document

INTRAVENOUS THERAPY GUIDELINES

Responsible Directorate:

Patient Care & Professions

Responsible Director:

Sheila Dilks

Date Approved: 27 January 2009

Committee: Governance Committee

NICE GUIDANCE Once NICE guidance is published, health professionals are expected to take it fully into account when

exercising their clinical judgment. However, NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in

consultation with the patient and/or their guardian or carer.

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Version Control Document Title: Intravenous Therapy Guidelines

Document number: 1

Author: Joanne Crewe

Contributors: Louise Hodgson

Version: 1

Date of Production: September 2008

Review date: September 2010

Postholder responsible for

revision:

Louise Hodgson

Primary Circulation List:

Web address:

Restrictions:

Standard for Better Health Map Domain: Safety, Cost Effectiveness, Governance

Core Standard Reference: C1,C3, C4, C5, C7, C9, C11, C136

Performance Indicators: 1. All practitioners who administer IV Therapy are

appropriately trained 2. All patients who receive IV Therapy are treated in

accordance with these guidelines 3. Documentation is complete for each intervention 4. Medicines are safely and securely prescribed,

prepared and administered and monitored accurately and in accordance with these guidelines

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Section CONTENTS Page

1. Introduction

5

2. Associated Policies and Procedures

5

3. Aims and objectives 5

4. Ethical and legal Considerations scope of guidelines 6

5. Accountability and responsibility for delivering intravenous therapy 6

6. Choosing the IV route 7

7. Methods of administration 7

8. Equipment 7

9. Procedure 8

10. Preparation of IV Drugs – common elements 9

11. Preparation of IV Drugs – individual elements 10

11.1 Single-dose ampoule (solution) 11

11.2 Single-dose ampoule (powder) 12

11.3 Multi-dose vial (solution) 12

11.4 Multi-dose vial (powder) 13

12. Care of the patient undergoing IV Therapy 14

13. Administration of Direct Intermittent injection (Bolus Injection) 15

14. Hazards of intravenous therapy 16

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14.1 Extravasations 16

14.2 Drugs capable of causing tissue necrosis 16

14.3 Signs and symptoms 16

14.2 Anaphylaxis 17

14.5 Clinical presentation 17

14.6 Recommendation for management 17

15. Outcomes 17

16. Audit process 18

17. Equality Impact Assessment 18

18. Knowledge, skills and competencies 18

18.1 Education and training 19

19. References 20

20. Bibliography 21

Appendices

A Key Stakeholders consulted/involved in the

development of the policy/procedure

22

B Equality Impact Assessment Tool 22

C Visual Infusion Phlebitis Score 23

D Cannula Care Plan 24

E NPSA Risk assessment tool for the preparation and administration of injectable medicines in clinical areas

26

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Policy Statement

NHS Kirklees is committed to implementing National Policy and Guidance. 1. Introduction Intravenous (IV) therapy is defined as the administration of fluids or drugs, or both, into the general circulation through a venepuncture (Mosby 1990). The reasons for choosing the IV route for a given therapy have grown in an effort to meet the complex care requirements of patients. There is a need, however, to exercise caution when choosing the IV route because, despite the benefits in terms of patient management, these devices are associated with significant risks (Campbell 1997), of which infection remains the most common (Richardson, D. 2000). Administration of intravenous therapy is a technical, highly specialised field that requires clinical knowledge as well as expertise. Practitioners undertaking intravenous therapy, involving the preparation and administration of drugs must be competent to do so, having undergone appropriate and approved theoretical training and supervised practice. These guidelines relate to INTRAVENOUS drug administration only. They do not cover other ‘injectable’ treatments. Within these guidelines, unless otherwise stated, the term ‘practitioner’ relates to any person involved in intravenous therapy, from prescription to administration. 2. Associated policies & procedures This local guideline should be read in accordance with the following Trust policies, procedures and guidance:

• Kirklees Primary Care Trust’s Medicines Management Policies • Kirklees Primary Care Trust’s Infection Control Policies – De-contamination,

disinfectants and antiseptics, Hand Decontamination, Management of clinical sharps injuries and high risk fluids and Waste Management guidelines.

• RCN Standard for infusion therapy (2005) • The Royal Marsden Hospital – Manual of Clinical Procedures (2007) • Guidelines for the Administration of Medicines (NMC 2004) • Guidelines for Records and Record Keeping (NMC 2004) • Code of Professional Conduct (NMC 2004) • Incident Reporting Policy • Medical Devices • NPSA

3. Aims and objectives

3.1 Aims:

To ensure safe and effective administration of intravenous preparations to patients in their home environment.

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3.2 Objectives:

To identify the ethical and legal consideration relating to IV therapy To identify inter-relating policies and guidelines To outline the knowledge, skills and competence required to administer IV therapy To identify the reason for choosing the IV route To outline the principles and practice related to the prevention of cross infection of the

IV site. To identify the correct procedure for the preparation and administration of IV therapy. To outline complications of IV therapy. To determine the audit process to monitor good practice.

4. Scope of the local guideline

This guideline must be followed by all NHS Kirklees employees who are trained and competent in the administration of intravenous therapy. It must be followed by all staff who work for NHS Kirklees, including those on temporary or honorary contracts, bank staff and students. Breaches of this guideline may lead to disciplinary action being taken against the individual. Independent Contractors are responsible for the development and management of their own procedural documents and for ensuring compliance with relevant legislation and best practice guidelines. Independent Contractors are encouraged to seek advice and support as required. 5. Accountabilities and responsibility for delivering intravenous therapy All practitioners involved with the administration of IV therapy, from prescription to administration, have a responsibility for their practice, ensuring it is safe. Practitioners should be satisfied with their knowledge relating to: the risks associated with preparation of intravenous therapies in the clinical

environment, including:

Complexity and risk of preparation error Potential for microbial growth in the finished preparation Toxicity risks to the handler Chemical stability of the prepared drug

the intravenous therapies used: their effects, side effects, contraindications, normal

dosage and clinical appropriateness for their intended use. the correct rate of administration for the therapy the equipment used to administer IV therapy, including needle-free intra-vascular

connectors what actions to take in the event of an adverse incident, including an anaphylactic

reaction to the therapy (Dougherty & Lister 2004). the mechanisms for reporting faulty devices both within the Trust and to the Medical

Devices Agency. the location of Emergency/Anaphylaxis drugs and how to use them. Where newly introduced Injectable medicines are prepared and / or administered in

clinical areas, the NPSA risk assessment tool will be used to assess risk (see appendix E) to identify high risk practice and take actions to reduce these risks if identified.

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6. Choosing the intravenous route The main reasons for using the intravenous route are:

Fluid and electrolyte replacement. Transfusion therapy. Intravenous drug therapy. (Workman 1999)

Before intravenous therapy is considered, the patient’s general condition must be assessed with regard to the reason for intravenous therapy administration, and the advantages and disadvantages to the patient of the therapy. The advantages can be summarised as:

Ability to have more accurate control over the administration rate. Immediate therapeutic effect. May be appropriate when the oral route is contra-indicated, e.g. when resting the gut. May be more appropriate than other routes, e.g. intramuscular or subcutaneous

injection.

The disadvantages can be summarised as:

Inability to recall the drug or fluid and potentially reverse the action of it. Insufficient control over an infusion may lead to speed shock or circulatory overload. Greater potential for adverse reactions The patient is put at risk of microbial contamination. Potential vascular irritation, e.g. chemical phlebitis. Drug/fluid incompatibilities and/or interactions. Usually more expensive and takes longer to administer. (Dougherty & Lister 2004)

Intravenous therapy should not be commenced or maintained on a patient where another more suitable and/or equally effective route is available. 7. Methods of administration

Direct intermittent injection (bolus injection)

The administration of an IV drug or drugs into a vascular access device. The time taken varies depending on the drug given (Weinstein 2000, Pickstone 1999). It is generally used when:

• a maximum concentration of the drug is required to vital organs • the drug cannot be diluted for pharmacological or therapeutic reasons • a peak blood level is required and cannot be achieved using an infusion • The drug is safe to administer as a bolus • The drug cannot be given by other routes or is less effective via other routes

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Intermittent intravenous infusion The administration of intravenous fluids / electrolytes and / or medicines in volumes generally greater than 50ml via a vascular access device. Infusions may be small volume or large volume, and have varied rates of administration: This type of administration is generally used where:

• Patients require rehydration • The daily fluid requirements of the patient cannot be administered via other routes • Medicines may need to be diluted in larger volumes of fluid than could be

administered via a bolus injection. Continuous intravenous infusion As for intermittent intravenous infusion. Plus additionally:

• Blood levels need to be maintained at a constant level. 8. Equipment 8.1 Registered practitioners involved in the preparation and administration of IV therapy

should be trained and competent with ALL equipment they use in the process. It is the responsibility of the practitioner to check carefully the limitations of use of all equipment, as some disposables, e.g. needle-free intra-vascular connectors, have a maximum time of use.

8.2 To prepare a drug, for direct intermittent injection into a patient, or as an additive to

add to a bag of infusion solution, the following is required:

Patient’s prescription chart Single use or disposable receiver or tray Non sterile gloves Prescribed drug and diluent if required. Needles and syringe 2% chlorhexidine gluconate in 70% alcohol soaked swab, e.g. Chloraprep wipe Appropriate IV flushing solution, compatible with the IV drug to be administered

(normally Sodium Chloride 0.9% injection or Glucose 5% injection) 9. Procedure Sections 11 to 13 detail the procedure for preparation and administration of IV Therapy. Single Practitioner Administration

For IV medications, the use of a second registered practitioner is considered best practice in order to help avoid medication errors. However, in practical terms, where a drug administration is not complicated by calculations, it can be administered by a competent practitioner without the need for a second witness (except controlled drugs). The practitioner who prepares and administers the medication is solely responsible for the correctness of the whole procedure throughout the IV drug administration.

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Involvement of a second witness

Where a second registered practitioner is involved, it is his or her responsibility to INDEPENDENTLY check the process from prescription, appropriateness of the medication, preparation, patient identity, method of administration and the appropriate disposal of any surplus medicine. The second witnesses responsibility ends with the start of the IV drug administration. Where controlled drugs are being prepared / administered by injection / infusion, a witness should always be used. Both practitioners need to have an understanding of the drugs to be administered. The second witness must sign in the appropriate documents providing evidence of their role in the checking procedure. The use of calculators to determine the volume or quantity of medication should not act as a substitute for arithmetical knowledge and skill (NMC, 2004). Under no circumstances should any practitioner give an IV drug, which has been prepared and checked by other practitioners. The exception to this is a medication prepared under the direction of a pharmacist from a central intravenous additive service which is clearly labelled for that patient (NMC, 2004). 10. Preparation of IV Drugs – common elements

Action Rationale 1 Explain and discuss procedure with the patient, allowing

time to ask questions To obtain informed consent

2 All stages of the procedure should comply with the principles of minimising infection. For example: • Good hand washing technique if a sink is not available

hands can be decontaminated with an alcohol hand rub, ensuring a good technique is employed.

• Wear a clean plastic single use apron and non-sterile gloves (DOH 2001, ICNA 2003).

• Preparation should take place in a clean environment. (NOT near to a sink, waste bin or window) Munro, 2003).

• Ensuring the area for preparation is washed with soap and water or detergent wipe and allowed to dry, or a sterifield is used.

• Careful handling of the equipment to prevent contamination and maintain sterility, especially syringe luer-lock and slip connectors and injection needles (Non-touch technique).

To minimise the risks of infection To reduce the number of micro-organisms harmful to health To minimise risks to the practitioner

3 IV therapy should be prepared immediately prior to administration. Unused preparation should be discarded and NOT saved for later use. (NHS 2004)

To comply with current Trust Medicines Management Policy

4 Ensure the correctness of the prescription by confirming:

• Patient’s name, NHS number and date of birth (DOB) present

• Patient has no allergy or sensitivity to any of the constituents of the therapy

• Prescription is legible and complete with: • start date

To ensure the prescription is checked as correct and thus minimise the risk of error. To ensure the safe and effective administration of the drug To enable anticipation of toxicities

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5 Consider and/or check as appropriate: • compatibility of all constituents of the therapy. • stability of the infusion/mixture over the prescribed

time. • special directions for dilution, e.g. pH, optimum

concentration. • sensitivity to external factors such as light, heat. • Any anticipated allergic reaction. • Clinical appropriateness of the drug for its intended

use.

To ensure the IV therapy is suitable for the purpose and the duration of the therapy. To ensure correct compatibility with other drugs and diluents. Stability and safe storage of reconstituted drug must be considered. To maintain safety of patient

If there are any doubts about the above points firstly check the package insert – then consult the pharmacist.

6 Check the integrity and sterility of all equipment before assembly, and discard if not intact. Batch numbers and expiry dates must also be checked.

To prevent patients from receiving a contaminated drug

7 If necessary wear any appropriate protective clothing as required by Control of Substances Hazardous to Health (COSHH) regulations

8 Inspect any solutions for unnecessary cloudiness, crystallisation or particulate matter. If this is present do not use, inform pharmacy immediately or, if out of hours, as soon as possible the next working day.

To protect individuals from any harmful effect from product.

11. Preparation of IV Drugs – Individual elements

• date and time to be given • name, dose and route (and rate of infusion if by

infusion) • method of administration, e.g. bolus • signature of the prescriber • the IV therapy is due and has not been given • all constituents of the therapy, including diluents

and drugs match the prescription and are not expired

and the implications of these

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Sections 12.1 to 12.4 should be used in conjunction with Section 11 - COMMON ELEMENTS. Identify from the list below the type of drug preparation and continue with the relevant section:

13.1 Single-dose glass or plastic ampoule (solution) 13.2 Single-dose glass or plastic ampoule (powder) 13.3 Single dose or Multi-dose vial (solution) 13.4 Single dose or Multi-dose vial (powder)

There are certain other preparations of drugs for injection e.g. vials with a transfer needle. In these instances the practitioner should follow the manufacturers’ instructions. Suggested needles used in the reconstitution of IV drugs are:

23 or 25 gauge needle – used when glass ampoules are involved in the procedure or for venting vials and for drawing up mixed IV solutions . N.B. consideration should be given to the total amount of reconstituted drug to be given when deciding on which needle to use. For example, where a large volume of drug or diluent is drawn from multiple glass ampoules, a 19 gauge filter needle with 5-micron filter or filter straw is recommended. Suggested syringes for administration of IV drugs:

The appropriate size of syringe should be used for the task to be undertaken with consideration given to the need for accuracy of the dose to be administered and the possible risks associated with excessive pressure. For example, a routine flush of 5mls Sodium Chloride 0.9% solution, where accuracy is not paramount, would require a 10mls syringe to reduce amount of excessive pressure applied to the vein, whereas for Diazemuls 5mgs in 1ml, a 2mls syringe would be used for accuracy. .

Dougherty & Lister (2004)

11.1 Single-Dose Glass or Plastic Ampoule (Solution)

Action Rationale 1 Wash hands with soap and water or alcohol hand rub.

Wear a clean plastic single use apron and non-sterile gloves.

To minimise risk of contamination. To protect against contamination and hazardous substances.

2 Tap neck of the ampoule gently. To ensure all of the solution is at the bottom of the ampoule

3 Cover the neck of the ampoule with a sterile gauze swab and snap it open

To promote aseptic technique. To prevent contact with the drug which could lead to a sensitivity reaction.

4 Inspect the solution for glass fragments, if present then discard

To minimise the risk of injecting particulate matter into the patient.

5 Withdraw the required amount of solution using an appropriate needle and syringe, tilting the ampoule if necessary.

Reduces the risk of injecting foreign matter into the patient.

6 Withdraw plunger slightly, tap syringe to dislodge any air bubbles, withdraw plunger slightly again, then carefully expel excess air to leave only the prepared IV drug in the syringe

To prevent aerosol formation.

7 Depress the plunger to the desired volume to expel any To ensure that the correct amount

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excess drug from the syringe of drug is in the syringe. 8 Remove the needle and discard in the sharps container. To reduce risk of infection. To

reduce the risk of injury to the practitioner.

9 Protect the luer-lock or slip-connector of the syringe from contact with non-sterile equipment

To minimise the risk of contamination of preparation

The preparation is now ready for administration

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11.2 Single-Dose Glass or Plastic Ampoule (Powder)

Action Rationale 1 Wash hands with soap and water or alcohol hand rub.

Wear a clean plastic single use apron and non-sterile gloves.


2 Tap neck of ampoule gently. To ensure that any lodged powder falls to the bottom of the ampoule.

3 Cover the neck of the ampoule with a sterile swab and snap open.

To promote aseptic technique. To prevent contact with the drug which could lead to a sensitivity reaction.

4 Add a sufficient amount (or specific amount where clearly specified by the manufacturer) of the correct diluent carefully down the wall of the ampoule.

To ensure the powder is fully wet before agitation and is not released into the atmosphere.

5 Agitate the ampoule. To dissolve the drug.

6 Inspect the contents to detect any particulate matter or glass fragments. If present continue agitation or discard accordingly.

To minimise the risk of injecting foreign matter into the patient.

7 Withdraw the required amount of solution using an appropriate needle and syringe, tilting the ampoule if necessary.

Further reduces the risk of injecting foreign matter into the patient.


To prevent aerosol formation. To ensure that the correct amount of drug is in the syringe.

9 Depress the plunger to the desired volume to expel any excess drug from the syringe

To ensure that the correct amount of drug is in the syringe.

10 Remove the needle and discard in the sharps container.

To reduce risk of infection. To reduce the risk of injury to the practitioner.


To minimise the risk of contamination of the IV preparation


11.3 Single or Multi-Dose Vial (Solution / suspension)

Action Rationale 1 Wash hands with soap and water or alcohol hand

rub. Wear a clean plastic single use apron and non-sterile gloves (DOH 2001, ICNA 2003).


2 Remove any protective cap. Clean rubber cap with a sterile swab and let it dry.

To prevent bacterial contamination of the drug.

3 For suspensions, gently agitate the vial to re-suspend the suspension

To ensure uniform concentration of the suspension / drug.

4 At a 45 - 60º angle, insert a 23 or 25 gauge needle, bevel up, into the cap to vent the bottle. (Not to be done with multi-dose insulin vials)

To enable pressure equalisation and minimise coring.

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5 For solutions - Inspect the solution for unnecessary cloudiness, crystallisation or particulate matter. If this is present do not use, inform pharmacy immediately or, if out of hours, as soon as possible the next working day.

To prevent patients from receiving a contaminated or unstable drug. To prevent the injection of foreign matter into the patient.

6 Withdraw the required amount of the drug using an appropriate syringe and needle (inserted at an angle of 45º to 60º, bevel up), tilting the vial if necessary.

Further reduces risk of injecting foreign matter into patient, by minimising coring.






To reduce risk of infection. To reduce the risk of injury to the practitioner.




11.4 Single or Multi-Dose Vial (Powder)

Action Rationale 1 Wash hands with soap and water or alcohol hand

rub. Wear a clean plastic single use apron and non-sterile gloves (DOH 2001, ICNA 2003).


2 Remove any protective cap. Clean rubber cap with a sterile swab and let it dry.

To prevent bacterial contamination of the drug.

3 Clean rubber cap with a sterile swab and let it dry. To prevent bacterial contamination of the drug.

4 At a 45 - 60º angle, insert a 23 or 25 gauge needle, bevel up, into the cap to vent the bottle.

To enable pressure equalisation.

5 Using an appropriate syringe and needle (inserted at an angle of 45º to 60º, bevel up), add a sufficient amount if the correct diluent carefully down the wall of the vial (or a specific volume if clearly indicated by the manufacturer)

To ensure the powder is fully wet before agitation and is not released into the atmosphere.

6 Remove needle and syringe (not the venting needle)

7 Place a sterile topical swab over the venting needle and agitate to dissolve the powder.

To prevent contamination of the drug or atmosphere. To dissolve the drug. To prevent patients from receiving a contaminated or unstable drug.

8 Inspect the solution for unnecessary cloudiness, crystallisation or particulate matter. If this is present do not use, inform pharmacy immediately or, if out of hours, as soon as possible the next

To prevent the injection of foreign matter into the patient.

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working day. (if the prepared drug is a suspension, this does not apply)

9 Withdraw the required amount of the drug using an appropriate needle at an angle of 45º to 60º, tilting the vial if necessary.

Further reduces risk of injecting foreign matter into patient.






To reduce the risk of injury to the practitioner



The preparation is now ready for administration.

N.B. To detect particulate matter, such as unmixed powder or glass, a careful visual examination of the ampoule or vial should be undertaken prior to drawing up the prepared drug. N.B. small glass shards are not always visible to the naked eye, thus a filter needle is recommended. 12. Care of the patient undergoing intravenous therapy • The venepuncture site should be inspected at least once a day and/or on each drug

administration, for complications such as infiltration and/or any indication of infection, e.g. pain, redness or pyrexia, using the Visual Infusion Phlebitis Score (Workman 1999, Jackson 1998). If a problem occurs, the cannula should be removed. In practice, inspection will be at least at every drug administration.

• The cannula should be removed/replaced after 72 hours use to reduce the risks of

developing complications of use, e.g. phlebitis. • Documentation of all interventions, including inspection of the cannula site should be

clear, accurate, contemporaneous and complete on the appropriate section of the patient’s record.

13. Administration of Direct Intermittent injection (BOLUS INJECTION) Practitioners administering IV drugs into a needle-free intra-vascular connector should follow the manufacturers’ instructions relating to asepsis and maximum time of use.

Action Rationale 1 Wash hands with soap and water or alcohol

hand rub. Wear a clean plastic single use apron and non-sterile gloves.


2 Prepare the drug for injection in accordance with Sections 10 to 12

To ensure the process is in accord with the Medicines Management Policy

Ensure Adrenaline Shock Pack available To ensure management of anaphylaxis if required

3 Draw up compatible flush, either Sodium Chloride 0.9% injection or Glucose 5% solution:

• 10 mls if one IV drug is to be given • 20 mls if 2 or 3 IV drugs to be given

To ensure there is sufficient flushing solution for the IV drugs to be given.



5 Check that all necessary equipment is present and place in a single use receiver or tray.

To ensure all equipment is present for the procedure to run smoothly.

6 If in a Care Home setting confirm identity of patient with a member of staff.

To ensure correct drug is given to correct patient. To protect patient from harm.

6 Inspect site of peripheral vascular device. Document the Visual Infusion Phlebitis (VIP) score. (see Appendix C)

To detect any signs of inflammation, infiltration/extravasation etc. If present then take appropriate action.

7 Use an alcohol swab to clean the injection port of the vascular device or administration set and allow to dry

To minimise risk of contamination.

8 Administer bolus injection as prescribed and according to manufacturer’s instructions

To ensure correctness of the rate of administration

9 Observe the site of peripheral vascular device throughout injection.

10 Consult patient (if able) throughout the injection about any unusual sensations, pain etc.

To detect any complications at an early stage e.g. extravasation.

11 Observe site of cannula carefully

To detect any complications

12 Flush with suitable volume of compatible solution after each drug has been administered (see point 3).

To help prevent chemical incompatibility and blockages in the cannula and to help prevent chemical irritation and phlebitis

13 Discard waste in the appropriate containers, e.g. sharps in a sharps bin etc.

To reduce risk of injury and prevent re-use of equipment.

14 Complete patient’s record chart and other necessary documents in accordance with the Trust’s current guidelines and standards on documentation.

To maintain accurate records. To provide a point of reference in the event of any queries. To prevent duplication of treatment.

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14. Hazards of intravenous therapy

14.1 Extravasations These guidelines apply to non-cytotoxic drugs only. Extravasation is the inadvertent leakage of a vesicant (causing blistering) infusion fluid from a vein into the surrounding tissues. It usually occurs when a cannula punctures a vein wall, but may also be caused by chemical irritation and is a particular risk if the administration is near a joint, for example, the ante-cubital space. It is a major problem encountered by nursing staff with an estimated occurrence of one in five patients. (Clarke 1997, Dougherty & Lister 2004).

14.2 Drugs Capable of Causing Tissue Necrosis. Prior to administering vesicant drugs the practitioner should know which agents are capable of producing tissue necrosis. The following is a list of agents that are more commonly used: Acyclovir Digoxin Amphoteracin Ganciclovir Calcium chloride Phenytoin Calcium gluconate Potassium Chloride (>40 mmols) Cefotaxime Sodium bicarbonate Diazepam

14.3 Signs and symptoms

Extravasation should be suspected if: • The patient complains of burning, stinging pain or any other acute change at the

injection site. This should be distinguished from a feeling of cold, which may occur with some drugs.

• Induration (hardness), swelling or leakage occurs at the injection site. • Erythema of the skin occurs around the injection site (this may not occur immediately). • No blood return is obtained when the plunger of the syringe is pulled back, this may

indicate lack of patency and incorrect position of a device. If no other signs are present this alone should not be regarded as a non-patent vein, as a vein may not bleed back for a number of reasons and extravasation may occur even in the event of good blood return. Any change in blood flow needs further investigation.

• A resistance is felt on the plunger of the syringe when flushing / administering bolus drugs.

NB. One or more of the above may be present. If extravasation is suspected or

confirmed, do not administer further IV treatments and contact medical practitioner with responsibility for patient (GP or Hospital Consultant)

(Weinstein 2000)

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14.4 Anaphylaxis The term anaphylaxis is commonly used for hypersensitivity reactions where mild to serious symptoms and signs occur which, when related to IV therapy, can be fatal. Anaphylactoid reactions are similar, but do not depend upon hypersensitivity. For simplicity the term anaphylaxis will be used here for both types of reactions. 14.4.1 Clinical Presentation Clinical presentation is inconsistent and could include: • Angio-oedema • Urticaria • Dyspnoea • Hypotension. • Cardiovascular collapse - caused by vasodilatation and loss of plasma from the blood

compartment Some patients may die from acute irreversible asthma or laryngeal oedema with few more generalised manifestations. Other symptoms include: • Rhinitis • Conjunctivitis • Abdominal pain • Vomiting & diarrhoea • A sense of impending doom • Flushing or pallor Reactions may follow exposure to a variety of agents – with antibiotic drugs among the most common. The lack of any consistent clinical manifestation and a wide range of possible presentations may cause diagnostic difficulty. Guidelines for the management of shock from anaphylaxis must therefore take into account the inevitability of some diagnostic errors, with an emphasis on the need for safety of any recommended measures.

14.4.2 Recommendation for management Guidance can be found on the Trust’s Intranet web site under Clinical Policies. The following documents apply: • Resuscitation Policy • Management of Acute Anaphylaxis • Administration of adrenaline contained in Patient Group Directions for Administration of

Immunisations in Primary Care • Adrenaline should be available each time an IV administration takes place. 15. Outcomes All practitioners who have received appropriate training in the preparation and

administration of intravenous therapy are able to assess the need for the therapy. Intravenous therapy is performed by practitioners who have received training and are

competent in the procedure.

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A patient who receives intravenous therapy is cared for in accordance with these guidelines.

Documentation in the patient’s nursing record is complete for each intervention.

16. Audit process The success of the implementation of these guidelines should be measured by audit, approximately 18 months after their introduction and thereafter at 2 yearly intervals to inform the regular review process. Timescales may differ, depending on what is felt to be appropriate. Audit should be locally determined, based on the types of IV therapy used. 17. Equality Impact Assessment All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.” This obligation has been increased to include equality and human rights with regard to disability age and gender. The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices. This guidance was found to be compliant with this philosophy (see appendix B). 18. Knowledge, Skill and competence To establish uniform practice, to a standard acceptable to the Trust, appropriate competences have been identified. The knowledgeable Registered Practitioner must be able to demonstrate that she or he: - meets the standards set out in the Guidelines for the Administration of Medicines (NMC

2004) or equivalent. abides by the local guidelines for practice has an understanding of the substances used for therapeutic purposes; their action,

dose and side effects is able to calculate correctly the quantity of drug which is to be administered is able to identify when a particulates are present within injection solutions, and what

actions to take maintain asepsis ensures use of correct diluent/concentration is aware of the correct speed at which individual drugs should be administered (refer to

the current version of the British National Formulary (BNF)or package insert is able to safely and effectively administer intravenous injections, via a cannula or a

needle free intra-vascular connector. is aware of and able to recognise any adverse reactions that may occur has up to date resuscitation skills and knowledge, thereby able to take any necessary

action in the event of adverse reactions occurring. Has attended medicines management mandatory training every 2 years.

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18.1 Education and Training In order to achieve competence, theoretical and practical education and training will be needed. Practical education and training will be provided at in the clinical workplace by Registered Practitioners who have themselves demonstrated their own knowledge and competence in this area of practice. Final assessment of competence will be undertaken by a competent practitioner who holds the ENB 997/998 certificate, or equivalent knowledge, using documentation approved for the purpose.

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19. References Auty, B. Types of infusion pumps and their risks. British Journal of Intensive Care. Feb supplement: 11 – 16 Bravery, K, (1999).‘Paediatric intravenous therapy in practice’. In Dougherty, L and Lamb, J (eds). Intravenous therapy in nursing practice. Edinburgh: Churchill Livingstone, Chapter 15, 401–446. (III) Campbell, J. (1997) Intravenous cannulation: Potential Complications. Professional Nurse vol. 12 No 8, (supplement S10 – S13) Clarke, A. (1997) The Nursing Management of Intravenous Drug Therapy. British Journal of Nursing. Vol 6 (4) pages 201-206 Department of Health (2001) ‘Guidelines for preventing infections associated with insertion and maintenance of central venous catheters’. In Journal of hospital infection, 47 (supplement), S47– S67. Department of Health (2001) Reference Guide to Consent for Examination or Treatment Department of Health (1990) Patient Consent to Examination and Treatment Dougherty L and Lister S (2007) The Royal Marsden Hospital – Manual of Clinical Procedures 6th Edition Blackwell Publishing, Oxford Fuller A, Winn C. The management of peripheral IV lines. Professional Nurse, (1998) 13; 10: 675 – 678 Infection Control Nurses Association (1999) Glove usage guidelines. Edinburgh: ICNA. JACKSON A. A battle in vein: infusion phlebitis. Nursing Times, 1998 94; 4: 68 – 71 Mosby CV, Mosby’s Dictionary, (1990). Philadelphia: CV Mosby and Co. Munro MJ, Millar BW, Radley AS.(2003) A Risk Assessment of the Preparation of Parenteral Medicines in Clinical Areas Hospital Pharmacy July/August Vol 10 303 - 308 NHS Pharmaceutical Quality Assurance Committee (2004) Multiple Use of Injections 3rd edition Nursing and Midwifery Council (2004) Guidelines for the Administration of Medicines Nursing and Midwifery Council (2004) The Code of Professional Conduct Perucca, R, (2001) ‘Obtaining vascular access’. In Infusion therapy in clinical practice. (2nd ed.). Pennsylvania: WB Saunders, Chapter 20, 338–397. (III) Pickstone, M (1999) A Pocketbook for Safer IV Therapy. Medical Technology and Risk Series, Scitech. Richardson, D (2000) Tracking Catheters - Journal of Intravenous Nursing vol 3 (1) pages 35 – 37 WEINSTEIN S.M. (2000) Plumer’s Principles and Practice of Intravenous Therapy, Seventh edition. Lippincott Williams and Wilkins, Philadelphia

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20. Biography

Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform London: DH. HOSPITAL INFECTION CONTROL PRACTICES ADVISORY COMMITTEE PART II. Recommendations for the prevention of nosocomial intravascular device-related infections. American Journal of Infection Control, 1996; 24: 262 - 293. LUNDGREN A, CHRISTINA A, WAHREN L. Handling & control of peripheral intravenous lines. Journal of Advanced Nursing, 1998; 27: 897 – 904 Dougherty L and Lister S (2004) The Royal Marsden Hospital – Manual of Clinical Procedures 6th Edition Blackwell Publishing, Oxford Nursing and Midwifery Council (2004) Guidelines for Records and Record Keeping MOJGAN H S, Guide to Intravenous Drug Therapy Administration (1996) Guy’s, St Thomas’ and Lewisham hospitals Pickstone, M (1999) A Pocketbook for Safer IV Therapy. Medical Technology and Risk Series, Scitech. Power, L (1999) Boning up on IV Push The Canadian Nurse Nov 1999 Royal College of Nursing IV Therapy Forum (2003) Standards for infusion therapy Scales, K (1997) Practical and professional aspects of IV therapy Professional Nurse (supplement) vol 12. No 8 TERRY J, BARANOWSKI L, LONSWAY RA, HEDRICK C. Intravenous Therapy – Clinical Principles and Practice. Philadelphia PA, 1995 WB Saunders WEINSTEIN S.M. (2000) Plumer’s Principles and Practice of Intravenous Therapy, Seventh edition. Lippincott Williams and Wilkins, Philadelphia WILKINSON R. Nurses concerns about IV therapy. Nursing Standard, 1996 10 (35) 35 – 37

WORKMAN B. Peripheral Intravenous Therapy Management. Nursing Standard, 1999. 14; 4: 53 – 60

Appendix A

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A. Key stakeholders consulted/involved in the development of the policy/procedure

Stakeholders name and designation Key

Participant Yes/No

Feedback requested

Yes/No

Feedback accepted Yes/No

Louise Hodgson Yes Yes Yes P. Horner, Service Manager Intermediate Care No Yes Yes

Intermediate Care Teams No Yes Yes Lucianne Ricketts, Medicine Management Yes Yes Yes Neill McDonald, Medicine Management Yes Yes Yes Catherine Smyth, Professional Development Yes Yes Yes

B. Equality Impact Assessment Tool

Insert Name of Policy / Procedure

Yes/No Comments

1.

Does the policy/guidance affect one group less or more favourably than another on the basis of:

• Race No

• Ethnic origins (including gypsies and travellers) No

• Nationality No

• Gender No

• Culture No

• Religion or belief

• Sexual orientation including lesbian, gay and bisexual people

No

• Age No

• Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2.

Is there any evidence that some groups are affected differently?

3.

If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

No

4.

Is the impact of the policy/guidance likely to be negative?

No

5.

If so can the impact be avoided? _

6.

What alternatives are there to achieving the policy/guidance without the impact?

_

7.

Can we reduce the impact by taking different action?

_

Appendix C Visual Infusion Phlebitis Score

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 in the patient’s record. The cannula site must also be observed when bolus injections are administered, when IV flow rates are checked or altered and 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 • Aseptic technique must be followed • Secure cannula with a proven intravenous

dressing • Plan and document continuing care

• Replace loose, contaminated dressings • Use the smallest gauge cannula most suitable for the patients need

• Cannula must be inserted away from joints whenever possible

• Consider re-siting the cannula every 48 - 72 hours

• Replace the cannula at the first indication of infusion phlebitis (stage 2 on the VIP Score)

TANDARDS FOR INFUSION THERAPY

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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

ALL of the following are evident:

• Pain along path of cannula • Erythema • Induration

ALL of the following signs are evident and extensive:

• Pain along path of cannula • Erythema • Induration • Palpable venous cord • Pyrexia

ALL of the following signs are evident and extensive:

• Pain along path of cannula • Erythema • Induration • Palpable venous cord

IV site appears healthy

0

1

2

3

4

5

Jackson 1998

Advanced stage thrombophlebitis

INITIATE TREATMENT RESITE CANNULA

Advanced stage of phlebitis or the start of thrombophlebitis

RESITE CANNULA

CONSIDER TREATMENT

Medium stages of phlebitis

RESITE CANNULA CONSIDER TREATMENT

Early stages of phlebitis

RESITE CANNULA

Possibly first signs of phlebitis

OBSERVE CANNULA

No sign of phlebitis OBSERVE CANNULA

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APPENDIX D PATIENT CARE MANAGEMENT PLAN Name: ________________________ NHS No: __________________ DOB __________ PROBLEM: The patient has a peripheral intravenous cannula insitu NEED: To prevent infection/phlebitis NURSING ACTION:

♦ Collect all the equipment required. ♦ Select the correct cannula size for the purpose and length of the infusion. ♦ Explain the procedure to the patient and determine any previous difficulties, gain patients

consent. ♦ Ensure hands are decontaminated with soap and water or alcohol hand gel. ♦ Wear protective clothing i.e. clean gloves and apron. ♦ Position the patient and select the most appropriate site. ♦ Disinfect the skin prior to insertion with an alcohol-impregnated swab for a minimum of 30

seconds. Allow to air dry. Do not re-palpate the skin and/or vein prior to insertion. ♦ Ensure insertion is achieved using an aseptic technique. ♦ Secure the cannula with a sterile transparent semi permeable dressing. Do not routinely

change dressing only if soiled, wet or insecure ♦ Record the date and time of cannula insertion on the dressing and complete insertion record. ♦ Check the cannula for patency before each use. ♦ Check the cannula site prior to flushing/introducing bolus drugs or 12 hourly for the signs of

infection: - redness, heat, pain, inflammation, swelling, tracking and purulent drainage. Record the Visual Infusion Phlebitis (VIP) score in the patient’s Cannulation record. If VIP score is 2 or more, re-site cannula.

♦ Remove cannula within 72 hours of insertion. If it is considered necessary to leave the cannula in longer, document reasons why in the patient’s record.

♦ If any signs of infection are evident remove the cannula immediately regardless of the length of time the cannula has been in place

♦ Clean Injection ports with an alcohol impregnated swab before accessing the system/device. ♦ Flush the cannula with prescribed normal saline, or compatible flushing solution, after each use

or 12 hourly if cannula not in use. ♦ When caps are removed from the circuit, ensure they are replaced with a sterile luer-lock cap

following each use. ♦ Do not routinely attach accessories i.e. stopcocks, (3 way taps). Cannula Insertion Record Date and Time Inserted

Size of Cannula

Manufacturer of Cannula

Position of Cannula

Location of patient when inserted

Inserted by:

Date and Time of Removal

Removed By

Routine Observation Nursing Team to Complete Nursing Care:

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= Achieved (no further comments needed) X = Not achieved, action needed

Record any problems in communication section. If VIP score is 2 or more, re-site cannula

Date: Time:

I.V. access site observed for signs of infection/phlebitis (record VIP score)

Occlusive dressing dry and intact Cannula flushed with normal saline 12 hourly (or compatible flush)

REVIEW CARE AND SIGN OPPOSITE

Date: Time:


Occlusive dressing dry and intact Cannulae flushed with normal saline 12 hourly (or compatible flush)


Date: Time:


Occlusive dressing dry and intact Cannula flushed with normal saline 12 hourly (or compatible flush)


References: Guidelines for Preventing Intravascular Catheter Related Infections. Infection Control

Nurse Association. 2001

1. Carry out a risk assessment in all clinical areas where injectable medicines are prepared and administered

2. A pharmacist and a senior clinical practitioner from the area being assessed should carry out the risk assessment

3. Risk assessments should be conducted annually, and when new injectable products or practices are introduced

4. Risk assess local practice, i.e. how injectable medicines are prepared and administered (see proforma 1)

5. Risk assess individual injectable medicine products used in the clinical area (see proforma 2) – there are examples to assist with this

6. A summary of products with high and moderate risk assessments should be completed (see proforma 3)

7. Identify risk reduction methods to minimise these risks (see guidance)

8. Where possible, implement appropriate risk reduction methods

9. Re-assess high and moderate-risk practices and products, and record the new scores following the introduction of risk reduction methods (see proformas 1 and 3)

10. Identify any remaining high-risk products and practices for consideration by the Drugs and Therapeutics Committee (or equivalent) and, if these risks cannot be minimised, they should recorded in the organisation’s risk register

Risk assessment tool for the preparation and administration of injectable medicines in clinical areas

The risk assessment process

document

Documents

given therapy

hazards of intravenous

iv route

individual patient

drugs individual elements

multidose vial solution

singledose ampoule solution

multidose vial powder