Arterial Puncture and Patient Identification

Transcription

1 Page 1 of 25 Arterial Puncture and Patient Identification POLICY It is the policy of Cochise Regional Hospital to positively identify patients prior to Arterial Puncture according to regulatory standards and practices to include the use of at least two patient identifiers. PROCEDURE 1. Identify patient a. Ask patient to state/spell their name and their date of birth. b. Check patient s armband if they are wearing one (notify nursing staff, if applicable on discrepancies on armband.) c. In emergency situations and an armband cannot readily be attached, ask a nurse to identify patient. Document nurse s initials or name on the requisition. d. Do not use room number or bed number as patient s identifiers. e. Label the specimen at the time of collection and in the presence of the patient. f. All information must be matched with identifying labels and with requisition information.

2 Page 2 of 25 COCHISE REGIONAL HOSPITAL Page 2 of 2 Introduction Arterial Puncture for Blood Gas Analysis Arterial blood is presented to all organs for their metabolic needs; its composition is uniform throughout the body. The composition of venous blood is conditioned by the metabolic activity of the tissue which it drains and therefore varies among different parts of the body. The largest difference between arterial and venous blood is its oxygen content, but ph and carbon dioxide content also vary. All differences between arterial and venous blood are magnified when the general or local circulation is impaired. Arterial blood is obtained via arterial line sample or by puncture of the radial or brachial artery in order to measure arterial blood gases and acid-base status of the patient. Only those individuals who have been certified in arterial blood gas collection by the Section's Medical Director may obtain arterial samples. POLICY Arterial Blood Gas Analysis includes the evaluation of arterial blood to assess the adequacy of oxygenation, level of ventilation and acid/base balance. It is essential for documenting the need for, and effectiveness of, oxygen therapy and efficiency of the bicarbonate buffer system. Arterial puncture competency will be validated annually by the Director of Nursing and documentation will be maintained in personnel files. SAFETY

3 Universal precautions must be observed when collecting blood specimens. Specimens from any patient could be infected with bloodborne pathogens. 1. Specific Recommendations for Arterial Puncture Page 3 of 25 a. Barrier Protection should be routinely used to prevent skin and mucous membrane contamination. b. Universal precautions guidelines should be followed. 2. Unintentional (Accidental) Injury a. Extreme care should be taken to avoid unintentional injuries caused by needles, scalpel blades, common laboratory instruments. b. In the event of an unintentional injury, the event must be immediately reported using established reporting guidelines. 3. Cleansing, Hands a. T-hetrea must wash hands and other skin surfaces thoroughly and immediately if contaminated with blood, and wash hands immediately after the gloves are removed. HAZARDS OF ARTERIAL PUNCTURE 1. Hematoma a. Because of the higher pressure in the arteries compared to veins, more blood is apt to leak through the puncture site. On the other hand, elastic tissue in the arterial wall tends to cause closure of the puncture more rapidly. The danger of hematoma or external bleeding is greatly enhanced in patients receiving anticoagulant therapy, or in those patient's with platelet counts below 100,000/mm Arteriospasm a. Arteriospasm is a reflex constriction of the artery in - response to pain or other stimuli; occasionally it may be induced by anxiety. Although it is transient, it may make it impossible to obtain blood, even though the needle is properly located in the lumen of the artery. 3. Thrombosis

4 Page 4 of 25 COCHISE REGIONAL HOSPITAL a. A thrombus forms if the intima of the vessel is injured. This is most likely to happen if a needle or cannula is left in place for some time. The presence or absence of collateral vessels is important to determine the primary site for arterial puncture. General Standard for Arterial Puncture Sites for arterial puncture, in order of preference, are radial artery of the wrist, brachial artery in the antecubital fossa and femoral artery. Arterial puncture of the femoral artery may only be performed by a physician. The respiratory therapist may only be perform arterial puncture of the femoral artery if authorized by the physician. A positive Modified Allen s test demonstrates adequate collateral circulation to the hand via the ulnar artery, indicating that the radial artery should be the puncture site of choice. A negative Allen s test demonstrates inadequate collateral circulation, indicating that the brachial artery should be the puncture site of choice. The femoral artery should be the puncture site of last resort due to its limited collateral circulation and should only be used in a code situation. Order Protocol 1. Date and time studies are to be done. 2. Percent of oxygen required for the study. 3. Any special considerations. EQUIPMENT AND SUPPLIES 1. Arterial blood gas sampling kit with heparinized syringe, needle, alcohol wipe, and sterile gauze. 2. Cup with ice. 3. Patient identification label.

5 4, Latex gloves. Page 5 of A puncture-resistant disposal container in which to place used needles and disposable syringes with attached needles. The container should be made of rigid plastic, have a lid, and be clearly marked as a biohazard. SPECIMEN COLLECTION 1. The Patient a. Physiologic Status-the patient should be as physiologically stable as possible when the blood specimen is collected. 2. Temperature Blood gas results are to be "corrected" to patient temperature by adjusting the analyzer setting to the correct temperature of the patient. The patient temperature must be obtained prior to performing blood gas analysis. 3. Ventilation Ideally, a patient's ventilation should be stable during collection. If the patient is breathing spontaneously, promote physical and mental comfort by quiet and reassuring talk. The patient should be in a comfortable position with a stabilized breathing pattern for at least five minutes before a sample is drawn. 3. Inspired Oxygen Concentration (FIO2) Patients receiving supplemental oxygen should be maintained on the same settings for at least 20 minutes before sampling. 4. PEEP and CPAP Patients on positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) should be maintained on the same PEEP or CPAP settings for at least 20 minutes before arterial sampling. PRINCIPLE 1. Single Arterial Puncture

6 Page 6 of 25 Arterial blood is obtained anaerobically by inserting a short-beveled, sharp needle, directly attached to a syringe, into an artery. The system should be leakproof and free of air bubbles. With 23 gauge or larger needles, the pressure in the artery will force blood into a well-lubricated syringe so that suction is not necessary. Excessive suction lowers the gas pressure of the sample and, therefore, the partial pressure of the individual gases. SELECTION OF THE SITE OF ARTERIAL PUNCTURE 1. Criteria for Selection of the Site Collateral blood flow Accessibility and size of artery Periarterial tissue (danger of injury to adjacent tissue) 2. Site of Arterial Puncture a. Guidelines Arterial punctures by critical care therapists will be performed only in radial (preferable) or brachial arteries. Femoral artery punctures will be done in selected cases by physicians or with a physician's special permission. 3. Radial Artery The radial artery is easily accessible at the wrist in most patients, and, in current practices is the most commonly used site for arterial puncture in clinical situations. Collateral circulation to the hand in addition to the radial artery is normally provided by the ulnar artery, which may be absent in some individuals. The Allen test or the Doppler ultrasonic velocity detector may be helpful in evaluating this collateral circulation. In the absence of an ulnar artery, the radial artery should not be punctured. 4. Brachial Artery The brachial artery may be difficult to puncture as it is located deep between muscles and connective tissues. Because of its deep

7 Page 7 of 25 COCHISE REGIONAL HOSPITAL location it is difficult to compress effectively, therefore hematoma formation is more common than at other sites. 5. Femoral Artery The femoral artery is a large vessel which usually is superficially located in the groin and is easily palpated and punctured. Disadvantages are poor collateral circulation to the leg and increased chance of infection. PROCEDURE 1. Check the patient's E.H.R. to determine that there is an order for the arterial blood gas and for the value of the patient's most recent platelet count. If the platelet count is below 100,000/mm 3 anticipate having to maintain pressure on the site for more than five minutes. 2. Feel for radial pulses on both wrists to determine which will be the better site from which to draw. Do not perform an arterial puncture on an extremity which appears to have an inadequate blood supply. 3. Perform the Allen's test on the hand which has been selected for the puncture. If the Allen's test is positive meaning a determination of adequate collateral flow the puncture may be done. The arm should be abducted with the palm facing up and the wrist extended about 30 degrees to stretch and fix the soft tissues over the firm ligaments and bone. 4. Remove the syringe cap and first pull back on the syringe and then express most of the heparin out of the syringe so that only a small amount of heparin remains (too much heparin will affect the accuracy of the arterial results). Recap the syringe until ready to perform the stick. 5. Prepare the puncture site aseptically. Put on sterile gloves and maintain sterile technique during the arterial puncture process. 6. Having already determined the optimal site to perform the arterial puncture, cleanse that area well with sterile alcohol swabs. 7. Remove the syringe cap and with the bevel of the needle pointing upwards, puncture the skin about 5 to 10 mm distal to the finger

8 Page 8 of 25 COCHISE REGIONAL HOSPITAL directly over the artery. The puncture angle should be approximately 45 degrees toward the direction of the blood flow. 8. Slowly advance the needle and syringe with one hand while continuing to palpate the artery with the other hand. When a flash of arterial blood is observed in the hub of the needle, do not advance the needle further. 9. While holding the syringe and needle stationary with one hand, gently pull back on the plunger of the syringe with the other hand to allow the syringe to fill. (NOTE: There are several types of AUTOSTICK blood gas kits on the market. The therapist should review the package insert for correct use of the product. The PULSATOR kit does not require presetting before sampling). Usually it is desirable to obtain one to two mls of blood. 10. As soon as the desired amount of blood has been obtained, the therapist should no longer aspirate the syringe, but should remove the needle and syringe rapidly and press down on the puncture site with sterile gauze. 11. Any air bubbles should be removed from the sample as quickly as possible, the syringe should be capped (not with a needle), labeled, and placed in the cup of ice until it can be run in the blood gas analyzer. It may require the assistance of a second person to briefly hold the site while the specimen is being prepared. 12. Pressure must be applied firmly on the puncture site with sterile gauze until blood no longer bleeds or oozes from the site. Most patients with normal coagulation parameters will require about five to ten minutes; patients with altered coagulation parameters may take more compression. In such cases, continue to firmly hold pressure on the site with gauze while checking to see if bleeding has ceased every five minutes. 13. Before leaving the patient bedside, a patient label must be affixed to the sample and the patient's current temperature should be written on it. 14. The sample should only be run by an authorized and competency proficient critical care therapist. Brachial Artery Puncture 1. The patient's arm is fully extended and the wrist rotated until the maximum pulse is palpated with the index finger just above the skin crease in the antecubital fossa. The arterial pulse is then followed proximally by palpation with the middle finger for 2 to 3 cm (see Appendix A).

9 Page 9 of 25 COCHISE REGIONAL HOSPITAL 2. Skill in performing the puncture is required to avoid hitting the median nerve which carries sensory fibers and lies very close to the brachial artery. 3. Cleanse the site. 4. Spread two fingers along the course of the artery which may be located by palpating the pulsations. Enter the skin just below the distal (index) finger and aim the needle along a line connecting the two fingers, using a 45 degree angle of insertion with the bevel up. The artery lies deep in the tissues, especially in obese individuals; it does not run parallel to the bone. 5. After the puncture, compress the artery against the humerus, if possible, for a minimum of five minutes to stop bleeding. Effective compression of the brachial artery may be difficult but is obviously important. Femoral Artery Puncture 1. The femoral artery is located quite superficially in the inguinal triangle, just below the inguinal ligament. The patient should lie flat with both legs extended. The pulsating vessel should be palpated with two fingers. 2. Cleansing of the puncture site should be very thorough because of the often heavy contamination of this area. The area around the puncture site should be shaved, if necessary. 3. The palpating fingers are spread 2 to 3 cm apart along the course of the artery to anchor the vessel. The needle puncture is made perpendicular to the skin surface, or at an angle against the blood stream, between two fingers. 4. Compression of the artery after the puncture is required. Pressure dressings are not an acceptable substitute. Inspect the site of puncture to ascertain that no hematoma is developing, and that the distal circulation is intact. POST PROCEDURE Discard any excess materials brought to the bedside for the arterial stick. Ascertain that the patient is in a comfortable position post procedure. Perform hand washing

10 Page 10 of 25 DOCUMENTATION After obtaining the arterial sample and sending it to laboratory document in Empower System; date, time, site where puncture was performed, note that the Allen's test was performed, and any complications of the procedure (i.e., hematoma, etc.). Certification Process i. Registered Nurses may perform arterial punctures only after the following required activities: ii. Attendance at a lecture of anatomy, technique and complications of arterial punctures. iii. Supervised performance of a minimum of one successful arterial stick by a Physician or a Supervisor (depending upon previous experience). iv. Successful completion of established written competencies (85% or greater). v. Performance of arterial sticks will be continually evaluated and assessed through quality data provided by the Laboratory REFERENCES 12.1 National Committee for Clinical Laboratory Standards: Percutaneous Collection of Arterial Blood for Laboratory Analysis, Second Edition, Document H11- A National Committee for Clinical Laboratory Standards: Clinical Laboratory Technical Procedure Manuals, Second Edition, Document GP2-A Shapiro, Barry A, Harrison, Walton: Clinical Application of Blood Gases (Third Ed: Year Book Medical Publishers) Ehrmeyer, Sharon S, Shrout, Joan B,: Blood Gases, ph and Buffer Systems Fundamentals of Clinical Chemistry, 2d ed. Philadelphia, Saunders, 1976.

11 Page 11 of 25 Arterial Puncture for Blood Gas Analysis (continued) The puncture site must be thoroughly cleansed with an alcohol swab and arterial puncture procedure performed with strict adherent to aseptic technique. The puncture technique should assure optimum prevention of bleeding, pain arterial obstruction, and infection, while providing an acceptable, anaerobic sample. This technique should be practiced by each Therapist or Technician as a matter of policy. Upon completion of the arterial puncture, direct pressure should be applied to the puncture site for a minimum of five (5) minutes. On patients undergoing anticoagulant therapy, the puncture site is to be compressed a minimum of ten (10) minutes, or until the bleeding stops. It should also be checked after the puncture every ten (10) minutes for half an hour in order to detect any seepage of blood. Air bubbles that mix with a blood sample will result in gas equilibration between the air and the blood, so that the technician must take great care to assure that air does not mix with the sample as it is drawn from the artery or as it is introduced into the electrode chamber. The sample should be analyzed within ten (10) minutes or cooled immediately to reduce the metabolic rate of the blood cells and prevent preanalytic error. Response to Adverse Reactions Should a patient continue to bleed from the puncture site after five (5) minutes of applied pressure, continue to apply pressure until the bleeding has stopped. If after ten (10) minutes the site has not stopped bleeding, the physician should be notified immediately. Continue to apply pressure until instructed to do otherwise by the physician. Should a hematoma develop, apply an ice pack to the site. This should be done only after adequate pressure has been applied to stop the bleeding. It is important to notify the supervisor should a hematoma develop and to document the steps taken to minimize its severity. Should the patient complain of loss of feeling in the arm or fingers, radiating pain, or any other complication from arterial puncture, the physician should be notified immediately.

12 Page 12 of 25 A suspected arterial occlusion as evidence by absent downstream pulses, or change in color/temperature of the distal extremity requires the notification of the physician. The area should be warmed with moist heat and positioned so that there is minimal impedance to blood flow. These steps should be taken under the supervision of the physician. The most important step to be taken should a complication arise as a result of an arterial puncture is to notify the patient s physician immediately. Complications should not be ignored or expected to just go away, and serious, life threatening, or debilitating injuries can be prevented through prompt action. Procedure in Case of Suspected Erroneous Blood Gas Results Inform the physician of the blood gas results. Inform the physician that you suspect the results are erroneous and why you believe this is the case. Request a repeat arterial study.

13 Page 13 of 25 Heel Punctures (For Obtaining Capillary Blood) Objective To determine the status of ventilation, oxygenation, and acid/base balance by obtaining a sample of blood from a well perfused infant when an umbilical artery catheter is not present or unstable, or when an arterial stick is not warranted. Indications Justification of oxygen therapy Monitoring of effectiveness of oxygen therapy Assessment of general cardiopulmonary status to aid in evaluation of ventilatory, acid/base and oxygenation status. Contraindications Cardiopulmonary Instability Abnormal perfusion status will render po2 data from capillary blood meaningless. Infant over the age of three (3) MONTHS Heel tissue becomes sclerotic after this age. Hypothermia Vasoconstriction is caused by hypothermia, which in turn leads to lowered peripheral perfusion and lowered oxygen tension. ORDERING PROTOCOL Equipment/Supplies Needed microliter capillary tube (heparinized) 2. 3 mm Monocet lancet 3. Alcohol sponge 4. Sterile gauze pad 5. Band-Aid 6. Heating source (towels, heating pad, chemical pad, etc.) 7. Ice slurry 8. Latex gloves

14 Page 14 of 25 PROCEDURE Wash hands, don gloves Warm site for minutes at a temperature of no more than 39C. Ø Use warm tap water, heated towels, heating pad, or chemical pad. Ø Monitor temperature with thermometer unless using special chemical pad. Cleanse heel with alcohol sponge, rubbing in a circular motion away from the puncture site. Allow prepped area to dry. Elevate foot approximately 45 degrees and, using the lancet, puncture the skin deeply on the lateral portion of the foot, just anterior to the heel. Ø Puncture mm deep (but no deeper) to allow for free blood flow. Ø Puncture should be several mm in front of the distal edge of the calcanean protuberance to avoid possible calcaneus osteomyelitis. Wipe away first drop of blood. Collect blood in sample tube by placing end of tube directly into blood flow at puncture site. Ø Have flea already in tube and magnet around tube prior to collecting sample. Ø Hold tube below level of puncture. Ø Do not remove tube from flow until enough blood has been collected for analysis (Prevents air entry) Ø Do not squeeze heel or leg as this introduces serum and venous blood which renders sample inaccurate. Wipe site with alcohol and apply pressure with gauze pad until bleeding stops. Mix blood and seal ends of tube. Place blood in ice water bath. Dress puncture site with Band-aid or soft bandage. Remove gloves and wash hands. Transport sample to lab for analysis. Hazards and Complications Obtaining false information (or misinterpretation of correct information), which may result in infants being exposed to improper amounts of supplemental oxygen. Bone osteoporosis. Infection.

15 Page 15 of 25 Arterial laceration. Burns from heating source. * Each of these may be prevented by careful attention to technique as described in the foregoing procedures. Factors Affecting Capillary Blood Gas Valves Undue squeezing of heel during sampling procedures. Ø Results in tissue damage with venocapillary admixture Ø Results in decreased po2. Corrective Measure: Refrain from applying excess pressure, and elevate the foot during procedure. Improper or inconsistent heel warming prior to sampling procedure. Ø Results in varying degrees of capillary blood arterialization. Ø Results in inconsistent and unreliable po2 and pco2. Corrective Measure: Refrain from applying excess pressure, and elevate the foot during procedure. Periodic capillary tube removal from sampling site during sampling procedure Ø Results in contamination of sample with atmospheric oxygen. Ø Results in decreased po2 (assuming FIO2 greater than 21%). Corrective Measures: Place capillary tube directly into sample at puncture site and refrain from removing until sufficient blood is obtained. Improper transport of sample. Ø Results in accelerated clotting and alteration of capillary blood values. Ø Results in increased pco2 and decreased po2. Corrective Measure: Mix thoroughly and place in ice water bath for transport. Infant age (birth 24 hours) Ø Results in low systemic output leading to vasoconstriction with poor peripheral circulation. Ø Results in increased pco2 and decreased po2.

16 Page 16 of 25 Corrective Measure: Delay capillary sampling until after first 24 hours or get arterial sample. Infant hypothermia Ø Results in vasoconstriction with lowered peripheral circulation. Ø Results in decreased pco2. Corrective Measure: Maintain infant thermoneutrality. Excessive crying Ø Results in hyperventilation. Ø Results in decreased pco2. Corrective Measure: Delay procedure or note results. Excessive breath holding Ø Results in hypoventilation and increased pco2 Corrective Measure: Delay procedure or note results. Excessive vomiting prior to procedure Ø Results in loss of hydrochloric acid (HCl). Ø Results in increased ph. Corrective Measure: Delay procedure or note on results.

17 Page 17 of 25 Contaminated Specimens POLICY As the aerosolization of blood occurs during the use of the blood gas analyzer, tonometer, or co-oximeter, the following guidelines should be adhered to. These guidelines are especially important when working with the blood of individuals who are being treated for Hepatitis B or AIDS. However, always assume that every patient is potentially infected and use appropriate precautions. Use of Non-Sterile Gloves The use of non-sterile gloves is particularly important for personnel who have cuts or abrasions on their hands. Regardless of the use of gloves, hands must be washed, especially if they are contaminated with blood, body fluids, secretions or excretions. Additional Puncture Wounds Special care should be taken to avoid accidental wounds from needles or other sharp instruments. If accidental puncture does occur, employees with such exposure should promptly notify their supervisor and the employee health service. The hospital infection control programs or committee should initiate an active surveillance system to evaluate and follow up on health care staff who have documented parenteral or mucous membrane exposure to blood from definite or suspected patient with AIDS. In these cases, the hospital should contact the Hospital Infections Program at the Center for Communicable diseases (Telephone number (404) ) or their local health department for additional information. Isolation Precautions Following the Blood/Body Fluid Precautions described in the Infection Control section of the department s Policy and Procedure Manual for every patient with whom you have contact, regardless of diagnosis. All blood and other specimens should be prominently labeled with a warning: Blood/Body Fluid Precautions. This label should accompany all such specimens through processing and disposal. If the outside of the specimen container is visibly soiled, it should be cleaned with disinfectant.

18 Page 18 of 25 All blood specimens should be placed in a second container, such as an impervious bag, for transport and checked carefully for leaks or cracks. Protective Clothing and Equipment Gloves, gowns, masks and protective eye wear should be worn in situations in which percutaneous or mucosal contact with any suspected material, such as blood, secretions, excretions or fluids is expected. Disposal of Needles and Syringes Needles and syringes should be disposable and disposed of in rigid, puncture resistant containers. Needles should not be recapped, bent or broken by hand, because accidental needle puncture may occur. The use of needle cutting devices is not recommended. All contaminated disposable items should be considered Infectious Waste and identified as such. Non-disposable articles contaminated with blood or body fluids should be bagged and labeled Blood Precautions before being sent for decontamination and reprocessing. Disposable items should be incinerated or disposed of in accordance with the hospital s policies for disposal of infectious waste. Disposal of Infectious Waste At this facility, the policy of infectious waste is as set forth in the Bloodborne Pathogen Policy Manual.

19 Page 19 of 25 Stat Blood Gas Orders POLICY When stat blood gases are ordered, it shall be done as soon as possible. Blood gases ordered at a specific time will be done within ten (10) minutes either way of the set time.

20 Page 20 of 25 Blood Gases on Patient on Anti-Coagulant Therapy POLICY All patients on anti-coagulant therapy having blood gases done will have radial puncture done using a 22 gauge needle. The site is to be doubled checked after the puncture at ten (10) minutes for any sign of seepage. This is mandatory. When arterial blood gases are ordered, the site of preference is the brachial artery. After this, the radial may be used. The femoral may not be used in most units without the specific orders for this. Capillary sticks are to be done on the heel after it has been warmed for fifteen (15) minutes. The earlobe, fingers and toes are not to be used for capillary sites for babies.

21 Page 21 of 25 Amount of Blood Drawn for Blood Gases POLICY Adult When drawing arterial blood on an adult for blood gases and using a heparinized syringe (5cc), 3.5 to 4 cc s of blood must be drawn to adequately mix with the heparin. This assures that the heparin does not alter the blood gas values, by being in a significant concentration. Make sure only the dead space of the needle and hubs contain heparin. No additional heparin should be left in the syringe. Pediatric Patient When drawing blood from a pediatric patient, you will be using a 1 cc tuberculin syringe with a clear hubbed needle (23 gauge). Heparin should be expelled from the syringe and only left in the needle dead space. Draw only 0.5 cc s of blood. Neonate When drawing blood from a neonate, you will be using a 1 cc tuberculin syringe with a clear hubbed needle (23 gauge). Heparin should be expelled from the syringe and only left in the needle dead space. Draw only 0.33 cc s of blood.

22 Page 22 of 25 Blood Gas Panic Values POLICY The physician is to be notified immediately of any of the following critical results: ph: Below 7.3 OR Above 7.5 pco2: Below 30 OR Above 55 po2: Below 54 OR Above 100 HCO3: Below 10 OR Above 35

23 Page 23 of 25 Use of Back-up ABG Machine POLICY If unable to bring machine into quality control standards and unable to resolve problem through use of troubleshooting guide: If blood gas is ordered, notify Dave Chappa, Hospital Courier. Tell him we need an emergency blood gas transported to Copper Queen Hospital blood gas lab. He will come to the hospital emergency room entrance to pick up sample. Draw sample from patient, label properly, and pack in ice slush. Call Copper Queen Hospital (520) tell them we are sending an emergency blood gas sample. They will page Cardiopulmonary and alert him/her so sample can be run. Results will be called to therapist at Southeast Arizona Medical Center by telephone. Therapist will double check patient ID and write results on blood gas slip. Physician will then be notified of result immediately. Notify Cardiopulmonary Director. Call Nova at (800) 545-NOVA for technical assistance or for service representative to come to facility.

24 Page 24 of 25 Corrective Actions Quality Control POLICY The following procedure will be performed and documented on Out of Control. In addition, the following personnel will be notified if controls do not come in after all reasonable attempts have been made to bring them in: Lab Manager Medical director PROCEDURE Run QA controls again if unable to get controls in, use trouble-shooting guide for assistance. Make copy of disk and send to Bayer. Check with QC for expired QC. Change out measurement/qc cartridge. Call Bayer at (800) 545-NOVA for technical assistance. If unable to get controls, send disk to technical assistance for further trouble-shooting procedures.

25 Page 25 of 25 Maintenance & Quality Control for Blood Gas Analyzer POLICY Cardiopulmonary staff will document for permanent records the quality control run on the blood gas analyzer. In addition, staff will document proper functions and corrective action taken when results are out-of-range on the computer for the Bayer Rapidlink 405. Necessary Information Usage Electronic Auto QC Blood Gas auto QC will run level III at least every 8 hours on the blood gas machine. Corrective action must be documented and taken if results are out-of-range. Quality Control is stored in the computer program. Quality Control Ranges Quality Control Ranges: Statistical mean/absolute limits are set by Westgard options. Standard deviations are calculated monthly from Confirmation Statistical Analysis program in the computer. This information will be documented in the department Permanent Record binder.