IV Antibiotics for Patients with Cellulitis

Policy Number LCH-93 This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form. Part A Information about this Document Policy Name IV Antibiotics for Patients with Cellulitis Policy Type Board Approved (Trust-wide) Trust-wide Divisional / Team / Locality Action No Change Minor Change Major Change New Policy No Longer Needed Approval As Mersey Care s Executive Director / Lead for this document, I confirm that this document: a) complies with the latest statutory / regulatory requirements, b) complies with the latest national guidance, c) has been updated to reflect the requirements of clinicians and officers, and d) has been updated to reflect any local contractual requirements Signature: Date: Part B Changes in Terminology (used with Minor Change, Major Changes & New Policy only) Terminology used in this Document New terminology when reading this Document Part C Additional Information Added (to be used with Major Changes only) Section / Paragraph No Outline of the information that has been added to this document especially where it may change what staff need to do Part D Rationale (to be used with New Policy & Policy No Longer Required only) Please explain why this new document needs to be adopted or why this document is no longer required Part E Oversight Arrangements (to be used with New Policy only) Accountable Director Recommending Committee Approving Committee Next Review Date LCH Policy Alignment Process Form 1

SUPPORTING STATEMENTS This document should be read in conjunction with the following statements: SAFEGUARDING IS EVERYBODY S BUSINESS All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child / adult; knowing how to deal with a disclosure or allegation of child / adult abuse; undertaking training as appropriate for their role and keeping themselves updated; being aware of and following the local policies and procedures they need to follow if they have a child / adult concern; ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust s safeguarding team; participating in multi-agency working to safeguard the child or adult (if appropriate to your role); ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation; ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session EQUALITY AND HUMAN RIGHTS Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership. The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices. Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act. Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 2 of 25

Policy for the Administration of Intravenous Antibiotics via a Patient Group Direction (PGD) in the Community for Patients with Cellulitis who are referred by Liverpool General Practitioners (GP) POLICY 93 Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 3 of 25

Title Policy reference number Aim and purpose of clinical document Author s title Policy for the Administration of Intravenous Antibiotics via a Patient Group Direction (PGD) in the Community for Patients with Cellulitis who are referred by Liverpool General Practitioners (GP) 93 The aim of the Policy is to provide framework for all qualified nurses within the Intravenous Therapy Team to provide a Patient Group Direction (PGD) driven service to ensure quality and consistency in the delivery of clinical care to patients requiring IV antibiotics for Cellulitis. Sara Caddick Medicines Management Pharmacist Type New document x Reviewed document Review date January 2020 Person/ group accountable for review Type of evidence base used IV Therapy Team C: Evidence which includes published and/or unpublished studies and expert opinion Issue date January 2018 Authorised by Clinical Standards Group Impact Assessment Undertaken 24 th January 2018 Yes X Date: 17/01/18 Evidence collated No Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 4 of 25

Version Number: Ratified by: V5 Clinical Standards Group Date of Approval: 24 th January 2018 Name of originator/author: Approving Body / Committee: IV Therapy Nurse Clinical Standards Group Date issued (Current version): January 2018 Review date (Current Version): January 2020 Target Audience: Name of Lead Director / Managing Director: Changes / Alterations Made To Previous Version: Director of Nursing Policy reference numbers 4 & 5 merged to create this policy Converting guideline to policy Change in title to include PGD Updated policy to include new Inclusion/Exclusion Criteria Updated policy for change in time deadline for same day treatment Change in referral form Changes in formatting Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 5 of 25

Key individuals involved in developing the document Name Designation Alison Smith IV Therapy Operational/Professional Lead. Liverpool Community Health NHS Trust. Christine Roberts Dr Emmanuel Nsutebu Dr Jonathon Folb Dr Richard Cooke Dr Peter Chamberlain Sue Wright Emma Hughes IV Team Leader. Liverpool Community Health NHS Trust. Infectious Diseases Consultant. Royal Liverpool and Broadgreen University Hospital NHS Trust. Consultant Microbiologist Royal Liverpool and Broadgreen University Hospital NHS Trust. Consultant Microbiologist. Aintree University Hospital NHS Foundation Trust. Clinical lead for strategy and innovation. South Sefton CCG Pharmacist. Liverpool Community Health NHS Trust Anti-infective Pharmacist. Aintree University Hospital NHS Foundation Trust This current document was circulated to the following individuals for consultation Name Dr Jonathon Folb Emma Hughes Anne Neary Tom Blanchard Designation Consultant Microbiologist Royal Liverpool and Broadgreen University Hospital NHS Trust. Anti-infective Pharmacist Lead for Liverpool Community Health Anti-infective Pharmacist Royal and Broadgreen University Hospital NHS Trust Consultant Microbiologist Royal and Broadgreen University Hospital NHS Trust Microbiologist for OPAT Page 6 of 25

Contents Section Page 1 Introduction 6 2 Purpose of the Guideline 6 2.1 Scope of the Guidelines 6 3 Definitions 7 4 Duties and Responsibilities 7 5 Policy 9 5.1 Eligibility Criteria 9 5.2 Exclusion Criteria 10 5.3 Consent 11 5.4 Responsibilities 11 5.5 Procedures 11 5.6 Referral Process 12 5.7 Treatment Regimen 12 5.8 Adverse Incidents 15 6 Training Requirements 16 7 Equality Impact Assessment 16 8 Monitoring Compliance 16 9 References 17 Appendix 1 Community IV Antibiotics Referral Form 18 Appendix 2 National Early Warning Score (NEWS) 19 Appendix 3 VIIAD Charts 20 Appendix 4 Patient Information Leaflet 22 Appendix 5 Visual Inspection Phlebitis Score (VIP) 23 Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 7 of 25

1. Introduction The administration of IV medication by nurses has become more widespread in recent years. The practice has now become part of the core skills for general nursing practice, allowing a holistic approach to total patient care. With today s emphasis on community care and patient empowerment, there is a growing need for community nurses to take on this role in order to facilitate home care. This policy is designed to give clarity around the management and administration of intravenous antibiotics in the community via a Patient Group Direction for the treatment of cellulitis. Administration of IV Antibiotics carries potential risks and should only be given if the benefits outweigh these risks. Stringent systems need to be in place to ensure that the correct product is given to the correct patient at the correct time and that any adverse reactions are dealt with promptly and efficiently. 2. Purpose The purpose of the policy is to ensure quality and consistency in the delivery of clinical care to patients receiving Intravenous Antibiotics for cellulitis in the community. 2.1 Scope This policy applies to all qualified nurses in the Intravenous Therapy Team within Liverpool Community Health NHS Trust and should only be used by professional registered clinical staff signed up to the Patient group Directions. T his will not be passed to District Nurses as a Patient Group Direction cannot be delegated Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 8 of 25

3. Definitions Community Intravenous (IV) Cannula Deep Vein Thrombosis TPR + BP GP AMU/MAU WIC SPC USS Out of hours - Liverpool VIIAD PGD AKI RR Refers to community clinics, the patient s own home, residential and nursing homes Refers to administering the antibiotic directly into the vein Refers to the short peripheral device through which the antibiotics are given directly into the vein Refers to a blood clot in one of the deep veins in the leg Temperature, Pulse, Respiration and Blood Pressure relating to clinical condition General Practitioner Acute Medical Unit/Medical Assessment Unit Walk In Centre Single Point of Contact Ultrasound Scan After 5pm and before 08.30am seven days a week. Visual Inspection Intravenous access devices Patient Group Direction Acute Kidney Injury Respiratory Rate 4. Duties and Responsibilities Liverpool Community Health NHS Trust is responsible for Ensuring that appropriate training is in place so that qualified nurses can fulfil their duties in accordance with this policy Providing the Hepatitis B vaccine free of charge to all employees at risk of exposure to blood and body fluids in the course of their duties Senior Managers and Team Leaders are responsible for The operational implementation of this policy and associated procedures Ensuring that appropriately trained staff are used to deliver the services Ensuring that a planned audit cycle is in place Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 9 of 25

Registered health practitioners are responsible for Securing the Hepatitis B vaccine series Observing standard infection control precautions in particular hand hygiene, wearing of protective clothing and safe handling and disposal of sharps Complying with the requirements of all relevant NHS Liverpool Community Health policies applicable to their area of operation Complying with the requirements (including training and sign off from an authorised peer) of all relevant Liverpool Community Health Patient Group Directions applicable to the area of operation Reporting all potential adverse incidents in line with Liverpool Community Health Risk Management Policy (including serious untoward incidents) Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 10 of 25

5. Policy 5.1 Eligibility Criteria The clinician responsible for care must use their professional judgement to determine the appropriateness of the individual patient for IV therapy via the PGD Cellulitis service based on the following criteria: The medical/ psychological condition of the patient is suitable and stable and does not require complex nursing/ medical interventions or care Over 18 years of age Registered with a Liverpool GP Medically Stable and GP satisfied that are within the following Clinical Parameters:* Respiratory Rate 9 and 20 Oxygen Saturations 92% (88% in COPD) Temperature 35 o C and 39 o C Systolic BP 90 mmhg and 200 mmhg (or 40 mmhg drop below normal) Heart Rate 50 bpm and 110 bpm Alert and Orientated *Based on National Early Warning Score (NEWS) Aggregate 0-4 and Sepsis Screening Tool Satisfactory home conditions exist, including access to either a landline telephone or a mobile connection The patient/carer/family understands the implications of the treatment and how to recognise and report potential complications relating to treatment Patients meeting eligibility criteria will need to be referred into the service using the Community IV Antibiotics Referral Form (see Appendix 1) A Homeless person would not be automatically declined. The IV Therapy Team would endeavour to establish a safe haven to administer therapy Page 11 of 25

5.2 Exclusion Criteria Under 18 years of age Not registered with a Liverpool GP History of anaphylactic reaction to intended antibiotics Medically unstable and are out-side the following Clinical Parameters* Respiratory Rate <9 and >20 Oxygen Saturations <92% (88% in COPD) Temperature <35 o C and >39 o C Systolic BP <90 mmhg and >200 mmhg (or 40 mmhg drop below normal) Heart Rate <50 bpm and >110 bpm Not Alert and Orientated *Based on National Early Warning Score (NEWS) Aggregate 5 and Sepsis Screening Tool (Appendix 2) Acute drug or alcohol misuse Suspected DVT Critical Ischaemia requiring surgical assessment Uncontrolled diabetes at risk of complications including Diabetic Foot Ulcers egfr<20 requires discussion with Infectious Diseases Consultant/ Medical Microbiology Unable to cope at home or unsuitable home conditions. Cellulitis of face or periorbital cellulitis Signs and symptoms of cellulitis suggesting joint involvement. Pain disproportionate to skin colour changes Human or animal bite Pregnancy or breast feeding - this is an exclusion for PGD purposes. GP wishing to refer would refer via the IV Antibiotic Policy 025 Note: GP wishing to refer a patient who meets exclusion criteria may do so if he retains the medical and prescribing responsibility as per IV Antibiotic Policy 25. Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 12 of 25

5.3 Consent Informed consent must be obtained before any procedure is undertaken. Every adult has the right to make their own decisions and must be assumed to have capacity to do so unless it is proved otherwise. 5.4 Responsibilities General Practitioner will be responsible for: Any unrelated medical conditions Liaising with Medical Microbiology if required The responsibilities of the Intravenous Therapy Team will be: To advise regarding suitability for treatment in the community To provide advice and information to patients concerning the condition, treatment and follow up including emergency telephone numbers To care for intravenous access devices in accordance with NHS Liverpool Community Health clinical guidance documents and corporate policies To cannulate or insert midline venous access devices To alert medical staff to any reaction to the antibiotics and report according to the yellow card scheme To be a point of contact for professional advice, support and training for patients and District Nurses To collate the results of blood tests and alert the patient s GP of any significant event. To maintain accurate records, reviewing care pathway of each patient receiving care from the Community Intravenous Therapy Team Enter clinical information contemporaneously on EMIS and hand held patient records 5.5 Procedures Peripheral cannulation see Policy 102 Insertion of Midline devices Administration of intravenous medication via bolus - see CINS policy Administration of intravenous medication via intermittent infusion see CINS policy Administration of intravenous medication via continuous infusion see CINS policy Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 13 of 25

Management of phlebitis and infiltration Management of extravasation Intravenous Antibiotic Policy see Policy 25 5.6 Referral Process GP to refer if they meet the criteria for home treatment GP to discuss with Infectious Diseases Consultant/ Medical Microbiology if require specific advice If patients do not meet criteria for home treatment, then GP is to consider admission to Secondary care SPC will highlight the services of the IV Team to the GP as an option of care If the GP initially suspects a Deep Vein Thrombosis then the patient will be referred via UCD for further tests Referrals for same day treatment must be received by 1pm, otherwise treatment will commence the following working day Patients will be referred by the GP to the IV Team via the following route: a) Firstly contacting UCD/SPC. Telephone Number No -0300 323 0240 b) By faxing the GP referral form (see Appendix 1) via the safe haven fax machine located within the office 0151 285-4698 c) If a Clinical conversation is required with the IV Team then they can be contacted on telephone No 0151 285 4696 5.7 Treatment Regimen The Intravenous Therapy Team will on the first visit take blood for the FBC, U&E and Random Glucose Wound swabs will be taken if a wound is present (the purpose of the wound swab is to ascertain whether the bacteria in the wound has caused the cellulites) Cellulitis boundaries will be marked with a surgical marker If the patient has tachycardia and has an increased respiratory rate this may be an indication of sepsis. The patient must be referred to Secondary Care by the Intravenous Therapy Team The Intravenous Therapy Team will discuss with GP if patient is experience any hearing problems as patients may require auditory assessment. This is because Teicoplanin may cause tinnitus, mild Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 14 of 25

hearing loss or vestibular disorder Written consent will need to be obtained using a Consent Form or verbal consent by the Intravenous Therapy Team. The purpose of this is for the patient to provide consent to the treatment with intravenous antibiotics at home and to be informed of the benefits and risks The Intravenous Therapy Team will cannulate the patient IV Antibiotics will be supplied and administered as per PGD Patient will be reviewed by the IV Team on day 4 for step down antibiotic therapy with 7 days oral therapy to ensure infection is resolving If egfr is 20-50 then normal Teicoplanin dosing is recommended If egfr is <20 during treatment then advice should be sought by Infectious Diseases Consultant/Medical Microbiology Consultant and the patient needs to be referred back to a prescriber. Treatment does NOT continue under a PGD Home treatment is not recommended for patients with Acute Kidney Injury (AKI) If the infection is not resolving on day 4 and step down to oral antibiotic therapy is not appropriate, the patient needs to be referred back to a prescriber. Treatment does NOT continue under a PGD DRUG DOSE FREQUENCY DURATION ROUTE Ceftriaxone 2 Grams Once a day 3 Days IV Followed by DRUG DOSE FREQUENCY DURATION ROUTE Flucloxacillin 500mg Four times a day 7 days Oral Amoxycillin 500mg Three times a day 7 days Oral Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 15 of 25

If Penicillin Allergic DRUG DOSE FREQUENCY DURATION ROUTE Teicoplanin 800mg Once a day 3 days IV Followed by DRUG DOSE FREQUENCY DURATION ROUTE Clindamycin 450 mg Four times a day 7 days Oral If DVT is suspected the IV Therapy Team will discuss with the GP. The patient will need to follow the DVT pathway for Liverpool patients and needs to be referred back to a prescriber. Treatment does NOT continue under a PGD The IV Team will monitor the patient s condition using the National Early Warning Score (NEWS) daily Cellulitis boundaries will be reviewed daily and re-marked accordingly Blood tests will be taken as indicated The cannula site will be observed daily for signs of phlebitis using the VIIAD score (Appendix 3). Patients will be re-cannulated as required refer to Policy 25 IV Antibiotics. The intravenous dressing will be changed following re-cannulation or if dressing is soiled At each visit the IV Team will advise the patient should they feel unwell out of hours that they should contact the Medical Assessment Unit at Royal and Broadgreen Hospital on 0151-706-2973 The patient will be educated on care of the cannula and a leaflet will be provided with contact details if they have problems with their cannula. (Appendix 4) The IV Team will liaise with GP / Medical Microbiology / Infectious Diseases Consultant regarding patients whom develop signs of extending cellulitis. If required patients can be reviewed on AMU as a ward attendee If the GP needs advice then a Senior Medical Microbiologist is available 24 hours a day. They can be contacted via the Royal Liverpool and Broadgreen Hospital Trust (RLBUHT) switchboard on 0151-706-2000 or Aintree University Hospital Foundation Trust on 0151-525-5980 If there are signs of vascular access device infection this will be reported to the Infection Control Team by the IV Team and an incident form will be completed via the Trusts electronic incident reporting system Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 16 of 25

Any infections or problems relating to vascular access devices will be audited If a wound is present then the patient will be referred to their District Nurses for on-going management Adverse reactions will be reported according to the yellow card scheme available on-line on www.mhra.gov.uk/yellowcard or on Trusts Homepage The cannula will be removed at the end of the IV treatment 5.8 Adverse incidents All patients with an intravenous access device in place must have the IV site checked daily or on each shift for signs of infusion phlebitis. The subsequent score and action(s) taken (if any) must be documented. Use the VIADD and VIP score (see appendix 3 and 5). The IV site must also be observed: When bolus injections are administered IV flow rates are checked or altered When solution containers are changed The incidence of infusion phlebitis varies; the following Good Practice Points may assist in reducing the incidence of infusion phlebitis: Observe IV site at least daily Secure venous access device with a proven highly permeable intravenous dressing Replace loose, contaminated dressings Venous access device must be inserted away from joints whenever possible Aseptic technique must be followed Active consideration must be given to re-siting the cannula every 48-72 hours as per IV Antibiotic Policy. If the line is compromised or the dressing soiled this must be changed every 24 hours as per policy Plan and document continuing care Use the smallest gauge cannula most suitable for the patient s need Replace the cannula at the first indication of infusion phlebitis (stage 2 on the VIP score See Appendix 5) Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 17 of 25

6. Training Requirements All members of the IV Team receive the level of training necessary for them to fulfil their individual responsibilities identified in this policy and have responsibility for maintaining their competencies. Before undertaking IV therapy administration, health care practitioners should ensure that they have attended an annual update of management of anaphylaxis and CPR within the last year. Before undertaking medication administration via a Patient Group Direction (PGD), the staff involved must have completed PGD training and assessment. This requires to be renewed every 2 years. With regards to the PGD for Cellulitis they need to have read, understood and signed the PGD. 7. Equality Impact Assessment The Equality Impact Assessment was assessed on 17/01/17 8. Monitoring Compliance This policy will be monitored by the number of incidents reported by the Trusts on-line incident reporting system relating to: Patient/carer satisfaction Incidents relating to infections linked with cannula Results from weekly point of prevalence audits on cannulas and insertion sites Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 18 of 25

9. References The following guidance was used in the production of this document: Royal College of Nursing October 2003 Standards for Infusion Therapy Nursing and Midwifery Council April `Standards for Medicine Management`(2008) Nursing and Midwifery Council ( March 2015) The Code CINS guidelines 2012-2014 Care and Maintanence of Venous Access Devices Pan Mersey Antimicrobial Guidelines and Management of Common Infections in Primary Care 2015/16 Pratt et al; National evidence-based guidelines for preventing healthcareassociated infections in NHS hospitals in England; Journal of Hospital Infection (2007) 65S, S1-s64, 5 th February 2007 National Early Warning Score (NEWS) 2 RCP London last accessed 18/01/18 at https://www.rcplondon.ac.uk/projects/outputs/national-earlywarning-score-news-2 Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 19 of 25

Appendix 1 Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 20 of 25

Appendix 2 Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 21 of 25

Appendix 3 VIIAD Charts Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 22 of 25

Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 23 of 25

Appendix 4 Patient Information Leaflet Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 24 of 25

Appendix 5 Visual Inspection Phlebitis Score (VIP) Policy for the administration of intravenous antibiotics via a PGD in the community for patients with cellulitis who are referred by Liverpool GPs Page 25 of 25