Policy Checklist. Working Group: Administration of Infusion of Intravenous Fluids & Medicines in Neonates (Chairperson: Dr Hogan) YES

Transcription

1 Policy Checklist Name of Policy: Purpose of Policy: Directorate responsible for Policy Name & Title of Author: Does this meet criteria of a Policy? Staff side consultation? Policy for the administration of Infusion of Intravenous Fluids & Medicines in Neonates To ensure that the SHSCT s ANNP s, registered nurses and midwives are aware of their responsibilities and apply the recommended clinical procedures in relation to the prevention of over infusion of intravenous fluids and medicines in neonates as set out in the National Patient Safety Agency (NPSA) Patient Safety Alert RRR015 and the DHSSPS Prevention of over infusion of intravenous fluids and medicines in neonates September Children s and Young Peoples Services Working Group: Administration of Infusion of Intravenous Fluids & Medicines in Neonates (Chairperson: Dr Hogan) YES Yes/No/Not Applicable Equality Screened by: Trust Equality Team Date Policy submitted to 27 May 2011 RM&PC: Members of RM&PC in Attendance: Policy Approved/Rejected/ Approved Amended Communication Plan Yes/no/not applicable required? Training Plan required? Yes/no/not applicable Implementation Plan Yes/no/not applicable required? Any other comments: Date presented to SMT Director Responsible Mr Paul Morgan SMT Approved/Rejected/Amended SMT Comments Page 1 of 22

2 POLICY DOCUMENT VERSION CONTROL SHEET Title Supersedes Title: Policy for the administration of Infusion of Intravenous Fluids & Medicines in Neonates Version: 1_0 Reference number/document name: Supersedes: N/A Description of Amendments(s)/Previous Policy or Version: Originator Name of Author: Working Group: Administration of Infusion of Intravenous Fluids & Medicines in Neonates (Chairperson: Dr Hogan) RM/Policy Committee & SMT approval Title: Policy for the administration of Infusion of Intravenous Fluids & Medicines in Neonates Referred for approval by: Dr Hogan Date of Referral: 27 May 2011 RM/Policy Committee Approval: 13 June 2011 SMT approval: Circulation Issue Date: 01 July 2011 Circulated By: Working Group Issued To: As per circulation List (details below) Review Review Date: June 2013 Responsibility of (Name): Working Group: Administration of Infusion of Intravenous Fluids & Medicines in Neonates (Chairperson: Dr Hogan Neonatologist) Circulation List: Associate Medical Director for CYP Neonatologists within CYP Paediatricians within CYP Assistant Director of Specialist Child Health & Disabilities Head of Service for Paediatrics Lead Nurse for Paediatrics Lead Nurse for Neonates Medicines Governance Pharmacist Page 2 of 22

3 Policy for the administration of Infusion of Intravenous Fluids & Medicines in Neonates Page 3 of 22

4 Contents Page No 1.0 Introduction Aim of Policy Policy Statement Scope of the Policy Responsibilities Chief Executive Director & Senior Management of CYP Medical Staff ANNPs Registered Nurses and Midwives Pharmacy Audit Legislative Compliance, Relevant Policies Equality & Human Rights Considerations Policy training and Education Requirements Alternative Formats Copyright Sources of Advice 10 Supporting Documents Appendices 1 NPSA Alert 2010 Rapid Response Report NPSA Clinical Briefing Sheet for Healthcare Professionals 3 Procedures for Administration of Intravenous Fluids & Medicines 4 Competency Framework (including expected responses) 5 Audit Tool Page 4 of 22

5 1.0 Introduction This policy has been developed in response to the National Patient Safety Agency (NPSA) Patient Safety Alert RRR015 and the DHSSPS Circular HSC (SQSD) 14/2010 (Appendix 1) and its addendum which advises that the administration of Intravenous fluids and medicines to neonates is often an integral part of their care. However, there is a risk of the inadvertent over infusion of these solutions associated with specific intravenous infusion set up procedures or where the safety mechanisms associated with the administration of intravenous fluids and medicines using infusion pumps have been over ridden. This risk has the potential to result in death or severe harm. 2.0 Aim of the policy This policy has been developed to provide assurance that all ANNP s, registered nurses and midwives are aware of their responsibilities and apply the recommended clinical procedures in relation to the administration and monitoring of intravenous fluids and medicines, as set out in the NPSA Patient Safety Alert RRR015 (Appendix 1) and the NPSA Clinical Briefing sheet for health care professionals (Appendix 2). 3.0 Policy Statement The Trust is committed to providing safe, high quality care to all neonates admitted to its neonatal and paediatric facilities. The Trust will ensure that all ANNP s, registered nurses and midwives are supported in delivering safe and effective care to neonates by:- Providing necessary training and updates to ensure all staff are appropriately trained in the administration of infusions of intravenous fluids and medicines in neonates; Clarifying the roles and responsibilities of those involved in the prescription, administration, monitoring and review of infusions of intravenous fluids and medicines to neonates; Setting in place clinical governance arrangements to provide assurance on safe, high quality practice. All adverse events relating to the infusion of intravenous fluids and medicines in neonates must be reported back via the IR1 process to the Trust governance systems for review, learning and action planning. Page 5 of 22

6 4.0 Scope of the Policy This policy applies to all Trust employees who are ANNP s, registered nurses and midwives who may be involved in, administration, monitoring and set up procedures associated with administration of infusions of intravenous fluids and medicines to neonates. Administration of intravenous fluids and medicines by techniques other than infusion (for example bolus injection) should be conducted in accordance with the relevant procedures and are not included within the scope of this policy. For the purpose of this policy the definition of a neonate is taken as any infant aged 0-28 days that may or may not require care on a neonatal unit, or any infant aged over 28 days who is an in-patient in a neonatal unit. 5.0 Responsibilities 5.1 Chief Executive The Trust Chief Executive, as Accountable Officer, has overall responsibility for ensuring the aims of this policy are met. The Chief Executive has devolved operational responsibility for the delivery of this Policy to the Director of Children and Young People (Neonatal and Acute Paediatrics). The Medical Director in respect of his lead role for Clinical and Social Care Governance systems and processes has devolved responsibility to provide assurance to the Chief Executive that this policy is effectively implemented. 5.2 Director and Senior Management of CYP The Director and senior management of CYP have responsibility for ensuring that arrangements are in place within the directorate to evidence compliance with this policy and that resources are available to support nursing and medical supervision, monitoring and reporting processes. 5.3 Medical Staff All doctors involved in the prescribing and reviewing of infusions of intravenous fluids and medicines to neonates must be aware of and adhere to appropriate documentation including the Neonatal/paediatric fluid prescription and fluid balance chart and complete a clinical management plan. Page 6 of 22

7 5.4 Advanced Neonatal Nurse Prescribers (ANNPs) ANNPs involved in the set up and administration of infusions of intravenous fluids and medicines to neonates must adhere to the procedures associated with this policy. These procedures are located at the end of this policy. ANNPs involved in the set up procedures (Appendix 3) and administration of infusions of intravenous fluids and medicines to neonates must attend awareness sessions provided in house. They must satisfy senior nursing staff at ward level of their competence using the framework. A training record will be held with respect to this. All newly appointed ANNPs who will be involved in the set up procedures and administration of infusions of intravenous fluids and medicines to neonates must complete the awareness session within one month of taking up employment. They must satisfy senior nursing staff at ward level of their competence using the framework. A training record will be held with respect to this. ANNPs involved in the prescribing, monitoring and reviewing of infusions of intravenous fluids and medicines to neonates must be aware of and adhere to appropriate documentation including the Neonatal/paediatric fluid prescription and fluid balance chart and complete a clinical management plan. ANNPs involved in the administration of infusions of intravenous fluids and medicines to neonates must facilitate and participate in the audit programme monitoring prevention of over infusion of intravenous fluids and medicines in neonates. ANNPs involved in the administration of infusions of intravenous fluids and medicines to neonates must administer in accordance with the relevant prescription and clinical management plan. Any ambiguities, lack of clarity or doubt as to the accuracy, safety, completeness or appropriateness of a prescription or clinical management plan should be referred to the prescriber or a pharmacist, as appropriate before administration. 5.5 Registered Nurses and Midwives Responsibility Page 7 of 22 Registered Nurses and Midwives involved in the set up and administration of infusions of intravenous fluids and medicines to neonates must adhere to the procedures associated with this policy. Registered Nurses and Midwives involved in the set up procedures and administration of infusions of intravenous fluids and medicines to neonates must attend awareness sessions provided in house. They must satisfy senior nursing staff at ward level of their competence usi. A training record will be held with respect to this.

8 Newly appointed Registered Nurses and Midwives who will be involved in the set up procedures and administration of infusions of intravenous fluids and medicines to neonates must complete the awareness session within one month of taking up employment. They must satisfy senior nursing staff at ward level of their competence using the framework (Appendix 4). A training record will be held with respect to this. Any Registered Nurse or Midwife involved in the administration of infusions of intravenous fluids and medicines to neonates who is not appropriately trained in the administration of infusions of intravenous fluids and medicines to neonates will be prohibited from doing so until appropriate training has taken place. This will include agency or temporary registered nurses and midwives employed by the Southern Trust. Registered Nurses and Midwives involved in the administration of infusions of intravenous fluids and medicines to neonates must facilitate and participate in the audit programme monitoring prevention of over infusion of intravenous fluids and medicines in neonates. Registered Nurses and Midwives involved in the administration of infusions of intravenous fluids and medicines to neonates must administer in accordance with the relevant prescription and clinical management plan. Any ambiguities, lack of clarity or doubt as to the accuracy, safety, completeness or appropriateness of a prescription or clinical management plan should be referred to the prescriber or a pharmacist, as appropriate before administration. 5.6 Pharmacy Responsibilities A clinical pharmacist monitoring or reviewing infusions for neonates must be aware of this policy and associated documents. 5.7 Audit Responsibilities A working group will be convened to undertake an annual organisational audit(appendix 5) within all facilities where neonates are cared for as inpatients which will identify, review and produce recommendations in respect of prevention of over infusion of intravenous fluids and medicines in neonates; The outcome of this work will be shared at directorate /divisional meetings. This will be achieved in conjunction with clinical teams. Page 8 of 22

9 6.0 Legislative Compliance, Relevant Policies and Procedures Staff must take cognisance of relevant professional standards and guidance and other relevant National, regional DHSSPS publications and local procedures. (Local procedures are listed in the Appendices to this policy). This policy should read in conjunction with following: National Patient Safety Agency (2010) Patient Safety Alert RRR015: Prevention of over infusion of intravenous fluids and medicines in neonates. Available at: Department of Health Social Services and Public Safety (2010) Circular HSC (SQSD) 14/2010 NPSA Patient Safety Alert (RRR015/2010) Prevention of Over Infusion of Intravenous Fluids and Medicines in Neonates. Available at: The Royal Marsden Hospital Manual of Clinical Nursing Procedures (7 th edition) 7.0 Equality & Human Rights Considerations This policy has been screened for equality implications as required by Section 75, Schedule 9, of the Northern Ireland Act, Equality Commission for Northern Ireland Guidance states that the purpose of screening is to identify those policies which are likely to have a significant impact on equality of opportunity so that greatest resources can be targeted at them. Using the Equality Commission s screening criteria, no significant equality implications have been identified. This policy will therefore not be subject to an equality impact assessment. This policy has been considered under the terms of the Human Rights Act, 1998, and was deemed to be compatible with the European Convention Rights contained in that Act. This policy will be included in the Trust s register of screening documentation and maintained for inspection whilst it remains in force. This document can be made available on request in alternative formats, e.g. Braille, disc, audio cassette and in other languages to meet the needs of those who are not fluent in English. Page 9 of 22

10 8.0 Policy Training/Educational Requirements A policy implementation and communication plan has been developed to support the circulation of this policy and meet any identified training need. It is the responsibility of the individual practitioner and his/her line manager to identify training needs and to ensure that these are met / facilitated. 9.0 Alternative Formats This document can be made available on request in alternative formats e.g. plain English, Braille, disc, audiocassette and in other languages to meet the needs of those who are not fluent in English Copyright The supply of information under the Freedom of Information does not give the recipient or organisation that receives it automatic right to re-use it in any way that would infringe on copyright. This includes, for example making multiple copies, publishing and issuing copies to the public. Permission to re-use the information must be obtained in advance from the Trust Sources of Advice Line managers should be contacted in the first instance, in relation to specific queries regarding policy content. Line managers should then escalate queries which they are unable to address to the Policy Author. Page 10 of 22

11 Appendix 1: NPSA Rapid Response Report Page 11 of 22

12 Appendix 2: Clinical Briefing Sheet Page 12 of 22

13 Appendix 3: Set Up Procedures SET UP PROCEDURE FOR ADMINISTRATION OF INTRAVENOUS FLUIDS & MEDICINES TO NEONATES Statement: The administration of intravenous fluids and medicines to neonates is often an integral part of their care. However there is a risk of the inadvertent over infusion of these solutions associated with specific intravenous infusion set up procedures or where the safety mechanisms with the administration of intravenous fluids using infusion pumps have been over ridden. The following procedures are also associated with this guidance Procedure for TPN and Intralipid administration Insertion and maintenance bundles for Central venous and peripheral lines Manufacturers operating instructions for infusion pump Equipment: Intravenous infusion pump and associated giving set. Appropriate documentation Clinical management plan Fluid balance chart Infusion identification labels ACTION RATIONALE PRIOR TO COMMENCING EACH INFUSION Interruptions and distractions during preparation and administration of Intravenous fluids should be avoided. Reduces the risk of error during the procedure When using a syringe pump to administer intravenous fluids a bag of fluid should not be left attached to a syringe Where bags of fluid are left connected to a syringe via a 3-way tap during administration of intravenous fluids to neonates, there is a risk of unintentional over infusion. Ensure administration equipment is loaded into the infusion pump correctly before connecting the infusion to the baby Double check the infusion rate and total volume to be infused with another registered nurse and against the prescription. Ensures adherence with the manufacturer s instructions and reduces risk of potential harm Ensures adherence to NMC standards for safe administration of medications. Page 13 of 22

14 MONITORING OF THE INFUSION PUMP, ADMINISTRATION SET AND THE PATIENT DURING THE INFUSION Ensure the infusion pump is plugged in or fully charged Check the settings on the infusion pump hourly alongside documentation on the infants fluid balance chart of the rate and cumulative total volume infused. Record the serial number of the pump on the back of the fluid balance chart Check the intravenous administration set hourly for patency to include observation of the position of clamps. All fluids whether infusing via a syringe or a bag should have a label placed on the syringe or the bag indicating the contents An identical label should be placed on the back of the fluid balance chart All infusion lines should have 2 identification labels: one positioned on the line close to the pump and a second label positioned close to the infant at infusion site. Record rate and cumulative volume infused hourly on the infants fluid balance chart. Double check the infusion rate and total volume to be infused at each rate change. Document rate change on infants fluid chart and in medical/nursing notes Ensures infusion pump has power back up to delivery fluids at set rate and volume Allows ease of track back information in event of infusion error. During the infusion open clamps ensure patency of administration set and appropriate infusion of fluids at the desired rate Ensures staff awareness and monitoring of fluid and additive content of infusion bags or syringes. Ensures staff able to track infusion lines from source to patient and to identify type of infusion line eg central venous, arterial or peripheral venous. Ensures safe administration of fluids in accordance with the infants requirements. Allows monitoring of fluid intake and alerts to possibility of fluid over load Monitor the baby throughout the infusion and record observation for signs of extravasations of the intravenous infusion site hourly or more frequently if required. Note any redness, tracking, blanching or swelling. Check blood glucose within one hour of start of Dextrose /Total Parenteral Nutrition infusions and subsequently in accordance with the clinical management plan for the infant. On the fluid balance chart mark with an asterisk the time when the blood glucose level is due to be checked Allows prompt detection of extravasation injury and prevention of tissue damage through prompt discontinuation of fluids and removal of intravenous line. Allows close monitoring of infants blood sugar and prompt detection and treatment of hypoglycaemia or hyperglycaemia Allows close monitoring of fluid requirements in response to urea and electrolyte results with early detection and treatment of electrolyte Page 14 of 22

15 Check urea and electrolyte parameters daily or more often if clinically indicated in infants clinical management plan imbalance. When using an infusion pump all clamps on the intravenous set must be closed before removing the administration set from the pump or switching the pump off. The clamp should be closed at the patient end and at the point closest to the infusion bag or syringe. Over infusion can occur if an intravenous administration set is removed from an infusion pump or the pump is switched off and the clamp not turned off. This risk applies even if the administration set contains an anti-free flow device. Intravenous fluids and the administration set should be changed every 24 hours or more often if indicated in the infants clinical management plan. AT HANDOVER OF CARE Double check the infusion rate and total volume to be infused with the registered nurse taking over care. For infants receiving Dextrose /Total Parenteral Infusion check the most recent blood sugar level and urea and electrolyte levels are within acceptable limits in accordance with the clinical management plan for that infant. Ensures staff taking over care are aware of infants fluid requirements and rate of infusion which will prompt early detection of /reduce the risk of fluid over load.. Regular monitoring and recording of changes in fluid requirements, blood glucose levels and urea and electrolyte results will ensure clinical management plan is updated in response to these variables Ensure that all discontinued infusions have been disconnected from the infant and removed from the pump and discarded as per unit policy Ensure all deviations from normal are reported to nurse in charge and to medical staff and are documented in the infants clinical management plan. Ensures adherence to NMC standards for record keeping. Alerts medical staff to review clinical management plan in response to any deviations from normal. Page 15 of 22

16 References Prevention of over infusion of intravenous fluid and medicines in neonates DHSSPS A mixed bag: An enquiry into the care of hospital patients receiving parenteral nutrition NCEPOD 2010 Nursing and Midwifery Council (2007) NMC Record Keeping Guidance. London NMC Performance and Ethics for Nurses and Midwives, London, NMC Nursing and Midwifery Council (2008), Standards for Medicines Management, London, NMC Southern Health and Social Care Trust, 2008, Medicines Management Policy SH&SCT Southern Health and Social Care Trust, 2008, Medicines Management Code SH&SCT Royal Marsden 2008 Hospital Manual of Clinical Nursing Procedures 7 th Edition Wiley- Blackwell Page 16 of 22

17 APPENDIX 4: COMPETENCY CHECKLIST FOR SAFE ADMINISTRATION OF INTRAVENOUS FLUIDS AND MEDICINES WITHIN NEONATAL SERVICES SHSCT STAFF MEMBER : Expected response/ rationale for action NAME : Has Read and Signed NPSA Prevention of over infusion of Intravenous Fluids and Medicines in Neonates Has received training in operation of volumetric and syringe infusion pumps yes yes PRIOR TO COMMENCING INFUSION Ensures iv pump is fully charged and switched on To ensure continual source of power to allow equipment to function fully Has loaded the administration equipment safely into the pump before connecting the infusion to the baby If administration set is not loaded safely through the pump before connecting to the baby there is a risk of over infusion which could occur if fluids were connected directly to the patient before loading administration set. Page 17 of 22

18 Ensures infusion syringe/bag has been labelled as per unit policy Bag: label on bag and duplicate label on back of fluid balance chart Syringe: label on syringe and duplicate label on back of fluid balance chart Ensures syringes and bags of fluid are labelled to identify contents, any additives etc. If rate adjustments are required then syringes and bags are clearly identified to ensure right infusion is altered. Duplicate label on fluid balance chart allows traceability of amount/type of fluids administered after infusion bag /syringe is discontinued and discarded. Ensures serial number of pump recorded on back of fluid balance chart Ensures all infusion lines have identification labels :one positioned close to pump and one positioned close to infant at infusion site Double checks the infusion rate and total volume to be infused with prescription chart and another registered nurse prior to commencing infusion Ensures traceability record for investigation purposes in event of pump malfunction /infusion error Ensures staff able to readily identify infusion lines from source to patient and to distinguish between intravenous / arterial/ central venous infusion lines. Facilitates independent check of fluid volumes/rate of infusion against prescription to ensure accuracy. Ensures adherence to NMC safe administration of fluids and medicines guidance Page 18 of 22

19 DURING THE INFUSION Checks and documents the infusion rate and total volume infused hourly Double checks and documents the infusion rate and total volume to be infused against prescription at each rate change Checks Blood Sugar within one hour of commencement of intravenous fluids containing Dextrose If multiple infusions are running ensures all infusion syringes /bags of fluid are labelled as per unit policy Allows continual recording of rate and cumulative fluid volume administered on an hourly basis and alerts staff to changes / discrepancies in rate and volume infused. Facilitates independent check and documentation of fluid volumes/rate of infusion against prescription to ensure accuracy. Ensures adherence to NMC safe administration of fluids and medicines guidance Using an asterisk on the fluid balance chart to highlight when a blood glucose level is due prompts staff to check glucose 1 hour after iv fluids erected and thereafter as indicated on the infants individual care plan. Staff members are alerted to any deviation from normal in blood glucose measurement in response to erection of intravenous fluids and to monitor infant closely for signs of hypoglycaemia or hyperglycaemia. Ensures staff able to readily identify infusion lines from source to patient and to distinguish between intravenous / arterial/ central venous infusion lines. Ensures syringes and bags of fluid are labelled to identify contents, any additives etc. If rate adjustments are required then syringes and bags are clearly identified to ensure right infusion is altered. Checks and records that IV site has been observed hourly for signs of extravasation and is able to articulate signs of extravasation Checks administration set hourly noting position of clamps during infusion Page 19 of 22 Duplicate label on fluid balance chart allows traceability of amount/type of fluids administered after infusion bag /syringe is discontinued and discarded. Allows prompt detection of extravasation and reduces risk of further tissue damage by prompt discontinuation of intravenous fluids and removal of intravenous cannula if necessary. Signs of extravasation: Redness, swelling, blanching, tracking,exudate leakage, discoloration e.g white area if calcium infusing. Alerts staff to visualise and check administration equipment hourly noting patency of administration set, position of clamps, kinks in tubing, air in line, and any other possible obstruction to flow which could lead to unnecessary interruption of intravenous fluids.

20 AT HANDOVER Double checks rate and total volume to be infused with registered nurse taking over care Relates to the most recent blood sugar and U&E and ensures they are within the acceptable limits of the clinical management plan for that infant AT END OF INFUSION Ensures all clamps on administration equipment are closed prior to removal of administration set from the pump Ensures all clamps on administration equipment are closed prior to switching of the pump If multiple infusions are in place ensures all discontinued infusions are clamped off, removed from the pump, disconnected from the infant and residual fluids disposed off as per unit policy Ensures nurse taking over care of infant calculates independently and with another registered nurse, the rate and infusion volume as indicated on the clinical management plan and as set on the infusion pump. Alerts staff taking over care to monitor blood glucose levels as indicated on the fluid balance chart and as documented in the clinical management plan. Alerts staff to follow up on further or outstanding U&E results as indicated in the infants clinical management plan, to alert medical staff to deviations from normal parameters and to ensure clinical management plan reviewed to address same Closing the clamps before removal of administration set from the intravenous pump is a further safety mechanism to prevent inadvertent fluid overload. Closing the clamps before switching off the pump is a further safety mechanism to prevent inadvertent fluid overload. Removal and disposal of intravenous fluids which are discontinued, eliminates the risk of inadvertent infusion of the wrong infusion or adjustment in rate of wrong infusion. Page 20 of 22

21 Appendix 5: Audit Tool Prevention of over infusion of intravenous fluids in Neonates Audit Criteria (C: Compliant NC: Non-Compliant NA : Not Applicable) WARD PRIOR TO COMMENCING INFUSION Date C NC NA SIGN 1. Staff preparing infusion for administration,loading the infusion pump and commencing the fluids are not distracted / interrupted during the procedure 2. When using a syringe pump, a 3 way tap is not used to connect a bag of fluids to the syringe pump and the baby. 3. Administration equipment is loaded into the infusion pump before connecting the infusion to the baby 4. The infusion rate and total volume to be infused is double checked with another registered nurse and against the prescription DURING THE INFUSION 5. The infusion rate and total volume infused is checked and documented hourly 6. At each rate change the infusion rate is documented and double checked with another nurse 7. A Blood Glucose is checked within one hour of the start of a Dextrose infusion The time when the blood glucose is due is highlighted with an asterisk on the fluid balance chart The blood glucose is recorded on the fluid balance chart 8. There is a documented Clinical Management plan indicating the frequency of Blood Glucose monitoring daily fluid requirements infusion rate with weaning plan if oral intake increasing 9. All infusion lines are identified appropriately as per unit policy Page 21 of 22

22 10. The settings on the Infusion pump are checked hourly alongside documentation of hourly infusion rate and total volume infused. 11. The infusion equipment is checked hourly for patency to include observation of clamp positions 12. If for any reason, the administration set has to be removed from the infusion pump or the pump switched off during the infusion all clamps on the infusion set must be closed off. AT HANDOVER OF CARE 13. The infusion rate and total volume to be infused is double checked with the Registered nurse taking over the infants care 14. For babies receiving Dextrose infusions the most recent blood glucose level is checked and is within acceptable limits in accordance with the clinical management plan for that infant AT END OF INFUSION 15. All clamps have been closed prior to removal of an administration set from the infusion device. This includes clamp at appropriate site at patient end and at site near bag/ syringe of fluids 16. All clamps have been closed prior to switching the pump off. 17. If multiple infusions are in place, all discontinued infusions have been clamped off disconnected from the baby and removed from the pump Page 22 of 22