1 advised when using guidelines after the review date

Transcription

1 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc.) Author: Contact Name and Job Title Guideline for Adult Nasal and Oropharyngeal Suction Eleanor Douglas, Lecturer/Practitioner Physiotherapist & Directorate & Speciality Diagnostics and Clinical Support Physiotherapy Date of submission March 2015 Explicit definition of patient group to which it applies (e.g. inclusion These guidelines are only intended to cover the and exclusion criteria, diagnosis) use of orotracheal and nasotracheal suction in the patient without an endotracheal or tracheostomy tube. Nasotracheal and orotracheal suction should only be performed by staff who, have been trained and deemed competent as per local guideline with relevant training and education being included in an in-service training programme Version 3 If this version supersedes another clinical guideline please be explicit about which guideline it replaces including version number. Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a meta-analysis of randomised controlled trials 2b at least one randomised controlled trial 3a at least one well-designed controlled study without 3b randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (i.e. comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Ratified by: Date: Target audience Review Date: (to be applied by the Integrated Governance Team) A review date of 5 years will be applied by the Trust. Directorates can choose to apply a shorter review date; however this must be managed through Directorate Governance processes. Guideline for Adult Nasal and Oropharyngeal Suction Fiona Moffatt, Critical Care Outreach Team Physiotherapist, NUH Queens Campus and Cheryl Crocker, Consultant Nurse Critical Care (original authors) 1, 5 and 6 Nursing Practice Guidelines Group, Ward Sisters/Charge Nurses, Nursing Development, Practice Development Matrons (PDMs), Clinical Leads, Matrons. Respiratory Physiotherapists, CCOT, Clinical Quality, Risk and Safety Manager, Trust Intranet Matrons Forum March 2015 All registered Nurses and Allied health Professionals This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. Nasal If and in Oral doubt Suction contact March a senior 2015 colleague Review March or expert Final Caution is 1 advised when using guidelines after the review date

2 Contents Introduction... 3 Description... 3 Abbreviations... 4 Indications... 4 Contraindications... 5 Orotracheal suction... 5 Relative Contraindications (Seek Medical Advice Prior To Insertion)... 5 Hazards... 5 Equipment List... 6 Actions of Care... 7 Further Reading & References Audit Points Appendix Appendix Appendix 3 - Checklist for the Review and Approval of Procedural Documents (to be used by authors and at the Matron s Forum)

3 NOTTINGHAM UNIVERSITY HOSPITALS NURSING PRACTICE GUIDELINES NASAL AND OROPHARYNGEAL SUCTION Introduction Description Oropharangeal and nasopharangeal suction is a technique intended to stimulate a cough to remove excess secretions and / or aspirate secretions from the airways which cannot be removed by the patient s spontaneous effort. A cough can be stimulated by the catheter in the pharynx (oropharangeal suction) or it may be necessary to pass the catheter between the vocal cords and into the trachea to stimulate a cough (nasopharangeal suction). The trachea is accessed by insertion of a suction catheter either via nasal passage and pharynx (nasotracheal suction) or via the oral cavity and pharynx (orotracheal suction) using an airway adjunct. Nasotracheal suction may be undertaken directly via the nostril without an airway adjunct. However, in some situations, repeated suction is anticipated and therefore a nasopharyngeal airway should be utilised. Secretions are removed by the application of sub-atmospheric pressure via wall mounted suction apparatus or portable suction unit. N.B. These guidelines are only intended to cover the use of orotracheal and nasotracheal suction in the patient without an endotracheal or tracheostomy tube. At all times, staff must adhere to their codes of professional conduct (Nursing Midwifery Council 2008, Chartered Society of Physiotherapy 2002). 3

4 Best Practice Nasotracheal and orotracheal suction should only be undertaken when other less invasive techniques have proved unsuccessful, and where the secretions are causing physiological deterioration and / or distress (Pedersen et al., 2008) Indications that the patients may need suctioning include audible secretions in upper airway or noisy crackles, on auscultation, palpable secretions, ineffective or weak coughing, desaturation despite increased oxygen requirements or raised respiratory rate. Nasotracheal and orotracheal suction should only be performed by staff who, have been trained and deemed competent as per local policy with relevant training and education being included in an in-service training programme. In addition, opportunities should be offered locally to competent practitioners at all levels wishing to maintain their skills in tracheal suction. Abbreviations mmhg kpa Sp0 2 Fi0 2 TB ICP ABGs NPA millimetres of mercury Kilopascals Oxygen saturation Fraction of inspired oxygen Tuberculosis Intracranial pressure Arterial blood gas Nasopharangeal airway Indications Airway suction is indicated to maintain a patent airway and remove excess secretions or aspirate from the trachea, when: 1. The patient is unable to clear the airway spontaneously 2. The secretions / aspirate are of detriment to the patient e.g. hypoxaemia 3. All other methods to remove secretions / aspirate have failed (such as positioning, physiotherapy techniques, cough assist methods & nebulisers). Best Practice Tracheal suction is an invasive, blind, high-risk procedure with uncertain outcome, and therefore should only be undertaken when a clear indication has been identified via assessment. Nurses should work closely with the physiotherapy team when considering any of these procedures. Secretions/aspirate may be deemed as detrimental when they cause the patient distress, or physiological derangement e.g. impaired ABGs, reduced SpO 2 and/or increased respiratory rate. 4

5 Contraindications Nasotracheal suction Severe coagulopathy and / or unexplained haemoptysis Laryngospasm (stridor) Basal skull fractures, or cerebrospinal fluid leakage via the ear Severe bronchospasm Recent oesophageal or tracheal anastamoses, or tracheo-oesophageal fistula Occluded nasal passages Nasal bleeding Recent oral / nasal surgery Orotracheal suction Severe coagulopathy and / or unexplained haemoptysis Laryngospasm (stridor) Acute neck, facial or head injury (particularly basal skull fractures, or cerebrospinal fluid leakage via the ear) Severe bronchospasm Recent oesophageal or tracheal anastamoses, or tracheo-oesophageal fistula Loose teeth or crowns Intact gag reflex (relative contraindication) Relative Contraindications (Seek Medical Advice Prior To Insertion) Acute neck, facial or head injury Haemodynamic instability Nasal/oral burns, due to infection risk Signs suggestive of raised or labile intracranial pressure Coagulopathy (Low Platelets <40) Hazards Mechanical trauma that is trauma to airway mucosa particularly associated with poor technique and excessive suction pressures Hypoxia / hypoxaemia Cardiac arrhythmias Fluctuations in blood pressure Vasovagal stimulation eliciting bradycardia and hypotension Respiratory arrest / apnoea Gagging / vomiting (particularly orotracheal suction) Aspiration Laryngospasm Bronchospasm 5

6 Pain Infection Bleeding Atelectasis area of lung collapse particularly associated with excessive suction pressures or prolonged coughing Increase in intracranial pressure Misdirection into the oesophagus (patient may swallow the catheter) Patient distress and discomfort Equipment List Suction source with adjustable pressure regulator Collection vessel and connector tubing Sterile, multi-eyed suction catheters of appropriate size use the smallest size catheter to be effective, ideally FG Sterile water (dated, named and timed) plus container Clean disposable examination gloves Apron Sterile disposable co-polymer examination gloves Eye protection and/or mask if indicated Orotracheal suction: Guedel airway of appropriate size (Appendix 1, diagram A) Nasotracheal suction: Lubricating gel, nasopharyngeal airway (optional) of appropriate size (Appendix 2, Diagram B). Oxygen supply and delivery device Sputum trap if specimen required Monitoring equipment (pulse oximeter) Ensure emergency equipment available if required Refer to General Actions for All Procedures. 6

7 Actions of Care 1. ACTION Assess the patient s requirements for suctioning: Abnormal breathing, physiological deterioration and / or distress, audible secretions in upper airway or noisy crackles on auscultation, coughing, desaturation or raised respiratory rate (AARC, 2010, & Wood, 1998b) Ensure informed consent is given where able as per Trust policy. Prepare patient by giving analgesia if required and reassurance and information RATIONALE To determine whether suctioning is necessary Oro or nasotracheal suctioning should be performed only when necessary (Pedersen et al., 2008) Patient must have information to consent to procedure and feel reassured. NB there will be patients who lack capacity to consent See NUH consent to Examination or Treatment policy (Ref CL/CGP/020) To maintain privacy & dignity and to avoid distress for other patients 2 Close Curtains 3 Wash & dry hands & put on non-sterile examination gloves, (on both hands at the patient s bedside), apron, and eye protection/mask if indicated. 4 Check correct functioning of vacuum source and set negative pressure to up to a maximum of 20kilo Pascals (kpa)/ 150 mmhg. To maintain patient privacy Minimises risk of cross infection to patient or operator (Saving lives DoH, 2007, Day et al., 2002) Minimises the risk of mechanical trauma. Note that increased pressures do not facilitate better removal of secretions. (Glas, 1995, Wood, 1998, Day et al., 2002, Branson, 1993) and may result in complication e.g. trauma & atelectasis Best Practice The use of eye protection and a mask is recommended if the patient has such infections as TB, meningococcal meningitis or any blood or air borne virus. For further advice, contact the Infection Control team. 7

8 ACTION 5. Where possible, position the patient to ensure their airway is open, either in high side lying or sitting upright 6. Patients with high oxygen requirements (>40%) may require pre-oxygenation prior to suctioning Optimise oxygenation if necessary by increasing the patient s fraction of inspired oxygen (Fi0 2 ) for at least 30 seconds. Oxygen must be prescribed, and should be given at maximum rate safely tolerated by the patient Caution in patients requiring controlled oxygen therapy. For example in patients with COPD(see NUH CLMM032 In-patient Oxygen Therapy Guideline ) 7a. Orotracheal suction: wash & dry hands & put on non-sterile examination gloves on both hands at the patient s bedside Insert a Guedel Airway if the patient has a GCS of 8 or less. (see appendix for sizing guide) RATIONALE Minimises the risk of misdirection of the catheter into the oesophagus. Care to keep position safe where spinal injury is involved Minimises the risk of hypoxia / hypoxaemia and cardiac dysrhythmias (Thompson et al., 2000, Branson et al., 1993) Prevent cross infection Provides a patent route for passage of the suction catheter and prevents the patient biting down on the catheter. Patient with a GCS of 8 or less will have an incompetent airway and there is a risk of aspiration should the patient vomit during suction. 7b. Nasotracheal suction: wash & dry & put on nonsterile examination gloves on both hands at the patient s bedside Insert nasopharyngeal airway, if repeated nasotracheal suction is anticipated. Provides a more comfortable route for repeated passage of the suction catheter and less damage to the mucosa with repeated suction. 8

9 (Appendix 2, diagram C) 8. Open suction catheter packaging. The suction catheter used should occlude less than 50% the lumen of the oro-or nasopharyngeal tube (AARC, 2010) Connect suction catheter tubing, ensuring that catheter remains within the sterile pack. Put sterile copolymer glove on dominant hand and use that hand to withdraw catheter from pack. Minimises risk of cross infection to patient or operator. Using the correct sized catheter minimises the risk of hypoxaemia ACTION RATIONALE 9. Insert suction catheter via guedel airway, or nostril. Aim to time this with patient s inspiratory phase. If using a nasopharyngeal airway or nostril, decant a small amount of sterile water into a jug or a receiver and then dip the end of the suction catheter into a small amount of sterile water this may facilitate passage prior to inserting the catheter by adding some lubrication. If performing suction directly via the nostril, introduce the catheter and progress it gently towards the back of the nose with an upward inclination. Once resistance is felt, gently rotate the catheter until the resistance is overcome. 9 Do not apply suction during insertion. The catheter should be inserted no further than the carina (or when resistance is Minimises mechanical trauma to airway passages and patient discomfort. (Wood, 1998b, Celik, 2000, Day et al., 2002) Reduces risk of damage to the carina and subsequent vagal stimulation. 9

10 felt) and retracted a maximum of 1 2 cms. 10. Continue to insert catheter until a resistance is felt or a cough elicited. Withdraw by a maximum1-2 cms before applying suction to ensure tip of catheter is not abutting the carina. 11. Remove catheter if misdirection into the oesophagus is suspected (e.g. gagging, absence of cough, aspiration of gastric contents). Minimises the risk of mechanical trauma to carina and subsequent vagal stimulation. Withdrawing the catheter too far from the point of resistance or from the point of cough stimulation may result in some secretions remaining in the airway. Maximises effectiveness of procedure and minimises risk of aspiration. ACTION RATIONALE 12. Apply suction continuously (not intermittently) throughout catheter removal. Withdraw catheter smoothly (without rotation). Ensure that this period of suction application does not exceed 15 seconds (Pedersen et al., 2008 & AARC, 2010). The catheter must be withdrawn cleanly and not reinserted during withdrawal. 13. Monitor patient s condition during and following treatment, e.g. colour, breathing pattern, evidence of trauma (bleeding), distress, cough secretions (colour, tenacity, quantity). The patients Sp0 2 should be monitored throughout the procedure and heart rate and BP monitoring should be undertaken where available. Continuous suction minimises adverse effects / hazards associated with suction, e.g. hypoxia / hypoxaemia, cardiac dysrhythmias, blood pressure fluctuations, pain, apnoea, atelectasis, raised intra-cerebral pressure etc (Czarnik et al., 1991, Stenqvist et al., 2001, Day et al., 2002, Celik & Elbas, 2000, Wood, 1998b) Ensures patient safety and assesses improvement in patient condition. Detects deterioration quickly. 10

11 Seek urgent help in the event of patient deterioration. 14. Remove sterile glove inverting it over the used catheter and dispose in clinical waste bin. 15. After the final episode of suction, remove airway adjunct, provided the patient is able to maintain a safe airway. If the patient has been preoxygenated prior to the procedure turn the Fi0 2 back to the previous level and monitor the patients Sp0 2 for at least 5 minutes (see CLMM032 Inpatient Oxygen Therapy Guidelines) to ensure the patient s oxygen saturations are within the target saturation level 16. Where possible encourage deep breathing. The patient should be allowed to recover between subsequent suction if further airway suction is indicated their Sp0 2 and cardiovascular status should be allowed to recover to presuction levels. The patients should be allowed to take at least 8 breaths between subsequent suctions. 17. Once treatment is completed, rinse suction connector tubing using a small amount of sterile water decanted from the bottle into a container. Ensure opening date and time has been marked on bottled water in order that it may be discarded after 24 hours. Turn suction off. Ensure suction tubing is supported well clear of the floor. Maximises effectiveness of procedure and minimises risk of cross infection. Ensures patient safety and comfort. Minimise atelectasis. Avoids patient distress and fatigue, and quick repeated suctions. Reduces the risk of an adverse event. Maintain safe, clean environment. Minimise risk of cross infection. 11

12 ACTION 18. Wash hands. Discard any disposable items in appropriate clinical waste bins and change suction bottle if necessary. 19. Reassess patient and report any adverse effects or changes in patient s overall condition to senior nursing and/or medical personnel. Return oxygen to pre suction levels if the patient s saturations are within their target range. RATIONALE Maintain safe, clean environment. Guedel airways are single use products and therefore must be discarded after use. Nasal airways can remain in situ but should be changed every 48 hours or sooner if indicated to prevent occlusion by dried secretions. To ensure patient safety. 20 Consider further management if the patient is going to require further /regular suction. For example if the secretions are thick consider hydration, humidification of oxygen (see Guideline for Humidification of Oxygen for adult self-ventilating and temporary tracheostomy patients) and/or regular saline nebulisation. If the patient has copious secretions consider if further airway management is indicated e.g. formal tracheostomy. Consider referring the patient to the ward physiotherapist and/or the critical care outreach team(ccot) for further management To ensure the patients secretions are correctly managed and ensure airway management is considered in the situations of tenacious or copious secretion production 21. Document procedure, effects and response as per Allows ongoing multidisciplinary team assessment and evaluation of patient s 12

13 documentation policies. condition. 13

14 Further Reading & References Acute Illness Management (AIMs) Manual (2011). Greater Manchester Critical Care Network. American Association of Respiratory Care (1992) Clinical Practice Guideline Nasotracheal Suctioning Respiratory Care Vol. 37, pp American Association of Respiratory Care (2010) Clinical Practice Guideline Endotracheal suctioning of mechanically ventilated patients with artificial airways Respiratory Care Vol. 38, pp Branson RD, Cambell RS, Chatburn RL, Covington J (1993) AARC clinical practice guideline: Endotracheal suctioning of mechanically ventilated adults and children with artificial airways. Respiratory Care; 38 (5): Celik SS, Elbas NO (2000) The standard of suction for patients undergoing endotracheal intubation. Intensive critical care Nursing; 16 (3) Chartered Society of Physiotherapy (2002) Rules of Professional Conduct. Czarnic RE, Stone KS, Everhart CC Jr, Preusser BA. (1991) Differential effects of continuous versus intermittent suction on tracheal tissue. Heart Lung ; 20 (2) : Day T, Farnell S, Wilson-Barnett J. (2002) Suctioning: a review of current research recommendations. Intensive Critical Care Nursing 18 (2): Department of Health (2007) Saving Lives: a delivery programme to reduce healthcare associated infection including MRSA London Frankell HL, Mathias CJ, Spalding JM (1975) Mechanisms of reflex cardiac arrest in tetraplegic patients The Lancet Vol. 2, pp Glass C, Grap MJ. Ten tips for safer suctioning American Journal of Nursing ; 95 (5): Higgens, D; (2005) Tracheal suction. 22 February, Nursing TimesVOL: 101, ISSUE: 08, P

15 Jones M and Moffatt F (2002) Cardiopulmonary Physiotherapy Oxford: Bios Scientific Publishers Jung RC, Gottlieb LS (1976) Comparison of tracheo-bronchial suction catheters in humans. Chest Vol. 69, pp Kleiber C, Krutzfield N, Rose EF (1988) Acute histologic changes in the tracheo-bronchial tree associated with different suction catheter insertion techniques. Heart & Lung Vol. 17, pp Leith DE (1985) The development of cough. American Review of Respiratory Disease Vol. 131, pp. S39-42 Mansell A, Bryan C, Levison H (1972) Airway closure in children. Journal of Applied Physiology Vol. 33, pp Nottingham University Hospitals NHS Trust (2012) Consent to Examination or Treatment policy, NUH, Nottingham Nottingham University Hospitals NHS Trust (2013) Medicines Policy: Code Of Practice Inpatient Oxygen Therapy NUH, Nottingham Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives (March 2015) Pedersen C, Rosendahl-Nielsen M, Hjermind J and Egerod I (2008) Endotracheal suctioning of the adult intubated patient What is the Evidence? Intensive and critical care Nursing (2009) 25, Rosen M, Hillard EK (1962) The effects of negative pressure during tracheal suction Anaesthesia and Analgesia Vol. 41, pp Stenqvist O, Lindgren S, Karason S, Sondergaard S, Lundin S (2001) Warning! Suctioning. A lung model evaluation of closed suctioning systems. Acta Anaesthesiol Scand ; 45 (2): Thomson L, Morton R, Cuthebertson S. (2000) Tracheal suctioning of adults with an artificial airway. Best Practice; 4 (4): 1-6 Quirke S (1997) Closed circuit suction systems. Care of the Critically ill. Vol.13, No. 6 Supplement. Widdicombe JG (1980) Mechanism of cough and its regulation. European Journal of Respiratory Disease Vol. 61: (Suppl 110) pp

16 Wood C J (1998b) Endotracheal suctioning: a literature review. Intensive Critical care nursing 14 (3): Young CS (1984) A review of the adverse effects of airway suction. Physiotherapy Vol. 70, pp Original Author: Fiona Moffatt, Critical Care Outreach Team Physiotherapist, NUH Queens Campus and Cheryl Crocker, Consultant Nurse Critical Care Reviewer: Eleanor Douglas, Lecturer/Practitioner Physiotherapist NPGG Link: Ellie Dring For Review: 2020 Audit Points 1. Have other less invasive techniques been attempted and proved unsuccessful prior to naso or oral tracheal suction being attempted? 2. Has the patient been prepared with explanation, reassurance, privacy & dignity and analgesia (if necessary)? 3. Has informed consent been obtained? 4. Has the vacuum been set to a negative pressure no greater than 20kPa / 150mmHg? 5. Has asepsis been maintained throughout the procedure? 6. Has the patient s condition during and following treatment been monitored? 7. Have any adverse effects or changes in patient s overall condition been reported to the relevant nursing or medical staff? 16

17 Appendix 1 Selection and Insertion of an Oropharyngeal Airway Resuscitation Council UK (20011) Advanced Life Support Course Provider Manual 6th Edition London: Resuscitation Council UK (reference is incorrect) Selection: Most commonly used sizes are 2, 3 and 4. For small, medium and large adults respectively. The length of the airway should correspond to the vertical distance between the patients incisors and angle of the jaw (see diagram). Diagram A ( Insertion: Only used in patients with a reduced level of consciousness, as vomiting and laryngospasm may occur if glossopharyngeal and laryngeal reflexes are present. Open patient s mouth and ensure that there is no foreign material that could be pushed into the larynx. Introduce airway into the oral cavity in an upside-down position (as far as the junction between the hard and soft palate), then rotate through 180. This rotation minimises the chances of pushing the tongue down and back Insert further until the airway lies in the oropharynx. Diagram B Remove airway immediately if any reflex responses are seen. 17

18 Appendix 2 Selection and Insertion of a Nasopharyngeal Airway Resuscitation Council UK (2011) Advanced Life Support Course Provider Manual 6th Edition London: Resuscitation Council UK Selection: The NPA should be sized according to the patient s size, sex and race. As a general guide a size 6 should be used for females and size 7 for males (AIMS, 2011). Insertion: Generally better tolerated than an oropharyngeal airway in patients who have a higher level of consciousness. Not suitable for patients with actual or suspected basal skull fracture. Can cause damage to the mucosal lining, leading to bleeding. It is essential to ensure that clotting is normal. If the tube is too long, it may stimulate laryngeal and glossophayngeal reflexes eliciting laryngospasm and vomiting (AIMS, 2011). Prepare the nasal airway by lubricating the airway with water-based gel. Some nasal airways have a wide flange to prevent inhalation via the nostril. Others have smaller flanges and these require the insertion of the supplied safety pin through the flange to prevent inhalation. Slowly and gently insert the bevel end first along the floor of the nose, with a slight twisting action. The curve of the airway should direct it towards the patient s feet. Once in place, establish the patency of the tube and adequacy of ventilation (look, listen, feel). In patients with coagulopathies this will need to be performed under platelet cover where there is significant risk of bleeding, and consultation should be made with the medical team prior to insertion. Diagram C 18

19 Appendix 3 - Checklist for the Review and Approval of Procedural Documents (to be used by authors and at the Matron s Forum) This should be the very last Appendix following all the others in the document Title of document being reviewed: Author Yes/No NPGG Yes/No Comments 1. Title Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy or protocol? 2. Rationale Are reasons for development of the document stated? 3. Development Process Is the method described in brief? Are individuals involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? 4. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes 19

20 Title of document being reviewed: Author Yes/No NPGG Yes/No Comments described? Are the statements clear and unambiguous? 5. Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Are local/organisational supporting documents referenced? 6. Approval Does the document identify which committee/group will approve it? If appropriate, have the Staff Side committee been consulted about the document? 7. Dissemination and Implementation NO N/A Is there an outline/plan to identify how this will be done? to inform staff of the update Does the plan include the necessary training/support to ensure compliance? 20

21 8. Document Control Does the document identify where it will be held? NO NPG intranet page Have archiving arrangements for superseded documents been addressed? 9. Process for Monitoring Compliance Are there measurable standards or KPIs to support monitoring compliance of the document? Is there a plan to review or audit compliance with the document? 10. Review Date Is the review date identified? Is the frequency of review identified? If so, is it acceptable? 11. Overall Responsibility for the Document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation? 12. Matron s Forum Approval Date Local competencies/ Acute Care Skills Course March

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