Clinical: Venepuncture SOP

Transcription

1 Clinical: Venepuncture SOP Document Control Summary Status: Version: Author/Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: New e.g. v1.0 Date: June 2017 Di Hughes Policy and Procedures Committee Date: 20 July 2017 Policy and Procedures Committee Date: 20 July 2017 Physical health Pathway Physical Health CQUIN August 2017 June 2020 Venepuncture, blood taking, blood samples, phlebotomy, bloods Associated Policy or Standard Operating Procedures Physical Health Change Control Amendment History Version Dates Amendments Page 1 of 17

2 Contents 1. Introduction Purpose Scope Precautions Exclusion Criteria 4 6. Equipment Procedure 6 8. Complications Process For Monitoring Compliance And Effectiveness References/Bibliography 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 Page 2 of 17

3 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 Page 3 of 17

4 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 Page 4 of 17

5 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 Page 5 of 17

6 7. Procedure Action 1 Approach the patient in a confident manner and explain and discuss the procedure with them 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 3 Check that the request form is correct, fully completed and signed 4 Check the identity of the patient matches the details on the request form by asking for their full name and date of birth 5 Checks hands for any visibly broken skin, cover with waterproof dressing 6 Assemble equipment required for the procedure (see list above) 7 Carefully wash hands using trust approved hand washing procedure and dry thoroughly 8 Check all packaging for any damage and expiry dates before opening and preparing equipment on chosen clean surface 9 Take all equipment to the patient, exhibiting a relaxed and confident manner 10 Support the chosen limb in a comfortable and extended position Rationale To ensure that the patient understands the procedure and gives their valid consent (NMC 2015) 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 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 To ensure that a) the request form has been completed correctly and b) that the sample is taken from the correct patient To minimise the risk of contamination to the practitioner To ensure that the procedure goes as smoothly as possible without interruption To minimise the risk of infection (DoH 2010) To maintain asepsis throughout and ensure no faulty equipment used To help the patient feel at ease To ensure patient comfort and facilitate venous access Page 6 of 17

7 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 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 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 To prevent inadvertent insertion of needle into other anatomical structure (e.g. artery) Page 7 of 17

8 13 Release the tourniquet until ready to actually enter the vein 14 Select device to be used, based on vein size, site and volume of blood to be taken To ensure the maximum time for tourniquet application, one minute, is not exceeded To reduce risk of damage/trauma to the vein and therefore prevent haemolysis 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 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 To maintain asepsis and minimize the risk of infection Allow to dry for at least 30 seconds. Do not re-palpate vein or touch the skin 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 19 Remove cover from needle and inspect carefully To dilate veins by obstructing the venous return To detect faulty equipment, e.g. bent or barbed needle Page 8 of 17

9 20 Anchor the vein by applying slight manual traction on the skin a couple of centimetres below the proposed insertion site 21 Holding needle with bevel uppermost, insert needle smoothly in one fluid movement, at an angle of approx º, dependant on depth and size of vein Immobilises the vein by providing counter tension. This will facilitate smoother needle entry 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 23 Hold the needle still and support with fingers/thumb and do not exert any pressure on the needle To prevent causing unnecessary pain and damage 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 Page 9 of 17

10 26 Disconnect bottle from holder and insert next one required. Remember to invert each bottle several times DO NOT shake 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 28 Remove the needle in a single smooth movement, activate safety device and dispose in sharps container 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 30 Fully label bottles before leaving the patient s side 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 32 Ensure patient is comfortable and not feeling faint or unwell in any way 33 Remove protective equipment and dispose of all waste according to trust policy 34 Ensure samples are correctly stored with the appropriate form and follow local procedure for collection/transportation of specimens 35 Document procedure in patient notes, according to local procedures To complete requested tests To ensure even distribution of additives whilst preventing haemolysis Be ready to apply pressure once needle removed To prevent unnecessary pain and potential damage to the intima of the vein Reduces pain to patient and risk of sharps injury to practitioner To prevent leakage and haematoma formation, thereby preserving integrity of vein for possible future use To reduce bleeding and bruising To ensure no mistakes are made with mixing up samples from different patients To ensure that the puncture site has sealed and to cover to prevent possible leakage or contamination To ascertain if it is safe for patient to leave the treatment room, or whether further measures need to be taken To ensure safe disposal of sharps and other equipment To ensure all samples reach their intended destination safely To ensure and maintain timely and accurate record keeping Page 10 of 17

11 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: Pain Problem Possible Cause Action Touched a nerve Remove needle Punctured an artery Remove needle/apply pressure Anxiety Reassure and calm patient Use of vein in sensitive area, Try alternative site if possible e.g. wrist/back of hand Anxiety Limited venous access Bruising and/or haematoma Fear of needles Previous bad experience General state of mind Repeated use of same veins Previous poor technique, choice of vein or device Peripheral shutdown Dehydration 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 Give patient time to ask questions and feel comfortable Offer continuous reassurance 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 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 Page 11 of 17

12 Needle stick injury to practitioner Accidental blood spillage Missed vein Spurt of blood on entry Blood stops flowing Unsafe practice Incorrect disposal of sharps Poor technique Faulty equipment Poor vein selection Inadequate anchoring of vein Wrong positioning Lack of light Poor concentration Difficult access Bevel tip of needle enters vein before entire bevel is under the skin Tourniquet is far too tight 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 Follow trust policy regarding needle stick injury Follow trust policy for clearing up blood spills Complete incident form and report faulty device 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 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 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 Page 12 of 17

13 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), Dougherty, L. and Lamb, J. (Eds) (2008) Intravenous Therapy in Nursing practice, 2 nd 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 9 th 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 5 th Lippincote Williams and Wilkins ed. Philadelphia: RCN (2010) Standards for Infusion Therapy 3 rd ed. London: Royal College of Nursing WHO (2010) WHO Guidelines on Drawing Blood: best practices in phlebotomy. Geneva: World Health Organization Press Page 13 of 17

14 Appendix One ORDER OF DRAW FOR MULTIPLE BLOOD SAMPLES Page 14 of 17

15 Appendix Two VEINS TO CONSIDER FOR VENEPUNCTURE ARM HAND Page 15 of 17

16 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 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 Assessors Name and Initials Assessors Name and Initials Assessors Name and Initials Assessors Name and Initials 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 ) Page 16 of 17

17 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:. Page 17 of 17