CLINICAL GUIDELINES/NURSING Guideline for Venepuncture Using the Vacutainer System Reference 1438 Date approved

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1 CLINICAL GUIDELINES/NURSING Guideline for Venepuncture Using the Vacutainer System Reference 1438 Date approved Approving Body Matron s Forum Supporting Policy/ Working in Venepuncture using vacutainer system New Ways (WINW) Package Implementation date January 2013 Supersedes Version 1 Consultation undertaken Nursing Practice Guidelines Group, Ward Sisters/Charge Nurses, Practice Development Matrons (PDMs), Clinical Leads, Matrons Target audience All Clinical Nursing Staff Document derivation / See main references evidence base: Review Date January 2016 Lead Executive Director of Nursing Author/Lead Manager Further Guidance/Information Distribution: Di Ryan, Colorectal Chemotherapy CNS, Oncology Ward Sisters/Charge Nurses, PDMs, Clinical Leads, Matrons, Nursing Practice Guidelines Group (includes University of Nottingham representative) This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using the guidelines after the review date. Venepuncture

2 NOTTINGHAM UNIVERSITY HOSPITALS NHS CLINICAL GUIDELINES Venepuncture Using the Vacutainer System for Adults "This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date." Please note: These guidelines outline the method to obtain blood using the vacutainer system. It is recognised, however, that in extreme cases and in some specialist areas, the use of a needle and syringe maybe required. A competent practitioner who is also aware of the implications of using this method should only undertake this. INTRODUCTION Venepuncture is one of the most commonly performed invasive procedures (Centre for Disease Control, 1997,Doherty 2008, McGowan 2010.Gabrielle 2011). But for the patient it is often a frightening experience and this should not be underestimated Litigation involving injuries that have occurred as a result of venepuncture have increased over recent years (McConnell & McKay, 1996; Price & Moss 1998). It is therefore of paramount importance that health care practitioners undertaking this procedure have received appropriate training and education together with a period of supervision and assessment to ensure that they are competent to undertake this invasive procedure (Dimond 2011, Royal College of Nursing (RCN), 2010 ; Dougherty, 2008; ). Within the Nottingham University Hospitals and the wards at Lings Bar Hospital and Highbury Hospital, the procedure of venepuncture may be performed by a health care practitioner who has been assessed as competent in accordance with the Working in New Ways - policy and guidelines A self-directed learning package has been developed to facilitate this. Venepuncture

3 DEFINITION OF VENEPUNCTURE Venepuncture is the procedure of inserting a needle into a vein, usually to obtain blood. In order to do this safely, the Intravenous Nursing Society (1998) Lavery I. Ingram P, (2005), and the RCN (2010) suggests the practitioner must have a basic knowledge of the following broad aspects: The relevant anatomy and physiology The criteria for selection of an appropriate vein and device The potential problems that may be encountered, how to prevent or minimise them and how to manage them if they occur The associated health and safety/risks involved in undertaking the procedure and the correct disposal of equipment. INDICATIONS FOR VENEPUNCTURE Venepuncture is carried out for the following reasons: To obtain a sample of venous blood for diagnostic purposes To establish and subsequently monitor levels of blood components To establish and subsequently monitor levels of drugs To monitor response to medical treatments (e.g. fluids, drugs) To provide a sample of blood to cross match for a blood transfusion To screen for infection. Venepuncture

4 ANATOMY AND PHYSIOLOGY Texas Heart Institute (2008) VEIN CONSTRUCTION -Veins consist of three layers: the tunica adventitia, the tunica media and the tunica intima The tunica adventitia is the outer layer of the vein and consists of connective tissue, which surrounds and supports the vessel. Its role is protective and in some patients/clients this can make penetration of the vein difficult. The tunica media is the middle layer of the vein and is composed of muscular tissue and nerve fibres that can stimulate the veins to contract or relax in response to stimuli from the vasomotor centre of the medulla. The muscle is not as well developed as that of an artery and therefore the veins can distend or collapse as blood pressure rises or falls (Weinstein, 2007). Venepuncture

5 Stimulation of this layer by changes in temperature, mechanical stimulation (e.g. introducing the needle into the vein) or chemical stimulation (e.g. drugs) can produce spasm which can make venepuncture more difficult. Additionally, if the patient is anxious or clinically unwell (dehydrated, hypotensive) the blood vessel will constrict also causing the procedure to be more difficult to perform. The tunica intima is the inner lining of the vein and is constructed of smooth endothelial cells which facilitates the passage of blood cells etc. Damage to the tunica intima results in the internal lumen of the vein becoming roughened and increases the risk of thrombus formation. In addition, the endothelial layer develops folds, which are known as semilunar valves. The purpose of the valves is to ensure that the blood moves towards the heart by preventing backflow. They are present in larger blood vessels and at points of branching. These can sometimes be seen visually by noticeable bulges in the veins; the practitioner needs to learn to palpate the vein to check for the presence of valves and ensure that venepuncture occurs above the valve in order to facilitate collection of the blood sample (Weinstein, 2001). SELECTING A SITE FOR VENEPUNCTURE -The veins normally used for venepuncture are those found in the antecubital fossa because they are usually of a good size and are capable of providing copious and repeated blood specimens (Weinstein, 2007; Phillips, Collins and Doherty 2011) ); They are also easily accessible thus ensuring that the procedure can be performed safely and with the minimum of discomfort for the patient/client (Marieb, 1998). The main veins of choice are: The median cubital vein The cephalic vein The basilic vein The median cubital vein may not always be visible, but its size and location make it easy to palpate. It is also well supported by subcutaneous tissue, which prevents it from rolling under the needle. On the lateral aspect of the wrist, the cephalic vein rises from the dorsal veins and flows upwards along the radial border of the forearm, crossing the antecubital fossa as the median cephalic vein. Care must be taken to avoid accidental arterial puncture, as this vein crosses the brachial artery. It is also in close proximity to the radial nerve (Perucca, 1995). Venepuncture

6 The basilic vein, originating in the ulnar border of the hand and forearm (Wilson & Waugh, 2001), is often overlooked as a site for venepuncture: this is for good reason. Although the basilic vein may be prominent (particularly in men), it is awkward to access and it is not well supported by subcutaneous tissue and tends to roll easily. These features make venepuncture of the basilic vein difficult. Care must also be taken to avoid accidental puncture of the median nerve. The metacarpal veins are easily visualised and palpated. However, the use of these veins is contraindicated in the elderly where the skin turgor and subcutaneous tissue are diminished (Weinstein, 2007; Lister and and Dougherty 2011,) Occasionally the veins of a lower limb may be used for venepuncture, although the practitioner must understand the relevant anatomy and specific problems associated with these sites. Venepuncture of veins in the lower limbs is associated with a higher risk of complications due to the increased presence of valves and the fact that, comparatively, the blood flow in the lower limb is diminished (Weinstein, 2007). CHOOSING A VEIN The choice of vein must be that which is best for the individual patient/client. The best veins are those where the vein is accessible, unused, easily detected and appear healthy and patent. However, the most prominent vein is not necessarily the most suitable vein for venepuncture (Weinstein, 2007 ). There are two stages involved in locating a vein: 1. Visual inspection 2. Palpation Visual inspection involves scrutinising the veins in both arms and is essential prior to choosing a vein. The following areas should be avoided: Veins adjacent to foci of infection, bruising and phlebitis due to the risk of causing more local tissue damage or systemic infection. An oedematous limb as there is danger of stasis of lymph that predisposes to such complications as phlebitis and cellulites (Hoeltke 2006, Smith, 1998). Areas of previous venepunctures, where possible, as repeated trauma to the vein can result in pain (Ahrens et al, 1991). Venepuncture

7 Palpation is an important assessment technique, as it determines the location and condition of the vein. It assists in distinguishing a vein from arteries and tendons, identifies the presence of valves and can detect deeper veins (Scales (2008). The practitioner should use the same fingers for each palpation to increase the sensitivity and ability of the practitioner in detecting the appropriate site to use ( Phillips,Collins and Dougherty, 2011 ). The thumb should not be used as it is not as sensitive and has a pulse, which may lead to confusion in distinguishing veins from arteries in the patient/client (Weinstein, 2007 ). Healthy veins feel soft and bouncy and will refill when depressed (Weinstein, 2007 ). VEINS TO AVOID Thrombosed veins these feel hard and cord-like Tortuous, sclerosed, fibrosed, inflamed, fragile veins these may not be able to accommodate the device being used Veins that cross over joints, bony prominences and those with little subcutaneous cover (e.g. the inner aspect of the wrist) these can subject the patient/client to more discomfort For renal patients with an arterio-venous fistula/graft, the nonfistula/graft arm should not be used as this increases risk of stenosis and thus decreases the success of future venous access for haemodialysis. OTHER FACTORS INFLUENCING VEIN SELECTION Injury, disease or treatment may prevent the use of a limb for venepuncture by reducing the venous access (e.g. amputation, fracture, cerebrovascular accident). Use of a limb may be contraindicated because of an operation on one side of the body, for example, mastectomy and axillary node dissection, as this can lead to impairment of lymphatic drainage, which can influence venous flow regardless of whether there is obvious lymphoedema (Smith, 1998; Rowland, 1991). Position of the patient/client, for example, having to lie on a particular side, may also dictate the site of the venepuncture (Millam, 1992; Rowland, 1991). The age of the patient/client the elderly may have prominent veins but they are often fragile. The largest vein should be selected along Venepuncture

8 with the smallest gauge device to reduce the amount of trauma to the vessel. The weight of the patient/client malnourished patients/clients will often present with friable veins. Obese patients/clients may cause practitioners to have difficulty in locating the vein due to extra subcutaneous tissue being present. Patients/clients who are dehydrated or in shock there will be poor superficial peripheral access. It may be necessary to take blood after the patient is rehydrated as this will promote venous filling and blood will be obtained more easily (Mallett & Dougherty, 2000). Medications or conditions that cause bleeding or slow healing (e.g. anticoagulants, steroids, thrombocytopenia) these situations predispose the patient/client to having more risk of bruising both during venepuncture and on removal of the needle; this then limits the availability of veins that are not damaged. IMPROVING VENOUS ACCESS The success of venepuncture is influenced by a number of factors related to the patient/client and the practitioner. The more experienced the practitioner is the easier venepuncture becomes. However, no matter how experienced the practitioner is, factors that cause the blood vessels to vasoconstrict will make the procedure of venepuncture more difficult. A number of approaches to improve venous access and thereby facilitate the procedure being successful are identified below. 1. Fear about the procedure of venepuncture may itself result in vasoconstriction. The practitioner s manner and approach will have a direct bearing on the patient s experience (Weinstein, 2007 ). Approaching the patient/client with a confident manner, giving an adequate explanation of the procedure together with careful preparation and an unhurried approach may help to reduce anxiety which will in turn increase vasodilation. 2. Ensuring the correct ambient temperature of the environment is important if it is cold the blood vessels of the patient/client may vasoconstrict to compensate. Venepuncture

9 3. Application of a tourniquet this promotes venous distension. The tourniquet should be tight enough to impede venous return but not restrict arterial flow. 4. Opening and closing the fist ensures the muscles will force the blood into the veins and encourage distension. 5. Lowering the arm below heart level may also increase blood supply to the veins. 6. The use of heat in the form of a warm pack or by immersing the arm in a bowl of warm water for 10 minutes helps to encourage vasodilation and venous filling. 7. Ointments or patches containing small amounts of glyceryl trinitrate have been used to cause local vasodilatation to aid venepuncture. A prescription is required to enable this technique. 8. Stroking the vein (rather than patting it) can also assist with venous dilation. HAZARDS ASSOCIATED WITH VENEPUNCTURE 1. Infection the circulation is a closed sterile system and a venepuncture, however quickly performed, is a breach of this system providing a means of entry for bacteria. Adherence to an Aseptic None Touch Technique (ANTT) will minimise the risk of cross infection from practitioner to patient/client (e.g. thorough hand cleansing using soap and water followed by alcohol hand rub). Non-sterile gloves may be required to protect the practitioner from cross infection from the patient/client but all other equipment should be sterile and single use only. 2. Accidental damage the nerve, tendon or artery might be inadvertently punctured if these have not been identified during visual inspection/palpation. This can result in pain, damage and haemorrhage for the patient/client as well as loss of confidence for the practitioner. 3. Haematoma this is the commonest complication arising from venepuncture (Weinstein, 2007 ). There are a number of factors that influence the development of a haematoma poor technique on the part of the practitioner, failure to release the tourniquet before removing needle and inadequate pressure on the venepuncture site once the Venepuncture

10 needle has been removed. A haematoma may also occur if the patient/client is asked to flex the arm on completion of the procedure (Weinstein, 2007 ). 4. Prolonged bleeding time this may be due to a medical condition or drug therapy (e.g. anticoagulation medication). It increases the risk of bruising/haematoma formation and worsens the consequences of inadvertent arterial puncture. Practitioners should ensure they are aware of the patient/client s relevant drug and medical history prior to performing venepuncture to reduce this risk. 5. Incorrect or lack of details on the request card and/or sample this increases the likelihood of errors occurring and therefore any discrepancies will cause the sample to be rejected by the laboratory, necessitating repetition of the procedure. WARNING: the wrong patient details on the card can result in a patient receiving unnecessary or dangerous treatment. All samples must be correctly labelled and the details must correspond with those on the request card. The patient s details, both on the request form and the specimen bottle should be ascertained using the Trust policy for the positive identification of Patients. 6. All cross match samples the bottle and form should be checked for correct labelling by 2 Registered nurses. The patient should already have an identity band on. If not, attach one to the patient that states the patient s last name, first name, gender, date of birth and NHS number. (NUH 2012)Check these details are correct with the patient and the patient s hospital notes. Patient labels should not be applied to cross match bottles- both the cross match form and the blood bottles should have hand written details on them. 7. Insufficient sample/wrong specimen bottle the laboratory will not be able to process the sample necessitating repetition of the procedure However, if the patient/client was difficult to bleed, check with the laboratory staff whether they might be able to process the smaller sample without it compromising the results. 8. Needlestick (sharps) Injury use of vacutainer systems helps to reduce the incidence of this occurring ( Centre for Disease Control, 1997). However, the use of a needle and syringe may be preferential to obtain blood from poor veins as it applies less pressure on the vein and thus has a higher success rate. Needles, if used, must not be resheathed, and practitioners must adhere to the Trust sharps policy. In the event of Venepuncture

11 a needlestick injury the practitioner must follow the NUH Safe handling, disposal and reporting of sharps and blood borne exposure injuries policy (2008). 9. Infected samples whether known or suspected, these pose a health risk to any staff that have to handle them this includes porters and laboratory staff. Appropriate identification through labelling and transportation of infected samples is covered in other documents which should be read by the practitioner (refer to Trust Policy and guidance as appropriate, e.g. Infection Control Guidelines). 10. Blood spillage use of the vacutainer system reduces the risk of blood spillage since the blood is drawn directly into the evacuated sample tube. However, there is a risk of blood spurting from the vein when venepuncture commences. For those blood samples that cannot be taken using the vacutainer system there is a risk of blood spillage when decanting blood from the syringe to the sample tube. Blood spillage kits are available in all clinical areas (refer to Trust Policy). Staff should be using goggles if there is any risk of the practitioner being splashed by blood 11. Needle or Blood Phobia if the patient/client has a needle or blood phobia it might make their behaviour difficult to manage. They might also faint at some point during the procedure. It is important to establish whether the patient/client has had previous problems with venepuncture and to take appropriate action. Venepuncture

12 EQUIPMENT LIST Alcohol hand gel Plastic apron Non-sterile gloves Goggles if required Clean tray or receiver DisposableTourniquet Low linting swab (e.g. gauze) Tape Vacutainer device Sharps container Patient identification labels (if available/appropriate) Specimen request form Specimen bottles See General Principles for all Procedures. PRIOR TO COMMENCING VENEPUNCTURE PRINCIPLE / ACTION RATIONALE 1 Assemble the equipment necessary for venepuncture. You should contact the pathology department if you are unsure what bottles are required for the blood samples requested 2 Check all packaging and expiry dates before use. 3 Select appropriate size device based on vein size and number of samples required (21g is the most frequently used size). 4 Discuss any previous experiences of venepuncture; To ensure that time is not wasted and that the procedure goes smoothly without unnecessary interruptions. To ensure the sterility of the products prior to use. To reduce damage or trauma to the vein. This might reduce anxiety which can reduce vasoconstriction. If the patient/client has a history of fainting, the practitioner can put measures in place to reduce/prepare for this. Venepuncture

13 5 Make the patient/client comfortable (with back well supported) in an environment that is suitable in terms of lighting, ventilation, privacy, positioning and safety. PRINCIPLE These factors will assist the practitioner to be successful with the procedure. RATIONALE 6 Discuss the procedure with the patient/client to include: Information about the procedure and obtain consent; What test(s) is (are) being done and why; Relevant medical history (and allergies); Relevant drug history (e.g. anticoagulant therapy); To ensure that the patient/client understands the procedure and gives informed consent. In addition to the patient/client understanding the procedure, the practitioner needs to ensure that the requirements of the test are met (e.g. if fasting blood sugar is being taken the patient needs to have fasted). This might influence choice of limb for venepuncture (e.g. if the patient/client has had surgery or ever suffered from lymphoedema) or choice of occlusive dressing. The practitioner may need to take additional precautions if the patient is known to have a blood borne infection (see relevant policy). The patient/client will be at higher risk of bleeding and therefore need to apply pressure on the venepuncture site for longer post procedure. Venepuncture

14 PRINCIPLE RATIONALE 7 Check that the patient/client identity matches the details on the venepuncture request form and label the sample tubes with patient details at the bedside. 8. If patient expresses anxietyrelating to a phobia about needles or concerns about pain offer local anaesthetic and apply prior to procedure, Emla cream, 45 minutes before Ametrop 15 minutes before To ensure that the correct sample is taken from the correct patient/client and comply with SHOT (Serious Hazards of Transfusion) guidelines. To ensure the comfort of the patient/client and increase venous access. COMMENCING VENEPUNCTURE USING THE VACUTAINER SYSTEM PRINCIPLE ACTION 1 Wash and dry hands thoroughly using antiseptic soap and dry. Check hands for any broken areas, and cover with an occlusive dressing. To reduce the risk of cross infection. NUH Hand Hygiene Policy (2011) Pratt et al (2007) DoH (2007) 2 Break seal on vacutainer needle, remove clear plastic cover and screw disposable syringe barrel onto the vacutainer needle (leave the coloured shield on the needle as this will be inserted into the patient/client s vein). In preparation for venepuncture of the patient/client s vein. Venepuncture

15 PRINCIPLE 4 Extend the upper limb (full elbow extension) and support it on a pillow. 5 Gel hands with alcohol hand rub and put on gloves (see Best Practice Box Glove Use) and apron. ACTION To ensure the comfort of the patient/client and increase venous access. To reduce the risk of cross infection and potential contamination of the practitioner NUH Hand Hygiene Policy (2011) Pratt et al (2007) DH (2007) 6 Apply tourniquet to chosen limb in appropriate location. It may be necessary to utilise other methods to facilitate venous distension (See IMPROVING VENOUS ACCESS page 6). Dilates the veins by obstructing venous return. Increase the prominence of the veins and/or promote blood flow Best Practice USE OF TOURNIQUETS Single-use tourniquets should be used for all patients. The use of reusable tourniquets as well as other reusable equipment (sphygmomanometer cuffs etc.) is starting to be questioned, as they are a potential source of infection. Single use tourniquets have financial implications but this could be offset against the increasing problem of iatrogenic infections occurring in hospitals. If using reusable tourniquets then it must be cleaned between each patient. The tourniquet should be applied with enough pressure to impede venous flow if the radial pulse cannot be felt the tourniquet is too tight. (Weinstein, 2007 ). Venepuncture

16 PRINCIPLE 7 Select an appropriate vein in relation to size, location and condition. Refer to the following sections: Anatomy and physiology Selecting a site, Choosing a vein appendix 1 Veins to avoid RATIONALE To complete procedure successfully page 6 Best Practice GLOVE USE Non sterile gloves are to be used when undertaking venepuncture and handling blood and body fluids (NUH, 2011). This may help prevent contamination from blood spills and cross infection but does not prevent needlestick injuries and prevent cross infection. Please refer to NUH Glove selection guidelines (2011) Best Practice SKIN CLEANSING cha The use of skin cleansing remains controversial. A study by Sutton et al (1999) concluded that there was no difference with respect to complications at the site of venepuncture that received skin cleaning when compared to those that had not. A cursory wipe is known to do more harm by disturbing the patient skin flora, thus increasing the risk of infection (Wilson, 2006). In addition alcohol that is left on the skin that has not completely dried can cause haemolysis of the sample (Perry and Potter, 2002.) See NUH Infection Prevention and Control intranet site for information on the use of Sanicloth Venepuncture and 2013 Chloraprep decontamination products. 16

17 PRINCIPLE 7 Remove the coloured needle shield and hold the syringe barrel with the needle bevel uppermost. 8 Anchor the vein by applying manual traction on the skin of the upper limb a few centimetres below the proposed insertion site 9 Insert the needle smoothly at an angle of approximately depending on the vein location (degree of superficiality) and advance slowly into the vein with experience it is possible to distinguish when the vein wall has been punctured. Introduce the blood bottle tube into the vacutainer holder. Placing forefinger and middle finger on the flange of the holder and the thumb on the bottom of the tube, push the tube to the end of the holder puncturing the stopper on the blood bottle. 11 If venepuncture has been successful, the bottle will automatically fill to its required volume. If nothing happens, draw the needle back slightly as long as the needle remains under the skin the tube will retain its vacuum and when the vein is found, blood will immediately flow into the tube. RATIONALE This provides the cutting edge to incise through skin and tunica layers of the vein. To immobilise the vein and prevent it from rolling. Traction also provides a counter-tension to the vein, which will facilitate a smoother needle entry. To promote a successful, pain-free venepuncture. Advancing the needle stabilises the device within the vein preventing it from becoming dislodged during withdrawal of blood. It is important to retain the position of the needle in the vein whilst pushing the tube home in the vacutainer holder. Venepuncture

18 Best Practice ATTEMPTS AT VENEPUNCTURE There should be no more than 2 unsuccessful attempts by the same practitioner on one patient at any given time. If the attempts are unsuccessful the patient must be reassured and a more experienced practitioner should undertake subsequent venepuncture attempts. PRINCIPLE 12 If more than one sample is required, remove filled tube by applying soft pressure with the thumb against the flange of the holder to disengage stopper from the needle. Introduce next tube as in step 11. (See Best Practice Box Order of Fill) RATIONALE To obtain all the samples necessary from the one venepuncture procedure. Best Practice ORDER OF FILL In order to prevent haemolysis, the recommended order of fill is as follows: 1. Bottles with no additives 2. Coagulation samples 3. Bottles with additive (Becan-McBride, 1999) PRINCIPLE 13 Bottles with additives should be mixed well by gently rolling/inverting the tube do not shake the tube. RATIONALE Additives must be mixed to ensure that the chemicals in the tubes are distributed evenly through the blood sample which will facilitate accurate laboratory assessment. Shaking of the tubes may cause haemolysis of the sample. Venepuncture

19 ON COMPLETION OF VENEPUNCTURE PRINCIPLE / ACTION 1 Once all the samples have been obtained, remove the last tube and release the tourniquet before withdrawing the needle from the vein. 2 Place a low lint swab over the puncture site applying pressure to site AFTER the needle has been removed. 3 Discard needle and vacutainer barrel in sharps container. 4 Check that the tubes and request documentation are correct. Check cross match samples with second nurse. 5 Check puncture site has sealed before applying an occlusive dressing to the puncture site. (NB check that the patient/client is not allergic to the occlusive dressing to be applied). Instruct the patient/client to remove the occlusive dressing after 24 hours. 6 Discard waste into appropriate receptacles (in accordance with Trust policies and procedures). 7 Record type of blood sample taken and any complications that occurred with the procedure in the appropriate documentation. RATIONALE To reduce the risk of: blood spillage discomfort for the patient/client damage to the vein/development of haematoma. To prevent pain on removal and damage to the intima of the vein. To prevent needlestick injury. To reduce the risk of incorrect or unnecessary treatment being initiated. To prevent the risk of blood spillage by ensuring the patient/client does not bleed after leaving the clinical area. To reduce the risk of contamination. Medico-legal reasons. Venepuncture

20 PRINCIPLE 8 Ensure samples are sent via the air tube system. At present, glass bottles (e.g. blood cultures) or high-risk specimens should not be sent via the air tube system but taken to the labs as soon as possible. Community samples are collected by van and taken to the appropriate laboratory. Urgent requests require a P1 priority number which can be obtained from the P1 line (55084) and written on the request form 9 Advise the patient/client when the blood results will be available and what action is required (if any) to obtain the result. RATIONALE The air tube system provides the quickest route to the laboratories and rapid processing of the samples. Effective communication Best Practice PATHOLOGY REQUESTS A role expansion package now exists in Nottingham University Hospital Trust to allow nurses and/or other health professionals to request pathology tests directly under certain circumstances. This package meets the requirements set out in the Working in New Ways Policy and Guidelines (NUH 2011). Venepuncture

21 REFERENCES Ahrens T, Wiestma R & Weiltz PB (1991) Differences in pain perception associated with intravenous catheter insertion. Journal of Intravenous Nursing. 14,( 2), pp Becan-McBride K (1999) Laboratory Sampling: Does the Process Affect the Outcome? Journal of Intravenous Nursing. 22,( 3), pp Centre for Disease Control (1997) Evaluation of safety devices for preventing percutaneous injuries among health care workers during phlebotomy procedures. Journal of the American Medical Association. 277( 6) pp Department of Health (2007) Saving Lives: reducing infection, delivering clean safe care (revised edition), London, Crown Copyright. Department of Scientific Publications, Texas Heart Institute (2008) Vasculature of the Arm Us/Depart/scipub.cfm accessed on Dimond B (2011) Legal Aspects of Nursing. 6 th Edition Prentiss Hall Dougherty L (1996) Intravenous Cannulation. Nursing Standard.11 (2) pp Dougherty L (2008) Obtaining vascular access. IN Dougherty L & Lamb J (eds) IV Therapy in Practice. 2 nd Edition Chapter 9 Edinburgh: Churchill Livingstone Gabriel J. British Joural of Nursing( 2012) ( I.v. supplement)21(2) Heath Protection Unit (2002) Infection Control Guidance on Cleaning and Decontamination Nottingham: NPU Intravenous Nursing Society (1998) Revised intravenous nursing standards of practice. Journal of Intravenous Nursing. 21, Supplement 1S Hoeltke LB (2006) the complete Textbook of Phlebotomy. 3 rd edition cited in Vennepuncture and Cannulation. Phillips, Collins and Dougherty L. chapter 5 Venepuncture

22 Inwood S (1996) Designing a nurse training programme for venepuncture. Nursing Standard. 10 ( 21) pp Lavery I Ingram P(2005) Venepuncture: Best practice. Nursing Standard 19 (49) Lister S & Dougherty L (2008) Royal Marsden Hospital: Manual of Clinical Nursing Procedures. 8 th edition Chapter 15, Oxford: Blackwell Science Marieb E N (1998) Essentials of Human Anatomy and Physiology. 5 th edition California: Benjamin/Cummings McConnell A A & McKay G M (1996) Venepuncture: the medico-legal hazards. Postgraduate Medicine Journal. Vol. 72, pp McGowan D (2010) British Journal of Nursing. 19,(14) p.878 Millam D A (1992) Starting IVs how to develop venepuncture skills. Nursing. 92, pp33 46 Nottingham University Trust (2008) Working in New Ways: Policy and Guidelines Nottingham: NAT NUH, Dept. of Microbiology (2008) BACTEC Blood Culture Collection Instructions NUH Nottingham University Hospitals NHS Trust Trust (2011) Hand Hygiene Policy Nottingham University Hospitals NHS Trust (2008) Glove Selection Guidelines Nottingham University Hospitals NHS Trust (2008) Safe handling, disposal and reporting of sharps and blood borne exposure injuries policy (2008). Perry AG & Potter PA (2002) Clinical Nursing Skills and Techniques 5 th Edition London: Mosby Perucca R (1995) Obtaining vascular access. IN Terry J, Baranowksi L, Lonsway R A, & Hedrick C (eds) Intravenous Therapy: Clinical Principles and Practices. Chapter 21 Philadelphia: WB Saunders Venepuncture

23 Pratt, R, Pellowe, C Wilson, J, Loveday, H, Harper, P, Jones, S, McDougall,,C, Wilcox, M (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England, Journal of Hospital Infection, Vol 65, Suppliment, S1-64. Price J & Moss J (1998) The pitfalls of practice nursing. Nursing Times. 94, (30) pp Rowland R (1991) Making sense of venepuncture. Nursing Times. 87( 32) pp Royal College of Nursing (1995) Universal Precautions. London: RCN Royal College of Nursing (2010) Standards for Intravenous Therapy. London: RCN Scales K ( 2008) A practical guide to Venepuncture and blood sampling. Nursing Standard vol. 22,no.29,pp29-36 Scales K ( 2009) Intravenous therapy ; the legal and professional aspects of practice. Nursing Standard. 23, pp51-57 Smith J (1998) The practice of venepuncture in lymphoedema. European Journal of Cancer Care. Vol. 7, pp Sutton CD, White SA, Edwards R, Lewis MH (1999) A prospective controlled trial of the efficacy of isopropyl alcohol wipes before venesection in surgical patients Annals of the Royal College of Surgeons of England. (3) May pp Weinstein S (2007) Plumer s Principles and Practice of Intravenous Therapy. 8 th edition. Philadelphia: JB Lippincott Wilson J (2006) Infection Control in Clinical Practice. 3 rd edition. London: Bailliere Tindall Wilson K J W & Waugh A (2001) Anatomy and Physiology. 9 th edition. Churchill Livingstone, Edinburgh Venepuncture

24 Author: Diane Ryan,Colorectal Chemotherapy Nurse Specialist,CAS Directorate NPGRG Link: Vivian Blackburn January 2013 Review: March 2015 SUGGESTED AUDIT POINTS 1. Has a suitable vein been chosen, using the criteria outlined in the guidelines? 2. Are all relevant details, including correct identification information, on the request card/sample bottles? 3. Has an appropriate size device been chosen? 4. Did the practitioner discuss the procedure with the patient? 5. Has the patient s identity been confirmed? 6. Have gloves been used appropriately? 7. Has the skin been cleansed according to guidelines? Venepuncture

25 8. Has no more than two unsuccessful attempts at venepuncture been attempted? 9. Has the puncture site been sealed correctly? Venepuncture