LABORATORY STANDARD OPERATING

PROCEDURES
FACILITY NAME……………………………………………………………..

COUNTY……………………………………………………………………….

SUB COUNTY…………………………………………………………………

SOP Title: CAPILLARY BLOOD COLLECTION SOP No: 004

Version: Original
Effective Date: January 2016 Page 1 of 16

Signatures and Dates:

Author: _ __________________________________________________________________
Laboratory Technologist Date

QA Review:
__________________________________________________________________________
QA Officer Date

Approving Authority: ________________________________________________________

County Medical Laboratory Coordinator Date

Review/Approval for unchanged documents

DATE Author QA Review Approving Authority

1.0 PURPOSE / INTRODUCTION:
1.1 Blood specimens are obtained by either venous or capillary punctures. The
source of the specimen is determined chiefly by the quantity of blood required
to perform the laboratory procedures, age and condition of the subject/patient.
1.2 Sample volume/test requirements will be as specified in the protocol and must
be in line with the clients safety standards.
1.3 The purpose of this Standard Operating Procedure is to provide guidelines
proper specimen collection in accordance to the required laboratory standards
and to safeguard on the quality of results received after analysis.
1.4 It will also outline the order of drawing, care of hematomas, color-coded
system for easy identification of collection tubes, emergency action to take if
the subject becomes ill during the phlebotomy procedure and Quality
Assurance/Quality Control procedures.
1.5 Strict adherence to SOP requirement ensures quality laboratory results.

2.0 SCOPE / RESPONSIBILITY:

2.1 This SOP applies to all Health Care Workers involved in the collection of
Capillary/Venous blood in facilities and during community activities.
2.2 It is the responsibility of the designated of the County Leads, Quality
Assurance and Quality Control (QC/QA) personnel, Laboratory Supervisors to
ensure that the current SOP is available to the Health Care Workers and the
procedure is followed as documented.

3.0 SAFETY/RISK ASSESSMENT:

3.1 Wear personal protective equipment.
3.2 Handle all samples as potential biohazards.
3.3 Never recap needles.

4.0 DEFINITIONS:
4.1 CPR: Cardiopulmonary Resuscitation.
4.2 EDTA: Ethylene diamine tetra-acetic acid
4.3 I.V.: Intravenous.
4.4 QA: Quality Assurance.
 4.5 QC: Quality Control.
4.6 SOP: Standard operating procedure.
4.7 SST: Serum Separation Tube

5.0 SPECIMEN:
5.1 Use capillary blood from the side of the finger in adults and children.
5.2 In infants, collect capillary blood from the side of the heel or big toe.
5.3 Volume of venous blood collected will depend with the individual tests
requested. Please see individual tests SOPs for the required blood volumes.

6.0 EQUIPMENT/ MATERIALS/ REAGENTS:

6.1 Equipment.
6.1.1 Not applicable.
6.2 Materials.
6.2.1 Vacutainer Holder
6.2.2 Syringes, Needles/ butterfly
6.2.3 Tourniquet
6.2.4 Isopropyl alcohol (70%)
6.2.5 Phlebotomy trays
6.2.6 Sharps container
6.2.7 Swabs
6.2.8 Gauze
6.2.9 Gloves
6.2.10 Lab coat
6.2.11 Rockers/Mixers/Rollers
6.2.12 Sample racks
6.2.13 Lancets
6.2.14 Hand paper towels
6.2.15 BD Vacutainer Tubes or equivalent
6.2.15.1 Red Top - Tubes do not contain anticoagulant and are
used to obtain clotted or serum specimens. Serum is required
for serology tests, most chemistries, compatibility tests, and
blood typing and cold agglutinins.
6.2.15.2 Serum Separation Tube (SST),{Marble top/gold
 topped} - Is a serum separation tube containing “Thixotropic
Gel” in the bottom of the tube. During centrifugation, the gel
temporarily becomes fluid and moves to the dividing point
between the serum and cells. These tubes are known as “Quick
Clot” tubes and are used for STAT chemistry testing.
6.2.15.3 Grey Top - Tubes that can contain anticoagulant
potassium/sodium oxalate or sodium fluoride or sodium
iodoacetate and are used to obtain whole blood or plasma. The
glucose tolerance test, fasting blood sugar, lipase, lactate,
alcohol test, protein, urea, bilirubin and bicarbonate are drawn
in these tubes. For lactate testing, tubes of blood should be kept
closed at all times in a vertical, stopper-up position. Keep
samples on ice. Plasma should be physically separated from
contact with cells within 15 minutes of sample collection, and
analysed without delay
6.2.15.4 Green Top - Tubes contain sodium or lithium heparin
anticoagulant. The most common test drawn is for whole blood
studies, chemistries, immunophenotyping and heavy metals.
6.2.15.5 Purple Top - Tubes contain the anticoagulant ethylene
diamine tetra-acetic acid (EDTA) and are used to obtain whole
blood or plasma. Most common tests drawn for are CBC
differential, CD4 T-cell enumeration, viral load, glycosylated
Hb analysis. Erythrocyte sedimentation rate, reticulocyte count,
red blood cell cholinesterase, sickle cell test and lead.
6.2.15.6 Yellow Top - Tubes contain Acid Citrate Dextrose
(ACD) anticoagulant and used to obtain whole blood for
PBMC separation and plasma for storage
6.2.15.7 Blue Top - Tubes contain Sodium Citrate and used to
obtain whole blood for coagulation determinations and
erythrocyte sedimentation rate.
6.3 Reagents.
6.3.1 Not applicable.

7.0 METHODOLOGY:
7.1 Procedure.
7.1.1 Sequence of blood specimen draws
7.1.1.1 Whole blood
7.1.1.2 First draw- blood culture tubes, sterile tubes
7.1.1.3 Second draw – tubes with no additives (i.e. red)
7.1.1.4 Third draw – coagulation tubes (i.e. light blue)
7.1.1.5 Last draw – tubes with additives.
7.1.2 Quality assurance/quality control
7.1.2.1 Procedures to be followed to ensure as little trauma to the
clients as possible include the following:
7.1.2.1.1 Label tubes IMMEDIATELY after phlebotomy.
7.1.2.1.2 If you notice the venepuncture area beginning to
swell while drawing the blood, immediately release
the tourniquet, remove the needle, and apply
pressure with gauze or equivalent.
7.1.2.1.3 Remove tourniquet after drawing the subject’s
blood.
7.1.2.2 If an accidental needle stick occurs, contact your co-
worker/immediate supervisor, safety officer, post exposure
prophylaxis designate and the site director. Wash the area with
soap and running water and follow up with medical treatment.
7.1.2.3 Do not collect venous blood from the arm of recent or with an
I.V infusion.
7.1.2.4 Collect venous blood from upper stream if both arms are on I.V
infusions or in case of disability situations.
7.1.2.5 Samples should be delivered to the lab within one hour of
collection unless specified otherwise.
7.1.2.6 Sample collection devices must be used within their expiration
dates.
7.1.3 Preparation of clients.
7.1.3.1 Properly identify the subject; this should be done in accordance
with the protocol requirement or method of patient/participant
identification. This should include but not limited to:
7.1.3.2 Call out the participant’s names.
 7.1.3.3 Sit the subject comfortably in the chair. Introduce yourself.
7.1.3.4 Explain the procedure to the patient/client.
7.1.3.5 Assemble all materials to ensure easy access, check tests
requested and select proper tubes.
7.1.3.6 If tubes are unknown, ask laboratory supervisor/designee for
correct tube and volume. Tubes that contain additives should be
gently tapped to dislodge any additive that may be trapped
around the stopper.
7.1.3.7 Wear the appropriate personal protective equipment (PPE)
7.1.3.8 Have the subject/patient roll up sleeve, place tourniquet above
elbow and tighten enough to find appropriate vein.
7.1.3.9 Palpate the antecubital fossa area and locate the desired vein.
Loosen tourniquet where necessary.
7.1.3.10 Starting from the centre and working outward, clean
area with 70% alcohol/ equivalent in a circular direction.
7.1.4 Vacutainer technique.
7.1.4.1 Open needle or butterfly package but do not remove the needle
shield.
7.1.4.2 Thread the needle into the holder until secure.
7.1.4.3 Do not re-palpate disinfected site. Have the subject make a fist
and straighten arm.
7.1.4.4 Remove the needle cover and inspect the needle to ensure that
it is not damaged.
7.1.4.5 Position needle with bevel up, parallel to and over the top of
the vein. Insert the needle quickly under the skin and then into
the vein.
7.1.4.6 After entry into the vein, loosen/release the tourniquet, then
push the tube all the way into the holder and allow the blood to
fill the tube.
7.1.4.7 To fill other tubes, remove the full tube and insert new tubes
until all required tube are filled.
7.1.4.8 Label the samples immediately after collection.
7.1.4.9 Countercheck client’s identification available on the request
and tube labels. Labels should include subject’s identification
 number, date and time of specimen collection
7.1.4.10 Place tubes in an appropriate rack/rocker/roller (where
applicable) for laboratory testing.
7.1.4.11 If no blood flows into the tube or blood ceases to flow
before an adequate specimen is collected, the following steps
are suggested to complete satisfactory collection:
7.1.4.11.1 Push tube forward until tube stopper has been
penetrated. If necessary, hold in place to ensure
complete vacuum draw.
7.1.4.11.2 Confirm correct position of needle/cannula in the
vein.
7.1.4.11.3 If the tube has a poor vacuum, remove the tube and
replace with a new tube.
7.1.4.11.4 If second tube does not draw, release and remove
tourniquet then remove needle and discard. Repeat
procedure.
7.1.4.12 Upon completion of the venepuncture, remove the
needle from the subject’s arm and apply pressure to the site
using a sterile piece of gauze/equivalent. Instruct the subject to
continue applying pressure for 2-3 minutes. Folding the arm is
not recommended.
7.1.4.13 Immediately dispose of needles into a sharps container.
7.1.4.14 When the venepuncture site has stopped bleeding, place
a Band-Aid over the site and escort the subject out of the
phlebotomy area.
7.1.4.15 Precautions
7.1.4.15.1 The only areas that are authorized for the
phlebotomist to draw blood from are arms and
hands.
7.1.4.15.2 Arterial sticks are strictly prohibited. In the event
that an accidental arterial stick occurs, immediately
loosen and remove tourniquet then remove needle
and place direct pressure on the site.
7.1.4.15.3 Maintain pressure on the site for minimum of three
 minutes.
7.1.4.15.4 After bleeding has clearly stopped, place a pressure
dressing on the site and have the subject apply more
direct pressure to the site for another 15 minutes.
7.1.4.15.5 If bleeding does not stop, a clinician should be
notified immediately.
7.1.4.15.6 Specimen collected for coagulation from
intravenous line should be flushed with saline
before drawing sample.
7.1.4.15.7 The first 5ml of blood should be drawn off and
discarded before the coagulation tube is filled.
7.1.4.15.8 The correct concentration of the anticoagulant is
fundamentally important to the precision of the
results for coagulation.
7.1.4.15.9 Do not under fill or overfill the tube for coagulation
studies.
7.1.4.15.10Specimens for coagulation studies should be
collected in 3.2% buffered sodium citrate
anticoagulant.
7.1.5 Syringe Technique:
7.1.5.1 Break seal in the syringe by removing the plunger up and down
in the barrel. Expel all air from the syringe.
7.1.5.2 Insert the needle into the syringe. Twist the needle on the
syringe and make sure it fits securely. Some syringes come
with the needle already in place.
7.1.5.3 Do not re-palpate disinfected site. Have the subject make a fist
and straighten arm.
7.1.5.4 The syringe should be placed below the venepuncture site to
prevent backflow, and the arm placed in the downward
position.
7.1.5.5 Hold the subject’s arm firmly 1 to 2 inches below the puncture
site pulling the skin tight with your thumb.
7.1.5.6 Hold the syringe with the opposite hand between the thumb and
the last three fingers. Rest the index fingers against the hub of
 the needle to serve as a guide.
7.1.5.7 The needle should be in the bevel up position, pointing in the
same direction as the vein, and should make an approximate
15-degree angle with the arm.
7.1.5.8 The vein should be entered slightly below the area where it can
be seen. In this way, there is tissue available to serve as an
anchor for the needle.
7.1.5.9 As the needle enters the vein slightly less resistance should be
felt.
7.1.5.10 A small amount of blood will flow into the neck of the
syringe as the needle enters the vein.
7.1.5.11 When using a syringe, care must be taken not to pull on
the plunger too rapidly or forcefully. This may cause the blood
to haemolyse, pull the wall of the vein down on the bevel of the
needle causing the blood flow to stop, or cause the needle to
inadvertently be pulled out of the vein.
7.1.5.12 When blood enters the syringe, release the tourniquet.
7.1.5.13 After the desired amount of blood is obtained, remove
the needle. A gauze pad should be placed lightly over the
venepuncture site and slight pressure applied to the pad as the
needle is slowly removed. The bevel should still be in the
upward position.
7.1.5.14 Instruct the subject to continue applying pressure for 2-
3 minutes.
7.1.5.15 Fill the required tubes by placing the needle into the top
of the tube and allowing the vacuum to draw blood into the
tube until the blood flow stops. This process should be
accomplished quickly before the blood begins to clot.
7.1.5.16 Label the samples immediately after collection.
7.1.5.17 Countercheck client’s identification available on the
request and tube labels. Labels should include subject’s
identification number, date and time of specimen collection
7.1.5.18 Place tubes in an appropriate rack/rocker/roller (where
applicable) for laboratory testing.
 7.1.5.19 Immediately place the syringe in a sharps container
with the unsheathed needle attached.
7.1.5.20 If an accidental needle stick occurs, contact your co-
worker/immediate supervisor/safety officer/post exposure
prophylaxis designate and the site director.
7.1.5.21 Wash the area with soap and running water and follow
up with medical treatment. (See needle stick injury protocol).
7.1.5.22 When the venepuncture site has stopped bleeding, place
a bandage over the site and escort the subject out of the
phlebotomy area.
7.1.5.23 Note: In case of difficult draw by this method, a
clinician can use the femoral vein to obtain blood.

7.2 Finger stick Procedure

7.2.1 The best locations for finger sticks are the 3rd (middle) and 4th
(ring) fingers of the hand. Do not use the tip of the finger as it
is very sensitive or the centre of the finger. Avoid the side of
the finger where there is less soft tissue, where vessels and
nerves are located, and where the bone is closer to the surface.
The 2nd (index) finger tends to have thicker, skin. The fifth
finger tends to have less soft tissue overlying the bone. Avoid
puncturing a finger that is cold, swollen, scarred, or covered
with a rash.
7.2.2 Massage finger gently 5-6 times from base to tip to aid blood
flow.
7.2.3 Have the client hold their hand in a defendant position to help
increase blood supply to the hand.
7.2.4 Clean the site with saturated 70% isopropyl alcohol pad. Allow
the site to dry completely so as to provide effective disinfection
and to prevent possible haemolysis by residual alcohol.
7.2.5 Using a sterile lancet or equivalent, make a skin puncture just
off the centre of the finger pad.
7.2.6 The puncture should be made perpendicular to the ridges of the
fingerprint so that the drop of blood does not run down the
 ridges.
7.2.7 Wipe away the first drop of blood, which tends to contain
excess tissue fluid.
7.2.8 Collect drops of blood into the collection device by gently
massaging the finger. Avoid excessive pressure that may
squeeze tissue fluid into the drop of blood.
7.2.9 Have the patient hold a small gauze pad over the puncture site
for a couple of minutes to stop the bleeding.
7.2.10 Dispose of contaminated materials/supplies in designated
containers.

7.2.11 Continued Bleeding:

7.2.11.1 Apply pressure to the site with a gauze pad until
the bleeding stops.
7.2.11.2 Wrap a gauze bandage tightly around the arm
over the pad.
7.2.11.3 Tell the subjects to leave the bandage on the site
for at least 15 minutes.
7.2.11.4 Excess Bleeding:
7.2.11.5 If the bleeding persists longer than 5 minutes,
contact the clinician in charge.
7.2.11.6 Continue applying pressure on the site as long as
necessary to control the bleeding.

7.3 Emergency Phlebotomy Procedure

7.3.1 In the event a subject starts feeling sick or appears to be
passing out, follow these steps:
7.3.1.1 Remove the tourniquet and withdraw the needle from
the arm at the first sign of reaction during the
phlebotomy.
7.3.1.2 If possible, clear the phlebotomy room area so that the
subject experiencing the adverse reaction can be
attended to in privacy.
7.3.1.3 If the subject does not respond rapidly to the measures
 listed below, contact the on-site supervisor or clinician
immediately.
7.3.2 Subject Feels Faint:
7.3.2.1 Talk to the subject to ensure that they are conscious and
able to follow simple instructions.
7.3.2.2 Call for assistance.
7.3.2.3 Administer small amounts of aromatic spirits of
ammonia by inhalation. Utilise an ice pack or a cold
compress for head and or/neck.
7.3.2.4 If subject is sitting, lower his/her head and arms. If
possible, assist the subject to the floor and elevate feet
above the level of the heart.
7.3.2.5 Allow the subject to drink water.
7.3.2.6 Continue to monitor the subject until he/she feels fully
recovered.
7.3.2.7 Notify the site supervisor or clinician of the situation.
7.3.3 Fainting Subject:
7.3.3.1 Seek assistance in the phlebotomy area.
7.3.3.2 Never leave the subject unattended.
7.3.3.3 Place the subject on their back and raise the subject’s
feet.
7.3.3.4 Be sure the subject has an adequate airway, is breathing,
and has a pulse.
7.3.3.5 Administer aromatic spirits of ammonia by inhalation.
The subject should respond by coughing.
7.3.3.6 Loosen tight clothing.
7.3.3.7 Apply cold compresses to the subject’s head and /or
neck.
7.3.3.8 Continue to monitor the subject’s breathing and pulse
until assistance arrives from a clinician.
7.3.4 Nauseated subject:
7.3.4.1 Make the subject as comfortable as possible.
7.3.4.2 Instruct the subject to breathe deeply and slowly.
7.3.4.3 Apply cold compresses on the subject’s forehead and
 back of neck.
7.3.5 Vomiting subject:
7.3.5.1 Give the subject an emesis basin/equivalent, and have
tissue/paper towel/equivalent ready.
7.3.5.2 Give the subject water to rinse out his/her mouth.
7.3.5.3 Report the incident to the site supervisor or clinician.
7.3.6 Convulsing subject:
7.3.6.1 Call for help and notify a physician immediately.
7.3.6.2 Prevent the subject from injury by placing him/her on
the floor.
7.3.6.3 Be sure the subject has an adequate airway, is breathing
and has a pulse.
7.3.6.4 Be cautious because some people exhibit great muscular
strength and are difficult to handle during severe
seizures.
7.3.6.5 Continue to monitor the subject’s breathing and pulse
until the clinician arrives.
7.3.7 Cardiac or Pulmonary Arrest subject:
7.3.7.1 Call for help and notify the clinician immediately.
7.3.7.2 If the subject is in cardiac arrest, begin CPR
immediately if you are trained, and continue until the
clinician arrives.
7.3.8 Care of Hematomas:
7.3.8.1 A hematoma is a small collection of blood under the
skin. Initially, it may appear as a small lump. This may
occur following a phlebotomy procedure when blood is
taken for laboratory testing. There might be slight pain
or discomfort at the site of the hematoma. The skin will
reabsorb this blood within several days. During the
reabsorption process the skin will appear “black and
blue”. Any extension of this area of discoloration
represents your body’s way of removing the blood from
a place it should not be. This extension of discoloration
DOES NOT mean that you are continuing to bleed. As
 the blood is reabsorbed, skin colours of brown and
yellow will be seen.
7.3.8.2 First and most importantly, do not engage in activity
that requires strenuous use of the arm. For the first 24
hours after blood collection, place crushed ice in a
plastic bag, wrap it in cloth, and hold on the hematoma
for approximately 15 minutes. Repeat at intervals
during the first 12 hours. If you secure the cold pack to
the site of the hematoma with a pressure dressing, make
sure the dressing is not applied too tightly. If the
pressure dressing becomes too tight as evidenced by
tingling or cold fingers, discoloration of the hand or
lower arm, or discomfort, unwrap the dressing and
rewrap with less pressure. Do not keep dressing on
longer than 15 minutes at any one time. Do not go to
bed with the dressing on.
7.3.8.3 After 24 hours, warm compresses are advised
periodically. A warm washcloth may be used for this
purpose. The warm compress should be applied to the
hematoma for 15 minutes. Warm soaks will quicken the
reabsorption process of blood and relieve any
tenderness that may be present.
7.3.8.4 Remember, the best way to prevent a hematoma from
occurring is by applying DIRECT PRESSURE to the
site of the blood collecting area. Direct pressure will
inhibit blood from seeping out of the vein; allow for the
needle punctured site in the vein to close, and therefore
decreases the chance of a hematoma developing.
Maintain direct pressure to the site for 3 to 5 minutes
after blood collection.
7.3.8.5 Any further questions you may have can be directed to
the site supervisor or clinician.
8.0 APPENDICES:
8.1 Not applicable.
9.0 REFERENCES:
9.1 AMREF (2008), Standard operating procedures for essential laboratory tests,
AMREF – MOH publication.

9.2 Monica Cheesbrough (1998), District laboratory practice in tropical

countries, Cambridge University press, Part 1.

9.3 Monica Cheesbrough (2006), District laboratory practice in tropical

countries, Cambridge University press, Part 2.

10.0 DOCUMENT CHANGE HISTORY:

10.1 Version Table:
Version 1: Collection of Capillary/Venous Dated: SOP No. No. Pages:
blood LGEN 0020 17.

Version 2: Dated: SOP No.: No. Pages:

Version 3: Dated: SOP No.: No. Pages:

10.2 SOP Review Log.

Date of Changes made. Name of reviewer. Signature.
review.
11.0 SOP AWARENESS LOG.

I, the under named, have read and understand the contents of this SOP. I agree to
contact my supervisor/ designee if I have any query.

NO. DATE NAME SIGNATURE