Policy Code: SET/PtCtCare (02) 2026

SOUTH EASTERN TRUST

1. Please include "The Great Ormond Street Hospital Manual of Children's Nursing Practices" in the links to other policies section
2. INTRODUCTION / PURPOSE OF POLICY

1.1 Venepuncture is one of the most frequently performed invasive clinical procedures. It involves inserting a sterile needle through the skin into a vein to withdraw blood or establish intravenous access

1.2 Difficult IV access (DIVA) is defined as ≥2 failed IV attempts with non‑visible or non‑palpable veins and/or a documented history of difficult access

1.3 This policy provides direction for staff who have attended the designated training and have been deemed competent by the agreed supervisor in performing venepuncture as set out at section 4.3

1.4 All staff who perform venepuncture must be employed as a Band 3 or.

1.5 The policy also provides direction and guidance to all staff on the assessment, management and escalation of patients with difficult intravenous access (DIVA).

2.0 SCOPE OF THE POLICY

The policy is for use by all South Eastern Health and Social Care Trust (the Trust) medical, nursing /midwifery and phlebotomists employed at Band 3 or above who have been deemed competent in performing venepuncture, via the relevant training in the Trust as delivered by CEC and where the remit of their role requires them to withdraw blood samples and send blood samples to the laboratory in inpatients and outpatients. Staff who can provide evidence of competency gained outside the Trust will be accepted as competent. (Excluding neonatal staff who follow their own guideline).

3.0 ROLES/RESPONSIBILITIES

3.1 Role of managers to ensure

• Staff have undergone the appropriate training and deemed competent.
• Review of training and competency if indicated by incident monitoring, observed omissions or failures in practice.
• Staff have access to appropriate equipment.

3.2 Role of individual staff

• Be competent to perform within scope of professional practice i.e. safely and competently carry out venepuncture.
• Follow policy and practice guideline in Royal Marsden/The Great Ormond Street Hospital Manual of Children's Nursing Practice (available on iConnect). If taking blood for blood culture refer to blood culture policy, if taking pre-transfusion sample refer to blood transfusion policy.
• Staff should be familiar with the escalation process for when they encounter a patient with DIVA

3.3 The policy facilitates Trust governance obligations to ensure safe and effective care for patients.

3.4 The staff member performing venepuncture will be accountable for the correct identification of the patient and the correct labelling of any blood specimens obtained (Patient Identification Policy), see 4.1.1.

3.5 Where difficulty is experienced or anticipated in obtaining a blood sample, medical staff, registered practitioners, advanced nurse practitioners,senior nursing staff or more experienced phlebotomists should be approached for advice and recorded where relevant. The Senior Nursing Assistant/Phlebotomist, junior doctor or junior nurse while attempting venepuncture must not puncture the skin more than twice and advice must then be sought.

3.6 All blood samples should be collected in line with skin cleaning and Aseptic Non-Touch Technique (ANTT), sharps handling and disposal and the safe use of personal protective equipment policies.

3.7 Staff responsible for obtaining a venous sample for pre-transfusion testing must be able to undertake venepuncture and have successfully completed Competency 1 ‘Obtaining a venous sample for pre transfusion sample’.

(SET Transfusion Policy Adult) (Right Patient; Right Blood Monitoring Compliance policy).

Blood transfusion policy (Neonates and Paediatrics)

3.8 Nursing staff

Nursing staff should:

• identify when prescribed IV therapy cannot be administered because IV access is absent or has failed;
• inform the responsible medical team promptly;
• communicate the urgency of prescribed treatment;
• escalate concerns where treatment is being significantly delayed;
• document omitted or delayed medication in accordance with medicines-management policy; and
• continue appropriate clinical observations while access is being obtained.

3.9 Resident medical staff

Resident medical staff should:

• assess the indication and urgency;
• make appropriate attempts within their level of competence;
• recognise Difficult intravenous access (DIVA)
• avoid repeated unsuccessful attempts; and
• escalate promptly according to this policy.

3.10 Registrar/senior medical staff

Senior medical staff should:

• provide or arrange timely assistance;
• determine whether further conventional attempts are appropriate;
• consider ultrasound-guided or alternative access;
• contact anaesthetics or other appropriate services where necessary; and
• ensure urgent treatment is not inappropriately delayed.

3.11 Consultant

The consultant is responsible for senior clinical oversight where failure to obtain vascular access is affecting the management of a significantly unwell patient or causing substantial delay to essential treatment.

3.12 Anaesthetic team

The anaesthetic team may provide assistance with difficult vascular access according to clinical urgency, expertise and local service arrangements.

Their involvement should not replace appropriate training, escalation and responsibility within the admitting clinical team.

4.0 KEY POLICY PRINCIPLES

4.1 BLOOD SAMPLES

4.1.1 When obtaining blood specimens for analysis and/or investigation all patients must be identified correctly prior to commencing sampling

4.1.2 Refer to SET Instructions to Ulster, Bangor and Ards Hospital Users for sending specimens to the Laboratory.

click here

4.1.3 The request form and sample container must contain full patient identification details. Where possible this should be by directly seeking information from the patient and details must only be completed at time of sampling.

• Patient’s identification number, (Hospital / H&C number / MRN);
• Patient’s surname;
• Patient’s first name;
• Patient’s Date of birth;
• Patient’s gender.

4.1.4 The signature of person taking blood must be completed on all forms containing a signature field, as per Laboratory Handbook.

4.1.5 The blood samples and forms must be completed at the patient’s side at the time of sampling and not be pre-prepared. It is recognised in some situations (as per SET Identification policy) that forms may need to be prepared; however, sample bottles/containers must never be pre-labelled. To promote patient safety, the practitioner undertaking collection of any sample should initial the bottle/container and sign the sample form after the specimen has been taken.

4.1.6 The request form must include the location of the patient at the time of the sampling and where the result should be sent to, if different from the patient’s location at the time of sampling.

4.2 PRINCIPLES FOR VENEPUNCTURE

4.2.1 In line with the Trust’s policy on identification, an identity band must be securely and immediately applied to all patients on hospital admission.

4.2.2 Patients should be identified prior to sampling in the following ways:

• Ask the patient/parent/ legal guardian to confirm his/her full name and date of birth. Check that these details are confirmed using the patient’s identification band. Check that the hospital number/H&C number/MRN match the sample request form.
• If a patient is unable to tell you his/her name, full name and date of birth, refer to the identification band, and if possible verify information by asking a relative (if one in attendance). Check that the details including the hospital number/H&C number/MRN match the sample request form etc.

4.2.3 The patient’s identity should NEVER be checked by reading out the details and asking the patient to confirm; local policy may apply e.g. Critical Care Unit. An interpreter may be contacted if required.

4.2.4 It is the responsibility of the staff member who obtains the specimen from the patient to leave it in the appropriate collection point and make arrangements for transfer to the laboratory.

4.2.5 Royal Marsden Clinical Procedure for venepuncture must be followed and ensure adequate skin decontamination, the wearing of protective clothing e.g. disposable gloves, timely hand hygiene and avoidance of harm e.g. haematoma and post procedure bleeding

*Useful tip sheets on Encompass, see Appendix 1

4.3 TRAINING/EDUCATION

4.3.1 Only staff who have undertaken the designated training and have been deemed competent through the training and or the agreed supervisor can perform venepuncture.

4.3.2 Staff attending CEC are provided the CEC competencies booklet to capture post training competencies. Once completed this should be handed to the the ward manager as evidence of sign off and to have the skill recorded on the Health Roster.

4.3.3 Supervised practice may be undertaken by a registered practitioner i.e. first level Nurse/Midwife or Operating Department Practitioner who has completed an approved educational programme (minimum one half day theoretical study) regarding venepuncture or by a member of the medical team at FY2 level or above.

4.3.4 Responsibility for appointing a supervisor rests with the Ward Sister/Charge Nurse/District Nursing Sister or his/her deputy.

4.3.5 On completion of training the practitioner must forward a copy of their Competency/Intention to Practice Form (see Appendix C) to their Lead Nurse /Primary Care Manager for retention in their personal file.

4.3.6 Responsibility for maintaining the skills lies with the individual practitioner with opportunities to update skills being provided by the Trust.

4.4 CONSENT

Verbal consent from the patient/parent/legal guardian should be sought prior to carrying out the procedure. The procedure should be explained and the opportunity to raise questions and concerns should be given to the patient/parent/legal guardian.

A patient information leaflet is available and should be given to all patients if possible. (Appendix B)

4.5 SPECIAL CONSIDERATIONS FOR CHILDREN AND YOUNG PEOPLE

4.5.1 Use of tourniquets in children may not be tolerated, if this is the case another staff member may be required to assist.

4.5.2 The use of distraction techniques and post procedure rewards are an effective way to minimise trauma and aid compliance.

Health Play Specialists are a valuable resource within Acute Paediatric areas to help support and prepare children and young people for invasive procedures including venepuncture. Their assistance within Acute Paediatrics should be utilised to help provide distraction during venepuncture procedures.

4.5.3 Children may require or benefit from being held by their parent/legal guardian throughout the procedure using a therapeutic hold.

4.5.4 Children may benefit from anaesthetic topical cream such as Tetracaine 4% gel (Ametop) or lidocane 4% cream (LMX) area prior to venepuncture, please allow 30 minutes for these to work effectively. Ethyl Chloride spray can be used immediately prior to the venepuncture to freeze the area and provide some pain relief.

4.5.5 Verbal consent from the child/young person should be sought prior to carrying out the procedure. The procedure should be explained and the opportunity to raise questions and concerns should be given to the patient/parent/legal guardian. If the child or young person refuses to comply with the procedure and is deemed Gillick competent, venepuncture should not be carried out. Further discussion and planning should be undertaken with the child/young person’s medical team and person with parental responsibility; with consideration given regarding the child/young person’s best interests and the clinical necessity of the procedure.

4.5.6 Staff who require additional training in paediatric venepuncture, can access support through the Clinical Education Centre. Where achieving competency is challenging, staff should liaise with the Paediatric Outpatient Department to arrange supervised practice opportunities.

4.5.7 Staff should be aware that the required volume of blood for investigations may vary in children and young people. Appropriately sized paediatric blood collection bottles are available and must be used where indicated. Needle gauge should be chosen according to the child’s age, vein size and clinical requirements.

4.5 RESPECT & DIGNITY OF THE PATIENT

All staff undertaking venepuncture are responsible for ensuring that their practice will promote and protect the interests and dignity of patients, irrespective of gender, age, race, sexuality, ability, economic status, culture and religious or political beliefs.

4.6 CONTRAINDICATIONS

Patients who are identified as being unsuitable for venepuncture for reasons of medical history or because a suitable vein is neither identifiable nor accessible, must be referred back to the care of their GP or Consultant.

4.7 DOCUMENTATION

4.7.1 All unsuccessful and successful attempts at IV access should be appropriately documented.

Documentation should include, where relevant:

• date and time;
• indication for IV access;
• urgency;
• site(s) attempted;
• number of attempts;
• grade/role of practitioner;
• escalation undertaken;
• use of ultrasound guidance;
• person/team contacted for assistance;
• significant delay to prescribed treatment;
• alternative treatment route used; and
• type and site of vascular access ultimately obtained.

Where a patient is identified as having particularly difficult vascular access, this should be clearly communicated during handover and documented to facilitate earlier escalation during future episodes of care.

5.0 Difficult intravenous access (DIVA)

Difficult intravenous access (DIVA) describes a situation in which peripheral venous cannulation is anticipated to be difficult or has been unsuccessful despite appropriate attempts by trained staff.

Factors associated with difficult access may include:

• previous history of difficult IV access;
• poorly visible or palpable veins;
• obesity;
• oedema;
• dehydration or hypovolaemia;
• previous chemotherapy;
• previous multiple venous cannulations;
• intravenous drug use;
• chronic illness associated with poor peripheral veins; or
• anatomical or other factors affecting venous access.

A patient reporting that they have previously required ultrasound-guided or specialist vascular access should be taken seriously and should prompt consideration of earlier escalation rather than repeated conventional attempts.

5.1 Difficult intravenous access; general principles

5.1.2 The clinical indication for IV access should be established before cannulation is attempted.

5.1.3 Where IV access is required, the urgency of treatment must be assessed.

5.1.4 The most appropriately experienced available clinician should perform cannulation, particularly when difficult access is anticipated.

5.1.5 Repeated attempts by multiple inexperienced operators should be avoided.

5.1.6 Unless there is a compelling clinical reason otherwise, an individual practitioner should undertake no more than two unsuccessful attempts before escalating to a more experienced practitioner.

5.1.7 The new practitioner should reassess the patient and potential sites rather than simply repeating the same approach.

5.1.8 Where difficult access is anticipated from the outset, escalation to an experienced practitioner and/or ultrasound-guided cannulation should occur early.

*Clinical urgency overrides the routine escalation sequence. A deteriorating patient must not progress slowly through each stage of the pathway if urgent vascular access is required

6.0 . ESCALATION PATHWAY

6.1 STAGE 1 – INITIAL ASSESSMENT AND CANNULATION

The doctor or appropriately trained practitioner responsible for the patient should:

1. Confirm the indication and urgency for IV access.
2. Review any history of difficult vascular access.
3. Assess both upper limbs for an appropriate peripheral vein.
4. Optimise positioning, lighting, warmth and venous filling where clinically appropriate.
5. Select an appropriate cannula size for the intended therapy.
6. Undertake cannulation using an aseptic technique.

Maximum attempts

A practitioner should normally make no more than two attempts.

After two unsuccessful attempts, further repeated attempts by the same practitioner should be avoided and escalation should occur.

6 .2 STAGE 2 – ESCALATION TO AN EXPERIENCED CLINICIAN

Escalate to an appropriately experienced member of the medical team, for example:

• Specialty Trainee;
• Specialty Doctor;
• senior clinical fellow;
• registrar; or
• consultant, depending upon local staffing arrangements and urgency.

The senior clinician should reassess the patient and determine:

• whether conventional peripheral access remains appropriate;
• whether they should attempt cannulation;
• whether ultrasound-guided peripheral cannulation is appropriate; or
• whether escalation to another service is required.

The senior clinician should normally undertake no more than two further attempts using conventional techniques.

There should therefore not ordinarily be an unrestricted sequence of attempts by successive junior doctors.

6.3 ULTRASOUND-GUIDED PERIPHERAL IV ACCESS

6.3.1 Where conventional peripheral access has failed or DIVA is recognised prospectively, ultrasound-guided peripheral venous cannulation should be considered.

6.3.2 Ultrasound-guided cannulation should only be undertaken by a practitioner who has received appropriate training and is competent in the technique.

6.3.3 Where such expertise is available within the Hospital at Night team, anaesthetic department or another locally designated vascular-access service, assistance should be requested according to local arrangements.

6.3.4 Ultrasound should not be regarded solely as a final option after numerous conventional attempts. In a patient with known or clearly anticipated difficult access, earlier use may reduce unnecessary cannulation attempts

6.4 ESCALATION TO THE ANAESTHETIC TEAM

6.4.1 Anaesthetic assistance should be requested when:

• the patient requires urgent or time-critical vascular access;
• alternative vascular access may be required; or
• the patient’s clinical condition makes further delay inappropriate.

The request should be made by an appropriately senior member of the medical team wherever circumstances allow and should clearly communicate:

• the patient’s clinical condition;
• the indication for vascular access;
• the urgency of access;
• the treatment being delayed;
• the number and nature of previous attempts; and
• whether difficult access was anticipated or previously documented.

Referral to anaesthetics does not transfer overall clinical responsibility for the patient’s underlying condition from the treating team.

6.5 URGENT/TIME-CRITICAL CLINICAL SITUATIONS

6.5.1 Immediate or early senior and/or anaesthetic escalation should occur where IV access is required for:

• major haemorrhage;
• suspected or established sepsis requiring urgent IV therapy;
• haemodynamic instability;
• significant clinical deterioration;
• urgent blood or blood-product transfusion;
• emergency intravenous medication;
• severe uncontrolled symptoms requiring IV treatment;
• preparation for emergency surgery; or
• any other situation in which delay in vascular access could result in patient harm.

In these circumstances, the routine sequential pathway should not delay resuscitation or definitive treatment.

6.5.2 The registrar and consultant should be informed according to the severity of the patient’s condition.

6.5.3 Where appropriate, emergency response/critical care pathways should be activated simultaneously.

6.6 OUT-OF-HOURS ESCALATION

6.6.1 Outside normal working hours:

1. The ward doctor should assess the patient and urgency of IV access.
2. Following unsuccessful appropriate attempts, the patient should be escalated to the on-call registrar/senior doctor.
3. Where locally available and appropriate, Hospital at Night or another practitioner competent in difficult/ultrasound-guided vascular access may be contacted.
4. If access remains unsuccessful or is clinically urgent, the on-call anaesthetic team should be contacted.

The absence of routine daytime vascular-access services must not result in prolonged delays in necessary treatment.

6.7 ALTERNATIVE ROUTES OF TREATMENT

6.7.1 While vascular access is being obtained, the responsible clinician should consider whether treatment can safely be administered by an alternative route.

Depending upon the medication and clinical circumstances, alternatives may include:

• oral;
• intramuscular;
• subcutaneous;
• rectal; or
• other clinically appropriate routes.

The choice must be based upon the patient’s clinical condition, pharmacological suitability and local medicines guidance.

Use of an alternative route must not delay obtaining appropriate vascular access where IV therapy is clinically required.

6.8 ALTERNATIVE VASCULAR ACCESS

6.8.1 Where peripheral IV access cannot be achieved or is inappropriate, the senior clinician and anaesthetic/vascular-access team should consider the most appropriate alternative.

This may include, depending upon the clinical circumstances:

• ultrasound-guided peripheral cannulation;
• longer peripheral catheter;
• midline catheter;
• peripherally inserted central catheter (PICC);
• central venous catheter; or
• other emergency vascular access where clinically indicated.

Selection should take account of:

• urgency;
• anticipated duration of treatment;
• type of treatment/infusate;
• patient factors;
• available expertise; and
• risks associated with the proposed device.

Central venous access should be undertaken only by appropriately trained and competent practitioners and in accordance with relevant Trust policy.

7.0 IMPLEMENTATION OF POLICY

It is the responsibility of managers and supervisors to ensure that this policy has been brought to the attention of all relevant staff and the responsibility of those staff to read and adhere to the contents of it.

8.0 MONITORING

8.1 The effectiveness of the policy will be evaluated on an on-going basis.

8.2 Incidents and near misses relating to venepuncture must be recorded via Datix.

8.3 The process will be monitored on a directorate basis through local governance arrangements.

9.0 EVIDENCE BASE / REFERENCES

• Patient Identification Policy
• ANTT Policy
• Sharps Policy
• Prevention and Management of Latex Allergy
• Royal Marsden clinical procedure for Venepuncture
• Northern Ireland Regional Infection Prevention and Control Manual
• Blood transfusion policy
• SET Consent Policy
• SET Laboratory Handbook
• Hand Hygiene and Standard IPC precautions on regional IPC manual
• http://niinfectioncontrolmanual.net/

10.0 CONSULTATION PROCESS

This policy has been circulated Trustwide for consultation.

11.0 APPENDICES/ATTACHMENTS

Appendix A - Useful tip sheets on Encompass

Appendix B – Patient Information

10.0 EQUALITY STATEMENT

In line with duties under the equality legislation (Section 75 of the Northern Ireland Act 1998), Targeting Social Need Initiative, Disability discrimination and the Human Rights Act 1998, an initial screening exercise to ascertain if this policy should be subject to a full impact assessment has been carried out.

The outcome of the Equality screening for this policy is:

Major impact

Minor impact

No impact.

SIGNATORIES

Prof David Robinson

Deputy Chief Executive

Executive Director of Nursing, Midwifery & AHPs

Director of Support Services

Date: 05.01.26

Maggie Parks,

Director of Surgery,

Elective Care, Maternity & Paediatrics

Date: 05/03/26

Appendix A

Useful tip sheets on Encompass

• Phlebotomy hub labs ordering and scheduling,            
• Phlebotomy hub labs specimen collection            
• Labs print one label for multiple labs
• Labs release and print labels

Appendix B

Adult

Patient Information - A Guide to having a blood test

There are a number of reasons why your Doctor may request that you have a blood sample taken. This might be to help with a diagnosis, to monitor treatment, or to exclude certain conditions. In most cases these samples will be taken by a procedure known as Phlebotomy or Venepuncture, i.e. taking blood from a vein. The information given below will explain the procedure in more detail.

How is a blood sample taken?

The procedure is performed by a trained member of staff, usually a phlebotomist, doctor or nurse.

A tourniquet is placed around your arm just above the elbow (or above other suitable area e.g. hand), the area is cleaned and then a small needle is inserted into the identified vein. Blood is withdrawn into sample bottles and the needle is then removed. Pressure is applied at the site with a piece of cotton wool or gauze until the bleeding has stopped and then a small plaster is applied. Please tell the person taking the blood if you are allergic to sticking plaster.

Will it hurt?

Putting the needle into the arm involves a pin prick sensation but after that the rest of the procedure should be quite painless. Some people may continue to feel some discomfort or pain, which is probably because of nerves under the surface of the skin; this should settle quite quickly. If not you should go to see your GP or a member of hospital staff.

Will it bruise?

You may get a bruise or a small lump after having blood taken. This will usually settle by itself and fade away in time.

In some instances there may be an increased risk of bruising. These include:-

• Drugs such as Warfarin, Aspirin & Direct Oral Anticoagulants (DOAC)
• Conditions such as a bleeding disorder or low platelets (thrombocytopenia)
• When it is hard to get a vein, for example if the arm is swollen (oedema)
• Elderly patients

To help reduce this risk as much as possible, please tell the person taking the blood if you have any of the above or if you have had a problem in the past after a blood test.

Pressing firmly on the site until the bleeding has stopped should help to reduce any bruising. If possible keep the arm slightly raised and avoid too much movement of the arm, such as lifting or carrying heavy parcels, for an hour or so after the blood test. Should you experience excessive bruising or prolonged bleeding, then apply further firm pressure to the area. A few ice cubes wrapped in a towel may help reduce any swelling and bruising.

Bruising can look very dramatic and some people may find this worrying especially if it appears away from the site where the blood has been taken or is visible for a few days following the procedure. However, it is usually harmless and should disappear in time.

What happens to the blood samples?

The samples are tested in the laboratory and the results sent to the person who asked for the sample to be taken. Some samples may need to be sent elsewhere for further tests or stored in case we need to refer to them in the future.

By law, we are expected to protect any information we have about you. All of your test results are stored and treated confidentially. No-one except the medical teams looking after you can look at, or have access to, your test results without your permission.

If you have any questions about this procedure please ask the member of staff taking the sample or the person responsible for your care.

Appendix B

SUPERVISION OF VENEPUNCTURE

• Each trainee must arrange as many supervised sessions as necessary prior to practice. A minimum of five supervised sessions is recommended.

The Clinical Supervisor should sign all sessions.

Supervision of ………………………………………...

Date signature and designation………………………………

This is not a certificate of competence. It serves only as a record of supervised

Sessions. Your Ward Sister/Charge Nurse will appoint a Clinical Supervisor.

Additional supervision if required, record below

Supervision of ………………………………………………………………………

Date Signature and designation

Appendix C

COMPETENCY/INTENTION TO PRACTICE FORM

To: Assistant Director/Medical Director

I have received theoretical training on venepuncture on the following date:

___________________

I have been deemed competent in Venepuncture and enclose a copy of my supervised practice form).

It is my intention to commence practice from ________________

Practitioner’s signature: ……………………………………………………………………

Supervisor’s signature: …………………………………………………………………….

Date: …………………………………………………………………………..