Policy Number / LCH-25

This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form.

Part A – Information about this Document

Policy Name / Intravenous Antibiotic Policy
Policy Type / Board Approved (Trust-wide) ☐ / Trust-wide ☐ / Divisional / Team / Locality ☒
Action / No
Change / ☐ / Minor
Change / ☐ / Major
Change / ☐ / New
Policy / ☒ / No Longer
Needed / ☐
Approval / As Mersey Care’s Executive Director / Lead for this document, I confirm that this document:
a)complies with the latest statutory / regulatory requirements,
b)complies with the latest national guidance,
c)has been updated to reflect the requirements of clinicians and officers, and
d)has been updated to reflect any local contractual requirements
Signature: / Date:

Part B – Changes in Terminology(used with ‘Minor Change’, ‘Major Changes’ & ‘New Policy’ only)

Terminology used in this Document / New terminology when reading this Document

Part C – Additional Information Added(to be used with ‘Major Changes’ only)

Section /
Paragraph No / Outline of the information that has been added to this document – especially where it may change what staff need to do

Part D – Rationale(to be used with ‘New Policy’ & ‘Policy No Longer Required’ only)

Please explain why this new document needs to be adopted or why this document is no longer required

Part E – Oversight Arrangements (to be used with ‘New Policy’ only)

Accountable Director
Recommending Committee
Approving Committee
Next Review Date

LCH Policy Alignment Process – Form 1
SUPPORTING STATEMENTS

This document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS
All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including:
  • being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child / adult;
  • knowing how to deal with a disclosure or allegation of child / adult abuse;
  • undertaking training as appropriate for their role and keeping themselves updated;
  • being aware of and following the local policies and procedures they need to follow if they have a child / adult concern;
  • ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust’s safeguarding team;
  • participating in multi-agency working to safeguard the child or adult (if appropriate to your role);
  • ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;
  • ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTS
Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.
The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.
Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.
Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy

Policy for the Management and Administration of Intravenous Antibiotics by staff working for Liverpool Community Health NHS Trust

POLICY NUMBER 25


Title

/ Policy for the Management and Administration of Intravenous Antibiotics
Policy reference
number /
25
Aim and purpose of policy / To provide the Trust with a policy on the safe management and administration of IV Antibiotics services in the community
Author / Medicines Management Pharmacist
Type / New Policy

Reviewed Policy

Review date / January 2020
Person/group accountable for review / Community Intravenous Therapy Team
Type of evidence base used / C/Evidence which includes published and or unpublished studies and expert opinion

Issue date

/ January 2018
Authorised by Clinical Standards /
24th January 2018
Equality Assessment undertaken / Yes
19/01/2018
No

Version Control

Version Number: / 5
Ratified by: / Clinical Standards Group
Date of Approval: / 24th January 2018
Name of originator/author: / IV Therapy Team
Name of reviewer: / Hillary Smith
Approving Body / Committee: / Clinical Standards Group
Date issued: / January 2018
Review date: / January 2020
Target audience: / Staff employed by Liverpool Community Health NHS Trust
Name of Lead Director / Managing Director: / Director of Nursing
Changes / Alterations Made To Previous Version: / Change in formatting
Inclusion of new referral form
Inclusion of new prescription sheet
Inclusion of cellulitis care pathway when referred by hospital or GP when prescribing responsibility remains with the referrer
Process detail expanded

Contents Page

  1. Introduction
/ 5
  1. Purpose
/ 5
2.1 Scope / 5
  1. Definitions
/ 6
  1. Duties & Responsibilities
/ 8
  1. Policy
/ 8
5.1 Eligibility Criteria / 8
5.2 Consent / 9
5.3 Medical Authorisation / 9
5.4 Responsibilities / 10
5.5 Procedures / 11
5.6 Methods of intravenous drug administration / 11
5.7 Routes of Administration / 11
5.8 Equipment / 12
5.9 General Process / 12
5.10 Adverse Incidents / 13
  1. Training Requirements
/ 14
  1. Implementation, Monitoring & Review
/ 14
  1. Linked Information
/ 15
  1. References
/ 16
Appendices
Appendix 1 Antibiotic Formulary / 17
Appendix 2 Community IV Antibiotics referral Form / 19
Appendix 3 Community IV Prescription Sheet / 20
Appendix 4 Peripheral IV Cannula Visual Inspection of Intravenous Access Devices (VIIAD) charts / 21
Appendix 5 Visual Inspection Phlebitis Score (VIP) / 23
Appendix 6NPSA Heparin Alert / 24
  1. Introduction

The administration of IV medication by nurses has become more widespread in recent years. The practice has now become part of the core skills for general nursing practice, allowing a holistic approach to total patient care. With today’s emphasis on community care and patient empowerment, there is a growing need for community nurses to take on this role in order to facilitate home care. This policy is designed to give clarity around themanagement and administration of intravenous antibiotics in the community.

Administration of IV Antibiotics carries potential risks and should only be given if the benefits outweigh these risks. Stringent systems need to be in place to ensure that the correct product is given to the correct patient at the correct time and that any adverse reactions are dealt with promptly and efficiently.

This policy will cover the referral into the service, including responsibilities and clinical procedures relating to the administration of anti-infective intravenous therapy by appropriately trained staff.

2. Purpose

This policy willdirect the safe management and administration of IV Antibiotics in the community by appropriately trained registered nurses employed by LCH.

By providing an Intravenous Antibiotic Servicein the community it will reduce the necessity for hospital admission or prolonged hospital admission.

The advice contained within this policy is drawn from the latest research based evidence and has been agreed by a number of professionals.

Liverpool Community Health is committed to ensuring that all staff are trained and equipped to perform their role effectively.

2.1Scope

This document describes the clinical procedures for patients who are suitable to have Intravenous Antibiotics in the community by the Community Intravenous Therapy Team, and District Nurses. It may be carried out in patients’ homes or in NHS Health Clinics.

This policy applies to all registered nurses employed by Liverpool Community Health NHS Trust who have been trained and maintain their competencies in IV therapies and peripheral cannulation.

3. Definitions

Word/phrase/abbreviation / Meaning
AHUT / Aintree Hospital University Trust
Bolus / A large dose of a drug administered by rapid injection
Cannula / A hollow tube designed for insertion into a body cavity such as a blood vessel. The tube contains a sharp pointed solid core (trocar) which facilitates its insertion and is removed when the cannula is in place
Cannulation / The procedure of inserting a cannula into the vein
CINS / Community Intravenous Nursing Services
Community / Refers to the patient’s own home and also includes residential and nursing homes and community health centres
CPR / Cardio pulmonary Resuscitation
Extravasation / The leakage and spread of blood or fluid from vessels into the surrounding tissues, which follows injury, burns, inflammation and allergy
GP / General Practitioner
Infiltration / The abnormal entry of a substance into a cell, tissue or organ
Infusion / The slow injection of a substance, usually into a vein
Intermittent / Occurring occasionally or at regular or irregular intervals; periodic
Intravenous (IV) / Refers to administering the medication directly into the vein
Intravenous Midline / Refers to the device that provides vascular access in a larger peripheral vein but without entering the central venous circulation. It is usually inserted in a vein near the elbow and a catheter threaded through the vein in the upper arm. Leaderflex® is the trade name for the product
NEWS / National Early Warning Score
OPAT / Outpatient Parenteral Antibiotic Therapy
Parenteral / Administered by any way other than through the mouth
Peripheral / Referring to or towards outer surrounding surfaces
Phlebitis / Inflammation of the wall of the vein
PICC / Peripheral Intravenous Central Catheter. It is a device that provides vascular access into the central venous circulation.
Positive pressure technique / The positive pressure technique for flush involves clamping the line while still flushing the last bit of saline so that there is little or no blood reflux into the catheter upon disconnection of the syringe
Skin Tunnelled Catheter / Refers to a device that is inserted into one of the large central veins. It is a long-term catheter that is tunnelled under the skin to the desired site
SPC / Single Point of Contact
TPR + BP / Temperature, Pulse, Respiration and Blood Pressure relating to clinical condition
VIIAD / Visual Inspection Intravenous Access Devices

4.Duties and Responsibilities

Liverpool Community Health NHS Trust is responsible for

  • Ensuring that appropriate training is in place so that qualified nurses can fulfil their duties in accordance with this policy
  • Providing the Hepatitis B vaccine free of charge to all employees at risk of exposure to blood and body fluids in the course of their duties

Senior Managers and Team Leaders are responsible for

  • The operational implementation of this policy and associated procedures
  • Ensuring that appropriately trained staff are used to deliver the services (this includes Bank staff and Agency staff)
  • Ensuring that a planned audit cycle is in place

Registered health practitioners are responsible for

  • Securing the Hepatitis B vaccine series
  • Observing standard infection control precautions in particular hand hygiene, wearing of protective clothing and safe handling and disposal of sharps
  • Complying with the requirements of all relevant NHSLiverpool Community Health policies applicable to their area of operation
  • Reporting all potential adverse incidents in line with Liverpool Community Health Risk Management Policy (including serious untoward incidents)

5. Policy

5.1 Eligibility criteria

The clinician responsible for care must use their professional judgement to determine the appropriateness of the individual patient for IV therapy based on the following criteria:

  • The medical condition of the patient is suitable and stable ( HR = 50-110; RR 9-20; BP systolic = 90-200; temp between 37-39C; alert; orientated) and does not require complex nursing/ medical interventions or care
  • The psychological condition of the patient is suitable and stable and does not require complex nursing/ medical interventions or care
  • The following conditions may be treated in the community:
  • Bronchiectasis
  • Endocarditis
  • Hepatic abscess
  • HIV
  • Intravenous access device infections
  • MRSA infections
  • Osteomyelitis
  • Prosthetic joint infections
  • Septic arthritis/ bursitis
  • Soft tissue infections/ cellulitis
  • Urinary tract infections (UTI)
  • Wound infections

This list is not exhaustive or exclusive

  • Satisfactory (minimal risks associated with hygiene, pets or children) home conditions exist, including access to a landline telephone or a mobile connection
  • The type of antibiotic must be suitable for administration in the community It is the duty of the prescribing clinician/GP/Consultant to liaise with a Consultant Microbiologist/Outpatient Parenteral Antibiotic Lead to establish a treatment plan that is suitable for community management (see Appendix 1 for list of antibiotics) i.e. once or twice daily administration ONLY.
  • Consideration is given to the arrangements for first and subsequent doses, where anaphylaxis is considered to be a high risk
  • The patient/carer/family understands the implications of the treatment and how to recognise and report potential complications relating to treatment

Patients meeting eligibility criteria will need to be referred into the service using the Community IV Antibiotics Referral Form (see Appendix 2)

5.2 Consent

Informed consent must be obtained before any procedure is undertaken. Every adult has the right to make their own decisions and must be assumed to have capacity to do so unless it is proved otherwise.

5.3 Medical authorisation

Written medical authorisation should be obtained and include:

  • Date of authorisation
  • Patients name and date of birth
  • Antibiotic name
  • Dose and rate of administration
  • Duration of treatment
  • Signature of medical officer
  • Special directions
  • Allergy status

The above constitutes a Patient Specific Direction and the prescribing responsibility and supply of the antibiotic (and diluents required to administer and flush) remains with the authoriser, either secondary care or the patient’s GP(see Appendix 3 for the Community IV Prescription Sheet).

The patients will remain under the care of the Consultant once discharged from secondary care. If patient is referred by GP then the GP will retain medical responsibility.

If the patient is to be treated for cellulitis (excluding facial or peri-orbital) under a PGD when referred into the service by the GP, please refer to Policy93 Administration of Intravenous Antibiotics via a Patient Group Direction (PGD) in the Community for Patients with Cellulitis who are referred by Liverpool General Practitioners (GP).

5.4 Responsibilities

Medical Microbiology/Outpatient Parenteral Antibiotic Lead will be responsible for:

  • Recommending relevant antibiotics in relation to the infection
  • Available for 24 hr advice

Consultant will be responsible for:

  • The medical care of the patient prior to discharge
  • In the case of hospital discharges referred to the community, the consultant will retain medical responsibility and will assess and prescribe IV antibiotics (supply of complete course to be given on discharge)

General Practitioner will be responsible for:

  • Any unrelated medical conditions
  • In the case of GP referrals, the GP will retain medical responsibility and will assess and prescribe IV antibiotics
  • Liaising with Medical Microbiology if required

The Intravenous Therapy Team will be responsible for:

  • Taking referrals from secondary care trusts across Merseyside and the North West for Liverpool patients
  • To advise regarding suitability for treatment in the community
  • To provide advice and information to patients concerning the condition, treatment and follow up including emergency telephone numbers
  • To care for intravenous access devices in accordance with NHS Liverpool Community Health clinical guidance documents and corporate policies
  • To cannulate or insert midline venous access devices
  • To alert medical staff to any reaction to the antibiotics and report according to the yellow card scheme
  • To be a point of contact for professional advice, support and training for patientsand District Nurses
  • To collate the results of blood tests and alert the patient’s Consultant/GP/Outpatient Parenteral Antibiotic lead of any significant event.
  • To maintain accurate records, reviewing care pathway (variances) of each patient receiving care from the Community Intravenous Therapy Team and District Nurses
  • Enter clinical information contemporaneously on EMIS and hand held patient records
  • To audit any infections or problems relating to vascular access devices

5.5 Procedures

  • Peripheral cannulation – see Policy 102
  • Insertion of Midline devices – this is generally done in hospital and should be in place before patient is accepted. However the IV Team is trained to insert using an ultrasound to aid placement
  • Administration of intravenous medication via bolus - see CINS policy
  • Administration of intravenous medication via intermittent infusion – see CINS policy
  • Administration of intravenous medication via continuous infusion – see CINS policy
  • Management of phlebitis and infiltration
  • Management of extravasation

5.6 Methods of intravenous drug administration

  • A bolus dose of medication
  • An intermittent infusion of medication
  • A continuous infusion of medication – this will not be accepted for community and needs to be referred back to secondary care

5.7 Routes of administration