Consultation Group: See relevant page in the PGD. Review Date: November Expiry Date: November 2019

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1 Patient Group Direction For The Administration Of Phosphate Enema By Nurses Working Within NHS Grampian To Patients Prior To Undergoing Bowel Investigations Lead Author: Nurse Endoscopist Consultation Group: See relevant page in the PGD Approver: Medicine Guidelines and Policies Group Signature: Signature: Identifier: NHSG/PGD/PhosEn/ MGPG853 Review Date: November 2018 Expiry Date: November 2019 Date Approved: November 2016 A Patient Group Direction is a specific written instruction for the supply or administration of named medicines in an identified clinical situation. It is drawn up locally by Doctors, Pharmacists and other appropriate professionals, approved by the employer and advised by the relevant professional advisory committees. In most cases, appropriate clinical care is provided on an individual basis by a specific prescriber to a specific individual patient. Patient Group Directions should only be considered where they offer a benefit to patient care without compromising patient safety in any way. Uncontrolled when printed Version 6

2 This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on (01224) or (01224) Revision History: Date of change September 2016 Approval date of PGD that is being superseded October 2014 Summary of Changes 2 yearly update onto new PGD template. Section heading Subject: Patient Group Direction Identifier: NHSG/PGD/PhosEn/MGPG853 Replaces: NHSG/PGD/PhosEn/MGPG677, Version 5 Keyword(s): PGD patient group direction administration phosphate enema bowel preparation endoscopy investigations nurses flexible sigmoidoscopy Policy Statement: It is the responsibility of individual nurse and their line managers to ensure that they work within the terms laid down in this PGD and to ensure that staff are working to the most up to date PGD. By doing so, the quality of the services offered will be maintained, and the chances of staff making erroneous decisions which may affect patient, staff or visitor safety and comfort will be reduced. Supervisory staff at all levels must ensure that staff using this PGD act within their own level of competence. The lead author is responsible for the review of this PGD and for ensuring the PGD is updated in line with any changes in clinical practice, relevant guidelines, or new research evidence. Review date: The review date for a PGD needs to be decided on a case-by-case basis in the interest of patient safety. The expiry date should not be more than 3 years from the date the PGD was authorised. Document: Drafted: June 2004 Completed: June 2004 Approved: June 2004, June 2007, May 2010, July 2012, October 2014 November 2016 (published December 2016) UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG853 - i -

3 Patient Group Direction For The Administration Of Phosphate Enema By Nurses Working Within NHS Grampian To Patients Prior To Undergoing Bowel Investigations Clinical indication to which this PGD applies Definition of situation/condition This Patient Group Direction (PGD) will authorise registered nurses to administer phosphate enema to patients aged 16 years and above in order to evacuate and clean the bowel prior to their undergoing bowel investigations. This PGD should be used in conjunction with the recommendations in the current British National Formulary (BNF) and individual Summary of Product Characteristics (SPC). Inclusion criteria All patients aged 16 years and above attending for bowel investigations who have not had an oral bowel preparation. Exclusion criteria Patients may be administered phosphate enema under this PGD unless they: are under 16 years of age. have known active inflammatory bowel disease such as Crohn s disease or ulcerative colitis. have acute gastro-intestinal conditions, including undiagnosed profuse rectal bleeding. have conditions causing decreased gastro-intestinal motility, e.g. known or suspected intestinal obstruction, paralytic ileus, anorectal stenosis, imperforate anus, congenital or acquired megacolon, Hirschsprung s disease, symptoms of appendicitis, intestinal perforation. have congestive heart failure. have dehydration and generally in all cases where absorption capacity is increased or elimination capacity is decreased. have known sensitivity to the product or its component. have clinically significant renal impairment. are pregnant or breastfeeding. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG

4 Precautions and special warnings Do not use when nausea, vomiting or abdominal pain is present; seek medical advice in such cases. Use with caution in patients with abnormal renal function, ascites, cirrhosis and uncontrolled hypertension. In cases of rectal bleeding or failure in bowel evacuation after use - seek medical advice. Verbally check allergies and previous usage of the preparation with the patient. Do not use where there has been a previous allergic reaction. Check the patients records for any documentary evidence regarding previous usage and any adverse reactions. Use with caution in the elderly/debilitated patients and those with known electrolyte disturbances, reduced sodium intake or are taking medications known to prolong the QT interval such as amiodarone, arsenic trioxide, astemizole, azithromycin, erythromycin, clarithromycin, chlorpromazine, cisapride, citalopram, domperidone, terfenadine and procainamide. Caution should be exercised in patients with colostomies who are taking diuretics or other medications which may affect electrolyte levels. Caution should be exercised in patients who are breastfeeding, as sodium phosphate may pass into the breast milk tissue it is advised that breast milk is expressed and discarded for 24 hours after receiving Cleen /Fleet ready-to-use enema or Phosphates enema (Formula B). Referral criteria Patients who fall into the categories detailed in the exclusion criteria. Action if excluded from treatment Medical advice should be sought refer to consultant (relevant medical practitioner). The reason why the patient was excluded under the PGD will be documented in the patient s medical notes. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG

5 Action if patient declines treatment Patient should be advised of the risks and consequences of not receiving treatment. Record outcome in Patient Medication Record if appropriate and refer the patient to their General Practitioner/Consultant (relevant medical practitioner). Consent Prior to the administration of the drug, valid consent must be obtained. Consent must be in line with current NHSG Staff Policy for Obtaining Consent for Clinical Procedures and Healthcare Interventions. See link below. nuid=460& Description of treatment available under the PGD Name of medicine Phosphates Enema BP (Formula B) and brand name Cleen /Fleet ready-to-use 133mL enema. Legal status Phosphates Enema is a Pharmacy Medicine (P). Form/Strength Rectal Solution (Enema). Phosphates Enema BP (Formula B) 128mL contains disodium hydrogen phosphate dodecahydrate 80mg per 1mL and sodium dihydrogen phosphate dihydrate 100mg per 1mL Cleen or Fleet ready-to-use 133mL enema contains disodium hydrogen phosphate dodecahydrate 80mg per 1mL and sodium dihydrogen phosphate dihydrate 181mg per 1mL. Route/Method of administration For rectal use only: The enema may be administered at room temperature or warmed in water before use. Lie on left side with both knees bent, arms at rest. Remove protective shield. With steady pressure, gently insert enema comfortip into anus with nozzle pointing towards navel. Squeeze bottle until nearly all liquid is expelled. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG

6 Discontinue use if resistance is encountered. Forcing the enema can result in injury. Gently remove nozzle from rectum, it is normal to experience some leakage of the enema liquid. Return enema to carton for disposal. Generally, 2 to 5 minutes are sufficient to obtain the desired effect. If delayed discontinue further use and consult a physician. Dosage/Total Dose Administer the full contents of the enema. Duration of treatment To be administered once only, up to 30 minutes prior to procedure. Storage requirements Do not store above 25 C. Do not refrigerate. Follow-up (if applicable) If the enema fails to work, the patient should be referred to a doctor or endoscopist. Administration should only be repeated if prescribed. Advice to patient (Verbal) Advice should be given on what to expect and what to do for major and minor reactions. The expected effects from the administration of the enema should be explained to patients and they should be advised that there may be a rapid response. Advice to patient (Written) The Patient Information Leaflet (PIL) contained in the medicine(s) should be made accessible to the patient, parent, guardian, or person with parental responsibility. Where this is unavailable, or unsuitable, sufficient information should be given in a language that they can understand. Copies of PIL and SPCs for all medicines can be found at or Concurrent Medications/Drug Interactions Use with caution in patients taking calcium channel blockers, ACE inhibitors, angiotensin receptor blockers, diuretics, lithium treatment or other medications that might affect electrolyte levels as hyperphosphataemia, hypocalcaemia, hypokalaemia, hypernatraemic dehydration and acidosis may occur. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG

7 No other sodium phosphate preparations including sodium phosphate oral solution or tablets should be given concomitantly. As hypernatraemia is associated with lower lithium levels, concomitant use of Cleen and Fleet Ready-to-Use Enema and lithium therapy could lead to a fall in serum lithium levels with a lessening of effectiveness. Identifying and managing possible adverse reactions Local irritation. Rarely, vasovagal attacks have occurred especially in elderly patients. Suspected adverse effects should be documented within the patients care pathway, and reported to medical staff. This list is not exhaustive. Please also refer to current BNF/BNFC and manufacturers SPC for details of all potential adverse reactions. BNF: SPCs/PILs: If an adverse reaction does occur give immediate treatment and inform relevant medical practitioner as soon as possible. Report the reaction to the MHRA using the Yellow Card System. Medical advice in cases of anaphylaxis Injections of IM adrenaline/epinephrine 1:1000 must be available to treat an anaphylactic reaction should this occur. Medical advice must be sought as soon as possible from a doctor if any patient develops any signs of hypersensitivity. If there is a delay in medical support arriving and the condition of the patient is deteriorating then an emergency ambulance must be called on 999 or direct via ambulance control or dial 2222 (hospital internal) according to local procedure, or seek urgent medical advice. (Refer to Patient Group Direction for the administration of adrenaline (epinephrine) in cases of suspected anaphylactic reactions by qualified health professionals) e.pdf. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG

8 Facilities and supplies required The following should be available at sites where the medication is to be administered: Appropriate storage facilities or Pharmaceutical refrigerator (or a validated cool box for storing vaccine if mobile unit). An acceptable level of privacy to respect patient s right to confidentiality and safety. Access to a toilet or commode. Resuscitation equipment. Access to medical support (this may be via the telephone). Approved equipment for the disposal of used materials. Clean and tidy work areas, including access to hand washing facilities. Copies of the current PGD for the medicine specified in the PGD. PGD for the administration of Adrenaline (epinephrine) in cases of suspected anaphylactic reactions by qualified health professionals. Characteristics of staff authorised to supply/administer medicine under PGD Professional qualifications Registered Nurses as recognised by the NMC. Specialist competencies Be competent to assess the patient s capacity to understand the nature and purpose of the administration in order for the patient to give or refuse consent. Has undertaken appropriate training to carry out clinical assessment of patients leading to a diagnosis that requires treatment according to the indications listed in the PGD. Be aware of current treatment recommendations and be competent to discuss issues about the drug with the patient. Is competent in the administration of the drug. Ongoing training and competency Have attended basic life support training which is required to be updated annually. Have undertaken the NHS e-anaphylaxis training session (and annual updates) which covers all aspects of the identification and management of anaphylaxis. This can be accessed via eksf, or the AT Learning tool. UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG

9 Maintain their skills, knowledge and their own professional level of competence in this area according to their individual Code of Professional Conduct. The practitioner must be familiar with the SPC for all medicines supplied in accordance with this PGD. Professional managers/lead Nurses will be responsible for: Ensuring that the current PGD is available to staff providing care under this direction. Ensuring that staff have received adequate training in all areas relevant to this PGD and meet the requirements above. Maintain up to date record of all staff authorised to administer drug specified in PGD. Documentation Authorisation of administration Nurses working within NHS Grampian can be authorised to administer the drug specified in this PGD by their Nurse Manager/Consultant/Nurse Endoscopist. All authorised staff are required to read the PGD and sign the Agreement to Administer Medicines under PGD (Appendix 1). A certificate of authorisation (Appendix 2) signed by the authorising doctor/manager should be supplied. This should be held in the individual practitioners records, or as agreed locally. Record of administration/ supply An electronic or paper record for recording the screening of patients and the subsequent administration of the drug specified in this PGD must be completed in order to allow audit of practice. This should include: Name and address of patient Patient CHI No and date of birth Details of parent/guardian, or person with parental responsibility where applicable Consultant/General Practitioner details Risk group, if appropriate Findings of physical examination, if appropriate Exclusion criteria, record why the drug was not administered UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG

10 Reason for giving Consent to the administration (if not obtained elsewhere) Signature and name in capital letters of practitioner who administered the drug Date drug given Record of any adverse effects (advise patient s doctor). These records should be retained: For children and young people, retain until the patient's 25th birthday or 26th if the young person was 17 at the conclusion of treatment. For 17 years and over retain for 6 years after last date of entry, for 3 years after death, or in accordance with local policy, where this is greater than above. Audit All records of the drug specified in this PGD will be filed with the normal records of medicines in each practice/service. A designated person within each H&SCP/practice/service will be responsible for auditing completion of drug forms and collation of data. References Electronic Medicines Compendium Cleen Ready-to-Use Enema. Date of revision of text 16/06/16, accessed 15/09/16 Phosphates Enema BP Formula B Date of revision of text 22/03/16, accessed 15/09/16 British National Formulary accessed 15/09/16 UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG

11 Management and Monitoring of Patient Group Direction PGD Consultative Group The consultative group is legally required to include a medical practitioner, a pharmacist and a representative of the professional group who will provide care under the direction Jane Beattie Hazel Buchan Claire Farrow Paula Johnston Sarah Kirkman Margo McMillan Vanessa Muir Perminder Phull Laura Sales Daphne Thomas Sandy Thomson Miriam Vinten Sister, Endoscopy Unit, ARI Sister, Day Surgery Unit, ARI Nurse Endoscopist, GI, ARI Senior staff nurse, Endoscopy Unit Nurse Endoscopist, GI, ARI Senior staff nurse, Endoscopy Unit Senior staff nurse, Endoscopy Unit Medical Professional: Consultant Gastroenterologist, Endoscopy Lead, ARI Lead Author: Nurse Endoscopist Sister, Surgical Unit, Dr Grays Lead Clinical Pharmacist, Dr Grays Pharmacist: Gastroenterology Pharmacist, ARI Authorising Managers Dr Nick Fluck Medical Director, NHS Grampian Mr David Pfleger Director of Pharmacy and Medicines Management, NHS Grampian Professor Amanda Croft Director of Nursing, Midwifery and AHPs, NHS Grampian UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG

12 Appendix 1 Health Care Professional Agreement to Administer Medicines Under Patient Group Direction I: (Insert name) Working within: e.g. H&SCP, Practice Agree to administer medicines under the direction contained within the following Patient Group Direction Patient Group Direction For The Administration Of Phosphate Enema By Nurses Working Within NHS Grampian To Patients Prior To Undergoing Bowel Investigations I have completed the appropriate training to my professional standards enabling me to administer medicines under the above Patient Group Direction. I agree not to act beyond my professional competence nor outwith the recommendations of the Patient Group Direction. Signed: Print Name: Date: Professional Registration No: UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG

13 Appendix 2 Certificate Of Authorisation To Administer Medicines Under Patient Group Direction This authorises: Working within: e.g. H&SCP, Practice To administer medicines under the following Patient Group Direction Patient Group Direction For The Administration Of Phosphate Enema By Nurses Working Within NHS Grampian To Patients Prior To Undergoing Bowel Investigations The above named person has satisfied the training requirements and is authorised to administer medicines under the above Patient Group Direction. The above named person has agreed not to act beyond their professional competence nor outwith the recommendations of the Patient Group Direction Signed: Authorising Manager/Doctor Print Name: Date: UNCONTROLLED WHEN PRINTED Review Date: November 2018 Identifier: NHSG/PGD/PhosEn/MGPG