Patient Group Direction For The Administration Of Medicines Included In The Sepsis Formulary To Adults With Suspected Sepsis By Registered Nurses Working In Community Hospitals Within NHS Grampian Lead Author: Lead Pharmacist Aberdeenshire Health & Social Care Partnership Consultation Group: See relevant page in the PGD Approver: Medicine Guidelines and Policies Group Signature: Signature: Identifier: NHSG/PGD/SepsisF/ MGPG839 Review Date: October 2018 Expiry Date: October 2019 Date Approved: October 2016 A Patient Group Direction is a specific written instruction for the supply or administration of named medicines in an identified clinical situation. It is drawn up locally by Doctors, Pharmacists and other appropriate professionals, approved by the employer and advised by the relevant professional advisory committees. In most cases, appropriate clinical care is provided on an individual basis by a specific prescriber to a specific individual patient. Patient Group Directions should only be considered where they offer a benefit to patient care without compromising patient safety in any way. Uncontrolled when printed Version 1
This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on (01224) 551116 or (01224) 552245. Revision History: Date of change Approval date of PGD that is being superseded Summary of Changes New PGD Section heading Subject: Identifier: Replaces: Keyword(s): Patient Group Direction NHSG/PGD/SepsisF/MGPG839 New PGD Patient group direction PGD sepsis formulary oxygen sodium chloride intravenous infusion Policy Statement: It is the responsibility of individual nurse and their line managers to ensure that they work within the terms laid down in this PGD and to ensure that staff are working to the most up to date PGD. By doing so, the quality of the services offered will be maintained, and the chances of staff making erroneous decisions which may affect patient, staff or visitor safety and comfort will be reduced. Supervisory staff at all levels must ensure that staff using this PGD act within their own level of competence. The lead author is responsible for the review of this PGD and for ensuring the PGD is updated in line with any changes in clinical practice, relevant guidelines, or new research evidence. Review date: The review date for a PGD needs to be decided on a case-by-case basis in the interest of patient safety. The expiry date should not be more than 3 years from the date the PGD was authorised. Document: Drafted: September 2016 Completed: September 2016 Approved: October 2016 (published December 2016) UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839 - i -
Patient Group Direction For The Administration Of Medicines Included In The Sepsis Formulary To Adults With Suspected Sepsis By Registered Nurses Working In Community Hospitals Within NHS Grampian Clinical indication to which this PGD applies Definition of situation/condition Sepsis is a leading cause of morbidity and mortality in the UK. The key element of management is to ensure early recognition of sepsis and treatment. This Patient Group Direction (PGD) will authorise nurses to administer Sodium Chloride 0.9% intravenous infusion and oxygen to adult patients presenting with signs of suspected sepsis in Community Hospitals. This PGD should be used in conjunction with Management of Sepsis in Community Hospitals Nursing Protocol. This PGD should be used in conjunction with the recommendations in the current British National Formulary (BNF) individual Summary of Product Characteristics (SPC). Inclusion criteria Patients with sepsis may present with: A. 2 or more of the following criteria: 1. Fever (>38 C) or hypothermia (<36 C) 2. Tachypnoea (>20/min) 3. Tachycardia (>90 bpm) 4. New onset of altered mental state (confusion) 5. Blood glucose >7.7mmol/l (not diabetic or patients on steroids). B. A presumed or confirmed clinical diagnosis of infection. C. Signs of organ dysfunction any of the following: 1. sbp <90mmHG (or>40mmhg drop from normal baseline) 2. SaO2 <94% 3. Clinical evidence/history of reduced urine output 4. New onset confusion/delirium. If A, B and C are present the Management of Sepsis in Community Hospitals Nursing Protocol must be initiated along with this PGD. UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-1 -
Exclusion criteria Children aged 16 years or under. Signs of fluid overload on examination, e.g. systemic or pulmonary oedema. Palliative care. Precautions and special warnings It is the responsibility of the nurse to check the strength, the expiry date and to record the batch numbers of the solutions infused. Sodium Chloride 0.9% w/v intravenous infusion must be administered using aseptic technique. Solution must be clear and free of particles. It is the responsibility of the nurse to check the expiry date of oxygen cylinders used. Oxygen should be administered with caution in those with hypercapnic respiratory failure/copd (target 88-92% saturation). GP/GMED must be contacted immediately regarding the patient when sepsis is suspected for review and consideration of escalation. Referral criteria Patients who fall into the categories detailed in the exclusion criteria. Action if excluded from treatment Medical advice should be sought urgent contact with General Practitioner/Consultant/Nurse Prescriber (relevant medical practitioner). The reason why the patient was excluded under the PGD will be documented in the patient s medical notes. Action if patient declines treatment Patient should be advised of the risks and consequences of not receiving treatment. Medical advice should be sought urgent contact with General Practitioner/Consultant/Nurse Prescriber (relevant medical practitioner). Documented in the patient s medical notes. UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-2 -
Consent Prior to the administration of the drug, valid consent must be obtained. Consent must be in line with current NHSG Staff Policy for Obtaining Consent for Clinical Procedures and Healthcare Interventions. See link below. http://intranet.grampian.scot.nhs.uk/ccc_nhsg/15692.html?pme nuid=460& Description of treatment available under the PGD Name of medicine See individual product monographs. Legal status Sodium Chloride 0.9% w/v intravenous infusion is a Prescription-only Medicine (PoM). Oxygen is a medical gas, classed as General Sales List (GSL). Form/Strength See individual product monographs. Route/Method of administration See individual product monographs. Dosage/Total Dose See individual product monographs. Duration of treatment See individual product monographs. Storage requirements See individual product monographs. Follow-up (if applicable) All patients with suspected sepsis should be reviewed by a doctor as per Management of Sepsis in Community Hospitals Nursing Protocol. Medical staff (Practitioner/Consultant/Nurse Prescriber) will assess need for escalation such as transfer to secondary care and consider the need for intravenous antibiotics. Observation of cannula site. UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-3 -
Advice to patient (Verbal) Advice should be given on what to expect and what to do for major and minor reactions. To report any pain, swelling or redness at the cannula site to staff immediately. To report any pain or discomfort on the administration of the Sodium Chloride 0.9% w/v intravenous infusion. Advice to patient (Written) The Patient Information Leaflet (PIL) contained in the medicine(s) should be made accessible to the patient, parent, guardian, or person with parental responsibility. Where this is unavailable, or unsuitable, sufficient information should be given in a language that they can understand. Copies of PIL and SPCs for all medicines can be found at http://www.medicines.org.uk or http://www.mhra.gov.uk/spcpil/index.htm Concurrent Medications/Drug Interactions Identifying and managing possible adverse reactions See individual product monographs. See individual product monographs. This list is not exhaustive. Please also refer to current BNF/BNFC and manufacturers SPC for details of all potential adverse reactions. BNF: https://www.medicinescomplete.com/mc/bnf/current/ https://www.medicinescomplete.com/mc/bnfc/2011/ SPCs/PILs: https://www.medicines.org.uk/emc/ http://www.mhra.gov.uk/spc-pil/index.htm If an adverse reaction does occur give immediate treatment and inform relevant medical practitioner as soon as possible. Report the reaction to the MHRA using the Yellow Card System. https://yellowcard.mhra.gov.uk/ UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-4 -
Medical advice in cases of anaphylaxis Injections of IM adrenaline/epinephrine 1:1000 must be available to treat an anaphylactic reaction should this occur. Medical advice must be sought as soon as possible from a doctor if any patient develops any signs of hypersensitivity. If there is a delay in medical support arriving and the condition of the patient is deteriorating then an emergency ambulance must be called on 999 or direct via ambulance control or dial 2222 (hospital internal) according to local procedure, or seek urgent medical advice. (Refer to Patient Group Direction for the administration of adrenaline (epinephrine) in cases of suspected anaphylactic reactions by qualified health professionals) http://www.nhsgrampian.com/grampianfoi/files/pgd_adrenalin e.pdf. Facilities and supplies required The following should be available at sites where the medication is to be administered: Appropriate storage facilities. An acceptable level of privacy to respect patient s right to confidentiality and safety. Resuscitation equipment. Access to medical support (this may be via the telephone). Approved equipment for the disposal of used materials. Clean and tidy work areas, including access to hand washing facilities. Copies of the current PGD for the medicine specified in the PGD. PGD for the administration of Adrenaline (epinephrine) in cases of suspected anaphylactic reactions by qualified health professionals. Characteristics of staff authorised to supply/administer medicine under PGD Professional qualifications Registered Nurses as recognised by the NMC. Specialist competencies Be competent to assess the patient s capacity to understand the nature and purpose of the administration in order for the patient to give or refuse consent. UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-5 -
Has undertaken appropriate training to carry out clinical assessment of patients leading to a diagnosis that requires treatment according to the indications listed in the PGD. Be aware of current treatment recommendations and be competent to discuss issues about the drug with the patient. Is competent in the administration of the drug and medical gas. Awareness and following Management of Sepsis in Community Hospitals Nursing Protocol. Ongoing training and competency Have attended basic life support training which is required to be updated annually. Have undertaken the NHS e-anaphylaxis training session (and annual updates) which covers all aspects of the identification and management of anaphylaxis. This can be accessed via eksf, or the AT Learning tool. Maintain their skills, knowledge and their own professional level of competence in this area according to their individual Code of Professional Conduct. The practitioner must be familiar with the SPC for all medicines supplied in accordance with this PGD. Professional managers/lead Nurses will be responsible for: Ensuring that the current PGD is available to staff providing care under this direction. Ensuring that staff have received adequate training in all areas relevant to this PGD and meet the requirements above. Maintain up to date record of all staff authorised to administer drug specified in PGD. Documentation Authorisation of administration Nurses working within NHS Grampian can be authorised to administer the drugs specified in this PGD by their Nurse Manager/Consultant. All authorised staff are required to read the PGD and sign the Agreement to Administer Medicines Under PGD (Appendix 1). UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-6 -
A certificate of authorisation (Appendix 2) signed by the authorising doctor/manager should be supplied. This should be held in the individual practitioners records, or as agreed locally. Record of administration/ supply An electronic or paper record for recording the screening of patients and the subsequent administration of the drug specified in this PGD must be completed in order to allow audit of practice. This should include: Name and address of patient Patient CHI No and date of birth Details of parent/guardian, or person with parental responsibility where applicable Consultant/General Practitioner details Risk group, if appropriate Findings of physical examination, if appropriate Exclusion criteria, record why the drug was not administered Reason for giving Consent to the administration (if not obtained elsewhere) Drug manufacturer, batch number and expiry date Sodium Chloride 0.9% w/v injection recorded on infusion fluid prescription chart documenting PGD in prescriber section Oxygen administration recorded on Prescription and Administration Record with flow rate and % recorded documenting PGD in prescriber section Signature and name in capital letters of practitioner who administered the drug Date drug given Record of any adverse effects (advise patient s doctor). These records should be retained: For children and young people, retain until the patient's 25th birthday or 26th if the young person was 17 at the conclusion of treatment. For 17 years and over retain for 6 years after last date of entry, for 3 years after death, or in accordance with local policy, where this is greater than above. UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-7 -
Audit References All records of the drug specified in this PGD will be filed with the normal records of medicines in each practice/service. A designated person within each H&SCP/practice/service will be responsible for auditing completion of drug forms and collation of data. Electronic Medicines Compendium http://www.medicines.org.uk Sodium Chloride Intravenous Infusion BP 0.9% w/v Date of revision of text 20/01/16, accessed 26/05/16 British National Formulary https://www.medicinescomplete.com/mc/bnf/current/ accessed 26/05/16 Management of Sepsis in Community Hospitals Nursing Protocol 2016 Sepsis: recognition, diagnosis and early management; NICE Guideline Published: 13 July 2016 https://www.nice.org.uk/guidance/ng51 Management and Monitoring of Patient Group Direction PGD Consultative Group The consultative group is legally required to include a medical practitioner, a pharmacist and a representative of the professional group who will provide care under the direction Name: Frances Adamson Dr Chris Allan Dr Kirsten Cassidy Dr Graham Gault Neil Hendry Fiona Mitchelhill Elaine Neil Dr Karen Simpson Lesley Thomson Title: Medicines Management Specialist Nurse GP Turriff, Clinical Lead Aberdeenshire H&SCP GP Insch, Macmillan Cancer & Palliative Care Lead GP Aberdeenshire GP Whinhill, SPSP-PC Clinical Lead Operational Lead Nurse Aberdeenshire H&SCP Patient Safety Programme Manager, Quality, Governance and Risk Unit Lead Pharmacist Aberdeenshire H&SCP GP Insch Medical Practice, Garioch Clinical Lead Lead Author: Lead Pharmacist Aberdeenshire H&SCP UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-8 -
Authorising Managers Dr Nick Fluck Medical Director, NHS Grampian Mr David Pfleger Director of Pharmacy and Medicines Management, NHS Grampian Professor Amanda Croft Director of Nursing, Midwifery and AHPs, NHS Grampian UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-9 -
Appendix 1 Health Care Professional Agreement to Administer Medicines Under Patient Group Direction I: (Insert name) Working within: e.g. H&SCP, Practice Agree to administer medicines under the direction contained within the following Patient Group Direction Patient Group Direction For The Administration Of Medicines Included In The Sepsis Formulary To Adults With Suspected Sepsis By Registered Nurses Working In Community Hospitals Within NHS Grampian I have completed the appropriate training to my professional standards enabling me to administer medicines under the above Patient Group Direction. I agree not to act beyond my professional competence nor outwith the recommendations of the Patient Group Direction. Signed: Print Name: Date: Professional Registration No: UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-10 -
Appendix 2 Certificate Of Authorisation To Administer Medicines Under Patient Group Direction This authorises: Working within: e.g. H&SCP, Practice To administer medicines under the following Patient Group Direction Patient Group Direction For The Administration Of Medicines Included In The Sepsis Formulary To Adults With Suspected Sepsis By Registered Nurses Working In Community Hospitals Within NHS Grampian The above named person has satisfied the training requirements and is authorised to administer medicines under the above Patient Group Direction. The above named person has agreed not to act beyond their professional competence nor outwith the recommendations of the Patient Group Direction Signed: Authorising Manager/Doctor Print Name: Date: UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-11 -
Appendix 3 - NHS Grampian Sepsis Formulary NHS Grampian Sepsis Formulary The information in these monographs is not exhaustive. They must be read in conjunction with the current issue of the British National Formulary, and the Summary of Product Characteristics for each product. October 2016 UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-12 -
NHS Grampian Sepsis Formulary Sodium Chloride 0.9% w/v Intravenous Infusion Presentation Clear solution for intravenous infusion. Available as 250mL infusion bag. Indication Suspected Sepsis. Dose/Administration Adults aged over 16 years old 250mLs to be administered over 30 minutes. Maximum dose under this PGD is 250mLs. Repeated administration is not permitted under this PGD. Contra-indications Aged 16 years or under. Signs of fluid overload on examination, e.g. systemic or pulmonary oedema. Palliative care patients. Precautions GP/GMED must be contacted immediately regarding the patient when sepsis is suspected for review and consideration of escalation. It is the responsibility of the nurse to check the strength, the expiry date and to record the batch numbers of the solutions infused. Sodium Chloride 0.9% w/v intravenous infusion must be administered using aseptic technique. Solution must be clear and free from particles. Concurrent Medications/Drug Interactions Caution is advised in patients treated with lithium. Renal sodium and lithium clearance may be increased during administration of Sodium Chloride 0.9%. Administration of Sodium Chloride 0.9% w/v intravenous infusion may result in decreased lithium levels. Steroids and carbenoxolone, are associated with the retention of sodium and water (with oedema and hypertension). These circumstances should not lead to a delay in treatment, however the General Practitioner/Consultant (relevant medical practitioner) should be informed. Side Effects Adverse effects are rare however, infusion of Sodium Chloride 0.9% w/v intravenous infusion may lead to fluid and electrolyte imbalances such as metabolic acidosis, hypokalaemia, sodium retention, hypertension, tachycardia, oedema and gastrointestinal effects. Storage This medicinal product does not require any special storage conditions. Further Information Observe cannula site. Legal Status Prescription-only Medicine (PoM). UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-13 -
NHS Grampian Sepsis Formulary Oxygen Presentation Medical gas for inhalation supplied in cylinders. Indication Suspected Sepsis. Dose/Administration Oxygen to be delivered until saturation levels improve >92%. The concentration will be adjusted according to response. In patients with COPD via fixed delivery system/mask of 28% at flow rate of 4L/min until saturation levels improve 88-92%. Oxygen therapy should be continued until there is an improvement of saturation levels (> 92% (88-92% COPD)) and the patient has been reviewed by medical staff. Maximum dose under this PGD is 4L/min. Contra-indications Aged 16 years or under. Palliative care patients. Precautions GP/GMED must be contacted immediately regarding the patient when sepsis is suspected for review and consideration of escalation. Oxygen should be administered with caution in those with hypercapnic respiratory failure/copd (target 88-92% saturation). Concurrent Medications/Drug Interactions Oxygen therapy is not known to interact with any medications. Side Effects Prolonged inhalation may cause dry mouth, coughing and fatigue. Storage Cylinder - stored at room temperature, away from flames, in a clinical room or other safe area. Further Information Explain why oxygen is being used and its effects. Give the patient/carer verbal instructions on how to use the mask, mouthpiece or delivery device. Advise on dangers of smoking and other potential sources of ignition. Legal Status General Sales List (GSL) medicine UNCONTROLLED WHEN PRINTED Review Date: October 2018 Identifier: NHSG/PGD/SepsisF/MGPG839-14 -