ADMINISTRATION BY INJECTION POLICY INTRAVENOUS, INTRAMUSCULAR AND CENTRAL LINES

Transcription

1 ADMINISTRATION BY INJECTION POLICY INTRAVENOUS, INTRAMUSCULAR AND CENTRAL LINES This policy should be read in conjunction with the Syringe Driver Policy, Medicines, Record Keeping and Records Management Policy, Consent policy for Mental/Community Health Services and Healthcare (Clinical) Waste Policy Version: 6 Date Issued: Review Date: October 2015 Relevant Staff Group(s): November 12 (February 2014 and May 2017 minor amendments) Registered Nurses in CH and MH Directorates, Medical staff working at inpatient units and community hospitals, Registered Nurses working in the community for CH Directorate, Physiotherapists in CH Directorate, STARS, CPNs This document is available in other formats, including easy read summary versions and other languages upon request. Should you require this please contact the Equality and Diversity Lead on V6-1 - February 2014 (May 2017)

2 DOCUMENT CONTROL Reference NV/Nov12/AbIP Version 6 Status Final Author Senior Nurse for Clinical Practice Amendments Intravenous: Merge of Policies for Intramuscular Injections and Management of Central Lines, training section updated, inclusion of depot injections policy, Addition of clinical audit standards, Inclusion of recommendations of the equality impact assessment, inclusion of Removal of PICC lines, Care and Management of Implanted Venous Access Devices and Cytotoxic Infusion Pumps Disconnection and Disposal May 2017 Update Appendix A with: Access to the Royal Marsden The appropriate drug monographs Document objectives: Somerset Partnership NHS Foundation Trust is committed to ensuring safe clinical practice in the administration of intravenous and intramuscular drugs through the provision of appropriate training and guidelines for staff to ensure safe clinical practices. Approving body Equality Impact Assessment Ratification Body Date of issue Clinical Governance Group Review date October 2015 Contact for review Lead Director Date: October 2012 February 2014 Impact Part 1 Date: November 2012 Date: November 2012 Senior Management Team February 2014 May 2017 November 12 (February 2014 and May 2017 minor amendments) Senior Nurse for Clinical Practice Chief Operating Officer CONTRIBUTION LIST Key individuals involved in developing the document Designation or Group Senior Nurse for Clinical Practice District Nurse Lead Clinical Trainer for the training department Out of Hours Lead and Interim Lead for District Nursing Clinical Skills Facilitator Lead for Equality and Diversity Clinical Skills Facilitator Chief Pharmacist Consultant Nurse for psychological therapies Lead Nurse for Medicines Management (Mental Health Services) Medicines Management Clinical Policy Review Group Clinical Governance Group Senior Managers Operational Group V6-2 - February 2014 (May 2017)

3 CONTENTS Section Page Doc Document Control 2 Cont Contents 3 1 Introduction 4 2 Purpose and Scope 7 3 Duties and Responsibilities 7 4 Explanations of Terms Used 9 5 Statement of Policy and Guidance 9 6 Training Requirements 10 7 Monitoring Compliance and Effectiveness 11 8 References, Acknowledgements and Associated Documents 12 9 Appendices 13 Appendix A Administering IV Drugs and Fluids 14 Appendix B Flow chart for red flag drugs 22 Appendix C Intramuscular Injections 23 Appendix D Central Line Management 36 Appendix E Cytotoxic Infusion Pumps Disconnection and Disposal 61 Appendix F Competency assessment for intravenous drug administration 69 Appendix G Competency assessment for the care of central lines 75 Appendix H Audit Standards for Injectable Medicines 82 V6-3 - February 2014 (May 2017)

4 1. INTRODUCTION 1.1 Somerset Partnership NHS Foundation Trust is committed to ensuring safe clinical practice in the administration of intravenous (IV) and intramuscular (IM) drugs through the provision of appropriate training and competency assessment for staff to ensure safe clinical practices. 1.2 The use of injectable medication has many healthcare benefits for patients. The complexities associated with the prescription, preparation and administration of injectable medicines means that there are greater potential risks for patients than for other routes of administration. Safe systems of work are required to minimise these risks (NPSA 2007). 1.3 Each nurse, midwife or health visitor is personally accountable for their practice and professional accountability in line with Nursing and Midwifery Code: Standards of conduct, performance and ethics for nurses and midwives (2008). 1.4 Staff should ensure the patient is able to understand the information given to them and are able to give their informed consent. This may necessitate the use of a professional interpreter and the translation of written information. A capacity assessment should be considered for those patients who are unable to consent to the procedure and reference should be made to the relevant Trust policy (refer to the consent policy for your service, Consent and Capacity to Consent to Treatment Policy Mental Health Services or Consent to Examination and Treatment Community Health Services). 1.5 The administration of any medication is an opportunity for assessment and information exchange with the patient and their carers (where appropriate). Preparation should include an assessment to see if the physical and /or mental health of the patient has changed since the previous contact. Any beneficial effects or side-effects experienced since the last injection should be considered and questions asked of the patient and their carer (if appropriate) to elicit any concerns or information needs. 1.6 For all ambulatory care patients please use the Ambulatory Care Documents. 1.7 Staff must consider the gender, beliefs and religious backgrounds of patients when approaching and gaining consent to administer an injection. For example, a patient may request same gender as the patient. This may not always be possible or practical in an emergency situation. Labelling of syringes prior to administration 1.8 All injections should be labelled immediately after preparation, except for syringes intended for immediate push (bolus) administration by the person who prepared them. Under no circumstances should an operator be in possession of more than one unlabelled syringe at any one time, nor must an unlabelled syringe be fitted to a syringe driver or similar device National Patient Safety Agency (NPSA) Where one IV drug and one IV Sodium V6-4 - February 2014 (May 2017)

5 Chloride 0.9% (normal saline) flush are prepared a pre-printed label can be used to identify the IV normal saline flush. Pre-printed labels will only be available for Sodium Chloride 0.9%. When approaching a patient with two IM injections for administration, e.g. rapid tranquilisation, then both must be labelled (refer to rapid tranquilisation guidelines). Intravenous 1.9 All practitioners involved in IV drugs administration must adhere to the guidelines of their professional bodies and must follow the flow chart when handling red drugs (Appendix B) The term intravenous (IV) refers to drugs administered using both peripheral and central venous access devices This policy should be read in conjunction with the following trust policies and protocols Medicines Policy Medical Devices Blood & Blood Components Transfusion Policy Infection Control Healthcare (Clinical) Waste Policy Safe handling of sharps policy Indwelling devices policy Untoward Events Reporting Policy Protocol for Assessing Competencies and Clinical Practice This policy should be read in conjunction with the following National Patient Safety Agency Alerts Promoting Safer Use of Injectable Medicines (March 2007) Risks with Intravenous Heparin Flush Solutions ( April 2008) Intramuscular 1.10 Evidence has identified a potential risk to patients from incorrect injection procedure. Somerset Community Health has a responsibility under clinical governance to examine and manage that risk It may be due to the misconception that administering an injection is a basic task that it has traditionally been overlooked by continuing professional development programmes (Diggle 2007), resulting in nurses relying on skills which they acquired during their original training (Chiodini 2000) Nurses have a duty to deliver care based on current evidence and best practice (NMC 2008). However, the traditional method of verbalising information down through generations of nurses has exposed clinical practice to rituals (Wynaden et al 2005). V6-5 - February 2014 (May 2017)

6 The Royal Marsden Hospital Manual (Dougherty and Lister 2011) recognises only one particular site for intramuscular injections. This policy will raise awareness of intramuscular sites and thereby reduce the risk of potential complications It is essential to consider whether an injection is justified (Nicoll and Hesby 2002) reaffirmed by World Health Organisation s (WHO) policy that injections must be safe and appropriate (WHO 2006) There is a nationally recognised manual for depot medication also available (Feetam and White 2011) available at for staff to refer to The purpose of an intramuscular injection is to deliver medication into the muscle layer beneath the subcutaneous tissue:- for rapid systematic uptake of a drug (Greenway 2004) when prolonged action is required (Hunter 2008) enables relatively large doses to be absorbed into well perfused muscle (Workman 1999) Certain drugs are only licensed to be administered intramuscularly to prevent local irritation or inflammation or those drugs that may be destroyed in the gastrointestinal tract (Nicoll and Hesby 2002). These include:- biological eg. vaccines, toxoids and immune globulins nonbiologicals eg. antibiotics and depot formulations such as neuroleptics, hormonal agents and cancer treatments allowing slow release. They are often oily solutions with potential to be irritating (Nicoll and Hesby 2002) Patient related reason for giving an injection:- inability to take medication orally (Higgins 2004) patient s preference for injection believing it to be more effective (Nicoll and Hesby 2002) reluctance to take medication necessitating an injection, but still considering the patients rights and need for medication (Nicoll and Hesby 2002). This is more likely in the mental health setting (Cocoman and Murray 2008) Central Line Management 1.11 This document outlines recommended practices relevant to the management of central venous access devices; Peripherally Inserted Central Catheters (PICC), Tunnelled Hickman Lines and Implanted Venous Access Devices (Portacath) It follows guidance issued from the Royal College of Nursing Standards for infusion therapy (2010) and Mallet and Dougherty (2008) Royal Marsden Hospital Manual of Clinical Nursing Procedures. The guidance will also reflect management differences recommended from the three main acute V6-6 - February 2014 (May 2017)

7 hospitals serving Somerset, namely, Musgrove Park Hospital (MPH), Yeovil District Hospital (YDH) and Royal United Hospital (RUH) which are detailed on page Due to the varying differences at the three main acute hospitals, staff must ensure they follow the patient s own care plan for management of their line which has been developed in conjunction with their specialist Nurse or Consultant. If the patient does not have a valid care plan, ensure the guidance recommended on page (may need to check this page number throughout the doc) of this policy and must be followed for each patient dependent on the referring acute hospital Practitioners undertaking this clinical skill must ensure they are trained and have been assessed as competent in the management of central lines. The training and competency assessment received must cover the main aspects of central line management including, flushing, dressing change, administration of medicines and blood sampling The Trust acknowledges and respects the diverse needs of its staff and will respect these at all times when implementing this policy. This includes respecting the privacy and dignity of patients at all times. The reasons for the intervention should be clearly explained to the patient and this may necessitate the use of a professional interpreter. 2. PURPOSE AND SCOPE 2.1 The purpose of this policy is to ensure the safe administration of injectable drugs and additives and:- informing all practitioners of their responsibility in the safe and effective administration of medicines and fluids by injection ensuring that all persons who undertake IV medicine administration have demonstrated that they are competent to do so ensuring staff are aware of current evidence surrounding injection procedures ensuring staff are familiar with all potential injection sites highlighting the importance of accurately locating intramuscular injection sites raising awareness of possible complications updating skills and technique to ensure patient safety and protect own accountability sharing knowledge to achieve best practice (NMC 2008) 3. DUTIES AND RESPONSIBILITIES All Staff 3.1 Intravenous drugs may only be administered by registered practitioners who have completed appropriate training (IVs and central lines) and have demonstrated that they are competent to safely administer intravenous medication to patients following completion of the relevant competency V6-7 - February 2014 (May 2017)

8 assessments (Appendices E and F). Staff must attend or complete the mandatory anaphylaxis training annually. The Prescriber 3.2 It is the responsibility of the prescriber to ensure that medicines are prescribed in accordance with Trust approved medicines. For the Community Health Services this is in accordance with NHS Somerset Formulary. They should only administered by injection when no other route is suitable. This decision will be based upon; the availability of other routes the clinical condition of the patient the available formulations of the specific medicine required relevant NICE or Trust clinical guidelines It is the responsibility of the prescriber to ensure that intravenous prescriptions are reviewed regularly and at least once every 24 hours, unless otherwise clinically indicated The prescription must be changed to a less hazardous route at the earliest clinically appropriate opportunity All intravenous antibiotics must be reviewed after 48 hours for consideration of converting to the oral route. All staff are responsible for ensuring this review and to clearly document the rationale for the extended duration of treatment Any nurse working in a community setting who is asked to prescribe IV medication (red flag drugs) should first confirm with their line manager and must follow the flow chart on page 22. Clinical Pharmacists 3.3 The Clinical Pharmacists and Technicians provide a broad based clinical advisory and medicine management service for community hospitals through the service level agreements in place with the relevant Trust pharmacy departments. The service includes: prescription review medicine choice pharmaceutical education and training information regarding storage, administration and use of medicines implementation and use of medicine management systems for ordering, storing, administration and supply of medicines preparation of IV fluids with additives The hospital pharmacies can be contacted to obtain advice and respond to specific enquiries raised by health care professionals regarding all aspects of drug therapies including: V6-8 - February 2014 (May 2017)

9 method of administration diluents and infusion fluids drug stability delivery systems e.g. pump drug compatibility rate of administration contraindications and side effects interactions unlicensed drugs and their use preparation of anaphylaxis boxes provision and updating of monographs in clinical areas 4. EXPLANATIONS OF TERMS USED Central Line sited centrally with the tip sitting at the entrance of the right atrium Hickman Line trade name for central line. Extends into the deeper veins Intravenous within a vein Intramuscular into a muscle PICC Line Peripherally (forearm/hand) Inserted Central Catheter SmPC Summary of Product Characteristics Portacath Implanted Venous Access Device Personal Protective Equipment (PPE) should be worn when all other measures are inadequate to control exposure. It protects only the wear, while being worn and includes such items as gloves, aprons, respirators and eye goggles. Cytotoxic literally means toxic to cells and hence cytotoxic medications will kill cells. 5. STATEMENT OF POLICY AND GUIIDANCE Authorisation of Drugs for Administration 5.1 The Trust does not provide a defined list of approved drugs for administration and expects staff to practice only within their sphere of competency and in accordance with the Trust Medicines Policy and Prescribing Formulary and the Nursing and Midwifery Council Code of Conduct Any nurse working in a community setting who is asked to administer IV medication (red flag drugs) should first confirm with their line manager and must follow the flow chart at Appendix B Criteria for assessors 5.2 To be able to assess an individual practitioner s knowledge and competencies for IV drug administration the assessor must: hold a recognised teaching and assessing qualification be a registered health care professional be confident and competent in performing the skill V6-9 - February 2014 (May 2017)

10 practice the skill regularly have sound knowledge of the relevant policies and procedure have a thorough understanding of the competency based assessment process Administration/ Recommendations for Safe Practice 5.3 In accordance with the Trust s Medicine Policy it is recommended that the administration of IV drugs and intravenous additives should be undertaken by a registered nurse who is competent and will be checked by a second member of the nursing team, preferably a Registered Nurse Registered practitioners working alone in the community must have demonstrated the necessary knowledge and competence to administer medicines by this route and should, where possible, have the drug checked by another individual who knows the patient. This could be a parent, carer or the patient. At a minimum any dose calculation should be independently checked (RCN 2010). Competency assessments for blood transfusions can be found on the internet: In accordance with Trust policy all blood transfusions should be administered by a registered nurse who must have completed the IV training and the blood transfusion training. Staff must be assessed as competent in both IVs and blood transfusions in addition to a second responsible person, usually a member of the nursing team When seeking information or a second check, the nurse should use the appropriate source, including pharmacy for medicine information, and be aware of the role and competence of any second person involved The administration of IV drugs must be carried out by a registered practitioner; however student nurses who have been assessed as competent during their training may act as the second checking person Controlled drugs may be administered intravenously in accordance with the Trust s Medicine Policy Appropriate personal protective equipment should always be used There are two main types of ampoules; spot ampoules always break away from the spot ring cut ampoules can be broken in any direction 6. TRAINING AND ASSESSMENT OF COMPETENCE 6.1 The Trust will work towards all staff being appropriately trained in line with the organisation s Staff Mandatory Training Matrix (training needs analysis). All training documents referred to in this policy are accessible to staff within the Learning and Development Section of the Trust Intranet; V February 2014 (May 2017)

11 6.2 All staff must complete the Trust Medicines Management training programme, including newly qualified and newly appointed Registered Nurses. Once attended training staff must be assessed as competent before commencing medicines administration of any form or route. All staff must have undertaken mandatory training in Anaphylaxis 6.3 Education and training will include theoretical knowledge and practical skills. This will be followed by a period of supervised practice and formal assessment of competence using the agreed Trust competency framework and documentation as supplied by the training department. Specialist training will be provided for staff who will be caring for patients with an implanted venous access device. This will be on a named basis only. This procedure is not to be undertaken otherwise. The training at present will be delivered by the assigned hospital for the patient. 6.4 Competencies for Medicines Management (includes sub-cutaneous and intramuscular administration), intravenous therapy and Management of Central Line Catheters (PICC/Hickman) lines must be achieved prior to unsupervised administration of IV therapy via central lines (refer to Appendix E Competency assessment for intravenous drug administration and Appendix F Competency assessment for the care of Central Lines. Competency assessment for implanted venous access devices will not be necessary proving the Registered Nurse has proved competence in IV administration and Care of Central Lines. 6.5 All training and competency records must be reviewed at appraisal. Records must be maintained by the individual and the Department Manager. This must include a record of how often this skill has been used in practice. 6.6 All staff should have access to further update training if it is required to enable them to continue to practice competently. This should be considered after periods of extended absence through sickness or maternity leave or where lack of administration opportunities has compromised potential competence. 6.7 Bank and agency staff who can provide written evidence of training and competency may administer IV drugs 7. MONITORING COMPLIANCE AND EFFECTIVENESS 7.1 Any reported incidents via DATIX will be investigated and necessary actions implemented. 7.2 An annual audit (Appendix H) will be undertaken to ensure compliance with policy and practice. The audit results will be made available to and monitored by the relevant Best Practice Groups and discussed at the Clinical and Social Care Effectiveness Group. V February 2014 (May 2017)

12 8. REFERENCES, ACKNOWLEDGEMENTS AND ASSOCIATED DOCUMENTS 8.1 References Education and Training Strategy Somerset Primary Care Trust 2008 Good Practice Statement for the Preparation of Injections in Near Patient Areas, including Clinical and Home Environments. NHS Scotland 2002 Injectable Drug Administration Guide UCL Hospitals. Edited by R Shulman et Al, Blackwell Science 1998 Mallet, J. and Dougherty, L th ed. Royal Marsden Hospital Manual of Clinical Nursing Procedures. Wiley- Blackwell. Medical Devices Agency Single Use Medical Devices: Implications and consequence of re-use. MDA DB 2000(04) August Multiple Use of Injections 3 rd ed NHS Pharmaceutical Quality Control Committee Nov 2004 NMC Code: Standards of conduct, performance and ethics for nurses and midwives (2008) NMC Standards for Medicines Management 2007, updated 2010 NPSA (2007) Patient Safety Alert No. 20 Promoting Safer Use of Injectable Medicines NPSA Patient Safety Observatory Safety in doses: Medication Safety Incidents in the NHS RCN Standards for Infusion Therapy Cross reference to other procedural documents Consent and Capacity to Consent to Treatment Policy (Mental Health Services) Consent to Examination and Treatment Policy (Community Health Services) Healthcare (Clinical) Waste Policy Infection Control Policy Medicines Policy Needlestick and Contamination Injury Policy Rapid Tranquillisation Guidelines Record Keeping and Records Management Policy Syringe Driver Policy V February 2014 (May 2017)

13 9. APPENDICES 9.1 For the avoidance of any doubt the appendices in this policy are to constitute part of the body of this policy and shall be treated as such. This should include any relevant Clinical Audit Standards. APPENDIX A Protocol for administering IV drugs and fluids APPENDIX B Flow chart for red drugs APPENDIX C Intramuscular Injections APPENDIX D Central Line Management APPENDIX E - Cytotoxic Infusion Pumps Disconnection and Disposal APPENDIX F Competency assessment for intravenous drug administration APPENDIX G Competency assessment for the care of central lines APPENDIX H Audit standards for safer use of injectable medicines V February 2014 (May 2017)

14 APPENDIX A ADMINISTERING IV DRUGS AND FLUIDS 1. For the detail of the procedure, registered nurses should refer to the most current Royal Marsden Manual of Clinical Nursing Procedures (found on the Trust intranet) 2. In accordance with the NPSA Patient Safety Alert, Promoting the Safer Use of Injectable Medicines (March 2007) the Trust must ensure that essential technical information on injectable medicines is available and accessible to healthcare staff in clinical areas at the point of use. 2.1 All staff administering IV medicine must use the Yeovil District Hospital IV monographs, accessed via the Somerset Partnership intranet site, on the homepage: and click on IV monographs. However, alternative Trust monographs may be used in specific circumstances, depending on patient safety, treatment continuation or complex needs. If a decision is made to use an alternative monograph, this must be documented in the patient s record. 2.2 If a patient has an adverse reaction or the version needs to be traced, contact must be made with Yeovil District Hospital s pharmacy to ascertain which version was used in conjunction with the date of administration. 2.3 It is the responsibility of the nurse administering the IV medication to ensure that an up to date IV monograph is available and stored with the prescription chart for each patient and referred to during the preparation of each dose. 2.4 On completion of the IV therapy the IV monograph should be destroyed and not kept in the notes. If a patient has an adverse reaction or the version needs to be traced, contact must be made with Taunton and Somerset NHS Foundation Trust pharmacy to ascertain which version was used in conjunction with the date of administration. Routes and Methods for the Administration of IV Drugs 3. IV drugs may be administered in the following ways; intermittent bolus dose using cannulae /y connections intermittent infusion continuous infusion of proprietary pre-prepared drugs addition to infusion fluids in bags, bottles or burette chambers central venous catheter port central lines triple lumen, quad lumen, drum catheter Hickman tunnelled lines and PICC lines (peripherally inserted central catheters) implanted devices (specific training will be required from the referring area prior to using these devices) V February 2014 (May 2017)

15 Consideration should be given to using needle free connectable ports where ever possible. 4. The practitioner may only administer drugs via the methods for which they have received education and training and for which the drugs have been prescribed and are licensed. 4.1 Where drugs need to be given using a syringe pump or volumetric infusion pump, the practitioner must have received education and training in the use of that equipment. 4.2 When IV drugs are being administered via a pump for infusions the system must be checked 15 minutes after commencing administration and then at each drug round unless otherwise directed on the monographs. The infusion must also be checked at each shift handover. 4.3 Changing of IV infusion lines must be carried out every 72 hours (RCN 2010) unless the following applies: if a drug is administered using the Central Venous Route this infusion line must be changed every 72 hours if a drug is being administered via an intermittent infusion the line, it must be changed at every dose if disconnected between doses for blood administration the line must be changed at least every 12 hours and immediately upon completion of the last unit A peripheral cannula which has been inserted in an emergency situation where asepsis may have been compromised must be changed after 24 hours. 4.4 The cannulation site should be reviewed on each shift change and on administration of IV drugs. This must be recorded on the Trust cannula care record see page All cannulae should be changed every 72 hours, or as per manufacturers recommendations, or sooner if complications are suspected. A suitable dressing must be used to ensure secure fixation and allow observation of site. Dressings should be changed if soiled on review. 4.6 Cannulation may only be carried out by a practitioner who has received Cannulation insertion training and assessed as competent. 4.7 Where drugs have been added to bags, mini bags or syringes, an intravenous additive label (available from Pharmacy) must be completed and attached to the bag or syringe. 4.8 After the addition of any drug to a bag, thorough mixing must be ensured. This prevents layering of drug and ensures a constant dose is given. 4.9 The following information must be included on the additive label as well as on the cannula care plan, see page 20. V February 2014 (May 2017)

16 patient s name and Hospital number drug name/dose/batch number/expiry date date and time drug added details of diluents signature of administering practitioner and checker (where appropriate) Use of Flushes to Maintain Patent Peripheral Lines 5. Maintenance of the patency of peripheral intravascular catheters is important to reduce the discomfort and expense of replacement. 5.1 The NPSA Rapid Response Report (April 2008) has identified a number of incidents of harm or potential harm from heparin flushes. Therefore, Practitioners are required to use 5ml sodium chloride 0.9% before and after the administration of IV drugs in order to flush the cannula. This may be administered against the patient group direction for 0.9% saline flush where the practitioner has been assessed as competent to use this and signed for on the prescription chart. 5.2 To maintain patency the method of flushing to be employed is the push pause technique and to end the flush with a positive pressure. 5.3 For central lines, specific flushing solution advice and guidance should be sought from the pharmacy department and recorded in the medical notes (refer to page 55). Potency and Incompatibility of IV Drugs 6. Drugs administered by the IV route have a more immediate and potentially greater effect than those administered by other routes. There is also a risk of incompatibility between drugs and intravenous solutions. 6.1 Potassium Chloride for injection must not be kept in stock due to the serious consequences of accidental administration. 6.2 IV fluids with added potassium are available from pharmacy. Potassium Chloride must never be administered by bolus dose and practitioners must not add Potassium Chloride to infusion fluids. 6.3 When adding and mixing drugs the monographs must be checked to ensure compatibility using the Monograph (page 22). Drugs must not be added to the following: blood, plasma and blood products parental nutrition regimes Mannitol Sodium bicarbonate 6.4 IV drugs must be administered or added to intravenous solutions immediately following reconstitution. Delay may result in degradation and loss of potency and microbial growth. V February 2014 (May 2017)

17 6.5 A 5ml Sodium Chloride 0.9% flush must be administered before and after giving any drug. 6.6 For flushing a 10ml syringe must be used to reduce the pressure using a push pause technique to minimise occlusion. 6.7 The registered practitioner who is to administer the drugs must prepare them. 6.8 Drugs must not be pre-prepared for another practitioner to administer unless that person is present or there are specific protocols agreed by the Pharmacy and department staff Education and Training - Basic Scope Package 7. All practitioners who undertake intravenous medicines administration shall undergo competency based training. This shall cover the following areas: Responsibilities of staff (e.g. nurse, doctors, and pharmacists) Anatomy and Physiology of the circulatory system and veins of the arms and hands. Theory and practical session in intravenous cannulation. Hazard involved in the preparation of injections Calculations including a drug calculation test. Drug incompatibilities Stability of prepared injections Displacement values Aseptic technique Checking procedures Documentation Labelling Disposal of waste Sources of information Awareness of COSHH and other health and safety considerations Care and management of vascular access devices Infection control principles Use of infusion equipment Practical session in drawing up and administering IV medicines. Complications of IV therapy. Assessment of Competency 7.1 Successful completion of this package shall enable the person to prepare and administer. 1. Ready to use IV medicines 2. IV bolus 3. IV infusions 4. Additions of a single medicine to an infusion bag 5. Administration via an IV infusion pump V February 2014 (May 2017)

18 6. Basic Scope plus Syringe Driver Competences now being delivered by competency assessed staff within the Trust (refer to syringe driver policy) 7.2 In addition to the Basic Scope package the training shall include Type of devices Specific hazards associated with syringe drivers Hazards associated mixing medicines Calculation in relation to syringe driver 7.3 Successful completion of this package shall enable the person to prepare and administer drug additions to a syringe for administration by a driver V February 2014 (May 2017)

19 Surname: Forename: Date of Birth: NHS No: Peripheral Cannula should be removed and replaced at 72 hours Always remove cannula as soon possible if no longer needed CANNULA ASSESSMENT TOOL Score Indications Action 0 Patient comfortable Site appears healthy Document site as satisfactory and continue observation Infusion runs/flushes well 1 Slight pain, redness or swelling and/or slight resistance to infusion Consider saline flush (if compatible Assess whether prescribed drugs or fluids may cause damage Document condition of site and observe more frequently 2 CANNULA 1 Pain, redness or swelling and/or inability to flush Be prepared to remove cannula Remove cannula Document condition of site and action taken Re-inspect and report after removal of cannula Involve pt/carer and doctor as appropriate Insertion of Cannula Date and time of insertion Device used: Size: Inserted by (print name): Date and time of removal: CANNULA 2 Insertion of Cannula Date and Time of Insertion Device used Size Inserted by (print name) Date and Time of Removal Cannula Record Site of cannula Day Date Score Initials Cannula Record Site of cannula Day Date Score Initials am pm am pm am pm am pm am pm am pm am pm am pm Mark with an X position of each cannula V February 2014 (May 2017)

20 Surname: Forename: Date of Birth: NHS No: Peripheral Cannula should be removed and replaced at 72 hours Always remove cannula as soon possible if no longer needed CANNULA ASSESSMENT TOOL Score Indications Action 0 Patient comfortable Site appears healthy Document site as satisfactory and continue observation Infusion runs/flushes well 1 Slight pain, redness or swelling and/or slight resistance to infusion Consider saline flush (if compatible Assess whether prescribed drugs or fluids may cause damage Document condition of site and observe more frequently 2 CANNULA 3 Pain, redness or swelling and/or inability to flush Be prepared to remove cannula Remove cannula Document condition of site and action taken Re-inspect and report after removal of cannula Involve pt/carer and doctor as appropriate Insertion of Cannula Date and time of insertion Device used: Size: Inserted by (print name): Date and time of removal: CANNULA 4 Insertion of Cannula Date and Time of Insertion Device used Size Inserted by (print name) Date and Time of Removal Cannula Record Site of cannula Day Date Score Initials Cannula Record Site of cannula Day Date Score Initials am pm am pm am pm am pm am pm am pm am pm am pm Mark with an X position of each cannula V February 2014 (May 2017)

21 Guidance on how to access the Intravenous Drug Monograph from the Taunton and Somerset NHS Foundation Trust Intranet for Community Health Services 1. Find available computer and log onto internet explorer. This is the homepage for your intranet. 2. At the bottom of the page under Local NHS Links find and click on Taunton and Somerset NHS Foundation Trust. 3. Once you have clicked on the link you will then be presented with Taunton and Somerset Trust s homepage. 4. At the top of the page click on Divisions and Departments. In the Department search box you will see the A-Z, click on P, you will then see a list of departments beginning with P, click on Pharmacy. This is now the Pharmacy Homepage. 5. On the left hand side of the page is a long narrow green box with subsections inside; left click on Injectable Medicines. 6. You are now on the Injectable Medicines Administration Guide page. You will also see the A-Z again, this time it represents the initial letter for the drug you are giving, for example, Metoclopramide, click on M and look down the list of drugs starting with M. When you see Metoclopramide left click on it and this will reveal the Monograph for this drug. 7. Once monograph found, print off and keep with the drug administration chart for that patient for the duration of the treatment in accordance with the IV Drug Administration Policy. 8. Remove and destroy IV Monograph once the course of treatment is complete. Please familiarise yourself with this site and the principles of always checking the monograph prior to administering the intravenous drug as the monograph guidelines are live and can be changed or updated at any time without any prior warning. V February 2014 (May 2017)

22 APPENDIX B PATHWAY FOR APPROVAL FOR ADMINISTRATION OF RED DRUGS Request to administer Red Drugs Yes Escalate to Head of Division to ascertain if it safe to administer and staff have capacity to undertake this role. Head of Medicines Management No Does it require specialist skills? Yes *Clinical Management Plan Is clinical management plan* in place and agreed with Prescriber and GP Yes Document request and arrange for administering nurse to have copy of clinical management plan* No Senior Nurse for the team to discuss with Clinical Practice team and confirm training and competency requirements, competent to administer Senior Nurse for the team to talk to referrer and arrange clinical management plan* to be agreed with Prescriber and GP No Senior Nurse for the team refers back to referrer with explanation Head of Division advised Referral letter Confirmation that patient consenting and agrees to treatment plan Somerset Partnership Prescription sheet completed by prescriber and submitted Contact details of prescriber confirmed Drug treatment protocol supplied to include possible side effects and responding actions required Skills requirement confirmed Confirmation that GP aware Confirmation of drug supply by prescriber or by patient (FP10) Start date agreed V February 2014 (May 2017)

23 APPENDIX C INTRAMUSCULAR INJECTIONS INCLUDING DEPOTS 1. The choice of injection site is crucial as the uptake of medication can be enhanced or diminished depending on the site chosen (Nicoll and Hesby 2002). 1.1 Knowledge and use of appropriate sites reduce likelihood of injuries (Rodger and King 2000) and can promote patient comfort. 1.2 There are 5 suitable sites for intramuscular injection (see pages 28, 29, 32), it is vital that nurses are aware of the current evidence relating to the use of all 5 sites in order to make an informed decision regarding administration (Rodger and King 2000). 1) Dorsogluteal (buttock) 2) Ventrogluteal (hip) 3) Deltoid (upper arm) provides the most rapid absorption rate 4) Vastus lateralis (thigh) quicker absorption rate than buttock 5) Rectus femoris (thigh) 1.3 The ventrogluteal site, see diagram 4, is recommended for the following reasons:- greatest thickness of gluteal muscle free of penetrating nerves free of major blood vessels consistently thinner layer of fat over the muscle 1.4 The use of the Z-track method (see page 32) appears to be widely practised (Rodger and King 2000). This technique creates a disjointed injection pathway which:- prevents seepage of medication can prevent skin staining diminishes subcutaneous irritation enhances patient care by reducing pain and injection site lesions (Beyea and Nicoll 1996) 1.5 A small test dose of injection must be given before the full treatment schedule is initiated for oil based depots to minimise the adverse effects (refer to product summary and BNF). V February 2014 (May 2017)

24 Intramuscular needle gauge size and length 2. It is essential to use the syringe and needle that is supplied with the medication, if this is not available then it is important for needles to be long enough to penetrate the muscle and still allowing a quarter of the needle length to remain external to the skin. The most common size is 23 Gauge or 21 Gauge ( cm long) for patients with more subcutaneous tissue. 2.1 It is important that when choosing the length of the needle that the muscle mass of the injection site is assessed to ensure that the needle does not end up in the subcutaneous tissue. 2.2 Where a product is provided in a pack with a syringe and needle for administration this technology will have been through a rigorous evaluation process in order for the company to gain a marketing authorisation (product licence) for the their product. The syringe and needle provided should ALWAYS be used. It is important to read the manufacturer s instructions regarding syringe and needle selection as packs and presentations may vary. Cytotoxic Therapy 3.1 For disconnection and disposal of cytotoxic infusion pumps, please refer to Appendix E 3.2 In accordance with national guidelines, only a registered nurse or medical practitioner, who has undergone further training, specifically in the administration of cytotoxic intramuscular drugs, may administer treatments. Proper Health and Safety risk assessments must be carried out prior to administration, particularly with regard to waste disposal and spillage. 3.3 The practitioner administering cytotoxic injection treatments must have the drug checked by a second practitioner. For cytotoxic treatment in the community setting: there must be a responsible clinician competent to prescribe cytotoxic therapy managing the treatment proper Health and Safety risk assessments must be carried out prior to administration, particularly with regard to waste disposal, spillage and extravasation the disposal of any remaining cytotoxic drugs or equipment should be in a purple lidded sharps bin as per the Trust Healthcare (Clinical) Waste policy Sciatic nerve injury 4. Current research is unanimous in advocating the ventrogluteal site as opposed to the dorsogluteal (Cocoman and Murray, 2008; Greenway et al, 2006; Small, 2004; Rodger and King, 2000). V February 2014 (May 2017)

25 4.1 Small (2004) conducted a systematic review and Meta-analyses to identify factors which can lead to sciatic nerve injury in adults and preventative measures which can be taken by nurses. Small (2004) concluded that:- the causative factors of sciatic nerve injury may be mechanical or chemical even if the needle does not penetrate the nerve, the medication or sheer volume could affect the nerve 4.2 Possible complications from sciatic nerve injury are:- excruciating burning pain unrelieved by analgesia motor loss e.g. foot drop, loss of toe flexion and extension sensory loss e.g. protective foot sensation complete paralysis 4.3 A retrospective study of 380 sciatic nerve injuries over 24 years at a University medical centre discovered 33% of cases were directly associated with intramuscular injection (Kline et al 1998). 4.4 The strength of Small s (2004) review is the inclusion of court cases from Canada and USA implicating sciatic nerve injury in association with intramuscular injection. Of 16 court cases identified:- 6 decisions were found in favour of the plaintiff 1 case was agreed by out of court settlement remaining 9 cases failed due to lack of proof or legal problems 4.5 Small (2004) emphasises the importance of accurate documentation. in 5 court cases the site of injection was identified as the buttock or quadrant method, resulting in claims against staff alternatively, in another case, a nurse documented that the injection was given in the hip and although the patient stated it was in the buttock, they were not found guilty of negligence. Advantages and disadvantages of intramuscular injections (with special reference to long acting antipsychotic depot injections) 4.6 Advantages may include; reduces necessity for tablets or capsules to be taken on a daily basis reduces uncertainty about the amount of medicine taken or not taken no influence of first-pass metabolism thus improved bioavailability more consistent delivery of antipsychotic medications with more stable plasma levels over time which can minimise side-effects and reduce variations in symptom control earlier detection of non-adherence which can be followed up quickly resulting in a potentially reduced relapse rate leading to better outcomes possibly a reduced risk of admission with potential resultant cost savings V February 2014 (May 2017)

26 potentially reduced need for repeat prescriptions since the dosing interval of such formulations is normally between one and four weeks reduces the risk of accidental or deliberate self harm through overdose the potential to enhance the therapeutic relationship and partnership working with the patient and their carer (if appropriate) by the regular frequent contact required 4.7 Disadvantages may include; pain, erythema, swelling at the site of injection as well as nodule formation particularly with oil-based injections risk of damage to nerves, arteries or veins if side-effects occur they will be prolonged until plasma levels fall, hence the necessity of a test dose of the oil-based depot formulations the need to confirm efficacy and tolerability to the oral formulations of the non-oil based long-acting injections where required and practical it can take several weeks for plasma levels to reach steady state some people have a dislike or even have a phobia of needles social embarrassment and the need for chaperoning and gender matching in Mental Health Services staffing and medicine storage requirements in the past depot injections in mental health services have been viewed by some as stigmatising and coercive Ethical Perspectives 5. Nurses have a legal and ethical duty to deliver evidence-based care (NMC 2008). However, researchers have been surprised to discover that the dorsogluteal site is still commonly used in practice in preference to the ventrogluteal site (Cocoman and Murray, 2008; Greenway et al, 2006; Small, 2004). 5.1 The moral obligation of non-maleficence requires nurses to respect others and take due care not to harm patients (Henry 1996). 5.2 In addition, justice relates to the moral principle of care whereby an organisation should have policies in place to support the welfare of patients and staff (Henry 1996). 5.3 For some cultures it is unacceptable to expose the gluteal region, therefore patients may prefer the deltoid site (Pandian et al 2006). 5.4 Prevailing obesity is another dimension to be considered with the gluteal muscles beyond the reach of standard needles in the majority of obese patients (Zaybak et al 2007). 5.5 This raises legal and ethical issues regarding the licensing agreement of medications which are licensed for intramuscular use and are in fact given subcutaneously (Greenway et al 2006). V February 2014 (May 2017)

27 REFERENCES Beyea, S.C; and Nicoll, L.H. (1995) Administration of Medications via the Intramuscular Route: An Integrative Review of the Literature and Research- Based Protocol for the Procedure, Applied Nursing Research, 8(1): Beyea, S.C; and Nicoll, L.H. (1996) Administering IM Injections the Right Way: Back to Basics, American Journal of Nursing, 96 (1): British National Formulary, March 2012, no. 63. BMJ Group and RPS Publishing. Campbell, J. (1995) Injections, Professional Nurse, 10(7): Chiodini, J. (2000) Vaccine Administration, Nursing Standard, 14(43): Cocoman, A; and Murray, J. (2008) Intramuscular Injections: A Review of Best Practice for Mental Health Nurses, Journal of Psychiatric and Mental Health Nursing, 15: Diggle, L. (2007) Injection Technique for Immunisation, Practice Nurse, 33(1): Feetam C. & White J. Eds. (2011) Guidance on the Administration to Adults of Oilbased Depot and other Long-Acting Intramuscular Antipsychotic Injections 3rd Edition. Available at accessed 15th September Commissioned by Janseen. Mallet, J. and Dougherty, L Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8 th ed. Blackwell Science Greenway, K. (2004) Using the Ventrogluteal Site for Intramuscular Injection, Nursing Standard, 18(25): Greenway, K; Merriman, C; and Statham, D. (2006) Using the Ventrogluteal Site for Intramuscular Injections, Learning Disability Practice, 9(8): Henry, C. (1996) Principles and Values: An Ethical Perspective in Healthcare Organizations, in Soothill, K; Henry, C; and Kendrick, K. (eds.) Themes and Perspectives in Nursing. 2 nd ed. London: Chapman & Hall. Higgins, D. (2004) IM Injection, Nursing Times, 100(45): Hunter, J. (2008) Intramuscular Injection Techniques, Nursing Standard, 22 (24): Kline, D.G; Kim, D.M; Midha, R; Harsh, C; and Tiel, R. (1998) Management and Results of Sciatic Nerve Injuries: A 24-Year Experience, Journal of Neurosurgery, 89: Nicoll, L.H. and Hesby, A. (2002) Intramuscular Injection: An Integrative Research Review and Guideline for Evidence-Based Practice, Applied Nursing Research, 16(2): V February 2014 (May 2017)

28 Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: NMC. Pandian, J.D; Bose, S; Daniel, V; Singh, Y; and Abraham, A.P. (2006) Nerve Injuries Following Intramuscular Injections: A Clinical and Neurophysiological Study from Northwest India, Journal of the Peripheral Nervous System, 11: Patel MX. Taylor M. David AS. Eds. Antipsychotic long-acting (depot) injections for the treatment of schizophrenia. (2009). British Journal of Psychiatry, 195(52): (Suppl) Promoting Safer Use of Injectable Medicines. Patient Safety Alert (2007), National Patient Safety Agency London, UK. (Accessed 23/09/08): Rodger, M.A. and King, L. (2000) Drawing up and Administering Intramuscular Injections: A Review of the Literature, Journal of Advanced Nursing, 31(3): Small, S.P. (2004) Integrative Literature Reviews and Meta-Analyses: Preventing Sciatic Nerve Injury From Intramuscular Injections: Literature Review, Journal of Advanced Nursing, 47(3): Workman, B. (1999) Safe Injection Techniques, Nursing Standard, 13(39): World Health Organisation [online] (2006) Injection Safety. (1 March 2009). Wynaden, D; Landsborough, I; and Chapman, R. (2005) Establishing Best Practice Guidelines for Administration of Intramuscular Injections in the Adult: A Systematic Review of the Literature, Contemporary Nurse: A Journal for the Australian Nursing Profession, 20(2): Zaybak, A; Güneş, Ü; Tamsel, S; Khorshid, L; and Eşer, İ. (2007) Does Obesity Prevent the Needle from Reaching Muscle in Intramuscular Injections? Journal of Advanced Nursing, 58(6): V February 2014 (May 2017)

29 INTRAMUSCULAR INJECTION SITES (refer to manufacturers instructions) 1) LOCATION OF THE DELTOID SITE (not recommended for depot injections apart from Risperidone long acting, unless specified by prescriber) Recommended for Hepatitis B vaccination The densest part of the muscle can be found by identifying the acromial process and the point on the lateral arm in line with the axilla. Asking patients to put their hand on their hip like a fashion model relaxes the muscle and makes it easier to access. The needle should be sited about 2.5cm below the acromial process at 90. The radial nerve and the brachial artery must be avoided (Workman 1999). Only small amounts (2ml volume) should be administered to this site. 2) LOCATION OF THE VASTUS LATERALIS & RECTUS FEMORIS SITES (not recommended for depot injections unless specified by prescriber) In an adult the vastus lateralis can be located by measuring a hand's breadth laterally down from the greater trochanter, and a hand's breadth up from the knee, V February 2014 (May 2017)

30 identifying the middle third of the quadriceps muscle as the injection site. The rectus femoris is in the middle third of the anterior thigh (Workman 1999). 3) LOCATION OF THE DORSOGLUTEAL SITE (recommended site for depot injections, in particular Depoprovera) Draw an imaginary horizontal line across from the top of the cleft in the buttocks to the greater trochanter of the femur. Then draw another line vertically midway along the first line, and the location is 'the upper outer quadrant of the upper outer quadrant' (Campbell 1995). That muscle is the gluteus maximus (Workman 1999). 4) LOCATION OF THE VENTROGLUTEAL SITE (recommended site for depot injections, including Depoprovera for obese women) Place the palm of your right hand on the greater trochanter of the patient s left hip or your left hand to patient s right hip (Workman 1999). Extend your index finger to touch the anterior superior iliac crest and stretch the middle finger to form a V as far as possible along the iliac crest as you can reach (Beyea and Nicholl 1995). V February 2014 (May 2017)

31 Clinical guidelines for administering intramuscular injections in adults 1. Check prescription for drug, time, dosage and route of administration with another nurse 2. Use 21 or 23 gauge for drawing up medication 3. Change needles after drawing up 4. Choose a needle of appropriate length to ensure medication is deposited in the muscle bed 5. Do not use the air bubble technique 6. Use the ventrogluteal as the site of choice unless contra-indicated 7. Assist patient into correct position to access site 8. Apply gloves and personal protective equipment if required 9. Swab the site with an alcohol pre-injection wipe 10. Use the Z-track method for all injections 11. Quickly plunge the needle into the skin at 90 degree angle leaving one third of the shaft of the needle exposed 12. Aspirate for blood if present, discard and prepare new injection 13. Inject medication at a rate of 1mL per 10 seconds 14. After 10 seconds withdraw the needle rapidly apply pressure to any bleeding point 15. Do not massage the site 16. Dispose of sharps safely and document procedure 17. Observe the site 2-4 hours after injection (inpatient areas) or minutes (community setting) to identify and monitor any side effects (Rodger and King 2000) V February 2014 (May 2017)

32 Checklist for Preparation of Intramuscular (IM) Injections Process 1 Check to see if the patient s physical or mental health has changed since the previous contact, including the health of the injection sites. Process 2 Ask about perceived benefit and any side-effects experienced since the last injection, if this is not the first. Process 3 Check to ensure: The prescription is legal and valid The dose is due The dose has not already been given There are no contra-indications or allergies The injection is in date Process 4 Confirm that the patient has the capacity to consent and gives their consent to the procedure. Process 5 Wash your hands according to accepted hand cleansing technique and apply disposable gloves. Process 6 Prepare the injection making any necessary dose calculation and using the correct equipment. Process 7 Get a second registered practitioner, if available, to double check all items in processes 3, 4 & 6. Process 8 If a second registered practitioner is not available, ask the patient to check that the correct injection and dose is to be administered and that the injection is in date. Process 9 Choose the site of administration according to the licensed indication for the injection and in collaboration with the patient, proceed according to appendices 4-7. V February 2014 (May 2017)

33 COMPARISONS OF DORSOGLUTEAL & VENTROGLUTEAL SITES (Greenway 2004) Dorsogluteal Location: Upper outer quadrant of buttock. Visually bisect the buttocks to locate site. Target muscle: Gluteus maximus Advantages: Ventrogluteal Location: Ball of opposing hand on greater trochanter and index finger on the anterior superior iliac crest. Form a V with middle finger site is within the V. Target muscle: Gluteus medius Advantages: Familiarity with procedure Free from major blood vessels & nerves Consistent thinness of subcutaneous tissue over injection site. Disadvantages: Disadvantages: If the injection is administered inferior or medially from the intended upper outer quadrant this may result in: New practice nurses unfamiliarity & lack of confidence Damage to the sciatic nerve, leading to pain or paralysis (temporary or permanent) Inadvertent administration of the drug intravenously by injecting into superior gluteal artery Varying amounts of subcutaneous tissue may result in injection not reaching muscle causing irritation & disrupting uptake of drug Dorsogluteal site is also associated with tissue necrosis, gangrene, pain, muscle contraction and fibrosis Contraindications: As above plus inflamed skin, abscess, administration of hepatitis B vaccine Contraindications: Inflamed skin, abscess, muscle contraction, administration of hepatitis B vaccine V February 2014 (May 2017)

34 5. Z-TRACK TECHNIQUE (BEYEA & NICOLL 1996) This has the advantage of achieving the correct plasma concentration whilst minimising the risk of pain or lesions at the injection site. Stretch the skin and subcutaneous tissue 2-3 cm using non-dominant hand Pierce the skin at 90 with a quick dart-like motion Aspirate for blood, and then if none, Slowly inject the medication at a rate of 1ml per 10 seconds. Withdraw the needle and release the tissue thereby locking in the medication. (Rodger and King 2000) Maximum volume for oil-based depot administration into a single site V February 2014 (May 2017)

35 Generic Name Brand/Trade name Max Volume Flupentixol decanoate 20mg in 1ml Flupentixol decanoate 100mg in 1ml Flupentixol decanoate 200mg in 1ml Fluphenazine decanoate 25mg in 1ml Fluphenazine decanoate 100mg in 1ml Haloperidol decanoate 50mg in 1ml Haloperidol decanoate 100mg in 1ml Pipotiazine palmitate 50mg in 1ml Zuclopenthixol acetate 50mg in ml Zuclopenthixol decanoate 200mg in 1ml Zuclopenthixol decanoate 500mg in 1ml Depixol Injection Depixol Concentrate Depixol Low Volume Injection Modecate Injection Modecate Concentrate Injection Haldol Decanoate 50mg in 1ml Haldol Decanoate100mg in 1ml Piportil Depot 5% w/v Clopixol Acuphase Clopixol Injection Clopixol Concentrate Injection 2ml 2ml 2ml Not specified in the SmPC Not specified in the SmPC 3ml 3ml Not specified in the SmPC 3ml 2ml 2ml SmPC Summary of Product Characteristics The product licences of individual antipsychotic injections indicate which sites are permitted. Currently none of the depot or other long acting antipsychotic injections is licensed for administration at the rectus femoris site. V February 2014 (May 2017)

36 APPENDIX D 1. GUIDANCE CENTRAL LINE MANAGEMENT 1.1 The following guidance on PICC and Hickman Line procedures are for general guidance only. Staff managing patients with PICC or Hickman Lines must ensure they follow the patient s own specific care plan compiled by their specialist Nurse or Consultant. If a care plan is not available then the hospital specific guidelines detailed on page 66 of this document should be followed. Dressing and cleaning the insertion site of PICC lines 1.2 Assess the dressing in the first hours after insertion, for accumulation of blood, fluid or moisture beneath the dressing. to prevent infection of the catheter, PICC line insertion sites needs redressing every 7 days, or as required if dressing becomes loose, damp, soiled/blood stained during all dressing changes, assess the external length of the catheter to determine if any migration/withdrawal of the catheter has occurred please refer to the patients specific care plan or page 55 for hospital specific management guidelines for PICC lines equipment required: sterile Dressing pack sterile Nitrile examination gloves Steri - strips (12mm x 100mm) x 5 Permeable sterile transparent dressing IV3000 cleaning agent 2% Chlorhexadine in 70% Isopropyl alcohol Chloraprep non- sterile gloves for removal of old dressing Statlock device (if required) Procedure Action No Procedure Rationale 1 Explain procedure to the patient Ensure patient understands and required to obtain informed consent 2 Wash hands thoroughly as per local policy To reduce risk of infection 3 Open sterile dressing pack and prepare dressing and cleaning equipment Te reduce risk of infection V February 2014 (May 2017)

37 Action No Procedure Rationale 4 Place sterile dressing towel under patient s arm To reduce risk of infection 5 Carefully remove old dressing and Steri Strips using a from the bottom up technique, whilst avoiding tugging or moving the catheter and avoid using scissors or other sharp instruments near the arm Reduce risk of dislodging the catheter and maintain its integrity 6 If there is a statlock device in situ replace the statlock device weekly. If it is causing irritation or discomfort on removal discuss this with the patient s referring hospital Ensures extra stability of the external catheter to prevent migration and less frequent device changes reduce risk of impaired skin integrity 7 Inspect the catheter exit site for signs of infection swelling, redness, or oozing. Notify GP or senior nurse if signs of infection are evident To ensure infection is recognised and treated promptly 8 Wash hands thoroughly and put on sterile Nitrile examination gloves Te reduce risk of infection 9 Clean the catheter exit site with 2% Chlorhexadine solution in circular movements moving away each time from the exit site until at least 5cms in diameter has been reached. Repeat twice and allow the skin to dry for 30 seconds To minimise risk of infection spread from a dirty to a clean area. To complete the decontamination process NB: the initial gauze dressing should be removed after 48 hours following insertion and not replaced unless excess oozing is observed 10 Apply new Steri strips - 2 horizontally and 2 vertically to hold catheter firmly in place and a new statlock device if required To ensure patient comfort and secure positioning of the PICC line 11 Apply new sterile dressing IV3000- using aseptic technique, ensuring the catheter exit site is in the middle of the dressing and the port is left uncovered for easy access To keep the line free from infection and secure 12 Tubifast Tubigauze may be applied over To aid patient comfort and V February 2014 (May 2017)

38 Action No Procedure the PICC to aid comfort and security Rationale PICC line security 13 Document external line length in cm, site observations, cleansing and dressing change in patients evaluation record and care plan To ensure good communication, documentation and continuity of care Flushing the PICC line 2. The Groshong PICC, in line with other Groshong catheters does not have a clamp, but has a three-position, pressure-sensitive Groshong valve at the internal tip of the catheter. The Groshong PICC line needs to be flushed once weekly with at least 10mls 0.9% Sodium Chloride to maintain patency. Ensure an asceptic technique is used please follow patients specific care plans or refer to page 55 for hospital specific management guidelines for flushing PICC lines equipment needed: sterile dressing pack sterile Nitrile examination gloves cleaning agent 2% Chlorhexadine in 70% Isopropyl alcohol wipes minimum size 10 ml syringe 10mls of 0.9% Sodium Chloride 21G needle (green) new sterile needless injection port if being used Procedure Action No PROCEDURE RATIONALE 1 Explain procedure to patient Ensure patient understands obtain informed consent 2 Wash hands and prepare sterile equipment To reduce risk of infection 3 Place sterile dressing towel under the patient s arm To reduce risk of infection 4 Draw up 10 mls 0.9% Sodium Chloride into 10-20ml syringe using a green needle To reduce risk of infection V February 2014 (May 2017)

39 Action No PROCEDURE RATIONALE 5 Remove needle from syringe To establish connection between cap an syringe 6 Put on sterile Nitrile gloves and clean the needle free injection port with 2% Chlorhexadine swab and allow to dry for 30 seconds To reduce risk of infection 7 Connect syringe to the needle free injection port using a firm twisting motion and flush using a push, pause technique. On the final push, maintain positive pressure as the syringe is withdrawn from the cap To create turbulence in order to flush the catheter thoroughly NB: some needle free injection ports already have an integral positive pressure mechanism e.g. BD Posiflow, CLC Please follow the patient s specific care plan or hospital specific guidance on page 55 for frequency of changing needle free injection port. To reduce risk of infection Using a sterile non-touch aseptic technique, remove the needle free injection port, clean the external part of the catheter hub with a sterile 2% chlorhexadine cleansing swab and allow to dry for 30 seconds. Attach new sterile needle free injection port and document 9 Dispose of sharps and clinical waste as per local policy To reduce risk of infection and adhere to Healthcare (Clinical) Waste Policy and Infection Control policy Blood sampling from PICC line 3. Ensure the patient s own specific care plan is followed or refer to page 55 for hospital specific management guidelines for PICC line if a care plan is not available. equipment: sterile dressing pack sterile Nitrile examination gloves 1 x 20 ml luer lock syringe V February 2014 (May 2017)

40 1 x 21G (green) needle 20mls 0.9% Sodium Chloride cleaning agent 2% Chlorhexadine in 70% Isopropyl Alcohol Vacutainer system and blood specimen tubes 1 x 6ml (yellow) Vactuainer sampling tube for discarding new sterile needle free injection port if required Procedure Action No PROCEDURE RATIONALE 1 Explain procedure to patient Ensure patient understands and obtain informed consent 2 Wash hands and prepare sterile equipment To reduce risk of infection 3 Place sterile dressing towel under the patient s arm To reduce risk of infection 4 Draw up 20mls 0.9% Sodium Chloride into 20ml syringe using the green needle To confirm line patency 5 If pre flush is required, clean the needle free injection port and allow to dry. Connect the 5ml flush onto the catheter hub and follow flushing technique above. Connect a compatible Vacutainer system/bottle holder onto catheter hub with a firm twisting motion. Attach a 6ml sampling bottle (yellow) and allow to fill. Remove the bottle and discard. Ensure line patency and position Ensure removal of any saline solution or heparin or other intravenous medications from the dead space that may result in obscured blood results NB: samples required for blood cultures do not require the disposal of this sample as line contents are required for analysis. 6 Using the correct order of draw, attach the required Vacutainer bottles and withdraw the required samples Ensuring blood sample follows correct procedures and guidelines 8 Remove the Vacutainer system, clean the port with a new sterile 2% Chlorhexadine cleansing swab To reduce risk of infection V February 2014 (May 2017)

41 Action No PROCEDURE RATIONALE 9 Following blood sampling, the PICC line MUST BE FLUSHED with 20mls 0.9% Sodium Chloride in 20 ml syringe, using the push, pause method To create turbulence and ensure removal of all blood in the catheter and prevent occlusion 10 Replace with a new sterile needless injection port unless otherwise stated in patients own care plan or hospital specific guidelines at page 55 To prevent infection Drug / fluid administration 4. An aseptic non-touch technique is required for administration of fluid and/or medications equipment: sterile dressing pack sterile Nitrile examination gloves 1 x 10ml leur lock sterile syringe 2 x ml luer lock sterile syringe 2 x 10ml 0.9% Sodium Chloride for pre and post flushing extra flushes and syringes for in between flushing after each medication being administered. 21G green needles for drawing up flushes and medication Taunton and Somerset NHS Foundation Trust (T+S) drug monographs for each medication being administered intravenously (IV) 2 x 2% Chlorhexadine in 70% Isopropyl Alcohol cleansing wipes sterile needless injection port if required. Procedure Action No Procedure Rationale 1 Explain procedure to patient Ensure patient understands and required to obtain informed consent 2 Wash hands and prepare sterile equipment and IV medications / fluids using T+S drug monograph To reduce risk of infection and to prepare and administer each IV medication as per policy V February 2014 (May 2017)

42 Action No Procedure Rationale 3 Draw up 2 x 10mls 0.9% Sodium Chloride into a 10-20ml syringe using a green needle To reduce risk of infection 4 Place a sterile dressing towel under the patient s arm To reduce risk of infection 5 Clean the needle free port with 2% Chlorhexadine and allow to dry. Connect an empty 10ml syringe onto catheter hub with a firm twisting motion, pull back slowly, pausing to allow catheter valve to open and blood to withdraw into the catheter. Continue to aspirate until at least 1-2mls of blood is obtained Ensure patency of the catheter and correct placement 6 Remove the syringe and discard To prevent risk of contamination 7 Cleanse the needle free injection port again with a second sterile 2% Chlorhexadine wipe To prevent risk of infection 8 Connect the syringe using a firm twisting motion to the needle free injection port and flush the catheter line with at least 10mls 0.9% Sodium Chloride using push/pause technique. Maintain positive pressure as the syringe is removed from the hub To create turbulence in order to flush the catheter thoroughly 9 Attach the bolus prepared IV medication or infusion onto the port, and administer at a rate directed by the Taunton and Somerset NHS Foundation Trust (T+S) drug monograph. Flush the line in between each IV medication being administered with 10mls of a compatible solution Administration of IV medications are per policy 10 On completion, a second flush of the line is required using the same method as described in point 8 To create turbulence and ensure removal of all medications in the catheter and prevent occlusion 11 Document the procedure and any observations in the MAR and nursing As per Medicines Policy V February 2014 (May 2017)

43 Action No evaluation notes Procedure Rationale 5. Removal of Central Venous Access Devices (PICC Lines Only) PICC Lines MAY NOT be removed until instructed by the medical team in charge of patient care. An aseptic non-touch technique is required for removal of PICC line. Equipment; Sterile dressing pack Sterile gloves Plastic apron Non- sterile gloves Sterile gauze occlusive transparent dressing Chlorhexidine gluconate 2% sterile aqueous solution Action No Procedure Explain the procedure to the patient Lie patient flat and place arm at 90 o angle to ease removal Wash hands thoroughly following infection control policy and prepare sterile equipment Using non sterile gloves remove existing dressing and STAT lock Open sterile dressing pack and put on sterile gloves Place sterile towel under PICC line Clean catheter exit site with Chlorhexidine Gluconate 2% sterile solution, starting at exit site and spiralling outwards until 5cms diameter has been cleaned, Repeat twice and allow to dry for 30 seconds Advice the patient to breathe in, hold their breath then exhale, Whilst exhaling gently and slowly pull back on the catheter until it is Rationale To ensure the patient understands the procedure and gives valid consent To prevent the risk of air embolism To minimise the risk of infection To prepare for catheter removal To prevent contamination of the site To remove the catheter and prevent damage to vein V February 2014 (May 2017)

44 completely removed from the exit site Apply pressure to the exit site for approximately 2-4 minutes with sterile gauze until haemostasis is achieved Stop if any resistance is felt and seek specialist advice Apply clean sterile gauze and an occlusive dressing and keep in place for 48 hours Examine tip of PICC line to ensure complete (straight clean horizontal cut and the length removed the same that was documented at insertion). There should be no ragged edges. If this is observed inform medical staff immediately, contact the centre where the PICC was inserted and retain the PICC for inspection. Catheter tip will only need to be sent to Microbiology if infection is queried, please send for M, C and S (microscopy, culture and sensitivity. Using sterile scissors cut off approx. 5 cm from the tip and place in a sterile pot Dispose of all clinical waste as per policy Ensure all details for removal are documented: Name of medical practitioner making decision for removal Reason for removal Any problems identified during removal Condition of insertion site (inflammation, bruising, pain, bleeding etc.) If infection is suspected, date and time tip sent to microbiology. To minimise blood loss and bruising To prevent breakage of line or damage to the patient s vein To provide protection to entry site To ensure complete catheter has been removed that catheter length of catheter is the same as at insertion To detect any infection related to the catheter and thus provide necessary treatment. (As per policy for MPH, RUH and YDH) To ensure safe disposal in the correct containers and avoid laceration or injury of other staff. To ensure records are kept up to date Continued care of the patient (Marsden 2011 and Royal United Hospitals Bath Care of Central Venous Access Devices 2007) 6. Hickman Lines Dressing and cleaning the insertion site V February 2014 (May 2017)

45 6.1 Always using an aseptic technique, the dressing must be changed 24 hours after insertion and weekly thereafter, or when the dressing becomes damp, loose or soiled. entry site Steri-strips must be removed after 7 days post insertion and sutures removed 21 days post insertion, or until the cuff fibroses and the surrounding catheter tissue secures the catheter in place ideally, the sutures should be removed within a hospital environment by experienced and competent nursing staff and where medical attention is immediately available, should the integrity of the catheter be compromised Hickman lines can be open ended or valved and have up to three lumens. Groshong catheters are valved open ended catheters have a clamp on each lumen which must remain closed/clamped at all times when not in use immediately after suture removal, each lumen must be flushed with heparinised saline solution 50iu/5mls to ensure catheter patency the patency of each lumen will be maintained by flushing with 10 or 20mls 0.9% Sodium Chloride and 5mls heparinised saline 50ui/5mls during all dressing changes, the external length of the catheter must be assessed and measured to determine if migration of the catheter has occurred and to ensure the Dacron cuff is not visible equipment: sterile dressing pack sterile Nitrile examination gloves transparent semi-permeable film dressing IV3000 non sterile gloves for removal of old dressing 2% Chlorhexadine in 70% Isopropyl Alcohol cleansing solution Chloraprep Procedure Action No Procedure Rationale 1 Explain procedure to the patient Ensure patient understands and obtain informed consent 2 Wash hands thoroughly as per local policy To reduce risk of infection 3 Open sterile dressing pack and prepare dressings and cleaning equipment. To reduce risk of infection 4 Place sterile dressing towel under exit site To reduce risk of infection 5 Carefully remove the old dressing using a from the bottom up technique, whilst avoiding tugging or moving the catheter Reduce risk of dislodging the catheter and maintain V February 2014 (May 2017)

46 and avoid using scissors or other sharp instruments near the area its integrity 6 Inspect the catheter exit site for signs of infection swelling, redness, or oozing. Notify GP or senior nurse if signs of infection are evident To ensure infection is recognised and treated promptly 7 Wash hands thoroughly and put on sterile Nitrile examination gloves To reduce risk of infection 8 Clean the catheter exit site with 2% Chlorhexadine in circular movements moving away each time from the exit site until at least 5cms in diameter has been reached including the part of the catheter that is under the dressing. Repeat twice and allow the skin to dry for 30 seconds To minimise risk of infection spread from a dirty to a clean area. To complete the decontamination process 9 Apply new sterile dressing IV3000- using an aseptic technique, over the whole site. Loop the catheter if required but avoid kinking To minimise risk of infection and provide security of the line 10 Document external line length in cm, site observations, cleansing and dressing change in the patients evaluation record care plan (page 67) To ensure good communication, documentation and continuity of care Flushing Procedure 6.2 The Groshong skin-tunnelled catheter does not have a clamp but has a three-position, pressure sensitive valve at the tip of the catheter. The Groshong lines and open ended lines need to be flushed when not in regular use. Groshong lines are flushed with at least 10mls 0.9% sodium chloride depending on patients specific care plan and hospital specific guidelines, (see page 67) to maintain patency. Open ended lines may require an appropriate heparin solution to maintain line patency depending on patients specific care plan and hospital specific guidelines (see page 67) after all catheter use or if blood is observed in the catheter, it should be irrigated with at least 10mls 0.9% sodium chloride to prevent occlusion positive pressure needleless connectors are usually used for open ended catheters. Where standard Bionector is in place it is very important to end flush using positive pressure technique to prevent clotting in the line an aseptic non- touch technique is used equipment: V February 2014 (May 2017)

47 sterile Nitrile examination gloves 2 x 2% Chlorhexadine in 70% Isopropyl Alcohol cleansing wipes 10ml or 20 ml syringe 10-20mls 0.9% Sodium Chloride 5mls Heparinised saline if required recommended needless injection port if required sterile dressing pack Procedure Action No 1 2 Procedure Explain procedure to patient Prepare equipment and wash hands Rationale Ensure patient understands and obtain informed consent To reduce risk of infection 3 Draw up the appropriate recommended flush or flushes (may require heparinised saline) as per patients care plan or hospital specific guidelines (page 55) 4 Place sterile dressing towel under line To ensure adequate flushing within the catheter line To reduce risk of infection Put on sterile gloves Clean needle free injection port thoroughly with Chlorhexidine/ alcohol wipe. Allow port to dry for 30 seconds Connect syringe directly onto needle free injection port using a firm twisting motion Flush with push -pause action and use positive pressure technique when removing syringe after flush complete Change needless injection port as recommended by the patients care plan or hospital specific guidelines (page 55) Remove the needle free injection port Clean catheter hub with a new 2 % Chlorhexidine wipe Allow to dry To prevent cross infection To reduce risk of infection Te reduce risk of infection and ensure safety of procedure To ensure adequate turbulence is created within the catheter To minimise risk of infection and provide security of the line V February 2014 (May 2017)

48 Action No Procedure Apply new needle free injection port Rationale 10 Dispose of equipment safely As per Healthcare (Clinical) Waste policy Blood Sampling 6.3 The red lumen is larger than the white so should be used for blood sampling if possible. drugs requiring levels should be given down the white lumen, so that blood can be taken from the red lumen. Using the same lumen for giving the drug and taking blood levels can lead to misleading results all infusions (both lumens) via the catheter should be stopped before taking blood, otherwise results may be unreliable. A suitable period of time should be allowed between stopping infusions and withdrawal of blood samples to prevent erroneous results if blood sampling is difficult it may help to lie the patient down as this will encourage venous filling and reduce the possibility of damage to the vessel wall due to suction V February 2014 (May 2017)

49 Procedure Action No PROCEDURE RATIONALE 1 Explain procedure to patient Ensure patient understands and obtain informed consent 2 Wash hands and prepare sterile equipment To reduce risk of infection 3 Draw up 20mls 0.9% Sodium Chloride into 20ml syringe using the green needle To reduce risk of infection 4 Put on sterile gloves To prevent cross infection 5 Place sterile dressing towel under the patient s arm To reduce risk of infection 6 Clean the needle free injection port with 2 % Clorhexidine and allow to dry for 30 seconds To reduce the risk of infection 7 Connect a compatible Vacutainer system/bottle holder to port with a firm twisting motion. Attach a 6ml (yellow) vacutainer sampling bottle and allow to fill Ensure removal of any saline solution or heparin or other intravenous medications from the dead space that may result in obscured blood results 8 Remove the sampling bottle and discard. To prevent risk of contamination to ensure an accurate sample result 9 Connect the necessary Vacutainer blood sampling tubes withdraw the necessary amount of blood for testing. Ensure the correct order of withdrawal is carried out Each vacutainer bottle requires a specified amount of blood for testing. Avoids cross contamination with mediums in the bottles. 10 Remove the Vacutainer system, clean the needle free injection port with a new sterile 2 % Chlorhexadine cleansing swab To reduce risk of infection. 11 Following blood sampling, the line MUST BE FLUSHED with 20mls 0.9% To create turbulence and ensure removal of all blood V February 2014 (May 2017)

50 Action No PROCEDURE Sodium Chloride in 20 ml syringe, using the push, pause method NB: dependent on the patients specific care plan, a second flush using heparinised saline solution may also be required RATIONALE in the catheter and prevent occlusion 12 Replace with a new sterile needless injection port unless otherwise stated in patients own care plan or hospital specific guidelines at page 67 To prevent infection 13 Dispose of equipment appropriately As per Healthcare (Clinical) Waste Policy 7. Potential Complications 7.1 This list is not exhaustive and serves as a brief guide for actions to take as what to do should problems arise. A degree of clinical judgement is called for, but do not hesitate to report any incidents and or complications to senior nurses and medical staff at the unit where the central line was originally inserted. It may also be necessary for the patient to be referred back to the original unit for further assessment. Persistent withdrawal occlusion 7.2. Carry out the following interventions: check for kinks or constriction on the line move patient s arm, shoulder, and head. Change their position attempt to aspirate blood clot (see below) if the blockage is known or thought to be due to a clot, aspiration can be attempted as small clots can be dislodged. This should be carried out with heparinised saline by competent staff NB: Under no circumstance should an attempt be made to force fluid into the line as this may result in the clot being forced into the circulation resulting in cerebrovascular or pulmonary embolism Aspiration difficulties 7.3 Carryout the following interventions: check for kinks or constrictions on the line get patient to move their arm, shoulder and head, change their position if no resistance is felt, flush vigorously with 10ml of 0.9% Sodium Chloride V February 2014 (May 2017)

51 if resistance to infusion is felt check for signs of extravasation Seek advice from the referring unit Bleed-back into the line 7.4 Carryout the following interventions: flush line and review frequency ensure line is kept clamped (if appropriate) ensure all flushes end with positive pressure Catheter damage 7.5 Carryout the following interventions: line repair is possible if the split is below where the line divides i.e. near the catheter hub if the split is high then the catheter will need to be removed by medical staff determine site of damage clamp catheter using non-toothed forceps and gauze to protect line, proximal to damage Seek advice from the referring unit Displacement 7.6 Carry out the following interventions: there is a risk that the line may become partially or completely displaced. This will be indicated by: - obvious line removal detectable lengthening of the external part of the line or visibility of the cuff difficulty aspirating or infusing fluids local pain swelling / pain on administration of fluids Partial displacement 7.7. Carry out the following interventions: if the catheter is partially displaced there is a risk of fluid extravasation seek advice from the referring unit Total removal 7.8 Carry out the following interventions: if the catheter falls out completely there is a risk of haemorrhage at the cut down and exit site V February 2014 (May 2017)

52 apply pressure dressing and seek immediate advice from the referring unit Air embolus 7.9 Carry out the following interventions: lie patient head down and administer oxygen if required clamp catheter using non-toothed forceps and gauze to protect line, proximal to damage attempt to aspirate as much air as possible inform medical staff ensure injection caps are correctly fitted ensure connections are not loose check catheter is not damaged, e.g. holes or splits Fluid leakage from around catheter exit site 7.10 Carry out the following interventions: check for catheter damage, e.g. punctured by suture needle, trocar, scalpel, scissors, ruptured if occluded inform medical staff seek advice from the referring unit 8. MANAGING BLOCKED CENTRAL CATHETERS 8.1 In the situation of a line failing to sample blood follow the simple measures in the algorithm on page 66. Expert advice should also be sought from the patient s specialist Nurse or Consultant and the patients referred back to the originator. 9. TOTALLY OCCLUDED CENTRAL CATHETER AND PERSISTENT WITHDRAWAL OCCLUSION (PWO) Occluded Lines 9.5 A totally occluded catheter is when there is an inability to infuse solutions into or withdraw from the vascular access device. Causes: fibrin sheath formation blood occlusion drug therapy e.g. chemotherapy agents, antibiotics and lipid residues catheter tip or valve pressed against the vein well or valve causing damage too large a catheter in too small a vein traumatic cannulation V February 2014 (May 2017)

53 health status- malignancy, dehydration, venous compression due to tumour or metastases, sepsis, previous history of venous access device placement, previous history of thrombus Preventative strategies 9.6 Adhere to recommended flushing protocols and techniques. Ensure prophylactic therapy with an anticoagulant for patients who are more at risk. Diagnosis 9.7. It is important to follow the Bristol Haematology and Oncology Centre (B.H.O.C) guidelines on the management of patients with possible Venous Access Device Occlusions; clinical signs and symptoms can often be absent in cases of catheter - related thrombus formation. In fact, by the time clinical signs are evident the thrombus is usually extensive however the following warning signs may be good indicators of catheter thrombosis frequent infusion pump alarms change in the ability to infuse or withdrawer from the catheter pain and/or swelling and/or limb discolouration around the chest/ neck/shoulder area headache dyspnoea pyrexia/ febrility 9.8 It is helpful to assess the cause of the occlusion by taking a history of events leading up to the event. Accurate documentation of line care by nursing staff is essential in order to obtain a clear record of care and history of events. 9.9 For instance, indentify when the catheter was last accessed for e.g. blood taking, the administration of a drug and if so what drug. Was the catheter flushed after use? 9.10 In the event of a line failing to flush or administer prescribed medication, expert advice should be sought immediately from the patient s specialist Nurse or Consultant and if necessary the patient referred back to the originator. 10. PERSISTENT WITHDRAWAL OCCLUSION (PWO) Definition 10.1 Persistent Withdrawal Occlusion is a common problem associated with Venous Access Devices such as Central Venous Catheters e.g. Skin tunnelled Groshongs and PICC s. It can be defined as the inability to withdraw blood back despite the fact that the catheter may be flushing/infusing well. V February 2014 (May 2017)

54 Causes 10.2 The most common causes are Fibrin Sheaths/Tails, which are attached to the catheter. During flushing this Fibrin Tail/Sheath moves away from the catheter tip allowing the infusion/bolus administration to be given. However when aspiration of blood is attempted, the Fibrin Tail/Sheath is pulled against the tip of the catheter, covering it and preventing this aspiration When Persistent Withdrawal Occlusion occurs, it is essential that the Nursing algorithm is followed closely and the patient is referred back to their specialised unit as there may be other possible causes for a sluggish/blocked line, which would require a different management approach When suspecting persistent withdrawal occlusion staff must follow the simple advice in the algorithm on page 66. Expert advice should also be sought from the patient s specialist Nurse or Consultant and the patients referred back to the originator. 11 IMPLANTED VENOUS ACCESS DEVICE 11.1 At present, care of the implanted venous access port is patient specific and training is provided only for the named staff caring for patients with these ports in situ. A competency assessment for this specific device will not be required as it is not a high risk procedure, providing those undertaking the care and management of the venous access port have previously undertaken training and assessment in Intravenous Administration and management of Central Lines Implanted ports are used for long term access and are implanted subcutaneously under surgical conditions (Marsden 2011). The port must not be used for venous blood sampling The portacath is comprised of two components; a reservoir with a self sealing septum which is attached to a silicone catheter. This can be either open ended or have a Groshong valve. The port is accessed by piercing the skin with a needle into the septum of the port reservoir. The needle is a specific non coring needle (Huber), ordinary needles must never be used so that when removed, this allows the septum to seal it itself (Marsden 2011). The ports are generally inserted into the chest wall. They require minimal care of the site as the skin is intact. When not in use they only require monthly flushing with heparinised saline. The risk of infection is low. They allow minimal interference with activities of daily living, such as bathing (Marsden 2011) The disadvantage is that when access to the port is required, it can cause discomfort for the patient as the skin is pierced with the needle. This discomfort can be overcome by using a topical anaesthetic gel (as prescribed) (Marsden 2011) The potential problems that can occur are that the needle may become dislodged during administration causing extravasation, or misplaced during V February 2014 (May 2017)

55 insertion causing infiltration into the surrounding tissue. There may also be difficulty in aspirating blood (Marsden 2011). The port is required to be flushed after treatment with 20 mls 0.9% sodium chloride followed with heparinised saline. Please refer to each hospital care plan for amounts and strengths of heparinised saline solution (Royal United Hospital Bath NHS Trust, Care of Central Venous Access Device 2007) Regular assessment of the port is required to check for signs of infection/ infiltration or extravasation during and following treatment The management of an implanted port are similar to those of any central line and therefore asepsis must be maintained throughout the procedure. (Marsden 2011) 12 Maintenance of the Implanted Port 12.1 Patients maybe discharged home with continuous intravenous therapy via the implanted port. The non - coring needle (Huber) is held in place with a transparent occlusive dressing, to maintain a barrier and prevent the needle from moving. This may already be in place prior at time of admission to the Trust. This must be confirmed at time of handover. Following discontinuation of the pump, the port must be flushed with 20mls 0.9% sodium chloride followed by heparinised saline to prevent clot formation. The port must then be maintained and flushed with heparinised saline on a four weekly basis when it is not in use for administration of medication (Royal United Hospital Bath NHS Trust, Care of Central Venous Access Device). The site does not required to be dressed routinely as the port is buried beneath the skin, occasionally following removal of the needle, where there maybe a small amount of blood, a small dressing is required (Marsden 2011) 13 Accessing the Port - procedure for disconnection of cytotoxic pump and removal of needle from the port 13.1 The needle and giving set may remain in situ for 7 days, then it must be changed (Royal United Hospital Bath NHS Trust, Care of Central Venous Access Device 2007) For disconnection and disposal of cytotoxic waste please refer to Appendix E - Disconnection And Disposal Cytotoxic Infusion Pumps. All waste, needles swabs, gloves etc. must be disposed of as per the clinical waste policy Procedure for disconnection of chemotherapy pump, flushing and removal of needle. Equipment 3 x 10 ml syringe no smaller to prevent increased pressure 2 x 21 g needle 2 x 2% Chlorhexadine in 70% Isopropyl Alcohol cleansing wipes 20 mls 0.9% sodium chloride Heparinised saline, please see patient specific care plan for strength and amount Self adhesive dressing if required V February 2014 (May 2017)

56 Action No Apron 2 pairs non sterile gloves Procedure 1 Explain procedure to patient 2 Wash hands thoroughly as per Trust s Infection Prevention Control Policy Put on non sterile gloves and plastic apron Rationale To ensure the patient understands the procedure and gives valid consent To minimise contamination 3 To minimise risk of contamination 4 To follow guidelines and Disconnect and dispose of pump as prevent risk from spillage or per protocol contamination 5 Remove dressing and dispose of as As per protocol to prevent cytotoxic waste contamination from waste 6 Check site for any redness or swelling or pain Signs of developing infection 7 Discard gloves and apron as above As above 8 Wash hands thoroughly As per infection, prevention and control, hand hygiene. 9 Put on apron, sterile gloves and prepare equipment 10 Draw up 0.9% sodium chloride Clean end of needleless connector with 2% Chlorhexadine in 70% Isopropyl Alcohol cleansing wipes and allow to dry Connect syringe to needleless connector Maintain stability of port with forefinger and index finger whilst flushing Draw back on syringe to check for return of blood Flush the port with 20 ml of 0.9% saline observing for swelling or complaints of pain. To minimise contamination Used to check positioning of needle and patency of port and to flush reservoir ensure the drug has been fully administered. To minimise risk of contamination Needles are not to be used, there fore risking damage to the catheter To ensure port remains stable and the needle does not move To check the needle is in the correct position and that the port is patent To check for patency and correct positioning and to flush through remaining medication that has accumulated in the reservoir 16 Following flushing, the port must be flushed with heparinised saline before the needle is removed. Draw up heparinised saline (ensure this is done after flushing with the This assists in maintaining the patency of the port and catheter over a period of time, by preventing formation of clots V February 2014 (May 2017)

57 saline to prevent mix up of solutions) Please refer to patient specific care plan for strength and amount Using a pulsating push/ pause technique administer heparinised saline finishing with positive end pressure before removing the syringe Discard of syringe into cytotoxic sharps waste Pressing down either side of the port with two fingers withdraw the needle using a steady traction, discard into cytotoxic sharps waste immediately If there is any resistance or inability to flush contact the patient s hospital where treatment is being delivered and seek advice. By finishing with positive pressure this prevents backflow of blood and possible formation of a clot As per protocol To support the port whilst removing the needle To prevent trauma to the skin and reduce the risk of needlestick injury as per policy To prevent injury to the patient or damage to the port. do not try to unblock the port, always obtain guidance (Marsden 2011, Royal United Hospital Bath NHS Trust, Care of Central Venous Access Device, 2007) Procedure for insertion of non coring needle (Huber) and for monthly maintenance of patency of port and catheter The insertion of the non coring needle (Huber) must be performed by a Registered Nurse trained and competent in the care and management of an implanted venous access port. This procedure is to be carried out every 4 weeks when the port is not in use. Equipment Dressing pack Sterile gloves Non coring needle (Huber)* Chlorhexadine 2% w/v sterile aqueous solution 1x 10 ml syringes 1x 21 gauge needles Heparinised saline, please see patient specific care plan for strength and amount Local anaesthetic cream, especially if the site is tender or if the port is newly implanted (will need prescribing). *A straight non - coring needle or an angled needle with integral extension set maybe used, if so this will need to be flushed to prime the needle. Action Procedure Rationale V February 2014 (May 2017)

58 No. 1 Explain the procedure to the patient 2 Apply local anaesthetic cream (if required) for approx minutes To ensure the patient understands the procedure and gives valid consent To reduce the feeling of pain on needle insertion Ensure cream is prescribed 3 Ensure the patient is comfortable To aid comfort and allow access to the port 4 Wash hands thoroughly, as per To prevent contamination policy 5 Locate the port and identify the In order to select the correct septum, assess the depth of the length of needle port and the thickness of the skin 6 Choose an appropriate sizes To prevent damage to the Huber needle (gauge and length) port, accidental infiltration of heparinised saline into surrounding tissue and patient discomfort 7 Wash hands again as per policy To prevent contamination 8 Open dressing pack using non To prevent contamination touch technique 9 open sterile items onto field, again using non touch technique 10 Clean hands and put on sterile gloves 11 Using Chlorhexidine 2% clean the skin over the port, using in a spiral motion, inside to outside. Allow to dry 12 Draw up heparinised saline into the 10 ml syringe using a green needle 13 Flush the needle (and if using, prime the extension line) with the heparinised saline and expel any air 14 Stabilise the port between forefinger and index finger with the non dominant hand. Holding the needle in the dominant hand, insert the needle into the middle of the port septum 15 Flush using a pulsating push/ pause technique administer heparinised saline finishing with To reduce risk of contamination and to prevent interruptions delaying the process To minimise risk of contamination To minimise risk of contamination and destroy skin flora Used to ensure patency is maintained over a 4 week period To check for patency of needle and set and to prevent injection of air To ensure the port is stabilised and does not move when needle is inserted This technique helps maintain patency and prevention of clot formation. V February 2014 (May 2017)

59 positive end pressure before removing the syringe. 16 Pressing down either side of the port with two fingers withdraw the needle using a steady traction. 17 Discard of all waste as per Trust policy the positive end pressure prevents backflow of blood To support the port to prevent it from moving To prevent risk of needlestick injury (Marsden 20011, Royal United Hospital Bath NHS Trust, Care of Central Venous Access Device 2007). 14. COMPLICATIONS If there are any concerns at any time, please contact the specialist unit in charge of the patient s care. Needle Dislodgement Remove needle as detailed above and arrange for another to be inserted. Extravasation of cytotoxic IV medication Stop the infusion, contact the patient s specialist unit. Persistent withdrawal occlusion when flushing Confirm the needle has not dislodged Check for kinks / clamps still closed on the extension set Request the patient to change position Contact the patient s specialist unit as a clot formation may have occurred Blockage The patient is referred back to their specialised unit as there may be other possible causes for a sluggish/blocked line, which would require a different management approach. Port Leak May occur if a forceful flush is attempted when the line is blocked or if the wrong type of needle is repeatedly used damaging the diaphragm. Diagnosis of this will need to be made at the patient s specialised unit. Suspected localised infection around the port Clean area, contact referring specialist unit for advice. Take bloods from patient for inflammatory markers. Under no circumstances should an attempt be made to force fluid into venous access port. This may result in a clot being forced into the patient s circulation potentially causing an embolism to occur. (Royal United Hospital Bath NHS Trust, Care of Central Venous Access Device 2007, Marsden 2011, BHOC Guidelines 2008). V February 2014 (May 2017)

60 15. REFERENCES Avon, Somerset and Wiltshire Chemotherapy Handbook January 2005 Update Bristol Haematology and Oncology Centre (B.H.O.C) Guidelines for the post insertion management of Central Venous Catheters (2008). Royal College of Nursing, Standards for infusion therapy. Dougherty, L and Lister. S (2011). Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8 th ed. Wiley Blackwell, Vascular Access Devices; Insertion and Management, (Peripherally Inserted Central Catheters, Inserted Ports) Musgrove Park Hospital - Guideline for the Insertion and Management of Central Venous Catheters in Adults. Weare.C, Roberts. J., (May 2013) Royal United Hospital Bath NHS Trust - Care of Central Venous Access Devices - Gilleece. C. (2007, reviewed 2009) Cross reference with other procedural documents (Somerset Partnership) Healthcare Waste (Clinical Waste) Policy 2012 Infection Control Policy Medicines Policy Medical Devices Policy Hand Hygiene Policy V February 2014 (May 2017)

61 CYTOTOXIC INFUSION PUMPS - DISCONNECTION AND DISPOSAL 1 Personal Protective Equipment required APPENDIX E 1.2 The use of Personal Protective Equipment (PPE) is imperative at all times when handling any cytotoxic products, waste and spillages, including other contaminated waste, such as soiled linen, and bodily fluids. The use of appropriate PPE is required to limit the level of exposure of health care workers to the cytotoxic medications, equipment and associated waste. 1.3 Double glove with sterile gloves when handling central venous access (PICC/Hickman line) devices and cytotoxic therapies and wear a disposable plastic apron at all times. Staff must ensure that the blue tray and the absorption mat are used within the tray prior to and during the procedure. 2 Disconnection and disposal of cytotoxic infusion pump and cytotoxic soft waste. 2.1 The infusion pump and giving set must be disposed of as a single unit into the purple lid sharps bin provided, in accordance with the Trust s Protocol for Handling of District Nursing and Domiciliary Clinical Waste and the Healthcare Waste (Clinical Waste) Policy. 2.2 Any change of needle-free intravenous connectors must also be disposed of in the same manner. 2.3 The central venous access device must be flushed and managed following disconnection of the infusion pump, in accordance with the Trust s Administration by Injections Policy 2.4 All medical devices and waste involved in this process will be hazardous and classed as cytotoxic waste and must be disposed of appropriately as described in the protocol. 2.5 All re-useable items, such as the plastic blue tray, must be rinsed with cold water (to remove traces of cytotoxic agents) and then washed with detergent and hot water (to prevent cross infection) (Infection Control Policy). 2.6 The patient, carers and family members, must be advised on safe storage of the sharps bin whilst it is in use. Health care staff must dispose of the sharps bins at the nearest Community Health Hospital, in accordance with the Trust s Protocol for Handling of District Nursing and Domiciliary Clinical Waste and the Healthcare Waste (Clinical Waste) Policy. 2.7 Any cytotoxic soft waste produced during treatment and for seven (7) days after, must be disposed of in appropriate clinical waste bags. The recommended waste bags for cytotoxic soft waste are yellow with a purple V February 2014 (May 2017)

62 stripe. These can be ordered through NHS Supply Chain using the order code MVN028. Used clinical waste bags must be disposed of for incineration in accordance with Trust s Healthcare Waste (Clinical Waste) Policy and completing the SRCL form for home care services. 3 Special risk groups 3.1 It is highly recommended that breast-feeding and/or pregnant women, do not act as caregivers for the patient during their chemotherapy treatments and for seven (7) days following completion of treatment. 4 Spillages 4.1 All spillages must be dealt with immediately. If a spill occurs on the floor or other hard surface, contact the service where they received their treatment, as a specific spill kit will be required and the manufactures instructions must be followed. 4.2 Spillage kits will be provided by the Trust where required. 4.3 Spillages that come into contact with the skin require the affected area to be washed thoroughly with soapy water as soon as possible as per the Trust s Healthcare Waste (Clinical Waste) Policy 5. TRAINING REQUIREMENTS 5.1 The Trust will work towards all staff being appropriately trained in line with the Organisation s Staff Mandatory Training Matrix (training needs analysis). All training documents referred to in this policy are accessible to staff within the Learning and Development Section of the Trust Intranet. 5.2 Clinical staff who are undertaking the disconnection and disposal of cytotoxic infusion pumps, must have received training and competency assessment in the following areas as directed by the Trust s Training Matrix: medicines management training and competency assessment anaphylaxis drugs calculations infection control medical devices training and competency assessment administration of intravenous drugs and competency assessment care and management of central lines and competency assessment 5.3 All registered health care professionals required to administer medications via a PGD, must ensure they have completed the PGD training and competency assessment framework as stipulated in the Trust s PGD policy. V February 2014 (May 2017)

63 6. References; HSE Information Sheet MISC615 Safe handling of cytotoxic drugs Dougherty, L. and Lister. S (2011). Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8 th ed. Wiley Blackwell Cross reference with other procedural documents (Somerset Partnership); Hand Hygiene Policy Healthcare Waste (Clinical Waste) Policy 2012 Infection Control Policy Learning Development and Mandatory Training Policy Medicines Policy Training Prospectus V February 2014 (May 2017)

64 ALGORITHM FOR SUSPECTED PERSISTANT WITHDRAWAL OCCLUSION Fluids can be infused freely by gravity but blood cannot be withdrawn from the catheter Blood return is absent Flush central venous catheter with 0.9% sodium chloride in 10 ml syringe using brisk push-pause technique Check for flashback of blood Ask patient to cough, deep breath, change position, stand up or lie with foot of bed tipped up. Ascertain possible cause of PWO Blood return is still absent Blood return obtained use central venous catheter as usual Blood return is still absent Proceed if happy to do as long as there are no other complications or pain NO Patient to receive highly irritant/vesicant drugs chemotherapy YES The following steps should initially be done prior to drug administration and documented in the patient s care plan and evaluation record so that all nursing staff are aware that patency has been verified. All patients require referring back to the specialist acute hospital for further management. Royal College of Nursing, (2010) Standards for infusion therapy. V February 2014 (May 2017)

65 DIFFERENCES BETWEEN HOSPITALS FOR CENTRAL LINE MANAGEMENT ACTION Change of statlock device Hickman line blood taking Hickman line flushing (If more than one lumen each should be flushed individually) Hickman needleless connector Hickman dressing change PICC line flushing (Ensure correct technique) MPH Beacon Centre Every 1-2 weeks or more frequent if soiled or loose Withdraw 5mls blood and discard Once within each 7 day period, with 20mls saline* for Groshong type line Or 20mls saline if open ended line Bionector, change weekly Every 7 days, with IV mls saline RUH William Budd ward Every week or more frequent if soiled or loose Flush with 10mls saline Withdraw 10mls blood and discard 10mls Sodium Chloride followed by flush with 5mls heparinised saline after each intermittent use and on completion of continuous infusions. Twice weekly when not in use with heparinised saline YDH Maria Ormisher Every 3 weeks or more frequent if soiled or loose Withdraw 3-5mls blood and discard Once weekly with 10mls 0.9% Sodium Chloride and 2mls heparinised saline DW Yeovil and they are happy for us to flush weekly in community Bionectors change weekly Bionectors change every 7 days Weekly unless damp or Every 7 days soiled Lumens not in continuous When not in use every 7 use-flush every 7 days with days, minimum of 10mls of 0.9% 10mls 0.9% Sodium saline using push/pause Chloride technique Manufacturer recommendations weekly PICC line blood taking PICC dressing change Withdraw 5mls blood and discard Every 7 days, with IV3000 Flush with 5mls 0.9% sodium chloride Withdraw 5ml blood and discard Weekly unless damp or soiled Withdraw 2-5mls blood and discard Weekly unless soiled/loose/damp V February 2014 (May 2017)

66 PICC needleless connector Bionectors Change weekly CLC 2000 change weekly with IV 3000 Bionectors change weekly BD 100 uses Cleaning ports 2% Chlorhexadine in 70% Isopropyl Alcohol wipes Skin cleansing at dressing change Use of gloves for dressing change and hub change Glove use for flushing and blood taking 2% Chlorhexadine in 70% Isopropyl Alcohol wipes 2% Chlorhexadine in 70% Isopropyl Alcohol wipes Chloraprep Chloraprep Chloraprep Sterile Sterile Sterile Non touch non sterile Non touch non sterile Sterile Open ended lines will usually have a positive pressure device. Groshong type lines may only have a bionector device where manual positive pressure flush technique is required V February 2014 (May 2017)

67 CENTRAL LINE MANAGEMENT EVALUATION RECORD Patient Name... Date of Birth... NHS Number... Type of Central Line... Date of insertion of line and length on insertion... INTERVENTIONS DATE External line length (cm) Exit site condition Site cleaned and dressing changed Steri- Strips changed Statlock device changed Needle free port changed Comments (include blood sampling, PWO/occlusion problems Review Date Name and Signature V February 2014 (May 2017)

68 INTERVENTIONS DATE External line length (cm) Exit site condition Site cleaned and dressing changed Steri- Strips changed Statlock device changed Needle free port changed Comments (include blood sampling, PWO/occlusion problems Review Date Name and Signature V February 2014 (May 2017)

69 APPENDIX F COMPETENCIES FOR THE ADMINISTRATION OF INTRAVENOUS (IV) DRUGS The competencies are to be used in conjunction with: - Musgrove Park Hospital Intravenous Drug Monographs (via T&S Intranet) Nursing and Midwifery Council (NMC) (2008) The Code: standards for conduct; performance and ethics for nurses and midwives NMC (2007), Standards for Medicines Management, updated NMC (2007) Standards to support learning and assessment in practice. NMC standards for mentors, practice teachers and teachers. Royal Marsden Manual of Nursing Procedures (eighth edition) Royal College of Nursing (RCN) (2010) Standards for Infusion Therapy. Somerset Partnership Policies: Administration by injection Policy Community Health Protocol for Assessing Competency in Clinical Practice Consent to Examination or Treatment Policy Healthcare (Clinical) Waste Policy Infection Prevention and Control Policy Needlestick and Contamination Injury Policy Record Keeping and Records Management Policy Syringe Driver Policy The purpose of these competencies is to clarify the knowledge and skills expected of practitioners, to ensure safe practice in administering IV Medications. Once the practitioner has reached a satisfactory level of competence following a period of supervised practice, ensure they are formally competency assessed - within three months of completing the initial theoretical/practical training. The self rating scale is to be used by the individual practitioner for self assessment of present performance during supervised practice, and to help identify learning needs. Their line manager, or other experienced practitioner, must then assess these skills and sign to confirm competency. Only qualified practitioners with a NMC recognised teaching and assessing in practice qualification and who have completed recognised training and assessment in administering intravenous drugs can be identified as assessors. Key for Self-Assessment 1 = No knowledge / experience 2 = Some knowledge / experience V February 2014 (May 2017)