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CLINICAL GUIDELINES/NURSING

Guideline for Venepuncture Using the Vacutainer System

Reference 1438

Date approved

 Approving Body Matron’s Forum

Supporting Policy/ Working inNew Ways (WINW) Package

Venepuncture using vacutainer system

Implementation date January 2013

Supersedes Version 1

Consultation undertaken Nursing Practice Guidelines Group, WardSisters/Charge Nurses, PracticeDevelopment Matrons (PDMs), ClinicalLeads, Matrons

Target audience All Clinical Nursing Staff

Document derivation /evidence base:

See main references

Review Date January 2016

Lead Executive Director of Nursing

 Author/Lead Manager Di Ryan, Colorectal Chemotherapy CNS,Oncology

Further Guidance/Information

Distribution: Ward Sisters/Charge Nurses, PDMs, ClinicalLeads, Matrons, Nursing Practice GuidelinesGroup (includes University of Nottinghamrepresentative)

This guideline has been registered with the Trust. However, clinicalguidelines are guidelines only. The interpretation and application ofclinical guidelines will remain the responsibilit y of the individualclinician. If in doubt contact a senior colleague or expert. Caution isadvised when using the guidelines after the review date.

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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 abasic 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 orminimise them and how to manage them if they occur

  The associated health and safety/risks involved in undertaking theprocedure 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.

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 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 ofconnective tissue, which surrounds and supports the vessel. Its role isprotective and in some patients/clients this can make penetration of the veindifficult.

The tunica media is the middle layer of the vein and is composed ofmuscular tissue and nerve fibres that can stimulate the veins to contract orrelax 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 veinscan distend or collapse as blood pressure rises or falls (Weinstein, 2007).

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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 bemore difficult to perform.

The tunica intima is the inner lining of the vein and is constructed of smoothendothelial cells which facilitates the passage of blood cells etc. Damage tothe tunica intima results in the internal lumen of the vein becoming roughenedand increases the risk of thrombus formation. In addition, the endotheliallayer develops folds, which are known as semilunar valves. The purpose ofthe valves is to ensure that the blood moves towards the heart by preventing

backflow. They are present in larger blood vessels and at points ofbranching. These can sometimes be seen visually by noticeable bulges inthe veins; the practitioner needs to learn to palpate the vein to check for thepresence of valves and ensure that venepuncture occurs above the valve inorder to facilitate collection of the blood sample (Weinstein, 2001).

SELECTING A SITE FOR VENEPUNCTURE -The veins normally used forvenepuncture are those found in the antecubital fossa because they are

usually of a good size and are capable of providing copious and repeatedblood specimens (Weinstein, 2007; Phillips, Collins and Doherty 2011) );They are also easily accessible thus ensuring that the procedure can beperformed 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 locationmake 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, thecephalic vein rises from the dorsalveins and flows upwards along the radial border of the forearm, crossing theantecubital fossa as the median cephalic vein. Care must be taken to avoidaccidental arterial puncture, as this vein crosses the brachial artery. It is also

in close proximity to the radial nerve (Perucca, 1995).

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The basilic vein, originating in the ulnar border of the hand and forearm(Wilson & Waugh, 2001), is often overlooked as a site for venepuncture: thisis for good reason. Although the basilic vein may be prominent (particularly inmen), it is awkward to access and it is not well supported by subcutaneous

tissue and tends to roll easily. These features make venepuncture of thebasilic vein difficult. Care must also be taken to avoid accidental puncture ofthe median nerve.

The metacarpal veins are easily visualised and palpated. However, the useof these veins is contraindicated in the elderly where the skin turgor andsubcutaneous tissue are diminished (Weinstein, 2007; Lister and andDougherty 2011,)

Occasionally the veins of a lower limb may be used for venepuncture,although the practitioner must understand the relevant anatomy and specificproblems associated with these sites. Venepuncture of veins in the lowerlimbs is associated with a higher risk of complications due to the increasedpresence of valves and the fact that, comparatively, the blood flow in thelower 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, easilydetected and appear healthy and patent. However, the most prominent veinis not necessarily the most suitable vein for venepuncture (Weinstein, 2007 ).There are two stages involved in locating a vein:

1. Visual inspection2. Palpation

Visual inspection involves scrutinising the veins in both arms and isessential prior to choosing a vein. The following areas should be avoided:

  Veins adjacent to foci of infection, bruising and phlebitis due to the riskof causing more local tissue damage or systemic infection.

   An oedematous limb as there is danger of stasis of lymph thatpredisposes to such complications as phlebitis and cellulites (Hoeltke2006, Smith, 1998).

   Areas of previous venepunctures, where possible, as repeated trauma

to the vein can result in pain (Ahrens et al, 1991).

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Palpation is an important assessment technique, as it determines thelocation and condition of the vein. It assists in distinguishing a vein fromarteries and tendons, identifies the presence of valves and can detect deeperveins (Scales (2008). The practitioner should use the same fingers for each

palpation to increase the sensitivity and ability of the practitioner in detectingthe appropriate site to use ( Phillips,Collins and Dougherty, 2011 ). Thethumb should not be used as it is not as sensitive and has a pulse, which maylead to confusion in distinguishing veins from arteries in the patient/client(Weinstein, 2007 ). Healthy veins feel soft and bouncy and will refill whendepressed (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 littlesubcutaneous cover (e.g. the inner aspect of the wrist) – these cansubject the patient/client to more discomfort

  For renal patients with an arterio-venous fistula/graft, the non-fistula/graft arm should not be used as this increases risk of stenosisand thus decreases the success of future venous access for

haemodialysis.

OTHER FACTORS INFLUENCING VEIN SELECTION

  Injury, disease or t reatment may prevent the use of a limb forvenepuncture by reducing the venous access (e.g. amputation,fracture, cerebrovascular accident). Use of a limb may becontraindicated because of an operation on one side of the body, forexample, mastectomy and axillary node dissection, as this can leadto impairment of lymphatic drainage, which can influence venousflow regardless of whether there is obvious lymphoedema (Smith,1998; Rowland, 1991).

  Position of the patient/client, for example, having to lie on aparticular 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

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with the smallest gauge device to reduce the amount of trauma tothe vessel.

  The weight of the patient/client – malnourished patients/clients will

often present with friable veins. Obese patients/clients may causepractitioners to have difficulty in locating the vein due to extrasubcutaneous tissue being present.

  Patients/clients who are dehydrated or in shock – there will bepoor superficial peripheral access. It may be necessary to takeblood after the patient is rehydrated as this will promote venousfilling and blood will be obtained more easily (Mallett & Dougherty,2000).

  Medications or conditions that cause bleeding or s low healing (e.g. anticoagulants, steroids, thrombocytopenia) – these situationspredispose the patient/client to having more risk of bruising bothduring venepuncture and on removal of the needle; this then limitsthe availability of veins that are not damaged.

IMPROVING VENOUS ACCESS 

The success of venepuncture is influenced by a number of factors related tothe patient/client and the practitioner. The more experienced the practitioneris the easier venepuncture becomes. However, no matter how experiencedthe practitioner is, factors that cause the blood vessels to vasoconstrict willmake the procedure of venepuncture more difficult. A number of approachesto improve venous access and thereby facilitate the procedure beingsuccessful are identified below.

1. Fear about the procedure of venepuncture may itself result in

vasoconstriction. The practitioner’s manner and approach will have adirect bearing on the patient’s experience (Weinstein, 2007 ). Approaching the patient/client with a confident manner, giving anadequate explanation of the procedure together with careful preparationand an unhurried approach may help to reduce anxiety which will in turnincrease vasodilation.

2. Ensuring the correct ambient temperature of the environment isimportant – if it is cold the blood vessels of the patient/client may

vasoconstrict to compensate.

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3. Application of a tourniquet – this promotes venous distension. Thetourniquet should be tight enough to impede venous return but notrestrict arterial flow.

4. Opening and closing the fist ensures the muscles will force the blood intothe veins and encourage distension.

5. Lowering the arm below heart level may also increase blood supply tothe veins.

6. The use of heat in the form of a warm pack or by immersing the arm in abowl of warm water for 10 minutes helps to encourage vasodilation andvenous filling.

7. Ointments or patches containing small amounts of glyceryl trinitrate havebeen used to cause local vasodilatation to aid venepuncture. Aprescription is required to enable this technique.

8. Stroking the vein (rather than patting it) can also assist with venousdilation.

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 meansof entry for bacteria. Adherence to an Aseptic None Touch Technique(ANTT) will minimise the risk of cross infection from practitioner topatient/client (e.g. thorough hand cleansing using soap and waterfollowed by alcohol hand rub). Non-sterile gloves may be required toprotect the practitioner from cross infection from the patient/client but allother equipment should be sterile and single use only.

2. Accidental damage – the nerve, tendon or artery might be inadvertentlypunctured if these have not been identified during visualinspection/palpation. This can result in pain, damage and haemorrhagefor the patient/client as well as loss of confidence for the practitioner.

3. Haematoma – this is the commonest complication arising fromvenepuncture (Weinstein, 2007 ). There are a number of factors thatinfluence the development of a haematoma – poor technique on the part

of the practitioner, failure to release the tourniquet before removingneedle and inadequate pressure on the venepuncture site once the

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needle has been removed. A haematoma may also occur if thepatient/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 drugtherapy (e.g. anticoagulation medication). It increases the risk ofbruising/haematoma formation and worsens the consequences ofinadvertent arterial puncture. Practitioners should ensure they are awareof the patient/client’s relevant drug and medical history prior toperforming venepuncture to reduce this risk.

5. Incorrect or lack of details on the request card and/or sample – thisincreases 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 apatient receiving unnecessary or dangerous treatment.  All samplesmust be correctly labelled and the details must correspond with those onthe request card. The patient’s details, both on the request form and thespecimen bottle should be ascertained using the Trust policy for thepositive 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 havean identity band on. If not, attach one to the patient that states thepatient’s last name, first name, gender, date of birth and NHS number.(NUH 2012)Check these details are correct with the patient and thepatient’s hospital notes. Patient labels should not be applied to crossmatch bottles- both the cross match form and the blood bottles shouldhave 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 procedureHowever, if the patient/client was difficult to bleed, check with thelaboratory staff whether they might be able to process the smallersample without it compromising the results.

8. Needlestick (sharps) Injury – use of vacutainer systems helps to reducethe incidence of this occurring ( Centre for Disease Control, 1997).However, the use of a needle and syringe may be preferential to obtainblood 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

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a needlestick injury the practitioner must follow the NUH Safe handling,disposal and reporting of sharps and blood borne exposure injuriespolicy (2008).

9. Infected samples – whether known or suspected, these pose a healthrisk to any staff that have to handle them – this includes porters andlaboratory staff. Appropriate identification through labelling andtransportation of infected samples is covered in other documents whichshould be read by the practitioner (refer to Trust Policy and guidance asappropriate, e.g. Infection Control Guidelines).

10. Blood spillage – use of the vacutainer system reduces the risk of bloodspillage since the blood is drawn directly into the evacuated sample tube.

However, there is a risk of blood spurting from the vein whenvenepuncture commences. For those blood samples that cannot betaken using the vacutainer system there is a risk of blood spillage whendecanting blood from the syringe to the sample tube. Blood spillage kitsare available in all clinical areas (refer to Trust Policy). Staff should beusing goggles if there is any risk of the practitioner being splashed byblood

11. Needle or Blood Phobia – if the patient/client has a needle or bloodphobia it might make their behaviour difficult to manage. They might

also faint at some point during the procedure. It is important to establishwhether the patient/client has had previous problems with venepunctureand to take appropriate action.

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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 equipmentnecessary for venepuncture.

You should contact thepathology department if you areunsure what bottles arerequired for the blood samplesrequested

To ensure that time is not wastedand that the procedure goessmoothly without unnecessary

interruptions.

2 Check all packaging and expirydates before use.

To ensure the sterility of the productsprior to use.

3 Select appropriate size devicebased on vein size and numberof samples required (21g is themost frequently used size).

To reduce damage or trauma to thevein.

4   Discuss any previousexperiences ofvenepuncture;

This might reduce anxiety which canreduce vasoconstriction. If thepatient/client has a history of fainting,the practitioner can put measures inplace to reduce/prepare for this.

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5 Make the patient/clientcomfortable (with back wellsupported) in an environmentthat is suitable in terms of

lighting, ventilation, privacy,positioning and safety.

These factors will assist thepractitioner to be successful with theprocedure.

PRINCIPLE RATIONALE

Discuss the procedure with thepatient/client to include:

  Information about the

procedure and obtainconsent;

To ensure that the patient/client

understands the procedure and givesinformed consent.

  What test(s) is (are) beingdone and why;

In addition to the patient/clientunderstanding the procedure, thepractitioner needs to ensure that therequirements of the test are met (e.g.if fasting blood sugar is being takenthe patient needs to have fasted).

6

  Relevant medical history(and allergies);

This might influence choice of limbfor venepuncture (e.g. if thepatient/client has had surgery or eversuffered from lymphoedema) orchoice of occlusive dressing.The practitioner may need to takeadditional precautions if the patient isknown to have a blood borne

infection (see relevant policy).  Relevant drug history (e.g.

anticoagulant therapy);The patient/client will be at higherrisk of bleeding and therefore needto apply pressure on thevenepuncture site for longer postprocedure.

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  PRINCIPLE RATIONALE

7 Check that the patient/clientidentity matches the details onthe venepuncture request formand label the sample tubes withpatient details at the bedside.

To ensure that the correct sample istaken from the correct patient/clientand comply with SHOT (SeriousHazards of Transfusion) guidelines.

8. If patient expressesanxietyrelating to a phobiaabout needles or concernsabout pain offer localanaesthetic and apply prior toprocedure,

Emla cream, 45 minutes before Ametrop 15 minutes before

To ensure the comfort of thepatient/client and increase venousaccess.

COMMENCING VENEPUNCTURE USING THE VACUTAINER SYSTEM

PRINCIPLE ACTION

1 Wash and dry hands thoroughlyusing antiseptic soap and dry.Check hands for any brokenareas, and cover with anocclusive dressing.

To reduce the risk of cross infection.

NUH Hand Hygiene Policy (2011)

Pratt et al (2007)

DoH (2007)

2 Break seal on vacutainerneedle, remove clear plasticcover and screw disposablesyringe barrel onto thevacutainer needle (leave thecoloured shield on the needleas this will be inserted into the

patient/client’s vein).

In preparation for venepuncture ofthe patient/client’s vein.

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  PRINCIPLE ACTION

4 Extend the upper limb (fullelbow extension) and support iton a pillow.

To ensure the comfort of thepatient/client and increase venousaccess.

5 Gel hands with alcohol hand ruband put on gloves (see BestPractice Box Glove Use) andapron.

To reduce the risk of cross infectionand potential contamination of thepractitioner

NUH Hand Hygiene Policy (2011)

Pratt et al (2007)

DH (2007)

6 Apply tourniquet to chosen limbin appropriate location.It may be necessary to utiliseother methods to facilitatevenous distension (SeeIMPROVING VENOUS ACCESS – page 6).

Dilates the veins by obstructingvenous return.Increase the prominence of the veinsand/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 apotential source of infection. Single use tourniquets have financialimplications but this could be offset against the increasing problem ofiatrogenic infections occurring in hospitals. If using reusable tourniquets thenit must be cleaned between each patient.

The tourniquet should be applied with enough pressure to impede venousflow – if the radial pulse cannot be felt the tourniquet is too tight. (Weinstein,2007 ).

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PRINCIPLE RATIONALE7 Select an appropriate vein – in

relation to size, location andcondition. Refer to the followingsections:

  Anatomy and physiology

  Selecting a site,

  Choosing a vein –appendix 1

Veins to avoid

 – page 6

To complete procedure successfully

Best PracticeGLOVE USE

Non sterile gloves are to be used when undertaking venepuncture andhandling blood and body fluids (NUH, 2011). This may help preventcontamination from blood spills and cross infection but does not preventneedlestick injuries and prevent cross infection. Please refer to NUH Gloveselection guidelines (2011)

Best Practice SKIN CLEANSING chaThe use of skin cleansing remains controversial. A study by Sutton et al(1999) concluded that there was no difference with respect to complicationsat the site of venepuncture that received skin cleaning when compared tothose that had not. A cursory wipe is known to do more harm by disturbingthe 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 cancause haemolysis of the sample (Perry and Potter, 2002.) See NUHInfection Prevention and Control intranet site for information on the use of‘Sanicloth and Chloraprep’ decontamination products.

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PRINCIPLE RATIONALE

7 Remove the coloured needleshield and hold the syringebarrel with the needle beveluppermost.

This provides the cutting edge toincise through skin and tunica layersof the vein.

8 Anchor the vein by applyingmanual traction on the skin ofthe upper limb a few centimetresbelow the proposed insertionsite

To immobilise the vein and prevent itfrom rolling. Traction also providesa counter-tension to the vein, whichwill facilitate a smoother needleentry.

9 Insert the needle smoothly at anangle of approximately 15 – 30°depending on the vein location(degree of superficiality) andadvance slowly into the vein –with experience it is possible todistinguish when the vein wallhas been punctured.

To promote a successful, pain-freevenepuncture.

 Advancing the needle stabilises thedevice within the vein preventing itfrom becoming dislodged duringwithdrawal of blood.

Introduce the blood bottle tubeinto the vacutainer holder.Placing forefinger and middlefinger on the flange of the holderand the thumb on the bottom ofthe tube, push the tube to theend of the holder puncturing thestopper on the blood bottle.

It is important to retain the positionof the needle in the vein whilstpushing the tube “home” in thevacutainer holder.

11 If venepuncture has beensuccessful, the bottle will

automatically fill to its requiredvolume. If nothing happens,draw the needle back slightly –as long as the needle remainsunder the skin the tube willretain its vacuum and when thevein is found, blood willimmediately flow into the tube.

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 ON COMPLETION OF VENEPUNCTURE

PRINCIPLE / ACTION  RATIONALE1 Once all the samples have been

obtained, remove the last tubeand release the tourniquetbefore withdrawing the needlefrom the vein.

To reduce the risk of:  blood spillage  discomfort for the patient/client  damage to the vein/development

of haematoma.

2 Place a low lint swab over thepuncture site applying pressureto site AFTER the needle has

been removed.

To prevent pain on removal anddamage to the intima of the vein.

3 Discard needle and vacutainerbarrel in sharps container.

To prevent needlestick injury.

4 Check that the tubes andrequest documentation arecorrect. Check cross matchsamples with second nurse.

To reduce the risk of incorrect orunnecessary treatment beinginitiated.

5 Check puncture site has sealedbefore applying an occlusivedressing to the puncture site.(NB check that the patient/clientis not allergic to the occlusivedressing to be applied).Instruct the patient/client toremove the occlusive dressingafter 24 hours.

To prevent the risk of blood spillageby ensuring the patient/client doesnot bleed after leaving the clinicalarea.

6 Discard waste into appropriatereceptacles (in accordance withTrust policies and procedures).

To reduce the risk of contamination.

7 Record type of blood sampletaken and any complicationsthat occurred with the procedurein the appropriatedocumentation.

Medico-legal reasons.

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PRINCIPLE RATIONALE

8 Ensure samples are sent via theair tube system. At present,

glass bottles (e.g. bloodcultures) or high-risk specimensshould not be sent via the airtube system but taken to thelabs as soon as possible.Community samples arecollected by van and taken tothe appropriate laboratory.Urgent requests require a P1priority number which can beobtained from the P1 line(55084) and written on therequest form

The air tube system provides thequickest route to the laboratories

and rapid processing of thesamples.

9 Advise the patient/client whenthe blood results will beavailable and what action isrequired (if any) to obtain theresult.

Effective communication

Best Practice PATHOLOGY REQUESTS

 A role expansion package now exists in Nottingham University HospitalTrust to allow nurses and/or other health professionals to request pathologytests directly under certain circumstances. This package meets therequirements set out in the “Working in New Ways Policy and Guidelines(NUH 2011).

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Churchill Livingstone, Edinburgh

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Venepuncture 2013 24

 

 Author: Diane Ryan,Colorectal Chemotherapy Nurse Specialist ,CASDirectorate

NPGRG Link: Vivian Blackburn

January 2013

Review: March 2015

SUGGESTED AUDIT POINTS

1. Has a suitable vein been chosen, using the criteria outlined in theguidelines?

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?

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 8. Has no more than two unsuccessful attempts at venepuncture been

attempted?

9. Has the puncture site been sealed correctly?