Administration of Intravenous Medication by Adults & Children s Services in the Community Setting and Adult Bed Based Units Policy

High Value Health Care Administration of Intravenous Medication by Adults & Children s Services in the Community Setting and Adult Bed Based Units Policy (Reference No. CP53 8016) Version: Version 5, July 2016 Version Superseded: Version 4, February 2016 Ratified by: Date ratified: 11 th August 2016 Name and designation of originator/ author (Lead Officer): Name of responsible committee/ individual: Name of executive lead: Clinical Effectiveness Group (CEG) Jo Jenkins/ Pharmacist Medicine Management Forum/ Clare Hawkins Clare Hawkins Date issued: August 29 2016 Review date: Target audience: 2 years from date issued or earlier at discretion of the Executive Lead or Author All Hertfordshire Community Trust (HCT) Staff working in Adult & Children s Community Services and Adults Bed Based Unit services 1

Contents 1. Introduction... 4 2. Purpose... 4 3. Scope... 4 4. Ownership, Roles and Responsibilities... 5 5. Anaphylaxis... 5 6. Accepting/declining a referal from primary, community or acute care for initation or continuation of IV therapy at home (Adults and Children)..6 7. Initial Cannulation... 6 8. Prescribing of Intravenous Medication... 6 9. Dispensing and Storage of Medication... 7 10. Preparation and Administration of Medication... 8 11. Documentation... 10 12. Reporting Adverse Reaction... 11 13. Reporting a drug/ administration Error... 11 14. Disposal of Waste, Sharps and Medication... 11 15. Arrangements for Recanulation... 11 16. Removal of the Cannula... 12 17. Dissemination and Access to Ratified Policy... 12 18. Implementation and Training... 12 19. Review and Revision Arrangements... 13 20. Document Control and Archiving Arrangements... 13 21. Equality Impact Analyses (EIA)... 13 22. References... 14 23. Appendices... 14 APPENDIX 1: Adult Community Teams/ Bed Based Unit Nurses/ Community Children s Nurses Intravenous drug administration competency framework... 17 APPENDIX 2: Adult Community Teams/ Bed Based Unit Nurses Record of supervised practice... 22 APPENDIX 3: Competencies for IV Drug Administration for Children s Community Nurses... 24 APPENDIX 4: Audit tool for the Clinical Guideline For The Administration Of Intravenous Medication For Adults And Paediatrics In The Community Setting And Bed Based Units (Adults)... 29 APPENDIX 5: Peripheral Venous Catheter Insertion/Continuing Care Tool... 30 APPENDIX 6: Central Venous Catheter Insertion/Continuing Care Tool... 31 APPENDIX 7: Adult Community Teams Assessment checklist for Intravenous Therapy in the Community... 32 APPENDIX 8: Adult Community Teams Intravenous medication prescription sheet... 33 APPENDIX 9: Visual Infusion Phlebitis Score... 35 APPENDIX 10: Criteria for Administration of Intravenous Medication by Adult Community Nursing Team and/or Intermediate Care Team and Bed Based Unit Nurses... 36 APPENDIX 11: Children s Community Nursing Protocol for Accepting a Referral for Intravenous Antibiotics (IVABs) In the Community... 38 IV Policy CP53 1015, V.5 Page 2 of 58

APPENDIX 12: Children s Community Nursing Protocol for the administration of Intravenous Antibiotics (IVABs) in the Community... 40 APPENDIX 13: Children who have not received the 2 nd dose of Intravenous Therapy 41 APPENDIX 14: Assessment Checklist for Intravenous Therapy in the Community 42 APPENDIX 15: Children s Community Nursing Protocol for Obtaining Blood sample from Central Venous Access Device (CVAD)... 425 APPENDIX 16: Guidance for Children s Community Nurse Team Regarding Medicines Administration Error... 48 APPENDIX 17: Algorithm for the Management of Persistent Withdrawal Occlusion (PWO)... 49 APPENDIX 18: Care Plan for the administration of medication via the intravenous route as a continuous infusion... 50 APPENDIX 19: Criteria for accepting or declining a referral for home IV therapy initation.61 APPENDIX 20: Policy Amendment(s) Template... 62 APPENDIX 21: Version Control Table... 645 APPENDIX 22: Equality Impact Analyses Form... 66 IV Policy CP53 1015, V.5 Page 3 of 58

1. Introduction 1.1 This policy sets out a framework in which to ensure safe and competent administration of intravenous medication within the community and Bed Based Unit settings. The policy applies to all nursing staff employed within Hertfordshire Community NHS Trust (HCT) delivering adult and children s services, and should be read in conjunction with highlighted documentation within the guidelines. Nurses employed by HCT must meet the training and education standards prior to undertaking any patient care. 1.2 This document should be read in conjunction with the following documents- The Code. Standards of conduct, performance and ethics for nurses and midwives (Nursing and Midwifery Council (NMC), 2015). Standards for medicines management (NMC, 2015) Record keeping: Guidelines for nurses and midwives (NMC, 2015). The Royal Marsden Manual of Clinical Nursing Procedures 9 th edition (2015). Cardio Pulmonary Resuscitation Policy Venous Access Devices Policy - Reducing the Risk of Infections Prevention of Exposure to Blood Bourne Viruses in the Workplace Policy (Sharps Policy) Antibiotic treatment of infections in community hospital and community services Cleaning, Disinfection and Sterilisation Hand Hygiene Standard Infection Control Precautions Waste Management Medicines and Medicines Safety Policy including cold chain guidance for the storage and transport of medications and vaccines Incident Policy and Procedure Serious Incident Policy and Procedure Consent to Examination or Treatment Policy Medusa IV/IM monographs accessed via http://medusa.wales.nhs.uk/ RCN Standards for Infusion Therapy Guidelines (2012) 1.3 This version supersedes any previous versions of this document. 2. Purpose 2.1 There are specific hazards and risks associated with the administration of intravenous medication to patients in their own homes in addition to those within a Bed Based Unit environment such as the non clinical environment, working space, lighting and external interruptions which need to be understood. 2.2 To reduce these risks, it is the responsibility of the registered nurse working in the community environment to ensure the sharing of information, the medication for intravenous administration, and the patients condition, fully meet the criteria outlined in Appendix 10 (Adult Services) and Appendix 11 (Children s Services) before the patient is accepted as part of the community nursing caseload. 3. Scope 3.1 This policy applies to all nursing staff employed within Hertfordshire Community NHS Trust (HCT) delivering Adult and Children s Community and Bed Based Unit care. IV Policy CP53 1015, V.5 Page 4 of 58

4. Ownership, Roles and Responsibilities The generic statement of roles and responsibilities of The Trust Board, Designated Committee, The Executive Team, Chief Executive Officer, Lead Executive Director, Lead Officer, Deputy Directors/ General Managers, Line Managers, All Staffs, Policy Lead and Communication Lead applicable to all the HCT policies/ procedural documents are in line with the HCT (Trust) GR1 0114 V.3. Roles and responsibilities specific to this particular policy are defined below. 4.1 Board Sub Committee (Designated Committee) 4.1.1 Medicine Management Forum (MMF) is the Designated Committee for this policy. 4.2 Lead Executive Director 4.2.1 The Medical Director is the identified Lead Executive Director for this policy. 4.3 Lead Officer 4.3.1 The identified Lead Officer for this policy is the Senior Pharmacist. 4.4 Specialist Group/ Individuals 4.4.1 Within HCT, only nurses currently on the Nursing and Midwifery Council (NMC) register (RN1 or RNA) are permitted to administer medication to patients via the intravenous route. It is the nurses responsibility to ensure they have the adequate knowledge, skills and ability for safe and effective practice when working without direct supervision (NMC, 2015). Nurses must act in the best interest of patients at all times. In a situation where there is doubt regarding the patients prescription, the patients condition or the venous access device, the nurse has the right to decline to administer the medication. In this situation, the nurse must inform the appropriate medical practitioner or independent supplementary prescriber as a matter of urgency to prevent a delay or interruption in care, and ensure the actions are fully documented in the patients record (NMC, 2009). 5. Anaphylaxis 5.1 All nurses administering intravenous medication must ensure they attend cardiopulmonary training (on induction and then annually) and anaphylaxis training (on induction and then annually) within the prescribed time frame. 5.2 In HCT Bed Based Units the necessary resuscitation resources (including immediate access to adrenaline) must be immediately available. 5.3 Community nurses administering medication in a patient s home must ensure they have immediate access to epinephrine (adrenaline) hydrochloride following most recent UK Resuscitation Council Guidelines, and the necessary knowledge and equipment to administer this medication in the event the patient suffers an anaphylactic reaction. This can be administered without a prescription in accordance with the guidelines within the HCT Cardio Pulmonary Resuscitation Policy IV Policy CP53 1015, V.5 Page 5 of 58

5.4 In situations when an adult patient will be receiving their first doses of an intravenous medication at home (i.e. not in the acute hospital setting), the registered nurse administering the medication should be accompanied by a second person (this can be a Health Care Assistant with NVQ level 3). The role of this person will be to summons assistance in case of anaphylactic reaction, while the registered nurse is following the anaphylaxis guidelines laid out within the HCT Cardio Pulmonary Resuscitation Policy. 6. Accepting/declining a referral from primary, community or acute care for initiation or continuation of IV antibiotics in a patient s home (adults and children) 6.1 Administration of a first dose of an intravenous therapy in a home environment must only be undertaken in adult services where HCT has approved a specific pathway for doing so (approved through HCT Medicines Management Forum/Clinical Effectiveness Sub-committee and allergy status/previous exposure to the prescribed antibiotic clearly documented). Continuation of therapy initiated in another care environment can be continued if the parameters described in sections 8 and 10 are met. 6.2 Before an adult patient is accepted for initiation of IV therapy in the home environment the Criteria for accepting/declining a referral (Appendix 19) must be completed in partnership with the referring clinician. A copy of the competed criteria must be filed in the patient s notes with any additional notes made concerning the acceptance/declining of the referral; no referral should be accepted or declined without discussion with the referring clinician. Additionally the parameters described in section 8 and 10 must be met. 6.3 No first doses of intravenous medication are permitted for home administration in children. However in clinical situations agreed with the Children s Community Nursing team 2nd doses of IV medications in children may be considered for administration in the home environment (Appendix 13/14). Continuation of therapy initiated in another care environment can be continued if the parameters described in sections 8 and 10 are met. 7. Initial Cannulation 7.1 Where a nurse is appropriately trained to do so cannulation may be undertaken in a patient s home in preparation for the initiation of IV therapy. See sections 14 and 15 for guidance on re cannulation and removal of a cannula (Appendix 5 and 6). 8. Prescribing of Intravenous Medication 8.1 Under the Medicines Act (1968) and the Misuse of drugs Act (1971) it is the responsibility of a medical practitioner or non-medical prescriber, to prescribe intravenous medication in advance. 8.2 Medication for intravenous administration by registered nurses within HCT should be clearly documented on an appropriate medication prescription sheet. For adult community services this refers to the Intravenous Medication Prescription Sheets (Appendix 7); for Children s Services this refers to the relevant acute trust drug chart or the community services this refers to the Intravenous Medication Prescription Sheets (Appendix 7); for HCT Bed Based units this refers to the inpatient drug chart. IV Policy CP53 1015, V.5 Page 6 of 58

8.3 It is the completion of this prescription by a medical practitioner, or independent and supplementary prescriber that authorises the administration of medication by appropriate nursing staff. 8.4 The medical practitioner or independent prescriber must ensure this document specifies: The patients name and NHS number The name of the drug(s) to be administered, including diluents and flushes, and the final volume of medication, diluents and flush to be infused. The route of administration The rate of administration The frequency and duration of treatment (or where appropriate a review date) Any known allergies (including previous exposure to the prescribed antibiotic) The planned review date, or duration of treatment 8.5 The prescription(s) must be signed and dated by the prescriber. 8.6 It is the responsibility of the administering nurse to ensure a valid prescription is available. Immediate advice should be sought, and the administration delayed, when there are doubts regarding the prescribers instructions or the patients condition. 8.7 Changes or adjustments to the patients treatment regime must be clearly documented on the medication prescription sheet by the prescriber. It is not acceptable to accept verbal messages for changes to intravenous treatment plans. 8.8 When accepting a referral for intravenous medication administration the accepting nurse/professional must ensure that all appropriate paperwork has been received by the referring team and should refer to the supplied monograph/written guidance for administration or Medusa guide to confirm all details of the drug, its dose route and rate of administration and diluent are all correct and clear on the prescription. If there is any doubt the prescriber must be contact for clarification before the referral is accepted (Appendix 8). 8.9 No prescribing or administration of cytotoxic or immumodulatory drugs should be undertaken by HCT staff in the community setting. 9. Dispensing and Storage of Medication 9.1 In situations when the discharging hospital holds overall responsibility for the delivery of intravenous medication, all necessary medicines, including those for diluting and flushing lines must be provided for the duration of treatment by the pharmacy at the discharging hospital. Additionally all consumables (i.e. giving sets, needles) must also be supplied in accordance with local agreement. 9.2 When the General Practitioner (GP) holds overall responsibility, medication will be dispensed from the community pharmacy chosen by the patient. The GP will additionally need to prescribe/supply all necessary consumables (i.e. giving sets, needles) in accordance with local agreement. IV Policy CP53 1015, V.5 Page 7 of 58

9.3 The prescribed medication is the property of the patient it was prescribed for. It will be the patients responsibility to ensure the nurse has the appropriate medication available for administration. 9.4 All medication should be stored in accordance with the manufacturers instructions, in a dry clean environment, within the prescribed temperature range, and out of the reach of children. Practitioners should offer advice regarding the safe storage of medicines as part of the information sharing process. 10. Preparation and Administration of Medication 10.1 Informed consent must be obtained from the patient before commencing treatment (Department of Health (DH), 2001). It is the responsibility of the nurse to ensure the patient has a clear understanding of the proposed treatment, and the potential side effects (NMC, 2015) Consent to Examination or Treatment Policy. 10.2 The nurse administering the medication must ensure the prescription meets the criteria outlined in section 6. They must also check that the medication has not already been administered, and make themselves aware of any difficulties or observations from previous visits by reading the previous entries made in the patients notes, and questioning the patient. 10.3 Unless the medication for administration is in a prefilled device, intravenous drugs must be prepared at the time of administration, by the person who will be administering the drug. (Dougherty and Lister (2008)). 10.4 A visual inspection of the venous access device, and the surrounding skin, should be performed prior to the administration of any drug. For peripheral lines only the Visual Infusion Phlebitis score (Appendix 9) should be used to guide the documentation of the condition of surrounding skin, and to assist in the decision making process when an infection may appear to be present (Venous Access Devices Policy - Reducing the Risk of Infections). 10.5 The patients condition; and the patency of the device and vein must be checked prior, during and following administration (Appendix 10). 10.6 Intravenous medication may be administered via a peripheral cannula or central venous access device in the patients home, using a needle free system for delivery. 10.7 The medication for administration should be prepared and delivered using standard precautions and an aseptic non touch technique (Pratt et al, 2007; DH, 2007) in accordance with the patients prescription, the manufacturers instructions, and the Venous Access Devices Policy - Reducing the Risk of Infections. Effective hand hygiene and Standard Infection Control Precautions should be an integral part of this. 10.8 Prior to preparing to administer any IV medication in both adults and children the appropriate intravenous monograph must be obtained via Medusa (http://medusa.wales.nhs.uk/). The Medusa monographs are to be used to support the administration of all intravenous medication. Where a patient is being discharged on an intravenous medication the discharging hospital should be informed that these guidelines will be followed before the patient is discharged home: where there is any doubt or question clarity should be sought from the discharging practitioner. Medusa monographs should be accessed via the website prior to administration and not printed off and stored for future reference as they are subject to continual review and update (Appendix 7). IV Policy CP53 1015, V.5 Page 8 of 58

Access to Medusa is available to all HCT staff via the HCT intranet without the need to input a username/password OR if being accessed other than via the HCT intranet the username and password to be used by all staff are: Username: hcntstaff Password: ivguide 10.9 When a discharging Trust requires an administration to differ from that set out in the relevant Medusa guideline, or a dosage which falls outside the licensed range, written confirmation of this must be provided by the discharging Trust prior to discharge as must a written guideline for administration of intravenous medication which has been approved by the discharging Trust s relevant authorising body. Clarity should be sought from the discharging practitioner where guidance is unclear. The same principle applies in Bed Based Units where a prescriber requests an intravenous drug be administered in a way that differs from the Medusa monograph or that a drug be given at a dose outside the licensed dosage (Appendix 14). 10.10 The nurse should have technical data information readily available regarding the reconstitution of the medication, the concentration of the final solution, dilution / drug solutions, stability in solution, administration rates, compatibility information, special handling information, specialist technical information (where relevant) and calculation examples (NPSA, 2007). This information can all be located in the relevant Medusa monograph. 10.11 The nurse administering the medication must consult Medusa (or other supplied monograph) to confirm if a patient requires any post dose monitoring (Appendix 15). 10.12 It is the responsibility of the administering nurse to ensure: The correct dose of the correct drug is administered via the correct route, in the correct concentration over the correct duration of administration. The patient has no previously recorded adverse reaction to the medication for administration. The medication is the correct formulation for administration via the intravenous route. There are no issues regarding drug incompatibility between the medication and the diluent used, or when different medication requires administration at the same time. The administration of the medication follows the correct regime regarding the times of administration. They are competent and familiar with the venous access device through which the medication will be delivered. They are aware of the patients current condition, and how this may be affected before, during and after the administration of the prescribed drug. If there is any concern regarding a patient s suitability to receive intravenous medication advice must be sought immediately from the prescriber or responsible medical practioner. The patients condition is monitored during the administration of the intravenous medication, and observed for any adverse reactions. The administration of the medication must be stopped immediately if there are any signs of a reaction. The procedure outlined in section 9 must be followed in response to an adverse, or suspected adverse reaction. In the event of the patient suffering anaphylaxis or cardiopulmonary arrest, the guidelines within the HCT Cardio Pulmonary Resuscitation Policy must be followed. The patient must be advised of possible side effects from the medication (see information leaflet supplied with the product or the Summary of IV Policy CP53 1015, V.5 Page 9 of 58

Product Characteristics available at www.medicines.org.uk), where and how these should be reported, and the immediate actions the patient should take until they have been able to seek medical advice. They must also be aware of the measures to be taken in the event of displacement of the device. Ensure any fluids for dilution and flushes are compatible with the drug prescribed. For medication that requires therapeutic drug monitoring, formal agreement must be made with an identified medical/non medical practitioner who will assume responsibility for titrating the drug and interpreting blood results. 10.13 Sharps and syringes contaminated with residual medicines (other than cytotoxic medication) must be disposed of in accordance with the HCT Waste Management policy. 10.14 Controlled Drugs must never be administered intravenously by adult community nurses. However, within the Children s Community nursing service controlled drugs may be administered via the IV route in palliative care/end of life patients. This administration is usually as subcutaneous administration but may also via the IV method where a central line is insitu and the patient is emaciated and the subcutaneous method is not suitable. This IV administration must always be checked by 2 trained nurses and administered via a locked syringe driver (Appendix 11, 12 and 13). 11. Documentation 11.1 Documentation must comply with the 2015 guidelines for record keeping (NMC, 2015), and should contain information regarding: 1. The type, length and gauge of vascular access device, (DH, 2003), 2. The number and location of attempts, 3. The patients tolerance of the insertion, and the name of the team placing the device (RCN, 2010) 11.2 The following information should be recorded in the patient held records or on the electronic patient record at each visit/administration: The patients condition throughout the visit/administration. The condition of the site of the venous access device using a standardised assessment scale (Appendix 16) and its care. Information regarding the administration of the drug i.e. the drug name and dosage, the batch number; the diluent; the volume of medication and length of time for administration, the batch numbers and their expiry dates. The information shared between the patient, the nurse and other health care professionals. Any complications, side effects or difficulties noted or encountered regarding the administration of the medication, as well as the actions taken in response to these. When a dose of the drug is omitted, for example due to extravasations of the cannula, no availability of the drug, or the patient declining treatment, this must be documented, and the reason for omission clearly stated. The prescribing practitioner, or their deputy, must be informed of the reason for omission, and the actions taken. Where appropriate, once the reason for omission has been addressed, the drug should be administered at the earliest opportunity. Measurable evidence should be provided regarding the insertion and care IV Policy CP53 1015, V.5 Page 10 of 58

of venous access devices with the aim of reducing the risk of Healthcareassociated infections in Intravenous Devices (DH, 2007, DH, 2007a). Following removal of the cannula, documentation must include details of its integrity, the appearance of the site, the dressing applied and the patient tolerance (RCN, 2007). 12. Reporting Adverse Reaction 12.1 Any adverse or suspected adverse reaction should be: Acted upon to reduce the harm caused to the patient in the first instance (i.e. seek medical advice/help if required). Reported to the responsible medical practitioner as soon as possible. Documented in the patient held records, outlining the symptoms experienced by the patient, the actions taken in response to these, the prescribing practitioner advised of the reaction or suspected reaction, the advice given by them, and the care planned for the future. Incident reported following the HCT Incident Policy and Procedure or Serious Incident Policy and Procedure The Yellow Card system for reporting suspected adverse reactions to the committee on the safety of medicines should be followed. (http://yellowcard.mhra.gov.uk) Appendix 14 13. Reporting a drug/ administration Error 13.1 All medication related errors; accidents and incidents must be reported and managed in accordance with the HCT Incident Policy and Procedure or Serious Incident Policy and Procedure. 13.2 When an error/ accident/ incident has occurred, immediate action must be taken to ensure the patients safety: The medical practitioner (i.e. GP or hospital consultant depending on who has prescribed the medication) or registered health professional, who has the overall clinical responsibility for the patient (e.g. non medical prescriber/opat team) should be contacted immediately the error, accident / incident is recognised, and advice sought (Appendix 14) Close observation of the patient s condition should be carried out and recorded in the patient s records. 14. Disposal of Waste, Sharps and Medication 14.1 A sharps box must be available and appropriately located during treatment, to facilitate the safe disposal of surplus medication and sharps, and should be available throughout the course of treatment (Prevention of Exposure to Blood Bourne Viruses in the Workplace Policy (Sharps Policy) 14.2 Clinical waste, including sharps and surplus medication should be disposed of following the HCT Waste Management policy, and the HCT Medicines and Medicines Safety Policy including cold chain guidance for the storage and transport of medications and vaccines 15. Arrangements for Recanulation 15.1 Only appropriately trained, competent and skilled practitioners should attempt to recannulate patients. When a team does not have a member available with the IV Policy CP53 1015, V.5 Page 11 of 58

appropriate skills, assistance should initially be sought from other teams, including the ICT team. Bedfordshire and Hertfordshire Ambulance and Paramedic service can also be approached for assistance, when patients are located in their area. In other situations, patients will need to be referred to a suitable acute service or to the ward/medical practitioner responsible for their care (Appendix 5 and 6). 16. Removal of the Cannula 16.1 Peripheral lines should be removed once venous access is no longer required, or replaced every 96 hours in line with local policy (RCN, 2010). However a cannula maybe left in place for in excess of 96 hours if the cannula remains patent and there are no clinical concerns this decision must be based on clinical advice depending on the patient factors involved. The cannula should be removed using an aseptic procedure, using a slow steady movement. Firm pressure should be applied to the site until bleeding has stopped, and it should then be covered with a sterile dressing (Dougherty and Lister, 2008) Venous Access Devices Policy - Reducing the Risk of Infections. 16.2 The cannula should be inspected to ensure it remains intact, and the information documented in the patients notes (Appendix 5). 16.3 Central venous access devices are designed to remain in place over a long period, and decisions and interventions regarding their removal should be made by the hospital overseeing their care (Appendix 6). 17. Dissemination and Access to Ratified Policy 17.1 The final reviewed & ratified Policy will be published on the HCT website electronically and is available to print through the Trust website Intranet Policy section. 17.2 All the Trust staffs will be made aware of the revised Policy once approved and ratified; electronically via the Staff Notice board. 18. Implementation and Training 18.1 The policy will be available for reference for all staff at all the times and the Trust (HCT) will ensure all staff implementing this policy has access to appropriate implementation tools, advice and training. 18.2 Nurses employed within HCT will be deemed competent in the care of intravenous devices and the delivery of intravenous therapy when they have met the following criteria: (Appendix 4) They have attended mandatory training in Basic Life Support, anaphylaxis and Infection Control within the prescribed HCT timeframe. Attended training approved by HCT in the care of intravenous devices and delivery of intravenous medication. Where appropriate to attend initial and update training on the insertion of cannulas. Completed a period of supervised practice, have been assessed as competent by their supervisor, and themselves feel they have appropriate skills and knowledge to safely deliver medication via the intravenous route (NPSA, 2007). Attend an annual update in the delivery of intravenous medication, to maintain IV Policy CP53 1015, V.5 Page 12 of 58

their skills, and have their competency reassessed when necessary, or at least annually. Arrange further supervised practice if they feel their skills have not been used enough to maintain competence. 18.3 Any new staff member joining HCT who has received training from a previous employer must provide documentary evidence of their attendance at appropriate training, and of assessed competence. Their competence must also be assessed by an approved HCT assessor before they are able to administer intravenous medication independently within HCT/ evidence of competency for externally contracted nurses. 18.4 Children s Community Nurses must additionally satisfactorily complete the competency for IV Drug Administration for Children s Community Nurses (Appendix 1 and 2). 18.5 An Approved Assessor - Only staff able to fulfil the following criteria will assess the competence of others: (Appendix 3) Approved assessors will themselves have been assessed as competent to deliver medication via the intravenous route. Assessors will consider themselves competent to deliver medication via this route. Assessors will ensure their knowledge; skills and competence are up to date. Assessors will have attended formal HCT training in the administration of medication through a peripheral line; a Hickman line; a Portacath and a Peripherally Inserted Central Catheter (PICC) line. Assessors must be up to date with all mandatory training outlined in the competency framework. Assessors will hold a recognised qualification in either Mentorship and Preceptorship CPAD 1 and CPAD5 (Continuing Professional Academic qualification in learning and teaching) Teaching Qualifications Relevant skills and competencies Assessors may have caseload responsibility 18.6 A register of approved assessors will be held by each business unit. 19. Review and Revision Arrangements 19.1 The review, updating and archiving process for this policy shall be carried out in accordance with the Trust (HCT) GR1 Policy for Procedural Documents, V.3 by the identified Lead Officer. 19.2 Minor revision and details of amendments are recorded as per Appendix 17. 20. Document Control and Archiving Arrangements 20.1 The version control table as listed in Appendix 18 enables appropriate control of the policy with listed personnel responsible for its implementation as well the date assigned/ approved/ circulated. 21. Equality Impact Analyses (EIA) 21.1 The completed EIA form has been undertaken by the Lead Officer (Appendix 19) IV Policy CP53 1015, V.5 Page 13 of 58

before submitting the policy for ratification. 22. References 22.1 Department of Health (2001) The Reference Guide for Consent for Examination or Treatment. Department of Health. London. Department of Health (2003) Winning Ways. Working together to reduce healthcare associated infection in England. London. DH. Department of Health (2007) Saving Lives: reducing infection, delivering clean and safe care. High Impact Intervention No 1. Central venous catheter care bundle. www.dh.gov.uk Department of Health (2007a) Saving Lives: reducing infection, delivering clean and safe care. High Impact Intervention No 2. Peripheral intravenous catheter care bundle. www.dh.gov.uk Dougherty L. Lister S. (2008) The Royal Marsden Manual of Clinical Nursing Procedures (9 th edition). Wiley-Blackwell. London. National Patient Safety Agency (NPSA) (2007) NPSA Alert 20. Injectable drugs. Nursing and Midwifery Council (2015) The Code. Standards of conduct, performance and ethics for nurses and midwives. NMC. London. Nursing and Midwifery Council (2008a) NMC Standards for medicine management. NMC. London Nursing and Midwifery Council. (2015) Record Keeping: Guidance for nurses and midwives. NMC. London. Pratt, R.J. et al (2007) epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection; Royal College of Nursing. (2012) Standards for infusion therapy. RCN London. www.rcn.org.uk. 23. Appendices 23.1 The following appendices are attached to support this policy: Appendix 1 - Adult Community Teams/ Bed Based Unit Nurses/ Community Children s Nurses Intravenous drug administration competency framework Appendix 2 - Adult Community Teams/ Bed Based Unit Nurses Record of supervised practice Appendix 3 - Competencies for IV Drug Administration for Children s Community Nurses Appendix 4 Audit tool for the Clinical Guideline For The Administration Of Intravenous Medication For Adults And Paediatrics In The Community Setting And Bed Based Units (Adults) Appendix 5 Peripheral Venous Catheter Insertion/ Continuing Care Tool Appendix 6 Central Venous Catheter Insertion/Continuing Care Tool Appendix 7 - Adult Community Teams Assessment checklist for Intravenous Therapy in the Community Appendix 8 Adult Community Teams Intravenous medication prescription sheet Appendix 9 Visual Infusion Phlebitis Score Appendix 10 Criteria for Administration of Intravenous Medication by Adult Community Nursing Team and/or Intermediate Care Team and Bed Based Unit Nurses Appendix 11 Children s Community Nursing Protocol for Accepting a Referral for IV Policy CP53 1015, V.5 Page 14 of 58

Intravenous Antibiotics (IVABs) In the Community Appendix 12 Children s Community Nursing Protocol for the administration of Intravenous Antibiotics (IVABs) in the Community Appendix 13 Children who have not received the 2 nd dose of Intravenous Therapy Appendix 14 Assessment Checklist for Intravenous Therapy in the Community (Children s Services) Appendix 15 Children s Community Nursing Protocol for Obtaining Blood sample from Central Venous Access Device (CVAD) Appendix 16 Guidance for Children s Community Nurse Team Regarding Medicines Administration Error Appendix 17 Algorithm for the Management of Persistent Withdrawal Occlusion (PWO) Appendix 18 Care Plan for the administration of medication via the intravenous route as a continuous infusion Appendix 19 Criteria for accepting/declining a referral for initiation of home IV therapy (adults) Appendix 20 Amendment(s) Template for the Policy Appendix 21 Version Control Table Appendix 22 - Equality Impact Analyses Form IV Policy CP53 1015, V.5 Page 15 of 58

APPENDICES IV Policy CP53 1015, V.5 Page 16 of 58

APPENDIX 1: Adult Community Teams/ Bed Based Unit Nurses/ Community Children s Nurses Intravenous drug administration competency framework Prior to the delivery of any medication via the intravenous route, staff must have attended the following mandatory training. Please complete the following to demonstrate your attendance. Training course Date attended Next due HCT Intravenous therapy training Basic Life support Anaphylaxis Infection Control Annual update Annual update 18 months Annual update Professional and legal issues You will be required to demonstrate a working knowledge of the following documents as part of the competency assessment. This evidence will be assessed within the following competencies: NMC Standards for medicine management NMC Record keeping : Guidance for nurses Evidence: competency 1;2;3;4;5;6;7;8 Evidence: competency 4;9;10 HCHS Record Keeping Policy HCT Waste Management policy HCT Prevention of Exposure to Blood Bourne Viruses in the Workplace Policy (Sharps Policy) Evidence: competency 5; 7; 8 Evidence: 5;6;7;8;10 IV Policy CP53 1015, V.5 Page 17 of 58

Competency Performance criteria Evidence of competence Date and sign 1, The candidate demonstrates knowledge regarding the correct completion of the prescription, and the actions to take when errors or omissions are identified. The candidate ensures the prescription relates to the patient. 2. The candidate ensures the medication; any diluents and flushes are suitable for intravenous administration. 3. The candidate gains informed consent from the patient.(demonstrates underpinning knowledge of HCT Consent to Examination or Treatment Policy) Candidate checks the prescription for the following information: 1. The prescription relates to the patient: 2. Ensures the following are clearly documented on the prescription 3. The name(s) and dose(s) of the medication to be administered 4. The name and volume of diluent: 5. The name and volume of medication for flushing the device: 6. The route, rate and times of administration: 7. The duration of the treatment (start date and date of review): 8. The patients allergy status(npsa, 2007; Dougherty and Lister, 2008) 1. Checks the expiry date of the medication 2. Carries out a visual inspection of the medication, the diluent and any flushing solution to ensure it is suitable for administration, and checks it has been correctly stored. 3. Ensures the compatibility of the solutions (NPSA 2007)(Dougherty and Lister, 2008) 1. Is able to discuss the treatment, and potential side effects in a manner the Patient is able to understand. 2. Is aware of how to access services when difficulties are identified with the Communication process. 3. Gains consent prior to administration of the medication (NMC 2008) (RCN 2010) (NPSA1, 2007) *policy awareness to be demonstrated throughout the procedure, and by written testing IV Policy CP53 1015, V.5 Page 18 of 58

Competency Performance criteria Evidence of competence Date and sign 3. The candidate ensures the patient has suffered no previous difficulties with the administration of the medication 5.The candidate prepares the medication correctly, using an aseptic non touch technique. (demonstrates knowledge and understanding of HCT Prevention of Exposure to Blood Bourne Viruses in the Workplace Policy (Sharps Policy)) 6. The candidate ensures the venous access device is suitable for the administration of medication, and is aware of the actions to take when this is not so. 1. Reviews the patient held record for evidence 2. Gains feedback from the patient / carer regarding previous difficulties 3. has knowledge regarding actions to take if previous difficulties have been encountered 1. Collects all equipment necessary to administer the medication, and ensures availability of adrenalin 2. Follows infection control guidelines regarding hand washing 3. Prepares medication using aseptic non touch technique 4. Calculates correct dosage for medication using an approved formula 5. Dilutes medication in accordance with the prescription, and the technical information provided with the medication, and ensures effective dilution of the medication prior to administration (NPSA3, 2007; )(Dougherty and Lister, 2008) 1. The cannula is observed and assessed for signs of infection / extravasations using an approved tool 2. Has knowledge of the actions to take when infection/extravasations may have occurred. *policy awareness to be demonstrated throughout the procedure, and by written testing IV Policy CP53 1015, V.5 Page 19 of 58

Competency Performance criteria Evidence of competence Date and sign 7. The candidate administers the medication using the correct technique (demonstrates knowledge of HCT Venous Access Devices Policy - Reducing the Risk of Infections) 1. Dressing change inspection of site and need for dressing change. 9. The candidate disposes of used equipment in the correct manner (can discuss and demonstrates knowledge and understanding of HCT Waste Management policy). 1. The needle free port is cleaned following guidelines from the discharging hospital or the Marsden Manual 2. The port is flushed with the prescribed fluid for flushing, gaining flashback to ensure line patency. 3. The medication is administered at the prescribed rate, in the correct order, over the prescribed timeframe, following the medication sheet, manufacturer s guidelines and the Summary of Product characteristics. 4. The port is flushed with the fluid prescribed for flushing the device 5. The site of administration, and the patient s condition, are monitored for signs of immediate adverse reactions throughout and following the delivery of the medication. (RCN, 2010; Dougherty and Lister, 2008) 1. Candidate demonstrates knowledge of appropriate dressing to use 2. Candidate demonstrates appropriate use of cleaning equipment for skin and hubs/ports 3. Candidate demonstrates use of ANTT 4. Candidate shows awareness that no sharp equipment is used during a dressing change 5. Used medication, sharps and waste are disposed of appropriately, following the HCHS Waste management policy. 6. Candidate has knowledge of the procedure to follow should a needle stick injury occur. (NPSA 3,2007) *policy awareness demonstrated throughout the procedure, and by written testing *policy awareness demonstrated throughout the procedure, and by written testing IV Policy CP53 1015, V.5 Page 20 of 58

Competency Performance criteria Evidence of competence Date and sign 10. The candidate correctly documents the correct information in the patient held records. 11.The candidate ensures the patient has clear information regarding actions to take if they have concerns about their general condition, or the venous access device. 12. The candidate has attended an HCT approved intravenous therapy course within the required time frame 1. Details of the medicines administered intravenously 2. The patients tolerance to the administration of the medication 3. Adverse drug reactions, or problems encountered during the visit 4. The results of the assessments undertaken as part of this process, e.g. formal assessment of the site and venous access device. (RCN, 2010) * policy awareness: record keeping policy 1. The patient has contact details for the G.P., the out of hour s medical service, and the district nurses. 2. The candidate ensures the patient has clear information regarding potential complications with their treatment, or with their venous access device, and has awareness of the actions they must take should these occur. (RCN, 2010) 1. Evidence of attendance at training course. 2. Reflection on learning following attendance IV Policy CP53 1015, V.5 Page 21 of 58

APPENDIX 2: Adult Community Teams/ Bed Based Unit Nurses Record of supervised practice Name. Date Evidence and areas requiring further development Date and sign IV Policy CP53 1015, V.5 Page 22 of 58

A copy of this competency framework must be returned to the Clinical Service Manager; to be retained in your records. I confirm that I believe I have the necessary knowledge and skills, to consider myself as competent to deliver medication via the intravenous route. I recognise the importance of maintaining competence in the administration of medication via the intravenous route, and agree to proactively ensure I maintain my competence in this procedure. I will ensure I attend all training related to the administration of intravenous medication, within the HCHS timeframe. Practitioner s Name Practitioner s Qualification... Practitioner s Signature... Date... I confirm I have assessed... as competent to administer medication via the intravenous route. Assessor s Name... Qualification... Assessor s Signature... Date... IV Policy CP53 1015, V.5 Page 23 of 58

APPENDIX 3: Competencies for IV Drug Administration for Children s Community Nurses PART 1 On receiving the referral, what must the CCN check? List possible 11 checks PART 2 IV Drug Calculations List of drugs to calculate IV Antibiotics IV Antifungals Using BNF Surface area IV Policy CP53 1015, V.5 Page 24 of 58

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TEST 1. Abby is 8 years old and has Cystic Fibrosis, she weighs 24kg. She is prescribed Cefuroxime 1.2g QDS. You are given 1.5g of Cefuroxime and 20mls of water for injection and 50mls of 0.9% sodium chloride. a. Would you give this dose of the drug? b. How do reconstitute the drug? c. How much of the reconstituted drug do you require? d. How much do you further dilute the drug? e. How would you administer the drug and over what time? f. If using an infusion pump what would the rate be set at? 2. Ben is 10 years old with Acute Lymphoblastic Leukaemia and he has chickenpox s. He is prescribed Aciclovir 550mg TDS. He weighs 32kg. You are given 250mg and 500mg vial of Aciclovir, 30mls of water for injection and 110mls of 0.9% sodium chloride. a. Would you give this dose of the drug? b. How do reconstitute the drug? c. How much of the reconstituted drug do you require? d. How much do you further dilute the drug? e. How would you administer the drug and over what time? f. If using an infusion pump what would the rate be set at? 3. Todd is 5 years old and he has Septicaemia and weighs 18kgs. He is prescribed Gentamicin 45mg TDS. You are given 3 times 20 mg vials of Gentamicin and 10mls of 0.9% sodium chloride. a. Would you give this dose of the drug? b. How much of the drug do you require? c. How much do you further dilute the drug? d. How would you administer the drug and over what time? e. If using an infusion pump what would the rate be set at? 4. Billy is on an infusion of Cefuroxime 1.5g in 50mls. If the infusion is to run for: a. 60mins what rate would you set the infusion pump to run at? b. 30mins what rate would you set the infusion pump to run at? c. 15mins what rate would you set the infusion pump to run at? PART 3 Considerations/steps prior to administering IVs in Community from arriving at the child s home to completing the IV administration. IV Policy CP53 1015, V.5 Page 26 of 58

There are a possible 28 considerations/steps Scenario 1 CCN is just about to prepare and administer IV drug. Parent insists on talking to CCN, what should the CCN do? Scenario 2 Family s pet dog is running around room, child and CCN. Television volume is loud. What should the CCN do? Scenario 3 Younger siblings are distracting you and wanting to play with you. What should the CCN do? IV Policy CP53 1015, V.5 Page 27 of 58

Scenario 4 What is your safe area for practice. CCN arrives to a house small, cramped area. Where should you set up? What can you do? Scenario 5 What are the actions to be taken if a drug error has been made? Scenario 6 Whilst giving an IV the cannula starts to leak. What must the CCN do/consider? IV Policy CP53 1015, V.5 Page 28 of 58

APPENDIX 4: Audit tool for the Clinical Guideline For The Administration Of Intravenous Medication For Adults And Paediatrics In The Community Setting And Bed Based Units (Adults) 1. Each community nursing locality maintains a central record of nursing staff that have been assessed as competent in the administration of intravenous medication. 2. All staff who administer medication via the intravenous route have attended appropriate approved HCT approved training within the past year. 3. All staff who administer medication via the intravenous route have been assessed as competent to administer medication by this method reviewed within the previous year, and have completed a competency statement to demonstrate this. 4. All staff who administer medication via the intravenous route have completed HCT approved basic life support, anaphylaxis and infection control training within the prescribed timeframe. 5. All staff who administer medication via the intravenous route have demonstrated a working knowledge of relevant HCHS policies. Patient records: 1. The records contain information regarding the type of venous access device, and the date it was inserted. 2. The records contain information regarding the patients allergy status. 3. The records contain information regarding the patients consent to treatment 4. The condition of the cannula site is recorded in the patients records, using the VIP score at each visit 5. Baseline observations (temperature, pulse and blood pressure) are recorded in the patients records. 6. The patients condition before, during and after treatment is recorded at each visit. 7. The medication administered, its dose, the batch number(s) and expiry date(s) are recorded at each visit on a record of administration sheet. 8. The records contain information about the information shared between the patient, the nurse, and other health care professionals at each visit. Only staff that have been approved as assessors in the assessment of competence to administer medication via the intravenous route will assess staff in their competence to administer medication intravenously. A register of approved staff will be held by each business unit. These staff will be senior clinical staff, who hold caseload responsibility and have a recognised qualification in either: Teaching and Assessing (ENB998), Mentorship and Preceptorship or the CPAD. They will have attended formal HCHS training in the administration of medication intravenously through a peripheral line, a Hickman Line, Portacath, and PICC line. They will have been assessed and ensure their knowledge, skills and competence, are updated as necessary, to ensure they remain effective assessors. Assessors must be up to date with their attendance of all mandatory training outlined in the competency framework. IV Policy CP53 1015, V.5 Page 29 of 58

APPENDIX 5: Peripheral Venous Catheter Insertion/Continuing Care Tool Site: Tick here if PVC not inserted in this Trust NHS No:... Ward/Area: Date PVC inserted:. /. /. Date PVC removed:. /. /. Name:... Site of PVC: No. of attempts at insertion: Please complete a row for each observation by ticking all relevant boxes, adding information as required and signing. Date Need for continuing PVC assessed? PVC site inspected? VIP Score (see below) Semi-permeable transparent dressing clean & intact? Aseptic technique used during use? Administration set in situ < 72 hrs Comments (Action taken, reasons for No responses & details of ward transfers) Signature Yes No Yes No Score Action Yes No Yes No Yes No / /.. / /. 72 hours - please review continuing clinical indication / /. / /. 96 hours (4 days) peripheral line should be re-sited/removed / /. IV Policy CP53 1015, V.5 Page 30 of 58

APPENDIX 6: Central Venous Catheter Insertion/Continuing Care Tool NHS No:... Site: Tick here if CVC not inserted in this Trust Name:... Ward/Area: Date CVC inserted:. /. /. Date CVC removed:. /. /. Site of CVC:. No. of attempts at insertion: Please complete a row for each observation by ticking all relevant boxes, adding information as required and signing. Date Need for continuation of CVC assessed? CVC site inspected? Semi-permeable transparent dressing clean & intact? If dressing changed, site cleaned with Chlorhexidine 2% in 70% IPA (skin preparation)? Standard precautions including aseptic technique during access to CVC? Chlorhexidine 2% in IPA (surface wipe) wipe used for access to hubs and ports only? Administration set replacement? (Refer to Section 6.5 of Reducing Infections in VAD policy) Comments (Action taken, reasons for No responses & details of ward Signature Yes No Yes No Yes No Yes No Yes No Yes No Yes No transfers) / /. / /. / /. / /. / /. / /. / /. IV Policy CP53 1015, V.5 Page 31 of 58

APPENDIX 7: Adult Community Teams Assessment checklist for Intravenous Therapy in the Community 1. Does the patient agree to receive intravenous medication in their home environment? 2. Have the risks of intravenous therapy been explained to the patient? 3. Is the patient s condition clinically stable? 4. Is the patient otherwise fit for discharge? 5. Does the patient have the required medication to complete the course of treatment? Medication, Diluents Flushing solution Heparin flush if required Data information sheet regarding the medication? Yes / No Yes / No Yes / No Yes / No Yes / No 6. What type of venous access device is in place (including whether valved or tunnelled)?... 7. Length of line exposed at exit site 8. Is the venous access device patent, and secured with a needleless system? 9. Will the patient have received at least one dose of the prescribed medication prior to discharge? 10. Has a community prescription form been completed to permit the delivery of medication in the community? 11. Will the patient be provided with at least 7 days of all equipment necessary to deliver medication in the community? 12. Has the patient been informed of who to contact for advice / or in an emergency? 13. Which team will be responsible for providing advice for this patient following discharge? Yes / No Yes / No Yes / No Yes / No Yes / No. Planned review date and time:. Signed.. Print name.. IV Policy CP53 1015, V.5 Page 32 of 58

APPENDIX 8: Adult Community Teams Intravenous medication prescription sheet To be completed by the prescribing doctor or nurse. Patients name: Address: Postcode: Known allergies NHS Number: Date of Birth GP details Intravenous Medication Therapy Relevant information Start date of treatment Medication for administration (including diluent and fluid for administration when required) Dose Route Total final volume for administration Rate Time (s) / frequency Signature and printed name of prescriber Of administration Evaluation date ------/-------/--------- -------/--------/-------- -------/--------/-------- Intravenous Flush Therapy pre and post IV administration Date Flush solution for administration Dose Route Volume Frequency Signature and printed name of prescriber Pre IV Post IV Flush solution for line maintenance Date Flush solution for administration Dose Route Volume Frequency Signature and printed name of prescriber Intravenous medication sheet number.. IV Policy CP53 1015, V.5 Page 33 of 58

DOCUMENTATION Documentation must comply with the 2009 guidelines for record keeping (NMC, 2009), and should include information regarding: 1. The type, length and gauge of vascular access device, (RCN, 2010), 2. The number and location of attempts 3. The patients tolerance of the insertion, and the name of the person placing the device (RCN, 2007) The following information should be recorded in the patient held records at each visit: The patients condition throughout the visit. The condition of the site of the venous access device and its care during the visit. Information regarding the administration of the drug i.e. the drug name and dosage, the batch number; the diluent and fluid for administration, the total volume and length of time for administration, and the expiry dates. Appropriate laboratory results, actions taken in response to these, and further tests undertaken. The information shared between the patient, the nurse and other health care professionals. Any complications, side effects or difficulties noted or encountered regarding the administration of the medication, as well as the actions taken in response to these. When a dose of the drug is omitted, for example due to extravasations of the cannula, no availability of the drug, or the patient declining treatment, this must be documented, and the reason for omission clearly stated. The prescribing practitioner, or their deputy, must be informed of the reason for omission, and the actions taken. Where appropriate, once the reason for omission has been addressed, the drug should be administered at the earliest opportunity. Following removal of a cannula at home, documentation must include details of the why the cannula was removed, cannula length, its integrity, the appearance of the site, the dressing applied and the patient tolerance (RCN, 2007) Following removal of the cannula, documentation must include details of the cannula length, its integrity, the appearance of the site, the dressing applied and the patient tolerance (RCN, 2007). IV Policy CP53 1015, V.5 Page 34 of 58

APPENDIX 9: Visual Infusion Phlebitis Score IV Policy CP53 1015, V.5 Page 35 of 58