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 Hand hygiene Policy, Asepsis Policy, Identification of Related Procedural Documents Patients Policy Phlebotomy, venepuncture, blood sampling, blood Key Words (to aid with searching) 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 IPT preparation 7 21/08/2015 Change of order of draw IPT

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 1 of 22 CONTENTS

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 2 of 22 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.

2. 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.

3. 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.

4. 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

5. 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.

6. 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.

7. 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

8. 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.

9. 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 pathology test database which can be found on the pathology intranet site.

10. 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

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

12. 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.

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 3 of 22 13. 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: i. A micro-organism inadvertently introduced into the sample from the environment, skin of the operator or patient which leads to a false positive result ii. 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

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 4 of 22 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: a.i. Pre vacuum blood sample tube a.ii. A double ended needle and plastic needle holder Or a.iii. 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

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 5 of 22 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 pathology test database for 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: i. The reason for the procedure ii. What the procedure involves iii. Any significant potential complications iv. 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: i. Hitting a nerve or valve in the vein ii. Poor technique iii. Failure to allow skin cleanser to dry before vessel puncture iv. Use of large-gauge device v. Use of veins in sensitive areas  Haematoma and bruising (2-3% incidence), caused by: i. Entering the vessel at too steep an angle or over-advancement of the needle ii. Using too large a needle for the vessel iii. Failure to release the tourniquet early enough iv. 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: i. Entering the vessel at too steep an angle

Indirect complications to patients include unnecessary 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

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 6 of 22  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 in blood 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 & Additive Laboratory Test No. of Order of Draw Inversions Blood cultures: Aerobic followed by anaerobic – if N/A ST N/A insufficient blood for both culture bottles use aerobic 1 bottle only

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 7 of 22 Clotting screen, INR, APTR ND Buffered Antithrombin III ) 5-6 2 Sodium Lupus anticoagulant ) 3 tubes Citrate Factor assays Antenatal antibody screening – Hep B, HIV, Syphilis & RD Plain Serum 3-4 3 Rubella. Viral and bacterial antibody serology

4TH RST ONLY USED IN A&E 5-6

Biochemistry – U&E, liver profile, bone profile, CRP, TH SSTTM II lipids, PSA 5-6 5 Serum B12, Folate, Ferritin Thyroid, Endocrine, Immunology, Proteins, Antenatal Downs Screening Dibucaine number

TH Lithium Chromosomes 8-10 6 Heparin

FBC, ESR, Retics, Sickle Screen, HbA1C, Plasma TH EDTA Viscosity (2 tubes), Methaemoglobin, 8-10 7 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. Crossmatch TH EDTA Group and Save 8-10 8 Antenatal group and antibody screen

TH Fluoride Blood glucose – diagnostic series or when delay in 8-10 9 Oxalate delivery is anticipated.

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:

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 8 of 22 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) i. Median Vein ii. Basilic Vein iii. Cephalic Vein  In the forearm i. 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. Inspection and palpation of the veins will reveal the position of the veins, direction in which they run and their size and other physical features. The vein should be straight and feel soft, cylindrical in shape and ‘bouncy’ when lightly pressed. Veins that are tender, sclerosed, thrombosed, fibrosed, hard or bruised from previous use should be avoided.

Equipment required for Venous Blood Sampling:  Sample request form  Single use disposable tourniquet  Clean single use non sterile gloves and disposable apron  2% CHG/70% IPA swab  Vacuum system components and appropriate sampling tubes. (All must be in date and if a butterfly system is used an additional tube is required to remove air from the butterfly system prior to samples being obtained)  Gauze swabs  Adhesive plaster  Appropriately labelled and tagged Sharps box  Dedicated tray or identified prepared area, cleaned with detergent wipe or soap and warm water  Sharps container

Process:  Approach patient, introduce yourself and check patient identity and obtain information regarding allergies (e.g. chlorhexidine)  Give explanation for venepuncture and ensure patient consents to the procedure  Adjust environment to comfortable working height and ensure adequate lighting- wherever possible  Decontaminate hands following the Trust Hand Hygiene Procedure  Clean tray or identified area with detergent wipe or soap and warm water  Place equipment / collection system onto clean tray or dedicated area, checking for defects, use by date and avoiding touching key parts. Take into account size of needle or butterfly required with regard to the condition of veins. Connect needle to Vacutainer  Select a suitable vessel that meets criteria for sampling, preferably in patients non- dominant arm  Clean insertion site with 2% CHG/70% IPA for 30 seconds  Apply single use tourniquet, without obstructing blood flow, 10 cm above insertion site  Do not re-palpate the key sites  Repeat hand decontamination  Apply clean non sterile gloves

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 9 of 22  Expose the needle and stabilise the vein below the chosen entry site without contaminating the cleaned area  Insert needle (bevel uppermost) through the skin at an angle of 15-30 degrees  Reduce the angle of the needle as soon as you feel the resistance change or flash back is seen along the tubing of the venepuncture device  Release the tourniquet  Observe correct order of draw and attach first sampling tube. If using a winged needle system (Butterfly), discard the first tube as soon as the blood enters the tube as it will not fill to the appropriate level, due to air in the tubing being released into the tube. Discard and attach another tube of the same colour  Remove initial blood sample and connect subsequent sample tube(s) if required. When sample has been removed gently invert sample tube to mix blood with tube additives  Place gauze over the puncture site and withdraw needle and holder in a continuous straight line. Withdraw needle with the hand closest to the sharps bin for safe disposal  Do not press firmly on the puncture site until after the needle has been removed  Immediately engage the sharp safety mechanism (if present) and dispose of the needle and holder into the sharps box without disconnecting  Press on site slightly for 1-2 minutes with gauze. The patient can do this if he/she is able. Advise patient to keep limb extended at this point. Do not bend the limb  Remove gloves and then decontaminate hands at the patient’s bedside / drawing area  Immediately label all samples at the bedside / drawing area  Recheck the puncture site before leaving the patient and apply an adhesive plaster  Ensure the sample is packed correctly with accompanying request form, and send to the laboratory immediately or made ready for collection

BLOOD CULTURE PROCEDURE:

Blood cultures help detect the cause of an infection leading to bacteraemia and guide appropriate treatment. Extreme care must be taken not to contaminate the blood culture with micro-organisms from the patients or operators skin or the environment or culture bottle. Contaminated blood cultures can lead to patients receiving inappropriate or unnecessary treatment which can be potentially harmful.

Appropriate indications for taking blood cultures: Blood cultures should only be taken where there is clinical identification of possible bacteraemia or sepsis. They should not be taken for routine assessment or for the investigation of localised infection. Reasons to suspect an infection and to consider taking blood cultures include4:  The core temperature is outside of the normal range >38°C or <36°C  Unexplained hypotension (Systolic BP <90*)  Tachycardia (Pulse >90) and / or Tachypnoea (RR >20bpm  Chills or rigors  Unexplained deterioration in the patient’s condition  Development of unexplained confusion  There are focal signs of infection  The white blood cell count is outside of the normal range >12x10/L or <4x10/L

An overall clinical assessment is essential when deciding if a blood culture is required as not all patients with the above symptoms will need investigation whilst in some patients, particularly the elderly, the signs of infection will be minimal.

Blood cultures should be taken prior to the administration of antibiotics. If a patient is on antibiotics, blood cultures should ideally be taken immediately before the next dose4. In patients with suspected bacteraemia, it is generally recommended that two sets of cultures are taken at separate times from separate sites. Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 10 of 22 Blood cultures should be taken using a new venepuncture site and not from existing central or peripheral venous cannulae4. The only exception to this is if it is believed that a central line may be the source of bacteraemia. It is then appropriate to take blood from both the central and from the peripheral vein, ensuring that the hub of the central line is thoroughly decontaminated with 2% CHG/70% IPA first. The peripheral vein sample should be collected first. Blood cultures must be taken using an aseptic non-touch technique performed with sterile gloves, and requires additional equipment.

Site selection: As for venous blood sampling. Avoid femoral vein puncture because of the difficulty in adequate skin cleansing and disinfection (DH Saving Lives 2007).

Equipment required for obtaining a blood culture:  Sample request form  Blood culture pack, containing;  Aerobic and anaerobic blood culture bottles  Single use disposable tourniquet  Chloraprep 2% CHG/70% IPA frepp  2 x 2% CHG/70% IPA swabs  Blood culture collection adaptor cap  Adaptor insert for Vacutainers  Winged blood collection set Adhesive plaster  Blood culture and Sepsis stickers  Sterile dressing pack, containing;  Appropriately sized sterile gloves  Sterile fields  Sterile gauze  Sterile bag  Appropriately labelled and tagged Sharps box  Dedicated tray or identified prepared area, cleaned with detergent wipe or soap and warm water

Process (see appendix):  Approach patient, introduce yourself and check patient identity and obtain information regarding allergies (e.g. chlorhexidine)  Give rationale for the blood culture and ensure patient consents to the procedure  Adjust environment to comfortable working height and ensure adequate lighting- wherever possible  Decontaminate hands following the Trust Hand Hygiene Procedure  Clean tray or identified area with detergent wipe or soap and warm water  Open the sterile pack, and arrange the field using the disposable bag to maintain sterility  Open the blood culture pack. Place the non-sterile items to the side of the sterile field and open the collection system onto the clean field, checking for defects, use by date and avoiding touching key parts  Check the colorimetric discs at the bottom of the culture bottles to ensure sterility and check expiry date. If the disks are yellow, the bottle is contaminated and should be discarded  Remove the plastic caps of the culture bottles and clean the septum using one 2% CHG/70% IPA swab for each bottle. Allow to air dry  Apply single use tourniquet, without obstructing blood flow, 10 cm above insertion site  Select a suitable vessel that meets criteria for sampling, preferably in patients non- dominant arm wherever possible  Clean insertion site with 2% CHG/70% IPA for 30 seconds  Do not re-palpate the key sites

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 11 of 22  Repeat hand decontamination  Apply sterile gloves and attach a winged blood collection set to a collection adaptor cap  Expose the needle and stabilise the vein below the chosen entry site without contaminating the cleaned area  Insert needle (bevel uppermost) through the skin at an angle of 15-30 degrees  Reduce the angle of the needle as soon as you feel the resistance change or flash back is seen along the tubing  Release the tourniquet with a piece of sterile gauze  Insert the blue topped culture bottle and allow to fill, followed by the purple topped bottle (min 5mls/bottle)  Once filled, invert the bottles 3 times to ensure mixing  If blood samples are required, insert the adaptor insert for Vacutainers into the blood culture collection cap and take samples as normal, observing order of draw  Place gauze over the puncture site and withdraw needle and holder in a continuous straight line. Withdraw needle with the hand closest to the sharps bin for safe disposal  Do not press firmly on the puncture site until after the needle has been removed  Immediately engage the sharp safety mechanism (if present) and dispose of the winged collection set into the sharps box  Press on site slightly for 1-2 minutes with gauze. The patient can do this if he/she is able Advise patient to keep limb extended at this point. Do not bend the limb  Remove gloves and then decontaminate hands at the patient’s bedside / drawing area  Immediately label the culture at the bedside  Recheck the puncture site before leaving the patient and apply an adhesive plaster  Ensure the sample is packed correctly with accompanying request form, and send to the laboratory immediately or made ready for collection  Complete the blood culture and sepsis sticker and place in the medical notes. All blood-cultures must be documented in the medical notes, including date, time, site and indications

ARTERIAL SAMPLING PROCEDURE: Arterial sampling may be indicated when there is:  the need to evaluate the adequacy of ventilation (PaCO2), acid base (PaCO2 & pH) and oxygenation status (PaO2)  the need to evaluate the patients response to therapeutic intervention or for diagnostic evaluation  the need to monitor the severity and progression of a documented disease process5

Arterial blood sampling should only be performed by practitioners who have completed formal training, demonstrated proficiency and are authorised to undertake the procedure. If repeated arterial samples are required then an arterial line will be required.

Criteria for exclusion  A negative Allen Test  Infectious skin process at or near the puncture site  Current GPIIb/IIIa inhibitor therapy  Current thrombolysis therapy Cautions  Warfarin (or other oral anti-coagulants)  Heparin  History of a clotting disorder (discuss with senior clinician)  Severe peripheral vascular disease (discuss with senior clinician)  Thrombolysis in the past: 24 hours (streptokinase therapy) OR: 4 hours (TNK-tPA)

Site selection: Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 12 of 22 Several different arteries can be used for blood collection. The first choice is the radial artery because:  the artery is relatively near the surface of the arm  the artery is relatively easy to palpate and stabilise  the artery normally has a good collateral blood supply The second choice site for access is the brachial artery (followed by the femoral arteries), but these have several disadvantages in that they:  may be harder to locate, because they are less superficial than the radial artery;  have poor collateral circulation;  are surrounded by structures that could be damaged by faulty technique

Prior to performing radial artery blood sampling, a modified Allen test must be performed to ensure good collateral blood supply.

Modified Allen test: The modified Allen test measures arterial competency, and should be performed before taking an arterial sample. The procedure for performing the test is as follows:  Instruct the patient to clench his or her fist; if the patient is unable to do this, close the person’s hand tightly  Using your fingers, apply occlusive pressure to both the ulnar and radial arteries, to obstruct blood flow to the hand  While applying occlusive pressure to both arteries, have the patient relax his or her hand, and check whether the palm and fingers have blanched. If this is not the case, you have not completely occluded the arteries with your fingers  Release the occlusive pressure on the ulnar artery only to determine whether the modified Allen test is positive or negative

 Positive modified Allen test – If the hand flushes within 5–15 seconds it indicates that the ulnar artery has good blood flow; this normal flushing of the hand is considered to be a positive test  Negative modified Allen test – If the hand does not flush within 5–15 seconds, it indicates that ulnar circulation is inadequate or nonexistent; in this situation, the radial artery supplying arterial blood to that hand should not be punctured

Equipment required for arterial blood sampling:  Pre-heparinised syringe Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 13 of 22  Appropriately sized safety needle with needle cover that allows the syringe to be capped before transport, without manually recapping  Sterile gloves and plastic apron  Eye / face protection  2% CHG/70% IPA swab  where applicable, local anaesthetic and an additional single-use sterile syringe and needle  Sterile gauze and pressure dressing

Process for radial artery sampling:  Approach patient, introduce yourself and check patient identity and obtain information regarding allergies (e.g. chlorhexidine)  Give rationale for the arterial blood sampling and ensure patient consents to the procedure  Adjust environment to comfortable working height and ensure adequate lighting- wherever possible  Decontaminate hands following the Trust Hand Hygiene Procedure  Clean tray or identified area with detergent wipe or soap and warm water  Place equipment onto clean tray or dedicated area and attach the needle to the heparinised syringe, taking care not to touch key parts  Conduct the Allen Test, recording the result, and abandon the process if the test is negative  Consider the use of local anaesthetic agent, and administer as prescribed if appropriate  Palpate the radial site with fingertips  Stabilise artery by positioning the arm on a flat surface, and supporting wrist on a rolled towel for example. Hyperextension should be avoided as it may obliterate a palpable pulse  Clean area of maximal impulse with 2% CHG/70% IPA for 30 seconds  Repeat hand decontamination  Apply plastic apron and eye / face protection  Apply sterile gloves to allow re-palpation of the artery once prepped  Keep fingertip on artery, just proximal to chosen site  Hold the needle bevel up and insert at 45-60 degree angle  Stop advancing needle when blood is noted returning to hub of needle  Allow arterial pulsation’s to pump 3ml of blood into syringe. At least 3ml of blood is needed to avoid dilution effect of heparin  When sampling is complete, hold gauze or swab over puncture site and withdraw needle  Activate the safety device on the needle immediately  Apply pressure over and just proximal to puncture site with gauze/swab  Maintain continuous pressure over and proximal to the site for at least 5 minutes (10 minutes) minimum if patient is anti-coagulated or has a bleeding disorder)  Visually inspect site for signs of bleeding or other complication  Palpate artery site distal to the puncture site, to determine if pulse quality has changed/alteration in arterial flow  Ensure appropriate immediate action is taken if complications are identified  Remove gloves, face protection and apron and wash hands  Make arrangements for patient to be observed for potential complications following the procedure and inform ward-nursing staff of action to take if complications are identified

7. TRAINING REQUIREMENTS

Only suitably trained and competent staff may take blood samples. Each member of staff must have undertaken a recognised training programme, which incorporates theory and simulated

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 14 of 22 practice. Following successful completion of this course component, practitioners should undertake supervised practice and may only practice venipuncture independently once certified competent to do so by a senior, competent colleague.

Staff trained in blood sampling must attend a venepuncture update every two years and, in order to maintain competency, carry out the skill on a regular basis. If their level of competency falls they must seek re-training.

Education and training will be provided by the Infection Prevention & Control Team via the Learning and Development Department. All individuals must meet the minimum requirements for maintaining this skill prior to applying for a place on the training course. This must be confirmed by their manager prior to a place being booked via Electronic Staff Record (ESR).

Medical and midwifery staff: final year medical students and FY1 doctors on induction will receive practical simulated training from the Infection Prevention & Control Team. FY2, ST doctors and Midwives are assumed competent unless otherwise identified by their supervisor. In order to take blood for the use in transfusion they must pass the NPSA competencies for taking blood and produce a certificate every 2 years. If problems are identified, the staff member will be required to:

a) Attend a phlebotomy training study b) Complete the Trust phlebotomy competency pack c) Complete a period of supervised clinical practice and assessment

8. REFERENCES AND ASSOCIATED DOCUMENTATION

1. Department of Health (2010). Reference guide to consent for examination or treatment. London: HMSO

2. WHO (2010). Guidelines on drawing blood/ best practices in phlebotomy. World Health Organization.

3. Loveday et al (2014). epic3: National Evidence-Based Guidelines for Preventing Healthcare- Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1 (2014) S1–S70

4. Department of Health (2007) Saving Lives: A delivery program to reduce Healthcare Associated Infection including MRSA

5. AARC clinical practice guideline (1992). Sampling for arterial blood gas analysis. American Association for Respiratory Care. Respiratory Care. Aug 1992;37(8):913-7

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 15 of 22 9. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do. We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity Quality of care Working together Efficiency

This policy should be read and implemented with the Trust Values in mind at all times.

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 16 of 22 10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assure compliance

Minimum Lead Tool Frequency of Reporting arrangements Lead(s) for acting on requirement to be Report of Recommendations monitored Compliance Individuals Infection Competency Quarterly Policy audit report to: Infection Prevention undertaking blood Prevention document Nursing Midwifery sampling will attend  the phlebotomy Committee training sessions and be assessed as competent Individuals Learning and Competency Quarterly Policy audit report to: Matrons undertaking Development document Nursing Midwifery phlebotomy must and ESR  reaffirm their Committee competency every two years. Policy audit report to: 

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 17 of 22 APPENDIX 1: BD Vacutainer guide

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 18 of 22 APPENDIX 2: Blood Culture Collection

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 19 of 22 Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 20 of 22 EQUALITY IMPACT SCREENING TOOL To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.

Stage 1 - Screening

Title of Procedural Document: Blood Sampling (adults) Policy

Date of Assessment 24/07/2017 Responsible Infection Prevention Department Name of person Kathryn Noble Job Title Infection Prevention completing Management/Analyst assessment Does the policy/function affect one group less or more favourably than another on the basis of : Yes/No Comments  Age No  Disability No Learning disability; physical disability; sensory impairment and/or mental health problems e.g. dementia  Ethnic Origin (including gypsies and travellers) No  Gender reassignment No  Pregnancy or Maternity No  Race No  Sex No  Religion and Belief No  Sexual Orientation No If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below www.legislation.gov.uk/ukpga/2010/15/contents

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 21 of 22 Stage 2 – Full Impact Assessment What is the impact Level of Mitigating Actions Responsible Impact (what needs to be done to minimise / Officer remove the impact)

Monitoring of Actions The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance Committee Clinical Service Centre Procedural Document: Clinical Service Centre Governance Committee Corporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee

Blood Sampling (Adults) Policy Version: 9 Issue Date: 05 September 2017 Review date: 04 September 2020 (unless requirements change) Page 22 of 22