Download Policy and Procedure for Venepuncture by Clinical

Policy and Procedure for Venepuncture by
Clinical Staff
Co-ordinator:
Gillian McKenzie Murray,
Mr Paul Murray
Reviewer:
Mrs Jane Ormerod
Approver:
Mr David Benton, Mrs
Elinor Smith
Signature:
Signature:
Signature:
Identifier:
GUH/ALL/POL/0007
Review Date:
31 May 2004
Date:
1 April 2003
UNCONTROLLED WHEN PRINTED
VERSION 1
GUH/ALL/POL/0007 - Policy and Procedure for Venepuncture by Clinical Staff
1
Title:
Policy and Procedure for Venepuncture by Clinical Staff
Policy Ref:
GUH/ALL/POL/0007
Across NHS
Boards
Organisation
Wide
Yes
Directorate
Clinical Service
Sub Department
Area
This controlled document shall not be copied in part or whole without the express
permission of the author or the author’s representative.
Review date:
31 May 2004
Author:
Gillian McKenzie Murray, Mr Paul Murray
Policy application:
NHS Grampian
Purpose:
To instruct clinical staff in the performance of venepuncture in
line with best practice
Responsibilities for implementation:
Organisational:
Clinical group:
Corporate:
Departmental:
Area:
Trust Management Teams and Chief Executives
Clinical Group Co-ordinators
Senior Managers
Heads of Service / Clinical Leads
Line Managers
Policy statement:
It is the responsibility of supervisory staff at all levels to ensure
that their staff are working to the most up to date and relevant
policies and procedures. By doing so, the quality of the services
offered will be maintained, and the chances of staff making
erroneous decisions which may affect patient, staff or visitor
safety and comfort will be reduced.
Review:
This policy will be reviewed annually.
Approved by:
Date:
Signature:
Designation:
GUH/ALL/POL/0007 - Policy and Procedure for Venepuncture by Clinical Staff
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Contents
Page 4
Policy for Venepuncture being performed by Clinical Staff
Page 6
Staff Roles
Page 7
Instruction Phase
Page 8
Documentation
Page 10
Procedure for Venepuncture being performed by Clinical Staff
Page 13
Blood Cultures
Page 14
References
GUH/ALL/POL/0007 - Policy and Procedure for Venepuncture by Clinical Staff
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Policy for Venepuncture being performed by Clinical Staff
In this document Nurses and Midwives will be referred to as practitioners
Medical staff will be referred to as clinicians
This policy relates to Venepuncture being performed on the upper limbs only.
Accountability
Practitioners must adhere to the relevant current copy of professional guidance from their
own professional body
1. Code of Professional Conduct, (Nursing and Midwifery Council 2002 Edition)
2. Guidelines for Records and Record Keeping, (NMC 2002 Edition)
3. Midwives Rules and Code of Practice UKCC (1998)
Prior to Venepuncture being performed, it is recommended the Practitioners have:1. Acquired the relevant education and training through attending an appropriate
venepuncture study session.
2. Undergone a successful specified period of supervised practice, eg a minimum of 6, or
until competent.
3. Awareness of their own accountability in relation to undertaking venepuncture.
PLEASE NOTE
All health care workers undertaking venepuncture are accountable for their own
actions.
To practice competently, you must possess the knowledge, skills and abilities required for
lawful, safe and effective practice without direct supervision. You must acknowledge the
limits of your professional competence and only undertake practice and accept
responsibilities for those activities in which you are competent (Code of Professional
Conduct NMC 2002 Edition)




Practitioners who wish to continue to perform Venepuncture must demonstrate the
ability and knowledge if there is a gap of more than three months between training
and practice.
Theoretical and practical competence will be assessed locally
Venepuncture by Practitioners may only be performed on adult patients.
Paediatric Venepuncture may only be undertaken following specific training.
Important: It is recommended that practitioners review their theoretical knowledge
and practical skill annually. The Clinical Competency Self-Assessment Tool
(Professional and Practice Development Nurses’ Forum Scotland) is recommended
for use.
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Performing Venepuncture Rationale:
Venepuncture is performed to obtain venous blood for a wide range of laboratory tests
either: haemotological, biochemical, bacteriological or other specialist tests. These tests
may be requested by the doctor to form the basis for diagnosis or treatment, or as part of
the ongoing disease management of a patient.
Venepuncture is a competency that must be achieved by midwives by the point of
registration and is an integral part of their total management of a pregnant woman.
Venepuncture should only be performed in the following instances by an experienced
practitioner with the relevant training:

Children
Blood gas analysis
NB: Dr Grays site: Emergency bloods, Cross matching and Blood Cultures should be
taken by Medical staff only.
ie: patient is admitted as an emergency and/or in any emergency situation.
Midwives however may perform Venepuncture for routine tests and cross matching.
Failure to Comply with Policy
Failure to comply with Policies and Procedures stated in this document will be investigated
by Line Managers immediately after ensuring:



Patient Safety/Practitioner Actions
Medical Staff Notification
Accident Form Completion
Advising Senior Nurse
Accident/Incident/Near miss must be reported and duly investigated as per Trust
Policy.
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Staff Roles
Venepuncture is a shared responsibility of medical and nursing staff. Individual patients
should be assessed and the most appropriate health care professional perform the
procedure for that patient.
1. Role of the Clinician
Venepuncture is a shared responsibility therefore Clinicians will continue to perform the
procedure in both emergency and elective situations. The Clinician will be available to
support routine/emergency venepuncture where the two attempts are not successful, thus
ensuring the patient has this procedure performed as required with minimal delay or
discomfort.
“Medicines injected by direct venepuncture (not through a cannula) must be administered
by appropriate medical staff” – Code of Practice for the Administration of Intravenous
Medicines and Infusion Fluids in Clinical Areas, Grampian Medicines Committee (2002).
* Midwifery – Ergometrine may be given in an emergency situation by direct venepuncture
2. Role of the Practitioner
If an aspect of practice is beyond your level of competence or outside your area of
registration, you must obtain help and supervision from a competent practitioner until you
and your employer consider that you have acquired the requisite knowledge and skill,
reference; (Code Of Professional Conduct, NMC 2002)
Any expansion of practice to incorporate changing boundaries such as venepuncture is
supported by the above document.
The practitioner must inform the patient what the blood sample is being taken for.
3. Legal issues
Staff are reminded that all practice should be carried out with the Grampian Health
Services Policy and Guidelines. Issues to be explored should include:



Vicarious Liability
Duty of care
Negligence
Accountability
4. Newly Qualified Practitioners
Must attend appropriate training and gain competence as required by the relevant Trust
5. Return to Practice Practitioners
Must attend the appropriate training and can obtain supervised practice, however, cannot,
perform this skill unsupervised until registered with the Nursing and Midwifery Council
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6. Other Clinical Staff
Other clinical staff e.g. (nursing auxiliaries etc), may take on the role of venepuncture at
the discretion of the Ward/Dept manager. The clinical staff member having clearly been
informed of his/her role and responsibilities in relation to this role.
The staff member will also have to attend a recognised course in the given skill to obtain
the appropriate underpinning knowledge and successfully complete supervised practice in
the given skill.
7. Bank Nurses / Agency Nurses
Grampian Health Services’ Bank Nurses may undertake venepuncture by fulfilling the
following criteria:



Attend appropriate training and gain competence as required by the relevant Trust
Must be able to demonstrate maintaining competence in the given skill
Individual claims to competence must be made to individual Ward Managers who will
then liase with the relevant Professional Development/Clinical Training Staff who will
review the evidence presented for this claim
Agency Nurses may perform venepuncture if they have worked regularly in a specific
area. The decision will be made in conjunction with the Individual concerned, the Ward
Manager and the Clinical Nurse Manager.
Individual claims to competency made to the Ward Manager must also be reviewed by the
relevant Professional Development/Clinical Training Staff
In Grampian Primary Care Trust, the Learner demonstrates competency with support
from their Supervisor, using the ‘3C’ Approach. GPCT have a checklist that is used by all
staff undertaking Venepuncture as a new skill, which is based on National Occupational
Standards
Instructional Phase
Gaining consent
During the period of supervised practice when a practitioner is learning to become
competent in the procedure of Venepuncture permission must be gained from the
patient/ parent/guardian.
The following Criteria must be followed:
The selection of the patient involved in the teaching must be an individual who is able
to understand and give consent or that consent can be obtained by the following as
appropriate i.e. a relative, next of kin or by staff when it is justified
GUH/ALL/POL/0007 - Policy and Procedure for Venepuncture by Clinical Staff
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
The “learning” situation must be explained clearly to the patient, i.e. the practitioner is
learning to perform Venepuncture and requires occasions of supervised practice to be
considered competent.

The supervisor’s role and competence must be explained clearly to the patient i.e. the
supervisor is a Senior Practitioner who has successfully gained competence in the
process of Venepuncture and is required to supervise other Nursing staff to achieve
competence.

The patient must then be asked if he/she agrees to the “learner” (qualified practitioner
under instruction) administering the medications.
a) If Yes - The practitioner may proceed with the supervised practice with this patient.
b) If No - The patient’s decision must be respected and the supervisor or Medical staff
will perform Venepuncture.
c) The patient’s decision to participate or not participate must be documented.
d) On each occasion that a practitioner requires to be supervised performing
venepuncture, the patient’s permission must be obtained.
PLEASE NOTE
Whenever a blood sample is required from a patient, consent must be obtained.
Documentation
Practitioners are reminded of their responsibilities in “the activity of making and keeping
records as an essential part of care, and not a distraction from its provision”. (Guidelines
for Records and Record Keeping (NMC 2002 Edition) Paragraph 13 is of specific
relevance in this situation.
For the purposes of practitioners performing venepuncture for cross matching the
Scottish National Blood Transfusion Service - Blood Transfusion Manual (2000) should be
referred to.
Specimen Request Forms
The following must be completed on request forms before venepuncture is performed:

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
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


Patient’s Surname
Patient’s First Name
Sex
Hospital Number or CHI (Community) number
Date of Birth
Ward/Department/Clinic/Hospital
Sender/Clinician if appropriate
Date and Time of Collection
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



Type of Specimen (Venous Blood)
Test(s) Required
Clinical Details
Private Patient if applicable
Specimen Labelling
The following details must be noted on each specimen tube immediately after this sample
has been taken:






Patient’s Full Name/Sex
Date of Birth and Unit Number
Ward / Department / Clinic & Hospital
Date of Collection
Time of Collection
Signature of person taking blood specimen
As per Guidelines for Records and Record Keeping (NMC 2002 Edition), Specimen
labelling should be written clearly and in such a manner that the text cannot be erased e.g.
black ink.
Important: Avoid contaminating specimens / specimen labels, request forms,
tubes and surfaces with blood splashing.
Specimen Bags
Important: Specimen bags not appropriately labelled, bagged or provided with
the appropriately completed matching form will not be dealt with by the
laboratory, causing inconvenience to the patient as well as staff.
Transport of Biohazard “Danger of Infection” Specimens



Preferably double bagged, sealed in both
The sample and request form must be clearly marked with a “Danger of Infection” label
(ensuring request form folded inward not exposing patients details)
The request form and sample must be in separate compartments of a polygrip bag
Labelling for Danger of Infection
Hepatitis B
Hepatitis C
HIV and other Hazard Group 3 Pathogens (details available from Pathology Laboratory)
Disposal of Sharps
All sharps should be placed directly into a sharps box at the point of use i.e.: bedside.
The sharps box must be replaced when ¾ full or after a maximum of 1 month.
Do not overload.
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VENEPUNCTURE
THIS IS A CLEAN PROCEDURE PERFORMED BY CLINICAL STAFF WHO HAVE
RECEIVED THE APPROPRIATE TRAINING
Definition
The planned introduction of a sterile needle into a vein to obtain a blood sample.
Indications
1. For diagnostic purposes
2. To monitor the effectiveness of drug therapy
Requirements
1.
2.
3.
4.
5.
6.
7.
Tourniquet
Disposable gloves – unsterile (latex/vinyl)
Alcohol swab
Vacutainer holder and needle or butterfly
Blood sample tubes - for the appropriate laboratory test(s)
Anaesthetic cream pack (Emla) - for children / adults if required (prescribed)
Request form completed and signed by doctor/ other recognised signatory i.e. Medical
Support / District or Practice Nurse
8. Double pocketed specimen bag(s)
9. Cotton wool
10. Injection tray
11. Small waterproof dressing
12. Polythene bag for waste (orange)
13. Variable height arm rest - if requested
14. Sharps container
15. Hand disinfection solution
Outpatient/patient in the community:
1. Ask patient to identify themselves by stating their name, date of birth and check that
the Information corresponds with the doctor’s form.
2. In children/adults anaesthetic cream is applied to the intended puncture site at least
one hour prior to venepuncture and covered with waterproof dressing.
3. Immediately prior the procedure remove waterproof dressing and remaining cream
from the intended puncture site.
In patient
1. Ask patient to identify themselves by stating their name.
2. Check the patient’s name and unit number on their identity band corresponds with the
doctor’s request form.
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PROCEDURE
1.
2.
3.
4.
5.
RATIONALE
Explain procedure to patient/parent and gain their co- 1.
operation
Wash and dry hands thoroughly
2.
Gather equipment and proceed to patient
Visually inspect both upper limbs
Position tourniquet loosely 5-6cm above site to be
punctured
Wash and dry hands thoroughly
3.
4.
5.
7.
8.
9.
Place disposable gloves on a clean surface
ADULT
Place fingers between skin and tourniquet and
tighten tourniquet
CHILD
Tighten tourniquet or request assistance to apply
pressure to the child’s limb above intended puncture
site
Palpate site and identify vein to be punctured
10.
Open alcohol swab and clean over chosen site
10.
11.
Allow skin to dry passively for a minimum of 30
seconds. DO NOT REPALPATE
Put on disposable gloves
11.
6.
7.
8.
12.
13.
(i)
(ii)
(iii)
6.
9.
12.
(a) Vacutainer
13.
Twist collection needle cover to break seal and screw
the multi-sample (rubber covered) end into the holder
Remove needle cover and hold needle bevel
upwards
With the skin below the puncture site held taut, insert (iii)
the needle at a 15 - 30º angle
Level off needle when puncture of the vein wall is felt
Advance needle one millimetre approximately into
the vein
(vi) Insert collecting tube into holder (see Box A)
(vii) Blood will continue to flow until collecting tube
vacuum is exhausted
(viii) Repeat procedure (vi) for any further samples that
may be required (see Box A)
(ix) Remove last tube
(x)
Release tourniquet (see note)
Informed patient
To minimise risk of
cross-infection
To minimise risk of
cross-infection
Prevent pulling of
patients skin
Ensure correct choice
of vein
Minimise introduction
of micro-organisms
Enhance microbial
destruction
See Trust Glove
Policy & Standard
Infection Control
Precautions
To prevent the vein
rolling and to facilitate
ease of access
(iv)
(v)
(x)
GUH/ALL/POL/0007 - Policy and Procedure for Venepuncture by Clinical Staff
To allow unrestricted
flow of the venous
circulation
11
(xi)
Place cotton wool ball over puncture site and slowly
remove needle – discard directly into sharps
container at bedside
(xii) Apply digital pressure until bleeding has ceased. Do
not request patient to flex arm
(xiii) Cover puncture site with small waterproof dressing
(xiv) Wash and dry hands thoroughly
(xi)
(xii)
To minimise the risk of
blood spillage and
needlestick injury
To prevent bruising
and haematoma
BOX A
Samples should be drawn off as follows:
1. Blood cultures; Anaerobic/Aerobic (if reqd.)
2. Tubes with no Additives
3. Coagulation tubes
4. Other tubes with Additives
* Gently invert each tube as per manufacturer’s instructions after collection
Please note that while using a needle and syringe to take bloods is actively
discouraged, there are still blood samples that require their use e.g. Clozapine
14.
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
15.
16.
(b) Winged Infusion System
13.
Twist collection needle cover to break seal and screw
the multi-sample (rubber covered) end into the holder
Open butterfly packaging, remove luer-lock hub and
the cover of the luer-slip connector and attach to
each other
With the skin below the puncture site held taut hold
(iii)
the wings of the butterfly set between thumb and
index finger ensuring needle bevel is uppermost
To prevent the vein
from rolling and to
facilitate ease of
access
Insert the needle at a 15-30º angle
Level off needle when puncture of the vein wall is felt
Advance needle one millimetre into the vein
Repeat procedure from 12(a)
Disposal of Sharps
All sharps should be disposed of at patient’s bedside
in sharps container. All containers should be
labelled, identified and disposed of when ¾ full
Clinical Waste
All clinical waste should be placed in appropriate bag
(i.e. orange), tagged accordingly, for disposal when
¾ full
Document Procedure in Patient’s Care Plan
NOTE:
The tourniquet may be required to be released at the beginning of sampling because
inaccurate measurement may be caused by haemostasis for example when blood is taken
for blood calcium levels.
GUH/ALL/POL/0007 - Policy and Procedure for Venepuncture by Clinical Staff
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BLOOD CULTURES - VENEPUNCTURE
BLOOD CULTURE
Include the following details on specimen labels (a) Patient’s name
(b) Unit number
(c) Date of Birth
(d) Time, date and location
(e) Source of sample
This is a clean procedure undertaken by a qualified nurse or doctor.
Blood cultures should be labelled EMERGENCY and collected without delay by porter for
delivery direct to the laboratory.
Important: Do not place blood culture bottles in the refrigerator.
DEFINITION
Blood culture samples to be tested by the laboratory by taking the blood from patient
through a venous route.
REQUIREMENTS
1. Tourniquet (of appropriate size eg small, medium or large)
2. Disposable non-sterile gloves (latex/vinyl)
3. Butterfly set and holder
4. Aerobic and anaerobic blood culture bottles
5. Cotton wool balls (non-sterile)
6. Alcohol swabs
7. Spot plaster or alternative if patient is allergic to elastoplast
8. Variable height armrest
PROCEDURE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11
12.
RATIONALE
Ask patient to identify themselves by stating their
name
Check the patient’s name and unit number on
their identity band corresponds with the Doctor’s
request form
Explain procedure to patient and gain cooperation
Wash and dry hands thoroughly
Gather equipment and proceed to patient
Visually inspect both upper limbs
Position tourniquet loosely 5-6cm above site to
be punctured
Wash and dry hands thoroughly
Place gloves on a clean surface
Connect butterfly set to vacutainer holder
Tighten the tourniquet
Palpate site and identify vein to be punctured
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13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Open alcohol swab. Clean over site. Leave to
dry passively for 30 seconds
Put on gloves
Remove flip top from the blood culture bottles and
swab with alcohol swab
Leave to dry passively for 30 seconds
Remove needle cover and hold needle bevel
upward by the wings
Puncture the vein and take the blood samples
using the appropriate blood culture containers - 8
-10mls of blood per bottle (culture bottles must
remain upright)
At the end of procedure, remove blood culture
bottle, loosen tourniquet, remove needle and ask
patient to press on area with cotton wool ball until
blood has clotted
Disposal of Sharps
All sharps should be disposed of at patient’s
bedside in sharps container. All containers
should be labelled, identified and disposed of
when ¾ full
Apply spot plaster or relevant dressing
Identify patient again by asking their:
a) Name
b) Address
c) Date of birth
Label blood cultures
Secure bottles into specimen bags
Ensure blood chits are sent with specimens
marked “Bacteriology” (other name Microbiology)
Wash and dry hands thoroughly
Record procedure in Patient Care Plan
Contact porter to collect specimens directly
References

Nursing and Midwifery Council (2002) Code of Professional Conduct. NMC, London

Nursing and Midwifery Council (2002) Guidelines for records and Record Keeping.
NMC, London

Aberdeen and North East Scotland Regional Transfusion Centre. Department of
Transfusion Medicine. (2002) Blood Transfusion Manual Aberdeen

Grampian University Hospitals Laboratory Medicine Handbook (2002)
GUH/ALL/POL/0007 - Policy and Procedure for Venepuncture by Clinical Staff
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