Management and Administration of Intravenous …...Management and Administration of Intravenous Medicines Policy Number: 25 Scope of this Document: Staff working within Community Services

COMMUNITY SERVICES DIVISION CLINICAL POLICY DOCUMENT

Management and Administration of Intravenous Medicines

Policy Number: 25 Scope of this Document: Staff working within

Community Services Division, who are responsible for the

administration of IV medicines Recommending Committee: N/A Approving Committee: Clinical Standards Group Date Ratified: January 2020 Next Review Date (by): January 2022 Version Number: 2020 – Version 6 Lead Executive Director: Executive Director of Nursing

& Operations Lead Author(s): IV Therapy Team

COMMUNITY SERVICES DIVISION CLINICAL POLICY

DOCUMENT

2020 – Version 6

Striving for Perfect Care and a Just Culture

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Policy 25 Management and Administration of Intravenous Medicines Version 6, 2020

COMMUNITY SERVICES DIVISION CLINICAL POLICY DOCUMENT

Management and Administration of Intravenous Medicines

Further information about this document:

Document name Management and Administration of Intravenous Medicines (025)

Document summary To provide the Division with a policy on the safe management

and administration of intravenous therapy services in the community

Author(s)

Contact(s) for further information about this document

Christine Roberts Service Lead Community IV Therapy

Telephone: 0151 475 4280 Email: [email protected]

Published by

Copies of this document are available from the Author(s) and

via the trust’s website

Mersey Care NHS Foundation Trust V7 Building

Kings Business Park Prescot

Merseyside L34 1PJ

Your Space Extranet: http://nww.portal.merseycare.nhs.uk Trust’s Website www.merseycare.nhs.uk

To be read in conjunction with

IC01 Infection, Prevention & Control 102 Peripheral Cannulation

SA36 Identification of Service users SA19 Management and Decontamination of Medical Devices

SA50 Management of Patient Group Directions IT04 Record Management

IT12 Information Governance IT15 Clinical Coding

SD06 Consent to Examination or Treatment SD51 NEWS2 – Management & Recognition of the Deteriorating Patient & the Recognition of Sepsis

54 Blood & Platelet Transfusion Policy 32 Cold Chain Policy

SA22 Waste Management SA02 Risk Management Strategy

SD34 Venepuncture Policy This document can be made available in a range of alternative formats including

various languages, large print and braille etc

Copyright © Mersey Care NHS Trust, 2015. All Rights Reserved

Version Control:

Version History: Version 5 Transferred onto new Mersey Care branded template June 2018

Version 6 Circulated to IV Team, ICCT, Infection Control and

Medicines Management for review. Changed focus to all IV medicines

October 2019

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mailto:[email protected]

http://nww.portal.merseycare.nhs.uk/Pages/MCNHSHome.aspx

http://www.merseycare.nhs.uk/

SUPPORTING STATEMENTS

This document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS

All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: • being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or

by professional judgement made as a result of information gathered about the child / adult; • knowing how to deal with a disclosure or allegation of child /adult abuse; • undertaking training as appropriate for their role and keeping themselves updated; • being aware of and following the local policies and procedures they need to follow if they have a child

/ adult concern; • ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team; • participating in multi-agency working to safeguard the child or adult (if appropriate to your role); • ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to

Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

• ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTS

Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy

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Contents

1. PURPOSE AND RATIONALE .................................................................................................. 5

2. OUTCOME FOCUSED AIMS AND OBJECTIVES ................................................................... 5

3. SCOPE .................................................................................................................................... 6

4. DEFINITIONS .......................................................................................................................... 6

5. DUTIES ................................................................................................................................... 8

6. PROCESS ............................................................................................................................... 9

6.1 Patient Eligibility Criteria ................................................................................................... 9

6.2 Consent .......................................................................................................................... 10

6.3 Medical Authorisation...................................................................................................... 11

6.4 Interdisciplinary/ Organisational Responsibilities across the Process .............................. 11

6.5 Legal Processes ............................................................................................................. 13

6.6 Procurement ................................................................................................................... 13

6.7 Procedural Techniques ................................................................................................... 14

6.8 Methods of Intravenous Drug Administration .................................................................. 14

6.9 Routes of Administration ................................................................................................. 14

6.10 Equipment ...................................................................................................................... 15

6.11 General Information to support staff administering IV therapy ......................................... 16

6.12 Process Pathway ............................................................................................................ 17

6.13 Adverse Incidents ........................................................................................................... 19

7. CONSULTATION ................................................................................................................... 21

8. TRAINING AND SUPPORT ................................................................................................... 21

9. MONITORING ....................................................................................................................... 21

10. EQUALITY AND HUMAN RIGHTS ANALYSIS .................................................................. 22

Appendices ................................................................................................................................... 25

Appendix 1 – Commonly used antibiotics administered intravenously in the Community Division .................................................................................................................................................. 25

Appendix 2 – Commonly used medicines (not antibiotics) administered intravenously in the Community Division ................................................................................................................... 29

Page 4 of 31 Policy 25 Management and Administration of Intravenous Medicines Version 6, 2020

1. PURPOSE AND RATIONALE 1.1 This policy will direct the safe management and administration of IV Medicines in

the community by appropriately trained registered nurses employed by Mersey Care NHS Foundation Trust - Community Services Division.

1.2 By providing an Intravenous Medicines Service in the community it will reduce the necessity for hospital admission or prolonged hospital admission.

1.3 “The complexities associated with prescribing, preparing and administering injectable medicines means that there are greater potential risks for patients than for other routes of administration. Weak operating systems increase the potential risk of harm and safe systems or work are needed to minimise these risks” (NPSA March 2007)

1.4 Mersey Care NHS Foundation Trust - Community Services Division is committed to ensuring that all staff are trained and equipped to perform their role effectively.

2. OUTCOME FOCUSED AIMS AND OBJECTIVES 2.1 Administration of IV medicines carries potential risks and should only be given if the

benefits outweigh these risks. Stringent systems need to be in place to ensure that the correct product is given to the correct patient at the correct time and that any adverse reactions are dealt with promptly and efficiently.

2.2 This policy will cover the referral into the service, including responsibilities and

clinical procedures relating to the administration of intravenous therapy by appropriately trained staff. This will be supported by full documentation.

2.3 The aim of this policy is to describe good practice for the safe preparation, checking, labelling, prescribing, administration and monitoring of injectable medicines: • To reduce risk and prevent harm to patients from injectable medicines

(reporting of incidents via Datix will be a measure) • To educate clinical staff on good injectable medicines practice (Learning &

Development Bureau will hold training records) • To standardise injectable medicine practice across the Trust • To comply with the NHS England patient safety alerts issued by Central Alerting

System (CAS) guidance


3. SCOPE 3.1 This document describes the clinical procedures for patients who are suitable to

have Intravenous Medicines in the community by the Community Intravenous Therapy Team, and District Nurses. It may be carried out in patients’ homes or in NHS Health Clinics.

3.2 This policy applies to all registered nurses employed by Mersey Care NHS

Foundation Trust - Community Services Division NHS Trust who have been trained and maintain their competencies in IV therapies and peripheral cannulation.

4. DEFINITIONS

Word/phrase/ abbreviation

Meaning

Bolus A large dose of a drug administered by rapid injection at 1ml/minute

Cannula A hollow tube designed for insertion into a body cavity such as a blood vessel. The tube contains a sharp pointed solid core (trocar) which facilitates its insertion and is removed when the cannula is in place.

Cannulation The procedure of inserting a cannula into the Vein.

Central IV Line A catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart.

Central Venous Catheter (CVC)

An indwelling catheter whose tip lies in the central venous system (lower third of the superior Vena Cava or right atrium. This type of catheter is often tunneled under the skin to a separate exit site where it emerges from underneath the skin. Passing the catheter under the skin helps to prevent infection and provides stability. Examples of such are single lumen leader cuff lines, double lumen Hickman lines, Single lumen Broviac lines, Groshing lines and peripherally inserted central catheter (PICC) lines.

Community Refers to the patient’s own home and also includes residential and nursing homes and community health centres.

Continuous Infusion The intravenous delivery of a medication or fluid at a constant rate over a prescribed time period ranging from several hours to days to achieve a controlled therapeutic response.

CPR Cardio Pulmonary Resuscitation


Direct Intermittent Injection

Also known as Intravenous Push or Bolus. The injection of a drug from a syringe into the injection port of the administration set or directly into a vascular access device.

Extravasation The leakage and spread of blood or fluid from vessels into the surrounding tissues, which follows injury, burns, inflammation and allergy.

GP General Practitioner Infiltration The abnormal entry of a substance into a cell, tissue

or organ.

Infusion The slow injection of a substance, usually into a vein.

Intermittent Infusion The administration of a small-volume infusion, generally 50 – 250ml, over a period of between 20 minutes and 2 hours.

Intravenous (IV) Refers to administering the medication directly into the vein.

Intravenous Midline Refers to the device that provides vascular access in a larger peripheral vein but without entering the central venous circulation. It is usually inserted in a vein near the elbow and a catheter threaded through the vein in the upper arm.

NEWS National Early Warning Score OPAT Outpatient Parenteral Antibiotic Therapy Parenteral Administered by any way other than through the

mouth. Peripheral Referring to or towards outer surrounding surfaces.

Peripheral IV Line (PVC or PIV)

A short catheter inserted through the skin into a peripheral vein (any vein not inside the chest or abdomen).

Phlebitis Inflammation of the wall of the vein. PICC Peripheral Intravenous Central Catheter. It is a device

that provides vascular access into the central venous circulation. It is usually inserted in a smaller vein in the upper arm (peripheral), and terminates in a larger vein in the chest near the heart (central). Port a Cath An implanted device situated in upper chest or upper arm. Requires a Hubber needle (safer sharps)


Positive pressure technique

The positive pressure technique for flush involves clamping the line while still flushing the last bit of saline so that there is little or no blood reflux into the catheter upon disconnection of the syringe.

Skin Tunneled Catheter

Refers to a device that is inserted into one of the large central veins. It is a long-term catheter that is tunneled under the skin to the desired site.

SPC Single Point of Contact

TPN Total Parenteral Nutrition

TPR + BP Temperature, Pulse, Respiration and Blood Pressure relating to clinical condition

Vascular Access Device (VAD)

A device inserted into a vein, which permits administration of intermittent or continuous infusion of parenteral solutions or medications. Also known as a cannula or venflon. These must be changed every 72 hours or before if there are two signs of phlebitis (see VIP score).

Visual Infusion Phlebitis Score (VIP)

A system for recognising signs or risks of infection at venous access sites.

VIIAD Visual Inspection Intravenous Access Devices.

5. DUTIES 5.1 Mersey Care NHS Foundation Trust - Community Services Division NHS Trust is

responsible for: a) Ensuring that appropriate training is in place so that qualified nurses can fulfil

their duties in accordance with this policy b) Providing the Hepatitis B vaccine free of charge to all employees at risk of

exposure to blood and body fluids in the course of their duties

5.2 The Director of Nursing is responsible for ensuring the implementation of this policy. This has been delegated to the IV Team Service Lead.

5.3 The Director of Nursing is responsible for ensuring that this document is reviewed,

and if required revised in the light of legislative guidance or organisational change. This process has been delegated to the IV Team Service Lead.

5.4 Senior Managers and Team Leaders are responsible for: a) The operational implementation of this policy and associated procedures b) Ensuring that appropriately trained staff are used to deliver the services (this

includes Bank staff and Agency staff) c) Ensuring that a planned audit cycle is in place

5.5 Registered health practitioners are responsible for:


a) Securing the Hepatitis B vaccine series b) Observing standard infection control precautions in particular hand hygiene,

wearing of protective clothing and safe handling and disposal of sharps c) Complying with the requirements of all relevant NHS Mersey Care NHS

Foundation Trust - Community Services Division policies applicable to their area of operation

d) Reporting all potential adverse incidents in line with Mersey Care NHS Foundation Trust - Community Services Division Risk Management Policy (including serious untoward incidents).

5.6 Health Care Professionals are responsible for: a) Staying with the patient during transfusion b) Baseline observations: temperature, blood pressure, pulse, respiratory

rate c) Bloods for cross matching

6. PROCESS

6.1 Patient Eligibility Criteria a) The clinician responsible for care must use their professional judgement to

determine the appropriateness of the individual patient for IV therapy based on the following criteria:

• The medical condition of the patient is suitable and stable ( HR = 50-110; RR

9-20; BP systolic = 90-200; temp between 37-39C; alert; orientated) • The patient does not require complex nursing/ medical interventions or care • The psychological condition of the patient is suitable and stable and does not

require complex nursing/ medical interventions or care b) The following conditions may be treated in the community:

• Bronchiectasis • Endocarditis • Hepatic abscess • HIV • Intravenous access device infections • MRSA infections • Osteomyelitis • Prosthetic joint infections • Septic arthritis/ bursitis • Soft tissue infections/ cellulitis • Palliative Care • Blood or platelet transfusion • Urinary tract infections (UTI) • Wound infections • Total Parenteral Nutrition (TPN) • Bisphosphonate therapy


• Diabetic foot ulcer infections • Palliative Care • Hydration • Spinal abscess • Meningitis

This list is not exhaustive or exclusive

c) Satisfactory (minimal risks associated with hygiene, pets or children) home

conditions should exist, and a clean area in which to prepare medicines must be available when administering via the intravenous route. If no such area is available, a risk assessment must be carried out and the results recorded in the patient’s notes.

d) The domiciliary setting must have access to a landline telephone or a mobile connection.

e) Where home conditions are not suitable, transfer of patient to a local clinic for administration should be considered before referring back to secondary care. If a decision has been made not to continue with administration, the prescriber must be informed immediately.

f) The type of medication must be suitable for administration in the community. It is the duty of the prescribing clinician/GP/Consultant to liaise with a Consultant/ Microbiologist/Outpatient Parenteral Antibiotic Lead to establish a treatment plan that is suitable for community management (see Appendix 1 for list of antibiotics and Appendix 2 for list of other IV therapies) based on once or twice daily administration ONLY.

g) Consideration must be given to the arrangements for first and subsequent

doses, where anaphylaxis is considered to be a high risk. h) The patient/carer/family understands the implications of the treatment and how

to recognise and report potential complications relating to treatment i) Patients discharged from hospital meeting eligibility criteria will need to be

referred into the service via the Intravenous Therapy Coordinators. j) Patients referred by a GP will refer through Single Point of Contact (SPC)

6.2 Consent

a) Assess the patient’s understanding of the procedure/ treatment.

b) Once informed, proceed to gain verbal consent from the patient. This must be obtained before any procedure is undertaken. Every adult has the right to make their own decision and must be assumed to have capacity to do so unless it is proved otherwise. Consent MUST be documented in the Electronic Patient Records.


c) Written consent also obtained at first visit, which is held in the patient’s paper

home along with the authorisation to administer documentation. At the end of treatment the consent document is to be scanned onto the patient’s electronic record.

d) Refusal of treatment must be documented and reported to the prescribing

medical practitioner or to the clinician responsible for the care of the patient as soon as possible.

e) Refer to the MC01 Overarching Policy & Procedure of the Mental Capacity Act

(MCA) 2005 Version 5, January 2017 if the patient lacks capacity to give consent.

6.3 Medical Authorisation

a) Written medical authorisation should be obtained and include:

• Date of authorisation • Patients name and date of birth • IV therapy name • Dose and rate of administration • Duration of treatment • Signature of prescriber • Special directions • Allergy status

b) The above constitutes a Patient Specific Direction and the prescribing

responsibility and supply of the medicine (and diluents required to administer) remains with the prescriber, whether it is secondary care or the patient’s GP.

c) In Mersey Care flushes are delivered using Posiflush which is classed as a device and does not require a prescription. It is stock carried by the nursing teams.

d) The patient will remain under the care of the Consultant once discharged from

secondary care. If patient is referred by GP then the GP will retain medical responsibility.

e) If the patient is to be treated for cellulitis (excluding facial or peri-orbital) under

the specially commissioned service for the Cellulitis Pathway this will be delivered by a Patient Group Direction (PGD). The patient will be referred into the service by their GP only.

6.4 Interdisciplinary/ Organisational Responsibilities across the Process

a) Medical Microbiology/ Outpatient Parenteral Antibiotic Lead will be responsible for:

• Recommending relevant antibiotics in relation to the infection • Available for 24 hour advice


b) Consultant will be responsible for:

• The medical care of the patient prior to discharge • In the case of hospital discharges referred out to the community, the

consultant will retain medical responsibility and will assess and prescribe IV medicines

• Supply of complete course to be given on discharge

c) General Practitioner will be responsible for:

• Any unrelated medical conditions • In the case of GP referrals, the GP will retain medical responsibility and

will assess and prescribe IV medications • Liaising with Medical Microbiology if required • Providing prescription for medicines to be administered, including diluents if

necessary

d) The Intravenous Therapy Team/ District Nurse/ Registered Healthcare Practitioner will be responsible for:

• Taking referrals from secondary care trusts across Merseyside and the North West for Liverpool and Sefton patients

• To advise regarding suitability for treatment in the community • To provide advice and information to patients concerning the

condition, treatment and follow up including emergency telephone numbers

• To care for intravenous access devices in accordance with Mersey Care NHS Foundation Trust - Community Services Division clinical guidance documents and corporate policies

• To cannulate or insert midline venous access devices. • To take bloods as requested by prescriber and direct results back to referrer.

GP name always to be included on the lab form • To alert medical staff to any reaction to the therapies and

report via Datix and the yellow card scheme • To be a point of contact for professional advice, support and training

for patients and District Nurses • To collate the results of blood tests and alert the patient’s

Consultant/GP/Outpatient Parenteral Antibiotic lead of any significant event

• To maintain accurate records, reviewing care pathway (variances) of each patient receiving care from the Community Intravenous Therapy Team, District Nurses and Registered Healthcare Practitioners

• Enter clinical information contemporaneously on EMIS and hand held patient records

• To report any infections or problems relating to vascular access devices


6.5 Legal Processes

a) Prescription – this will be written by a prescriber and must include all the relevant particulars to ensure safe administration of the medicine. These will include:

• Name and details of the patient • Name of the drug to be administered • Dose • Frequency of administration • Duration of treatment • Details of the precise route of administration • The intravenous fluid to be used if appropriate, and the quantity to be

infused • The type of diluent/ reconstitution solution and its quantity; this must

also be prescribed • The concentration of administration • The rate of administration • If flush is to be used; this must also be prescribed

b) Patient Specific Direction (PSD) – this is where the prescriber delegates the

administration of the medication to a trained practitioner. The PSD will need to be signed and dated by the prescriber retaining responsibility and carry the same information as a prescription would.

c) Authorisation to Administer – similar in principle to a PSD. See team specific

Standard Operating Procedures. d) Patient Group Direction (PGD) – this is a legal framework to allow continuity of

care of a specific drug for a specific condition for a defined group of patients. Mersey Care currently is commissioned to deliver the Cellulitis Pathway to patients under care of Liverpool University Hospitals NHS Trust in the community using Patient Group Directions.

6.6 Procurement

a) Hospital (includes Pharmacy & Blood Bank) – medicines which have been prescribed by the hospital will be supplied in full by the hospital pharmacy when the patient is discharged. The consultant will retain responsibility but administration will be delegated to the community team.

b) Community Pharmacy – where a GP has prescribed the medication on an FP10, this will be dispensed in the community to the patient.

c) Medicines Distribution Service (MDS) – where medication has been prescribed

electronically by Mersey Care prescribers, stocks may be sourced from MDS, or where the service is to be delivered via Patient Group Directions, then medicine supplies will be ordered directly from MDS

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6.7 Procedural Techniques

a) Peripheral cannulation See Policy 102.

b) Insertion of Midline devices

This will be done in hospital and should be in place before patient is accepted. c) Administration of intravenous medication via bolus

See RCN Standards for Infusion 2019 d) Administration of intravenous medication via intermittent infusion

See RCN Standards for Infusion 2019 e) Administration of intravenous medication via continuous infusion using a

balloon pump device

6.8 Methods of Intravenous Drug Administration

a) A bolus dose of medication or a direct intermittent injection (intravenous push or bolus) of medication is where small volumes of drugs are given directly into the cannula via:

• A closed needle free IV access system (one or two lumen) • The injection port of the cannula

b) Peripheral Intravenous Administration methods via:

• By the addition of the drug to an intravenous fluid container • By injection of the drug through the injection port of the intravenous giving

set • Intermittently through an indwelling needle or cannula • By syringe driver, pump or other infusion device (balloon pump device)

c) Administration via a Central Venous Line requires specific authorisation and

evidence of achieved competency d) A continuous infusion of medication using a continuous 24 hour pump device by

referral from secondary care.

6.9 Routes of Administration

6.9.1 Balloon pump or ball pump (single use only)

a) Continuous infusion over a 24 hour period.


b) Equipment to be supplied by secondary care to cover full course of treatment.

c) See Standard Operating Procedure for Balloon Pump Device

6.9.2 Peripherally inserted cannula

a) Short term cannula (may be inserted by a suitably trained health care practitioner) – refer to Peripheral Cannulation Policy 102.

b) Midline cannula – hospital procedure c) Peripherally inserted central catheter (PICC line) – hospital procedure

6.9.3 Central venous catheter

a) Implanted Device e.g. Port a Cath – hospital procedure b) Skin tunneled catheter e.g. Hickman Line – hospital procedure

6.9.4 Care of the access device is almost identical for each procedure. a) Flushing using a Posiflush Device which is a solution of 0.9% sodium chloride

for each flush unless otherwise stated.

b) Heparinised saline may be used for the final flush for Port a Cath implants only and must be prescribed and supplied by hospital.

c) PICC lines – see referral information. See NPSA Alert on Heparin flushes. d) Complications. When monitoring for complications, it is important to monitor the

insertion point for all devices but midline and central venous access devices and PICC lines will also require monitoring at the point of termination of the device. For complications to IV line, District Nurses to contact the IV Team.

e) A cannula inserted in an emergency situation i.e. when existing cannula

displaced/ fallen out or if dressing is soiled and where asepsis has been compromised, should be replaced within 24 hours of placement when it is safe to do so rather than leaving for 48-72 hours. (See Peripheral Cannulation Policy 102)

6.10 Equipment

• Adrenaline Anaphylaxis Pack • Dressing Pack containing sterile towel, sterile field, disposal bag, gauze,

apron and gloves • Procedure tray


• Arm support with disposable procedure towel covering • Surgical tape • 2% Chlorhexidine in 70% Isopropyl alcohol impregnated applicator ( SEPP) • Chlorhexidine 2% wipe (e.g. sani cloth) • Skin fixation device (e.g. Stat lock or grip lock) • Semi- Permeable transparent IV dressing • Alcohol hand rub or gel • Small sharps container with yellow or orange lid (purple lid for cytotoxic

drugs) • Needle free device • Curos Cap (single use) • Posiflush device • Needles and syringes (safer sharps)

For more information see RCN Standards for Infusion 2019

6.11 General Information to support staff administering IV therapy

a) A clear management plan is required prior to a patient being discharged from hospital. Patients from Liverpool University Hospitals will be discharged on IV medicines that are suitable for community management and will generally commence their therapy in hospital prior to discharge to the community.

b) Patients being referred by their GP will commence their therapy in the

community/ at home. c) If the patient is mobile, arrangements should be made to attend the clinic. d) Plan and document continuing care ensuring that the Patients Electronic

Record is contemporaneously updated. e) Use the smallest gauge cannula most suitable for the patient’s needs. f) For secondary care referrals a Midline, PICC or Skin Tunneled Catheter or

peripheral cannula will be inserted dependent on the patient’s venous access and the length of intravenous antibiotic therapy required.

g) Patients receiving TPN, whether on a single or double lumen vascular device,

must be referred back as access device must not be used by Mersey Care staff to deliver medication.

h) The Intravenous Therapy Team can insert a midline or cannula in the patient’s

home/clinic. i) If there are any signs of vascular access device infection or a significant event

then this will be reported to the Consultant Microbiologist, Consultant, GP and Infection Control Team and reported via Datix.

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j) Aseptic technique must be followed. k) The IV Team/ District Nurses will administer IV medicines according to

prescribed instructions and manufacturers product information sheet which will be supplied with the drug and prescription.

l) Injectable medicines mixed in domiciliary settings are for immediate use only and once prepared, must not be stored for later use.

m) Exceptions to using within the licence are where specialist guidance is in

place, when the specialist guidance or formulary should be followed. n) Intravenous medicines must not be added to containers of blood or blood

products. o) They will also take blood weekly FBC, U+E, LFT, CRP, ESR, eGFR and

drug levels as required, the results of which will be reviewed at the virtual ward rounds at respective hospitals. Appendix 1 and 2 list the drugs and monitoring requirements.

p) The Consultant/ GP/ Outpatient Parenteral Antibiotic Lead will clearly state in the

patient’s notes how they intend to review the patient, when and where and an appointment made.

q) The Nurse Practitioner should always carry an anaphylaxis pack in case of an

emergency when administering the IV therapy.

6.12 Process Pathway

a) Suitable patients will be referred between the working hours of 9.00am and 5pm: • By telephone enquiry to Single Point of Contact call centre who will pass the

information on to the IV Team. Telephone number: 0300 323 0240 • IV Coordinator telephone number: 07771 858817

b) An appointment will be made with the patient for either a clinic visit or a

home visit.

c) If it is administration of the first dose or there is a complex calculation required to determine the dose/ volume to be administered, a second check is strongly advised.

d) At each visit confirm the patient’s identity by obtaining verbal confirmation

of personal details from the patient e.g. date of birth and full name.

e) At each visit explain and discuss the procedure with the patient and carer and answer any questions they may have at a level and pace taking into consideration:

• Their level of understanding • Their culture and background


• Their preferred way of communicating • Their needs

f) At each visit obtain verbal consent for the administration of the drug via

intravenous injection and record the consent in the patient’s electronic healthcare record.

g) At each visit the health care practitioner must conduct NEWS2 and must

assess the cannulation site using the VIP score. This MUST be recorded in the patient’s electronic record.

h) Verify the patient’s name with the prescription sheet and pharmacy

dispensary label. Any discrepancies MUST be raised immediately with the prescriber. Do not proceed with administration until concerns have been allayed.

i) Check that there are no contraindications to the administration of the drug,

including allergies. Any concerns identified MUST be discussed with the prescriber. Do not proceed with administration until concerns have been allayed.

j) Assist the patient into a comfortable position, preserving privacy, dignity and

warmth. k) Wash hands according to Trust policy and put on fresh gloves and apron. Use

any other Personal Protective Equipment (PPE) following risk assessment. l) Prior to accessing, ports and needle free connectors must be decontaminated

with Curos Cap (2% chlorhexidine in 70% isopropyl alcohol medical device), applied with friction for a minimum of 30 seconds and allowed to dry. A new sterile medical device swab must be used at each intervention.

m) Monitor the patient using baseline observations and check administration site

during administration as well as afterwards. n) During administration the infusion set, container and its contents must be

monitored for: • Contamination • Damage • Occlusion • Discolouration of the solution • Particles or precipitate in the solution or giving set • The amount of volume remaining in the container

o) Act swiftly to stop, alter or titrate administration according to patient’s clinical condition and response to medication.

p) Once finished, ports and needle free connectors must be decontaminated

with Curos Cap, applied with friction for a minimum of 30 seconds and allowed to dry. A new sterile medical device swab must be used at each intervention.


q) Assist the patient into a comfortable position and readjust clothing if necessary, at all times maintaining privacy and dignity.

r) Ask patient or carer if they require more information and give assurances if

required. If monitoring required explain this to patient/ carer. s) Dispose of used equipment and personal protective clothing in accordance

with the Trust Waste Management Policy.

t) Wash hands thoroughly. u) Active consideration must be given to re-siting the cannula every 48-72 hours

by a suitably trained health care practitioner. v) All nurses will report any hearing loss to the patients Consultant/ GP/

Outpatient Parenteral Antibiotic Lead. In particular Amikacin, Teicoplanin and Tobramycin may cause tinnitus, mild hearing loss or vestibular disorders. An auditory assessment may be required.

w) Patients who feel unwell during working hours can contact the Community

Intravenous Therapy Team/District Nurses, but out of hours patients will be advised to telephone the Liverpool University Hospital for advice. Contact Numbers will be given to the patients.

x) Any patient who requires urgent medical attention will be referred to

secondary care. Their GP will be informed immediately. y) If patients have diarrhoea (Bristol Stool Chart 7 or 8) and vomiting, advice will

be sought from Medical Microbiology and patient’s GP/ consultant. A stool sample will be obtained to determine cause of diarrhoea. All advice will be clearly documented in patient’s notes. Liaise with infection control if appropriate.

z) Make a clear record in the patient’s EPR of the administration. The

Vascular Access Device will be removed by Community Teams upon completion of treatment as detailed in referral and actions documented on the patient’s EPR.

6.13 Adverse Incidents

a) Complications of intravenous drug administration are: • Infiltration or “tissuing” • Extravasation which can lead to swelling, pain, necrosis and sloughing

of the skin • Haematoma • Air embolism

b) All patients with an intravenous access device in place must have the IV site

checked on every contact visit for signs of infusion phlebitis. The subsequent


score and action(s) taken (if any) must be documented. Use the VIP score and update the template on the patient’s EPR.

c) The IV site must also be observed:

• When bolus injections are administered • IV flow rates are checked or altered • When solution containers are changed

d) Allergic Reactions – a patient who is receiving or has received intravenous medication must be observed for signs of any reaction to the medication: • Signs and symptoms of anaphylaxis - use adrenaline • Changes in vital signs • Changes in alertness or orientation • Changes in fluid balance • Unpleasant side effects from the medication

e) Blocked Lines – the patency of the cannula must always be checked prior to

injection, either by increasing the infusion rate or by the administration of Sodium Chloride 0.9% injection. Maintenance of the patency is important to reduce the discomfort to the patient and expense of replacement. The Sodium Chloride 0.9% injection must be prescribed. Occasionally Heparin 50 units in Sodium Chloride 0.9% IV flush may be used for flushing.

f) The incidence of infusion phlebitis varies; the following Good Practice Points

may assist in reducing the incidence of infusion phlebitis:

• Observe IV site at least daily • Secure venous access device with a proven highly permeable

intravenous dressing • Replace loose, contaminated dressings • Venous access device must be inserted away from joints whenever possible • Aseptic technique must be followed • Active consideration must be given to re-siting the cannula every 48-72

hours • Plan and document continuing care • Use the smallest gauge cannula most suitable for the patient’s need • Replace the cannula at the first indication of infusion phlebitis (stage 2 on

the VIP score)


7. CONSULTATION 7.1 Intravenous Therapy Team 7.2 Intensive Care Community Team 7.3 Medicines Management Team

7.4 Infection Control Team

7.5 Medicines Optimisation & Safety Group including Antimicrobial Lead Pharmacist

7.6 District Nursing Teams and nurses with a special interest

8. TRAINING AND SUPPORT 8.1 All members of the IV Team receive the level of training necessary for them to fulfil

their individual responsibilities identified in this policy and have responsibility for maintaining their competencies.

8.2 The Community Intravenous Therapy Team will also provide support and

competency based training (both practically and theoretically) to all District Nurses. 8.3 Before undertaking IV therapy administration, health care practitioners should

ensure that they have attended an annual update of management of anaphylaxis and CPR within the last year.

9. MONITORING

9.1 This policy will be reviewed in 3 years unless practice alters in the interim.

9.2 This policy will be audited by: • Family & Friends - ongoing reported back to Quality & Governance via Datix • Activity, Response Times and Treatment duration – this data is collected

through the template on EPR and will be collated via EMIS annually • Outcomes will be assessed by 2 clinical audits per year


10. EQUALITY AND HUMAN RIGHTS ANALYSIS

Title: Policy for the Management and Administration of Intravenous Medicines

Version 6, 2019

Area covered: Liverpool & Sefton Community Services Division What are the intended outcomes of this work? To provide assurance that the management and administration of intravenous medicines is implemented with a quality of care that is consistent with the national and professional guidelines Who will be affected? All Mersey Care employees, patients/ service users and carers Evidence

What evidence have you considered? Recommendations from National Patient Safety Agency Alerts that remain relevant to the never Events List 2018 (NHS Improvement – January 2018) NICE Clinical Guidelines (CG174) IV fluid therapy in adults in hospital Royal College of Nursing Standards for Infusion Therapy Local Guidelines and advice from Liverpool and Aintree hospital trusts Disability (including learning disability) This policy is offered in alternative formats as a reasonable adjustment where this is applicable Sex There is no notable relationship to this protected characteristic identified within this policy Race There is no notable relationship to this protected characteristic identified within this policy Age There is no notable relationship to this protected characteristic identified within this policy Gender reassignment (including transgender) There is no notable relationship to this protected characteristic identified within this policy Sexual orientation There is no notable relationship to this protected characteristic identified within this policy Religion or belief There is no notable relationship to this protected characteristic identified within this policy Pregnancy and maternity There is no notable relationship to this protected characteristic identified within this policy Carers There is no notable relationship to this protected characteristic identified within this policy Other identified groups For those patients who may be living in conditions that would be considered to increase the risks to the patient for the procedure, alternative arrangements will be considered to transfer to a local clinic before resorting to a hospital admission. Cross Cutting There is no notable relationship to this protected characteristic identified within this policy


Human Rights Is there an impact? How this right could be protected?

Right to life (Article 2) This policy has identified that an assurance can be provided that patients/ service users will not be exposed to procedures that may endanger life

Right of freedom from inhuman and degrading treatment (Article 3)

This policy is “not Engaged”

Right to liberty (Article 5) This policy is “not Engaged”

Right to a fair trial (Article 6) This policy is “not Engaged”

Right to private and family life (Article 8)


Right of freedom of religion or belief (Article 9)


Right to freedom of expression Note: this does not include insulting language such as racism (Article 10)


Right freedom from discrimination (Article 14)


Engagement and Involvement

This policy and procedure is written in alignment with National Standards and Mersey Care NHS Foundation Trust has an accountability to develop this policy and assure Local Safety Standards are implemented to optimise Patient Safety Summary of Analysis

Eliminate discrimination, harassment and victimisation This Policy does not discriminate or lend itself to harassment and victimisation Advance equality of opportunity This is not applicable to this policy Promote good relations between groups This is not applicable to this policy


What is the overall impact? This Policy will impact positively on the organisation’s ability to assure and optimise Patient Safety Standards for the management and administration of intravenous medicines in domiciliary settings Addressing the impact on equalities This is not applicable to this policy

Action planning for improvement

Detail in the action plan below the challenges and opportunities you have identified. Include here any or all of the following, based on your assessment • Plans already under way or in development to address the challenges and priorities

identified. • Arrangements for continued engagement of stakeholders. • Arrangements for continued monitoring and evaluating the policy for its impact on

different groups as the policy is implemented (or pilot activity progresses) • Arrangements for publishing the assessment and ensuring relevant colleagues are

informed of the results • Arrangements for making information accessible to staff, patients, service users and

the public • Arrangements to make sure the assessment contributes to reviews of DH strategic

equality objectives. For the record Name of persons who carried out this assessment: Christine Roberts Debbie Bowden Hillary Smith Date assessment completed: 16/10/2019 Name of responsible Director: Trish Bennett, Executive Director of Nursing & Operations Date assessment was signed:


Appendices Appendix 1 – Commonly used antibiotics administered intravenously in the Community Division

DRUG AND STRENGTH

Indication Usual Dose/

Dose & Frequency

Method of Reconstitution

IV Bolus IV Infusion (usual dilution and rate)

Suitable Access

Monitoring

Amikacin (Max 15g per course)

Serious gram-negative infections resistant to Gentamicin

15mg/kg (max dose 1.5g)

Once daily 10mls Sodium Chloride 0.9% NO

Add to 100ml Sodium Chloride 0.9% Administer over 30mins

Central venous device

Weekly bloods eGFR Audiometry

Amoxicillin 500mg, 1g

Endocarditis, UTI, sinusitis, oral infections, community acquired pneumonia

500mg – 1g

Every 8 hours

1g in 20mls water for injection 3-4 mins

Add to 100mls sodium chloride 0.9% Administer over 30 – 60 mins

Peripheral cannula, midline, PICC, skin tunneled central catheter

As per consultant or GP request

Benzylpenicillin 1.8g, 2.4g Pneumonia, cellulitis 1.8g,

2.4g Every 6 hours

Reconstitute 600mg in 10mls sodium chloride 0.9% or sterile water

Slow IV injection

(max rate 300mg/min)

Add to 100ml 0.9% sodium chloride or 5% Dextrose Administer over 30-60 mins


Monitor for hyper-natraemia in patients with renal failure/ heart failure

Ceftazidime 1g 2g/3g

Infections of the respiratory tract, bronchiectasis

1-3g Twice daily (bd)

2g, add 10mls sodium chloride 0.9% 3g, add 15mls sodium chloride 0.9%

3-5mins

2g in 50mls sodium chloride 0.9% 3g in 100mls sodium chloride 0.9% Administer over 30 mins

Peripheral cannula, midline, PICC, Skin tunneled central catheter

Weekly bloods

Ceftriaxone 1g/2g

Pneumonia, septicaemia, bacterial meningitis, bone/skin/soft tissue infections, liver and brain abscess

1-4g Once daily

1g, add Water for injections 10ml – BOLUS

2g, add 40mls sodium chloride 0.9%

2-5mins

2g in 40mls sodium chloride 0.9% Administer over 30mins


Weekly bloods

Ciprofloxacin 400mg/200ml

Pyelonephritis/ urinary sepsis 400mg Twice a day N/A NO Over 60mins


As per consultant or GP request Only to be used in Bed Based Intermediate Care


Clarithromycin 500mg Pneumonia 500mg Every 12

hours Reconstitute with 10mls sterile water NO

Add to 250mls 0.9% sodium chloride or 5% Dextrose Administer over 1 hour



Co-amoxiclav 1000mg/200mg (1.2g)

Skin/ soft tissue infections, animal bites, dental abscess

1.2g Every 8 hours 20mls water for injection Over 3-

4mins

Add to 100ml sodium chloride 0.9% Administer over 30mins



Only to be used in Bed Based Intermediate Care

Colomycin Serious aerobic gram negative infections

Dose dependent on renal function Check with Meds Man before administration

Reconstitute the contents of the vial with not more than 10ml water for injection or 0.9% sodium chloride

Via PICC only over

5mins

Add to 50mls sodium chloride 0.9% Administer over 30 mins



Daptomycin 350mg, 500mg

Complicated skin and soft tissue infections caused by Gram- positive bacteria

4mg/kg Once daily

Reconstitute 350mg in 7mls or 500mg in 10mls sodium chloride 0.9% Stand for 10mins then rotate gently to dissolve

Minimum 2 mins

Add to 50mls sodium chloride 0.9% Administer over 30mins

Via central venous device or large peripheral vein

Weekly bloods & CPK

Ertapenem 1g

Infections of the abdomen, skin and skin structures, UTI, community acquired pneumonia

1g Once daily Add 10mls water for injection or sodium chloride 0.9%

NO Add to 50mls sodium chloride 0.9% Administer over 30mins


Weekly bloods

Flucloxacillin 1g Bone/skin/soft tissue infections 1g-12g Four times

a day

1g, add 15-20mls water for injection 2g, add 40mls water for injection

1-2g only over 6mins

Add 2g solution to 100ml sodium chloride 0.9% or Glucose 5% Administer over 30mins


As per consultant or GP request Only to be

Page 26 of 31


Gentamicin 80mg/2ml

Suspected Sepsis MICROBIOLOGY RECOMMENDED ONLY

Dose based on

weight

Stat dose only N/A NO

Add to 50-100ml sodium chloride 0.9% Administer via infusion pump over 60mins



Meropenem 500mg, 1g Pneumonia, UTI 500mg –

2g Daily or

twice daily

500mg, add 10mls water for injection 1g, add 20mls water for injection

Over 5mins

1g, add to 50ml 2g, add to 00mls sodium chloride 0.9%


Weekly bloods

Tazocin/ Piperacillin/ Tazobactam 2.25g, 4.5g

Lower respiratory tract, UTI, bronchiectasis 4.5g Every 8

hours 20mls water for injection for 4.5g 3-5 mins

Add to 50-100mls sodium chloride 0.9% Administer over 30mins



Teicoplanin 400mg

Osteomyelitis, endocarditis, UTI, skin/soft tissue infections (Need to have eGFR above 20)

400mg-1.2g Once daily

Add water for injection 3mls (vial supplied) Gently rotate vial

Each

400mg over 3-5

mins Max

800mg

1.2 g reconstituted added to 50-100mls sodium chloride 0.9% Administer over 30mins


Weekly bloods, Teicoplanin levels, U&E. LFT and eGFR Audiometry

Tigecycline 50 mg

Complicated intra- abdominal infection, complicated skin and soft tissue infections

50mg (following initial dose of 100mg

Twice daily (bd)

5.3mls sodium chloride 0.9%

NO

Add to 100mls sodium chloride 0.9% Administer over 30-60 minutes


Weekly bloods


Tobramycin 40mg/ml

Infections of respiratory tract including pneumonia, biliary tract infections

3mg/kg daily

Twice daily (bd) N/A

Slow IV injection

50 -100mls sodium chloride 0.9% over 20-60 mins


Weekly bloods Audiometry


Appendix 2 – Commonly used medicines (not antibiotics) administered intravenously in the Community Division PRODUCT TO BE ADMINISTERED

Indication Usual Dose/

Dose & Frequency

Method of Reconstitution

IV Bolus IV Infusion (usual rate)

Suitable Access

Monitoring

Blood See 054 Blood Platelet Transfusion Policy

As directed by GP or Haematologist N/A N/A 1 unit over 90mins Via 200U filter

giving set Baseline Obs prior to transfusion. Repeat 15 mins after start Repeat 60 mins after finish

Platelets See 054 Blood Platelet Transfusion Policy

As directed by GP or Haematologist N/A N/A 30-60mins

Separate fresh administration set to be used

Zoledronic Acid Symptomatic hypercalcaemia See 020 Zoledronic Acid Policy

3-4mg

Stat (may be repeated after 7 days)

N/A N/A 100ml of Na Cl 0.9%30mins

Peripheral cannula,

midline, PICC, skin tunneled

central catheter

Serum Ca after 7 days Ca, K, Mg and eGFR

Furosemide 20mg/2mls

When a prompt diuresis is required

20mg-40mg Stat N/A Max

4mg/min

Add to 100ml sodium chloride 0.9% Administer over at least 15mins

Peripheral cannula,


central catheter



Paracetamol 1000mg/100ml Pain, pyrexia 1000mg

Four times a

day N/A N/A Over 15mins

Peripheral cannula,


central catheter

Only give if patient nil by mouth Only to be used in Bed Based Intermediate Care

Phytomenadione 2mg/0.2ml Vitamin K agonist As directed by GP or

Haematologist N/A Over 30 seconds N/A

Peripheral cannula,


central catheter


Sodium Chloride 0.9% infusion Hydration 500ml-

1000ml As

needed N/A N/A Rate and volume depends on patient and care provider setting

Peripheral cannula,


central catheter


Glucose 5% infusion Hydration 500ml-

1000ml As

needed N/A N/A Rate and volume depends on patient and care provider setting

Peripheral cannula,


central catheter


Hydration fluids See 074 Overarching Hydration Policy As directed by GP N/A N/A 20 – 60mins

Peripheral cannula,


central catheter

Daily renal function tests


Total Parenteral Nutrition

Maintaining nutritional status when enteral therapy not possible

As directed by GP or Dietician

Prepared by TPN contracted company N/A 8-24hrs

MUST use separate access line to one used by IV team for medicines

N/A

Insulin

Emergency situations, applicable only for Ward 35 prior to patient being transferred to hospital

Administered by Medical Emergency

Team (MET) N/A N/A

Variable rate intravenous insulin infusion (VRIII)

As per MET N/A

The following IV Medication is stocked on Ward 35 (Bed based Intermediate Care Ward at Liverpool University Hospitals) and are to be used under the direction of the hospital trust’s Medical Emergency Team: • Actrapid Insulin 100units/ml injection • Chlorphenamine 10mg/1ml injection • Diazepam Emulsion 10mg/2ml injection • Heparin Sodium 50units/5ml injection • Naloxone 400mcg/1ml injection • Geloplasma Infusion • Potassium Chloride 0.15% in Glucose 5% infusion • Potassium Chloride 0.15% in sodium Chloride 0.9% infusion


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Management and Administration of Intravenous …...Management and Administration of Intravenous Medicines Policy Number: 25 Scope of this Document: Staff working within Community Services