GNAH_0331: Blood alcohol sampling
Local Clinical
Procedure
Document Number: GNAH_0331
Blood Alcohol Sampling
Sites where Procedure applies:
Greater Newcastle Acute Hospitals
Target audience:
All medical officers and nursing staff
Description:
This local clinical procedure applies to:
1. Adults
Yes
2. Children up to 16 years
15 years and above
3. Neonates – less than 29 days
No
Keywords:
Emergency department, trauma, accident, traffic,
road, driver, rider, marine, blood, alcohol, vessel,
surgery, theatre, retrieval, ICU, JHH, RNC, JHCH,
Belmont
Replaces Existing Procedure:
Yes
Registration Number(s) and/or name and JHH Emergency Department Blood alcohol testing for
of Superseded Documents:
patients injured on a public road JEM 10-4-05
Relevant or related Documents, Australian Standards, Guidelines etc:
 NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
 NSW Health Policy Directive PD 2007_036 Infection Control Policy
 NSW Road Transport (Safety and Traffic Management) Act 1999 No 20
 NSW Marine Safety Act 1998
 NSW Health Policy Directive PD2005_572 Blood Alcohol and Drug Test Kits - Modification
of
 NSW Health Policy Directive PD2005_029 Blood and Urine Testing of Drivers Apparently
Under the Influence of Drugs
 NSW Health Policy Directive PD2005_495 Blood Alcohol Sampling by Hospital Staff
 Work Health and Safety Act 2011 no. 10
 Work Health and Safety Regulation 2011
Note: Over time some links in this document may cease working. Where this occurs please source the
document in the PPG Directory at: http://ppg.hne.health.nsw.gov.au/
Procedure Summary:
Authorised medical practitioners who have successfully completed
training and competent assessment in venipuncture.
This procedure sets out the steps to be followed to ensure collection
of blood alcohol samples required by legislation. The procedural
components are considered mandatory.
Date initial authorisation:
25 September 2012
Authorised by:
GNAH Patient Safety and Clinical Risk Committee
Contact Person:
Contact Details:
Date Reviewed:
Review due date:
Responsible for review:
Version:
Emergency Department Service Manager
Deborah Bick
Prerequisites:
September 2015
Emergency Department Service Manager
Version 1.0 8 October 2012
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GNAH_0331: Blood alcohol sampling
RISK STATEMENT
This local clinical procedure has been developed to provide direction to staff and to ensure that the
risks of harm to patients and staff associated with non-compliance to legislation relating to
collection of blood alcohol samples are identified and managed.
Any unplanned event resulting in, or with the potential for, injury, damage or other loss to
patients/staff/visitors as a result of this procedure must be reported through the Incident
Information Management System and managed in accordance with the Ministry of Health Policy
Directive: Incident management PD2007_061. This would include unintended injury that results in
disability, death or prolonged hospital stay.
OUTCOMES
1
Staff shall comply with the legislation that provides for compulsory blood samples to be taken by
medical officers and registered nurses.
2
Blood samples taken as per legislation.
3
Staff awareness of liability related to non-compliance with blood sample collection legislation.
ABBREVIATIONS and GLOSSARY
Abbreviation/Word
Definition
ED
Emergency Department
Greater Newcastle
Acute Hospitals
John Hunter Hospital – Royal Newcastle Centre, John Hunter Children’s
Hospital and Belmont Hospital
Hospital / Service Manager Responsibility
Hospital / service managers must ensure that the principles and requirements of this procedure are
applied, achieved and sustained, and that relevant staff are made aware of their obligations in
relation to this procedure.
Line management responsibility
Line managers are responsible for ensuring this procedure is distributed to all relevant clinical staff,
for provision of training and competency assessment in venipuncture and ensuring required
equipment is available.
Employee responsibility
All staff are responsible for complying with the requirements of this procedure, NSW Health policy
directives and relevant legislation.
Medical practitioners are responsible for collection of blood alcohol samples as described in the
legislation.
PREAMBLE
The Road Transport (Safety and Traffic Management) Act 1999 which applies to traffic (motor, other
vehicle, horse and pedestrian) accidents; and the Marine Safety Act 1998 which applies to marine
accidents, authorise the compulsory blood testing of persons of or above the age of fifteen years
who attend or are admitted into a hospital for examination or treatment as a result of an accident by
any medical practitioner by whom the person is attended (NSW Health PD2005_495 Blood Alcohol
Sampling by Hospital Staff).
The Road Transport (Safety and Traffic Management) Act 1999 Section 20: Blood samples to be
taken in hospitals from accident patients, states:
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GNAH_0331: Blood alcohol sampling
“In this section, accident patient means a person at least 15 years of age who attends at or is
admitted into a hospital for examination or treatment in consequence of an accident on a road or
road related area (whether in New South Wales or elsewhere) involving a motor vehicle or other
vehicle or a horse”.
Under the Road Transport (Safety and Traffic Management) Act 1999 :
road means an area that is open to or used by the public and is developed for, or has as one of its
main uses, the driving or riding of motor vehicles.
road related area means:
a.
b.
c.
d.
an area that divides a road, or
a footpath or nature strip adjacent to a road, or
an area that is open to the public and is designated for use by cyclists or animals, or
an area that is not a road and that is open to or used by the public for driving, riding or
parking vehicles, or
e. a shoulder of a road, or
f. any other area that is open to or used by the public and that has been declared under
section 15 of the Road Transport (General) Act 2005 to be an area to which specified
provisions of this Act or the regulations apply
Section 21 of the Road Transport (Safety and Traffic Management) Act 1999 makes it an offence
for a medical practitioner or nurse to fail to take a person’s blood sample as required. That section
also provides various defences to a medical practitioner or nurse who are being prosecuted for
failing to take a blood sample.
Under the Marine Safety Act 1998, a “vessel” includes water craft of any description used or capable of
being used as a means of transportation on water.
PROCEDURE
This procedure requires mandatory compliance.
Patient Preparation
The medical practitioner is under a duty to take the sample whether or not the accident patient
consents to the taking of the sample. The patient identification, correct procedure and correct site
process must still be completed prior to any procedure.
Staff Preparation
It is mandatory for staff to follow relevant: “Five moments of hand hygiene”, infection control,
moving safely/safe manual handling, and documentation practices.
Equipment Requirements

Hand washing equipment

Personal Protective Equipment: protective eyewear, impervious disposable gloves

Certified Blood Sampling Kit
Procedure Steps
1. Any person 15 years and above involved in an accident to which this local Clinical
Procedure applies and who was:
•
•
•
•
•
•
admitted into or attended at the hospital for examination or treatment as a result of
such accident
driving a motor vehicle involved in the accident; or
occupying the driving seat of a motor vehicle involved in the accident and
attempting to put the motor vehicle in motion; or
a pedestrian involved in the accident; or
driving or riding a vehicle (not being a motor vehicle) involved in the accident; or
driving or riding a horse involved in the accident; or
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GNAH_0331: Blood alcohol sampling
•
•
the holder of a driver’s licence and occupying the seat in the motor vehicle next to a
holder of a learner’s licence who was driving a motor vehicle involved in the
accident; or
involved in an accident while operating a vessel.
must have a blood alcohol sample taken for testing as soon as practicable.
2. Any medical practitioner who attends to an accident patient at a hospital is under a duty to
take a sample of the patient’s blood for analysis as soon as practicable, unless a blood
sample has already been taken. The medical practitioner is under an ongoing duty to take
the sample whether or not the accident patient consents to the taking of the sample. If there
is no medical practitioner present to attend the accident patient at the hospital, the blood
sample is to be taken by a registered nurse who is attending the patient and who is
accredited by a hospital as competent to perform the sampling procedures.
3. The blood sample is to be taken for analysis as soon as practicable after the person arrives
at the hospital. It is desirable for the sampling procedure to be witnessed by a member of
the Police Force, but sampling should not be delayed for this reason.
4. A blood sample should be taken from any person who meets the abovementioned criteria
unless:
• Blood sampling would prejudice the proper care and treatment of the person;
• The behaviour of the patient is such that taking a blood sample is not possible; or
• the patient did not attend the hospital until more than 12 hours after the accident
occurred.
If a blood alcohol sample is not taken for the above reasons, the reason is to be
documented in the patient’s health care record. The ED consultant in charge of shift must
be informed that a blood alcohol sample was not taken.
NOTE. If prosecuted for failure to take a person’s blood sample as required, Section 21 of
the NSW Road Transport (Safety and Traffic Management) Act 1999 No 20 provides
possible defences.
5. Blood samples may also be taken at Police request, and such requests should be
documented in the patient’s health care record.
6. If a patient meets the above mentioned criteria (point 1), and a blood sample is not taken,
the reason for not taking the sample and the circumstances should be entered into the
patient’s health record. The medical practitioner or accredited nurse (refer to point 2) taking
the sample does not incur any civil or criminal liability in respect to anything properly or
necessarily done in the course of taking a blood sample in accordance with the Act.
7. Should there be doubt about the need for forensic sampling police must be contacted as a
matter of urgency and their advice sought and recorded in the patient’s health care record,
including the name of the police officer and the reason for the doubt.
8. An approved blood alcohol sampling kit (appendix 1) must be used for collecting each
blood sample and recording the necessary details. Each kit contains all equipment needed
for sampling, packaging, identification of samples and certification by the medical
practitioner. A medical certificate must be filled out by the medical practitioner or accredited
nurse (refer to point 2) taking a sample under the Act. The collection system is
manufactured by Sarstedt Australia and has been incorporated into modified blood alcohol,
drug and urine test Kits. The S- Monovette vial has a screw top lid although decanting is not
recommended due to the risk of occupational exposure.
9. Verify correct patient against available details.
10. Don protective eyewear, perform hand hygiene and don impervious gloves then take the
sample as per instructions in appendix 2.
11. Label and verify the sample tubes immediately as per instructions within the kit. All samples
must have certificates completed following collection including:
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GNAH_0331: Blood alcohol sampling
•
•
WHITE original and YELLOW duplicate which are to be placed with the sample into the
biohazard bag
Pink copy of the certificate which must be given to the patient / client.
12. The medical practitioner or accredited nurse (refer to point 2) collecting the sample must
then place the biohazard bag in the Police Security Box near the Ambulance Bay at JHH
ED and in Belmont ED (see appendix 3) and
 Complete the local register
 Document blood alcohol collection date and time
 Document blood alcohol number in the patient’s health care record. For trauma
patients the alcohol specimen number will be documented on the Trauma
Admission Sheet HNEMR86 (appendix 4)
13. The Police Security box will be cleared by the Police and an empty replacement box
installed. No extra charge is to be raised for collection of blood samples for alcohol analysis
regardless of the insurance status of the patient. Police will also use the security boxes for
depositing samples taken under legislation allowing for intoxicated drivers to be tested for
drugs. These samples are normally taken only under Police direction. The Police involved
will deposit samples within the security box when such samples are collected and will
advise the security box couriers to collect the samples within 24 hours.
14. It is the legal responsibility of all attending medical practitioners to ensure that the blood
sample is taken. In a team practice environment those doctors who attend the patient
earliest will be in the best position to carry out the requirements of the Act. Where
circumstances lead to a patient being transferred through ED without the required sample
being taken the doctor in ED who attends to or becomes aware of the transfer will
communicate with the admitting doctor to ensure that a sample is taken and placed in the
security box as soon as practicable. As a backup to this the hospital trauma team conduct a
routine tertiary survey the morning after admission for all trauma patients, and will check
the health record for the sample number.
15. For patients who meet the criteria for sample collection and are admitted directly to a
hospital ward, ICU or operating theatre (i.e. who bypass ED) the consultant in charge,
together with the admitting team who see the patient earliest in the course of their
attendance, will be responsible for ensuring the blood alcohol sample is taken as soon as
practicable and documented in the patient’s health care record. The ED senior could be
contacted for help in such cases, 24 hours, on 55582.
16. Where patients are transferred to the John Hunter from another hospital after an accident
occurring, the staff at the originating hospital are responsible for taking the blood alcohol
sample and documenting this in the patient’s health care record.
In the absence of documentation in the patient’s health care record that a blood sample has
been taken at the originating hospital, a blood alcohol sample must be taken, as described
above, by John Hunter Hospital.
17. Failure to Collect Samples
Medical Officers and accredited Registered Nurses are liable for prosecution for failing to
obtain samples as prescribed by the aforementioned Acts.
APPENDICES
Appendix 1: Blood sampling kit / documentation
Appendix 2: Instructions for using the S-Monovette® blood collection tube
Appendix 3: Police security box
Appendix 4: Trauma Admission Sheet HNEMR86
REFERENCES
Sarstedt Sampling Kit Instructions – Blood testing for alcohol.
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GNAH_0331: Blood alcohol sampling
FEEDBACK
Any feedback on this document should be sent to the Contact Officer listed on the front page.
Appendix 1: Blood alcohol sampling kit list of kit contents












Security S-Monovette® 8.5ml
Red security cap
S-Monovette® needle
Membrane adapter
Multi-adapter
Antiseptic wipe
Security label (blood)
Protective container with liner and with yellow cap
Instructions for using the S-Monovette® blood collection tube
Sampling kit instructions – blood testing for alcohol
3-part form certificates
Specimen bag biohazard
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GNAH_0331: Blood alcohol sampling
Appendix 2: Instructions for using S-Monovette blood collection tube
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For further information on use of the S-Monovette® blood collection system a representative from Sarstedt
Australia can be contacted by phoning 1800 803 308 during normal business hours.
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GNAH_0331: Blood alcohol sampling
Appendix 3: NSW Police blood and urine sample security box (located in the Emergency
Department)
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Appendix 4: Trauma Admission Sheet HNEMR86
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