NUH Medicines Policy: Code of Practice. NUH Intravenous Drug Administration Policy
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1 NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST NUH Medicines Policy: Code of Practice Reference CL/MM/036 Approving Body Directors Group Date Approved 5 Implementation Date 5 Summary of n/a Changes from Previous Version Supersedes NUH Guide to Intravenous Therapy (2011) (Part A) Sixth Edition Consultation Medicines Management Committee Undertaken Nursing and midwifery board Matrons Ward Sisters/ Charge Nurses Practice Development Matrons Nursing Development Department Medical prescribers- those on Medicines Safety Committee. Interventional Radiography- vascular access practitioner Specialist Pharmacist for Theatres/anaesthetics, along with consultation from senior nursing/ ODP team in theatres Infection control Nurse Specialists Out Patient Antibiotic Therapy Specialist Nurses School of Nursing and Midwifery, University of Nottingham Neonatal senior nurses and consultants. Matron clinical procurement Date of Completion 6 th September 2015 of Equality Impact Assessment Date of Completion 6 th September
2 of We Are Here for You Assessment Date of Environmental Impact Assessment (if applicable) Legal and/or Accreditation Implications Target Audience 6 th September 2015 MHRA mixing of medicines guidance 2010 CQC standards April 15 (standards 17 and 19) NMC standards for medicines management 2010 This policy applies to: Staff Groups Registered nurses and midwives (NMC) including bank and agency staff Medical staff (GMC registered) including locum medical staff Radiography staff who undertake diagnostic procedures (HCPC registered) Operating department practitioners (HCPC registered) Non-registered healthcare workers competent in intravenous cannulation Other staff groups authorised to administer IV medicines by the Medicines management Committee (MMC) Clinical areas All in-patient wards- adult, paediatrics and Neo-natal areas. Operating theatres and recovery rooms (not including anaesthetists practice in theatres) All outpatient areas Maternity areas Assessment areas and emergency departments Clinical procedural areas NUH staff working at Kings Mill and intermediate care beds and in the community. Exclusions This policy covers intravenous therapy only and does not apply to patients undergoing subcutaneous or epidural infusions/therapy. This policy does not apply to administration of IV 2
3 medicines or fluids in the Circle Treatment Centre This policy does not include the use of specialist infusion equipment used in anaesthesia delivery or radiology contrast media. In these areas the therapy and use of medical devices falls under the remit of the department specialist infusion equipment This policy does not apply to anaesthetic practice in the operating theatre department. Review Date February 2017 Lead Executive Author/Lead Manager Further Guidance/ Information Chief Nurse for Nursing and Midwifery at NUH Medical Director Mohamed Rahman Head of Pharmacy, Clinical Director Medicines Management, Chair of Medicines Management Committee Ext Sonia Gilmore Professional secretary to Medicines Management Committee Ext Lynn Fullerton Practice Development Matron (Corporate) Ext
4 CONTENTS Paragraph Title Page 1. Introduction 7 2. Executive Summary 7 3. Policy Statement 7 4. Definitions (Glossary and Abbreviations) Roles and Responsibilities Policy and/or Procedural Requirements 6.1 Prescription Authorisation to administer Two-person checking (also called second checking) Timing of medicine preparation Preparing the medicines or fluid for administration 6.6 Calculations Compatibility and mixing of medicine and suitability 21 of venous access device 6.8 Preparing the intravenous medicine Administration of the IV medicine Administration of medicines requiring double 26 pumping 6.11 Administration of medicines to be given by titration After administration Non-administration Interruptions to infusions Disposal Administration set changes Identifying and managing possible complications of 30 IV administration 6.18 Administration via a verbal order Administration by NUH staff working in the 30 community 6.20 Administration of an OPAT medicine Removal of access devices Training, Implementation and Resources Impact Assessments Monitoring Matrix Relevant Legislation, National Guidance and
5 Appendix 1 Appendix 2 Appendix 3 Appendix 4 Associated NUH Documents The Procedure for administering intravenous Drugs using Aseptic Non-Touch Technique (ANTT) (NUH (2015) Aseptic Non-Touch Technique Policy) Best Practice for the administration of medication via intravenous route. Summary Steps for medication intravenous drug administration. Procedure for withdrawing a solution from an ampoule (glass or plastic) into a syringe Appendix 5 Procedure for withdrawing solution or suspension from a vial into a syringe Appendix 6 Procedure for reconstituting powder in a vial and 47 drawing the resulting solution or suspension into a syringe. Appendix 7 Procedure for using multiple dose vials to withdraw a solution or suspension into a syringe. Appendix 8 Procedure for adding a medicine to an infusion fluid in a bag. Appendix 9 Procedure for diluting a medicine in a syringe for use in a syringe pump Appendix Information on Administration an infusion (with or without an additional medication) Appendix Preparing an administration set ( giving set or intravenous infusion set ) Appendix Procedure for administering Intermittent or continuous infusion of intravenous medicines (with or without additional medicines) Appendix Procedure for the intravenous medication administration via a bolus/ push. Including medication that may need to be administered over several minutes Appendix Summary of Flushing and Locking in Adults Appendix Summary of Flushing and Locking in Children Appendix Summary of flushing and locking in Neo-natal Appendix Table of possible complications of intravenous
6 17 medication administration Appendix Guidance for the management of extravasation following administration of cytotoxic medication Appendix Double pumping Appendix What involvement students can have in medicines administration? Appendix Equality Impact Assessment Appendix 22 Environmental Impact Assessment Appendix 23 Appendix 24 Here For You Assessment Certification Of Employee Awareness 85 6
7 1.0 Introduction 1.1 This policy is to inform staff working at Nottingham University Hospitals NHS Trust (NUH) of the correct practice and procedures when administering intravenous (IV) therapy to patients. 2.0 Executive Summary 2.1 This policy outlines the responsibilities of all staff groups involved in the administration of IV therapy in all areas at NUH (adults and paediatrics). It ensures that there is a safe, consistent level of practice in the care of these patients. IV therapy in this policy includes all medication via: direct/ bolus injection or infusion, flushes, IV parental nutrition, line locks, infusion fluids. 3.0 Policy Statement 3.1 The Trust supports the safe administration of IV therapy by all NUH staff Practitioners involved in the prescribing or administration of IV medicines should act within their sphere of competence at all times. This includes having the relevant training and competency to use the medical devices in their area to administer IV drugs. Practitioners are accountable for their practice in accordance with the standards of their professional body and with the requirements of the NUH medicines policy. 4.0 Definitions and Glossary of abbreviations Healthcare professional: A registered member of staff, including nurses, operating department practitioners, doctors, dentists and radiographers. This also includes individuals employed by a third party to work within NUH. 7
8 4.1.2 Healthcare support workers: Non-registered staff employed as band 2, 3 or 4. This group will include phlebotomists Scrubbed Practitioner: Authorised professional who assists the Operating Surgeon, handing the surgical instruments or other items Operator: These are registered medical practitioners e.g. the surgeon, endoscopist, cardiologist, obstetrician, radiologist or other healthcare professional or practitioner performing the invasive procedure Competence: Is defined as demonstrating the knowledge and skills to perform the task to NUH standards, consistently and without supervision IV trained practitioner: A practitioner who has satisfactorily completed the NUH training for IV administration or has had their training and competency from another organisation verified, has undergone a competency check in their area of practice and has reviewed associated NUH policies and procedures to align their practice Direct Intravenous injection: Introduction of a small volume of medicine solution into the cannula or the injection site of an administration set. A direct intravenous injection should be administered slowly over 3-5 minutes unless otherwise specified. Sometimes referred to as intravenous bolus Intermittent infusion: Administration of an infusion over a set time period, either as a one-off dose or repeated at specific time intervals. This will involve repeated use of a single cannula. This may be a central venous access device for example PICC lines/port-acatheter devices/hickman lines Continuous infusion: Intravenous administration of a volume of fluid with or without medicines added over a number of hours to achieve a clinical end point. The infusion may be repeated over a period of days. Large volume i.e mL or small volume infusions may be delivered continuously. 8
9 Infiltration: the deposition of a solution (e.g. local anaesthetic) directly into tissue often during surgical procedures. Due to the associated risks the same procedure as for IV preparation and administration should apply Irrigation: washing or filling of an organ, body cavity or wound by a stream of fluid. Due to the associated risks the same procedure as for IV preparation and administration should apply Two person check procedure (also known as second checking): At NUH the accepted standard is to have two registered health care practitioners both check the medicine for administration. This is usually two registered nurses/ midwives. All steps of the process are checked from drug selection and preparation to administration. Where a calculation is involved, both practitioners must perform an independent calculation and then share their individual calculation result to confirm accuracy Extravasation: The inadvertent administration of vesicant medication or solution into the surrounding tissue instead of into the intended vascular pathway (also sometimes called tissued) ANTT: Aseptic Non Touch Technique VIPS: Visual Infusion Phlebitis Score IV administration monographs: Detailed guidance on the preparation, reconstitution and administration of specific intravenous injections and infusions are available on every ward/ unit. The most up to date version of the guidance available in that area must be used. Trust wide versions currently in use include NUH Part B ( blue pages - adults), and Medusa IV drug guide. In the Neonatal unit this includes the Neonatal Pharmacopeia TPN: Total Parenteral Nutrition Peripheral cannula: a cannula that is less than or equal to 7.5cm in length. Ideally for short term therapy of 3-5 days. Often referred to as venflons. 9
10 Midline catheter for adults: a cannula that is cm in length. Are used where the patient has poor peripheral venous access and the use of a central venous catheter is contraindicated. Drugs that require central access are NOT suitable to be administered via a Midline. Ensure that the drug prescribed is suitable for midline administration PICC: Peripherally Inserted Central Catheter in neonatal, referred to as long lines. These are suitable for all drugs as per Central venous catheter/ Hickman line/ Portacath Central Venous Catheter (CVC) Central line, central venous line is placed into a large vein in the neck (internal jugular), chest (subclavian vein) or groin (femoral line). In neonates, this also includes umbilical artery & venous catheters. Some medication are best delivered via a central line e.g. inotropes; chemotherapy; TPN. Additional evidence of competency to use this type of access is required before administering medication via this device Skin tunnelled catheter is a long-term catheter that lies in a subcutaneous tunnel before entering a central line. Examples include: Hickman line; Broviac line. Additional evidence of competency to use this type of access is required before administering medication via this device Implantable ports such as Portacath are used for long term intermittent venous access. Additional evidence of competency to use this type of access is required before administering medication via this device Preceptorship nurse: A newly qualified nurse who upon commencing post undergoes a programme of supported learning in their practice environment. Supported learning programmes are available for other newly appointed nurses to the Trust, where this is deemed essential to their role Y site connector- This is a connector device that is used to deliver IV medicines from different sources into one vein. 10
11 Mixing of medicines- This is the combining of two or more medicinal products together for the purpose of administering them to meet the needs of an individual patient. This technically produces an unlicensed product. The Medicines Healthcare products Regulatory Agency (MHRA) has put into place changes to medicines regulations to enable the mixing of IV medicines prior to administration in clinical practice. See OPAT: Out Patient Antibiotic Therapy Double Pumping: Use of two pumps simultaneously. Used when changing infusions of very short acting drugs where a break in therapy could be detrimental to the patient. 5.0 Roles and Responsibilities 5.1 Committees Nursing and Midwifery Board Responsible for ensuring that this policy reflects best practice for nursing Medicines Management Committee (MMC) Responsible for approving the policy, managing the monitoring arrangements for the policy and to address barriers to implementation of the policy. 5.2 Individual Officers The Chief Nurse is responsible for implementation of this policy by nurses at NUH The Head of Pharmacy is responsible for ensuring the content of this policy aligns with the necessary legislation and accreditation standards through the Medicines Management Committee Divisional Nurses and Heads of department are responsible for ensuring that necessary measures are in place to support the safe implementation and monitoring of the use of the policy in practice. 11
12 They will need to take measures where practice has been deemed potentially unsafe Matrons and department managers are responsible for ensuring that all staff accountable to them are aware of and adhere to this policy. It is the manager in practice. They will investigate and rectify any discrepancies identified Ward sister/ charge nurse/ department leader will act as excellent role models and are responsible and accountable for the policy implementation among staff in practice, and the monitoring of standards and best practice associated with it. They will ensure that all staff in the sphere of their responsibility have access to training to develop the skills and competence. This includes the completion of the associated work books, medical equipment competency documents and study sessions in a timely manner All registered healthcare professionals have a duty of care to their patients. This is a legal and professional requirement of state registration that cannot be delegated. All registered healthcare professionals are personally responsible and professionally accountable in ensuring that they receive training in the safe use and observation of any medical device used in the delivery of intravenous therapy (MHRA, 2010). It is the responsibility of the healthcare professional to ensure that any IV access or IV therapy is appropriately prescribed for the patient and that the patient and therapy delivery are monitored accordingly according to associated policies and procedures Pharmacists are responsible for monitoring both the prescribing and overseeing the administration of medicinal therapies and alerting prescribers and other health care professionals to potential or actual problems in line with NUH pharmacy procedures and Royal Pharmaceutical Society standards All staff are required to prevent and manage healthcare acquired infection as part of The Health Act 2008: Code of Practice on the control of infections and related guidance (Department of Health, 2015). 12
13 5.2.9 Allied health professionals not required to take part in IV therapy administration This group of staff should not be involved in, or action any part of the delivery of IV therapy including use of medical devices. This includes disconnection of lines and starting infusion devices or pumps between the point of delivery and the patient. In the event of the need to access a patient where therapy may need to be discontinued for any reason, the advice of a registered person should be sought. 6.0 Policy and/or Procedural Requirements 6.1 Prescribing Prescription requirement All medicines to be administered must be prescribed on a NUHapproved prescription chart- see Prescribing policy CLMM006. If the medicine is not suitable for peripheral line administration this must be stated on the prescription, e.g. for central line only. It is good practice for IV medicines to state details of any diluting fluid and duration of the injection or infusion, which vascular access should be used, the date, rate or duration of infusion and signature Prescribing of IV loading doses For IV loading doses only: Direct injections should be prescribed on the once-only section of the drug chart. Infusions (which must be administered via a rate controlling device) should be prescribed on the infusion therapy prescription section of the drug chart Prescription of other IV drugs For IV maintenance doses and other infusions: Maintenance doses of medicines administered intermittently by direct injection or infusion should be prescribed on the regular or as required sections of the drug chart Insulin infusions either as a continuous or variable rate should be prescribed on an Insulin Chart Opioids being administered via Patient Control Analgesic Pump (PCA) should be on PCA chart 13
14 Chemotherapy should be prescribed via a Chemocare (where Chemocare in place) Maintenance doses of antibiotics should be prescribed on the antibiotics section of the drug chart. All other infusions (large volume infusion bag, or small volume syringe or bag) which must be administered continuously via a rate controlling device should be prescribed on the infusion therapy prescription section of the drug chart. The prescription must be rewritten in full at least every 24 hours. Prescribers changing the rate must document; new rate, date, time and initials. Includes: o Crystalloids, plasma expanders, or fluids o Drugs added to a large volume infusion bag, or in a small volume syringe, or ready to administer from the manufacturer for continuous infusion Prescribing of IV drugs which require mixing prior to administration By definition mixing is the combination of two or medicinal products together for the purpose of administering them to meet the needs of a particular patient. This does not include reconstitution or dilution with the infusion fluid which is permitted. The prescriber must state mixed or mixing in line on the prescription. This may be pre-printed on the prescription, e.g. in critical care areas. Under MHRA regulations, prescribers are legally authorised to mix medicines to administer to a patient themselves. Other practitioners may mix medicines on the authorisation of a prescriber prior to administration. This also applies to concurrent administration of multiple drugs via a Y site connector Prescribing of Infiltration or irrigation for intraoperative use Administration via these routes requires that the practitioner has completed their NUH approved Intravenous Drug administration Training, as well as practice based assessment. The practitioner must also be able to provide evidence of training in the use of any medical device required to administer the medication they are 14
15 administering. Medication for administration via infiltration or irrigation in theatres is prescribed an electronic Kardex system; this is an approved medicine order which is validated by the operator. The electronic Kardex system, gives details of the medicines which the operator will expect to administer during a specific operative procedure. The system allows a practical way for the theatre practitioner to plan and safely prepare for operative procedures. All medicines which are selected for intra-operative administration must be checked against the operator s medicine order as detailed in the electronic theatre Kardex. Irrigation and infiltration preparations should prepared and administered using a two person check for all stages. If a verbal order is made from the operator that differs from the Kardex, the registered practitioner will instruct the circulating practitioner to select the medicine. The selected medicine will be checked against the verbal order by the registered practitioner before the medicine enters the sterile field. The registered practitioner is responsible for second checking this with the operator prior to administration. For local anaesthetics the scrub practitioners must check that the operator and anaesthetist have communicated and agreed on the concentration and volume of local anaesthetics which are ordered by the operator before preparing the infiltration. This is to safeguard against local anaesthetic toxicity. 6.2 Authorisation to administer IV medicines All registered healthcare professionals MUST be competent to be involved in the administration process of IV medicines. If they are unfamiliar with the advised administration method, e.g. using a central line, then this MUST be highlighted and an alternative appropriate staff competent in administering the drug should be sought. The following practitioners are permitted to administer medicines intravenously, providing they have the relevant underpinning knowledge and competencies to do so (also see 7.0 Training) : 15
16 6.2.1 Registered Nurse or midwife: Must have evidence of successful completion of the NUH approved Intravenous Drug administration Training and competency package, as well as practice based assessment. Must also be able to provide evidence of training in the use of any medical device required to administer the medication they are administering Newly appointed nurse or midwife who have completed an IV package/training at another organisation: Having previously worked at another organisation, practitioners are required to supply evidence of training, along with proof of supervised practice and verification of competence in order to continue to administer IV medication. Without this evidence, staff will be required to complete the current NUH Intravenous administration competency package Newly Qualified nurse or midwife PLUS registered nurses that have NOT worked within an acute care hospital in the last 6 months PLUS registered nurses from overseas: Must successfully complete the NUH approved Intravenous Drug administration Training and competency package, as well as practice based assessment prior to administering IV medication. However, once they have successfully completed the IV medication calculations section of the NUH approved Intravenous Drug administration Training and competency package they may participate in the preparation (including separate calculations if required), checking and recording of the administration as part of the 2-person check. They cannot administer the drug to the patient or connect an infusion. NB The only exception where IV medication maybe administered by this staff group prior to successfully completing the NUH approved Intravenous Drug administration Training and competency package, is in in a time critical emergency situation, taking into consideration both the patient s critical condition and the practitioner s knowledge and skills Agency nursing staff (including NHS Professionals and other external Agency organisations) must not administer 16
17 intravenous medication unless they have received additional training and have a documented competence assessment. Where staff are working outside of their usual area of work, their competence must be assessed in that area prior to administering intravenous medication. They must have the knowledge and skills for safe and effective practice when working without direct supervision (NMC, current version). Agency staff cannot check IV drugs for administration with another flexible worker; these must be checked with a permanent member of staff within the clinical area. In addition, agency staff must also be able to provide robust evidence of Trust specific medical device training for any device they are using Health care assistants may administer a single 0.9% sodium chloride flush immediately after peripheral cannulation to adults (completion of venepuncture and cannulation education package required). Also refer to NUH medicines administration policy CL/MM/ Medical students under the direct supervision of a doctor who is then responsible for the correct administration and recording of the medicines prescribed Other practitioners approved by the Trust as Designated by the Trust e.g. radiographers, physiotherapists, Operating department practitioners Must have the relevant underpinning knowledge, AND following successful completion of the NUH IV training and assessment of competence AND must have a list of medicines/local agreement in place ratified by Medicines Management Committee. Also refer to NUH medicines administration policy CL/MM/ Other practitioners: If any other named individual or staff group need to administer IV medicines, there must be a local agreement in place which has been ratified by the Medicines Management Committee Patients or carers: This group will not normally self-administer IV medicines. In some circumstances, patients or carers are taught to self-administer OPAT antibiotics in hospital for further administration after discharge where they may prepare and administer IV medicines 17
18 and flushes under the supervision Student nurses or student midwives who are not registered, can assist in the preparation and recording of intravenous infusions and direct injections under the direct supervision of 2 registered nurses but CANNOT administer the medication. The supervising registered nurses are responsible for the correct process throughout. 6.3 Two-person checking (also called second-checking) The following groups of practitioners are authorised to second check injectable medications: A doctor A registered nurse or Midwife that has completed the calculation section of the NUH approved Intravenous Drug administration Training and competency package. A Pharmacist that has completed the theory section of expansion to practice IV administration of medicines (an exception is that a pharmacist working within their sphere of competence may second check a calculation without completion of this pack, but should not check other steps in the process). All injectable medicines (except prophylactic doses of enoxaparin) including IV fluids and irrigation and infiltration fluids must have a two person check before administration. All rate changes of IV infusions must also have a two-person check, and must be within the rates specified on the prescription. Refer to NUH medicines administration policy CL/MM/008 for other drugs requiring a two person check. Both practitioners: MUST check all stages of any intravenous drug/medication/fluid preparation (include undertaking separate drug calculations if required), up until the injection or infusion is commenced. MUST observe the preparation. Take equal responsibility for the correct administration of the drug/ medication/ fluid to the correct patient. Should sign the prescription chart. 18
19 6.4 Timing of medicine preparation A venous access device must be in place before an injectable is prepared. Intravenous medicines must not be prepared in advance of their use. Administration must be commenced as soon as possible after preparation, and must be within one hour of preparation (considered to be the time when the sterile seal of the primary packaging is breached). Any medicine prepared in advance must be discarded if the clinical need ceases, and in any case after 24hours (or less if physically unstable- refer to IV administration monographs in use in your area). Exceptions to this must be made for the benefit of the patient, not the convenience of the staff. An exception to this is when IV medication is prepared within the pharmacy department, e.g. Total parenteral nutrition (TPN) and cytotoxic medicines. Areas that have a clinical need to routinely prepare medicines in advance (e.g. paediatric retrieval team, procedural areas such as cardiac catheter lab) must: o Have a current local agreement in place (ratified by MMC) o Complete a full risk assessment o Use tamper proof packaging o Discard any prepared products if clinical need ceases, and within 24hours (or sooner if product unstable) 6.5 Preparing the medicines or fluid for administration Refer to Procedures on Appendix for details. All steps of preparing medication must occur, and involve 2 persons. However they may occur in a different order, ensuring patient safety at all times Check the patient s prescription for: The right patient The right drug chart The right date/ day/ time Right Route Right drug, preparation, dose and indication Check patient allergies 19
20 See Appendix 3 Summary of steps of administration for more details Patient consent All patients should give valid consent to receiving healthcare, including receiving medicines. Consent should happen at all stages of the process. Refer to NUH Consent policy CL/CGP/020 for more information Prepare for one patient at a time Prepare and administer IV medicines for each patient individually. Preparing medicines for multiple patients simultaneously is a high risk practice and must be avoided. If a patient requires more than one parenteral medicine at a given time, it is good practice to fully prepare, check and administer the first medicine before preparing the second Single use vial policy Sterile fluids intended for injection, including infusion fluids, water and medicines (other than approved Multiple Dose Vials) must be for single use only. If only part of the container is used, the remainder must be discarded. It must not be kept for multiple uses on separate occasions, even for the same patient. Other equipment used to prepare or administer intravenous medicines that has been designated as single use must not be re-processed or re-used under any circumstances including needles, syringes, lines, catheters and tubing. Refer to CL/MM/028 Medicines Policy: Code of Practice: Use of Single and Multiple dose vials. 6.6 Calculations You may need to calculate: concentration or total quantity of medicine in the final infusion container or syringe; volume of diluent and/or infusion fluid; rate and duration of administration; All calculations MUST be 2-person checked. Calculations must be done independently and any discrepancies must be re-calculated. If 20
21 necessary seek advice from a pharmacist. Confirm that your answers are consistent with the IV administration monographs in use in your area. Dose calculation tools are available in some areas. 6.7 Compatibility, mixing of medicines, and suitability of venous access device. Confirm that the medication is suitable for the venous access the patient has in place. Ensure compatibility or incompatibility of the IV medication by referring to the IV administration monographs in use in your area. Where multiple drugs are being administered through the same lumen through a Y-site connector or multiway adaptor fixed to a patient s cannula, confirm that they are both compatible with other medicines and fluids and suitable for the route of administration i.e. peripherally/ centrally. This is particularly important for medicines administered via the same lumen of a CVC. If necessary seek advice from a pharmacist. Ensure that the prescriber has stated mixing in line on the prescription as above, or that a specific approved local policy is in place. Patient Controlled Analgesia (PCA) style lines containing an antireflux valve must be used when potent drugs are running together or when a potent drug and an intravenous fluid are running into the same cannula and the fluid is running under gravity rather than being pumped. 6.8 Preparing the intravenous medicine Also Refer to Appendices: Appendix 2: Best Practice for the administration of medication via intravenous route Appendix 3: Summary Steps for medication intravenous drug administration. Use a ready-made product, e.g. a pre-filled syringe, where available 21
22 Right diluent or infusion fluid. If in powder form identify correct diluent and volume required. If medication needs to be given in an infusion, select correct infusion fluid. Right expiry. Check the expiry date of ALL medication, diluents and fluids to be administered. Ensure area in which medicine is prepared is as clean, uncluttered and free from interruption as possible. Medication intended for injection should not be put into gallipots. Some areas may choose to wear red tabards for medicines administration e.g. the neo-natal areas. Assemble all medicines in line with the NUH (2015) Aseptic Nontouch Technique (ANTT) Policy (see Appendix 1). The key principles of ANTT are: o Always decontaminate hands effectively o Never contaminate key parts of the equipment or the patients susceptible site. o Touch non key parts of the equipment with confidence o Take appropriate infection prevention and control precautions. Procedures for the preparation of the following can be found in the appendices and must be followed by all practitioners: o Appendix 1: The Procedure for administering intravenous Drugs using Aseptic Non-Touch Technique o Appendix 4: Procedure for withdrawing a solution from an ampoule (glass or plastic) into a syringe o Appendix 5: Procedure for withdrawing solution or suspension from a vial into a syringe o Appendix 6: Procedure for reconstituting powder in a vial and drawing the resulting solution or suspension into a syringe. o Appendix 7: Procedure for using multiple dose vials to withdraw a solution or suspension into a syringe. o Appendix 8: Procedure for adding a medicine to an infusion fluid in a bag. o Appendix 9: Procedure for diluting a medicine in a syringe for use in a syringe pump o Appendix 10: Information on Administration of an infusion (with or without an additional medication) o Appendix 11: Preparing an administration set ( giving set or 22
23 intravenous infusion set ) o Appendix 12: Procedure guideline: Intermittent or continuous infusion of intravenous medicines (with or without additional medicine) o Appendix 13: Procedure for the intravenous medication administration via direct injection. Including medication that may need to be administered over several minutes. Refer to the pharmacist or individual drug monographs for up to date technical information on preparation and administration/ or current information available in your area Labelling injections, infusions and giving sets Unless in a hand-held syringe for immediate direct injection, administered by the person who prepared the medicine, ALL intravenous medication should be labelled immediately after preparation with a fully completed NUH IV additive label. An operator should not be in possession of more than one unlabelled syringe at a time. An unlabelled syringe must not be fitted to a syringe driver or similar device, e.g. when preparing multiple medicines for one patient. For medication being administered via continuous infusion the givingset must also be labelled with the date on which it is due to be changed Infusion devices See Appendix 10: Information on Devices to Administer an infusion (with or without an additional medication) for further information. Key points: Select and prepare an appropriate infusion device, e.g. a gravity flow device or a rate controlled device. The staff member must be competent to use device selected. Select an appropriate administration set for the pump and the drug to be infused, i.e. it may be necessary to use a giving set that incorporates a filter, an anti-reflux valve and/or flow-control line. A rate controlled infusion device must be used for administering: 23
24 Infusions to neonates and children Medicines where the rate of infusion is important, e.g. when treating hypokalaemia, you must use a rate controlled infusion device where administering an infusion containing a concentration of 40mmol of potassium per litre, or greater. Staff using infusion pumps operating Drug Error Reduction Software (DERS) must ensure they have the necessary competence to operate the device. They must ensure that they select the appropriate infusion programme, and that the medicines they are administering match the prescription and DERS and fall within the upper and lower parameters for that regime. 6.9 Administration of the IV medicine Responsibility for administration Practitioners must only administer IV medication that has been prepared in their presence (unless the medication is provided in a pre-prepared syringe or bag from Pharmacy). If both practitioners involved in the preparation have to leave the room before administration the medicines must be kept securely. In cases of transfer with a continuous infusion, the practitioner may delegate the ongoing administration to another practitioner. In exceptional circumstances e.g. when a patient is transferred between units, the practitioner may delegate administration of an IV medicines to another practitioner, where not doing so would be a disadvantage to the patient. There should be a formal documentation of a handover in the patient s notes Positive patient identification Positive patient identification MUST occur by both practitioners prior to IV medication administration. This includes full confirmation of the wrist band details with the drug chart; and positive patient identification by the patient to confirm their identification verbally, where possible. Where possible explain to the patient and/or family and carers what is about to happen, the likely benefit and possible side-effect, and obtain patient s verbal consent to treatment and answer any concerns the patient has. Refer to NUH positive patient identification policy CL/CGP/037 24
25 6.9.3 Check allergy status of patient- two person check This needs to be done at the bedside, confirming the red wrist band, checking the drug chart and where possible asking the patient to state any known allergies and / or sensitivities Confirm route/cannula The details of what specific intravenous device(s) a patient has are located in the patient s medical notes on the IV Device Insertion Sticker. If the patient has multiple IV devices, confirm with the prescriber if in doubt as to which route should be used. This can be of particular importance for some medication Ensure central or peripheral route appropriate for the medication and concentration which you are administering Check patency of cannula The practitioner must check the patency of the device prior to administration of medicines and/or solutions Lines should be flushed initially to check patency and between incompatible drugs and infusions. All flushes must be prescribed, unless a Patient Group Direction is being followed. See Appendix 14 for Summary of Flushing and Locking guidelines in Adult and Appendix 15 for Flushing and Locking guidance in Children. With PICC catheters check that external length has not increased by >2cm- indicates that may not be correctly positioned. Seek medical advice Set rate on pump if applicable (must be two person checked) Prepare giving set/administration set The practitioner must prepare the administration set as per Appendix 11: Procedure for preparing an administration set ( giving set or intravenous infusion set ) Connect administration set as per Appendix 12: Procedure for administering intermittent or continuous infusion or intravenous medicines (with or without additional medicines) 25
26 6.9.9 Commence administration Connect the syringe or infusion to access device, and deliver the medication over the correct time period To ensure minimal medication being left in giving sets. If giving a medication in a volume of less than 50mL, do not use a giving set through a volumetric pump, due to the risk of the drug being left in the line and incomplete administration of the drug. If less than 50mL, this should be administered by a syringe driver or a non-volumetric pump. Ensure the line is flushed after administration Administration of drugs requiring double pumping Best practice is that only one drug should be double pumped at any one time, in areas where more than one drug requires double pumping local guidance must be followed. Inform the nurse co-ordinating the shift prior to commencing procedure. Refer to Appendix 19 for procedure on Double Pumping 6.11 Administration of medicines to be given by titration (e.g. procedural areas) Where the medicine is available in a multi-dose vial, draw up each dose increment and administer as it is required. The vial should be appropriately labelled and kept in the designated place when not in use, and discarded when no longer needed, e.g. at the end of the procedure. Where the medicine is only available in an ampoule, the contents of the ampoule(s) should be drawn up, ideally to a standard amount or concentration, as used in that area. After each dose the syringe should be disconnected if cannula is required for other drug administration. The syringe should be labelled, and kept securely in a designated place when not in use (which must be the CD cupboard if a CD). The total amount of drug given must be documented After administration Locking and flushing 26
27 Flushing of the access device is required after administration of ALL medication, and between medications being administered consecutively. See the following appendices for further information: Appendix 14: Summary of Flushing and Locking in Adults Appendix 15: Summary of Flushing and Locking in Children Appendix 16: Summary of Flushing and Locking in Neonates All flushes must be either prescribed or administered via a Patient Group Direction. When flushing/locking an intravenous device note the device condition, patient comfort, ease of use. For peripheral cannula complete a Visual Infusion Phlebitis (VIPS) chart Rate changes Rate changes of IV medicines or fluids must have a two person check. Both practitioners should sign in the appropriate location (e.g. drug chart or observation chart) details of the new rate, date and time of the change. In areas where rate changes are changing rapidly e.g. critical care; labour suite, the patient may be stabilised with several rate changes over a short period of time. In these cases it is acceptable to have the new rate checked and documented hourly with a second practitioner once the patient is stable Recording administration of intravenous medication Both practitioners involved in the preparation and administration of the medicine must sign their initials on the drug chart, with the date and time of administration if appropriate 6.13 Non-administration It is important to communicate with the medical staff / prescriber any medication that is unable to be administered so that appropriate action can be taken i.e. route change; new cannula; ordering of drug. Document on the medication chart why medication not administered and actions taken. Contact On-call pharmacist out of hours to obtain drugs / ward pharmacist in normal hours. 27
28 6.14 Interruptions to infusion Best practice is to discard interrupted infusions and to record volume administered and remaining dose required. The maximum time an infusion can be paused is an hour as it should be clear whether the infusion would need to be restarted within this time. Exceptions to this are time critical medication where the patient would be at clinical risk if there was a delay in restarting the medication i.e. critical care areas; neo-natal. If disconnection is unavoidable use ANTT for both disconnection and reconnection; and ensure any administration sets or extension lines are clamped before disconnection and a sterile bung is placed at the patient end of the administration set. The administration set must be replaced if the reconnection is not immediate. If it is not necessary to disconnect between infusions leave the administration set in situ, but clamped off. If the dose of an infusion containing a medicine has been delivered by volumetric infusion pump and more remains in the bag, this can be used for the next dose provided that the infusion is not disconnected from the venous access device (and the infusion fluid is still in date for the next infusion. The administration set should be clamped between infusions. If the prescribed dose is taken from a bag into a syringe pump for administration, then the remainder of the bag has to be discarded and cannot be used for subsequent infusions Disposal Disposal of equipment Dispose of all equipment (including but not limited to syringes, needles, stylets and surgical blades) from the patient s bedside and area used for preparation. Follow the NUH Waste Handling and management policy (HS/EI/017) For disposal of equipment used to administer cytotoxic or cytostatic medication use a yellow body purple lidded sharps bin. Refer to NUH Medicines Policy: cytotoxic policy CL/MM/ Disposal of used and unwanted medication Discard empty ampoules and vials from which the injection was 28
29 prepared. Recheck the identity of empty ampoules and vials as they are discarded after the infusion or injection has commenced. In procedural areas (i.e. those areas performing procedures to multiple patients e.g. cardiac catheter lab) all medicines prepared must be discarded at the end of each individual procedure. Systems should be in place to ensure that the area is cleared after each procedure; ensuring medicines drawn up for one patient are not administered to another patient. In procedural areas it is best practice to keep all vials, ampoules and syringes used until the end of the procedure in the designated location, and perform a reconciliation of these against medicines administered during the procedure. A designated tray as used in theatres may be used for this purpose. Also refer to: CLMM013 for disposal of cytotoxic medicines CLMM012 for disposal of Controlled Drugs CLMM011 Return and disposal of non-controlled medicines Disposal of IV therapy infusions that have not completed Any medicine infusion that is still in progress and has not yet been administered must be disposed of after the following times: <24hours- where pharmaceutical stability is a concern At 24 hours- any infusion that has been prepared on a ward or department (i.e. a drug added into an infusion fluid or a dilution into a syringe for insertion into a syringe pump). Exceptions for Nottingham Children s Hospital as per local guidelines. At 48 hours for an infusion drawn into a syringe from a single vial or ampoule already in solution and without further dilution on the ward (e.g. ISOKET 0.05% solution, morphine 50mg in 50mL, heparin 20,000 units in 20mL) At 72 hours for an infusion that has been prepared in Pharmacy aseptic unit, theatre recovery or prepared ready made by the manufacturer. After 72 hours both the infusion and the administration set will need to be replaced if further administration of the drug required Administration set changes Administration sets must be changed: 29
30 Following a blood transfusion or every 12 hours during transfusion (whichever is sooner) When the administration set becomes disconnected and has not been immediately reconnected using ANTT When a central venous access device is replaced After 24 hours of administration of IV parenteral nutrition (unless the solution contains only glucose and amino acids or Vamin infusion in neo-natal areas that lasts for 48 hours). After 72 hours in all other circumstances When it has not been possible to replace the peripheral cannula immediately (consider putting a white cap/bung onto the line whilst waiting for another peripheral cannula to be inserted). NB: If used, add- on devices used as part of the administration set should be changed with the administration set Identifying and managing possible complications of IV administration Refer to: Appendix 17: Table of possible complications of intravenous medication administration Appendix 18: Guidance for the management of extravasation following administration of cytotoxic medication 6.18 Administration via a verbal instruction During drug administration in procedural areas it is common practice for the doctor to issue verbal instructions on the drug and dose to be administered at that time to a patient. In these areas there is a local agreement covering how to do this Administration by NUH staff working in the community Where possible the right drug, dose, indication checked in advance at NUH. Calculations should be performed and checked in advance at NUH. IV medication administered in the community by NUH staff should be checked by one registered nurse and by another competent person who knows the patient. This could be a parent, carer or the patient themselves. The patient or carer is acting as a second checker to confirm a: positive patient identification, that they are expecting the drug intended; that they are not allergic to the drug being 30
31 administered. In the event of emergency, call an ambulance Administration of OPAT medicines May be administered on the ward, and patient may self-administer following proper assessment/under supervision of nurse. The patient can act as the second checker providing they have the necessary competence at that time Removal of access devices The removal of any vascular access device must only be undertaken by an appropriately trained practitioner. Those commonly removed by nurses include cannulas, midline catheters, PICCs and non-tunnelled CVCs. Exit sites must be inspected for signs of infection at every manipulation and at least twice a day. Assessment of the site must be documented on the patients Visual Infusion Phlebitis (VIPs) chart. Use the VIPS score to determine whether the access device needs to be removed or changed immediately. Access devices must be kept in place for the minimum time necessary. However, consideration to patient s clinical requirements for further infusion must be considered prior to removal, particularly with regards to central lines; PICC lines etc. Best practice is to remove a peripheral cannula must be changed at least every 72 hours unless. However in some areas it maybe in the patients best interest to leave in situ. The rationale for this decision must be documented in the patient s records. A peripheral cannula inserted in an emergency situation, where aseptic technique has been compromised, should be replaced within 24 hours. The optimal dwell time for removal of midline catheters, PICCs, tunnelled catheters or implanted ports is unknown. Ongoing and frequent monitoring of the access site must therefore be performed. A midline catheter should be removed if the tip location is no longer appropriate for the prescribed therapy. 31
32 Caution should be used in the removal of central venous catheters, including precautions to prevent air embolism (patient should be flat with head down if tolerated). Digital pressure should be applied until haemostasis is achieved, then a sterile occlusive dressing should be applied to the access site upon catheter removal, and checked regularly to ensure it is intact. It should remain in situ for 72 hours after removal. If a Luer lock needle free injection access device is removed for any reason, it must be discarded and a new sterile needle free device attached: the previous bung must never be re-attached. 7.0 Training and Implementation 7.1 Training Prior to commencing IV administration, all staff must have read this document (NUH IV drug administration policy) and be able to demonstrate this as part of their training. All staff must have successfully completed: The Medicines Management Assessment test on appointment to the Trust (and every 2 years if moving post), and have completed any additional part(s) of the Medicines Assessment that are required in addition (depending on score on test). Completed NUH approved Intravenous Drug administration Training and competency package, as well as practice based assessment. The NUH Anaphylaxis package located on: (excluding staff working in the neonatal units) Accountability self-assessment package. Accessed training and completed the competency forms for the Trust infusion pumps/medical devices relevant to role and practice. They will also need to be aware of the associated content of a number of Trust Policies- Refer to section 10 It is expected that staff completed the above packages as soon as they feel they are able, ideally within 6 months Training updates for IV administration 32
33 All practitioners have a professional obligation to maintain their knowledge and skills, including taking part in regular educational activities which maintain and further develop competence and performance. Practitioners must be able to evidence an update in their knowledge 3 yearly. Evidence of this update can be used for revalidation and as part of staff appraisals. All staff giving IV drugs must complete the following at a minimum every 3 years: Accountability Self- Assessment Package Evidence that the maths section of the IV section on the IV competency package has been repeated. Evidence that the practitioner has identified any individual learning needs i.e. up-to-date knowledge and understanding of medication they are currently administering (i.e. staff member may have moved speciality since previous assessment) Evidence that they have been assessed safely performing 3 IV drug administrations, a direct injection (bolus); an infusion and one of the most regularly administered drugs in their area Parental cytotoxic medications: must not be administered unless staff have completed additional training, demonstrated competency and working in a location where administration of cytotoxic medication is allowed Total Parental Nutrition: see local procedures 7.2 Implementation Incident Reporting: Incidents related to intravenous drug administration are reported locally via the hospital patient safety incident reporting tool, DATIX. Incidents are collated by the Hospital Medicines Safety Officer. Themes and actions are then shared with the Medicines Safety Committee, which has representatives from all of the directorates/ diversions Monitoring: See 9.0 Policy / Procedure Monitoring Matrix 7.3 Resources No additional resources are required. 33
34 8.0 Trust Impact Assessments 8.1 Equality Impact Assessment An equality impact assessment has been undertaken on this document and has not indicated that any additional considerations are necessary. 8.2 Environmental Impact Assessment An environmental impact assessment has been undertaken on this document and has not indicated that any additional considerations are necessary. 8.3 Here For You Assessment A Here For You assessment has been undertaken on this document and has not indicated that any additional considerations are necessary. 34
35 9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Responsible individual/ group/ committee Process for monitoring e.g. audit Frequency of monitoring Responsibl e individual/ group/ committee for review of results Responsible individual/ group/ committee for development of action plan Responsible individual/ group/ committee for monitoring of action plan Trust wide risk assessment on intravenous drug preparation and administration Medicines Safety Committee (MSG) Risk assessment of current risk plus Essence of care benchmark to audit current practice Annually and reported to MSG Results from the Essence of care benchmark are reported to the Trust Board. Individual clinical areas are required to develop locally agreed action plans to improve practice. MSG and Essence of Care Steering group September
36 10.0 Relevant Legislation, National Guidance and Associated NUH Documents 10.1 List all of the following which are relevant: 1. Legislation MHRA medicines regulations 2. National Guidance British National Formulary- current version NMC code (2015) NMC standards for medicines management RCN standards for infusion therapy National Patient Safety Agency (2006) Safer Use of Injectable Medicines in Near-Patient Areas Consultation Document London: NPSA 3. Associated NUH Documents (with NUH referencing) All policies referred to are the current versions. NUH Medicines Policy: Code of Practice including CL/MM/008 NUH administration policy and CL/MM/006 Prescribing policies CL/MM/013 for disposal of cytotoxic medicines CL/MM/012 for disposal of CDs, and CL/MM/011 Return and disposal of non-controlled medicines CL/MM/028 Medicines Policy: Code of Practice: Use of Single and Multiple dose vials. CL/MM/014 Medicines in the Operating theatre HS/EI/017NUH Waste Handling and management policy HS/SP/011 Blood borne virus policy HS/SP/003 Management of Latex Policy & Procedures CL/CGP/008 Transfusion policy CL/CGP/072 Aseptic Non Touch Technique (ANTT) Policy CLCGP039 Hand Hygiene Policy CLCGP031 NUH Infection Prevention and Control Manual CL/CG/001 Cardiopulmonary Resuscitation Policy (Adult and Paediatric) NUH current approved Intravenous Drug administration Training and competency package NUH Current Self-Assessment Accountability package NUH Current Anaphylaxis package 36
37 10.2 References Medical device(s) competencies Peripheral venous cannulation guidelines Central venous catheterisation Nursing Practice Guidelines Department of Health Gateway ref:14330 Mixing of medicines prior to administration in clinical practice: medical and non-medical prescribing Pratt RJ, Pellowe CM, Wilson JA, et al. epic2: National Evidence- Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection.65S: S1-S64. Available from: s/epic2-final%20glines.pdf [Accessed 27 September 2010]. Department of Health (2003) Winning Ways - Working together to reduce healthcare associated infections in England London: HMSO Infection Control Nurses Association (2000) Guidelines for Preventing Intravascular Catheter-related Infection. London: ICNA McCulloch, J. (2000) Infection Control: Science, management and practice London: Whurr NHS England (2015) Stage One Working Risk of death or severe harm due to inadvertent injection of skin preparation solution. 37
38 Appendix 1: The Procedure for administering intravenous Drugs using Aseptic Non-Touch Technique (ANTT) (NUH (2015) Aseptic Non-Touch Technique Policy) The ideal environment for ANTT procedures at ward level is a designated clinic room. Where this is impractical, clinical procedures performed at the patients bedside must not occur directly after activities such as bed making which may contribute to airborne contamination. Windows must also be kept closed and fans turned off during the clinical procedure. Use ANTT for ALL IV therapy procedures including: insertion, administration, manipulation and removal. Ensure the patient is informed, has given consent and is prepared for the procedure. Never put down a syringe attached to an unsheathed needle. 1. Clean hands with soap & water followed by alcohol hand rub Action Rationale Clean hands as per Trust Effective hand hygiene is vital to Hand Hygiene policy with reduce the risk of contaminating key soap & water and alcohol parts/sites hand rub 2. Clean aseptic surface (plastic tray). Whilst drying, gather equipment, drugs etc. Clean plastic tray with To establish a clean working surface sanitising wipe. Allow 30 seconds to dry before use To eliminate bacteria/micro-organisms Collect equipment and place next to tray while it is drying 3.Clean hands with alcohol gel Decontaminate hands with alcohol hand rub Hands may have become contaminated by handling equipment 4. Prepare drugs and equipment and protect key parts at all times using a non-touch technique Identify key parts and Prevents contamination of key parts remove equipment from during removal from packaging packaging carefully An orderly aseptic field decreases Assemble equipment and chance of contaminating key parts arrange in an orderly Exposed key parts increase risk of manner in aseptic field contamination Ensure key parts are A non-touch technique protects key protected at all times parts/sites (syringe tips etc.) Handle non key parts with confidence 5. Decontaminate hands with alcohol gel. Put on non-sterile gloves and clean the port 38
39 with 2% chlorhexidine/70% alcohol Put on non-sterile gloves Using a non-touch technique clean the port with 2% chlorhexidine/ 70% alcohol then wipe away from the tip for 30 seconds then allow to dry for 30 seconds 6. Administer drugs and dispose of sharps Administer drugs using a non touch technique Drying of cleaning solution is vital for disinfection to be completed To avoid risk of sharps injury Dispose of sharps in sharps bin at bedside. Dispose of all other equipment as per Trust policy Adjust patient clothing or resecure bandage 7. Remove gloves. Decontaminate hands with alcohol hand rub or soap and water Remove gloves Decontaminate hands with alcohol hand rub or soap and water Clean plastic tray after use with sanitising wipe Sign drug chart/ complete VIPS chart Gloves must only be used for one procedure Hands must be cleaned after glove removal as organisms thrive in the warm moist environment beneath gloves To prevent cross-infection when next used 39
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