Phlebotomy for Health Care Support Workers

Lynne Powell RN. MSc. IP

Aims of the day

Understand the legislation, policy and practice used when obtaining a venous blood sample

Be able to recognize the anatomy and physiology relevant to obtaining a venous blood sample. From the ante-cubital fossa of adults and children over 12 years

Understand patient care while taking a venous blood sample. Demonstrate an understanding of possible adverse effects and how to

manage them should they occur while taking a venous blood sample Demonstrate and understanding of safe waste disposal. Demonstrate an understanding of infection control especially hand hygiene. Recognize the procedure, technique, materials and equipment for obtaining

venous blood samples. Recognise how to report, record and document venous blood samples. Safely perform venepuncture.

Accountability, competence & consentLynne Powell RN.MSc. ip

Objectives

Discuss the health care support worker code of conduct

Briefly define accountability, competence & consent

Briefly identify the issues and your responsibilities surrounding accountability, competence & consent

Define consent

Discuss the legal issues surrounding accountability, competence & consent

Code of Conduct for Healthcare Support Workers in Wales

(2011)&

Code of Conduct for Employers in Wales

(2011)

Codes of Conduct (2011)

Code of Conduct for Healthcare Support Workers in Wales

Code of Conduct for Employers in Wales

The purpose of both codes is to ensure a high quality service that focuses on the needs & experiences of individuals

The basic principle is service user safety and public protection

7 StandardsAs a health care support worker in Wales you must;

1. Be accountable for your actions & omissions

2. Promote and uphold privacy, dignity, rights and wellbeing of service users

3. Work in collaboration with colleagues and as part of a team

4. Communicate in an open and effective way

5. Respect a person’s right to confidentiality

6. Improve quality of care by updating your knowledge, skills and experience through personal & professional development

7. Promote equality

Answerability Responsibility Liability To be held to account Authority Autonomy Open Transparency

What is accountability?

Accountability

To make a decision and be held responsible for the decision made

Things to consider:-Are you working in the best interest of the patient?Do you have the knowledge and skills to perform the task? If not – don’t do it, you must be competentIf you’re unsure ASKEnsure to keep up to date

Nurse/HCSW

EmployerLaw PatientNMC

Accountability

Competence

Specific knowledge, skills, judgments and personal

attributes required to practice safely

Competency Assessment Scale

1. I do not know the knowledge and skills required2. I know the knowledge and skills required but I don’t

have them.3. I know and I am developing the knowledge and skills4. I have the knowledge and skills, but I don’t use

them.5. I have the knowledge and skills, and I use them

regularly

(WiPP /NHS UNIT 3 – Competence from a HCA’s perspective)

There are National standards to describe the performance level expected of someone doing a particular task.

To find out more access Working in Partnerships Programme

(WiPP) – NHS. Skills for Health (competencies for the

healthcare workforce) (http://www.skillsforhealth.org.uk)

Consent

Permission for something to happen

or

agreement to do something

Informed consent

Informed consent is based on a clear appreciation and understanding of the facts, implications and future consequences of an action

Patients have the right to make decisions about their own health and medical care

Balance of risks and benefits of treatment

Consent must be voluntary

Failure to obtain consent can be viewed as assault

Implied consent

Code of Conduct for Employers in Wales (2011)

• Employers have to provide mentoring, supervision, monitoring and assessment for the HCSW

• HCWS should have a named mentor

Employers must:

1. Employ suitable individuals who understand their roles, accountability & responsibilities

2. Ensure HCSW are able to meet the requirements of the Code of Conduct (2011)

3. Provide education and training

4. Promote the HCSW Code of Conduct

Employers

Employers are legally responsible for the actions you carry out during the course of your employment. This is known as vicarious liability, and your employer will have insurance for this purpose. Vicarious liability is not optional and employers cannot choose to opt in or out. (RCN)

Vicarious Liability – (English Law) imposes a strict liability on employers for the wrongdoing of their employees while conducting their duties

Lister v Romford Ice and Cold Storage Co[81] created a controversial principle at common law that entitled an employer to recover the indemnity from the employee

The Legal System of the United Kingdom

The United Kingdom of Great Britain and Northern Ireland (UK) consists of four countries: England, Wales, Scotland and Northern Ireland. Some law applies throughout the whole of the UK; some applies in only one, two or three countries.

The four principal sources of UK law are legislation, common law, European Union law and the European Convention on Human Rights. There is no single series of documents that contains the whole of the law of the UK.

For practical purposes, the most significant distinction is between civil law and criminal law.

Civil law covers such areas as contracts, negligence, family matters, employment, probate and land law.

Criminal law, which is a branch of public law, defines the boundaries of acceptable conduct. A person who breaks the criminal law is regarded as having committed an offence against society as a whole.

How CRIMINAL LAW is enforced in England and Wales

A person who believes that a crime has been committed contacts the police, who conduct an investigation. If, after arresting and interviewing a person, the police believe that he or she committed the crime, that individual is charged. A report of the case is then sent to the Crown Prosecution Service (CPS).

If the CPS believes that the case has a reasonable prospect of success, and that it would be in the public interest to do so, it will start criminal proceedings against the suspect, who becomes the defendant in the case. In court, the CPS bears the burden of proving, beyond reasonable doubt, that the defendant committed the crime.

How CIVIL LAW is enforced in England and Wales

A person who believes that another individual or organisation has committed a civil wrong can complete a claim form and send it to the appropriate court.

The person who starts a civil case is called a claimant, and he or she has the burden of proving that, more probably than not, the other party (the defendant) committed a civil wrong. If the claimant is successful, the usual remedy is damages: a sum of money paid by the defendant to the claimant.

Negligence

The law of negligence

This allows a civil action to be taken to financially compensate the person who has suffered unwarranted harm, or damage at the hands of another.

Negligence has been defined as :

The omission to do something which any reasonable man would do, or to do something which a reasonable man would not do

For a case of negligence to be proved by the claimant, three elements must be satisfied.

The defendant owed a duty of care to the claimant

There was a breach of that duty of care

Harm occurred as a direct result of that breach in duty of care

Personal Development Plan

(PDPs)

Up to date job description

Personal development plans

Helps identify own training and development needs

Demonstrates personal development and career progression

Can be used as a tool for annual performance review/appraisal

Assists employers and managers to identify areas that need improvement in the practice

http://www.wales.nhs.uk/sites3/home.cfm?orgid=739

Infection control and safe waste disposal

Infection control

Taking blood is the most common intervention that breaches the circulatory

system. Therefore compliance with policies and procedures is important to prevent infection

Why hand washing is so important?

Good hand hygiene is one of the single most effective measures for preventing

the spread of infection

Our hands move germs from one place to another

By hand washing, we remove transient micro- organisms acquired by recent contact with infected patients, or with the environment

Hand washing protects both patients, and staff

What Lives on our hands?

Transient flora – acquired by contact these micro-organisms survive on the skin for less than 25 hours and can be removed by hand washing.

Resident flora – part of our normal skin flora these micro-organisms survive and multiply on the skin, they rarely cause infections (other than skin infections) except when introduced into the body through invasive procedures

When to decontaminate hands.

Every healthcare worker should conduct a risk assessment to determine when to

decontaminate

Before contact with a patient

After completing tasks where hands may have become contaminated with micro-organisms

When hands are visibly dirty or soiled

Between different types of cleaning procedures

Types of Hand Washing

SocialHygienic (aseptic)Surgical scrub

Social Hand Washing

Soap and Water

Reduces the numbers of transient micro-organisms upon hands.

Renders hands socially clean

Sufficient for most daily activities

Social Hand Hygiene with Alcohol Gel

• Visibly Clean Hands

• Utilise approx 3 mls

• Allow hands to dry prior to patient contact.

• NOT in cases of D&V

• Hands must be dry prior to patient contact

Hand Drying

Micro-organisms transfer most effectively from wet

surfaces so always dry hands thoroughly with

disposable paper towels.

Skin Care

Frequent hand washing can cause long term changes in the skin.

• Always put soap onto wet hands.

• Apply hand cream regularly to protect skin

• Report any skin irritation/ abnormality to occupational health advisor.

Other Measures

• Wear Short Sleeves

• Do not wear wrist watches

• No jewellery to hands or wrists other than wedding band

• Short Nails

• No False nails/ Nail Extensions

• Moisturise Hands

Protective clothing

It is appropriate for practitioners to wear non-sterile disposable gloves and disposable apron

Wearing gloves does not protect against needle-stick injury but will protect against splashing or spillage

Always ask about latex allergy if gloves are worn – use latex free gloves

Waste disposal

Hazardous Waste Regulations 2005

Defined with the European Waste Catalogue (EWC)

Doesn’t include domestic waste

Regulated by the Environment Agency

Failure to comply can incur fixed penalty notices, fines and even terms of imprisonment

Duty of care applies to everyone in the management chain; from the person who produces it to the person who finally disposes of, or recovers it.

Use and disposal of sharps

needle-stick injuries lead to increased exposure to blood-borne viruses. This can cause pain and anxiety. Sharps injuries can be prevented by careful adherence to good practice.

Needles should never be re-sheathed

All sharps should be disposed of at point of use

Needle Stick Injuries

Bleed the site and wash under running water

Inform the patient

Take the patient’s full details and contact number

Report the incident and give patient’s details to Clinical Governance lead for risk assessment.

Incident report

Environment

Check that the area where venepuncture is to be carried out is clean and tidy.

Ensure that all equipment is easily accessible, sterile where necessary, intact and in-date.

Ensure good lighting.

Tourniquets can be a source of infection.

Pre-test checks and record keeping

Aim

Discuss anxiety

Identification

confidentiality

Record keeping

Anxiety

Anxiety can be caused by: -

The undergoing investigations

Previous bad experience

‘needle phobia’

General dislike of medical procedures

Reducing anxiety

Talk to the patient (check identity).

Ask if they’ve had blood taken before.

Do they know what the blood test is for?

Explain how to obtain the results.

Distraction can be useful (cough technique; creams).

Be honest with the patient – regarding pain.

Talk the patient through the procedure.

Identification

Implications of mis-identification

Unnecessary tests performed

Wrong procedure performed

Wrong results given

Wrong medication

HARM TO PATIENT

Patient Identification

Full name

Date of birth

Address

NHS number

All these are used to identify a patient – remember if this information is lying about others can identify the individual and confidentiality may be breached

Confidentiality

You have a duty to protect the patient’s information.

It is generally accepted that information provided by patients is given in confidence.

The Data Protection Act (1998)

Caldicott Report

The Human Rights Act (1998)

Data protection Act (1998)

In March 2000, the Data Protection Act 1998 became law and applies to all organisations. It covers computer and manual records across all departments where patient information may be collected and used.

The principles in the Act state that information must be: 

Held securely and confidentially

Obtained fairly and efficiently

Recorded accurately and reliably

Used effectively and ethically

Shared appropriately and lawfully

The Caldicott Report

Caldicott Report provides a number of principles & recommendations aimed at supporting the NHS in improving the way it handles identifiable information.

Access to patient information is granted on a strict need to know basis.

Staff have a responsibility to keep information confidential and ideally should have a confidentiality clause in their contract of employment.

The Human Rights Act 1998Article 8 – The Right to Respect for Private and Family Life

The right to respect for private life The right to respect for family life The right to respect for one’s home The right to respect for correspondence The Act can be used only against a public

body therefore the NHS are subject to the Act

Failure to comply with either the

The Human Rights Actor

The Data Protection Actcould lead to litigation

Good record keeping

meets legal requirements.

protects staff in legal situations.

meets professional statutory requirements.

supports clinical audit.

Good record keeping helps to protect the welfare of patients by promoting:

High standards of clinical care.

Continuity of care.

Better communication and dissemination of information between members of the inter-professional health care team.

An accurate account of treatment and care planning and delivery.

The ability to detect problems, such as changes in the patient’s condition, at an early stage.

Record keeping

ENSURE YOU HAVE THE CORRECT PATIENT Remember the patient’s record is a legal document. Remember patients have the right to access their

medical records. Record information as soon as it is obtained to

minimise the chance of mistakes. Involve the patient in the compilation of their records. Enter recordings into the correct Read codes. Record the facts. Avoid abbreviations as they can be confusing Avoid duplication.

Taking a blood sample

Aims

Describe the anatomy of the ante-cubital fossa

Discuss the appropriate choice of vein

Preparing the patient for taking blood

Idendtify the order of draw

Factors affecting venepuncture

Discuss adverse effects and how to manage them

Choice of vein

The vein should be easily accessible.

Choose a vein that can accommodate repeated blood samples.

Choose sites that are less sensitive.

Do not choose veins that are adjacent to an infected area.

CVA/mastectomy – do not use affected arm.

The tourniquet may cause pain if joints are inflamed through rheumatoid arthritis.

Preparation

1. Wash hands

2. Assemble the equipment - maintain sterility

3. Identify the patient

4. Identify the tests required on the form

5. Allow the patient time to ask questions & express concerns

6. Site patient – comfortable position arm extended & supported

Action & observation

• Determine the patient’s preferred site.

• Ensure patient’s skin is clean.

• Apply tourniquet (quick release) to upper arm approximately 3-4 ins above puncture site.

• Apply enough pressure to stop venous flow but not arterial flow – check pulse.

• Observe and palpate selected vein (do not over palpate).

• Instruct the patient to hold still.

Action & observation

Insert the needle into the vein. Once blood is flowing freely release tourniquet. Fill each tube to its mark. Invert the tube 8-10 times (do not shake) Place cotton wool over site. Remove needle. Apply pressure to site. Dispose of needle appropriately. Check site and apply dressing, ensure patient comfort. Complete labels on sample bottles.

Order of draw

Blue tubes

Red tubes

Yellow tubes

Purple tubes (EDTA)

Grey tubes

Factors affecting the sample

Wrong bottle used

Wrong order of draw (contamination)

Tourniquet too tight

Sample left overnight

Mislabeling

Bottles not filled

Potential complications

Excessive bleeding

Drug therapy (e.g. aspirin; clopidogrel; warfarin; heparin)

Disease process (liver disease; hemophilia; von Willebrand disease; deficiency of vitamin k.)

Prevention – ASK; don’t overuse tourniquet; may need clotting therapy before venepuncture

Potential complications

Haematoma – collection of blood leaked from the vein at the puncture site.

Causes

Overshooting the vein

Inadequate pressure applied after procedure

Failure to release the tourniquet before removing the needle

If haematoma occurs during the procedure, remove tube, release tourniquet, remove needle, apply firm pressure for 2-3 mins and raise arm.

Potential complications

Bruising caused by blood seeping into the tissue. May occur in patients that bleed easily. Drugs(e.g. aspirin)

Preventable by

Using suitable veins

Correct angle and insertion technique.

Do not apply excessive pressure during procedure, with tourniquet.

Use skin traction during insertion.

Apply adequate pressure after procedure

Potential complications

Arterial puncture – leads to bright red blood pulsating into the tube. Preventable by thorough assessment of site and correct insertion technique.

Management: -

Remove needle, apply digital pressure for 5 mins then pressure bandage for 5 mins. Do not reapply tourniquet to that arm for 24 hrs. seek medical help. Needs to be reported (pt records and incident reporting)

Potential complications

Excessive pain – caused by frequent use of vein, poor technique (blind plunging where a nerve or valve is touched), anxiety, fear or low pain threshold.

Ensure patient is comfortable, arm supported

Avoid sites of known nerves (lower part of cephalic vein, near wrist),

Consider local anaesthetic cream

Distraction – ask pt to concentrate on breathing

If possible nerve damage – seek help from Dr. or nurse

Potential complications

Fainting

Some patients may feel weak and become dizzy or faint. Patients have no control over this condition.

Call for help.

Ask the patient to put their head between their knees.

If they feel no better help them to the floor – lie them flat - ensure a safe environment.

Get help (phone).

Potential complications

Remember

Most complications are preventable

Assess site thoroughly

Use correct insertion technique

Use appropriate use of tourniquet

Avoid blind plunging

Safety checklist

Do you have the right person? Is the patient comfortable and easily accessible? Are you comfortable? Is there a history of fainting? Is equipment ready and accessible (e.g. sharps bin)? Is your work area clean and tidy? Do you have adequate lighting? Ensure you have the correct patient Enquire about allergies (e.g. latex; plasters) Use quick release tourniquet. Do not re-sheath used needles.

All adverse incidents should be reported and an

incident form filled in

Finally