Clinical: Venepuncture · PDF fileClinical: Venepuncture SOP Document Control Summary ... Physical health Pathway ... clinical investigation has been requested by the Clinician or

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Clinical: Venepuncture SOP

Document Control Summary

Status: New

Version: e.g. v1.0 Date: June 2017

Author/Owner/Title: Di Hughes

Approved by: Policy and Procedures Committee Date: 20 July 2017

Ratified: Policy and Procedures Committee Date: 20 July 2017

Related Trust Strategy and/or Strategic Aims

Physical health Pathway Physical Health CQUIN

Implementation Date: August 2017

Review Date: June 2020

Key Words: Venepuncture, blood taking, blood samples, phlebotomy, bloods

Associated Policy or Standard Operating Procedures

Physical Health

Change Control – Amendment History

Version Dates Amendments

Venepuncture SOP June 2017

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Contents

1. Introduction ..................................................................................................................... 3

2. Purpose ............................................................................................................................ 3

3. Scope ............................................................................................................................... 3

4. Precautions....................................................................................................................... 4

5. Exclusion Criteria………………………………………………………………………………………………………………4

6. Equipment ........................................................................................................................ 5

7. Procedure…………………………………………………………………………………………………………………………6

8. Complications ................................................................................................................. 11

9. Process For Monitoring Compliance And Effectiveness ..................................................... 12

10. References/Bibliography ................................................................................................. 13

Appendix 1. Order of draw for multiple blood samples……………………………………………………………….14

Appendix 2. Veins to consider for venepuncture…………………………………………………………………………15

Appendix 3. Clinical Skills Competency Assessment / Re-assessment for:

Peripheral Venepuncture……………………………………………………………………………………….16


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1. Introduction

Venepuncture is a procedure that involves entering a vein with a needle in order to obtain a

venous blood sample for haematological, biochemical or bacteriological analysis where the

clinical investigation has been requested by the Clinician or it is in the best interest for the

client to receive treatment in line with the service users care plan.

This SOP should be read in conjunction with Infection Control policies/SOPs regarding hand

washing, disposal of sharps, needle stick injuries and universal precautions

2. Purpose

This SOP sets out the training and competency requirements for all staff to undertake

venepuncture.

It also covers the full procedure to be followed, including risks and contraindications.

It does not cover interpretation of blood results.

3. Scope

This SOP applies to any member of staff who wishes to undertake venepuncture. All staff

grades are eligible to undertake training to enable them to practice venepuncture, at the

discretion of their manager, dependant on the needs of the service where that staff member

works.

Staff undertaking venepuncture will be equipped with the knowledge and skills required to

undertake this procedure safely and appropriately, through attending relevant, approved,

theoretical and practical training.

Managers must ensure that members of staff intending to perform venepuncture have

completed such training and attained the requisite current competences before undertaking

such duties.

Any non-medical staff required to obtain samples in this way will require documented

supervised practice following training. If a new member of staff has practiced venepuncture

in a previous role and has documented evidence of formal training received, they may

practice venepuncture within this trust following supervised practice and being signed off as

competent.

All staff undertaking venepuncture will be responsible for:

ensuring that their practice will promote and protect the interests and dignity of

patients, irrespective of gender, age, race, sexuality, ability, economic status, culture

and religious or political beliefs

maintain competency and confidence

a contemporaneous knowledge and understanding of their legal, ethical and

organisational responsibilities in relation to venepuncture

where there has been a significant break in the individuals practice then documented

supervised practice and competency update should be completed

obtaining informed consent

being able to provide research based explanations for their practice


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recognising and acting on their personal limitations

seek appropriate assistance if they make two consecutive unsuccessful attempts

desist, report and record if at any time there is risk of harm or injury

Approved training minimum standards

Formal training session

Completion of a minimum of two successful supervised practices

Competence signed off by a competent practitioner who is able to assess

competence. This assessor must be competent in venepuncture themselves, but

does not necessarily need to be a doctor or a qualified nurse.

A copy of this signed competency document must be given to the line manager to be

held on the individual’s personal file

No update of theoretical training required, but competency must be reassessed

annually, or following any extended period of non-practice

4. Precautions Standard precautions must be observed at all times, including hand washing and

decontamination

All items used must be sterile single use

All sharps used must be safety devices

A closed vaccumised blood collection system must be used, e.g. Vacutainer

It is not acceptable to use a needle and syringe for obtaining blood samples, as this

not only increases the risk of needle stick injuries, but it also compromises the

integrity of the blood sample by increased risk of contamination and increased risk of

damage to blood cells, leading to a haemolysed sample, which cannot be used

Aseptic non-touch technique (ANTT) should be used

Personal protective equipment must be used, including non-sterile latex-free gloves

and aprons. Safety goggles or a face shield should be considered if the patient is

known to have a blood borne virus and/or is likely to do anything that may increase

risk of blood splatter

Skin must be cleansed using the recommended swab (Chloraprep®) and allowed to

air dry

5. Exclusion Criteria

Do not take blood from:

Limbs with arterial-venous fistula

Contraindicated limbs, e.g. post mastectomy surgery or affected by a stroke

Limbs affected by severe disabling conditions such as rheumatoid arthritis

Veins that are damaged or traumatised, bruised, inflamed, fibrosed or fragile

Veins that are adjacent to infection or phlebitis

Veins close to, or that have, existing or recent intravenous or subcutaneous

cannulation

Anyone on whom you have failed to obtain a sample on two consecutive attempts –

in this case you should refer to another practitioner


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Intravenous infusions:

Wherever possible, blood should not be taken from the same limb where an intravenous

infusion is running. Where this is absolutely necessary, an appropriate clinician must be

informed and infusion stopped by them at least 30 minutes prior to blood sampling, and

restarted immediately after

6. Equipment Ensure all equipment is available before commencing procedure. If possible, position sharps

container and blood collection system nearest to your dominant hand, and position all

necessary blood bottles and swabs nearest to your non-dominant hand. This will help

procedure to be carried out more smoothly and efficiently.

Equipment required:

Plastic apron

Non-sterile latex-free gloves of an appropriate size (well-fitting gloves will make

palpating the vein much easier)

Sharps container

Single use disposable tourniquet

Chloraprep® skin preparation

Appropriate safety device needle or butterfly with vacutainer blood collection system

attached

All required blood bottles (please see Appendix 1 “order of draw”)

Lint-free swabs

Plaster and/or surgical tape


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7. Procedure

Action Rationale 1 Approach the patient in a confident manner

and explain and discuss the procedure with

them

To ensure that the patient understands the

procedure and gives their valid consent

(NMC 2015)

2 Allow patient to ask questions and discuss

any concerns they may have.

Check previous history to identify any history

of stroke or mastectomy or any previous

difficulties with venous access

Anxiety results in vasoconstriction, therefore

a patient who is relaxed will have more

dilated veins and access will be easier.

Previous history may influence limb or vein

selection

3 Check that the request form is correct, fully

completed and signed

Blood samples must not be taken unless the

responsible clinician has correctly completed

a request form for the appropriate lab, clearly

identifying full patient details and all tests

required

4 Check the identity of the patient matches

the details on the request form by asking for

their full name and date of birth

To ensure that a) the request form has been

completed correctly and b) that the sample is

taken from the correct patient

5 Checks hands for any visibly broken skin,

cover with waterproof dressing

To minimise the risk of contamination to the

practitioner

6 Assemble equipment required for the

procedure (see list above)

To ensure that the procedure goes as

smoothly as possible without interruption

7 Carefully wash hands using trust approved

hand washing procedure and dry thoroughly

To minimise the risk of infection (DoH 2010)

8 Check all packaging for any damage and

expiry dates before opening and preparing

equipment on chosen clean surface

To maintain asepsis throughout and ensure

no faulty equipment used

9 Take all equipment to the patient,

exhibiting a relaxed and confident manner

To help the patient feel at ease

10 Support the chosen limb in a comfortable

and extended position

To ensure patient comfort and facilitate

venous access


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11 If possible, palpate and choose the vein

without the use of a tourniquet, if not then

apply single use tourniquet to selected limb,

approx. 4 fingers above target area. It should

be tight enough to make inserting 2 fingers

under it difficult, but not tight enough to

occlude the pulse. If palpation of the vein is

difficult try

a) Allowing patient to warm up if cold

b) Ask patient to make a fist – but not to

clench and unclench, as this

adversely affects the blood results

c) Gently stroke veins in a downward

motion – DO NOT TAP

d) Allow limb to hang down

Reusable tourniquets not to be used under

any circumstance, due to infection control.

To increase prominence of the vein without

disrupting circulation

To promote blood flow and therefore distend

the veins

Allowing gravity to assist distention of the

veins

12 Select the vein by observation and careful

palpation to determine size, depth and

condition. Whilst the antecubital fossa is the

most common site, it is also acceptable to

use forearm, hand or foot if preferable or

necessary

To prevent inadvertent insertion of needle

into other anatomical structure (e.g. artery)


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13 Release the tourniquet until ready to

actually enter the vein

To ensure the maximum time for tourniquet

application, one minute, is not exceeded

14 Select device to be used, based on vein

size, site and volume of blood to be taken

Standard vacutainer needle is usually first

choice if using antecubital fossa, but if using

any other site, e.g. lower arm, hand or foot, a

23 gauge winged infusion device (blue

butterfly) should be utilised

To reduce risk of damage/trauma to the vein

and therefore prevent haemolysis

15 Decontaminate hands using alcohol foam To maintain asepsis and minimize the risk of

infection/cross-infection

16 Clean patients skin around selected site

using the chloraprep® swab. Squeeze

between finger and thumb to break internal

seal, press against patients skin a couple of

times to release liquid flow, rub over selected

area for approximately 30 seconds

Allow to dry for at least 30 seconds.

Do not re-palpate vein or touch the skin

To maintain asepsis and minimize the risk of

infection

To prevent pain on insertion and reduce risk

of contamination of blood sample

To maintain asepsis

17 Put on well-fitting non-sterile gloves To prevent cross-infection

18 Reapply tourniquet as before, ensure time

is noted to monitor length of time tourniquet

is used

To dilate veins by obstructing the venous

return

19 Remove cover from needle and inspect

carefully

To detect faulty equipment, e.g. bent or

barbed needle


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20 Anchor the vein by applying slight manual

traction on the skin a couple of centimetres

below the proposed insertion site

Immobilises the vein by providing counter

tension. This will facilitate smoother needle

entry

21 Holding needle with bevel uppermost,

insert needle smoothly in one fluid

movement, at an angle of approx. 15-30º,

dependant on depth and size of vein

To facilitate a successful, pain-free

venepuncture

22 If you have missed the vein, do not sweep

the needle around in search of the vein,

gently withdraw until the tip is just below the

skin, adjust angle and try again

To prevent causing unnecessary pain and

damage

23 Hold the needle still and support with

fingers/thumb and do not exert any pressure

on the needle

To avoid puncturing through the back of the

vein wall

24 Following the correct “Order of Draw”

(Appendix 1), insert first blood bottle into

vacutainer holder, being sure to support the

holder to prevent applying pressure to the

needle

To Minimize the risk of transference of

additives from one bottle to another,

therefore potentially contaminating the

sample

25 Release tourniquet To decrease the pressure in the vein and

decrease risk of haemolysis and ensure the

maximum one minute is not exceeded


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26 Disconnect bottle from holder and insert

next one required. Remember to invert each

bottle several times – DO NOT shake

To complete requested tests

To ensure even distribution of additives

whilst preventing haemolysis

27 Select a cotton wool ball or swab and

position above needle entry point without

touching

DO NOT apply pressure until needle is totally

out

Be ready to apply pressure once needle

removed

To prevent unnecessary pain and potential

damage to the intima of the vein

28 Remove the needle in a single smooth

movement, activate safety device and

dispose in sharps container

Reduces pain to patient and risk of sharps

injury to practitioner

29 Immediately needle is out of skin, apply

digital pressure for at least one minute, or

until bleeding has stopped (whichever is

longer). You may ask the patient to apply

pressure themselves, whilst you deal with

the samples, but discourage them from

bending the elbow, as this causes bruising

If haematoma noted, apply firm pressure for

at least 5 minutes

To prevent leakage and haematoma

formation, thereby preserving integrity of

vein for possible future use

To reduce bleeding and bruising

30 Fully label bottles before leaving the

patient’s side

To ensure no mistakes are made with mixing

up samples from different patients

31 Inspect puncture site and if happy, apply

either a plaster, or a clean swab and surgical

tape if patient is sensitive to plasters. Ideally,

this should stay in place for 1-2 hours, but

may be removed after 15 minutes

To ensure that the puncture site has sealed

and to cover to prevent possible leakage or

contamination

32 Ensure patient is comfortable and not

feeling faint or unwell in any way

To ascertain if it is safe for patient to leave

the treatment room, or whether further

measures need to be taken

33 Remove protective equipment and

dispose of all waste according to trust policy

To ensure safe disposal of sharps and other

equipment

34 Ensure samples are correctly stored with

the appropriate form and follow local

procedure for collection/transportation of

specimens

To ensure all samples reach their intended

destination safely

35 Document procedure in patient notes,

according to local procedures

To ensure and maintain timely and accurate

record keeping


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8. Complications There are a number of possible problems associated with practice of venepuncture. The

prevention and treatment of potential complications are outlined in more detail in The Manual

of Clinical Nursing Procedures (2015).

Some main complications are detailed below:

Problem Possible Cause Action

Pain Touched a nerve Punctured an artery Anxiety Use of vein in sensitive area, e.g. wrist/back of hand

Remove needle Remove needle/apply pressure Reassure and calm patient Try alternative site if possible

Anxiety Fear of needles Previous bad experience General state of mind

Give patient time to ask questions and feel comfortable Offer continuous reassurance

Limited venous access Repeated use of same veins Previous poor technique, choice of vein or device Peripheral shutdown Dehydration

Look at alternative sites Consider use of smaller butterfly device Consider trying to warm skin Making patient drink will not make this better Consider referring to someone with more experience

Bruising and/or

haematoma

Needle punctured posterior wall of the vein Inadequate pressure on removal of needle Failure to remove tourniquet before removing needle Poor technique/bad choice of vein or device

Ensure correct technique and choice of vein and device used at all times If bleeding or haematoma occurs, apply pressure for at least 5 minutes and keep patient still and calm

Infection at venepuncture

site

Poor aseptic technique Refer for medical treatment – ensure good asepsis maintained in future

Vasovagal syncope (faint) Fear of needles Sight of blood Pain Extremely hot environment Extreme emotional distress

Occurs when body overreacts to certain triggers, it causes heart rate and blood pressure to drop suddenly, causing reduced blood flow to brain, producing the faint Usually does not require treatment other than keep patient lying down until they feel better, release tight clothing and cool the environment if possible


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Needle stick injury to

practitioner

Unsafe practice Incorrect disposal of sharps

Follow trust policy regarding needle stick injury

Accidental blood spillage Poor technique Faulty equipment

Follow trust policy for clearing up blood spills Complete incident form and report faulty device

Missed vein Poor vein selection Inadequate anchoring of vein Wrong positioning Lack of light Poor concentration Difficult access

Correct issues that can be corrected regarding light, technique, concentration etc. Try one more time, if still unable to get access then refer to another practitioner

Spurt of blood on entry Bevel tip of needle enters vein before entire bevel is under the skin Tourniquet is far too tight

Angle of entry is too steep, adjust angle of entry to between 15 and 30º Check and adjust tourniquet, you should still be able to palpate the pulse

Blood stops flowing Needle has been advanced through the back of the vein Bevel may be lying against vein wall or valve The vein has collapsed due to device being too big for vein or vein was too tiny

Gently withdraw about 1mm, if flow does not return then remove needle and apply pressure Remove needle, apply pressure, consider choosing a larger vein and/or smaller device before attempting again

9. Process For Monitoring Compliance And Effectiveness

Patient feedback and incident reports will be monitored and reviewed

Training and competence will be recorded on ESR and in staff members’ personal files


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10. References/Bibliography

Campbell, H., Carrington, M. and Limber, C. (1999) A Practice Guide to Venepuncture and

Management of Complications. British Journal of Nursing, 8(7), 426-431

Dougherty, L. and Lamb, J. (Eds) (2008) Intravenous Therapy in Nursing practice, 2nd ed.

Oxford: Blackwell

Hoke, R.F. (2015) Phlebotomy. London: National Association of Phlebotomists

Mallet, J. and Dougherty, L. (Eds) (2015) The Royal Marsden Manual of Clinical Nursing

Procedures 9th ed. London: Blackwell Scientific Publications

NMC (2015) The Code: Standard of Conduct, Performance and Ethics for Nurses and

Midwives. London: Nursing and Midwifery Council

McCall, R.E. and Tankersley, C.M. (2012) Phlebotomy Essentials 5th ed. Philadelphia:

Lippincote Williams and Wilkins

RCN (2010) Standards for Infusion Therapy 3rd ed. London: Royal College of Nursing

WHO (2010) WHO Guidelines on Drawing Blood: best practices in phlebotomy.

Geneva: World Health Organization Press


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Appendix One

ORDER OF DRAW FOR MULTIPLE BLOOD SAMPLES


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Appendix Two

VEINS TO CONSIDER FOR VENEPUNCTURE

ARM

HAND

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Appendix Three

Clinical Skills Competency Assessment/Re-Assessment for: Peripheral Venepuncture Candidates must be assessed a minimum of twice before completion of the final declaration on the last page

Correctly demonstrate the following: Date Date Date Date

Assessors Name and Initials




Preparation of equipment for venepuncture. Assembles appropriate equipment on a clean tray. Needles (must be safety devices), sharps bin, disposable tourniquet, gloves, apron, skin disinfectant. Prepares tray and equipment using ANTT. Collects appropriate blood bottles. Ensures all equipment in date and sterile. Has correct blood forms for patient

Prepares patient for Venepuncture. Correctly identifies patient. Appropriate consent obtained. Explanation of procedure given.

Prepares self for procedure. Hand washing performed as trust policy and alcohol hand rub applied. Non sterile gloves and apron worn. Ensures appropriate environment. Well lit, ventilated, flooring is as clinical area.

Selects appropriate site for venepuncture. Identifies most suitable vein for sampling. Applies tourniquet 5-10cms from the intended puncture site applying enough pressure to obstruct venous but not arterial flow. Ensures site for sampling is warm and well perfused. Cleanses skin according to SOP

Demonstrates needle insertion Immobilises limb and applies traction to skin in order to anchor the vein maintaining asepsis. With bevel uppermost inserts needle at an angle of about 30 degrees depending on depth of vein. Successfully obtains blood sample / acts appropriately in the event of non-success

Demonstrates safe removal of needle. Releases tourniquet, occludes the vein and removes needle, applying direct pressure for approximately 1 minute Disposes of needle and syringe in appropriate sharps bin. Applies appropriate dressing

Demonstrates appropriate documentation

Puts blood in correct specimen bottles in correct order to prevent contamination. Labels blood bottles correctly and sends to lab safely. Documents procedure on Clinical system (e.g. RiO/Lily )

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Declaration of Competence to Practice Venepuncture Independently

Practitioners name:……………………………………………………

Once both assessor and practitioner are satisfied that competence has been achieved, both must

sign below and a copy given to the individual’s manager for insertion in the personal file.

Assessor’s Declaration

I confirm that I have completed a clinical workplace assessment and can confirm that the above

named practitioner is competent at carrying out the venepuncture procedure

Name:……………………………………………….. Job Title:……..………………………………...

Signature:……………………………………………Date:…………………………………………….

Practitioner’s Self Declaration

I confirm that I am competent to practice venepuncture and understand that I am

responsible and accountable for my professional practice.

I have completed the theoretical venepuncture training and have undertaken

supervised practice for venepuncture in the clinical setting

I understand that this is an invasive procedure that requires frequent practice and that I must have

my competence re-assessed every year.

I am responsible and accountable for keeping my practice up-to date and in line with Trust and

national polices.

Name:……………………………………………….. Job Title:……..………………………………...

Signature:……………………………………………Date:…………………………………………….