PR OCE DUR E FOR VE NE PUNCTUR E (USING THE VACUETTE BLOOD COLLECTION S YS TE M)

Transcription

1 PR OCE DUR E FOR VE NE PUNCTUR E (USING THE VACUETTE BLOOD COLLECTION S YS TE M) Issue History Issue Version One Purpose of Issue/Description of Change Planned Review Date To promote the safe and effective procedure for venepuncture 2016 Named Responsible Officer:- Approved by Date Quality & Governance Service Quality, Patient Experience and Risk Group August 2013 Section:- Diagnostics CP20 Target Audience Multi-Disciplinary UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

2 CONTROL RECORD Title Procedure for Venepuncture (using the Vacuette blood collection system). Purpose To promote the safe and effective procedure for venepuncture Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Mary Lyden-Rodgers Document Librarian QGS Groups consulted with:- Clinical Policies and Procedures Group Infection Control Approved 16 th July 2013 Date approved by Quality, Patient Experience and Risk Group 31 st July 2013 Method of Distribution Intranet:- Staff Zone Archived Date Location:- Datix Librarian Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments One Quality & Governance N Status New / Revised / Trust Change 2/13

3 (using the Vacuette blood collection system) INTR ODUCTION Venepuncture is a procedure of entering a vein, most commonly of the upper limb with a needle. It is carried out for two reasons: To obtain a blood sample for diagnostic purposes To monitor levels of blood components Dougherty & Lister (2011) Procedure complies with NHS Litigation Authority (NHSLA 2013) Risk Management Standards for Acute and Community Services clinical diagnostic tests. TARGET GROUP This procedure should only be undertaken by a member of the clinical team who has had appropriate training in Venepuncture and is required to undertake the procedure in their job description. TRAINING All staff in the Trust are required to comply with mandatory training as specified in the Trusts Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. RELATED POLICIES Please refer to relevant Trust policies and procedures. CONTR AINDICATIONS Indicators include:- Bruising and phlebitis as indicates risk of local tissue damage or systemic infection Oedematous limb as danger of stasis of lymph predisposing to such complications; phlebitis and cellulitis Avoid scarring from previous venepuncture site Be aware if patient has had a stroke as the affected limb should not be used Be aware if patient has a dialysis shunt in situ as this limb should be avoided Avoid limb that has had pre-existing thrombophlebitis or constriction Dougherty & Lister (2011) 3/13

4 CONS E NT Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult who is deemed to lack capacity regardless of whether the impairment is temporary or permanent. However, such patients can be treated if it is deemed to be within their best interest. This must be recorded within the patient s health records with a clear rationale stated at all times. Refer to Trust Patient Information and Consent Policy for further information and guidance or the Clinical Protocol for Assessing Mental Capacity and Best Interests. EQUIPMENT REQUIRED Laboratory form with investigations required marked clearly by requesting officer Blood collection bottles appropriate to the investigations being undertaken (check expiry dates before use) Single use Vacuette needle or butterfly Single use Vacuette needle adapter and chamber Tourniquet (single patient use) Single use Non-sterile gloves and apron Single use Sterile gauze swabs Medical adhesive tape Sharps container Point of use disposal system (POUDS) tray Trust approved cleaning wipe Trust approved transport container CHOOS ING A VE IN The choice of vein must be that which is best for the patient. There are two stages to locating a vein: 1. Visual inspection 2. Palpitation SUITABLE SITES FOR VENEPUNCTURE The median cubital veins The cephalic vein The basilic vein The metacarpal veins (used only when the others are not accessible) Scales (2008) 4/13

5 Diagnostic and Screening Standards to Promote and Maintain Patient Safety a. How the Screening/Diagnostic procedure is requested b. How the clinician treating the patient is informed of the results (including timescales) c. How the patient is informed of the results (including timescales) d. Taking action on the result of diagnostic /screening tests (including timescales) :- documentation of the result interpretation of the result how patient is followed up or referred following a screening Which staff are authorised to request this test? Description of how each step in the process is undertaken Requests can be made verbally but must be accompanied by a written request form or electronically using the Wirral Remote Order Communications System (WROCS) The General Practitioner/Health Professional will receive the results within 3 working days however it remains the responsibility of the staff member requesting the procedure to ensure results are dealt with within 5 working days or earlier if urgent. Via General Practitioner (GP) or relevant Health Professional within 5 days of receiving results. This is usually done by phone or planned appointment. Patients requiring further intervention, referral or prescribing should be implemented as soon as possible following receipt of results. Recorded in health records. By the referring clinician. By the referring clinician. All clinical staff that have a clinical rationale, within their role as to why they are requesting the proposed procedure. Additional comments:- In the event of WROCS down time, paper request forms either provided by or approved by the laboratory must be completed. Urgent blood results may be received within 24 hours. This request must be noted on the request form and blood bottle as urgent (McCreadie 2011). Patient should be informed at time of procedure to contact GP within the appropriate time scales to confirm results and ascertain if further intervention is required. All actions to be recorded in the patient s health records within 5 working days. Note: A maximum of 2 attempts should be made to obtain blood sample in order to reduce the risk of trauma and minimise distress to the patient. (If unsuccessful, obtain assistance from a more experienced member of staff) 5/13

6 ACTION 1. Introduce yourself as a staff member and any colleagues involved at the contact. 2. Wear identity badge which includes name, status and designation. 3. Verbally confirm the identity of the patient by asking for their full name and date of birth. If client unable to confirm, check identity with family/carer. Complete a patient risk assessment. 4. Ensure verbal consent for the presence of any other third party is obtained. 5. Explain procedure to patient including risks and benefits and gain valid consent. 6. Assess patient to determine if any contraindications to procedure. Check for allergies or phobias/anxiety and reassure the patient. (WH0 2010) 7. Clean tray using a Trust approved cleaning wipe and gather equipment check expiry dates. Decontaminate hands and put on single use disposable apron if indicated. Prepare procedure equipment, avoid touching any part of the procedure equipment that will come into direct contact with the patient i.e. needle. Apply single use non-sterile gloves which should fit well to assist procedure. 8. Visually inspect and palpate the veins of the arms to find a suitable vein for venepuncture. The vein should be visible without applying tourniquet (WHO 2010) RATIONALE To promote mutual respect and put client at their ease. For patients to know who they are seeing and to promote mutual respect. To avoid mistaken identity. The practitioner needs to be aware of any risk factors (e.g. patient is on anticoagulant therapy and potential for nonconcordance with procedure). Students, for example, as the client has the choice to refuse. To ensure patient understands procedure and relevant risks. The procedure requires patient to fully understand and co-operate in order to ensure safety for patient and clinician. Actively involve the patient in his or her treatment and maintain patient/practitioner safety. To familiarise the nurse with the patients medical history as this may influence procedure or choice of vein. To prepare for procedure and maintain safety. To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands to the patient. To protect clothing or uniform from contamination and potential transfer of micro-organisms. To prevent contamination of key parts. To protect hands from contamination with organic matter and transfer of microorganisms. Vein should be easily palpable with good capillary refill. Consider veins with largest diameter possible avoiding joints, lymphoedema, superficial veins or infected/broken skin. 6/13

7 9. If selected area is visibly dirty, clean area with soap and water and dry. Clean site using 70% alcohol swab to cleanse skin prior to venepuncture. Gently massaging area when cleansing/swabbing will also encourage veins to surface and ease access. Clean site with swab for 30 seconds and allow to dry for at least 30 seconds. Do not re-palpate site after cleansing skin. 10. Remove the cover of the valve section and inspect the device carefully. Reduce the risk of transfer of skin contaminants into the puncture site. To help reduce amount of bacteria on skin reducing the risk of transfer of any transient and resident micro-organisms from skin to subcutaneous tissues or bloodstream. To reduce cross-infection. To detect faulty equipment, e.g. bent or barbed needles. 11. Thread the needle into the Vacuette needle holder, ensuring that it is firmly seated. 12. Place patient's arm in a downward position and support with pillow if necessary, ensuring patient is comfortable. Advise patient on importance of maintaining position to reduce risk of needle moving/needle injury. 13. Apply tourniquet to the chosen arm approximately 7cm to 8cm above the proposed venepuncture site (Dougherty & Lister 2011). To prevent needle from unthreading during use. To ensure the patient s comfort and facilitate venous access and maintain safety for patient and clinician. Increases venous pressure to facilitate vein identification and entry. (Tourniquet remains in place no longer than 1 minute) 14. Remove needle shield. To prepare needle for procedure. 15. Using the non-dominant hand, pull the skin below the tourniquet taut over the vein. 16. Using the dominant hand, hold the needle at a angle and with bevel edge of needle facing upwards, insert the needle into the vein (length inserted will be dependent on the individual patient) reducing the angle of descent as soon as flashback of blood is seen. (Dougherty & Lister 2011) To immobilise the vein and provide counter tension. To ease access into the lumen of the vein. To prevent advancing too far through vein wall and causing damage to vessel. 7/13

8 17. Push vacuum collection tube into the needle holder and onto the needle valve. Blood specimen tubes are filled in accordance with manufacturer s order of draw instructions. To puncture the rubber diaphragm. 1 st Ochre 2 nd Blue 3 rd Red (4ml) 4 th Green 5 th Lavender 6 th Pink 7 th Grey 8 th Dk Blue 18. Centre tubes in holder when penetrating the cap. 19. Hold tube in place by pressing the tube with the thumb. 20. Remove tourniquet as soon as blood appears in tube. 21. Do not allow contents of tube to contact the cap or end of the needle during procedure. 22. When the first tube is filled to the required level gently remove it from needle holder. Gently invert blood tube 8-10 times to aid mixing blood immediately on removal from needle. Exceptions: Coagulation tubes - invert 4 times. Note: Do not shake the tubes. Vacuette (2010) Insert subsequent sample tubes into needle holder, puncturing diaphragm to begin flow. 23. When all samples are obtained, place a piece of sterile gauze over the needle entry site and gently remove the needle without applying pressure. Prevents penetration of the sidewall of the cap which can result in loss of vacuum. Ensures complete withdrawal of blood by vacuum. Reduces pressure within the vein to assist the vacuum withdrawal of blood and reduce risk of haemoconcentration. Tube contents can contaminate subsequent samples. Minimise movement of needle within vein. One complete inversion is achieved by turning the filled tube upside-down and returning it to upright position. Insufficient mixing or delayed mixing in serum tubes may result in delayed clotting. In tubes with anticoagulants, inadequate mixing may result in platelet clumping, clotting and /or incorrect test results. Vigorous mixing may cause foaming or haemolysis (break down of red blood cells). Prevent pain on removal and minimises the potential for vein damage. 8/13

9 24. Place needle and needle holder into sharps container immediately. 25. Using the gauze, ask the patient to apply digital pressure directly over the puncture site until bleeding stops for a minimum of 1 minute Do not bend arm upwards. 26. Check puncture site if site has sealed, apply a clean piece of sterile gauze to the site and secure with tape. 27. On completion of procedure, clean tray using Trust approved cleaning wipe, remove and disposal of Personal Protective Equipment (PPE) to comply with waste management policy. Decontaminate hands following removal of PPE. 28. Label all collection tubes / laboratory forms accurately and legibly with the relevant patient information available pre-printed. 29. Transport specimens to collection point in accordance with Clinical Protocol for the collection, transportation, handling and labelling of specimens (CP24). 30. Document all actions and observations or difficulties obtaining access (include consent and patient perceptions of care) in nursing records. Liaise with GP as required. Explain to patient how and when they should expect to get the results of their blood tests and record in the patient s health records. Reduce the risk of inoculation injury. To stop leakage and reduce the potential for haematoma formation Reduces the potential for vein and tissue damage To cover puncture site and prevent leakage of blood until healing complete. To prevent cross infection and environmental contamination. To remove any accumulated transient skin flora that may have built up under the gloves and possible contamination following removal of PPE. To ensure the correct test are undertaken for the correct patient. To ensure safe transport of specimens and protection of patient identifiable information. Ensure compliance with NMC and local record keeping procedures. To promote continuity of care and ensure results are acted on appropriately Patient to be fully informed of how and when they will get their results as part of giving informed consent Note: In exceptional circumstances, when the nurse has been unable to obtain blood samples using the Vacuette system, it may be necessary to obtain the sample using a needle and syringe. (Document rationale in patients records) In these circumstances, the following changes to the procedure above should be made: Replace the Vacuette needle and needle holder with a 21 gauge needle butterfly and syringe of an appropriate size for the amount of blood to be collected 9/13

10 When using a needle and syringe, the tourniquet should be removed AFTER the sample has been collected Vacuette collection tubes must still be used as they are compatible with the diagnostic equipment used within the laboratories. The caps of these tubes can be removed by twisting in an anti-clockwise direction with a twist-pull motion. Only fill the collection tubes to the mark identified on the side DO NOT OVERFILL. PROCEDURE FOR VENEPUNCTUR E USING A BUTTER FLY WITH A VACUUM ADAPTOR Assess and prepare the patient as detailed in steps 1 15 of venepuncture procedure. ACTION Device size is dependent on the patient s vein size and site that is 23 gauge for a frail, and/or older patient with small veins. RATIONALE To reduce damage or trauma to the vein. Assemble the necessary equipment. Insert butterfly needle, bevel up, into vein. Hold in place with non-dominant hand. To ensure efficiency of procedure. To ensure needle is kept in correct place during blood collection Apply blood specimen bottles in turn. After filling and removing, inverting each tube the required number of times to mix (refer to 22). Complete procedure as in steps of venepuncture procedure. CLINICAL INCIDE NTS Any related incidents arising from obtaining blood tests which may involve a clinical error or near miss must be reported using Datix system, following the Trust Datix Incident Reporting Policy. Patients must be given relevant contact numbers to ring in case they do not get the results of their blood tests as expected. 10/13

11 REFERENCES Dougherty, L. and Lister, S.E. (2011) The Royal Marsden Manual of Clinical Nursing Procedures, Eighth Edition. Blackwell Publishing, Oxford. NHSLA (2013) NHS Litigation Authority Risk Management Standards Version 1: Standard 5 Acute and Community Services. Accessed 1 July, Available online at McCreadie J (2011) A Guide to Haematology Laboratory Services. Wirral University Teaching Hospital NHS Foundation Trust. Accessed 21 June 2013 Available on line at gust_2011.pdf Scales K (2008) A practical guide to venepuncture and blood sampling. Nursing Standard. 22, 29, Accessed Available on line at WHO (2010a) Guidelines on drawing blood. Best practices in phlebotomy. p13 World Health Organisation. Accessed 5 July, 2013 Available on line at WHO (2010b) Practical guidance on venepuncture for laboratory testing. World Health Organisation. Accessed 1 July 2013 Available on line at VACUETTE (2010) Handling Recommendations. Vacuette Blood Collection System. Accessed 21 June 2013 Available on line at BIBLIOGRAPHY CGS 132 (2010) CHS 132 Obtain venous blood samples. Skills for health. Accessed 19 June Available on line at Gould D (2012) Skin flora: implications for nursing. Nursing Standard. 26, 33, Accessed 20 June Available on line at HSE (2013) Health and Safety (Sharp Instruments in Healthcare) Regulations Guidance for employers and employees. HSE Information sheet. Accessed 1 July 2013 Available on line at Lavery I and Ingram P (2005) Venepuncture: best practice. Nursing Standard Accessed 19 June Available on line at NHS European Office (2013) Briefing : Protecting healthcare workers from sharps injuries. What 11/13

12 NHS employers and employees need to do from May 2013 to implement new health and safety requirements. May 2013 Issue 13 Accessed 1 July Available on line at _injuries_kl_ pdf RCN (2011) Sharps Safety. RCN guidance to support implementation of the EU Directive 2010/32/EU on the prevention of sharps injuries in the health care sector. Accessed 19 June Available on line at Scales K (2009) Correct use of chlorhexidine in intravenous practice. Nursing Standard. 24, Accessed 20 June Available on line at Strauss K and Dickinson B (2012) Risk of Needlestick injury from injecting needles. Nursing Times; 108: 40, Accessed 1 July 2013 Available on line at Webster J, Bell-Syer SEM and Foxlee R (2013) Skin preparation with alcohol versus alcohol followed by any antiseptic for preventing bacteraemia or contamination of blood for transfusion (Review). The Cochrane Collaboration. The Cochrane Library. Accessed 20 June Available on line at WUTH (2012) Blood Culture Collection Policy and Procedure Version : 2 Policy Reference : 141 Accessed 26 June Wirral University Teaching Hospital. NHS Foundation Trust. Available on line at %20Blood%20Culture%20Collection%20Policy%20%20Procedure-% %20v2.pdf 12/13

13 R ISK ASSESSMENT FOR SCR E E NING/DIAGNOS TIC PR OCE DUR E S Name of Screening/Diagnostic Procedure: Venepuncture Date risk assessed: July 2013 Risk assessed by: Specialist Practitioner Likelihood that process Risk identified in process Mitigation/Controls Criteria will fail Low Medium High a. Process for requesting the WROCS system may have down time In the event of WROCS downtime, paper request forms either provided by or screening/diagnostic procedure approved by the laboratory must be completed. b. Process for informing the clinician treating the patient of the result c. Process for informing the patient of the result d/e. Process for action from a diagnostic test or following-up or referring the patient after a screening test Identify risks from the process of conducting the test if relevant GP may not be in practice to review results Patient may not be informed of their results within an appropriate timeframe Results may not be reviewed and actioned within an appropriate timeframe Inadequate amount of sample may be obtained Clinician who originally obtained sample to check with GP whether they have received the result. If not, staff member is to contact the laboratory. Clinician who originally obtained blood sample to discuss with relevant person(s) regarding informing the patient of their results. It is the responsibility of the Clinician who has obtained the blood sample to ensure the results are actioned within 2-5 working days. Ensure all clinical staff adheres to Trust standards to ensure blood samples are collected, analysed and reported back in a timely manner.