HEEL PRICK PROCEDURE FOR NEWBORN BLOOD SPOT SCREENING First Issued April 2007 Issue Version Two Purpose of Issue/Description of Change To promote a safe and effective blood spot screening procedure Planned Review Date 2012 Named Responsible Officer:- Approved by Date Service Improvement Team Nursing Policy Group June 2009 Policy File:- Nursing Policy File N o 43 Impact Assessment Screening Complete Date: May 2009 Full Impact Assessment Required Y/N UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE PCT WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION
HEEL PRICK PROCEDURE FOR NEWBORN BLOOD SPOT SCREENING CONTENTS CONTENTS PAGE Introduction Target Group 3 Related Policies and Documents Request for Repeat Blood Spots Responsibilities When to carry out the procedure 4 Audit Equipment Required Parents who decline 5 Performing the Heel Prick Procedure 6 After taking the blood sample 9 References 10 Appendix 1 11 Appendix 2 12 Appendix 3 14 2 /15
Procedure for Performing Heel Prick for Newborn Blood Spot Screening Introduction Newborn screening aims to identify babies who are at high risk of having certain serious but rare conditions before they develop symptoms. Screening is not the same as diagnosis; instead it identifies which babies need to go on to have diagnostic tests to determine whether or not they do have the condition. By detecting these conditions early it is possible to treat them and reduce their severity. Newborn blood spot screening is a crucial part of the national child public health programme and is offered to all babies in the United Kingdom. Five conditions are screened for in the Northwest region which are Congenital Hypothyroidism (CHT), Phenylketonuria (PKU), Sickle cell disorders, Cystic Fibrosis (CF) and Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCADD) The blood spot sample should ideally be taken on day 5 by the midwife, and certainly between day 5 and 8 for all babies regardless of milk feeding and prematurity. Target Group Screening Link coordinator and Designated Screening Link Health Visitors Related Polices and Documents this list is not exhaustive, it highlights the most relevant policies for the safety of patients and staff Consent Policy Sharps Usage and Disposal Policy Risk Assessment Policy Infection Control Policies Policy for the Management of Exposure to Body Fluid / Sharps Injury Department of Health (2005) Newborn blood spot screening in the UK Policies and Standards Department of Health (2005) Newborn Blood Spot Screening in the UK Health Professional Handbook Department of Health (2008) Guidelines for Newborn Blood Spot Sampling Department of Health (2008) Standards and Guidelines for Newborn Blood Spot Screening PCT Record Keeping Policy PCT Health Visitor Record Keeping Procedure 3 /15
Request for Repeat Blood Spots Designated Screening Link Health Visitors will be requested to take repeat blood samples; this should be after 28 days post delivery. Repeat blood spots will be requested by the Laboratory for inadequate samples, inconclusive results and for premature infants and for babies who have had a blood transfusion Please refer to Policies and Standards for Newborn Blood Spot Screening (DH 2005). The Laboratory will inform the Screening Link Coordinator when these tests are due to organize sample collection. Responsibilities Dried Blood Spot samples will be taken only be designated Screening Link Health Visitor within the Community setting. When to carry out Procedure Screening Link coordinator will contact Screening Link Health Visitor to see if available to take sample (see appendix 1). Screening Link Health Visitor will need to establish reason for repeat test. Screening Link Health Visitor will contact family Health Visitor for family details and arrange a joint visit if possible. Family Health visitor will need to ensure a first class stamp is available on day of procedure. Screening Link Health Visitor will contact family to arrange appointment explaining rational for repeat sample Screening Link Health Visitor will complete the Health Visitor Neonatal Screening Information Form (see Appendix 2) which will be faxed to the family Health Visitor, and the family General Practitioner to be put into the child s records. The hard copy will be sent to the Family Health Visitor. Audit The Screening Link Coordinator will be responsible for auditing the request for repeat heel prick test as part of the Clinical Governance process to feedback at local and regional level. Equipment Required Blood spot card and glassine envelope Automated newborn Tenderfoot lancet device Yellow soft paraffin Envelope 1 st class stamp Self addressed stickers of the Laboratory 4 /15
Cotton wool Non-sterile protective gloves Micro pore Spot plaster (if required) Sharps box Health visiting notes Personal Child Health Record (PCHR) Water or alcohol swab (if skin is visibly soiled) Parents who decline If parents decline retesting, the reason for their decision should be explored and further information offered. However, parents should not be unduly pressured, though need to be making an informed choice. Documentation Complete all boxes on the blood spot card and NHS number should be handwritten on blood spot card. Confirm baby s name, date of birth and parent s contact details. Send completed card (without blood sample) clearly marked DECLINE Record decline, including reasons for decision, on Health Visitor Neonatal Screening Information Form and Personal Child Health Records. Confirm the parents understand the risks of the baby not being screened. Offer further information and who to contact if they change their minds. Inform General Practitioner and family health visitor in writing of decline Performing the heel prick Taking the blood spot involves balancing the need to collect sufficient blood, with the potential for discomfort for the baby and unease for the parents. The following procedures have been drawn from the Newborn blood spot screening in the UK Health Professional Handbook (2005) to ensure the procedure goes as smoothly as possible. 5 /15
PROCEDURE ACTION Complete all boxes on the card and apply baby s barcode label (when available). If label is unavailable the NHS number should be handwritten on the card. When completing the card care must be taken to avoid contamination through placing the card on a dirty surface of through touch Verbally confirm baby s full name, date of birth and parents contact details Verbally confirm parental informed consent to procedure and document in records Recommend comfort measures for the baby. Feeding, sucking and engaging the baby through face-to-face contact, voice and touch, is beneficial. Ensure that the baby is cuddled and in a secure position for taking the sample. The blood sample should be taken from a clean heel. If skin is not meticulously clean it should be washed with plain water or alcohol swab. REASONING To ensure correct details and to enable sample / results to be tracked. To avoid contaminating the blood spot sample To ensure you have the correct label/information recorded on the card Comply with NHS Wirral Consent Policy To comfort the baby. To make it easier for the baby to regain his/her calm and comply with the procedure. To prevent contamination of the sample that can affect the results of the test. Decontaminate hands and apply gloves Screening Link Health Visitor will apply yellow soft paraffin to the heel before carrying out the test using a newborn automated device. Depth of incision to be less than or equal to 2.0 mm. Safely dispose of all equipment Decontaminate hands Document in records Universal precaution of taking blood to prevent spread of micro-organisms To reduce pain, bruising and obtain the sample more quickly. To reduce the risk of accidental injury from manual lancets. Manual lancets are not recommended as there is no control on depth of incision. Health and safety of staff and clients To prevent spread of micro-organisms NHS Wirral Record Keeping Policy 6 /15
ACTION Allow foot to hang down to increase blood flow. Heel puncture should be performed on the plantar surface of the heel, beyond the lateral and medial limits of the calcaneous, marked by the shaded areas in the diagram. Avoid posterior curvature of the heel. Before activation place automated device firmly against the heel. REASONING To minimize the risk of calcaneal puncture that may lead to calcaneal osteomyelitis (inflammation of the heel bone). The heel puncture should only be taken from the shaded areas indicated by the arrows. Circle filled and Layering Insufficient Evenly saturated multiple applications ACTION REASONING The aim is to fill the circles on the newborn blood spot card completely. Wait up to 15 seconds to allow blood to flow. The laboratory punches out several circles of the blood spot for analysis. The sample needs to be sufficient to screen for all of the conditions and to be retained if retesting is required to check equivocal or positive results. Apply the blood drop to one side of the card. Allow the blood to fill the circle by natural flow, and seep through to the back of the card. Fill the circle completely and avoid layering blood. Dispose of automated device in sharps bin Layering of the blood is unacceptable for testing (see diagram above) because too much blood can cause erroneous results To ensure safe disposal of lancet as per infection control policy, sharps usage and disposal 7 /15 To prevent excessive bleeding and bruising
Wipe excess blood from the heel and apply gentle pressure to the wound with cotton wool ball. and to protect the wound. If the blood flow ceases: The congealed blood should be wiped away firmly with cotton wool or gauze. Gently massage the foot, avoid squeezing, and drop the blood onto the card. To disturb the clot and encourage blood flow. Reduce the amount of pain and bruising caused by the procedure. If the baby is not bleeding a second prick is necessary: The second prick should be taken from a different part of the same foot (within the area indicated above) or the other foot. Apply cotton wool and secure with micropore, or spot plaster if required. Remove gloves and dispose in accordance with infection control policy, clinical waste The original site is avoided to prevent sample containing excessive tissue fluid and reduce pain. To avoid soiling linen. To prevent cross infection. 8 /15
After taking the blood sample It is important that the laboratory receives the blood sample promptly to ensure that babies with the conditions are seen quickly. Parents also need to know when to expect the results. This will help reduce their concerns about the results, as well as providing an additional safety net in following up missing results. ACTION If a parent does not wish to be contacted about future research about newborn blood spot screening, the health professional collecting the blood sample should mark NO RESEARCH CONTACT on the blood spot card Allow blood spots to air-dry before placing in the glassine envelope The glassine envelope should be placed in an envelope with pre-printed address stickers inserted on and be posted with a first class stamp within 12 hours of taking the sample The professional taking and posting the sample should record the sample date and posting/dispatch date Record taking the test in the Personal Child Health Records and fax the Health Visitor Neonatal Screening Information Form to the family Health Visitor and General Practitioner, followed by the hard copy being sent to the Family Health Visitor complying with Nursing and Midwifery Council and NHS Wirral record keeping guidelines Inform parents how and when they will receive results REASONING In accordance with the Code of Practice for the storage and use of residual blood spots. Wet samples can stick to the envelope and a repeat sample will be required Timeliness of dispatch enables early analysis and subsequent treatment In the event that a sample is delayed/missing this information may be requested to audit the process as part of ongoing quality improvements To comply with record keeping guidelines from the Nursing and Midwifery Council To ensure parents know what to expect in terms of the reporting of results and assists parents getting results 9 /15
REFERENCES 1. UK Newborn Screening Programme Centre (2005), Newborn blood spot screening in the UK, Policies and standards. DH, London 2. UK Newborn Screening Programme Centre (2008). Guidelines for newborn blood spot sampling. DH, London 3. UK Newborn Screening Programme Centre (2005) Newborn blood spot screening in the UK, Health Professionals Handbook, DH, London 4. UK Newborn Screening Programme Centre (2008) Standards and guidelines for newborn blood spot screening. DH, London 10 /15
Appendix 1 Flowchart for repeat heel prick test for designated Screening Link Health Visitor Laboratory will contact Screening Link coordinator of request for sample. If Health Visitor directly contacted by laboratory or midwife for repeat test please contact Screening Link coordinator at Prenton Clinic Screening Link coordinator will contact nearest Screening Link Health Visitor to see if available. Screening Link Health Visitor will contact family Health Visitor for family details and arrange visit informing family of the reason for the request. A first class stamp needs to be available on day of visit. Screening Link Health Visitor will follow lone worker policy. Informed consent for blood sample must be obtained and recorded in child section of notes and recorded in PCHR. New born screening procedure for performing heel prick followed. Screening Link Health Visitor to record sample taken in PCHR and in Child section of Health visiting notes and send sample off by post on the same day as taking sample. 11 /15
(Appendix 2) Health Visitor Neonatal Screening Information Form Child s name Date of birth Family address Family telephone Family GP HV base & tel. no. Risk assessment Relevant clinical information Relevant family history Results discussed for Sickle Cell Trait Results discussed for Cystic Fibrosis Trait Sweat test appointment discussed MCADD appointment discussed Yes / No Yes / No Yes / No Yes / No Neonatal Blood Sample Date sample taken SLHV Signature PKU CHT Haemoglobinopathies Cystic Fibrosis MCADD Further information i.e. informed consent obtained, leaflets given: Family Health Visitor please contact the lab on 0151 252 5489 on and inform the family of the results. Thank you. 12 /15
Name of HV Bloodspot Screener Distribution Fax completed form to family GP Fax completed form to family Health Visitor Send completed original form to family Health Visitor Date 13 /15
Appendix 3 Overview of screening pathway for Family Health Visitors - Page1 Positive results See page 2 Birth Day 5 Lab Not suspected Results sent to Child Health. Carrier results for sickle cell and cystic fibrosis sent to Child Health and Screening Link Coordinator. Child Health sends the results to General Practitioner and Family Health Visitor. Family Health Visitor enters the date that the results are received into the Birth Book. At 6 8 week contact the Family Health Visitor completes page 24 6 8 week review in Personal Child Health Record (red book) and also attaches a photocopy of the results from Child Health. The original results are stapled to the Child Health Visiting Planner Front Sheet in child s records, dated and signed when results are given to the family. Enter the date given to family in Birth Book. Screening Link Coordinator will allocate Screen Link Health Visitor to inform family of results. Screening Link Health Visitor contacts Family Health Visitor to arrange a joint visit, if available, to discuss results with the family. Results and outcome of visit are recorded in the child health record (in the same way as a not suspected result) and Screening Link Health Visitor completes a Neonatal Bloodspot Screening Form. This form is faxed to family General Practitioner and Family Health Visitor, followed up by the hard copy being sent to the Family Health Visitor. TRANSFERS INTO AREA Family Health Visitors must offer blood spot screening to any child who transfers in under the age of 12 months who has incomplete, or unrecorded, blood spot screening results. If consent is given, the Family Health Visitor should contact the Screening Link Coordinator to arrange for a sample to be taken. Please note that this type of screening will not identify Cystic Fibrosis / trait in a child older than 8 weeks. 14 /15 Any queries about results received from Child Health, please phone Alder Hey Lab on 0151 252 5489
Overview of screening pathway for Family Health Visitors Page2 Positive results page 2 Birth Day 5 Lab Positive results: PKU and CHT These are dealt with by the hospital not the Screening Link Health Visitors. Sickle Cell or other Haemoglobinopathy Families will be referred to the haemoglobinopathy counsellor / specialist nurse in Liverpool; contact numbers are: Dorothy Zack-Williams 0151 708 9370 Louise Smith 0151 252 5079 MCADD If a child has had a positive blood spot test s/he has to be seen the next day for a repeat test. The hospital will contact a Screening Link Health Visitor and notify the time and place for an appointment for the family to attend the following day. The Screening Link Health Visitor will then contact the Family Health Visitor (or team) and arrange to go out to visit the family in the late afternoon of that same day. The Screening Link Health Visitor will inform the parents of the hospital appointment and ascertain whether the child is feeding well. Cystic Fibrosis If a child has had a positive blood spot test s/he has to be seen in the next day or two for a repeat test. The hospital will contact a Screening Link Health Visitor and notify the time and place for an appointment for the family to attend. The Screening Link Health Visitor will then contact the Family Health Visitor (or team) and arrange to go out to visit the family in the late afternoon the day before the appointment. The Screening Link Health Visitor will inform the parents of the positive screening result, discuss and leave the leaflet Cystic Fibrosis is suspected and give the date, time and venue for the sweat test and appointment with the Consultant. 15 /15