Considerations in obtaining quality specimens from DVA patients

Aug. 22, 2018

Imagine having the kind of job in which customers are reluctant, if not unwilling, to use the service you provide; they want as little contact with you as possible; and are unforgiving if the service is not provided flawlessly on first try. This is the type of pressure phlebotomists (for this article‘s purposes, “phlebotomist” refers to anyone who performs the act of collecting blood, not just those with the job title) feel daily with every patient. In addition to being confident and knowledgeable about the types of equipment to use and proper draw order, tube labeling, mixing, and handling, phlebotomists must be compassionate, offering words of comfort and reassurance to gain cooperation from even the most needle-averse patients.

Difficult venous access (DVA)

Obtaining a high-quality blood sample that accurately reflects the patient’s clinical status for laboratory testing can be challenging. Even healthy, active, and well-hydrated individuals can present problems for a phlebotomist on a given day. Patients exhibiting a clinical condition called difficult venous access (DVA) lack readily visible or palpable veins and require multiple attempts, multiple operators, or specialized interventions to achieve and maintain peripheral venous access, and they challenge even the most skilled of phlebotomists.¹ DVA occurs in an estimated 12 percent of patients.² Patient populations exhibiting DVA and fragile veins include children, the elderly, those who are chronically or critically ill (chemotherapy, dialysis, sickle cell disease) and, sometimes, those who are fearful of having their blood drawn.3 Of the patients who report difficult collections, 95 percent report that two or more attempts were required before blood was obtained.4 Blood collection success may require using technology other than a 21- or 22-gauge straight needle.

Selecting the appropriate device

Selecting the appropriate device and gauge size may involve a tradeoff between the ability to obtain a high-quality sample and collecting one that might have its quality compromised by hemolysis. The 2010 World Health Organization Guidelines on Drawing Blood recommended that either a 22-gauge straight needle or a 23-gauge winged set (butterfly) be used for pediatric, neonatal, and elderly patients and other patients with small veins.5 Use of needles with a smaller bore, such as a 25-gauge needle, was discouraged because of the risk of hemolysis and slower fill times. Such circumstances can lead to rejected specimens.6,7 Potential for repeat draws increases as the risk of compromised sample quality also increases.

Impact on patient satisfaction

Multiple attempts to collect a specimen, as well as issues with pain or bruising, may negatively impact the patient’s phlebotomy experience. An American Opinion Research (AOR) study (2012) indicated that one bad experience in blood collection decreases patient satisfaction and may cause significant anxiety in future blood draws.4 The survey found that three-fourths of 200-plus patients reported that the phlebotomist had difficulty collecting their blood, and, of those, 90 percent suffered bruising and 84 percent felt more pain.8 Overall, eight of 10 patients surveyed indicated that the experience of their blood collection affected their satisfaction with the care institution, as well as their confidence in the staff and its ability to provide good customer service. Hospital administrators are more concerned than ever, with reimbursements increasingly being tied to patient satisfaction.8

Patient circumstances that affect device selection

Patient population. Pediatric and neonatal patients have considerably smaller veins than adults. Veins in elderly patients can be elusive, and the further complications of dehydration, low blood pressure, and limited range of motion from injury or structural diseases may restrict the number of available collection sites. Veins become more fragile with aging, and loss of strength and elasticity in connective tissue decreases over time.3

Critical conditions. Critically ill and/or oncology patients may demonstrate similar issues to those presented by the elderly. Oncology patients receiving chemotherapy may have veins that are harder to locate and exhibit sclerosis from multiple draws and injections. Critically ill, non-ambulatory patients may exhibit edema because of the treatments received and lack of activity.3 Other conditions that also may prohibit routine venipuncture include obesity, chronic illness,hypovolemia, intravenous drug abuse, and vasculopathy.9

Vein location. Veins in the antecubital fossa, located just below the elbow crease, are preferred; however, these veins may not be accessible because of intravenous fluid administration, frequent injections in the past, or surgery involving the lymphatic system. Existing lymphedema prohibits the use of tourniquets to palpate veins. The only accessible veins may be in the hand, and they are significantly smaller.3

Patient preference. The AOR participants were shown a collage of devices used to draw blood. No explanation was given about any of the devices. Approximately 40 percent preferred wingsets to others; other devices were not viewed as favorably. Afterward, the participants were given brief descriptions of each. The information provided increased the percentage of those who preferred wingsets to 60 percent. Patients perceived that the wingsets created less bruising, were less painful, appeared less intimidating, were easier to insert and withdraw; and contributed to more success in collection from the first attempt.8

Collector circumstances that affect device selection

Surveys of phlebotomists, nurses, and other medical professionals reveal that about 50 percent prefer to use wingsets for blood collection. The patient-centric reason is that the patients have a better experience, particularly those who exhibit delicate or fragile veins, where use of a smaller bore needle, such as the 25-gauge, is indicated.10

Some phlebotomists like using wingsets because of the “flash,” the observance of blood in the hub or tubing, a visual indication that entry into the vein has been achieved. Personal safety also is of concern. Wingsets with in-vein activation of a retractable needle minimize the possibility of the user experiencing a needle stick after collection is complete. Phlebotomist skill with using any device can influence device preference.8

Phlebotomists, faced with time constraints and the need to keep up with workload demands, look for ways to increase success rates on the first attempt. Patients with DVA can require up to 13 minutes of time dedicated to intravenous access, significantly higher than an average of 2.5 minutes to collect a sample routinely. If multiple attempts or multiple phlebotomists are required, that time commitment can increase to 30 minutes or more.9

Previous editions of the Clinical and Laboratory Standards Institute (CLSI) document GP41, Collection of Diagnostic Venous Blood Specimens, specifically discouraged phlebotomists from using needles as small as the 25-gauge variety because of the risk of hemolysis and potentially slower blood flow. The seventh edition was modified to recognize that the interior diameters of needles vary. It states that use of 25-gauge needles should only be avoided if frequent hemolysis is observed.6

DVA can challenge even the most skilled phlebotomist. Awareness of the patient’s condition, as well as leveraging skill and available technology, can produce specimens of high quality and accurately reflect the patient’s clinical status. Higher patient satisfaction may also be achieved by minimizing the number of attempts, and incurring less pain or bruising.


  1. Witting MD, Moayedi S, Beverly SK, et al. Incidence of advanced intravenous access in two urban EDs. Amer J Emerg Med. 2015; 33(5):705-707.
  2. Fields JM, Piela NE, Au AK, Ku BS. Risk factors associated with difficult venous access in adult ED Patients. Amer J Emerg Med. 2014;32(10):1179-1182.
  3. Paxton A. Sticking points: how to handle difficult blood draws. March 2011.
  4. American Opinion Research. Patient preference for blood collection devices. July 2012.
  5. WHO. WHO guidelines on drawing blood: best practices in phlebotomy. WHO Press: Geneva, Switzerland. 2010 ISBN 978 92 4 159922.
  6. Clinical and Laboratory Standards Institute (CLSI). Collections of Venous Blood Specimens, Standard GP41, 7th Edition. CLSI: Wayne, PA. April 2017. ISBN 1-56238-813-814.
  7. BD White Paper VS9249. Evaluation of Tube Fill Time of the BD Vacutainer UltraTouch Push Button Collection Set with Thin Wall 3-Bevel Cannula.
    Becton, Dickinson and Company, Franklin Lakes, NJ.
  8. Stankovic A. Putting patients first during blood collection. MLO. 2013;45(8):44-45:
  9. 2011 ENA Emergency Nursing Resources Development Committee, Crowley M, Brim C, Proehl J, et al. Emergency nursing resource: difficult intravenous access. J Emerg Nurs. 2012; 38(4):335-343.
  10. The Lewin Group. The value of diagnostics: innovation, adoption, and diffusion into health care. Advanced Medical Technology Association, 2005.
  11. Hotaling M. Efficacy of a retractable safety winged steel needle (butterfly needle performance improvement project). The Joint Commission Journal on Quality and Patient Safety; 2009;35(2):100-105.