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NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST MEDICINES POLICY: CODE OF PRACTICE MEDICINES IN RADIOLOGY –INTERVENTIONAL AND DIAGNOSTIC DEPARTMENTS Reference Approving Body Date Approved Implementation Date Version Summary of Changes from Previous Version Supersedes Consultation Undertaken Date of Completion of Equality Impact Assessment Date of Completion of We Are Here for You Assessment CL/MM/015 Directors’ Group 30 June 2015 30 June 2015 4 Change in authorisation process within Diagnostic radiology. Medicines in the radiology and diagnostic departments CLMM015 Version 3 April 2012 Clinical Director, Associate Clinical Director for Diagnostics, Modality managers and Clinical Leads for MRI, CT and Intervention, Clinical Lead for MSK and Intervention, Matron and Lead Nurse in Intervention. 28/4/2015 28/04/2015 28/04/2015 Date of Environmental Impact Assessment (if applicable) Legal and/or Accreditation Implications Target Audience 28/04/2015 Review Date May 2018 Lead Executive Medical Director ISAS Radiology Accreditation Ready This policy applies to whole of the Radiology Department in the Trust excluding Medical Physics. CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 1 Chief Operating Officer Author/Lead Manager Mo Rahman Head of Pharmacy and Clinical Director for Medicines Management Ext 61199 Further Guidance/Information Jagrit Shah Consultant Neuroradiologist and Head & Neck Radiologist Extension: 61949 Shashi Gupta Specialist Pharmacist Extension:67622 Sonia Gilmore Medicines Management pharmacist, professional sec to MMC Extension 59374 CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 2 CONTENTS Paragraph Title 1. 2. 3. 4. 5. 6. 6.1 6.2 4 4 5 5 5 6 6 8 Appendix 1 Introduction Executive Summary Policy Statement Definitions (including Glossary as needed) Roles and Responsibilities Policy and/or Procedural Requirements Specialist professional groups Prescribing and authorisation for administration of medicines Training, Implementation and Resources Impact Assessments Monitoring Matrix Relevant Legislation, National Guidance and Associated NUH Documents Equality Impact Assessment Appendix 2 Environmental Impact Assessment 16 Appendix 3 Appendix 4 Here For You Assessment Certification Of Employee Awareness 18 20 7. 8. 9. 10. CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 Page 9 9 11 12 13 3 1.0 Introduction 1.1 This policy applies to whole of the Radiology Department in the Trust excluding Medical Physics. All staff that use and are responsible for medicines in these areas must incorporate the principles of safe and secure custody and use of medicines as defined in the Medicines Code of Practice with any additional policy for the safe use of specific types of substances (e.g. radioisotopes) The Trust CL/MM/006 Prescribing policy should be followed. However some of the processes in Radiology are different, for these processes, local policy should be followed as described below. 2.0 Executive Summary 2.1 Radiology is split into two categories Diagnostic and Interventional radiology sections both of which must have a system of procedures to ensure the safety and security of medicines stored and used in these areas. Diagnostic sections include: CT MRI Ultrasound Plain film service Interventional Radiology Section includes the following procedures carried out in the Theatre setting: Vascular intervention Neuro intervention General body intervention CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 4 3.0 Policy Statement 3.1 The Trust supports the safe use (prescribing, supply, administration and storage) of all medicinal products. The measures outlined in the policy below must be adhered to by all staff in order that potential harm to patients is minimised. 4.0 Definitions 4.1 Medicinal products as defined under the Medicines Act and other legislation. This definition of medicines includes contrast media, isotopes and other diagnostic agents which enter a patient’s body by any route for a physical or pharmaceutical effect. 5.0 Roles and Responsibilities 5.1 Committees 5.1.1 Medicines management committee- responsible for ensuring that this policy is in place and up to date 5.2 Individual Officers 5.2.1 The Chief Pharmacist and the Clinical Director of the Radiology and Diagnostics Department have executive responsibility for establishing and maintaining a system for the security of medicines. This responsibility may be delegated to the Section Manager, medical, nursing, professional and technical staff as appropriate. 5.2.2 The Appointed Practitioner in Charge of the Department (Matron in Interventional Theatres, Lead Nurse in MRI and Superintendent/Modality Manager in other diagnostic sections) at any given time shall have the responsibility for ensuring that the system is followed and that the security of medicines in the Department is maintained. The Appointed Nurse or Practitioner in Charge is responsible for ensuring that checks of the Controlled Drug stocks and records are made on each working day. For all details regarding Controlled Drug CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 5 management refer to section 12 of this Medicines Code of Practice (CLMM012) The Appointed Practitioner in Charge and Designated Practitioner in Charge (Nurse in charge or Superintendent Radiographer) are responsible for: Ordering medicines. Receiving, checking and recording stock from Pharmacy Ensuring the stock is stored securely. Holding medicine cupboard (including Controlled Drug cupboard) keys. 5.2.3 Individual practitioners must ensure they are familiar with this policy 6.0 Policy and/or Procedural Requirements 6.1 SPECIALIST PROFESSIONAL GROUPS 6.1.1 Operating department practitioners (ODPs) working within interventional radiology / theatres A registered ODP must be registered with the Health and Care Professions Council. ODPs will be included under the term ‘practitioner’ throughout this procedure. A registered ODP who has received the appropriate training and assessment may undertake an expanded role in drug administration and have the same responsibilities as a registered nurse regarding the management of medicines in theatre. 6.1.2 Radiographers Radiographers must be registered with the Health and Care Professions Council. Radiographers who have received Trust approved training in IV Cannulation and administration of diagnostic imaging specific medicines may undertake this as an extended role under a local agreement under indirect supervision of a Radiologist or a Doctor. CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 6 6.1.3 Registered Nurses Nurses must be registered with the Nursing and Midwifery Council. Registered Nurses must undertake and maintain by updates, the Trust training in IV Drug Administration and Sedation package prior to being able to administer and/or assist in procedures requiring sedation or any IV Drug administration. 6.1.4 Vascular Access Practitioners Registered Nurse/Radiographer whom have at least 1 years post registration experience; and hold registration with either the NMC or HCPC. Vascular Access Practitioners who have received Trust approved training in IV Cannulation and administration of diagnostic imaging specific medicines may undertake this as an extended role under a local agreement (Administration of subcutaneous 1% Lidocaine and Heparin Sodium (50units in 5ml) intravenous flushes for the placement of peripherally inserted central catheter (PICC)/Mid lines in Adults by Vascular Access Practitioners within Interventional Radiology.) 6.1.5 Radiologists Radiologists must be members of the Royal College of Radiologists and are registered with the General Medical Council (GMC). Radiologists may direct, supervise or undertake administration of medications according to individual competencies, training and good medical practice guidance by the GMC. 6.1.6 Anaesthetists Anaesthetists are doctors who have completed full medical training and must be registered with the Royal college of Anaesthetists with specialist knowledge and training. They hold responsibility for administration and management of Medicines according to local and hospital procedures. CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 7 6.2 PRESCRIBING AND AUTHORISATION FOR ADMINISTRATION OF MEDICINES Any medicine administration must be against a written prescription, Local Agreement or local protocols. Practical guidance for use of contrasts is in the standards for intravascular contrast agent administration to adult patients by the Royal College of Radiologists. This outlines the standard doses of contrasts for procedures, cautions, contraindications and dose adjustments which should be used as a guide at NUH. 6.2.1 Diagnostic radiology A referral is authorised for a specific procedure by a Radiologist with consideration of renal function etc. The type of contrast and dosage range is set by local scanner protocols which can be referred to via the intranet under Radiology Policy Documents. When the Radiologist authorises the procedure they delegate authority to the radiographers to administer contrast as outlined in the local scanner protocols within the set limits. All contrasts/medications should be double checked by two practitioners and recorded along with the administration, name and volume of contrast and who has completed the checks electronically on Radiology CRIS system (or on request form which should be scanned on to CRIS). If not requested electronically the request form should have the date and name printed in full of the practitioner. The Radiology Report should mention the use of contrast in the study title or the body of the report. Other non-contrast medications e.g. hyoscine butylbromide or lidocaine or flushes must be prescribed on the drug chart for inpatients. For outpatients, the request should be written on CRIS to authorise the Radiographer to administer and the details of the medication used should be detailed on the Radiology Report as per contrast. These reports should be ideally authorised on the day of the procedure. 6.2.2 Intervention radiology Contrasts should be prescribed on the pre-printed Interventional radiology drug chart. The Radiology Report should also mention the CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 8 use of contrast in the study title or the body of the report. Dose and type of contrast used should be mentioned for intra-arterial procedures and if more than the usual dose of contrast is used for intravenous contrast. For Non contrast medications if the medicine is to be continued post procedure it must be prescribed on the inpatient prescription chart. Administration of any medicines that have been given in interventional radiology which affect the subsequent dose of the same (or another) medicine must be documented on the inpatient prescription chart. Any other medications e.g. local anaesthetics etc. should all be prescribed on the interventional radiology drug chart and this should be filed in the patient’s notes. 7.0 Training and Implementation 7.1 Training See section 6.1.1 to 6.1.6 of this policy. Health professionals must ensure they have received any appropriate and relevant training. 7.2 Implementation Health professional should ensure they are familiar with this policy. It is the responsibility of the accountable manager to monitor any incidents arising from its use. 7.3 Resources No additional resources are required. 8.0 Trust Impact Assessments 8.1 Equality Impact Assessment An equality impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 9 8.2 Environmental Impact Assessment An environmental impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.3 Here For You Assessment A Here For You assessment has been undertaken on this document and has not indicated that any additional considerations are necessary. CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 10 9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Responsible individual/ group/ committee Process for monitoring e.g. audit Review of Scanner protocols must be undertaken every 2 years, with expiry at 3years if not reviewed and ratified. Superintenden Annual Ongoing t/ documentation Modality audit. Manger CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 Frequency of monitoring Responsible individual/ group/ committee for review of results Clinical Improvement Group (CIG) Responsible individual/ group/ committee for development of action plan Operational Management team Responsible individual/ group/ committee for monitoring of action plan CIG 11 10.0 Relevant Legislation, National Guidance and Associated NUH Documents 10.1 1. Standards for Intravenous Contrast agents for adult Patients, Third Edition (Royal College of Radiologists) https://www.rcr.ac.uk/publication/standards-intravascularcontrast-administration-adult-patients-third-edition 2. Radiology Scanner Protocols – Link to Radiology Intranet to be added. 3. NUH Prescribing Policy (CLMM006) 4. NUH Medicines Code of Practice (CLMM012) CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 12 APPENDIX 1 Equality Impact Assessment (EQIA) Form (Please complete all sections) Q1. Date of Assessment: 28.4.15 Q2. For the policy and its implementation answer the questions a – c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) a) Using data and supporting b) What is already in place in c) Please state any Protected information, what issues, the policy or its barriers that still need to Characteristic needs or barriers could the implementation to address be addressed and any protected characteristic any inequalities or barriers to proposed actions to groups experience? i.e. are access including under eliminate inequality there any known health representation at clinics, inequality or access issues to screening consider? The area of policy or its implementation being assessed: Race and Ethnicity Gender n/a n/a n/a n/a n/a n/a Age n/a n/a n/a Religion n/a n/a Disability n/a n/a n/a Sexuality n/a n/a CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 n/a n/a 13 Pregnancy and Maternity Gender Reassignment Marriage and Civil Partnership Socio-Economic Factors (i.e. living in a poorer neighbour hood / social deprivation) n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Area of service/strategy/function Q3. What consultation with protected characteristic groups inc. patient groups have you carried out? None Q4. What data or information did you use in support of this EQIA? None Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? No Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups identified or to create confidence that the policy and its implementation is not discriminating against any groups CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 14 What Q7. Review date By Whom By When Resources required May 2018 CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 15 Environmental Impact Assessment- APPENDIX 2 The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area of impact Environmental Risk/Impacts to consider Waste and Is the policy encouraging using more materials/supplies? materials Is the policy likely to increase the waste produced? Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled? Soil/Land Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) Does the policy fail to consider the need to provide adequate containment for these substances? (e.g. bunded containers, etc.) Water Is the policy likely to result in an increase of water usage? (estimate quantities) Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal) Air Is the policy likely to result in the introduction of procedures and equipment with resulting emissions to air? (e.g. use of a CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 Action Taken (where necessary) No No No No No No No No No 16 Energy Nuisances furnaces; combustion of fuels, emission or particles to the atmosphere, etc.) Does the policy fail to include a procedure to mitigate the effects? Does the policy fail to require compliance with the limits of emission imposed by the relevant regulations? Does the policy result in an increase in energy consumption levels in the Trust? (estimate quantities) Would the policy result in the creation of nuisances such as noise or odour (for staff, patients, visitors, neighbours and other relevant stakeholders)? CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 No No No no 17 APPENDIX 3 We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit The We Are Here For You service standards have been developed together with more than 1,000 staff and patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization. Please rate each value from 1 – 3 (1 being not at all, 2 being affected and 3 being very affected) Value 1. Polite and Respectful Whatever our role we are polite, welcoming and positive in the face of adversity, and are always respectful of people’s individuality, privacy and dignity. 2. Communicate and Listen We take the time to listen, asking open questions, to hear what people say; and keep people informed of what’s happening; providing smooth handovers. 3. Helpful and Kind All of us keep our ‘eyes open’ for (and don’t ‘avoid’) people who need help; we take ownership of delivering the help and can be relied on. 4. Vigilant (patients are safe) Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates attention to detail for a clean and tidy environment everywhere. CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 Score (13) 1 1 1 1 18 5. On Stage (patients feel safe) We imagine anywhere that patients could see or hear us as a ‘stage’. Whenever we are ‘on stage’ we look and behave professionally, acting as an ambassador for the Trust, so patients, families and carers feel safe, and are never unduly worried. 6. Speak Up (patients stay safe) We are confident to speak up if colleagues don’t meet these standards, we are appreciative when they do, and are open to ‘positive challenge’ by colleagues 7. Informative We involve people as partners in their own care, helping them to be clear about their condition, choices, care plan and how they might feel. We answer their questions without jargon. We do the same when delivering services to colleagues. 8. Timely We appreciate that other people’s time is valuable, and offer a responsive service, to keep waiting to a minimum, with convenient appointments, helping patients get better quicker and spend only appropriate time in hospital. 9. Compassionate We understand the important role that patients’ and family’s feelings play in helping them feel better. We are considerate of patients’ pain, and compassionate, gentle and reassuring with patients and colleagues. 10. Accountable Take responsibility for our own actions and results 11. Best Use of Time and Resources Simplify processes and eliminate waste, while improving quality 12. Improve Our best gets better. Working in teams to innovate and to solve patient frustrations TOTAL CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 1 1 1 1 1 1 1 1 12 19 APPENDIX CERTIFICATION OF EMPLOYEE AWARENESS Document Title Medicines In Radiology- Interventional And Diagnostic Departments Version (number) 4 Version (date) 30 June 2015 I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is; Clinical directorates - general manager Non clinical directorates - deputy director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilize this form in a similar way, but this would always be an additional (not replacement) action. CL/MM/015 Medicines in radiology- interventional and diagnostic departments Version 4 June 2015 20