Title: for the supply/admin of: Supplemental oxygen to all adult patients undergoing nurse led GI Endoscopy with conscious sedation and patients with heart disease or chronic lung disease without sedation. Authors Name: Sally Atkins Contact Name: Sally Atkins Contact Phone No: 60217 Authors Division: Salford Health Care Departments/Groups This Document Applies to Scope: Endoscopy Unit Keywords: Oxygen, GI Endoscopy, Lung disease Classification: Patient Group Direction Replaces: Previous Patient Group Direction To be read in conjunction with the following documents: 219TD(C)51 Unique Identifier: PGD242TD(P)81 Review Date: July 2017 Issue Status: Approved Issue No: 5 Issue Date: 2007 Authorised by: Dr P Paine Consultant Gastroenterologist. Clinical Governance Lead Gastroenterology. Authorisation Date: 13/06/2013 Document for Public Display: YES After this document is withdrawn from use it must be kept in an archive for 10 years. Archive: PATIENT GROUP DIRECTION Date added to Archive: Officer responsible for archive: ASSOCIATE DIRECTOR OF CORPORATE GOVERNANCE Issue [5] [????????] Page 1 of 13
Directorate/Department : Gastroenterology / Endoscopy 1.Clinical Condition Define situation / condition Criteria for inclusion Adults referred to the nurse led GI endoscopy clinic by a GP or Consultant Physician/Surgeon. These adults must have consented to GI endoscopy with intravenous sedation and present with none of the specified contraindications. Patients presenting with gastric and colorectal symptoms that require investigation by upper or lower GI endoscopy. Patients must be classified as class I or II according to the American society of Anesthesiologists Classification of Physical Status (ASA Classification) Appendix 1. Criteria for exclusion Patients whom are ASA classification IV V Caution Action if excluded Action if patient declines 2. Characteristics of Staff Qualifications required Patient should be referred to an appropriate member of medical staff. Patient should be referred to an appropriate member of medical staff. Registered nurse with current licence to practice. 5 years post registration experience. Recognised gastrointestinal endoscopy qualification JAG initiated or compliant course In house training in sedation Practising endoscopist accredited with the Joint Advisory Group on Gastrointestinal Endoscopy. Page 2 of 13
Additional requirements Completion of a minimum of 25 conscious sedation episodes and demonstrate a knowledge of reversal agents. A Consultant must supervise these episodes and this supervision be documented in the nurse s portfolio. Training and competence in all aspects of the use of benzodiazepines for sedation, including contraindications and the recognition of overdose. Proficient in intravenous cannulation as per Trust policy. Up to date basic life support skills. Continued training Requirements Maintain annual up to date relevant training and competency in the administration of conscious sedation. Annual assessment by Consultant Clinical Supervisor. 3. Description of Treatment Name of Medicine Oxygen POM/P/GSL POM Dose/s Delivered continuously at 2-6 litres per minute. Route/Method Via facemask or nasal specs/sponge. Frequency Total dose/number Information on follow up treatment Throughout the procedure and after the procedure until the patient s oxygen saturation levels are within normal limits on room air. Up to 6 litres per minute as oxygen saturation level dictates. After receiving midazolam, patients should remain under medical/nursing supervision until at least one hour has elapsed from the time of injection. Observations of blood pressure, pulse and oxygen saturation should be monitored and recorded at quarter hourly intervals throughout this period. Page 3 of 13
Written / verbal advice for patient / carer before / after treatment Prior to discharge all patients should meet the criteria within the GI Unit s discharge policy (appendix 2) and all patients should be given a discharge information sheet (appendix 3). The nurse endoscopist is responsible for the safe discharge of patients at a time appropriate to their condition and for the discharge information and advice given. Procedure for reporting ADR s to Doctor: Plan a review to enable completion prior to the date above and the date the new protocol to follow on immediately, also retain a copy of each version of the protocol for ten years. Audit data on the use of PGD must be submitted to Medicines Management Group at the review date. If changes are made to the PGD it must be resigned by all signatures. If no changes have been made and MMG are satisfied with the audit data, a further review date of two years will be granted by MMG. The PGD is to be read, agreed to, and signed by all health professional staff it applies to. The original copy is given to the Corporate Affairs Manager; copies are given to the health professional, Clinical Informatics and the Pharmacy Department. Copies of all PGD s are also available on the Trust Intranet Site. Page 4 of 13
Salford Royal Hospitals NHS Trust PATIENT GROUP DIRECTION (PGD) Nurse Signature Sheet This master document for this PGD is held by the Corporate Affairs Manager. PGD for the supply / administration of: OXYGEN Directorate/Department: ENDOSCOPY / MEDICAL DIRECTORATE (This sheet is to be signed by all nurses who have read and agreed to this PGD) I have read the Patient Group Direction and agreed to use it in accordance with the criteria described. Name Sally Atkins Signature Review Date Date 12/06/2013 Sally Atkins June 2017 Issue [5] [????????] Page 5 of 13
APPENDIX 1 American Society of Anaesthesiologists Classification of physical status (American society of Anaesthesiologists, 1996) Class I The patient has no organic, physiological, biochemical or psychiatric disturbance. The pathological process for which surgery is to be performed is localised and does not entail a systemic disturbance. Examples: a fit patient with an inguinal herna, a fibroid uterus is an otherwise healthy woman. Class II Mild to moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiological processes. Examples; non or slightly limiting organic heart disease, mild diabetes, essential hypertension or anaemia. The extremes of age may be included here, even though no discernible systemic disease is present. Extreme obesity and chronic bronchitis may be included in this category. Class III Severe systemic disturbance or disease from whatever cause, even though it may not be possible to define the degree of disability with finality. Examples: severely limiting organic heart disease, severe diabetes with vascular complications, moderate to severe degrees of pulmonary insufficienty, angina pectoris or healed myocardial infarction. Class IV Severe systemic disorders that are already life threatening, not always correctable by operation. Examples: patient with organic heart disease showing marked signs of cardiac insufficiency, persistent angina, or active myocarditis, advanced degrees of pulmonary, hepatic, renal or endocrine insufficiency. Class V The moribund patient who has little chance of survival but is submitted to operation in desperation. Examples: the burst abdominal aneurysm with profound shock, major cerebral trauma with rapidly increasing intercranial pressure, massive pulmonary embolus. Most of these patients require operation as a resuscitative measure with little if any anaesthesia. References: American Society of Anesthesiologists (1996); Practice guidelines for sedation and analgesia by non-anesthesiologists. A report by the American society of Anesthesiologists Task Force on Sedation and Analgesia by non-anesthesiologists. Anesthesiology, 84, 459-471 Page 6 of 13
Discharge Policy for Endoscopy May 2007 APPENDIX 2 Patients having undergone endoscopic examination with sedation should remain in the recovery area for 2 hours and MUST fufil the following criteria before discharge. 1. Stable vital signs 2. The ability to walk without support (if they were able to do so before sedation) 3. The toleration of oral fluids after gastroscopy (this is one hour following local anaesthetic throat spray having been administered) 4. The ability ot void urine (following the administration of Buscopan-hyoscine-Nbutylbromide) 5. Escort home Endoscopy patients following the administration of sedation should be accompanied home by a responsible adult, who can support/care for them over the 12 hour period following endoscopy. If the patient has no escort: Or The patient should be offered the endoscopy without sedation The appointment is re-arranged when an escrort can be arranged An overnight bed arranged for an appointment at a later date if non can be found on the day 6. Patients should be told NOT to drink alcohol, drive, carry out any activity involving motor skills or any actions where the patients judgement is involved for 24 hours following the administration of sedation 7. All patients should be discharged home with written advice and instructions 8. Check that any venflon or intravenous catheter has been removed Page 7 of 13
APPENDIX 3 GI Unit Hope Hospital COLONOSCOPY/SIGMOIDOSCOPY AFTERCARE If you have had sedation for the examination: Do not drive your car, operate any machinery or drink alcohol for 24 hours after your examination You should not sign any legally-binding agreement for 24 hours Go home and rest today You may feel a little bloated with wind pains but these unsually settle quite quickly. Or If you have had colonic biopsies (a small sample of the lining of the bowel) Polyps have been removed from your bowel You may notice a slight blood loss from your back passage or when you open your bowels. This is nothing to worry about and is quite normal. HOWEVER ANY SEVERE ABDOMINAL PAIN, BLACK TARRY STOOLS, PERSISTENT OR HEAVY BLEEDING SHOULD BE REPORTED TO YOUR DOCTOR (Details of the results and any necessary treatment should be discussed with your General Practitioner. He will be sent a copy of your Endoscopy report immediately following your Endoscopy. Please allow four working days for the post before contacting your GP). Page 8 of 13
Endorsed by: Dr Peter Paine Consultant Gastroenterologist. Clinical Governance Lead Gastroenterology. Consultant Gastroenterologist. Clinical Governance Lead Date 13/06/2013 Page 9 of 13
Anyof Changes to Document Issue number: 2 None required 12/06/2013 Changes approved in this document by - Date: March 2011 Section Number Title 1. Clinical Condition Define Condition Criteria for inclusion Criteria for exclusion 2. Characteristics of staff Qualification required Additional requirements Amendment (shown in bold italics) Flexible sigmoidoscopy deleted and replaced with lower GI endoscopy with conscious sedation and patients with heart disease or chronic lung disease without sedation Flexible sigmoidoscopy replaced with lower GI endoscopy Flexible sigmoidoscopy replaced with lower GI endoscopy Patients must be classified as class l to lll for non-sedated patients and class l or ll for sedated patients, ASA classification amended to IV-V from IIIV. Completion of a minmum of 100 conscious sedation episodes amended to: Completion of a minimum of 25 conscious sedation episodes Deletion Addition Reason Recognised gastrointestinal endoscopy qualification (e.g. ENB ~DO3 management and care of clinents requiring sigmoidoscopy and biopsy. Successful completion of level III conscious sedation module and 5 reversal episodes deleted (gained through above course and supervised practice) deleted 3. Front page Review Date Review Date JAG (Joint Advisory on Gastrointestinal Endoscopy) initiated or compliant course Completion of in house sedation training (see appendix 4) and demonstratates knowledge of reversal agents Issue [5] [????????] Page 10 of 13
Diversity & Equality Screening Questionnaire The Trust is legally required to ensure that all new policies and documents are assessed for their impact both positive & negative on equality target groups; religion/beliefs, disability, age, gender, religion, sexual orientation & transgender. Have you been trained to carryout this assessment:? YES If 'yes' continue with the assessment, if 'no' arrange to have the training first. Name of policy or document : Supplemental oxygen to all adult patients undergoing nurse led. a) At whom is this policy or document aimed? (Patients, specific staff group or both?) b) What is the profile of your target group? (will this policy be relevant to any groups more than others by age, gender, ethnicity, disability etc or is it applicable to all Salford patients/staff) c) How will you ensure that this policy is cascaded to the target group? 2) a) Is there any evidence to suggest that different groups have different needs in relation to this policy or document (eg health or employment inequality outcomes)? 1a) Nurse Endoscopist 1b) N/A 1c)N/A 2a)N/A Page 11 of 13
b) What action have you taken to reduce these inequalities? 2b)N/A 3) a) Does the document require any decision to be made which could result in some individuals receiving different treatment, care, outcomes to other groups/individuals? b) if yes, on what basis would this decision be made? (It must be objectively justified) c) Have you included where you may need to include reasonable adjustments for disabled users or staff to ensure they receive the same outcomes? 4) a) Have you undertaken any consultation/involvement with service users or other groups in relation to this policy? b) If yes, what format did this take? face/face or questionnaire? (please attach evidence of this) 3a)N/A 3b)N/A 3c)N/A 4a)N/A 4b)N/A c)has any amendments been made as a result? 4c)N/A Page 12 of 13
5) a) Are you aware of any complaints from service users in relation to the application of this policy? b) If yes, how was the issue resolved? Has this policy been amended as a result? 5a)NO 5b)N/A 6) a) Looking at all of the above information is there any evidence to indicate that any groups listed below have different needs, experiences or priorities in relation to this document? Yes No unsure Age / Disability / Gender / Marital Status / Racial group / Religious belief / Sexual orientation / Transgender / Low Income / b) How will these differences be reduced or eliminated by this policy?n/a 7) If any impact has been highlighted by this assessment, you will need to undertake a full equality impact assessment: Will this policy require a full impact assessment? No (if yes please contact Equality Advisor, HR for further guidance) signed Elaine Dyson date: 12/06/2013 Page 13 of 13