Hounslow SPA (for Richmond & Hounslow GP registered patients): Tel: (7-7pm Monday-Sunday)

Transcription

1 HOSPITAL PATIENT INCLUSION CRITERIA FOR COMMUNITY INTRAVENOUS (IV) THERAPY SERVICE If the patient meets all following criteria, please contact the Community IV Nurse to discuss referral to the service Community IV Nurse Maggie Clark Teddington Memorial Hospital Mobile No: pm Monday-Friday (if unavailable contact Single Point of Access (SPA). Hounslow SPA (for Richmond & Hounslow GP registered patients): Tel: (7-7pm Monday-Sunday) PATIENT INCLUSION CRITERIA Y N N/A Patient registered with a NHS Richmond or Hounslow GP. Patient over 18 years old. Patient has a definite diagnosis and is referred by a medical practitioner. Patient medically stable other than requiring intravenous treatment. Patient fully informed and consents to intravenous therapy. Patient has access to a carer 24 hours a day. Patient known history of drug or alcohol abuse. Patient has access to a telephone and to running water. Patient has any known history of dementia/confusion. Patient has any known history of poor compliance to treatment. Medication infusion time to be no more than 30 minutes. Referring medical team has accepted responsibility for patient and will provide 24 hour advice. Discharge letter/tta available. Venous access - appropriate device inserted prior to discharge (if hospital patient), for example:- Cannula for short term therapy (Up to 2 weeks). Piccline/Midline/Implanted Port - for long term therapy (More than 2 weeks). Additional information for referring ward Nurse or Doctor A minimum of 1 working day notice should be given for elective discharges. Once the referral has been discussed and accepted by the Community IV Nurse/SPA/ District Nursing Team, new referral documentation will be faxed to the referrer by Hounslow SPA. Patients in hospital must be discharged with all medication, diluents, flushes and all other necessary equipment for the duration of treatment. Page 1 of 4 Version 1:2 Revised 22/04/2014

2 COMMUNITY IV THERAPY SERVICE REFERRAL DOCUMENTATION Ward Checklist for all patient s discharged from Hospital to HRCH for community IV Therapy To be completed by the Ward Nurse Patient s Name: Patient s Address: NHS Number: Patient s DOB Discharging Hospital & Ward: Planned Discharge Date: Name of Support or Next of Kin/Carer & Ward contact number: Planned District Nurses Start Date & Time GPSurgery Name: The following checks need to take place before discharge: Referral discussed and accepted verbally by Community IV Nurse/Single Point of Access/District Nursing Team Tick Type of IV access (Please circle and complete insertion date): Cannula Midline PICC Line Hickman Line Implanted Port (NB: a new cannula must be inserted on day of discharge and IV dressing dated and initialled). Date of Insertion: Complications or poor venous access (If yes please provide details): Y / N For CVAD s (i.e. Piccline, Implanted Port): Checked by Xray: Yes No Length Inserted:. cms Length of catheter exposed at site:.. cms MEDICATION & EQUIPMENT TO BE SUPPLIED BY REFERRING HOSPITAL FOR THE DURATION OF TREATMENT IV Medication and solutions Quantity given Drug/Antibiotic Diluents and reconstitution solutions e.g. Sodium chloride 0.9%, water for injection, and Sodium Chloride 0.9% 50ml/100ml bags (if required for infusion) (check TTA s). Flush solution e.g. Sodium chloride 0.9% 10ml pre-filled syringes or 10ml ampoules and Heparin Sodium units per ml if prescribed (check TTA s) Equipment:- Dressings i.e. Cannula dressing one dressing required every 72 hrs. Piccline/Midline dressing one dressing required per week. Luer Lock Syringes i.e. 1 x 10mls for drawing up medications and 2 for flushes each visit. Safety Needles and filter needles for glass vials if applicable Cannulae 22G (blue) or 20G (pink) i.e. one required every 72 hrs. IV administration sets i.e. one per infusion. Bungs/Needle Free Device for lines i.e. one per week. Chlorhexidine 2% based wipes. Chloraprep 1.5ml Sponge Applicator i.e. 1 per dressing change or re-cannulation. Name of discharging nurse: Signature: Date: Page 2 of 4 Version 1:2 Revised 22/04/2014

3 COMMUNITY IV THERAPY SERVICE REFERRAL DOCUMENTATION Authorisation for all patient s discharged from Hospital for HRCH Community IV Therapy to be completed by the Referring Doctor Patient s Name: NHS Number: Have you sought advice from the Antimicrobial Review Team (Microbiologist) regarding medication use and duration of treatment? Yes No Patient s Infection Status (please circle): N/A MRSA ESBL/ MSSA CDIFF VRE Name of Microbiologist: Name of Pharmacist: ANAPHYLAXIS RISK ASSESSMENT Allergy Status: Patient s that have suffered a previous anaphylactic reaction to a medication MUST NOT be prescribed the same medication. Is there any cross sensitivity between the medication to be administered and the substance that caused a previous reaction? (circle) Y N N/A Has the patient had the prescribed medication before (orally or intravenously)? How many doses of the current regimen have been administered? DIAGNOSIS (Reason for IV Therapy) Name of IV Antibiotic(s) Dose IV Duration List All Other Current Medication or attach discharge letter: DIRECTIONS FOR ANTIBIOTIC RECONSTITUTION: Date and time treatment has commenced in hospital: Date of review of treatment or follow-up appointment: What follow-up treatment or appointment has been arranged for this patient? Page 3 of 4 Version 1:2 Revised 22/04/2014

4 Patients Name BLOOD MONITORING: Is Blood Monitoring Required? Y / N NHS Number If yes, what blood monitoring is required, when and by whom? Any other relevant information: e.g. Key safe number PRESCRIBER'S DETAILS Name of Referring Doctor to be contacted for advice: (Please print) Contact No: Bleep No:.. Doctors Signature: Date:... Name of Registrar or Consultant with Continuing Overall Responsibility Contact number.bleep No NOW COMPLETE P2 RECORD OF MEDICATION AUTHORISATION AND ADMINISTRATION INCLUDING MEDICATION/DRUG SODIUM CHLORIDE 0.9% 50mls or 100mls FOR INFUSION IF APPLICABLE SODIUM CHLORIDE 0.9% FOR PRE AND POST FLUSHES (10MLS) AND ANY DILUTENTS FOR RECONSTITUTION OF DRUGS (e.g. water for injection) then Fax all completed documents and discharge summary/tta to Hounslow Single Point of Access(SPA) on Fax: Page 4 of 4 Version 1:2 Revised 22/04/2014

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