Policy and Procedure for Venepuncture – Performed by Nurses, Doctors and Phlebotomists

Introduction

This document is designed to ensure the safety of the patient and practitioner during venepuncture and ensure that there is standardized practice across the Trust.

Only practitioners who have received the appropriate training – both practical and theoretical – in Velindre NHS Trust can practice Venepuncture. Each practitioner should possess a certificate of competency which requires updating 2 yearly.

  1. Definition

Venepuncture is the ‘insertion of a needle into a vein for the …. Withdrawal of blood’ (Bailliere’s 2000)

  1. Purpose

Venepuncture is carried out:

  • To withdraw blood for the intention of diagnosis
  • To monitor levels of blood components
  1. Framework
  1. The practitioner must hold a verification certificate that they have undertaken an approved venepuncture study day or completed the competency assessment workbooks to an agreed standard. Formal assessments can only be conducted by a recognised assessor within the Trust.
  2. The practitioner must be aware of his/her individual responsibility and accountability to the patients and for his/her own safety.
  3. The practitioner must be familiar with and comply with all relevant Trust policies relating to Venepuncture. The following policies are all relevant:
  • Health and safety
  • COSHH
  • Prevention and management of sharps injury
  • Clinical waste disposal
  • Infection Control
  1. Venepuncture is an invasive procedure. All practitioners must adopt universal precautions and use appropriate infection control measures to minimize the risk of injury and/or infection to both patient and staff when undertaking this procedure.
  2. Following the training period, the practitioner must observe at least 3 venepuncture procedures and perform the procedure a minimum of 5 times under direct supervision before being considered for competency assessment.
  1. Guidelines
  1. The protection of patients and staff is paramount when handling blood and body fluids, therefore the presumption should be that every person might be potentially infectious
  2. Gloves MUST always be worn when performing Venepuncture. Non sterile gloves can be used.
  3. The safest method for collecting blood samples is via the use of the vacutaner system. The Vacutaner system MUST be used to reduce the risks to the practitioner from needlestick injury and to minimise the incidence of haemolysed samples.
  4. The two main methods used for blood sampling (both using the vacutaner method) are the single needle system and the butterfly system. The butterfly system is usually used when blood withdrawal is undertaken from the hand or when difficulty is experienced obtaining a blood sample in the antecubital fossa.
  5. ONLY the practitioner undertaking the procedure will be responsible for the disposal of the equipment used. This includes any clinical waste and sharps.
  6. Many patients, whether familiar or not with the procedure may be frightened or tense. Anxiety can cause the veins to constrict and make Venepuncture more painful for the patient or more difficult for the practitioner. Reassurance should be given prior to the procedure.
  7. It is important to consider the environment prior to the procedure. Ensure that the lighting, ventilation, privacy and positioning of the patient is appropriate. If there is evidence that the patient has fainted previously or is exhibiting symptoms which may indicate that he/she may faint, ensure that the patient is lying down or is in a suitable recliner chair.
  8. Vein Selection must follow guidelines from the workbook. The ideal vein will be straight, bouncy, refills when depressed and well supported
  9. Disposal of clinical waste, including sharps, must follow Velindre NHS Trust policy and guideline. Clinical waste must be placed in a yellow bin and tagged and labeled correctly according to where the waste has been collected. Sharps are to be disposed of immediately into a non-cytotoxic sharps bin.
  10. The tourniquet should be placed aprox 10cm above the venepuncture site. It is important that the vein is compressed but the arterial circulation in not obstructed. The latter will impair blood flow into the specimen tube. If in doubt, check for a pulse. It should be palpable.The tourniquet should be left in place for no longer than 2 minutes when vein selection is taking place. If further time is required, the tourniquet should be released and re-applied. It should not be in place for longer than 1 minute prior to accessing the vein and must be released on the first filling of the tube. Prolonged use of tourniquet will affect the result of the sample i.e potassium, total protein, calcium, bilirubin, ALT, AST,cholesterol, albumin, haemoglobin.
  11. All practitioners must be aware of the risks of a vasovagal attack and it’s management. NEVER take blood when a patient is standing .
  12. If IV fluids are infusing on the side where venepuncture is to be performed, stop the infusion for 5-10 minutes prior to proceeding
  13. Always refer to a more experienced practitioner after 2 failed attempts
  14. Blood samples must be taken according to the recognised order of draw for Velindre Cancer centre.
  15. Documentation identifying the correct order of draw will be available in all clinical areas and in the Venepuncture workbook.
  16. Needle sizes for adults need to be between 19 and 23 gauge. 24 and 25gauge needles will cause heamolysis
  17. Blood cultures: Blood culture bottles should be stored between 2 and 25 degree C in a dry location away from direct sunlight. When taking blood cultures, the optimum fill is 8 – 10 mls. Taking blood cultures must be completed using strict infection control guidelines. Cleanse the skin well with chlorhexidine in alcohol and leave to dry, gel hands, apply sterile gloves and withdraw the sample using the blood device with extension tubing (single use needle must not be used). Ensure that the bottles are kept below the level of the vein to prevent the inadvertent infusion of the contents of the vial into the vein. Observe the direction of the flow at all times
  18. A patient who is known to be high risk will be identified by a yellow round sticker in the medical notes. All blood forms must be labeled with a yellow sticker prior to transportation to the laboratory.
  19. Any unwanted blood samples should be disposed of in the sharps bin
  20. Any blood specimens transported from one site to another must be placed in a plastic bag
  1. Equipment
  1. Clean tray or receptacle
  2. Tourniquet
  3. Alcohol swab
  4. Vacutaner barrel (holder) and straight needle or butterfly needle
  5. Gauze swab
  6. Hypoallergenic tape
  7. Specimen requisition forms
  8. Gloves – those practitioners with an allergy to latex or if a patient has a latex allergy should ensure that latex free gloves are used
  9. Sharps bin

Prior to the procedure – check all the equipment to ensure all packaging is intact and that the expiry date has not lapsed.

  1. Preparation of the patient
  1. Approach the patient in a confident manner and explain and discuss the procedure with the patient. Take time to answer any questions or discuss any problems
  2. Discuss with the patient if he/she has any past problems or preferences and obtain verbal consent before the procedure
  3. Ensure that the correct details that have been entered onto the specimen requisition form match those of the patient who is undergoing the procedure. The patient MUST relay their details to the practitioner where possible. Where the patient is an inpatient, the identity must be checked with the identity label on the arm and a verbal clarification can also be used. The sample must include all the details requested on the bottle.
  4. A Cross Match or group and save samples MUST be hand written – no labels. The detail on the bottle must include: Surname, forename, date of birth, hospital number,1st two lines of address, signature of person taking the blood and date and time of sampling. The blood form can be labeled using an addressograph and it is crucial that both details are correct and correspond. Only a Doctor can request a X-match.
  1. Procedure for venepuncture
  • Wash hands
  • Ensure that the patient is comfortable
  • Identify if the patient has experienced any past difficulties with venepuncture
  • Obtain verbal consent
  • Confirm the identity of the patient – patient to relay details to practitioner
  • Gather all the necessary equipment and ensure that the sharps bin is within a comfortable range to enable immediate disposal
  • Place the bottles according to the correct order of draw
  • Extend the arm out (this assists with bringing the veins closer to the surface)
  • Support the arm
  • Apply the tourniquet if necessary
  • Lowering of the limb may help venous filling
  • Select a good vein – usually in the antecubital fossa
  • Refrain from slapping the vein as this can cause vasoconstriction and pain
  • Refrain also from asking the patient to open and close their fist. This can lead to minor alterations in some blood results i.e potassium
  • Once the vein has been identified release the tourniquet
  • Clean hands with alcohol gel
  • Clean the site for 30 seconds using a 70% alcohol swab. Allow to dry.
  • Re-apply the tourniquet
  • Put on gloves
  • With one hand anchoring the skin, enter the vein smoothly with the bevel of the needle facing upwards. Use a shallow angle, aprox 15 degrees. Once the vein has been entered, release the skin and stabilise the needle
  • Place the vacuumed bottle into the barrel
  • Release the tourniquet when the first sample has started to fill
  • Fill the tubes to full capacity and invert immediately after removal from the vacutaner 5-8 times
  • When sampling is complete, withdraw the last bottle from the vacutainer, remove the needle and cover the site with gauze. Do not apply pressure to the site until the needle is completely removed
  • Apply digital pressure to the vein for 1-2 minutes and DO NOT allow the patient to bend his/her arm as direct pressure cannot be applied
  • Transfer the needle and the vacutaner holder as a single unit immediately into a sharps bin
  • Ensure that the bottles are fully and correctly labeled immediately by the patients side – never transport unlabeled bloods
  • Check that the bleeding has ceased and place adhesive tape over the site
  • Dispose of any items containing blood into a clinical waste bin
  • Document the procedure and state the blood samples that have been collected

8. Training

  1. All practitioners should request training through their Annual Performance Review
  2. Each assessment will be signed and dated by the observing assessor and the practitioner
  3. All practitioners undertaking venepuncture are responsible for their own practice

9. References

H3-A% Procedures for the Collection of Diagnostic Blood Specimens by Venepuncture: Approved Standard – Fifth Edition NCCLS Vol 23, No 7

The RoyalMarsdenHospital. Manual of Clinical Nursing Procedures (5th Edn) 2000

University Precautions, RoyalCollege of Nursing 1997 Order No 000264

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Venepuncture policy/updated Nov 2011/VelindreCancerCentre