Blood Sampling Policy (Adults)

BLOOD SAMPLING POLICY (ADULTS)

Version / 9
Name of responsible (ratifying) committee / Infection Prevention Management Committee
Date ratified / 02 August 2017
Document Manager (job title) / Consultant in Infection Prevention
Date issued / 05 September 2017
Review date / 04 September 2020
Electronic location / Infection Control Policies
Related Procedural Documents / Hand hygiene Policy, Asepsis Policy, Identification of Patients Policy
Key Words (to aid with searching) / Phlebotomy, venepuncture, blood sampling, blood cultures, arterial sampling

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
9 / 02/08/2017 / Competency update period changed to every two years / IPT
8 / 17/03/2017 / Inclusion of Pathology test database and patient preparation / IPT
7 / 21/08/2015 / Change of order of draw / IPT

CONTENTS

QUICK REFERENCE GUIDE

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

APPENDIX 1: BD Vacutainer guide

APPENDIX 2: Blood Culture Collection

EQUALITY IMPACT SCREENING TOOL

QUICK REFERENCE GUIDE

This policy must be followed in full when undertaking blood sampling in adults.

1. Requests for ward phlebotomy should be undertaken using the ICE system and paper forms only used in areas where this is not available. Requests should be in time for the morning phlebotomy rounds and these rounds should not interfere with protected mealtimes.

1. Four patient identifiers must be used when checking the identity of a patient and filling out the details on the sample bottle, which should be completed at the patient’s side (surname, given name, date of birth and unique identification number which corresponds to the notes and identity band). The bottles should also have the date, time and signature recorded by the individual undertaking the blood sampling.

1. Patients must consent to having their blood taken. If they refuse this should be documented and the clinician in charge of the patient’s care informed.

1. The risks to practitioners associated with blood sampling include needle-stick injury and associated blood-borne viruses from hollow bore needles. Practitioners must not:

• recap used needles;
• recap or disassemble vacuum-containing tubes and holders;
• overfill sharps containers
• work alone with confused or disoriented patients

1. Direct risks to patients are rare but include; pain, infection, haematoma, peripheral nerve damage and bleeding. Indirect risks include erroneous sample results or mislabeling of samples.

1. Blood sampling must be undertaken using a non-touch aseptic technique (venous and arterial blood sampling) or full aseptic technique (blood cultures) with the correct personal protective equipment (PPE), correct vehicle for sampling (Vacutainer) and correct sample bottles. Hand hygiene policy must be followed and waste disposed of appropriately in line with the Sharps policy and Waste Management policy.

1. Blood cultures should only be taken when possible bacteraemia or sepsis is suspected and not for routine assessment or for the investigation of localised infection

1. Skin must be cleaned with 2% Chlorhexidine gluconate in 70% Isopropyl alcohol (Sanicloth or Chloraprep) for 30 seconds, and allowed to air dry for 30 seconds before any blood sampling attempt.

1. Some blood tests require patient preparation such as fasting or sampling relating to physiological or pharmaceutical status. Inappropriate sampling can invalidate results. Please refer to pathologytest databasewhich can be found on the pathology intranet site.

1. Correct order of draw must be observed at all times to avoid contaminating samples with tube additives.

1st BC / 2nd / 3rd / 4th / 5th / 6th / 7th / 8th / 9th

1. Some Blood tests require special handling; please refer to pathologytest database. Samples should reach the laboratory as soon as possible.

1. All staff undertaking blood sampling must receive the necessary training and have their practical competency formally assessed, documented and reaffirmed every 2 years by a phlebotomy assessor.

1. Where a member of staff fails their training or errors are made leading to a question of competence they must not undertake blood sampling until they have received further training and been signed off as competent.

1.INTRODUCTION

Blood sampling refers to the collection of blood from a patient for the purpose of:

• diagnostic or therapeutic monitoring
• provision of a cross match sample for blood transfusion

This may include procedures such as arterial sampling, capillary sampling, blood culture collection and venous blood draws.

This policy regulates venous blood sampling, arterial sampling and the collection of blood cultures from adults.

2.PURPOSE

The purpose of this policy is to provide a consistent, best practice approach to blood taking which minimises the risks to staff and patients, ensures the correct samples are collected and reduces the number of sampling errors reaching the laboratory

3.SCOPE

This document sets out the standards to be followed by medical and non-medical members of staff employed by Portsmouth Hospitals NHS Trust whose role involves blood sampling. For the purpose of this policy a non-medical member of staff is defined as a registered nurse, midwife, support worker or phlebotomy technician.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4.DEFINITIONS

Adult: For the purpose of this policy this relates to a person over 16.

Asepsis:is recognised as the state of being free from pathogenic microorganisms

Aseptic technique:is defined as a means of preventing or minimising the risk of introducing harmful micro-organisms onto key parts or key sites of the body when undertaking clinical procedures

Aseptic Non-Touch Technique (ANTT) - the overriding basic principle is that the key sites/components e.g. IV devices must not come into contact with any item (hand, equipment, solution) that is not sterile. Sterile gloves are not always required for Standard ANTT

Contaminant: A contaminant may be:

1. A micro-organism inadvertently introduced into the sample from the environment, skin of the operator or patient which leads to a false positive result
2. A tube additive, which may be carried over to subsequently drawn samples producing erroneous results which may interfere with the analysis of the sample

Disposable Tourniquet - A disposable single use device that promotes vein distension for insertion of a needle, it should remain taut for a maximum of 60 seconds

Haemoconcentration: Applying a tourniquet for over 60 seconds causes stasis, trapping blood cells and larger molecules within the vein whilst water and small solutes are able to pass through the vein walls. This results in cells and large molecules becoming more concentrated in the sample leading to erroneous results.

Haemolysis: Damage to the red blood cells which releases potassium and other intracellular components into the serum invalidating a number of biochemistry parameters. Haemolysis can be caused by shaking a sample.

Order of Draw: The sequence of obtaining blood samples to prevent contamination of tube additives.

Vacuum System: A specially designed vacuum system which comprises of:

1. Pre vacuum blood sample tube
2. A double ended needle and plastic needle holder

Or

1. A winged needle and associated bung, luer adaptor and plastic holder.

This system is designed to minimize haemolysis and micro-clot formation in the sample and minimize the risk of needle-stick injuries.

5.DUTIES AND RESPONSIBILITIES

Infection Prevention Team: are responsible for providing blood sampling training, reviewing competency and managing the blood sampling policy.

Phlebotomy Manager: is responsible for leading, developing and managing the phlebotomy team and setting and monitoring standards of performance.

Ward/Department/Line Managers:need to ensure adequate stock of appropriate sampling equipment is held and that all staff members who are required to perform phlebotomy are appropriately trained and have their practical competency formally assessed, successfully achieved and documented.

Individuals undertaking Blood Sampling: should ensure they meet the training requirements, are safe and competent to undertake this skill and follow all relevant Trust policies to support safe practice. Staff must be aware of their roles and responsibilities and must identify and communicate any training needs to their Line Manager.

6.PROCESS

Whilst each blood sampling procedure (phlebotomy, blood cultures etc) has different elements, all staff must adhere to the following principles:

Patient identification:

Prior to performing blood sampling, practitioners must positively identify the patient in line with the Trust policy for the Identification of Patients.

• Outpatients:the patient should be asked to state their full name, date of birth and address, with these details checked against the details on the request form
• Inpatients: All request forms must be checked against the patient’s ID band (containing the four patient identity markers; surname, first name, date of birth and unique identification number). Where possible, the patient should be asked to give their name, date of birth and address to further confirm their identity.

Patient preparation:

Some blood tests will require the patient to have been prepared before sampling can occur. This may include fasting, sampling at a particular time of day or sampling at a particular point in their medication cycle. Inappropriate sampling can invalidate the test results so if there are special requirements, the sampling conditions must be documented on the request form. Please refer to pathologytest databasefor advice on patient preparation.

Consent:

Informed consent must be obtained from all patients who have capacity prior to any blood sampling procedure1. Consent may be given verbally or non-verbally and may be the act of the patient holding out their arm for the practitioner to carry out a procedure, providing the patient has received appropriate information prior to this1.

The key principles of informed consent include:

• The patients right to consent voluntarily without pressure or coercion
• The patients right to withdraw consent at any time
• The provision of sufficient information to allow informed consent. This includes:

1. The reason for the procedure
2. What the procedure involves
3. Any significant potential complications
4. Other relevant information, which may include when the blood results will be available and the potential consequences or treatments arising from the investigation

If the patient does not consent to the procedure this must be documented on the request form and in in-patient areas the team in charge of the patient’s care should be informed.

Potential complications2:

• Pain, caused by:

1. Hitting a nerve or valve in the vein
2. Poor technique
3. Failure to allow skin cleanser to dry before vessel puncture
4. Use of large-gauge device
5. Use of veins in sensitive areas

• Haematoma and bruising (2-3% incidence), caused by:

1. Entering the vessel at too steep an angle or over-advancement of the needle
2. Using too large a needle for the vessel
3. Failure to release the tourniquet early enough
4. Failure to secure haemostasis after needle removal

• Vasovagal reaction or fainting due to anxiety (0.2-1.7% incidence)
• Delayed faint (syncope) (1 in 10,000)
• Arterial puncture during intended venepuncture (1 in 30-50,000)
• Arteriospasm during arterial puncture
• Infection
• Bleeding
• Nerve injury and damage to adjacent anatomical structures (infrequent), caused by:

1. Entering the vessel at too steep an angle

Indirect complications to patients includeunnecessary or omitted interventions due to erroneous blood results due to contamination or mislabeled blood samples.

Prevention and management of incidents and adverse events:

Blood sampling involves the use of large, hollow needles that have been in a blood vessel. The needles can carry a large volume of blood that, in the event of an accidental puncture, may be more likely to transmit disease than other sharps2.

• Syringes and needles should not be used for venepuncture because of the potential for needle-stick injury when transferring the sample from syringe to the specimen bottle
• Blood sampling should be performed using a closed vacuum blood collection system which requires the use of a Vacutainer holder to protect staff from sharps injury
• Whenever possible, blood sampling systems should have sharps-safe systems. These systems should be activated immediately after use prior to disposal
• Used sharps must be disposed of in a sharps bin which complies to UN 3921 and BS7320 standards immediately at the point of use

Certain practices are known to increase the risk of needle-stick injury and transmission of disease. Dangerous practices include2:

• recapping used needles;
• recapping and disassembling vacuum-containing tubes and holders;
• overfilling sharps containers
• reusing tourniquets and vacuum-tube holders that may be contaminated with bacteria and sometimes blood;
• working alone with confused or disoriented patients who may move unexpectedly, contributing to needle-sticks injuries

In the event of a needle-stick injury, staff should contact the Occupational Health Department in working hours or the Emergency Department out of hours. A DATEX incident form must be completed for all clean and dirty sharps injuries.

Hand hygiene:

Hand hygiene with liquid soap and water or alcohol hand-rub must be performed before and after each patient procedure, before putting on gloves and after removing them3. The Trust standard 7-stage hygiene technique should be used at all times.

Personal protective equipment (PPE):

When taking blood, health workers should wear well-fitting gloves (non sterile for venepuncture, sterile for blood cultures) and plastic aprons to protect uniforms/clothes. These are single use items and must be disposed of immediately after use2,3.

Skin Preparation:

Skin must be prepared with 2% chlorhexidine gluconate in 70% isopropyl alcohol (2% CHG/70% IPA) (Sanicloth or Chloraprep) 3. Cleaning should cover the whole area, ensuring that the skin area is in contact with the disinfectant for at least 30 seconds. The area they should then be allowed to dry for at least 30 seconds3.

Number of attempts:

Only two attempts should be made to obtain a blood sample from the patient, using new equipment on each occasion. If unsuccessful, support should be obtained from another member of staff qualified inblood sampling. Failed attempts should be documented in the patient notes.

Use of the AccuVein device (available from the Infection Prevention Department) can increase successful blood sampling in difficult venous sampling cases (e.g. IVDU, oncology patients).

Blood bottles and order of draw:

The following order of draw of specimens and mixing guidelines recommended by BD Vacutainer (see appendix 1) must be followed when drawing multiple tubes to avoid possible test error due to cross contamination from tube additives.

Tube Colour & Order of Draw / Additive / Laboratory Test / No. of Inversions
1ST / N/A / Blood cultures: Aerobic followed by anaerobic – if insufficient blood for both culture bottles use aerobic bottle only / N/A
2ND / Buffered Sodium Citrate / Clotting screen, INR, APTR
Antithrombin III )
Lupus anticoagulant ) 3 tubes
Factor assays / 5-6
3RD / Plain Serum / Antenatal antibody screening – Hep B, HIV, Syphilis & Rubella.
Viral and bacterial antibody serology / 3-4
4TH / RST / ONLY USED IN A&E / 5-6
5TH / SSTTM II / Biochemistry – U&E, liver profile, bone profile, CRP, lipids, PSA
Serum B12, Folate, Ferritin
Thyroid, Endocrine, Immunology, Proteins, Antenatal Downs Screening
Dibucaine number / 5-6
6TH / Lithium Heparin / Chromosomes / 8-10
7TH / EDTA / FBC, ESR, Retics, Sickle Screen, HbA1C, Plasma
Viscosity (2 tubes), Methaemoglobin,
Haemoglobinopathy, Cyclosporin, Tacrolimus,
Sirolimus, Everolimus, HLAB27 (10mls), Antenatal FBC, Malaria screen, DNA studies, Nucleic acid detection eg HIV, Hep B/C, CMV, EBV viral load
Porphyrin, Renin/Aldosterone, ACTH, Homocysteine, Lead. / 8-10
8TH / EDTA / Crossmatch
Group and Save
Antenatal group and antibody screen / 8-10
9TH / Fluoride Oxalate / Blood glucose – diagnostic series or when delay in delivery is anticipated. / 8-10

Labelling and transportation:

• The minimum requirements for the specimen / sample label are the 4 patient identity markers (surname, first name, date of birth and unique identification number
• The bottles should also have the date, time and signature recorded by the individual undertaking the blood sampling
• Specimen containers must be labeled, with the patient’s identification taken from their ID band, not the request form or patient records
• The container must not be pre-labeled but labeled, by the person taking the specimen, after it is placed into the container
• The container must be labeled beside the patient and not removed to another location until the labeling is complete
• Samples should reach the laboratory as soon as possible, without batching as results may be affected if they take more than 4 hours between bleeding to analysis
• Blood bottles should be filled, gently mixed and handled correctly to minimize the risk of inaccurate results due to uneven distribution and incorrect concentration of tube additives such as anticoagulant or preservative

VENOUS BLOOD SAMPLING:

Site selection:

Before performing venepuncture both upper limbs should be inspected to select the most appropriate site for venepuncture. Veins should be looked for in the following order:

• At the bend of the elbow of each arm (antecubital area)

1. Median Vein
2. Basilic Vein
3. Cephalic Vein

• In the forearm

1. Cephalic Vein

• On the back of each hand

Inspection will reveal clinical conditions that may prevent the arm being used, for example, phlebitis, lymphoma, ateriovenous fistulae or bruising.