Administration of Intravenous Medication to Adults and Children within the Community and Community Hospital. -Policy and Procedure Description: The document prescribes how clinicians will administer medication via the intravenous route using a peripheral cannula. Key Words: Version: Adopted by: Intravenous peripheral cannula Five Quality Assurance Committee Date adopted: April 2012 Name of David Leeson originator/author: Name of Clinical Effectiveness Group responsible committee: Date issued for 2014 publication: Review date: January 2017 Expiry date: April 2017 Target audience: Clinical Staff Type of Policy (tick appropriate box) Clinical NHSLA Risk Management Standards if applicable: State Relevant CQC Standards: 1,2,4,8,9. Non Clinical - 1 -
CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Karen Connor Original Policy Developer 2009 Jo Potts Original Policy Developer 2009 David Leeson Clinical Education Lead 2011 and 2014 update Julie Grant Clinical Education Lead 2011 Circulated to the following individuals for consultation Name Caroline Barclay Colin Bourne Corinne Hutton Debbie Leafe Jane Bulman Jo Bowley Joan Carter Joanne Charles Julie Neville Katie Willetts Lesley Tooley Lindsay Bowles Mary Marson Mel Hutchings Satheesh Kumar Vyv Wilkins Zoe Larosa Designation Nurse Consultant Advanced Practice - CCHS Clinical Trainer / Development Nurse MSOP Diana Nurse Bridge Park Plaza Clinical Education Lead CCHS Team Leader Unscheduled Care Team West Locality CCHS Unscheduled Care Team Sister - Loughborough Unscheduled Care Team Sister - Loughborough Lead Pharmacist CCHS Clinical Trainer / Development Nurse Senior Nurse Diana Service Clinical Education Lead CCHS Ward Manager Wd 1 St Lukes Hospital Unscheduled Care Team Sister Melton Infection Prevention and Control Nurse Medical Director - LPT Equality and Diversity Officer Ward Manager Feilding Palmer Hospital - 2 -
CONTENTS Section Contents Page - Title Page 1 - Contribution and Circulation List 2 - Contents 3 - Version Control 4 - Equality Statement, Due Regard, NHS Constitution 5 - Links to CQC standards 6 - Definitions 6 1 Introduction 7 2 Summary of Policy 7 3 Scope of Policy 8 4 Statutory Requirements 8 5 Roles and Responsibilities 8 6 Training and Education 10 7 Audit and Monitoring 11 8 References 12 APPENDICES 1 Preparation of bolus dose of drug 13 2 Administration of a peripheral intravenous bolus dose of 15 drug 3 Adding a drug to an infusion bag. 17 4 Administration of a drug added to an intravenous infusion 18 Information regarding Electronic Infusion Devices Formula and calculation for infusion without an Electronic Infusion device 5 Visual Infusion Phlebitis Score and Checklist 20 6 Competency Assessment Criteria Generic LCAT tool 22 LCAT Competency Assessment sign off sheet 7 Policy Training Requirements 24 8 Due Regard Screening 25 9 Monitoring and Audit 26-3 -
Version Control and Summary of Changes Version number Date Comments (description change and amendments) 1.0 October 2006 Adopted for LCR PCT 2.0 December 2009 3.0 April 2012 Updated and adopted for LPT Procedure tables created for ease of reading. Updated list of other relevant policies. Added links to Medical Devices for Electronic Infusion Devices. Updated Reference list. Added Visual Phlebitis Score and Cannula Chart 4.0 May 2014 Updated references, updated infection prevention and control measures, updated relevant reading. 5.0 February 2015 Removal of 10% rule and yellow labels on syringes for community hospitals. Updated VIPs scoring chart allows for clearer signatures and scoring. Updated to reflect Ulearn system. Updated references NMC code. All LPT Policies can be provided in large print or Braille formats, if requested, and an interpreting service is available to individuals of different nationalities who require them. Did you print this document yourself? Please be advised that the Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. For further information contact: David Leeson Clinical Trainer / Practice Development Manager, Leicestershire Partnership NHS Trust Charnwood Mill, Sileby Rd, Barrow on Soar, Leics, LE12 8LR Tel: Mobile: 07500 097908 / Office: 01509 410265 Email: david.leeson@leicspart.nhs.uk - 4 -
Equality Statement Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and advances equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development, review and implementation. Due Regard The Trusts commitment to equality means that this policy has been screened in relation to paying due regard to the Public Sector Equality Duty as set out in the Equality Act 2010 to eliminate unlawful discrimination, harassment, victimisation; advance equality of opportunity and foster good relations. Please refer to Appendix 8 which provides a detailed overview of the due regard undertaken in support of this activity. NHS Constitution Core Principles The NHS will provide a universal service for all based on clinical need, not ability to pay. The NHS will provide a comprehensive range of services The following core principles apply to this policy. Shape its services around the needs and preferences of individual patients, their families and their carers Respond to different needs of different sectors of the population Work continuously to improve quality services and to minimise errors Support and value its staff Work together with others to ensure a seamless service for patients Help keep people healthy and work to reduce health inequalities Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance - 5 -
Links to CQC standards TARGET/STANDARDS KEY PERFORMANCE INDICATOR Use of individualised care plans that clearly show user 1 involvement. Documented evidence of informed and ongoing consent to 2 treatment. 4 8 Evidenced by thorough assessment of clinical need and multidisciplinary involvement in decision making. In addition this policy draws on the latest of guidance regarding intravenous medication. Evidenced by the use of involvement of infection prevention and control team in drawing up this policy. Evidenced through the use of personalised prescribing and 9 safe administration of medication utilising the latest guidance. Definitions that apply to this Policy Aseptic Technique Bolus Cannula Extravasation Infiltration Non-Vesicant Phlebitis Thrombophlebitis Vesicant Mechanisms employed to reduce potential contamination. Concentrated medication and / or solution given rapidly over a short period of time. Hollow tube made of silastic, rubber plastic or metal used for accessing the body. Inadvertent infiltration of a vesicant solution or medication into the surrounding tissue. Inadvertent administration of a non-vesicant solution or medication into the surrounding tissue. Intravenous medication that generally does not cause tissue damage or sloughing if injected outside of a vein. Inflammation of a vein; may be accompanied by pain, erythema, oedema, streak formation and / or palpable cord; rated by a standard scale Visual infusion phlebitis score. Inflammation of the vein in conjunction with the formation of a blood clot (thrombus) Agent capable of causing injury when it escapes from the intended vascular pathway into surrounding tissue. Inadvertent infiltration of a vesicant solution or medication into the surrounding tissue. - 6 -
1. INTRODUCTION 1.1 The majority of medicines that are administered in the community setting are via the oral route. However, in certain clinical circumstances, administration of medicines via the intravenous route is preferred. Traditionally, this activity was carried out within acute hospitals as an in-patient or within the out-patient setting. 1.2 Our health, Our care, Our Say a new direction for community services (DOH 2006) highlighted the need for more care to take place nearer to the patient s home. This is reiterated in Care in Local Communities A New Vision and Model for District Nursing (DH 2013). As a result, there is more administration of intravenous medicines taking place in the community setting either within patients own homes or within community hospitals. 1.3 The organisation appreciates the importance of having such service provision in the community but also recognises the risks associated with such activities. 2. SUMMARY 2.1 This policy sets out the standards that must be adhered to by clinicians administering intravenous medicines within a community or community hospital setting in order to maintain patient safety. 2.2 This policy includes the administration of intravenous medication via o Peripheral IV cannula 2.3 This policy excludes the administration of intravenous medication via o Central Lines such as Skin Tunnelled catheters (Hickman Lines) or PICC lines (Peripherally Inserted Central Catheter) or Portacaths. The exclusions are dealt with specifically in separate relevant policies. 2.4 This policy excludes the administration of blood and blood products outside the community hospital environment. 2.5 There is specific guidance for the following procedures: Appendix 1. Preparation of a bolus dose of drug Appendix 2. Administration of a peripheral intravenous bolus dose of drug. Appendix 3. Adding a drug to an infusion bag. Appendix 4. Administration of a drug added to an intravenous infusion. - 7 -
3 SCOPE 3.1 This policy is applicable to nursing staff employed by the organisation and should be applied in conjunction with the following local and national policies and standards: o Administering Medication in the Community Setting Standard Operating Procedure LPT o Anaphylaxis LPT Policy o Aseptic Non Touch Technique LPT Policy o Hand Hygiene - LPT Policy o Management of Medical Devices and Equipment LPT Policy o Management of Sharps and exposure to Blood Born Virus LPT Policy o NPSA (2007) Promoting the Safer use of Injectable Medicines. London. NPSA. o Procedure Manual for the Care of Skin Tunnelled Catheters LPT Guidance o Royal College of Nursing (2010). Standards for Infusion Therapy, London. RCN. o Royal College of Nursing (2011). The Health and Safety (Sharp Instruments in Healthcare) Implementing Council Directive 2010/32/EU. Registered Nurses must always work within their professional NMC Code (2015) and adhere to the NMC Standards for Medicines Management (2008). 3.2 Training for the administration of blood and blood products within the designated community hospitals will be addressed separately however the training for administration of IV medicines MUST be completed prior to this mandatory training. 4. STATUTORY REQUIREMENTS 4.1 The Care Quality Commission standard 9b states that the provider has clear procedures followed in practice, monitored and reviewed for medicines handling that include administration of medicines 4.2 The National Health Service Litigation Authority states that the organisation has approved documents which describe the process for the administration of medication in all care environments. 4.3 Care Quality Commission requires standards 1, 2, 4, 8, and 9 to be met in relation to this activity. 5. ROLES AND RESPONSIBILITIES 5.1 Medical Staff / Non-Medical Prescribers To clinically assess the patient as required in order to manage and treat the clinical condition of the patient. Consider the 5 Rs of fluid replacement therapy. Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment in line with NICE guidance CG174. Initiate intravenous therapy when no other alternative is appropriate and ensure it is safe for drug to be given via the prescribed route. - 8 -
To correctly prescribe medication and where required authorise for the patient in order that treatment is facilitated in a timely fashion. Access information from the IV Monographs http://medusa.wales.nhs.uk / BNF as required. Within Childrens services the CBNF or Monograph from the Childrens Hospital would be accessed. Ensure compatibility exists between the infusion fluid and medication, which is to be administered; ensuring the amount of medication prescribed is adequate until the patient is reviewed again. 5.2 Community Service Managers / Hospital Matrons To ensure that this policy is adhered to in the clinical setting and that there is a clear process for dissemination. To ensure that staff are released for clinical mandatory training requirements. To ensure that line mangers are clear in their roles and responsibilities in implementing this policy. To act in accordance with the organisations policy on the actions required of reporting untoward incidents. 5.3 Line Managers To ensure that their staff have had access to appropriate intravenous training and competency assessment and keep records of competence within the Nurses personal file. To ensure that staff attend the appropriate clinical essential to role training and updates. To ensure that staff have access to the correct equipment required to manage intravenous access safely. To ensure that their staff are working in line with this policy. 5.4 Staff undertaking intravenous administration Registered Nurses are responsible and accountable for their practice and should always work within their competence in accordance with The Code (NMC, 2015) and adhere to the Standards for Medicines Management (NMC, 2008). Registered Nurses must attend the required training run within house by the Clinical Education Team CHS or for Childrens Nurses that run by the Clinical Team Leads and also identify to their line manager any ongoing training needs. Registered Nurses must maintain their clinical skills within this area and must seek to refresh their knowledge and skills as required. - 9 -
Registered Nurses must access information from the IV Monographs http://medusa.wales.nhs.uk / BNF as required. Within Childrens services the CBNF or Monographs from the Childrens Hospital would be accessed. Registered Nurses must be familiar with and demonstrate a working knowledge of policies and procedures. Registered Nurses must be adequately prepared and equipped to deal with an anaphylactic or untoward reaction. In community hospitals two Registered Healthcare Practitioners should check drugs to be given intravenously before administration, in accordance with the Trust Medicines Management Policy. Where applicable, calculations must be undertaken independently and the results compared by the two practioners. In the Community where Registered Nurses are administering the drug in the patient s home and have demonstrated the necessary knowledge and competence they may administer intravenous drugs without a second check. If involved with the administration of blood or blood products staff must have undertaken mandatory blood transfusion training (see section3.2). 5.5 Staff undertaking intravenous administrations using infusion pumps If the infusion requires to be given with the use of an electronic infusion device in line with monographs or information from the drug manufacturer, it is the Registered Nurses professional responsibility to ensure their competence by accessing training or by reading instruction manuals and declare such competence to the organisation prior to using the equipment. This is in line with the Management of Medical Devices and Equipment policy and The Code (NMC. 2015) 6. TRAINING / EDUCATION There is a need for training identified within this policy. In accordance with the classification of training outlined in the Trust Learning and Development Strategy this training has been identified as role development training. The Ulearn system will identify: who the training applies to, delivery method, the update frequency, learning outcomes and a list of available dates to access the training. A record of the staffs training will be recorded on the Ulearn system. 6.1 Practitioners must be Registered Nurses. Before accessing an intravenous line independently all staff must: Have completed the organisations competency based training and assessment programme to include Intravenous Therapy, Medicines Management, Anaphylaxis as well as Adult or Paediatric Basic Life Support. - 10 -
Have commenced a period of supervised practice within 4 months of attending the training. Provide evidence of assessment and competency signed by an appropriate assessor. Observation, supervised practice and assessment should ideally be carried out in the clinical area in which the practitioner normally works. It is possible to carry out assessment using a simulation dummy outside of the work place should the need arise. The dates of supervision and assessments must be documented in the LCAT record of supervision held by the practitioner, the assessor and supervisor must sign this document. The practitioner must keep a record of competency in their professional portfolio as well as having a copy lodged in their personal file held by the line manager. See LCAT assessment criteria form and information (Appendix 6) Staff employed from another trust must provide evidence of a completed training and assessment programme and completed competencies that should be current. A supportive competency assessment of the staff must be carried out to ensure that they have the required skills in line with this organisations policy. 6.2 Criteria for Supervisors For staff new to accessing intravenous ports and delivering medication via this route, supervision should be carried out by a specified member of staff with experience and competence in this skill. The specified member of staff must: Be a Registered nurse. Have a sound knowledge of the relevant policies and documents. 6.3 Criteria for Assessors Final assessment of Competency must be carried out using the LCAT (Leicester Clinical Assessment Tool) by an accredited LCAT assessor. A register of accredited assessors is held by the Clinical Education Leads. 7. AUDIT and MONITORING 7.1 Line managers will be expected to assess individual s ability prior to delegating the procedures associated with the access of intravenous ports and administration of intravenous medication. Nurses giving rise to cause of concern will be referred to the Clinical Education Lead in the relevant locality for further assessment and education in the procedures. Practitioners are expected to have completed the organisations competency based training and assessment programme to include Intravenous Therapy, Medicines Management, Anaphylaxis as well as Adult or Paediatric Basic Life Support. This will be monitored by the use of the Ulearn system and the use of appraisals by line managers. - 11 -
Regular audits looking at the administration of medicines intravenously will be carried out by the organisation in accordance with the audit calendar. The policy will be reviewed every 3 years in order to ensure clinical currency or before should evidence from relevant bodies emerge. The policy will be available electronically via intranet in all clinical areas. 8. REFERENCES: Department of Health (2006) Our Health, Our Care, Our Say a new direction for community services. London. TSO Department of Health (2013) Care in Local Communities A new Vision and Model for District Nursing. London. DH National Patient Safety Alert (2007) Alert 20 Promoting the Safer use of Injectable Medicines. London. NPSA. NICE (2013) Clinical Guideline 174 - Intravenous fluid therapy in adults in hospital. London. NICE Nursing and Midwifery Council (2008) Standards for Medicines Management, London. NMC Nursing and Midwifery Council (2015) The Code, London. NMC Nursing and Midwifery Council (2009) Record Keeping: Guidance for Nurses and Midwives, London. NMC Royal College of Nursing (2010) Standards for Infusion Therapy, London. RCN Royal College of Nursing (2011) Sharps Safety: Guidance to support implementation of the EU Directive 2010/32/EU on the prevention of sharps injuries in the health care sector. London. RCN - 12 -
APPENDIX 1 INTRAVENOUS ADMINISTRATION PROCEDURE (PREPARATION OF BOLUS DOSE OF DRUG) ACTION 1 Discuss procedure with patient or parent / carer and obtain informed consent to the treatment. 2 Read all prescription and authorisation details and confirm they relate to the patient to be treated. Check that the medication has not inadvertently been given already. RATIONALE To check that the patient or parent / carer understands the procedure and treatment and gives his or her consent To ensure patient safety and that the prescription is detailed enough to safely administer from and to ensure that it is legal. 3 Check for patient allergies. To ensure patient safety and reduce the risk of an allergic and anaphylactic reaction 4 Ensure that the area in which the To reduce the risk of contamination and medication is to be prepared is as clean mistakes. and uncluttered and free of distraction as possible. 5 Assemble all equipment required. Check all expiry dates and that medication, diluents, and flushes are not damaged and have been stored correctly. 6 Check that the medication formulation, dose, infusion fluid and rate of administration correspond to the prescription and product information. 7 Calculate the volume of medicine solution needed to give the prescribed dose. If required check this with another registered nurse. To ensure patient safety and comply with NMC Standards for Medicines Management (2008) To ensure patient safety and comply with NMC Standards for Medicines Management (2008) To comply with NMC Standards for Medicines Management (2008) 8 Put on a clean single use disposable plastic apron. 9 Disinfect your work surface using 70% alcohol and 2% Chlohexidine swab. Wash hands with liquid soap and water and dry thoroughly. To reduce the risk of bacterial contamination during the procedure. 10 Open sterile field and unpack equipment onto it. Open diluents, flushes and medications ready to draw up. 11 Decontaminate hands using alcohol sanitiser and apply sterile latex free gloves. Allows for the preparation of equipment prior to the procedure without contamination. To reduce the risk of bacterial contamination during the procedure. - 13 -
12 Using latex free sterile gloves and ANTT (Aseptic Non Touch Technique) assemble needles and syringes. Prepare the injection by following the manufacturer s instructions. Draw up pre and post bolus flushes as required. 13 REMEMBER if piercing a rubber seal always cleanse with a swab of 70% alcohol and 2% Chlohexidine and leave to dry for 30 seconds. Using ANTT reduces the risk of bacterial contamination during the procedure. To ensure that bacterial contamination risk is reduced. 14 REMEMBER some medications require to be gently swirled to dissolve all of the powder and should not be allowed to bubble up. It may take several minutes to dissolve powders. Check monograph or reconstitution notes if unsure. 15 Always keep ampoules and any unused medicine until administration to the patient is complete and no untoward reactions have occurred. 16 Once solutions have been drawn up, remove the needle from the leur loc syringe and either fit a blind hub or a new sheathed needle to maintain asepsis. Once ampoules or vials have been disposed of they cannot be retrieved from sharps safes in the case of untoward reactions. Reduces the risk of accidental sharps injury and maintains asepsis of key parts. 17 Remove gloves and apron disposing of correctly according to policy. - 14 -
ADMINISTRATION OF A PERIPHERAL INTRAVENOUS BOLUS DOSE OF DRUG APPENDIX 2 ACTION 1 Before administering any drug check the following: Right patient, Right drug, Right dose, Right time, Right route. RATIONALE To comply with Standards for Medicines Management NMC (2008) 2 Obtain informed consent. To check that the patient understands the procedure and treatment and gives his or her consent 3 Check for allergies. To ensure patient safety and reduce the risk of an allergic and anaphylactic reaction 4 Check that an appropriate venous access device is in place this should include the use of an extension / octopus line and that the administration site is free of leakage, infection and inflammation. 5 Take all equipment to the patient. Use of an octopus / extension line enables ease of access and reduces the risk of vascular damage and device mobility. Leakage, inflammation and infection are possible contra indications to the use of the access device. RCN (2010) See Appendix 5 6 Wash and dry hands thoroughly Reduces the risk of bacterial contamination. 7 Apply fresh sterile non latex gloves and apron. 8 AT ALL TIMES TAKE CARE NOT TO TOUCH KEY PARTS - Clean the needleless valve (bionector) located at the end of the extension / octopus line thoroughly using Chlohexidine 2% and alcohol 70% swab and allow to dry for 30 seconds. 9 Ask the patient to promptly report any soreness at the access site or any discomfort at all. Recheck the access site and device for any signs of leakage, infection or inflammation. 10 Attach a 10ml leur loc syringe filled with sodium chloride 0.9% and flush with 5ml of the sodium chloride 0.9%. DO NOT FORCE. Reduces the risk of bacterial contamination. To prevent bacterial contamination during the procedure. Early detection of untoward reactions and prompt action will reduce further complications. To ensure patency of the device. 11 Disconnect the syringe. 12 Attach leur loc syringe containing drug as prescribed and inject over the appropriate amount of time. 13 Disconnect the syringe All drugs must only be injected over the prescribed rate and time as set out by IV monographs and manufacturer s instructions. Reduces the risk of speed shock - 15 -
14 Attach a 10ml leur loc syringe filled with sodium chloride 0.9% and flush with 5ml of the sodium chloride 0.9% using a push / stop motion. To ensure the patient receives the full dose of the prescribed medication. Push / stop effectively cleanses the lumen of the device. 15 Clear away equipment and ensure the patient is comfortable and the line is secure. 16 Remove gloves and apron and dispose of appropriately then wash and dry hands thoroughly. 17 Make a detailed record of administration using appropriate documentation to include batch numbers and expiry dates. 18 Finally discard used ampoules / vials and sharps into the appropriate sharp safe. To comply with local policies and Record Keeping Guidance for Nurses and Midwives NMC (2009) Once ampoules or vials have been disposed of they cannot be retrieved from sharps safes in the case of untoward reactions - 16 -
APPENDIX 3 INTRAVENOUS ADMINISTRATION PROCEDURE (ADDING A DRUG TO AN INFUSION BAG) ACTION RATIONALE 1 Prepare the medicine in the syringe using the method described in appendix 1. 2 Check the outer wrapper of the infusion solution is not damaged 3 Check the infusion solution is free of particles, haziness, discolouration and is intact. Remove the wrapper. 4 Using sterile gloves remove the tamper evident seal on the additive port according to manufacturer s instructions. Cleanse with 70% alcohol and 2% chlorhexidine swab and leave to dry for 30 seconds. 5 On a flat surface inject the medicine into the infusion through the centre of the injection point taking care to keep the tip of the needle away from the side of the infusion bag. 6 Once the drug has been added to the infusion bag remove the syringe and needle and gently invert the bag at least 5 times. 7 Check the appearance of the final infusion solution for haziness, discolouration and particles. 8 AT ALL TIMES TAKE CARE NOT TO TOUCH KEY PARTS On a flat surface attach administration / giving set to the infusion bag using the port provided. 9 Prime the administration / giving set slowly to reduce air gaps in the line. Ensure the end of the line is covered. 10 Community Hospital Nurses must fully complete the yellow infusion label and attach it to the bag. To ensure that asepsis of the contents have not been contaminated. Particles, haziness, discolouration would indicate contamination and must not be used. To reduce the risk of bacterial contamination. To prevent accidental piercing of the infusion bag. To ensure the medication is completely mixed within the infusion solution. Haziness, discolouration, and particles would indicate incompatibility or contamination and the infusion should not be used. Reduces the risk of bacterial contamination Reduces the risk of air embolus and prevents bacterial contamination. To ensure that all staff are aware of the addition of the drug to the infusion solution. - 17 -
ADMINISTRATION OF A DRUG ADDED TO AN INTRAVENOUS INFUSION APPENDIX 4 ACTION 1 Before administering any drug check the following: Right patient, Right drug, Right dose, Right time, Right route. RATIONALE To comply with local policies and NMC Standards for Medicines Management (2008). To keep the patient safe. 2 Obtain informed consent. To check that the patient understands the procedure and treatment and gives his or her consent. 3 Check for allergies. To ensure patient safety and reduce the risk of an allergic and anaphylactic reaction. 4 Check that an appropriate venous access device is in place which should include the use of an extension / octopus line and that the administration site is free of leakage, infection and inflammation. 5 Take all equipment to the patient. Use of an octopus / extension line enables ease of access and reduces the risk of vascular damage and device mobility. Leakage, inflammation and infection are possible contra indications to the use of the access device. RCN (2010).See appendix 5 6 Wash and dry hands thoroughly Reduces the risk of bacterial contamination. 7 Apply fresh sterile gloves. Reduces the risk of bacterial contamination. 8 AT ALL TIMES TAKE CARE NOT TO TOUCH KEY PARTS - Clean the needleless valve (bionector) located at the end of the extension / octopus line thoroughly using Chlohexidine 2% and alcohol 70% swab and allow to dry for 30 seconds. 9 Attach a 10ml leur loc syringe filled with sodium chloride 0.9% and flush with 5ml of the sodium chloride 0.9%. DO NOT FORCE. To prevent bacterial contamination during the procedure. To ensure patency of the device. 10 Disconnect the syringe. 11 Attach the administration / giving set and regulate and run the infusion as required 12 At this point the nurse may remove the gloves and apron dispose of appropriately. 13 Once infusion is complete stop the infusion. 14 Put on a fresh apron, decontaminate hands using hand sanitiser and apply fresh sterile gloves. All drugs must only be injected over the prescribed rate and time as set out by the prescription / authorisation or IV monographs and manufacturer s instructions. Reduces the risk of speed shock. Prevent accidental contamination of equipment or surroundings To reduce bacterial contamination - 18 -
15 AT ALL TIMES TAKING CARE NOT TO TOUCH KEY PARTS Detach the administration / giving set from the access device. 16 Attach a 10ml leur loc syringe filled with sodium chloride 0.9% and flush with 5ml of the sodium chloride 0.9% using a push / stop motion. 17 Clear away equipment and ensure the patient is comfortable and the line is secure. 18 Discard used ampoules / vials and sharps into the appropriate sharp safe. 19 Ask the patient to promptly report any soreness at the access site or any discomfort at all. Recheck the access site and device for any signs of leakage, infection or inflammation. To prevent contamination of key parts To ensure the patient receives the full dose of the prescribed medication. Push / stop effectively cleanses the lumen of the device. To prevent cross infection Once ampoules or vials have been disposed of they cannot be retrieved from sharps safes in the case of untoward reactions Early detection of untoward reactions and prompt action will reduce further complications. 20 Make a detailed record of administration. To comply with local policies and Record Keeping Guidance for Nurses and Midwives NMC (2009) 21 Check that arrangements for monitoring fluid balance or clinical parameters have been made. Ensure that relevant documentation is made available for subsequent regular monitoring to take place. N.B. ELECTRONIC INFUSION DEVICES To keep patient safe and monitor for early complications. If the medication requires to be given with the use of an electronic infusion device in line with monographs or information from the drug manufacturer, it is the Registered Nurses professional responsibility to ensure their competence by accessing training or by reading instruction manuals and declare such competence to the organisation prior to using the equipment. This is in line with the Management of Medical Devices and equipment policy and The Code (NMC. 2008) N.B. WORKED EXAMPLE OF THE FORMULA FOR CALCULATING DRIP RATES IF NOT USING AN ELECTRONIC INFUSION DEVICE mls to be infused (500) X Drops per ml (20) = 10000 = 13.8 dpm (14) Hours to run (12) X Convert to min (60) 720-19 -
VISUAL INFUSION PHLEBITIS SCORE (VIPS) Taken from: Jackson A (1998) APPENDIX 5 IV Site appears healthy. No pain evident. No signs of phlebitis 0 OBSERVE CANNULA ONE of the following is evident: Slight pain near IV site Slight redness near IV site 1 Possible first signs of phlebitis OBSERVE CANNULA TWO of the following are evident: Pain at IV site Erythema Swelling ALL of the following signs are evident: Pain along the path of cannula Erythema Induration All of the following are evident and extensive: Pain along path of cannula Erythema Induration Palpable venous cord Pus All of the following are evident and extensive: All of the above PLUS Pyrexia Tissue damage Early stages of phlebitis 2 RESITE CANNULA Medium stage of phlebitis 3 RESITE CANNULA and CONSIDER TREATMENT Advanced stage of phlebitis or the start of thrombophlebitis RESITE CANNULA and INITIATE TREATMENT 4 COMPLETE INCIDENT FORM Advanced stage of thrombophlebitis 5 RESITE CANNULA and INITIATE TREATMENT COMPLETE INCIDENT FORM 20
VISUAL INFUSION PHLEBITIS SCORE AND CANNULA CHECKLIST (ANY SCORE GREATER THAN 0 REQUIRES AN ENTRY IN THE EVALUATION OF CARE) Patients Full Name: Date of Birth: NHS Number: Cannula No 1 2 3 4 5 Date of cannulation Insertion of cannula Inserted by Insertion site Size / colour of cannula Manufacturer Batch no & expiry date VISUAL INFUSION PHLEBITIS SCORE Day 1 Night 1 Day 2 Night 2 Day 3 Night 3 Day 4 Night 4 Day 5 Night 5 Score Signature Score Signature Score Signature Score Signature Score Signature Remove the cannula unless the patient has poor venous access or clinician can justify leaving in situ. Removal of cannula Date of removal Removed by Swab Taken? Y / N Y / N Y / N Y / N Y / N Tip sent for C&S? Y / N Y / N Y / N Y / N Y / N Sterile dressing to site? Y / N Y / N Y / N Y / N Y / N 21
COMPETENCY ASSESSMENT CRITERIA GENERIC LCAT TOOL. Competency will be assessed by an authorised LCAT assessor using the LCAT assessment tool see next page - in conjunction with the procedure guides as per appendices 1-4 of this document. Prior to assessment candidates must: Attend the Intravenous Therapy theory session run throughout the organisation. Work through this policy. APPENDIX 6 Be aware of the areas of assessment as per the LCAT assessment tool below all five categories will be assessed. LCAT COMPETENCY ASSESSMENT SIGN OFF SHEET The LCAT sign off sheet is contained in the LCAT Record of Supervised Clinical Practice and is held by the practitioner. The LCAT record of Supervised Clinical Practice will be sent to the practitioner prior to attendance on the theory session in conjunction with a copy of this policy. It is recommended that copies of assessments are taken and held by the line manager and assessor for future reference.
Category and component competence 1.0 Communication and working with the patient and/or representative 1.1 Introduces self to patient and/or their family 1.2 Shares information about the procedure appropriately 1.3 Listens attentively 1.4 Answers questions honestly 1.5 Checks patient s understanding 1.6 Obtains valid and continuing consent 1.7 Works with the patient to maintain co-operation 1.8 Use of communication skills 1.9 Performs procedure in a compassionate and patient-centred manner 2.0 Safety 2.1 Checks patient s identity correctly 2.2 Checks/completes request and/or documentation correctly 2.3 Labels samples/printouts correctly 2.4 Applies procedure-specific safety measures correctly 2.5 Is aware of limitations of personal competence and role, and acts appropriately 2.6 Maximises own and others safety 2.7 Offers appropriate post-procedure care to the patient 3.0 Infection Prevention 3.1 Washes and/or decontaminates hands 3.2 Prepares patient s skin appropriately 3.3 Uses anti-infection barriers as required 3.4 Displays appropriate practice of aseptic technique 3.5 Disposes of waste appropriately 3.6 Optimises infection prevention within environmental limitations 4.0 Procedural Competence 4.1 Assesses the patient appropriately 4.2 Appropriately assesses the indications for and contra-indications to the proposed procedure 4.3 Plans the procedure with respect to patient factors 4.4 Prepares the patient appropriately 4.5 Selects and checks equipment, disposables, and consumables 4.6 Performs procedure fluently 4.7 Displays familiarity with equipment 4.8 Displays knowledge of the procedure 4.9 Uses assistance appropriately 4.10 Handles samples/ensures quality control of outputs correctly 4.11 Deals appropriately and sensitively with the evolving situation 4.12 Demonstrates respect for tissue 5.0 Team working 5.1 Displays understanding and respect for the roles of team members 5.2 Communicates effectively with the team 5.3 Leaves clinical area clean and tidy 5.4 Documents procedure correctly
APPENDIX 7 Policy Training Requirements The purpose of this template is to provide assurance that any training implications have been considered Training topic: Intravenous Access and Administration of Medication via Peripheral Cannulae Type of training: Role specific Division(s) to which the training is applicable: Adult Mental Health Services Community Health Services Families Young People Children Staff groups who require the training: Registered Nurses who are required as part of their job to access peripheral cannulae. Update requirement: Who is responsible for delivery of this training? Have resources been identified? Has a training plan been agreed? Where will completion of this training be recorded? Not fixed. Staff must work within NMC Standards. Clinical Education Team and Clinical Team Leads (Diana service) In place already Ongoing training programme In place already Trust learning management system and within apraisals as LCAT documents How is this training going to be monitored? Via Learning and Development team in conjunction with Clinical Education Team
APPENDIX 8 Section 1 Name of activity/proposal DUE REGARD SCREENING TOOL Administration of medication via peripheral cannulae Date Screening commenced 14 th May 2014 Directorate / Service carrying out the CCHS assessment Name and role of person undertaking David Leeson Clinical Education Lead this Due Regard (Equality Analysis) Give an overview of the aims, objectives and purpose of the proposal: AIMS: Update policy prescribing the standards to be adhered to when preparing and administering medication via a peripheral cannula OBJECTIVES: To ensure that any medication given via a peripheral cannula is given safely PURPOSE: To ensure both patient wellbeing and guard against staff errors.. Section 2 Protected Characteristic Could the proposal have a positive impact Yes or No (give details) Could the proposal have a negative impact Yes or No (give details) Age No No Disability No No Gender reassignment No No Marriage & Civil Partnership No No Pregnancy & Maternity No No Race No No Religion and Belief No No Sex No No Sexual Orientation No No Other equality groups? No No Section 3 Does this activity propose major changes in terms of scale or significance for LPT? For example, is there a clear indication that, although the proposal is minor it is likely to have a major affect for people from an equality group/s? Please tick appropriate box below. Yes High risk: Complete a full EIA starting click here to proceed to Part B No Low risk: Go to Section 4. Section 4 It this proposal is low risk please give evidence or justification for how you reached this decision: Implementation of this policy should not have a negative impact on any protected characteristics. It simply prescribes good clinical practice.
Process for Monitoring Compliance and Effectiveness APPENDIX 9 Minimum Requirements Process for Monitoring Frequency Responsible Group Ensure staff attend training to deliver the care as described in section 6 of this policy. Review by team managers of records of training that is recorded on the Ulearn system Quarterly Community Managers / Matrons Locality Governance Forum Ensure staff are competent to deliver the care as detailed in appendices 1-4 of this policy Review of staff LCAT assessments at appraisal by team managers. Annual Community Managers / Matrons Locality Governance forum Regular ongoing review of intravenous medication related incidents / complaints by Patient Safety and Experience Groups. The number of incidents/complaints reported via safeguard. Reported as required and as exception PSEG The use of the Visual Infusion Phlebitis Score and Cannula Checklist. Local audit process on the use of the Visual Infusion Phlebitis Score and Cannula Checklist to be carried out within teams. Annual CHS CAEG and Locality Governance Forum Where monitoring identifies any shortfall in compliance the group responsible for the Policy (as identified on the policy cov er) shall be responsible for developing and monitoring any action plans to ensure future compliance