen

If you are unable to obtain a specimen on the first try, evaluate the situation that
resulted in the failure to establish blood flow and try again looking for a more suitable
site. If the patient’s veins are small or fragile it may be necessary to use a butterfly on
the second attempt.

Never probe for a vein. It is painful and can injure the patient. If blood fails to enter
the evacuated tube, it could be for the following reasons:

The needle was not introduced far enough; you must lower the angle and
advance it a little more
If the needle appears to have missed the vein, make sure the vein is secured
with the thumb, partially pull the needle back and attempt to puncture the vein
again.
If you think that you have gone through the vein, slowly pull back the needle, as
the needle moves back into the center of the vein blood will flow. Be careful not
to pull back the needle further once flow is established.
If at anytime during the above, a hematoma appears, release the tourniquet
immediately withdraw the needle and apply pressure for at least 5 minutes. You
must notify the nurse of this incident immediately.
After you have obtained all blood samples, place the dry clean gauze over the
needle puncture and apply pressure.
On rare occasions, the blood flow may not stop readily. This continued flow
might be related to patient’s condition; in this case, keep pressure on the site
for 5 minutes or more. If bleeding has stopped, apply a pressure adhesive
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bandage.

11. Resident’s Rights:

It is the goal of our facility to promote and protect the rights of each resident. We
believe that each resident has a right to a dignified existence, self-determination, and
communication with and access to persons and services inside and outside the facility.

Therefore, each of residents has:

IX. The right to be informed of any charges for services not covered under Medicare,
Medicaid, private insurance carries, or by the facility’s basic per diem charge.
X. The right to confidentiality of personal and clinical information.
XI. The right to refuse blood or specimen collection.
XII. The right to be treated fairly and without discrimination, and free of fear.
XIII. The right to be treated with kindness, dignity, and respect.

PREVENTION OF RESIDENT ABUSE

HCFA is actively addressing the prevention and reporting of Elder abuse. Our company agrees
wholeheartedly with this endeavor. Please review the attached policy on prevention of Resident
Abuse

If abuse is witnessed or suspected please contact your direct supervisor and/or Peter Gudaitis,
President. Your help in this would be greatly appreciated.

POLICY: Prevention of resident abuse

PURPOSE: To prevent a resident from being abused by another resident, staff, visitor or family
member in the facility.

PROCEDURE: Through the following policy the facility will develop a procedure for screening,
training and protection of residents. This will specifically be achieved by the prevention, identification,
and investigation and reporting of abuse, neglect, mistreatment and misappropriation of property.

Screening: Prior to hiring any new employee, the following criteria must be followed:

 A complete and comprehensive interview process

 Reference check
 Inquiry regarding work performance and attitude in the previous setting.
 Review reason for leaving the previous job
 If he/she is a certified nursing assistant/nurse, a license number and status will
be checked with the Nursing Assistant Registry and Board of Nursing.
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 A personal background check will be conducted by the facility.

12. Importance of your mileage sheets and time keeping:

The following applies to all phlebotomists and are mandatory requirements.

Mileage sheets are a “must” they are required to be sent to the lab on a daily
basis and are used for travel reimbursements.
Clock in using the company phone or the Novatime phone in system (You will
be instructed on which system you will be using upon hire.)
Mileage sheets must be completed properly.
Clock in errors must be documented by completing a time correction form and
submitting it to your supervisor immediately, failure to do can result in a delay
thus affecting your pay check.
Your supervisor and human resources must be informed of any changes of
address or contact information for proper submitting of memorandums.
You must ensure accuracy when submitting mileage sheets and well as when
clocking in and out. Failure to do so will result in a first and final for inaccurate
time keeping.
The information that you provide on a daily basis is required by Medicare for
the laboratory to properly bill the patients.
For additional information and sample sheets please refer to your Company
Phone Manual)
Warning, not following or neglecting this mandatory policy will subject
violators to disciplinary action up to and including termination.

13. Staff Meeting

You will be notified through memorandums and/or text messages for any group in-
services, workshops, and or seminars. It is mandatory for you to attend any of these
scheduled meetings. This will also apply on an individual basis. Regional Phlebotomy
Supervisors and/or designees with any concerns related to technique or quality of the
specimens should bring the issue to the Regional Quality Assurance Supervisor who will
follow-up with appropriate steps of training, retraining and the necessary feedback to the
phlebotomist. Records of the counseling must be retained in HR.

For those who are unable to attend any meeting that is scheduled a second one will be
rescheduled for you on a date that works for yourself and your Supervisor and/or QA
Supervisor. Failure to attend the rescheduled meeting will result in suspension; you will
also be required to come to headquarters for the meeting. Your suspension will not be
lifted until your meeting is completed. Failure to show within three days from the time you
are suspended will result in discharge for job abandonment.

Phlebotomist will receive training out in the field upon hire; a training evaluation will be
submitted upon completion of your training.
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You will receive your next evaluation after 4 months from the time you were hired, and
annually after that. Annuals are conducted at the end of each calendar year.

14. Communication Devices:

Aculabs provides electronic communication devices to be used for company
purposes only.
These devices do not become your personal property.
They are to be safeguarded and protected from misuse or abuse.
Batteries are to be charged or changed as needed. No excuse of a dead
battery will be accepted as a reason for not performing a task assigned or an
absence from work.
You must have the cell phone on and available for communication during
scheduled shifts.
When in the extended care facilities keep all cell phones on silent and or
vibration mode until leaving the facility.
Upon receiving work whether it is via text messaging or voicemail you must
either send a text or call back and respond to whoever assigned you work as
confirmation that you received the assignment.
You will have fifteen (15) minutes to respond. If you fail to respond within the
given timeframe it will result in the ending of your shift as well as a deficiency
for failure to follow the policy and do assigned work.
Anyone who refuses work for any reason during their assigned shift will be
disciplined for insubordination and his/her shift will end at the time of refusal.
Anyone who is ON CALL and does not receive any work must call in every
hour throughout their on-call shift to whoever is assigning work for that day.
You will have to sign a form of responsibilities for all company property and
devices. If any company property is lost, stolen, and/or damaged you will be
responsible for the amounts indicated on the form signed by you.
If stolen and you posses a police report, the theft may be reported to the
insurance company. However, any reimbursement cost will be the
responsibility of the employee.

***Please Note***
Work assigned to you can come from your direct supervisor, QA supervisor, and/or any
member of the dispatching department depending on the day, volume, and/or absences
within the department.

15. Illness/Absenteeism:

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Aculabs needs all their employees to meet their schedules to ensure the quality
performance we have contracted to provide Nursing Homes. The current Corporate
Policies & Procedures details approved means for obtaining time off. If you are ill or
need to call out because of a personal emergency, you must do the following:

XIV. The procedure requires advance notice except for emergency medical needs and
notice as soon as possible connected with medical absences.
XV. The FTO form should be submitted in sufficient time for management to make
reasonable schedule change to ensure coverage.
XVI. Any other absence is considered a call out.
XVII. If an employee calls-out a third day within a year they will receive a verbal warning
from their supervisor and notified of the following disciplinary actions on any
additional call-outs:
 4th call-out- Written Warning
 5th –call-out Final Warning.
 6th –mandatory discharge for excessive absences.
XVIII. All such absences will either be charged toward accrued FTO time or will be unpaid if
FTO time is not available. Unpaid hours could affect full time status and
therefore other benefits.
XIX. When calling out; call your supervisor so replacements can be arranged. It is
unacceptable to call out one hour prior to work or one hour after you are due at
work. You must notify your supervisor two hours prior to the start of your shift.
XX. It is the supervisor/dispatchers’ responsibility to call your facility making them aware
and that a replacement will be there shortly.
XXI. No call/ no show, will result in a first and final warning, a second offense will result in
immediate dismissal. Any employee who is a NO CALL NO SHOW for two (2)
consecutive workdays without communicating directly to their direct supervisor
the reason for absence is considered to have voluntarily resigned his/her
employment with the company.
XXII. Failure to follow the above guidelines will result in termination of employment with no
option for rehire at Aculabs.
XXIII. For any employee who accrues three (3) call outs within their first 120 days of
employment will automatically be terminated for failure to comply with
attendance policy during their probationary period.

1) Phlebotomy Call out Policy for North Region

When calling out you must follow the steps below each and every time you cannot report to work:
 Call your North QA Supervisor, Ramon Fernandez, at 732-512-8488.
 If you get his voicemail you MUST leave a message including your FULL NAME, and
all the facilities you were scheduled to cover for that day.

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2) Phlebotomy Call Out Policy for South Region

When calling out you must follow the steps below each and every time you cannot report to work:
 Call your Supervisor, Sherri Stewart, at 732-735-3970
 If you get her voicemail you MUST leave a message including your FULL NAME,
and all the facilities you were scheduled to cover for that day.

TO ALL PHLEBOTOMISTS:
 DO NOT send a text message to anyone for call outs.
 DO NOT wait until after your scheduled start time to call out. Proper notification
requires you to call out at least two hours prior to your scheduled start time.

The next couple of pages are reference guides for you to utilize when needed to assist
you with performing according to standards.

1. Tube Collection Guide

2. Troughs and Peaks Policy
3. Incidents and Accidents Policy
4. Driver Qualification Program
5. First and Final Warnings

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TUBE COLLECTION GUIDE
Tube Additive Laboratory Use Tests

Buffered sodium citrate For coagulation determinations. CTAD for selected Prothrombin Time (PROTIME), APTT and Fibrinogen
0.109 M (~3.2%) plastic platelet function assays and routine coagulation may be drawn in the same blue top. When D-Dimer is
Citrate, theophylline, determination. Tube inversions prevent clotting. ordered, draw an extra blue top.
adenosine, dipyridamole
(CTAD)

Clot activator and gel for For serum determinations and diagnostic testing of The following tests require an additional SST CA-125,
serum separation HOMOCYSTEINE, TROPONIN 1, PTH-(Intact),
serum for infectious disease.
TESTOSTERONE, PROLACTIN and CORTISOL (AM and
Tube inversions ensure mixing of clot activator
PM must be clearly labeled on SST label).
with blood. Blood clotting time: 30 minutes.
Serology testing may be combined in a single SST but
separate from the above: RPR, RHEUMATOID FACTOR,
and HCG (Pregnancy). Hepatitis and HIV testing
require a separate SST. LITHIUM must be drawn in a
separate SST tube.

Lithium Heparin For plasma determinations in chemistry. May The following Chemistry may be drawn in the same
be used for routine blood screening FULL green top:
Tube inversions prevent clotting LYTES(ELECTROLYTES),BASIC METABOLIC
PANEL(CHEM7 / CMP), COMPREHENSIVE METABOLIC
PANEL (CHEM12 / CMP), HEPATIC (LIVER) PANEL,
RENAL FUNCTION PANEL, LIPID PANEL
(CHOLESTEROL, HDL, TRIGLYCERIDES), TSH, FT3, FT4,
CEA, PSA, B12, FOLATE, FERRITIN, MAGNESIUM,
PHOSPHORUS, GGT, AMYLASE, URIC ACID, IRON-
UIBC-TIBC,CK, LDH, CARBAMAZEPINE,
PHENYOIN(DILANTIN), DIGOXIN, VALPROIC ACID
(DEPAKENE),THEOPHYLLINE, PRIMIDONE (MYOLINE),
T3 UPTAKE, T4, LIPASE, PREALBUMIN, CK-MB, CRP
(I and hs), and VITAMIN D25 OH.
The following must not be combined with any other
tests and must be drawn on TIME:
VANCOMYCIN (Peak/Trough), GENTAMICIN(Peak/
Trough), TOBRAMYCIN (Peak/Trough), and
AMIKACIN.

K2EDTA with gel For use in molecular diagnostic test methods (such Ammonia (NH3) is always drawn in a white top tube
as, but not limited to, polymerase chain reaction (on ice). Also used for HIV PCR. No additional tests
[PCR] and/or branched DNA [bDNA] amplication may be drawn with these tubes.
techniques).

Liquid K2EDTA K2EDTA and K3EDTA for whole blood hematology The following tests may be drawn in the same
Spray-coated K2EDTA determinations. K2EDTA may be used for routine Lavender (Purple) top tube: CBC, SED Rate (ESR), and
(plastic) immunohematology testing and blood donor Reticulocyte. Draw an extra lavender for each
screening. Tube inversions prevent clotting. Glycohemoglobin and BNP.

Potassium oxalate/sodium For glucose determinations. Oxalate and EDTA Glucose is always drawn in a gray top. No additional
fluoride. Sodium anticoagulants will give plasma samples. Sodium tests may be drawn with this tube.
fluoride/Na2 EDTA Sodium fluoride is the antiglycolytic agent. Tube inversions
fluoride (serum tube) ensure proper mixing of additive and blood.

The tubes above are documented in the proper Order of Draw for your convenience.
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Scheduling Trough and Peak Therapeutic Drug Levels

It has become increasingly evident that protocols for testing

patients who are receiving intravenous(IV) antibiotics need to be
reinforced. The clinical usefulness of the information provided by
this testing is only as good as the relevance of the results being
transmitted.
In order to meet these scheduling requirements you MUST call and
schedule each TROUGH/PEAK occasion.
Blood drawn for any of these tests that has not been scheduled at
least one day (24 hours) in advance of the Drug administration will
be considered a RANDOM test making it of limited clinical use for monitoring the antibiotic level. The
phlebotomist is not permitted to schedule TROUGH and PEAK levels at the draw sit. ALL requests for
scheduling must be placed through our Call Center at 732-777-2588 or 855-ACULABS, option 1.Once your
request has been scheduled appropriately you will receive a preauthorization number which must be written at
the bottom of the requisition form.
The client always has the option to draw the specimens for these tests themselves, in which case it is not
necessary to call and schedule with ACULABS. In this case, it is only necessary to call and request a BLOOD
pick up once both specimens have been obtained. Please do not call in a blood pick up until you have collected
all samples.
Please note any random Vanco/Genta/Tobra tests are not subject to this policy as they are not considered timed
tests.
The proper scheduling of VANCOMYCIN, GENTAMICIN and TOBRAMYCIN testing should be as follows:

Trough Peak
Levels should be drawn just Levels should be drawn 2
Vancomycin
prior to (up to 1 hour) initiating hours (+/- 30 minutes) after
a dose completion of an IV infusion

Levels should be drawn just Levels should be drawn 30

Gentamicin prior to (up to 1 hour) initiating minutes after completion of an
a dose IV infusion (or 1 hour after
intramuscular injection)

Levels should be drawn 30

Levels should be drawn just
minutes after completion of an
Tobramycin prior to (up to 1 hour) initiating
IV infusion (or 1 hour after
a dose
intramuscular injection)

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POLICY REGARDING INCIDENTS AND ACCIDENTS

All employees are required to follow the protocol below in the event of an accident/injury.

Please remember regardless of how minor it may be and even if no injury was
sustained it MUST be reported either way.

The steps below MUST be followed:

1. Report any injury/accident to your direct supervisor IMMEDIATELY.

2. For incidents that occur at a nursing facility, make sure to obtain an incident report from
the facility. If the facility refuses to provide one, the name of the person whom you
reported the incident to and their title must be reported to your supervisor and/or Human
Resources. Human Resources will verify this with the facility.
3. You must submit a detailed statement in your own words regarding what happened and
fax it to 732-839-1071. (This is the Human Resources confidential fax) HR will be in
contact with you the same day to review the information to ensure timely submission of
the claim.
4. If you are injured we will send you for treatment at an authorized medical center.
5. If medical attention is not needed at the time of the incident, report it to your supervisor,
and you must sign the appropriate medical waiver which must be faxed to the HR fax,
732-839-1071.
6. For car accidents, you must obtain a police report and submit it to Human Resources no
later than two (2) weeks from the date of the incident. If you are given a report number
you must inform HR of this as well. If authorities are not contacted and/or do not report to
the scene you must provide proof of an accident by providing us with the information of
the other party(s) involved. You must provide HR with the other parties full Name, phone
number, plate information, vehicle make and model, and the name of their auto insurance
policy.
7. Your supervisor will contact you to schedule a MANDATORY in-service, regardless of
injury/accident type at Aculabs headquarters in East Brunswick, NJ. If you are put out of
work or placed on restricted duty, your in-service will be scheduled when you are released
to full duty with no restrictions. If you are unable to keep your appointment you will be
given one opportunity to reschedule an appointment that works for both you and your
supervisor. Failure to attend the re-scheduled in-service will result in suspension
until you have completed the in-service. If you still have not come in after 3
business days, it will be considered voluntary job abandonment. All mandatory in-
services will be compensated for.

Steps 1-5 must be completed within 2 hours of an incident. Failure to complete any of the
above steps or failure to follow this policy will result in a FIRST AND FINAL WARNING,
a second offense will result in immediate termination.
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DRIVER QUALIFICATION PROGRAM

The development of a driver qualification program is vitally important to the successful

operation of Aculabs. The selection and retention of the best available drivers can avoid
future financial losses resulting from accidents and abuse of vehicles.

Motor vehicle records will be utilized as a tool to determine driver eligibility at time of hire and
annually thereafter. The minimum criteria acceptable for operation of any vehicle during
company time:
(1) No more than 3 moving violations and/or accidents within the 2 most recent years.
(2) No more than 2 moving violations and/or accidents in the most current year
(3) Drivers should have no “major convictions” within the last 5 years.
Major Convictions constitute:
(a) Driving while intoxicated or under the influence
(b) Leaving the scene of an accident
(c) Homicide or assault through use of a motor vehicle
(d) Attempting to elude a police officer
(e) Drivers who have a suspended or revoked license or those who have had 3 or
more license suspensions.

Employees who fail to meet the criteria mentioned above will not be fulfilling their job
requirements and therefore will be considered to have voluntary resigned.
Employees must maintain an acceptable driving record throughout the course of
employment. Employees must notify Human Resources of any and all Motor Vehicle
Violations and Accidents whether they occurred while driving a company vehicle, customer
vehicle or any other vehicle. This notification must be in writing within 24 hours of the
violation/accident. Failure to report Motor Vehicle Violations and accidents will result in
disciplinary action up to and including termination.
Employees must also ensure we have up to date information that is not expired with
regards to your Driver License, Vehicle Registration, and Car Insurance. Failure to do
so will result in suspension until the appropriate documents are obtained. Anyone who
fails to submit the appropriate documents after three days of being suspended will be
dismissed for failure to meet the driver qualification program.

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FIRST AND FINAL WARNINGS

Below are all violations of company policy that will be considered a first and final warning. A
second violation of any of the below will result in immediate dismissal.

1. Any OSHA violations. This includes failure to have a sharps container, failure to properly
dispose of used needles, and/or any other biohazard materials, overfilling a sharps container.
2. Failure to properly report any incident and/or accident.
3. Failure to update HR with any documentation and all documentation as mentioned in the
driver qualification program.
4. Failure to wear appropriate PPE when in healthcare setting.
5. Sticking the wrong patient, and/or failure to properly identify the patient(s).
6. Falsifying time and/or attendance records, mileage forms, time corrections, time of draw on
requisition forms.
7. Being a NO CALL NO SHOW for work.
8. Violating the Health Insurance Portability and Accountability Act.
9. Sticking a patient in a prohibited site, and/or drawing from a site where an IV, Fistula,
Shunt, Arterial Lines, Heparin Lock, Indwelling line, and implanted port is located.
10. Leaving a tourniquet on a residents arm, leaving a used needle and/or any other
biohazard materials in a nursing home, parking lot, or any other area.
11. Improper specimen handling and transportation
12. Leaving specimens in a car, kit, cooler, and/or leaving them behind in a facility.
13. Failure to wear appropriate shoes and clothing while in healthcare setting.
14. Engaging in confrontational behavior with anyone at an extended care facility.

Please Note: The above are most, but not all violations that can be considered a first and
final.

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DATE

PROCEDURE ADOPTED
SIGNATURE

PROCEDURE REVIEWED
SIGNATURE

PROCEDURE REVIEWED
SIGNATURE

PROCEDURE REVIEWED
SIGNATURE

PROCEDURE REVIEWED
SIGNATURE

PROCEDURE REVIEWED
SIGNATURE

PHLEBOTOMY MANUAL
POLICIES AND PROCEDURES
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I acknowledge that I have received a copy of Aculabs Phlebotomy Manual,

Policies and Procedures. I agree to read it thoroughly, including the
statements in the foreword describing the purpose and effect of this Manual. I
agree that if there is any policy or provision in the Manual that I do not
understand, I will seek clarification from the Human Resources Department.
I understand that Aculabs is an “at will” employer and as such, employment
with Aculabs is not for a fixed term or definite period and may be terminated at
the will of either party, with or without cause, and without prior notice.
No supervisor or other representative of Aculabs (except the President, in
writing) has the authority to enter into any agreement for employment for any
specified period of time or to make any agreement contrary to the above.
In addition, I understand that this Handbook states Aculabs policies and
practices for Phlebotomy in effect on the date of publication. I understand that
nothing contained in the Handbook may be construed as creating a promise of
future benefits or a binding contract with Aculabs for benefits or for any other
purpose. I also understand that these policies and procedures are continually
evaluated and may be amended, modified, or terminated at any time.

Print Name Signature Date

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