BLOOD SAMPLING POLICY (ADULTS)
Version
6
Name of responsible (ratifying) committee
Infection Prevention Management Committee
Date ratified
December 2014
Document Manager (job title)
Consultant in Infection Prevention
Date issued
11 December 2014
Review date
10 December 2016
Electronic location
Infection Control Policies
Related Procedural Documents
Hand hygiene Policy, Asepsis Policy, Identification of
Patients Policy
Key Words (to aid with searching)
Phlebotomy, venepuncture, blood sampling, blood
cultures, arterial sampling
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
1
December
2014
New document
IPCT
Blood Sampling (Adults): Issue Number: 1, Issue Date: 11 December 2014
(Review date 10 December 2016 (unless requirements change))
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CONTENTS
QUICK REFERENCE GUIDE ............................................................................................................. 3
1.
INTRODUCTION ......................................................................................................................... 4
2.
PURPOSE ................................................................................................................................... 4
3.
SCOPE ........................................................................................................................................ 4
4.
DEFINITIONS .............................................................................................................................. 4
5.
DUTIES AND RESPONSIBILITIES .............................................................................................. 5
6.
PROCESS ................................................................................................................................... 5
7.
TRAINING REQUIREMENTS .................................................................................................... 14
8.
REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 15
9.
EQUALITY IMPACT STATEMENT ............................................................................................ 16
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS ........................................ 17
APPENDIX 1..................................................................................................................................... 18
Blood Sampling (Adults): Issue Number: 1, Issue Date: 11 December 2014
(Review date 10 December 2016 (unless requirements change))
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QUICK REFERENCE GUIDE
This policy must be followed in full when undertaking blood sampling in adults.
1.
Requests for ward phlebotomy should be undertaken using the ICE system and paper forms
only used in areas where this is not available. Requests should be in time for the morning
phlebotomy rounds and these rounds should not interfere with protected mealtimes.
2.
Four patient identifiers must be used when checking the identity of a patient and filling out the
details on the sample bottle, which should be completed at the patient’s side (surname, given
name, date of birth and unique identification number which corresponds to the notes and
identity band). The bottles should also have the date, time and signature recorded by the
individual undertaking the blood sampling.
3.
Patients must consent to having their blood taken. If they refuse this should be documented
and the clinician in charge of the patient’s care informed.
4.
The risks to practitioners associated with blood sampling include needle-stick injury and
associated blood-borne viruses from hollow bore needles. Practitioners must not:
 recap used needles;
 recap or disassemble vacuum-containing tubes and holders;
 overfill sharps containers
 work alone with confused or disoriented patients
5.
Direct risks to patients are rare but include; pain, infection, haematoma, peripheral nerve
damage and bleeding. Indirect risks include erroneous sample results or mislabeling of
samples.
6.
Blood sampling must be undertaken using a non-touch aseptic technique (venous and arterial
blood sampling) or full aseptic technique (blood cultures) with the correct personal protective
equipment (PPE), correct vehicle for sampling (Vacutainer) and correct sample bottles. Hand
hygiene policy must be followed and waste disposed of appropriately in line with the Sharps
policy and Waste Management policy.
7.
Blood cultures should only be taken when possible bacteraemia or sepsis is suspected and not
for routine assessment or for the investigation of localised infection
8.
Skin must be leaned with 2% Chlorhexidine gluconate in 70% Isopropyl alcohol (Sanicloth or
Chloraprep) for 30 seconds, and allowed to air dry for 30 seconds before any blood sampling
attempt.
9.
Correct order of draw must be observed at all times to avoid contaminating samples with tube
additives.
1st BC
2nd
3rd
4th
5th
6th
7th
8th
10.
Some Blood tests require special handling; please refer to pathology handbook which can be
found on the intranet under pathology or contact pathology for advice. Samples should reach
the laboratory as soon as possible.
11.
All staff undertaking blood sampling must receive the necessary training and have their
practical competency formally assessed, documented and reaffirmed every 3 years by a
phlebotomy assessor.
12.
Where a member of staff fails their training or errors are made leading to a question of
competence they must not undertake blood sampling until they have received further training
and been signed off as competent.
Blood Sampling (Adults): Issue Number: 1, Issue Date: 11 December 2014
(Review date 10 December 2016 (unless requirements change))
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1.
INTRODUCTION
Blood sampling refers to the collection of blood from a patient for the purpose of:
 diagnostic or therapeutic monitoring
 provision of a cross match sample for blood transfusion
This may include procedures such as arterial sampling, capillary sampling, blood culture
collection and venous blood draws.
This policy regulates venous blood sampling, arterial sampling and the collection of blood
cultures from adults.
2. PURPOSE
The purpose of this policy is to provide a consistent, best practice approach to blood taking
which minimises the risks to staff and patients, ensures the correct samples are collected and
reduces the number of sampling errors reaching the laboratory
3. SCOPE
This document sets out the standards to be followed by medical and non-medical members of
staff employed by Portsmouth Hospitals NHS Trust whose role involves blood sampling. For
the purpose of this policy a non-medical member of staff is defined as a registered nurse,
midwife, support worker or phlebotomy technician.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
Adult: For the purpose of this policy this relates to a person over 16.
Asepsis: is recognised as the state of being free from pathogenic microorganisms
Aseptic technique: is defined as a means of preventing or minimising the risk of introducing
harmful micro-organisms onto key parts or key sites of the body when undertaking clinical
procedures
Aseptic Non-Touch Technique (ANTT) - the overriding basic principle is that the key
sites/components e.g. IV devices must not come into contact with any item (hand, equipment,
solution) that is not sterile. Sterile gloves are not always required for Standard ANTT
Contaminant: A contaminant may be:
i.
A micro-organism inadvertently introduced into the sample from the environment, skin of
the operator or patient which leads to a false positive result
ii.
A tube additive, which may be carried over to subsequently drawn samples producing
erroneous results which may interfere with the analysis of the sample
Disposable Tourniquet - A disposable single use device that promotes vein distension for
insertion of a needle, it should remain taut for a maximum of 60 seconds
Haemoconcentration: Applying a tourniquet for over 60 seconds causes stasis, trapping blood
cells and larger molecules within the vein whilst water and small solutes are able to pass
Blood Sampling (Adults): Issue Number: 1, Issue Date: 11 December 2014
(Review date 10 December 2016 (unless requirements change))
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through the vein walls. This results in cells and large molecules becoming more concentrated in
the sample leading to erroneous results.
Haemolysis: Damage to the red blood cells which releases potassium and other intracellular
components into the serum invalidating a number of biochemistry parameters. Haemolysis can
be caused by shaking a sample.
Order of Draw: The sequence of obtaining blood samples to prevent contamination of tube
additives.
Vacuum System: A specially designed vacuum system which comprises of:
i. Pre vacuum blood sample tube
ii. A double ended needle and plastic needle holder
Or
iii. A winged needle and associated bung, luer adaptor and plastic holder.
This system is designed to minimize haemolysis and micro-clot formation in the sample and
minimize the risk of needle-stick injuries.
5. DUTIES AND RESPONSIBILITIES
Infection Prevention Team: are responsible for providing blood sampling training, reviewing
competency and managing the blood sampling policy.
Phlebotomy Manager: is responsible for leading, developing and managing the phlebotomy
team and setting and monitoring standards of performance.
Ward/Department/Line Managers: need to ensure adequate stock of appropriate sampling
equipment is held and that all staff members who are required to perform phlebotomy are
appropriately trained and have their practical competency formally assessed, successfully
achieved and documented.
Individuals undertaking Blood Sampling: should ensure they meet the training
requirements, are safe and competent to undertake this skill and follow all relevant Trust
policies to support safe practice. Staff must be aware of their roles and responsibilities and
must identify and communicate any training needs to their Line Manager.
6. PROCESS
Whilst each blood sampling procedure (phlebotomy, blood cultures etc) has different elements,
all staff must adhere to the following principles:
Patient identification:
Prior to performing blood sampling, practitioners must positively identify the patient in line with
the Trust policy for the Identification of Patients.
 Outpatients: the patient should be asked to state their full name, date of birth and
address, with these details checked against the details on the request form
 Inpatients: Aall request forms must be checked against the patient’s ID band (containing
the four patient identity markers; surname, first name, date of birth and unique
identification number). Where possible, the patient should be asked to give their name,
date of birth and address to further confirm their identity.
Consent:
Informed consent must be obtained from all patients who have capacity prior to any blood
sampling procedure1. Consent may be given verbally or non-verbally and may be the act of the
patient holding out their arm for the practitioner to carry out a procedure, providing the patient
has received appropriate information prior to this1.
The key principles of informed consent include:
Blood Sampling (Adults): Issue Number: 1, Issue Date: 11 December 2014
(Review date 10 December 2016 (unless requirements change))
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 The patients right to consent voluntarily without pressure or coercion
 The patients right to withdraw consent at any time
 The provision of sufficient information to allow informed consent. This includes:
i. The reason for the procedure
ii. What the procedure involves
iii. Any significant potential complications
iv. Other relevant information, which may include when the blood results will be available
and the potential consequences or treatments arising from the investigation
If the patient does not consent to the procedure this must be documented on the request form
and in in-patient areas the team in charge of the patient’s care should be informed.
Potential complications2:
 Pain, caused by:
i. Hitting a nerve or valve in the vein
ii. Poor technique
iii. Failure to allow skin cleanser to dry before vessel puncture
iv. Use of large-gauge device
v. Use of veins in sensitive areas
 Haematoma and bruising (2-3% incidence), caused by:
i. Entering the vessel at too steep an angle or over-advancement of the needle
ii. Using too large a needle for the vessel
iii. Failure to release the tourniquet early enough
iv. Failure to secure haemostasis after needle removal
 Vasovagal reaction or fainting due to anxiety (0.2-1.7% incidence)
 Delayed faint (syncope) (1 in 10,000)
 Arterial puncture during intended venepuncture (1 in 30-50,000)
 Arteriospasm during arterial puncture
 Infection
 Bleeding
 Nerve injury and damage to adjacent anatomical structures (infrequent), caused by:
i. Entering the vessel at too steep an angle
Indirect complications to patients include unnecessary or omitted interventions due to
erroneous blood results due to contamination or mislabeled blood samples.
Prevention and management of incidents and adverse events:
Blood sampling involves the use of large, hollow needles that have been in a blood vessel. The
needles can carry a large volume of blood that, in the event of an accidental puncture, may be
more likely to transmit disease than other sharps2.




Syringes and needles should not be used for venepuncture because of the potential for
needle-stick injury when transferring the sample from syringe to the specimen bottle
Blood sampling should be performed using a closed vacuum blood collection system
which requires the use of a Vacutainer holder to protect staff from sharps injury
Whenever possible, blood sampling systems should have sharps-safe systems. These
systems should be activated immediately after use prior to disposal
Used sharps must be disposed of in a sharps bin which complies to UN 3921 and
BS7320 standards immediately at the point of use
Certain practices are known to increase the risk of needle-stick injury and transmission of
disease. Dangerous practices include2:
 recapping used needles;
 recapping and disassembling vacuum-containing tubes and holders;
 overfilling sharps containers
 reusing tourniquets and vacuum-tube holders that may be contaminated with bacteria and
sometimes blood;
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 working alone with confused or disoriented patients who may move unexpectedly,
contributing to needle-sticks injuries
In the event of a needle-stick injury, staff should contact the Occupational Health Department in
working hours or the Emergency Department out of hours. A DATEX incident form must be
completed for all clean and dirty sharps injuries.
Hand hygiene:
Hand hygiene with liquid soap and water or alcohol hand-rub must be performed before and
after each patient procedure, before putting on gloves and after removing them3. The Trust
standard 7-stage hygiene technique should be used at all times.
Personal protective equipment (PPE):
When taking blood, health workers should wear well-fitting gloves (non sterile for venepuncture,
sterile for blood cultures) and plastic aprons to protect uniforms/clothes. These are single use
items and must be disposed of immediately after use2,3.
Skin Preparation:
Skin must be prepared with 2% chlorhexidine gluconate in 70% isopropyl alcohol (2%
CHG/70% IPA) (Sanicloth or Chloraprep) 3. Cleaning should cover the whole area, ensuring
that the skin area is in contact with the disinfectant for at least 30 seconds. The area they
should then be allowed to dry for at least 30 seconds3.
Number of attempts:
Only two attempts should be made to obtain a blood sample from the
patient, using new equipment on each occasion. If unsuccessful,
support should be obtained from another member of staff qualified in
blood sampling. Failed attempts should be documented in the patient
notes.
Use of the AccuVein device (available from the Infection Prevention
Department) can increase successful blood sampling in difficult
venous sampling cases (e.g. IVDU, oncology patients).
Blood bottles and order of draw:
The following order of draw of specimens and mixing guidelines
recommended by BD Vacutainer must be followed when drawing multiple tubes to avoid
possible test error due to cross contamination from tube additives.
Tube Colour &
Order of Draw
Additive
Laboratory Test
1ST
N/A
Blood cultures: Aerobic followed by anaerobic – if
insufficient blood for both culture bottles use aerobic
bottle only
2ND
Sodium
Citrate
Coagulation Tests, Heparin & Warfarin Control, Anti-Xa,
Thrombophilia Screen, Lupus Screen, Confirmation
Platelet Clumps
3-4
3RD
SSTII Clot
activator and
gel for serum
separator
Clot activator
Routine chemistry, Endocrinology, Serology (viral,
bacterial, parasite and fungal), Drug levels (Vancomycin,
Gentamycin, Amikacin and Tobramycin) Immunology,
B12, Ferritin, Serum Folate, EPO,
Serum Porphyrins, HIT, Screens, CDT, Fluoride,
Thyroglobulin, Calcitonin
5-6
4TH
No. of
Inversions
N/A
5-6
Blood Sampling (Adults): Issue Number: 1, Issue Date: 11 December 2014
(Review date 10 December 2016 (unless requirements change))
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5TH
Sodium
Heparin
Genetics, Homocysteine, Ammonia, Renin, Aldosterone,
Gut Hormones/ Chromogranins
8-10
6TH
EDTA
FBC, ESR, Sickle cell, Malaria, HBA1C, G6PD, Red cell
Folate, Electrophoresis, Glandular Fever
8-10
7TH
K2EDTA
Blood Group, Cross match
8-10
8TH
Fluoride
Oxalate
Alcohol, lactate, glucose (if only glucose requested)
8-10
Labelling and transportation:
 The minimum requirements for the specimen / sample label are the 4 patient identity
markers (surname, first name, date of birth and unique identification number
 The bottles should also have the date, time and signature recorded by the individual
undertaking the blood sampling
 Specimen containers must be labeled, with the patient’s identification taken from their ID
band, not the request form or patient records
 The container must not be pre-labeled but labeled, by the person taking the specimen,
after it is placed into the container
 The container must be labeled beside the patient and not removed to another location
until the labeling is complete
 Samples should reach the laboratory as soon as possible, without batching as results
may be affected if they take more than 4 hours between bleeding to analysis
 Blood bottles should be filled, gently mixed and handled correctly to minimize the risk of
inaccurate results due to uneven distribution and incorrect concentration of tube additives
such as anticoagulant or preservative
VENOUS BLOOD SAMPLING:
Site selection:
Before performing venepuncture both upper limbs should be inspected to select the most
appropriate site for venepuncture. Veins should be looked for in the following order:
 At the bend of the elbow of each arm (antecubital area)
i. Median Vein
ii. Basilic Vein
iii. Cephalic Vein
 In the forearm
i. Cephalic Vein
 On the back of each hand
Inspection will reveal clinical conditions that may
prevent the arm being used, for example, phlebitis,
lymphoma, ateriovenous fistulae or bruising.
Inspection and palpation of the veins will reveal the
position of the veins, direction in which they run and
their size and other physical features. The vein
should be straight and feel soft, cylindrical in shape
and ‘bouncy’ when lightly pressed. Veins that are
tender, sclerosed, thrombosed, fibrosed, hard or
bruised from previous use should be avoided.
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Equipment required for Venous Blood Sampling:
 Sample request form
 Single use disposable tourniquet
 Clean single use non sterile gloves and disposable apron
 2% CHG/70% IPA swab
 Vacuum system components and appropriate sampling tubes. (All must be in date and if
a butterfly system is used an additional tube is required to remove air from the butterfly
system prior to samples being obtained)
 Gauze swabs
 Adhesive plaster
 Appropriately labelled and tagged Sharps box
 Dedicated tray or identified prepared area, cleaned with detergent wipe or soap and warm
water
 Sharps container
Process:
 Approach patient, introduce yourself and check patient identity and obtain information
regarding allergies (e.g. chlorhexidine)
 Give explanation for venepuncture and ensure patient consents to the procedure
 Adjust environment to comfortable working height and ensure adequate lightingwherever possible
 Decontaminate hands following the Trust Hand Hygiene Procedure
 Clean tray or identified area with detergent wipe or soap and warm water
 Place equipment / collection system onto clean tray or dedicated area, checking for
defects, use by date and avoiding touching key parts. Take into account size of needle or
butterfly required with regard to the condition of veins. Connect needle to Vacutainer
 Select a suitable vessel that meets criteria for sampling, preferably in patients nondominant arm
 Clean insertion site with 2% CHG/70% IPA for 30 seconds
 Apply single use tourniquet, without obstructing blood flow, 10 cm above insertion site
 Do not re-palpate the key sites
 Repeat hand decontamination
 Apply clean non sterile gloves
 Expose the needle and stabilise the vein below the chosen entry site without
contaminating the cleaned area
 Insert needle (bevel uppermost) through the skin at an angle of 15-30 degrees
 Reduce the angle of the needle as soon as you feel the resistance change or flash back
is seen along the tubing of the venepuncture device
 Release the tourniquet
 Observe correct order of draw and attach first sampling tube. If using a winged needle
system (Butterfly), discard the first tube as soon as the blood enters the tube as it will not
fill to the appropriate level, due to air in the tubing being released into the tube. Discard
and attach another tube of the same colour
 Remove initial blood sample and connect subsequent sample tube(s) if required. When
sample has been removed gently invert sample tube to mix blood with tube additives
 Place gauze over the puncture site and withdraw needle and holder in a continuous
straight line. Withdraw needle with the hand closest to the sharps bin for safe disposal
 Do not press firmly on the puncture site until after the needle has been removed
 Immediately engage the sharp safety mechanism (if present) and dispose of the needle
and holder into the sharps box without disconnecting
 Press on site slightly for 1-2 minutes with gauze. The patient can do this if he/she is able.
Advise patient to keep limb extended at this point. Do not bend the limb
 Remove gloves and then decontaminate hands at the patient’s bedside / drawing
area
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(Review date 10 December 2016 (unless requirements change))
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 Immediately label all samples at the bedside / drawing area
 Recheck the puncture site before leaving the patient and apply an adhesive plaster
 Ensure the sample is packed correctly with accompanying request form, and send to the
laboratory immediately or made ready for collection
BLOOD CULTURE PROCEDURE:
Blood cultures help detect the cause of an infection leading to bacteraemia and guide
appropriate treatment. Extreme care must be taken not to contaminate the blood culture with
micro-organisms from the patients or operators skin or the environment or culture bottle.
Contaminated blood cultures can lead to patients receiving inappropriate or unnecessary
treatment which can be potentially harmful.
Appropriate indications for taking blood cultures:
Blood cultures should only be taken where there is clinical identification of possible
bacteraemia or sepsis. They should not be taken for routine assessment or for the investigation
of localised infection. Reasons to suspect an infection and to consider taking blood cultures
include4:
 The core temperature is outside of the normal range >38°C or <36°C
 Unexplained hypotension (Systolic BP <90*)
 Tachycardia (Pulse >90) and / or Tachypnoea (RR >20bpm
 Chills or rigors
 Unexplained deterioration in the patient’s condition
 Development of unexplained confusion
 There are focal signs of infection
 The white blood cell count is outside of the normal range >12x10/L or <4x10/L
An overall clinical assessment is essential when deciding if a blood culture is required as not all
patients with the above symptoms will need investigation whilst in some patients, particularly
the elderly, the signs of infection will be minimal.
Blood cultures should be taken prior to the administration of antibiotics. If a patient is on
antibiotics, blood cultures should ideally be taken immediately before the next dose4. In patients
with suspected bacteraemia, it is generally recommended that two sets of cultures are taken at
separate times from separate sites.
Blood cultures should be taken using a new venepuncture site and not from existing central or
peripheral venous cannulae4. The only exception to this is if it is believed that a central line may
be the source of bacteraemia. It is then appropriate to take blood from both the central and
from the peripheral vein, ensuring that the hub of the central line is thoroughly decontaminated
with 2% CHG/70% IPA first. The peripheral vein sample should be collected first.
Blood cultures must be taken using an aseptic non-touch technique performed with sterile
gloves, and requires additional equipment.
Site selection:
As for venous blood sampling. Avoid femoral vein puncture because of the difficulty in
adequate skin cleansing and disinfection (DH Saving Lives 2007).
Equipment required for obtaining a blood culture:
 Sample request form
 Blood culture pack, containing;

Aerobic and anaerobic blood culture bottles

Single use disposable tourniquet

Chloraprep 2% CHG/70% IPA frepp

2 x 2% CHG/70% IPA swabs

Blood culture collection adaptor cap
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





Adaptor insert for Vacutainers
Winged blood collection set Adhesive plaster
Blood culture and Sepsis stickers
Sterile dressing pack, containing;

Appropriately sized sterile gloves

Sterile fields

Sterile gauze

Sterile bag
Appropriately labelled and tagged Sharps box
Dedicated tray or identified prepared area, cleaned with detergent wipe or soap and
warm water
Process (see appendix):
 Approach patient, introduce yourself and check patient identity and obtain information
regarding allergies (e.g. chlorhexidine)
 Give rationale for the blood culture and ensure patient consents to the procedure
 Adjust environment to comfortable working height and ensure adequate lightingwherever possible
 Decontaminate hands following the Trust Hand Hygiene Procedure
 Clean tray or identified area with detergent wipe or soap and warm water
 Open the sterile pack, and arrange the field using the disposable bag to maintain
sterility
 Open the blood culture pack. Place the non-sterile items to the side of the sterile field
and open the collection system onto the clean field, checking for defects, use by date
and avoiding touching key parts
 Check the colorimetric discs at the bottom of the culture bottles to ensure sterility and
check expiry date. If the disks are yellow, the bottle is contaminated and should be
discarded
 Remove the plastic caps of the culture bottles and clean the septum using one 2%
CHG/70% IPA swab for each bottle. Allow to air dry
 Apply single use tourniquet, without obstructing blood flow, 10 cm above insertion site
 Select a suitable vessel that meets criteria for sampling, preferably in patients nondominant arm wherever possible
 Clean insertion site with 2% CHG/70% IPA for 30 seconds
 Do not re-palpate the key sites
 Repeat hand decontamination
 Apply sterile gloves and attach a winged blood collection set to a collection adaptor cap
 Expose the needle and stabilise the vein below the chosen entry site without
contaminating the cleaned area
 Insert needle (bevel uppermost) through the skin at an angle of 15-30 degrees
 Reduce the angle of the needle as soon as you feel the resistance change or flash back
is seen along the tubing
 Release the tourniquet with a piece of sterile gauze
 Insert the blue topped culture bottle and allow to fill, followed by the purple topped bottle
(min 5mls/bottle)
 Once filled, invert the bottles 3 times to ensure mixing
 If blood samples are required, insert the adaptor insert for Vacutainers into the blood
culture collection cap and take samples as normal, observing order of draw
 Place gauze over the puncture site and withdraw needle and holder in a continuous
straight line. Withdraw needle with the hand closest to the sharps bin for safe disposal
 Do not press firmly on the puncture site until after the needle has been removed
 Immediately engage the sharp safety mechanism (if present) and dispose of the winged
collection set into the sharps box
 Press on site slightly for 1-2 minutes with gauze. The patient can do this if he/she is able
Advise patient to keep limb extended at this point. Do not bend the limb
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(Review date 10 December 2016 (unless requirements change))
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 Remove gloves and then decontaminate hands at the patient’s bedside / drawing
area
 Immediately label the culture at the bedside
 Recheck the puncture site before leaving the patient and apply an adhesive plaster
 Ensure the sample is packed correctly with accompanying request form, and send to the
laboratory immediately or made ready for collection
 Complete the blood culture and sepsis sticker and place in the medical notes. All bloodcultures must be documented in the medical notes, including date, time, site and
indications
ARTERIAL SAMPLING PROCEDURE:
Arterial sampling may be indicated when there is:
 the need to evaluate the adequacy of ventilation (PaCO2), acid base (PaCO2 & pH) and
oxygenation status (PaO2)
 the need to evaluate the patients response to therapeutic intervention or for diagnostic
evaluation
 the need to monitor the severity and progression of a documented disease process5
Arterial blood sampling should only be performed by practitioners who have completed formal
training, demonstrated proficiency and are authorised to undertake the procedure.
If repeated arterial samples are required then an arterial line will be required.
Criteria for exclusion
 A negative Allen Test
 Infectious skin process at or near the puncture site
 Current GPIIb/IIIa inhibitor therapy
 Current thrombolysis therapy
Cautions
 Warfarin (or other oral anti-coagulants)
 Heparin
 History of a clotting disorder (discuss with senior clinician)
 Severe peripheral vascular disease (discuss with senior clinician)
 Thrombolysis in the past: 24 hours (streptokinase therapy) OR: 4 hours (TNK-tPA)
Site selection:
Several different arteries can be used for blood collection. The first choice is the radial artery
because:
 the artery is relatively near the surface of the arm
 the artery is relatively easy to palpate and stabilise
 the artery normally has a good collateral blood supply
The second choice site for access is the brachial artery (followed by the femoral arteries), but
these have several disadvantages in that they:
 may be harder to locate, because they are less superficial than the radial artery;
 have poor collateral circulation;
 are surrounded by structures that could be damaged by faulty technique
Prior to performing radial artery blood sampling, a modified Allen test must be performed to
ensure good collateral blood supply.
Modified Allen test:
The modified Allen test measures arterial competency, and should be performed before taking
an arterial sample. The procedure for performing the test is as follows:
 Instruct the patient to clench his or her fist; if the patient is unable to do this, close the
person’s hand tightly
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 Using your fingers, apply occlusive pressure to both the ulnar and radial arteries, to
obstruct blood flow to the hand
 While applying occlusive pressure to both arteries, have the patient relax his or her
hand, and check whether the palm and fingers have blanched. If this is not the case,
you have not completely occluded the arteries with your fingers
 Release the occlusive pressure on the ulnar artery only to determine whether the
modified Allen test is positive or negative
 Positive modified Allen test – If the hand flushes within 5–15 seconds it indicates that
the ulnar artery has good blood flow; this normal flushing of the hand is considered to be
a positive test
 Negative modified Allen test – If the hand does not flush within 5–15 seconds, it
indicates that ulnar circulation is inadequate or nonexistent; in this situation, the radial
artery supplying arterial blood to that hand should not be punctured
Equipment required for arterial blood sampling:
 Pre-heparinised syringe
 Appropriately sized safety needle with needle cover that allows the syringe to be
capped before transport, without manually recapping
 Sterile gloves and plastic apron
 Eye / face protection
 2% CHG/70% IPA swab
 where applicable, local anaesthetic and an additional single-use sterile syringe and
needle
 Sterile gauze and pressure dressing
Process for radial artery sampling:
 Approach patient, introduce yourself and check patient identity and obtain information
regarding allergies (e.g. chlorhexidine)
 Give rationale for the arterial blood sampling and ensure patient consents to the
procedure
 Adjust environment to comfortable working height and ensure adequate lightingwherever possible
 Decontaminate hands following the Trust Hand Hygiene Procedure
 Clean tray or identified area with detergent wipe or soap and warm water
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 Place equipment onto clean tray or dedicated area and attach the needle to the
heparinised syringe, taking care not to touch key parts
 Conduct the Allen Test, recording the result, and abandon the process if the test is
negative
 Consider the use of local anaesthetic agent, and administer as prescribed if appropriate
 Palpate the radial site with fingertips
 Stabilise artery by positioning the arm on a flat surface, and supporting wrist on a rolled
towel for example. Hyperextension should be avoided as it may obliterate a palpable
pulse
 Clean area of maximal impulse with 2% CHG/70% IPA for 30 seconds
 Repeat hand decontamination
 Apply plastic apron and eye / face protection
 Apply sterile gloves to allow re-palpation of the artery once prepped
 Keep fingertip on artery, just proximal to chosen site
 Hold the needle bevel up and insert at 45-60 degree angle
 Stop advancing needle when blood is noted returning to hub of needle
 Allow arterial pulsation’s to pump 3ml of blood into syringe. At least 3ml of blood is
needed to avoid dilution effect of heparin
 When sampling is complete, hold gauze or swab over puncture site and withdraw
needle
 Activate the safety device on the needle immediately
 Apply pressure over and just proximal to puncture site with gauze/swab
 Maintain continuous pressure over and proximal to the site for at least 5 minutes (10
minutes) minimum if patient is anti-coagulated or has a bleeding disorder)
 Visually inspect site for signs of bleeding or other complication
 Palpate artery site distal to the puncture site, to determine if pulse quality has
changed/alteration in arterial flow
 Ensure appropriate immediate action is taken if complications are identified
 Remove gloves, face protection and apron and wash hands
 Make arrangements for patient to be observed for potential complications following the
procedure and inform ward-nursing staff of action to take if complications are identified
7. TRAINING REQUIREMENTS
Only suitably trained and competent staff may take blood samples. Each member of staff must
have undertaken a recognised training programme, which incorporates theory and simulated
practice. Following successful completion of this course component, practitioners should
undertake supervised practice and may only practice venipuncture independently once certified
competent to do so by a senior, competent colleague.
Staff trained in blood sampling must attend a venepuncture update every three years and, in
order to maintain competency, carry out the skill on a regular basis. If their level of competency
falls they must seek re-training.
Education and training will be provided by the Infection Prevention & Control Team via the
Learning and Development Department. All individuals must meet the minimum requirements
for maintaining this skill prior to applying for a place on the training course. This must be
confirmed by their manager prior to a place being booked via Electronic Staff Record (ESR).
Medical and midwifery staff: final year medical students and FY1 doctors on induction will
receive practical simulated training from the Infection Prevention & Control Team. FY2, ST
doctors and Midwives are assumed competent unless otherwise identified by their supervisor.
In order to take blood for the use in transfusion they must pass the NPSA competencies for
taking blood and produce a certificate every 3 years. If problems are identified, the staff
member will be required to:
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a) Attend a phlebotomy training study
b) Complete the Trust phlebotomy competency pack
c) Complete a period of supervised clinical practice and assessment
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1.
Department of Health (2010). Reference guide to consent for examination or treatment.
London: HMSO
2.
WHO (2010). Guidelines on drawing blood/ best practices in phlebotomy. World Health
Organization.
3.
Loveday et al (2014). epic3: National Evidence-Based Guidelines for Preventing HealthcareAssociated Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1 (2014)
S1–S70
4.
Department of Health (2007) Saving Lives: A delivery program to reduce Healthcare
Associated Infection including MRSA
5.
AARC clinical practice guideline (1992). Sampling for arterial blood gas analysis. American
Association for Respiratory Care. Respiratory Care. Aug 1992;37(8):913-7
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9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
All policies must include this standard equality impact statement. However, when sending for
ratification and publication, this must be accompanied by the full equality screening assessment
tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy
Documentation
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
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10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement to be
monitored
Lead
Tool
Individuals undertaking blood
sampling will attend the
phlebotomy training sessions
and be assessed as
competent
Infection
Prevention
Competency document
Individuals undertaking
phlebotomy must reaffirm
their competency every three
years.
Learning and
Development
Competency document
and ESR
Frequency of Report
of Compliance
Quarterly
Reporting arrangements
Policy audit report to:

Quarterly
Infection Prevention
Nursing Midwifery Committee
Policy audit report to:

Lead(s) for acting on
Recommendations
Nursing Midwifery Committee
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Matrons
APPENDIX 1
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