antecubital fossa venipuncture

Question 1

What is the equipment to take?

Answer 1

7. Gather 12 equipment from bottom of trolley and put it on the top of trolley:
8. Blood-draw order form (already in folder on the top of trolley)
9. Sticker labels for blood vacutainer (already in folder on the top of trolley)
10. Biohazard specimen bag (already on the top of trolley)
11. Kidney dish with:
12. Non-sterile gloves
13. Black and white Luer vacutainer needle
14. Transparent Luer vacutainer needle holder
15. Vacutainer
16. Blue latex-free tourniquet – to avoid allergies
17. 2 alcohol swabs (they come in sets of 2, just take 1 extra as backup)
18. Gauze
19. Plaster
20. “After gathering my equipment, I will check the expiry date of each equipment.” Look for the expiry date on the equipment packaging OR the boxes for some equipment (eg. for gloves, the expiry date is on the box, but for alcohol swabs, the expiry date is on the packaging itself). Some equipment may not have expiry dates, but just show that you are looking for the expiry date on both the equipment and their boxes, even if there turns out to be no expiry date in the end. You will have a lot of time anyway! 

Question 2

How do you approach the patient?

Answer 2

I will now approach the patient.”

10. 3rd hand rub (from bottle on trolley) – show 7 steps. Do this 3rd hand rub as you are approaching the patient’s environment with bare hands.
11. Place the kidney dish next to the dummy on the side of your non-dominant hand. Place the blood-draw order form + sticker labels + biohazard specimen bag next to the dummy on the side of your non-dominant hand too.
12. “I will approach the patient and:
13. Introduce myself
14. Explain the procedure to the patient, and inform them that it might be a little painful when drawing blood from their veins
15. Obtain patient consent
16. Ask the patient which is their non-dominant hand
17. Double-check the patient’s full name and NRIC against 4 things: The patient’s verbal identifiers, the blood-draw order form (read out the full name and NRIC on the form), the patient’s wrist tag on the dummy’s arm, (read out the full name and NRIC on the wrist tag), the sticker labels (read out the full name and NRIC on the sticker labels).”
18. “If everything is in order, I will proceed with the procedure.”

Question 3

PAN- Palpate

Answer 3

14. Don non-sterile gloves.
15. Apply latex-free tourniquet using half-tie method about 5-7cm above elbow. (https://www.youtube.com/watch?v=t3TSq07KByg)
16. “I will ask the patient to clench their fist.”
17. Palpate using your index and middle fingers for accessible vein in median cubital fossa.
18. “I will ask patient to release their fist.” Do not need to release the tourniquet now if you can assemble everything in 1 minute.

Question 4

PAN- alcohol swab

Answer 4

19. Tear open alcohol swab and leave packaging in kidney dish.
20. Alcohol swab the area around your chosen vein in a circular motion, from inside to outside. (Do this first to give it enough time to dry.)
21. Place the used alcohol swab back in the kidney dish.
22. Verbalize: “Alcohol dry.”

Question 5

PAN- needle system assembly

Answer 5

23. Twist open white cap from top of Luer vacutainer needle and screw grey rubber vacutainer adapter part into the transparent vacutainer needle holder.
24. Remove bottom black needle cap from vacutainer needle, into the kidney dish, using one-hand-drop-down method. (You can use 2 hands to loosen needle cover initially, but when you drop the cover down, it must be using 1 hand only.) DO NOT DISCARD THE NEEDLE COVER IN CASE YOU NEED TO RECAP THE NEEDLE IF YOU MAKE MISTAKES (EG. FORGET TO ALCOHOL SWAB THE SKIN).
25. Using your dominant hand, hold the transparent vacutainer needle holder between the thumb and last three fingers. With the free index finger, stabilize the hub of the vacutainer needle.
26. Using your other non-dominant hand, stabilize the chosen vein by pulling down on the skin area BELOW the vein using the thumb. DO NOT REPALPATE FOR THE CHOSEN VEIN AS YOU HAVE ALREADY DISINFECTED THE AREA.

Question 6

Proceeding with the actual procedure (up to the point where you get blood at the vacutainer)

Answer 6

28. Using your dominant hand, insert the vacutainer needle SLOWLY, with bevel facing upwards, at a 15-30o angle.
29. As you advance, observe for a flashback of blood into the front of the vacutainer needle. Do not need to poke the needle all the way through as the vein is quite superficial.
30. Note: Advance the needle SLOWLY, above 3-5mm everytime, if you do not see a flashback.
31. DO NOT dig or fish around for the vein in median cubital fossa as it is extremely painful.
32. Possible scenario: You do not get any flashback of blood (failed to gain entry to the chosen vein). DO NOT PANIC AS YOU HAVE A LOT OF TIME  Release tourniquet immediately and ask patient to release fist too. “As I did not gain entry into the vein on the first attempt, I will remove the tourniquet and ask patient to release their fist first.” Use non-dominant hand to grab gauze on kidney dish and put it over the needle puncture site. Remove needle system with dominant hand swiftly and discard into sharps bin immediately, do not need to recap. “I will ask patient to apply pressure for 1-2 minutes while I prepare a new needle. For patients with a poor coagulation profile, I will increase the time to 3-5min.” Empty the rubbish from the kidney dish into ANY rubbish bin, but do not throw kidney dish itself as you need it to gather a new set of equipment. Remove gloves using aseptic technique. Hand rub (from bottle on trolley) – show 7 steps. Gather new set of 7 equipment from bottom of trolley into the kidney dish:
33. Non-sterile gloves
34. Black and white Luer vacutainer needle
35. Transparent Luer vacutainer needle holder
36. Vacutainer
37. 2 alcohol swabs (they come in sets of 2, just take 1 extra as backup)
38. Gauze
39. Plaster
40. Repeat “PAN” but do not poke the needle in the exact same spot as the previous attempt.
41. Instruct patient to release fist once flashback is seen. “Once I see a flashback of blood, I will ask the patient to release their fist.”
42. Using non-dominant hand, grab the vacutainer from the kidney dish. Insert vacutainer into the needle holder until it engages with the needle system, without applying excess pressure on the needle system which may cause the needle to dislodge out of the vein.
43. Press the needle holder downwards and press the vacutainer upwards using non-dominant hand to ensure it keeps engaging with the needle system.
44. Continue to stabilize the needle system with your dominant hand.
45. Allow vacutainer to fill with blood (usually about one-third to half the vacutainer will be filled from the pressure in the dummies is not that high).

Question 7

What do you after you get blood?

Answer 7

35. Release the tourniquet once you see the blood flow slowing down.
36. Remove vacutainer FIRST using non-dominant hand and invert it 10x for the purple vacutainer/according to the number of inversions indicated by the vacutainer system chart on the trolley if it is a different colour. (NOTE: If you do not remove the vacutainer first, when you remove the whole needle system, blood will gush out from the puncture site and needle, because the vacuum from the vacutainer is still drawing blood into the needle.)
37. Set vacutainer aside in kidney dish.
38. Use non-dominant hand to grab gauze from kidney dish and put it over the needle puncture site.
39. Use dominant hand to remove needle system swiftly. Discard needle system in sharps box immediately, do not need to recap.
40. “I will instruct patient to use their other hand and apply pressure over the puncture site for 1-2min. For patients with a poor coagulation profile, I will increase the time to 3-5min.”
41. Open the plaster packaging. Remove the gauze and place it into the kidney dish. Paste plaster over the puncture site.
42. “I will thank the patient and tell them to inform the nearest medical staff if they experience any pain or continual bleeding from the needle puncture site.”
43. Peel off a patient sticker label and paste it over the white vacutainer label. Put it in the Ziploc compartment of the biohazard bag. Do not block view of the blood itself. Set the bag aside, on top of the blood-draw order form and the sticker labels which were earlier placed next to the dummy on the examination table.
44. Throw entire kidney dish with all the rubbish into the rubbish bin (there will be a small plastic bag at the side of the trolley that acts as a rubbish bin, and a big rubbish bin with a foot pedal, you can choose from either one).
45. Remove non-sterile gloves using aseptic technique – outside of glove can only touch outside of other glove. Pinch wrist part of 1st glove and pull it down, turning 1st glove inside-out along the way to trap any pathogens. Ball up 1st glove in 2nd-gloved hand. Use exposed finger to insert under the cuff of 2nd glove and pull down to remove 2nd glove inside-out. Discard both gloves into ANY rubbish bin.
46. Hand rub (from bottle on trolley) – show 7 steps.
47. “I will double-check the patient’s full name and NRIC against 4 things FOR A SECOND TIME: The patient’s verbal identifiers, the blood-draw order form (read out the full name and NRIC on the form), the patient’s wrist tag on the dummy’s arm, (read out the full name and NRIC on the wrist tag), the sticker label pasted on the vacutainer in the biohazard bag (read out the full name and NRIC on the sticker label on vacutainer).
48. Fold the blood-draw order form in half and place it in the non-Ziploc compartment of the biohazard bag, with the part of the form that has patient’s full name and NRIC facing outwards.
49. Put the blood-draw order form in the dispatch box, usually found at the foot of the examination bed in OSCEs.
50. Put sticker label sheet back on top of trolley.
51. Medical hand wash – show 7 steps.