Standards Update: Post-venipuncture care

The newly revised venipuncture standard released by the Clinical and Laboratory Standards Institute in April, 2017 is the most comprehensive revision in the document's history. With over 140 new mandates, facilities have a lot of changes to implement. This series discusses one or more substantive changes each month.

One of the most critical aspects of performing a venipuncture is post-venipuncture care. Bruising is not only unsightly and impacts patient satisfaction, but hematomas can cause permanently disabling injuries when they exert pressure on nearby nerves. The committee that revised the CLSI venipuncture standard instituted a comprehensive rewrite of the section on caring for the venipuncture site. 

While the popular standard always instructed collectors to "observe for hematoma," prior to this version the document never defined what "observe" really meant. Merely lifting the gauze for a millisecond would suffice. However, a quick peek won't alert the collector to a site that is still bleeding. Worse yet, it would be impossible to know if a hematoma is forming. As a result, a patient could be bandaged too quickly, and continue to bleed into the tissue, causing not only an unsightly bruise, but inflict a permanent nerve injury from the pressure of a subcutaneous hemorrhage. Yet technically the standard would have been followed.

The standard now instructs healthcare professionals to observe the site for hematoma formation by watching the skin for at least 5-10 seconds. That should be enough time to detect the telltale mounding of the skin at the puncture site, which indicates blood is leaking from the vein into the tissue. If observed, or if blood is seen pooling on the skin, the standard requires additional pressure to be applied until the bleeding has stopped. At least five minutes of additional pressure is required if bleeding from the brachial artery is suspected, and the nursing staff and physician must be notified.

The revision continues to forbid patients from being allowed to bend their arm up after the draw as a substitute for direct pressure. Neither cotton nor rayon balls can be used for applying pressure, only clean gauze.

Cooperative patients can be allowed to apply direct pressure. However, it is the responsibility of the collector to ensure pressure is adequate in order to prevent bruising and any bleeding into the tissue that could lead to complications. If necessary, collectors must provide adequate pressure themselves if patients are unable.

When the collector is sure bleeding has stopped---both superficially and subcutaneously---the site can be bandaged, preferably with a hypoallergenic bandage or wrap. The patient should be instructed to leave the bandage on for at least 15 minutes, and cautioned against using the arm with exertion for several hours.

Editor's note: Readers are urged to obtain their own copy of the standard as soon as possible and begin implementing all new provisions immediately. The document, Collection of Diagnostic Venous Blood Specimens (GP41-A7), is the standard to which all facilities will be held if a patient is injured during the procedure or suffers from the consequences of an improperly performed venipuncture. It can be obtained from CLSI or the Center for Phlebotomy Education, Inc.