Earlobe Capillary Blood Gas Sampling in Adults Clinical Guideline V1.0

Transcription

1 Earlobe Capillary Blood Gas Sampling in Adults Clinical Guideline V1.0 June 2018 Page 1 of 12

2 1. Aim/Purpose of this Guideline Arterialised capillary blood samples obtained from the earlobe of stable adult patients may be used to measure a number of variables that are required to safely monitor patients undergoing treatment with Non-Invasive Ventilation (NIV). In the assessment of blood gas tensions, capillary blood specimens have been shown in the literature to be comparable to arterial blood specimens with the added benefits of improved patient satisfaction and decreased risk of complications This guidance applies to all healthcare professionals performing this procedure. Those undertaking the procedure should ensure that it is appropriate for each patient and that they have achieved an adequate level of competency. It is the responsibility of the person performing the procedure to document the results in the medical notes and refer to medical staff if required Competency in this procedure is assessed through the Earlobe Capillary Blood Gas Sampling - Supervised Practice Workbook. Completion of the associated elearning package and ten supervised procedures are required prior to final competency sign off. 2. The Guideline 2.1. Arterial Blood Gas (ABG) sampling provides essential information for the management of patients with a wide range of conditions. In particular, those patients requiring NIV require serial monitoring with several samples over days 1,2. This is known to cause discomfort to patients 3 and carries a small risk of complications such as haematoma formation or vessel injury Capillary Blood Gas (CBG) samples taken from an earlobe that has been arterialised by use of a rubefacient cream represent a significantly less painful eperience for patients and provide comparable results to ABGs in stable patients Variations in technique can introduce significant differences in results thereby making a standardised procedure essential for all staff Indications: There are a number of indications for CBG sampling in in-patients. These include: Monitoring of patients receiving NIV 2 in line with trust policy: The Use of Non-Invasive Ventilation in Patients with Acute Type 2 Respiratory failure; V1.0; May In the assessment of respiratory function in haemodynamically stable patients 4. Assessment of supplementary oygen requirements Contraindications: Page 2 of 12

3 Haemodynamically unstable/shocked patients. Abnormal puncture site e.g. inflamed, localised infection or oedematous earlobe. Previous reaction to Transvasin cream or chlorheidine swabs. Arterial access available (e.g. radial arterial line) 2.4. Equipment: Clean tray with sharps bo Clean gloves and other Personal Protective Equipment (PPE) Transvasin cream 2% chlorheidine swab Size 11 retractable scalpel Heparinised capillary tube with miing wire and end caps Sterile gauze Appropriate dressing (e.g. plaster) 2.5. Procedure: Identify the patient in accordance with the Positive Patient Identification Policy. Eplain the procedure to the patient and obtain informed verbal consent in accordance with the Consent Policy. Wash hands and don appropriate PPE. Minimum requirements are clean gloves and apron. Apply Transvasin cream to the earlobe. Leave for a few minutes whilst preparing other equipment the earlobe should become warm and erythematous. Insert the miing wire into the capillary tube and attach an end cap to one end Remove the cream and disinfect the earlobe using a chlorheidine swab. Allow to dry. Use a size 11 scalpel blade to make an incision to a depth of 3mm, parallel to and in the middle of the edge of the earlobe. Wipe away the first droplet of blood to ensure sample accuracy. Allow a second, large droplet of blood to form. Page 3 of 12

4 Place the end of the capillary tube into the droplet of blood and allow to fill, avoiding introducing air bubbles into the sample. Do not squeeze the earlobe. Once full, apply the end cap to the capillary tube. Apply firm pressure to the wound until bleeding has stopped, apply dressing. Run the magnet the length of the capillary tube 10 times to ensure thorough miing. Attach a patient identification label to the tube at the patient s bedside and note the inspired oygen concentration (F i O2). Immediately analyse the sample, in accordance with Point of Care Testing Policy. Document result and FiO2 in medical notes. Refer results to medical team immediately Interpreting Results: When using a standardised technique, arterialised CBG results closely correlate to ABG results and have similar normal ranges. An eception is for values for p a O 2 greater than 20kPa where significant variation is encountered 4. For these patients the F i O2 should be reduced and the test repeated. The adjusted reference ranges 4 are shown in Table 1. Table 1. Current Trust ABG ranges with adjusted CBG ranges. Calculated using method described by Richter et al 4. ph p a O 2 (kpa) p a CO 2 (kpa) Page 4 of 12

5 2.7. Audit Tool To be undertaken annually, with results reported at Respiratory Weekly Meeting. Criteria Epected Compliance Staff undertaking procedure to have completed competency 100% sign off or be directly supervised Result documented in medical notes 100% F i O2 documented 100% Documentation that result has been referred immediately to 100% medical team 3. Monitoring compliance and effectiveness Element to be monitored Lead Adherence to full guideline Ward Managers/Lead Consultant Tool Adult Tool in Section 2.7. Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Annual Respiratory weekly meeting Where changes required, a lead person will be identified, reporting to the respiratory meeting Required changes to practice will be identified and actioned within 3 months. A lead member of the team will be identified to take each change forward. These will be presented at the weekly respiratory meeting where required. Page 5 of 12

6 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendi 2. Page 6 of 12

7 Appendi 1. Governance Information Document Title Earlobe Capillary Blood Gas Sampling in Adults Clinical Guideline V1.0 Date Issued/Approved: 1 June 2018 Date Valid From: 1 June 2018 Date Valid To: 1 June 2021 Directorate / Department responsible (author/owner): Contact details: Brief summary of contents Suggested Keywords: Target Audience Eecutive Director responsible for Policy: Date revised: This document replaces (eact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Respiratory Directorate Dr Aleander Lomas Dr James Pickering alelomas@nhs.net james.pickering1@nhs.net Procedural guidance on sampling and processing of earlobe capillary blood specimens in adult patients Capillary blood gas, non-invasive ventilation, CBG, NIV RCHT PCH CFT KCCG Medical Director New document New document Respiratory Governance Meeting, Cardio-respiratory Directorate, Divisional Business and Governance Divisional Manager, Medicine/ED Not Required Name and Signature of {Original Copy Signed} Page 7 of 12

8 Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Eecutive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key eternal standards Name: {Original Copy Signed} Internet & Intranet Intranet Only Clinical / Respiratory Guideline for emergency oygen use in adult patients. British Thoracic Society. Emergency Oygen Guideline Group. Thora 2008; 63 (Suppl VI):vi1 vi68. doi: /th BTS/ICS Guidelines for the Ventilatory Management of Acute Hypercapnic Respiratory Failure in Adults. British Thoracic Society/Intensive Care Society Acute Hypercapnic Respiratory Failure Guideline Development Group. Davidson AC, et al. Thora 2016; 71:ii1 ii35. doi: /thorajnl Related Documents: 3. An audit of the patient's eperience of arterial blood gas testing. Crawford A. Br J Nurs May 13-26; 13 (9): Capillary blood gas as a substitute for arterial blood gas: a meta-analysis. Richter et al. British Journal of Hospital Medicine, March 2014, Vol 75, No Vaquer et al.: Earlobe arterialized capillary blood gas analysis in the intensive care unit: a pilot study. Annals of Intensive Care : Sampling Techniques Collecting a capillary sample from an adult or a child three months of age or older. Radiometer Available at Page 8 of 12

9 files/sampling_tech_collect_capillary_adult_ child_3_months_older.pdf (accessed 03/02/2017) 7. Capillary blood gas analysis for long term oygen therapy assessment. Ridley et al. Clinical Medicine Vol 1 No 4:326. Training Need Identified? Yes Version Control Table Date Version No Summary of Changes 8 Nov 17 V1.0 Initial Issue Changes Made by (Name and Job Title) Dr Aleander Lomas ACCS CT1 All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of epiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the epress permission of the author or their Line Manager. Page 9 of 12

10 Appendi 2. Initial Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed:. Directorate and service area: Respiratory Directorate/ Medicine Inpatient Wards Name of individual completing assessment: Dr Aleander Lomas Is this a new or eisting Policy? New Telephone: Policy Aim* Who is the strategy / policy / proposal / service function aimed at? Guidance on the safe and accurate sampling of earlobe blood specimens for blood gas analysis in adult in-patients 2. Policy Objectives* Standardised care, technique to ensure patient and staff safety 3. Policy intended Outcomes* Standardised care 4. *How will you measure the outcome? Audit 5. Who is intended to benefit from the policy? Medical and nursing staff, patients 6a Who did you consult with Workforce Patients Local groups Eternal organisations Other b). Please identify the groups who have been consulted about this procedure. Please record specific names of groups What was the outcome of the consultation? Page 10 of 12

11 7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Eisting Evidence Age Se (male, female, trans-gender / gender reassignment) Race / Ethnic communities / groups Disability -Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy maternity Seual Orientation, Biseual, heteroseual, Lesbian and Gay, You will need to continue to a f ull Equality Impact Assessment if the following have been highlighted: Page 11 of 12

12 You have ticked Yes in any column above and No consultation or evidence of there being consultation- this ecludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please eplain why. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment 1. Dr Aleander Lomas 2. Human Rights, Equality & Inclusion Lead Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD Signed: Dr. Aleander Lomas Date: 13 February 2018 Page 12 of 12