Download medication via a subcutaneous cannula

MMSOP07
PROCEDURE FOR THE
ADMINISTRATION OF ‘AS REQUIRED’
MEDICATION VIA A SUBCUTANEOUS
CANNULA
Issue
History
Issue
Version
Two
Purpose of Issue/Description of Change
Planned
Review
To assist and support community practitioners
in the administration of ‘as required’
medication via a subcutaneous cannula to
promote safe and effective care
Named Responsible Officer:-
Quality and Governance Service
Section:- Medicines
Management
2014
Approved by
Quality, Patient
Experience and Risk
Group
Date
August 2013
Target Audience
All Community Nurses
MMSOP: 007
UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE
THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION
Procedure for Administration of “As Required” Medication via a Subcutaneous Cannula
CONTROL RECORD
Title
Purpose
Author
Impact Assessment
Subject Experts
Document Librarian
Groups consulted with :Infection Control Approved
Date formally approved by
Risk and Governance Group
Method of distribution
Archived
Access
Procedure for the Administration of ‘As Required’
medication via a subcutaneous cannula
To ensure a safe and effective procedure for the administration
of ‘As required’ medication via subcutaneous route by
Community nurses
Quality and Governance Service (QGS)
Integrated into procedure
Yes No
Annie Baker
QGS
Medicines Management Group
13.08.2012
5th September 2012
Email
Date:
Via QGS

VERSION CONTROL RECORD
Version Number
Author
Version 1
A Baker
Version 2
A Baker
Status – New / Revised / Trust Change
2
Intranet

Location: S Drive QGS
Status
R & TC
Changes / Comments
To update procedure with the
implementation of Saf-T-Intima cannula
for ‘As required’ Medication
R
To change name of Liverpool Care Pathway
To Wirral End of Life Care Plan as advised by
NHS England (NHS England, 16th July 2013)
INTRODUCTION
The Trust is committed to providing high quality nursing services to all patients who
require frequent doses of break through medication, via the subcutaneous route to
establish symptom control.
PROCEDURE AIM
This procedure aims to promote safe and effective administration of medicines for
patients in the community setting who require medication for symptom management via
a subcutaneous cannula.
PROCEDURE OUTCOME
All registered nurses will comply with this procedure
TRAINING
All staff within the Trust are required to follow the Trust’s mandatory training matrix and
their service core training matrix
RELATED POLICIES – see relevant policies and procedures
RATIONALE FOR USE
• When the oral route is unavailable to patients the subcutaneous (SC)
route is the preferred method of administration of medicines.
• Patients requiring frequent doses of break through medication via
the subcutaneous route to establish symptom control e.g. Dexamethasone
or Levomepromazine (Nozinan)
• Patient choice
• Patients requiring single daily dose medication via the subcutaneous
route
For single dose controlled drugs or for “as required” medication where there
are no calculations to be made; this can be checked and administered by one
registered nurse.
CONTRA INDICATIONS
• Lymphoedema. Choose site unaffected by lymphoedema
• Severe bleeding disorder
3
CONSIDERATIONS PRIOR TO ADMINISTRATION OF “AS REQUIRED”
MEDICATION VIA A BUTTERFLY
If cannula insitu prior to administration, check site for signs of infection e.g. redness,
pain or swelling
Saf-T-Intima cannula can remain insitu for up to seven days
The administration of “as required” medication should not be a substitute for
reviewing/adjusting the doses of medication given via continuous subcutaneous infusion
The administration of a “as required” dose may be indicated for symptom
management when initially setting up a syringe driver
The amount of flush required to prime or flush the cannula will be determined by the length of
the tubing, as individual manufacturer’s instructions may vary.
It is recommended that the cannula be flushed with at least twice the amount of the length of
tubing (RCN, 2010), the Saf-T-Intima cannula will require flushing with 0.5ml flush.
To flush the cannula use a flush that is compatible with the medication to be administered.
Once the Saf-T-Intima cannula has been primed a bionnector will need to be attached to the
cannula for administration of medication.
The maximum volume for drug administration for “as required” medication by subcutaneous
injection is 2ml (this includes 0.5ml flush)
EQUIPMENT REQUIRED
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Saf-T-Intima cannula
Bionnector
1ml luer lock syringe (unless volumes over 1ml are required)
Single use disposable apron
Single use disposable non sterile gloves
If indicated single use sterile dressing pack
Point of Use Disposal System (POUDS) tray
Green needle
DOOP kit (for disposal of prescribed controlled drugs in the community)
Patient Medicines Administration Chart (PMAC)
Relevant documentation for “as required” medication
Prescribed medication
2% chlorhexidine and 70% alcohol impregnated swab/applicator (Chloraprep)
Sharps container
Semi-permeable film dressing
Solution for flushing
Trust approved cleaning wipe
Single use disposable sterile scissors
PROCEDURE
RATIONALE
Verbally confirm the identity of the patient by asking
for their full name and date of birth. If the patient is
unable to confirm, check identity with family/carer
To avoid mistaken identity
Introduce yourself as a staff member and any
colleagues involved at the contact
To promote mutual respect and put the
patient at their ease
4
Wear identity badge which includes name status and
designation
Ensure verbal consent for the presence of any other
third party is obtained
Explain procedure to patient including risks and
benefits and gain valid consent.
Establish patient has no known allergies, check in
patient’s records and also ask patient/family of any
known allergies
Ensure patient is comfortable and maintain patient
privacy
Give clear explanation of procedure to be
performed and the care that will follow
Check the PMAC specifies the following information:
Patient’s full name
Patient’s date of birth (DOB)
NHS Number
Prescriber’s signature and date prescribed
Name of medicine to be administered
Route of administration and frequency
The allergy status of the patient
Check the manufacturer’s label on the vial/ampoule
against the pharmacy label checking:
• The name of the medicine
• Strength of the medicine
• Dose of the medicine
Check that the pharmacy label corresponds to the
medicine details on the Patient Medicines
Administration Chart.
(If a dosage is prescribed as a sliding scale ensure
the dose is within the dosage range prescribed)
Check batch number and expiry date and record
in patient’s records
Provide opportunity for questions to be asked
Provide emotional and physical support as required
Record outcome of discussions and document in
care plan, including consent to procedure
Note, when patient is unconscious or does not have
capacity to consent, medicines are prescribed in the
patients’ best interests. Evidence of wider
consultation must be recorded on consent form 4 (if
required).
Copy to be kept in base notes.
Decontaminate hands
Gather equipment
5
For patients to know who they are
seeing and to promote mutual respect
Students for example, as the patient has
the choice to refuse
To ensure the patient understands the
procedure and relevant risks and the
patient can make informed decisions
To reduce allergic reactions
To maintain privacy and dignity
To gain patient co-operation and
enable informed and understood
consent to the procedure
Effective medicines management and
maintain patient safety
To check the pharmacy has
dispensed the correct medicine
To check that the PMAC and
pharmacy label correspond and that
there are no discrepancies
To provide an audit trail of batch
numbers used and avoid out of date
drugs being given
Patients or carers need time for
queries or concerns to be discussed
As specified in the patient’s care plan
Health records policy
Consent Policy
Working in partnership with carers
and other health care professionals
To reduce the risk of transfer of
transient micro-organisms on the
healthcare worker’s hands
Clean tray using Trust approved cleaning wipe or if
indicated open sterile dressing pack onto a clean
area and place all sterile single use equipment
required within aseptic field. To maintain key part
protection at all times.
Decontaminate hands prior to procedure
Apply single use disposable apron
Trim excess hair from selected site (if required) using
single use disposable sterile scissors.
Apply single use non sterile gloves or if indicated
apply single use disposable sterile gloves after
cleaning of skin
Choose an appropriate site in consultation with
patient (See Appendix One for choice of site)
Using an Aseptic Non Touch Technique
Attach a bionnector and prime cannula with
prescribed flush
Clean area of chosen site with 2% chlorhexidine and
70% alcohol impregnated swab/applicator
(Chloraprep) for a minimum of 30 seconds and allow
to dry
Insertion of cannula
Grasp ridged yellow side wings of the cannula
between thumb and index finger,
Remove needle sheath from Saf-T-Intima cannula
making sure the eye of the needle is facing upwards
at the sharpest point to enter the skin.
Using Aseptic Non Touch Technique
Insert BD Saf-T-Intima cannula at 45º angle into the
subcutaneous tissue; cover the cannula and wings
only with transparent dressing.
Hold wings of cannula firmly and pull back on the
introducer until you see four distinct parts (needle
encasements, wire and white introducer.
Grip “Y” connection with one hand and the yellow
needle encasement with the other hand.
With a gentle pulling action, pull the needle
encasement away from the “Y” connection.
This should leave a bung in place this bung is not
used for the administration of medicines), pull the
needle encasement away and dispose in sharps
container.
Using 2% chlorhexidine and 70% alcohol impregnated
swab (Chloraprep) thoroughly clean the end of
bionnector for at least 30 seconds and allow to dry,
administer the medication and flush via the bionnector
ALL MEDICATION MUST BE ADMINISTERED
THROUGH THE BIONNECTOR
6
To create clean work area, promote
asepsis and prevent contamination of
key parts
To reduce the risk of transient microorganisms on the healthcare worker’s
hands
To protect clothing or uniform from
contamination and potential transfer of
micro-organisms
To ensure dressing adheres to patient
skin and reduce the risk of causing pain
or discomfort when removing the
dressing
To protect hands from contamination
with organic matter and transfer of
micro-organisms
Patient may wish to express a personal
preference
In preparation for administration of
medication
To reduce the risk of transfer of any
transient micro-organisms and resident
micro-organisms from skin to
subcutaneous tissues
To ensure accuracy of placement
To promote asepsis and prevent
contamination of key parts
Reduce transfer of micro organisms
Staff must use one ml luer syringe for
calculating drugs less than one ml
Check compatibility of medicines with any
required diluents and flushes
After administration of prescribed medication,
flush the cannula with the appropriate flush
compatible
Dispose of sharps directly into a sharps container
On completion of procedure remove and dispose
of Personal Protective Equipment (PPE)
to comply with Trust policy
Decontaminate hands
Document procedure, site location and medication
administered on ‘As required’ documentation
Any related incidents arising from carrying
out this procedure which may involve a clinical
error or near miss must be reported following the
Trust’s
Incident Reporting System
REMOVAL OF A CANNULA
The cannula must be removed if no further
medicines are required or if there are clinical signs
Gather all equipment
Clean tray using Trust approved cleaning wipe or
if indicated open sterile dressing pack onto a
Decontaminate hands
Apply single use disposable apron
Apply single use disposable non-sterile gloves, or if
indicated single use sterile gloves
When removing the cannula the device should
be removed carefully using a slow, steady
movement and pressure should be applied.
The site should be inspected and the site
covered with a sterile dressing.
The cannula integrity should be inspected to
ensure the complete device has been removed
Dispose of clinical waste as per Trust policy
On completion of the procedure remove and
dispose
of Personal Protective Equipment (PPE) to
Decontaminate hands
7
To promote safe administration of
medication
Insulin syringes must not be used
as this may lead to drug errors
To avoid drug interactions
To keep cannula patent and
ensure prescribed dose of drug
has been administered
To reduce the risk of inoculation
injury
To prevent cross infection and
environmental contamination
To reduce the risk of transfer of transient
micro-organisms on the healthcare
worker’s hands
Recording medication details complies
with Trust SOP for Administration of
Medicines
To maintain patient safety and comply with
Trust Incident Reporting System for
effective clinical governance
To prevent the introduction of infection
To create clean work area
To reduce the risk of transient microorganisms on the healthcare worker’s
hands
To protect clothing or uniform from
contamination and potential transfer of
micro-organisms
To protect hands from contamination
with organic matter and transfer of
micro-organisms
To prevent cross infection and
environmental contamination
To prevent cross infection and
environmental contamination
To reduce the risk of transient microorganisms on the healthcare worker’s hands
WHERE TO GET ADVICE FROM
Trust staff need to contact their Line Manager or Team Leader if further guidance
and clarification is required.
INCIDENT REPORTING
Clinical incidents or near misses must be reported using Trust Incident Reporting
System
SAFEGUARDING ADULTS
In any situation where staff may consider the patient to be a vulnerable adult, they
need to follow the Trust Safeguarding Adult Policy and discuss with their line manager
and document outcomes.
EQUALITY ASSESSMENT
During the development of this procedure the Trust has considered the clinical needs
of each protected characteristic (age, disability, gender, gender reassignment,
pregnancy and maternity, race, religion or belief, sexual orientation). There is no
evidence of exclusion of these named groups.
If staff become aware of any clinical exclusions that impact on the delivery of care,
this should be reported using the Trust Incident reporting system and an appropriate
action plan put in place.
REFERENCES –
Dougherty L, Lister S (2011) The Royal Marsden Hospital Manual of Clinical
Nursing Procedures, 8th Edition, Wiley-Blackwell, Oxford.
National Institute of Clinical Excellence (NICE) 2004 Guidance on Cancer
Services: Improving Supportive and Palliative Care for Adults with Cancer: The
Manual http://www.nice.org.uk/nicemedia/pdf/csgspmanual.pdf
Nursing and Midwifery Council (NMC) (www.nmc-uk.org
RCN (2010) Standards for Infusion therapy. www.rcn.org.uk
Wirral Guidelines for Care of the Dying Patient: Wirral Community NHS Trust.
Locally adapted version of the Wirral End of Life Care Plan available on the Trust
intranet
Useful websites:
British National Formulary (BNF) www.bnf.org.uk
Current learning in palliative Care
http://learningzone.mariecurie.org.uk/endoflife/syringedrivers.htm
Palliative Care Formulary textbook is available free online following registration with
the website: www.palliativedrugs.com
8
Appendix One
SUBCUTANEOUS INSERTION SITES
Shaded areas that can be used to insert a cannula for a subcutaneous
site.
UPPER BACK (Scapula region)
SUBCLAVICULAR
AREA
Use when:
• other sites are unsuitable
• patient confused
Anterior
chest wall
Anterior aspect of
upper arm
Anterior
abdominal wall
of ten
Anterior
aspect of thighs
ABD
Te
Ensure caution is taken
when using the
subclavicular space as
the insertion site. In a
cachectic individual
there may be a small
amount of tissue
between the chest wall
and the underlying lung,
which results in the risk
of a pneumothorax. To
decrease this risk, pull
the skin away from the
chest wall and insert the
needle at a shallow
angle or choose a
different site for
insertion.
ABDOMEN – Avoid in
presence of tense abdominal
dissention
The following areas should be avoided when inserting a subcutaneous needle:
•
•
•
•
•
•
•
•
Areas with Lymphoedema or oedema
Areas with broken skin
Skin sites that have recently been irradiated
Sites with infection or inflammation present
Skin folds
Tumour sites
Areas that have too little subcutaneous tissue
Areas with bony prominences
PROCEDURE FOR THE ADMINISTRATION OF ‘AS REQUIRED’ MEDICATION
VIA A SUBCUTANEOUS BUTTERFLY
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