Clinical Guideline for Nurse-Led Indocyanine Green Angiography Summary. Obtain brief medical history including allergies & renal function. Informed verbal consent gained and documented and procedure and after effects explained to the patient. Relevant equipment prepared and hand hygiene undertaken. Cannulate of chosen vein undertaken and sharps disposed as per Trust policy. Pupil dilation checked and patient introduced to photographer and second part of the procedure explained. Rapid injection of dye on signal of photographer whilst observing cannulation site. Cannula flushed on completion of the procedure as per Trust protocol and sharps disposed of as per Trust policy. Patient moved to appropriate waiting area post dye injection. After 30 minutes providing patient is feeling well, remove cannula and dress wound. Patient advised regarding bright lights and distance judgement until pupil dilation reduced. Page 1 of 8
Aim/Purpose of this Guideline 1.1. This guideline outlines the minimum standard expected from clinical staff performing Indocyanine Green Angiography (ICG) as part of their duties within ophthalmology. The primary purpose of this policy is to ensure that practice is safe and based on best possible evidence. 2. The Guidance 2.1. Equipment Required 2.1.1. Sharps bin 2.1.2. IV Indocyanine Green vial 25mgs to be mixed with 5ml water for injection as supplied by manufacturer. 2.1.3. Syringe 5mls 2.1.4. Blunt filter needle 2.1.5. Gloves sterile 2.1.6. Vomit bowl 2.1.7. Tissues 2.1.8. Red topped alcohol wipes to clean chin and arm rest prior to patient use 2.1.9. Anaphylaxis tray 2.1.10. Oxygen Action Obtain brief medical history including allergies and renal function, informed verbal consent and documented as per Trust protocol Explain procedure to patient and the after effects of the dye. Position patient comfortably with arm supported. Hand hygiene as per Trust protocol. Prepare relevant equipment. Hand hygiene Rationale To ensure allergies and medical conditions are documented. To ensure the patient understands the procedure and gives verbal consent. To promote patient understanding and to allay patient concerns To ensure safety and comfort during cannulation procedure. Promote patient safety and prevention of transmission of infection. To ensure everything required is available. Patient safety and the prevention of bacteraemia as per Trust policy Page 2 of 8
Action Rationale Cannulate chosen vein as per peripheral intravenous cannulation RCH Trust Policy. Use 22g cannula (blue) Water for injection should be used for: missing the drug and for flush Site: Venous access ante-cubital fossa To provide safe venous access. This medical product must not be diluted with solutions containing salts. Antecubital Fossa is a large vein with rapid access for the dye to travel to the back of the eye. Dispose of sharps as per Trust protocol Check pupil dilation Introduce patient to photographer and aid positioning at the camera. Photographer to explain next part of procedure. When photographer ready, on their signal, inject dye as rapidly as able whilst observing cannulation site. Nurse to remain with patient throughout the whole procedure. On completion of the procedure flush the cannula as per protocol. All sharps disposed of as per Trust protocol. Patient is accompanied to an appropriate area to wait for approximately 30 minutes post dye injection. Providing the patient is feeling well, remove cannula, apply pressure for 2-3 minutes and dress wound with sterile gauze and tape. To prevent needle stick injury Administer more dilating drops to ensure good dilation for ease of photography and to ensure dilation remains under bright lights from the camera. To put patient at their ease and ensure maximum comfort during procedure Rapid injection of dye ensures a bolus dose, desirable for good photography. Observation of the cannula site for extravasations. To monitor any adverse effects from the injection. Reassurance for the patient and support for the photographer. To clear cannula of remaining dye and ensure clear access in the event of anaphylaxis. To prevent needle stick injury. To acclimatize to natural light after dazzling camera lights. To ensure no late onset allergic reactions are occurring. To minimize risk of bacteraemia and prevent a haematoma around the injection site. Page 3 of 8
Action Advise patient in regards to the bright light and caution with their judgment for stairs and pavements until their pupil dilation reduces. Complete all relevant paperwork. The photographer files photographs in the notes and forwards them accordingly. Rationale To ensure the patient is educated when leaving the department. To ensure documentation is legible and in line with Trust policies and protocols. To ensure comply with Trust policies and procedures. 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared All aspects of compliance with procedure Ophthalmology Sister and CNS Ophthalmology Audits Infection, prevention and control and angiography audit tool Compliance for infection, prevention and control audited monthly. Angiography audit annually. Both reported at staff meeting. The report will be used to identify gaps in staff training and the results fed back to staff to reinforce good practice. The Ophthalmology Sister and CNS in Ophthalmology will be responsible for implementing any actions or changes recommended to improve the service. Any required changes to practice will be identified and actioned by the Ophthalmology sister and CNS within four weeks. Any changes will be discussed at the relevant staff meetings. 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 4 of 8
Appendix 1. Governance Information Document Title Date Issued/Approved: 01 Sept 2016 Clinical Guideline for Nurse-Led Indocyanine Green Angiography Date Valid From: 01 Sept 2016 Date Valid To: 01 Sept 2019 Directorate / Department responsible (author/owner): Karen Bowers, Eye Unit Sister Contact details: 01872 252244 Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Defines safe practice in regards to performing ICG angiography Indocyanine Green Angiography Page 5 of 8 RCHT PCH CFT KCCG Director of Nursing Date revised: August 2016 This document replaces (exact title of Clinical Guideline for Nurse-Led Indocyanine previous version): Green Angiography Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Senior Matron, Surgery Not Required {Original Copy Signed} Name: {Original Copy Signed} Internet & Intranet Clinical / Ophthalmology None None No. Intranet Only
Version Control Table Date Version No 2011 V1 Initial Issue August 2013 V2 27.08.13 V2.1 Summary of Changes Addition of Monitoring Compliance table Format updated to comply with Trust documentation policy Changes Made by (Name and Job Title) Alison Halloren, Sister Ophthalmology Anne Pinch, SSN Alison Halloren, Sister Ophthalmology Anne Pinch, SSN Alison Halloren, Sister Ophthalmology Anne Pinch, SSN 22.08.16 V3 Guideline reviewed and format updated. All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 6 of 8
Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Clinical Guideline for Nurse-Led Indocyanine Green Angiography Directorate and service area: Is this a new or existing Policy? Existing Ophthalmology Name of individual completing Telephone: 01872 252244 assessment: Alison Halloren 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? This guideline outlines the minimum standard expected from clinical staff performing Indocyanine Green Angiography ( ICG) as part of their duties within ophthalmology. 2. Policy Objectives* The primary purpose of this policy is to ensure that practice is safe and based on best possible evidence. 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? Safer clinical practice As per section 3 Ophthalmology patients No C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Sex (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Page 7 of 8
Disability - Learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. No negative impact identified. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment 1. 2. Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Date Page 8 of 8