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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. 8 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: 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. 9 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: 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: 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 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: 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