Blood Sampling via Vascular Access Devices

Establishes standards for blood specimen collection from peripheral venipuncture, arterial puncture, peripheral intravenous catheters, central venous access devices, and intraosseous access devices, including patient identification, blood conservation, preanalytical error prevention, and blood culture collection requirements.

policies•Jun 2024•Diagnostic Procedures

Blood Sampling via Vascular Access Devices Policy

1. Policy Statement

All blood specimen collection at this institution, whether obtained by direct venipuncture, arterial puncture, or via an indwelling vascular access device (VAD) or intraosseous (IO) access device, must be performed in accordance with standardized procedures that ensure accurate patient identification, correct specimen labeling, blood conservation, preanalytical error prevention, and Aseptic Non-Touch Technique (ANTT). Blood sampling utilization must be managed through interprofessional collaboration to limit unnecessary testing and minimize patient harm from iatrogenic anemia and specimen errors.

2. Purpose

The purpose of this policy is to:

2.1 Establish patient identification and specimen labeling requirements to eliminate mislabeled and misidentified sample events.

2.2 Define blood conservation strategies to reduce iatrogenic anemia, minimize transfusion needs, and decrease daily blood testing frequency.

2.3 Standardize techniques for blood specimen collection from peripheral venipuncture, arterial puncture, peripheral intravenous catheters (PIVCs), central venous access devices (CVADs), and intraosseous access devices.

2.4 Specify requirements for blood culture collection to reduce contamination and improve diagnostic accuracy.

2.5 Define requirements for therapeutic drug monitoring sample collection to ensure result validity.

2.6 Reduce preanalytical errors, specimen rejection rates, and blood culture contamination through standardized procedural requirements.

3. Scope

This policy applies to:

3.1 All clinical personnel authorized to collect blood specimens, including registered nurses, vascular access specialists, physicians, advanced practice providers, and laboratory phlebotomists.

3.2 All blood specimen collection methods: direct venipuncture, arterial puncture, and sampling via indwelling PIVCs, CVADs, and IO access devices.

3.3 All patient care settings in which blood specimens are collected, including inpatient units, intensive care, emergency department, perioperative services, ambulatory clinics, and home care settings operating under organizational oversight.

3.4 All specimen types subject to this policy: routine laboratory tests, blood cultures, coagulation studies, therapeutic drug monitoring specimens, arterial blood gases, and blood collected for point-of-care testing.

4. Policy Requirements

4.1 Patient Identification and Specimen Labeling

4.1.1 Positive Patient Identification

4.1.1.1 Two unique patient identifiers must be verified prior to initiating any blood specimen collection procedure, in accordance with organizational patient identification policy.

4.1.1.2 Electronic patient identification systems utilizing barcode labeling are the preferred standard for specimen labeling and must be used where available. Electronic identification systems have demonstrated superior error reduction compared to manual labeling methods.123

4.1.2 Labeling at Bedside

4.1.2.1 All blood sample containers must be labeled at the time of specimen collection and in the physical presence of the patient. Pre-labeling containers before collection or labeling away from the patient is strictly prohibited.

4.1.2.2 Labels must include all required identifiers and pertinent documentation per the laboratory’s specimen labeling requirements (e.g., specimen source, collection sequence, collection time).4

4.2 Blood Conservation

4.2.1 Test Utilization Management

4.2.1.1 Blood sampling utilization must be actively managed through interprofessional collaboration among laboratory management, clinical managers, and ordering providers. Blood tests must be limited to those with a clear clinical indication for the individual patient.56

4.2.1.2 Effective blood conservation strategies that must be employed or made available include: targeted testing based on individual patient clinical needs; use of minimum volume collection requirements; validated small-volume collection tubes when appropriate; point-of-care testing when it reduces venipuncture frequency; closed-loop systems that return clearing volumes to the patient; and the push-pull sampling method.789101112131415

4.2.1.3 In obstetric and neonatal settings, delayed umbilical cord clamping in stable term and preterm infants is a supported strategy to reduce postnatal iatrogenic anemia risk.161718

4.2.2 Institutional Blood Conservation Program Goals

4.2.2.1 Institutional blood conservation programs must target the following outcomes: reduction in transfusion needs attributable to iatrogenic anemia; decreased frequency of daily blood testing; reduction in rejected specimen rates; reduced blood culture contamination rates; and lower hemolysis rates across the institution.19202122232425

4.3 Preanalytical Error Prevention

4.3.1 Standardized Procedures

4.3.1.1 Standardized, written procedures must be developed and maintained for direct venipuncture and for blood sampling from PIVCs and CVADs. These procedures must specify: flush solution type and volume; discard volume requirements; site selection criteria; required infusion hold times prior to sampling; and order of draw per applicable manufacturer instructions for use (IFU).2627282930

4.3.2 Supplies and Order of Draw

4.3.2.1 The correct collection supplies must be used in the correct sequence. Collection tube color and order of draw must follow manufacturer IFU to prevent additive cross-contamination between tubes.28313233

4.3.3 Specimen Preparation

4.3.3.1 Tubes must be filled to the appropriate volume and inverted the correct number of times per manufacturer instructions to ensure proper mixing of additives with the specimen.

4.3.4 Transport

4.3.4.1 Specimens must be sent for processing promptly following collection. When transport is delayed, specimens must be stored as specified by the laboratory until transport is possible. Specimens must be prepared and secured per manufacturer instructions to prevent hemolysis, clot formation, or container breach during transport.34353637

4.3.5 Specimen Rejection Risk Factors

4.3.5.1 Clinical personnel must be aware of the following conditions that increase specimen rejection risk and take measures to mitigate them:

4.3.5.2 Higher rejection rates are associated with: specimens drawn in the emergency department compared to other clinical areas; specimens drawn by nursing or medical staff compared to dedicated phlebotomists; specimens drawn from indwelling PIVCs compared to direct venipuncture; use of hand or forearm veins compared to antecubital fossa veins; pneumatic tube systems not designed for blood transport or in which specimens are improperly secured; collection tubes filled to less than half of required volume; and tourniquet application times exceeding 1 minute.3839404142434445

4.4 Therapeutic Drug Monitoring

4.4.1 Sampling Site Selection

4.4.1.1 For therapeutic drug monitoring (TDM) specimens, blood must be drawn from a dedicated lumen or separate VAD not used for administration of the drug being monitored whenever possible.

4.4.2 Variables Affecting TDM Results

4.4.2.1 Personnel obtaining TDM specimens must be aware of variables that affect result accuracy: the specific medication being monitored; flush volumes preceding the draw; VAD device design; VAD material composition; and whether a waste/discard or push-pull technique was used.46474849

4.4.3 Elevated TDM Results

4.4.3.1 Elevated TDM results obtained from a VAD must be evaluated in the context of the full clinical examination before dose adjustment. Retesting via direct peripheral venipuncture may be necessary to confirm results prior to any dosage change.

4.4.4 TDM Documentation Requirements

4.4.4.1 The following information must be documented in the patient record with each TDM specimen collection: drug name; dose administered; time of last infusion or administration; and exact collection time.

4.5 Blood Culture Collection

4.5.1 Timing of Collection

4.5.1.1 Blood cultures must be obtained prior to the administration of antibiotics whenever clinically feasible. When multiple blood specimens are to be collected in a single encounter, blood cultures must be drawn prior to other specimen types whenever possible.505152

4.5.2 Standardized Collection Methods

4.5.2.1 Standardized blood culture collection methods must be implemented, including the use of dedicated phlebotomy teams and standardized sterile collection kits, to reduce contamination rates.53545255565758

4.5.2.2 Blood culture contamination rates must be monitored on an ongoing basis and used to inform process improvement initiatives.

4.5.2.3 Initial specimen diversion devices must be considered for use to reduce blood culture contamination from skin core or luminal microorganisms.596061626364

4.5.3 Blood Culture Collection from PIVCs and Peripheral Arterial Lines

4.5.3.1 Blood cultures must not be drawn from indwelling PIVCs during their dwell period. If blood cultures are to be drawn from a newly inserted PIVC, full ANTT must be maintained throughout the insertion and collection procedure.

4.5.3.2 Blood cultures must not be drawn from peripheral arterial lines during their dwell period.

4.5.4 Blood Culture Collection from CVADs

4.5.4.1 CVADs must be used for blood culture collection only when the catheter is the suspected source of infection.

4.5.4.2 When blood cultures are drawn from a CVAD, a simultaneous blood culture must be drawn from a peripheral vein to support the diagnosis of catheter-related bloodstream infection (CR-BSI) by differential time to positivity (DTP) methodology.

4.5.4.3 The needleless connector must be replaced before obtaining a blood culture sample from a CVAD.

4.5.4.4 For multilumen CVADs, separate blood culture samples must be drawn from each lumen. Evidence exists supporting pooling of samples from multiple lumens; the institutional standard must be defined by the Laboratory and Infection Prevention in collaboration with the Vascular Access Governance Committee.6566

4.5.4.5 The initial blood volume aspirated from a CVAD for blood culture purposes must be used for the blood culture without application of a discard volume.

4.5.5 Blood Culture Volume and Sensitivity

4.5.5.1 A minimum of 2 sets of blood cultures must be obtained per collection encounter to maximize diagnostic sensitivity. Volume per set must comply with manufacturer recommendations and age-related guidelines.6751

4.5.6 Transport Requirements for Blood Cultures

4.5.6.1 Blood culture bottles must reach the laboratory within 2 hours of collection. Blood culture bottles must not be refrigerated at any time, as refrigeration may inhibit or kill certain organisms and compromise diagnostic yield.5451

4.6 Device-Specific Blood Sampling Technique

4.6.1 Direct Venipuncture

4.6.1.1 Repetitive fist clenching or hand pumping must be avoided immediately before and during venipuncture, as these actions alter local hemodynamics and specimen composition.6826

4.6.1.2 Tourniquet application time must be limited to less than 1 minute. The tourniquet must be released as soon as blood begins to flow into the collection tube.6840

4.6.1.3 Infrared venous visualization devices may be used and can eliminate the need for tourniquet application entirely.69

4.6.1.4 Phlebotomy must be performed on the extremity opposite an active infusion whenever possible. If the same extremity must be used, the collection site must be below (distal to) the infusion site.

4.6.1.5 Venipuncture in the ipsilateral upper extremity of a dialysis arteriovenous fistula or graft must be restricted to the dorsum of the hand whenever possible.

4.6.1.6 In patients with actual or at-risk lymphedema (from axillary lymph node dissection or radiation), venipuncture must be restricted to the contralateral upper extremity whenever possible.707172

4.6.1.7 Venipuncture must be avoided in extremities with altered venous blood flow, including extremities affected by paralysis, hemiparesis from cerebrovascular accident, or decreased sensation.

4.6.1.8 When performing venipuncture at the antecubital fossa using a straight needle (median cubital, cephalic, or basilic vein approaches), caution must be exercised due to the risk of injury to the median nerve, anterior interosseous nerve, or lateral and medial antebrachial cutaneous nerves.

4.6.1.9 In neonates, venipuncture by a skilled phlebotomist is the preferred collection method over heel lance. When heel lance is necessary, automatic lancing devices must be used to control puncture depth and reduce risk of bone and cartilage injury or infection.7374

4.6.2 Direct Arterial Puncture

4.6.2.1 Prior to radial artery puncture, the clinician must assess circulation of the affected hand by evaluating radial and ulnar pulses, performing the Allen test, assessing pulse oximetry, or obtaining a Doppler flow study.7576

4.6.2.2 The patient’s medical history must be reviewed for factors that increase radial artery puncture risk, including prior ipsilateral radial artery trauma, previous radial artery cannulation, radial artery harvesting (e.g., coronary artery bypass surgery), and current anticoagulation therapy.

4.6.2.3 A 20-gauge or smaller needle must be used for direct arterial puncture to reduce patient pain and arterial wall damage. Clinicians must be aware that needles smaller than 20-gauge may increase hemolysis risk.

4.6.2.4 Ultrasound guidance must be used when available to improve first-attempt success and reduce procedural complications.77

4.6.3 Blood Sampling via Indwelling PIVC

4.6.3.1 Before using a PIVC for blood sampling, the clinician must confirm that the device is patent, free of signs of complication, and appropriate for continued use. Structured clinical decision-making tools, such as the I-DECIDED framework, support assessment of PIVC suitability prior to access.78 The infusing solution must then be paused for 1 to 2 minutes and a waste volume of 1 to 2 mL must be discarded before obtaining the blood sample from a PIVC.7980

4.6.3.2 When appropriate technique is used, PIVC-drawn samples for complete blood count (CBC), blood chemistry panels, and coagulation studies are not significantly different from direct venipuncture results and are acceptable for clinical decision-making. Comparative studies in pediatric inpatients confirm that blood samples obtained from short peripheral catheters using standardized technique yield results comparable to simultaneous venipuncture samples across common laboratory parameters.8182838485

4.6.3.3 For midline catheter blood sampling, evidence remains limited. Available data suggests a hemolysis rate of approximately 0.69% in midline-drawn samples; further research is needed to establish definitive technique standards for midline sampling.8687

4.6.4 Blood Sampling via CVADs

4.6.4.1 When selecting a blood sampling method from a CVAD, the clinician must evaluate and apply the appropriate technique based on clinical context and test requirements:

4.6.4.2 Push-Pull Method: The push-pull method is the preferred approach. It reduces the volume of blood wasted and minimizes hub manipulation. The push-pull method produces accurate results for complete blood count, electrolytes, renal and liver function panels, glucose, coagulation studies, arterial blood gases, C-reactive protein, and therapeutic drug monitoring specimens.888990

4.6.4.3 Discard Method: When the discard method is used, the discard volume must be determined based on the CVAD’s internal volume, the lock solution used, the pre-draw flush volume, and the specific laboratory tests ordered. Coagulation studies require the largest discard volumes among standard laboratory tests. The discarded syringe must never be reinfused into the patient due to contamination and clot formation risk.499192

4.6.4.4 Closed-Loop Systems: Closed-loop blood sampling systems return the blood volume withdrawn for catheter lumen clearing back to the patient following specimen collection and are recommended for blood conservation purposes.901312

4.6.4.5 Blood sampling from CVADs currently infusing parenteral nutrition (PN) must be avoided as a routine practice due to the increased risk of catheter-associated bloodstream infection (CABSI) associated with additional hub manipulation during PN infusion.93949596

4.6.4.6 The accuracy of coagulation test results obtained from heparinized CVADs is not definitively established due to confounding variables including collection technique, heparin adherence to catheter materials and biofilm, and variable discard volumes. Results from heparinized CVADs must be interpreted with clinical caution, and direct venipuncture retesting may be required.494847

4.6.5 Blood Sampling via Intraosseous Access

4.6.5.1 When no other sampling option is clinically available, the initial IO aspirate may be reserved for laboratory analysis.97

4.6.5.2 IO-derived blood sample results must be interpreted with significant caution in critically ill patients. Evidence demonstrates inconsistent correlation between IO samples and peripheral venous and arterial samples in this population. Clinical decisions based on IO-derived laboratory values must account for this limitation.

5. Compliance

5.1 Key Performance Indicators

5.1.1 Blood culture contamination rate, monitored monthly against the institutional benchmark and national standards (target <3% per collection encounter).

5.1.2 Specimen rejection rate by collection method (venipuncture, PIVC, CVAD) and by care area, monitored monthly in collaboration with the Laboratory.

5.1.3 Rate of patient identification and specimen labeling errors reported through the organizational event reporting system.

5.1.4 Percentage of blood sampling encounters documented with required pertinent information (source, collection time, infusion status at time of draw) per audit cycle.

5.1.5 Hemolysis rate by collection method, monitored in collaboration with the Laboratory.

5.1.6 Percentage of TDM specimens with complete required documentation per Section 4.4.4.

5.1.7 Compliance with ANTT for blood sampling procedures assessed via direct observation audit.

5.1.8 Annual blood utilization metrics: frequency of daily blood tests per patient day, transfusion rates attributable to iatrogenic anemia, and institutional blood conservation program outcomes.

5.2 Enforcement

5.2.1 Compliance with this policy is the professional responsibility of all clinical personnel involved in blood specimen collection.

5.2.2 Individual non-compliance identified through audit or event review will be addressed through unit-based coaching and performance management processes with escalation to clinical leadership as warranted.

5.2.3 Patterns of elevated contamination or rejection rates at the unit or collector level will trigger targeted education intervention, direct observation audit, and re-measurement within 30 days.

5.2.4 Patient harm events attributable to blood sampling errors (mislabeling, wrong-patient specimens, hemolysis, excessive blood loss, vascular injury) must be reported through the organizational event reporting system and reviewed by Patient Safety and the Vascular Access Governance Committee.

6. Exceptions

6.1 The requirement to draw blood cultures from a peripheral vein simultaneously with CVAD blood culture collection (Section 4.5.4.2) may be waived when peripheral venous access is unobtainable after documented attempts, or when the patient’s clinical condition precludes additional venipuncture. The exception and clinical rationale must be documented in the patient record.

6.2 The requirement to avoid PIVC blood culture collection during dwell (Section 4.5.3.1) may be modified in critically ill patients when no alternative access method is available and clinical urgency necessitates immediate blood culture collection. The rationale and clinical context must be documented.

6.3 The requirement to avoid blood sampling from CVADs during PN infusion (Section 4.6.4.5) may be modified in clinical scenarios where the patient has no other vascular access and the clinical urgency of laboratory results outweighs the risk. Rationale must be documented.

6.4 Tourniquet time limits and antecubital fossa preference may require modification in specific patients with limited access or anatomical variations. Clinical judgment governs site selection when standard sites are unavailable, with documentation of the rationale.

6.5 Clinical research protocols approved by the Institutional Review Board (IRB) may specify alternative sampling methods, volumes, or intervals per approved protocol parameters, with contemporaneous documentation.

  • ANTT Policy
  • Patient Identification Policy
  • Needleless Connector Management Policy
  • Vascular Access Device Flushing and Locking Policy
  • Vascular Access Device Post-Insertion Care Policy
  • Blood and Blood Product Administration Policy
  • Parenteral Nutrition Administration Policy
  • Central Line-Associated Bloodstream Infection (CLABSI) Prevention Bundle
  • Blood Culture Collection Standard Operating Procedure (Laboratory)
  • Specimen Collection and Transport Policy (Laboratory)
  • Order of Draw Reference — Laboratory
  • Vascular Access for Hemodialysis Policy
  • Vascular Access Adverse Event Management and Reporting Policy
  • Blood Conservation Program — Patient Blood Management Policy

8. Revision History

VersionDateAuthorDescription
1.02024-06-17Vascular Access Governance CommitteeInitial policy
1.12025-12-01Vascular Access Governance CommitteeAdded IO blood sampling cautions for critically ill; clarified push-pull as preferred CVAD sampling method; expanded blood culture CVAD requirements including needleless connector replacement and multilumen draw standards; updated TDM documentation requirements; added specimen rejection risk factor table

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