AMPH-PGN-10 Practice Guidance Note Intramuscular Injection (IMI) V01 Date Issued Planned Review PGN No: Issue 1 Sep 2017 Sep 2020 AMPH-PGN-10 (Part of NTW(C)29 Trust Standard for Physical Assessment and Examination Policy Author/Designation Responsible Officer / Designation Kevin Chapman - Tissue Viability - Modern Matron Kevin Chapman - Tissue Viability - Modern Matron Contents Section Description Page No 1 Introduction 1 2 Prescribing of Injectables 1 3 Consent to Treatment 2 4 Equipment 2 5 Mechanical Safety Devices 2 6 Injection Sites 2 7 Patient considerations 3 8 Violence and Aggression considerations Injection under restraint 3 9 Allergic Reaction / Anaphylaxis 4 10 Training Implications 4 11 References 5 Appendices listed separate to PGN Document No: Appendix 1 Description Issue Issue Date Standard operating procedures for preparation and administration of intramuscular injections Review date 1 Sep 2017 Sep 2020 Appendix 2 Anatomical sites 1 Sep 2017 Sep 2020 Appendix 3 Administration of oil-based depot and other long acting intramuscular antipsychotic injections - site poster 1 Sep 2017 Sep 2020 AMPH-PGN-10 Intramuscular Injection (IMI) V01-Iss Sep17
1 Introduction 1.1 An Intramuscular Injection (IMI), deposits medication into deep muscle tissue under the subcutaneous tissue where the vascularity of the muscle aids the absorption of the medication. In Intramuscular injection (IMI) the skin is punctured with a needle and medication is administered deep into a large muscle of the body for prophylactic or curative purposes. 1.2 The preparation and administration of an Intramuscular Injection is a medical/nursing procedure that occurs frequently across all clinical and community areas covered by Trust staff on a daily basis. Whilst the reporting and recording of untoward incidents in relation to the administration of IMI within the Trust appears low, anecdotal evidence suggest that clinicians practice a variety of techniques and procedures. 1.3 Poor injection techniques can put the patient at risk of complications such as abscesses, cellulitis, haematoma and injury to blood vessels, bones and peripheral nerves (Cocoman et al 2006). Therefore it is important that a good, unified injection technique be adopted throughout the Trust. 1.4 Much of the procedural content of this document closely follows that which is described in the consensus document Guidance on the administration to Adults of oil-based Depot and other Long-Acting Intramuscular Antipsychotic Injections (5 th Edition, 2016) and Royal Marsden Hospital Manual of Clinical Procedures, 8th edition. This is available on the intranet. 1.5 A number of possible injection sites and techniques are described in this document. 1.6 Competence and capability in the safe and proficient use of intramuscular injections are ultimately an individual practitioner s responsibility. 1.7 This document covers the general principals of good practice in relation to the administration of intramuscular injections, but cannot cover all the detailed requirements of all injectable medicines currently available. 1.8 It is essential that practitioners are familiar with the requirements for administration of medicines as laid out with the product SPC (Summary of Product Characteristics) or PIL (Patient Information Leaflet). Practitioners should only administer medicines within their sphere of competency and specific product requirements. 2 Prescribing of Injectables 2.1 The administering clinician must reference to (UHM-PGN 02 - Part of NTW(C)17 Medicine Policy), checking that the injection is being administered either under a valid prescription or within the authorisation of a Patient Group Directive (PGD). Such a prescription must specify the following: The name of the patient 1
The printed name and designation of the prescriber (including signature) The approved medicine name full (i.e Decanoate etc.) The dose The frequency of administration The start / Stop and review date and route of administration 2.2 In addition to this any administration of an IMI under a PGD can be done by a clinician who has been specifically authorised by the PGD. Administration of an IMI under a PDG cannot be delegated to an unauthorised clinician. 3 Consent to Treatment 3.1 Please refer to Appendix 1 for an outline detail of the Mental Capacity Act Consent to Treatment. The Trust policy for consent to examination or treatment should also be consulted. In the case of any patient whose first language is not English staff should also refer to the Trust Policy for the provision of, access to and use of interpreters for patients and carers for further guidance. 4 Equipment 4.1 The area in which the medicine is to be prepared must be clean, uncluttered and free from any interruption/distraction. Once the administering clinician is satisfied that the prescription is valid, prepare administration as per the appropriate standing operating procedures (SOP) and pharmaceutical manufacturers instructions. Appendix 1 5 Mechanical safety devices 5.1 If a device is available the Trust must provide staff administering intramuscular injections with medical devices that incorporate safety-engineered protection mechanisms. 5.2 These devices have a built-in safety feature to reduce the risk of a sharps injury before, during or after use. 5.3 Staff should not only be aware of mechanical safety devices but also be aware of how to respond to an inoculation incident - specific guidance on this is and safe disposal of sharps is available in NTW(C) 46 Inoculation Injury Policy and IPC-PGN-03.1 Safe use and disposal of sharps. You can also seek specific advice and guidance from the IPC Matrons. 6 Injection sites 6.1 At present current research and evidence suggests that there are five sites that can be utilised for the administration of intramuscular injections, and selecting the injection site requires correct identification of the muscle groups by land marking correct anatomical features. For full details staff are to refer to Appendix 2 2
6.2 With regard to which injection site to choose, this will be influenced by the patient s physical condition including age weight etc and the licence and instructions from the pharmaceutical manufacturers and where possible the patients individual preference. 6.3 Intramuscular injections should be given into the densest part of the muscle, and an active patient will probably have a greater muscle mass than older or emaciated patients. 7 Patient considerations 7.1 NTW respects the cultural and religious needs of its patient group and will take every step to respect these requirements during the process of providing injectable medication. 7.2 Staff will make every effort to accommodation any specific gender requirements during the exposure of sites and subsequent administration. (i.e. Female to female) 7.3 Staff when considering injection sites for patients under observation by others will choose a site that preserves the dignity of the patient. 7.4 Staff will consider and make reasonable adjustments for any of the following reasons - Physical considerations due to BMI (Making allowances for reduced or increased adipose tissue) - Access and administration requirements such as restrictive clothing, cleansing of the skin etc. 8 Violence and Aggression considerations injection under restraint. Staff should also read this PGN in conjunction with NTW(C) 02 The Management of Rapid Tranquillisation policy and its associated appendices. Staff should ensure a pre-injection briefing takes place ahead of planned administration to ensure the team are familiar with their individual roles and responsibilities. This is to ensure seamless administration, prevent confusion during the process and ensure the intervention is as timely and safe as possible. Staff must consider elements which include - Is physical restraint or coerced injection necessary have all other options been exhausted? Wherever possible implement Talk First principles. - Is it likely that the person will be resistive, in what way? How do we mitigate the risks while using the principle of least restriction? 3
- Ensuring staff are communicating clearly to the patient what is happening during the intervention and responding to any complaints of pain or discomfort in a safe manner - Who is leading / co-ordinating the intervention? - Use of safer sharps - Site and administration requirements (see above and Appendix 2) - Access and egress to the administration area, especially if a treatment room is not used. - Safe disposal of sharps (Refer to Waste Management policy) - Recording and incident reporting where applicable - Ensure all staff involved are aware of the person s clinical history, risks, preferences, communication needs and considerations as outlined above - Have the team got legal authority to administer (T3/T62) - How to mitigate obstructions and potential risks in the environment? - Which restraint position is planned and is a contingency plan required in the event of an escalation of risk? - How do we preserve the dignity of the individual during intervention? - Who is responsible for post injection monitoring, and how will this be done? Particularly if the individual continues to present as aggressive in conjunction with seclusion policy etc - To update carers/imha next of kin if applicable - Recording of intervention on RiO and through Safeguard system - Debriefing of patient and staff following incident 9 Allergic reaction / Anaphylaxis 9.1 Allergic reactions and anaphylaxis are emergency conditions which any patient could be potentially at risk of, and it is well documented that the emergency treatment of anaphylaxis is more effective the earlier it is commenced, and may be lifesaving in the first few minutes. Within the Trust training for anaphylaxis is provided as a component of the Immediate Life Support course. 9.2 All in-patient units, and other services where a specific risk of severe allergic reaction has been identified, are required to stock/carry Adrenaline for use by suitably trained staff in an emergency situation. The administration of adrenaline by staff to a person to save life is permissible by law and does not require a prescription. However, if this action is taken, a full record of the incident must be made in the patient clinical records and a web-based electronic reporting form completed. Details of the patients reaction and the need for adrenaline to be administered must be reported to the relevant Consultant at the earliest opportunity, or to the on call Doctor outside of normal working hours. 10 Training Implications 10.1 Training to clinical staff in the administration of intramuscular injections will be provided as follows: 4
Staff undertaking IM injections should have completed the relevant Medicines Management competency (MM Comp 3 Management and administration of Intra-Muscular Depot / Injectable Medication) As part of their local induction for any newly appointed staff Updates to staff through peer to peer instruction /supervision As required more formal training can be arranged by the Trust Learning and Development Department by utilising more experienced staff across the Trust 10.2 In addition to this Registered Nurses are required to maintain their own competence and access updates as necessary. 11 REFERENCES Cocoman A and Murray J (2006) IM injections: How s your technique Clinical Practice. DH (2005b) Hazardous waste (England) regulations. Department of Health, London. DH (2005) mental Capacity Act Code of Practice DH (2010) Health and Social Care Act 2008. Code of practice on the prevention and control of infections and related guidance. London. Crown Copyright. European Union Council Directive 2010/32/EU. Framework agreement on prevention from sharps injuries in the hospital and healthcare setting. Griffith, R. & Jordan, S. (2003) Administration of medicines part 1: the law and nursing. Nurse Stand, 18(2), 47-53. Pub Med Mental Capacity Act 2005 Mental Health Act 2007 MHRA (2004) Reducing Needle stick and Sharps Injuries. Medicines and Healthcare Products Regulatory Agency, London. National Institute for Health and Clinical Excellence (2012)- Prevention and control of healthcare associated infections in primary and community care. NICE clinical guideline 139. NMC (2005) Guidelines for Records and Record Keeping. Nursing and Midwifery Council, London. NMC (2006b) A-Z Advice Sheet Consent. www.nmc.org. NMC (2008a) Standards for Medicines Management, Nursing and Midwifery Council, London. NMC (2008b) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. Nursing and Midwifery Council, London. 5
NPSA (2005) Wristbands for Hospital Inpatients Improves Safety) Safer Practice Notice 11). NPSA, London. NPSA (2007) Promoting Safer Use of Injectable Medicines, Alert No. 2007/20, 28th March. NPSA, London. NPSA (2007) Promoting Safer Use of Injectable Medicines, Alert No. 2007/20, 28th March. NPSA, London. Royal Marsden on line 8th edition United Kingdom Psychiatric Pharmacy Group (UKPPG) (2016) Guidance on the Administration to Adults of Oil based Depot and other Long Acting Intramuscular Antipsychotic Injections, 5 th Edition. http://www.reach4resource.co.uk/sites/default/files/pdf6.pdf Workman, B. (1999) Safe injection techniques. Nurse Stand, 13(39), 47-52. Pub Med. 6