Consulted With Post/Committee/Group Date

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1 NEONATAL HEEL PRICK BLOOD SAMPLING CLINICAL GUIDELINES Register No: Status: Public Developed in response to: Intrapartum NICE Guidelines RCOG guideline Contributes to CQC Standards No 12 Consulted With Post/Committee/Group Date Anita Rao/ Alison Cuthbertson Clinical Director for Women s and Children s Directorate October 2016 Paula Hollis Chris Berner Toni Laing Sarah Moon Carole Hughes Emma Towler Niki Waterson Lead Midwife Acute Inpatient Services Lead Midwife Clinical Governance Lead Nurse Neonatal Unit Specialist Midwife for Guidelines and Audit Senior Community Midwife Neonatal Unit Practice Facilitator Neonatal Unit Practice Facilitator Professionally Approved By Dr Hassan Consultant Lead for Risk Management October 2016 Version Number 3.0 Issuing Directorate Women s and Children s Ratified By Document Ratification Group Ratified On 23 rd February 2017 Trust Executive Board Date March 2017 Next Review Date January 2020 Author/Contact for Information Sharon Pilgrim, ANNP Policy to be followed by (target staff) Midwives, Obstetricians, Paediatricians and Neonatal nurses Distribution Method Intranet & Website. Notified on Staff Focus Related Trust Policies (to be read in Standard Infection Prevention conjunction with) Hand Hygiene Hypoglycaemia high risk infant Blood Spot Screening Eastern Neonatal - Glove and Apron Policy Analgesia in Neonates Document History Review: Version No Authored/Reviewed by Active Date 1.0 Sharon Pilgrim July Sharon Pilgrim 23 rd May Sharon Pilgrim ANNP 28 th February

2 INDEX 1. Purpose 2. Introduction 3. Scope 4. Indication for heel pricks 5. Risks associated with heel pricks 6. Equipment 7. Procedure 8. Documentation and reporting 9. Infection Prevention 10. Staff and Training 11. Audit and Monitoring 12. Guideline Management 13. Communication 14. References Appendix A - Appropriate site for sampling 1.0 Purpose 1.1 The purpose of the neonatal heel prick procedure is to safely obtain capillary blood from the neonate. 2.0 Introduction 2

3 2.1 The capillary blood sampling by heel prick is an accepted form of blood sampling within the neonatal unit. Performed correctly, blood can be taken with the minimal discomfort to the neonate. Capillary samples should only be done by appropriately trained staff. 3.0 Scope 3.1 All infants who require capillary blood sampling from a heel prick, to ensure that they experience the minimal discomfort and to reduce the risk of excessive tissue damage. 3.2 Use of soft Paraffin solutions such as Vaseline should not be used for heel punctures for the following reasons Can alter the blood results It increases the risk of infection It can clog the equipment. 4.0 Indications for heel prick samples Blood sugar monitoring Newborn blood spot screening tests Blood gas analysis Serum bilirubin levels Full blood counts Urea and electrolytes Drug levels (e.g. gentamicin, Vancomycin, Amikacin levels etc.) 5.0 Risks associated with heel pricks 6.0 Equipment 7.0 Procedure Pain Local trauma Excessive blood loss Infection Damage to nerves, blood vessels and bone Clean tray to hold equipment Gloves Cotton wool or gauze Lancet-appropriate to size of baby or Tenderfoot Capillary tube, Glucometer, blood spot card or blood bottle required 7.1 Prepare equipment in a clean dry tray and ensure baby is lying in a secure and safe position, either in the cot/incubator or securely held by parent. 7.2 Ensure the heel is clean prior to the procedure. Wash with warm water and allow it to dry. Avoid using alcohol impregnated wipes. 7.3 Give sucrose within 2 minutes of the procedure as per the sucrose guideline 3

4 7.4 Choose the appropriate site for sampling. Heel lancing should be limited to the medial and lateral borders of the heel (Appendix A). Rotate site to avoid previous puncture wounds. 7.5 Using the non dominant hand, hold the ankle with the index and middle finger partly encircling the heel with the thumb. 7.6 Gently compress the heel and keep under tension. Place the lancet securely against the heel and depress button to activate lancet to puncture the skin. 7.7 When blood appears from the puncture site gently compress the heel to form a large droplet of blood. Touch the blood droplet with the capillary tube or collect the droplets in a blood bottle or on a blood spot screening card. Following each drop slightly release the heel to allow it to refill. Continue to compress and relax grip on the heel to collect subsequent blood. DO NOT SQUEEZE. 7.8 Continue until enough blood has been collected. If the blood flow stops prior to completing the blood sample another heel puncture should be carried out. 7.9 Once the sample has been obtained, apply pressure to the wound site with sterile cotton wool or gauze. Maintain pressure until bleeding has stopped DO NOT USE SPOT PLASTERS The baby should be left comfortable post procedure and the tolerance to the procedure documented Continue to monitor the heel for any complications and check regularly as part of the skin integrity score. 8.0 Documentation and Reporting 8.1 Record the date, time and name of the person taking the sample in the investigations sheet. 8.2 Bloods should be correctly labelled with all the required information and sent for analysis as soon as possible. 8.3 An incident report form Datix must be completed for any baby who is identified as having sustained tissue damage from incorrect heel prick blood sampling, or if the heel prick blood sampling was undertaken incorrectly. 9.0 Infection Prevention 9.1 All staff should follow Trust guidelines on infection prevention by ensuring that they effectively decontaminate their hands before and after undertaking any patient contact. 9.2 All waste including apron and gloves must be disposed of according to hospital policy Staff and Training 10.1 All medical, nursing and midwifery staff undertaking a capillary blood sampling will have received the correct training and be judged to be competent to undertake the procedure Venepuncture although less painful, requires higher level of training and skill than heel pricks. The skills for heel pricks can be taught and assessed on the ward with minimal impact on staffing. 4

5 11.0 Audit and Monitoring 11.1 As a minimum the following specific requirements will be monitored: Correct documentation of the date time and person undertaking the blood spot. Skin integrity scoring pre and post procedure. Correct position of wound on heel with minimal skin and tissue damage. Use of analgesia if appropriate. Process for reporting and learning the lessons from incorrectly performed procedures A review of a suitable sample of health records of patients to include the minimum requirements as highlighted in point 11.1 will be audited. A minimum compliance 75% is required for each requirement. Where concerns are identified more frequent audit will be undertaken The findings of the audit will be reported to the Lead Nurse for Neonatal Unit, and an action plan with named leads and timescales will be developed to address any identified deficiencies Key findings and learning points will be disseminated to relevant staff Guideline Management 12.1 As an integral part of the knowledge, skills framework, staff are appraised annually to ensure competency in computer skills and the ability to access the current approved guidelines via the Trust s intranet site Guideline monitors have been nominated to each clinical area to ensure a system whereby obsolete guidelines are archived and newly approved guidelines are now downloaded from the intranet and filed appropriately in the guideline folders. Spot checks are performed on all clinical guidelines quarterly Communication 13.1 Approved guidelines are published monthly in the Trust s Staff Focus that is sent via to all staff Approved guidelines will be disseminated to appropriate staff quarterly via References Arena J, Emparanza Ji, Nogues A, Burls A (2005) Skin to calcaneous distance in the neonate. Archieves of disease in childhood, Fetal and neonatal, Vol 90(4) Clinical Guideline on capillary blood sampling (2006) 5

6 Gibbins S, Stevens B, Hodnett E, Pinelli J, Ohlsson A, Darlington G (2002) Efficacy and safety of sucrose for procedural pain relief in preterm and term neonates. Nursing Research Vol 51.6 pp Harrison D, Johnston l, Loughnan P (2003) Oral sucrose for procedural pain in sick hospitalised infants: A randomized controlled trial. Journal of paediatrics and child health Vol 39 (1) pp Shah V, Taddio A, Kulasekaran K, O Brien L, Perkins E, Kelly E. (2003), Evaluation of New lancet device (BD Quick heel) on pain response and success of procedure in term neonates, Archieves of pediatrics and Adolescent medicine, Vol 157 (11) Shepherd A, Glenesk A, Niven C, Mackenzie J, (2006) Midwifery Vol 22 (2) Appendix A Choose an appropriate site for sampling 6

7 Appropriate sites for Heel prick sampling 7