All Sites IV THERAPY GUIDELINES VIA PERIPHERAL VASCULAR DEVICES FOR ADULTS IN A COMMUNITY SETTING/HOSPITAL. Vicky Preece.

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1 Trust Guideline All Sites IV THERAPY GUIDELINES VIA PERIPHERAL VASCULAR DEVICES FOR ADULTS IN A COMMUNITY SETTING/HOSPITAL Lead Clinician (s) Vicky Preece Jill Doyle Associate Director of Nursing IV Therapy Team Leader Lead Director Sandra Rote Director of Clinical Development and Executive Nurse Ratified by Worcestershire PCT Quality and Safety Group This Policy should not be used after end of: Links into Healthcare Standard: Impact Analysis (Race equality) Impact Analysis (Mental Capacity Act) 26 th September 2007 September 2009 These guidelines apply to adult patients only All healthcare professionals must exercise their own professional judgement when using guidelines. However any decision to vary from the guideline should be documented in the patient records to include the reason for variance and the subsequent action taken. WORCESTERSHIRE PCT Page 1 of 26

2 CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Vicky Preece Associate Director of Nursing Jill Doyle IV Therapy Team Leader NB. These guidelines were adapted from the Worcestershire Acute Hospitals NHS Trust Policy for Intravenous Medication key individuals involved in developing the guidelines were: R Stock Practice Facilitator Professional Development H Gentry Senior Infection Control Nurse, Alexandra Hospital A Smith Principal Pharmacist Medicine Safety, Worcs Acute Trust Circulated to the following individuals for comments Name Designation Ann Butterworth ICT District Nurse Carole Clive Nurse Consultant Infection Prevention and Control Beth Housden ICT District Nurse Lindy Lovell ICT Team Leader Sue Lunec Senior Pharmacy Advisor Debbie Narburgh Team Leader, Wyre Forest Community Unit Sally-Ann Osbourne Intermediate Care Manager Tracy Walker ICT Community Staff Nurse Maria Wilday Hospital Matron/Manger POWCH Karen Young Matron Pershore Cottage Hospital WPCT IV Therapy Guidelines Page 2 of 26

3 CONTENTS NO TITLE PAGE 1 Introduction 4 2 Competencies required 4 3 Patients covered 5 4 General principles 5 5 Responsibilities of medical staff Responsibilities of nursing staff 6 7 Peripheral Vascular Devices 71. Site Selection 7.2 Procedure 7.3 Care of cannula 7.4 Complication and Prevention 7.5 Removal of cannula Documentation 11 9 Examination of IV containers and fluids Preparation of intravenous fluids for administration Intravenous administration by direct intravenous (Bolus) 13 injection via peripheral cannula 12 Procedure for reconstituting and drawing up intravenous 14 drugs 13 Adverse reaction/anaphylaxis during/following intravenous 15 therapy 14 References Appendix 1 IV Injections for Adults for administration in Intermediate Care, Version 5 Appendix 2 Potassium Chloride Infusions 23 Appendix 3 Peripheral Vascular Devices Record Sheet Appendix 4 - Department of Health (2005) Saving Lives Programme 26 WPCT IV Therapy Guidelines Page 3 of 26

4 1. INTRODUCTION This policy is intended to be used in conjunction with: Worcestershire Primary Care Trust Medicines Policy Worcestershire Primary Care Trust Resuscitation Policy Worcestershire County Guidelines on Anaphylaxis Treatment Worcestershire Non Acute NHS Infection Control Guidelines The policy covers the administration of all medicines administered via a Peripheral Vascular Device. The policy is intended for use by: Registered Nurses who are administering IV medication via this route Medical Staff and General Practitioners working on behalf of the PCT. 2. COMPETENCIES REQUIRED A Registered Nurse who has undertaken training recognised by the Trust and assessment in practice can perform the administration of Intravenous (IV) Medication and the insertion of Peripheral Vascular Devices (PVDs). The nurse must demonstrate validated competency in clinical judgement and practice and maintain their knowledge and skills (RCN 2003). The nurse will at all times, act in accordance with the NMC Code of Conduct: Standards for Conduct, Performance and Ethics (2004). It is the responsibility of the Trust to provide training in IV therapy associate skills and to ensure that all relevant staff maintain their competency by attending regular, mandatory, updates every 3 years. Medical Officers/GPs should ensure that they are familiar with this policy on responsibilities concerned with the addition of medicines to intravenous infusion fluids. Medical officers or any trained nurses who have attended a cannulation course can establish peripheral vascular access for the administration of medicine by the IV route. An appropriately trained and competent nurse is able to administer all prescribed intravenous drugs including first doses, and should be able to handle any anaphylactic reactions. It is the Nursing & Midwifery Council s recommendation that, in the majority of circumstances, a first level registered nurse, a midwife or a second level nurse, each of whom has demonstrated the necessary knowledge and competence, should be able to administer medicines without a second person. It should be noted, however, that the incidence of human error is reduced when administration of drugs are double checked. It is, therefore, recommended that a second person should check administration of medicines intravenously (bolus or infusion). However, the Trust recognises that ward-based nurses, District Nurses, community nurses and practice nurses, who work alone cannot realistically undertake a double check involving two persons. WPCT IV Therapy Guidelines Page 4 of 26

5 A student nurse under the supervision of a trained nurse, is permitted to replace fluid only bags, if the trained nurse is satisfied with their competence. 3. PATIENTS COVERED All adult patients requiring medication via the intravenous route through a Peripheral Vascular Device that are either assessed as suitable for receiving IV therapy in the community, or meet an agreed local criteria if in place. 4. GENERAL PRINCIPLES 4.1 Drugs may be given intravenously by one of the following methods:- a) Direct injection (bolus) into a vein b) Direct injection into infusion line tubing (bolus) c) Intravenous infusion either continuous or intermittent Not all drugs may be given by intravenous bolus injection. Some drugs must be further diluted before administration. Some drugs must only be given by infusion. Some drugs must not be diluted before administration. 4.2 Nursing staff must familiarise themselves with the method of administration of the drug that they are to administer, by reference to the pharmacist, manufacturer's literature or the British National Formulary (BNF). Package inserts can be consulted but should not be removed from the drug packages. NB: Nurses working in the PCT who administer IV drugs can refer to the I.V. Injections for Adults for Administration in Intermediate Care Version 4 that has been developed by the pharmacy team at the Alexandra Hospital, Redditch. (APPENDIX 1). Please note that individual hospitals may advise separately for different drugs but this appendix can be referred to by nurses working across the PCT. It is a guide to the most frequently prescribed drugs for intravenous administration and is NOT intended to be exclusive of any other drugs that may be prescribed. 4.3 Two or more drugs should not be mixed together unless the compatibility has been confirmed. Where more than one drug is given intravenously, the line should be flushed between the separate drugs (usually with sodium chloride 0.9%). If you are required to administer by bolus or infusion 3 separate drugs, you are advised to check that the prescribed drugs are compatible by contacting a pharmacist. Advice can be sought from the pharmacy department at Worcestershire Acute Hospitals NHS Trust or through an on-call pharmacist. 4.4 DRUG CALCULATIONS the calculation of IV drug doses is a potential source of error. All trained nurses/medical officers must be satisfied that they have the ability to calculate drug doses safely and accurately. If in any doubt, contact the pharmacy department at Worcestershire Acute Hospitals NHS Trust where there is a service level agreement with the PCT for clinical support. WPCT IV Therapy Guidelines Page 5 of 26

6 5. RESPONSIBILITIES OF MEDICAL STAFF 5.1 It is the responsibility of all Medical Officers/GPs prescribing intravenous medicines to ensure that they are appropriate for this route, and take into account the stability and incompatibility information. 5.2 If in doubt, Medical Officers/GPs should seek information from a pharmacist or Consultant Microbiologist. 5.3 Medical officers/gps must write intravenous prescriptions clearly and IN CAPITALS on the relevant IV medication/prescription chart. 5.4 Medical officers are responsible for establishing the administration of all medicines by intravenous route. This may be delegated to an appropriately trained person who has attended and attained competency on a PCT approved cannulation course. A registered nurse may add authorised medicines to an infusion fluid container to be given via an established IV line in line with the Trusts Medicine Policy paragraph RESPONSIBILITIES OF NURSING STAFF 6.1 A registered nurse may add authorised medication to an IV infusion fluid container or pump and administer prescribed intravenous drugs in line with these guidelines if: The registered nurse has completed training recognised by the PCT, and attained competency in the administration of IV drugs before administering drugs via the intravenous route and making additions to infusion bags or Has evidence of prior competency. A registered nurse, or student under the supervision of a registered nurse, is permitted to replace infusion bags, if s/he is satisfied with her/his competence and mindful of her/his personal accountability Nursing staff will be expected to have documentary evidence of competence and evidence of regular updated training in line with the PCT mandatory training requirements. 6.2 The registered nurse is responsible for:- Checking the prescription/medication chart Checking the container and fluid show no obvious faults or contamination. Checking the expiry dates of all drugs and fluids. Ensuring that the prescribed product is administered to the right patient. Checking that the intravenous line remains patent Ensuring the IV lines are changed, in accordance with EPIC 2 guidance (2007) and Department of Health (2005): Administration Sets for Clear fluids - every 72 hours. In general solution administration sets in continuous use need not be replaced more frequently than at 72 hour intervals unless they become disconnected or the device is replaced. WPCT IV Therapy Guidelines Page 6 of 26

7 Administration sets for blood and blood components should be changed when the transfusion is complete or every 12 hours whichever is sooner, or according to manufacturers recommendations. (EPIC 2007) Administration sets used for total parenteral nutrition infusions should generally be changed every 24 hours. If the solution contains only glucose and amino acids, administration sets in continuous use do not need to be replaced more frequently than every 72 hours. NB. if at any time the administration set is disconnected, it must be discarded and a new set attached. Regular observation of the site for signs of infection should occur as a minimum each time the devices is accessed or on a daily basis whichever is the more frequent. The Phlebitis score should be documented and any abnormality reported. Re-siting of the peripheral vascular device should occur if the phlebitis score is above zero (see page 11 of this guideline for further information). Department of Health (2005) Flushing the IV line/device before and after administration with 5 10 mls of 0.9% Sodium Chloride or other agent prescribed for the purpose. NB. Suitably trained nurses may administer up to 5mls of 0.9% Sodium Chloride to establish initial patency of a peripheral intravenous cannula Maintaining the infusion at the prescribed rate, either manually or electronically. In the latter case the nurse must have received appropriate instruction with regard to the use of electronic pumps/infusion devices. Observing and reporting on the condition of the patient and maintaining patient records. 7.0 PERIPHERAL VASCULAR DEVICES Intravenous therapy is becoming ubiquitous in health care, impacting on nurses, midwives and many other health care professionals daily practice (Finlay 2004). Safe, simple and reliable venous access is necessary to meet the needs of any patient requiring a vascular access device (VAD), to ensure that his or her prescribed treatment is as comfortable and uneventful as possible (Gabriel 2005). A Peripheral Vascular Devices (PVD) provides an easy method of obtaining instant intravenous access with minimal complications (Finlay 2004). The following guidance is intended to improve patient care in the insertion and management of PVD s by standardising practice and is based on current knowledge and evidence. The use of extension lines is desirable. They help reduce mechanical phlebitis, combat bacterial contamination and maintain the patency of the cannula for longer. A bionector on the extension line needs to be changed every 100 accesses or every 7 days, whichever occurs first. However, at present they are not universally in use across the PCT. WPCT IV Therapy Guidelines Page 7 of 26

8 Before the practitioner is allowed to cannulate independently the following criteria must be met; The practitioner will have received theory & practice relating to IV cannulation via a course recognised by the PCT. Achievement of 10 successful supervised cannulations by a competent mentor or 1 successful cannulation if evidence of prior competency can be shown. Nursing staff will be assessed as above, and will be expected to have documentary evidence of competence and evidence of regular updated training in line with the PCT mandatory training requirements. It is expected that Medical Practitioners will have undertaken competency based training in accordance with their own medical training. Health Care Assistants are able to remove peripheral venous devices only if they have completed the Intermediate Skills Programme (provided by Central Training Services) and can demonstrate their competency via a completed certificate of competency for that specific skill. Peripheral vascular devices should be removed as soon as they are no longer required. Devices requiring re-siting should be routinely replaced every hours unless phlebitis score or clinical need indicates requirement for earlier change. If venous access is limited, the cannula can remain in situ if there are no signs or symptoms of infection and following a local documented risk assessment. (Department of Health 2005). NB. In these circumstances, the practitioner should document the reason for leaving the cannula in situ for longer than 72 hours on the Peripheral Vascular Device Record Sheet (appendix 3). 7.1 SITE SELECTION It is important to make a full assessment of the patient and their veins before the vein and the device are chosen. When selecting a vein for cannulation there are a number of factors, which should be taken into consideration Insertion site Condition of the vein Purpose of the infusion (rate and solution to be infused) Duration of therapy over 7 days consider alternative device The sites of choice are branches of the metacarpal veins, basilic vein, the cephalic vein and the median cubital vein in the antecubital fossa. The Metacarpal veins are accessible easily visualised and palpated and are well suited to short term or outpatient IV therapy. Please note that these veins are WPCT IV Therapy Guidelines Page 8 of 26

9 contraindicated in the elderly as there is diminished skin turgor and loss of subcutaneous tissue making the veins difficult to stabilise (Whitson 1996) Preference should be given to a vessel which is unused, easily detected by inspection and or palpation, patent and healthy. These veins feel soft, bouncy and will refill when depressed. They should be straight and free of valves to ensure easy advancement of the cannula into the vein. Valves can be felt as small bumps in the vein or may be visualised at bifurcations (Mallet & Bailey 1999). VEINS TO AVOID Visual inspection will enable the practitioner to avoid areas of phlebitis, infection or oedema, bruised or inflamed veins, or any veins which have undergone multiple punctures. If previous phlebitic or infiltrated areas are used for cannulation, accurate site assessments cannot be performed. Also if damaged veins are used, greater injury to the skin and vein will occur (Perucca 1995) Using veins which are tender, sclerosed, thrombosed, fibrosed or hard is unacceptable and can result in pain and undue stress (Weinstein 1993) It is important to note that veins should not be re-cannulated at a point lower than a recently used site in the same vein. Healing will be adversely affected as the vein continues to be used for infusion. Problems relating to phlebitis, thrombophlebitis and infection could be exacerbated for the same reason (Finlay 2004) 7.2 PROCEDURE (See Appendix 4 for a complete summary of infection control considerations) a) Prepare all equipment needed to cannulate the patient b) Approach the patient and explain the procedure and gain their consent. Ascertain any previous problems the patient may have had and any allergies. c) Wash and dry hands or use alcohol hand gel if hands are visibly clean. Use a recognised procedure for Hand Hygiene and put on appropriate single use nonsterile gloves. d) Create adequate venous filling by applying a tourniquet designed for the purpose to the upper arm on the chosen side, 5-10cms above the cannulation site. The tourniquet should be tight enough to obstruct venous return but not arterial flow (you should still be able to feel a pulse):- Use the non-dominant area where possible. NOTE. Caution the recommendations for tourniquet application is no more than 1 minute prior to venepuncture and no more than 2-3 minutes for the whole procedure (Cella & Watson 1989). Tourniquets should be visibly clean and decontaminated in accordance with the manufacturers guidance. In some areas of the Trust the use of disposable single use tourniquets may be considered. Avoid limbs with compromised circulation (i.e. lymphoedema or arm following breast surgery) Avoid veins that have had recent venepunctures Avoid joint areas Avoid access near long term indwelling devices WPCT IV Therapy Guidelines Page 9 of 26

10 e) If necessary, encourage venous filling by tapping the vein lightly, gently opening and closing the fist, lowering the extremity below heart level, by applying a warm compress or immersing the limb in warm water. f) Clean the selected skin site using either a 2% Chlorhexidine Gluconate Swab with 70% Isopropyl Alcohol or a 70% Isopropyl Alcohol Swab (Steret) and allow to dry. If the patient has a sensitivity use a single patient use povidone iodine application. The prepared skin area should be 4-5 cms in diameter and the solution applied in a circular motion from the insertion site outwards, (Perucca 1995). The skin should be cleaned for 30 seconds 1 minute (Weinstein 1993). The area should be allowed to air dry for a minimum of 30 seconds. Fanning, blowing or blotting of the prepared area is contraindicated (Dougherty & Lamb1999). Do not re-palpate the vein or touch the skin. d) Remove the device from the packaging and inspect for any faults. e) Anchor the vein by applying manual traction on the skin a few centimetres below the proposed insertion site with the non-dominant hand f) Using the dominant hand insert the IV device, bevel side uppermost, into the skin at an angle of 15-40º (dependent on the depth of the vein). g) Entry of the needle tip into the vein is indicated by the presence of blood in the flashback chamber. h) Level the device by decreasing the angle between the cannula and the skin and advance the cannula a further 2 mm into the vein. This ensures that both stylet and cannula have entered the vein. i) Either hold the stylet stationary while advancing the cannula off the stylet OR withdraw stylet slightly so that the stylet is within the cannula but still accessing the vein, observe for secondary flashback and slowly advance cannula and stylet as one into the vein. j) Release the tourniquet, apply pressure to the vein above the cannula tip (to avoid blood spillage) and remove stylet completely. k) Dispose of the stylet immediately into an appropriate sharps container at point of use l) Attach the injection cap, administration set or an appropriate primed extension set, for example - Vygon Octopus with Bionector. m) Secure the cannula with a sterile, semi permeable transparent dressing to allow observation of insertion site. eg - Smith & Nephew IV Flush the cannula with 2-5 mls of 0.9% normal saline using a push-pause method to check patency, observing the site for signs of swelling or leakage. Ask the patient to report any pain or discomfort. n) Document on the Peripheral Vascular Devices record sheet who inserted the cannula, the type and gauge of the cannula, site used and the reason for the cannulation. Date of removal of the device must also be recorded in the clinical record. WPCT IV Therapy Guidelines Page 10 of 26

11 o) Practitioners should only make two attempts at cannulation. If both attempts fail the procedure should be referred to a more experienced colleague. 7.3 CARE OF PERIPHERAL VASCULAR DEVICE Site should be inspected daily and before and after intermittent injection of drugs, for signs of phlebitis, inflammation or infiltration. Remove and re-site cannula if phlebitis score stage 1 or above, if the device is still required. Phlebitis Score is 0 SIGNS No pain or symptoms apparent. ACTIONS Continue to monitor Phlebitis Score is 1 SIGNS Pain or redness around insertion site ACTIONS Remove & replace cannula in a different site Continue to observe site Phlebitis Score is 2 SIGNS Pain, swelling, redness, palpable venous cord ACTIONS Remove & replace cannula in a different site, if still required. Continue to observe site and involve medical team to assess for systemic symptoms Phlebitis Score is 3 SIGNS Pain, swelling, induration, redness, palpable venous cord above 3cm, presence of pus, pyrexia ACTIONS Remove cannula, send tip to microbiology for Cultures and Sensitivity (C&S). Arrange for a set of blood cultures to be taken and involve medical staff to assess for systemic symptoms and discuss treatment with microbiologist. Phlebitis Score is 4 SIGNS Pain, swelling, induration, redness, palpable venous cord above 3cm, presence of pus, pyrexia and tissue damage ACTIONS Remove cannula, send tip for Cultures and Sensitivity (C&S). Take set of blood cultures and involve medical staff to assess for systemic symptoms and discuss treatment with microbiologist. Complete an incident form. Routinely, peripheral vascular devices should be removed and/or re-sited every hours unless phlebitis score or clinical need indicates requirement for earlier change. If venous access is limited, the cannula can remain in situ if there are no signs or symptoms of infection and following a local documented risk assessment. WPCT IV Therapy Guidelines Page 11 of 26

12 Remove and change dressing carefully if wet or soiled using a clean no touch technique Always use a clean no touch aseptic technique and wear gloves when handling equipment and associated apparatus to avoid cross contamination. Administration sets should be changed every 72 hours for clear fluids; every 12 hours for colloid and blood products and every 24 hours for IV drug infusions/feeding. If at any time an administration set is disconnected it must be discarded and a new set attached. All connections should be checked for tightness and the port cap should be kept closed at all times Flush the cannula with 5 10 mls 0.9% sodium chloride prior to and following intermittent administration of IV therapy. NB. In circumstances in the community setting where cannula s are not being actively used, it is recommended to flush the cannula daily to maintain patency. 7.4 COMPLICATIONS AND PREVENTION Haematoma: - To avoid insertion related haematoma ensure adequate venous filling and plan procedure carefully. To prevent withdrawal haematoma apply pressure for 3-4 minutes after removal of cannula. Infiltration and extravasation: - Avoid areas of flexion wherever possible, use flexible plastic cannula and ensure good fixation of cannula. Thromboembolism: - Avoid using veins in the lower extremities. Use the smallest gauge cannula into the largest vein possible for the treatment required. If an infusion stops as a result of clot formation the cannula should be re-sited. Flushing the cannula to dislodge a clot should not be attempted Air Embolism: - Ensure all devices attached to cannula primed and all air removed. Ensure infusions are discontinued before bag or bottle completely empty. Ensure all luer lock fittings are hand tight Phlebitis and septicaemia :- Use a clean no touch technique aseptic techniques; choose smallest gauge cannula for prescribed treatment; good secure fixation; Dilute and administer irritant drugs as prescribed; check cannula site and document cannula site daily and before and after intermittent injection of drugs; rotate site every time cannula is re-sited; use polyurethane catheter wherever possible. 7.5 REMOVAL 0F PERIPHERAL VASCULAR DEVICE Prepare all equipment needed to remove device from the patient Explain the procedure and gain patient consent. WPCT IV Therapy Guidelines Page 12 of 26

13 Wash and dry hands or use alcohol hand gel if hands are visibly clean. Use a recognised procedure for Hand Hygiene and put on appropriate single use non-sterile gloves. Remove dressings (Do not use scissors) Hold a piece of dry sterile non linting gauze over insertion site and remove cannula Apply firm pressure for 2-3 minutes or until bleeding has stopped. Elevate arm if bleeding persists. Apply fresh sterile non linting gauze and secure with tape Check device to ensure cannula is complete and undamaged 8.0 DOCUMENTATION 8.1 All intravenous infusion therapy must be given in accordance with the instructions prescribed by the medical officer/gps on the appropriate medication book/chart. 8.2 When using syringe drivers/pumps, the size of the syringe to be used must be specified and be in accordance with the manufacturer s recommendations. 8.3 When a medicine has been added to an infusion an additive label MUST be attached to the container or syringe with the following information, ensuring that no information details/graduation markings are obscured: a) Patient s name b) Name of ward if applicable c) Name and dose of the medicine d) Date and time of the addition e) Signature of those making and checking the additions NB. Additive labels may not be necessary for infusions delivered to patients in their own home but ONLY if the patient is accompanied by a nurse for the complete duration of the infusion AND only if the nurse is the same individual who has added the drugs to the infusion. If there is a change of nurse staying with the patient during an infusion, then an additive label MUST be used. 8.4 On cessation of an infusion i.e. on the death of a patient or discontinuation of the infusion, the remainder should be destroyed and a record to this effect must be made in the appropriate drug book/medication chart and nursing notes. Depending on the nature of the drug infused, any remainder that has been prepared should be disposed of in a yellow topped sharps bin appropriate for the disposal of sharps/syringes contaminated with medicinal products and their residue, unless the syringe/vial contains a controlled drug (this should be rendered irretrievable by emptying into a sharps bin followed by the placing of the syringe/vial into the sharps bin. WPCT IV Therapy Guidelines Page 13 of 26

14 a cytotoxic or cytostatic drug was being administered, this must be disposed of into a purple topped sharps container. Waste should be appropriately segregated prior to disposal and consigned in accordance with HTM 07:01 relating to the safe management and disposal of health care waste. Any unused medication in the home setting should be returned to a community pharmacy for disposal by the patients relatives/carer. Further guidance can be obtained from the PCT Medicines Policy. 9.0 EXAMINATION OF IV CONTAINERS AND FLUIDS 9.1 The Container should be examined for:- Cracks Faults in the plastic Defects in the closure, or other damage. The Fluid should be examined for:- Particles Cloudiness Change in colour 9.2 Evidence of defects should lead to rejection of the container. Rejected containers should be labelled and returned to the dispensing pharmacist as soon as possible, with details of the nature of the defect in case it has implications for other drug/product stocks PREPARATION OF INTRAVENOUS FLUIDS FOR ADMINISTRATION 10.1 A strict no touch aseptic technique should be used when preparing and administering intravenous drugs Addition of medicines to intravenous fluids: Only prescribed medicines should be added to infusions. When continuous infusion is prescribed, the medicine must be THOROUGHLY mixed with the fluid and given slowly. Prepare the solution immediately before administration and use within time stated on the package insert. NB Potassium Chloride infusions are not generally administered or recommended in a community hospital or community setting. For specific advice in administration of Potassium Infusions, please see appendix 2. Registered nurses should be aware that for intravenous use most antibiotics should be given intermittently. Multiple additions of medicines to a fluid should be avoided. WPCT IV Therapy Guidelines Page 14 of 26

15 Medicines should not be added to, or run through the same giving set as:- Blood Lipid Preparations Plasma Mannitol Parenteral Amino Acids Sodium Bicarbonate Total Parental Nutrition 10.3 The examination of the IV drugs and fluids procedure should be repeated after adding and mixing any medicine and again during administration, rejecting the solution if any opalescence or precipitation is present, and immediately inform the prescriber and pharmacy department for advice A label should be attached to the container with the added medicine Infusion pumps must be used when administering drugs via an infusion in a community ward/unit environment. For IV infusions administered in the community setting, it is best practice to use an infusion pump as this helps avoid the risk of the infusion running through at speed. Where infusion pumps are used, it is important that staff receive training in the correct use of the equipment and in the fundamental technical issues related to that pump (Medical Devices Agency, 1995) INTRAVENOUS ADMINISTRATION BY DIRECT INTRAVENOUS (BOLUS) INJECTION VIA PERIPHERAL VASCULAR DEVICES This is used to give a small volume of drug into a cannula or injection port of the administration set, using a size 10 or 20 ml syringe/needle. This may take a few seconds, as in an emergency, to get maximum concentration of the drug to vital organs, or 3 to 5 minutes, as for most antibiotics unless specific time stated Administration into the injection port of a fast running infusion may be advised if the infusion is compatible. Alternatively a stop-start procedure is employed. If the infusion is incompatible with the drug, the line must be switched off and 5 10 mls Sodium Chloride Solution 0.9% used as a flush between and after the administration, to prevent interactions. The insertion site should be checked throughout the procedure for swelling or redness Patients must be consulted constantly about any pain or discomfort they may be experiencing. This procedure may be carried out via: The injection port of any intravenous administration set. The capped port of the peripheral cannula. NB: Use 70% isopropyl alcohol (Steret) or 2% chlorhexidine gluconate in a 70% isopropyl alcohol and allow to dry prior to accessing the device for the administration of fluids or bolus. Which ever route is accessed for drug administration, it must be cleaned prior to procedure. WPCT IV Therapy Guidelines Page 15 of 26

16 11.4 Registered nurses should ensure that: There are no incompatibilities prior to administration. The line or port should be flushed with 2 to 5ml 0.9% Sodium Chloride after administration of the drug, or between more than one prescribed drug, to maintain the patency of the line and reduce risk of incompatibility. The injection port of the cannula should be recapped after use. If caps have been removed to administer drugs, replace with new sterile caps When administering an infusion via a syringe pump then either the syringe pump should be connected to an I.V. access separate from a normal drip or if venous access is difficult, use a 3-tailed device with non-return valves PROCEDURE FOR RECONSTITUTING AND DRAWING UP INTRA VENOUS DRUGS. a) Ensure correct identification of the patient. Then check the cannula site for inflammation and pain and record phlebitis score. If the phlebitis score is above 1, the IV cannula should be replaced (refer to page 11). b) Collect all the equipment required to give the drug. Check that the packaging of all equipment is intact prior to use. c) Check the drug against the appropriate drug book/medication chart and check the expiry date. Also check the compatibility between the drug and the reconstitution/insertion fluid. d) Wash and dry hands or use alcohol hand gel if hands are visibly clean. Use a recognised procedure for Hand Hygiene and put on appropriate single use nonsterile gloves. e) Open the vial of diluent and draw up the appropriate amount using a blue 22 gauge needle attached to the syringe. f) Flick the cap off the drug vial. The exposed rubber bung will only need cleaning if contaminated during the process. Use a 70% Isopropyl Alcohol swab to clean the bung and leave it to dry. g) Inject sufficient fluid into the vial to dissolve the drug. h) To avoid aerosol formation, keep the needle above the fluid and withdraw air from the vial equal to the amount of diluent inserted (e.g. 3 ml). i) Unless otherwise directed, gently agitate the diluent and the drug in the vial until the solution is clear. Keep the needle and syringe attached. Gently reinsert the air from the syringe into the vial. j) Draw up the drug solution from the vial into the syringe; angle the vial until the last few drops of the solution can be drawn up into the syringe. WPCT IV Therapy Guidelines Page 16 of 26

17 k) Disconnect the syringe containing the drug solution, leaving the needle in the vial. Place a new Blue needle on the end of the syringe if required. l) Put the prepared syringe, drug vial, diluent container and alcohol swab in a suitable receptacle. m) Carry out the pre and post line flushing of the cannula with 5 10 mls of normal saline using a push-pause method to check patency, observing the site for signs of swelling or leakage. Ask the patient to report any pain or discomfort. NB. It may be advisable to administer the pre flush before drawing up the prescribed drug, to prevent wastage of drugs if the line were found to be non-patent. n) Administer the drug and dispose of all equipment according to local waste management policy. o) Document the administration in appropriate drug administration chart/book 13.0 ADVERSE REACTION/ANAPHYLAXIS DURING/FOLLOWING IV THERAPY 13.1For full details please follow procedures as set out in the Worcestershire County Guidelines on Anaphylaxis Treatment. 13.2If a patient exhibits any adverse reaction during an infusion, if must be stopped and the medical officer/gp informed. It should only be continued on his/her decision. A full clinical history should be taken by the medical officer/gp, including symptoms, temperature, all current medication and the times and batch number of any infusion fluids given. 13.3Following a reported adverse reaction in a patient, any additional patients receiving infusions from the same batch (if known) should be observed. When the infusions are complete the containers should be retained for a period of 24 hours to ensure that they can be examined should any reaction follow. All suspect containers and accessories should be labelled and kept. 13.4The PCT Pharmacist should be informed immediately or as soon as possible. The incident should be fully documented in the patients notes and appropriate incident reporting documentation completed Nurse should be able recognise possible signs and symptoms of Anaphylactic shock as: o Angio-laryngeal oedema o Rash urticaria/erythema o Hypotension o Bronchoconstriction o Rhinitis/conjunctivitis o Abdominal pain, vomiting or diarrhoea o Collapse If anaphylactic reaction is suspected stop infusion or injection and follow anaphylaxis procedures WPCT IV Therapy Guidelines Page 17 of 26

18 REFERENCES FOR THE MAIN GUIDELINES Alexandra Hospital Pharmacy Department (Version 4, 2006). IV INJECTIONS for Adults - For Administration in Intermediate Care. Worcestershire Acute Hospitals NHS Trust. Cella J H, Watson J (1989) Obtaining peripheral blood specimens. Nurses Manual of Lab Tests. FA Davis USA Appendix 1 p DeCarolis, D, et al (1995) Nursing Intravenous Drug Handbook Pennsylvania: Springhouse Corporation Department of Health (2006) Environment and Sustainability - Safe Management of Healthcare Waste. Health Technical Memorandum (HTM) London. Dougherty, L. Lamb, J (2002) Intravenous Therapy in Nursing Practice London: Churchill Livingstone Mallett J. Bailey C. (1996) The Royal Marsden Trust Manual of Clinical Nursing Procedures 4th Edition Oxford: Blackwell Science Limited Medical Devices Agency (1995). Infusion Systems Device Bulletin. MDA DB 9503, May NMC (2004). Code of Conduct: Standards for Conduct, Performance and Ethics. London NMC (2004). The Standards for the Administration of Medicines London Pickstone M (1999) The Pocket Book for Safer IV Therapy (drugs giving sets and infusion pumps) Kent UK: Alpha Publishing RCN (1999) Royal College of Nursing Guidance for Nurses Giving Intravenous Therapy London RCN Scales K (1997) Practice and Professional Aspects of IV Therapy Professional Nurse Vol: 12 (supp 8) pp Springhouse Corporation (1993) Medication Administration and IV Therapy Manual 2nd Edition Philadelphia PA Springhouse Corporation Todd J (1998) Peripherally Inserted Central Catheters Professional Nurse Vol: 13 No 5 REFERENCES IN RELATION TO PERIPHERAL VASCULAR DEVICES Worcestershire PCT would like to acknowledge the kind agreement of the Worcestershire Acute Trust in allowing us to use their protocol for the Insertion of Peripheral Vascular Devices. WPCT IV Therapy Guidelines Page 18 of 26

19 Department of Health (2005) Saving Lives. High Impact Intervention II Peripheral Intravenous Cannula Care Bundle. quiredinfection/healthcareacquiredgeneralinformation/thedeliveryprogrammetoreduc ehealthcareassociatedinfectionshcaiincludingmrsa/index.htm Department of Health (2006) Essential Steps to Safe Clean Care. quiredinfection/healthcareacquiredgeneralinformation/thedeliveryprogrammetoreduc ehealthcareassociatedinfectionshcaiincludingmrsa/index.htm Dougherty L and Lamb J (1999) Intravenous Therapy in Nursing Practice in nursing Practice Churchill Livingstone Edingburgh. Finlay T (2004) Intravenous Therapy Blackwell Science London Gabriel J (2005) Vascular Access: indications and implications for patient care. Nursing Standard March 9/vol 19/no 26/2005 Mallet and Baily C (1999) Vascular Access Devices: Insertion and Management in: Mallett J, Bailey C (eds) The Royal Marsden NHS Trust Manual of Clinical Nursing Procedures, 5 th Edition, Blackwell Science London Perucca R (1995). Obtaining Vascular Access in Intravenous Therapy: Clinical Principles and Practices (eds Terry J, Baranowski R A, Lonsway R A, Hedrick C) WB Saunders, Philadelphia Pratt R.J, et. al. (2007) EPIC 2. National Evidence Based Guidance for Preventing Healthcare Associated Infections in NHS Hospitals in England. Journal of Hospital Infection. 65 (supplement 1). February Weinstein S M (1993) Plumer s Principles and Practice of Intravenous Therapy. 5 th edition, J B Lippincott Philladelphia Whitson M (1996) Intravenous therapy in the older adult: special needs and considerations. Journal of Intravenous Nursing 19(5) WPCT IV Therapy Guidelines Page 19 of 26

20 Appendix 1 Sept 2007 Pharmacy Department Alexandra Hospital IV INJECTIONS for Adults - For Administration in Intermediate Care Version 5 Hospital doctors will ensure the prescribed dose is appropriate for the patient s renal and liver function Nurses For convenience, wherever possible the administration method shown here is IV bolus (except gentamicin, vancomycin, ertapenem and 2g ceftriaxone). Please use this method unless an infusion is necessary. AMOXICILLIN DRUG PRESENTATION METHOD & ADMINISTRATION Powder for reconstitution 250 or 500mg vials Dissolve with water for injection, 5ml for 250mg, 10ml for 500mg. Administer immediately after reconstitution as a bolus over 3-4 minutes. ADVERSE REACTIONS/MONITORING Anaphylactic reactions have been reported rarely. Discontinue if an itch or wheezing develops, a rash appears, or if there are any signs of collapse. BENZYLPENICILLIN Powder for reconstitution 600mg Dissolve with water for injection (10ml per 600mg). Administer over 1-2 minutes. Doses greater than 1200mg should be given at a rate of at least 1 minute per 300mg. Occasionally hypersensitivity to penicillin in the form of a rash. Anaphylactic reactions have been reported rarely - see amoxicillin. CEFOTAXIME 500mg, 1g & 2g powder Dissolve in water for injection : (250mg and 500mg in 2ml; 1g in 4ml; 2g in 10ml). Can be given as a bolus over 3-5 minutes. Diarrhoea and rarely pseudomembraneous colitis or allergic reaction. Anaphylactic reaction have been reported rarely see amoxicillin. MONITORING With high doses (greater than 8g daily) and concurrent aminoglycosides (gentamicin or tobramycin) or potent diuretics such as frusemide, renal function may be adversely affected: check U & Es 2-3 days after discharge. CEFTAZIDIME Powder for reconstitution 250mg, 500mg, 1g and 2g vials Dissolve with water for injection or sodium chloride 0.9% (250mg in 2.5ml, 500mg in 5ml and 1 and 2g in 10ml). Administer slowly over 3-5 minutes. NB. As the antibiotic dissolves, carbon dioxide is released causing frothing which clears quickly. Any small bubbles remaining in syringe are carbon dioxide and can be injected without ill effects. Phlebitis, thrombophlebitis and hypersensitivity reactions are rare. Anaphylactic reactions have been reported rarely - see amoxicillin. Reduced dose in renal impairment. MONITORING With high doses (greater than 4g daily) and concurrent aminoglycosides (gentamicin or tobramycin) or potent diuretics such as frusemide, renal function may be adversely affected: check U & Es 2-3 days after discharge. CEFTRIAXONE Powder for reconstitution 250mg, 1g & 2g Reconstitute with water for injection, 5ml for 250mg, 10ml for 1g. Give by slow intravenous bolus over 2-4 minutes, or via drip tubing. 2g should be reconstituted with 50ml -100ml glucose 5% or sodium chloride 0.9% and infused over at least 30 minutes. Care required in patients who have previously shown hypersensitivity (especially anaphylactic reaction) to penicillins or other non-cephalosporin beta-lactam antibiotics. Avoid if both renal AND liver impairment, or in patients with cholestatic jaundice. WORCESTERSHIRE PCT Page 20 of 26

21 ERTAPENEM DRUG PRESENTATION METHOD & ADMINISTRATION FLUCLOXACILLIN Powder for reconstitution 1g vial Powder for reconstitution 250/500mg vials Reconstitute 1g with 10ml water for injection or sodium chloride 0.9% Shake well to dissolve. Add to 50ml sodium chloride 0.9% and give over 30 minutes. Dissolve with water for injection, 5ml for 250mg, 10ml for 500mg. Give as an intravenous bolus over 3-4 minutes within 30 minutes of reconstituting. ADVERSE REACTIONS/MONITORING Most common side effects are: Headache. Diarrhoea. Nausea, vomiting. Rash, itching. Inflammation, formation of a lump, swelling at the injection site. Rarely: allergic reactions Very rarely: Anaphylaxis. Hallucinations. Anaphylactic reactions have been reported rarely - see amoxicillin. Avoid in liver impairment. CSM advise that cholestatic jaundice may occur up to several weeks after stopping treatment. Courses longer than two weeks and elderly patients at most risk. GENTAMICIN Multi dose vials 80mg in 2mls Dilute the prescribed dose in 100ml 0.9% sodium chloride and give over 60 minutes. Ototoxicity and nephrotoxicity can occur so serum levels should be monitored, especially in renal impairment. Nausea, vomiting and urticaria can be seen. MONITORING Check level 6 14 hours after the start of the first infusion. (Important - Record the infusion start time and the sample time precisely) and, similarly, twice a week thereafter, provided renal function remains stable. Check U & Es at same time. Do not omit doses while results awaited (unless side effects apparent seek advice) More frequent monitoring is needed where renal function is unstable.** Microbiology advice should be obtained for courses longer than 7 days. TAZOCIN TEICOPLANIN Powder for reconstitution 2.25g & 4.5g Powder for reconstitution 200mg & 400mg Reconstitute with either water for injection or saline (10ml for 2.25g or 20ml for 4.5g). Swirl (DO NOT SHAKE) until dissolved. Given by slow intravenous bolus over 3-5 minutes. Reconstitute each 200mg vial with 3ml water for injection supplied. Give 3ml. Reconstitute each 400mg vial with 3ml water for injection supplied. Give 3ml. DO NOT SHAKE. Give by slow intravenous bolus over 3-5 minutes. Serious and occasional fatal anaphylactic reactions have been reported in patients receiving therapy with penicillins. Reduced dose in renal impairment. Caution in patients known to be hypersensitive to vancomycin, since cross hypersensitivity may occur. Reduced dose in renal impairment. Check U & Es 2-3 days after discharge if patient has pre-existing renal impairment. VANCOMYCIN Powder for reconstitution 1g vial Reconstitute 1g vial with 20ml water for injections. Add resulting solution to 250ml of sodium chloride 0.9% or glucose 5% Maximum infusion rate = 10mg per minute (approx 2 hours for 1g dose) to avoid rapid infusion-related reactions Anaphylaxis, ototoxicity, nephrotoxicity. Monitor drug levels and renal function. Reduce dose in renal impairment. MONITORING Twice daily administration - check the pre-infusion level prior to the 3 rd or 4 th dose and twice a week thereafter. Check U & Es at same time. Do not omit doses while results awaited (unless side effects apparent seek advice.) Earlier and more frequent monitoring is needed in once daily administration and/or changing renal function.** Microbiology advice should be obtained for courses longer than 7 days. If giving more than one antibiotic, do not mix together. Flush with saline before and after each drug given. ** Contact Microbiologist or Medicines Information Pharmacist (via Hospital Switchboard) if further advice needed on dose reductions or monitoring ** Dr Anne Dyas, Consultant Microbiologist Rosemary Pickford, Community Services Pharmacist, Pharmacy, Alex Review date Sept 2008 WPCT IV Therapy Guidelines Page 21 of 26

22 IV Non antibiotic INJECTIONS for Adults - For Administration in Intermediate Care Version 2 Sept 2007 Pharmacy Department Alexandra Hospital Hospital doctors will ensure the prescribed dose is appropriate for the patient s renal and liver function Nurses For convenience, wherever possible the administration method shown here is IV bolus. Please use this method unless an infusion is necessary. DRUG PRESENTATION METHOD & ADMINISTRATION ADVERSE REACTIONS/MONITORING Furosemide 10mg in1ml solution for injection 2ml(20mg),5ml(50mg) and 25ml(250mg) ampoules Slow intravenous bolus injection. Doses above 80mg at a rate not to exceed 4mg per minute or Intravenous infusion in 0.9% sodium chloride. Doses above 80mg at a rate not to exceed 4mg per minute Cautions hypotension, prostatic enlargement, renal or hepatic impairment, pregnancy. Side effects hypotension, electrolyte disturbances, gout. With large parenteral doses tinnitus, deafness, pancreatitis. Monitor electrolytes Methylprednisolone Sodium Succinate 1 gram vials containing powder with water for injection as diluent for reconstitution NB For 1 gram, displacement value is 0.4ml i.e.1 gram when reconstituted with 15.6mls WFI produces a 1 gram/16ml solution Reconsitute the powder by adding the total contents of the water vial. Draw up the required dose. Doses up to 250mg may be given as a bolus over at least 5 minutes, but doses over 250mg should be given as an infusion in 100ml 0.9% sodium chloride or 5% glucose over at least 30 minutes Ref1. SPC 2. UCL Injectable Drug Administration Guide Steroids have many side effects, see package insert. They can be minimised by using the lowest effective dose for the minimum period of time. If giving more than one drug, do not mix together. Flush with saline before and after each drug given. ** Contact the Medicines Information Pharmacist (via Hospital Switchboard) if further advice needed on dose reductions or monitoring ** Rosemary Pickford, Community Services Pharmacist, Pharmacy, Alex Review date Sept 2008 WPCT IV Therapy Guidelines Page 22 of 26

23 Appendix 2 POTASSIUM CHLORIDE INFUSIONS NB. Potassium Chloride is treated as a controlled drug and must be signed for by 2 trained nurses and/or medical officer. Potassium Chloride for Addition to IV Infusion If Potassium Chloride is prescribed, solutions with Potassium Chloride included are available, and should be used whenever possible to avoid the need to add concentrated solutions of Potassium Chloride to infusions. All intravenous infusions containing Potassium Chloride should be delivered via a pump or syringe driver. This especially MUST be done when delivering any infusion containing more than 40mmol per litre. Where the strength needed is higher than 40mmol/litre the medical officer should take advice from a pharmacist before prescribing so that pre-mixed bags can be used wherever possible. Pre mixed IV fluids containing Potassium Chloride in various different strengths are available for administration. Potassium Chloride ampoules are only available at a pharmacy department, Intensive Care Units (including neonatal Intensive Therapy Unit (ITU)), High Dependency Units (HDU) and Critical Care Units (CCU). Only in these units will trained nurses be routinely permitted to add Potassium Chloride. In all of the other areas ONLY MEDICAL OFFICERS may add potassium, with the administration, including any calculation, checked by a trained nurse, other medical officer or a pharmacist. THOROUGH MIXING IS ESSENTIAL Potassium Chloride is treated a controlled drug and, in this instance, MUST be signed for by 2 trained nurses/midwives and or medical officer. WPCT IV Therapy Guidelines Page 23 of 26

24 Patient name.. Address/ Ward... Appendix 3 Worcestershire PCT PERIPHERAL VASCULAR DEVICE RECORD SHEET FOR COMMUNITY NURSING SERVICE OR COMMUNITY HOSPITAL To be completed daily for the life of the cannula. A new form to be started when and if the cannula is resited. REASON FOR CANNULATION (please circle all that apply) IV infusion / IV Antibiotics / Blood / Other (please specify) DETAILS OF INSERTION Date of insertion./../ Lot No of Cannula Expiry date of cannula. Cannula size/gauge (please circle) Insertion site (please circle) L or R - Hand / Wrist / Forearm / Anticubital Fossa / Other Dressing type : IV 3000 / Other (please state) Flush (please circle) Normal Saline 0.9% / Other (please state) mls / 10mls / Other (please state) Any problems on insertion (please state) Number of attempts at insertion (please circle) 1 / 2 / 3 / 4 NB seek assistance after 2 attempts Signature of person inserting cannula Please print name and designation Date and time of insertion WPCT IV Therapy Guidelines Page 24 of 26

25 PLEASE COMPLETE / MAINTAIN THE FORM OVERLEAF WHILST CANNULA IS IN PLACE To be completed daily or at each cannula access for the life of the cannula (New form to be started if cannula resited) Please state the reason for a cannula remaining in situ for longer than the recommended hours. DATE TIME CANNULA STILL REQ D Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No PHLEBITIS SCORE ANY TAKEN ACTION SIGNATURE REMOVAL OF CANNULA Reasons for removal (tick relevant box) Phlebitis score of 1 or above Infiltration Extravasation Treatment completed Patient discharged from service Other (please state) Evidence of infection Yes or No (please circle) Cannula tip sent for culture Yes / No Blood cultures taken Yes / No Treatment for infection commenced Yes / No If yes, please state Removal of cannula Date and time of removal of cannula Signature of person removing cannula Print name and designation WPCT IV Therapy Guidelines Page 25 of 26

26 APPENDIX 4 Department of Health (2005) Saving Lives Programme The Department of Health (2005) Saving Lives Programme details High Impact Interventions (HII) for the minimisation of healthcare associated infections, a summary of which are detailed below. The full publication and section relating to peripheral vascular devices which details simple evidence based tools to reinforce the practical actions that clinical staff need to undertake every time they access a peripheral vascular device is available at: eacquiredinfection/healthcareacquiredgeneralinformation/thedeliveryprogramme toreducehealthcareassociatedinfectionshcaiincludingmrsa/index.htm WPCT IV Therapy Guidelines Page 26 of 26