Joint and Soft Tissue Injections - Salford Royal NHS

Joint and Soft Tissue Injections Reference Number: TWCG24(11) Version Number: 5 Issue Date: 24/12/2018 Page 1 of 13

It is your responsibility to check on the intranet that this printed copy is the latest version

Joint and Soft Tissue Injections

Lead Author: Paul Barratt, Consultant Physiotherapist

Additional author(s) Victoria Dickens, Consultant Physiotherapist

Division/ Department:: CSSTM

Applies to: (Please delete) Salford Royal Care Organisation

Date approved: 22/11/18

Expiry date: November 2021

* This includes documents relevant to multiple Care Organisations, Corporate and Support Services

Contents

Contents

Section Page

Click here for the document summary sheet:

1 What is the policy about? 2

2 Where will this document be used? 2

3 Why is this document important? 2

4 What is new in this version? 3

5 What is the Policy? 3

5.1 ANTT Process relating to Joint and Soft Tissue Injections 3

5.2 Specific Equipment 4

5.3 Documentation 5

5.4 Consent 5

6 Roles and responsibilities 5

7 Monitoring document effectiveness 7

8 Abbreviations and definitions 8

9 References and Supporting Documents 8

10 Document Control Information 10

11 Equality Impact Assessment (EqIA) screening tool

12 Appendices

Appendix 1 Patient information leaflet for STJI 16

Appendix 2 Consent Form 17

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)



1. What is this policy about? 1.1 This protocol aims to promote the prevention of healthcare associated infection (HCAI)

when a joint or soft tissue injection is performed, ensuring all staff are competent in carrying out the procedure according to this protocol. Clinical teams will demonstrate consistently high standards of injection therapy practise, by ensuring all appropriate sterile and non-sterile equipment is available, that the setting is prepared, that hand decontamination is carried out appropriately and that the key parts (equipment) and key sites (the site to be injected) are protected.

If you have any concerns about the content of this document please contact the author or advise the Document Control Administrator.

2. Where will this document be used?

2.1 This document applies to all Healthcare Professionals undertaking therapeutic and diagnostic joint and soft tissue injections.

3. Why is this document important?

3.1 Patients with musculoskeletal disease often require joint aspiration, intra-articular injection or soft tissue injection as part of their ongoing management (Dixon A and Emery 1992). Historically these procedures are largely undertaken only by doctors and are often needed at short notice for symptom relief. Many rheumatological and orthopaedic conditions gain benefit from corticosteroid injections; orthopaedic waiting lists can be reduced by utilising suitable trained health professionals (Weale and Bannister, 1995). Physiotherapists have been shown able to manage simple orthopaedic conditions requiring interventions such as corticosteroid injections (Hockin and Bannister, 1994). Physiotherapists and allied health professionals have developed skills and competence to provide joint injections. Registered health care practitioners, who are trained to give joint injections, can also provide support and training for junior doctors and other musculoskeletal health professionals. Maintaining adequate precautions can reduce potential complications of corticosteroid injections (Kumar & Newman, 1999). An aseptic no touch technique (ANTT) forms an important part of these precautions (Saunders & Longworth, 2006). Although rare (Philipose et al, 2011), the rate of post injection infection has been reported as 1:50000 (Gray & Gottlieb, 1983). Charalambous et al (2003) reported an incidence of complications of less than 1:1000, with a variety of aseptic techniques, but non with ANTT. The potential cost of performing ANTT should be weighed against the potential cost of subsequent infection management and consequences to the patient. This policy applies to health professionals with the skills and competence to provide joint injections to provide timely care to patients.

3.2 None



4. What is new in this version?

4.1 This is an update of a previous version.

- Refers to updated non-medical prescribing policy relating to the mixing of medicines prior to administration

- Expanded to include occupational therapists - ANTT process updated in line with trust guidelines - Consent form updated (Appendix 2) - Linked to LocSSIP .

5. Policy & Procedure

Patients are referred by General Practitioners, Orthopaedic and Rheumatology Consultants for joint aspiration and/or injection of corticosteroid and/or local anaesthetic into an intra-articular space or soft tissues. They are then assessed by the registered healthcare practitioner (Doctor, Physiotherapist, Podiatrist, occupational therapist or Specialist Nurse). The patient must have a full clinical assessment and the opportunity to provide verbal informed consent before the procedure takes place. The patient is provided with an information leaflet (Appendix 1). All clinicians must obtain written consent from the patient, prior to injection (Appendix 2). Patient Group Directions (DOH Crown 1998) set out the legal framework by which health professionals, working in a specific specialty, can supply and administer specified medications to a particular group of patients. The patient group directions for the administration of corticosteroid and local anaesthetic are central to the policy for joint aspiration and injection of corticosteroid and/or local anaesthetic into the intra-articular space or soft tissues. For guidance relating to the mixing of medicines prior to administration please refer to the Non-Medical Prescribing Policy (TC23(05) page 12). Other drugs may be injected using this policy, but they must be prescribed by an independent prescriber or as part of an agreed clinical management plan prior to administration.

5.1 ANTT Process relating to Joint and Soft Tissue Injections

5.1.1 Protocol

Environment Ensure patient can wait for 20 minutes after the injection

Ensure environment is suitable and optimised prior to injection e.g. close windows, switch off fans to minimise airborne contamination

Preparation Explain the procedure, its risks and benefits, drugs checked by an appropriately qualified colleague and consent form countersigned, provide the patient with the injection leaflet and obtain written consent.

Wash hands with soap and water, as per the Trust Hand Hygiene Policy.



Clean trolley and tray with 70% alcohol wipes

Collect equipment placing equipment on bottom of trolley (if used)

Move to patient

Move to Patient Wash hands with soap and water as per Organisation Hand Hygiene Policy

Apply Apron

Clean inside and outside of tray with 70% alcohol wipe. Allow to air dry (Air drying eliminates organisms).

Alcohol gel hands and apply non sterile gloves

With a 2% chlorhexidine & 70% alcohol wipe. - scrub the bung of vial using different parts of the wipe for 30 secs - allow to air dry

Assemble equipment in a blue tray using ANTT protecting all key parts

Draw up drugs protecting key parts.

Mark planned injection site on patient

Remove non-sterile gloves

Wash hands or use Alcohol hand gel as per Organisation Hand Hygiene Policy

Apply non-sterile gloves

Disinfect skin using 2% chlorhexidine gluconate & 70% isopropyl solution [Frepp (1.5ml) or Chloraprep (3ml)] - using a friction scrub technique for 30 seconds - allow to air dry for 30 secs

Perform injection

Dispose of sharps and equipment at the point of care

Remove aprons/gloves and dispose of as per infection control policy

Wash hands as per Organisation Hand Hygiene Policy

Clean tray and trolley with 3 in 1 wipes at the point of care

Wash hands with soap and water

Return trolley & tray to store cupboard

5.2 Specific Equipment

5.2.1

- Single use gauze packs to be used for compression post injection. - 2% chlorhexidine gluconate & 70% isopropyl solution ain applicator of appropriate

size (Frepp 1.5ml or Chloraprep 3ml) to be used, in line with trust standardisation. - Medicines in glass vials (e.g. Lidocaine) to be drawn up using filter needle (in line with

standardised trust needles)



5.3 Documentation

5.3.1 Document procedure, along with date and time. Documentation to include that consent was obtained; drug name(s), strength, volume, batch number and expiry date. To enable drugs to be tracked in the event of an ADR.

5.4 Consent

5.4.1 Consent will be taken and recorded in line with Organisational standards and Local Safety Standards for Invasive Procedures (LocSSIP) policy. Participation in Organisation Consent Audit mandatory

6. Roles and responsibilities

Criteria for competence: The registered healthcare practitioner must be a Doctor, registered Occupational Therapist, Physiotherapist, Podiatrist or Nurse. They must have completed relevant education and training in joint aspiration and injection of corticosteroid and/or local anaesthetic into an intra-articular space or soft tissue, as recognised by this policy.

The registered health care practitioners will have a working knowledge of and be competent in the administration of corticosteroid and local anaesthetic, using PGDs or be a Non-medical Prescriber or Independent Prescriber.

Evidence of competence must be provided and a copy kept in the registered health care practitioner’s personal file.

Evidence of continuing professional development and maintenance of skill level will be required.

Registered health care practitioners new to the organisation, who have been performing the skill elsewhere, must familiarise themselves with this policy. Evidence of appropriate education and competence must be provided before undertaking this expanded practice; competence will be assessed formally and informally by a practitioner competent in joint injection practicing in the service. It is the injection practitioner’s responsibility to escalate problems implementing the guidance to their line manager and to report adverse incidents in line with trust policy.

6.1 All Trust Clinical Staff will: - Apply JSTIP to all appropriate procedures - Remain up to date and competent with ANTT mandatory training - Inform the infection control team about any issues or concerns relating to JSTIP - Be competency assessed for JSTIP on an annual basis - Promote good practice and challenge poor compliance



Non-Medical Prescribers must maintain competence in line with the NMP policy annual requirements.

Practice Educators/Clinical Skills trainers will: Will ensure that their training, protocols and guidelines are joint and soft tissue injection procedure (JSTIP) compliant Act as a resource for information and support Provide education, training and competency testing in all clinical areas Promote good practice and challenge poor compliance Consultant Physiotherapist and CATS team will: Regularly review and update this policy Act as a resource for information and support Provide education, training and competency testing. The Senior AHP’s, Nurses, Matrons and Ward Managers on behalf of the Executive Directors, the Associate Medical Directors and Clinical Directors will: Ensure that all health care workers comply with this policy Ensure that all healthcare workers attend mandatory training Ensure that all healthcare workers are competency assessed on joint and soft tissue injection technique annually Ensure joint and soft tissue injection technique practices are regularly audited and results acted upon accordingly Feedback audit results to their directorate clinical governance meeting Promote good practice and challenge poor compliance The Executive Directors of Nursing and Medicine (DIPC) on behalf of the Chief Executive will ensure that the Clinical Directors take clinical ownership of the policy. The Associate Medical Directors and Clinical Directors on behalf of the executive directors will:

- ensure that all health care workers comply with this policy

- ensure that all healthcare workers attend mandatory infection control training

- ensure that all healthcare workers are competency assessed on joint and soft tissue

injection technique annually

- promote good practice and challenge poor compliance

7. Monitoring document effectiveness

7.1 Complete the following:

Key standards:

100% of staff will complete IV ANTT mandatory training annually

100% of staff will have completed hand hygiene training annually

The trust wide consent audit.

Method(s)*: Trust wide consent audit compliance, individual evidence of competency portfolio

Team responsible for monitoring: Individuals and their Line manager



Frequency of monitoring: Annual monitoring

Process for reviewing results and ensuring improvements in performance: Feedback of audit at governance meetings, individual review of own practice annually. If non-compliance with Policy is reported through adverse incident reports (DATIX) these will be investigated and presented back at governance meetings with agreed action plans where appropriate.

.

8. Abbreviations and definitions

Terms explained in document.

9. References and Supporting Documents

9.1 References

British National Formulary (BNF), Chapter 10 'Musculoskeletal and joint disease'.evidence.nhs.uk Chartered Society of Physiotherapy (April, 2103). 'The use of medicines with injection-therapy in physiotherapy services’. Medicines and Injection Therapy PD003. Charalambous.C.P, Tryfonidis.M, Sadiq.S, Hirst.P, Paul.A (2003) Septic arthritis following intra-articular steroid injection of the knee – a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee, Clinical Rheumatology. Hockin.J & Bannister.G (1994) The Extended Role of a Physiotherapist in an Out-patient Orthopaedic Clinic, Physiotherapy, 80 (5): 281-84. Gray.R.G & Gottlieb.N.L. (1983) Intra-articular corticosteroids: an updated assessment. Clin Orthop Relat Res.;177:235-263. Philipose.J, Baker.K, O’Rourke.K.S, Deodhar.A (2011) Joint aspiration and injection: A look at the basics, The Journal of Musculoskeletal Medicine, 28 (6) Saunders.S & Longworth.S (2006) Injection Techniques in orthopaedics and sports medicine: a practical manual for doctors and physiotherapists, Third edition, Elselvier, Churchill Livingstone. Weale.A.E & Bannister.G.C (1995) Who should see orthopaedic outpatients-physiotherapists or surgeons? Annals of the Royal College of Surgeons of England, 77 (2): 71-3.

9.2 Related SRFT/PAT documents

SRFT Non-Medical Prescribing Policy (TC23(05) page 12).

SRFT Hand Hygiene Policy TC20N(05) Issue No 2 SRFT Aseptic Non Touch Technique, Infect4(09) Issue No 3.2

NatSSIPs and LocSSIPS (National/Local Safety Standards for Invasive procedures)

9.3 Acknowledgement of sources

None

http://intranet.srht.nhs.uk/EasysiteWeb/getresource.axd?AssetID=45566&type=Full&servicetype=Attachment



10. Document Control Information

It is the author’s responsibility to ensure that all sections below are completed in relation to this version of

the document prior to submission for upload. Remove instructions once completed.

Nominated Lead author:

Paul Barratt Consultant Physiotherapist

Lead author contact details:

0161 206 1639 or secretary 2062502

[email protected]

Lead Author’s Manager:

Victoria Dickens Consultant Physiotherapist

Applies to: Please indicate which Care Organisation(s) this document applies to:

Salford CO

Yes

Oldham CO North Manchester CO

Bury & Rochdale CO

Northern Care Alliance Group (NCA)

Document developed in consultation with :

Nicola McNicholls, IV Nurse Carol Mitchell, Infection Control Team

Keywords/ phrases:

Injection policy Soft tissue injections Joint injections Steroid injection

Communication plan:

Intranet Governance meetings Email relevant teams

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

Approval: CSS & TM Divisional Governance

Chair: David Fitzgerald 12/7/18

Rheumatology Governance 24/7/18

Orthopaedic Governance 22/11/18

How approved: Chair’s actions: Formal Committee decision: Approved



11. Equality Impact Assessment (EqIA) screening tool Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document? If yes, specify what.

Yes Consultation with staff, Infection control team and IV Nurses

1b) Have any amendments been made as a result? If yes, specify what.

Yes Improvements to ANTT for injections Standardising equipment used e.g. filter needles

2) Does this policy have the potential to affect any of the groups listed below differently? Place an X in the appropriate box: Yes, No or Unsure This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure

Age (e.g. are specific age groups excluded? Would the same process affect

age groups in different ways?) x

Sex (e.g. is gender neutral language used in the way the policy or

information leaflet is written?) x

Race (e.g. any specific needs identified for certain groups such as dress,

diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

x

Religion & Belief (e.g. Jehovah Witness stance on blood transfusions;

dietary needs that may conflict with medication offered.) x

Sexual orientation (e.g. is inclusive language used? Are there different

access/prevalence rates?) x

Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or

breastfeeding women?) x

Marital status/civil partnership (e.g. would there be any difference

because the individual is/is not married/in a civil partnership?) x

Gender Reassignment (e.g. are there particular tests related to gender? Is

confidentiality of the patient or staff member maintained?) x

Human Rights (e.g. does it uphold the principles of Fairness, Respect,

Equality, Dignity and Autonomy?) x

Carers (e.g. is sufficient notice built in so can take time off work to attend

appointment?) x

Socio/economic (e.g. would there be any requirement or expectation that

may not be able to be met by those on low or limited income, such as costs incurred?)

x

Disability (e.g. are information/questionnaires/consent forms available in

different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.

x

Joint and Soft Tissue Injections Reference Number: TWCG24(11) Version Number: 5 Issue Date: 24/12/2018 Page 10 of

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Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

x

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? n/a

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? n/a

Will this policy require a full impact assessment? No (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or

if you believe there is a potential for it to affect a group differently and do not know how to mitigate

against this - Please contact the Inclusion and Equality team for advice on [email protected]) Author: Type/sign: Paul Barratt Date: 24/5/18 Sign off from Equality Champion: Jules Wall Date: 11/12/18

mailto:[email protected]


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12. Appendices

Appendix 1 - Injection patient information leaflet Appendix 2 – Consent form for Injection Therapy


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Appendix 1 – Injection Leaflet


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Appendix 2 Consent form

All CONTRAINDICATIONS have been checked for as listed in PGD

Injection Details Steroid Local Anaesthetic

Drug Name: Drug Name

Batch No: Batch No:

Expiry Date: Expiry Date:

Dose: Dose:

Checked: Checked:

Patient Name:

NHS / Hospital No:

Structure / Site To Be Injected:

EXPLANATION

Treatment Options Yes No

Benefits (Symptomatic Relief / Diagnostic)

Risks and Side Effects (The main risks include anaphylaxis, infection, skin depigmentation, fatty atrophy, bleeding and bruising)

Leaflet & Verbal Information

Post injection advice given to Patient

Future Appointment Yes No

Patient offered copy of consent form Yes No Copy Accepted? Yes No

Patient Consent

I understand the risks and benefits of the explained corticosteroid/local anaesthetic injection and give my consent for it to be carried out. Signature: Date: Print Name:

Injection administered using Aseptic Non-Touch Technique (ANTT) Technique performed as per guidelines with safe disposal of sharps Clinician Name: Signature: Date: Job Title: Advanced MSK Practitioner / Consultant Physiotherapist (delete as appropriate)

Consent Form for Injection Therapy