Download REFERRING DOCTOR PATHWAY FOR PATIENTS SUITABLE FOR

HOSPITAL PATIENT INCLUSION CRITERIA FOR
COMMUNITY INTRAVENOUS (IV) THERAPY SERVICE
If the patient meets all following criteria, please contact the
Community IV Nurse to discuss referral to the service
Community IV Nurse Specialist
Teddington Health & Social Care Centre
Mobile No: 07946841338/07920700032
9-5pm Monday-Friday (if unavailable contact Single Point of Access (SPA)
SPA (for Richmond & Hounslow GP registered patients):
Tel: 0208 630 3943 (7-7pm Monday-Sunday)
PATIENT INCLUSION CRITERIA
Y
N
Patient registered with a NHS Richmond or Hounslow GP.
Patient over 18 years old.
Patient has a definite diagnosis and is referred by a medical practitioner.
Patient medically stable other than requiring intravenous treatment.
Patient fully informed and consents to intravenous therapy.
Patient has access to a responsible person 24 hours a day.
Referring Doctor has accepted responsibility for patient and will provide
24 hour advice.
Patient has access to a telephone and to running water.
Medication infusion time less than 30 minutes. (Max 30 mins)
Exclusions
Patient has any known history of drug or alcohol abuse.
Patient has any known history of dementia/confusion.
Patient has any known history of poor compliance to treatment.
Venous access
Cannula – for short term therapy (Up to 2 weeks)
Piccline/Midline/Implanted Port - for long term therapy (More than 2 weeks).
NB: Only cannulae can be inserted in the community.
Please provide patient discharge summary when available
Additional information for referring ward Nurse or Doctor
 A minimum of 1 working day notice should be given for elective discharges.
 Once the referral has been discussed and accepted by the Community IV Nurse/SPA/
District Nursing Team, new referral documentation will be faxed to the referrer by
Hounslow SPA.
 Patients must be discharged with all medication, diluents, flushes and all other
necessary equipment for the duration of treatment.
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Version 1:5 Revised 06/10/2015
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COMMUNITY IV THERAPY SERVICE REFERRAL DOCUMENTATION
Ward Checklist for all patient’s discharged from Hospital to HRCH for community IV Therapy
To be completed by the Ward Nurse
Patient’s Name:
NHS Number:
Patient’s Address:
Patient’s DOB
_____________________
Contact Number:
Discharging Hospital
& Ward:
Planned Discharge
Date:
Name of Support or
Next of Kin/Carer &
Contact Number:
Ward contact number:
Planned District Nurses
Start Date & Time
GPSurgery Name:
Contact Number:
The following checks need to take place before discharge:
Referral discussed and accepted verbally by Community IV Nurse/Single Point of
Access/District Nursing Team
Tick
Type of IV access
(Please circle and complete insertion date):
Cannula
Midline
PICC Line
Hickman Line
Implanted Port
(NB: a new cannula must be inserted on day of discharge and IV dressing dated and initialled).
Date of Insertion:
Complications or poor venous access (If yes please provide details):
For CVAD’s (i.e. Piccline, Implanted Port):
Length Inserted: ………………. cms
Y / N
Checked by Xray: Yes  No 
Length of catheter exposed at site: …………….. cms
MEDICATION & EQUIPMENT TO BE SUPPLIED BY REFERRING HOSPITAL
FOR THE DURATION OF TREATMENT
IV Medication and solutions
Quantity given
Drug/Antibiotic
Diluents and reconstitution solutions e.g. Sodium chloride 0.9%, water for injection, and
Sodium Chloride 0.9% 50ml/100ml bags (if required for infusion) (check TTA’s).
Flush solution e.g. Sodium chloride 0.9% 10ml pre-filled syringes or 10ml ampoules and
Heparin Sodium 50-100 units per ml if prescribed (check TTA’s)
Equipment:- Dressings i.e. Cannula dressing – one dressing required every 72 hrs.
Piccline/Midline dressing – one dressing required per week.
Luer Lock Syringes i.e. 1 x 10mls for drawing up medications and 2 for flushes each visit.
Safety Needles and filter needles for glass vials if applicable
Cannulae 22G (blue) or 20G (pink) i.e. one required every 72 hrs.
IV administration sets i.e. one per infusion.
Bungs/Needle Free Device for lines i.e. one per week.
Chlorhexidine 2% based wipes.
Chloraprep 1.5ml Sponge Applicator i.e. 1 per dressing change or re-cannulation.
Name of discharging nurse:
Signature:
Date:
___________________________________________ __________________________________________
_
Page
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Version 1:5 Revised 06/10/2015
COMMUNITY IV THERAPY SERVICE REFERRAL DOCUMENTATION
Authorisation for all patient’s discharged from Hospital for HRCH Community IV Therapy
to be completed by the Referring Doctor
Patient’s Name:
NHS Number:
Have you sought advice from the Antimicrobial Review Team (Microbiologist) regarding medication
use and duration of treatment?
Yes

No

Patient’s Infection Status (please circle):
N/A
MRSA
ESBL/ MSSA
CDIFF
VRE
Name of Microbiologist:
Name of Pharmacist:
ANAPHYLAXIS RISK ASSESSMENT
Allergy Status:
Patient’s that have suffered a previous anaphylactic reaction to a medication MUST NOT be
prescribed the same medication.
Is there any cross sensitivity between the medication to be administered and the
substance that caused a previous reaction? (circle)
Y – N – N/A
Has the patient had the prescribed medication before (orally or intravenously)?
How many doses of the current regimen have been administered?
DIAGNOSIS (Reason for IV Therapy)
Name of IV Antibiotic(s)
Dose
IV Duration
In Days
List All Other Current Medication or attach discharge letter:
DIRECTIONS FOR ANTIBIOTIC RECONSTITUTION: (If different to Medusa)
Date and time treatment of last dose in hospital:
Date of review of treatment or follow-up appointment:
What follow-up treatment or appointment has been arranged for this patient?
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Version 1:5 Revised 06/10/2015
Patients Name
NHS Number
BLOOD MONITORING:
Is Blood Monitoring Required?
If yes, what blood monitoring is required, when and by whom?
Y / N
Any other relevant information: e.g. Key safe number
PRESCRIBER'S DETAILS
Name of Referring Doctor to be contacted for advice: (Please print)
…………………………………………………………………………………………………………………
Contact No: ………………………………………
Doctors Signature: ………………………………
Bleep No: …………………………………………..
Date: ………………………...................................
Name of Registrar or Consultant
with Continuing Overall Responsibility……………………………………………………………
Contact number……………………………………….Bleep No…………………………………………
NOW COMPLETE
P2 RECORD OF MEDICATION AUTHORISATION AND ADMINISTRATION
INCLUDING ANTIBIOTIC
SODIUM CHLORIDE 0.9% 50mls or 100mls FOR INFUSION IF APPLICABLE
Sign the pre-printed SODIUM CHLORIDE 0.9% FOR PRE AND POST FLUSHES (10MLS)
AND ANY DILUTENTS FOR RECONSTITUTION OF DRUGS (e.g. water for injection)
then Fax all completed documents and discharge summary/TTA to
Hounslow Single Point of Access(SPA) on
Fax: 0208 630 3639
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Version 1:5 Revised 06/10/2015