Year 2 MBChB

Clinical Skills Session

Venepuncture

Authors: The Clinical Skills Lecturer Team Reviewed & ratified by: Dr Jamie Fanning, Theme Lead Clinical Examination and Procedural Skills, University of Liverpool 2019

Learning Objectives

To understand reasons for undertaking venepuncture.

To understand hazards of venepuncture including needle stick guidelines.

To apply the principles of ANTT (Aseptic Non Touch Technique).

To be able to carry out venepuncture safely and within Trust guidelines.

Theory and Background

Vascular anatomy left anterior forearm;

Images of Shoulder girdle and arm; Standring, Susan, MBE, PhD, DSc, FKC, Hon FAS, Hon FRCS, Gray's Anatomy, Chapter 48, 797-836.e1

Legal Implications

NHS trust have two forms of liability:

o Direct liability – the Trust itself is at fault

o Vicarious or indirect liability – the Trust is responsible for the faults of others.

When you perform venepuncture you will be measured by the same standard as other health professionals that

have this skill, you have a duty of care and cases of negligence can be brought if you fall below the standard of

care. Ensure that you are supervised at all times and that you are aware of the Trust policies when you are in

clinical practice.

Reasons for undertaking venepuncture:

The common use for blood sampling is to guide clinical management based on laboratory testing. This could be

routine or urgent.

Further training is required before you do;

o Blood transfusion sampling

o Blood culture sampling

o Arterial blood sampling

o Venepuncture on a child

o Invasive line sampling

o Venepuncture on a child/ infant

Hazards of Venepuncture;

Consider your safety and patient safety:

Your safety, fainting;

You will practise taking a blood sample from a simulated manikin, and have the opportunity to practise this skill

in your teaching session and in the Learning Zone. If you feel faint or queasy during the teaching, sit down and

alert a tutor at once.

Needle stick injury

Care should be taken at all times to prevent needle stick injuries. If you come across unsafe practice, you

should inform your supervisor.

What happens if you sustain a needle stick?

There will be a policy in the Trust that you are working in and the School of Medicine has a Health and Safety

code of practice available on the School’s Intranet.

However there are some vital first steps:

o Squeeze it, make it bleed

o Wash it under running water

o Dry it

o Apply a dressing

Then report it and document it thoroughly.

This needs to be reported on the ward / area that you are working, an incident report will be filed and you

may be sent to Occupational Health or Accident and Emergency for further tests. You must report it to the

Nurse in Charge and / or your supervisor.

You will then need to complete an incident report form from the University’s School of Medicine;

Contact Departmental Safety Coordinator: Dr Emma Beddoes, email: ebeddoes@liv.ac.uk

If you need any further support please contact the Wellbeing team at the school.

Sharps

Sharps disposal goes into a yellow sharps box, there are various coloured lids. The lids dictate what can go into

the bin:

o Orange - for sharps with no medication contamination

o Yellow - for sharps including medication contamination

o Purple - for sharps and cytotoxic drugs, eg; chemotherapy

The sharps bins are for:

o Needles and syringes (do not disconnect - dispose as one)

o Suture needles

o Scalpel blades

o Glass vials if no option otherwise

In order to reduce sharps injury, be aware of HSE regulations (2013) and:

o NEVER attempt to re-sheath a needle

o Always ensure that lid is fitted correctly and the sharps bin is signed, stating the date it was put

together

o Activate needle safe devices prior to disposal, and never try to adapt equipment.

o Do not overfill the boxes past the fill line, as this is a safety hazard. Image below is from the Learning

Zone with artificial blood…..

o Close the bin lid firmly when full, and sign the label on the front to

confirm you have locked it.

o Irrespective how full the box is, change it every 3 months

o DO NOT DISPOSE OF SHARPS in clinical waste bags!

Incorrect disposal of sharps may cause injury or death

Rice et al (2015) found that sharps injuries increased by 67% over a 10 year period prior to the latest

regulations.

Patient Safety Considerations

Venepuncture is an invasive and sometimes uncomfortable routine procedure, occasionally a patient may

have developed a needle phobia due to previous experiences, and you should discuss this when gaining

consent, assist the patient into the most comfortable position. If the patient does not give informed consent

then you should not be practicing venepuncture, always consult your supervisor.

Many clinical practices have different equipment, depending on training and organisational decisions,

therefore you need to know how to use the venepuncture system that your clinical placement uses. If you

don’t know how to use it - DON’T USE IT.

Complications

Some other complications are listed below;

o Haematoma, be aware that patients having repeated samples could develop haematomas, patients

who are on anti-coagulants are at greater risk of haematoma formation.

o Infection, if ANTT is not applied or if the patient has an underlying infection

o Allergy, check with skin cleanser or reactions to tape are common

o Mental health – phobia, consider administering topical anaesthetic prior to sampling.

o Medical device failure, this would need reporting, please do not alter any equipment prior to use as

this would affect the way it is licensed to be used.

o Sharps injury- see sharps section.

o Nerve damage, be conscious of anatomy and if you touch a nerve with the needle a patient will

complain of pain. Remove needle and document including any neuralgic symptoms.

o Arterial puncture- the blood will pulse into bottles, be brighter in colour, pressure will need to be

applied to the insertion site.

o Skin damage (often from tourniquet if skin is fragile)

o Thrombus

o Bruising, increased risk if patient is on anticoagulants or the needle goes through the vein.

o Pain, consider topical anaesthetic

o Syncope/ fainting, lie the patient flat and call for help

o Haemolysis- the samples may need repeating

WHO (2010) states that there are 3 major errors in blood sampling, these are haemolysis, contamination and

inaccurate labelling.

Haemolysis can be caused by;

o The use of a needle of too small a gauge (23 or under), or too large a gauge for the vessel

o Under filling of a blood tube

o Failing to let alcohol or disinfectant dry;

o Using too great a vacuum; for example, using too large a tube for a paediatric patient if a patient has

reduced circulation

WHO (2010)

Ensure any complications are documented clearly in the patient’s notes and that complications are reported to

your supervisor immediately.

ANTT

Venepuncture should utilise an Aseptic non touch technique (ANTT) approach, ANTT minimises the transmission

of virulent pathogenic organisms in sterile or aseptic procedures. Understanding and adhering to the concept of

ANTT is paramount in patient and staff safety. The aim of ANTT is asepsis, which is done by “protecting Key-

Parts and Key –Sites from microorganisms” carried by the person doing the procedure. (ANTT Clinical Practice

Framework, Principle 2, 2018)

The increase of antibiotic resistant bacteria requires clinicians to prevent the spread of infection and practicing

ANTT with good hand hygiene can contribute to this.

ANTT is practiced when:

o Carrying out invasive clinical procedures, such as taking blood,

o Maintaining indwelling medical devices, such as a peripheral venous cannula,

o When handling equipment and carrying out procedures involving key parts and key sites,

(Loveday et al, 2014)

“Key parts are the critical parts of procedure equipment, that if contaminated are most likely to cause

infection.” (ANTT Clinical Practice Framework, Safeguard 2, 2018)

Some key parts:

o Syringe tip, needles, tip of a cannula, patient’s skin, catheter tip, wounds, rubber seals on IV lines, drug

bottles, etc.

(ANTT, 2018)

Differences in Clinical Practice

Differences may be due to clinician preference, trust policies and clinical context (e.g. patient on ward, separate

from equipment area).

You need to understand the concepts of the technique so that once on placement, you can be flexible with the

procedure in any given circumstance, and comply with local trust policy.

Venepuncture equipment and policy varies from Trust to Trust. Ensure that you are familiar with local policy

and equipment before carrying out the procedure on a patient.

For the purposes of demonstration this guide will use two of the most common systems currently in use at local

Trust sites; Monovette and Vacutainer.

Monovette/ Sarstedt System

o Push the syringe/sample bottle into the hub of the needle

o The hub contains the second part of a double ended needle covered with a rubber sleeve

o The lugs should be aligned with the channels in the hub

o The lugs are rotated into the bayonet fitting to secure

Please ensure when you are collecting kit that you check expiry dates and that you get equipment that works

together.

Vacutainer/ Vacuette System

o The needle is screwed into the base of the container

o A rubber sleeve sits within the container over a second needle bevel

Vacuum bottle, do not activate

until it is in the vein, activation is

when the rubber lid is pierced by

the needle in the cover, as

above.

The Procedure

There are various ways of carrying out this procedure in practice and these steps are not rigid and can be

interchangeable, dependent on clinician experience and local policy/ equipment:

Sequence;

o Patient safety including consent / check ID

o Gather appropriate equipment

o Tourniquet & site selection

o Skin preparation

o Venepuncture (using ANTT)

o Apply pressure & dressing

o Safe disposal of sharps

o Documentation

o Clean up & wash hands

Butterfly Vacutainer, these are

available with Monovette and

Vacuette. Each safety needle activation

is different and you must be shown this

in clinical practice.

Images supplied and permission granted by

Greiner Bio-One

Patient Safety

On first meeting a patient introduce yourself, confirm that you have the correct patient with the name and date

of birth, if available please check this with the name band and written documentation such as the blood request

form and the NHS/ hospital number/ first line of address. Many blood requests are done via computer order

and a form will be printed, take the form to the patient whilst gaining consent.

Check the patient’s allergy status, being aware of the equipment you will be using in the procedure, ie; skin

preparation or Elastoplast or Latex. Ensure the procedure is explained to the patient in terms that they

understand, gain informed consent and ensure that you are supervised, with a chaperone available as

appropriate. Allow the patient to ask any questions that they may have and discuss any past problems (e.g.

fainting). Assist patient into a comfortable position, support arm with a pillow. If the patient has a history of

fainting, they may be positioned better on a trolley, ask the relatives if they have any problems with needles.

Also consider the patient’s own personal preference (e.g. choice of arm) or issues preventing the use of 1 arm,

eg; lymphoedema. Your explanation of the procedure to the patient should include appropriate detail of the

tests you are taking and why they are being taken and when the results will be available. Don personal

protective equipment as you are coming into contact with bodily fluids (Loveday 2014) and use sharps in

accordance with HSE (2013).

Be aware of hand hygiene and preventing the spread of disease, WHO (2009) https://www.who.int/infection-

prevention/tools/hand-hygiene/en/

This procedure may require the presence of a chaperone if requested. A chaperone is someone who is familiar

with the procedure and can ensure that nothing inappropriate occurs by either party. The chaperone can be a

useful resource, not just being present to ensure the patient is treated appropriately, but to help and support

the patient. If patient is needle phobic, or has a history of fainting, it is best to lie the patient flat before the

procedure.

The Blood Request Form

Ensure that you read through the request form, many will tell you which samples are required and which bottles

these samples go in. You will also need some additional information on occasion, so taking the form with you

will enable you to confirm identity of the patient and ask any appropriate questions.

Below is the form used at the clinical skills teaching and learning centre:

Check this against the name band if the patient has one.

Areas to be completed:

Patient details - may be hand written or a patient label used, ensuring labels don’t cover any required

information. Some Trusts do not allow labels in some instances e.g. on cross match forms, which

students are not to fill in. Some forms will be pre-printed with the patient details, if the bloods are

ordered on the computer system.

Indication for the test(s) – in this example renal (kidney) failure.

Test(s) to be taken – in this example, U&E (urea & electrolytes) and FBC (full blood count).

Sample obtained by/ designation – To be signed by person obtaining bloods at the bottom of the form,

for students please get countersigned.

Date and time of specimen - The person who has obtained the blood sample must complete this

section after bloods have been taken. If incomplete, the sample will not be processed by the lab.

High Risk - If aware that the patient is high risk (e.g. HIV+, hepatitis B or C +) then the “Y” should be

circled next to “HIGH RISK?” If unsure, ask the patient, “Have you ever been told that you are a high

infection risk?” and they will either tell you they have or have no idea what you are asking. If the patient

is High Risk- you need to notify the Labs and put high risk warning on the bloods, follow trust policy.

Look at the patient and request form to see which blood bottles you will need. There are different coloured

blood bottles for different tests. If you are taking more than one bottle there is a specific order the samples

should be taken in, in order to ensure the optimum processing. The CSTLC has an order of draw, however this

often varies from Trust to Trust, so please consult the Trust’s ‘order of draw’ chart to check the order you

should take the samples. Be careful when using a butterfly system, explained below.

Once consent gained, prepare equipment.

Example of standard equipment:

A tray

Request form

Venepuncture system - bottles and needles

Skin prep/ Alcohol/ Chlorhexidine swab(s)

Tourniquet- single use

Gauze and adhesive tape

Gloves

Apron

Portable sharps bin

Pillow

Hand wash (De Verteuil, 2011; Brooks, 2014)

If you are using a tray or a trolley and tray, please ensure all surfaces are cleaned with an appropriate wipe.

Once area cleaned, ensure hands are washed. Check packaging of equipment is intact and all equipment is

within its expiry date prior to preparing equipment, maintaining ANTT.

Using a Tourniquet

A tourniquet must not be left on for more than 60 seconds (NHS Clinical Evaluation Team 2018)

A tourniquet is used to assist in finding potential veins suitable for venepuncture, it can be applied twice once to

find a suitable vein, it must then be released whilst the skin is cleaned, and reapplied prior to the procedure.

The tourniquet used should be capable of being released with one hand. Most trusts use disposable ‘single use’

tourniquets to reduce the spread of infection- these should be used.

The tourniquet is applied approximately 8cm above the chosen site. This will usually mean it is applied to the

upper arm. The tourniquet should not be so tight as to cause pain or impede arterial blood flow (check pulse is

present if unsure). Please be aware if a patient has delicate skin that could bruise or tear and exercise extreme

caution.

Occasionally patients have very large veins that are easy to palpate, you do not need to use the tourniquet to

identify veins in this instance, and you may not require it for blood sampling.

Fist clenching as a means of emphasising location of veins is not recommended as this can cause

pseudohyperkalaemia, especially in conjunction with tourniquet use. (Bailey and Thurlow, 2008; Garza, D. and

Becan-McBride, K, 2010)

If a tourniquet is left in situ for too long, it can also affect the clotting samples and repeat specimens maybe

required, delaying patient treatment.

If the veins are not prominent, then consider:

o Positioning the arm below heart level helps dilate the vein

o Light tapping may be useful but NEVER slap the vein

o The use of a warm pack helps encourage vasodilation and venous filling (Brooks, 2014)

Vein Selection

The usual site for venepuncture is the antecubital fossa (median cubital, cephalic and basilic veins).

Suitable veins should be easily palpated and may be visible, on palpation they should be soft and bouncy,

refilling when compressed.

You may also see blood taken from the metacarpal

veins in the back of the hand, however these are used

less commonly due to often causing more pain to the

patient. Additionally less subcutaneous tissue can

make it more difficult due to increased mobility of the

vein. In most cases a butterfly needle would be used,

please see blood sampling systems.

You should be aware of other structures, arteries pulsate so avoid these and ensure that you can easily palpate

the vein before attempting venepuncture, feel for a pulse and choose a vein furthest away if unsure. (Dougherty

and Lister, 2015; Skarparis and Ford, 2018). Valves tend to be where the vein bifurcates, in order to reduce

damage to the valves; avoid bifurcations.

Difficulty accessing Vein

There are patients where you will struggle to find a vein, whilst you are practicing this skill, it is recommended

that you only attempt venepuncture when you feel happy that you can access the vein. You should be

supervised at all times and do not attempt venepuncture more than twice on a patient who has given informed

consent.

You may also come across ultrasound guided vascular access, this is often used in hospital to access vessels that

are difficult to find for a variety of reasons, and you should have the opportunity to see this used during your

clinical placements. Short video available to show pulsation of artery on the website.

Sites to avoid:

Certain sites should be avoided, please consider avoiding;

o Areas where the overlying skin has a rash, bruising, burns or infection.

o Areas where there is scar tissue from previous venepuncture, or hardened cord like veins.

o Limbs if they are oedematous.

o A limb if there is an arterio-venous fistula (used for dialysis).

o A limb affected by a stroke.

o An arm with a drip in-situ (as this may affect the blood results).

o The distal portion of the Cephalic vein (it is used for cannulation and so should be preserved).

The above list is not exhaustive, discuss with the patient when gaining consent.

Ensure all equipment is prepared and then:

Preparation of Skin

Skin preparation = cleaning the skin at the chosen site to eliminate skin flora.

Please refer to Trust Policy regarding skin

preparation, as there are variations in practice.

The WHO (2010) states the skin needs cleaning

with 70% alcohol for 30 seconds

If using ChloraPrep® this needs 30 seconds of

application to activate as well as drying time

Time must be allowed for most skin preparation

to dry (normally 30 seconds)

Never puncture skin through “wet” alcohol as

this increases pain and risk of infection

Once you have cleaned the site, you must not touch it again. If you need to re-palpate you must re-

clean or war sterile gloves.

Taking Blood Sample:

Vacutainer

You must don an apron prior to taking blood, but this can be done earlier if required.

Then when you and the patient are ready, re-apply the tourniquet, wash or apply hand wash to your hands and

then don gloves.

You are now be ready to take the blood sample. Safely

remove the sheath from the needle and hold with the

bevel (hole of the needle) upwards. Ensure you do not

touch the needle or the chosen site during the

procedure. Ensure the safety needle cover is pulled

back.

Anchor the vein below the insertion site with your non

dominant hand, to prevent the vein moving, by

applying gentle traction at a point distal to the

intended point of insertion. (Dougherty 2008;

Dougherty and Lister, 2015; Skarparis and Ford,

2018)

Ensure prior to piercing the skin that key parts and

key sites of the needle and area of disinfected skin

are not contaminated by your gloved hands.

Warn the patient there will be a sharp scratch,

hold the barrel of the needle holder and insert

the needle at an angle of 15-45 degrees. (The

angle tends to be bigger on manikins.) Insert

needle slowly until you know that it is in the

vein.

Release tourniquet once the needle is in the

vein, blood starts to fill bottle, flashback is

obtained or once sufficient blood obtained,

following Trust or local guidance.

Ensure blood bottles filled to blood fill line.

Insert further bottles as required following the

Trust’s order of draw.

Maintain the position of the needle and holder

with your non dominant hand.

Insert the vacutainer bottle piercing the seal until

blood flows.

If the position of the holder is not maintained the

needle can go through the vein, which would

necessitate repeating the procedure and no blood

sample.

(The vacutainer bottle has a vacuum in it, if you

are using a manikin and do not draw blood, the

bottle will fill with air and cannot be used again.)

Invert the bottle numerous times, as per

manufacturer guidelines.

When the blood has been drawn, place gauze over the

insertion site but apply no pressure until the needle has been

removed. Once the needle is removed apply pressure over

the site. Activate the needle safe device, preferably on a hard

surface (see image of Monovette’s needle safe.)

Apply pressure for approximately 1 minute. Discourage the

patient from bending their arm (Ernst 2000).

Monovette/ Sarstedt

You must don an apron prior to taking blood, but this can be

done earlier if required.

Then when you and the patient are ready, re-apply the

tourniquet, wash or apply hand wash to your hands and then

don gloves. You are now be ready to take the blood sample.

As with the Vacutainer/ Vacuette, anchor below vein, bevel

upwards and insert needle at 15-45 degrees, when you have

flash back (once the needle is within the vein expect “flash

back” – a small amount of blood seen in distal portion of

syringe.) release tourniquet.

Pull back on the plunger until the bottle is filled to the fill line,

ensuring the needle does not move in the vein image shows

the plunger on the Sarstedt system being pulled back and

simulated blood filling the bottle. The clinician is ensuring the

needle does not move in the vein. This is shown by the

clinician holding the system stable where the needle connects

to the bottle and then pulling on the plunger without

contaminating the insertion site.

Each collection tube is a sample bottle. If more than one

sample is required the full sample must be detached and

further bottles attached whilst the needle remains insitu.

Hold needle securely whilst detaching filled sample bottle and

reattaching new sample bottle. (Dougherty 2008; Dougherty

and Lister, 2015; Skarparis and Ford, 2018),

Upon filling final sample bottle, remove the last collection

bottle keeping the needle in place.

Now remove the needle. Dispose of the needle

immediately in the SHARPS BIN (Loveday et al, 2014) and

place a piece of gauze/cotton wool over site of needle

insertion.

If a sharp safety device is being used ensure it is activated on a

hard surface for example the top of a sharps bin or an ANTT

tray. Do not use your hand, as you might increase your risk of

a sharps injury.

Apply pressure to the insertion point once the needle is removed. This reduces pain associated with needle

removal. Continue to apply pressure for approximately 1 minute. Discourage the patient from bending their

arm (Ernst 2000). Inspect the puncture site (to check that the site has sealed) and then apply a dressing (check

for allergies).

Snap the plunger off the sample bottles.

Post Procedure

Ensure that your patient is ok, and invert sample bottles back and forth (gently) to ensure the blood is

adequately mixed with bottle contents, if not already done so. Do NOT shake the samples as this can affect the

results. Label the bottles with the relevant details at the patient’s side - to ensure that the specimens from the

Source: Sarstedt

Source: Sarstedt

right patient are delivered to the lab (NPSA 2008). Only label the sample bottles once the sample has been

obtained to reduce risk of error.

Pre-printed blood labels with

the patient details may be

used. Some healthcare Trusts

will require/ allow printed

labels on the bottles however

the date and time must be

visible if not on the label.

Place labelled bottle in plastic

bag with request form ensuring

any necessary biohazard

warning requirements are

followed (see the Trust

guidelines)

If unable to obtain a full sample bottle contact the laboratory staff, they may be able to still analyse the sample

if warned ahead of time (this applies to accidental arterial stabs also), but most will not be able to process under

filled coagulation bottles.

Finish the consultation with the patient, advise them you have finished, check they are OK and assess that the

site has stopped bleeding. Give the patient information on how to get the results and when they will be

available.

Wash hands, clean tray and tidy equipment away, ensuring that tourniquet is away from the patient. Transfer

the samples to the lab and document the procedure in notes if appropriate, including who is expected to review

and when the results need to be reviewed.

Additional considerations

Prior to taking blood, please be aware of the order of draw, this will either be on the blood form or in clinical

practice. If using a butterfly blood collection system, there is air in the tube; If the coagulation bottle is taken

first the vacuum will draw the air into the bottle first- this will affect the fill line! If the situation is difficult to

avoid, partially fill the 1st bottle and waste or follow other recommended Trust guidelines.

Please ensure that you know how to activate the

needle safe device appropriately if using this system.

Troubleshooting

If you are unsuccessful (i.e. you don’t get flashback or blood):

Release tourniquet

Remove sample bottle

Remove needle

Put pressure on site with gauze

Consider a second attempt with fresh equipment and at a different site, or seek senior help.

(Brooks, 2014)

Please do not make more than 2 attempts and ensure that you are supervised throughout. This is a skill that you

need to be comfortable and safe with, please practice in the Learning Zone and ensure you are familiar with the

different systems and processes in clinical practice.

Acknowledgements

With thanks to Sarstedt and Bio-Greiner One for their kind permission to use some of the images contained

within this guide

References

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