To the Editor,
Regular healthcare has come to an abrupt standstill because of the SARS CoV-2 pandemic. As in some countries the enormous pressure of COVID-19 on critical care nowadays seems to diminish, regular care should be taken up again . As a consequence clinical laboratory testing and blood sampling is increasing .
Safe phlebotomy activities on a large scale, however, cannot be done without additional measures. Triage of symptomatic COVID-19 patients and non-symptomatic patients is not enough, since a large proportion of infectious patients are asymptomatic [3−7].
The main challenge lies in spreading patients in time and place so that safety during blood sampling is guaranteed in accordance with infection prevention guidelines. Here we describe a number of measures based on best practices and recommendations from the Working Group Preanalytical Phase of the Dutch Society for Clinical Chemistry and Laboratory Medicine.
The measures are aimed at a restart of phlebotomy activities in a so-called “1.5 m society” with social distancing measures as obliged by the Dutch government and Dutch infections prevention standards. Measures differ from country to country . In this paper we refer to the situation in The Netherlands .
The measures are preferably in concordance with best practices in other parts of society, like supermarkets or public transport. Some are based on concrete evidence, others are based on the precautionary principles and common sense. The list may not be complete, but is based on the authors’ best knowledge at the time of preparing this paper.
COVID-19 will probably last for a long time . However, certain long-term measures, like the application of phlebotomy robots, are beyond the scope of this paper.
The practical measures described below are meant as an advice or suggestion to aid in adapting phlebotomy services after COVID-19. This paper is not an obligatory guideline. Local regulations should always be observed.
The authors are well aware that organisation of and responsibility for blood sampling facilities differ in different countries , but we believe that the practical measures in this paper apply to most settings.
Digital requests are preferred, to reduce physical contact with potentially contaminated paper request forms
Hospital information systems
Primary care order entry systems
Application of Point-of-care testing
Patients are requested to visit the phlebotomy service unattended if possible
Spread outpatient phlebotomy services in space and time
Increase opening hours; opening during evening and weekend
Inform patients about peak and off times of outpatient phlebotomy services
Blood sampling by appointment; special locations or opening hours for patients with (possible) SARS CoV-2 infection
Necessity for fasting blood sampling (lipids, glucose) 
Avoid any priority procedures for specific patient groups in order to optimize the flow of patients
Blood sampling on parking lots, so that patients can wait in their car 
One way routing in phlebotomy services
Refer the patient directly to the blood collection room (working without a counter, registering the application and performing the blood collection by the same person at the same place)
Reception and waiting rooms:
Minimize the number of chairs and tables. Clearly mark fixed seats as out of use in case a minimum distance of 1.5 m cannot be met
Place chairs at a minimum distance of 1.5 m
Maximum number of patients allowed in facility
Grid on the floor (with instruction that only one person is allowed per square)
Provide counters with screens if necessary
Physical barriers, such as plexiglass, can also help in situations where a 1.5 m distance is not possible
Disinfectant dispenser for patients and attendants at the entrance and exit of the blood collection site
Instruction for applying hand hygiene
Instruction for averting face during blood draw 
Seats and tables are easy to clean (no fabric furniture) 
Clean regularly all contact points in central areas and waiting areas (e. g. chairs, tables, counters) 
No newspapers or magazines offered or allowed in waiting areas
No food or drink offered or allowed in waiting areas
Washable keyboards 
Blood collection booths equipped with screens 
Use disposable thrust belts and disposable blood collection sleeves
Personal protective equipment for employees (mouth-nose mask, splash goggles, gloves, apron)
Possibly also a mouth-nose mask for the patient/attendant after triage
Communicate to both physicians and patients about the limited capacity of phlebotomy services due to safety measures related to the COVID-19 situation
The authors thank Joyce Curvers, Marco Wouters and Adrian Kruit for their critical remarks.
1. McCall, B. Shut down and reboot—preparing to minimise infection in a post-COVID-19 era, The Lancet April 28 2020. https://doi.org/10.1016/s2589-7500(20)30103-5. [Epub ahead of print]. Search in Google Scholar
2. Lippi, G, Plebani, M. The critical role of laboratory medicine during coronavirus disease 2019 (COVID-19) and other viral outbreaks. Clin Chem Lab Med 19 Mar 2020. pii: /j/cclm.ahead-of-print/cclm-2020-0240/cclm-2020-0240.xml. https://doi.org/10.1515/cclm-2020-0240. [Epub ahead of print]. Search in Google Scholar
3. Ganyani, T, Kremer, C, Chen, D, Torneri, A, Faes, C, Wallinga, J, et al. Estimating the generation interval for COVID-19 based on symptom onset data. medRxiv. 8 March 2020. https://doi.org/10.1101/2020.03.05.20031815. [Epub ahead of print]. Search in Google Scholar
4. Ferretti, L, Wymant, C, Kendall, M, Zhao, L, Nurtay, A, Abeler-Dörner, L, et al. Quantifying SARS-CoV-2 transmission suggests epidemic control with digital contact tracing. Science, 31 March 2020. https://doi.org/10.1126/science.abb6936. [Epub ahead of print]. Search in Google Scholar
5. Wei, WE, Li, Z, Chiew, CJ, Yong, SE, Toh, MP, Lee, VJ. Presymptomatic Transmission of SARS-CoV-2 — Singapore, January 23–March 16, 2020. MMWR Morb Mortal Wkly Rep 2020;69:411–15. https://doi.org/10.15585/mmwr.mm6914e1. [Epub ahead of print]. Search in Google Scholar
6. World Health Organization. Report of the WHO- China Joint Mission on Coronavirus Disease 2019(COVID-19) 16-24 February 2020. Available from: https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on- covid-19-final- report.pdf. [Accessed 4 May 2020]. Search in Google Scholar
7. Arons, MM, Hatfield, KM, Reddy, SC, et al. Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. New Engl J Med 24 April 2020. https://doi.org/10.1056/NEJMoa2008457. [Epub ahead of print]. Search in Google Scholar
8. European Centre for Disease Prevention and Control. National information resources on COVID-19. Available from: https://www.ecdc.europa.eu/en/COVID-19/sources-updated. [Accessed 4 May 2020]. Search in Google Scholar
9. Dutch National Institute for Public Health and the Environment (RIVM), National Center for Infectious Diseases (LCI). COVID-19 Guideline. Available from: https://lci.rivm.nl/richtlijnen/covid-19. [Accessed 4 May 2020]. Search in Google Scholar
10. Kissler, SM, Tedijanto, C, Goldstein, E, Grad, YH, Lipsitch, M. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science 14 Apr 2020. https://doi.org/10.1126/science.abb5793. [Epub ahead of print]. Search in Google Scholar
11. Simundic, AM, Cornes, M, Grankvist, K, Lippi, G, Nybo, M, Kovalevskaya, S, et al. Survey of national guidelines, education and training on phlebotomy in 28 European countries: an original report by the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) working group for the preanalytical phase (WG-PA). Clin Chem Lab Med 2013;51:1585–93. https://doi.org/10.1515/cclm-2013-0283. Search in Google Scholar
12. Willan, J, King, AJ, Hayes, S, Collins, GP, Peniket, A. Care of haematology patients in a COVID‐19 epidemic. Br. J. Haematol, 15 March 2020. https://doi.org/10.1111/bjh.16620. [Epub ahead of print]. Search in Google Scholar
13. Nordestgaard, BG, Langsted, A, Mora, S, Kolovou, G, Baum, H, Bruckert, E, et al. Fasting Is Not Routinely Required for Determination of a Lipid Profile: Clinical and Laboratory Implications Including Flagging at Desirable Concentration Cutpoints-A Joint Consensus Statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine. ClinChem 2016;62:930–46. https://doi.org/10.1373/clinchem.2016.258897. Search in Google Scholar
14. Koo, JR, Cook, AR, Park, M, Sun, Y, Sun, H, Lim, JT, et al. Interventions to mitigate early spread of COVID-19 in Singapore: a modelling study. Lancet Infect Dis 2020;23 March 2020. https://doi.org/10.1016/S1473-3099(20)30162-6. Search in Google Scholar
15. Asadi, S, Bouvier, N, Wexler, AS, Ristenpart, WD. The coronavirus pandemic and aerosols: Does COVID-19 transmit via expiratory particles?. Aerosol Science and Technology 2020;54:03 Apr 2020. https://doi.org/10.1080/02786826.2020.1749229. [Epub ahead of print]. Search in Google Scholar
16. Anfinrud, P, Stadnytskyi, V, Bax, CE. Visualizing Speech- Generated Oral Fluid Droplets with Laser Light Scattering. NEJM, 15 April 2020. https://doi.org/10.1056/NEJMc2007800 [Epub ahead of print]. Search in Google Scholar
17. Van Doremalen, N, Bushmaker, T, Morris, DH, Holbrook, MG, Gamble, A, Williamson, BN, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med 2020;382:1564–67. https://doi.org/10.1056/NEJMc2004973 [Epub ahead of print]. Search in Google Scholar
18. World Health Organization. Rational use of personal protective equipment for coronavirus disease (COVID-19): interim guidance, 27 February 2020. Available from: https://apps.who.int/iris/bitstream/handle/10665/331215/WHO-2019-nCov-IPCPPE_use-2020.1-eng.pdf. [Accessed 4 May 2020]. Search in Google Scholar