THE MANAGEMENT OF ACUTELY ILL CHILDREN · PDF fileStandard Operating procedures (SOP) Holistic Intravenous Therapy Service (HITS) ... clinical governance Paediatric clinical governance

- 1 - Children’s Community Nursing team Referral & Risk Assessment – updated March 2016 by M Wallace, C Nicholls & C Williams

Children’s Ward & Children’s Community Nursing Team

THE MANAGEMENT OF ACUTELY ILL CHILDREN REQUIRING INTRAVENOUS OR INTRAMUSCULAR MEDICATIONS AT HOME

Standard Operating Procedures (SOP)


Standard Operating Procedure Title: Children’s Ward & Children’s Community Nursing Team.

The Management of Acutely Ill Children Requiring Intravenous or Intramuscular Medications at Home. Standard Operating Procedures (SOP)

Reference No: Version No: 2

Issue Date: April 2016 Review Date: April 2019

Purpose & Background These standard operating procedures (SOP) have been adapted from the Standard Operating procedures (SOP) Holistic Intravenous Therapy Service (HITS) in July 2012 in order to provide the Children’s ward and Children’s Community Nursing Team (CCNT) with safe and robust procedures for the referral, acceptance and management of the acutely ill child requiring intravenous medications and intramuscular at home. The CCNT, as directed in the Operational Policy is to facilitate a patient’s early discharge from the acute sector to community setting and where appropriate prevention of readmission to hospital. This guidance when followed will assist in the promotion of safe and consistent administration of medicines via intravenous and intramuscular route for staff working within East Cheshire NHS Trust Children’s Ward and Children’s Community Nursing Team. Changes for 2016 include the addition of Intramuscular Injection Technique and changes to the CCNT referral form and Risk Assessment

Scope This SOP applies to the following staff groups who will access the CCNT.

Community Service Managers

Children’s Services Manager

Specialist Nurses and Specialist Nurse Teams.

CCN Team leader & CCNT generally

Pharmacy Teams

Discharging doctors (acute paediatric)

Ward Nurses (acute paediatric)

Issued By: Children’s Community Nursing Team

Contributing Authors: (Full Job title ) Service Manager, Lead Nurse IV Therapy, Lead Community Pharmacist, Children’s Ward Charge Nurse

Monitoring Compliance

Requirement to be monitored. Must include all requirements within NHS LA Standards

Process to be used for monitoring e.g. audit

Responsible individual/ committee for carrying out monitoring

Frequency of monitoring

Responsible individual/ committee for reviewing the results

Responsible individual/ committee for developing actions plan

Responsible individual/ committee for monitoring action plan

Audit Author/CCNT or ward sisters

Initially yearly

Paediatric clinical governance

Paediatric clinical governance

Children’s Unit practice development nurse

Escalations (if you require any further clarification regarding this procedure please contact):

Malcolm Wallace (Charge Nurse, Children’s Unit)

Committees / Group Date

Consultation: Children’s Services Manager Children’s Ward Manager Children’s Community Nursing Team Paediatric Consultants Lead Nurse IV Therapy

Feb 2016

Approval Committee: Medicines Management April 12th 2016

Ratified by Committee: Women & Children’s SQS April 20th 2016

Received for Information:


Summary These standard operating procedures (SOP) have been adapted from the Standard Operating procedures (SOP) Holistic Intravenous Therapy Service (HITS) in July 2012 in order to provide the Children’s ward and Children’s Community Nursing Team (CCNT) with safe and robust procedures for the referral, acceptance and management of the acutely ill child requiring intravenous or intramuscular medications at home. The scope of these procedures extends no further than those children referred from within the trust. Children from other trusts should be referred as per the policy and guidelines of the referring centre. This can be reviewed once these procedures are fully established at East Cheshire NHS Trust. The CCNT, as directed in the Operational Policy is intended to facilitate a patient’s early discharge from the acute sector to community setting and where appropriate the prevention of readmission to hospital. The continued development of this service provides a pro active platform from which East Cheshire NHS Trust can promote organisational efficiency and maintain optimum standards of patient care. This guidance, when followed, will assist in the promotion of safe and consistent administration of medicines via intravenous route for staff working within East Cheshire NHS Trust Children’s Ward and Children’s Community Nursing Team. This guidance should be used in conjunction with the Integrated Care Pathway for the Management of Acutely Ill Children Requiring Intravenous and Intramuscular Medications at Home [up to 14 days] (ECT 2014) and the Integrated Care Pathway for Cystic Fibrosis Patients Requiring Intravenous Antibiotics (ECT 2003). Neither of these pathways is included as appendices due to their length. A future consideration will be to merge these two pathways. This consideration will be part of the review of this document in 2017. This SOP will impact on: All practitioners involved in the facilitation of home intravenous and intramuscular therapies for acutely ill children requiring intravenous and intramuscular therapies at home, to include, CCNT, acute paediatric nurses; acute paediatric medical team, pharmacy and general practitioners. Related Trust Policies and Professional Guidance Accident and Incident Reporting policy (2007) Hospital Antibiotic Policy (2011) Infection prevention & Control Aseptic Technique Policy (2009) Care of Substances Hazardous to Health (COSHH) Policy (2009) Royal College of Nursing (RCN) Standards for Infusion Therapy (2010) ECT Policy for Consent to Examination or Treatment ECT Medicines policy ECT Clinical Guidelines – Intravenous Access: Care and Maintenance for Adult Patients in Hospital and at Home (CINS 2012) NMC Code of Professional Conduct (2008) SOP Replaces Version 1 - 2014 Process Formatting and Reviews Community Services Manager, Children’s Services Manager, Lead Paediatric Pharmacist and CCN Team Leader/original author to review this SOP on a two yearly basis, or as the service dictates due to clinical incident, or significant service development that would require further extension/revision of the SOP and practices within.


Contents Pg 6: AIM of SOP for the Management of Acutely Ill Children Requiring Intravenous or Intramuscular Medications at Home

SOP Objective Target Audience Service Objectives Scope

Pg 7: Introduction Pg 8: Responsibilities

Associate Directors, Locality Managers and Community Service Managers Team Leaders Registered Nurses Medical Staff (Discharging Consultant or Registrar) CCNT

Pg 9: SOP 1 - STANDARD OPERATING PROCEDURE FOR DISCHARGING A PATIENT HOME INTO THE CARE OF CCNT FOR IV/IM MEDICATIONS

1.1 Purpose 1.2 Procedure 1.3 The CCNT 1.4 Patient Accepted by the CCNT 1.5 Clinical responsibility signature sheet 1.6 Signature identification sheet 1.7 GP discharge letter 1.8 Phlebitis scale 1.9 Community IV/IM prescription 1.10 Progress/evaluation report 1.11 Clinical review sheet 1.12 Preparing for transfer of care 1.13 Establishing Venous Access 1.14 Discharging the Patient

Pg 13: SOP 2 - STANDARD OPERATING PROCEDURE FOR ORDERING THE HOME INTRAVENOUS/INTRAMUSCULAR THERAPY PRESCRIPTION

2.1 Purpose 2.2 Procedure 2.3 Once the prescription is complete 2.4 Equipment 2.5 The prescription is ready

Pg 15: SOP 3 - STANDARD OPERATING PROCEDURE FOR CHILDREN’S COMMUNITY NURSES ACCEPTING TRANSFER OF CARE FROM ACUTE SETTING

3.1 Purpose 3.2 Procedure 3.3 Entering the Patient Home/Clinic Setting 3.4 The Environment is assessed as safe 3.5 Assess Venous Access 3.6 Checking a Cannula 3.7 Flushing the Cannula 3.8 Checking patency of an established line 3.9 Preparing for IV/IM drug administration

Pg 18: SOP 4 - STANDARD OPERATING PROCEDURE FOR THE RECONSTITUTION & ADMINISTRATION OF INTRAVENOUS/INTRAMUSCULAR DRUGS IN THE COMMUNITY

4.1 Purpose 4.2 Procedure 4.3 Withdrawing solution from an ampoule into a syringe 4.4 Withdrawing a solution or suspension from a ready mixed vial into a syringe 4.5 Reconstituting powder in a vial and drawing the resulting solution or suspension into a syringe 4.6 Adding a medicine to an infusion 4.7 Intravenous Administration into Cannula: Infusion via Braun Infusomat® 4.8 Intravenous Administration into Cannula: Infusion via Braun Perfusor®


4.9 Intravenous Administration into Skin Tunnelled Catheter, PICC, Longline: Infusion via Braun Infusomat® 4.10 Intravenous Administration into Skin Tunnelled Catheter, PICC, Longline: Infusion via Braun Perfusor® 4.11 Bolus Injection via Cannula, Skin Tunnelled Catheter, PICC, or Longline 4.12 Intramuscular Injection Technique 4.13 Blood sampling

Pg 26: SOP 5 - STANDARD OPERATING PROCEDURE FOR COMMUNITY INTRAVENOUS/INTRAMUSCULAR THERAPY FOLLOW UP

5.1 Purpose 5.2 Procedure 5.3 Clinical review sheet

Pg 27: Appendices Appendix 1 – IV/IM Therapy Flowchart Appendix 2 - CCNT referral form Appendix 3 – CCNT Opening Hours Appendix 4 – CCNT Risk Assessment Appendix 5 - National Patient Safety Agency (NPSA) Risk Rating Appendices 6a-6d: PEWS scores for children from birth to 18 years. Appendix 7 – Results Algorithm Appendix 7 – Anaphylaxis Algorithm Appendix 8 – Equality Analysis


AIM of SOP for the Management of Acutely Ill Children Requiring Intravenous or Intramuscular Medications at Home SOP Objective East Cheshire NHS Trust is committed to providing optimum quality of care across all areas; this extends to all patients who require the administration of IV/IM therapies in the home or community clinic setting. This SOP aims to equip the practitioner with the appropriate underpinning theoretical knowledge to confidently deliver seamless and effective care to paediatric patients within a supportive and evidence based framework. All staff administering IV/IM medications at home should have up to date Aseptic Non Touch technique competencies. Target Audience The target audience of this SOP principally lies within secondary care areas. This document, in conjunction with the Integrated Care Pathway for the Management of Acutely Ill Children Requiring Intravenous or Intramuscular Medications at Home provides a cohesive management framework from which any member of the multidisciplinary team can access and become knowledgeable about the process of managing CCNT patient requiring Intravenous or Intramuscular Medications at home. The document covers inpatient management, referral processes and community management so to illustrate a fluid process of patient care across both areas. Service Objectives

To equip the practitioner with theoretical knowledge to deliver quality services between key areas.

To promote safe and standardised practice to paediatric patients receiving IV/IM therapies in a community setting.

To promote effective change and embrace development of practice in recognition of the wider health service agenda.

Scope This SOP applies to the following staff groups who will support the CCNT.

Community Service Managers

Children’s Services Manager

Specialist Nurses and Specialist Nurse Teams.

CCN Team leader & CCNT generally

Pharmacy Teams

Discharging doctors (acute paediatric)

Ward Nurses (acute paediatric)


Introduction Due to the continued development of complex care in the community, IV/IM Therapy is now increasingly being provided in community settings. The Royal College of Nursing (RCN) IV forum ‘Standards for Infusion Therapy’ July 2003 is incorporated into this document to promote best practice. Infusion is now an integral part of the majority of nurses’ professional practice. The code of professional conduct (NMC) encouraged nurses to expand their practice provided they had the necessary knowledge and skills and accepted responsibility for their actions’ RCN (2003). SOP 1&2 are aimed at acute paediatric registered nurses and doctors who will access the CCNT from within the acute setting. The aim of these SOP is to guide the nurse when referring to the CCNT and aims to promote a seamless discharge process for the patient from the acute sector to the community setting. SOP 3-5 are aimed at registered paediatric nurses in the CCNT that have the necessary knowledge and skills in preparing and administering intravenous and intramuscular therapies and that are confident and competent to carry out this practice. These SOP should be used in conjunction with the Integrated Care Pathway for the Management of Acutely Ill Children Requiring Intravenous and Intramuscular Medications at Home [Up To 14 Days] (ECT 2016) and were developed to:

Enable patients to safely receive intravenous and intramuscular therapy in their own homes or in a community health care setting, thereby facilitating early discharge from hospital or preventing hospital admissions.

Ensure safe and consistent practice in administration of intravenous and intramuscular therapies by Registered Nurses thereby reducing the risk of complications.

Provide an educational platform from which to promote effective change in order to facilitate guidance of clinical practice which is evidence based.


Responsibilities Associate Directors, Locality Managers and Community Service Managers are responsible for ensuring the services they manage are aware of these Standard Operating Procedures for the Management of Acutely Ill Children Requiring Intravenous and Intramuscular Medications at Home and amendments are cascaded in a timely manner. Team Leaders are responsible for ensuring the relevant specifications outlined in these SOP are adhered to in practice and all new starters are made aware of their existence on the internet site where the most up to date version will be available. Registered Nurses All professionals are personally and professionally accountable for their actions and omissions in their practice and must always be able to justify their decisions and ensure compliance to East Cheshire NHS Trust operating procedures/policies and NMC Standards for Medicines Management. Medical Staff (Discharging Consultant or Registrar) These clinicians will accept overall clinical responsibility for the patients they discharge from their care. CCNT These team members are responsible for assessing the patients overall suitability to continue IV/IM treatment in the home/community setting. The CCNT member must ensure clinical responsibly has been accepted by a discharging Doctor. Then take into account a patients psycho-social complexities and use intuitive methods to assess whether discharge to the community is appropriate at that time. They will assess capacity of the service and whether suitably trained staff are available to support the patient and family.


SOP 1 - STANDARD OPERATING PROCEDURE FOR DISCHARGING A PATIENT HOME INTO THE CARE OF CCNT FOR IV/IM MEDICATIONS 1.1 Purpose

To guide assessment of an in-patient receiving IV/IM therapy

To promote an efficient and cost effective service

To assess the suitability of the patient receiving ongoing IV/IM treatment in the home/community setting

To safely facilitate discharge of the patient into a safe environment that promotes safe community care delivery.

To ensure effective communication between community & secondary care areas 1.2 Procedure A patient is receiving IV/IM therapy and a decision between ward staff (nurse in charge) and the paediatric medical team is that the patient no longer requires in-patient care. However the patient requires further IV/IM therapy. Ward staff should consider referring to CCNT by using the following criteria and by instigating the Integrated Care Pathway for the Management of Acutely Ill Children Requiring Intravenous and Intramuscular Medications at Home [Up To 14 Days] (ECT 2016)

Patient should be over 2 weeks old and under 16 years. Older patients may be accepted if they are still under a Paediatric Consultant.

Patients fits general CCNT acceptance criteria (see CCNT Operational Policy 2015)

Is the patient medically stable and no longer require in-patient care? (Patient may have existing chronic health problems that are being managed). The patient must have a definite diagnosis and a clinician from their speciality willing to take clinical responsibility for discharging the patient as medically fit, and provide ongoing support, whilst the patient is being treated for that condition at home.

All other processes are complete from a multidisciplinary perspective and all safeguarding concerns are resolved.

Medical stability is confirmed including a consideration of whether blood pressure is normal (for that patient), patient is haemodynamically stable (for that patient) and patient is apyrexial. Patient has no new symptoms at current time.

Family has consented to treatments being carried out at home.

The patient registered with a GP within the East Cheshire Clinical Commissioning Group (CCG).

A nurse from the Children’s Community Nursing Team (CCNT) must assess the patient and agree eligibility to commence IV therapy at home

Patient has access to a telephone and transport for return to hospital if required.

Ward staff to complete CCNT referral form comprehensively (see appendix 1)

A verbal confirmation of receipt of referral will aid effective communication and efficiency of service, see appendix 2 for CCNT contacts and hours of service.

1.3 The CCNT A member of the CCNT will discuss the referral with ward staff and assess the suitability of the patient for acceptance to the service. The assessment will include:

A review of the medical notes to achieve a medical history to determine; demographic data, known drug allergies, existing medical conditions, reason for admission, definitive diagnosis, treatment of diagnosed condition, current IV/IM and oral drug regimes. A review of the nursing documentation will take place to determine the biological, psychological, social and spiritual individuality of the patient and family. (This is done to avoid repetition during consultation with the patient & family).

The CCNT will liaise with any multi-disciplinary member currently involved in caring for the patient (physiotherapy, occupational therapy, psychiatry etc) to gauge a history (again to avoid repetition).

Once the above preparation has taken place the team will attend (with the responsible nurse) the patient and introduce themselves, their role within the organisation and the relevance of them attending the patient.


Information leaflets will be provided at this point that will reflect the ideology of the service.

Informed verbal consent for referral to CCNT should be obtained from the patients family and recorded in the medical notes

A decision will be made and documented in the patients medical notes as to the patient’s suitability for the service.

If the patient is not suitable then they should continue treatment as an in-patient.

The CCNT will document this in the notes and set a review date if there is a possibility of the patient meeting the criteria at a later date. (For example the patient may have a high temperature on the day of assessment).

1.4 Patient Accepted by the CCNT Once the patient is accepted by CCNT the Integrated Care Pathway for the Management of Acutely Ill Children Requiring Intravenous and Intramuscular Medications at Home [Up To 14 Days] (ECT 2014) should be commenced.

Confirm informed consent to pursue discharge obtained from the patient using open communication techniques to gauge understanding of risk and benefits of being treated at home.

Risks include: anaphylaxis, infection of established line, (cannula, midline, peripherally inserted central catheter (PICC) or skin tunnelled line), extravasation injury, whereby and irritant fluid leaks from an established line and causes local tissue damage, bleeding from dislodged line.

Benefits include; hospital acquired infection (HAI) avoidance, improved quality of life, and speedier recovery.

Complete risk assessment as part of the CCNT referral form (appendix 4)

If the home risk assessment deems the environment unsuitable this should be documented in the case notes and rationale for the decision shared with the patient.

Discharge (from ward) checklist, all of the above plus:

IV access established; if so what is it?

Date and time of 1st community nurse visit

IV treatment and number of doses supplied to coincide with the prescription

Dose, frequency, date started and review date

Details of additional care needs (dressing, blood pressure, drugs etc).

Date, time and place of review, to include which practitioner within reason. (Nurse Specialist, Doctor, Matron etc).

Supply of stock (see SOP 2). 1.5 Clinical responsibility signature sheet A registrar or consultant must sign the signature sheet within the Integrated Care Pathway that details they deem the patient to be in adequate health (for that individual patient) to be discharged into the community to continue current doses of the IV regime. 1.6 Signature identification sheet A signature identifier should be completed as part of the Integrated Care Pathway so that any member of staff writing in the patients notes can be identified by their individual signature. They are required to print their name also. 1.7 GP discharge letters An EDNF letter will inform the GP of the patient’s admission to the acute sector and the decision to allow the patient home to continue their treatment at home. However, clinical responsibility remains with the discharging consultant. A further letter will be sent to the family once community treatments are completed to ensure the GP is made fully aware of the full course of treatment.


1.8 Phlebitis scale This is a universally used risk assessment tool that community teams use to assess the phlebitis risk of a cannula. A copy of this can be found within the Integrated Care Pathway and is taken from ECT IV POLICY (2014) 1.9 Community IV/IM prescription A responsible Doctor should write an appropriate community prescription for the required medications that should be sent to Pharmacy. Essential information for this prescription includes:

The patient’s full name

Date of birth

Patient Weight

Prescriber’s signature, date prescribed and contact details

The approved medicine(s) name

The dose and frequency of administration

The route of administration

Any known allergies

The name and volume of flushes (for total course)

The name and volume of reconstitution agents (for total course)

The prescription should clearly state “For use by the Children’s Community Nursing team”

Where relevant the following should also be included:

The brand name and formulation of the medicine

The concentration or total quantity of the medicine in the final infusion container or syringe

The name and volume of diluents and/or infusion fluid.

The rate and duration of administration

The date on which treatment should be reviewed

The recorded administration and batch numbers of drugs & diluents 1.10 Progress/evaluation report An ongoing progress and communication form used by community staff to communicate procedures they have carried out in accordance with the patients care plan. This document in the form of the Integrated Care Pathway (ICP) provides accounts of procedures, dates, equipment used, changes in treatment, improvement in condition and deviation from the care plan (patient refusal for instance). 1.11 Clinical Review This records the patient’s re-attendance to the clinical area from where they were discharged. Information to be documented would include, blood results, clinical observation of wounds, general observations, switch from IV/IM to oral treatments or request to continue treatment for a further length of time prior to next review. Another prescription is completed at this stage if necessary and the Integrated Care Pathway (ICP) can continue. The Clinical Responsibility Signature Sheet should be countersigned by the responsible clinician. 1.12 Preparing for transfer of care Once the CCNT referral is complete and accepted by the CCNT service, SOP 2 for preparing the community prescription should be implemented. Prior to discharge venous access must be established in the patient. 1.13 Establishing Venous Access It is the responsibility of ward team to ensure the patient has healthy venous access prior to discharge from hospital. (If a cannula is already in situ it must checked for patency and infection prior to discharge). Selection of appropriate device is as follows:


Cannula: A short radiopaque polyurethane tube inserted into the peripheral veins of the arm. Ideally this should be changed every 72 hours (CINS 2012). If treatment is for more than 1 week a mid–line should be considered.

Mid-line: Longer line inserted into peripheral veins. This line dwells in the auxiliary vein after insertion for treatments lasting up to 2 weeks (up to and including day 14).

PICC: This would not be inserted into a paediatric patient at East Cheshire NHS Trust

Skin tunnelled catheter: This would not be inserted into a paediatric patient at East Cheshire NHS Trust

Totally Implanted Venous Access Device. This would not be inserted into a child at East Cheshire NHS Trust

A patient being discharged home under CCNT that requires non-vesicant/irritant drugs for up to and including 1 week should be cannulated prior to discharge by qualified ward staff that have undergone sufficient training and competency based assessment. If the patient requires anything other than a cannula this should be noted in the appropriate section of the Integrated Care Pathway. CCNT should refer the patient back to the children’s ward if the IV device requires changing. 1.14 Discharging the Patient Check:

Discharge is still appropriate (no change in condition)

The intended discharge is documented in the medical notes along with a review date, where and with whom the patient should attend

The CCNT referral is complete to include prescription and the Integrated Care Pathway including the signed Clinical Responsibility Signature Sheet.

SOP 2 has been followed and the drugs, diluents and flushed along with other oral medication have been delivered to CCNT.

The patient has suitable venous access if required.

A bag of equipment (see SOP 2) has been collated by CCNT.

Patient has information booklets and contact numbers for the CCNT and discharging ward.

Family are aware that they must return to the ward if the venous access device needs changing.

Discharge patient (once all ward policies and procedure around discharging a patient have been met).


SOP 2 - STANDARD OPERATING PROCEDURE FOR ORDERING THE HOME INTRAVENOUS/INTRAMUSCULAR THERAPY PRESCRIPTION 2.1 Purpose

To discharge the patient with the appropriate drug, diluents and flushes as prescribed.

To minimise risk to staff and patients when preparing a patient for IV/IM therapy in the community.

To facilitate a seamless transfer of care between the acute and community setting

To avoid drug errors relating to IV/IM administration in the community

To provide a fluid and unambiguous service 2.2 Procedure The decision has been made between the clinically responsible medical professionals, the CCNT and the ward staff that the patient is eligible and able to be transferred into the care of community staff to continue IV/IM treatment at home. Therefore a legible and appropriate prescription is required to be written by the doctor, sent to, checked and produced by the pharmacy department. In some cases the microbiologist may have to be referred to for advice on appropriate antibiotics to use in the community. Clinical responsibility remains with the consultant/registrar who chooses to follow that advice. (For example if an antibiotic is required four times daily, there may be a suitable drug that achieves the same outcome but only requires once daily administration). The community specific drug prescription needs to be completed to include the following:

The patient’s full name

Date of birth

Prescriber’s signature, date prescribed and contact details

The approved medicine(s) name

The dose and frequency of administration

The route of administration

Any known allergies

The name and volume of flushes (for total course)

The name and volume of reconstitution agents (for total course)

Where relevant the following should also be included:

The brand name and formulation of the medicine

The concentration or total quantity of the medicine in the final infusion container or syringe

The name and volume of diluents and/or infusion fluid.

The rate and duration of administration

The date on which treatment should be reviewed

The recorded administration and batch numbers of drugs & diluents This must be overseen by the person accepting clinical responsibility, either registrar or consultant, although a junior doctor may prescribe the necessary drugs. The patient must have been reviewed by the registrar or consultant in the last 24 hours and again prior to discharge. (The doctor should know the patient as the patient’s condition may have changed e.g. the patient may have deteriorated and requires prolonged admission or has improved negating the need for IV antibiotics). 2.3 Once the prescription is complete:

The prescription should be sent to Pharmacy straight away.

Pharmacy staff will work out any special instructions e.g. displacement values, drug level monitoring, check dose is appropriate for height and weight, and provide CCNT with this information.

Ward staff inform the patient that the prescription is pending in pharmacy and when medications have arrived on the ward.

Initial dose(s) of drug should always be administered within the ward environment.


Note: If a specific drug is not in stock then the patient may have to remain hospitalised. Preparation should continue but the patient informed of the delayed discharge. This should be documented clearly in the medical notes. 2.4 Equipment Whilst waiting for the prescription a bag of equipment needs to be prepared prior to discharge and includes the following (this is the responsibility of the CCNT): The following list is for patients with a cannula or mid line. For equipment lists for patients referred from other centres with other devices please contact the referring centre for guidance. For as many doses as is required:

Giving sets

10ml luer-lock syringes as will be required to reconstitute the infusion for six courses of treatment.

Larger syringes should be considered if the infusion and medication dictates.

Filter & non filter needles

A small sharps bin

Alcohol hand rub

Dressing Packs

ANTT Blue Tray

2% chlorhexidine in 70% alcohol impregnated wipes.

Bandages

Roll of tape

Reconstitution labels

Anaphylaxis kit

Braun Infusomat® or Perfusor® dependant on type of administration If patient needs to be recannulated this is not to be done in the community. The patient should be referred back to the children’s ward for a review. 2.5 The prescription is ready Once the prescription is ready it will need to be collected from the pharmacy department.

The CCNT must check that all diluents and flushes correspond with the prescription; this can be done either in pharmacy or on the ward.

Check expiry dates.

All vials must be checked that they will remain in date for the duration of treatment. (Follow pharmacy advice if certain items need to be used first).

To promote efficiency, if there is any oral medication ready it would be sensible to collect this at this time.


SOP 3 - STANDARD OPERATING PROCEDURE FOR CHILDREN’S COMMUNITY NURSES ACCEPTING TRANSFER OF CARE FROM ACUTE SETTING 3.1 Purpose

To ensure a seamless transfer of care from the acute setting to the community setting

To promote effective communication between key areas

To promote effective cross boundary relationships between key multi-disciplinary team members

To improve the patient experience and improve quality of life

To enable staff to work in a safe and risk reduced environment when delivering IV drugs in the home/community setting.

3.2 Procedure You receive a referral from the Children’s Ward. Out of area referrals should not be commenced on the Integrated Care Pathway. This process should be discussed with the referring centre. You must check the referral form is completed fully (see appendix 1) but should include:

Name

DOB

Hospital Number

Address

Telephone number(s)

Discharging ward and contacts

Date of referral

Date of 1st visit and estimated length of visit

Time of 1st visit (if required)

Safeguarding concerns

GP details

GP phone number

School

Health Visitor (if applicable)

Accountable consultant

Next of kin & relationship

Referring person

Diagnosis/Intervention received

Proposed IV/IM therapy

Review date, place, time and with whom

Current venous access

Allergy Status

Discharge Observations If any information is missing the referral form must be returned to the referrer for completion before CCNT will accept the patient. You must also ensure that the Integrated Care Pathway is passed onto the CCNT and is filled in correctly as this contains the confirmation that the patient meets the inclusion criteria. If there is any doubt in the content of the information then the discharging nurse should be contacted for verification. Add patient to admissions book and caseload list and allocate the appropriate time to manage the specific patient from the estimated time provided on the referral form. (This has to be realistic, an exact time cannot be guaranteed but an estimate of infusion time should be established).


3.3 Entering the Patient Home/Clinic Setting Upon meeting the patient/family you must:

Introduce yourself, who you are, your organisation, and your reason for being there.

Establish the patient/family understanding for you being there.

Using subtle communication techniques assess the environment to ensure it is suitable for the procedure.

You are looking for a clean space, a flat surface on which to place your equipment, a sink with running water, lighting, a chair for the patient, and no immediate risks to yourself.

Complete risk assessment form if not yet completed

If the environment is unsuitable then again use subtle communication techniques to inform the patient that unfortunately they cannot have their treatment in their home.

Contact the CCNT Sister or Nurse in Charge of the Children’s Ward. A number of things could happen:

The patients is treated locally in an available clinic space

The patient is treated as a day case and return to the hospital for doses

The risk is removed and the patient can have treatment at home

3.4 The Environment is assessed as safe

The risk assessment has been completed and the environment is deemed safe for you to carry out the procedure and safe for the patient to have the treatment administered over the prescribed time.

3.5 Assess Venous Access It is the responsibility of the discharging ward ensure the patient has healthy venous access. However the cannula may be come dislodged prior to the community nurse visit or may be found to have tissued when accessed. The patient may need to be recannulated.

Cannula: A short polyurethane tube inserted into the peripheral veins of the arm. This should be changed every 72 hours ECT IV POLICY (2014). If treatment is for more than 1 week a mid line should be considered.

A patient being discharged home into the care of CCNT that requires non-vesicant/irritant drugs for up to and including 1 week should be cannulated prior to discharge by qualified ward staff that have undergone sufficient training and competency based assessment. If the patient requires anything other than a cannula this should be noted in the appropriate section of the Integrated Care Pathway. CCNT should continue to refer the patient back to the children’s ward if the IV device requires changing. 3.6 Checking a Cannula

Use Visual Infusion Phlebitis (VIP) scoring sheet as found the Integrated Care Pathway (ICP).

If the cannula is unsuitable for use i.e. redness, swelling, oedema, pain at site refer back to the Children’s ward for recannulation following ECT IV POLICY (2014) to replace the cannula

Continue to monitor previous insertion site. 3.7 Flushing the Cannula

If the cannula has been deemed visually suitable for use then you must establish that the device is functionally acceptable for drug administration, (That it flushes with saline).

Follow ECT IV POLICY (2014) to flush the cannula.

If the cannula will not flush follow ECT IV POLICY (2014) as above.


3.8 Checking patency of an established line (mid-line, PICC, Skin tunnelled catheter)

Follow ECT IV POLICY (2014)

3.9 Preparing for IV drug administration

It is essential to be organised to ensure patient confidence in the practitioner is maximised, therefore check the following:

Confirm consent with the patient/parent (the patient/parent can reconsider at any time).

Check the prescription for all of the correct details listed in STANDARD OPERATING PROCEDURE FOR DISCHARGING A PATIENT HOME INTO THE CARE OF CCNT FOR IV/IM MEDICATIONS and compare to pharmacy instructions.

Check all equipment is available to perform the procedure using the appropriate venous access device as indicated in SOP 2. STANDARD OPERATING PROCEDURE FOR ORDERING THE HOME INTRAVENOUS/INTRAMUSCULAR THERAPY PRESCRIPTION and the trust IV policy (CINS 2012)

Set up a clean area and prepare to reconstitute the drug for administration (a clean area is an area free from visible dirt and large enough to set up dressing towel/dressing pack to use as you clean area).

Now refer to SOP 4: STANDARD OPERATING PROCEDURE FOR RECONSTITUTING IV DRUGS IN THE COMMUNITY SETTING

Prepare the required equipment depending upon the drug that needs administering.

Reconstitute the drug in the clean field you have established


SOP 4 - STANDARD OPERATING PROCEDURE FOR THE RECONSTITUTION & ADMINISTRATION OF INTRAVENOUS/INTRAMUSCULAR DRUGS IN THE COMMUNITY 4.1 Purpose

To safely reconstitute intravenous drugs in the community setting

To minimise risk

To promote patient safety

To promote safe working environments for anyone involved in delivering intravenous therapy in the community

To promote a optimum standards of patient care

To increase patient and staff satisfaction thorough continual support and education 4.2 Procedure You are preparing to reconstitute the prescribed IV/IM drug. Please see manufacturing instructions or pharmacy instructions for guidance on the specific drug. You have set up the clean field and have all relevant equipment required to perform the task of reconstituting an intravenous drug, to be administered to the patient whose home you are currently in. Be aware that the patient must NEVER be left unaccompanied during any intravenous therapy. It must be documented in the patient notes that Aseptic Non Touch Technique (ANTT) has been used and local trust policy adhered to. 4.3 Withdrawing solution from a glass ampoule into a syringe

Don protective equipment (gloves, apron)

Use aseptic non touch technique (ANTT) at all times

Tap the ampoule gently to dislodge any medicine in the neck

Snap open the neck of the glass ampoules, using an ampoule snapper if required

Attach a filter needle to a syringe and draw the required volume of solution into the syringe. Tilt the ampoule if necessary.

Invert the syringe and tap lightly to aggregate the air bubbles at the needle end.

Expel the air carefully.

Remove the needle from the syringe and fit a new needle.

Label the syringe if the medicine is not administered immediately. Only one unlabelled medicine must be handled at one time

Keep the ampoule and any unused medicine until administration is complete to enable further checking

If the ampoule contains a suspension, it should be gently swirled to mix the contents immediately before they are drawn into the syringe

4.4 Withdrawing a solution or suspension from a ready mixed vial into a syringe

Don protective equipment (gloves, apron).

Use ANTT at all times.

Remove the tamper-evident seal from the vial and wipe the rubber septum with a 2% chlorehexidine in 70% alcohol wipe. Allow to dry for 30 seconds.

With the needle sheathed attach the needle to a syringe using a non-touch technique, draw into the syringe a volume of air equivalent to the required volume of solution to be drawn up.

Remove the needle cover and insert the needle into the vial through the rubber septum.

Invert the vial. Keep the needle in the solution and slowly depress the plunger to push air into the vial.

Release the plunger so that the solution flows back into the syringe

If large volumes are to be withdrawn, use a push-pull technique. Repeatedly inject small volumes of air and draw up an equal volume of solution until the required total is reached.

With the vial still attached, invert the syringe. With the needle and vial uppermost, tap the syringe lightly to aggregate the air bubbles at the needle end. Push the air back into the vial.

Fill the syringe with the required volume of solution then draw in a small volume of air. Withdraw the needle from the vial.

Expel excess air from the syringe. Administer immediately.


The vial(s) and any unused medicines should be kept until administration is complete. 4.5 Reconstituting powder in a vial and drawing the resulting solution or suspension into a syringe

Don protective equipment (gloves, apron).


Remove the tamper-evident seal from the vial and wipe the rubber septum with a 2% chlorehexidine 70% alcohol impregnated wipe. Allow to dry for at least 30 seconds.

Withdraw the required volume of dilutent from the ampoule(s) into the syringe

Inject the dilutent into the vial. Keeping the tip of the needle above the level of the solution in the vial, release the plunger. The syringe will fill with the air which has been displaced by the solution (if the contents of the vial were packed under a vacuum, solution will be drawn into the vial and no air will be displaced). If a large volume of dilutent is to be added use a push-pull technique, as detailed earlier.

With the syringe and needle still in place, gently swirl the vial(s) to dissolve all the powder, unless otherwise indicated by the product information. This may take several minutes.

Withdraw the required volume of solution into the syringe, as detailed earlier.

For Intramuscular administration please see section 4.12. 4.6 Adding a medicine to an infusion

Don protective equipment (gloves, aprons).


Prepare the medicine in a syringe using one of the methods described above.

Check the outer wrapper of the infusion container is undamaged.

Remove the wrapper and check the infusion container itself in good light. It should be intact and free from cracks, punctures/ leaks.

Check the infusion solution, which should be free from haziness, particles and discolouration.

Where necessary, remove the tamper evident seal on the additive port according to the manufacturer’s instructions or wipe the rubber septum on the infusion container with a 2% chlorehexidine in 70% alcohol impregnated wipe and allow to dry for 30 seconds.

If the volume of the medicine solution to be added is more than 10% of the initial contents of the infusion container (more than 50ml to a 500ml infusion), an equivalent volume must first be removed with a syringe and needle.

Inject the medicine into the infusion container through the centre of the injection port, taking care to keep the tip of the needle away from the side of the infusion container. Withdraw the needle and invert the container at least five times to ensure thorough mixing before starting the infusion.

Label the infusion with the name of the patient, name of drug, DOB, batch number of both drug and diluents; this should also be documented clearly in the patients’ notes.

Also document the drug calculation used to achieve the final dose and administration rate of the IV infusion (if applicable) or follow instructions provided by Pharmacy.

4.7 Intravenous Administration into Cannula: Infusion via Braun Infusomat®

Once the drug is reconstituted connect a giving set by piercing the seal on the infusion bag. Keep the bag of fluid and the giving set flat and spike the bag with the giving set, smoothly and confidently (ensuring not to pierce the bag of fluid).

Hang the infusion from the drip stand that has been provided to you. Slowly open the clamp to allow the fluid to prime the line. (Do this slowly and observe as if done too rapidly some of the drug can be lost and the patient will not receive an accurate dose).

Once the line is primed, use ANTT to clean the hub of the extension set that is attached to the cannula. Clean the hub for 30 seconds using the 2% chlorehexidine with 70% alcohol wipe. Allow to dry.

Connect the giving set to the hub and screw on and be careful not to cross thread as this may lead to leakage.

Some intravenous therapies require slow administration; this information should be recorded on the medicines administration chart by the prescriber.

Refer to the manufacturer’s information or pharmacy guidelines for full details on time required for injection. If in doubt contact the Children’s Ward or discuss with the paediatric pharmacist.


Ensure no air bubbles are evident.

Administer the IV drug over the required time by manually calculating the required rate and entering this information into the machine.

If anaphylaxis occurs locate anaphylaxis kit (this should be taken into the patient house at each visit. Implement anaphylaxis procedure.

4.8 Intravenous Administration into Cannula: Infusion via Braun Perfusor®

Once the drug is reconstituted add to an appropriate sized syringe and dilute to the recommended amount.

Attach syringe to giving set and prime the line. (Do this slowly and observe as if done too rapidly some of the drug can be lost and the patient will not receive an accurate dose).

Once the line is primed, follow instructions onscreen insert the syringe into the Braun Perfusor® device and secure accordingly.

Use ANTT to clean the hub of the extension set that is attached to the cannula. Clean the hub for 30 seconds using the 2% chlorehexidine with 70% alcohol wipe. Allow to dry.



Refer to the manufacturer’s information or pharmacy guidelines for full details on time required for injection. If in doubt contact the Children’s Ward or discuss with the paediatric pharmacist.

Ensure no air bubbles are evident.


If anaphylaxis occurs locate anaphylaxis kit (this should be taken into the patient house at each visit. Implement anaphylaxis procedure.

4.9 Intravenous Administration into Skin Tunnelled Catheter, PICC, Longline: Infusion via Braun Infusomat®

Once the drug is reconstituted connect a giving set by piercing the seal on the infusion bag. Keep the bag of fluid and the giving set flat and spike the bag with the giving set, smoothly and confidently (ensuring not to pierce the bag of fluid).

Hang the infusion using appropriate apparatus in agreement with the patient and their environment. Slowly open the clamp to allow the fluid to prime the line, (do this slowly and observe as if done too rapidly some of the drug can be lost and the patient will not receive an accurate dose).

Once the line is primed, use ANTT to clean the hub of the bionector that is connected to the venous access device. Remove cap and clean the hub for 30 seconds using the 2% chlorehexidine with 70% alcohol wipe. Allow to dry. Then aspirate a flash back of blood from the venous access device as per ECT IV POLICY (2014).



Refer to the manufacturer’s information or pharmacy guidelines for full details on time required for injection.

Ensure no air bubbles are evident


If anaphylaxis occurs locate anaphylaxis kit (this should be taken into the patient house at each visit. Implement anaphylaxis procedure).

Once the infusion is complete all sharps to be disposed of in a yellow sharps disposal bin. (For cytotoxic drugs follow trust policy).

Refer to trust policy, Sharps Usage and Disposal.

Record administration of flushes and drugs in the patient’s record, including full details of batch numbers, manufacturer’s and expiry dates, along with a comprehensive account of the visit and your general assessment of the patient.


Observe for any signs of inflammation, infiltration.

Venous access devices and administration sets should be disconnected and flushed using ANTT and refer to ECT IV POLICY (2014) guidance for further details.

Advise patient / carer what actions to take if any side effects occur.

Ensure patient has contact details of the CCNT.

Clearly state in records when next contact will be made by CCNT.

Review care plan if required to meet patient’s ongoing health care needs. 4.10 Intravenous Administration into Skin Tunnelled Catheter, PICC, Longline: Infusion via Braun Perfusor®

Once the drug is reconstituted add to an appropriate sized syringe and dilute to the recommended amount.

Attach syringe to giving set and prime the line. (Do this slowly and observe as if done too rapidly some of the drug can be lost and the patient will not receive an accurate dose).

Once the line is primed, follow instructions onscreen insert the syringe into the Braun Perfusor® device and secure accordingly.

Use ANTT to clean the hub of the bionector that is connected to the venous access device. Remove cap and clean the hub for 30 seconds using the 2% chlorehexidine with 70% alcohol wipe. Allow to dry. Then aspirate a flash back of blood from the venous access device as per ECT IV POLICY (2014).



Refer to the manufacturer’s information, BNF or Pharmacy instructions for full details on time required for Injection.

Ensure no air bubbles are evident


If anaphylaxis occurs locate anaphylaxis kit (this should be taken into the patient house at each visit. Implement anaphylaxis procedure).

Once the infusion is complete all sharps to be disposed of in a yellow sharps disposal bin. (For cytotoxic drugs follow trust policy).

Refer to trust policy, Sharps Usage and Disposal.

Record administration of flushes and drugs in the patient’s record, including full details of batch numbers, manufacturer’s and expiry dates, along with a comprehensive account of the visit and your general assessment of the patient.

Observe for any signs of inflammation, infiltration.

Venous access devices and administration sets should be disconnected and flushed using ANTT and refer to ECT IV POLICY (2014) guidance for further details.




Review care plan if required to meet patient’s ongoing health care needs. 4.11 Bolus Injection via Cannula, Skin Tunnelled Catheter, PICC, or Longline

Slow IV bolus injection involves the injection of a drug over several minutes (normally 3-5 minutes depending upon the drug) via an indwelling catheter, this is indicated when a rapid serum concentration of a drug is required.

For bolus doses of drugs, the required volume of antibiotic should be administered directly from the syringe into the venous access device (Cannula, Skin tunnelled catheter, PICC or Mid-line).

Flush any device using ANTT and refer to ECT IV POLICY (2014) for further details.

Clean the hub of the bionector/ extension set of the device with 2% chlorehexidine in 70% alcohol impregnated wipes for 30 seconds.

Connect the syringe (luer lock best practice) used to draw up the drug to the device and slowly apply pressure to the plunger (excessive pressure will result in damage to the venous access device and harm


to the patient). The patient may complain if too much force is exerted as the infusion will sting or the patient will feel uncomfortable pressure. In this case ease off the plunger.

Maintain dialogue with patient if age appropriate and ask them to describe the sensation (usually a cold sensation is felt) and monitor the site of the venous access device.

Also monitor for anaphylaxis and implement anaphylaxis procedure if necessary.

Once complete flush device as per ECT IV POLICY (2014).

Record administration of flushes and drugs in the patient’s record, including full details of batch numbers, manufacturer’s and expiry dates along with a comprehensive account of the visit and your general assessment of the patient.

Observe the venous access device for any signs of inflammation, infiltration.

If any of the above are observed refer back to the Children’s Ward.




Review care plan if required to meet patient’s ongoing health care needs. Continue this process of prescribed care until:

The patient is due for medical review

The CCNT suggest early review

Patient becomes unwell e.g. anaphylaxis or pyrexia, deteriorating sepsis For patient reviews follow SOP 5: STANDARD OPERATING PROCEDURE FOR COMMUNITY INTRAVENOUS THERAPY FOLLOW UP 4.12 Intramuscular Injection Technique Intramuscular injections should be given into the densest part of the muscle tissue under the subcutaneous tissue. The vascularity of muscle aids the rapid absorption of medication (Dougherty and Lister, 2011). The medicine should be prepared as per SOP 4 - STANDARD OPERATING PROCEDURE FOR THE RECONSTITUTION & ADMINISTRATION OF INTRAVENOUS/INTRAMUSCULAR DRUGS IN THE COMMUNITY. 4.12.1 Standard UK Needle Lengths

Length Gauge

Brown 10mm 26

Orange 16mm 25

Blue 25mm 23

Green 38mm 21

4.12.2 Choice of Needle Size

Needle sizes are known as gauges and this indicates their diameter, the higher the gauge the finer the needle and selection is made depending on the viscosity of the liquid to be injected. The length of the needle will depend on the on the size and weight of the patient, and the type of tissue the medicine is being injected into, for example a longer needle for an intramuscular injection and a shorter needle for a subcutaneous injection. For intramuscular injections, the needle needs to be sufficiently long to ensure that the medication is injected into the muscle or for subcutaneous injections the medication needs to be injected deep into the subcutaneous tissue. An individual assessment must be made to determine the correct size needle to be used (Immunisation against infectious disease, chapter 4, DH 2012).


Careful attention must be paid to pre-filled syringes with fixed needles in respect of needle length as these may vary and therefore influence the angle of insertion. Always refer to the manufacturer’s guidance on administration.

4.12.3 Choice of Syringe

The size of syringe must be appropriate to the volume of drug to be given. Use the appropriate single use sterile syringe. If administering insulin from vials, only insulin syringes must be used (NPSA 2010 RRR013)

4.12.4 Skin Cleansing

For skin that is visibily soiled, wash with soap and water and dry thoroughly.

For deep intramuscular injections, the skin must be cleaned using an isopropyl alcohol based swab/ applicator.

Use an isopropyl alcohol based swab/ applicator for any situation where the clinical judgement of the practitioner warrants use

4.12.5 Injection Sites

Site Rationale

Anterolateral aspect of the thigh: Is the preferred site for intramuscular injections for immunisation of children under 12 months of age (DH, 2012). Maximum volume to be administered is up to 5ml in adults and 1-3 ml for children (Dougherty and Lister, 2011).

The anterolateral aspect of the thigh provides a large muscle mass, free from major blood vessels and nerves minimising risk of damage.

Deltoid muscle: Preferred site for intramuscular injections for older children and adults (DH, 2012) The maximum volume that should be administered at this site is 1ml (Dougherty and Lister, 2011)

The site is easy to access, however in infants under one year of age, the muscle is not sufficiently developed. Owing to the small area of this site.

Dorsogluteal site: (upper outer quadrant of the buttock) In adults up to 4ml can be safely administered into this site by deep intramuscular injections (Dougherty and Lister, 2011).

This site should only be used if recommended by the medicine’s manufacturer (Rodger and King 2000)

4.12.6 Equipment

Sharps bin and tray

If indicated single use disposable sterile dressing pack

Needle (single use) - size (gauge) and length dependant on route of administration.

Syringe (single use) - size appropriate to the volume of drug to be given


Medication to be administered

Diluents if required

Prescription chart

Dosing instructions in form of pharmacy label (unless following PGD)

Anaphylaxis box

If indicated single use disposable apron

If indicated single use dispsoable non sterile gloves

Isopropyl alcohol swab/applicator if indicated

Sterile gauze

4.12.7 Procedure

1. Verbally confirm the identity of the patient by asking for their full name and date of birth. If the patient is unable to confirm, check identity with family/carer

2. Ensure verbal consent for the presence of any other third party is obtained 3. Explain procedure to patient including risks and benefits of the medication to be administered

and gain valid consent. 4. Establish the patient has no known allergies, check in patient’s records and also ask

patient/family of any known allergies 5. Ensure patient is comfortable and maintain patient privacy, closing doors / curtains where

appropriate 6. Check the prescription chart specifies the following confirming they relate to the patient to be

treated: a. Patient’s full name b. Patient’s date of birth (DOB) c. Prescriber’s signature d. The approved medicines name e. The dose and frequency of administration f. The date and route of administration g. The allergy status of the patient h. NHS Number, if available i. The weight of the patient

7. Check no ambiguities in the drug, dose, frequency, route of administration and start and finish dates

8. The person administering the medicine should know the usual therapeutic dose to be administered, its normal dosage, side effects, precautions and contra-indications. In the case of unfamiliar medicines refer to the package insert for manufacturer’s information or a current British National Formulary (BNF). If the dosage is not within usual ranges contact the prescriber or a pharmacist for advice

9. Check all details on the label issued by the supplying pharmacy correspond to the prescription chart and the manufacturer’s packaging

10. Check the expiry date of the medication to be administered 11. Read the patient’s care plan and know its current contents and check that the medicine is due for

administration at that time and check record of treatment chart to establish that the injection has not already been given.

12. Ensure that the area in which the medicine is to be prepared is clean, uncluttered and free from interruption and distraction

13. Assemble and check all equipment and ensure that the packaging of the equipment is intact 14. Prepare the medication for administration following SOP 4 - STANDARD OPERATING

PROCEDURE FOR THE RECONSTITUTION & ADMINISTRATION OF INTRAVENOUS/INTRAMUSCULAR DRUGS IN THE COMMUNITY and take prepared injection directly to the patient

15. Having selected the appropriate site (follow manufacturer’s instructions), assist patient into a comfortable position and expose the site to be injected (may involve removal of tight sleeved shirt etc.)

16. Decontaminate hands 17. Apply single use disposable apron if there is a risk of contamination with blood or body fluids 18. Apply single use disposable non-sterile gloves if there is a risk of contamination with blood or

body fluids


19. If skin at injection site is visibly soiled wash with soap and water and dry completely (WHO, 2010). If indicated, clean the injection site with the isopropyl alcohol swab/applicator using a circular motion for 30 seconds and allow to dry thoroughly. Avoid damaged skin when injecting

20. Hold the skin firmly. Introduce the needle at a 90 degree angle to the skin. The skin should be stretched not bunched, leaving ¼ of needle length exposed

21. It is not necessary to aspirate the syringe after the needle is introduced into the muscle (WHO, 2004; Plotkin and Orenstein, 2004). Avoid injecting during needle insertion. Proceed to give the injection slowly and withdraw smoothly

22. If bleeding occurs at site following removal of needle, apply gentle pressure with a sterile gauze swab for a few seconds – do not massage the area

23. Do not re-sheath needles – dispose of needle and syringe as a single unit directly into sharps container to comply with Trust Policy

24. Ensure patient is comfortable following procedure 25. On completion of procedure remove and dispose of Personal Protective Equipment if work (PPE)

to comply with waste management policy 26. Decontaminate hands following procedure and removal of PPE if worn 27. Document actions in records 28. If medication NOT given – document in the records and explain reasoning

4.13 Blood sampling Some antibiotic regimes will require specific blood sampling. In all cases the patient must be bled peripherally to ensure accurate trough levels. The CCNT will be responsible for organising this and will check results with Paediatric Medical Team.


SOP 5 – STANDARD OPERATING PROCEDURE FOR INTRAVENOUS/INTRAMUSCULAR THERAPY FOLLOW UP 5.1 Purpose

To be able to advise the patient regarding follow up arrangements

To minimise risk to the patient

To ensure effective cross boundary working relationships

To promote safe working environments for anyone involved in delivering intravenous therapy in the community

To promote an optimum standard of patient care

To increase patient and staff satisfaction thorough continual support and education 5.2 Procedure The patient has been receiving IV/IM treatment in the community setting or at home. The date for review will be documented on the CCNT referral and in the Integrated Care Pathway (ICP) as discussed in SOP 1. When the patient is due for review they should be seen by either the team who accepted clinical responsibility or the on call paediatric team. 5.3 Clinical review This records the patient’s re-attendance to the clinical area from where they were discharged. Information to be recorded would include, blood results, clinical observation of wounds, general observations, switch from IV/IM to oral treatments or request to continue treatment for a further length of time prior to next review. (Another prescription is completed at this stage if necessary and the Integrated Care Pathway should be discontinued or continued as appropriate). For review the patient should report to the Children’s Ward unless otherwise specifically informed to report elsewhere. The review appointment should have been made at the point of initial discharge by the team accepting clinical responsibility for the patient. Subsequent review appointments will be made at the preceding review. The CCNT where possible will provide support to the patient during their review and be accessible to the patient by phone. The CCNT will make their notes available for the staff on the Children’s Ward to review. At the review a decision will be made either to:

Continue on IV/IM drug regime

Stop IV/IM drug regime

Change to a different IV/IM regime If continuing on IV/IM drug regime re-implement practice starting from and including SOP 2 until next review and continue using Integrated Care Pathway. If a new IV/IM regime is prescribed the medications should be ordered from pharmacy as stated in SOP 2 and the relevant processes from SOP 1, 2 & 3 should be followed. Once IV/IM therapy is no longer required and the discharging doctor has made this explicit in the medical notes, the CCNT can discontinue the IV/IM care pathway and collect superfluous equipment from the home.

The patient can then either be discharged or followed up by CCNT as appropriate.


Appendix 1 – IV/IM Therapy Flowchart The aim of this flowchart is to facilitate the patient journey from decision to commence IV/IM MEDICATIONS in a child’s home to completion of the course.

The first dose of IV/IM medication in the home must be within the 2 hour therapeutic window and within CCNT hours.

Consultant/registrar on duty confirms patient meets criteria for home IV therapy and signs ICP document (page 3)

Consent obtained from parent/carer for child to receive IVs at home and information leaflet given to family.

Ward staff contact CCNT specifying times and duration of IV course required. CCNT gives verbal agreement to accept the referral and must utilise RAG rating system in order to facilitate home IV/IM

therapy.

Initial visit to be arranged and risk assessment commenced by CCNT prior to patient discharge. On discharge CCNT contact details to be given to family.

CCNT continue to visit and deliver IV/IM therapy until blood cultures are confirmed as negative in the case of suspected systemic infection or instructed to stop by the child’s consultant or when planned course of antibiotics completes.

CCNT receives all medication required for the course from pharmacy and collates together all consumables and paperwork that will be needed, along with a syringe driver.

CCNT makes initial visit to child’s home to deliver all equipment ensuring appropriate prescription chart is present. This chart and pathway to be kept with CCNT at all times.

CCNT referral form to be completed by ward staff. TTO prescription chart to be sent to pharmacy clearly stating that the antibiotics are to be given at home by CCNT.

Ward staff contact CCNT to confirm that patient has been discharged.

If IV/IM Therapy is required to continue beyond 14 days, a new pathway must be commenced and a new prescription sent to pharmacy.


Appendix 2 - Children’s Community Nursing Team Referral

Name: M / F Consultant:

Date of Birth: Age: Diagnosis:

Hospital Number: Plan of Care/Instructions for Follow Up:

Address:

Home Telephone No:

Parent/Guardian Name(s):

Mother’s Mob No:

Father’s Tel No:

Parental responsibility:

Mum Dad Both Other (please specify)

First Language: Religion:

Named GP:

GP Practice:

Midwife / Health Visitor / School Nurse:

School / Nursery / Child Minder:

Discharge Medications (Drug, Dose & Frequency):

Social Worker/Family Support Worker:

CAF Child Protection Plan Child in need plan

Y / N Y / N Y / N

Specify safeguarding concerns as part

of Risk Assessment (over page)

CCNT leaflet & Contact information given:

OPD Date Ward Rev Date

Date & Source of referral: Y / N Y / N

DISCHARGE OBSERVATIONS & INFORMATION

Sign & Print: Allergies:

CCNT USE ONLY Temp: O2 Sats: BP:

Admi No: Discharge date: Heart rate: Resps: Weight:

Wound site:

Reason for discharge: Dressing:

Clips/Sutures:

Type of IV line:

Sign & Print: Enteral feeding device type, Size & length @ nose:

29 THE MANAGEMENT OF ACUTELY ILL CHILDREN REQUIRING INTRAVENOUS OR INTRAMUSCULAR MEDICATIONS AT HOME Standard Operating Procedures (SOP) – Version 2

Appendix 3 Service Hours & Contacting CCNT The CCNT service is available 7 days per a week including bank holidays:

07:30am to 20:00pm every day except bank holidays and weekends in the summer months when the service reduces its opening times to 10:00am to 18:00pm Contact Details: Tel: 01625 661194 Fax: 01625 661210 Children’s Community Nursing Team, Children’s Ward, Macclesfield District General Hospital, Victoria Road, Macclesfield, Cheshire SK10 3BL


Appendix 4 – CCNT Risk Assessment

Directions (if applicable)

Type of housing:

Visiting risks/Hazards

High Medium Low Details

Car parking

Property access

Location

Infection control

Pets (specify)

OTHER PEOPLE WHO LIVE IN THE PROPERTY RELATIONSHIP TO CHILD

1.

2.

3.

4.

5.

SAFEGUARDING CONCERNS (continued from front page)

MODIFIED BRADEN Q RISK ASSESSMENT SCORE CARE PLANS INITIATED

(If patient scores 23 or lower a Tissue Viability Care Plan (based on diagnosis and referral instructions)

should be initiated)

Score <10 = Very high risk

Score 10 – 12 = High risk

Score < 16 = At risk

Score 16+ = Low risk

Score 23+ = No risk

OVERALL RISK ASSESSMENT INITIAL RAG RATING

High – Daylight visits / 2 staff members: Name & Signature:

Medium – Anytime visits / 2 staff members:

Low – Anytime visits / 1 staff member: Date:


Appendix 5 - National Patient Safety Agency (NPSA) Risk Rating Each method box has a coloured bar indicating the NPSA risk rating. The risk rating refers to the method of preparation and administration described along the row. The risk rating is not essential for administration; however, you should understand that the colour of the bar is indicative of the complexity of the task. Medicines that are complex to prepare and require specialist equipment or infusion devices have a high NPSA risk rating and are coloured red. You should take additional time to plan and prepare these medicines and ensure that local protocols are adhered to before giving the medicine. Less complicated tasks are likely to have a lower NPSA risk rating and are coloured amber (moderate risk) or green (low risk).

How the risk rating is assigned Each injectable practice has been assessed against eight criteria:

Number Risk factor Applies when

1 Therapeutic risk There is significant risk of patient harm if the injectable medicine is not used as intended1

2 Use of a concentrate The product must be further diluted (after reconstitution) before it can be injected

3 Complex calculation A complicated calculation must be performed in order to prepare or administer the product. This includes calculations with more than one step, or conversions between dose units, e.g. percentage to milligram’s per millilitre

4 Complex method More than five non-touch manipulations are required to prepare the product, or when syringe-to-syringe transfer or a filter is used

5 Reconstitution of powder in a vial Where a dry powder preparation must be reconstituted

6 Use of a part vial or ampoule, or use of more than one vial or ampoule

Part or multiple vials/ampoules are required to fulfil the prescription

7 Use of a pump or syringe driver An infusion device is required to give the injectable

8 Use of a non-standard giving set/device required

A low sorption, air inlet or light-protected administration set needs to be used to administer the injectable


Appendices 6a-6d: PEWS scores for children from birth to 18 years.


Frequency of obs

Every

hourly

Name

Date of Birth

NHS Number

Consultant

Ward

PEWS Form

0-11 Months

Date 30/11

Time 18:00

Initial SNM

Doctor/Nurse/Family concern?

Respiratory Rate

(Over 1 minute)

ad

Respiratory Rate (number) 65

Heart Rate & Blood Pressure

Heart Rate (Number) 130

200

190

180

170

160

150

140

130

120

110

100

90

80

70

60

50

40

30

BP

NO

T u

se

d t

o c

alc

ula

te P

EW

S

A

B

C

Conscious Level

Normal

Decreased

Temperature

°C

Temperature (Number) 38

EX

AM

PL

E

X

X

40

39

38

37

36

35

Respiratory Distress

Severe/Mod Mild/None

O2 Saturation % 95

Receiving O2 l/min 2

70

60

50

40

30

20

10

5

Total PEWS = Number of entries of shaded boxes Total

PEWS 0-2

3-4

5-6

PTO For Action PTO For Action


Name

Date of Birth

NHS Number

Consultant

Ward

3

4

PEWS Form

0-11 Months

PEWS Escalation Aid

S Situation:

I am (name), a nurse on ward (X)

I am calling about (child X)

I am calling because I am concerned that…

(e.g. BP is low/high, pulse is XXX

temperature is XX, Early Warning Score is XX)

B

Background:

Child (X) was admitted on (XX date) with

(e.g. respiratory infection)

They have had (X operation/procedure/investigation)

Child (X)’s condition has changed in the last (XX mins)

Their last set of obs were (XXX)

The child’s normal condition is…

(e.g. alert/drowsy/confused, pain free)

A

Assessment:

I think the problem is (XXX)

and I have…

(e.g. given O2 /analgesia, stopped the infusion)

OR

I am not sure what the problem is but child (X)

is deteriorating

OR

I don’t know what’s wrong but I am really worried

R

Recommendation:

I need you to…

Come to see the child in the next (XX mins)

AND

Is there anything I need to do in the meantime?

(e.g. stop the fluid/repeat the obs)

Download SBAR prompt cards and pads at www.institute.nhs.uk/SBAR

Download documents to use or edit at

www.institute.nhs.uk/PEWScharts © NHS Institute for Innovation

and Improvement 2012

Record Call When PEWS 3 Or More Record Time of Review, Who by & Plan

Remember: If you feel you need more help at any time, call for help – regardless of PEW Score

Continue monitoring Minimum 4 hourly observations

Nurse in charge MUST review Repeat observations within 2 hrs

Nurse in charge & Doctor MUST review Increase frequency of observations to 1-2 hourly

Nurse in charge & Doctor MUST review & inform Consultant Increase frequency of observations to 1/2hrly-hourly

Nurse in charge & Consultant MUST review Continuous monitoring in place Observations to be documented a minimum of every 15 mins

0 1

2

5 6


Frequency of obs

Every

hourly

5

PEWS Form

1- 4 Years

Name

Date of Birth

NHS Number

Consultant

Ward Date 30/11

Time 18:00

Initial SNM


Respiratory Rate

(Over 1 minute)

a




200

190

180

170

160

150

140

130

120

110

100

90

80

70

60

50

40

30

BP

NO

T u

se

d t

o c

alc

ula

te P

EW

S

A

B

C

Conscious Level

Normal

Decreased

Temperature

°C


EX

AM

PL

E

X

40

39

38

37

36

35



O2 Saturation % 95


60

50

40

30

20

10

0

X

Total PEWS = Number of entries of shaded boxes PTO For Action PTO For Action

Total PEWS 0

-2

3-4

5-6


3

4

PEWS Escalation Aid

S Situation:






B

Background:








A

Assessment:


and I have…


OR


is deteriorating

OR


R

Recommendation:

I need you to…


AND







Date Time PEWS Print Name (nurse) Time Plan Print Name

PEWS Form

1- 4 Years

Name

Date of Birth

NHS Number

Consultant

Ward





Nurse in charge & Doctor MUST review & inform Consultant Increase frequency of observations ½-hourly

Nurse in charge & Consultant MUST review Continuous monitoring in place. Observations should be documented a minimum of every 15 minutes

0 1

2

5 6


Frequency of obs

Every

hourly

Date 30/11

Time 18:00

Initial SNM


Respiratory Rate

(Over 1 minute)

a




180

170

160

150

140

130

120

110

100

90

80

70

60

50

40

30

BP

NO

T u

se

d t

o c

alc

ula

te P

EW

S

A

B

C

Conscious Level

Normal

Decreased

Temperature

°C


40

39

38

37

36

35



O2 Saturation % 95


50

40

30

20

10

0

X

X

EX

AM

PL

E

5


Total PEWS 0

-2

3-4

5-6

PEWS Form

5-12 Years

Name

Date of Birth

NHS Number

Consultant

Ward


3

4

PEWS Escalation Aid

S Situation:






B

Background:








A

Assessment:


and I have…


OR


is deteriorating

OR


R

Recommendation:

I need you to…


AND









PEWS Form

5-12 Years

Name

Date of Birth

NHS Number

Consultant

Ward




Nurse in charge & Doctor MUST review Increase frequency of observations 1-2 hourly

Nurse in charge & Doctor MUST review & inform Consultant Increase frequency of observations to ½ hourly - hourly

Nurse in charge & Consultant MUST review Continuous monitoring in place Observations should be documented a minimum of every 15 mins

0 1

2

5 6


Frequency of obs

Every

hourly

Date 30/11

Time 18:00

Initial SNM


Respiratory Rate

(Over 1 minute)

a




180

170

160

150

140

130

120

110

100

90

80

70

60

50

40

30

BP

NO

T u

se

d t

o c

alc

ula

te P

EW

S

A

B

C

Conscious Level

Normal

Decreased

Temperature

°C


EX

AM

PL

E

40

39

38

37

36

35



O2 Saturation % 95


50

40

30

20

10

0

Name

Date of Birth

NHS Number

Consultant

Ward

PEWS Form

13 + Years

X

X

5


Total PEWS 0

-2

3-4

5-6

Children’s Ward & CCNT IV at home SOP – M.Wallace RNC June 2014 - 40 -

3

4

PEWS Escalation Aid

Remember: If you feel you need more help at any time, call for help – regardless of PEW Score S

Situation:






B

Background:








A

Assessment:


and I have…


OR


is deteriorating

OR


R

Recommendation:

I need you to…


AND







Nurse in charge & Doctor MUST review & inform Consultant Increase frequency of observations to 1/2hrly -hourly

Nurse in charge & Consultant MUST review Continuous monitoring in place. Observations should be documented a minimum of every 15 mins

0 1

2

5 6






01/01/12 09:00 5 SN Morton 09:15 ED consultant called Anaesthetic

review Sister JACKS

Name

Date of Birth

NHS Number

Consultant

Ward

PEWS Form

13 + Years


Appendix 7 – Results Algorithm

INTEGRATED CARE PATHWAY FOR THE MANAGEMENT OF ACUTELY ILL CHILDREN REQUIRING INTRAVENOUS AND INTRAMUSCULAR MEDICATIONS AT HOME [UP TO 14

DAYS]

Algorithm to follow when blood culture results are available

What are the results of the child’s blood

cultures?

Do you have any concerns about this

patient despite clinical indicators showing

improvement?

Positive?

CCNT completes audit and faxes GP discharge sheet (found at end of

this audit)

Discharged from the service when

appropriate.

CCNT informed of the

continuation of IV antibiotics with a stop/review date clearly indicated. CCNT to be given

copy of new

prescription

Further IV treatment will require the child to return

to POBS for a ward review.

Child will require a new

prescription to be completed and the ICP

confirmation to be countersigned by the

assessing doctor.

Ward clinician informed of concerns. Review of

patient required to determine further management plan.

Cannula left in place until decision on further

treatment. Family offered ongoing support from

CCNT.

Contact made with consultant on call/child’s consultant for a plan of

further management.

Negative?

No Yes


Appendix 8 – Anaphylaxis Algorithm

***** DIAL 999 AND GET HELP *****

Documents

THE MANAGEMENT OF ACUTELY ILL CHILDREN · PDF fileStandard Operating procedures (SOP) Holistic Intravenous Therapy Service (HITS) ... clinical governance Paediatric clinical governance