Procedure for Heel Prick Sampling

CLINICAL GUIDELINE FOR HEEL PRICK SAMPLING IN
INFANTS AND CHILDREN.
1. Aim/Purpose of this Guideline
1.1 Heel prick sampling can be used to obtain capillary blood from a neonate or infant. The
sample may be used for a range of tests (e.g. serum bilirubin, drug levels) or as part of a
screening programme. If the foot is well perfused it will give an accurate pH and Co2
measurement for blood gas tests. The aim of this guideline is to provide clear and
standardised guidance for all health care professionals performing this procedure, using
up to date evidence from research.
1.2 This guidance applies to all health care professionals performing this procedure. It is
the responsibility of those undertaking heel prick sampling to have achieved competency
in the procedure. The nursing/midwifery staff caring for the patient must ensure the
appropriateness of the procedure and follow-up the results, the procedure may be
delegated providing competency has been achieved.
2. The Guidance
2.1Equipment
• Clean gloves and personal protective equipment
• Relevant paediatric blood collection bottles, capillary tube or blood collection
card
• Blood letting device
• Gauze
• Sterile water
• Clean tray to hold equipment
• Sharps disposal box
2.2Procedure:
1. The patient should be identified as per Positive Patient Identification Policy and
Procedures. V4: June 2010 and a full explanation of the procedure should be
given to the parents to ensure their consent is obtained as per Policy for consent
to examination or treatment. V6.1: June 2011.
2. The request forms should be ordered via the electronic order coms. System. If
hand written the request card must be filled in with all details clearly and in
black ink. If crucial information is missing or the test is inadequate a repeat test
may be requested by the laboratory.
3. A clinical hand wash must be performed prior to starting the procedure.
Appropriate personal protective clothing should be worn (e.g. Gloves, apron).
Clinical guideline for heel prick sampling in infants and children.
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4. The heel should be cleaned with sterile water and gauze. Allow the area to dry.
Alcohol impregnated wipes should not be used, due to absorption and
drying to the skin, association with chemical burns in preterm infants, minimising
chemical exposure in the newborn and injury to delicate/healing tissue.
5. Safely position the infant either with a parent or in the cot. If possible encourage
breastfeeding or EBM or skin to skin contact for pain relief. Consider using
prescribed oral pain relief i.e. 24% sucrose solution.
6. Select an appropriate site for blood sampling. The chosen site should continually
be rotated and free from previous injury.
7. Keeping dominant hand free to carry out the procedure, hold the baby’s heel
firmly and upright in your non dominant hand, hold the ankle with index and
middle finger, and use the other fingers to steady the baby’s leg. Partly encircle
the baby’s heel with thumb,
8. Prick the baby’s heel once using an automated blood-letting device that is
appropriate for the age and size of the infant (as per manufacturer’s
instructions).
9. Relax tension and wipe away initial blood flow with gauze.
10. Whilst maintaining grip, hold the heel so that blood is allowed to hang. Gently
compress the baby’s heel to form a large droplet of blood- Do not squeeze.
11. Fill Collection sample in the relevant paediatric blood collection tubes or on the
blood collection card.
Note - Change in Recommendations: Warming the heal is not necessary and should be
viewed as unnecessarily prolonging the process as it has no effect on the outcome of the
sampling in terms of time taken to collect a sufficient sample, the number of repeat
samples needed or the infant's behavioural response.
Squeezing the heel in order to encourage blood flow is sometimes necessary, but is
recognised as causing or increasing pain in the neonate .It can also cause haemolysis and
soft tissue damage. The heel should not therefore be routinely squeezed, and if it is, then
gentle squeezing and releasing should be used. Ensuring the infant is in a position where
the heel is lower than the body may facilitate blood flow.
Soft paraffin solutions such as Vaseline® should not be used for heel punctures, due to
increased risk of infection, altering of blood results and clogging of equipment.
12. Once the samples have been taken, apply pressure the puncture site to stop the
bleeding with gauze.
13. When bleeding has stopped, dispose of all sharps, clinical waste including gloves
and PPE. Hands must then be re-washed.
14. If used, label tubes whilst at patients’ bedside. Place collection tubes/card in the
plastic sleeve attached to the request card and seal before sending for analysis.
15. Document the procedure within Patients’ notes as per Clinical record keeping
policy.May2012.
Clinical guideline for heel prick sampling in infants and children.
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2.3 Acceptable Sites for Sampling
Heel lancing should be limited to the medial and lateral borders of the heel (please
see diagram above.)
In preterm infants, who undergo many repeated capillary blood samples during the
course of their care, the close clustering of puncture sites may lead to significant
trauma and tissue injury over time. Newer devices have been introduced for heel
lancing that limit the depth of penetration of the blade (generally to a depth of
2.4mm), therefore reducing the risk of inadvertent injury to deep structures, including
the calcaneum. Capillary blood sampling may generally be safely carried out over the
whole of the heel pad, allowing repeated samples to be taken over a wider area and
reducing the trauma to the heels overall.
Clinical guideline for heel prick sampling in infants and children.
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3. Monitoring compliance and effectiveness
Element to be
monitored
Lead
Adherence to full guideline
Ward managers
Tool
Frequency
Reporting
arrangements
Acting on
recommendations
and Lead(s)
Audit and weekly safety audits
Annually
Ward Mangers. Lead Nurse. Practice development forum.
Ward Mangers. Lead Nurse. Practice development forum
Change in practice
and lessons to be
shared
Required changes to practice will be identified and actioned within 3-6
months. A lead member of the team will be identified to take each
change forward where appropriate. Lessons will be shared with all the
relevant stakeholders
4. Equality and Diversity
4.1 This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and
Diversity statement.
4.2 Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Clinical guideline for heel prick sampling in infants and children.
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Appendix 1. Governance Information
Document Title
Date Issued/Approved: 1 September 2013
Clinical Guideline for Heel Prick Sampling in
Infants and Children.
Date Valid From: 1 September 2013
Date Valid To: 1 September 2016
Directorate / Department responsible
(author/owner):
Tabitha Fergus-Child Health
Contact details: 01872 25 2800
Brief summary of contents
Guideline outlining best practice and full
guidance in obtaining a heel prick sample
from an Infant or Child.
Suggested Keywords:
Target Audience
Executive Director responsible for
Policy:
Neonate
Child
Heel prick
Blood sample
RCHT PCT CFT
Medical Director
Date revised: August 2013
This document replaces (exact title of
previous version):
Approval route (names of
committees)/consultation:
Divisional Manager confirming
approval processes
Procedure for heel pricks sampling.
Senior nursing staff Child Health and
Neonatal Unit.
Paediatric consultants
Child Health Audit and Guidelines
Practice development forum
Name and Post Title of additional
signatories
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies – Approvals and
Ratification):
Document Library Folder/Sub Folder
Not required
{Original Copy Signed}
Internet & Intranet Intranet Only
Paediatric and neonatal
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Links to key external standards
Related Documents:
Training Need Identified?
RCHT Policy for consent to examination
or treatment. V6.1:June 2011
RCHT Positive Patient Identification.
Policy and ProceduresV4:June 2010
RCHT Clinical record Keeping Policy. May
2012
Association of Women’s Health, obstetric
and neonatal nurses and the national
association of neonatal nurses. 2001.
Evidence based clinical practice guideline:
neonatal skin care.
Barker et al.Warming capillary blood
sample .Should heels be warmed?
Archives of disease in childhood. 2009
Gerds.Nursing care and sensory
enrichment of the normal newborn. In
Reeder. Maternity Nursing.1997
Jain and Rutter.Topical pain relief for heel
prick blood sampling. 2001
Great Ormond Street Hospital for
Children. Blood sampling, neonatal
capillary.
Johnston and Taylor. Skills for midwifery
practice. 2000
Vertanen et al.The automatic incision
device for obtaining blood samples from
the heel. Archives of disease in
childhood.2001
Warren. Blood without tears. The
practising Midwife.1998
Waughten. Midwives magazine. Royal
college of midwifery. March 2005
Image created by T. Fergus
Yes- All staff will be sent new guidelines
to read and sign off as new practice is
advised.
Version Control Table
Date
Version
No
July 2007 V1.0 Document created
April 2009 V2.0
Sep 2013 V3.0
Summary of Changes
Review and re format
Review, re format and re write. Addition of
image.
Clinical guideline for heel prick sampling in infants and children.
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Changes Made by
(Name and Job Title)
Tabi Fergus and
Practice development
Team
Deputy ward manager
Tabi Fergus
Deputy ward manager
Tabi Fergus
Deputy ward manager

All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
Clinical guideline for heel prick sampling in infants and children.
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Appendix 2. Initial Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to
as policy) (Provide brief description): Clinical guideline for heel prick sampling in infants and
children.
Directorate and service area: Child Is this a new or existing Policy? Existing
Health
Name of individual completing
Telephone: 01872 252800
assessment: Tabitha Fergus
1. Policy Aim*
Who is the strategy /
policy / proposal /
service function
aimed at?
Clear instructions and guidance for medical and nursing staff obtaining
heel prick samples in neonatal and paediatric settings.
2. Policy Objectives* Standardised care, evidence based practise.
3. Policy – intended
Outcomes*
4. *How will you
measure the
outcome?
5. Who is intended to
benefit from the
policy?
6a) Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around
this policy?
Standardised care, evidence based practise.
Audit. Quality Nursing matrices.
Medical and nursing staff. Patients and families.
No
b) If yes, have these
*groups been
consulted?
C). Please list any
groups who have
been consulted about
this procedure.
7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands: Yes No Rationale for Assessment / Existing Evidence
Age x Neonatal and child health guideline.
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Sex (male, female, transgender
/ gender
reassignment)
Race / Ethnic
communities /groups
Disability -
learning
disability, physical
disability, sensory
impairment and
mental health
problems
Religion /
other beliefs
Marriage and civil
partnership
Pregnancy and maternity
x
x
x
x
x
x
Sexual Orientation,
x
Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
You have ticked “Yes” in any column above and
No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
Major service redesign or development
8. Please indicate if a full equality analysis is recommended. Yes No
x
9. If you are not recommending a Full Impact assessment please explain why.
Neonatal and child health guideline. No fields marked yes.
Signature of policy developer / lead manager / director
T. Fergus
Date of completion and submission
5/9/13
Names and signatures of
members carrying out the
Screening Assessment
1.
2.
Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
A summary of the results will be published on the Trust’s web site.
Signed ___T. Fergus____________
Date ______5/9/13__________
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