Venepuncture self learning package

CDHB Venepuncture self learning package

2011

Index Page 3

Venepuncture competency flowchart

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Introduction

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Patient identification

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Anatomy & physiology

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Infection prevention

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Sharps safety

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Preparation

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Patient education & consent

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Vein selection

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Equipment selection

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Venepuncture procedure for adults

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Blood samples

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Order of draw

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Documentation

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Adverse event management

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References and links

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CDHB Venepuncture Learning Package. Version 3

Venepuncture Competency Flowchart Complete on line training package Return completed questions via e-mail to: - [email protected] Coordinator, Clinical Skills Unit, Level 5, Riverside, Christchurch Hospital. Once marked you will receive an email with available dates for attending the venepuncture workshop Return confirmation of attendance to:- PDU Administrator [email protected] Attend workshop Complete clinical practice and assessment Return completed paperwork to:- Chris Beasley Coordinator, Clinical Skills Unit, 5th floor, Riverside, Christchurch Hospital Email of successful completion Details placed on competency database

There is no further re assessment requirements for competency instead venepuncture skill will be assessed through ongoing audit and incident reporting

Evidence of prior learning When transferring from other healthcare providers you will be required to:Produce evidence of prior learning with written endorsement form Clinical Nurse Manager Read self learning package Complete online test and return to Clinical Skills Unit One Observed Venepuncture assessed by designated Venepuncture assessor (listed) Return assessment form to Clinical Skills Unit Email from Clinical skills confirming receipt Details entered onto competency database For further information: - [email protected] Phone: - External- 36401673 Internal- 81673

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CDHB Venepuncture Learning Package. Version 3

INTRODUCTION Venepuncture is the puncture of a vein with a needle to withdraw blood as part of a medical procedure. It is also called phlebotomy and /or blood draw. Venepuncture is one of the most routinely performed invasive procedures and is carried out to obtain blood for diagnostic and monitoring purposes. Blood analysis is one of the most important diagnostic tools available to clinicians. Even when an analytical procedure is performed correctly and precisely variables of collection can affect the test results. These may include age, gender, hydration, stress, activity, bed rest, time of day, diet, smoking and drug treatments. Pre-analytical factors such as misidentification of the patient, and specimen collection errors including volume, tube selection, sample handling and contamination may lead to the unnecessary re-bleed of the patient and a delay in treatment. With increased scope of practice comes increased professional accountability established through: 1. Demonstrating a level of practice and professional accountability, appropriate to the extending of skills. 2. Having sound knowledge of the normal patient response to venepuncture. 3. Possessing the necessary interpersonal skills for accurate assessment and treatment negotiation. 4. Performing accurate assessment through identifying patient-specific indications, contraindications and associated risks. 5. Acquiring and maintaining competence in the technical skills necessary to perform Venepuncture. 6. Utilising critical thinking skills and evidence based practice to achieve best patient outcomes. 7. Confidently articulating scope of practice, identifying and acknowledging limitations and seeking assistance appropriately. 8. Compliance with HPCA, code of health and disabilities services consumer’s rights. COMPETENCE Competent clinicians are able to carry out Venepuncture without direct supervision. At Canterbury District Health Board (CDHB) competency in venepuncture is achieved through: 1. 2. 3. 4.

Completing the online self learning package and test. Returning the completed test to the Clinical Skills Unit (CSU). Completing the workshop and lab practicum. Completing the work place practical assessment with an IV / venepuncture assessor, IV link nurse or midwife educator/ phlebotomy assessor (refer to individual department policy). 5. Returning completed assessment forms to the CSU. 6. On successful completion name is entered onto the competency database.

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CDHB Venepuncture Learning Package. Version 3

Competency will be assessed through ongoing audit (with exception of Canterbury Health Labs staff. Please refer to manager/ trainer) SELF LEARNING PACKAGE This self learning package is designed as a resource for clinicians who are routinely required to perform Venepuncture of adult patients as part of their practice. The workbook describes the knowledge and techniques needed for attending venepuncture training. LEARNING OUTCOMES On completion of the self learning package and test in conjunction with attending the workshop, the practitioner will be able to: Describe relevant anatomy and physiology of the peripheral venous system. Identify blood borne pathogens. Demonstrate familiarity of the equipment to meet the goals of venepuncture and blood sample collection. Identify the peripheral veins suitable for venepuncture. Perform venepuncture safely under simulated conditions. Identify measures to minimize and address difficulties encountered during venepuncture. List complications associated with venepuncture, their prevention, management strategies and removal of needle. Describe infection prevention measures. Identify the action required in the event of a needle stick injury or blood and blood fluid exposure. Articulate essential aspects of patient communication.

PATIENT INDENTIFICATION All patients who present to Canterbury DHB facilities or receive CDHB services within the community must be accurately indentified by staff using at least two identifiers to ensure the correct patients receives the right treatment i.e. full name, date of birth or hospital number. Within Canterbury Health Laboratories it is expected that the identifiers given by the patients are circled on the request form. It is the staff member’s responsibility to ensure they have clearly identified the patient they are interacting with. The identity of the patient will be confirmed: On admission / entry to the service or department. Either as an inpatient or out patient. Transfer between departments / wards / hospitals. Prior to consultation. Prior to administration of drugs. Prior to administration of intravenous fluids including blood products. Prior to blood, body fluids or tissue sampling.

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CDHB Venepuncture Learning Package. Version 3

Prior to radiology examination or intervention. Prior to any therapeutic procedure. Upon entry to theatre or procedure room. IDENTIFICATION OF THE COMPETENT PATIENT Staff must ask the patient to state their full name and date of birth. Confirm their care / treatment where applicable. Check these details are compatible with relevant identifying information. Patients who have an identity bracelet should have the NHI confirmed against another written record. IDENTIFICATION OF INCOMPETENT / UNCONSCIOUS PATIENTS (USING AT LEAST TWO IDENTIFIERS) Children: - for children who are unable to identify themselves, identification is confirmed by the parent or guardian. Adults: - initial identification is to be confirmed by a family member or person known to the patient, then ongoing identification by reference to the Identification bracelet. Patients unable to be formally identified: - a pre-allocated / temporary identification number must be used for the duration of that stay in hospital. SPECIAL CIRCUMSTANCES Wherever possible, a patient must wear an identification bracelet, excluding outpatients either on the wrist or ankle. If this is impractical it must be secure using strapping or transparent adhesive film on an appropriate site. Patients who refuse to wear an identification bracelet must be advised of the potential risk and have their refusal documented in the clinical records. Patients that have a similar name to another patient must have a sticker “special note” – “there is another patient with the same or similar name – CHECK”. Currently a QL2 sticker attached to the clinical records and patient information board. MENTAL HEALTH SERVICES Consumers under the Special Mental Health Services do not wear identification bracelets therefore: Identity is confirmed with the consumer or family on admission or through staff handover. Ongoing identification is assisted by documentation defining features or inserting a photograph of the consumer in the clinical records, after consent is taken.

ANATOMY & PHYSIOLOGY Seventy five percent of the blood volume is contained in the venous system. The veins, because of their abundance and location, present the most readily accessible route for venepuncture. An understanding of anatomy and physiology is important for successful venepuncture.

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CDHB Venepuncture Learning Package. Version 3

SKIN STRUCUTRE Consists of two layers: Epidermis: - is the least sensate layer. Consists of largely dead squamous cells. The thickness can vary depending on age and exposure to the sun and wind. The most important function of the epidermis is to act as the first line of defence against infection. Dermis: - is the thicker and more sensitive layer, as it is well supplied with nerves. It also contains blood vessels, hair follicles, sweat glands, sebaceous glands, and small muscles.

VEIN STRUCTURE Tunica externa / adventitia: - is the outermost layer of the vein and is comprised of connective tissue, which supports the vein. Tunica Media: - is the middle layer of the vein and is primarily composed of smooth muscle. It contains nerve fibres that cause the veins to contract and dilate in response to cold and heat. The tunica media also responds to chemical or mechanical stimulation, such as pain. Pain sensed in the tunica media can elicit vasovagal response. (Hadaway 1999) Tunica Intima: - are the third layer of the vein and the innermost layer. It is a thin layer, accounting for only 10% of the vessel diameter. It consists of three distinct parts: 1. An innermost layer of squamous epithelium 2. A basement membrane, overlaying some connective tissue 3. A layer of elastic fibres, or Elastin

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CDHB Venepuncture Learning Package. Version 3

Elastic fibres make the lumen very distensible and one-way valves of endothelial tissue direct the blood flow. This means that the needle should only be placed in the direction of the blood flow. The valves are usually found near branches of the vein and may inhibit threading of the needle into the lumen. There are approximately 40 venous valves between the hand and axilla. It is important to understand that any damage or abrasion occurring to the vein can result in haematoma and bruising

DIFFERENCE BETWEEN ARTERIES AND VEINS It is important to be able to distinguish between arteries and veins. The aim if venepuncture is to draw venous blood not arterial. Whilst an artery can inadvertently be punctured it is uncommon. Having good understanding of venous anatomy and checking for pulsation prior to venepuncture will reduce this event occurring.

Arteries

Veins

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Muscles More muscle for their diameter

Valves No valves

Visibility Not visible deep and protected

palpable Pulsating

other

Less muscle

Valves present

Often visible

Non-pulsating

Stress relaxation phenomena

CDHB Venepuncture Learning Package. Version 3

VEIN LOCATION & CHARACTERISTICS VEINS OF THE FOREARM 1. Cephalic vein. Runs the entire length of the arm from wrist to shoulder. Best located above anterior cubicle fossa but may be difficult to visualise. Good choice for venepuncture although should not be used for patients that require fistula formation. Radial nerve runs parallel to this vein so avoid the wrist area where they are closer together 2. Median Cubital vein. Lies in the antecubital fossa. It is a large vein which is easily seen and accessed. Usually used to draw blood and are the veins of choice for shock or trauma patients. Joint articulation makes this access site limited in its use. Complications of this site mean that the veins below the point of entry are not recommended. 3. Accessory Cephalic vein. Branches off the Cephalic vein, it is located on the top of the forearm and is usually of a good size. This vein is easy to stabilize. 4. Basilic vein. Runs the entire length of the arm from wrist to shoulder. The veins rotate around the arm and need firm skin tension to stabilize. Increased success can be achieved by placing the patients arm across their chest and approaching from the opposite side. 5. Dorsal Basilic vein. Branches off the cephalic vein located at the lower end of the forearm on the underside. Easy access is gained by having the patient flex the forearm at the elbow and face the patient to expose the underside of the arm. Or arm straight with palm up. 6. Median vein. Arises from the palm of the hand and flows upwards in the centre of the underside of the forearm. It is of medium size and generally easy to visualise. May be difficult to palpate and runs close the nerve.

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CDHB Venepuncture Learning Package. Version 3

VEINS OF THE HAND AND WRIST 1. Dorsal digital veins. Found along the lateral portion of the fingers and thumb. A last resort for venepuncture and should only be accessed by an expert. 2. Dorsal metacarpal veins. Found between the metacarpal bones on the back of the hand. Superficial veins that are usually of a good size and easily visualized. Good site for venepuncture for some patients. Ensure the needle lies flat on the back of the hand 3. Dorsal venous network. Formed by a union of the metacarpal veins on the dorsal aspect of the forearm and may not always be prominent. Angle o the vein may dictate the choice of site for venepuncture.

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CDHB Venepuncture Learning Package. Version 3

INFECTION PREVENTION Risk if infection with venepuncture can be minimised by adherence to standard precautions, including the 5 Moments for Hand Hygiene and using an aseptic non-touch technique (ANTT). RISKS FOR INFECTION Venepuncture presents risks for infection for several reasons: A device penetrates and bypasses the protective barrier of the patient’s skin. Inadequately performed skin antisepsis or hand hygiene may permit micro-organisms to enter the venepuncture site. Immunosuppressed or compromised patients are especially vulnerable to infection. Infection may develop where the needle enters the skin. Infection is indicated by inflammation or the presence of pus and may progress to cellulitis in the surrounding tissues, with inflammation of the vein or phlebitis. Bacteraemia (bloodstream infection) may also occur. HAND HYGIENE Hand hygiene is the key to minimizing cross contamination and infection during venepuncture. Effective hand hygiene for venepuncture is achieved by hand washing with an antimicrobial liquid soap or hand decontamination using an alcohol based hand rub (ABHR). FIVE MOMENTS FOR HAND HYGIENE Moment 1: before patient contact Moment 2: before a procedure Moment 3: after a procedure or contact with body fluid exposure risk Moment 4: after patient contact Moment 5:after contact with patient’s surroundings

The Five Moments of Hand Hygiene must be adhered to throughout the venepuncture procedure

ASEPTIC NON-TOUCH TECHNIQUE Sterile equipment and a non-touch technique is used for venepuncture. Non sterile gloves should be used because of the significant health and safety risk of infection from blood borne pathogens. ANTISEPSIS

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CDHB Venepuncture Learning Package. Version 3

Chlorhexidine 2% combined wit 70% Isopropyl alcohol is an effective skin disinfectant (WHO 2010), thus the skin antisepsis of choice at CDHB is either Medi Swab or SoluIV. The cleaning technique of using friction to remove pathogens is very important.

SHARPS SAFETY The CDHB is sharps safety conscious and to protect staff from potential needle stick injuries provides sharps safety devices engineered to minimise needle safety

It is the responsibility of the person using the sharp to ensure it is safely disposed. Safe disposal of equipment into a sharps container should occur at the point of use. If a needle stick injury or blood/blood fluid exposure should occur locate a blood and body fluid exposure (BBFE) pack in your clinical area and follow the instructions. Alternatively follow the CDHB policy found in the infection prevention and control manual. Healthcare workers exposed to blood or body fluids who incur a sharps or splash injury are at risk of sero-conversion with HIV, Hepatitis B or Hepatitis C. in addition to less well known pathogens including Streptococcus Pyrogenes and Staphylococcus aureus.

PREPARATION When the decision is made to perform venepuncture on a patient there are a number of factors that need to be considered through careful patient assessment through the understanding of indications for venepuncture, samples to be collected, appropriate vein selection and access device to be used. PATIENT ASSESSMENT Venepuncture preparation depends on individual patient needs and requires careful assessment of the patient, equipment available, samples required, environment and competency of the practitioner. Does the patient have a history of lymphoedema, mastectomy, previous access device insertion problems, surgical, radiology or chemotherapy intervention near access point and the presence of current or previous fractures? What is the allergy status of the patient? (local anaesthetic, skin antiseptic or dressings) Does the patient have good or poor venous access? (poor vein visibility, bruising or thrombosed veins) What is the patient’s preference? What is the knowledge and skill of the practitioner performing the venepuncture procedure?

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CDHB Venepuncture Learning Package. Version 3

In addition to these questions a careful review of the clinical records and consideration of any other factors that may influence effective venepuncture is important. Age of patient Steroid therapy Repeated venepuncture access History of phlebitis History of previous venepuncture experiences including vasovagal episodes. Patients with a positive history of vasovagal reactions are 75% more likely to have a similar reaction during further venepuncture procedures exacerbated by anxiety and pain. (Hadaway. 1999).

PATIENT EDUCATION AND CONSENT The Code of Rights states that “patients have the right to be fully informed and to have informed consent”. For this reason it is important the practitioner is confident in the explanation of the procedure and can answer question competently. The need for venepuncture Tested to be performed Probable duration How the patient may feel Possible related complications (infection, haematoma formation, arterial puncture and nerve damage) A competent response to any questions or concerns Consideration of family/whanau wishes An adequate explanation and precise information to the patient should help reduce the autonomic fear response and minimise venous vasoconstriction which can potentially hinder successful venepuncture. Explaining the procedure and ongoing care of the access site will encourage patient participation in monitoring for possible complications and side effects.

VEIN SELECTION There are two key determinants to consider when selecting a vein for venepuncture 1. SELECTION OF A SUITABLE VENEPUCTURE SITE Patients who have had several cannulation and venepuncture procedures are likely to have fewer suitable veins and restricted access. These patients should be assessed by an experienced and competent practitioner. Select veins in non-dominant hand or arm if possible Always examine both limbs before making a decision Start at the distal sites of the limb so that if a failure occurs other more proximal attempts can be made. If frequent venepuncture procedures alternate access sites and limbs to aid recovery of previously accessed sites.

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CDHB Venepuncture Learning Package. Version 3

Before performing venepuncture palpate for evidence of arterial pulsation to prevent inadvertent arterial puncture. The brachial and ulnar arteries can be shallow and need careful examination. 2. SELECTION OF A SUITABLE VEIN Selection of a suitable vein is achieved by examining the veins of the patient’s forearm or hand. The tourniquet will need to be applied to assist in this assessment. A suitable vein should feel Round. Firm Elastic Engorged with blood. Inspect and palpate the vein for any bruising, inflammation, skin disease or other injury Avoid sites that are thrombosed (hard and/or tortuous) or distal to site of phlebitis or joint flexion.

The importance of proper and adequate lighting when assessing veins for venepuncture should not be overlooked

EQUIPMENT SELECTION Ensure there is a selection of equipment and devices available in the procedure area as the decision on the device to use may change following assessment of the patient’s veins. EQUIPMENT Vacutainer with safety needle 21 or 23 gauge safety butterfly device Appropriate blood sample tubes Pathology request form Tourniquet (disposable tourniquets are recommended due the risk of cross contamination) Sterile gauze squares Chlorhexidine and alcohol swab Band aid or sterile gauze and tape or IV pressure pad Non sterile gloves Accessible sharps waste container Specimen bag Kidney dish (if no IV trolley available)

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CDHB Venepuncture Learning Package. Version 3

VENEPUCTURE PROCEDURE FOR ADULTS Step 1 2

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Action Rationale Prepare equipment Identify blood tests required from the completed pathology request form, select the correct blood sample tubes and determined amount of blood required Note: if required to take specimen for blood cultures refer to “Blue Book” Management guidelines for Common Medical Conditions (pg 65) Decide the method of venepuncture to be used and assemble the correct equipment : The evacuated system is the most commonly Evacuated System (Vacutainer) Note: Vacutainers have an expiry used means of collecting specimens. This method is generally preferable to the needle date. and syringe method as it allows the blood to pass directly from the vein into the evacuated blood sample tube. The system comprises of three basic elements: A sterile blood collection needle A holder to secure the needle and the evacuated blood sample tube An evacuated blood sample tube, containing a premeasured vacuum and premeasured additive Butterfly technique

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Inspect the equipment to be used for its functionality Explain the procedure to the patient Identify the patient by checking the patient’s identity bracelet if available and NHI number, which must correspond with the data on the pathology request form. Note: all in-patients requiring a cross match specimen must be wearing an identification bracelet

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This method is becoming more popular with the introduction of the safety butterfly device. This method is also used for veins that are difficult to access including feet , hands and children

To ease anxiety and aid co-operation If an in- patient is not wearing an identification bracelet do not proceed with the cross match sample. Notify ward staff i.e. ward clerk or nursing staff, to arrange for the bracelet to be put in place

CDHB Venepuncture Learning Package. Version 3

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If appropriate check that dietary restrictions have been adhered to.

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Position the patient comfortably with limb well supported and accessible for venepuncture

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Apply tourniquet approximately 10cm above venepuncture site

Impeding venous return while still allowing arterial flow produces venous dilation and increases blood flow to the arm.

Ask patient to gently form a fist several times

Rigorous hand clenching may increase potassium levels

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Preferred vein sites: Although the larger and fuller median Cubital and cephalic veins are used the most frequently, wrist, hand, feet and ankle veins may be accessed for venepuncture

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Blood can be taken form the hand and foot as well but must be executed by an experienced venepuncturist Factors in site selection. Excessive scarring and healed burns must be avoided Mastectomy –do not take blood form the mastectomy side without permission of the Medical officer Haematoma – specimens collected from a haematoma area If another vein site is not available, the specimen must be collected distal to the haematoma Intravenous therapy – avoid the arm with an Intravenous infusion in progress. If this is unavoidable ensure the tourniquet is applied distal to any infusion to prevent accidental contamination or dilution of the specimen. Or check with the medical officer if the infusion can be clamped for 20 minutes prior to the venepuncture

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Some tests require patients to fast and / or eliminate certain foods from their diet prior to blood drawing. Time and diet restrictions may vary according to the test. Such restrictions are necessary to ensure accurate test results.

Care should be taken to avoid penetrating deeper tissues e.g. By using a shallow angle to enter the vein

May cause inaccurate test results.

Collection of a blood sample whilst the infusion is still in progress or not turned off could result in inaccurate results.

CDHB Venepuncture Learning Package. Version 3

cannula - do not collect blood samples from a cannula unless the luer has just been inserted

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Procedure for vein selection. When feeling for a vein consider the following: Bounce - to determine whether it is a vein. Direction of the vein Size of needle - 21 gauge is suitable for most collections, but smaller may be required. Depth – sometime deep, large veins, are the best but they may not be visually sighted Loosen tourniquet. Perform hand hygiene with antimicrobial liquid soap or alcohol based hand rub (ABHR)

Collecting blood samples from an established luer increases the likelihood of bacterial contamination of both the patient and the specimen

To prevent cross infection

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Put on non sterile gloves

For health and safety reasons

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Swab the selected venepuncture site and surrounding skin with Chlorhexidine and alcohol swab and allow to dry

To reduce the risk of bacterial invasion during the needle insertion

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Tighten tourniquet. Lift away from the skin to avoid pinching the patient. This can be achieved by placing a finger beneath the tourniquet or by stretching the skin

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Hold the device horizontal with the hand on top of the device.

Precautions to be taken when using a tourniquet: The tourniquet must be released after no more than one minute as localised stasis can occur. Haemoconcentration may result in erroneously high values for all protein-based analytes, packed cell volume and other cellular elements. If the patient has a skin problem, the tourniquet should be applied over the patient’s clothing or gauze to ensure there is not pinching. Proper entry angle is assured and allows maximum flexibility of the wrist when inserting the device

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Fingers should be well behind the sharp needle Stabilise the vein with the non dominant hand by pulling gently the skin in a downward motion and maintain until the needle has been inserted into the vein.

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To prevent the risk of need stick injury Stretching the skin distal to the vein will maintain the vein in a taut, distended, stable position and reduce its movement

CDHB Venepuncture Learning Package. Version 3

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Insert the needle at an angle of 15 -30 degrees smoothly and stop when a slight decrease in resistance is felt

The needle should puncture the vein wall and enter the lumen without piercing the opposite vein wall.

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Reduce the angle of the needle and collect blood samples as required and invert gently several times Note: collection of blood samples need to follow a clearly documented order of draw Release tourniquet as blood flows into the sample tubes The patients hand should be relaxed and open Apply sterile dressing With vacutainer and needle and syringe method apply firm pressure immediately after the removal of the needle With safety butterfly devices active the needle withdrawal device whilst still in the vein and apply firm pressure Pressure should be maintained until bleeding stops

to prevent puncture of other vein wall

Keep the patient’s arm extended whilst pressure applied

Increased risk of haematoma with arm bent

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to ensure mixing with additives To reduce the risk of contaminated samples and erroneous results

Applying pressure before withdrawal of the needle will cause pain and damage to the vein

Activating the withdrawal device whilst still in the vein reduces the risk of needle stick injury.

To prevent the formation of possible haematoma

Once bleeding stopped aptly adhesive dressing 26

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Dispose of sharps in an appropriate sharps container as assembled Note: DO NOT disassemble the equipment Label blood sample tubes after they have been drawn either hand written or use of official pre-printed label whilst still with the patient Remove gloves and dispose in clinical waste bag Perform hand hygiene

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Risk of needle stick injury and contamination of blood borne pathogens Leaving the patient with unlabelled sample tubes increases the risk of wrong sample for wrong patient

CDHB Venepuncture Learning Package. Version 3

BLOOD SAMPLES BLOOD CULTURE COLLECTION Blood cultures should ideally be taken via the Vacutainer compatible (safety) butterfly method rather than using a needle and syringe, which may result in a poor quality sample and increase risk to staff. EQUIPMENT Vacutainer safety butterfly 3 alcohol swabs Tourniquet Blood culture bottles Vacutainer hub Sharps container Tape Sterile dressing

PROCEDURE Prepare and access vein as previously outlined in the venepuncture procedure Attach plastic hub to safety butterfly Remove caps from blood culture bottles and wipe with alcohol swab leaving on top until ready for use Once vein accessed secure with tape Ensuring the bottles remain upright push the Aerobic bottle into the plastic hub and fill with 10mls of blood (increment markings on side of bottle) Repeat with anaerobic bottle Take other blood tests if required Follow venepuncture procedure for removal of needle, discarding of sharps, hand hygiene and dressing There is a small amount of air within the safety butterfly tube. To prevent this air from being introduced into the anaerobic bottle it is important to fill the aerobic bottle first

CROSSMATCH SAMPLES Correctly identifying the patient both before and after the collection of the blood sample is vital in avoiding “wrong blood “episodes.

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CDHB Venepuncture Learning Package. Version 3

At the time of taking the sample the conscious patient must be asked to state their first name, family name and date of birth. This information is checked against the patient’s identification bracelet to ensure they are identical. Blood sample should be collected into the pink tube The sample tube must be accurately labelled by hand whilst still at the patient’s side. In the case of unconscious patients a medical practitioner should complete the request form, take the sample and label the sample tube Sample tubes MUST NOT be relabelled before the sample is taken to reduce the risk of putting the wrong blood episodes.

Order of draw The following order of draw is recommended when drawing multiple specimens for laboratory testing during a single venepuncture. Its purpose is to avoid possible test result errors due to additive carryover. E.g. heparin will affect coagulation testing. Blood cultures are collected first to ensure the best aseptic collection. All tubes should be filled to their stated volumes.

Correct volume is critical for coagulation testing. When using a butterfly and the first sample is coagulation (light blue) a discard tube is needed first to clear air from the line

If an error is made in the sequence it may be helpful to take a discard tube to clear the needle and avoid rebleeding the patient.

Clotting serum bottles often contain activator so may affect subsequent tubes in the collection order.

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CDHB Venepuncture Learning Package. Version 3

Documentation A completed request form must accompany specimens meeting the minimum requirements for efficient and correct reporting of results to authorised requestors and primary samples need to have a clear audit trail. A request form can be signed by an approved requestor and is required prior to obtaining any samples. Minimum labelling requirements for request forms are: Surname First name (s) Date of birth Sex Location/ward Consultant/team Test required Relevant clinical details Date & time of collection Initials of collector Requestors signature and designation Contac details of requestor Drug therapy and time if applicable Urgent samples must be indicated on form with a fax number provided

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CDHB Venepuncture Learning Package. Version 3

Adverse event management Injury related to venepuncture are covered by ACC. It is important that all adverse events listed may require: Complete incident form Document in clinical notes if inpatient Informing nursing /medical staff

Adverse event Haematoma Causes: Small frail vein, needle too large Excessive probing to find the vein Removing the needle prior to releasing the tourniquet Needle going all the way through the vein Needle partially entering vein and allowing leakage Applying pressure to gauze before the needle as been removed Nerve Strike Causes: Inappropriate sites Excessive probing to find vein

Signs & symptoms Collection of blood under the skin. This can be painful and can potentially cause nerve damage.

Accidental arterial puncture Causes: Inappropriate site identification

Bright red blood flow, pulsating blood flow, sample bottle fills immediately

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Patient complains of severe pain radiating down the arm into their thumb feeling like hot needles

Action If a haematoma begins to form while blood is being drawn: Release tourniquet remove needle immediately maintain pressure over the site Complete incident form Alert medical/nursing staff Document in clinical notes (inpatients only)

Release tourniquet Remove needle Assess pain once needle removed If pain persists Complete incident form Alert medical/nursing staff Document in clinical notes (inpatients) Remove tourniquet Removal needle Apply pressure for at least 5 minutes or until bleeding stops Alert nursing /medical staff Complete incident form Document in clinical notes (inpatient)

CDHB Venepuncture Learning Package. Version 3

Adverse event Syncope

Complete incident form and document in clinical notes only in the event of injury due to syncope i.e. fall

Signs & symptoms Patient complains of feeling weak, faint, dizzy Pale in colour, tremor and may feel nauseous. Faint

Pain While some discomfort is expected. Pain should not be prolonged. Consider nerve strike Failed venepuncture Causes: Poor technique Poor vein access Scaring Bruising Age and condition of patient

Patients will usually give a good history of previous venepuncture experience. This information can be useful in performing an success procedure

Action Remove tourniquet Remove needle Lower head below heart Give cold water if appropriate Give reassurance to patient Alert nursing/medical staff Release tourniquet Remove needle Apply pressure & dressing Alert nursing /medical staff 2 attempts only Refer to more experienced venepuncturist At 4 failed attempts advice should be sort from medical staff regarding options Consideration must be given to urgency of test, patient condition, planned treatments and frequency of blood tests required. Consider PICC, Midline, other CVAD device. Returning to unit another time. Document in clinical notes (inpatient)

Canterbury Medical laboratory employees please refer to local policy regarding the reporting of incidents within blood test centre areas

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REFERENCES Canterbury district Health board (2009). Management Guidelines for Common Medical Conditions 13thed .NZ: Internal Medicine Services Canterbury District Health Board (2007). Sample request form labelling policy. Policy and Procedures. Section 9. (Laboratories). Clinical and Laboratory Standards Institute (2010). Procedures for the collection of diagnostic blood specimens by venepuncture. 6th ed. Hadaway. L. (1999). Vascular Access Devices. Meeting patient needs. Medsurg nursing, 8(5) 296-303 New Zealand Blood Service (2009) transfusion medicine Handbook. Retrieved from: http://redbook.streamliners.co.nz/5103two.pdf World Health organisation (2010). Guidelines for Drawing Blood. Best practice for phlebotomy. Retrieved from: http://whqlibdoc.who.int/publications/2010/9789241599221

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