GUIDELINES FOR THE COLLECTION OF BLOOD FROM PATIENTS (VENEPUNCTURE)
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GENERAL
PRECAUTIONS FOR VENEPUNCTURE
It is recommended that protective clothing and disposable
gloves be worn when
performing venepuncture. Hands should be washed after wearing gloves. Any
cut or abrasion on the hand must be covered with a waterproof dressing or
plaster.
Appropriate precautions to prevent injuries from needles used during venepuncture should be taken. Used needles should never be recapped and the entire unit of hub and needles should be disposed of into a designated sharps bin. The yellow sharps bins should be filled to the line only and be accessible during venepuncture. Never overfill as this can lead to injuries when attempting to close the lid. Sharps bins should always be stored upright to prevent contaminated needles falling out.
PRELIMINARY
CHECKS
Some
blood tests such as Lipids, Glucose or Glucose Tolerance Test (GTT)
require the patient to fast overnight. Check before performing
venepuncture that the patient has not eaten or drank anything but water
since the night before. If the patient has fasted ensure the fasted box is
ticked on the request form so the correct tests will be ordered. If the
patient has not fasted but the test required them to do so, venepuncture
should not be undertaken and the patient should be advised to re-attend
when they have fasted.
Samples for
tests related to a drug regime are dependent on correct timing of
collection. Ensure all relevant information regarding dosage is included
on the request form.
Tests
for Basildon site only
Certain
tests must only be performed at Basildon, as they need to be received in
the laboratories within a specified timescale. Details are available on
the Test Directory section of this handbook or contact Clinical
Biochemistry if in doubt.
Groups
of patients needing special treatment
Some
patients will either not be able to be bled or need to be bled in an
alternative area due to their clinical condition or situation.
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Patients without a wristband |
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Patients where the information on form and wristband does not match |
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Patient
receiving a blood transfusion at the time of venepuncture |
There are patient groups that require special consideration before venepuncture but this should not stop them from being bled: -
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Blood
should never be collected from a vein proximal to an infusion site
i.e. on a drip. Blood can be collected from the opposing arm as long
as this does not also contain a drip. |
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Patients who have an indwelling fistula should have blood taken from the opposing arm and never from the fistula arm as this can damage the area. |
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Patients
who have had mastectomies will need blood taken from the opposing
arm. If patients have double mastectomies seek the advice of your
supervisor before venepuncture. There are rare occasions when
bleeding from the foot is acceptable but this must never be
performed by inexperienced staff. |
Staff
should gain the patient’s confidence and generally reassure the patient
at all times, as venepuncture can be a frightening procedure.
Phlebotomists must assume that informed consent will have been obtained by
the requesting source for any tests ordered. If a patient questions what
tests have been requested they should be referred back to their doctor.
Phlebotomists should never attempt to give advice about tests requested,
as this is not their role.
If the patient refuses a blood test their wishes must be respected and the
procedure terminated. Under no circumstances proceed once a refusal has
been given as this could constitute an assault.
Only two attempts at venepuncture
should be made on adults, and only one attempt on a child by one
phlebotomist. A more experienced member of staff must always be called if
difficulties arise, and patients from GP surgeries may be forwarded to the
hospital phlebotomy sites for venepuncture.
Confidentiality
Patients’ attendance and associated test ordering is classed as
confidential information and must not be disclosed to an unauthorized
third party. Unauthorised disclosure of confidential information
constitutes gross misconduct and renders the member of staff liable for
dismissal.
PATIENT
IDENTIFICATION / REQUEST FORMS
Correct
patient identification is essential to
ensure that the specimens collected are from the patient named on the
request form. Ask directly “What is your name” and NOT indirectly
“Are you X”. The Date of Birth (DOB) should be ascertained in the same
way.
Certain
information must be present on the request form before venepuncture is
performed.
If insufficient information has been supplied, the patient must be asked
to supply any additional information required and the phlebotomist is
allowed to write this on the form.
The
minimum amount of information acceptable on the Request
form is as follows: -
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Hospital In-patients and Out-patients must provide the patient’s surname plus two of the following: |
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First
name |
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Hospital
number |
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NHS number |
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A&E number |
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Date of Birth |
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GP request forms must provide patient’s surname and first name plus one of the following: - |
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Hospital
number |
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NHS number |
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This
information should be checked with the patient verbally. For patients on
the ward the wristband must also match the request form before
venepuncture can proceed. Any discrepancies should be highlighted with
ward staff and the patient must not be bled until corrected.
If
the request is from
a GP but the GP information is missing, the patient may be asked to supply
this information and the phlebotomist may write it on the form.
Blood
Transfusion Identification
Blood
Transfusion forms must be correctly completed with full patients name,
DOB, hospital number plus location of request, consultant and reason for
test. The doctor making the request must sign them.
It
is acceptable for the phlebotomists to verbally verify this information
with the patient in an OPD setting and a corresponding letter does not
need to be produced. This is because not all patients are given admission
letters for sensitive reasons and asking for the letter can be upsetting
for the patient.
On
the wards the blood transfusion request form needs to be checked against
the wristband. Any discrepancies should be highlighted with ward staff and
the patient must not be bled until corrected.
The availability of patient’s veins may be of paramount
importance to the ongoing care of the patient, especially in cases where
repeated transfusions, infusions and/or injections of therapeutic agents
are indicated. Great care should be taken, therefore, to avoid injury by
poor technique.
Any outer clothing over the arm should be removed; the sleeve of the inner
clothing should be folded up over the elbow if required. Care should be
taken to ensure there is no tightness above the elbow, as this will
restrict blood flow. The patient should be seated with their arm
outstretched and elbow supported to prevent bending.
The patient should have nothing in the mouth (except dentures) during
venepuncture.
Any special considerations should be noted i.e. drips, fistulas or
mastectomies.
As a preliminary step potential sites should be inspected by asking the
patient to clench the fist or the arm on which venepuncture is intended to
be made. This will cause the veins of the arm to become more prominent.
The veins should be felt; the best ones are not always visible.
Areas
of inflammation, infection or extensive scarring, such as healed burns
should be avoided.
Blood specimens should not be taken from an area with a haematoma as
erroneous results might ensue.
Blood must not be taken from drip arms, arms with indwelling fistulas or
canulas or on patients undergoing blood transfusion.
A tourniquet should never be applied for more than one minute prior to
venous blood collection, as haemoconcentration will occur and may
adversely affect the test results.
The chosen vein should be palpitated and its path traced.
PREPARATION
BEFORE VENEPUNCTURE
Before
attempting venepuncture all consumables required should be available,
including any special blood bottles. The needle should be inserted into
the hub in preparation to bleed the patient.
Cleansing
the venepuncture
site
After
selecting the vein, the skin around the site is cleansed with an Isopropyl
swab (Steret) and allowed to dry for a few seconds before proceeding.
VENEPUNCTURE
The
patient’s arm should be held straight with the wrist extended. Suitable
support should be placed behind the elbow to keep it steady during
insertion of the needle.
To make it easier to pierce the skin draw it tight below the chosen site
of puncture. This will also help the vein from moving.
The needle and hub assembly should be held at an angle of 15º to the
patient’s arm as the vein is punctured.
It is necessary to push the needle about 1cm through the skin to ensure
that its beveled point is completely inside the vein. If the needle is
pushed further than this there is a risk that it will perforate the
opposite wall of the vein. Once inserted the blood bottles can be inserted
in turn into the hub and will be filled automatically by vacuum.
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The order of draw is important and should be as follows: - |
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Blood
culture bottles (if required) |
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Tubes
with no additives (Red or Yellow topped tubes) |
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Coagulation tubes |
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Other tubes with additives |
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Coagulation tubes must be mixed immediately by thorough but gentle inversion.
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Cleanse
puncture site thoroughly with a Steret |
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Assemble
the holder and open the Safety-Lok™ butterfly. |
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Perform
venepuncture and secure the needle with tape. |
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Press adapter down over the aerobic bottle first and fill with 10ml blood using the 5ml scale on the bottle label as a guide. |
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Repeat for anaerobic bottle. |
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If
further blood samples are required insert the adaptor into the
holder and collect blood as normal. |
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Once finished hold the yellow safety shield on the butterfly and pull the tubing taut to advance the shield to cover the needle. |
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Dispose of all the equipment into a burn bin. |
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Remove the bar code stickers from the blood culture bottles and fix to request form. |
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Label the samples |
CARE
OF THE VENEPUNCTURE SITE AND DISPOSAL OF THE NEEDLE
Before
removing the needle from the vein, check that the tourniquet is released
and that the fist is unclenched.
The site of the needle entry is covered with a fresh dry sterile dressing.
Firm pressure is applied to the dressing by the patient (where possible)
until the bleeding stops. Bending of the elbow should be discouraged.
The dressing should be secured with microtape before the patient leaves
the area.
Immediately after extraction from the arm the needle and hub unit should be placed carefully into a burn bin.
LABELLING BLOOD SAMPLES
The only exception is for barrier-nursed patients where the blood bottles
can be pre labelled before venepuncture.
Samples with inadequate information will normally be discarded and the patient will require a re-bleed.
Routine samples
On
all samples other than Blood Transfusion the minimum
acceptable labelling is listed below.
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Hospital In-patients and Out-patients must provide the patient’s surname plus two of the following: |
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First
name |
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Hospital
number |
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NHS number |
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A&E number |
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Date of Birth |
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In addition the date must be written on the sample. The form must be dated, time sample taken written in the box and, when indicated, the phlebotomy number written in the space provided.
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GP request forms must provide patient’s surname and first name plus one of the following: - |
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NHS number |
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Blood
transfusion samples must always have the following information written on
them to be acceptable to the laboratory.
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Patient’s
surname |
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Patient’s
forename |
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Date
of Birth |
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Patient identification number (not NHS number) |
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Hospital ward or department |
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Date and time of specimen collection |
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Phlebotomy
number or signature of person collecting blood |
The
form must also be signed to confirm a positive identification of the
patient was performed.
All
samples once completed should be placed in the appropriate rack or bag for
transport to the central reception area of Pathology for processing.