IV Policy...5.3.6 Staff moving between units/ specialities remain competent to administer IV fluids...

IV (Intravenous Therapy) UHL Policy*

(*excluding cytotoxic, epidural, PN and radiopharmaceuticals)

Approved By: Policy and Guideline Committee

Date Approved: 13 August 2010

Trust Reference: B25/2010

Version: V4 – 20 January 2017

Supersedes: V3 approved January 2013

Author / Originator(s): Jackie Elton, Senior Nurse Medicines Management

Name of Responsible Committee/Individual:

Medicines Optimisation Committee

Review Date: January 2021 Review Date Extension Approved at PGC 18.09.2020

of 47 IV (Intravenous Therapy) UHL Policy

Latest version approved by Policy and Guideline Committee on 20 January 2017

Trust Ref: B25/2010 Next Review: Jan 2021

NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents

Section Page

1 Introduction 3

2 Policy Aims 3

3 Policy Scope 3

4 Definitions 5

5 Roles and Responsibilities 5

6 Policy Statements, Standards, Procedures, Processes and Associated Documents

7

7 Education and Training 12

8 Process for Monitoring Compliance 13

9 Equality Impact Assessment 14

10 Legal Liability 14

11 Supporting References, Evidence Base and Related Policies 15

12 Process for Version Control, Document Archiving and Review 16

Appendices Page

1 Procedure for Checking IV medications prior to administration – Role of the Independent Checker

17

2 ADULTS: Procedure for the Preparation and Administration of Bolus Intravenous Medications

20

3 ADULTS: Procedure for the Preparation and Administration of a Medication or clear Fluid Infusion

25

4 BABIES, CHILDREN AND YOUNG PEOPLE: Procedure for the Preparation and Administration of Bolus and Infusion medication via a central Line in Babies, Children and Young People (under 18 yrs)

31

5 BABIES, CHILDREN AND YOUNG PEOPLE: Procedure for the Preparation and Administration of Bolus and Infusion Medication via a Peripheral line in Babies, Children and Young People (under 18 yrs)

38

6 Peripheral IV Cannula Care Bundle 44

7 Sample pump check chart 46

8 ASEPTIC PRODUCTS ROUTINELY MADE IN THE ASEPTIC UNIT 47

REVIEW DATES AND DETAILS OF CHANGES MADE DURING THE REVIEW

November 2016 – In all procedures reference changed to blunt fill filter needle or green/ blue safety needle. This is to reflect the change to safety sharps within the Trust following an HSE improvement notice in December 2015, and subsequent episodes of coring being noted within the trust when using non-filter blunt fill needles. The MHRA are currently (November 2016) undertaking an investigation as to the safety of the non-filter blunt fill needles.

Additional section added to address issue of competence of temporary staff administering IV medication.





Expanded to include Loading Doses, and amendments to checking procedures in ITUs and midwifery KEY WORDS

Intra-venous (IV)

Administration

Clear fluids

1 INTRODUCTION

1.1 This document sets out the University Hospitals of Leicester (UHL) NHS Trusts Policy and Procedures for the safe preparation and administration of intravenous (IV) medication and fluids.

1.2 The intravenous administration of medication is most commonly achieved by injecting the appropriately prepared medication by a bolus injection through a cannula, or by an infusion, with or without using a volumetric infusion device. (Clarke 1997).

2 POLICY AIMS

This Policy aims to provide safe and effective IV therapy by ensuring that:

2.1 Medications are only given intravenously where it is positively indicated, for example (not a definitive list)

a) For therapeutic control and medication titration

b) A rapid therapeutic action is required

c) When there is a clinical need for sustained plasma concentrations

d) When a medication cannot be taken orally or by another alternative route

e) Administration of an IV Medication / Media for clinical investigation procedures

2.2 As soon as possible IV medications are changed to oral / alternative route.

2.3 Wherever possible ready made injections, infusions or mini-bags with adaptors are used.

2.4 The principles of aseptic no touch technique (ANTT) and five moments of hand hygiene are embedded within the IV preparation and administration procedures

3 POLICY SCOPE

3.1 This policy and procedures apply to all health care staff working in the University Hospitals of Leicester NHS Trust competent and able to undertake this role (including bank, agency and locum and those operating under an honorary contract).





3.2 This policy and procedures apply to all adult, babies, children and young people

3.3 All venous administration lines unless otherwise stated

3.4 This policy must be used in conjunction with the UHL approved Patient Group Directives (PGD) and IV Medication Monographs. The monographs are produced by Pharmacy and Medicines Information and detail the safe preparation and administration of medications, correct diluent for each medication and safe administration intervals. These monographs can be found on the Medicines Management INsite link or on INsite Documents by putting the name of the medication in the search box and / or within ward / department / unit IV information folders. It should be noted the hardcopy IV information folders are being withdrawn as the move to the on-line medicines monographs (MEDUSA) is completed by Spring 2017.

If a particular medication does not have an IV monograph please ring Medicines Information ext 6491 between 9 and 5 Monday to Friday or pharmacy. Outside core pharmacy hours please contact the on-call pharmacist via switchboard for advice.

3.5 This policy does not cover the following:

a) IV administration of Cytotoxic Medications (please see LNR Cytotoxic Policy, available on the East Midlands Clinical Senate web site link below )

http://www.emsenate.nhs.uk/downloads/documents/Chemotherapy/Policies Guid elines/EMCNDC000310EMCNCytotoxicDrugPolicyv7.pdf

b) Epidural Medication Administration (please search Policy and Guideline library with the term Epidural for relevant policies)

c) Administration of Parenteral Nutrition (please see Policy for the administration of Parenteral nutrition via a central venous catheter in adults B21/2003.

d) Preparation of IV medications within the aseptic unit of the Pharmacy department (please see Pharmacy specific policies and guidelines for further information). A list of all products prepared aseptically within the organisation is included as an appendix 8. The aseptic lab can be contacted on extn 6405 for further information

e) Administration of Radiopharmaceuticals (please see specific protocols within nuclear medicine department)

f) This policy excludes medications being administered within an Operating Theatre – please refer to the Leicestershire Medicines Code Chapter 15 – Medicines in Operating Theatres.

3.6 UHL is a teaching hospital and provides placements for pre-registration training for students such as Medicine, Nursing, Midwifery, Paramedic, Radiography and Pharmacy. If IV medication administration is a specific competency requirement of their placement or programme then these students are able to prepare and administer IV medications under direct supervision of their mentor supervisor.

If IV medication administration is not a specific competency requirement of their placement or programme then the pre-registration student is only allowed to participate in the process of preparation of IV medications under direct supervision of their mentor / supervisor and must not administer IV medications.

http://www.emsenate.nhs.uk/downloads/documents/Chemotherapy/Policies__Guidelines/EMCNDC000310EMCNCytotoxicDrugPolicyv7.pdf






4 DEFINITIONS

Patient Group Directives: A written direction relating to the supply and administration of a description or class of prescription only medicine or a written direction relating to the administration of a description or class of prescription only medicine, and which in the case of either is signed by a doctor and by a pharmacist; and relates to the supply and administration, or to administration, to persons generally (subject to any exclusions which may be set out in the Direction).

IV Medication Monographs: IV Monograph outlines the permissible conditions of use and labeling requirements, such as dose, intended use, directions for use, warnings, active ingredients and combinations.

Leicester Clinical Assessment Tool (LCAT): An assessment tool which provides the theoretical background for a skill.

Open systems: the practice of emptying injectable medicines into a gallipot or other container to then be withdrawn multiple times into a syringe prior to use.

5 ROLES AND RESPONSIBILITIES

5.1 The executive director responsible for oversight of this policy is the Chief Nurse.

5.2 Line Managers

5.2.1 Line managers are responsible for:

a) Identifying and supporting the appropriate staff to attend the necessary training and complete the assessment of competence in practice

b) Verifying the competence of staff in the administration of IV medicines every three years through the appraisal process and in line with the Competency Refresher Assessment for the Administration of Medicines by Nurses and Midwives Policy and Procedure (Trust reference number B13/2009)

c) Maintaining a record via euhl of staff who are competent in the preparation and administration of IV medicines ensuring that numbers of staff trained meet service need

5.3 Authorised Staff - Preparation and Administration

5.3.1 All staff who undertake IV medication preparation and administration must be authorised by their line manager and carry out this activity as an integral part of the key responsibilities within their role and not considered outside their scope of professional practice.

5.3.2 Staff who may undertake this role will normally be on a statutory register (e.g. Nursing and Midwifery Council (NMC), General Medical Council (GMC)) and the practice of preparation and administering IV medications considered ‘within normal scope of practice’. These include (not a definitive list) Doctors, Registered Nurses,





Registered Children’s Nurses, Registered Midwives, Scientific Staff, Radiographers, Operating Department Practitioners (ODP’s).

5.3.3 Staff who have access to a voluntary register or a Self Regulatory Body (e.g. Perfusionists) can prepare and administer IV medications subject to the following requirements:

a) The preparation and administration of medicines has been identified as an integral part of the key responsibilities within their role by the appraisal process with their line manager

b) Have the role approved and documented by the appropriate Clinical Management Group (CMG) for expanding / out of scope roles (for more advice please contact your CMG Education and Practice Development Lead or equivalent)

c) Register on the voluntary register

5.3.4 All authorised staff must have undertaken appropriate education and training (see section 7) which must be identified through the appraisal process and be included in their Personal Development Plan (PDP).

5.3.5 There is no set timeframe expected for staff to undertake this role, this is down to the discretion of the individual CMG however it is recommended that where appropriate staff should have successfully completed an oral medication assessment prior to undertaking their IV training. Further advice can be sought from the CMG Education and Practice Development Teams or equivalent

5.3.6 Staff moving between units/ specialities remain competent to administer IV fluids and medications within their area of competence

5.4 Authorised Staff - Checking

5.4.1 All IV medicines must be independently checked by two authorised staff, one of which must be trained in the preparation and administration of IV medications and who will then administer the IV medication.

5.4.2 All staff who undertake IV medication checking must be authorised by their line manager and carry out this activity as an integral part of the key responsibilities within their role and not considered outside their scope of professional practice.

5.4.3 The role of the independent checker is to make sure that:

a) The correct medication has been selected

b) The medication and all diluent / flushes are in date

c) The medication has been correctly prepared as per prescription and IV monograph

d) The correct dose / rate of administration have been calculated and undertake any calculations independently to verify

e) The correct medication is administered to the correct patient





f) The checking procedure can be found in Appendix one

5.4.4 Any alteration / titration of the infusion rate in ward areas must also be checked by two authorised staff, one of whom must be IV competent. This change in rate must then be documented and signed by both practitioners on a pump check chart (sample pump check chart is in appendix 7)

In adult critical care areas it is not possible to check all alterations/ titrations due to the sheer number of titrations The Protocol for the checking of IV drug administration within adult intensive care units (ICU) (Trust ref number C18/2017) governs IV checking and administration on intensive/ high dependency units and can be found at pagdocuments/Intravenous (IV) DrugAdministrationinAdultIntensiveCareUnits(ICU)UHLGuideline.pdf

The same situation with large numbers of titrations applies within midwifery in relation to the titration of oxytocin infusions. The Guideline Augmentation of Labour (C29/2007) governs the use of Oxytocin on the Labour wards.

5.4.5 The person checking the IV medication has equal accountability for their practice to that of the person administering the IV medication

5.4.6 Staff able to undertake the role of checker should be made aware of their responsibilities at local induction by their line manager or delegated deputy

5.5 Chief Pharmacist

5.5.1 The Chief Pharmacist holds ultimate responsibility for the adequate resourcing of the aseptic unit to ensure it meets Quality Assurance of Aseptic Preparation Services

(QAAPS) Guide standards.

6 POLICY STATEMENTS, PROCEDURES AND ASSOCIATED DOCUMENTS

6.1 Pre-preparing IV Medications

.

6.1.1 In UHL pre-preparing injectable medications in advance of their administration is not permitted except in the following exceptional situations.

a) Paediatric Cardiac arrest medications drawn up at the beginning of a shift and calculated based on the specific weight of a patient (to ensure patient safety in critically ill paediatric patients)

b) Medications pre-prepared for patients requiring retrieval and transportation

c) Critically ill patients where the risk of pre-preparing intravenous medication is less than the risk of a rapid life threatening deterioration

d) An already established infusion

e) Medications which are required by their product manufacturing data sheet to be pre prepared e.g. some chemotherapy treatments

http://insitetogether.xuhl-tr.nhs.uk/pag/pagdocuments/Intravenous%20(IV)%20Drug%20Administration%20in%20Adult%20Intensive%20Care%20Units%20(ICU)%20UHL%20Guideline.pdf





6.1.2 All clinical areas requiring such preparation must ensure that these have been formally risk assessed and documented through their CMG Quality & Safety arrangements. Convenience of pre-preparing IV medications because of staffing issues, shift change over and ward routine are not sufficient reason to allow for pre- preparation of IV medications.

6.1.3 Any medications that are pre-prepared in these exceptional situations must be checked by two authorised practitioners, labelled with the name of the medications, the dose, the time prepared. The medications must be stored in a sealed tamper evident bag, or where in a syringe driver have tamper evident luer locks in place, the security of these medications remain the responsibility of the nurse caring for the patient.

6.1.4 In very few clinical situations medications (i.e. retrievals and paediatric cardiac arrest medications or established infusions) the pre-prepared medications will need to be transferred to another member of staff. This formal transfer requires the relevant clinical staff that have drawn up or mixed the medicine to formally hand over the medications to the staff that will be responsible for its custody and potentially its administration. This requires documentation which must be completed in the clinical notes, which must adhere to local guidelines and meet the professional standards regarding documentation.

6.2 Open systems

6.2.1 The Medicines and Health Regulatory Agency (MHRA) alert NHS/PSA/D/2016/008 stipulates that the use of open systems is not acceptable and that injectable medicines must be drawn directly from their original ampoule or container into syringes, and then either administered immediately or, if they are not for immediate use, the syringe is labelled and checked before later use.

6.2.2 The use of open systems such as gallipots is not allowed in UHL. Work is currently progressing to identify where such practice is happening and to identify solutions to resolve the issues. All practice must cease prior to June 2017

6.2.3 The only exemptions to the above are embolization procedures involving embolic

agents that need to be prepared openly

6.3 Administering IV Medications where a loading dose is required

6.3.1 There have been incidents where the rate has not been reduced following an initial loading dose.

6.3.2 Loading dose and maintenance doses need to be made up in separate syringes.

6.4 Potassium

6.4.1 Potassium ampoules are only kept in specific authorised areas stored in Controlled drug Cupboards. Areas which have been authorised to keep the ampoules will them listed on the controlled drug stock list.

6.4.2 When potassium is removed to be prepared for administration it must be placed in a red tray separate from all other medicines.





6.5 Administering IV Medications in Special Circumstances

6.5.1 IV Atropine or Adrenaline (epinephrine) in an emergency: in certain circumstances those professional groups referred to in this policy may be required to administer intravenous Atropine or Adrenaline (epinephrine) without a prescription for the purpose of saving life.

(a) To administer Adrenaline these individuals should have successfully completed an appropriate immediate or advanced life support course where it states that such medications can be administered.

(b) To administer Atropine individuals should have successfully completed an appropriate advanced life support course where it states such medications can be administered

(Please see the Cardiopulmonary Resuscitation Policy E4/2015)

6.5.2 Directly into a vein: Intravenous medication must only be administered directly into a vein in special circumstances by:

a) Doctors in an emergency in the absence of a cannula

b) Midwives administering IV ergometrine

c) Diagnostic radiographers.

6.6 Labelling

6.6.1 Additive Labels

All IV fluid bags to which a medication has been added must be labelled using the yellow IV additive labels (opposite)

All relevant details must be completed, all units apart from mg and mls must be written in full e.g. micrograms not mcg

This label is available within UHL

6.6.2 Syringe Labels

All syringes which have been drawn up for IV administration must be labelled to identify the contents of the syringe during preparation as outlined in the appropriate IV procedure. As a minimum the following four syringe labels must be used in all clinical areas:

1 White pre-printed with Sodium Chloride 0.9%

(Henley product code: SLS1487)





2 White pre printed with Antibiotic, with room to write on which antibiotic


3 Peach pre-printed with Anti-Emetic, with room to write on which anti-emetic

(Henley product code: SLSC13)

4 Blue blank label for all other medications, with room to write on which medication


this label also comes without the mg/ml if preferred

(Henley product code: SLS719) Either is acceptable within UHL

The labels can be ordered from the non-catalogue section on the Cedar system, the supplier code is 100071. The supplier is:

Henleys Medical Supplies Ltd.

Brownfields,

Welwyn Garden City,

Hertfordshire, AL7 1AN

Phone: - 01707 333164

Fax: - 01707 334795

Email: - [email protected]

Website: - www.henleysmed.com

Henley’s have a huge range of pre-printed labels available, all of which can be used in UHL. Clinical areas that already use labels above and beyond the minimum listed above may continue to do so.

6.6.3 All IV administration lines

Must be labelled with the medication that is being administered through it (These are also available from Henleys Medical supplies Ltd as detailed in 6.5.2 and can be ordered pre-printed or blank)

Plus an orange administration set label detailing when the set was changed. These are available from the LRI print room ordered as ‘Orange IV Line Labels’

mailto:[email protected]

http://www.henleysmed.com/





6.7 This policy is supported by the following procedures which must be used in conjunction with this policy:

Procedure Appen dix

Procedure for checking IV medications prior to administration – Role of the Independent Checker

1

ADULTS:

Procedure for the Preparation and Administration of Bolus Intravenous Medications

2

ADULTS:

Procedure for the Preparation and Administration of a Medication or clear Fluid Infusion

3

BABIES, CHILDREN AND YOUNG PEOPLE under 18 years:

Procedure for the Preparation and Administration of Bolus and infusion medication via a Central line in Babies, Children and young People (under 18 years)

4

BABIES, CHILDREN AND YOUNG PEOPLE under 18 years:

Procedure for the Preparation and Administration of Bolus and Infusion Medication via a Peripheral Line in Babies, Children and Young People (under 18 years)

5





7 EDUCATION AND TRAINING REQUIREMENTS

7.1 All staff who undertake IV Medication preparation and administration must:

a) Complete the Trust competency based training and assessment programme run by the Clinical Skills Unit (CSU) and booked through eUHL.

b) To be able to prepare and administer IV medications to babies, children and young people staff must attend the Children’s IV Study Day currently run by the Children’s Hospital Education Team. They can be contacted on 0116 258 7684

c) For Perfusionists and Radiographers the attendance of a professionally recognised approved IV programme is also accepted eg. The College of Radiographers, Imaging Academy

d) Have completed a period of supervised practice, the time span of which will be agreed by the assessor but ideally to be completed within 6 months.

e) Have evidence of assessment and competency signed by an LCAT or other appropriate assessor (see section 7.4)

f) Accept responsibility for updating knowledge and skills and provide evidence every three years of this as agreed with line manager as part of the appraisal process or other competency refresher programmes within the Trust.

7.2 Staff new to the Trust and / or who have been trained elsewhere must:

a) Provide evidence accepted by their line manager of the training and assessment of competence they have successfully completed. If the member of staff does not have any evidence of successful completion then they may need to undertake the UHL training. This must be discussed with their line manager and the Clinical Skills Unit.

b) Read the relevant Trust policies and undertake additional local training relating to equipment and documentation as required.

c) Undertake a one off practical assessment by an LCAT or other appropriate assessor within own Ward / Unit / Department.

7.3 There may be special circumstances where further individuals require training relating to IV medication preparation and administration within a particular speciality, this must be discussed and actioned with the Line Manager.

7.4 To be able to assess the knowledge and competencies of others in IV Medication preparation and administration the assessor must:

a) Be confident and competent in performing the skill and practice the skill regularly

b) Have a sound knowledge of current policies and procedures

c) Ideally be identified by the line manager as an LCAT assessor (Contact the CSU on 0116 252 3251 for LCAT training) and have completed or be working towards a relevant mentor / assessor course

d) Further advice can be sought from the CMG Education and Practice Development Lead.





7.5 Temporary staffing - This section concerns healthcare professional staff recruited via the central staff bank or via local arrangement

a) Staff recruited via the central staff bank will have qualifications checked as part of

that recruitment process and e.roster will make clear if they are IV trained or not. (i) Agency staff with certificate evidence of attending a practical course in the administration of IV therapy alone will be acceptable.

b) Staff recruited locally by the CMG are required to present evidence of their IV

competence which will be recorded and kept at department level

c) Agency staff administering IV medication will have a single observed administration to verify competence by an IV competent member of UHL staff. This assessment should ideally be undertaken by an LCAT assessor, if an LCAT assessor is not on duty/ available then the observation should be undertaken by an experienced IV competent individual.

d) A record of this observed administration should be recorded in the comment section

of the green temporary staffing booklet, noted as i. ‘IV administration observed and satisfactory…signed (RN/LCAT

assessor).

e) The single observed administration should be undertaken each time the agency RN or AHP works in a new area.

8 PROCESS FOR MONITORING COMPLIANCE

8.1 Audits regarding IV Medication preparation administration practices must be identified by CMGs in conjunction with the Clinical Audit, Standards and Effectiveness (CASE) Team and the Medicines Optimisation Committee (MedOC).

8.2 Implementation and compliance with this Policy will be audited through the following:

8.2.1 The annual Leicestershire Medicines Code Audit

a) All IV Medications are checked by two appropriately trained registered professional, one of whom must be competent in IV Medication administration (LMC Audit Q9)

b) All IV Medications are signed for by two appropriately trained registered professional, one of whom must be competent in IV Medication administration (LMC Audit Q9)

8.2.2 High Impact Interventions audits led by the Infection Prevention and Control Team.

8.2.3 The Medicines Optimisation Committee will monitor incidents involving IV Therapy on a quarterly basis and share lessons learnt across the organisation.





POLICY MONITORING TABLE

Element to be monitored

Lead(s) Tool Frequency Reporting arrangements

Medication Errors

Medicines Safety Officer

DATIX – incident reporting

Quarterly


CMG Heads of Nursing

Policy Compliance


Leicestershire Medicines Code Audit

Annual



High Impact Intervention Audits

Infection Prevention & Control Team

Audit Tool

Quarterly



9 EQUALITY IMPACT ASSESSMENT

9.1 The Trust recognises the diversity of the local community it serves. Our aim therefore is to provide a safe environment free from discrimination and treat all individuals fairly with dignity and appropriately according to their needs.

9.2 As part of its development, this policy and its impact on equality have been reviewed and no detriment was identified.

10 LEGAL LIABILITY

The Trust will generally assume vicarious liability for the acts of its staff, including those on honorary contract. However, it is incumbent on staff to ensure that they:

a) Have undergone any suitable training identified as necessary under the terms of this policy or otherwise.

b) Have been fully authorised by their line manager and their CMG to undertake the activity.

c) Fully comply with the terms of any relevant Trust policies and/or procedures at all times.





d) Only depart from any relevant Trust guidelines providing always that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible clinician it is fully appropriate and justifiable - such decision to be fully recorded in the patient’s notes.

It is recommended that staff have Professional Indemnity Insurance cover in place for their own protection in respect of those circumstances where the Trust does not automatically assume vicarious liability and where Trust support is not generally available. Such circumstances will include Samaritan acts and criminal investigations against the staff member concerned.

Suitable Professional Indemnity Insurance Cover is generally available from the various Royal Colleges and Professional Institutions and Bodies. For advice please contact: Assistant Director - Head of Legal Services on Ext 8585

11 SUPPORTING REFERENCES, EVIDENCE BASE AND RELATED POLICIES

11.1 References

Clarke A (1997) “The Nursing Management of Intravenous Drug Therapy” British Journal of Nursing (review article) 6(4) : 201-6

Department of Health (2007) Saving lives: reducing infection, delivering clean and safe care using High Impact Interventions (HII): HII no 1 Peripheral Venous Catheter Care Bundle

Dougherty L & Lister S (eds) (2004) The Royal Marsden Manual of Clinical Nursing Procedures 6th Ed Blackwell Science, Oxford

Macqueen S. (2005) The special needs of Children receiving Intravenous Therapy, Nursing Times, Vol 108, no 8

Pratt, R.J., Pellowe, C.M., Wilson, J.A., Loveday, H.P., Harper, P.J., Jones, S.R.L.J., McDougall, C., and Wilcox., M.H (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England, Journal of Hospital Infection 65(S) S1-S64

Rowley S (1992) Aseptic Non-Touch Technique: a safe and efficient handling technique for IV therapy & other clinical procedures – Training Pack University College Hospitals London.

Canadian Agency for Drugs and Technologies in Health (2012), Filtered needles for withdrawing medication from glass ampoules: A review of the cost-effectiveness and incidence of complications 2010

11.2. Policies

Leicestershire Medicines Code (available via INsite Documents)

LNR Cytotoxic Policy http://www.emsenate.nhs.uk/downloads/documents/Chemotherapy/Policies Guidelines/E MCNDC000310EMCNCytotoxicDrugPolicyv7.pdfUHL IV Monographs (Medusa) (available via INsite Documents)

Policy for the Administration of Parenteral Nutrition via a Central Venous Catheter in Adults (B21/2003) )







UHL Patient Identification Band Policy (B43/2007)

Patient Group Directions Policy (B43/2005)

Policy for the Identification of Actual or Suspected Latex allergy (B29/2005)

UHL Infection Prevention & Control Policies (available via INsite Documents)

UHL Health and Safety Policy (A17/2002)

UHL Control of Substances Hazardous to Health (COSHH) Policy (B10/2002)

UHL Personal Protective Equipment at work Policy (PPE) (B9/2004)

UHL Cardiopulmonary Resuscitation Policy E4/2015)

The Assessment of Administration of Medicines by Nurses and Midwives Policy and Procedure (B13/2009)

UHL Injectable Medicines Guide

ITAPS : Protocol for the checking of IV drug administration within adult intensive care units (ICU) Trust ref: C18/2007 pagdocuments/Intravenous (IV) DrugAdministrationinAdultIntensiveCareUnits(ICU)UHLGuideline.pdf

Policy and Procedures for the Management of Controlled Drugs (CDs) on Wards, Departments and Theatres’ (B16/2009)

Administration of Medicines and Intravenous Fluids via a Cardiopulmonary Bypass Circuit within the Clinical Perfusion Team for Adult Cardiac Surgery Policy’ (B16/2016)

11.3. Professional Guidelines

GPhC (2012) Standards of Conduct, Ethics and Performance

HCPC (2016) Standards of conduct, performance and ethics

NMC (2015) The Code: Professional standards and behaviour for nurses and midwives

NMC (2007) Standards for Medicines Management – minor update 2015

RCN (2010) Standards for Infusion Therapy

Society of Radiographers (2013) Code of Professional Conduct

The Society of Clinical Perfusion Scientists of Great Britain and Ireland, Code of Practice (2010)

12 PROCESS FOR VERSION CONTROL, DOCUMENT ARCHIVING AND REVIEW

12.1 This document will be uploaded onto SharePoint and available for access by Staff through INsite. It will be stored and archived through this system.

12.2 This policy will be reviewed every 3 years by the Senior Nurse in Medicines Management

http://insitetogether.xuhl-tr.nhs.uk/pag/pagdocuments/Intravenous%20(IV)%20Drug%20Administration%20in%20Adult%20Intensive%20Care%20Units%20(ICU)%20UHL%20Guideline.pdf

https://www.nmc.org.uk/standards/code/





Procedure for Checking IV medications prior to

administration – Role of the Independent Checker

Appendix 1 Preparation and Administration of

IV Medications Policy

1. Introduction

1.1 All IV Medicines must be double checked by two authorised staff, one of which must be trained in the preparation and administration of IV medications and who will then administer the IV Medication.

1.2 The role of the independent checker is to make sure that:

a) The correct medication has been selected

b) The medication and all diluents / flushes are in date

c) The medication has been correctly prepared as per prescription and IV monograph

d) The correct dose / rate of administration have been calculated and undertake any calculations independently to verify

e) The correct medication is administered to the correct patient

1.3 The person checking the IV medication has equal accountability for their practice to that of the person administering the IV medication

2. Authorised Staff

All staff who undertake IV medication checking must be authorised by their line manager and carry out this activity as an integral part of the key responsibilities within their role and not considered outside their scope of professional practice.

3. Checking Procedure

Procedure for Checking IV medications prior to administration - Role of the Independent Checker

No Check Actions

1 Patient Confirm the patient has a patent cannula or other suitable access for IV administration

2 Prescription Check that there is a valid prescription / Patient Group Direction and consult the prescription to ascertain the following:

a) The whole prescription is legible.

b) Medication has not been given.

c) Allergies and contraindications are documented

d) Signed and dated by the authorised prescriber






No Check Actions

3 Medication a) Check the products selected against the prescription

b) Check the expiry date

c) Know the therapeutic uses of the medicine to be administered, its normal dosage, general side effects, precautions and contraindications, method and duration of administration and appropriateness to patients plan of care

d) Be aware if additional care or monitoring is required e.g cardiac monitoring for concentrated potassium solutions (see IV monographs (Medusa))

4 Dose Correct dose selected against the prescription using the IV monographs or BNF, considering patients weight where appropriate

5 Calculations a) Some medication administrations can require complex calculations to ensure that the correct volume or quantity of medication is administered

b) The independent checker must undertake the calculation independently from the person preparing the medication in order to minimise the risk of error

c) The use of calculators to determine the volume or quantity of medication should not act as a substitute for arithmetical knowledge and skill

6 Diluents / Preparation

a) Confirm that the correct solution and correct volume of diluent have been used if appropriate

b) Confirm that the correct infusion equipment has been appropriately selected

7 Solution Integrity

Check the solution has no leaks, particles, discolouration, precipitation or other potential contamination

8 Label Check the appropriate label has been used:

a) Yellow IV label for additives - Where possible the label should include the patients name, medication name, dose, route, date and time reconstituted, expiry date of reconstituted infusion, batch number, signature of administrator and checker

b) Labels attached to syringes to identify contents e.g. flush, antibiotic, heparin

9 Patient a) Cross check the medication against the prescription

b) Check the patients details either verbally or using the patient ID band against the prescription chart

c) Cross check allergy status






No Check Actions

10 Route and Rate

a) Check that any infusion rate settings on infusion device are correct and all lines are labelled. Line label corresponds to the medicine on the infusion label.

b) Confirm that the correct IV access has been selected, which is appropriate to the concentration of the solution.

c) Independent checker to sign the prescription chart

d) Check and document any subsequent alteration / titration of the infusion rate


Latest version approved by Policy and Guideline Committee on 20 January 2017 Trust Ref: B25/2010 Next Review: January 2021


ADULTS Procedure for the Preparation and Administration of Bolus Intravenous Medications

Appendix 2

Preparation and Administration of IV Medications Policy

1. Introduction

1.1 This document sets out the University Hospitals of Leicester (UHL) NHS Trust procedure for the preparation and administration of bolus intravenous medication with the aim to provide safe and effective care and prevent micro-organism contamination of the line.

1.2 This procedure uses the principles of aseptic non-touch technique and protecting the key parts.

1.3 All IV medication preparation should occur in the clean treatment room or within an area dedicated to preparation of medications.

1.4 All substances for injection that are reconstituted within the ward / department / unit must be drawn up immediately prior to administration by the practitioner who will administer the medication.

2. Scope

This procedure applies to all Health Professionals authorised and competent to prepare and administer IV medications as per sections three and four of the main policy

3. Equipment required for this procedure

a) Supply of sterile syringes. Blunt fill filter needle or blue/ green safety needle and sterile blind hub (if required)

b) Needlefree hub (if changing)

c) 2% chlorhexidine gluconate in 70% alcohol wipe for cleaning tops of vials / hubs / access ports

d) Medication and diluent.

e) Clean gloves, plastic apron and goggles if appropriate

f) Compatible fluid to flush cannula (5-10mls)

g) Prescription Chart.

h) Syringe and line labels

i) IV Monograph to check doses and method of administration.

j) Aseptic field to prepare and carry medication – in this case a large plastic tray or trolley

k) Sharps bin (to be taken to patients side)

4. Key Parts for this procedure

Syringe tip, needle, needlefree hub, top of vial, blind end hub




ADULTS: Procedure for the Preparation and Administration of Bolus Intravenous Medications

No Action

1 Explain and discuss the procedure with the patient

Ensure they have a patent cannula or other suitable IV access

2 Check that there is a valid prescription / Patient Group Direction (or equivalent for Imaging) and ascertain the following:

correct medication which is suitable to be given as a bolus.

correct dose, units written in full e.g. micrograms not mcg

allergies and contraindications are documented

signed and dated by the authorised prescriber including bleep number

date and time of administration

route and method of administration

the whole prescription is legible

medication has not been given

3 Two authorised staff, one of whom is IV competent, must check the preparation and patient identification prior to the administration of the intravenous medication. (independent checker to follow the checking procedure as detailed in Appendix One of the IV Policy)

4 Clean hands, as per UHL hand hygiene policy (INsite Document No 23813) Check hands for any visibly broken skin and cover with a waterproof dressing

Put on a plastic apron and clean gloves from a dedicated box – you only need to wash rather than use alcohol hand rub on your hands if you have been in contact with bodily fluids, an infected patient or your hands are visibly soiled

Clean all sides of a large plastic tray / trolley with Chlorclean, starting on the inside and then the outside, the tray / trolley will be the aseptic field for the procedure.

Either allow to air-dry (for a minimum of three minutes) Alternatively dry with paper towels and then disinfect using 70% Industrial Methylated Spirits – your tray / trolley now provides an aseptic field.

Remove gloves and apron, clean hands

5 Assemble appropriate equipment. Check packages are intact and equipment is all in date. Place next to the tray on a clean surface or on the bottom of the trolley

6 A pair of clean gloves and plastic apron must be worn when drawing up and administering all medications. Goggles / mask to be worn as appropriate

7 Assemble all medication required, check the name of the medication, dose against the prescription chart including expiry dates





No Action

8 Refer to the IV monographs to correctly identify the diluents and reconstitution methods for the medication and compatible flush.

Further advice can be sought from Medicine Information Department, Pharmacist, BNF, Medicines Management web pages on INsite

Both staff must independently undertake any medication calculations

9 Put on a clean apron, clean your hands and apply clean gloves and then pick-up and open the syringes attach the needles straight onto the syringes tips and loosen sheaths protecting the key parts at all times. Arrange in an orderly manner in the tray so syringe tips remain sterile once the needles have been removed. Open other equipment ensuring they are placed in the tray protecting key parts.

10 Open one of the Chlorhexidine 2% and Alcohol 70% wipes using this to wipe the top of the medication vial then open the vials of flush and diluent and place them outside of the tray on a clean surface

11 If required draw up the required amount of diluent

Use a blunt fill filter needle for drawing up all solutions except for emulsions, or if it is difficult to draw the solution up through the filter in which case a green/ blue safety needle should be used

If drawing up from a glass ampoule the filter needle must be changed before injection the solution for reconstitution as the filter will trap and glass particles and re-infusion of glass particles must be avoided

Coring occurs when small fragments of rubber sheer off when the needle

punctures the vial top. Any solutions drawn up through a rubber vial top should be closely observed for signs that the vial top may have ‘cored’. Any indication that coring has occurred should be reported to Health and safety and the cored vial and syringe/ needle retained for later collection

12 Where a diluent is required to reconstitute the medication, add it into the vial of medication and gently rotate the vial to mix or follow manufacturers instructions

13 Draw up all the fluid from the medication vial and replace any unwanted amount of medication or fluids back into the vial

14 Check the final solution has no particles, discolouration, precipitation or other potential contamination, retain all vials until after the administration is complete in case of reactions and batch numbers are required.

15 Check and draw up an appropriate flush as indicated in IV monographs file

16 Label all syringes with their contents, including the flush using pre-printed labels

17 Using an aseptic non-touch technique all needles should be removed without re- sheathing prior to leaving the preparation area and disposed of into a sharps bin. Key parts can be protected by carefully placing the syringes back into the syringe packaging or using a blind end hub





No Action

18 Remove gloves but take a clean pair in your tray ensuring that they do not contaminate the key parts of the equipment- a bottle of alcohol hand rub must be available at the bedside

19 Take the prepared medication to the patients bedside and re-explain the procedure if necessary

20 Both staff must check the patient’s identity against the prescription chart. If the patient is unable to verbally confirm their identity use the patients ID band

Check if the patient has a red ID band which will indicate they have an allergy

21 If another intravenous infusion is in progress, check for medication or fluid incompatibilities and consider stopping the infusion temporarily

NB: 3-way taps must never be used on central or peripheral lines in general ward areas.

22 If the infusion needs to be disconnected protect the open line with a sterile blind end hub

Ensure the correct IV administration line is used for the administration

23 Remove the bandage completely and check the cannula site throughout administration of medication or fluids for signs of redness, swelling, leakage and / or pain. Document observations on the cannula care pathway (appendix six of the IV Policy)

24 The intravenous medication must be administered into a ‘closed system’ via a needlefree hub.

The top cap of the cannula must never be used except in an emergency situation

25 Clean hands before applying the clean gloves from the tray

Hold the end of the line firmly and using a Chlorhexidine 2% and Alcohol 70% wipe firstly scrub the top of the hub for at least 10-15 seconds and then using an alternative place on the wipe scrub the sides for at least 10-15 seconds wait for the hub to dry for at least 30 seconds. To prevent contamination of the hub you must continue to hold the end of the line firmly.

Remove the wipe and place back onto the aseptic field ensuring you do not contaminate the key parts of the other equipment.

26 Gently inject the appropriate flush compatible with the medication to be given

27 Inject the medication smoothly in the direction of flow at the specified rate

Observe patient through the administration for positive / adverse effects

28 If administering more than one medication or fluid the cannula must be flushed between medications with a compatible flush

29 On completion of medication administration flush the line with a compatible flush

30 Record the administration of the IV medication and flush on the patients prescription chart, both staff must sign. Document the phlebitis score





No Action

31 If intravenous fluids were stopped temporarily, recommence the infusion.

If fluids have been stopped for more than 30 minutes this must be recorded on the fluid balance chart

32 Replace the bandage / dressing as appropriate around the cannula site

33 Ensure the patient is comfortable, has the call bell within reach, remove gloves and clean hands before leaving the patients side

34 Ensure correct disposal of sharps into sharps bin at the site of use and waste into clinical waste bins

Clean tray / trolley with Chlorclean as before and store safely

Store sharps bin safely with aperture closed

Discard gloves into clinical waste bags, clean hands




ADULTS

Procedure for the Preparation and Administration of a Medication or Clear Fluid Infusion

Appendix 3

Preparation and Administration of IV Medications Policy

1. Introduction

1.1 This document sets out the University Hospitals of Leicester (UHL) NHS Trust procedure for the preparation and administration of bolus intravenous medication with the aim to provide safe and effective care and prevent micro-organism contamination of the line.

1.2 This procedure uses the principles of aseptic non-touch technique and protecting the key parts.

1.3 All IV medication preparation should occur in the clean treatment room or within an area dedicated to preparation of medications.

1.4 As far as reasonably practicable IV fluid infusion bags should be stored in the original box and decanting avoided. If decanting is unavoidable then bags must be stored separately and not placed in the same container

1.5 All substances for injection that are reconstituted within the ward / department / unit must be drawn up immediately prior to administration by the practitioner who will administer the medication.

1.6 There have been numerous errors where the incorrect fluid has been selected and administered, therefore particular attention should be paid to the correct selection of the infusion.

1.7 Where a volumetric / syringe driver is in use it must not be disconnected/ removed when a patient is transferred between locations

2. Scope

This procedure applies to all Health Professionals authorised and competent to prepare and administer IV medications as per sections three and four of the main policy

3. Equipment required for this procedure

a) Supply of sterile syringes. Blunt fill filter needles and/ or green and blue safety needles for drawing up.

b) 2% chlorhexidine gluconate in 70% alcohol wipe for cleaning tops of vials / hubs / access ports

c) Medication and diluent, IV fluid

d) Clean gloves, plastic apron, goggles if appropriate

e) Compatible fluid to flush cannula (5-10mls)

f) Prescription Chart.

g) Additive, syringe and line labels

h) IV Monograph to check doses and method of administration.

i) Appropriate infusion device (e.g. syringe driver or volumetric pump), relevant administration sets / equipment, anti-reflux valves or multiple port needlefree device and drip stand




j) Aseptic field to prepare and carry medication – in this case a large plastic tray or trolley

k) Sharps bin (to be taken to patients side)

4. Key Parts for this procedure

Syringe tip, needle, needlefree hub, top of vial, both ends of giving set, hub on fluid bag

ADULTS: Procedure for the Preparation and Administration of a Medication or Clear Fluid Infusion

No Action

1 Explain and discuss the procedure with the patient

Ensure they have a patent cannula or other suitable IV access

2 Check that there is a valid prescription / Patient Group Direction (or equivalent for Imaging) and ascertain the following:

correct medication / fluid

correct dose, units written in full e.g. micrograms not mcg

allergies and contraindications are documented

signed and dated by the authorised prescriber including bleep number

date and time of administration

route and method of administration

the whole prescription is legible

medication / fluid has not been given

3 Two authorised staff, one of whom is IV competent, must check the preparation and patient identification prior to the administration of the intravenous medication. (independent checker to follow the checking procedure as detailed in Appendix One of the IV Policy)

4 Clean hands, as per UHL hand hygiene policy (B32/2003) Check hands for any visibly broken skin and cover with a waterproof dressing

Put on a plastic apron and clean gloves from a dedicated box – you only need to wash rather than use alcohol hand rub on your hands if you have been in contact with bodily fluids, an infected patient or your hands are visibly soiled

Clean all sides of a large plastic tray / trolley with Chlorclean, starting on the inside and then the outside, the tray / trolley will be the aseptic field for the procedure.

Either allow to air-dry (for a minimum of three minutes) Alternatively dry with paper towels and then disinfect using 70% Industrial Methylated Spirits – your tray / trolley now provides an aseptic field.

Remove gloves and apron, clean hands

5 Assemble appropriate equipment. Check packages are intact and equipment is all in date. Place next to the tray on a clean surface or on the bottom of the trolley

6 A pair of clean gloves and plastic apron must be worn when drawing up and administering all medications. Goggles / mask to be worn as appropriate





No Action

7 Assemble all medication / fluid required, check the name of the medication, dose against the prescription chart including expiry dates (if putting up clear fluids only please go to no 19)

8 Refer to the IV monographs to correctly identify the diluents and reconstitution methods for the medication and compatible flush.

Loading doses must be prepared as a separate syringe as per 6.3.

Further advice can be sought from Medicine Information Department, Pharmacist, BNF, Medicines Management web pages on INsite

Both staff must independently undertake any medication and infusion rate calculations



11 If required draw up the required amount of diluent

Use a blunt fill filter needle.

Use a blue or green safety needle if diluent is an emulsion or is difficult to draw up via a filter needle

12 Where a diluent is required to reconstitute the medicine, add it into the vial of medication and gently rotate the vial to mix or follow manufacturers instructions

13 Draw up all the fluid from the medication vial and replace any unwanted amount of medication or fluids back into the vial

14 Syringe driver:

Draw up or add all medications and diluents to an appropriate sized luer lock syringe using aseptic non- touch technique

Gently invert the syringe 3-5 times to mix the contents

Infusion Bag:

Check the fluid bag has no leaks, particles, discolouration, precipitation or other potential contamination

Add either ready prepared or reconstituted medication to the appropriate fluid bag using aseptic non- touch technique

Gently invert the bag 3-5 times to mix the contents

15 Once final solution has been prepared check that it has no leaks, particles, discolouration, precipitation or other potential contamination





No Action

16 Complete additive label and attach to the syringe / fluid bag containing the medication where it can be clearly read

The label must include

Date and time of preparation

Name of the patient

Name of the medication and diluent used and including their batch numbers

Signatures of both practitioners preparing, checking and administering the medication.

17 Check and draw up an appropriate flush as indicated in IV monographs file and label.

18 Remove gloves but take a clean pair in your tray ensuring that they do not contaminate the key parts of the equipment- a bottle of alcohol hand rub must be available at the bedside

19 Assemble and open all other administration equipment, checking expiry dates and seals are intact. Ensure infusion device is clean. If using a flow regulator device for clear fluids attach as per manufacturers instructions

20 Syringe Driver:

Insert syringe correctly into driver, follow manufacturer’s instructions

Confirm syringe size if asked

Attach extension line ensuring that end not attached to syringe remains covered with blind hub

Zero volume administered

Purge the line

Volumetric Pump:

Hang bag onto drip stand

Attach and prime the IV giving set using a no touch technique

Ensure the giving set chamber is filled no more than 1/3 full

Thread giving set through the pump following manufacturers instructions

Zero volume administered

21 Ensure drip stand is stable and not overloaded with too many devices. Use a 4 or 5 pronged drip stand

22 Take the prepared medication to the patients bedside and re-explain the procedure if necessary

23 Both staff must check the patient’s identity against the prescription chart. If the patient is unable to verbally confirm their identity use the patients ID band

Check if the patient has a red ID band which will indicate they have an allergy

24 If another intravenous infusion is in progress, check for medication or fluid incompatibilities and consider stopping the infusion temporarily

If the infusion needs to be disconnected protect the open line with a sterile blind end hub

Ensure the correct IV administration line is used for the administration

25 Remove the bandage completely, if one in place, to be able to observe the cannula site throughout administration of medication or fluids for signs of redness, swelling, leakage and / or pain.





No Action

26 Clean hands before applying the clean gloves from the tray


Remove the wipe and place back onto the aseptic field ensuring you do not contaminate the key parts of the other equipment

Administer appropriate flush to check the line is still patent

27 Connect the line to the patient using a no-touch technique. Label line

If other infusions are required use a anti reflux valve and / or multiple port device

NB: 3-way taps must never be used on central or peripheral lines in general ward areas.

28 IV giving sets administering medications must be replaced every 24 hours or as per manufacturers instructions

29 Clear fluid IV giving sets must be replaced every 72 hours or as per manufacturers instructions

30 Set the infusion device at the correct rate and the correct volume to be infused and press the start button

This must be independently checked by both practitioners and recorded on the pump check chart.

Run the infusion device from the mains whenever the patient is stationary

31 Any alteration / titration of the infusion rate must also be checked by two authorised staff, one of whom must be IV competent.

This change in rate must then be documented and signed by both staff on the pump check chart. In critical care / theatre / high dependency areas where this may happen frequently (e.g. many titrations over a few minutes) and any double checking would delay life sustaining / emergency treatment local documentation procedures should be followed

Subsequent checks of the rate and total volume infused should be done at least hourly and documented on the pump check chart (see Appendix seven for a sample pump check chart)

32 Replace any extra protective dressing

33 Make sure the patient is comfortable, has call bell within reach and is aware of what the machine should be doing and when to call for assistance, clean hands before leaving patients side

Record the administration of the medication on the prescription chart, both staff to sign. Document phlebitis score

34 If patient requires monitoring of fluids document volume administered and any discontinuation of fluids on fluid balance chart





No Action

35 Ensure correct disposal of sharps into sharps bin at the site of use and waste into clinical waste bins

Decontaminate plastic tray / trolley as before and store safely

Store sharps bin safely with aperture closed

Discard gloves into clinical waste bags, clean hands

36 Check with the patient during the infusion for any discomfort, observing for signs of positive or adverse effects. Ensure the patient understands any potential complications and know who to inform if the occur.




Procedure for the Preparation and Administration of Bolus and Infusion Medication via a Central Line in Babies, Children and Young People (under 18yrs)

Appendix 4 preparation and

administration of IV medications policy

1. Introduction

This guidance provides a step-by-step procedure for the Administration of Bolus and Infusion Medication via a Central Line with the aim to provide safe and effective care and prevent micro- organism contamination of the line.

2. Scope

This procedure applies to all registered professionals who administer Central Intravenous Medication to babies, children or young people under 18yrs in UHL.

Staff authorised to ADMINISTER medicines to children MUST have had the appropriate training and been assessed as competent. (For more details refer to the Leicester Medicines Code)

This procedure should be used in conjunction with the UHL consent policy to ensure the child receives safe care and children and families are able to understand the reasons for care to facilitate co-operation and the UHL Intravenous Medication Policy, UHL Venous Access Policy, Insertion Maintenance and Care of Central Line Guideline (PICU/CICU) 2016 and Procedure for the Independent Checking of Medication in Babies, Children and Young People (under 18yrs)

The procedure excludes:

All Cytotoxic Chemotherapy (Covered by Leicester Medicines Section 14 & EMCN Cytotoxic Policy)

3. 1 Recommendations, Standards and Procedural Statements

This procedure should be used in conjunction with the Leicester Medicines Code (Section 13)

3:1.1 The date of birth, weight in kilograms and where appropriate body surface area of the child MUST be written on the prescription charts. The person taking these measurements must sign and date the chart in the relevant boxes.

3:1.2 If the child is uncooperative and has to be weighed with a parent or carer, the calculation

used to subtract the parents weight (& therefore leaving the child’s weight) must be shown alongside the weight box on the prescription chart and signed and dated by the practitioner doing the subtraction.

3:1.3 When administering injections or medicines of doses less than 1ml in volume, a 1ml syringe

graduated to 0.01ml must be used.




3:1.4 Paediatric formulations must be used when these are available. Where they are not available and multi-dose or adult strength preparations have to be used, extra vigilance should be exercised when calculating and preparing the dose.

3:1.5 In UHL all babies, children and young people must wear identity bracelets to enable staff to identify the patient, especially during the medicines administration process.

3:1.6 Only the correct volume of medication should be taken to the patient (this mainly applies to

bolus and short infusions). In Neonatal Unit an additional 10% medication can be taken to the child due to the smaller amounts being infused. The excess medication must be withdrawn from the bottle or bag or the correct dose drawn into a new syringe or infusion bag. The volume limits on pumps should not be used to control the amount of medication given.

3:1.7 Practitioners must know the therapeutic uses of medication to be administered, its normal

dosage, general side effects, precautions, contra-indications, methods and duration of administration and how appropriate the medication is to the child’s plan of care.

3:1.8 All IV medication preparation should occur in the clean treatment room or within an area

dedicated to preparation of medications.

3:1.9 All substances for injection that are reconstituted within the ward / department / unit must be drawn up immediately prior to administration by the practitioner who will administer the medication.

3.2 Locking Central Lines using Heparinised Sodium Chloride

3:2.1 When using Central Lines (including Tunnelled and Non-Tunnelled Central and PICC Lines) if accessing line within 8 hours lock using Sodium Chloride 0.9% 4mls, if not accessing for more than 8 hours lock you must use 2-4mls Heparinised Sodium Chloride 10 units/ml.

3.2.2 When using Needled Portacaths after each use you must lock with 2-4ml Heparinised Sodium Chloride 100units/ml. Before removing the needle you must also flush with 10mls Sodium Chloride 0.9% before locking with 2-4ml Heparinised Sodium Chloride 100units/ml.

3:2.3 When using Longlines after each use you must lock with Heparinised Sodium Chloride 10 units/ml unless the line is more prone to blocking for example when using Neonatal Longlines when 2ml Heparinised Sodium Chloride 100units/ml can be considered

Other Care

3:2.4 It is important to remember with double/triple lumen lines that the lumens are separate and therefore the mixing of medication running concurrently does not occur until they exit the catheter – however there are exceptions therefore compatibilities must be checked before any medication is administered via any Central Line.

3:2.5 You must only use syringes of 10mls or greater as smaller size syringes may cause the line to rupture due to excess pressure the exceptions are where syringes are pre-mixed, giving smaller quantities or when accessing Central Lines in Neonates.

3:2.5 All babies, children and young people with a central line should be commenced on daily Stellisept wash and nasal Mucopiricin TDS or Octenisan for Neonates whilst they are in- patients.




3:2.6 Equipment

a) A selection of 10ml Luer- Lock Sterile Syringes

b) Blunt Fill Filter Needles for drawing up flush/diluent

c) Chlorhexidine 2% and Alcohol 70% wipes (Large PDI Wipes)

d) Clean gloves and aprons

e) Prescription Chart

f) Sodium Chloride 0.9% (or other compatible diluent)

g) Heparinised Sodium Chloride 10units/ml (Central Lines) Heparinised Sodium Chloride 100units/ml (Neonatal Longlines & Portacath) or Sodium Chloride 0.9% (or other compatible flush).

h) Bonded Triple Lumen with Double Lumen anti-reflux valve connector (Squid) if giving more than one Medication

i) Large Plastic Tray or Trolley

j) Polo skin fixes or Mepore Tape

k) Appropriate Fluid Administration Set

l) Paediatric IV Monographs to check doses/administration (Can be viewed on Intranet)

Procedure for The Administration of Bolus & Infusion Medication via a Central Line in Children

No Action

1 Approach the child or young person and family in a friendly and open manner

Depending on the age and development of the child or young person, explain the procedure to them and their parents or carers and obtain their verbal consent.

(You may need to involve a play specialist in the explanation to gain a suitable level of understanding)

2 Reassure child and parent throughout procedure

3 Before starting the procedure you must clean your hands, put on a plastic apron and gloves from a dedicated box – you only need to wash rather than use alcohol hand rub on your hands if you have been in contact with bodily fluids or an infected patient

4 Clean a large plastic tray or trolley with Distel Wipes (or Chlorclean). If using a tray you must clean both the inside and out. You do not need to use any additional solutions if you allow them to air dry but if you dry the tray/trolley with paper towels you must also disinfect using 70% Industrial Methylated Spirits – your tray/trolley now provides an clean surface. Remove gloves and apron, clean hands

5 Gathering the equipment you need check the packages are intact and the equipment is in date, place next to the tray on a clean surface or the bottom of the trolley

6 Two qualified practitioners, one of whom is Paediatric IV and Central Line competent must check and administer intravenous medication together.

7 Collect the prescription chart and both practitioners must check child’s name, DOB, Hospital number and allergies are completed, that the prescription is legible and the medication has not been given





Both nurses must independently check the correct medication flush and dose has been prescribed against the child’s weight – both practitioners must follow the Procedure for the Independent Checking of Medication in Babies, Children and Young People (under 18yrs)



10 Check with an appropriate independent practitioner and draw-up diluents, appropriate flush(s) in one or two syringes

You must label all syringes

- Use a Blunt Fill Needle with 5 Micron Filter for drawing up

11 Add the diluent into the vial of medication and gently rotate the vial or follow manufacturer’s instructions.

12 Draw up all the fluid from the medication vial both practitioners must check the amount of medication to be given and then the unwanted amount of medication must be put back into the vial.

13 For Bolus Medication:

If the medication needs to be diluted further check the amount and content of the fluid bag/vials and ensure the outer wrapper of the fluid package is undamaged prior to opening take bag out of outer wrapper carefully and place onto a clean surface

14 Swab the latex access port of fluid bag with a Chlorhexidine 2% and Alcohol 70% wipe firstly scrub the top of the port for at least 10-15 seconds and then using an alternative place on the wipe scrub the sides for at least 10-15 seconds wait for the port to dry for at least 30 seconds.

Aspirate the amount of fluid required from the infusion bag using a luer-lock syringe and a blunt fill needle or dispensing pin or draw up smaller amounts of fluid from vials – this must be independently checked by both practitioners

15 For Infusions:

When adding medication to a bag of fluid the medication must be reconstituted with diluent and then added to the bag of fluid/syringe using an aseptic non-touch technique – this must be independently checked by both practitioners

16 All infusion bags containing medication, syringes and lines must be labelled and signed by both practitioners before being connected to the Central line

17 For Infusions using fluid bag:

- Pick up fluid administration set, close roller clamp and clamp the line.

- Remove the protective cap from the fluid bag and also from the spike end of the administration set ensuring you are using a aseptic non-touch technique

- Insert the sharp end of the administration set into the entry port of the fluid bag





pushing firmly to ensure full connection

- Hang the fluid onto a drip stand and squeeze the giving set chamber until 1/3rd full.

- Open clamp slowly and allow fluid to run through the rest of the line (inverting the soft section of line and controlling the speed of priming).

- Clamp the line and thread the giving set through the infusion device noting the direction of the arrows.

18 For Infusions using a syringe:

- Pick up fluid administration set and remove protective cap from the female end of the set and screw onto luer lock syringe using an aseptic non-touch technique.

- Apply gently pressure to the syringe plunger to prime the line, ensuring the fluid reaches the patient end of the administration set.

- Place the syringe into a syringe infusion device ensuring the syringe is secured and clamped into placed.

- Ensure the infusion volume counters are cleared and reset.


20 Remove gloves and apron but take a clean pair in your tray ensuring that they do not contaminate the key parts of the equipment, a bottle of alcohol hand rub and clean aprons must be available at the bedside

21 Take the prepared tray/Infusion to the child’s bedside, re-explain the procedure to the child and family and gain consent

Clean hands using the alcohol hand rub and apply clean apron. Both practitioners must check the child’s details both verbally and from their identity band against the prescription chart

For Bolus Medication: at this stage the independent checker must sign the chart ensuring that they clean their hands before leaving the bed space, they do not have to wait until the medication has been fully administered

18 If a child is not wearing an identity band then this must be replaced before any medication or flush is given.

19 Reassure the child and family throughout procedure.

20 Take the Central Line from the protective tapes or dressing uncovering the majority of the line so you are able to easily access the needlefree hub.

If an intravenous infusion is in progress on another line, check for medication incompatibilities and consider stopping the infusion temporarily. Infusions must not be disconnected therefore you must consider using a bonded triple lumen, double anti- reflux device (squid) to administer several infusions at the same time

21 Clean your hands before applying the clean gloves from the tray

Hold the end of the line firmly and using a Chlorhexidine 2% and Alcohol 70% wipe firstly scrub the top of the hub for at least 10-15 seconds and then using an alternative





place on the wipe scrub the sides for at least 10-15 seconds wait for the hub to dry for at least 30 seconds. To prevent contamination of the hub you must continue to hold the end of the line firmly.

You must remove the wipe and place back onto the aseptic field ensuring you do not contaminate the key parts of the other equipment.

22 Connect 10 ml luer-lock syringe containing the flush to the end of the needlefree hub, undo the clamp and pull back gently for a flashback (longlines will not bleed back) administer a small amount of the flush into the line checking for signs of leakage, pain or swelling around the wound site, observe for line damage, ballooning or rupture.

23 For Bolus Medication: Attach the syringe containing the medication and administer the medication at the prescribed rate, continuing to check for signs of leakage, swelling and/ or pain.

If administrating more than one medication you must flush the line between and at the end of giving the medications with a compatible fluid using a second syringe filled with flush.

24 For Infusions: Attach the fluids/infusion by connecting the male end of the administration set to the needlefree hub using an aseptic non-touch technique.

Set the fluid rate on the infusion device (this must be checked independently by two practitioners) in order to administer the fluid/infusion at the prescribed rate, undo the clamp on the administration set and press the start button on the infusion device continuing to check for signs of leakage, extravasation and/ or pain.

At this stage the independent checker must sign the chart ensuring that they clean their hands before leaving the bed space, they do not have to wait until the medication or infusion has been fully administered

25 Any further alteration / titration of the infusion rate must also be checked by two registered practitioners, one of whom must be IV competent.


The rate and total volume infused should be checked hourly and documented on the pump check chart (see Appendix eight of the IV Policy for a sample pump check chart)

26 Before leaving the child’s bedside you must check the pressure counter on the infusion device and note the established pumping pressure and record this on the child’s fluid balance chart.

27 On completion of fluid/infusion administration finally lock the line with Sodium Chloride 0.9% or Heparinised Sodium Chloride. This should be given using a push-pause turbulent flow technique and a positive pressure lock with the last 0.5 ml (ensuring the line is firmly clamped at the appropriate part of the line). At the end of the





procedure wipe the needlefree hub using the Chlorhexidine 2% and Alcohol 70% wipe.

28 If intravenous fluids were stopped temporarily, recommence the infusion. If the fluids have been stopped for more than 30 minutes this must be recorded on the fluid balance chart.

29 Remove the apron and gloves, ensure the child is comfortable and then the primary practitioner must document on the prescription sheet that the Medication and Sodium Chloride 0.9% Flush have been administered,

Clean hands before leaving the bedside

30 Dispose of all sharps, syringes into a sharps container and other equipment into an orange bag and decontaminate the tray before putting it away

31 Document procedure in child’s notes




Procedure for the Preparation and Administration of Bolus and Infusion Medication via a Peripheral Line in Babies, Children and Young People (under 18yrs)

Appendix 5 preparation and administration of IV medications

policy

1. Introduction

This guidance provides a step-by-step procedure for the Administration of Bolus and Infusion Medication via a Peripheral Line with the aim to provide safe and effective care and prevent micro- organism contamination of the line.

2. Scope

This procedure applies to all registered professionals who administer Peripheral Intravenous Medication to babies, children or young people under 18yrs in UHL.

Staff authorised to ADMINISTER medicines to children MUST have had the appropriate training and been assessed as competent. (For more details refer to the Leicester Medicines Code)

This procedure should be used in conjunction with the UHL consent policy to ensure the child receives safe care and children and families are able to understand the reasons for care to facilitate co-operation and the UHL Intravenous Medication Policy, UHL Venous Access Policy, and Procedure for the Independent Checking of Medication in Babies, Children and Young People (under 18yrs)

The procedure excludes:

All Cytotoxic Chemotherapy (Covered by Leicester Medicines Code 5th Edition 2011 Section 14 update July 2013 & EMCN Cytotoxic Policy)

3. 1 Recommendations, Standards and Procedural Statements

This procedure should be used in conjunction with the Leicester Medicines Code (5th Edition 2011 Section 13 update Jan 2015)

3:1.1 The date of birth, weight in kilograms and where appropriate body surface area of the child MUST be written on the prescription charts. The person taking these measurements must sign and date the chart in the relevant boxes.

3:1.2 If the child is uncooperative and has to be weighed with a parent or carer, the calculation

used to subtract the parents weight (& therefore leaving the child’s weight) must be shown alongside the weight box on the prescription chart and signed and dated by the practitioner doing the subtraction.

3:1.3 When administering injections or medicines of doses less than 1ml in volume, a 1ml syringe

graduated to 0.01ml must be used.

3:1.4 Paediatric formulations must be used when these are available. Where they are not available and multi-dose or adult strength preparations have to be used, extra vigilance should be exercised when calculating and preparing the dose.




3:1.5 In UHL all babies, children and young people must wear identity bracelets to enable staff to identify the patient, especially during the medicines administration process.

3:1.6 Only the correct volume of medication should be taken to the patient (this mainly applies to bolus and short infusions). In Neonatal Unit an additional 10% medication can be taken to the child due to the smaller amounts being infused. The excess medication must be withdrawn from the bottle or bag or the correct dose drawn into a new syringe or infusion bag. The volume limits on pumps should not be used to control the amount of medication given.

3:1.7 Practitioners must know the therapeutic uses of medication to be administered, its normal

dosage, general side effects, precautions, contra-indications, methods and duration of administration and how appropriate the medication is to the child’s plan of care.

3:1.8 All IV medication preparation should occur in the clean treatment room or within an area

dedicated to preparation of medications.

3:1.9 All substances for injection that are reconstituted within the ward / department / unit must be drawn up immediately prior to administration by the practitioner who will administer the medication.

3:2 Equipment

m) A selection of 10ml Luer- Lock Sterile Syringes

n) Blunt Fill Filter Needles for drawing up flush/diluent

o) Chlorhexidine 2% and Alcohol 70% wipes (Large PDI Wipes)

p) Clean gloves and aprons

q) Prescription Chart

r) Sodium Chloride 0.9% (or other compatible diluent)

s) Sodium Chloride 0.9% (or other compatible flush).

t) Bonded Triple Lumen with Double Lumen anti-reflux valve connector (Squid) if giving more than one Medication

u) Large Plastic Tray or Trolley

v) Appropriate Fluid Administration Set

w) Tubifast to cover peripheral cannula

x) Paediatric IV Monographs to check doses/administration (Can be viewed on Intranet)

Procedure for The Administration of Bolus & Infusion Medication via a Peripheral Line in Children

No Action

1 Approach the child or young person and family in a friendly and open manner

Depending on the age and development of the child or young person, explain the procedure to them and their parents or carers and obtain their verbal consent.

(You may need to involve a play specialist in the explanation to gain a suitable level of





understanding)

2 Reassure child and parent throughout procedure

3 Before starting the procedure you must clean your hands, put on a plastic apron and gloves from a dedicated box – you only need to wash rather than use alcohol hand rub on your hands if you have been in contact with bodily fluids or an infected patient

4 Clean a large plastic tray or trolley with Distel Wipes (or Chlorclean). If using a tray you must clean both the inside and out. You do not need to use any additional solutions if you allow them to air dry but if you dry the tray/trolley with paper towels you must also disinfect using 70% Industrial Methylated Spirits – your tray/trolley now provides an clean surface. Remove gloves and apron, clean hands

5 Gathering the equipment you need check the packages are intact and the equipment is in date, place next to the tray on a clean surface or the bottom of the trolley

6 Two qualified practitioners, one of whom is Paediatric IV competent must check and administer intravenous medication together.

7 Collect the prescription chart and both practitioners must check child’s name, DOB, Hospital number and allergies are completed, that the prescription is legible and the medication has not been given

Both nurses must independently check the correct medication flush and dose has been prescribed against the child’s weight – both practitioners must follow the Procedure for the Independent Checking of Medication in Babies, Children and Young People (under 18yrs)



10 Check with an appropriate independent practitioner and draw-up diluents, appropriate flush(s) in one or two syringes

You must label all syringes

- Use a Blunt Fill Needle with 5 Micron Filter for drawing up

11 Add the diluent into the vial of medication and gently rotate the vial or follow manufacturer’s instructions.

12 Draw up all the fluid from the medication vial both practitioners must check the amount of medication to be given and then the unwanted amount of medication must be put back into the vial.

13 For Bolus Medication:

If the medication needs to be diluted further check the amount and content of the fluid bag/vials and ensure the outer wrapper of the fluid package is undamaged prior to opening take bag out of outer wrapper carefully and place onto a clean surface





14 Swab the latex access port of fluid bag with a Chlorhexidine 2% and Alcohol 70% wipe firstly scrub the top of the port for at least 10-15 seconds and then using an alternative place on the wipe scrub the sides for at least 10-15 seconds wait for the port to dry for at least 30 seconds.

Aspirate the amount of fluid required from the infusion bag using a luer-lock syringe and a blunt fill needle or dispensing pin or draw up smaller amounts of fluid from vials – this must be independently checked by both practitioners

15 For Infusions:

When adding medication to a bag of fluid the medication must be reconstituted with diluent and then added to the bag of fluid/syringe using an aseptic non-touch technique – this must be independently checked by both practitioners

16 All infusion bags containing medication, syringes and lines must be labelled and signed by both practitioners before being connected to the Peripheral line

17 For Infusions using fluid bag:

- Pick up fluid administration set, close roller clamp and clamp the line.

- Remove the protective cap from the fluid bag and also from the spike end of the administration set ensuring you are using a aseptic non-touch technique

- Insert the sharp end of the administration set into the entry port of the fluid bag pushing firmly to ensure full connection

- Hang the fluid onto a drip stand and squeeze the giving set chamber until 1/3rd full.

- Open clamp slowly and allow fluid to run through the rest of the line (inverting the soft section of line and controlling the speed of priming).

- Clamp the line and thread the giving set through the infusion device noting the direction of the arrows.

18 For Infusions using a syringe:

- Pick up fluid administration set and remove protective cap from the female end of the set and screw onto luer lock syringe using an aseptic non-touch technique.

- Apply gently pressure to the syringe plunger to prime the line, ensuring the fluid reaches the patient end of the administration set.

- Place the syringe into a syringe infusion device ensuring the syringe is secured and clamped into placed.

- Ensure the infusion volume counters are cleared and reset.


20 Remove gloves and apron but take a clean pair in your tray ensuring that they do not contaminate the key parts of the equipment, a bottle of alcohol hand rub and clean aprons must be available at the bedside

21 Take the prepared tray/Infusion to the child’s bedside, re-explain the procedure to the child and family and gain consent

Clean hands using the alcohol hand rub and apply clean apron. Both practitioners





must check the child’s details both verbally and from their identity band against the prescription chart

For Bolus Medication: at this stage the independent checker must sign the chart ensuring that they clean their hands before leaving the bed space, they do not have to wait until the medication has been fully administered

22 If a child is not wearing an identity band then this must be replaced before any medication or flush is given.

23 Reassure the child and family throughout procedure.

24 Before starting the procedure pull back the Tubifast from the child’s cannula site and move the tray as close to the cannula as you can

If an intravenous infusion is in progress on another line, check for medication incompatibilities and consider stopping the infusion temporarily. Infusions must not be disconnected therefore you must consider using a bonded triple lumen, double anti- reflux device (squid) to administer several infusions at the same time

25 Clean your hands before applying the clean gloves from the tray


You must remove the wipe and place back onto the aseptic field ensuring you do not contaminate the key parts of the other equipment.

26 Connect 10 ml slip-lock syringe containing the flush to the end of the needlefree hub, undo the clamp and administer a small amount of the flush into the line checking for signs of leakage, pain or swelling around the cannula site.

27 For Bolus Medication: Attach the syringe containing the medication and administer the medication at the prescribed rate, continuing to check for signs of leakage, swelling and/ or pain around the cannula site

If administrating more than one medication you must flush the line between and at the end of giving the medications with a compatible fluid using a second syringe filled with flush.

28 For Infusions: Attach the fluids/infusion by connecting the male end of the administration set to the needlefree hub using an aseptic non-touch technique.

Set the fluid rate on the infusion device (this must be checked independently by two practitioners) in order to administer the fluid/infusion at the prescribed rate, undo the clamp on the administration set and press the start button on the infusion device continuing to check for signs of leakage, extravasation and/ or pain.

At this stage the independent checker must sign the chart ensuring that they clean their hands before leaving the bed space, they do not have to wait until the medication or infusion has been fully administered

29 Any further alteration / titration of the infusion rate must also be checked by two





registered practitioners, one of whom must be IV competent.


The rate and total volume infused should be checked hourly and documented on the pump check chart (see Appendix eight of the IV Policy for a sample pump check chart)

30 Before leaving the child’s bedside you must check the pressure counter on the infusion device and note the established pumping pressure and record this on the child’s fluid balance chart.

31 On completion of fluid/infusion administration finally lock the line with Sodium Chloride 0.9% or Heparinised Sodium Chloride. This should be given using a push-pause turbulent flow technique and a positive pressure lock with the last 0.5 ml (ensuring the line is firmly clamped at the appropriate part of the line). At the end of the procedure wipe the needlefree hub using the Chlorhexidine 2% and Alcohol 70% wipe.

32 If intravenous fluids were stopped temporarily, recommence the infusion. If the fluids have been stopped for more than 30 minutes this must be recorded on the fluid balance chart.

33 Remove the apron and gloves, ensure the child is comfortable and then the primary practitioner must document on the prescription sheet that the Medication and Sodium Chloride 0.9% Flush have been administered,

Clean hands before leaving the bedside

34 Dispose of all sharps, syringes into a sharps container and other equipment into an orange bag and decontaminate the tray before putting it away

35 Document procedure in child’s notes




Peripheral IV Cannula Care Bundle Appendix 6

Name :

Hospital number:

Ward:

Care Bundle Elements during insertion

Hand Hygiene

Clean hands prior to contact with patient and before touching any of the sterile equipment inside the insertion pack

Personal protection

Gloves are required when completing any interactions that involves touching or manipulation of the vascular access device or associated equipment. Aprons are required if risk of clothing contamination

Aseptic Field

An aseptic field is required to protect key parts from contamination

ANTT (Aseptic Non Touch Technique)

During insertion ensure key parts are protected from inadvertent touch contamination

Skin preparation

Clean the skin with 2% chlorhexidine gluconate in 70% isopropyl alcohol for thirty seconds and allow to dry

Flushing

Flush the cannula with sodium chloride 0.9% for intravenous use. Use a short extension and needlefree device to reduce the risk of infection and trauma to lumen of vein

Transparent Dressing

A semi-permeable transparent dressing is used allowing observation of insertion site. Securing strips must not cover insertion site. Apply a date strip to indicate date of insertion

Sharps safety

Following removal of the sharp from the patient, it must be discarded immediately into a sharps container. Sharps must not be used to administer via a needlefree device.

Documentation

Documentation must evidence reason for insertion, size, name and grade (clearly legible) with signature of inserter

R L

IV Cannula Insertion Record or manufacturers label

R L


Date Date

Time Time

Size and Lot Number Size and Lot Number

Number of attempts Number of attempts

Reason for insertion Reason for insertion

Signature Signature

Inserted by (print) Inserted by (print)

IV Cannula Removal Record IV Cannula Removal Record Date removed Date removed

Number of days in situ Number of days in situ

VIP score upon removal VIP score upon removal

Reason for removal Reason for removal

Signature Signature

Please mark successful

cannulation with an X and failed cannulations with an

Removed by (print) Please mark successful cannulation with an X and failed cannulations with an F

Removed by (print)

R L

Please mark successful cannulation with an X and failed cannulations with an


R L


Date Date

Time Time

Size and Lot Number Size and Lot Number

Number of attempts Number of attempts

Reason for insertion Reason for insertion

Signature Signature

Inserted by (print) Inserted by (print)

IV Cannula Removal Record IV Cannula Removal Record Date removed Date removed

Number of days in situ Number of days in situ

VIP score upon removal VIP score upon removal

Reason for removal Reason for removal

Signature Please mark successful cannulation with an X and failed cannulations with an F

Signature

Removed by (print) Removed by (print)

Care Bundle Elements during ongoing care

Hand Hygiene Continuing Clinical Indication Cannula

Hands are cleaned before and after each Need for IV access must be assessed twice Replacement episode of patient contact, and again daily and cannula removed if no longer Do not remove cannula routinely to before contact with device if hands had clinically indicated. If multiple cannulations reduce the risk of infection. Cannulae contact with any other surface refer to venous access team to assess should be replaced upon clinical

appropriateness of device indication. VIP score Dressing Intact Administration sets

Administration sets must be labelled with the date they are due to be changed (96 hours fluid sets, 24 hours TPN, and 12 hourly for blood or according to

The insertion site should be inspected and Ensure that the dressing is intact and does the VIP score documented at a minimum not obscure visual inspection of the insertion

during each shift. site

Cannula Access Sharps safety Documentation Ensure key parts are protected when Following removal of the cannula from the Document date and time of removal, accessing the device. Scrub the hub with patient, it must be discarded immediately into identifying grade and name of operator 2% chlorhexidine gluconate in 70% a sharps container. Sharps must not be used legibly with signature isopropyl alcohol for fifteen seconds and to administer via a needlefree device

allow to dry

Date: Date: Date: Date: Date: Date: Date:

VIP Score

AM PM AM PM AM PM AM PM AM PM AM PM AM PM

Device used in last 12 hours (Y/N) if N remove

Signature

Date: Date: Date: Date: Date: Date: Date:

VIP Score

AM PM AM PM AM PM AM PM AM PM AM PM AM PM

Device used in last 12 hours (Y/N) if N remove

Signature

All saline flushes must be documented as administered on the prescription

IV (Intravenous Therapy) UHL Policy of 47 Latest version approved by Policy and Guideline Committee on 20 January 2017 Trust Ref: B25/2010 Next Review: January 2021





Appendix 7

SAMPLE - Ward Infusion Pump Check Chart

Patient Name:

NHS / Hospital Number:

Date of Birth:

Date:

Ward / Unit: Site:

Pump Type: Frequency of checking:

Medication: Start Rate:

Volume to be Infused:

Exact Time

Rate Volume Infused

Volume Remaining

Comments / Actions taken

e.g. prescription / rate change, discontinued

Signature(s) 2 required for rate

change




ASEPTIC PRODUCTS ROUTINELY MADE IN THE ASEPTIC UNIT

Appendix 8

All Cytotoxic Chemotherapy (including some monoclonal antibodies)

Amphotericin Intracameral & Intravitreal Injections

Baclofen Intrathecal Injection

Bleomycin Intralesional Injection

Caspofungin Eye Drops

Cidofovir Intravenous & Intra-lesional Injections

Clonidine & Levobupivaciane Epidural Infusion

Cyclophosphamide & Mesna Infusion

Fluorouracil Subconjunctival Injection

Fluorouracil Topical Solution for Ophthalmology

Foscarnet Infusion for peripheral line administration only (for central lines

administered neat from ready to use infusion bottles). N.B. This has a high

workload impact on the unit and needs discussion before ordering

Ganciclovir IV Infusion

Ganciclovir Intravitreal Injection

Methotrexate Intramuscular Injection for ectopic pregnancies

Mitomycin Topical Solution for Ophthalmology

Ribavirin Injection (unlicensed medicine not routinely stocked at UHL)

Products prepared in the aseptic unit for renal wards only:

Anti-human Thymocyte Immunoglobulin (ATG Rabbit) IV infusion

Ciclosporin IV infusion

Mycophenolate IV infusion

Tacrolimus IV infusion

Eye drops now purchased as unlicensed medicines but if necessary could be

made as a one-off

Amphotericin Eye Drops

Voriconazole Eye Drops

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