Phlebotomy Protocol - Southern Health NHS Foundation Trust · 2 SH CP 83 Phlebotomy Protocol...

1 SH CP 83 Phlebotomy Protocol Version 4 October 2018

SH CP 83

Phlebotomy Protocol

Version: 4

Summary: To enable Southern Health Staff to be confident and competent, undertaking

phlebotomy when it is judged clinically safe and appropriate to do so.

Keywords: Phlebotomy, venepuncture, consent, competency, blood tests, Vacutainer,

butterfly, blood cultures, disposable tourniquet, restraint, order of draw

Target Audience: Health Care Professionals according to agreed roles and responsibilities within

their job description

Next Review Date: October 2021

Approved &

Ratified by:

Patient Safety Group Date of meeting: 20th September 2018

Date issued: October 2018

Author: Clinical Education Team

Accountable

Executive Lead:

Director of Nursing and Allied Health Professionals


Version Control

Change Record

Date Author Version Page Reason for Change

Aug 2014

Jane Byrnell 2 all Replace ANTT terminology with ‘Aseptic Technique’

Nov 2015

Wendy Eastman 3 Review date extended from Nov 15 to Feb 16 to allow for policy review

15.12.15 Wendy Eastman 3 4 6 7 10/11 13 14 15 17

Policy review Definition of aseptic technique changed as per IPC Policy Included wording Safety devices in line with Trust policy Included wording Blood cultures should only be collected by members of staff who have been trained …. Add the wording Do not re-palpate the skin after cleaning Add the wording Also check the blood culture bottles to ensure it is in date Add Do not re-palpate the skin after cleaning After blood cultures are taken clearly document in medical records Updated reference NMC The Code 2015 Review date extended for further 2 years

4.5.16 Wendy Eastman 2 4 2.2 additional wording regarding phlebotomy on the under 18s

20/10/17 2 Review date extended for 6 months (February to August 2018)

June 2018

Clinical Education Team

4 4 & 8 4 4 5 7 8 9 10 12 13 18-25

Policy review - Multiple changes throughout to clarify protocol, including rearranging sections. Included best practice and updated to be in line with current national guidance and SHFT policy. Use of non-sterile not sterile gloves for blood cultures according to aseptic policy and IPC team advice Definitions clarified and checked against other updated policies Blood cultures definition changed as per IPC and Aseptic technique policy from sterile gloves to non-sterile gloves Restraint definition changed to be in line with restraint policy on advice of supporting safer services Phlebotomy under restraint section written by lead supporting safer services team Update skin cleansing with regard to iodine allergy Clarifying four points of identification in alignment with IV, Medicines and Blood transfusion policy Section on problems in practice added to Clarified training and competency requirements References updated Procedures removed from main text, updated and added as appendices. Review date set for 3 years.

Reviewers/contributors

Name Position Version Reviewed & Date

Simon Johnson Resuscitation Officer Version 1 2012

Marie Corner Medical Device Advisor Version 1 2012

Wendy Eastman GP Development Lead V 3 Nov-Feb 2016

Sue Gasparro Clinical trainer V 3 Nov-Feb 2016

Mandy Lyons Clinical educator V 3 Nov-Feb 2016 & Jan 2018

Sharon Guy Lead Clinical educator V 3 Nov-Feb 2016 & V4April 2018

Theresa Lewis Lead Nurse IPC V3 Feb 2018

Steve Coopey Head of clinical development Bands 5 and above V 4 Feb 2016

Claire Hollywell Clinical educator V 4 June 2018

Virginia Roberts Clinical educator V 4 June 2018

Claire Rawasa Clinical educator V 4 June 2018

Jacky Hunt Lead Nurse Infection Control V3 June 2018

Lucy Abraham Supporting safer services Team V 4 June 2018

Sam Boyes Supporting safer services Team V 4 June 2018

Lee Spencer Supporting safer services Team V 4 June 2018

Tracy Hammond Medical Devices Adviser (MDSO V4 October 2018


Contents

Section Title

Page

1. Introduction

4

2. Scope

4

3. Definitions

4

4. Duties and responsibilities

6

5. Assessment and preparation for phlebotomy

8

6. Management of problems in practice

10

7. Training requirements

11

8. Associated Documents

12

9.

Supporting references 12

Appendices

A1

Training needs analysis 14

A2 Evidence of clinical practice

15

A3 Evidence based guidelines of clinical practice – Phlebotomy procedures

18

A4

Level of competency rating scale 26


Phlebotomy Protocol

1. Introduction 1.1 This protocol details the correct technique for obtaining a specimen of blood for the purposes of

phlebotomy, and reduces the risk associated with phlebotomy for both patients and staff. The risks include haematoma, pain, localised infection and sepsis, inappropriate blood sampling, errors in collection and occupational sharps injury for staff. Adherence to the protocol will substantially reduce the risk to both patients and staff.

1.2 Phlebotomy is the drawing of blood from a vein by the insertion of a needle to collect samples for

analysis. Poor collection technique can lead to inaccurate and misleading blood results. The three major errors in collection are haemolysis, contamination and inaccurate labelling (WHO 2010).

2. Scope 2.1 This protocol is for all healthcare professionals working within Southern Health who are

performing adult phlebotomy within Southern Health as part of their job description in all hospital and community settings.

2.2 When required for services that provide phlebotomy to patients under the age of 18, this must be

agreed with their clinical manager who must ensure that staff are competent to undertake this task and it is within their job description.

3. Definitions/ Glossary of terms 3.1 Adult - A person aged 18 years or more. 3.2 Aerobic Bacteria – Bacteria that can only replicate in the presence of oxygen. 3.3 Anaerobic Bacteria – Bacteria that can only replicate in the absence of oxygen. 3.4 Aseptic technique – Aseptic Technique is defined as a means of preventing or minimising the

risk of introducing harmful micro-organisms onto key parts or key sites of the body when

undertaking clinical procedures.

3.5 Bacteraemia – The presence of bacteria in the blood stream. 3.6 Blood Cultures – Blood Cultures are a test used to detect the presence of pathogenic micro-

organisms, such as bacteria, in the blood. Blood culture samples must be drawn before any other samples and the procedure must adhere to an aseptic technique as these samples are subject to contamination with normal skin flora. Always obtain using non-sterile gloves and a disposable apron.

3.7 Blood Test - Obtaining a representative blood sample for analysis. 3.8 Butterfly Collection System - A system for blood collection to be used when a patient has

fragile skin and /or thin veins 3.9 Central Line Sampling - Taking blood samples from central lines requires specific competencies

and is therefore outside the scope of this policy. Refer to SHFT Policy SH CP 137 Intravenous therapy and peripheral cannulation policy


3.10 Collection System - A disposable singe use device such as Vacutainer or BD used to withdraw

blood into pre-vacuumed blood bottles 3.11 Competency - Can perform an activity with understanding of theory and practice principles

without assistance and/or direct supervision

3.12 Consent - “Consent is based upon giving accurate information which is confirmed as having been understood, either verbally, by gesture or in writing.”

3.13 Contaminant –

a) A micro-organism inadvertently introduced into the sample from the environment, skin of the operator or patient which leads to a false positive result.

b) A tube additive, which may be carried over to subsequently drawn samples producing incorrect results.

3.14 Culture and Sensitivity (C&S) - A microbiology investigation to assist in the management of the

septic patient, identification of the causative organism and antibiotic therapy. 3.15 Disposable Single Use Tourniquet - A disposable single use device that promotes venous

distension for insertion of a needle. It should remain taut for a maximum of 60 seconds. 3.16 Haemoconcentration - Applying a tourniquet for over 60 seconds causes stasis trapping blood

cells and larger molecules whilst water and small solutes are able to pass through. This results in cells and large molecules becoming more concentrated in the sample leading to erroneous results.

3.17 Haemolysis - Damage to red blood cells which releases potassium into the serum invalidating a

number of biochemical parameters. 3.18 Health Care Professional - Health Care Professionals, staff who are registered with their

appropriate governing body (e.g. GMC , NMC, HCPC GDC). A registered practitioner or non- registered practitioners specially trained to perform phlebotomy e.g. bands 2, 3, 4 and phlebotomists.

3.19 Order of Draw - The sequence of obtaining blood samples to prevent contamination of tube

additives. It is in accordance with local pathology department procedures. 3.20 Personal Protective Equipment (PPE) - Single use disposable equipment designed to protect

the patient and member of staff, these include disposable gloves and aprons. 3.21 Phlebotomy - Phlebotomy is the drawing of blood from a vein by the insertion of a needle to

collect samples for analysis. 3.22 Restraint - Restrictive interventions are defined as deliberate acts on the part of another person

(persons) that restrict a service users movement, liberty and/or freedom to act independently. Refer to Restrictive interventions policy SH NCP 23

3.23 Sepsis - A systemic and life-threatening response to infection that can lead to tissue damage,

organ failure and death 3.24 Sharps Box - A container approved and tested to the appropriate standard for the safe disposal

of items that may present a sharps injury risk 3.25 Skin Preparation - All inpatients or those requiring blood cultures require skin to be cleaned

using a Clinell 2% chlorhexidine in 70% isopropyl alcohol sterile wipe or a suitable alternative.


Care should be taken with the use of products containing chlorhexidine as evidence suggests, although rare, it is known to induce hypersensitivity, including generalised allergic reactions and anaphylaxis in some individuals. In this case a suitable alternative i.e.: povidone-iodine in 70% alcohol should be used.

3.26 Povidone-iodine in 70% alcohol – a solution to be used to cleanse the skin or equipment if a patient is allergic to chlorhexidine gluconate. Checks must be made against manufacturers guidelines of compatibility with the equipment in use.

3.27 Vacuum System - A specifically designed vacuum system which comprises of:

a) Pre vacuumed blood sample tube b) A double ended needle and plastic needle holder or a c) A ‘winged’ needle (Butterfly) and associated tubing, Luer adaptor and plastic

Holder

It must include safety devices in line with Trust policy to minimise the risk of needle-stick injuries. 4. Duties / Responsibilities 4.1 Ward/Department Managers need to ensure adequate stock of appropriate sampling equipment

is held and that all staff members who are required to perform phlebotomy are appropriately trained and have their practical competency formally assessed, successfully achieved and documented. Staff performing this task must also have completed an aseptic technique competency assessment (on line eLearning followed by practical assessment in the workplace, at least once in their employment with Southern Health, a copy of which should be retained by employer and manager – see Aseptic and Clean Technique SHCP13.

4.2 Professional Accountability and Legal Issues

Health Care Professionals should uphold their professional standards e.g. “The Code” (NMC 2015). When delegating to a non registered practitioner the trained nurse must ensure the health care support worker or phlebotomist has completed phlebotomy training and has successfully passed the practical competency assessment.. Competency can be signed off by a healthcare professional who is competent at a level 4 or above according to the SHFT competency rating scale. Competencies must be signed off within six months of completing training. The healthcare professional must successfully undertake ten withdrawals of blood using a vacutainer needle in the antecubital fossa before their competency is completed.

Any Health Care Professional has the right to refuse undertaking phlebotomy if they have concerns about the patient’s veins or the patient’s condition; if they do not feel confident to undertake the procedure or if no blood sample request form has been completed.

All healthcare professionals should identify the patient prior to phlebotomy using a minimum of four forms of identification that includes the forename and surname and NHS number or hospital number and Date of Birth and address. NHS numbers must be stated on all relevant documentation and on Community Hospital patient identification bracelets. Information should be obtained using open questions.

It is a legal and ethical principle that practitioners obtain valid informed consent prior to this procedure. Consent is based upon giving accurate information which is confirmed as having been understood, either verbally, by gesture or in writing. Practitioners need to adhere to the principles and practices of the Mental Capacity Act 2005.


All record keeping must adhere to standards set out by the Southern Health Clinical Record Keeping Policy SH CP 221. Additionally, only the person who takes the sample can label the blood bottle. Blood cultures should only be collected by members of medical or nursing staff that have been trained in the collection procedure and whose competence in blood culture collection and aseptic technique has been assessed and maintained. Blood sampling prior to blood transfusion including cross match and group and save can be taken by any member of staff who is competent in phlebotomy. Refer to Blood Transfusion Policy SH CP 42

4.3 Restraint

Patients requiring phlebotomy, who are detained under the Mental Health Act (2005), may require restraint to obtain the blood sample. When considering using restraint there must be objective reasons to justify that restraint is necessary. It must be a multidisciplinary decision making process, and will require assessment for mental capacity to consent to phlebotomy. Staff should be able to identify that the person being cared for is likely to suffer harm should the blood test not be performed. Proportionate restraint should be used. A carer or professional must not use restraint just so that they can do something more easily. The recording of the decision making process and the rationale must be documented in the patients notes including care plan and risk assessment. This decision making should be individualised and include the rationale regarding device and site to be used. Staff undertaking restraint should have attended and be in date with training in Supporting Safer Services (sSs) and are confident and competent in undertaking restraint. The staff undertaking the phlebotomy should be competent and experienced in phlebotomy. If restraint is necessary to prevent harm to the person who lacks capacity, it must be the minimum amount of force for the shortest amount of time It is recommended that the team practice holds and positioning prior to engaging with the patient. Further advice and support can be sought from the SSS team . If considering taking blood under restraint staff should first refer to SH NCP 23 Restrictive Interventions Policy and Restrictive Practices Policy SH NCP 83.

4.4 Infection Control

All phlebotomy procedures require the use of an aseptic technique, with observation of the standard precautions and product sterility. The practitioner should ensure a thorough hand hygiene technique with alcohol sanitising foam or soap and water if hands are visibly soiled, ensuring arms are bare below the elbow, no nail varnish or false nails; any cuts and abrasions to be covered with secure waterproof plaster. Infection Prevention and Control policies should be followed at all times. Skin cleansing - Outpatient clinics and patients in their own homes only require skin cleansing –with soap and water and 2% chlorhexidine in 70% isopropyl alcohol – if the skin is visibly soiled or if the patient is immunocompromised. Inpatients should have skin cleansed with 2% chlorhexidine in 70% isopropyl alcohol. Wipe the area for 30 seconds then allow at least 30 seconds for skin to air dry In the event of patient allergy to chlorhexidine, use povidone iodine as an alternative cleanser if compatible with equipment (see manufacturers guidelines). Aseptic Technique - A closed sterile system should be used at all times. (E.g. Vacutainer system components and appropriate vacuum system sampling tubes.) Protect key parts (the needle) from contamination before insertion. Do not re-palpate site after cleansing, even whilst wearing gloves.


Non-sterile NITRILE single use gloves must be worn for a phlebotomy procedure and a disposable apron should be worn. Refer to Aseptic and Clean Technique Procedure SH CP 13 for further guidance. For blood cultures, non-sterile gloves and an apron must be used. Single use disposable tourniquets must always be used.

5. Assessment and preparation for phlebotomy 5.1 Patient preparation

Phlebotomy is performed to provide diagnostic or therapeutic monitoring information, including the provision of compatible samples for blood transfusion. It is essential that samples obtained are accurate and representative of the patient’s true condition and free from contamination. Correctly matching patient details to the blood sample(s) is absolutely vital. The procedure must be explained to the patient, discussing the need for the blood sample to be taken, and informed consent for the procedure must be obtained, also establishing whether the patient has any known allergies. If the patient is anxious or expresses that they are needle phobic, or any other condition that might make phlebotomy difficult they may benefit from a topical anaesthetic. This requires a prescription. Two possible phlebotomy sites should be chosen for application of the topical anaesthetic to give the phlebotomist a choice of site. These areas should be covered with a transparent film dressing, and left for 45-60 minutes as per prescription advice. Prior to obtaining samples the cream must be removed from the sites.

5.2 Blood form

Before undertaking phlebotomy, a blood form must be completed by a clinician. This form should contain the rationale for taking blood, the tests that are required and four points of identification of the patient as well as the signature of the clinician. There should be a clear identification of clinical need for blood to be drawn. Ideally the blood form should be present for the procedure to enable accurate identification checking. If an order to take blood is given verbally or via telephone, the following needs to be recorded:

The blood requested and rationale

Signature of the person (or people) taking the request – ideally this would be two healthcare professionals

Whether it is a verbal or telephone request In the event of a telephone request, the blood form must still be sent with the sample and four points of identification should still be taken place when labelling blood bottles and checking the blood form.

Identify patient by the forename and surname, NHS number or hospital number, date of birth and address (by using open questions).

The correct order of draw must be used when taking blood, to eliminate the risk of additive cross-contamination during phlebotomy and to reduce the risk of clotting in some blood tubes. Blood bottles must be labelled immediately, at the patient’s side, by the person who took the blood to avoid labelling errors (SHOT 2016).


5.3 Sites for phlebotomy When undertaking routine phlebotomy,

First choice is the antecubital fossa with a Vacutainer needle.

The second choice is the antecubital fossa with a butterfly collection set.

The third choice is the dorsal aspect of the hand with a butterfly collection system.

In exceptional circumstances, other alternative sites may be used such as feet. This must be a clinician’s decision and should only be used by an experienced practitioner upon medical advice.

When using the dorsal aspect of the hand for phlebotomy, ONLY a butterfly collection system can be used. Rationale for using any site other than the antecubital fossa must be clearly documented. When these areas are not available or suitable, then medical advice must be sought.

Sites considered unsuitable for phlebotomy would include:

Infection - signs might include redness, hot to touch, tracking, swelling or pain.

Phlebitis

Trauma/ burns

Inflammation

CVA – although an affected limb could be used if there are no contracture or swelling and good circulation is present

Mastectomy with lymph node removal

Arm with below elbow amputation

Fracture

Bruising

Previous blood sampling or cannulation- causing thrombosed/sclerosed/fibrosed hard veins

Lymphoedema

Oedema

Eczema

Contractures

Existing IV lines- avoid arm if IV infusion in progress or cannula in situ

Fistula site for haemo-dialysis

Drug users who have over-used veins

Tattoos Only two attempts should be made to obtain a blood sample from the patient, using new equipment on each occasion. If second attempt is unsuccessful, a different competent practitioner may attempt phlebotomy one more time from a different site. A maximum of three attempts should be made at any one time. Failed attempts should be documented in the patient notes. Document the site used and seek further medical advice.

5.4 Sharps Needle safe devices MUST be used. Sharps should not be passed directly from hand to hand at any point during the procedure and handling should be kept to a minimum. Sharps should be disposed of immediately into a sharps container which is at the patient’s side. Specimens and sharps must be transported safely, with the sharps container aperture closed between uses, and according to the Transport of Clinical Specimens procedure SH CP 34.

5.5 Blood Cultures

Blood culture samples should only be requested, if systemic and localised bacterial infection, including suspected acute sepsis meningitis, osteomyelitis, acute untreated bacterial pneumonia, or fever of unknown origin is suspected. This must be an aseptic technique, and requires additional equipment.


If blood cultures are required they should be taken prior to the administration of antibiotics. If a patient is already on antibiotics, blood cultures should ideally be taken immediately before the next dose (with the exception of paediatric patients). (DH Saving Lives 2007).

In patients with suspected bacteraemia, it is generally recommended that two sets of cultures are taken at separate times from separate sites. DO NOT use existing peripheral lines/cannula or sites immediately above peripheral lines. If a central line is present, blood may be taken from this and from a separate peripheral site when investigating potential infection related to the central line; the peripheral vein sample should be collected first. Identify a suitable phlebotomy site before decontaminating the skin. Avoid femoral vein puncture because of the difficulty in adequate skin cleansing and disinfection (DH Saving Lives 2007). Ideally, remove the plastic cover of the blood culture bottles immediately before collecting the sample; the top of the bottle will be clean but not sterile. Disinfect the tops of the culture bottles with a 2% chlorhexidine in 70% isopropyl alcohol impregnated swab. Allow the alcohol to fully evaporate for 30 seconds before proceeding with obtaining blood culture.

6. Management of potential problems in practice

Venous spasm is a sudden involuntary contraction of the vein, resulting in temporary cessation of blood flow in the vein caused by fear, anxiety- stimulated by cold or mechanical or chemical irritation. In the event of venous spasm withdraw the needle and try a different site – using new equipment – aiming to get the needle into the centre of the lumen. The reluctant vein: Identify – and address where possible – any factors that are contributing to the constriction of blood vessels such as anxiety, temperature, mechanical or chemical irritation as well as the clinical state of the patient e.g. dehydration and deterioration. When attempting to take blood samples you must only ever have two attempts on a patient. Try to have both attempts on the same arm so another member of staff can have an untouched arm. If the second nurse is unsuccessful after one attempt then seek advice from the GP. Difficulty locating a suitable vein- Application of the tourniquet can promote venous distention. Lowering the arm below the level of the heart may also help. Vasodilation can be encouraged by application of a warm pack or immersion of the arm into warm water. Haematoma is a localised collection of blood outside the blood vessels, due to trauma which involves blood continuing to seep from broken capillaries. This is the most common complication arising from venepuncture. Causative factors are generally, poor technique, failure to release the tourniquet before removing the needle, inadequate pressure on the site after the needle has been removed, especially in patients receiving anticoagulation therapy. If the patient bends their arm up following the procedure, this may also lead to extensive bruising; encourage keeping arm straight and applying direct pressure. Pain/ nerve injury/ damage to adjacent structures: When inserting a needle into a vein it is important to look and feel for the valves so that the needle is not inserted into a valve. If this occurs the patient will experience pain which may be described as an ‘ electric shock’ or a ‘pins & needles’ sensation if nerve has been injured. Aim to minimise patient anxiety and discomfort. Consider use of topical local anaesthetic prior to the procedure. Accidental damage although rare, the nerve, artery or tendon may be punctured. This can cause pain, damage or excessive bleeding. This can be reduced by spending time ensuring the vein is identified before cleaning and commencing the procedure. Should this occur, stop, apply pressure, reassure the patient, obtain help from a colleague if required, document in the patient’s record report incident.


Accidental arterial sample – An artery will have a pulse. In the rare event of placing a needle in an artery rather than a vein, the blood bottle will fill very quickly with bright red, frothy blood. This sample can still be sent to pathology. On the blood bottle, identify that it is a possible arterial sample. Once the needle is removed, immediately place a gauze swab with very firm pressure. Ensure firm pressure is maintained for 15 minutes. If bleeding has not stopped at this point or the bleeding is excessive, seek medical attention. Bleeding – Some patients may be taking medications or have conditions that thin their blood and can cause prolonged bleeding. These medications may include but are not limited to warfarin, aspirin, heparin and clopidogrel. Identify this risk before undertaking phlebotomy. After withdrawing the needle, apply firm pressure to the site for 15mins. If bleeding continues, seek medical attention. Local and systemic infection – There is a risk of infection and sepsis from the introduction of a key part (the sterile needle) into a key site (patient’s vein). Phlebotomy must be undertaken as an aseptic procedure and correct Personal Protective Equipment worn during the procedure. The patient must be informed of signs of infection post procedure such as redness, swelling, temperature or feeling unwell. If these occur, they need to seek medical attention. Errors in collection/ inaccurate labelling – This can lead to samples being discarded by laboratory; repeat sampling required and delay in patient treatment. Inappropriate blood sampling such as patient identification errors result in repeated tests and therefore increased risk to the patient. Incomplete filling of blood bottle – A blood bottle may not completely fill if the bottle is damaged, the batch is faulty or the blood bottle is out of date. Always check the expiry dates of blood bottles before use. Ensure correct storage, avoiding extreme temperatures. In the instance of a blood bottle not filling completely, remove and discard. Use another bottle of the same colour to continue the procedure.

7. Training Requirements (refer to TNA in Appendix 1)

All staff must complete the aseptic technique e-learning package and have successfully completed the aseptic technique e-assessment before attending training – see section 4.1. If staff have received training within another trust, and can provide evidence of their competency and training, it may be an option to passport this training to their record. Prior to undertaking any phlebotomy procedure [including undertaking blood cultures, if appropriate], all staff must have attended and passed phlebotomy training, be able to demonstrate clinical competence at a minimum of level 3 competency and have a clear understanding of the underlying principles of practice. All staff who take blood samples as part of their job description should attend update training every three years, as recommended by WHO (2010).Any staff who are not confident or competent should attend a phlebotomy training course prior to practice and have successfully completed a period of supervised practice and competency which will include ten successful supervised withdrawals of blood from the antecubital fossa using a vacutainer needle. Patients who are detained under the Mental Health Act who require blood sampling – such as to monitor Clozapine or Lithium levels – may require restraint. Staff undertaking restraint should have attended and be in date with training in Supporting Safer Services (sSs) and are confident and competent in undertaking restraint. The staff undertaking the phlebotomy should be competent and experienced in phlebotomy.


8. Associated Documents

This policy needs to be read in conjunction with the current organisational policies for:

Aseptic and Clean Technique Procedure SH CP 13.

Blood Transfusion Policy SH CP 42

Clinical record keeping policy SH IG 01

Consent for Examination and Treatment Policy SH CP 16Hand Hygiene procedure SH CP 12.

Hand hygiene policy SH CP 12

Handling and Disposal of Healthcare Waste Policy SH NCP 47

Mental Capacity Act Policy SH CP 39

Patient Identification Policy SH CP 127

Restrictive interventions policy SH NCP 23

Restrictive practices policy SH NCP 83.

Standard Precautions procedure SH CP 19

Sharps and Inoculation management SH CP 14

Transport of clinical specimens procedure SH CP 34 9. Supporting References

Department of Health. Saving Lives: a delivery programme to reduce Healthcare Associated Infection including MRSA. (October 2007). Department of Health. Saving Lives: summary of best practice for blood cultures. (2011). Dept. of Health Reference Guide to Consent for Examination or Treatment. (2009). Epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England Ernst DJ, Calam R NCCLS simplifies the order of draw: a brief history. Medical Laboratory Observer.( May 2004: 36(5): 26-8). Golder M, Chan CL, O’Shea S, Corbett K, Chystie IL, French G. Potential risk of cross-infection during peripheral-venous access by contamination of tourniquets. The Lancet,Jan (2000; 355(9197):44) Mental Capacity Act (2005). Department of Health. London: Her Majesty’s stationary office. Madeo M, Jackson T, Williams C. Simple measures to reduce the rate of contamination in blood cultures in Accident and Emergency, Emergency Nursing 2011 National Association of Phlebotomists. Phlebotomy Manual 2004. National clinical policy and procedural guidelines for nurses and midwives undertaking venepuncture in adults. Office of the nursing services director – Ireland ( Nursing Midwifery Council (2015) The Code Nursing Midwifery Council. (2009) Standards for Record keeping . Norberg A, Christopher NC, Ramundo ML, Bower JR, Berman SA,


Contamination rates of blood cultures by phlebotomy Vs intravenous catheter. JAMA, (Feb 12; 2003: 289(6). 726-9). Rouke C, Bates C, Read RC. Poor hospital infection control practice in venepuncture and use of tourniquets. Journal of Hospital Infection. (2001;49: 59-61). Serious Hazards of Transfusion (SHOT) 9th Annual Report: (2016). UK Health Departments. Guidance for Clinical Health Care Workers: Protection from Blood-borne Viruses. Recommendations for the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis. Weinbaum FI, Lavie S, Danek M, Sixsmith D, Heinrich GF, Mills SS. Doing it right first time: quality improvement and the contaminant blood culture. Journal of Clinical Microbiology. (1997: 35(3), 563-5). Journal. (2005; 22:810-11). The World Health Organisation (WHO) Best practice in Phlebotomy. (2010)Grey A, Illingworth J. Right Blood, right patient, right time. Royal College of Nursing (2004). www.phlebotomy.org Further Reading The Blood Safety and Quality Regulations (2005). Her Majestys Stationary Office.

http://www.phlebotomy.org/


Appendix 1: Training Needs Analysis If there are any training implications in your policy, please complete the form below and make an appointment with the LEaD department (Louise Hartland, Quality, Governance and Compliance Manager or Sharon Gomez, Essential Training Lead on 02380 874091) before the policy goes through the Trust policy approval process.

Training Programme

Frequency Course Length Delivery Method Facilitators Recording Attendance Strategic & Operational

Responsibility

Phlebotomy after completion of

Aseptic Technique

Once after completion of aseptic technique

4 hours Face to face Clinical training

team MLE

Director of Nursing

Phlebotomy update

3 yearly update following initial training

4 hours Face to face Clinical training

team MLE Director of Nursing

Directorate Service Target Audience

MH/LD/TQ21

Adult Mental Health

All Health Care Professionals required to take phlebotomy samples from adult patients as part of their job description

Specialised Services

Learning Disabilities

ISD’s

Older Persons Mental

Health

ISD’s

Adults

ISD’s

Childrens Services

Not applicable

Corporate

All

Not applicable


Appendix 2: Evidence of Clinical Practice

Name: Role:

Base: Date initial training completed: Date aseptic technique e-assessment passed:

Competency Statement: To become a competent practitioner, it is the responsibility of each person to undertake supervised practice in order to perform phlebotomy in a safe and skilled manner. Please document successful phlebotomy attempts. You must have achieved 10 successful attempts before completing the competency.

Performance criteria Assessment method Level achieved Date Assessors signature

Details; gender, age, vein used

Comments e.g. number of insertions, reason

Pass or fail

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.


Phlebotomy Clinical practice competencies

Name: Role:

Base: Date initial training completed:

Competency Statement: The participant must perform this activity without assistance and/or direct supervision (level 3) See page 24 for level descriptors

Performance criteria Assessment method Level achieved Date Assessor/ Self assessed

The Participant will be able to:

1. The staff member must be able to demonstrate the following clinical skills

a) Identify and select appropriate equipment including needle, collection system, winged needle collection sets, blood collection tubes for routine tests.

Direct observation and questioning

b) Correctly identify the patient by open questioning, and explain procedure to gain informed consent

Direct observation

C) Select suitable phlebotomy sites.

Direct observation

d) Pre-pare puncture site and identify if the patient requires skin to be cleansed, if so what to use

Direct observation

e) Correctly apply and use a disposable tourniquet

Direct observation

f) State optimum time for tourniquet application

Direct observation

g) Apply PPE and perform phlebotomy safely using an aseptic technique

Direct observation

h) Perform phlebotomy safely causing minimum distress to patient Using appropriate techniques to reduce distress and anxiety

Direct observation

i) State the correct filling order of sample tubes (Order of draw)

Discussion and explanation

j) Invert sample tubes to ensure adequate mixing of tube additive.

Direct observation

k) Did the member of staff remove gloves decontaminate hands then label all samples correct ly at the patients side

Direct observation

l) Dispose of sharps immediately after use in the correct sharps bin

Direct observation

m) Does the sample tube show

the following information

Full name

Date of Birth

NHS Number Gender

Date sample taken

Are all details correct

Signature if required

2. Health and safety - Can the member of staff identify:

a) Safe practice when

assembling and handling

sharps

Direct observation


b) Carry out effective risk

assessment using appropriate

personal protective clothing e.g.

gloves and apron

Direct observation

c) Name three of the main blood

borne viruses and their risks

Questioning and answers

d) State the trust procedure

when dealing with a sharps

injury


e) Identify potential adverse

incidents or near misses and

report appropriately


3. Infection Control - The staff member can-

a) Demonstrate effective hand

hygiene in accordance with

Trust policy

Direct observation

b) Demonstrate an aseptic

technique

Direct observation

c) Identify single use items Questioning and answers

d) Describe how components of

the technique may change

according to the degree of risk


Date all elements of Competency Tool completed to level 3………………………………………

I confirm that I have attended initial training on …………………………………………………….

and that I am confident and competent in phlebotomy procedure.

Clinician ……………………………………………..Signature………………………………………

Status…………………………………………………. Date…………………………………………..

I confirm that I have assessed the above named Clinician and can verify that he/she demonstrates competency in phlebotomy practice. Verifier……………………………Signature………………….. Status………………. Date………..

Review Dates: Competent –

Yes / No Clinician Signature Verifier signature Comments


Appendix 3: Evidence Based Guidelines for Practice – Phlebotomy Procedures

Procedure for Vacutainer and Butterfly collection system phlebotomy

Action Rationale

Check the sample request form and ensure all required / relevant information has been entered. This should contain:

The rationale for taking blood

The tests that are required

Four points of identification of the patient

The signature of the clinician. There should be a clear identification of clinical need for blood to be drawn.

To ensure the request form is complete and accurately matches the patient’s personal identification details.

Equipment required for Venous Blood Sampling

Sample request form.

Single use disposable tourniquet.

Clean single use non sterile NITRILE gloves and consider disposable apron.

Appropriate skin cleansing agent such as 2% Chlorhexidine gluconate and 70% Isopropyl alcohol wipe or Povidone Iodine, if the patient is an in-patient on a ward, or if the patient is immuno-compromised.

Vacuum system components and appropriate sampling tubes. (All must be in date and if a butterfly system is to be used, then an additional tube is required to remove air from the butterfly system prior to samples being obtained).

Gauze swabs.

Appropriately labelled and tagged Sharps box.

Plastic, wipe clean tray or identified prepared area, cleaned with Clinell universal sanitising equipment wipes should be used to prepare equipment area.

All components must be within date.

To ensure the procedure has no unnecessary interruption and that all correct equipment is ready before procedure to promote aseptic technique.

Identify the patient by their first name, surname and date of birth, NHS number if available (verbally wherever possible using open questioning technique). Check these details match exactly with the request form. In-patients must be wearing a name band and the

details including hospital number checked. Any discrepancy, no matter how slight e.g. spelling error, must be clarified before procedure is performed.

To ensure correct identification of the patient and avoid erroneous results.

Explain the procedure to the patient allowing time for the patient to discuss previous difficulties or

anxieties. Obtain informed consent.

To obtain the patients informed consent.

To ensure patient cooperation and

reduce anxiety.

Observe the patients skin: If the patient has fragile This is to identify the correct site


skin, and/or thin skin consider using a winged needle (Butterfly) collection system with extension tubing if competent and confident to do so.

Cleanse tray or identified area with Clinell universal wipe and allow to air dry. Place equipment / collection system onto clean tray or dedicated area and ensure the sharps bin is located close by to ensure easy, safe access for immediate disposal of needle.

As per Aseptic technique and clean technique procedure SH CP 13.

Decontaminate hands following the Trust Hand Hygiene Procedure with soap and water or alcohol hand sanitizing foam if visibly clean

To reduce risk of infection.

Put on an apron and clean non sterile NITRILE gloves in order to connect needle to Vacutainer. Do not unsheathe the needle at this point.

As per Aseptic technique and clean technique procedure SH CP 13.

Position patient comfortably with the appropriate limb below the level of the heart, on a supported pillow or phlebotomy chair. Consider your own safety and moving and handling position when preparing to undertake phlebotomy.

To ensure comfort of the patient and reduce risk to staff.

If anaesthetic cream has been used, remove dressing and wipe the sites with a clean swab.

To ensure no contamination of site.

Apply single use disposable tourniquet 10cm above insertion site. Do not leave tourniquet on for more than 60 seconds. For very fragile skin, place a piece of single use gauze or single use paper towel between the tourniquet and the skin to prevent the skin from tearing. When selecting a vein, palpate potential sites, by looking and feeling for veins. They should feel springy when depressed and refill immediately when released. Avoid nodules (valves) in the veins and junctions where veins meet. Ensure there is no pulse felt before considering the site for phlebotomy. Suitable sites include the antecubital fossa, and the dorsal aspect of the hand. Should these sites not be available or suitable then medical advice must be sought. When accessing from a non-recommended site, documentation must contain who granted permission and rationale. Remove the tourniquet.

To avoid discomfort for patient and ensure a suitable site. To prevent fragile skin being damaged by tourniquet

Never attempt blood sample collection from any limb with an IV infusion, previous lymph node removal or any oedema or current fracture.

To minimise risks to the patient.

For ROUTINE samples, if required (for in patients or those visibly contaminated) cleanse the proposed puncture site with 2% Chlorhexidine gluconate and 70% Isopropyl alcohol wipe for at least 30 seconds and allow air-drying for at least 30 seconds.

To reduce risks of infection and cross contamination.


In the event of patient allergy to chlorhexidine, use povidone iodine as an alternative cleanser if compatible with equipment (see manufacturers guidelines).

Assemble needle and holder at the patient’s bedside / drawing area. Do not unsheathe until ready to use.

Do not attach blood bottle until after needle is inserted.

To ensure sterile needle is used each time. To maintain vacuum in bottle

Re-apply single use disposable tourniquet 10cm

above insertion site. Do not leave tourniquet on for

more than 60 seconds as this will affect blood

sample quality and results.

DO NOT RE-PALPATE THE PUNCTURE SITE after cleansing. All phlebotomy procedures must be performed as an ‘aseptic technique’.

Do not ask patient to vigorously open and close their hands.

To ensure patient comfort, safety and

reduce erroneous results through haemo-concentration.

To prevent cross infection to ensure

aseptic technique

To prevent erroneous results

Using correct ‘aseptic technique’, stabilise the vein at the distal end – below the point of entry – by slightly stretching the skin.

To perform safe phlebotomy without contaminating puncture site.

Using a Vacutainer needle:

1. Take blood samples ensuring correct order

of draw as per local pathology guidance 2. Insert needle (bevel uppermost) through the

skin at an angle of 15 degrees. 3. Advance in to the vein (a flashback of blood

can be seen if using flash back needle, at this point).

4. Attach first blood bottle into the vacutainer holder with free hand, keeping the hand holding the needle still.

5. Release the tourniquet 6. Remove initial blood sample and connect

subsequent sample tube(s) if required. When sample has been removed from the patient gently invert sample tube five to eight times times to mix blood with tube additives as per pathology order of draw guidance.

7. Place swab over the puncture site and withdraw needle and holder in a continuous straight line and operate the sharp safe mechanism..

8. Do not press firmly on the swab until after the needle has been removed.

9. Dispose of the needle and holder immediately into the sharps box without disconnecting.

10. Maintain pressure on the puncture site for approximately 3 minutes. The patient may do this providing they are willing and the healthcare professional is satisfied they are able to do so.

To prevent contamination by sample tube additives or bacteria.

To mix sample with any tube additives. To prevent blood from leaking from the

puncture site.

To prevent needle stick injury. To dispose of sharp at point of use in accordance with Handling and Disposal of Healthcare Waste policy.


11. Advise patient to keep limb extended at this point. Do not bend the limb.

To avoid pain and trauma to the puncture site

Using a butterfly needle:

1. If the back of the hand is to be used as a phlebotomy site ONLY a winged needle (Butterfly) collection system with extension should be used.

2. Take blood samples ensuring correct order of draw as per local pathology guidance

3. Insert needle (bevel uppermost) through the skin at an angle of 15 degrees.

4. Advance in to the vein (a flashback of blood can be seen at this point).

5. Attach first sampling tube using free hand, keep the hand holding the needle still.

6. Discard the first tube as soon as blood enters the bottle to prime the line. If this is

not undertaken, the bottle will not fill to the appropriate level, due to air in the tubing being released into the bottle and the sample will be rejected.

7. Attach another tube of the same colour as the discarded bottle.

8. Release the tourniquet 9. Remove initial blood sample and connect

subsequent sample tube(s) if required. When sample has been removed from the patient gently invert sample tubes five to eight times to mix blood with tube additives as per pathology order of draw guidance.

10. Withdraw needle using the sharp safe mechanism, keeping the butterfly wings static. Withdraw needle with the hand closest to the sharps bin for safe disposal.

11. Cover the site with a gauze swab. 12. Dispose of the needle and holder immediately

into the sharps box without disconnecting. 13. Maintain pressure on the puncture site for

approximately 3 minutes. The patient may do this providing they are willing and the healthcare professional is satisfied they are able to do so.



To ensure the needle does not move within the vein causing the vein to spasm or pain for the patient.

To ensure that the blood bottle fills to the top by removing the air in the tube, avoiding an insufficient sample being sent to the pathology laboratory.

To mix blood bottle additives and to avoid haemolysis

To prevent blood from leaking from the

puncture site.


To avoid pain and trauma to the puncture site.

Remove gloves and discard into the waste bin, decontaminate hands at the bedside/clinical area and immediately label all samples. These must be labelled at the patient side ensuring four points of identification, signature, date and time.

Pre-labelled tubes must not be used.

Unlabelled or incorrectly labelled / illegible samples will not be processed. There will be no opportunity to change or add anything once the sample arrives

To accurately identify and match all samples to the patient thus avoiding clinical errors. To avoid errors attributed to patients with same / similar names.


in the laboratory.

Recheck puncture site before leaving patient and apply a suitable dressing. In the event of bleeding after 15mins, seek medical attention.

To maintain asepsis and ensure no ongoing bleeding

Remove remaining PPE and decontaminate hands.

BLOOD CULTURE SAMPLES

Only doctors and specially trained nurses may take blood samples for blood cultures.

These can only be taken using a butterfly system with a blood culture conversion collection system.

Blood culture samples are subject to contamination with normal skin flora or other bacteria that can contaminate intravenous lines. As a result of this potential contamination, it is essential that blood cultures are only obtained by direct venepuncture using a strictly aseptic technique and non-sterile gloves.

NOTE: Blood cultures should not normally be taken through a pre-existing venous access device (VAD) unless the line is suspected to be associated with sepsis. In which case, another blood culture, taken by peripheral phlebotomy should also be collected. This must be performed as a full aseptic procedure using non-sterile gloves and an apron. The extra-luminal component of the VAD must be thoroughly decontaminated using 2% Chlorhexidine solution in 70% isopropyl alcohol wipe for at least 30 seconds and allowed to air-dry for 30 seconds prior to use. In the event of patient allergy to chlorhexidine, use povidone iodine as an alternative cleanser if compatible with equipment (see manufacturers guidelines).

Blood culture samples must be drawn before any other samples following the correct order of draw (Aerobic (BLUE) followed by Anaerobic (RED) via a winged needle (Butterfly), Luer adaptor and culture bottle holder.

To ensure correct technique due to higher risk of procedure To prevent contamination of blood culture samples by skin flora or those associated with indwelling venous access devices. To avoid contamination sterile bottles from unsterile sampling tubes.

Bottles must be visually inspected to ensure colorimetric disc in base of bottle is a blue/green colour prior to use. A yellow colour indicates the contents are unsterile.

Check the bottle expiry date.

Discard any bottles which appear cracked or where the cap seals are not intact.

To ensure no contamination of sample or cross infection


Bottles must be held upright and never inverted during sampling.

To prevent the inadvertent intravenous injection of culture medium.

Technique

Gather and check all equipment required to perform procedure

To avoid unnecessary interruptions.

Equipment required

Request form signed by medical practitioner

Non sterile gloves and disposable apron

Skin cleanser and equipment cleanser containing Chlorhexidine solution 2% in isopropyl alcohol70% single use wipes or povidone iodine solution in instance of allergy.

Single use disposable tourniquet

Sterile winged needle collection system for blood cultures (Butterfly).

Blood culture bottles – one aerobic, one anaerobic – check colorimetric indicator discs to ensure sterility and check expiry date. Discard bottles where caps are not intact.

Other blood bottles as required

Sharps bin and suitable clinical waste bag.

To ensure correct equipment prepared and uninterrupted procedure

Cleanse tray or identified area with Clinell universal wipe and allow to air dry. Place equipment / collection system onto clean tray or dedicated area and ensure the sharps bin is located close by to ensure easy, safe access for immediate disposal of needle. Also check the blood culture bottles to ensure they are in date

A ensure good aseptic technique and safe use of equipment To prevent incorrect blood results

Blood culture samples must be drawn before any other samples and the procedure must adhere to an aseptic technique as these samples are subject to contamination with normal skin flora.

To ensure no cross contamination of samples

When the potential site is identified, position patient comfortably with appropriate limb below the level of the heart, on a supported pillow or phlebotomy chair. Consider your own safety and moving and handling position when preparing to undertake phlebotomy.

To ensure comfort of the patient and reduce risk to staff.

If anaesthetic cream has been used, remove dressing and wipe the sites with a clean swab.

To ensure skin is clean and there is no cross contamination

Apply single use disposable tourniquet 10cm above insertion site. Do not leave tourniquet on for more than 60 seconds. When selecting a vein, palpate potential sites, by looking and feeling for veins. They should feel springy when depressed and refill immediately when released. Avoid nodules (valves) in the veins and junctions where veins meet. Ensure there is no

To avoid discomfort for patient To ensure the correct access point is selected


pulse felt before considering the site for phlebotomy. Suitable sites include the antecubital fossa, and the dorsal aspect of the hand. Should these sites not be available or suitable then medical advice must be sought. When accessing from a non-recommended site, documentation must contain who granted permission and rationale. Remove the tourniquet.

To ensure clear clinical rationale and good documentation

Never attempt blood sample collection from any limb with an IV infusion, previous lymph node removal or any oedema or current fracture.

To minimise risks to the patient.

If required for in patients or those visibly contaminated, cleanse the proposed puncture site with 2% Chlorhexidine gluconate and 70% Isopropyl alcohol wipe for at least 30 seconds and allow air-drying for at least 30 seconds.

In the event of patient allergy to chlorhexidine, use povidone iodine as an alternative cleanser if compatible with equipment (see manufacturers guidelines).

To reduce risks of infection and cross contamination. To avoid allergic reaction

In line with the SHFT aseptic technique policy a sterile procedure should be followed to obtain blood cultures to reduce the risk of sample contamination. Sterile winged needle collection system (Butterfly) should be used when obtaining ALL blood culture specimens.

To reduce risk to staff and patient To ensure no damage to vein and correct equipment use

Put on non-sterile gloves and disposable apron To ensure aseptic technique

Reapply disposable tourniquet 10cm above

insertion site. Do not leave tourniquet on for more

than 60 seconds as this will affect blood sample

quality and results.

DO NOT RE-PALPATE THE PUNCTURE SITE after cleansing. All phlebotomy procedures must be performed as an ‘aseptic technique’.

Do not ask patient to vigorously open and close their hands.

To ensure patient comfort, safety and

reduce erroneous results through haemo-concentration.

To prevent cross infection

To prevent erroneous results

Assemble needle and holder at the patient’s bedside / drawing area. Do not unsheathe until ready to use.

Do not attach blood bottle until after needle is inserted.

To ensure sterile needle is used each time. To maintain vacuum in bottle

Using correct ‘aseptic technique’, stabilise the vein at the distal end – below the entry site – by slightly stretching the skin.

To perform safe phlebotomy without contaminating puncture site.

Using a butterfly needle:

1. If the back of the hand is to be used as a phlebotomy site ONLY a winged needle (Butterfly) collection system with extension



should be used. 2. Take blood samples ensuring correct order

of draw as per local pathology guidance – starting with blood cultures

3. Insert needle (bevel uppermost) through the skin at an angle of 15 degrees.

4. Advance in to the vein (a flashback of blood can be seen at this point).

5. Insert blood culture bottle onto Blood culture vacutainer receiver ensuring bottle upright to avoid risk of inserting chemicals from the bottle into the patient. Obtain aerobic sample first. Use gauge on the label to measure volume obtained (a minimum of 5mls is required per bottle).

6. Remove tourniquet. 7. Holding culture bottle upright obtain anaerobic

sample. Use gauge on label to measure sample obtained (min 5mls).

8. If other blood samples are required insert sample tubes in correct order of draw.

9. Remove needle and apply direct pressure to the puncture site.

10. Dispose of the needle immediately into the sharps bin.

11. Maintain pressure on the puncture site for approximately 3 minutes. The patient may do this providing they are willing and the healthcare professional is satisfied they are able to do so.


To ensure the needle does not move within the vein causing the vein to spasm or pain for the patient.

To prevent the inadvertent intravenous injection of culture medium.

To prevent blood from leaking from the

puncture site.


To avoid pain and trauma to the puncture site.

Remove gloves and apron into waste bin and then decontaminate hands at the patient’s bedside /drawing area,

To prevent infection and contamination

Immediately label all samples at the bedside / drawing area.

To ensure correct identification of patient

and prevent labelling errors.

The sample tube and request form should include the surname, first name, date of birth, and NHS number or hospital number, the date the time the specimen was obtained and the healthcare professionals signature and any other relevant clinical information.

To ensure four point identification and all the relevant information to prevent samples being rejected by the laboratory

or incorrect patient identification

Recheck the puncture site before leaving the patient and apply a suitable dressing

To ensure the patient’s comfort and no bruising or bleeding

Ensure the sample is packed correctly with accompanying request form, and sent to the laboratory immediately or made ready for collection.

To ensure good infection control and appropriate transport of specimen

After blood cultures have been taken the procedure should be documented clearly in the patients’ medical notes.

To ensure good record keeping


Appendix 4

Level of Competency Rating Scale

Level Descriptor

0 Cannot perform this activity to participate in the clinical environment

1 Can perform this activity but not without constant supervision and assistance

2 Can perform this activity with basic understanding of theory and practice principles, but requires some supervision and assistance

3 Can perform this activity with understanding of theory and practice principles without assistance and/or supervision

4 Can perform this activity with understanding of theory and practice principles without assistance and/or supervision at an appropriate pace and adhering to best practice guidelines.

5 Can perform this activity with thorough understanding of theory and practice principles without assistance and/or supervision at an appropriate pace and adhering to best practice guidelines. Additionally demonstrating initiative and adaptability to special problem situations

6 Can perform this activity with thorough understanding of theory and practice principles, without assistance and/or supervision, at an appropriate pace, adhering to best practice guidelines. Demonstrating initiative and adaptability to special problem situations and can lead others in performing this activity.

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