Download Holistic Intravenous Therapy Service Standard Operating Procedure

Holistic Intravenous Therapy Service
Standard Operating Procedure (SOP)
Version
Date approved
Date to be reviewed
2.0
July 2015
Feb 2017
Reason for review
Update of SOP and documents.
1
Policy Title:
Purpose &
Background
Standard Operating Procedures (SOP) Community Intravenous Therapy
These standard operating procedures (SOP) have been written in
response to the expansion of the home intravenous (IV) therapy service
(HITS). The HITS has been developed using national evidence that
illustrates the benefits of community led IV services, which facilitate a
patient’s early discharge from the acute sector to community setting and
where appropriate prevention of hospital admission.
This guidance when followed will assist in the promotion of safe and
consistent administration of medicines via intravenous route for staff
working within East Cheshire Community District and HIT Nursing
Services.
Scope
This SOP applies to the following staff groups who will access the HITS

Community service managers

Specialist Nurses and Specialist Nurse Teams.

HITS Team leader & HITS Team generally

District Nurse Team Leaders & District Nurses generally

Pharmacy Teams

Discharging doctors (acute)

Ward Nurses (acute)

GPs
Policy Area:
Community Services
Version Number:
2
Document Reference:
Issued By:
Home Intravenous Therapy
Team.
Lead Nurse IV Therapy &
HITS
Effective Date:
May 2015
Review Date:
April 2015
SQS
July 2015
Contributing
Authors:
(Full Job title )
APPROVAL
RECORD
2
Summary
These standard operating procedures (SOP) have been written in response to the
expansion of the home intravenous therapy service. The HITS has been developed
using national evidence that illustrates the benefits of community led IV services,
which facilitate a patient’s early discharge from the acute sector to community setting
and where appropriate prevention of hospital admission. The development of such a
service provides a pro active platform from which East Cheshire NHS trust can
promote organisational efficiency and maintain optimum standards of patient care.
This guidance when followed will assist in the promotion of safe and consistent
administration of medicines via intravenous route for staff working within East
Cheshire Community District and HIT Nursing Services.
This SOP will impact on:
All practitioners involved in the facilitation of home intravenous therapies, to include,
HITS Team; Community Nurses; Acute Nurses; Pharmacy and General Practitioners.
Related Trust Policies and Professional Guidance
Accident and Incident Reporting policy (2007)
Hospital Antibiotic Policy (2011)
Infection prevention & Control Aseptic Technique Policy (2009)
Care of Substances Hazardous to Health (COSHH) Policy (2009)
Royal College of Nursing (RCN) Standards for Infusion Therapy (2010)
ECT Policy for Consent to Examination or Treatment
ECT Medicines policy
ECT IV Policy
SOP Replaces
Standard Operating Procedures (SOP) Community Intravenous Therapy (first version
of this document.)
Process Formatting and Reviews
Community Services Manager, Lead Community Services Pharmacist and HITS
Team Leader to review this SOP on a two yearly basis, or as the service dictates due
to clinical incident, or significant service development that would require further
extension/revision of the SOP and practices within.
3
Contents
AIM of SOP for Community Intravenous Therapy ...................................................... 6
SOP Objectives...................................................................................................... 6
Target Audience..................................................................................................... 6
Scope .................................................................................................................... 6
Introduction ............................................................................................................... 7
Responsibilities ......................................................................................................... 8
Associate Directors, Locality Managers and Community Service Managers .......... 8
Team Leaders ........................................................................................................ 8
Registered Nurses ................................................................................................. 8
Medical Staff (Discharging Consultant or Registrar) ............................................... 8
General Practitioners (G.P’s) ................................................................................. 8
HITS Team ............................................................................................................ 8
The HITS team..................................................................................................... 10
Patient Accepted by the HITS Team .................................................................... 11
The HITS folder.................................................................................................... 11
Patient demographics .......................................................................................... 11
Copy of last Registrar or consultant review .......................................................... 11
The assessment checklist .................................................................................... 11
Clinical responsibility signature sheet................................................................... 12
Signature identification sheet ............................................................................... 12
GP discharge letter .............................................................................................. 12
Phlebitis scale ...................................................................................................... 12
Pink community IV prescription ............................................................................ 12
Progress/evaluation report ................................................................................... 13
Clinical review sheet ............................................................................................ 13
Preparing for transfer of care ............................................................................... 13
Establishing Venous Access ................................................................................ 14
Discharging the Patient ........................................................................................ 15
SOP 2. STANDARD OPERATING PROCEDURE ................................................... 16
FOR ORDERING THE HOME INTRAVENOUS THERAPY PRESCRIPTION ......... 16
Once the prescription is complete ........................................................................ 17
Equipment............................................................................................................ 18
The prescription is ready ...................................................................................... 20
Educating the patient ........................................................................................... 20
SOP 3. STANDARD OPERATING PROCEDURE ................................................... 22
FOR COMMUNITY NURSES ACCEPTING TRANSFER OF CARE FROM ACUTE
SETTING ................................................................................................................ 22
Entering the Patient Home/Clinic Setting.............................................................. 23
The Environment is assessed as safe .................................................................. 23
Checking a Cannula ............................................................................................. 24
Flushing the Cannula ........................................................................................... 24
Checking patency of an established line .............................................................. 24
Preparing for IV drug administration ..................................................................... 25
SOP 4: STANDARD OPERATING PROCEDURE FOR THE RECONSTITUTION OF
INTRAVENOUS DRUGS IN THE COMMUNITY ..................................................... 26
Withdrawing a solution or suspension from a ready mixed vial into a syringe ....... 27
Reconstituting powder in a vial and drawing the resulting solution or suspension
into a syringe........................................................................................................ 27
Adding a medicine to an infusion.......................................................................... 28
Manually Controlled Drips .................................................................................... 29
Infusion via Venous Access Device: Skin tunnelled catheter, PICC, Mid-line ....... 30
4
Bolus Injection via Cannula, Skin
tunnelled catheter, PICC or Mid-line ..................................................................... 32
For patient reviews follow SOP 5: STANDARD OPERATING PROCEDURE FOR
COMMUNITY INTRAVENOUS THERAPY FOLLOW UP ........................................ 33
SOP 5: STANDARD OPERATING PROCEDURE FOR COMMUNITY
INTRAVENOUS THERAPY FOLLOW UP ............................................................... 34
Clinical review sheet ............................................................................................ 34
SOP 6: STANDARD OPERATING PROCEDURES FOR OUTPATIENT BASED HITS
REFERRALS........................................................................................................... 36
SOP 7: STANDARD OPERATING PROCEDURE FOR COMMUNITY
ADMINISTRATION OF INTRAVENOUS FUROSEMIDE .......... Error! Bookmark not
defined.
Written in conjunction with Cardiology Nurse Clinician Julie Walker ..........Error!
Bookmark not defined.
Pathway for giving IV Furosemide in the Community ....... Error! Bookmark not
defined.
Pre treatment checks ............................................ Error! Bookmark not defined.
Procedure .............................................................. Error! Bookmark not defined.
Post infusion checks ............................................ Error! Bookmark not defined.
Follow up ............................................................... Error! Bookmark not defined.
Appendix 1: Guidance on Referral Information ........................................................ 43
Appendix 1: Guidance on Referral Information ........................................................ 43
Appendix 2: Service Hours & Contacting HITS ........................................................ 44
Appendix 3: HITS patient assessment Form
Appendix 4a: HITS: Acute Referral Pathway ........................................................... 46
Appendix 4b: Community Pathway .......................................................................... 47
Appendix 5:
Home Visit Risk Assessment........................................................... 49
National Patient Safety Agency (NPSA) Risk Rating ............................................ 50
Appendix 7: Cardiology Discharge Form ................................................................. 52
5
AIM of SOP for Community Intravenous Therapy
SOP Objectives
East Cheshire NHS Trust is committed to providing optimum quality of care across all
areas; this extends to patients who require the administration of IV therapies in the
home or community clinic setting. This SOP aims to equip the practitioner with the
appropriate underpinning theoretical knowledge to confidently deliver seamless and
effective care to patients within a supportive and evidence based framework.
Target Audience
The target audience of this SOP extends across primary and secondary care areas.
This document provides a cohesive management framework from which any member
of the multidisciplinary team can access and become knowledgeable about the
process of managing a HITS patient. The document covers inpatient management,
referral processes and community management so to illustrate a fluid process of
patient care across both areas.
Service Objectives:




To equip the practitioner with theoretical knowledge to deliver quality services
between key areas.
To promote safe and standardised practice to patients receiving IV therapies
in a community setting.
To promote effective change and embrace development of practice in
recognition of the wider health service agenda.
To ensure an efficient seamless patient experience from the acute to
community setting with all roles and responsibilities clearly identified.
Scope
This SOP applies to the following staff groups who will support the HITS








Community service managers
Specialist Nurses and Specialist Nurse Teams
HITS Team leader & HITS Team generally
District Nurse Team Leaders & District Nurses generally
Pharmacy Teams
Discharging doctors (acute)
Ward Nurses (acute)
GP’s
6
Introduction
Due to the development of complex care in the community, IV Therapy is now being
provided in community settings. The RCN IV forum ‘Standards for Infusion Therapy’
July 2003 is incorporated into this document to promote best practice. Infusion is now
an integral part of the majority of nurses’ professional practice. The code of
professional conduct (NMC) encouraged nurses to expand their practice provided
they had the necessary knowledge and skills and accepted responsibility for their
actions’ RCN (2003).
SOP 1&2 are aimed at acute registered nurses and doctors who will access the HITS
team from within the acute setting. The aim of these SOP is to guide the nurse when
referring to the HITS team and aims to promote a seamless discharge process for
the patient from the acute sector to the community setting.
SOP 3-5 are aimed at registered nurses in community nursing teams that have the
necessary knowledge and skills in preparing and administering intravenous therapies
and that are confident and competent to carry out this practice.
These SOP were developed to:

Enable patients to safely receive intravenous therapy in their own homes
or in a community health care setting, thereby facilitating early discharge
from hospital or preventing hospital admissions.

Ensure safe and consistent practice in administration of intravenous
therapies by Registered Nurses thereby reducing the risk of
complications.

Provide an educational platform from which to promote effective change
in order to facilitate guidance of clinical practice which is evidence based.

To ensure an efficient seamless patient experience from the acute to
community setting with all roles and responsibilities clearly identified.
7
Responsibilities
Associate Directors, Locality Managers and Community Service Managers are
responsible for ensuring the services they manage are aware of these Standard
Operating Procedures for Community Intravenous Therapy and amendments are
cascaded in a timely manner.
Team Leaders are responsible for ensuring the relevant specifications outlined in
these SOP are adhered to in practice and all new starters are made aware of their
existence on the internet site where the most up to date version will be available.
Registered Nurses All professionals are personally and professionally accountable
for their actions and omissions in their practice and must always be able to justify
their decisions and ensure compliance to East Cheshire NHS trust operating
procedures/policies and NMC Standards for Medicines Management.
Lone Working All professionals working alone in the community are responsible for
adhering to the lone worker policy. For HITs nurses specifically, a lone working form
must be complete and sent to district nurse OOH. These nurses will act as the lone
worker contact for the last nurse on shift or alone at weekends. HITS will contact
01625 430906 when arriving home from work. Failure to do so will result in a phone
call from OOH, or further escalation to on-call manager where appropriate.
Medical Staff (Discharging Consultant or Registrar)
These clinicians will accept overall clinical responsibility for the patients they
discharge from their care.
General Practitioners (G.P’s)
GP’s will continue to refer patients to AAU until governance can be agreed for
community led prescribing. .
HITS Team
These team members are responsible for assessing the patients overall suitability to
continue IV treatment in the home/community setting. The HITS team member must
ensure clinical responsibly has been accepted by a discharging Doctor. Then take
into account a patients psycho-social complexities and use intuitive methods to
assess whether discharge to the community is appropriate at that time. This may
include a discussion with the district nursing team to whom the patient is to be
discharged to, ensuring capacity and suitably trained staff are available to support
the patient.
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SOP 1. STANDARD OPERATING PROCEDURE
FOR DISCHARGING A PATIENT HOME ON THE
HITS PROGRAMME
PURPOSE





To guide assessment of an in-patient receiving IV therapy
To promote an efficient and cost effective service
To assess the suitability of the patient receiving ongoing IV treatment in the
home/community setting
To safely facilitate discharge of the patient into a safe environment that
promotes safe community care delivery.
To ensure effective communication between community & secondary care
areas
PROCEDURE
A patient is receiving IV therapy and a decision between ward staff (nurse in charge)
and the medical team is that the patient no longer requires in-patient care. However
the patient requires further IV therapy.
Ward staff should consider referring to HITS by using the following criteria:

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Is the patient medically stable and no longer require in-patient care? (Patient
may have existing chronic health problems that are being managed). The
patient must have a definite diagnosis and a clinician from their speciality
willing to take clinical responsibility for discharging the patient as medically fit,
and provide ongoing support, whilst the patient is being treated for that
condition at home.
All other processes are complete from a multidisciplinary perspective
Medical stability is confirmed including a consideration of whether blood
pressure is normal (for that patient), patient is haemodynamically stable (for
that patient) and patient is apyrexial. Patient is not confused or has any new
symptoms at current time.
Patients with a history of drug/substance abuse will be considered for the
community IV service on an individual basis by a member of the HITS team.
The patient must be registered with an East Cheshire GP.
A nurse from the Home Intravenous Therapy Nurse (HITS) must assess the
patient and agree eligibility to commence IV therapy at home
Complete single point of referral to HITS team through the CRIS system
The HITS team may be in the community at the time of the referral. E-mails
will be cleared periodically.
A verbal confirmation of receipt of referral will aid effective communication
and efficiency of service, see appendix 2 for HITS contacts and hours of
service.
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The HITS team
A member of the HITS team will attend the department to assess the patient at the
earliest opportunity. The assessment will determine the patient suitability for
discharge home on the programme.
The assessment will include:
 A review of the medical notes to achieve a medical history to determine;
demographic data, known drug allergies, existing medical conditions, reason
for admission, definitive diagnosis, treatment of diagnosed condition, current
IV and oral drug regimes. A review of the nursing documentation will take
place to determine the biological, psychological, social and spiritual
individuality of the patient. (This is done to avoid repetition during consultation
with the patient).

The HITS team will liaise with any multi-disciplinary member currently
involved in caring for the patient (physiotherapy, occupational therapy,
psychiatry etc) to gauge a history (again to avoid repetition).

Once the above preparation has taken place the team will attend the patient
and introduce themselves, their role within the organisation and the relevance
of them attending the patient.

A discussion will take place where the HITS programme is explained and the
patients questions answered.

Information leaflets will be provided at this point that will reflect the ideology of
the service.

HITS service should be introduced to the patient and informed verbal consent
should be obtained and recorded in the medical notes

See appendix 3 for HITS assessment form.

A decision will be made on the form as to the patient’s suitability for the
service.

If the patient is not suitable then they should continue treatment as an inpatient.

The HITS team will document this in the notes and set a review date if there
is a possibility of the patient meeting the criteria at a later date. (For example
the patient may have a high temperature on the day of assessment).
10
Patient Accepted by the HITS Team
Once the patient is accepted by HITS a pathway is triggered see below and
appendix 4.
 Confirm informed consent to pursue discharge obtained from the patient
using open communication techniques to gauge understanding of risk and
benefits of being treated at home.
 Risks include: anaphylaxis, infection of established line, (cannula, midline,
peripherally inserted central catheter (PICC) or skin tunnelled line).
Extravasation injury, whereby an irritant fluid leaks from an established line
and causes local tissue damage. Bleeding from dislodged line.
 Benefits include, hospital acquired infection (HAI) avoidance. Improved
quality of life, speedier recovery.
 Complete a ‘Home Risk Assessment’ form appendix 5 with the patient to
establish if their home is an appropriate environment for the administration of
IV drugs. (Running water, telephone for emergencies, lighting).
 If the home risk assessment deems the environment unsuitable this should be
documented in the case notes and rationale for the decision shared with the
patient.
 If suitable then the risk assessment should be stored in the HITS folder for the
community nursing team to complete their section at the first home visit
(shown in appendix 5).
The HITS folder (HITS to bring to ward)
The hits folder is the communication between community and secondary care areas.
Essential documentation contained within includes:
Patient demographics: Full name, date of birth, address, hospital number, home
phone number, and next of kin details (repeat above). General Practitioner (GP)
contacts details, and allergy status.
Copy of last Registrar or consultant review: To establish that the patient has been
reviewed in the last 24hrs and to provide medical input and opinion as to the current
condition of the patient, to include blood results, and diagnostic review (is the
diagnosed condition stable or improving). Review date is essential and must be
established in the medical notes to include date, time and location and with whom.
The assessment checklist (see appendix 3)
Discharge checklist, all of the above plus:
 IV access established, if so what is it?
 Date and time of 1st community nurse visit
 IV treatment and number of doses supplied to coincide with the prescription
 Dose, frequency, date started and review date
 Details of additional care needs (dressing, blood pressure, drugs etc).
 Date, time and place of review, to include which practitioner within reason.
(Nurse Specialist, Doctor, Matron etc).
 Supply of stock (see SOP 2).
11
Clinical responsibility signature sheet
A registrar or consultant must sign the basic signature sheet that details they deem
the patient to be in adequate health (for that individual patient) to be discharged into
the community to continue current doses of the IV regime.
Signature identification sheet
A signature identifier so that any member of staff writing in the patients notes can be
identified by their individual (and usually illegible) signature as they are required to
print their name also).
GP discharge letter (EDNF)
This is a form of communication from the acute sector. This will inform the GP of the
patient’s admission to the acute sector and the decision to allow the patient home to
continue their treatment at home. However clinical responsibility remains with the
discharging consultant this pro forma is sent as a courtesy to keep the GP updated
and is useful in case of a GP call out at the patients home.
Phlebitis scale
A universally used risk assessment tool that all teams use to assess the phlebitis risk
of a cannula or other invasive line.
Pink community IV Administration sheet
A pink sheet of paper makes up the community administration sheet. Essential
information listed here includes:

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The patient’s full name
Date of birth
Prescriber’s signature and date prescribed
The approved medicine(s) name
The dose and frequency of administration
The route of administration
Any known allergies
The name and volume of flushes (for total course).
The concentration or total quantity of the medicine in the final infusion
container or syringe
The name and volume of diluents and/or infusion fluid.
The rate and duration of administration
The date on which treatment should be reviewed
The recorded administration and batch numbers of drugs & diluents.
12
Progress/evaluation report
An ongoing progress and communication form used by community staff to
communicate procedures they have carried out in accordance with the patients care
plan. This document provides accounts of, procedures, dates, equipment used,
changes in treatment, improvement in condition and deviation from the care plan
(patient refusal for instance).
Clinical review sheet
This records the patient’s re-attendance to the clinical area from where they were
discharged. Information of this form would include, blood results, clinical observation
of wounds, general observations, switch from IV to oral treatments or request to
continue treatment for a further length of time prior to next review. (Another
prescription is completed at this stage if necessary).
Note: The responsibility for checking the appropriate documents are with the patient
prior to discharge will be the HITS team member (or nurse in charge in their
absence). This is a vital communiqué between the two areas and needs to be
comprehensive and complete to ensure a seamless transfer of care.
Preparing for transfer of care
Once the HITS documentation is confirmed as complete by the HITS team member
(or nurse in charge of the ward in the absence of the HITS service), SOP 2 for
preparing the HITS prescription should be implemented. Once SOP 2 is fully
implemented the HITS team (or senior alternative) will phone the appropriate
community nursing team to inform them that the patient is being discharged to their
care. A referral form will be sent to the district nurses via Single point of referral.
Following this venous access must be established before discharge from hospital.
13
Establishing Venous Access
It is the responsibility of the HITS team, or in their absence the nurse in charge of the
ward, to ensure the patient has healthy venous access prior to discharge from
hospital. (If a cannula is already in situ it must be changed prior to discharge, unless
sited that day and checked for patency and infection =0). Selection of appropriate
device is as follows:

Cannula: A short radiopaque polyurethane tube inserted into the peripheral
veins of the arm. This should ideally be changed every 72-96 hours but can
remain in longer if agreed by senior clinician and rational documented (EPIC
3). If treatment is for more than 1 week a mid –line should be considered.

Mid-line: Longer line inserted into peripheral veins. This line dwells in the
axillary vein after insertion and can remain in for several weeks.

PICC: A longer line again that dwells in the superior vena cava accessed
through the peripheral venous system. Dwell time for treatments up to 6
months. (Up to and including month 6).

Skin tunnelled catheter: similar in length than that of a PICC except this line
is much more robust with a much wider gauge and requires surgical insertion
using ultrasound guidance. Used typically for chemotherapy or treatments
lasting in excess of 1 year. This type of line withstands drugs with increased
PH and toxicity and so is favoured for drugs not suitable for peripheral
administration.
HITS/Ward staff may insert a cannula 20g-22g pink and blue respectively. This is
to be done in line with ECT IV Policy and infection control guidelines.
A patient being discharged home on the HITS programme that requires nonvesicant/irritant drugs for up to and including 1 week should be cannulated prior
to discharge by either the HITS service or qualified ward staff who have
undergone sufficient training and competency based assessment.
If the patient requires anything other than a cannula (e.g. patient with poor
venous access), this needs to be discussed with a member of the HITS team who
will refer the patient to the appropriate practitioner who will assess for a longer
line insertion.
14
Discharging the Patient
Check:
 Discharge is still appropriate (no change in condition)

The intended discharge is documented in the medical notes along with a
review date, where and with whom the patient should attend

The HITS documentation is complete to include community prescription
and the pro forma of signed clinical responsibility

SOP 2 has been followed and the drugs, diluents and flushed along with
other oral medication is present with the patient.

The district nurses are aware of the transfer of care

Single point of referral sent referral form

The patient has suitable venous access

A bag of equipment (see SOP 2) has been provided.

Patient has information booklets and contact numbers for the HITS
service and discharging ward.

Ensure environment where review is taking place are aware of the time
the patient will attend (see SOP5).

Discharge patient (once all ward policies and procedure around
discharging a patient have been met).
15
SOP 2. STANDARD OPERATING PROCEDURE
FOR ORDERING THE HOME INTRAVENOUS THERAPY
PRESCRIPTION
PURPOSE





To discharge the patient with the appropriate drug, diluents and flushes as
prescribed.
To minimise risk to staff and patients when preparing a patient for IV therapy
in the community.
To facilitate a seamless transfer of care between the acute and community
setting
To avoid drug errors relating to IV administration in the community
To provide a fluid and unambiguous service
PROCEDURE
The decision has been made between the clinically responsible medical
professionals, the HITS team and the ward staff that the patient is eligible and
able to be transferred into the care of community staff, to continue IV treatment at
home or in the community clinic setting. Therefore a legible and appropriate
prescription is required to be written by the doctor, sent, checked and produced
by the pharmacy department.
In some cases the microbiologist may have to be referred to for advice on
appropriate antibiotics to use in the community. Clinical responsibility remains
with the consultant/registrar who chooses to follow that advice. (For example if an
antibiotic is required four times daily, there may be a suitable drug that achieves
the same outcome but only requires once daily administration).
The community specific drug prescription needs to be completed to include the
following:

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The patient’s full name
Date of birth
Prescriber’s signature, date prescribed and contact details
The approved medicine(s) name
The dose and frequency of administration
The route of administration
Any known allergies
The name and volume of flushes (for total course).
16
Where relevant the following should also be included:


The brand name and formulation of the medicine
The concentration or total quantity of the medicine in the final infusion container
or syringe
The name and volume of diluents and/or infusion fluid.
The rate and duration of administration
The date on which treatment should be reviewed
The recorded administration and batch numbers of drugs & diluents

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
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This must be done by the person accepting clinical responsibility, either registrar or
consultant. Although a junior doctor may prescribe the necessary drugs. The patient
must have been reviewed by the registrar or consultant in the last 24 hours and again
prior to discharge. (The doctor should know the patient as the patient’s condition may
have changed e.g. the patient may have deteriorated and requires prolonged
admission or improved negating the need for IV antibiotics).
Once the prescription is complete:
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The discharging doctor must complete a HITS prescription and pink admin
sheet ensuring to mark the prescription as HITS, to ensure appropriate
labelling takes place. (Or complete the prescription pathway booklet with all
the sheets combined into one document.)
EDNF system is to be completed by the qualified individual and marked as
HITS in the ‘pharmacy notes’ section.
Ward staff to approach ward pharmacist who will work out any special
instructions e.g. displacement values, coagulation reading, drug level
monitoring, height, weight confirmation etc.
In the absence of the ward pharmacist, the HITS prescription with the ward
prescription, along with any patient medications, should be sent to pharmacy.
If appropriate (for that drug pathway) administer the 1st dose of the drug on
the ward or unit prior to discharge, e.g. IV antibiotics.
Inform the patient that the prescription is pending in pharmacy
Liaise with ward staff to organise transport for the patient if necessary
Inform the patient that the first dose (in some cases 2nd dose or later) is to be
administered in the hospital to allow for the unlikely event of adverse reaction
to the drug. (Anaphylaxis, shortness of breath (SOB), bronchospasm, itching
or anything the patient describes as abnormal).
Note: If a specific drug is not in stock then the patient may have to remain
hospitalised. Preparation should continue but the patient informed of the delayed
discharge. This should be documented clearly in the medical notes.
17
Equipment
Whilst waiting for the prescription a box of equipment needs to be prepared prior to
discharge and includes the following (this is the responsibility of the HITS team):
The HITS nurse will have equipment to change an IV cannula as necessary and all
community nurses will have available at each visit an anaphylaxis kit (including
adrenaline 1mg in 1ml).
Example:
For a cannula administering once daily drug for 1 week (change of cannula
every 72hrs). If more frequent doses-please alter stock accordingly.
6x dressing packs
A small sharps bin
12 x 2% chlorehexidine in 70% alcohol
impregnated wipes. (6 for cleaning the
cannula & six based on six vials of drug
for reconstitution. Use intuition for
differing regimes. )
Alcohol hand rub
3 x bandages for securing
Roll of tape
10ml luer-lock syringes (enough for
treatments and flushes-depending on
medication prescribed.)
Reconstitution labels (if applicable)
Community drip stand (if applicable)
As many filter and non-filter needles as is
required for 6 courses of treatment.
6 x giving sets if infusion (as 1st dose
given as inpatient.
For a Mid-line & PICC once daily based on 1 week treatment (1st dose given on
ward)
6 x dressing packs.
filter needles and non-filter needles
(As many as is required for 6 courses of
treatment).
Spare Needle free access device (ie.
Swanlock) follow care plan.
12 x 2% chlorehexidine in 70% alcohol
impregnated wipes. (6 for cleaning the
line and 6 for reconstitution. Use intuition
for differing regimes.)
6 x giving sets if infusion (as 1st dose
given as inpatient.
Reconstitution labels (if applicable)
As many 10ml luer-lock syringes as will
be required to reconstitute the infusion
for six courses of treatment and flush the
line.
Spare Dressing to secure Midline or
PICC line.
Roll of tape
A small sharps bin
Alcohol hand rub
Community drip stand (if applicable)
Daily flushing of the line with heparin is
necessary using 50u in 5mls Heparin
saline. (or weekly if maintaining line
only.)
3 x bandages for securing.
18
For a Hickman line once daily, based on 1 week of treatment (1st dose given
on ward)
6 x dressing packs.
filter needles and non-filter needles
(As many as is required for 6 courses of
treatment).
Spare Needle free access device (ie.
Swanlock) follow care plan.
As many 10ml luer-lock syringes as will
be required to reconstitute the infusion
for six courses of treatment and flush the
line.
12 x 2% chlorehexidine in 70% alcohol
impregnated wipes. (6 for cleaning the
cannula & six based on six vials of drug
for reconstitution. Use intuition for
differing regimes.)
Alcohol hand rub
6 x giving sets if infusion (as 1st dose
given as inpatient.
Reconstitution labels (if applicable)
Roll of tape
A small sharps bin
Community drip stand (if applicable)
3 x bandages for securing.
Daily flushing of the line with heparin is
necessary using 50u in 5mls Heparin
saline. (or weekly if maintaining line
only.)
A minimum of 5 days of equipment and 7 days of drugs should be supplied.
If the patient is on more than one week of treatment then the HITS team will discuss
this with the community nursing teams and pharmacy to devise a management plan.
The above lists are an example. Please use intuition or seek advice from a senior
member of staff if unsure. The HITS team (or nurse in charge) is responsible for
ensuring the correct equipment is sent with the patient. To re-stock the patient at
follow up see SOP 5: Community Intravenous Follow up.
19
The prescription is ready
Once the prescription is ready it will need to be collected from the pharmacy
department.





The HITS team or in their absence the discharging nurse must check all
diluents and flushes correspond with the prescription, this can be done either
in pharmacy or on the ward.
Ensure a copy of the HITS prescription is in the bag with the medication (if not
then contact pharmacy to get a copy).
Check expiry dates.
All vials must be checked that they will remain in date for the duration of
treatment. (Follow pharmacy advice if certain items need to be used first).
Check all diluents and flushes correspond with the prescription.
To promote efficiency, if there is any oral medication ready it would be sensible to
collect this at this time.
Educating the patient
As soon as the drugs enter the department where the patient resides the
following should happen:

Check the prescription with the arm band of the patient whilst asking them to
verbally confirm their date of birth, & 1st line of address

Re-confirm allergy status

Discuss the contents of the prescription (ward staff explain oral medication),
discuss the number of doses, number of vials, flushes and diluents to avoid
anxiety and surprise. (Often the number of vials, diluents & flushes, needles,
syringes etc, may be off putting or worrying to the patient).

Discuss the equipment included and the importance of taking care not to
disturb packaging on sterile packs.
20
Following discussion prepare initial does of infusion in accordance with the
relevant policies:







UCLH Hospitals Injectable Medicines Administration Guide
Hospital Antibiotic Policy
Infection prevention & Control Aseptic Technique Policy
Royal College of Nursing (RCN) Standards for Infusion Therapy (2010)
ECT Policy for Consent To Examination or Treatment
ECT Medicines policy
ECT IV Policy
During the infusion/injection administration on the ward observe the patient for
the following:

Severe dyspnoea


Bronchospasm
Hypoxia


Hypotension
Fever




Chills
Rigors
Urticaria
Angiodema
If the patient presents with these symptoms:






The management of suspected anaphylaxis/anaphylactoid reactions should
be conducted in accordance with the Resuscitation Council (UK) Guidelines
for the Management of Anaphylaxis. www.resus.org.uk
STOP the infusion
Seek senior and medical assistance
Monitor patient
Implement emergency CPR if necessary
DELAY DISCHARGE
This list is by no means exhaustive individual assessment of the
patient is necessary using intuition and experience
If the infusion is uneventful and the patient remains well then refer back to SOP 1.
STANDARD OPERATING PROCEDURE FOR DISCHARGING A PATIENT HOME
ON THE HITS PROGRAMME section: Discharging the patient P14.
21
SOP 3. STANDARD OPERATING PROCEDURE
FOR COMMUNITY NURSES ACCEPTING TRANSFER OF
CARE FROM ACUTE SETTING
PURPOSE





To ensure a seamless transfer of care from the acute setting to the
community setting
To promote effective communication between key areas
To promote effective cross boundary relationships between key multidisciplinary team members
To improve the patient experience and improve quality of life
To enable staff to work in a safe and risk reduced environment when
delivering IV drugs in the home/community setting.
PROCEDURE
The District nursing team will receive a referral from single point of referral. A
member of the HITS team will contact the district nursing team and verbally inform
them of the upcoming discharge from the hospital.
Out of area referrals must be discussed with the HITS team, who will follow specific
processes to enable this.
The District nursing team must:
Check the referral form is completed fully (see guidance appendix 1) but should
include:
















Demographic data (must include house number)
Discharging ward and contacts
Date of referral
Date of 1st visit and estimated length of visit
Time of 1st visit (if required)
GP details
GP phone number
Contact number
Accountable consultant
Next of kin & relationship
Referring person
Diagnosis/Intervention received
Proposed IV therapy
Review date, place, time and with whom
Current venous access
Allergy Status
22
If there is any doubt in the content of the information then the discharging
ward should be contacted for verification.
Once the relevant information has been confirmed, check the patient meets local
criteria for being accepted into the community nursing team (valid GP, address within
East Cheshire locality etc).
Patients discharged from a hospital out of area will need to be discussed with the
HITS team prior to the patient being discharged from that area.
Add patient to case load and allocate the appropriate time to manage the specific
patient from the estimated time provided on the referral form. (This has to be realistic,
an exact time cannot be guaranteed but an estimate of infusion time should be
established).
Entering the Patient Home/Clinic Setting
Upon meeting the patient you must:






Introduce yourself, who you are, your organisation, and your reason for being
there.
Ask for the HITS folder (see SOP1 STANDARD OPERATING
PROCEDURE FOR DISCHARGING A PATIENT HOME ON THE HITS
PROGRAMME)
Whilst doing this you need to establish the patients understanding for you
being there.
Using subtle communication techniques to assess the environment and
complete the risk assessment form (appendix 5 is in the HITS folder).
You are looking for a clean space, a flat surface on which to place your
equipment, a sink with running water, lighting, a chair for the patient, and no
immediate risks to yourself.
If the environment is unsuitable then again use subtle communication
techniques to inform the patient that unfortunately they cannot have their
treatment in their home.
Contact the HITS team or community service manager in their absence. A number of
things could happen:



The patients is treated locally in an available clinic space
The patient is treated as a day case and return to the hospital daily
The risk is removed and the patient can have treatment at home
The Environment is assessed as safe
The risk assessment has been carried out and the environment is deemed safe for
you to carry out the procedure and safe for the patient to have the treatment
administered over the prescribed time.
23
Assess Venous Access
It is the responsibility of the discharging ward and/or the HITS team to ensure the
patient has healthy venous access. (If a cannula is already in situ it must be changed
prior to discharge, unless sited that day and checked for patency). However the
cannula may be come dislodged prior to the community nurse visit.
A patient discharged home on the HITS programme that requires nonvesicant/irritant drugs for up to and including 1 week should be cannulated prior
to discharge by either the HITS Team or qualified ward staff who have undergone
sufficient training and competency based assessment.
The community nurses if competent (HITS will assess this on an individual basis)
may insert a cannula 22g cannula if the current one is unsuitable. This is to be
done in line with ECT IV Policy and ANTT.
If the patient requires anything other than a cannula this needs to be discussed
with a member of the HITS team who will refer the patient to the appropriate
person.
Checking a Cannula



Use Visual Infusion Phlebitis (VIP) scoring sheet in the HITS folder
If the cannula is unsuitable for use i.e. redness, swelling, oedema, pain at site
Contact the HITS team to replace the cannula and continue to monitor
previous insertion site.
Flushing the Cannula
If the cannula has been deemed visually suitable for use then you must establish that
the device is functionally acceptable for drug administration. (That it flushes with
saline challenge).


Follow ECT IV Policy to flush the cannula.
If the cannula will not flush follow ECT IV Policy as above.
Checking patency of an established line (mid-line, PICC, Skin tunnelled
catheter)

Follow ECT IV Policy
24
Preparing for IV drug administration
It is essential to be organised to ensure patient confidence in the practitioner is
maximised, therefore check the following:

Confirm consent with the patient (the patient can reconsider at any time).

Check the pink community prescription or administration booklet for all of the
correct details listed in SOP 1 STANDARD OPERATING PROCEDURE FOR
DISCHARGING A PATIENT HOME ON THE HITS PROGRAMME.

Check all equipment is available to perform the procedure using the
appropriate venous access device as indicated in SOP 2. STANDARD
OPERATING PROCEDURE FOR ORDERING THE HOME INTRAVENOUS
THERAPY PRESCRIPTION.

Set up a clean area and prepare to reconstitute the drug for administration (a
clean area is an area free from visible dirt and large enough to set up
dressing towel/dressing pack to use as you clean area).

Gather the required equipment for that visit depending upon the drug that
needs administering.

Reconstitute the drug in the clean field you have established

Now refer to SOP 4: STANDARD OPERATING PROCEDURE FOR
RECONSTITUTING IV DRUGS IN THE COMMUNITY SETTING
25
SOP 4: STANDARD OPERATING PROCEDURE FOR THE
RECONSTITUTION OF INTRAVENOUS DRUGS IN THE
COMMUNITY
PURPOSE




To safely reconstitute intravenous drugs in the community setting
To minimise risk
To promote patient safety
To promote safe working environments for anyone involved in delivering
intravenous therapy in the community
To promote a optimum standards of patient care
To increase patient and staff satisfaction thorough continual support and
education


PROCEDURE
You are preparing to reconstitute the prescribed IV drug. Please see manufacturing
instructions for guidance on the specific drug. You have set up the clean field and
have all relevant equipment required to perform the task of reconstituting an
intravenous drug, to be administered to the patient whose home you are currently in.
Be aware that the patient must NEVER be left unaccompanied during any
intravenous therapy.
Withdrawing solution from an ampoule into a syringe











Don protective equipment (gloves, apron)
Use aseptic non touch technique (ANTT) at all times
Tap the ampoule gently to dislodge any medicine in the neck
Snap open the neck of the glass ampoules, using an ampoule snapper if
required
Attach a filter needle to a syringe and draw the required volume of solution
into the syringe. Tilt the ampoule if necessary
Invert the syringe and tap lightly to aggregate the air bubbles at the needle
end.
Expel the air carefully
Label the syringe if the medicine is not administered immediately. Only one
unlabelled medicine must be handled at one time
Keep the ampoule and any unused medicine until administration is
complete to enable further checking
If the ampoule contains a suspension, it should be gently swirled to mix the
contents immediately before they are drawn into the syringe.
Put syringe onto clean tray-remembering not to touch key parts.
26
Withdrawing a solution or suspension from a ready mixed vial into a syringe

Don protective equipment (gloves, apron).

Use ANTT at all times.

Remove the tamper-evident seal from the vial and wipe the rubber septum
with a 2% chlorhexidine in 70% alcohol wipe. Allow to dry for 30 seconds.

With the needle sheathed attach the needle to a syringe using a non-touch
technique; draw into the syringe a volume of air equivalent to the required
volume of solution to be drawn up.

Remove the needle cover and insert the needle into the vial through the
rubber septum.
Invert the vial. Keep the needle in the solution and slowly depress the plunger
to push air into the vial.
Release the plunger so that the solution flows back into the syringe
If large volumes are to be withdrawn, use a push-pull technique. Repeatedly
inject small volumes of air and draw up an equal volume of solution until the
required total is reached.
With the vial still attached, invert the syringe. With the needle and vial
uppermost, tap the syringe lightly to aggregate the air bubbles at the needle
end. Push the air back into the vial.
Fill the syringe with the required volume of solution then draw in a small
volume of air. Withdraw the needle from the vial.
Expel excess air from the syringe. Administer immediately or protect key parts
and place on tray until ready to administer.
The vial(s) and any unused medicines should be kept until administration is
complete.







Reconstituting powder in a vial and drawing the resulting solution or
suspension into a syringe






Don protective equipment (gloves, apron).
Use ANTT at all times.
Remove the tamper-evident seal from the vial and wipe the rubber septum
with a 2% chlorhexidine 70% alcohol impregnated wipe. Allow to dry for at
least 30 seconds.
Withdraw the required volume of diluents from the ampoule(s) into the syringe
Inject the diluent into the vial. Keeping the tip of the needle above the level of
the solution in the vial, release the plunger. The syringe will fill with the air
which has been displaced by the solution (if the contents of the vial were
packed under a vacuum, solution will be drawn into the vial and no air will be
displaced). If a large volume of diluent is to be added use a push-pull
technique, as detailed earlier.
With the syringe and needle still in place, gently swirl the vial(s) to dissolve all
the powder, unless otherwise indicated by the product information. This may
take several minutes.
27

Withdraw the required volume
of solution into the syringe, as
detailed earlier.
Adding a medicine to an infusion

Don protective equipment (gloves, aprons).

Use ANTT at all times.

Prepare the medicine in a syringe using one of the methods described above.

Check the outer wrapper of the infusion container is undamaged.

Remove the wrapper and check the infusion container itself in good light. It
should be intact and free from cracks, punctures/ leaks.

Check the infusion solution, which should be free from haziness, particles and
discolouration.

Where necessary, remove the tamper evident seal on the additive port
according to the manufacturer’s instructions or wipe the rubber septum on the
infusion container with a 2% chlorhexidine in 70% alcohol impregnated wipe
and allow to dry for 30 seconds.

If the volume of the medicine solution to be added is more than 10% of the
initial contents of the infusion container (more than 50ml to a 500ml infusion),
an equivalent volume must first be removed with a syringe and needle.

Inject the medicine into the infusion container through the centre of the
injection port, taking care to keep the tip of the needle away from the side of
the infusion container. Withdraw the needle and invert the container at least
five times to ensure thorough mixing before starting the infusion.

Label the infusion with the name of the patient, name of drug, DOB, batch
number of both drug and diluents; this should also be documented clearly in
the patients’ notes.

Also document the drug calculation used to achieve the final dose and
administration rate of the IV infusion (if applicable).
Intravenous Administration: Infusion via Cannula

Once the drug is reconstituted connect a giving set by piercing the seal on the
infusion bag. Keep the bag of fluid and the giving set flat and spike the bag
with the giving set, smoothly and confidently (ensuring not to pierce the bag of
fluid).

Hang the infusion from a suitable height using HITS drip stand. Slowly open
the clamp to allow the fluid to prime the line. (Do this slowly and observe as if
done too rapidly some of the drug can be lost and the patient will not receive
an accurate dose).
28

Once the line is primed, use ANTT to clean the hub of the extension set that
is attached to the cannula. Clean the hub for 30 seconds using the 2%
chlorehexidine with 70% alcohol wipe. Allow to dry.

Connect the giving set to the hub and screw on and be careful not to cross
thread as this may lead to leakage.

Some intravenous therapies require slow administration; this information
should be recorded on the medicines administration chart by the prescriber.

Refer to the manufacturer’s information for full details on time required for
administration. If in doubt contact the HITS team or discuss with a community
pharmacist.

Gravity infusion devices (giving set without pump) are not appropriate if the
rate of infusion needs to be very accurate, therefore the appropriate pump
must be sourced. Contact the HITS team if in doubt.

Ensure no air bubbles are evident.

Administer the IV drug over the required time by manually calculating drops
per minute, and then open the clamp to allow for required drops observe the
patient for anaphylaxis symptoms.

If anaphylaxis occurs locate anaphylaxis kit (this should be taken into the
patient house at each visit.) Implement anaphylaxis procedure.
Manually Controlled Drips
To set up a manually controlled drip accurately by eye, you need to be able to count
the number of drops per minute. To achieve the rate (drops/minute), the formula
below may be used. The drop factor (DF), which is the number of drops in a milliliter
(ml), is normally indicated in the packaging of the “IV giving set.” The time in hours
(T) is the number of hours prescribed for the fluid to run. The number “60” is
constant as it is the number of minutes in an hour.
Rate (drops/minute) = Total volume of fluid in ml (TVF) x drop factor (DF)
Time in hours (T) x 60 min
For example, how many drops/minute should 500 ml of normal saline be regulated to
if it is to run for 8 hours? The giving set indicates that the drop factor is 20 drops/min.
Rate =
500 ml x 20
8 x 60
Rate =
10000
480
29
Rate = 20.8
Rate = 21 drops/min
Answer: The infusion will be regulated at 21 drops/min









Once the infusion is complete all sharps to be disposed of in a yellow sharps
disposal bin, for (cytotoxic drugs follow trust policy).
Refer to trust policy, Sharps Usage and Disposal.
Record administration of flushes and drugs in the patient’s record, including
full details of batch numbers, manufacturer’s and expiry dated. Along with a
comprehensive account of the visit and your general assessment of the
patient.
Observe the cannula for any signs of inflammation, infiltration.
Cannulation devices and administration sets should be disconnected and
flushed using ANTT and refer to ECT IV Policy for further details.
Advise patient / carer what actions to take if any side effects occur.
Ensure patient has contact details of the HITS team.
Clearly state in records when next contact will be made by HITS/District
Nursing team.
Review care plan if required to meet patient’s ongoing health care needs.
Infusion via Venous Access Device: Skin tunnelled catheter, PICC, Mid-line
Once the drug is reconstituted connect a giving set by piercing the seal on the
infusion bag. Keep the bag of fluid and the giving set flat and spike the bag with the
giving set, smoothly and confidently (ensuring not to pierce the bag of fluid).
Hang the infusion using appropriate apparatus in agreement with the patient and
their environment. Slowly open the clamp to allow the fluid to prime the line, (do this
slowly and observe as if done too rapidly some of the drug can be lost and the
patient will not receive an accurate dose).
Once the line is primed, use ANTT to clean the hub of the bionector that is connected
to the venous access device. Remove cap and clean the hub for 30 seconds using
the 2% chlorehexidine with 70% alcohol wipe. Allow to dry. Then aspirate a flash
back of blood from the venous access device as per ECT IV Policy.
Connect the giving set to the hub and screw on and be careful not to cross thread as
this may lead to leakage.
Some intravenous therapies require slow administration; this information should be
recorded on the medicines administration chart by the prescriber.
Refer to the manufacturer’s information for full details on time required for
administration. If in doubt contact the HITS team or discuss with a community
pharmacist.
Gravity infusion devices (giving set without pump) are not appropriate if the rate of
infusion needs to be very accurate, therefore the appropriate pump must be sourced.
Contact the HITS team if in doubt.
Ensure no air bubbles are evident
30
Administer the drug IV drug over the
required time by manually calculating
drops per minute, and then open the clamp to allow for required drops observe the
patient for anaphylaxis symptoms.
If anaphylaxis occurs locate anaphylaxis kit (this should be taken into the patient
house at each visit. Implement anaphylaxis procedure).
Once the infusion is complete all sharps to be disposed of in a yellow sharps disposal
bin. (For cytotoxic drugs follow trust policy).
Refer to trust policy, Sharps Usage and Disposal.
Record administration of flushes and drugs in the patient’s record, including full
details of batch numbers, manufacturer’s and expiry dates, along with a
comprehensive account of the visit and your general assessment of the patient.
Observe for any signs of inflammation, infiltration.
Venous access devices and administration sets should be disconnected and flushed
using ANTT and refer to ECT IV Policy guidance for further details.
Advise patient / carer what actions to take if any side effects occur.
Ensure patient has contact details of the HITS team.
Clearly state in records when next contact will be made by HITS/District Nursing
team.
Review care plan if required to meet patient’s ongoing health care needs.
31
Bolus Injection via Cannula, Skin tunnelled catheter, PICC or Mid-line
Slow IV bolus injection involves the injection of a drug over several minutes (normally
3-5 minutes depending upon the drug) via an indwelling catheter, this is indicated
when a rapid serum concentration of a drug is required.
For bolus doses of drugs, the required volume of antibiotic should be administered
directly from the syringe into the venous access device (Cannula, Skin tunnelled
catheter, PICC or Mid-line).
Flush any device using ANTT and refer to ECT IV Policy for further details.
Clean the hub of the bionector/ extension set of the device with 2% chlorehexidine in
70% alcohol impregnated wipes for 30 seconds.
Connect the syringe (luer lock best practice) used to draw up the drug to the device
and slowly apply pressure to the plunger (excessive pressure will result in damage to
the venous access device and harm to the patient). The patient may complain if too
much force is exerted as the infusion will sting or the patient will feel uncomfortable
pressure. In this case ease off the plunger.
Maintain dialogue with patient and ask them to describe the sensation (usually a cold
sensation is felt) and monitor the site of the venous access device.
Also monitor for anaphylaxis and implement anaphylaxis procedure if necessary.
Once complete flush device as per ECT IV Policy.
Record administration of flushes and drugs in the patient’s record, including full
details of batch numbers, manufacturer’s and expiry dates along with a
comprehensive account of the visit and your general assessment of the patient.
Observe the venous access device for any signs of inflammation, infiltration.
If any of the above are observed refer to the HITS team.
Advise patient / carer what actions to take if any side effects occur.
Ensure patient has contact details of the HITS team.
Clearly state in records when next contact will be made by HITS/District Nursing
team.
Review care plan if required to meet patient’s ongoing health care needs.
Continue this process of prescribed care until:
32

The patient is due for medical review

The HITS team suggest early review

Patient becomes unwell e.g. anaphylaxis or pyrexia, deteriorating sepsis
For patient reviews follow SOP 5: STANDARD OPERATING PROCEDURE FOR
COMMUNITY INTRAVENOUS THERAPY FOLLOW UP
Blood sampling
Some antibiotic regimes will require specific blood sampling. In all cases the patient
must be bled peripherally to ensure accurate trough levels. The HITS team will be
responsible for organising and checking this and advising the District Nurses.
33
SOP 5: STANDARD OPERATING PROCEDURE FOR
COMMUNITY INTRAVENOUS THERAPY FOLLOW UP
PURPOSE






To be able to advise the patient regarding follow up arrangements
To minimise risk to the patient
To ensure effective cross boundary working relationships
To promote safe working environments for anyone involved in delivering
intravenous therapy in the community
To promote an optimum standard of patient care
To increase patient and staff satisfaction thorough continual support and
education
PROCEDURE
The patient has been receiving IV treatment in the community setting or at home.
The date for review will be documented in the patients HITS folder as discussed in
SOP 1. When the patient is due for review they should be seen by the team who
accepted clinical responsibility. This will mean either review by:


The acute hospital
The GP
Clinical review sheet
This records the patient’s re-attendance to the clinical area from where they were
discharged. Information on this form would include, blood results, clinical observation
of wounds, general observations, switch from IV to oral treatments or request to
continue treatment for a further length of time prior to next review. (Another
prescription is completed at this stage if necessary).
If the GP (as part of admission avoidance) needs to review the patient then the HITS
documentation should be provided to the GP when he/she visits. They should then
make a decision to either continue or discontinue the IV therapy.
If the patient requires follow up in the acute sector then the patient should report to
the stated location documented in the HITS notes. The review appointment will have
been made initially by the team accepting clinical responsibility for the patient.
Subsequent review appointments will be made at the preceding review.
The HITS team where possible will provide support to the patient during their review
and be accessible to the patient by phone.
The patient should present with the HITS folder, which contains up to date
information including:
34














Demographic data
Clinical assessments and treatments by the district nurse/HITS team
Clinical review sheet
Discharging ward and contacts
Date of referral
GP details
GP phone number
Contact number
Accountable consultant
Next of kin & relationship
Diagnosis/Intervention received
IV therapy prescription
Current venous access
Allergy Status
A decision will be made either to:



Continue on IV drug regime
Stop IV drug regime
Change to a different IV regime
If continuing on IV drug regime re-implement practice starting from and including
SOP 2 until next review (If the drug regime is approved by HITS).
If a new regime is prescribed the patient will collect the relevant prescription from
pharmacy (a member of the HITS team should be made aware of the change in
regime so they can communicate this to the appropriate district nursing team). The
prescribing doctor or nurse in charge on EAU or OPD should contact the HITS team
using the contacts provided in appendix 2.
The clinical review sheet should be completed comprehensively and should contain:




Name and dose of new/ continued prescribed IV therapy
Any new or continued monitoring instruction e.g. blood pressure, temperature
specific blood tests etc
Next review date, (with whom, where, when & what time)
Goal or outcome e.g. to cure infection (this may be the same or different from
the original goal/outcome)
The patient should be sent home with:



Oral switch (in the case of antibiotics)
Re-prescribed IV medication, diluents and flushes
Equipment, giving sets, syringes, needles, chlorehexidine 2% in 70% alcohol
impregnated wipes etc. Contact the HITS team if in doubt.
Once IV therapy is no longer required and the discharging doctor has made this
explicit in the HITS folder The HITS team will collect superfluous equipment from the
home and the HITS notes.
For follow up of the patient, re-implement this SOP until discontinuation of IV therapy.
35
SOP 6: STANDARD OPERATING PROCEDURES FOR
OUTPATIENT BASED HITS REFERRALS
PURPOSE





To guide assessment of an in-patient receiving IV therapy
To promote an efficient and cost effective service
To assess the suitability of the patient receiving IV treatment in the
home/community setting
To safely facilitate treatment of the patient in a safe environment that
promotes optimum community care delivery.
To ensure effective communication between community & secondary care
areas
PROCEDURE
The HITS team receive a phone call, e-mail or fax from any of the following:





General Practitioner (GP)
Acute sector department on behalf of GP (admission avoidance)
Outpatient department
Single point of referral
A different NHS Trust (out of area)
Requesting that the HITS team administer an IV infusion in the community for a
patient requiring IV therapy.
HITS member should:
Take all relevant details e.g. demographic data, condition, proposed IV therapy,
general condition of the patient.
And
Request a referral in writing (by email or fax) with the key information from:




General Practitioner
Acute sector department on behalf of GP (admission avoidance)
Outpatient department
A different NHS trust
So that more comprehensive information can be established.
The HITS team will then contact the GP
36
Once clinical responsibility has been established a member of the HITS team will visit
the patient at home or on the relevant ward to assess the following:

If the patient is being referred as an out-patient - HITS team member will
review medical notes.

If a community referral is made the HITS team member will refer to GP/
district nursing notes in order to achieve a medical history, to determine,
demographic data, known drug allergies, existing medical conditions,
definitive diagnosis, treatment of diagnosed condition, current oral drug
regimes, proposed IV therapy.

A review of the nursing documentation will take place to determine the
biological, psychological, social and spiritual individuality of the patient. (This
is done to avoid repetition during consultation with the patient).

The HITS team will liaise with any multi-disciplinary member currently
involved in caring for the patient (physiotherapy, occupational therapy,
psychiatry, district nurse etc) to gauge a history (again to avoid repetition).

Once the above preparation has taken place the team will attend (either to
outpatients department or the patient’s home) the patient and introduce
themselves, their role within the organisation and the relevance of them
attending the patient.

A discussion will take place where the HITS programme is explained and the
patients questions answered.

Information leaflets will be provided at this point.

If at home carry out a home risk assessment

If returning as an out-patient establish the ability of the patient to return daily
for treatment, e.g. have transport, are they fit to travel, why can’t they be
treated at home?

Confirm agreement with emergency admissions unit (EAU) Dr. Srivastava will
be clinical key contact or a member of the team of the clinically responsible
consultant.

Discuss with ward staff about booking patient in their ‘ward diary’ so the
patient is expected, and this is communicated between staff members.

Or risk assess the patient prior to going home enquire as to whether their
home environment is suitable e.g. do they have a, phone, electricity, running
water etc.
37

HITS service should be introduced to the patient and informed verbal consent
should be obtained and recorded in the medical/nursing notes See (appendix
3) for HITS assessment form

A decision will be made on this form as to the patient’s suitability for the
service.

If the patient is not suitable then they should continue/begin treatment as an
in-patient.

The HITS team will document this in the notes and set a review date (in acute
setting) if there is a possibility of the patient meeting the criteria at a later
date.

The medication must be obtained from the acute trust pharmacy.

If the patient has never experienced an allergic reaction either as an in-patient
or at home (SOB, wheezing, fainting, swelling, rash) to any drug or food to
their knowledge then 1st dose of drug at home or in the out patient
department. Unless the drug is know to cause reaction e.g. monoclonal
antibodies, iron, chemotherapy. These drugs will be risk assessed on an
individual basis if ever considered for community administration.

In such cases, as part of the risk assessment, a decision will be made as to
how many doses of that particular drug needs to be administered in the acute
setting

If they have experienced any of the above with another drug then intuition and
discussion with pharmacy/microbiology/medical team/GP must be
undertaken. UCL guide for IV drug administration should be checked for
identified risks.

Either admit patient because they are unsuitable for outpatient or home IV
therapy or proceed with treatment in the appropriate environment suitable.

If Furosemide follow SOP 7 for community administration of IV Furosemide

If antibiotic or drug is currently included in the risk assessment appendices
within these SOP then follow the administration and reconstitution guidelines
in SOP 4 for community IV drug reconstitution.

If a drug is prescribed that is not used in the SOP, then it will be risk
assessed using the UCL administration guidelines and discussed with the
doctor accepting clinical responsibility/ community pharmacist and/or
microbiologist

If the drug requires specific tests, monitoring and/or complicated calculations
then this is to be included in the SOP list or discussed with the appropriate
(professional GP, microbiologist, consultant) and may be refused until the
appropriate pathway can be developed to minimise risk.
38
SOP 6a: STANDARD OPERATING PROCEDURES FOR OUT
OF AREA PATIENT REFERRALS
PURPOSE






To guide assessment of an Out of area patient receiving IV therapy
To promote an efficient and cost effective service
To assess the suitability of the patient receiving IV treatment in the
home/community setting
To safely facilitate treatment of the patient in a safe environment that
promotes optimum community care delivery.
To ensure effective communication between community, secondary and out
of area
Out of area consists of patients residing within ECCCG locality but being
discharged from another hospital that is not within East Cheshire
PROCEDURE
Accepting a discharge from an out of area hospital
HITS receive a phone call from an out of area hospital e.g. central
Manchester. .
E-mail or have admin e-mail Andrea Lunt from ECCCG to alert that we are accepting
an out of area referral and include all demographic details, medication, definitive
diagnosis and treatment length.
Admin or nurse should inform the caller to send an e-mail to the referral inbox
[email protected]
This e-mail should include the following information:







Patient demographics
NHS number
Relevant clinical history
Definitive diagnosis
Drug therapy
IV access
Duration of treatment
Once received HITS nurse or admin to fax or e-mail (safe haven fax/nhs e-mail
only)
Documents will include:









A covering medical referral stating patient medically fit
Clinical responsibility sheet – whom, review date, place, time
MAR Sheets (Medication administration record)
Details of IV access (when inserted, type, length, duration, valve)
Covering IV policy for line management
Copy of DNAR after informing GP
Blood levels (teicoplanin)
Blood results (historical picture)
Observations
39
Information on those documents should include:
A covering medical referral stating patient medically fit








Presenting complaint with history of presenting compliant
Relevant medical history –include allergies
Definitive diagnosis
Key symptoms to look out for
Treatment start date
Predicted stop date
Contact details – secretary
Predicted outcome
Clinical responsibility sheet –

Only registrar or consultant can accept clinical responsibility – need to include
details for these individuals for communication

Review date, with whom, where and what time

Bloods required prior to review

Blood levels due and how to get these to team eg fax or email a nurse
specialist?
Pink sheets
This acts as the patient Medication Administration Record and is essential for each
individual drug item
Prescription
Drug, dose, frequency, indication, allergies, - HITS to fax a pre-printed script
Hospital to send copy of original script with signed HITS script
Assessment form
See embedded
V3 Hits assessment
Feb2015-Out of area form.doc
Details of IV access
What is it?
Where was it inserted?
Who inserted?
Length of line
Expected duration
Covering policy for managing lines for discharging organisation
40
Covering IV policy for line
management
The organisation that inserts the line retains clinical responsibility for the line and
therefore has the right to dictate terms of management – as long as they have sent a
copy of the policy for that organisation. Failure to do so will result in HITS using ECT
IV policy or refusing to accept the patient. This may result in the patient returning to
the discharging organisation.
Copy of DNAR after informing GP
This is a vital proforma for communication. At the very least HITS and GP must be
aware of this prior to the patient being discharged. A copy of the DNAR in the first
instance is required followed by the patient being sent home with the appropriate
DNAR order.
HITS Nurse Should Check:

The patient is medically stable and no longer requires in-patients care. This
will take the form of written medical referral (Patient may have existing
chronic health problems that are being managed).

The patient must have a definite diagnosis and a clinician from their speciality
willing to take clinical responsibility for discharging the patient as medically fit,
and provide ongoing support, whilst the patient is being treated for that
condition at home.

All other processes are complete from a multidisciplinary perspective, OT,
Physio, scans (complete or booked), transport etc.

Medical stability is confirmed including a consideration of whether blood
pressure is normal (for that patient), patient is haemodynamically stable (for
that patient) and patient is apyrexial. Patient is not confused or has any new
symptoms at current time. (This information with historical trends should be
faxed).

Patients with a history of drug/substance abuse will be considered for the
community IV service on an individual basis by a member of the HITS team.

The patient must be registered with an East Cheshire GP.

A nurse from the Holistic Intravenous Therapy Nurse (HITS) must assess the
patient and agree eligibility to commence IV therapy at home

The HITS team may be in the community at the time of the referral. E-mails
will be cleared periodically.

The discharging hospital should communicate an estimated time of arrival
that the patient will arrive back home (taking into consideration transport etc)

HITS will have contact details for the patient and should negotiate a visit
within ASAP within the patient arriving home

Two nurses will attend on this occasion to assess the patient in the first
instance, but also to act as a second checker for the drug supply, and
complete relevant assessment documentation.
41

If the nurse is not happy then
the patient will have been pre-warned before leaving hospital that they will be
sent back – in an ambulance if necessary.

Inappropriate discharges should be escalated to the director of nursing for the
discharging organisation with the understanding that future referrals may be
declined if quality does not improve.

Drugs requiring refrigeration will only be accepted if the discharging hospital
supplies a fridge or pays for transport of medication
42
Appendix 1: Guidance on Referral Information
Appendix 1: Guidance on Referral Information
[email protected]
When referring a HITS patient please include the following Information:
Patient details:






First Name and Surname
Date of Birth
Hospital Number / NHS number (if applicable)
Address (including a house number)
Contact details – phone numbers
Next of kin details – phone numbers preferably
Treatment details:










Diagnosis
What is the organism we are treating? (If known)
Where is the infection or problem?
Any medical conditions
Any allergies.
What equipment stock has been issued to the patient? (Eg.
Dressings for IV cannula)
What treatment do they require?
What type of IV access do they have? (IV cannula/PICC/skin
tunnelled catheter)
When is the next dose required?
How often is the treatment? (Once or four times a day)
Plan and Review details:




When and where is the treatment review?
Who is the responsible consultant?
Do antibiotic levels need to be checked?
If so when is this due and how often?
Patient specific details:


Any other medical problems that are ongoing
Any issues with access to the house
43
Appendix 2: Service Hours & Contacting HITS
The HITS service is available 7 days per a week including bank holidays.
9am to 7pm Monday to Friday and
9am to 5pm Saturday, Sunday and bank holidays.
[email protected]
HITS Mobile number: 07795520985
HITS bleep number: Bleep 5156
The Team:
Brian Nicol
HITS Team leader
Amanda Gould
Ext.3381 (66),
Ext. 3337 (66), e-mail: [email protected]
HITS Associate Nurse Specialist
e-mail: [email protected]
Alison Howman
Ext 3340 (66)
HITS Associate Nurse Specialist
email: [email protected]
Lauren Wilson
Ext 3381 (66)
HITS Associate Nurse Specialist
email: [email protected]
Kate Clappison
Ext 3340
HITS Nurse
Julie Goulden
HITS Secretary
Ext 1744
email: [email protected]
Address:
Home Intravenous Therapy Service
The New Alderley Building, 1st floor
Macclesfield Hospital
Victoria Road
Macclesfield
Cheshire
SK10 3BL
44
Appendix 3 HITS assessment form
45
Appendix 4a: HITS: Acute Referral Pathway
Patient identified as a potential HITS patient.
Ensure they meet the inclusion criteria: (see SOP or HITS folder for reference).
Requires East Cheshire GP,
must be documented as medically stable and
must have a definitive diagnosis.
Send the referral to the Single point of referral via the CRIS system who will contact the
HITS team.
The HITS team will assess the patient on the ward and ensure risk assessments
are completed and informed consent obtained.
Accepted for HITS
Declined for HITS
Acute medical staff to complete:
 HITS pharmacy prescription for IV treatment, including
prescriptions for saline flushes and heparin (10mg/ml) if
indicated.
 To ensure a named Consultant will take responsibility for patient
at home.
 Sign clinical responsibility document in HITS notes.
(Need to state a review date and stipulate where patient should
attend clinic eg. MAU/ward 6)
Acute nursing staff to:
 Ensure HITS prescription taken to pharmacy.
 Send referral to Single point of referral for District Nurse input for
all care required and to administer IV medications.
Please include information such as: (see HITS folder for guidance)
* Time and date of first visit. (Try to plan first visit for following day please.)
* Type of IV access (cannula or longer line).
*Any special requirements for that patient – eg. Key entry into the home.
* Any other ongoing treatments for district nurses to undertake –
eg. Tinzaparin injections, wound dressings.

Before discharge
Acute nursing staff to:
 Ensure patient has a stock of any other dressings in
use (for wounds etc.)
 Ensure ALL Medications arrived from pharmacy
(usually 7 days stock).
 Give first dose of IV medication, if possible.
 HITS team to review patient before discharge, and will
check IV access.





If patient is not suitable at
present – they may be
reassessed in the future.
HITS team will:
HITS team to supply 7 days worth
of stock equipment for District
Nurses for administration of IV
medication only.
Patient information leaflets on the
HITS service and how to deal with
the IV cannula.
Provide patient with HITS notes for
them to take home for District
nurses to make records in.
Contact numbers for support at
home.
New IV access prior to discharge if
required.
Ensure HITS discharge checklist
46
completed.
Appendix 4b: Community Pathway
HITS: District Nurse Intravenous Delivery Pathway
Receive referral and
telephone call regarding
HITS patient.
(Usually day prior to
discharge)
All information received
Further information
required.
Contact HITS team.
Available Seven days a week
9am-7pm weekdays.
9am-5pm Sat and Sun
Mobile: 07795520985
See HITS Troubleshooting Guide
First visit can be done by DN Team.
HITS Notes will be given to patient in
hospital.
If appropriate, ensure evening service aware
of the patient.
In patient’s home:
Introduce yourself to the patient and explain that
different nurses may call during the course of treatment.
Complete home risk assessment in HITS notes.
Obtain consent to proceed.
Check the prescription is correct.
Check all necessary equipment is available, including
drug doses, flushes, heparin and cleaning equipment.
(HITS team will provide 7 days of equipment but DN’s
may need to order more stock if required.)
All present and
correct
Any problems
Check IV access.
Complete VIP score.
Prepare IV medication in line with ECT
IV Policy and ANTT (Aseptic non touch
technique).
Out Of Hours: Line Displaced
If IV Cannula – care for site and
leave message for HITS
If longer line – refer patient to
A&E for position check.
Administer medication to patient
and observe patient throughout.
Initiate Anaphylaxis guidelines.
If severe dial 999.
Contact next of kin.
Inform emergency staff of drug
administered.
Complete incident form.
Inform manager and escalate.
No complications
Any signs
of reaction
Dispose of waste safely.
Complete nursing documentation.
Inform the patient of when the next dose
will be, and ensure all contact numbers are
available in case of any problems.
47
Appendix 4c: GP Admission
Avoidance Pathway
GP referral & Prescribing
GP assess patient at home or
in surgery and would like the
patient to undergo IV therapy at
home
GP refers to specific pathway
i.e cellulitis or UTI
If the patient is acutely
unwell send to A&E via
ambulance
Patient meets criteria for home
IV treatment
Yes
Refer to HITS via
e-mail ecntr.HITSreferrals@nhs.
net and follow up with
phone call to HITS
mobile: 07795520985
No
HITS will attend and
assess the patient at
home. (see SOP
1a)The patient will be
high priority and
should have been
assessed by a nurse
within 2 hours
GP
Follow specific prescribing pathway
Prescribe medication on FP10 prescription
Sign clinical responsibility sheet
Sign community administration sheets
Prescribe analgesia if needed
Dictate bloods and specific monitoring
requirements
7. Set a date for reviewing the patient and IV
drug
1.
2.
3.
4.
5.
6.
If not acutely unwell
negotiate with EAU at
MDGH for guidance &
support
Patient accepted by
HITS
No
Yes
HITS
1. Where appropriate HITS refer to DN team
2. Ensure FP10 prescription reaches pharmacy
3. Liaise with community pharmacy for
dispensing
4. Venous access will be established (see SOP
1a)
5. Observations will be recorded
6. Ancillary equipment will be provided by HITS
7. Will take specific blood levels etc
Community Pharmacy
Orders and dispenses drugs diluents and flushes
Arrange delivery or collection
See SOP 2a
8. liaise with HITS re progress
8. HITS treat and review daily
9. review patient and bloods at specified intervals
9. admit patient if anaphylaxis occurs
10. if specific treatment pathway dictates then
10. admit patient if specific treatment pathway
admit the patient
dictated
11. If improving consider switch to oral and
11. complete treatment
discharge from HITS
12. discharge patient
48
13. satisfaction survey
Appendix 5:
Home Visit Risk Assessment
Patient Name ………………….
Date Assessed: …………………..
NHS number ………………….
First Visit Date …………………
Address: ………………………..
…………………………
Pre- visit Risk Assessment
1) Is the patient a permanent resident in UK?
YES / NO
2) Is the patient registered with an East Cheshire GP?
YES / NO
3) What type of residence is it? (House/flat etc)
……………………………………………………………………
4) Is there parking at the patient’s house?
YES /NO
State any further details…………………………..
5) Are there any pets? (Can dogs be locked away?
YES / NO
Cats out of the house during procedure.)
6) Are there smokers in the household? (Refrain whilst nurse is present,
YES / NO
and 1 hour before visit.)
7) Any history of drug or alcohol abuse in the household?
YES / NO
8) Does the patient live alone?
YES / NO
If so, is there an issue with this? (E.g. Attending clinic?)
YES / NO
Home Environment – Risk Assessment
1) Is there adequate lighting?
YES / NO
2) Is there a landline phone available for emergencies?
YES / NO
3) Is there enough space to prepare the injection?
YES / NO
4) Is there an area where the practitioner can work without disturbance? YES / NO
5) Is there a flat level surface available?
YES / NO
6) Is there facilities for hand washing and drying?
YES / NO
7) Is there anywhere to store medicines, notes and equipment safely?
YES / NO
Any issues identified or further comments:
49
Appendix 6: Individual Drug Risk
Assessments
National Patient Safety Agency (NPSA) Risk Rating
Each method box has a coloured bar indicating the NPSA risk rating. The risk rating
refers to the method of preparation and administration described along the row. The
risk rating is not essential for administration; however, you should understand that
the colour of the bar is indicative of the complexity of the task. Medicines that are
complex to prepare and require specialist equipment or infusion devices have a high
NPSA risk rating and are coloured red. You should take additional time to plan and
prepare these medicines and ensure that local protocols are adhered to before giving
the medicine. Less complicated tasks are likely to have a lower NPSA risk rating and
are coloured amber (moderate risk) or green (low risk).
How the risk rating is assigned
Each injectable practice has been assessed against eight criteria:
Number
Risk factor
Applies when
1
Therapeutic risk
There is significant risk of patient harm if the
injectable medicine is not used as intended1
2
Use of a concentrate
The product must be further diluted (after
reconstitution) before it can be injected
3
Complex calculation
A complicated calculation must be performed
in order to prepare or administer the product.
This includes calculations with more than one
step, or conversions between dose units, e.g.
percentage to milligram’s per millilitre
4
Complex method
More than five non-touch manipulations are
required to prepare the product, or when
syringe-to-syringe transfer or a filter is used
5
Reconstitution of
powder in a vial
Where a dry powder preparation must be
reconstituted
50
Number
Risk factor
Applies when
6
Use of a part vial or
ampoule, or use of
more than one vial or
ampoule
Part or multiple vials/ampoules are required to
fulfil the prescription
7
Use of a pump or
syringe driver
An infusion device is required to give the
injectable
8
Use of a non-standard
giving set/device
required
A low sorption, air inlet or light-protected
administration set needs to be used to
administer the injectable
51
Patient Name
Appendix 7: Cardiology Discharge
Form
Hospital Number
DOB
Address
PAS Number
Heart Failure Admission Prevention or Early Supported
Discharge
Date :
Inclusion Criteria:
Fully investigated heart failure including echo
Known to cardiology team
Failure to respond to increased oral diuretics
Renal stability (eGFR > 25ml/min
Sufficient and appropriate carer support
Capacity to consent
Able to monitor weight daily
Referred by:
Assessing clinician’s
signature/Print name
Exclusion Criteria:
Difficult IV access
Symptomatic hypotension
Frailty
Cognitive impairment
Not under care of cardiologist
Insufficient carer support
eGFR < 25ml/min (unless approved
by consultant)
HF team
Consultant
contact details
GP
*NO NEW PATIENTS FRIDAYS UNTIL & DAY SERVICE AVAILABLE*
Date of commencement
Proposed vascular access:-
Proposed Drug &
Dose
Suitable for
HITS?
Allergies:Y/N
Mobile Y/N
Lives alone independently or with carer
Y/N
Additional
Information
Informed Consent obtained Y/N
If no possible in
future?
Y/N
Home environment suitable Y/N
Baseline observations
BP
Weight
Heart rate
Baseline bloods
team if:
Contact HF
Sodium
(<128mmols)
Current
52
Dry weight (if known)
If BP <90mmHg contact HF team
If weight increases or not decreased by 2kg
2 days after therapy commenced contact HF
team to discuss dose increase
Potassium
>5.5mmols)
Urea
Creatinine
eGFR
decrease)
(<3.4 or
(>30%
Date & Time
Clinical Notes
(each entry must be signed, dated & timed)
Date
Weight
Sodium
Potassium
Urea
Creatinine
eGFR
53