Phlebotomy SOP - srft.nhs.uk

Phlebotomy SOP

Reference Number TWCG02(21) Version 1 Issue Date: 25/02/2021 Page 1 of 18

It is your responsibility to check on the intranet that this printed copy is the latest version

Phlebotomy SOP

Lead Author: Hilary Richardson Phlebotomy Clinical Manager

Additional author(s) James Barham CUR project nurse

Division/ Department:: Integrated Care Division

Applies to: Salford Royal Care Organisation

Approving Committee ICD Governance board

Date approved: 11/09/2020

Expiry date: September 2025

Contents

Contents

Section Page

Document summary sheet

1 Overview 2

2 Scope & Associated Documents 2

3 Background 2

4 What is new in this version? 3

5 Guideline 4

5.1 PREPARATION OF SELF, FACILITIES AND EQUIPMENT 4

5.2 PREPARATION OF PATIENT 7

5.3 COLLECTION OF SPECIMEN 7

5.4 COMPLICATIONS 10

6 Roles and responsibilities 11

7 Monitoring document effectiveness 13

8 Abbreviations and definitions 13

9 References 14

10 Appendices 14

11 Document Control Information 15

12 Equality Impact Assessment (EqIA) screening tool 17

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)

Phlebotomy SOP



1. Overview (What is this guideline about?)

This guideline is for the safe practice of phlebotomists in SRFT to ensure that interactions with patients reduce the risk of harm. The guideline lays out the correct procedures relating to venepuncture as delineated by SRFT and the safe management of blood products.

If you have any concerns about the content of this document please contact the author or advise the Document Control Administrator.

2. Scope (Where will this document be used?)

This document applies to phlebotomists only. This document applies only to the care of adults. This is relevant only to hospital services. Phlebotomists need to have a good working knowledge of this guideline Associated Documents

Aseptic Non-Touch Technique Policy Issue 3.5

NCA Venepuncture in Adults Issue: 1.1

Needlestick injury, Occupational Exposure To Blood Borne Viruses, HIV, PEP Issue: 6

Working Safely During Covid 19

3. Background (Why is this document important?)

Venepuncture can be defined as ‘The insertion of a needle into a vein, usually to obtain a blood specimen’ (Dougherty and Lamb 2008)

Phlebotomy may be described as the collection of blood from the vein of a patient without harm to the patient, self or specimen followed by the prompt delivery of the correctly labelled specimen to the laboratory.

Phlebotomists are specialised clinical support workers/assistant healthcare scientists who collect blood from patients for examination in laboratories, the results of which provide valuable information to diagnosing and treat illness.

HEALTH & SAFETY When obtaining any blood sample, the Trust Procedure for Venepuncture and Control Of Substances Hazardous to Health (COSHH) regulations must be adhered to at all times. Blood collection tubes should be checked for expiry date.

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)

Phlebotomy SOP



A single person use tourniquet should be used to support prevention of contamination between patients.

The tourniquet should be applied so as to promote venous dissention and to impede venous but not arterial flow.

Rubber gloves MUST NOT be used as a tourniquet.

Needlestick Injuries

Please read the current version of ‘Prevention & Management of exposure to Blood Borne Viruses’ which can be found on the Trust Intranet. In summary the following action must be taken:

o Occupational exposure to blood borne viruses is unnecessarily common and can

ultimately result in a serious illness or death. In order to prevent such occurrences it is essential that all staff pay careful attention to the appropriate policy, procedure or protocol when handling sharp instruments, syringes, blood and other body fluids. Any significant exposure to blood and some other body fluids or tissue has the potential to transmit blood borne viruses such as Hepatitis B (HBV), Hepatitis C (HCV) and HIV.

o First aid should be carried out immediately following any exposure to blood or a body

fluid. Wash the area liberally with soap and water but without scrubbing. Antiseptics and skin washes should not be used. In the case of a puncture wound or needlestick injury, encourage the wound to bleed freely but do not suck the wound. Dry the area and cover any percutaneous injury with a waterproof dressing. Exposed mucous membranes, including conjunctivae, should be irrigated copiously with water, before and after removing any contact lenses.

o If percutaneous or mucocutaneous exposure to blood or a body fluid occurs you

should attend the Occupational Health department (8am-4pm Monday-Friday) or the Emergency Department (out of hours) immediately.

Spillage procedure

o All spillages of blood must be cleaned up immediately.

o Ensure that all appropriate protective clothing is worn during procedure and is disposed of correctly after use.

o Blood spillages that occur on the wards must be dealt with according to the policies of

each ward. Small spillages may be cleaned up using 3 in1 Disinfectant Wipes held on each Phlebotomy trolley. If a gross spillage occurs the Ward Sister must be informed and ward protocols followed.

o Small blood spillages that occur in the Phlebotomy Clinic can be cleaned up with 3

in1 Disinfectant Wipes o Gross blood spillages must be dealt with using the ‘Blood Spillage Kit’ kept in the

locked COSHH situated in the Phlebotomy Clinic Room. Seek advice/help/ assistance (if needed) from Head Phlebotomist, Central Reception Manager or Phlebotomy Line Manager.

Phlebotomy SOP



o Disposal of Blood Spillage Kit to be facilitated in the Pathology Department sluice (Door 2-195) Next to microbiology laboratory.

4. What is new in this version?

This guideline highlights changes to consumables used in venepuncture by the phlebotomy department. The policies and procedures quoted are the latest NCA or SRFT versions. This guideline contains reference to the NCA guidelines for working during the Covid 19 pandemic.

5. Guideline

5.1 PREPARATION OF SELF, FACILITIES AND EQUIPMENT

Self In line with NCA working with Covid 19 guidelines Coming to Work: Please do not travel to or from work in uniform • If using public transport please use the fabric face coverings provided • Please familiarise yourself with and use the dedicated entrances and exits for staff on all sites. • Security checks will be in force at all entry points. • Please clean your hands upon entering the buildings and provide a valid ID for checking • Staff will be asked some screening questions such as: If they have had a temperature over 37.8 or felt very hot or shivery cold in the last 48 hours o If they have developed a new, dry, persistent cough in the last 48 hours o If they have developed a change or loss of taste or smell in the last 48 hours o If they share a household with or have associated closely with anyone who has had the above symptoms or confirmed positive for Covid-19 within the last 14 days Staff members may also have their temperature checked using the infrared thermometer If they answer yes to any of the above questions and/or have a temperature 37.8°C, the member of staff will be asked to wear a face mask and to leave the hospital. Their details will be documented (name and place of work). They will be informed that they need to notify their manager to activate the HR process for staff testing. They will be advised that they should seek medical advice if unwell. • After cleaning your hands please put on a face mask (not a fluid repellent surgical mask). Face masks used in public areas are different to clinical masks and will be a different colour (white) • Infection Prevention and Control (IPC) Safety Officers will be available to give advice should you need it Please observe social distancing (keep 2m apart from others) if you have to queue at any of our staff entrance points

Phlebotomy SOP



COVID Conduct in Public Areas Public areas are defined as any non-clinical areas either on the hospital sites/community buildings and include corridors, public staircases, on-site shopping/restaurant facilities/gardens/grounds etc. • All members of staff should wear their public area face mask at all times in public areas when inside buildings, apart from when they move into a clinical area where they will need to change to a medical mask • It is not necessary to wear public area face masks outside, however social distancing must be maintained • Public area face masks should be worn even when social distancing (keeping 2m apart) is in place • Public area face masks can be removed whilst the member of staff is outside but should be replaced on re-entry to buildings (see below for more advice on facial coverings) • Staff should practice strict social distancing, keeping 2m apart at all times, whether inside buildings or in the communal grounds (see below for advice on how to socially distance). • Staff are asked to follow directional signage where applicable • Staff are asked not to congregate in groups • Staff are asked not to overcrowd lifts and to consider taking the stairs if possible • Staff are asked to provide a sensible and sensitive challenge to other staff members not adhering to bio-security measures including social distancing • Fluid repellent surgical masks should not be worn in public areas and staff should not wear any additional PPE in public areas (unless transferring a patient). • IPC safety officers will be available to support and advise

The appropriate clean uniform must be worn at all times and a high standard of general appearance maintained. The uniform must be changed immediately if it becomes soiled or contaminated whilst on duty, otherwise the uniform should be changed on a daily basis. Protective clothing including disposable gloves and disposable aprons MUST be worn when taking blood from all patients. In line with current working COVID 19 policy: Entering a General Ward/Clinical Environment/Clinic • Remove non clinical face mask, fold inwards on itself and place inside pocket/bag. • Perform check point hand hygiene • Put on fluid resistant surgical face mask (FRSM) • Risk assess for eye protection (dependent on task) • Enter the clinical area • Follow directional signage where applicable Moving within 2m of a patient (general ward/clinical environment/clinic): • Add in the additional necessary PPE - apron, gloves, eye protection • Change apron and gloves between every patient and perform hand hygiene • Use FRSM and eye protection for sessional use unless becomes soiled/damaged Leaving the Patient Area (general ward/clinical environment • Remove apron, gloves within patient care area (unless transporting clinical waste – in which case remove apron and gloves, clean hands and replace with fresh apron and gloves) • Perform check point hand hygiene • Keep FRSM and eye protection on

Phlebotomy SOP



When moving into communal ward spaces (corridors/utility rooms etc) or leaving Ward/Clinical Environment • Remove FRSM • Perform check point hand hygiene • Put on public facing mask All protective clothing must be changed between each patient and before leaving the patient or clinic area. Protective clothing must NOT be worn in dining rooms, staff rooms, corridors or other clean areas. All skin lesions must be covered. Any rashes or lesions of the skin must be reported to the Head Phlebotomist for a decision to be made regarding any necessary action. Hands MUST be washed BEFORE each patient. Hand washing or alcohol gel may be used after each patient and when entering and leaving a bay, ward, department or clinic. Do not use alcohol gel on more than 3 occasions as effectiveness is reduced i.e. every 4th occasion use soap & water. Please note that alcohol gel has no effect against Norovirus. In line with the COVID 19 policy: Leaving Work • Please do not travel to or from work in uniform (excludes community staff) • Staff should remove their uniform and either place securely in a bag to take home for washing, or leave at work for laundering. Staff laundering their own uniforms should wash at the hottest possible wash allowed for the garment. • Remove your face mask. Your face mask is disposable and should be disposed of at the end of each shift. • Please clean your hands upon exiting the buildings • Please wear your fabric face covering when travelling on public transport. • Your fabric face covering can be laundered with other household laundry.

Facilities and Equipment

Each Phlebotomy trolley must be kept clean and tidy. The trolley must be cleaned with 3in1 Disinfectant Wipes The trolley must be adequately stocked with tubes, safety needles, non-sterile gauze, alcohol pre pad, adhesive/hypo-allergenic tape,, disposable gloves, sharps bin, alcohol gel 3in1 Disinfectant Wipes and clear plastic bags. There MUST be a sharps bin with each Phlebotomy trolley. The sharps bin must NOT be filled over the black line indicated on the side of the sharps bin. All sharps bins MUST be signed when assembled and signed off when ready for disposal. The sharps bin must be taken to a Clinical Waste Room for disposal.

A tub of 3 in 1 Disinfectant Wipes must be stored on the trolley and must be used for cleaning small spillages of blood. In line with the COVId 19 policy:

Phlebotomy SOP



Where movement between areas is considered essential staff must practice stringent IPC measures and try to adhere to the following: Green Areas: When working in a Green Area of the hospital, staff may move around other Green and Public areas, following the advice above in relation to conduct within public areas. Yellow and Blue Areas: Staff should remain within Yellow and Blue areas for the duration of their shift where possible.

5.2 PREPARATION OF PATIENT

Approach the patient in a manner that will ensure their co-operation, particularly nervous patients and elderly patients.

Explain what you are going to do and request verbal permission to proceed.

If the patient is confused, violent or resists blood collection, seek help from the nursing or medical staff. Try to calm the patient and reassure them. DO NOT go ahead with blood collection if the patient is adamant that they do not want the procedure to go ahead. Inform the medical staff requesting the blood specimen that you have been unable to collect the specimen giving the reason for non-collection of sample.

Check the request form for ambiguities or errors. Any errors must be followed up with nursing, medical staff before blood can be taken from the patient.

Personnel authorised to request blood samples must be authorised & trained practitioners; this includes Trust medical staff, GPs and some registered nursing staff. If you have any doubts do not proceed and check that the person requesting the test has authority to do so.

Check that the patient has received and followed any special instructions e.g.: fasting for a specified period.

Make a positive identification of the patient

The patient must be identified before obtaining a blood sample using their ID band and/or confirming personal details with the patient. Inpatients: The name, hospital number and date of birth should be checked on the wristband against the request form for ambiguities. Outpatients: The patient must be asked his/her name, date of birth and address which is checked against the request form for ambiguities.

If there are any discrepancies blood collection MUST NOT go ahead and the phlebotomist must seek clarification from medical or nursing staff caring for the patient. Details must be corrected before venepuncture takes place.

Phlebotomy SOP



5.3 COLLECTION OF SPECIMEN

Please remember that consent must be obtained before proceeding.

Selection of tube

Select the appropriate tube and size of safety needle for test requested. Check all packaging before opening in order to ensure that the equipment is sterile, if applicable.

Volume ml Type Colour

7.5 Clotted Gel S Brown Top

9 Heparin Orange Top

2.7 Glucose Yellow Top

4.3 Coagulation/Citrate Green Top

4.5 Blood Transfusion EDTA

Blue Top

3.4 Red EDTA Red Top

Selection of vein

Assess the patient for tight clothing and ask the patient which arm they would prefer to have the blood collected from, usually non-dominant side. Ensure that the patient is sitting comfortably in the correct posture for specimen collection. The elbow should be in a fully extended position if possible, in order to prevent constriction of the superficial veins. If the patient is recumbent, extension is obtained by holding the arm over the edge of the bed. If in a chair then with a pillow behind the elbow, if needed. Distend the veins by applying a disposable tourniquet to the upper arm just above the elbow. Success in venepuncture depends on being able to dilate the vein. Always allow adequate time for inspection and palpation of the patient’s forearm and dorsum of hand to select a site. The veins most frequently used are the median basilic and the median cephalic veins in the ante-cubical fossa. Veins on the dorsum of the hand may be used if the ante-cubital fossa is difficult to identify. However, it should be noted that these thin walled, easily moveable superficial veins are often more difficult to puncture than the larger, less mobile but palpable deeper veins around the ante-cubital fossa. Please note that veins on any other part of the body i.e.: feet, are NOT used by Phlebotomists.

A suitably distended vein should be chosen. This should be palpated to assess the degree of distension and mobility. Distal veins should be used first with subsequent venepuncture proximal to previous sites. Veins in the medial side of the elbow should be used with care because of the presence of the Brachial Artery, which can be noted by the pulsation of the vein. It is always preferable to avoid this sight if possible. If the median basilic vein must be used, great care must be taken to avoid pushing the safety needle through the vein with the risk of entering the artery. If the patient has known restricted venous access, seek advice from the medical staff. In the case of a patient with fistula for dialysis this arm must not be used for venepuncture.

Phlebotomy SOP



Collection of blood Refer to current Trust Policy ‘Venepuncture in adults’ which can be found on the Intranet

Please remember that hands MUST be washed BEFORE each patient. Hand washing or alcohol gel may be used after each patient and when entering and leaving a bay, ward, department or clinic. Do not use alcohol gel on more than 3 occasions as effectiveness is reduced i.e. every 4th occasion use soap & water Please note that alcohol gel has no effect against Norovirus. Check wristband with request form. Read request form to familiarise yourself with blood test(s), tubes and laboratory departments. Prepare receiver dish with equipment required for patient’s blood test. Put on disposable apron and gloves. Take receiver dish and sharps bin to the patient area. Assess patient for tight clothing, comfort etc. Apply disposable tourniquet. Palpate ante-cubital fossa area to distend vein. Clean the puncture site with an alcohol pre pad and allow to dry. Inspect equipment carefully and attach safety needle to tube with bevel of safety needle facing upwards. Anchor the vein by applying manual traction a few centimetres below and/or above proposed insertion site. Insert the safety needle smoothly at an approximate angle keeping the needle slightly lateral to the vein. Advance the safety needle approximately 1 to 2 mm into the vein. Observe for flashback in the hub of the safety needle, as this indicates successful entry into the vein. DO NOT exert pressure on safety needle and ensure the tube and safety needle are stabilised. This will prevent through puncture occurring. Pull back plunger gently withdrawing required amount of blood. If more than one blood sample is required, detach tube from safety needle and replace with appropriate primed blood sampling tube. Release disposable tourniquet, to decrease pressure within vein. Remove the final blood filled tube from the safety needle.

Phlebotomy SOP



Remove safety needle from patient’s arm then apply immediate pressure with non-sterile gauze. The patient may be able to hold non-sterile gauze themselves. Thus preventing leakage of blood that may cause a haematoma. THE ARM SHOULD NOT BE BENT. Dispose of safety needle in yellow sharps bin IMMEDIATELY after removal from patients arm. Break off plunger from filled tubes and rotate tubes NB: DO NOT SHAKE. Inspect puncture site to achieve haemostasis. Check with patient for plaster/tape allergies. Tape non-sterile gauze/apply plaster to puncture site, if appropriate. Ensure that the patient is comfortable. Labelling of samples

IT IS AT THIS STAGE THAT ERRORS CAN OCCUR. All tubes must be labelled immediately after the blood has been taken and before bleeding any other patient so that a mix up of tubes does not occur. The patient’s identity should be confirmed as described in section 7.7. Labelling should include the patients’ name, hospital number, date of birth, ward / department/GP, date. If applying electronically printed labels, check label against request form before applying to tube(s). If sample is for blood bank, tube(s) MUST be hand-written and initialled by the Phlebotomist. The date/time of collection must be entered onto the request form and the Phlebotomist must then initial the front of each request form. If electronic request forms are used, the date/time will be automatically logged when the blood test is electronically ‘collected’ on ‘Sunrise’ The specimen must be placed in a specimen bag and sealed. The request form is then placed in the pocket at the front of the specimen bag. Ward blood samples are sent to the laboratory using the POD system if installed on the ward, or if not available placed in the specimen collection boxes situated on each ward for the Messengers Service to collect and transport to the laboratory. Specimens taken in the Phlebotomy Clinic Room are taken directly to Pathology Central Reception. Haematology FBC samples are labelled and sent by the POD system (or taken by hand) straight to the Haematology Laboratory.

5.4 COMPLICATIONS

When blood cannot be obtained

o This may be due to the inexperience on the part of the Phlebotomist. The choice of veins is important and even though the vein chosen may not be visible, a deeper vein which may be felt to be distended is always better than a smaller easily visible but mobile superficial vein.

o The patient may have been previously subjected to venepuncture or cannulation and the veins may be thrombosed.

o The patient may be shocked, cold or dehydrated, the peripheral veins will be constricted and venepuncture may technically be extremely difficult.

Phlebotomy SOP



o If venepuncture is unsuccessful at the first attempt, the patients other arm may be used. If this in turn fails ask for advice from the Head Phlebotomist when in the Clinic or medical staff when on the ward.

o Only two (2) failed attempts should be made per patient. o Blood should NOT be taken from patients who have active double drips (dripped in

both arms). The drip MUST be switched off/removed for a minimum of fifteen (15) minutes before attempting venepuncture.

Haematoma formation: o Haematoma is a collection of blood. o It can be formed following a leakage of blood from the vein into the tissues

surrounding the safety needle insertion site. Whilst this is not a serious complication the development of any degree of bruising around the needle site is an indication of pressure NOT being immediately applied to puncture sight after withdrawal of the safety needle. This should be avoided if possible, as patients are very conscious of bruising.

Thrombosis: o Veins which have been used for venepuncture may thrombose. o The patient may complain of some aching in the area and on palpation the vein may

be felt to be ‘like a cord’. There is no need for concern because the vein will re-cannulise in due course but should be avoided for immediate venepuncture.

Puncture of an artery:

o This occurs on rare occasions when a vein over the medial side of the elbow is chosen.

o The blood is bright red in colour and fills the tube without suction being necessary. o When this occurs the procedure should be abandoned and immediate, firm pressure

applied to the puncture wound for five minutes or until bleeding has stopped. o Please inform medical staff on ward of action taken.

Infection: o Infection should not occur. o If infection does occur this will be due to major defects in technique or the use of

unsterile equipment. o All cases of infection must be referred to Infection Control in order that the source of

infection can be investigated.

Patient feels unwell during/after procedure:

o If the patient feels in any way or faints, they should be allowed to rest until they have recovered.

o The recumbent position may be necessary. If recovery does not occur rapidly, medical advice must be sought.

The Crash Team may be contacted on 2222, if needed.

Phlebotomy SOP



6. Roles & responsibilities

RESPONSIBILITIES OF PERSONNEL In line with Covid19 policy: If you have any of the following symptoms: • Fever or high temperature. • New onset, persistent cough. • Muscle pain/general ache (myalgia). • Fatigue. • Shortness of breath (Dyspnoea). • a loss of, or change in, normal sense of taste or smell (anosmia) in isolation or in combination with any other symptoms If you have none of the symptoms listed above you should go to work as normal, following the guidance around PPE. If you have answered yes to any of the above questions you should not come into work. You should go home, inform the Phlebotomy supervisor and self-isolate until testing is arranged for you.

Phlebotomists have responsibility to take blood without harming the patient or disturbing the nursing care they are receiving at the time. They need to ensure that blood is taken correctly as if specimens are harmed during collection, test results may be unobtainable or worthless

All Phlebotomists are responsible to the Pathology Phlebotomy Manager. Day to day issues are dealt with via the Head Phlebotomist

The day-to-day supervision and organisation of the Phlebotomists is the responsibility of the Head Phlebotomist

Only Phlebotomists who are trained and have a signed competency record are allowed to take blood from patients whilst unsupervised

ORGANISATIONAL PROCEDURES Phlebotomists must report to the Head Phlebotomist at the beginning and end of each shift to receive daily information regarding their duties. In the absence of the head phlebotomist an allocated staff member will be assigned this role.

Phlebotomists must report any Accidents/Incidents to the Head Phlebotomist

Phlebotomists should attend for appropriate vaccinations or health surveillance as required

All sickness/absence must be reported to the Head Phlebotomist before the beginning of the morning shift between 07:30 and 08:00 (Ring Clinic on 0161 2062490) Returns to Work interviews are carried out either by the Head Phlebotomist or the Phlebotomy Manager on return.

Phlebotomy SOP



Requests for annual leave are granted with due regard for provision of the service and availability of other staff. Requests for emergency leave will be available following Trust policy. Phlebotomists must ensure that trolleys are never left unsupervised in any area.

In line with new Covid19 guidelines: In The Workplace

• Keep 2 metres apart from others not within your household • Use your face mask at all times unless you are working alone • Staff are asked to follow directional signage where applicable • Don’t congregate in groups/mass gatherings • Clean your hands when coming into and when leaving your work place • Cover coughs and sneezes with a tissue, dispose of it and clean your hands immediately afterwards • Keep your work area clean and clutter free. Clean daily ETHICS AND BEHAVIOUR The Phlebotomist must behave with discretion and courtesy towards patients, relatives and all Trust colleagues at all times. The Phlebotomist must maintain patient confidentiality at all times.

The Phlebotomist must behave according to Trust values and cooperate with medical and other professional staff.

7. Monitoring document effectiveness

This guideline is standard embedded practice and does not require oversight beyond in-house local competencies.

8. Abbreviations and definitions

COSHH Care of Substances Hazardous to Health EDTA Ethylenediaminetatraacetic acid FBC Full Blood Count FRSM Fluid Resistant Surgical Mask GP General Practitioner HBV Hepatitis B HCV Hepatitis C HIV Human Immunodeficiency Virus HR Human Resources IPC Infection Protection Control NCA Northern Care Alliance NICE National Institute for Health and Care Excellence PEP Post Exposure Prophylaxis PPE Personal Protective Equipment

Phlebotomy SOP



9. References

SRFT Policies

Aseptic Non-Touch Technique Policy Issue 3.5

NCA Venepuncture in Adults Issue: 1.1

Needlestick injury, Occupational Exposure To Blood Borne Viruses, HIV, PEP Issue: 6

10. Appendices

None

Phlebotomy SOP



11. Document Control Information

Part 1

Must be fully completed by the Author prior to submission for approval

Name of lead author: Hilary Richardson

Job Title: Phlebotomy manager

Contact number: 0161 2060212

Email address: [email protected]

Consultation: List persons/groups included in consultation. N.B Include Pharmacy/PADAT/D&T/MMG for

documents containing drugs.

Indicate whether feedback used (FU), not used (FNU) or not-received (NR)

Name of person or group Role / Department / Service / Committee

/ Corporate Service

Date Response:

FU / FNU / NR

Louise Bell Pathology Laboratory 11-2019 FU

Carol Howard Infection Control 11-2019 FU

Richard Warner ICD Governance board 11/09/2020 FU

EqIA sign off: See Appendix 11

Name: (Insert named lead from EDI Team) Date:

J McMahon 11/02/2021

Communication plan:

The document reflects current embedded practice. All members of phlebotomy will read and sign to state

compliance.

Part 2

Must be fully completed by the Author following committee approval.

Failure to complete fully will potentially delay publication of the document.

Submit to Document Control/Policy Support for publication.

Approval date: Method of document approval:

11/09/2020 Formal Committee decision

Yes

Chairperson’s approval

Yes

Name of Approving

Committee

ICD Governance board

Chairperson Name/Role Richard Warner

Amendments approval: Name of approver, version number and date. Do not amend above details.

NA

Part 3

Must be fully completed by the Author prior to publication

Keywords & phrases: Phlebotomy, Venepuncture, Taking Blood

Document review

arrangements

Review will occur by the author, or a nominated person, within five years or earlier

should a change in legislation, best practice or other change in circumstance

dictate.

Phlebotomy SOP



11. Equality Impact Assessment (EqIA) tool

The below tool must be completed at the start of any new or existing policy, procedure, or guideline development or review. N.B. For ease, all documents will be referred to as ‘Policy*’. The EqIA should be used to inform the design of the new policy and reviewed right up until the policy is approved and not completed simply as an audit of the final Policy itself.

All sections of the tool will expand as required.

EqIAs must be sent for review prior to the policy* being sent to committee for approval. Any changes made at committee after an EqIA has been sign off must result in the EqIA being updated to reflect these changes. Policies will not be published without a completed and quality reviewed EqIA.

Help and guidance available:

Click here for the Policy*EqIA Tips for Completion QRG

Email the Group EDI Team: [email protected] for advice or training information.

Submission of policy* documents requiring EqIA sign off to: [email protected]. Allowing an initial four week turnaround.

Where there is a statutory or significant risk, requests to expedite the review process can be made by exception to the Group Equality & Inclusion Programme Manager [email protected]

1. Possible Negative Impacts

Protected Characteristic Possible Impact Action/Mitigation

Age na

Disability Communication barriers Use appropriate communication tools, skills and work with patient advocates

Ethnicity Communication barriers Access to interpreter services

Gender na

Marriage/Civil Partnership na

Pregnancy/Maternity na

Religion & Belief na

Sexual Orientation na

Trans na

Other Under Served Communities (Including Carers, Low Income, Veterans)

Communication/Reassurance Carers to be involved n communication

2. Possible Opportunity for Positive Impacts

Protected Characteristic Possible Impact Action/Mitigation

Age na

Disability na

Ethnicity na

Gender na

http://nm-ashanti.pat.nhs.uk:86/DMS/Default.aspx?tabid=8541&pnode=8&seltype=0

mailto:[email protected]



Phlebotomy SOP



3. Combined Action Plan

Action (List all actions & mitigation below)

Due Date Lead

(Name & Job Role)

From Negative or Positive Impact?

Disability – communication barriers - Use appropriate communication tools, skills and work with patient advocates

11/2/2021 Hilary Richardson Phlebotomy manager

negative

Ethincy – communication barriers - Access to interpreter services

11/2/2021 Hilary Richardson Phlebotomy manager

Negative

Carers to be involved n communication Negative

5. EqIA Update Log

(Detail any changes made to EqIA as policy has developed and any additional impacts

included)

Date of Update Author of Update Change Made

na

Marriage/Civil Partnership na

Pregnancy/Maternity na

Religion & Belief na

Sexual Orientation na

Trans na


na

4. Information Consulted and Evidence Base (Including any consultation)

Protected Characteristic Name of Source

Summary of Areas

Covered

Web link/contact info

Age Na

Disability Na

Ethnicity Na

Gender Na

Marriage/Civil Partnership Na

Pregnancy/Maternity Na

Religion & Belief Na

Sexual Orientation Na

Trans Na


Na

Phlebotomy SOP



6. Have all of the negative impacts you have considered been fully mitigated or resolved? (If the answer is no please explain how these don’t constitute a breach of the Equality Act 2010 or the Human Rights Act 1998) Impact has been mitigated as described in section 1

7. Please explain how you have considered the duties under the accessible information standard if your document relates to patients? Yes as stated in section 1 The policy will be available to staff in different formats, including large print, enlarged on computer screen and/or on different colour paper

8. Equality Impact Assessment completed and signed off? (Insert named lead from EDI Team below). Please also add this information within Section 11.

Name: Date: 11/02/2021