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Version Number: 7 Date developed: March 2005 Last review date: March 2006 Next review date: March 2008 1 Venepuncture

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Version Number: 7 Date developed: March 2005

Last review date: March 2006 Next review date: March 2008

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Venepuncture

Version Number: 7 Date developed: March 2005

Last review date: March 2006 Next review date: March 2008

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Collaborative Working

The Multi-Professional Clinical Skills Project is funded by the TUHT Endowment Fund with the remit of establishing standardised training for procedural clinical skills for medical, nursing and relevant allied health care professions. NHS Tayside, NHS Fife and Dundee University, Faculty of Medicine, Dentistry and Nursing are all collaborative partners in the venture. The packs are created by authors who are experts from various professions involving primary and secondary care. The packs have been designed to be adaptable to the local context, with agreement between the collaborators to alter only sections 1, 4 and 5. All other sections are standardised and cannot be altered out-with the agreed review process.

Version Number: 7 Date developed: March 2005

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Venepuncture

Contents Page No. Section 1 Rationale for the Venepuncture Programme 4 How to Use this Programme 4 – 5 Learning Outcomes – Venepuncture 6 – 7 Section 2 Introduction 8 Indications for Venepuncture 8 Anatomy and Physiology 9 – 11 Patient/Venous Assessment 12 – 13 Procedural Guidelines: Venepuncture 14 – 16 Other Methods of Venepuncture 17 – 18 Blood Cultures 19 Labelling of “High Risk” Specimens 20 Central Vision Test Requesting 21 – 22 Completing Blood Request Forms 22 Risk Factors of Venepuncture 23 – 26 Section 3 Child/Neonatal Considerations 27 – 30 Section 4 Theoretical Assessment (adult) 31 – 34 Theoretical Assessment (child) 35 – 38 Supervised Practice Assessment (Assessment of Skill Acquisition) 39 – 40 Section 5 Record of Completion of Programme 41 Practitioners’ Evaluation Questionnaire 42 – 43 References 44 Authors, Contributors & Reviewers 45 – 46 Appendices A – Clinical Skills Framework for Practitioners 47 B – Venepuncture Procedural Checklist (Adult) 48 C – Venepuncture Procedural Checklist (Child) 49 D – Venepuncture Equipment List (Adult) 50 E – Venepuncture Equipment List (Child) 51

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Section 1

Rationale for the Venepuncture Programme This clinical skills programme has been developed by authors from different health care professions to enable practitioners to develop their knowledge and skills in venepuncture. Adopting a multi-professional approach to clinical skills training will promote standardised practice in the delivery of health care procedures, will encourage effective working relationships and will provide patients with access to multi-skilled, flexible health care practitioners. The programme is suitable for any health care practitioner currently working in the NHS, in the UK, who is involved as part of their work in the delivery of procedural clinical skills.

How to Use this Programme This clinical skills programme will support practitioners in their studying, enabling them to work at their own pace, learning about venepuncture in the context of their own practice. Each participant should negotiate a suitable time frame for completion of the suggested activities contained within the programme with their assessor. Participants should aim to complete the programme within a 6 weeks time frame. Practitioners should begin working through the pack prior to attending a simulated practice session. Practitioners should arrange supervised practice with an assessor in their own clinical area. There are circumstances when practitioners will require supervised practice out-with their own clinical area and this should be negotiated with senior charge nurses/managers. Supervised practice should only occur following attendance at a simulated practice session. Unsupervised practice should only occur when the assessor deems the practitioner competent (successful completion of both theoretical and practical assessments). An assessor will be a practitioner who is competent in the skill of venepuncture and familiar with this programme. A flow diagram explaining the process of clinical skills training can be found at Appendix A. Throughout the text, activities are provided which will encourage the use of reflective, decision-making, observational and cognitive skills. N.B The Professional Issues good practice study guide is a core pack designed to prevent repetition of content in subsequent packs. All practitioners must complete the Professional Issues pack prior to commencing any other skills pack. Some activities in subsequent packs will require you to refer back to the Professional Issues good practice study guide. The study guide is available for download from the NHS Tayside intranet via Learning and Development > Clinical Skills > Good Practice Study Guides.

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Assessment includes: • Answers to theoretical assessments must be checked by the assessor using the

marking guide provided. Assessors should guide practitioners to reference material in the resource pack if the practitioner does not provide similar answers to the marking guide.

• Practitioners will be assessed using procedural checklists during simulated practice

sessions. Practitioners successfully completing this assessment are deemed safe to undergo supervised practice in their clinical areas.

• Assessors must use the ‘Assessment of Skill Acquisition’ tool provided to assess the

practitioners’ practical application of the skill during supervised practice. The Assessment of Skill Acquisition form should be completed a minimum of 3 times. The number of assessments required will depend on individual competency. Completed assessment forms should be retained by the practitioner and not the assessor. The practitioners who are deemed not yet competent must undergo a further period of supervised practice.

Evaluation: This is a new clinical skills training pack, therefore we would like to know what you

thought of the pack by taking a few minutes to fill in the evaluation form on completion. To ensure accurate recording and update of the clinical skills database, please ensure you return the completion certificate enclosed when you have finished the pack.

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Learning Outcomes - Venepuncture Aim: On completion of the venepuncture programme (completion of the pack, attendance at simulated practice session, supervised practice and successful completion of assessments) the practitioner will be competent in the clinical skill of venepuncture.

Competency Standard Performance Indicators Understands and debates professional issues in relation to venepuncture

• Applies ethical principles and guidelines to inform

decision making in practice • Actively involves the patient in the decision making

process • Demonstrates the ability to work in accordance with legal

and statutory guidelines • Exercises autonomy and initiative • Demonstrates responsibility and accountability for own,

and applicable others’ practice • Maintains accurate record keeping

Performs accurate assessment of patient requiring venepuncture

• Demonstrates knowledge of the anatomy and physiology

of the blood vessels of the upper arm • Identifies and analyses the appropriateness of

venepuncture • Provides patient education regarding venepuncture to aid

decision-making • Recognises when assistance is required from specialists • Selects appropriate venepuncture equipment with

rationale for choice • Shows awareness of psychological impact of

venepuncture for the patient • Discusses the indications of venepuncture • Details the precautions of venepuncture

Demonstrates competence in the procedure of venepuncture

• Obtains consent and prepares the patient for the

procedure • Assembles necessary equipment, in accordance with

devised checklist • Practises skill competently (see checklist) • Justifies the skill/procedural checklist of venepuncture

using evidence (published and other sources) • Critically analyses the clinical risks associated with

venepuncture and takes appropriate action to manage risks

• Recognises the difference of venepuncture in children and the need for specialist assistance

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Engages in evaluation and critical analysis post procedure

• Responds promptly and appropriately to complications • Takes action to prevent commonly known associated

complications of venepuncture • Recognises limitations and accesses assistance as

required • Reflects on attitude, behaviour (skill) and cognitions post

procedure • Appraises context in which skills were practised • Identifies learning which has occurred to influence future

practice • Identifies area/enquiries for further learning • Draws on a range of resources for further

learning/reading

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Section 2

Introduction

Venepuncture, by definition, is the puncture of a vein with a needle for any therapeutic purpose, for example to remove blood. The collection of blood samples for analysis is almost routine in current clinical practice and performed by a variety of health care professionals throughout various health care settings. This clinical skill pack aims to provide the practitioner with the appropriate knowledge and skills to enable him/her to perform venepuncture successfully. It is recognised that practitioners enrolled in this training programme will have different professional backgrounds and also that the situations in which venepuncture is performed will vary. It is, however, the intention that these guidelines apply to all.

Indications for Venepuncture

There are many reasons why venepuncture is carried out in the clinical area. The following lists potential indications, but is not exhaustive:-

• Blood analysis • Cross Matching • Drug level monitoring • Disease diagnosis • Pregnancy screening • Blood cultures • Virology and serology

Activity

What blood tests would you consider taking from a patient who is admitted with pyrexia of unknown origin? Discuss your answer with your assessor.

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Anatomy and Physiology

In order to perform venepuncture safely and competently practitioners need an understanding of the anatomy and physiology of the venous system. The walls of veins consist of three layers:

1. The tunica intima (inner layer) consists of endothelium with a variable amount of connective tissue. The endothelium secretes vasoactive substances, e.g. nitric oxide, and acts as a barrier to the passage of larger molecules, e.g. plasma proteins.

2. The tunica media (middle layer) consists of smooth muscle cells, elastin and

collagen. Being innervated by motor neurones, the layer is responsible for contracting the vein.

3. The tunica adventitia consists of collagen, elastin and is innervated by

sensory neurons. Veins are described as distensible which means they can stretch to accommodate increases in blood volume without increasing the venous pressure. The pressure in small veins is approximately 10-15mmHg and 2-3mmHg in the great veins (Kindlen, 2003). Many veins, especially those in the limbs, have valves as a continuation of the tunica intima. These valves are responsible for preventing the backflow of blood, thus maintaining venous return when standing. Veins also have a small pulse which is normally undetectable. However, in poor cardiac function and circulatory overload the veins distend; the pulse becomes evident and can be seen quite clearly. The median cephalic and basilic veins are normally used for venepuncture (see venous assessment). In certain circumstances, e.g. acute circulatory failure, burns or trauma to the upper limb, it may be necessary to access veins at other sites, such as the anterior tibial vein or the small saphenous vein (see figure 2). Arterial system: An awareness of the arterial system and nerve supply is essential to ensure the practitioner can differentiate between an artery and a vein, thereby preventing damage and maximising patient care. Distal to the ante-cubital fossa the brachial artery divides medially into the ulnar artery and laterally into the radial artery. As with all other arteries a palpable pulse can be felt (at the wrist). A dominant radial artery can have a large branch in the scaphoid which it is possible to puncture if carrying out venepuncture of the superficial palmar arch veins (Dykes,2002).

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Figure 1. Venous Supply to the arm. The axillary artery is the continuation of the subclavian artery into the arm, and itself continues down the medial aspect of the upper arm as the brachial artery. The brachial artery is easily felt in the ante-cubital fossa where it lies between the biceps tendon and median nerve, and below the medial cubital vein. It is possible to hit the artery when performing venepuncture at this site. Below the elbow the brachial artery divides into the radial artery (lateral) and the ulnar artery (medial). Both arteries are usually easy to feel at the wrist. A dominant radial artery may have a large branch in the anatomical snuffbox and it is possible that this might be punctured accidentally. The terminal branches of the radial and ulnar arteries provide blood supply to the hand through deep and superficial palmar arches. Arterial puncture will result in blood at high pressure being released. The blood will pulsate rather than ‘ooze’ and will be bright red (oxygenated) rather than dark red (deoxygenated) in colour. If arterial puncture is suspected, remove the needle at once and apply direct compression over the puncture site for at least five minutes. Nerve supply: The nerve supply to the upper limb is complex and this summary is limited to those nerves located in or near the common venepuncture sites. The median nerve lies in the ante-cubital fossa medial to the brachial artery and under the median cubital vein.

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It extends down the limb and is vulnerable again at the palmus longus tendon of the wrist. However this is well clear of the accepted venepuncture sites. The ulnar and radial nerves are deep and should be clear of sites of venepuncture. Figure 2: Waugh, A. and Grant, A. (2001) Anatomy and Physiology in Health and Illness; Ross and Wilson, Churchill Livingstone, Ninth Edition, London, p99, fig.5.33.

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Patient/Venous Assessment Patient assessment requires the addressing of the individual’s physical and psychological status. The duration of the assessment process will be dependent on the context of the environment, as well as the patient’s condition. Before attempting venepuncture assess how appropriate / necessary this invasive procedure is. Patient consent must be gained. Adequate preparation and selection of the vein will maximise accurate and safe venepuncture. The condition of the veins can be influenced by many factors. These are listed in table one.

A “good” vein for venepuncture can be characterised by: • it should be bouncy • it should be soft • it should refill when depressed • it should be visible • it should be well supported • it should be straight Dougherty(1996) Location of the vein is also important. Preferred veins for venepuncture include (refer to figure 1):- • basilic veins • cephalic vein • median cubital vein These veins lie superficially and are usually visible in adults, the most accessible being the median cubital vein, although all have wide lumens and thick walls making venepuncture easier for practitioner and patient.

Table One Factors Affecting Condition of the Patient’s Veins. Age of patient Previous use of the vein Obese or malnourished patient Clinical status i.e. oedema, dehydrated Drug therapy i.e. warfarin, long-term steroid use Patient co-operation

Temperature

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Venous access can be improved by: • using a tourniquet to promote venous distension. • lowering the extremity below the level of the heart. • if the above fails, applying warm compresses or immersing the limb in a bowl of

warm water increases vasodilation and promotes venous filling. Contraindications

Veins should be avoided if they are:- • thrombosed • inflamed or bruised • hard • near bony prominences • near previous multiple punctures • near sites of infection • near sites of previous surgery e.g. avoidance of limb according to mastectomy

site Precautions

• patient currently receiving anti-coagulant therapy – increased bleeding time post procedure

• those with known blood borne infections – advisable for competent practitioner to obtain the sample

Psychological considerations

• previous personal experience – the patient may have had an unpleasant experience of having blood taken previously. The patient may be able to inform you of veins which were easier to access.

• relatives/friends experiences – listen to any concerns they may have based on previous accounts that they may have heard.

• needle phobia – consider using local anaesthetic. • fear - reassure the patient that only two attempts will be made before seeking

assistance. The use of distraction may also be a useful strategy for those who are anxious (Lavery & Ingram, 2005).

• understanding – having too much/too little information. • be aware that the patient may have concerns about possible blood results and

inform the patient how and when they are likely to receive their results (Lavery & Ingram, 2005).

Patient Education Anxiety and fears can be reduced by communicating and informing the patient of exactly what the procedure involves. The patient should be made aware of why he/she is having the procedure, the benefits and the potential complications before obtaining informed consent. Establish if the patient has any known allergies prior to the procedure – the patient may have an allergic reaction to elastoplast. Activity

What points would you consider when assessing a patient for venepuncture in your own clinical area? Discuss your answer with your assessor.

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Procedural Guidelines: Venepuncture An equipment list is available at Appendix D and a Procedural Checklist can be found at Appendix B. These will be of use to you during the simulated practice session. Although there are other methods for carrying out venepuncture, the most common method is using the Vacutainer ™ system.

• It is crucial that information on the patient request form matches the information on the notes and wrist band – confirm verbally

• For patients who are unable to confirm verbally - confirm identity with carer/relative

• When patients identity is unknown use Typnex • Samples must be taken and labelled from ONE patient at a time • Sample tubes must be labelled AFTER venepuncture

1) Introduce yourself to the patient.

2) Explain the procedure to the patient and obtain informed consent. 3) Gather appropriate equipment. 4) Perform hand wash and apply non-sterile gloves.

5) Ensure patient is sitting or lying comfortably with the arm supported. Ascertain If the patient has had blood taken before.

6) Apply a tourniquet proximal to selected vein to raise the vein. A pumping action

of the fist is not advisable and may affect results. 7) Palpate selected vein. 8) Cleanse the skin using 70% isopropyl alcohol swab and allow to dry. Visually

check the sterility seal of the needle. If the seal is broken do not use. If the seal is unbroken twist to break and dispose of the white cover. Screw the rubber covered end of the needle on to the holder.

9) Remove the coloured sheath to reveal the needle and hold it with the bevel upward. Hold the skin taught over the vein. Using the holder like a syringe, insert the needle at a 15° angle to enter the vein. Ensure the needle remains in the lumen of the vein rather than passing through it. 10) Once in the vein, steady the holder with the non-dominant hand to anchor the needle in the venepuncture site. With the dominant hand place the collecting tube within the holder, grasp the holder wings between index and middle fingers and, using the thumb, push the collecting tube in until the rear needle pierces its stopper. 11) The vacuum built into the collecting tube will extract precisely the pre-

determined amount required. The flow will automatically stop. In tubes containing anticoagulants it is essential that the correct volume of blood is added to the tube.

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12) If possible, release the tourniquet when blood begins to flow. 13) Remove the tube and rock gently if it is to be mixed with an additive. Do not shake vigorously as this may cause haemolysis (break down of blood cells). 14) Change the sample tubes to obtain multiple samples. Blood should be collected

in the following order:

Recommended Order of Draw 1. Red top tubes – All tubes without additives (areas that do not have red tops would draw in same order but commence with light blue tops). 2. Light blue tubes – Tubes for coagulation studies – contain sodium citrate. 3. Gold tubes – contain a clot activator. 4. Green tubes – contain heparin. 5. Purple tubes – mainly for Haematology – contain EDTA. 6. Pink tubes – for blood transfusion – contain EDTA. 7. Other tubes e.g. grey tops. It is possible that the needle used to fill one tube can transfer some of the blood/anticoagulant mixture from that specimen into the next tube filled. The anticoagulants and additives in some tubes can adversely affect results of tests performed on others. For example, purple top tubes contain an anticoagulant rich in potassium. If the tube filled after a purple top tube is going to be tested for potassium, any carry over of the blood/anticoagulant mixture from the purple top tube can falsely elevate the potassium level. It can also add enough potassium to make the hypokalemic patient appear normal. The order of draw can also impact coagulation studies. If the needle transfers a minute amount of anticoagulant from a previous tube into a blue top tube, the introduction of the foreign anticoagulant can make the patient appear to have a coagulation disorder or to be over medicated. It can also make an under medicated patient appear well within therapeutic range. Therefore blue top tubes should never be filled after a tube that contains an additive.

15) Remove tourniquet if this has not already been done. When blood sampling is complete, remove the needle while holding a sterile cotton wool ball or gauze swab on the site. After removal of the needle, apply pressure to the site to stem the leakage.

16) Dispose of needle at point of use. DO NOT DISMANTLE NEEDLE AND

HOLDER. 17) Ask patient to apply digital pressure until bleeding ceases (average time – 30- 60secs). Do not bend the arm as this increases the risk of haematoma formation. 18) Check wound site has stopped bleeding and apply a skin plaster, after confirming that the patient is not allergic to plaster.

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19) Label tubes with surname, first name, full 10 digit date of birth and CHI number, ward number, initial and date. If Central Vision Test Requesting is in operation apply appropriate sticky label to the tube – see instructions.

20) Apply a high- risk red sticker to tubes if appropriate. Bag sample tubes and appropriate forms. Leave at collection point. If the samples are urgent, follow the guidelines from the laboratory service for collection.

21) Dispose of gloves; disinfect or wash hands. 22) Document the any difficulties encountered with the procedure.

Best Practice Statement Following venepuncture practitioners should document the procedure in the patients’ notes. Rationale: To provide evidence that the blood sample was taken, to prevent repetition of task by other colleagues and to follow principles of good documentation. Source of Evidence: Expert opinion and documentation advice given by the NMC, 2005 and GMC, 2003.

Activity If when attempting to obtain a blood sample from a patient you inadvertently puncture an artery instead of a vein, what action would you take? Make short notes.

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Other Methods of Venepuncture Butterfly system This system is used when venepuncture is difficult, when taking blood from children or sometimes when using veins in the back of the hand. When learning, it is easier with another practitioner helping. The `butterfly’ consists of a winged needle device (21G or 23G) and attached plastic tubing. The patient is prepared and the needle is inserted as per the Vacutainer ™ needle. Confirmation of correct positioning in the vein is seen as a `flashback’ (blood present at the end of the tubing). There is a Vacutainer ™ attachment to allow the blood to enter directly into the collection tube which is attached to the end of the tubing. Various types of butterfly systems are available including retraction needles (Safety-Lok), which reduce the risk of needlestick injury. Once the appropriate samples have been taken, the rest of the procedure is as outlined previously.

Needle and syringe This method is used as a last resort for fragile veins which can collapse when pressurised systems are used, but less commonly used due to increased risk of needlestick injury. A 23G (blue) needle or butterfly system can be used. The syringe (5ml, 10ml or 20ml) is attached to the needle and vein entered. A flashback will be seen if successful, and the plunger of the syringe should be pulled back gently to allow blood to draw into the syringe. Pulling the plunger too quickly can result in haemolysis. Once sufficient blood has been collected, the tourniquet can be released and needle withdrawn. The blood must then be put into appropriate tubes. This can be done by placing the tubes in a wire rack (NEVER by holding in hand); remove the needle using the grip on the sharps box; remove the top of the tube and dispense the blood slowly into the tube by gently pushing the plunger. All needles must be disposed of safely, and the rest of the procedure followed as above. N.B. When using a syringe, blood must be transferred to the appropriate tube and mixed as soon as possible to prevent clotting.

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Activity Why should obtaining blood using the needle and syringe method be used as a last resort? Discuss your answer with your assessor.

Best Practice Statement Assistance should be sought from a more experienced practitioner after two or three unsuccessful attempts at venepuncture (McConnell & Mackay, 1996) Rationale: Initial consent to the procedure may not extend to cover multiple attempts and may even be regarded as demonstrating assault through recklessness in a court of law. Source of Evidence Descriptor: McConnell & Mackay (1996) Venepuncture: the medicolegal hazards; Postgraduate Medical Journal. A review of the law in relation to specific case studies. N.B: Practitioners must recognise their limitations and know when it is appropriate to seek assistance.

Activity The patient requires a blood sample to determine baseline measurements of full blood count, urea and electrolytes and INR. In what order would you draw these samples and why?

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Blood Cultures

Obtaining a sample for blood cultures requires skilled practitioners to adhere to infection control policies and procedures. Samples which have been contaminated by practitioners can lead to a false positive result. The consequences of a false positive result range from an increased length of hospital admission for the patient and the unnecessary administration of antibiotics (Lavery and Ingram, 2005). Some clinical areas have equipment to obtain blood cultures via a vacuum system, however, most still use the needle and syringe method. As well as adhering to the procedural guidelines for the vacuum system/needle and syringe method, practitioners should note the following good practice points:-

• after removing the caps from the blood culture bottles clean the rubber top with an alcohol wipe and leave for 30 seconds to dry.

• fill the anaerobic bottle first to prevent air entering the bottle from the

syringe. • 20mls (1-3mls for neonates) of blood should be distributed evenly between

both cultures bottles (overfilling can cause false positives).

• ensure prompt transport to the laboratory.

• culture samples that cannot be transferred to the laboratory immediately should be stored at room temperature and not in the fridge.

Best Practice Statement If practitioners are unable to obtain 20mls, 10mls should be evacuated into the aerobic vial. Rationale: 98% of septicaemias are caused by aerobic organisms and most causative organisms can still be detected even when the anaerobic bottle contains less than the desired volume. Source of Evidence Descriptor: Meta-analysis by Ernest (2001) The right way to do blood cultures. RN, 64, 3, 28-31.

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Labelling of “High Risk” Specimens This is to remind staff of the need to label “high risk” specimens correctly. The latest guidance in safe working and the prevention of infection in clinical laboratories is that “…where there is a high risk of exposure to a Hazard Group 3 biological agent (e.g. blood borne viruses, TB, Brucella) laboratory staff may need additional information… the most common method…is to use a danger of infection label”. Using a standard label (for example in Tayside a red sticker, in Fife a blue/yellow sticker) reduces the scope for confusion and allows reception staff in laboratories to deal with specimens appropriately. For requests from patients known or suspected to be “ high risk” a red sticker must be attached to each copy of the request form and to all of the specimens on each occasion that a sample is submitted. If Central Vision Test Requesting is in operation, the “high risk” patient should be identified by the requesting clinician. Other organizations may use other markers to signify high risk samples, for example NHS Fife use a blue and yellow sticker.

• High risk samples must be sent via a porter and never via the tube system

• Laboratory services in Tayside investigate thousands of specimens per day and

the correct identification of “high risk” samples is essential on each occasion to allow appropriate processing.

• All specimens must be submitted in the appropriate container with a fully

completed request form.

• Failure to do this may lead to delays in testing or in some cases the rejection of the sample. Audit and review of requests will be carried out and followed up to address non- compliance.

• No specimens should be taken from a patient suspected of Hazard Group 4

infection (Lassa, Ebola, Rabies) until a Consultant Microbiologist has been informed.

Further information is available in the laboratory handbooks on Fountain/Odyssey or by contacting the laboratories.

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Central Vision Test Requesting Some areas have a system of Central Vision Test Requesting. Use of modern high speed automated laboratory analytical platforms means there is an absolute requirement for Ward Test Requesting labels to be attached correctly. The following diagram illustrates how to apply Test Requesting Labels.

The barcode edge of the Test Requesting label should be aligned with the sample tube label edge and applied covering the existing tube label, leaving a small gap. This gap is necessary for visual inspection of tube contents.

When using Ward Test Requesting to arrange tests deemed to be urgent the laboratory must be informed of the Test Request and an ‘urgent sample’ sticker must be applied to the test request form. Before dispatching the sample, an ‘URGENT SAMPLE’ sticker must be completed and attached to the sample bag. Samples arriving at the laboratory without an urgent sticker or without informing the lab will be treated as routine samples.

URGENT SAMPLE

USE ONLY IF LAB CONTACTED

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Activity

A patient who is admitted to your ward is known to have Hepatitis B. You are required to obtain a blood sample. Make notes on the actions you would take to protect yourself and the laboratory staff. Discuss your answer with your assessor.

Completing Blood Request Forms

Ideally all information should be completed on blood request forms, however the minimum amount of information on a blood form required to ensure correct and prompt dispatch of results is:-

• Patient's name • Date of birth • CHI number • Gender • Consultant/GP • Clinical diagnosis • Source • Date • Tests required

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Risk Factors of Venepuncture

As with any invasive procedure, there are risks to the patient and practitioner. Practitioners need to be able to assess the risk and decide if the benefits outweigh the risks, to reduce risks where possible and to be able to troubleshoot when things do not go to plan. The table below is not exhaustive, but highlights some of the risks and problems associated with the procedure.

Risks Associated with Venepuncture

Risk Cause Practitioner’s Action

1) Limited Venous Access • Repeated use of veins • Phlebitis • Bruising • Peripheral Shut Down

Use all methods to improve venous return; use winged device of 21/23G. Ensure, where possible, all blood samples are obtained at the same time.

2) Infection • Poor aseptic technique Correct aseptic technique.

3) Missed Vein • Inadequate anchoring • Poor lighting • Wrong position

Withdraw needle to bevel and realign.

4) Flow of blood stops • Overshooting vein or advancing needle while withdrawing blood • Vein collapses due to contact with vein wall.

Gently ease back and retry. Manoeuvre gently.

5) Haematoma formation • Perforation of opposite wall of vein. • Patients on warfarin/heparin or who are thrombocytopenic

Insert needle at correct angle and stop when flashback appears; do not advance needle during taking of sample; apply direct pressure post procedure; advise patient not to bend arm post procedure.

6) Anxiety • Fear of venepuncture pain. Reassure about procedure; use all methods to dilate veins; limit to two attempts; question patient about previous experience; consider use of local anaesthetic.

7) Arterial Puncture • Incorrect landmark targeted. Review anatomy; if artery punctured – apply direct pressure for at least 5 minutes; reassure the patient; attempt procedure at another site or obtain assistance.

8) Fainting • Fear and anxiety. Reassure the patient; ensure the patient is sitting or lying down for the procedure.

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Anterior interosseous nerve injury – Anatomically the anterior interosseous nerve lies in close proximity to the superficial veins at the cubital fossa (Zubairy, 2002). Injury to this nerve can cause paralysis of the thumb and fingers. Although the risk is rare, practitioners should be aware of this potential.

Best Practice Statement Practitioners should choose a large, visible vein and insert the needle at a 5-15 degrees angle with the skin (Sheu & Yuan, 2001) Rationale: To reduce the risk of nerve injury during venepuncture. Source of Evidence: International Journal of Clinical Practice (2001) – Report of case study. Action to be Taken When Wrong Sample is Sent To the Laboratory:- If practitioners realise they have sent a sample to the lab with incorrect details on it – labelled the sample with another patients details, the following action must be taken in a timely manner:-

• Be honest – to take no action could result in further harm to patients • Inform all relevant laboratories where the sample has been sent and request

that the sample and any results be destroyed • Consider if other patients will be effected and take any necessary action • Explain to the patient the reason for a repeated sample • Report the incident to your immediate supervisor and complete local incident

report forms • Reflect on the incident and consider what you have learnt from the experience

Risks to Practitioner should also be considered:-

• needle stick injury • blood contamination • blood spillage

Needle stick injury A flow chart outlining the course of action to be taken following a needle stick injury can be found Section 3, page 15 of the Infection Control Policy (2003). Safe handling and disposal of sharps is the responsibility of the person conducting the procedure. The Tayside NHS procedure for safe disposal of sharps can be found in Section 3, page of the Infection Control Policy (Dec 2003). Other area should access local policies on infection control. Blood contamination Health care workers who come into contact with patients’ blood/body fluid are at continual risk of occupational exposure to viral and other bloodborne infections. Standard Infection Control Precautions are designed to protect staff, patients and others from transmission of infection where the risk is known or unknown. They incorporate and replace the old terminology of Universal Precautions.

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Activity Make short notes on what action you would take on sustaining a needle-stick injury in the workplace. Discuss your answer with your assessor.

Best Practice Statement Inexperienced venepuncturists should become accustomed to the wearing of gloves from the beginning of their training and should not take blood from patients known to be infected with blood-borne viruses until trained and considered competent. Rationale: To reduce the practitioner’s risk of exposure to blood-borne infections. Source of Evidence: UK Health Department (1998) - National Guidelines. Blood spillage Blood spillage should be cleaned up immediately to prevent spread of infection. All practitioners have a responsibility to clear up blood that they have spilled. Domestic staff do not clean up bodily fluids. Further information for dealing with blood spillage are available in Section 5, page 19 of the Tayside University Hospital Infection Control Policy (Dec 2003).

Best Practice Statement All venepuncturists, including those who are experienced, should wear gloves if there are cuts or abrasions on the hands and it is not practical for them to be covered by waterproof dressings alone, or if the patient is so restless that the risk of injury to the health care worker is increased. Rationale: To reduce the practitioner’s risk of exposure to blood-borne infections. Source of Evidence: UK Health Department (1998) – National Guidelines.

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Activity Why should practitioners undergoing supervised practice not obtain blood samples from a patient who is known to have a blood-borne infection? Discuss your answer with your assessor.

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Section 3

Child/Neonatal Considerations

Child Introduction Venepuncture may be frightening and upsetting for young children. The technique described in this document is that which is most commonly used in paediatrics in Tayside and is thought to be the most efficient and least traumatic way of taking blood from a child. It is a simple technique, and can be learned by observing an experienced practitioner. A child procedural checklist can be found at Appendix C. Main points:-

• The Vacutainer System is generally not used in children under 10years old • Butterfly needles and syringes are used instead of Vacutainer™ system • Offer local anaesthetic cream for skin anaesthesia pre-injection • Consent needs to be obtained from guardian before procedure • Use an assistant to stabilise child’s limb • Helpful to have some means of distraction in the young child e.g. toys • Smaller bottles are available for blood collection – screw tops, which require

lower volumes for a blood test • Tourniquets are only used in children over 10 years old (it is usual practice in

paediatrics to have assistant applying pressure to limb whilst stabilising it)

Local anaesthetics

• Establish known allergies before using local anaesthetic • ‘EMLA’ cream or ‘Ametop’ cream can be applied for venepuncture • Ametop takes effect in 30 minutes and EMLA takes 60 minutes to become

effective Royal College of Paediatrics and Child Health (2003) Technique Same preparation as per adult procedure with hand washing, gloves, skin cleansing, etc (see procedural checklist at appendix C).

1. Establish if parents wish to be present 2. Assistant stabilises the limb and applies pressure

like tourniquet 3. Insert needle of butterfly into vein 4. Withdraw blood directly into syringe 5. Remove syringe and butterfly 6. Ask assistant, parent or patient to apply pressure

with sterile cotton wool ball as described for general technique

7. Discard butterfly needle into sharps bin 8. Inject blood from syringe into open bottles 9. Discard syringe into sharps bin

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Other Tips • Smaller, chubbier infants and preschool children tend to have veins which are

more visible on the backs of hands and feet. • Rationalise blood taking in order to make as few attempts at venepuncture as

necessary. • Know which blood samples are the more essential ones before you start, in

order that samples which are left undone in the case of abandonment are not the most important ones. Please note the order of draw recommended in the adult procedural guidelines is not applicable in paediatrics when the Vacutainer™ system is not used.

• Do not attempt bloodletting on more than two unsuccessful occasions. Seek assistance.

Activity

When obtaining a blood sample from a young child what methods of distraction might you employ? Discuss your answer with your assessor.

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Neonatal Introduction When taking blood from infants, it is important to determine which type of sample is needed, according to the type of analysis that is required, and what volume of blood is required. All babies aged six days have a blood sample taken by Heel Prick by the midwife (the ‘Guthrie Test’). The sample is collected onto a card to create dried blood spots for later analysis by the labs. Those practitioners wishing to become competent in the procedure of heel prick (capillary) blood sampling, rather than venepuncture should access the capillary blood sampling good practice study guide. Venepuncture is the recommended route for blood sampling in neonates because there is evidence to suggest that Venepuncture is less painful than heel prick sampling in newborn infants (Ogawa et al, 2005) The exceptions are:

a. routine blood sampling at 6 days (the ‘Guthrie Test’), b. Babies with difficult venous access c. Babies in intensive care where it is desirable to preserve good veins for

cannulation. d. Capillary Blood gas analysis e. Capillary Blood Glucose monitoring

N.B: HEEL PRICK SAMPLE=CAPILLARY BLOOD

VENEPUNCTURE =VENOUS BLOOD Caution for heel prick samples:

1. Types of sample may be contaminated by tissue fluid or affected by haemolysis: Urea and electrolytes (potassium goes up); LFTs (Transaminases go up); lactate (goes up).

2. Samples which are affected by stasis (sluggish bleeding from whichever site): Full blood count (platelets go down); Calcium (goes down).

The Techniques Areas of the foot to be used

NB: Avoid sampling over the calcaneum (heel bone) as this can lead to infections.

Heel prick: • The baby’s foot should be warmed beforehand,

especially if the child has just come in from outside.

• The area of the heel to be sampled should be cleaned with a Steriswab.

• The foot is held by the foot and ankle with the heel appearing between the forefinger and thumb, so that the foot can be gently dorsiflexed in order to assist the flow of blood (this may not be necessary).

• Prick the heel with an appropriate lancet (Genie lancet, BD).

• Blood droplets form at the skin surface which can be collected onto card or into container.

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Equipment:

• Sterile lancets are made by BD (Genie lancet). • “Broken needles” are made by Vygon.

Venepuncture: • Babies and small children have poorly visible,

and difficult to access veins in the ante-cubital fossa.

• Easier sites for venepuncture are the back of the hand, top of the foot and, occasionally, the front of the wrist.

• Blood samples can be taken with a butterfly type needle, as described in the appendix on older children, or using a broken needle - specifically designed for this purpose.

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Section 4

Theoretical Assessment Adult Venepuncture

Guidance notes for the theoretical assessment are available to download from the NHS Tayside intranet via Learning and Development > Clinical Skills > Clinical Skills Programmes to enable your assessor to give you feedback on your work. Practitioners should cover key points for each question. Practitioners who have not considered key points in their answers should be guided by their assessor to further reading, before attempting to answer the questions again.

Question One All practitioners have a responsibility to keep up to date and prevent skill fade. Explain what actions you can take to keep up to date with venepuncture and prevent skill fade. Case Study Mr Brown, 52 years, attends the medical outpatient department for a routine follow up appointment, having suffered a small posterior Myocardial Infarction six months ago. You are required to obtain a blood sample from Mr Brown. Question two Discuss what information you would give the patient in order to obtain informed consent.

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Question Three Make brief notes on the points you would consider when assessing Mr Brown for the procedure of venepuncture. Question Four Following assessment, it appears the Mr Brown has a phobia of needles. There is pressure of time to get the blood sample as the clinic is already running 40 minutes late. Document what your actions would be and what ethical principles have informed your decision-making. Question Five Following vein assessment, Mr Brown has ‘poor’ visible and palpable veins. Explain what equipment you would choose for the procedure, providing a rationale for your choice.

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Question Six You are unable to obtain a blood sample following two attempts. Discuss what action you would take now, justifying your actions. Question Seven Critically analyse the risks associated with venepuncture and make notes on what actions you would take to reduce these risks. Question Eight If when attempting venepuncture you inadvertently puncture an artery instead of a vein, what action would you take? Discuss what you may learn from this incident.

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Question Nine Reflect on what learning has occurred and discuss the changes this will make to your clinical practice. Question Ten Regarding venepuncture identify areas where you can further improve your practice and learning. Explain what possible sources you may obtain further information from.

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Theoretical Assessment Child Venepuncture

Guidance notes for the theoretical assessment are available to download from the NHS Tayside intranet via Learning and Development > Clinical Skills > Clinical Skills Programmes to enable your assessor to give you feedback on your work. Practitioners should cover key points for each question. Practitioners who have not considered key points in their answers should be guided by their assessor to further reading, before attempting to answer the questions again.

Question One All practitioners have a responsibility to keep up to date and prevent skill fade. Explain what actions you can take to keep up to date with venepuncture and prevent skill fade. Case Study Gillian Brooks, nine years old, is admitted to your ward for an elective insertion of grommets. You are required to obtain a sample for pre-operative bloods. Gillian’s mother is present on admission. Question Two Discuss what information Gillian and her mother would require in order to obtain informed consent.

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Question Three Make brief notes on the points you would consider when assessing Gillian for the procedure of venepuncture. Question Four Following assessment, it appears that Gillian is afraid of needles. The ward is busy and Gillian is first on the theatre list. Discuss what your actions would be and what ethical principles have informed your decision-making. Question Five Following vein assessment, Gillian has ‘poor’ visible and palpable veins. Explain what equipment you would choose for the procedure, providing a rationale for your choice.

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Question Six You are unable to obtain a blood sample following two attempts. Discuss what action you would take now, justifying your actions. Question Seven Critically analyse the risks associated with venepuncture and make notes on what actions you would take to reduce these risks. Question Eight If when attempting venepuncture you inadvertently puncture an artery instead of a vein, what action would you take? Discuss what you may learn from this incident.

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Question Nine Reflect on what learning has occurred and discuss the changes this will make to your clinical practice. Question Ten Regarding venepuncture, identify areas where you can further improve your practice and learning. Explain what possible sources you may obtain further information from.

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Assessment of Skill Acquisition Assessor: ____________________ Status: _____________________ Practitioner: _________________ Status: _____________________ Clinical Skill: ________________ Date: ______________________ Number of Supervised Evaluations: ______ Practitioners should be assessed until competence is achieved in all domains or if competence is achieved on first attempt they must undergo a minimum of 3 observations. Competence is achievement when all criteria are met in all domains. Assessors should indicate if competence has been achieved in each domain by circling ‘YES’ or ‘NOT YET.’ Feedback should be entered in each remarks box, identifying criteria to be achieved or demonstrated. Competence Achieved YES/NOT YET 1. Professionalism Criteria - applies ethical principles to inform decision making - involves patient in decision making process - practices in accordance with professional code - demonstrates autonomy and initiative - maintains accurate record keeping Competence Achieved YES/NOT YET 2. Patient Assessment Criteria - assesses patient suitability for the procedure - selects equipment (providing rationale for choice) - discusses the potential psychological impact with the patient - critically analyses potential risks

Competence Achieved YES/NOT YET 3. Knowledge and Application Criteria - demonstrates knowledge of relevant A&P - provides appropriate patient information - discusses indication and contraindications with patient - seeks information from appropriate sources when necessary Competence Achieved YES/NOT YET 4. Communication Criteria - skill explained to patient/significant others to obtain informed consent - practitioner demonstrates accurate and legible documentation of skill 5. Organisational Criteria Competence Achieved YES/NOT YET - correct equipment is prepared and checked - skill is carried out in a timely, logical sequence - responds appropriately to any complications

Remarks:

Remarks:

Remarks:

Remarks:

Remarks:

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Competence Achieved YES/NOT YET 6. Technical Ability Criteria - skill is performed accurately and efficiently - recognises limitations of technical ability and seeks assistance as required - takes appropriate action to reduce risk of complications i.e. aseptic technique as required

Competence Achieved YES/NOT YET 7. Overall Competence Criteria - achievement of all of the above qualities - practitioner’s ability to practice skill in accordance with standardised procedure - demonstrates aptitude to reflect on learning and identifies areas for further learning. Assessor’s Feedback (indicating areas for improvement as necessary): Agreed Action Plan (Between assessor and practitioner):

Time to achieve action plan I week 2 weeks other please specify___________

Practitioner Signature:______________________ Assessor Signature:_________________________

Remarks:

Remarks:

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Section 5

Record of Completion of Programme (Venepuncture) All staff must complete and return this slip to the appropriate person. All Nursing and Midwifery Staff: Return to Manager (i.e. Senior Charge Nurse). Postgraduate Medicine: Return to Training & Research Officer, Postgraduate Office, Level 7, Ninewells Hospital, Dundee. Full Name: ________________________________ Profession (Please circle one): Nursing & Midwifery / Medicine / AHP Job Title: __________________________ Clinical Area: _____________________________ Directorate (If applicable): ______________________________________________________ Hospital/Primary Care Facility: ___________________________________________________

Signature (Practitioner)

Signature (Assessor/Facilitator) Date

Attendance at simulated practice session

Completion of theoretical assessment/s

Completion of practical assessment/s

Competent to carry out Venepuncture

Practitioners will not be deemed competent until this information is entered into the Tayside Training Database and appears in their personal training record. It is vital, therefore, that the Manager/Training & Research Officer photocopies this form and returns it to: Lorna Ferri, Nursing & Patient Services, Level 7, Ninewells Hospital, Dundee.

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Practitioners’ Evaluation Questionnaire (Venepuncture)

This questionnaire has been devised to address potential deficits and improve the service of clinical skills programmes. To enable practitioners to influence future developments please take a few minutes to complete this questionnaire. Questionnaires should be completed following completion of each clinical skills pack. Responses will remain confidential and will only be seen by those evaluating the multi-professional clinical skills project. 1. What is your profession? __________________________________________________________________________ 2. Which ward/department do you work in? _____________________________________________________________ 3. Which hospital/primary care facility do you work in? ____________________________________________________ Paper-based Online (Virtual Learning Environment)

4. Which version of the clinical skills pack was chosen?

5. How was the clinical skills pack accessed? (i.e. paper-based from the intranet, paper-based from the Charge Nurse,

VLE from the ward computer, VLE from a home computer etc) ___________________________________________

Please rate the following statements Agree Undecided Disagree

6. The best practice statements were useful.

7. The activities throughout the pack assisted learning.

8. The theoretical assessment was a useful method of testing knowledge.

9. The marking guide enabled you to measure your learning.

10. If you disagreed with statement 9, please explain why: ________________________________________________

11. Assessors in practice provided adequate support and feedback.

12. If you disagreed with statement 11, please explain why: _______________________________________________

13. Procedural checklists were valuable in practice.

14. The practical assessment was usable in practice.

15. The simulated practice session was useful.

16. If you disagreed with statement 15, please explain why: _______________________________________________

17. The trainer answered any questions/queries appropriately.

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18. The programme has enabled you to attain competency in the skill.

19. If you disagreed with statement 18, please explain why: ________________________________________________

20. The skill will benefit patients in your clinical area.

21. If you disagreed with statement 20, please explain why: ________________________________________________

Please choose an appropriate answer Too much Just right Too little

22. The volume of the skills pack was:

Too difficult Just right Too easy

23. The level of theoretical content was:

24. Please add any additional comments that may assist in this evaluation:

Please return all completed questionnaires to:

Multi-Professional Clinical Skills Project Secretary,

Clinical Skills Centre,

Level 6,

Ninewells Hospital,

Dundee, DD1 9SY.

Many thanks for taking the time to complete this questionnaire

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References Dougherty, L. (1996) Intravenous Cannulation, Nursing Standard, 2, 11, p47-51. Dykes, M. (2002) Crash Course Anatomy. 2nd Edition. London: Mosby. General Medical Council (2001) Good Medical Practice Handbook, 3rd Edition, GMC, London. Kindlen, S. (ed) (2003) Physiology for Health Care and Nursing. Edinburgh: Churchill Livingstone. Lavery, I. and Ingram, P. (2005) Venepuncture: best practice; Nursing Standard; Aug. 17th, Vol. 19, No. 49, p55-65. McConnell, A. A. & Mackay, G. M. (1996) Venepuncture: the medicolegal hazards; Postgraduate Medical Journal; Jan, 72 (843), p23-24. NHS Fife (2004) Specimen Rejection Policy; Directorate SOP. NHS Tayside (2003) Infection Control Policy. Nursing and Midwifery Council (2005) Guidelines for Records and Recordkeeping, NMC. Ogawa, S, Ogihara, T, Fujiwara, K, Nakano, M, Nakayama, S, Hachiya, T, Fujimoto, N, Abe, H, Ban, S, Ikeda, E. and Tamai, H. (2005) Venepuncture is preferable to heel lance for blood sampling in term neonates. Arch Dis Child Fetal Neonatal Ed; 90, F432-436. Robertson, N. (2000) Textbook of Neonatology; Third Edition, Churchill Livingston. Royal College of Paediatrics and Child Health (2003) Medicines for Children; Second Edition. Sheu, J. J & Yuan, R.Y (2001) Superficial radial neuropathy following venepuncture; International Journal of Clinical Practice; 55 (6), 422-3, Jul-Aug. UK Health Departments (1998) Guidance for Clinical Health Care Workers: Protection Against Infection With Blood Borne Viruses; Recommendations of the Advisory Group on AIDS and the Advisory Group on Hepatitis. P17-18. Waugh, A. and Grant, A. (2001) Anatomy and Physiology in Health and Illness; Ross and Wilson, Churchill Livingstone, Ninth Edition, London, p99, fig. 5.33. Zubairy, A. I. (2002) How safe is blood sampling? Anterior interosseus nerve injury by venepuncture; Postgraduate Medical Journal; Vol.78, p625.

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Authors, Contributors & Reviewers

The Multi Professional Clinical Skills project, based at the clinical skills centre in Ninewells, has been funded by the TUHT Endowment Fund. The project team are as follows: - Project Director: Dr Jean Ker Project Manager: Michelle Lorente Project IT Facilitator: Chris Lawrie Project Secretary: Michelle Harvey Authors: Caroline Ackland – Research Nurse/Coordinator, Ward 32, Ninewells Hospital. Santosh Chima – Clinical Educator, Tayside Primary Care. Ann Graham - Senior Charge Nurse, Haematology, Ninewells Hospital, Dundee. George Hogg – Senior Clinical Skills Tutor, University of Dundee, School of Medicine, Clinical Skills Centre, Ninewells Hospital. Peter McEwan – SpR, Paediatrics, Ninewells Hospital. Louisa McIlwaine – SpR Haematology, Ninewells Hospital, Dundee. Elaine Roberts - Phlebotomy Manager, Biochemical Medicine, Ninewells Hospital, Dundee. Rona Solley – Senior Staff Nurse, Ward 32, Ninewells Hospital. Scott Williamson – Paediatric Academic Fellow, Honorary Specialist Registrar, Maternal and Child Health Sciences, Ninewells Hospital and Medical School. Contributor to Guide: Michelle Lorente - Multi-Professional Clinical Skills Project Manager, Clinical skills Centre, Ninewells Hospital. The pack was distributed to the following reviewers: Internal Review: Paul Christie - Senior Staff Nurse, Tayside Cancer Centre, Ninewells Hospital. Education Shared Governance Council, NHS Tayside. Karen Gibson – District Nursing Sister, NHS Tayside, Primary Care. Multi-Professional Clinical Skills Steering Committee:-

Fiona Anderson – Training & Educational Development Manager, NES

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Madge Balfour - Practice Development Nurse, Acute Care, NHS Fife Santosh Chima – Clinical Educator, Primary Care, NHS Tayside Fiona Drimmie – Associate Dean, University of Dundee Jim Foulis – Former Lead Nurse, Acute Care, NHS Tayside George Hogg – Senior Clinical Skills Tutor, University of Dundee Jean Ker – Project Director, Undergraduate Medicine, University of Dundee

Michelle Lorente – Project Manager, Acute Care, NHS Tayside

Julie Peacock – Former Clinical Practice Development Officer, Primary Care, NHS Fife Iain Rennie – Clinical Educator, Acute Care, NHS Tayside Phillip Roddam – Postgraduate Medicine, Acute Care, NHS Fife Charles Sinclair – Head of Practice & Professional Development, Acute Care, NHS Fife

Kay Wilkie – Director of Learning & Teaching. University of Dundee Alison Wynne – District Nursing Sister, NHS Tayside, Primary Care. External Review: Madge Balfour – Practice Development Nurse, Acute Division, NHS Fife. Mike Jones – Royal College of Physicians of Edinburgh. Alistair Lawrie – Head of English, Cults Academy, Aberdeen. Sam Rawlinson – Clinical Director East of Scotland, Blood Transfusion Service. Professor Rowley - Director of Education, Royal College of Surgeons of Edinburgh. Date developed: March 2005 Last review date: March 2006 Next review date: March 2008 Persons responsible for review: The Multi-Professional Clinical Skills Project Team will be responsible for reviewing this pack and liaising with appropriate authors and contributors.

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Appendix A

Clinical Skills Framework for Practitioners

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Appendix B

Venepuncture Procedural Checklist (Adult)

Task a r N/A Introduce self to patient by name and title Ensure you have the correct patient – check name, DOB, CHI (in-patients) or address (primary care) or Typenex number (unknown identity)*

Explain procedure to patient and ask about preferred site / side Gain verbal consent

Select appropriate container(s) and needle for procedure Organise gloves, tourniquet, gauze swabs/cotton wool, tape Take sharps bin to the bedside* Decontaminate hands* Put on gloves (disposable non-powdered latex not vinyl) and apron* Apply tourniquet and select appropriate vein Swab skin with antiseptic wipe (70% isopropol alcohol) and allow to dry for 30 secs

Ensure bevelled edge of needle is upmost Enter vein with needle at an angle of approximately 15° to the skin Avoid contamination of needle with hands* Collect blood in appropriate containers If unsuccessful, gently manoeuvre needle to attempt to collect blood If blood collection fails

Release tourniquet Place a swab/cotton wool over the needle

Remove needle Dispose of needle in sharps bin*

Apply pressure to vein for 30-60 seconds or until bleeding stops Explain to patient and try again at a different site / side

Release tourniquet prior to removing needle Remove needle and cover area with swab/cotton wool Dispose of needle safely into sharps bin* Apply pressure to site for 30-60 seconds or until bleeding stops, with swab/cotton wool

Keep arm extended and elevated Write details (name, DOB, CHI, ward, time, initial, date or apply sticky label if Test Requesting in use) on blood bottles at the side of the patient

Place blood sample(s) into sealed polythene bag (one bag per patient) Dispose of gloves into clinical waste bag Decontaminate hands* Check that bleeding has ceased

Adapted from L. Malek – SCOTS Project, Procedural Checklists

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Appendix C

Venepuncture Procedural Checklist (Child)

Task a r N/A Introduce self to child by name and title Ensure you have the correct patient – check name, DOB, CHI (in-patients) or address (primary care)*

Explain procedure to child and guardian and ask about preferred site / side Gain verbal consent Identify any known allergies Establish if local anaesthetic will be required and wait until this takes effect

Select appropriate container(s) and needle for procedure Organise gloves, tourniquet, gauze swabs /cotton wool, tape Take sharps bin to bedside* Decontaminate hands* Put on gloves (disposable non-powdered latex not vinyl) and apron* Ensure assistant stabilises limb and applies pressure Swab skin with antiseptic wipe (70% isopropol alcohol) and allow to dry for 30 secs

Ensure bevelled edge of needle of butterfly is upmost Enter vein with needle of butterfly at an angle of approximately 15° to the skin

Avoid contamination of butterfly needle with hands* Withdraw blood using syringe If unsuccessful, gently manoeuvre needle to attempt to collect blood If blood collection fails

Place a swab/cotton wool over the needle Remove butterfly needle

Dispose of butterfly needle in sharps bin* Apply pressure to vein for 30-60 seconds or until bleeding stops

Explain to child and guardian and try again at a different site / side

Remove butterfly needle and syringe and cover area with swab/cotton wool Dispose of butterfly needle safely into sharps bin* Apply pressure to site for 30-60 seconds or until bleeding stops, with swab/cotton wool

Keep arm extended and elevated Transfer blood into appropriate containers Write details (name, DOB, CHI, ward, time, initial, date or apply sticky label if Test Requesting in use) on blood bottles at the side of the patient

Place blood sample(s) into sealed polythene bag (one bag per patient) Dispose of gloves into clinical waste bag Decontaminate hands* Check that bleeding has ceased

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Appendix D

Venepuncture Equipment List (Adult)

• Sharps receptacle and tray • Disposable gloves • Apron • Tourniquet • 70% isopropyl alcohol wipe • Blood collection system • Appropriate sample bottles • Transport bag(s) • Forms (high risk labels may be required) • Elastoplast or cotton wool ball and tape • Computer generated labels (if using CentralVision Test Requesting)

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Appendix E

Venepuncture Equipment List (Child)

• Sharps receptacle and tray • Local anaesthetic cream - Ametop (amethocaine) or Emla (lidocaine

2.5% and prilocaine 2.5%) • Disposable gloves • Apron • Tourniquet (for children over 10 years old) • 70% isopropyl alcohol wipe • Butterfly needle 23 gauge (blue) or 21 gauge (green) and syringe • Paediatric sample bottles • Transport bag(s) • Forms (high risk labels may be required) • Elastoplast or cotton wool ball and tape • Computer generated labels (if using CentralVision Test Requesting)