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Introduction ⬇

Drug and alcohol specimens are collected to help identify a patient’s drug or alcohol use.1 This information may be needed to obtain evidence for a possible criminal charges (such as after an accident), to help determine a cause of death, and to screen for employment suitability or adherence to an ongoing drug addiction rehabilitation program. It’s also used to establish a differential diagnosis for a patient experiencing an altered mental state or who has signs and symptoms as slurred speech, dizziness, confusion, blurred vision, anxiety, hallucinations, memory impairment, lack of muscle coordination, or hyperthermia. The collection method and source of the specimens vary, based on the reason for testing. Because of the variability in local and state laws, each facility’s guidelines must be strictly followed.

Drug testing that’s performed to determine employment suitability and rehabilitation program adherence usually involves a urine sample collected under highly controlled conditions.1 Although collection requirements may vary slightly, depending on the employer and type of employment or rehabilitation program, most include a designated collection site, security for the collection site, use of authorized personnel, privacy during collection, integrity and identity of the specimen, and chain-of-custody documentation. Some rehabilitation programs and employment circumstances may require the specimen collection to be observed. Testing is usually limited to five drug types: marijuana, cocaine, opiates, amphetamines, and phencyclidine (PCP). In the case of employment screening, if the results of the initial test are positive, a test using gas chromatography–mass spectrometry follows to confirm the results.

Depending on the reason for collection and state laws, the patient or a family member may need to provide informed consent before you obtain the sample. Consent may not be required if it’s an emergency, if results will be used only for a differential diagnosis in an acute crisis, or if the patient is not in a condition to grant permission.2 In a criminal case, a law enforcement officer can’t order blood to be drawn and doesn’t have the legal right to grant permission if the patient refuses consent.

Blood specimens are collected in 10-mL gray-top blood collection tubes that contain a preservative (100 mg of sodium fluoride) to help prevent deterioration of the specimen, including changes in alcohol concentration and the breakdown of cocaine. The tubes also contain an anticoagulant (20 mg of potassium oxalate) to prevent the sample from clotting.3 The integrity and identity of the specimen must be maintained and, if indicated, chain-of-custody documentation preserved.

In general, prescription and over-the-counter drugs can be detected in blood within 4 to 24 hours and in urine for 2 to 4 days. Detection times for alcohol and other drugs vary. (See Drug detection times.)

This procedure focuses on drug and alcohol specimen collection for medicolegal reasons. When specimens are collected for a patient who’s experiencing an altered mental state or other signs and symptoms, be sure to use the appropriate collection tubes. (See the "Venipuncture" procedure.)

Equipment ⬆ ⬇

Equipment

Gloves • chain of custody labels • chain of custody form with multiple copies • labels • pen • "limited access" signs • Optional: vital signs monitoring equipment, pulse oximeter and probe, secure refrigerator.

Urine Specimen Collection

Urine collection container with temperature measurement device attached in sealed covering • 90-mL plastic, screw-top specimen container in sealed covering • adhesive label • plastic sealable shipping bag • absorbent material • bluing agent for toilet water • lockable cabinet or box

Blood Sample Collection

Two 10-mL gray-top Vacutainer blood tubes containing sodium fluoride and potassium oxalate with adhesive labels • venipuncture supplies • alcohol-free swab (povidone-iodine) • evidence seals • padded transport box • laboratory biohazard transport bag • Optional: 2" × 2" (5 cm × 5 cm) gauze pads, soap (non-alcohol containing) and water solution.

Note: Prepackaged blood and urine collection kits are commercially available and contain everything necessary to collect and preserve the chain of custody for the specimens.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility. Make sure that access to collection materials and specimens is adequately restricted. Make sure that LIMITED ACCESS signs are posted in the specimen collection area to ensure patient privacy during the specimen collection process.

Implementation ⬆ ⬇

Implementation
  • Verify the practitioner’s order.
  • If required by your facility, confirm that informed consent has been obtained and that the signed consent form is in the patient’s medical record.5,6,7,8
  • Perform hand hygiene.9,10,11,12,13,14
  • Confirm the patient’s identity using at least two patient identifiers.15
  • Provide privacy.16,17,18,19
  • Explain the procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.20
  • Perform hand hygiene.9,10,11,12,13,14
  • Assess the patient’s level of consciousness and behavior. If applicable, obtain the patient’s vital signs, including heart rate, respiratory rate, blood pressure, temperature, and oxygen saturation using pulse oximetry.
  • Obtain a thorough current and past medication history that includes prescription and nonprescription drugs as well as herbal supplements.

Urine Sample Collection

  • Prepare the collection site by turning off the water supply or securing water sources.21
  • Add bluing agent to the toilet and water tank to prevent undetected specimen dilution by the donor.21
  • Remove the waste container, soap dispenser, and any unnecessary items from the bathroom.21
  • Perform hand hygiene.9,10,11,12,13,14
  • Put on gloves to comply with standard precautions.22,23,24
  • Gather and prepare the necessary equipment and supplies.
  • Instruct the patient to remove any unnecessary outer clothing, such as a coat, hat, or extra shirt. If the patient refuses to remove a head covering based on religious practices, the patient may be exempt unless the collector has a visual indicator that the patient may be concealing something under the covering. Keep personal items such as a briefcase or purse with the patient’s outer clothing.21
  • Instruct the patient to empty pockets into a lockable cabinet or box, and have the patient turn pockets inside out to ensure that they’re emptied and that the patient doesn’t have anything that could be used to adulterate the specimen. If the patient brought medications, lock them in the cabinet or box.21
  • Have the patient wash and dry hands.21
  • Provide the patient with the sealed collection kit or urine specimen container, and have the patient unwrap or break the seal on the kit or container.21
  • If direct observation isn’t mandated for specimen collection, have the patient enter the bathroom and instruct the patient to provide a urine specimen of at least 45 mL into the collection container,21 to not flush the toilet,21 and to immediately leave the bathroom with the specimen and hand it to you when the patient’s finished urinating.21
  • If direct observation is mandated, observe the patient during the collection procedure. (See Direct observation specimen collection.)
  • If the patient has a medical condition that requires an indwelling urinary catheter or an external urine collection bag, collect a fresh specimen. Instruct the patient to empty the urine collection bag in the bathroom and then show you the empty bag, drink sufficient fluid to provide a specimen, and pour the urine from the bag into the collection container in the privacy of the bathroom when the bag has collected at least 45 mL of urine.21
  • Check the specimen’s temperature by reading the temperature strip, and note it on the chain-of-custody form.21
  • Check the specimen volume to ensure that the specimen contains the required amount of urine.21
  • Open the sealed screw-top specimen container and transfer the urine into the container.
  • Label the specimen container with the patient’s name and identification number and the date and time in the presence of the patient to prevent mislabeling.15
  • Complete the required information on the chain-of-custody seal, initial the seal, have the patient initial the seal, and place it over the top of the specimen container.21
  • Turn the water on and allow the patient to wash hands.
  • Complete the chain-of-custody form and have the patient sign the form.21
  • Give the patient a copy of the chain-of-custody form.
  • Place the specimen, absorbent material, and completed chain-of-custody form in the plastic sealable shipping bag.
  • Seal the bag in the presence of the patient.
  • Remove and discard your gloves.24
  • Perform hand hygiene.9,10,11,12,13,14
  • Place the specimen in a secure refrigerator if it won’t be immediately transported to the laboratory.
  • Make sure the person who removes the specimen for transport signs the chain-of-custody form. Retain a copy and place it in the patient’s medical record.
  • Document the procedure.25,26,27,28

Blood Sample Collection

  • Perform hand hygiene.9,10,11,12,13,14
  • Put on gloves to comply with standard precautions.22,23,24
  • Gather and prepare the necessary equipment and supplies.
  • If applicable, ensure that the collection is observed by the law enforcement officer as required by your facility and state law.
  • Choose a venipuncture site. The most common sites are the veins in the antecubital space of the arms; however, if the patient has scarring in this area from self-injected drugs, you may need to find an alternate venipuncture site.
  • Clean the skin at the venipuncture site with an alcohol-free swab such as a povidone-iodine swab. If an alcohol-free antiseptic isn’t available, use a gauze pad with a solution of soap and water, making sure that the soap doesn’t contain any alcohol.
  • Use proper venipuncture technique to collect the blood sample. (See the "Venipuncture" procedure.)
  • Fill the collection tubes completely to minimize the air space above the specimen, which can change the testing results.
  • Slowly invert the tubes completely at least five times to ensure proper mixing of the additives. Don’t shake them vigorously.
  • Label the specimen tubes with the patient’s name and identification number and the date and time in the presence of the patient to prevent mislabeling.15 Obtain the law enforcement officer’s initials on the tubes, if applicable.
  • Complete the required information on the evidence seals, initial the seals, and have the patient initial the seals.
  • Place a completed evidence seal across the top of each tube.
  • Complete the chain-of-custody labels and form, and have the patient sign the form.
  • Place the tubes into a padded transport box and then into a biohazard laboratory transport bag.24
  • Seal the bag with the chain-of-custody and evidence labels.
  • Remove and discard your gloves.24
  • Perform hand hygiene.9,10,11,12,13,14
  • Attach the chain-of-custody form.

NURSING ALERT Complete all of the above steps in full view of the patient and, if applicable, the appropriate law enforcement officer.

  • Place the specimen in a secure refrigerator if it won’t be immediately transported to the laboratory.
  • Perform hand hygiene.9,10,11,12,13,14
  • Make sure the person who removes the specimen for transport signs the chain-of-custody form. Retain a copy and place it in the patient’s medical record.
  • Document the procedure.25,26,27,28

Special Considerations ⬆ ⬇

Special considerations
  • Consent must be obtained if your state law doesn’t cover the specimen collection.
  • If the specimen is being collected for a law enforcement agency, make sure that an officer has notified the patient of the patient’s rights and explained the procedure before you obtain the sample.
  • Temperature strips attached to urine collection containers allow temperature certification between 90° F and 100° F (32.2° C and 37.8° C), which are acceptable under most standards.21 However, some testing standards require that the urine’s temperature be taken with a digital thermometer and be between 96° F and 99° F (35.6° C and 37.2° C).
  • If the urine specimen volume is inadequate, discard any specimen collected and the specimen collection container used for that attempt, have the patient sit in a waiting area where you can continuously observe the patient, and provide the patient with up to 40 ounces of water to drink (which should be evenly spread out over a 3-hour period or until the patient can provide an adequate specimen). Instruct the patient to tell you when the patient feels able to provide the specimen. If, after 3 hours, the patient can’t provide a specimen, the collection should be terminated and you should notify the person who requested the test.21

Complications ⬆ ⬇

Complications

If specimen collection is performed with no subsequent medical follow-up, serious medical conditions may go unidentified, causing the patient to experience adverse effects. Mishandling of the specimen or improper documentation of the chain of custody may lead to the evidence being inaccurate or inadmissible in court.

There are many ways for patients to circumvent testing: adding adulterants to urine at the time of testing, diluting urine through excessive water ingestion, consuming substances that interfere with testing, and substituting a clean urine sample. Appropriate collection techniques and tests of specimen integrity can reduce the risk of tampering.1

Documentation ⬆ ⬇

Documentation

Record the date and time, what test was performed, the reason for the test, and the type of specimen that was obtained. Note whether a law enforcement officer was present for the specimen collection, including the agency the officer represented and the officer’s badge number. Document that the chain of custody was preserved. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

  1. KaleN. (2019). Urine drug tests:

    Ordering and interpretation

    . American Family Physician, 99(1), 33–39. https://www.aafp.org/afp/2019/0101/p33.html (Level VII)
  2. HoffmanR. J. (2021). Testing for drugs of abuse (DOA). In: UpToDate, TraubS. J., (Ed.).
  3. LabCorp. (n.d.). Blood drug testing. https://www.labcorp.com/drug-testing/types-of-drug-tests/blood-drug-testing
  4. LabCorp. (2016). Drugs of abuse reference guide. https://files.labcorp.com/labcorp/L1123-0216-5.pdf
  5. The Joint Commission. (2021). Standard RI.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  6. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Patient’s rights. 42 C.F.R. § 482.13(b)(2)

    .
  7. Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.11. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  8. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.3. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  9. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:

    Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

    . MMWR Recommendations and Reports, 51(RR-16), 1–45. https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
  10. The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  11. World Health Organization. (2009). WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean care is safer care. https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (Level IV)
  12. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Infection control. 42 C.F.R. § 482.42

    .
  13. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  14. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  15. The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  16. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Patient’s rights. 42 C.F.R. § 482.13(c)(1)

    .
  17. Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.16. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  18. The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  19. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.5. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  20. The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  21. U.S. Department of Transportation, Office of Drug and Alcohol Policy and Compliance. (2018). Urine specimen collection guidelines. https://www.transportation.gov/sites/dot.gov/files/docs/resources/partners/drug-and-alcohol-testing/2567/urine-specimen-collection-guidelines-january-2018.pdf (Level VII)
  22. SiegelJ. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)
  23. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  24. Occupational Safety and Health Administration. (2019). Bloodborne pathogens, standard number 1910.1030. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS (Level VII)
  25. The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  26. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Medical record services. 42 C.F.R. § 482.24(b)

    .
  27. Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  28. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)