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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 • • • • • • • • • • • • • • • • • • 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 9/9