Policy for Administration of Intravenous Antibiotic Therapy to Adults in the Community and Community Hospital

Author(s): In consultation with: Community Services Manager, Out of Hospital Care RRRT Pharmacist, RRRT Nurses Anaphylaxis PGD Infection Control Policy Medicines Management Policy Incident Reporting Policy and Procedure Vascular Access Devices The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Seventh Edition (PCT POLICY Use of the Royal Marsden). Professional Executive Committee August 2009 August 2011 or sooner in the light changes to national or local guidance or clinical practice

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Issuer: PS

Policy No: 348

Issue Date: 08/2009

Issue No: 1

Review Date: 08/2011

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Contents
1. Purpose 2. Scope 3. Background 4. Training Requirements 5. Referral and Assessment of New Patients by Registered Nurses 5.1. Considerations 6. Prescribing 7. Supplies of Intravenous Antibiotics 8. Responsibilities for Administration 9. Preparation of Medicine 10. Methods of Administration 10.1. 10.2. 11.1. 11.2. 13. Audit 14. References Appendix 1 Procedure for IV bolus administration Appendix 2 Procedure for IV intermittent infusion Appendix 3 Drug Calculations Appendix 4 Phlebitis Score Policy Statement Appendix 5 Referral Checklist Appendix 6 Patient Information Leaflet Intravenous Bolus Injection Intravenous Intermittent Infusion Peripheral Cannula Central, Mid and Peripheral Lines page 3 page 3 page 3 page 3 page 4 page 4 page 5 page 6 page 6 page 7 page 8 page 8 page 8 page 8 page 8 page 9 page 9 page 10 page 10 page 11 page 14 page 17 page 18 page 19 page 23

11. Intravenous Access Devices

12. Complications

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Purpose

This policy has been written to: Enable registered nurses to assess whether patients are suitable for intravenous antibiotic therapy in the community. Define professional responsibilities in prescribing, preparation and administration of intravenous antibiotics. Provide an evidence base for practice Provide a vehicle for practitioners to exercise clinical judgement within the realms of professional accountability (NMC 2002)

This policy is aimed at registered nurses in community nursing teams and community hospitals This policy was developed to: Enable patients to safely receive intravenous antibiotic therapy in their own homes or in a community health setting, e.g. community hospital, nursing or residential home, thereby facilitating early discharge from hospital or preventing hospital admission. Ensure safe and consistent practice in administration of intravenous antibiotics by Registered Nurses thereby reducing the risk of complications. Provide a knowledge base to guide clinical practice based on evidence of best practice.

Scope

Background

Due to the development of complex care in the community, intravenous (IV) therapy is now being provided in community settings.

The drive to perform these therapies outside the hospital setting is patient choice, continual pressure on hospital beds, lengthening waiting lists, Kayley (2000) The RCN IV forum Standards for Infusion Therapy July 2003 is incorporated into this document to promote best practice. Infusion is now an integral part of the majority of nurses professional practice. The code of professional conduct (NMC) encouraged nurses to expand their practice provided they had the necessary knowledge and skills and accepted responsibility for their actions RCN (2003).

Training Requirements

Intravenous antibiotics may only be administered by registered nurses that have the necessary knowledge and skills in preparing and administering intravenous antibiotics and are confident and competent to carry out this practice.
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Individuals involved in any aspect of intravenous therapy have a responsibility to acquire and maintain the necessary knowledge and clinical skills, through theoretical and practical training under supervision. Training is currently accessed through line managers. It is the responsibility of individual nurses to maintain and update their knowledge and skills and keep their own record of continuing professional development.

Patients are referred to the Rapid Response and Rehabilitation Team (RRRT), District Nurses (DNs) and Clevedon Community Hospital by: a) the discharging hospital doctor or nurse for patients requiring intravenous antibiotics on discharge from hospital (Appendix 5) or b) the patients own GP; for patients requiring initiation of intravenous antibiotics in the community to avoid admission to hospital (see Appendix 5) A thorough and comprehensive assessment must be carried out by the nursing team to assess the patients suitability for administration of intravenous antibiotics in the community (see Referral checklist Appendix 5). 5.1 Considerations There must be a reliable diagnosis of an infection requiring IV rather than oral therapy as the IV route should only be used if the antibiotic cannot be administered by any other route. Medication should be changed to oral treatment at the earliest opportunity (usually 3 days). There must be a completion date or date of review of treatment if needed. Commonly accepted referrals are for the treatment of cellulitis and osteomyelitis. However, other conditions will be considered on an individual basis, following a risk assessment of the patient and the antibiotics involved. IV antibiotic treatment via a peripheral cannula should not normally exceed two weeks duration, if treatment is expected to last longer than two weeks a central line or PICC line (Peripherally inserted central catheter) should be considered. Patients who will be receiving antibiotics in the community should have the relevant medical complications excluded. The prescriber must document any known allergies and complete the anaphylaxis risk assessment (see Referral Checklist Section 2 Appendix 5). Patients that have suffered a previous anaphylactic reaction must not be accepted for IV antibiotics in the community. If allergies are not documented, the nurse must check before administering the medicine.

Referral and Assessment of New Patients by Registered Nurses

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The treatment must be appropriate and manageable, (e.g. up to three times a day) in the community setting e.g. bolus injection or infusion time of no more than 30 minutes are preferable, however longer infusions may be negotiated. The patients home situation must be suitable. There should be running water, access to a telephone and support in an emergency. If these are not available, a more suitable community health setting should be considered e.g. community hospital. The following issues should be discussed with the patient: the prescribed treatment, the vascular access device, how to recognise and deal with complications/ infections and who to contact throughout the day or night, and the patients consent recorded. A patient information leaflet regarding these issues should be given to the patient (see Appendix 6). The patient must be able to understand and comply with the treatment regime, for example, elevation of limb, time off work for resting, and must understand the implications of the treatment and be able to give consent. The family/carer must agree that they will take the patient to the Emergency Department if it is necessary for re-cannulation, if the nurse fails to re-cannulate. Oral antibiotic therapy may need to be instigated if there is a time lag. There must be adequate numbers of trained nurses available within the RRRT, District Nurses & Clevedon Hospital to ensure continuation of the IV antibiotic regime at the prescribed times.

It is the responsibility of the discharging doctor or patients own GP or other appropriately authorised prescriber (e.g. non-medical prescriber) to prescribe the intravenous antibiotics on an authorised prescription e.g. Discharge prescription or FP10. All diluents and flushes required must also be prescribed as these are prescription only medicines. The prescriber must also complete and sign a community prescription chart including details of antibiotics prescribed, diluents, flushes and how the drug is to be given. The prescriber must provide clear, precise written instructions regarding the medicine, dose, route and frequency of administration. The referring doctor must also complete Section 2 of the Referral Checklist (Appendix 5). Where intravenous antibiotic therapy is initiated in hospital,

Prescribing

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agreement that the patient be treated in the community must also be obtained from the patients GP. This will be co-ordinated by the Community Discharge Liaison Nurse or REACT team. Verbal orders for commencement of, or changes to intravenous medications must not be taken. It is also good practice to prescribe a supply of appropriate oral antibiotic cover for the patient to facilitate conversion from IV to oral therapy and provide antibiotic cover if recannulation is delayed.

Supplies of Intravenous Antibiotics

For patients being discharged from hospital, the antibiotics plus diluents and flushes must be prescribed and dispensed by the discharging hospital. Administration equipment to be provided by the discharging hospital. For patients referred by their own GP, the antibiotics plus diluents, flushes must be prescribed by the GP on FP10 prescription and obtained from the community pharmacy. All other equipment is provided by community staff. Adrenaline must be carried by all registered nurses who administer medicines including IV antibiotics.

The nurse administering IV antibiotics has a responsibility to ensure that he/she has knowledge and understanding of the medicine to be administered, including: Indications for use Recommended dose and frequency of use Methods of preparation and administration Rate of administration Any special monitoring or health and safety requirements Contra-indications Side effects and potential adverse reactions and the appropriate interventions particularly related to the management of anaphylaxis. The nurse administering the medicines must be satisfied with the prescription, ensuring it is clear and unambiguous and appropriate for the patients age and condition in accordance with the PCT policy for the identification of patients. Prior to administration the nurse should check: The patients name and address The date treatment is to commence and a review/completion date The correct medicine name, form and strength The dose to be given The route of administration The time and date of administration

Responsibilities for Administration

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The frequency of administration The expiry date of the medicine and diluent (if required) The method of administration Any known allergies

The nurse should delay administration and seek immediate advice if there are any doubts or concerns regarding either the prescribers instructions or the patients condition. The first three doses of IV antibiotic treatment must be administered in the presence of two healthcare professionals; at least one of these must be a registered nurse. For six months following introduction of this policy, two trained nurses must administer the first three doses. Intravenous therapy should be recorded in the patients community nursing record or inpatient medical record. The main considerations recorded in the care plan include, the type of vascular access, site used and care of the site, the medicine, dose, rate, time and method of administration. The phlebitis score should also be recorded at least daily. If at any time during or following treatment, the patients condition has not responded or has worsened, the nurse must arrange a medical review.

Further information is included in: Appendix 1 and 2 Procedures for Administration Appendix 3 for Drug Calculations Advanced preparation of substances before their prescribed time is not acceptable. Medication must not be prepared by one practitioner for administration by another practitioner. The medication must be prepared aseptically immediately prior to administration in accordance with the manufacturers instructions for reconstitution. Individual Drug Monographs for antibiotics and diluents are available on request from the Pharmacy Department at Weston Hospital. For further information refer to the manufacturers information - the summary of product characteristics (SPC) (which is in the medicine packaging) local formulary, traffic light scheme and the British National Formulary.

Preparation of Medicine

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The nurse must carefully examine all medicine and fluid containers ensuring they are the correct medicine /diluent /fluid, and appear free from particles, contamination and faults and that they have not passed their expiry dates. Where necessary the nurse should appropriately label all containers, vials and syringes used to ensure that the contents are identifiable. Any surplus of the prepared medicine or any unused medicine must be discarded and must not be kept for future use. Surplus prepared medicines should be discarded in the sharps box for the individual patient. Unused medicine should be returned by the patient to a community pharmacy at the end of their treatment. Medicines prescribed for an individual patient must not be used for another patient and should be returned to a pharmacy if no longer needed.

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Further information is included in: Appendix 1 - Procedure for Intravenous Bolus Injection Appendix 2 - Procedure for Intravenous Intermittent Infusion 10.1 Intravenous Bolus Injection Direct injection of a small volume of fluid / medicine contained within a syringe administered directly into the injection port of an infusion line or directly into an indwelling cannula over a short period of time. 10.2 Intravenous Intermittent infusion Infusion of a volume of fluid / medicine over a period of time at prescribed intervals and stopped until next dose is required. The nurse must ensure that all IV antibiotics are administered at the correct rate. The manufacturers recommendations of rates of administration must be adhered to. For bolus and intermittent infusions the nurse must stay with the patient for the duration of the infusion in order to monitor the flow rate. N.B. The use of electronic flow control devices (pumps) is not covered by this policy. Staff must be aware of the risks associated with the use of pumps and the need for specialised knowledge and training in the use of pumps.

Methods of Administration

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11.1 Peripheral Cannula (read in conjunction with the policy on peripheral venous cannulation) The nurse must:
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Intravenous Access Devices

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Check/observe the site and the patency of any device before, during and post administration and report/act on any concerns Follow The Royal Marsden Hospital Manual of Clinical Nursing Procedures (6 Edition) regarding the care of devices. Ensure the removal of the cannula at the end of intravenous antibiotic treatment (see policy for peripheral venous cannulation) Ensure the patient is aware of the measures to take in the event of displacement and has the patient information leaflet (Appendix 6).
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Recannulation must only be performed by a nurse, emergency care practitioner (ECP) or doctor who has received theoretical and practical training and is competent in cannulation. The patient must be taken to the Emergency Department if necessary for recannulation, if the nurse/doctor/ECP fails to recannulate in the community. 11.2 Central, Mid and Peripheral Lines The nurse has a responsibility to ensure he/she is aware of the potential complications of these lines and has received theoretical and practical training in the care of such access devices before administering medications via them. Community nurses should follow the guidelines of the referring hospital treating the patient (if available) or The Royal Marsden Hospital Manual of Clinical Nursing Procedures (6th Edition) for the care and management of these lines.

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Complications

Appendix 4 Phlebitis scale

The potential hazards and risks of IV therapy include anaphylaxis, interactions and infections and therefore the priorities are patient safety, asepsis and comfort. Infusion related complications might be local or systemic and include phlebitis, infiltration, extravasation, haematoma, speed-shock, infection and air embolus. The nurse should advise the patient of possible side effects and how to recognise complications and tell them whom to contact for advice (see Patient Information Leaflet Appendix 6). During IV medicine administration the nurse must monitor the patients condition, observing for any adverse reactions. The nurse must act immediately if there is any sign of an adverse reaction by stopping administration (refer to the PCT Medicines Management Policy and PCT Incident Reporting Policy).
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All Registered Nurses must be familiar with the Anaphylaxis PGD. Nurses must have Adrenaline injection 1 in 1000 available at all times when administering IV antibiotics. This must be carried by all nurses. Any adverse or suspected adverse reaction must be reported to the prescriber as soon as possible. The details should also be documented in the patients community nursing records and reported to the Committee on Safety of Medicines using a yellow card, which can be found in the British National Formulary.

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Adherence with this policy will be audited. Potential and significant risks will be identified through the PCT incident reporting system (DATIX) and the areas identified will be incorporated into the PCT annual audit programme. Department of Health (2001) Reference Guide to Consent for Examination or Treatment. London: Department of Health. Jackson (1997) Phlebitis Scale. Specialist Nurse IV Therapy and Care, Rotherham General Hospital Trust Standards for Infusion Therapy, RCN IV Therapy Forum, July 2003 Kayley J (2000) Home IV Antibiotic Therapy, Primary Health Care. Vol. 10.No 6. July/August NMC (2202) Code of Professional Conduct SWAGE T (2000) Quality Initiatives: The Process of Clinical Effectiveness. In: SWAGE T (ed) Clinical Governance in Health Care Practice. Oxford: Butterworth Heinemann Ch 4 Addenbrookes Intravenous Administration & Infusion Pumps Education Package 2000 Dougherty & Lamb (1999) Intravenous Therapy in Nursing Practice, Churchill Livingstone The Royal Marsden Hospital (2000), Manual of Clinical Nursing Procedures, 6 edition, Blackwell Publishing
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Audit

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References

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Appendix 1 PROCEDURE FOR INTRAVENOUS BOLUS ADMINISTRATION The Procedure for Administration of Antibiotics by Direct Injection into a Peripheral Cannula, Central Venous Catheter or Peripherally Inserted Central Catheter (PICC) Equipment Non sterile gloves and apron Sterile gloves Patients prescribed medicines Flushing solution Alcohol based cleaning wipe (Steret) Luer-loc syringes Needles for drawing up solutions Needle free injectable bung (not if changed in last 7 days) Sterile dressing towel or clinically clean tray Label for identifying medicines Sharps bin Prescribed adrenalin Drug chart / prescription Action Check the identity of the patient against the prescription Explain and discuss the procedure with the patient and obtain consent. Let the patient read the manufacturers patient information leaflet for each medicine if required Wash hands in liquid soap and water and dry with paper towels. Put on non sterile gloves and apron Prepare medicines in clean environment and use aseptic principles Assemble the necessary equipment Prepare the medicine as per manufacturers instructions. Use BNF or IV drug monograph for extra guidance. (Monographs available via WAHT MAU or Pharmacy departments) Prepare flushes in separate syringes. Flushes are usually sodium chloride 0.9% injection and the quantity is 5 -10mls or equal to at least twice the length of the
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Rationale To minimise the risk of error and ensure the correct patient. To ensure the patient understands the procedure, the medicines involved and agrees to co-operate To minimise the risk of infection To minimise the risk of infection from contaminated surfaces To be prepared for the procedure To ensure the medicine is given as the manufacturer intended To flush line before, between and after medicines

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To detect extravasation of cannula and blockage To check patency of line. Pulsating action when instilling flush creates turbulence removing debris from catheter wall. NB if no blood can be aspirated prior to instilling flush see Appendix 5 for guidance Inject the medicine at the rate recommended To detect early signs of an allergic reaction by the manufacturer. Observe the patient and complications around the insertion site and injection site whilst administering the medicine. If more than one medicine is to be given To prevent medicine incompatibility occurring flush with sodium chloride 0.9% injection or in the line. recommended flush in between each medicine. Ensure a final flush is given following the To flush any remaining medicine away from final dose of the medicine. The final flush the cannula.
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cannula and add on devices. Advice on flushes should be checked against the manufacturers guidance Use the tray to transport flushes and medicines to patient, where possible prepare medicines next to the patient Ensure medicines and flushes can be identified by a label Remove bandage on peripheral line. Inspect insertion site for sign of infection. On central lines check sutures are secure and amount of line visible is unchanged. Also check for signs of local infection Peripheral Cannulae should be renewed every 72-96 hours or sooner if complications are suspected. If venous access limited, the cannula can remain in situ if there are no signs of infection Remove non-sterile gloves, wash hands as before and put on sterile gloves If giving the medicine via a central line, place the sterile sheet from the glove packet or a new sterile towel under the central line Clean the needle free injectable bung with a steret. Allow to dry before making connections. The bung should be cleared with a steret before and after each syringe connection. Inject flush into needle free bung and observe for resistance and pain. If injecting the flush into a central line, aspirate 1ml of blood prior to injecting the flush. Flushes into central lines should be 10mls and given with a pulsating action.

To minimise the risk of infection and to ensure safe transportation of medicines To identify contents of syringes and prevent medicines being given incorrectly To detect signs of inflammation, infiltration or extravasation. If present take appropriate action (see Appendix 4 for Phlebitis Score on Peripheral Cannulae) High Impact Intervention No 2: Peripheral intravenous cannula care bundle To prevent infection To prevent infection and create a sterile filed around the central line. To reduce the number of pathogens introduced by the syringe at the time of insertion

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given into a central line should end with positive pressure Heparin can be instilled into central lines following the final flush if prescribed. Re-apply a bandage, change if soiled and make sure the patient is comfortable Central line dressing should not remain in place longer than 7 days and should be changed if the integrity of the dressing is compromised. Once the injection has been administered place all used syringes with needle unsheathed directly into sharps container. Do not disconnect needles from syringe prior to disposal. Other waste should be placed into the appropriate plastic bags. Ensure the patient is able to recognise complications and knows whom to contact for advice. Patients should have their temperature recorded daily, before antibiotics are administered Record the medicine administration on the administration record chart and enter the visit in the patients nursing notes. Amend the care plan if any changes occur which affect the treatment and/or care of the patient.

Heparin reduces bacterial colonisation. To minimise the risk of contamination of the insertion site and reduce the risk of dislodging the cannula. To prevent infection.

To promote infection control measures

To detect early signs of complications and ensure the therapy continues as planned To detect early signs of systemic infection from the central line. To monitor the efficacy of treatment. To maintain accurate records, provide a point of reference in the event of any queries and prevent duplication of treatment.

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Appendix 2 PROCEDURE FOR INTRAVENOUS INTERMITTENT INFUSION For the Administration of antibiotics by short infusion into a Peripheral Cannula, Central Venous Catheter or Peripherally Inserted Central Catheter (PICC) Equipment Non sterile gloves and apron Sterile gloves Patients prescribed medicines Patients care plan Flushing solution Alcohol based cleaning wipe (Steret) Giving set Needles for drawing up solutions Needle free injectable bung (not if changed in last 7 days) Sterile dressing towel or clinically clean tray Label for identifying medicines Sharps bin Adrenalin Drug chart / prescription Action Check the identity of the patient against the prescription Explain and discuss the procedure with the patient and obtain and record consent. Let the patient read the manufacturers patient information leaflet for each medicine if required Wash hands in liquid soap and water and dry with paper towels. Put on non sterile gloves and apron Prepare medicines in clean environment and use aseptic principles Assemble the necessary equipment Prepare the medicine as per manufacturers instructions. Use BNF, or IV drug monograph for extra guidance. (Monographs available via WAHT MAU or Pharmacy departments). Ensure the bottle or bag containing the medicine to be infused is labelled Prepare flushes in separate syringes. Flushes are usually sodium chloride 0.9% injection and the quantity is 5
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Rationale To minimise the risk of error and ensure the correct patient To ensure the patient understands the procedure, the medicines involved and agrees to co-operate To minimise the risk of infection To minimise the risk of infection from contaminated surfaces To be prepared for the procedure To ensure the medicine is given as the manufacturer intended

To identify the medicine, its strength, total amount in volume, route of administration, and date and time of administration To flush line before, between and after medicines

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10mls or equal to at least twice the length of the cannula and add on devices Connect the giving set to the infusion bag or bottle containing the medicine. Prime the line. Use a no touch, sterile technique Use the tray to transport flushes and medicines to patient, where possible prepare medicines next to the patient Remove bandage on peripheral line. Inspect insertion site for sign of infection. On central lines check sutures are secure and amount of line visible is unchanged. Also check for signs of local infection Peripheral Cannulae should be renewed every 72-96 hours or sooner if complications are suspected. If venous access limited, the cannula can remain in situ if there are no signs of infection Remove non-sterile gloves, wash hands as before and put on sterile gloves. If giving the medicine via a central line, place the sterile sheet from the glove packet or a new sterile towel under the central line Clean the needle free injectable bung with a street. Allow to dry before making connections. The bung should be cleaned before and after any connections Inject flush into needle free bung and observe for resistance and pain If injecting the flush into a central line, aspirate 1ml of blood prior to injecting the flush. Flushes into central lines should be 10 mls and given with a pulsating action Connect the giving set to the needle free injectable bung. Open the roller ball and allow the medicine to drip. To calculate the rate at which the medicine should be given use the number of drops per ml as stated on the giving set packaging. Number of drops per ml may vary with different manufacturers Observe the patient whilst the medicine is being given. Stay with the patient and observe the
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To minimise the risk of infection

To minimise risk of infection To detect signs of inflammation, infiltration or extravasation. If present take appropriate action (see Appendix 4 for Phlebitis Score on Peripheral Cannulae) High Impact Intervention No 2: Peripheral intravenous cannula care bundle To prevent infection To prevent infection and create a sterile field around the central line To reduce the number of pathogens introduced by the syringe at the time of insertion To detect extravasation of cannula and blockage To check patency of line. Pulsating action when instilling flush creates turbulence, removing debris from catheter wall. NB if no blood can be aspirated prior to instilling flush (see Appendix 5 for guidance). To ensure the medicine is dripped under gravity into the patient at the correct rate (see Appendix 3 for drug calculations). Pump to be used if available

To detect early signs of adverse reactions. To ensure that the infusion rate does not
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infusion. Check that the drip rate stays the same until the entire medicine is given. Infusion pump to be used if available Once the medicine is given disconnect the giving set and discard in sharps bins If more than one medicine is to be given, flush with sodium chloride 0.9% injection or prescribed flush in between each medicine Ensure a final flush is given following the final dose of the medicine. The final flush given into a central line should end with positive pressure. Heparin can be instilled into central lines following the final flush if prescribed. Re-apply the bandage, change if soiled and make sure the patient is comfortable Central line dressing should not remain in place longer than 7 days and should be changed if the integrity of the dressing is compromised. Once the injection has been administered place all sharp items into sharps container. Other waste should be placed into the appropriate plastic bags. Ensure the patient is able to recognise complications and who to contact for advice. Patients should have their temperature recorded daily prior to antibiotic administration. Record the administration on the prescription chart and enter the visit in the patients nursing notes. Amend the care plan if any changes occur which affect the treatment and/or care of the patient.

change and the medicine is not infused too quickly. To prevent infection by only using the giving set once To prevent medicine incompatibility occurring in the line To flush any remaining medicine away from the cannula and to prevent reflux of blood occurring at the end of the central line Heparin reduces bacterial colonisation To minimise the risk of contamination of the insertion site and reduce the risk of dislodging the cannula To prevent infection

To promote infection control measures

To detect early signs of complications and ensure the therapy continues as planned. To detect early signs of systemic infection from the central line and monitor efficacy of treatment To maintain accurate records, provide a point of reference in the event of any queries and prevent duplication of treatment

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Appendix 3

DRUG CALCULATIONS

To calculate the amount of medicine to give from a solution: Dose to be given Strength available Or What you want What youve got Example: If a patient is prescribed 200mg of a medicine that comes as 250mg in 5ml the calculation will be: 200 250 x 5ml = 4ml x What its in x Volume of Solution

To calculate the flow rate of an infusion in drops per minute: Flow rate (drops/min) = Volume of solution (mls) x Number of drops per ml Duration of infusion (mins) A standard administration set delivers 20 drops per ml (The number of drops per ml may vary with different manufacturers refer to packaging) Example: To administer 100mls over 30 minutes the calculation would be: 100(mls) x 20 (drops) 30 (mins) = 66.6 drops per minute

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Phlebitis Score Policy Statement All patients with an intravenous access device in place must have the IV site checked at least daily for signs of infusion phlebitis. The subsequent score and action(s) taken (if any) must be documented. The cannula site must also be observed: When bolus injections are administered IV flow rates are checked or altered When solution containers are changed The incidence of infusion phlebitis varies, the following Good Practice Points may assist in reducing the incidence of infusion phlebitis. Observe cannula site at least daily Secure cannula with a proven intravenous dressing Replace loose, contaminated dressings Cannula must be inserted away from joints whenever possible Aseptic technique must be followed Consider re-siting the cannula every 72-96 hours Plan and document continuing care Use the smallest gauge cannula most suitable for the patients needs Replace the cannula at the first indication of infusion phlebitis (Stage 2 on the VIP Score)
SITE APPEARS HEALTHY No signs of phlebitis

Appendix 4

0 1 2 3

OBSERVE CANNULA
Possibly the first signs of phlebitis

ONE of the following is evident: Slight pain near IV site OR Slight redness near IV site
TWO of the following are evident: Pain at IV site Erythema Swelling

OBSERVE CANNULA

Early stage of phlebitis RESITE CANNULA

All of the following signs are evident: Pain along path of the cannula Erythema Induration

Medium stage of phlebitis RESITE CANNULA CONSIDER TREATMENT

ALL of the following signs are evident and extensive Pain along path of the cannula Erythema Induration Palpable venous cord ALL of the following signs are evident and extensive Pain along path of the cannula Erythema Induration Palpable venous cord & pyrexia

Advanced stage phlebitis or start of thrombophlebitis CONSIDER TREATMENT RESITE CANNULA Advanced stage Thrombophlebitis INITIATE TREATMENT RESITE CANNULA

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Appendix 5 REFERRAL CHECKLIST FOR INTRAVENOUS ANTIBIOTICS IN THE COMMUNITY SECTION 1 INITIAL REFERRAL SECTION 1 TO BE COMPLETED FOR PATIENTS IN AREA OR REFER TO DISCHARGE LIAISON NURSE FOR PATIENTS OUT OF AREA PATIENT LOCATION Is the patient registered with a GP in North Somerset PCT? Yes / No If yes, refer to RRRT to complete Section 1 & 3 and referring doctor to complete Section 2 If no, refer patient to Discharge Liaison Nurse Referred to: Signature: Date: PATIENT DETAILS Name: GP: Date of Birth: Hospital No: Address: Address: Telephone No: Mobile No: Next of Kin: Relationship: Address: Telephone No: District Nurse: Based at:

Contact No: Contact Nos: Allergies (Patients that have suffered a previous anaphylactic reaction must not be accepted for IV antibiotics in the community): DOCTORS DETAILS Referring Doctor: Date of Referral: Telephone No: Bleep No: Address / Ward: Expected Date of Discharge:

Consultant: HOSPITAL ADMISSION DETAILS Date of Admission: Reason for Admission: Details of Current Admission: Reason for Referral: Current Medication: Relevant Past Medical History: Referral Checklist Page 1 of 4

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REFERRAL CHECKLIST FOR INTRAVENOUS ANTIBIOTICS IN THE COMMUNITY SECTION 1 (Cont.) Patient Name: Date of Birth: Yes No

The Patient: Medically stable and well enough for discharge Any significant abnormalities in blood results eg. renal function (if yes, see blood monitoring in Section 2) Fully informed and given patient information leaflet and consents to home intravenous treatment Is cognitively impaired? Can understand and comply with treatment regime (eg. elevation of limb, time off work for resting, compliance with regime) Has support from family or carer (the family/carer agrees that they will take the patient to the ED at Weston for re-cannulation, if the nurse fails to recannulate). Has adequate venous access Home Setting: Has access to a telephone Has running water and electricity in house Has no other known problems with home environment The Medicine: Cannot be administered by any other route Manageable in the community setting (eg. Bolus or Infusion time no more than 30 minutes longer infusions may be negotiated) Is prescribed for a licensed indication (if no, confirm reason for use) Treatment is not expected to last longer than two weeks (if longer than 2 weeks a PICC line may be required) Has no special monitoring or safety requirements Primary Medical Health Care: The patients GP has been advised of the intravenous antibiotic treatment plan, medical responsibility has been confirmed and the details have been faxed to the respective GP practice (date time by) Patient Accepted (continue with Section 2) Yes / No

Patient Declined/Deferred: (please give reason and any follow up required)

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REFERRAL CHECKLIST FOR INTRAVENOUS ANTIBIOTICS IN THE COMMUNITY SECTION 2 TO BE COMPLETED BY REFERRING DOCTOR AND FAXED TO RELEVANT NURSING TEAM (RRRT FAX: 01275 546566) Patient Name: Date of Birth: TREATMENT Intravenous antibiotics to be Administered: Date and Time Antibiotics Commenced: Date of Review of Treatment if needed: Expected Date of Completion of Treatment: BLOOD MONITORING Is Blood Monitoring Required? Who will review the results?
Type: Complications with line/poor venous access: Yes No If yes, consider insertion of PICC line

Yes

No

If yes, what blood monitoring is required and how often? Where will the results be reviewed? Date of Insertion: Comments:

IV ACCESS

ANAPHYLAXIS RISK ASSESSMENT Patients that have suffered a previous anaphylactic reaction must not be accepted for IV antibiotics in the community Known Allergies: If the patient has had a previous allergic reaction, what type of reaction was it?

Is there any cross sensitivity between the medicine to be administered and the substance that caused a previous reaction? Has the patient had the prescribed antibiotic before (orally or intravenously)? How many doses of the current regime have been administered? Is the patient taking tricyclic antidepressants, monoamine oxidase inhibitors (MAOI), or noncardioselective beta blockers? If yes, then a half dose of Adrenaline is needed due to interaction (see Anaphylaxis protocol) Is the patient on any medication that could interact adversely with the IV antibiotic? Are there any additional specific precautions to note e.g. warfarin therapy, renal failure, impaired liver function? PRESCRIBERS DETAILS Referring Doctor to be Contacted for Advice: Contact Nos: Doctors Signature: Print:

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REFERRAL CHECKLIST FOR INTRAVENOUS ANTIBIOTICS IN THE COMMUNITY SECTION 3 TO BE COMPLETED BY RRRT PRIOR TO DISCHARGE AFTER RECEIVING SECTION 2 PRESCRIPTION FROM REFERRING DOCTOR Patient Name : Date of Birth: Yes No

The Patient: Allergy status known and anaphylaxis risk assessment completed Has received information and instruction about the cannula/line and what to do if there are any problems Has received verbal and written information about the medication regime Understands how to obtain help and support in an emergency Has a review date if required The Setting: Adequate numbers of trained nurses available (within RRRT and /or community nursing team) If blood monitoring required, agree who will take blood, review and advise on results Appropriate equipment is available (provided by community staff) Anaphylaxis PGD and Adrenaline injection 1 in 1000 is available at all times when administering IV antibiotics The Medicines: The prescriber has provided clear, precise written instructions regarding the medicine, dose, route, duration and frequency of administration (faxed copy of Discharge prescription/TTO/eDischarge or written prescription provided by GP). A copy of the referral checklist for intravenous antibiotics in the community has been forwarded to RRRT and/or community nursing team Diluents and flushes are prescribed Manufacturers instructions for reconstitution are available (pharmacy, medicine package or www.emc.medicines.org.uk) Patient information leaflet available (as above) Individual Drug Monographs for medication and diluent are available (request from discharging department, hospital or community pharmacy) Full supply of medicine, diluent and flushes available with full instructions on labels (from hospital pharmacy, community pharmacy, GP or RRRT stock) Care Plan:

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Appendix 6 Patient Information Leaflet for Intravenous Antibiotics

Intravenous Therapy in the Community

If you require this information in another format or if English is not your first language and you would like a translation please contact PALS on 01275 546770. All details were correct at the time this document was printed.

Patient Information Leaflet

Author: Rapid Response Team Date of Implementation: January 2009 Review Date: January 2011

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Information for Patients with a Cannula It has been decided that you may start/continue your intravenous (into a vein) therapy at home. In order for us to give you your treatment into a vein, it is necessary for you to have a small hollow plastic tube inserted into your hand/arm. This plastic tube is called a cannula. The cannula goes through your skin into a vein where it stays for up to three days to allow us to give your medicines directly into your blood stream. You will have a waterproof dressing over the cannula to keep it in place. As the cannula is sitting in a vein, there is a risk of bleeding if the cannula becomes accidentally dislodged. There is no need to panic if this does happen. Usually any bleeding will stop within a few minutes of applying pressure to the site. If your cannula comes out Apply pressure to the area with gauze or a tissue Keep this pressure by pressing with your hand until the bleeding has completely stopped Once the bleeding has stopped, apply a plaster or dressing If the bleeding has stopped, there is no need to call anyone Contact the nursing team administering your intravenous therapy as soon as possible to arrange for a cannula to be reinserted If the bleeding does not stop, keep applying pressure to the area, lift your affected arm above your head and telephone the nursing team

It may be necessary for you to attend the emergency department for this to be reinserted if the nurse is unable to do this in the community. If the cannula site is painful or inflamed (red and swollen) Contact the nursing team giving your intravenous therapy as soon as possible to arrange for the cannula to be moved. Additional Information Regular blood monitoring may be needed throughout your treatment; the nurse will be able to do this for you. Hairy skin may stop the cannula from being properly secured. Hair may have to be removed from the area before the cannula is inserted. An allergic reaction (anaphylaxis or hypersensitivity) is a rare complication of intravenous therapy. The nurse treating you has been trained to deal with this reaction. The nurse will stay with you for up to 15 minutes after administration of your medicine to monitor your condition and check for any side effects. Contact Details The nursing team can be contacted on 01275 546592 (08:30-17:00) or 01934 627138 (17:00-08:30) Any further questions? Please ask the nurse administering your intravenous therapy

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