GUIDELINES FOR ADMINISTRATION OF MEDICINES BY INTRAMUSCULAR INJECTION. Quality, Safety and Governance Committee Consultation & Approval:

Transcription

1 GUIDELINES FOR ADMINISTRATION OF MEDICINES BY INTRAMUSCULAR INJECTION Author: Sponsor/Executive: Responsible committee: Ratified by: Non Medical Prescribing Lead Advanced Clinical Pharmacist Director of Nursing and Quality Medicines Management Group Quality, Safety and Governance Committee Consultation & Approval: (Committee/Groups which signed off the policy, including date) This document replaces: Date ratified: 23 April 2015 Date issued: May 2015 Review date: 23 April 2018 Version: 2 Guidelines for Administration of Medicines by Intramuscular Injection Version 1 Policy Number: Purpose of the Policy: If developed in partnership with another agency, ratification details of the relevant agency CL50 Provide correct procedures for administration of IM medications Policy in-line with national guidelines: Signed on behalf of the Trust:.. Aidan Thomas, Chief Executive Elizabeth House, Fulbourn Hospital, Fulbourn, Cambs, CB21 5EF Phone:

2 Version Control Page Version Date Author Comments 1.0 April 2006 Nephat Chege 2.0 March 2015 Julia Ferris Chris Jenkins Reviewed to reflect new guidance Notification of policy release: All recipients; Staff Notice Board; Intranet; Key words to be used in DtGP search. Policy Circulation Information CQC Standards Other Quality Standards 2

3 CONTENTS 1. Introduction Purpose Scope CPFT good practice principles Prescription Charts.5 6. Preparation for administration of Deep IM injection..6 7 Z-track intramuscular injection technique guidance Injection site information 8 9. Post administration general guidance Medication understanding and teaching Specific Notes on Antipsychotics Depot/Long acting injections Education and Training Requirements Links to Other Documents References and Acknowledgements

4 1. Introduction Intramuscular injections can form part of the treatment of acute and long-term conditions. Intramuscular (IM) injections, as the name implies, administer drugs directly into the muscle beneath the subcutaneous tissue. Within CPFT the most common treatments administered by intramuscular injection are vitamin supplements, depot/long-acting antipsychotics and psychotropic agents for the management of acute behavioural disturbance by rapid tranquilisation. 2. Purpose The administration of intramuscular (IM) injections requires a complex series of considerations, decisions and a high level of technical competence to ensure that the process is carried out safely and to minimise the risk of human error. The Z-track technique of injection is widely used and has some advantages in that it controls leakage of the substance into the surrounding tissues, and is generally more comfortable for the patient. To promote and facilitate the safe administration of intramuscular injections to individuals under the care of CPFT practitioners. To describe the basics of the Z track technique to facilitate the training of practitioners within the Trust. 3. Duties and Responsibilities Chief Executive and Trust Board The Chief Executive and the Trust Board have overall responsibility for ensuring that there are appropriate systems and processes for the administration of medicines by intramuscular injection delegated to relevant staff across the Trust. Medicines Management Group The Medicines Management Group has responsibility for ensuring that the guidelines on administration of medicines by intramuscular injections are current and clinically appropriate. Senior Managers/ Consultants Senior managers and consultants have responsibility for ensuring that medical and nursing staff within their areas are aware of and are practising within these guidelines Clinical Staff : Administration of intramuscular injections may be carried out by medical staff and Nurses who have completed their nurse training and are now registered with the Nurses and Midwives Council under sub-part 1 or sub-part 2. Nurses should be working within the CPFT medicines administration competency framework. 4

5 4. CPFT good practice principles The Z track technique will be used for intra-muscular injections within the Trust. The Trust recommends the dorsogluteal and ventrogluteal as injection sites of choice where appropriate. However, it is understood that the final decision will be based on the product license requirements, the preference of the service user and the clinical judgment of the practitioner. Reasons for departure from a proposed/licensed injection site must be documented in the patient record. Appropriate reference and detail of the injectable medication should be made in the service user s care plan. Ongoing use of a non-approved site must be agreed with the prescriber. This guideline should be read in conjunction with Infection Control policies and procedures (needle stick injuries, safe disposal of needles, aseptic techniques, etc). 5. Prescription charts Intramuscular injections may only be administered according to instructions on the service user s prescription chart. The medicines policy states that the authorisation of a suitably qualified prescriber must be obtained before medicines can be administered to service users, this should be in the form of an instruction written on a trust medicines chart, prescription or depot administration card. Prescription charts must be written legibly, dated, signed and include the following: o o o o o Name of medication ordered Amount prescribed Dosage Frequency of administration Route The administration should be recorded on the medicine chart or the depot administration card (whichever is in use) and in the patient s RiO progress notes. 5

6 6. Preparation for administration of Deep IM injection: a. Check the patient s physical and mental health. Check the sites of recent previous injection sites, as this may influence the administration of the current dose. Use this opportunity to discuss any patient concerns regarding treatment side-effects/benefits. b. Check to ensure that the prescription is valid and legal. Ensure that the dose is due, and that it has not already been given. Check the patient s allergy status (including the patient in the checking process), any contra-indications and that the injection to be given is within its expiry date. c. Confirm that the patient has capacity to consent to treatment, and currently gives their consent to the injection. If the injection is part of rapid tranquilization please refer to Guidelines for the management of acute behavioral disturbances in in-patient wards (including Rapid Tranquillisation): d. Wash hands using the approved technique and use appropriate personal protective equipment (see CPFT Infection Prevention and Control Manual). e. Prepare the injection by following the manufacturer s instructions. Take time to ensure any dose calculations are correct using the product for use. Where a product is supplied with its own administration needle(s), this should ALWAYS be used taking into account the intended injection site. Where a syringe is not supplied with the product, a clinical decision will need to be made about the appropriate needle for the client. This should take into account the patient s body-mass index (BMI), as service users with large body mass may require a needle longer than 37mm (see section 9 for more details). Check the expiry date on any consumables to be used in the process. f. Where it is possible, a second practitioner should provide a second check to the processes carried out above. Where it is not possible to obtain a second check from a practitioner, the patient could be used to confirm that the injection is what they expect and that it is in date. g. Identify the intended site of administration, taking into account the site of previous injections, the patient s preference and the manufacturer s licensed route(s)*. If the skin of the intended site is clean, no further preparation is required. Where the skin is visibly dirty it should be washed with soap and water and thoroughly dried. h. The choice of needle to be used may be specified by the manufacturer. Where a needle is not provided, it is necessary to consider the length of needle required to reach the muscle. In service users under 90kg it is expected that a 21G 38mm(1½ ) is likely to be sufficient. For service users 6

7 over 90kg it may require a 21G 51mm(2 ) needle or longer. Individual clinical assessment should influence the final decision. Signs of inappropriate needle length may include pain at the injection site, bruising at the injection site or localised abcesses. 7.. Z-track intramuscular injection technique guidance: N.B. Extra guidance for specific muscle group injections follows later in this document. a. Pull the skin of the target area taut and to one side with either the thumb or side of the non-dominant hand and maintain this through the injection procedure. b. Insert the needle with a darting motion at 90 degree to the skin surface and at an appropriate depth so as to penetrate the muscle. Keep graduation markings on the syringe barrel visible at all times. For dorsogluteal injections only, draw back the plunger slightly to ensure that no blood appears in the syringe. If blood is not present it is safe to continue, but if blood is seen the whole procedure should start again. c. Depress the plunger slowly (1ml every 10 seconds) to allow the muscle fibres to expand to accommodate the drug. Once the total volume to be administered has been inserted, wait a further 10 seconds before removing the needle. Once the needle has been removed the tension on the skin surface can be stopped. 7

8 8. Injection site information Five sites are typically used for the administration of intramuscular injections. The Trust proposes the dorsogluteal (see 7.2) and ventrogluteal (see 7.4) as intramuscular injection sites of choice, although the final decision should come from consideration of the product license, patient choice, and the appropriateness of the route in general. These sites are: a. Mid-deltoid site See figure a). This site has the advantage of being easily accessible whether the patient is standing, sitting or lying down. Owing to the small area of this site, the number and volume of injections which can be given into it are limited. If injecting by this route, follow the general preparation and Z track guidance given above, and: Ask the service user to sit down and expose the arm and shoulder. Ask the service user to position their arm across their body and to relax the arm. Locate the correct site by its relative position to the acromion process and axilla. 8

9 b. Dorsogluteal site See figure b. This is used for deep intramuscular and Z-track injections. This muscle group has the lowest drug absorption rate. The muscle mass is also likely to have atrophied in older people, non-ambulant and emaciated patients. This site carries with it the danger of the needle hitting the sciatic nerve and the superior gluteal arteries. If injecting by this route, follow the general preparation and Z track guidance given above, and: Ask the service user to lie down and to loosen clothes to allow the injection site to be exposed. A position taken with the femur internally rotated will minimise administration pain. Locate the injection site within the upper right portion of the upper right quadrant of the buttock. When the needle has been inserted pull back the plunger slightly to ensure that no blood comes back into the syringe. Do not continue if blood is seen in the syringe; otherwise continue with injecting in the medication. 9

10 c. Rectus femoris and vastus lateralis sites These sites are also able to be used for some intramuscular injections. Both sites are located on the quadriceps (see figure c). i. If injecting by one of these routes, follow the general preparation and Z track guidance given above, and: ii. Ask the service user to lie down and loosen clothing to expose the hip area for the injection site to be used. iii. Locate the injection site by the relative location to the greater trochanter and anterior superior ileac spine. Be particularly careful to avoid needlestick injury by administration by this route. 10

11 d. Ventrogluteal site See figure d. This can be used for a variety of medicines. This is considered by some to be the site of choice for intramuscular injections as up to 2.5 ml can be safely injected. Injecting by this route should follow the general preparation and Z track guidance given above, and: i. Ask the service user to lie down and loosen clothing to expose the hip area for the injection site to be used. ii. Locate the injection site by the relative location to the greater trochanter and anterior superior ileac spine. Be particularly careful to avoid needlestick injury by administration by this route. 9. Post administration general guidance: a. If necessary a dry dressing may be applied to the injection site. A plaster may also be used if wanted by the service user, and they are not allergic to one. b. Dispose of equipment immediately, safely disposing of broken ampoules and needles into a labelled sharps bin. c. Remove gloves and other personal protective equipment and wash hands thoroughly. d. Complete all sections of the appropriate chart/card to record the administration. Make an entry in the service user s notes to record the administration, including the day and time of the administration, the dose given, and the route (to include which side of the body was used). e. Ensure the patient is aware of what to do should any complications arise before their next consultation, and offer help with any questions that the service user may have in relation to their treatment. 11

12 f. If any significant issues arise from the administration, the nurse should inform the service user s doctor(s) as soon as it is appropriate to do so. 10. Medication understanding and teaching a. Before undertaking intramuscular injection of any product, the practitioner should familiarize themselves with the product literature recommendations for administration, and have knowledge of the medication they are preparing to administer. The product literature often accompanies the medication, but if not available, it can be accessed by looking at the patient information leaflet (PIL) or summary of product characteristics (SPC) at: b. For basic information about medication refer to the latest edition of the British National Formulary (BNF), this can be accessed for free from Trust computers at: c. The practitioner should continue to explore the client s knowledge and understanding of their current medication during treatment. Written and/or verbal information given to the service user should be documented in the service user s notes. Information from Choice and Medication available through the Trust s internet and intranet sites - is a useful starting point. A direct link to the site is available below: Specific Notes on Antipsychotic Depot/Long acting Injections a. Antipsychotic depot injections should be administered as recommended in the manufacturer s product literature. Most commonly this is into the upper outer quadrant of the buttock. Alternative routes exist for some, but not all medicines (see following page). b. The reasons for the choice of site should be explained to the patient. c. In the exceptional circumstance of a patient absolutely refusing a depot neuroleptic injection into an approved site (see following page) and an alternative site is accepted, the full justification for this must be recorded in the nursing and/or medical records. Continued use of an alternative site must be discussed with the prescriber. 12

13 d. The choice of needle to be used may be specified by the manufacturer. Where this is not the case, it is necessary to consider the length of needle required to reach the muscle. In service users under 90kg it is expected that a 21G 38mm(1½ ) is likely to be sufficient. For service users over 90kg it may require a 21G 51mm(2 ) needle or longer. Signs of inappropriate needle length may include pain at the injection site, bruising at the injection site or localised abscesses. DRUG Dorsogluteal (buttock) Ventrogluteal (thigh) Deltoid (arm) Pipotiazine Palmitate (Piportil) Note: Pipotiazine Palmitate (Piportil) is due to be discontinued in 2015 Fluphenazine Decanoate (Modecate) Haloperidol Decanoate (Haldol Decanoate) Risperidone (Risperdal Consta) Flupentixol Decanoate (Depixol) Paliperidone* (Xepilon) Zuclopenthixol Decanoate # (Clopixol) Aripiprazole (Abilify Maintena) Olanzapine Pamoate Monohydrate (Zypadhera) Note: Olanzapine Pamoate Monohydrate is not a formulary option and requires approval before use. This is NOT the same product used for rapid tranquilisation. + indicates suitable site, endorsed by the product literature. Where a product is indicated for administration into gluteal or deltoid muscle, the correct needle provided with the product should be used. Consult product literature for more details. 13

14 * The product license requires the first two injections to be given by the deltoid, with subsequent injections allowable by both dorsogluteal and deltoid route consult product literature for details. # Note there is an important difference between zuclopentixol decanoate (Clopixol) used for maintenance treatment of psychoses, and zuclopentixol acetate (Clopixol Acuphase) used for the short term treatment of acute psychoses and mania. Consult product literature for more details. Maximum volume on any one site will normally be 2ml. The volume should never exceed 3ml at any one site. 12. Education and Training Requirements The Nursing Leadership Group has stipulated that in-patient and community registered nurses should complete the competency workbook for the administration of medication by nurses as part of the Appraisal process in a three year cycle. Staff have a responsibility to keep updated on CPFT policy and current best practice 13. Links to Other Documents This guideline should be read in conjunction with Infection Control policies and procedures (needle stick injuries, safe disposal of needles, aseptic techniques, etc), medicines policy.and rapid tranquilisation policy all available via the intranet within policies section 14. References and Acknowledgements Dougherty, L., Lister, S (2015). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 9 th Edition. Blackwell Publishing. Workman, B. (1999). Safe Injection Techniques. Nursing standard 13 (39), pg Rodger, M. A., & King, L. (2000). Drawing Up and Administering Intra-muscular injections: A Review of the Literature. Journal of Advanced Nursing, 31 (3), pg Beyea, S. C., & Nicholl, L. (1995). Administration of medications via the Intramuscular Route: an integrative review of the literature and research based protocol for the procedure. Appl Nurs Res, 5(1), pg Mac Gabhann, L (1996). A Comparison of two depot injection techniques. Nursing Standard. 12 (37), pg

15 Greenaway, K. (2004). Using the ventrogluteal site for intramuscular injection. Nursing Standard. 18 (25), Nesbit, Andrew Charles. Intramuscular gluteal injections in the increasingly obese population: retrospective study. BMJ 2006; 332: Feetam C. & White J. Eds. Guidance on the Administration to Adults of Oilbased Depot and other Long-Acting Intramuscular Antipsychotic Injections 4th Edition (2014) available at accessed (24/3/2015) Health and Safety Executive (2013) Health and Safety (Sharp Intruments in Healthcare) Regulations 2013 Guidance for employers and employees. Available at 15