NHS FORTH VALLEY. Venepuncture Policy

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Version 1.2 1st August 2015 Page 1 of 14 UNCONTROLLED WHEN PRINTED

NHS FORTH VALLEY

Venepuncture Policy

Date of First Issue 21/12/2011

Approved 07/08/2015

Current Issue Date August 2015 Review Date August 2017

Version 1.2

EQIA Yes 05/01/2012 Author / Contact Sharon Faulds

Group Committee – Final Approval

Nursing Policy Forum Group

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Consultation and Change Record – for ALL documents

Contributing Authors: Sharon Faulds Trisha Miller Mark Gilmour Consultation Process: Chris Brammer

Mandy Dawson Graeme Inglis Jacqueline Bryceland Chris Beech Vicky Chisholm Gail Bell Fiona Grant Melanie Kavanagh Karen Storey Jacqueline Maher

Nursing & Midwifery Policy Forum Distribution: NHSFV Intranet

Change Record

Date Author Change Version

11/06/2013 SF Equipment section updated. Risk Management section added.

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21/07/2015 SF

SF/MG

Responsibility, education & training, infection control, equipment, blood culture samples, after procedure and bibliography updated

New Section added - Order Communications (Order Comms)

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Contents Page Page 1 Aim 4 2 Objective 4 3 Responsibility 4 4 Background 5

5 Education & Training 5

6 Risk Management 6

7 Infection Control 6

8 Prior to Procedure 6

9 Order Communications (Order Comms) 7

10 Venepuncture Sites 7

11 Equipment 8

12 Blood Transfusion Samples 8

13 Blood Culture Sample 9

14 After procedure 9

15 Bibliography 10

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1. Aim

 To ensure the correct blood sample is taken from the right patient in a safe, correct manner first time

 To minimise the risk of introducing harmful micro-organisms into the blood stream 2. Objective

This policy is to ensure all clinical staff (including medical staff) that are responsible for venous blood sampling within NHS Forth Valley are fully aware of the policy content and control measures required to perform the procedure correctly, and to minimise infection and risk of harm to the patient.

3. Responsibility

a All clinical staff:

i) must adhere to the policy

ii) are responsible for minimising the potential of cross infection

iii) are responsible for maintaining their competency in venepuncture

b Venepuncture Assessors:

i) must be experienced and competent in venepuncture

ii) must be able to offer help and support to learners and practitioners

performing venepuncture

iii) must act as a role model and actively promote good practice within their clinical area

iv) must peer assess other staff members within their own clinical area annually

using the assessment criteria provided by Practice Development Unit

v) must keep records of these assessments at ward level for audit purposes

vi) must challenge inappropriate practice

vii) must ensure a copy of signed competency sheet is sent to Practice

Development Unit for entry into database

viii) must attend an assessors update day, at least every 3 years, to ensure their knowledge is up-to-date

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c Managers:

i) are responsible for ensuring that clinical staff are aware of this policy and that it is adhered to

d Practice Development Unit:

i) are responsible for delivering initial evidence based venepuncture training,

either face to face training or via e-learning module

ii) will supply all clinical staff at training session with a competency sheet to complete following theory session and advise staff how to achieve

competency

iii) will fast-track and familiarise new clinical staff with Forth Valley guidelines who have completed training and competency within another Health Board

iv) will annually invite venepuncture assessors to attend an update session

v) must keep the policy up to date

vi) will audit compliance with the policy

vii) will hold a database of all current venepuncture assessors

4. Background

Venepuncture or phlebotomy is the term used to describe the insertion of a needle into a vein to withdraw blood, for haematological, biochemical or bacteriological analysis. Venepuncture is a practical skill that can be performed by a range of health care professionals. It is the most common invasive procedure undertaken in healthcare.

5. Education and Training

 Only clinical practitioners who have received appropriate training and supervision will undertake venepuncture

 Following training, a period of supervised practice with a final competency assessment will be undertaken

 There is an expectancy that competency will be achieved within 6 months of initial theory training – if this is not achieved further discussion with Practice Development will be required

 The individual practitioner and the Practice Development Unit will keep written records of competency

 Ward based nominated venepuncture assessors and Practice Development Unit staff

can assess competence

 Annual update and re-assessment will occur for all clinical staff to ensure competency is maintained

 All clinical staff undertaking venepuncture are responsible for ensuring that their practice will promote and protect the interests and dignity of the patients

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 Detailed information regarding the venepuncture procedure can be found in the

LearnPro e-learning module

6. Risk Management

To manage the risk, it is advisable that a risk assessment is carried out to identify why staff are unable to obtain blood using the safest method of blood collection, for example, very small or difficult veins, and also to ensure control measures are in place to make blood collection as safe as it can be, for example, using the Blood Transfer Device.

7. Infection Control

In order to reduce the risk of cross infection, standard infection control precautions must be adhered to at all times. In particular:

 Sharps management

i. A safety device must be used to prevent needlestick injury

ii. sharps must be disposed of immediately after use in a sharps bin

 Hand hygiene

i. level 2 handwash must be performed prior to undertaking the procedure ii. the use of gloves does not negate the need for hand hygiene

iii. hands must be decontaminated after removing gloves and apron

 Personal Protective Equipment (PPE) – apron and gloves must be worn during the

procedure

 Skin must be cleaned using an antiseptic containing 70% isopropyl alcohol and

allowed to air dry for thirty seconds before venepuncture. After cleaning the skin, the insertion site must not be re-palpated. If under certain circumstances this is not possible then sterile gloves must be worn

8. Prior to Procedure

 The request form must be completed before the blood sample is taken

 Informed consent must be obtained prior to the procedure. If consent directly from the patient is not possible then it must be obtained as per Adults with Incapacity (Scotland ) Act 2000

 The correct identification of the patient must be confirmed prior to the procedure: o The patient must be asked to positively identify him or herself by giving their

full name (first and last name) and date of birth prior to being bled o Identity must not be assumed even for familiar patients who are regular

attenders or long-standing in-patients

o This must be checked against the details on the request form and, for in-patients, what is on the patient identification band

o All inpatients must wear a patient identification band (with exception to Mental Health, Learning Disabilities and Older People Services)

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o The full name and date of birth stated by the patient must EXACTLY MATCH the information on the patient’s identification band and the information on the request form – if there is any doubt, the patient should be asked to spell out their name to the requestor

 The person taking the sample must be satisfied that the identity of the patient matches the information on the request form, and the sample, and (for in-patients) the patient identification band BEFORE signing the request form and sending it to the laboratory

 If a patient is unconscious or unable to positively identify him/herself for other

reasons (ie, confusion, neonates and small children), then identity must be confirmed by rigorous inspection of the patient’s identification band. Verification of the patients identification should be obtained from a carer, if present at the patients beside and checked against the patient identification band

Patients whose identity is unknown:

 If a patient is admitted unconscious and their identity is unknown, the following procedure must be followed:

o The patient must be allocated a unique identification number

o The minimum identifying dataset must include this number plus the gender of the patient (ie, Unknown Male A123456)

o An identification wristband including this minimum data must be attached to the patient

o This dataset must be used on samples and request forms until additional identification details become available

o When additional identification details become available, the laboratory must be informed

o The use of such temporary identification numbers increased the risk of confusion and errors in patient identification and should only be used when absolutely necessary

9. Order Communications (Order Comms) Samples

NHS Forth Valley are in the process of transferring blood sample requesting from paper to electronic. Tests are requested as per the Order Comms Instructions within the DatrOCM Order Communications Application. When using this system the following is required when labelling the blood bottles prior to sending them to the laboratory:

 Labels are placed length ways on the sample bottle.

 Place label away from ends - do not allow ends to be covered.

 Label needs to be smooth and clear for the scanner.

 Please make sure the colour of the bottle matches the colour printed on the label.

 Always check the patient’s information printed on the label (Name, DOB, CHI) is

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10. Venepuncture Sites

 Suitable veins for venepuncture are:

- antecubital veins

- cephalic or basilic veins on the forearm

- metacarpal veins on the dorsum of the hand

 Unless justified by senior medical staff venepuncture must not be performed on

patients:

- following breast surgery on the arm of the same side as surgery

- undergoing haemodialysis on the arm where their fistula is present

- lower limbs (except in children)

 Venepuncture must not be attempted more than twice. It must be passed to a more

experienced practitioner

 Venepuncture must not be performed using a vein proximal to an infusion site

11. Equipment

 When choosing the device to use for the procedure, consider the following:

- are blood cultures required first?

- 21g (green) needle for normal use

- 22g (black) for more difficult access

- butterfly is used for small and difficult vein sampling in adults and always in younger children and babies

 In normal circumstances in adults, blood collection must only be obtained by using the components of the Vacutainer system as this allows blood to flow directly from vessel to bottle

 In paediatric and adult patients with difficult access a butterfly/needle and syringe may be used, however, a Vacutainer Blood Transfer Device must be used to safely transfer the blood from syringe to bottles

 Safety devices must be activated either, after removal from vein and disposed of in sharps bin straight away

 All equipment is disposable/single use only and must be disposed of as clinical waste

 A disposable single use tourniquet must be used to prevent cross infection. If this is not possible a rubber wipeable tourniquet can be used. This must be thoroughly cleaned between patient use.

12. Blood Transfusion Samples

An error when labelling a blood transfusion sample could result in an incorrect blood component being transfused to a patient, with potentially very serious consequences. The Hospital Transfusion Laboratory (HTL) operates a “zero tolerance” approach to sample labelling and those taking blood samples for Group & Save or Cross-Match purposes must take extra care to ensure they identify the patient correctly and label the samples accurately:

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 The sample bottle must be labelled by hand at the bedside immediately after the sample has been drawn

 The sample must be labelled with the minimum transfusion dataset:

o Forename and surname,

o CHI number (or ED or major incident number if CHI not available) o Date of birth

o Gender of the patient

 This dataset must precisely match that on the request form (an addressograph label

is permissible on the request form, but care must be taken to ensure it is for the right patient

If the identity of the patient is unknown, then the minimum dataset is “unknown male/female” and a unique identifier (ED or major incident number)

This procedure is described in greater detail in the NHS Forth Valley Transfusion Protocol.

13. Blood Culture Samples

Contaminated blood cultures are time wasting for the lab and potentially misleading for the clinician therefore correct equipment must be used.

 The use of a standard syringe and needle to inoculate blood culture bottles carries a high risk of contamination and needlestick injury therefore must not be done. Dedicated blood culture equipment is available for use

 Contamination is significantly reduced if the following 5 instructions are followed when taking blood cultures:

o Tops of blood culture bottles must be cleaned with an antiseptic containing 2% chlorhexidine gluconate & 70% isopropyl alcohol and allow to air dry

o Hand hygiene must be performed and PPE must be worn

o Skin must be thoroughly disinfected with an antiseptic containing 2%

chlorhexidine gluconate & 70% isopropyl alcohol for 30 seconds and allowed to fully air dry. After cleaning the site must not be re-palpated.

o Procedure must be performed using strict aseptic non-touch technique o Blood cultures must always be taken first, before other blood samples

 Non-sterile gloves can be worn as long as care is taken to avoid touching the venepuncture site after skin preparation. If this is not possible then sterile gloves must be worn (compulsory for neonates)

 Blood culture procedure must be performed as per national guidelines DOH (2010)

14. After Procedure

 Samples must be taken in correct order of draw (see appendix 1)

 Samples must be mixed immediately following collection (see appendix 1)

 Large addressograph labels on the specimen bottle will NOT be accepted by the

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 The specimen must be labelled at the bedside AFTER blood is drawn into the

sample bottle – NEVER pre-label sample bottles

 The procedure must be fully completed BEFORE moving on to take blood from

another patient

 High risk samples and request form must be labelled accordingly

 Samples must be transported to lab as soon as possible after procedure

Bibliography

Department of Health (2010) Taking Blood Cultures – A Summary of Best Practice Available at:

http://webarchive.nationalarchives.gov.uk/20120118164404/http://hcai.dh.gov.uk/files/2011/ 03/Document_Blood_culture_FINAL_100826.pdf

Lavery I, Ingram P (2005) “Venepuncture: Best Practice”, Nursing Standard, Vol. 19, No. 49, pp. 55-65

NHS Forth Valley (2014) Blood Transfusion Protocol Available at:

http://nhsforthvalley.com/__documents/qi/ce_guideline_transfusionpolicies/transfusion-protocol.pdf

NHS Forth Valley (2013) Blood & Body Fluids COSHH Generic Risk Assessment. Available at: http://staffnet.fv.scot.nhs.uk/wp-content/uploads/2012/05/Bld-BFs-COSHH-RA-10.06.13.doc

NHS Forth Valley (2014) Clinical Chemistry Laboratory Handbook Available at:

http://www.nhsforthvalley.com/__documents/qi/ce_guideline_laboratories/chemistry_handbo ok.pdf

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NHS Forth Valley (2014) Haematology and Blood Transfusion Laboratory Handbook Available at:

http://www.nhsforthvalley.com/__documents/qi/ce_guideline_laboratories/haematology_han dbook.pdf

NHS Forth Valley (2009) Management of Exposure to Blood Borne Virus Infection Policy Available at:

http://www.nhsforthvalley.com/__documents/qi/CE_Guideline_InfectionControl/Management ofExposuretoBBVPolicy.pdf

NHS Forth Valley (2014) Microbiology Laboratory Handbook Available at:

http://www.nhsforthvalley.com/__documents/qi/ce_guideline_laboratories/microbiology_han dbook.pdf

NHS Forth Valley (2014) Management of Exposure to Blood Borne Virus Infection Policy Available at:

http://www.nhsforthvalley.com/__documents/qi/ce_guideline_infectioncontrol/managementof exposuretobbvpolicy.pdf

NHS Forth Valley (2015) Venepuncture Theory – Part 1 Training Module on LearnPro

NHS National Services Scotland (201) National Infection Prevention & Control Manual. Available at:

http://www.nhsforthvalley.com/__documents/qi/ce_guideline_infectioncontrol/national-standard-infection-control-precautions-policy.pdf

Scottish Government (2000) Adults with Incapacity (Scotland) Act 2000 Available at: http://www.scotland.gov.uk/Topics/Justice/law/awi

Thompson, F & Madeo, M (2009) Blood cultures: towards zero false positives, Journal of Infection Prevention, Vol 10, Sup 1, pp S24-S26

WHO (2010) WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy Available at: http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf

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Publications in Alternative Formats

NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print.

To request another language for a patient, please contact 01786 434784. For other formats contact 01324 590886,

text 07990 690605, fax 01324 590867 or