ph le botomy handbook

7/30/2019 Ph Le Botomy Handbook

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252

Phlebotomy Handbook

1

12 July 2013

Service Manager - Community Services

Master ID

Document Name

Version

Type

Date adopted

Review Date

Responsibility

for Review

12 July 2010

Clinical

Equality Impact

Assessment

PerformedYes

Approved by

CHO

community Health Oxfordshire Policy Group


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252 Phlebotomy Handbook, 2010 1of20

PhlebotomyTraining Handbook


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Contents;

PageIntroduction.. 4

Roles and responsibilities 5

The Laboratory 6

Limitations of duties.. 6

Training.. 6

The Theory: 7

- Anatomy and physiology 7

- The criteria for choosing a vein 7

- The device to use.. 9

- Skin preparation 9

- Personal safety infection control policy. 10

The Practical 11

- Equipment.. 11

- Disposal of used equipment.. 11

- Procedure, techniques and after-care of puncture site 11

- Care of samples storage and transport.. 12

- Trouble shooting.. 13

Special notes 14

- RAID.. 14

- Calcium levels 13

- Urea and electrolytes... 14


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Accountability.. 15

Training Process: 16

- taught session... 16

- practical experience. 16

Competency framework 17

Practical competency checklist.. 18

Appendix 1 sharps, needlestick & splash incidents to staff 19


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Introduction

The purpose of this handbook is to provide a framework for use when teaching and

learning phlebotomy/venepuncture in primary care. It is designed to be used inconjunction with Community Health Oxfordshire Trust Policy on issues such as infectioncontrol and needle stick injury. The handbook contains a comprehensive guide to takingblood samples and a competency checklist for those recently trained in the technique.

Venepuncture is carried out for several reasons;1. to obtain a blood sample for diagnostic purposes2. to monitor levels of blood components.3. To maintain accurate cross match bloods


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Roles and responsibilities of phlebotomists;

To provide a Safe, efficient cost effective service to patients in Oxford City Primary

Care Trust (PCT) To prepare patients/check identity and ensure consent is given to obtain blood

samples for laboratory analysis

To display behaviour that justifies public trust and confidence (working within theNMC code of conduct)

To maintain confidentiality by adhering to the Caldicott Principles and the DataProtection Act.

To comply with The Community Health Oxfordshire PCT Partnership aims andvalues to improve the service delivered to patients, ensuring that the service is ledby patient needs.

To comply with The Community Health Oxfordshire PCT Partnership Health andSafety Policy

To transfer samples safely to the laboratory

To ensure at all times that accurate information is recorded when blood containerlabel is completed, also to keep accurate records of specimens

To deliver a safe and consistent service participate in regular audit and qualityassurance of equipment used in service delivery

To maintain an excellent standard of service through education, training, researchand development

To participate in regular updates and personal development programmesorganized and supported by The Community Health Oxfordshire PCT Partnership

To adhere to infection control-national policy and guidance currently January 2008


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The Laboratory

The laboratory dealing with specimens collected from primary care is based on Level 4 of

the John Radcliffe (JR) Hospital or the Horton General Hospital (HGH). There are severalsections within the laboratory, each one dealing with a specific range of diagnostic tests;i.e. haematology, biochemistry, histopathology, microbiology, immunology etc.Specimens are collected from all PCT surgeries and delivered to the Specimen Receptionwhere they undergo a secondary sorting, hence the need to ensure that the sample tubematches the request and the patient. From the specimen room, the specimens are thensent to the appropriate sections of the laboratory where they go through the testing stage.Results are then sent to the relevant GP surgery or via RAID scheme where they contactthe patients directly. Bearing in mind the enormous throughput of specimens in thelaboratory, the phlebotomist must always be diligent in the careful and accurate labelingand presentation of the sample tubes and request cards.

Limitation of Duties

a) Infusions and InfectionsPhlebotomists must not, on any account, give any type of injection, set up or re-sitesyringe drivers or attend to Hickman lines. They must refer to IV team, GP or DistrictNurses.

b) Advice on drug dosagesPhlebotomists must not, on any account, give advice to patients re: changing their drugdosages e.g. Warfarin but refer to GP or anticoagulation.

c) Difficulty in samplingIf Phlebotomists have difficulty in obtaining samples of blood, this could be brought to theattention of the nursing staff to whom the phlebotomist reports, or other responsiblemember of staff (GP or other nursing colleague). The limitations of the role should beclearly stated in the job description and understood by all members of the medical andnursing staff within Community Health Oxfordshire.

Training

Venepuncture is a routine procedure. In order to do this safely, the phlebotomist musthave a basic understanding of the following;

1. Anatomy and physiology

2. The criteria for choosing a vein

3. The device to use


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4. Skin preparation

5. Personal safety infection control policy

1. Anatomy and physiology;The circulation is a closed sterile system and venepuncture, however quickly completed,is a breach of this system providing a method of entry for bacteria. Infection sustained atthe venepuncture site can at its worst result in septicaemia.The superficial veins of the upper limbs are most commonly used for venepuncture.These veins are numerous and accessible ensuring that the procedure can be performedsafely and without discomfort. If venepuncture is unsuccessful in these sites alternativesmay be sought i.e. back of hand, but this may require a more experienced phlebotomist.

2. Criteria for choosing a site for venepuncture;i. The condition and accessibility of superficial veins.Veins may be tortuous (twisted), sclerosed (narrow), fibrosed (hard) or thrombosed(clotted), inflamed or fragile and unable to provide sufficient blood for sampling. If thepatient complains of excessive pain or soreness over a particular site, this should beavoided, as should areas that are bruised or adjacent to infection sites. Preference shouldbe given to a vein which is unused, easily detected by inspection and/or palpation, patentand healthy. These veins feel soft, bouncy and will refill when depressed.

ii. Anatomical considerations.The vein layout of each individual differs, but care must always be taken to avoid adjacent

structures e.g. arteries and nerves. Accidental puncture of an artery my cause painfulspasm and could result in prolonged bleeding. If a nerve is touched, this can result insevere pain and the attempted venepuncture should be stopped. Palpation is of value indistinguishing structures clinically, e.g the presence of a pulse indicates an artery,resistance indicates a tendon. Deeper veins may also be detected by palpation.


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The sites of choice are branches of: the Basilic vein, the Cephalic vein, the Median cubitalvein in the antecubital fossa.These are sizeable veins capable of providing copious and repeated blood specimens.The brachial artery and median nerve are very close by and must not be damaged. Thechoice of vein, however, must be that which is best for the individual patient.

iii. The clinical status of the patient.

Injury or disease may prevent the use of a limb for venepuncture. Amputation, fracture orstroke are good examples of conditions that affect venous access. Use of a limb may becontraindicated because of an operation on one side of the body e.g. mastectomy. Anoedematous limb should be avoided as there is danger of complications such as phlebitisand cellulitis as a result of the static fluid in the limb.

iv. Physiological factorsThere are several factors which can influence dilation of veins:


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a) Anxiety this may be reduced by presenting a confident manner together with anadequate explanation of the procedure. Careful preparation and an unhurriedapproach will help relax the patient and their veins:

b) Temperature the temperature of the environment will influence venous dilation. Ifthe patient is cold, no veins may be evident on first inspection. Application of heat,e.g. in the form of soaking arms in warm water, and encouraging the patient to wearwarm clothing in anticipation of a blood test, will increase the size and viability of theveins.

c) Mechanical irritation good technique prevents trauma and reduces the likelihood ofvein collapse.

d) The clinical state of the patient a reduction in body fluids e.g due to dehydrationand poor peripheral circulation as in heart failure, also affect the size of the veins.

3. The device

The device now commonly used to perform venepuncture for blood sampling is a closedvacuum container system, such as Vacutainer.The system includes a multi sample needle, a plastic shell and a vacuum filled tube with acolour coded stopper to indicate the type of additive in it, so the correct tube is used forthe blood test requested. It is essential that the expiry date is checked on the tubes beforeuse, and that tubes where the expiry date is past, must be discarded appropriately andnot used. With a closed vacuum container system, the blood sample is transferred fromthe vein via a double ended needle, directly into the collecting tube. The blood is drawninto the tube by the vacuum within it and the flow will stop automatically when the tube isfilled to its vacuum capacity. The technique avoids the need for manual transfer fromsyringe to tube, thereby minimizing the handling of blood. It also ensures the sample

remains biologically accurate as the exact amount is drawn and the blood comes intoimmediate contact with the additive.For patients who have veins that are difficult to access and for who the procedure isessential, a butterfly linked to the closed vacutainer is the only advisable system to use.

4. Skin preparationSkin cleansing has been a controversial subject as it has been acknowledged that wipingthe skin with an alcohol swab disturbs the skin flora and causes increase discomfort forthe patient. Normally clean skin is all that is required. Asepsis however is vital whenperforming venepucture as the skin is breached and an alien device is introduced into asterile circulatory system.

The two main sources of microbial contamination are:

a) The hands of the phlebotomistb) The skin of the patient


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Good hand washing and drying techniques are therefore essential on the part of thephlebotomist. If hand washing facilities are unavailable, an alcohol based hand washsolution is an acceptable substitute.

The phlebotomist must be aware of the Community Health Oxfordshire PCT InfectionControl Policy (Ref C027 Guidance on Infection Control, Communicable Diseases andImmunisation for Primary and Community Care in Thames Valley, Berkshire, Oxfordshireand Buckinghamshire.)

5. Personal SafetyProtection for all personnel is paramount when handling blood products and body fluids.In order to avoid any risk to personal safety, the phlebotomist must, at all times adhere tothe Universal Precautions:

a) Every patient should be regarded as a potential biohazardb) Latex or vinyl gloves MUST be wornc) Avoid needle stick injury this is a potential source for many infections but especially

dangerous are the Hepatitis B and HIV viruses transmitted in blood and body fluidsd) Dispose of sharps and or soiled equipment appropriately and safely; keep gloves on

whilst disposing of equipment, then dispose of gloves safely. * All vacutainers shouldbe single use only and disposed of with the needle after use.

e) Suitably protect cuts or other skin breaks on handsf) Ensure you are immunized against Hepatitis B Occupational health or your GP will

be able to advise.

In order to perform a safe and successful venepuncture it is important that thephlebotomist considers carefully the choice of vein, maintains good technique and appliesthe principles of asepsis.


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The Practical

1. Equipment

2. Disposal of used equipment3. Procedure, technique and aftercare of puncture site4. Care of samples storage and transport5. Troubleshooting

1. Equipment

Clean surface on which to place equipment

Gloves

Tourniquet

Vacuum device needle , shell, appropriate tubes

Cotton wool/gauze swab and tape

Request card/bag

Sharps container and clinical waste disposal bag

2. Disposal of used equipment

Phlebotomists must be responsible for the disposal of their own venepunctureequipment

Use an approved sharps container

Keep gloves on whilst disposing of used equipment, then dispose of gloves safely turn gloves inside out when removing

Discard shell and needle as one unit into sharps container

Any other non disposable equipment which may have become contaminated withblood should be discarded tourniquet needs to be washed regularly in hot soapywater or use disposable tourniquet

Equiptment Container should be regularly cleaned during phlebotomist duties

3. Procedure, technique and aftercare of puncture site

Check the specimen request and select the appropriate tubes place in order ofdraw.

Orderof

Draw

Bottle Colour Additive invert.

1 BLUE Sodium Citrate 3-4 Times

2 YELLOW Serum 5-6

3 GREEN Lithium Heparin 8-10

4 PURPLE EDTA 8-10

5 GREY Fluoride/Oxalate 8-10

6 RED 5-6 TIMES No anticoagulant; containsclot activator; yields serum-


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Approach the patient in a confident manner and explain the procedure, consultingthe patient on preferences and experiences related to previous venepuncture

Gather the necessary equipment Position the patient in a suitable place, taking into account lighting, ventilation,

privacy, phlebotomist and patient safety and comfort. Where possible, request thepatient to sit upright, although in those with a history of fainting it is best to positionthe patient lying on a bed or couch.

Examine both arms and choose the most suitable according to the aforementionedcriteria

Fully extend the chosen arm and position it downwards. The arm should besupported, comfortable and relaxed

Wash your hands

Assemble the device

Apply a tourniquet above the elbow, ensuring that it does not obstruct the arterialflow

The veins may be tapped lightly

Select the vein

Put gloves on

Anchor the vein by applying manual traction to the skin just below the proposedinsertion site

Hold the assembled device, with the needle bevel upwards, between thumb andindex finger, penetrate the skin and insert the needle into the vein, smoothly at anangle of approximately 15 degrees. Level off the needle after entry, so it is flush with

the skin Advance the needle approximately 1cm into the vein if possible

Once satisfied the needle is safely anchored, swap hands and whilst supporting thedevice, press the tube home with the thumb of the free hand. Blood should then bedrawn into the tube. Continue to hold the device until the tube fills; flow will stopautomatically.

Once the blood has begun to flow release the tourniquet within one minute.

Once the tube is filled, hold the device steadily with one hand and with the otherhand disengage the tube and gently agitate, but do not shake, to mix the blood andthe additive, side to side shaking causes haemoloysis

Should more than one sample be required, remove the filled tube and replace with

another immediately, in the following order: Blue, Yellow, Green, Purple, Grey Once all the samples have been obtained, remove the needle.

Place cotton wool over the puncture site and ask the patient to apply gentle pressureuntil the bleeding stops ( approximately; longer for those on warfarin or heparin).

Inspect the puncture site and apply a clean swab, secured with tape.

Dispose of sharps and soiled equipment safely.

Check that the patient feels well and comfortable.

Label and pack tubes for transport to the laboratory. Lab requests only to usestickers on INR bottles and hand write all others.


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4. Care of samples-storage and transportThe importance of clear and correct labelling has been identified and is the continuedresponsibility of the phlebotomist to ensure that this final stage in the venepuncture

service is performed thoroughly.Ensure that the tubes and the request cards are filled in correctly and that the bags arethen sealed. For blood collected from patients in their own homes, the bags should thenbe placed ideally in a cool box, (hospital phlebotomy dept say it is more important thatthey are not in direct sunlight i.e. a dashboard). Samples should not remain in the coolbox for any longer than necessary and certainly not overnight.


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5. Trouble shooting

Problem Possible cause Suggested action

Excessive pain Anxiety, fear, low painthreshold

Nerve touched

Reassure the patient.Confident unhurriedapproach,Remove the needleimmediately and proceedto a different site if thepatient is agreeable;venepuncture may needto abandoned for that day

Missed vein Inadequate anchoring ofthe needle

Wrong positionPoor lightingLess than 100%concentration

Withdraw the needlealmost to the bevel and

manoeuvre and advancegently to realign needleand vein, but if itbecomes painful removethe needle and proceedto a different site.Better preparation nexttime

Spurt of blood on entry Bevel tip of needleentering vein before

entire needle is under theskin, due to vein beingvery superficial

Ignore the blood spurtand proceed with

venepuncture. Reassurepatient if a small bloodblister develops

Blood flow stops Overshooting vein oradvancing needle whilewithdrawing bloodVein collapse due tocontact with valve or veinwall

Poor blood flow

Gently ease the needleback and continue

Gently manoeuvreneedle within the vein, ifstill unsuccessful, removeit and proceed to adifferent site

Haematoma Perforation of oppositewall of vein

Forgetting to release thetourniquet beforeremoving the needle

Insert the needle atcorrect angle and holdsteady while blood flowsDo not advance theneedle during taking ofsampleRemember to release thetourniquet when bloodbegins to flow


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Inadequate pressure atpuncture site after

removal of needle

Ensure firm pressure isapplied for at least aminute- the patient is not

always able to do thiseffectively

Inability to collect sample Various reasons Inform health careprofessional i.e. GP,Practice Nurse, DistrictNurse

Fainting AnxietyPainOverheating

Summon helpEnsure airway ismaintained by positioningpatient in recoveryposition, loosen tight

clothing and ensureadequateventilationReassure patient andencourage to rest for awhile lying down untilrecovered.Remind patient torequest futurephlebotomy in a lyingposition.

Report incident andrecord appropriately

With experience and continued effort to maintain a good technique, incidence ofdifficulties will lessen and the phlebotomist will grow in confidence and expertise inperforming venepuncture.

Special notes:

RAID Rapid Anti- coagulation Interpretation and DosingThis is a nurse led service, run through the haematology department at the Churchill,

where a nurse after referral from a patients GP undertakes the anticoagulant dosing ofpatients and arranges the next INR testing date. Tel: 01865 857 555/6

Blood testing for calcium levelsWhen this is required, the blood should be taken uncuffed * can be cuffed but releaseafter one minute to prevent raised calcium and potassium levels.The advice of the laboratory is to take 3 tubes of blood and to discard the first 2. It is notnecessary to completely fill the tube for this test, - full is adequate.


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Urea and electrolytesBlood taken for urea and electrolytes, must not be stored overnight as this process canlead to inaccurate results in respect of potassium levels.

Accountability

Phlebotomists when taking blood are accountable for their actions and must report alluntoward incidents to their line manager. It is in the interests of both the patient and thephlebotomist, for the phlebotomist to acquire some indemnity insurance through themembership of a professional body National Association of Phlebotomist or Trades Unioni.e. Unison, Royal College of Nursing.


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The Training Process:

Taught session:

This will comprise of the following:-

Theory as outlined earlier in the handbook, to include policies.

Practical

Explanation of the handbook

Competency framework

Preparation for practical experience, identification of mentor.

Practical Experience:This will involve work in a practice or out in the community, with a phlebotomist trainerwhose work has been observed and deemed competent by a registered nurse (mentor).The practice of the trainee phlebotomist needs to be observed during a minimum numberof 6 venepunctures or as many as required until the mentor and phlebotomist feelsatisfied that the trainee is competent.

Sue Agnew 01865 265 081


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Competency Framework

Criteria AuthorizationAttended theory session DateSignature

Read handbook andunderstood the principles ofphlebotomy

DateSignature

Completed practical session DateSignature

1 DateSignature

2 DateSignature

3 DateSignature

4 DateSignature

5 DateSignature

6 DateSignature

Reflective supervisedpractice, with mentor

DateSignature

I declare myself competent at venepuncture;Signature ofcandidatedate

Place ofworkSignature oftrainer..date.Signature ofmentor..date.


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Practical Competency ChecklistCompetency Date

achievedSignature of trainer/mentor

1. Understands scope of practice

2. Understands accountability

3. Demonstrates the procedure in asafe and competent manner;

preparation of the patient

ensure appropriate equipmentis at hand and is assembledcorrectly

wash/clean hands and apply

tourniquet to patients upperarm

correct choice of vein

insertion of needle

appropriate choice of tube

correct application of tube

4. Demonstrates high standards ofpatient care and communicationthroughout procedure

5. Once sample has been obtained,applies pressure over the puncture

wound, using a clean swab andsecuring if necessary

6. Samples labelled correctly

7. Demonstrates safety whendisposing of equipment

8. Demonstrates correct storage andtransport of specimens

9. Is aware of the importance ofdocumentation and communication withappropriate health care professionals

Signature of trainee.date

Signature of trainer.date

Signature of mentor.date


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Complete an incident form and contact Occ. Health Dept. on 01865 246900If out of office hours contact on the following numbers:

01527577242A practitioner will answer and give advice plus appointment date

Source (Patient)

Known?

Appendix 1

Source known tobe/strongly suspected

to be HIV/Hep B/C Pos

Collect clotted blood sample/brown or orangevaccutainer from exposed person & send to

Virology for Hep B Antibody and Serum save

Collect clotted blood sample/brown ororange vaccutainer from exposed

person & send to Virology for Hep B

Antibody and Serum save

Collect clotted blood sample/brown ororange vaccutainer from

patient/source with consent for

appropriate virology screen

Further action will depend on status ofpatient/source & Hep B immune status ofthe person exposed. If person exposedis not immune an accelerated course ofHep B vaccine or booster immunisation

is recommended.

YES

Repeat blood test onexposed person after6 months for Hep C

Screen

Risk assessment to be carried out by any oneof the following doctors:

Microbiologist/Virologist

via JR Switchboard

01865 741166

Communicable Diseasesvia Churchill Hospital

01865 741841

Genito-Urinary medicine

Risk of transmission HIGH?

Prophylactic treatmentrecommended.

Counselling is available

Prophylactic treatment notrecommended. Counselling

is available

YES

NO

NO

If person exposed is not immuneto Hepatitis B an accelerated

course or booster immunisation

is recommended

Repeat blood test onexposed person after 6

months for Hep C

screen

YES NO

IMMEDIATE ACTIONRinse site of exposure e.g. skin/mucous membranes with running water.

Encourage bleeding if there is a puncture wound.

Flow Chart for Accidental Exposure to High Risk BodyFluids

(Needlestick Injuries or Splash Incident)

ph le botomy handbook

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