Standard Operating Procedure (SOP) Neonatal Service Changing bed linen. Standard Operating Procedure for the changing of bed Full Title of Guideline: linen in incubators and cots on the Neonatal Intensive Care Unit. Author (include email and role): Barbara Howard - Practice Development Matron, Neonatal Service Division & Speciality: Division: Family Health - Children Specialty: Neonatal Version: 1 Ratified by: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Summary of evidence base this guideline has been created from: Strategic Children s and Neonatal Nursing Group All staff working on the Neonatal Intensive Care Unit 01/10/2019 All babies being cared for on the Neonatal Intensive Care Unit N/A Supports compliance with CQC standards. Consultation undertaken with NUH Infection Prevention and Control and Health and Safety departments. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. Date 15/09/2016 Version 1.1 Page 1 of 6
Nottingham Children s Hospital/Neonatal Service How to write a Standard Operating Procedure Definition: SOP s are a set of step-by-step instructions to achieve a predictable, standardized, desired result often within the context of a longer overall process. Standard operating procedures (SOPs) are written instructions intended to document how to perform a routine activity. They help to ensure consistency and quality of the product. Format: Use the SOP template Complete the front page for document control Approval of SOP s: Children s Hospital/Neonatal Service: SOP s need to be ratified by the Nursing Strategy Group or other relevant group identified by them. Storage of SOP s: SOP s will be stored on the intranet in the guidelines and policies section Departmental Procedures Children s Hospital Standard Operating Procedures or Neonatal Standard Operating Procedures. Reviews: All SOP s will be reviewed within 3 years. Tips: Use the SOP template Use simple English to explain the steps. Remember to involve the stakeholders whenever possible, so that the documented process is the actual process. Ensure document history is documented for every version change. Check if an old version of the SOP exists before you write yours. You may just be able to make a few quick changes. Make sure you still document them, though! Use flowcharts and pictorial representations so that the reader is clear about the process. Check for clarity. Make sure there aren't multiple interpretations. Show the procedure to someone unfamiliar with the process and have them tell you what they think it says; you may be surprised. Get people to review your document before getting approval. Ratified by Strategic Children s and Neonatal Nursing Group on 18 th May 2016 Date 15/09/2016 Version 1.1 Page 2 of 6
NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST Documentation Control Title Neonatal Service SOP: Changing Bed Linen Reference Approving Body Neonatal Service SOP: Changing Bed Linen Nursing Strategy Group Date Approved Implementation Date 1/10/2016 Version 1.1 Summary of Changes from Previous Version Supersedes Consultation Undertaken Accreditation Implications Target Audience N/A N/A Neonatal Matron, Neonatal Ward Sisters, Neonatal Practice Development Matron, Neonatal Clinical lead, IPFC, Health & Safety department. Supports compliance with CQC standards. All clinical staff in the neonatal service. Review Date 1/10/2019 Lead Executive Author Lead Manager Barbara Howard Barbara Linley Date 15/09/2016 Version 1.1 Page 3 of 6
Further Guidance/Information Nottingham Neonatal Service Nottingham Neonatal Service Standard Operating Procedure Changing Bed Linen Introduction The purpose of this standard operating procedure (SOP) is to ensure all staff in the neonatal service are educated on how to safely change the bed linen in a patient s cot or incubator. The objective of this SOP is to outline the roles and responsibilities expected of clinical staff when changing a patient s bed linen. The method outlined in the SOP should be used at all times. This SOP will apply to any neonatal staff member who undertakes the task of changing a patient s bed linen within the Nottingham Neonatal Service, family health division of Nottinghamshire University Hospitals NHS Trust. The SOP will be widely disseminated and readily accessible. Background During investigation of a Serious Incident it became apparent that there was wide variation in practice with regards to number of people present when changing patients bed linen. At times staff were operating a single person technique for changing bed linen, which has been recognised as a patient safety risk. General Principles This SOP seeks to standardise practice to ensure that every bed linen change is performed with 2 people present. PROCEDURE 01 Assess condition of baby and calculate number of nursing and/ or support staff needed to safely lift baby and change bed linen. Minimum of 2 staff present for this procedure OR one staff and one parent/ carer confident to hold baby or change bed linen 02 Prepare baby for procedure 1. Optimise temperature control 2. Visualise all medical devices attached to the baby ( e.g. respiratory tubing, central and peripheral venous and arterial access lines, nasogastric tubing) 03 Prepare equipment for procedure 1. Clean sheets 2. Linen basket for soiled linen 04 Wear Gloves and Aprons in line with Neonatal Infection Control Guidelines 05 Identify who is lifting baby this person leads the procedure and observes any Date 15/09/2016 Version 1.1 Page 4 of 6
medical devices attached to the baby 06 Identify who is changing bed linen - this person leads the procedure and observes any medical devices attached to the baby if a parent/ carer is lifting the baby 07 Lift baby, remove soiled bed linen and replace with clean bed linen 08 Replace baby 09 Place soiled bed linen in linen basket in line with infection control policy 10 Remove gloves and aprons and wash hands Date 15/09/2016 Version 1.1 Page 5 of 6
CERTIFICATION OF EMPLOYEE AWARENESS Document Title Neonatal Service SOP: Changing Bed Linen Version (number) 1.1 Version (date) I hereby certify that I have: Identified the staff groups within my area of responsibility to whom this procedure applies. Made arrangements to ensure that such members of staff have had the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Explained the mandatory nature of this procedure to my staff and I have informed them that no staff members should undertake this procedure without appropriate local training. Signature Print name Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). Date 15/09/2016 Version 1.1 Page 6 of 6