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Phlebotomy in primary care

Venepuncture is the practice of introducing a needle into a vein to obtain a sample of circulating blood for one of two reasons: therapeutic, as in the case of venesection, the removal of a required amount of the blood volume for patients with certain medical conditions such as polycythemia rubra vera; or diagnostic, where samples are sent to the laboratory for haematological, biochemical or bacteriological analysis.

In many ways venepuncture and peripheral intravenous cannulation (PIC) are very similar, and in areas such as accident and emergency departments, cannulation is performed to obtain samples for analysis before it is clear whether the patient requires a PIC or not.

Phlebotomists were introduced into hospitals in the 1990s. Junior doctors had to reduce their working week to less than 83 hours, so many of the tasks that had been previously undertaken by them had to be carried out by others.1

Venepuncture and electrocardiography (ECG) were passed over to phlebotomists, nurses, clerical workers and ECG technicians, to name but a few.

Phlebotomists are people trained to draw blood from a live person or animal for tests. Some countries require phlebotomy personnel to be licensed or registered, as in many states in America. However, this does not seem to be the case in the UK. A wide variety of people take up these roles, and phlebotomy services are provided by a number of means within a community setting. Within our division, half of the phlebotomy service is provided by the Acute Trust, using a service level agreement (SLA) and the other half by phlebotomists who are employed by community health services.

The main criteria for the role is that the person has a level two national vocational qualification (NVQ) in Health and Social care or equivalent. We employ seven phlebotomists on a band two according to Agenda for Change2 and they are based in integrated nursing teams along with the community matrons, nurses and treatment room nurses. They work in geographic areas across the division and are attached to a number of general practitioners (GPs).

The phlebotomists work part-time, mainly in the mornings, in order to provide early clinics which not only benefit patients who are fasting, but also patients who need to leave early for work. They can, if they choose, become a member of the National Association of Phlebotomists (NAP). This body has in the past recognised the need to develop a more standardised, comprehensive training package for phlebotomists, and tried to introduce an NVQ without success - although it would appear that a similar qualification seems to be available in some areas by different means.

Training typically consists of a half day theory session covering topics such as:
- Basic anatomy and physiology.
- Infection control issues.

- Consent.
- Order of draw.
- Preparation of the patient.
 - The procedure and equipment used.

The phlebotomists then work alongside a more experienced practitioner, and following 100 draws they can then be assessed and signed off as competent if appropriate.

The referrals to the phlebotomy service are very high. A high number of home visits are carried out for housebound patients requiring regular testing for warfarin dosing. Phlebotomy clinics which provide drop-in sessions see around 90 patients daily, with many patients requiring two or more samples. One of the reasons that the provision of this service is so challenging is the high levels of sickness and absence within the service, and the ever-increasing workload which has been brought about by moves from secondary care to GPs who must now provide community-based phlebotomy services.

Community nurses
There is a wide variety in the ability of community nurses to undertake venepuncture. Some nurses will never have learned how to do it and some nurses will not have maintained their competency. Recent changes in healthcare that have been brought about by government policy3 and to move care into the community have meant there has not only been an increase in the volume of work that community nurses now undertake but also the complexity of the cases. The addition of IV therapy administration is one example where difficult and time-consuming therapies are regularly undertaken within the patients own home.

Phlebotomists were introduced into the community later than in secondary care but the nurses were more than happy to pass this role over to them because of capacity issues in their own service. As a consequence of this, nurses have lost the skill.

As Lavery and Ingham4 point out “in order to maintain competence, regular practice, supervision and assessment is required”. Since frequency of practice is so varied within this group, just as it is with PIC, competency is difficult to maintain. Again, as in cannulation, it is a skill that nurses are able to choose to do or not to do regardless of the basic nature of the skill and the amount of times it needs to be carried out.

Venepuncture should be an easier skill to maintain than PIC since the equipment used should be simpler and more straightforward and certainly within local trusts only two methods of collection are used.

Within our community, consideration needs to be given to the number of patients who require blood sampling, for example for therapeutic drug monitoring (TDM). Since the introduction of IV therapy, a cohort of patients have required twice-weekly blood monitoring to ensure therapeutic levels of antibiotics are maintained.

Most of these patients have vascular access devices (VAD) in situ and could therefore potentially have blood taken from their line. Phlebotomists would not be able to perform this task, therefore it would need to be done by the nurse who is administering the antibiotics.

As previously thought, a study by McBeth et al.5 has shown that there is no statistical significant difference in the levels, particularly from peripherally-inserted central catheters (PICC), which most central lines seem to be. This also prevents duplication of visits by a number of different healthcare professionals, which is not only wasteful but confusing for some patients.

The problems with venepuncture and PIC are the same in many ways. Not only is the training for both nurses and phlebotomists sporadic and varied, the procedures that can be undertaken by each person differ greatly. While nurses can be taught to take samples from the back of the hand using a winged butterfly device, most phlebotomists do not do this.

Hefler et al.6 undertook a study which indicated that the use of these devices was not only more successful, but less painful to patients. Universities are providing clinical skill sessions in venepuncture for student nurses, however they find it difficult to practice the skill because policies in the different trusts and healthcare providers vary so much, depending upon where they are based.

There is a general consensus that two attempts by one person should be the maximum before referring to a more experienced person. Interestingly, this is not mentioned in the Standards for Infusion therapy.7 This document is used by many clinicians when writing local policies. According to Harty-Golder, a pathologist-attorney consultant in the USA,8 the real issue in venepuncture is not “how many attempts” but “when to stop”.

Knowing when to stop or when to defer a venepuncture requires assessing the patient and the clinical situation, and assessing whether or not the initial attempt has already produced a complication. This is particularly pertinent when considering both clinic and home visits, which if failed not only cause more upheaval for the patient, but lead to increased workloads. More attention needs to be paid to skill mix when rotas for phlebotomy clinics are completed, so that more experienced staff are placed with more junior staff.

Venepuncture has been identified as a basic, common clinical skill carried out by a number of different personnel. Since nurses are one of the few professions who work 24 hours a day, it seems sensible that they acquire and maintain this skill and be able to use it at all times.

Phlebotomists need to be taught in a much more structured and standardised way, perhaps to include different methods of obtaining samples, if they are to provide not only the service the patients require but the support that the community nurses need during this time of great change.

1.     NHS Management Executive. Junior doctors. The New Deal. London:
    NHSME; 1991.             
2.     NHS Executive. Agenda for change - Modernising the NHS pay
    system. Health service Circulars 1999:199/035.
3.     Department of Health. Our health, our care, our say: a new direction
    for community services. London: DH; 2006.
4.     Lavery I, Ingram P. Venepuncture: best practice. Nursing Standard
5.     Mc Beth L, Mc Donald RJ, Hodge MB. Antibiotic sampling from central
    venous catheters versus peripheral veins. Pediatric Nursing
6.     Hefler L, Grimm C, Leodolter S, Tempfer C. To butterfly or to needle:
    the pilot phase. Annals of Internal Medicine 2004;140(11):935-6.
7.     Royal College of Nursing. Standards for Infusion Therapy. Third edition
    London: RCN; 2010.
8.     Harty-Golder B. How many times should a phlebotomist try to draw
    blood? Mio Online 2010;54. Available at: