Infection Control in Phlebotomy: Standard Precautions for the NHA CPT Exam

Infection control is not a minor topic on the NHA CPT exam. The Safety and Compliance domain makes up 15% of the test, and infection control questions are woven through almost every scenario in that section. You will see questions about what PPE to wear, what to do after a needlestick, how to handle sharps containers, and when to wash your hands versus use hand sanitizer. Get comfortable with this material and those points will come easily.

The foundation of everything here is one idea: you cannot look at a patient and know what infections they carry. Some people do not know they are infected. Some will not tell you. So the rules apply to every patient, every time, no exceptions.

Standard Precautions

Standard Precautions treat the blood, body fluids, non-intact skin, and mucous membranes of every patient as potentially infectious. It does not matter what their chart says, what they tell you, or how healthy they look. You follow the same protective measures for every single draw.

You may also see the older term "Universal Precautions" in study materials or on older signage in facilities. The CDC replaced that language with Standard Precautions in 1996. The concept expanded slightly — Universal Precautions covered blood and certain body fluids, while Standard Precautions added sweat-free body fluids, non-intact skin, and mucous membranes. On the NHA CPT exam, standard precautions is the correct current term.

OSHA's Bloodborne Pathogens Standard (29 CFR 1910.1030) sits behind all of this on the regulatory side. It requires employers to protect workers from exposure to blood and other potentially infectious materials (OPIM). That standard mandates exposure control plans, engineering controls, work practice controls, PPE, training, and post-exposure follow-up. As a phlebotomist, you work inside this regulatory framework every day.

The three bloodborne pathogens you need to know best for the exam are HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV). HBV is the most stable of the three — it can survive on a dry surface at room temperature for up to seven days. That fact alone should reinforce why surface decontamination and sharps safety matter so much.

Hand Hygiene

If you had to pick one infection control measure that has the biggest impact, hand hygiene is it. Hands are the primary route of pathogen transfer in healthcare. Gloves are not a substitute — you still wash after removing them.

The CDC and WHO guidelines specify the same core moments for hand hygiene in phlebotomy practice:

• Before patient contact
• Before a clean or aseptic procedure (venipuncture counts)
• After exposure to blood, body fluids, or contaminated surfaces
• After patient contact
• After removing gloves

That last point trips people up. Gloves develop micro-tears you cannot see. Pathogens can contaminate your hands during removal. Always wash after gloves come off.

Soap and water vs. alcohol-based hand rub (ABHR): ABHR is faster and effective for most situations. Use it when your hands are not visibly soiled. But soap and water is required when hands are visibly dirty or contaminated with blood, when you have been in contact with a patient with Clostridioides difficile (C. diff), and after using the restroom. Alcohol does not kill C. diff spores. This is a common exam question — know when soap and water is the right call.

Technique matters. An application of ABHR that takes three seconds does nothing. The proper method for both soap-and-water and ABHR involves these steps: apply enough product to cover all surfaces, rub palm to palm, interlace fingers to clean between them, rub the backs of both hands, clean under the fingernails, and continue for at least 20 seconds before rinsing. For soap and water, 20 seconds is the minimum. A useful trick: humming "Happy Birthday" twice gets you close to that time.

Keep nails short and clean. Artificial nails and nail extenders are restricted in many clinical settings because they harbor more organisms and make thorough hand hygiene harder. Some facilities prohibit them outright for patient-care staff.

Personal Protective Equipment (PPE)

PPE is a secondary barrier — it protects you after engineering and work practice controls have been applied. OSHA 29 CFR 1910.1030 requires employers to provide appropriate PPE at no cost to workers. Your job is to select the right PPE for the task and use it correctly.

Gloves

Gloves are required for every venipuncture and capillary puncture. No exceptions. Change gloves between patients — never wear the same pair for multiple draws. A single pair that goes from one patient to the next cross-contaminates both.

Nitrile is the standard choice in most phlebotomy settings. Latex gloves are effective but cause allergic reactions in some patients and healthcare workers — reactions can range from contact dermatitis to anaphylaxis. If you or your patient has a latex sensitivity, nitrile or vinyl is the alternative. Know your facility's policy, and if a patient mentions a latex allergy before you start, act on that information before you open any supplies.

Gloves do not replace hand hygiene. Remove them properly — peel the first glove off by gripping the outside at the wrist, hold it in the gloved hand, slip fingers under the wrist of the second glove and peel it off over the first, dispose of both without touching the outer surfaces. Then wash or sanitize your hands.

When to Add More PPE

Gloves alone are sufficient for routine venipuncture on a cooperative patient with no active bleeding or splash risk. Additional PPE is needed when the situation changes:

• Gown: When clothing contamination is likely — heavy bleeding, a combative patient, certain isolation precautions.
• Mask and eye protection or face shield: When there is risk of splash, spray, or splatter to mucous membranes. This applies during arterial draws, certain collections from patients with respiratory infections, or when a patient is coughing heavily.
• N95 respirator: Required for airborne precautions (see Isolation Precautions below). A standard surgical mask does not provide the same level of protection against airborne particles.

Donning and Doffing Order

Putting PPE on in the right order keeps clean surfaces from contacting contaminated ones. Donning order: gown first, then mask or respirator, then eye protection, then gloves. Doffing order: gloves first (most contaminated), then eye protection, then gown, then mask last. Perform hand hygiene after removing each piece, and definitely after everything is off. The mask comes off last because the front of it is contaminated and you want clean gloves removed before you touch your face.

Sharps Safety

Needlestick injuries are the primary mechanism of bloodborne pathogen exposure for phlebotomists. OSHA's 2001 revision of the Bloodborne Pathogens Standard (implementing the Needlestick Safety and Prevention Act of 2000) made engineered sharps injury prevention devices a requirement, not a suggestion. Employers must evaluate and implement safer needle devices, and frontline workers must be involved in that evaluation process.

The rules for sharps are short and non-negotiable:

• Never recap used needles. The two-handed recap — holding the cap in one hand and guiding the needle into it with the other — is the single most preventable cause of needlestick injuries. Do not do it.
• Activate the safety device immediately after use. Every safety-engineered needle has a mechanism — a retractable sheath, a hinged guard, a blunt cannula that deploys on withdrawal. Activate it with one hand while the needle is still in a controlled position, not after you've set it down.
• Dispose of sharps directly into the container. Do not set a used needle on the counter and come back to it. Go directly from patient to container.

Sharps Containers

Sharps containers must be puncture-resistant, leak-proof on the sides and bottom, and clearly labeled with the biohazard symbol. They must be red or labeled with the biohazard symbol (or both). Position them as close as practical to the area of use — within arm's reach is ideal.

The fill line matters. Containers are marked at approximately the 3/4 full level. Once waste reaches that line, close and replace the container. Overfilling forces you to push items in, which puts your fingers near used sharps. Never reach into a sharps container under any circumstances.

Disposal of full sharps containers is regulated as biohazardous waste. Containers must be closed before transport, handled with minimal agitation, and processed by a licensed medical waste handler. Your facility will have a specific procedure — know it.

Post-Exposure Protocol: Needlestick Injury

A needlestick or other exposure to blood or OPIM requires immediate and specific action. The sequence matters.

1. Wash the site immediately. For a needlestick or cut, wash with soap and water for several minutes. For a splash to mucous membranes (eyes, mouth, nose), flush with water or sterile saline. Do not squeeze or "milk" the wound — there is no evidence this reduces exposure and it may cause tissue damage. Do not use bleach or other caustic agents on skin.

2. Report to your supervisor right away. Do not finish your shift and report the next day. Reporting triggers the post-exposure process and creates a record. Under OSHA requirements, employers must have a written post-exposure procedure and must make medical evaluation available at no cost to the employee.

3. Seek medical evaluation. A clinician will assess the exposure, review the source patient's known infectious status, and discuss post-exposure prophylaxis (PEP) options. For HIV, PEP is most effective when started within 72 hours — ideally within 2 hours. Time is real here.

4. Document the incident. OSHA requires employers to maintain a sharps injury log (29 CFR 1904.35) that records the type and brand of device involved, where in the facility the injury occurred, and a description of how it happened. This log is confidential and is used to identify patterns and evaluate safer devices.

5. Source patient testing. With the source patient's consent, they may be tested for HBV, HCV, and HIV. This helps determine actual exposure risk and guides treatment decisions. Consent is required — the patient cannot be forced to test.

Isolation Precaution Levels

Standard Precautions apply to all patients. Transmission-based precautions layer on top of them for patients with known or suspected infections that require additional protection. As a phlebotomist, you enter isolation rooms regularly — you need to know what each level requires.

Contact Precautions

Used for organisms spread by direct contact with the patient or their environment. Common examples: MRSA (methicillin-resistant Staphylococcus aureus), VRE (vancomycin-resistant enterococci), C. diff, wounds with draining secretions.

Required PPE: gloves and gown before entering the room. Equipment (tourniquet, blood pressure cuff) should stay in the room or be single-use. For C. diff specifically, remember that alcohol-based hand rub is not sufficient — use soap and water.

Droplet Precautions

Used for organisms spread by respiratory droplets — particles larger than 5 microns that travel up to about 3 feet. Examples: influenza, pertussis (whooping cough), bacterial meningitis, mumps, rubella.

Required PPE: a surgical mask when within 3 feet of the patient (most facilities require it upon entry to the room). Gloves and gown per Standard Precautions.

Airborne Precautions

Used for organisms that remain infectious in tiny particles (under 5 microns) that can travel long distances through air currents. Examples: tuberculosis (TB), measles (rubeola), varicella (chickenpox).

Required PPE: an N95 respirator or higher. N95 masks must be fit-tested before use. The room itself requires negative pressure ventilation — air exhausts outside or through HEPA filtration. The door must stay closed. If you have not had fit testing for an N95, coordinate with your supervisor before entering an airborne isolation room.

Know these four levels — Standard, Contact, Droplet, Airborne — and what triggers each one. Exam questions will describe a patient scenario and ask which precautions apply or what PPE is required.

Practice Questions