Intravenous Therapy Workbook. For Cheshire and Merseyside NHS North West. Intravenous Access Care and Maintenance in Hospital and Home

Transcription

1 Intravenous Therapy Workbook For Cheshire and Merseyside NHS North West Intravenous Access Care and Maintenance in Hospital and Home Name: Clinical area: Hospital / Clinic: Trust / PCT Developed by Collaborative Intravenous Nursing Service (CINS) Version 9.1 Adult September 2009

2 Intravenous Access Care and Maintenance in Hospital and Home The aim of this programme is to develop a uniform approach towards training and assessment for IV access, care and maintenance therefore developing a standardised approach to practice and reducing the need for repeated assessment when practitioners move between health care organisations. While this workbook may initially appear intimidating, on closer inspection you will notice that it consists of a lot of reference material to aid you in your future practice. By completing this workbook and the programme of learning you will gain a solid foundation of knowledge and have a personal record of your skill expansion to aid you in your career development. Good Luck CINS Group Acknowledgements Substantial sections of this workbook have been developed by the following on behalf of the CINS group Mid Cheshire Hospital Trust The Royal Liverpool and Broadgreen University Hospitals NHS Trust Liverpool Primary Care Trust Special thanks also to all those within and outside of the CINS group who have contributed their time and effort to reviewing this workbook. The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 3

3 Table of Content Page Introduction to workbook and assessment strategy 2 Introduction to Intravenous therapy Legal, professional and ethical issues Anatomy and physiology Vascular access devices Medical infusion devices best practice guidelines Drug calculations Pharmacology and pharmacotherapeutics related to reconstitution and administration of IV medication Local and systemic complications Infection control issues Home Intravenous Therapy Summery References and further reading Appendices 90 Annotated careplan for peripheral cannula care 91 Clinical Competency Frameworks& documentation 94 KSF dimensions and levels 103 Peripheral Cannula 105 Central venous catheters 115 Totally Implanted Venous Access Devices (TIVAD) 127 Disconnecting Ambulatory Chemotherapy form Central Venous Access Devices 131 Competency Checklist and Statement of Intent 135 The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 1

4 INTRODUCTION TO WORKBOOK AND ASSESSMENT STRATEGY This intravenous (IV) access workbook has been created to assist practitioners to become competent and confident in the safe administration of IV medication It has been developed to complement the IV training day held at your local organisation and support you in your practice. The Collaborative Intravenous Nursing Service (CINS) project has produced these educational resources in order to support the guidelines for best practice, ensure uniformity of approach and set a high standard of care in IV therapy. All practitioners have a responsibility to deliver care based on current evidence, best practice and, where applicable, validated research when it is available. It is recommended that practitioners managing IV therapy will have undergone theoretical and practical training (RCN 2005). This workbook contains theoretical elements of the course. It is important that you read, reflect and perform the required exercises to help you better understand the concepts which will be developed and tested on the study day. Please bring the completed workbook and any remaining queries with you to the study day. It is imperative that you collect this workbook at least 2 weeks prior to the study day so that you can complete this pre-course material. Failure to collect the workbook will cancel your place in the course. In order to meet the recommended training (NPSA 2003, NICE 2003, RCN 2005) this pack will include: Legal, professional and ethical issues Anatomy and physiology Vascular access devices advantages, disadvantages & care Medical infusion devices best practice guidelines Possible complications risk management / Health and Safety Drug preparation and administration Calculations Home Intravenous therapy The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 2

5 Learning Outcomes It is hoped that by completing all the elements in this book and the theoretical and practical assessments that you will meet the following learning outcomes: Discuss the importance of legal and professional issues Analyse the principles of relevant anatomy and physiology for IV therapy e.g fluid and electrolyte balance Identify the indications for Intravenous drug / fluid administration Analyse the range of IV access devices suitable for IV therapy Analyse possible risks of IV therapy and take appropriate measures to limit them Identify the infection control measures that need to be instigated when undertaking IV therapy Demonstrate safe and effective practice when preparing, administering and managing IV therapy in accordance with CINS guidelines Calculate drug dosages correctly Demonstrate competence in relation to standards in the CINS guidelines and Trust policy To achieve competence in the skills of IV therapy the candidate must: Successfully complete both the theoretical and practical assessments Keep up to date with any change in practice Seek an update session from practice educators/skills lab if the skill is not carried out in 6 months The practical elements of the course are: Safe management of vascular access devices Preparation and administration of IV medications via different vascular access devices Use of most common infusion devices for IV therapy The following are the underpinning knowledge, psychomotor and affective competencies you need to achieve to be deemed competent and safe in the administration of IV medications: The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 3

6 Demonstrate the ability to use and validate the correctness of the prescription sheet. Demonstrate knowledge on the therapeutic use of medicines to be administered including normal dosage, side effects, precautions and contraindications. Demonstrate the ability to prepare and use appropriate equipment. Undertake the administration of IV medications following the 5 rights (5R s) in medication administration. Ensure that patients are informed and that they understand the reason for the medication in relation to the plan of care. Accept any limitations in knowledge and skills and takes measures to remedy them. Make good and proper use of local and national clinical guidelines on IV administration of medications and identify how to access further information Demonstrate the ability to use and care for venous access devices. Demonstrate compliance with standard precautions in the control and prevention of infection. Identify clinical and safety risks and takes actions to avoid potential complications. Demonstrate knowledge of medical devices best practice guidelines and uses the devices correctly. Demonstrate professional behaviour in accordance with the NMC Code (2008) IV Therapy and the NMC To practice competently you must possess the knowledge, skills and abilities required for lawful, safe and effective practice without direct supervision and acknowledge the limitations of your professional competence (NMC, 2008). In addition, the NMC (2008) states that the administration of medicines is not solely a mechanical task to be performed in strict compliance with the written prescription of a medical practitioner; it requires thought and the exercise of professional judgement. In order to develop and assess this, it is important to have validated competency in clinical judgement and practice. This workbook will help to provide the knowledge needed to underpin this professional clinical judgement. The explanation and diagrams The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 4

7 on the next few pages are intended to provide you with further guidance on the assessment processes. Becoming Competent in IV Therapy and in 5 Easy Steps Step 1 Get support from your manager Ensure that your manager would like you to learn this skill. It s hoped that this will be done at your individual performance review / appraisal where both you and your manager will have had time to reflect upon those skills and experiences you have acquired and those that you need to develop for your role. Upon completion of the learning programme your manager will be required to sign the competency checklist to demonstrate their support for you in undertaking this skill and that it is needed in developing you for your job. Step 2 Getting help to learn If you haven t done so already book yourself on a IV therapy training course. You will also need to identify a suitable practice supervisor within your work area who can guide and support you in acquiring the skill. You may find you will need more than one practice supervisor in-order to have some one present when the skill needs to be performed. The person you choose must meet the following criteria; Be competent in the skill of IV therapy for which you are being assessed Be familiar and practice in accordance with the CINS guidelines Have practised the skill for at least 6months on a regular basis within the Trust Hold a relevant teaching and assessing qualification eg; City & Guilds, ENB998, Mentorship in Clinical Practice Step 3 Undertake the learning programme Next you need to complete the Reflective practice contained within this learning package prior to attending the training course. Failure to do this may lead to your The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 5

8 place being cancelled. The study day will consist of an assessment of skills using simulated scenarios and post course theoretical exam. When you pass these assessments you can progress to supervised practice. You only need to be supervised in the IV clinical competencies you will actually use in your place of work. So for example if you don t disconnect chemotherapy treatment you do not need to complete this element. Note though that you will not be competent in a skill if you have not done supervised practice on it, even if you learnt about it on the study day! Supervised practice must be completed within 3 months. These should be logged on the Supervised practice assessment sheet You need a minimum of 3 supervised practices but the number supervisions may vary between individuals and work areas so you may need more. Spare forms can be obtained from the training department. When you feel confident with the procedure contact a member of the learning & development team or specialist nurse practitioner to come and assess you. They will assess you using the final assessment of practice record sheet. When they sign you off as competent complete the competency checklist (making sure to tick the boxes of the competencies have been assessed in) and make 3 copies; Copy 1 To be sent to the skills lab upon receipt you will be issued with a certificate. Copy 2 To be held by your manager as a record of competency Copy 3 To be retained by you for your professional portfolio and KSF Only when you receive a certificate will you then be able to practise the skill unsupervised. The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 6

9 Step 4 Independent practice Ensure you have accessed, read and understood your health care organisation s guidelines and policies relating to IV therapy, the CINS guidelines and any specific guidelines that have been adopted for your area. It is up to you to maintain your clinical competency. Don t lose all the effort you put into the learning the skill. Continue to update your knowledge and keep practising. Step 5 Seeking advice Don t be frightened to ask for help if you need it. If you have any questions contact a member of your learning and development team and they should be able to help you overcome any issues you may have. More details regarding the assessment process can be found under the clinical competency framework in the appendix The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 7

10 Training pathway for registered practitioners in the extended role of IV medication administration Newly qualified nurses signed off for single nurse drug administration Nominated by line manager for IV therapy training Book place with local training department Collect workbook 2 weeks prior to course date and complete Attend course (will include skills assessment using simulated scenarios on use of venous access devices, use of infusion devices, reconstitution of drugs ) Post course written test (theoretical assessment) Pass Pt 1: Drug Calculations score of 100% Pt 2: MCQ score of 80% Pt 3: Prescribing errors score of 80% Fail written test Re-take written test within 2 weeks Work- based supervised practice with a qualified assessor No Fail written test Remedial session within 1 week Undertake final assessment of practice. Meets required standard? Yes No 3 rd Fail? Yes Retake written test within 2 weeks Fail written test Sign off Send competency checklist and statement of intent to; Copy 1 - skills lab Copy 2 line manager Copy 3 For your professional portfolio Referred to line manager. Trust Capability Policy or KSF review will apply. The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 8

11 Training pathway for registered nurses with previous experience in IV medication administration Evidence of IV training and has practiced skill in last 6 months? Yes No Trained according to CINS guidelines? Meet with PEF / CST to discuss previous experience Yes No No Limited experience? Collect workbook and complete within 2 weeks Yes Retrain Sit written test Pass Drug calculations Pass mark 100% MCQ Pass mark 80% Identify errors on drug chart Pass mark 80% Fail written test Retake within 2 weeks Book a drop in session for clinical skills session in the lab (1 hour) Will include skills assessment including simulated scenarios on use of venous access devices, use of infusion devices and reconstitution of drugs. No Fail Remedial session within 1 week Undertake final assessment of practice. Meets required standard? Yes No 3 rd Fail? Yes Retake within 2 weeks Fail Sign off Send competency checklist and statement of intent to; Copy 1 Learning & Development Copy 2 Line manager Copy 3 For your professional portfolio Refer to line manager. Trust capability policy / KSF appraisal will apply The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 9

12 INTRODUCTION TO INTRAVENOUS THERAPY IV therapy and haemodynamic monitoring via vascular access devices e.g. central lines, is commonplace in clinical practice. Use of the IV route for fluids or medication is a decision made by the prescribing practitioner, based upon patient condition. If the intravenous route is required, account should be taken of how long the treatment is intended to last, whether the drugs / infusates are vesicant, how frequently and what volumes are to be infused (RCN 2005). Many of these patients are distributed across both hospital and community settings. IV therapy presents a potential risk to patient safety, with associated risks varying from minor complications to death. The number of patients who require IV therapy is increasing, because more patients are being recognised as acutely ill and also because of changes in prescribing patterns. It is important therefore to ensure that best practice is evidence based and that those involved in the management of IV therapy have sufficient knowledge, skills and competence within their professional scope of practice to optimise care. Advantages and Disadvantages of the Intravenous Route. The risks and costs associated with the IV route should be considered before a drug is administered intravenously. If the oral route is available and therapeutically practical, it should be used. Subcutaneous, intramuscular, transdermal, enteral, rectal, buccal and sublingual routes may offer advantages in some situations. The intravenous route should be considered for the following reasons: 1. Facilitates a rapid, predictable response providing an immediate therapeutic effect 2. Allows administration of fluid and drugs when other routes are unavailable. The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 10

13 3. Affords 100% bioavailability. If drugs are administered orally, not all the dose may be absorbed from the gastrointestinal tract; some may even be destroyed in the gut. 100% of the administered dose of an injection or infusion enters the circulation. 4. Some drugs are not active orally e.g. heparin, insulin and naloxone can only be administered parenterally. 5. Less painful than IM, less trauma particularly if cachexic 6. More acceptable to patients than the rectal route. 7. To achieve constant plasma levels and allow fine control over the rate administration of drugs. Prolonged action can be provided by administering a dilute infusion intermittently or over a prolonged period of time. However the intravenous route also presents the following disadvantages. 1. Time o Time taken for administration or potential for reduced mobility of patient 2. Infection risk o Every time the skin is pierced, the potential to introduce micro-organisms exists. In addition, infection can be introduced through the bag or giving set. Bags made on the ward have a higher risk of contamination and patients who are frail or immunocompromised may be at higher risk of infection. 3. Stability and compatibility problems o Once a drug is reconstituted, its rate of breakdown increases rapidly. The presence of other drugs or fluids in the same bag, syringe, or line may result in compatibility problems. 4. Thrombophlebitis and embolism risks The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 11

14 o Most drugs are irritant to the veins, but some, for example clarithromycin, are especially so. Some drugs must be administered through an in-line filter to reduce particles such as infusions of phenytoin. 5. Toxicity o Some drugs may cause toxicity if adequate therapeutic drug monitoring (TDM) is not in place to check levels e.g. aminophylline, gentamicin. 6. Adverse effects o Some drugs given intravenously can cause adverse effects not normally associated with the drug especially if not used according to manufacturer s instructions e.g. vancomycin can cause "red man" syndrome and furosemide can cause deafness if administered too quickly. 7. Fluid balance problems o A patient receiving several intravenous doses may also receive substantial volumes of fluid. This may be clinically important in fluid restricted and paediatric patients. 8. Hypersensitivity o This is also a problem with other routes but may develop faster or more aggressively following an intravenous injection. Anaphylaxis may develop following penicillin or cephalosporin administration. This can happen after any number of doses. 9. Speed shock o Insufficient control may lead to speed shock from too rapid a rise in serum concentration of the drug or circulatory overload. 10. Extravasation and infiltration risks o The potential for patient discomfort from the IV access device. This is most commonly caused by a poorly sited or inserted cannula. Any drug with a too high or low osmolality or ph may also cause this problem, e.g. aciclovir The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 12

15 11. Cost o Drug- injections are more expensive than oral medication. E.g. ciprofloxacin - 16p per 250 mg tablet. 22 for 200mg injection. In a similar manner, a 500mg twice daily regime of clarithromycin costs for the drug alone before bags or CIVAS costs, much more expensive than oral erythromycin. (British Medical Association & the Royal Pharmaceutical Society of Great Britain, 2007). o Staff time - even if CIVAS bags are prepared in pharmacy, there is still a staff cost which must be borne by the Trust. o Equipment - needles, syringes, bags, lines etc. 12. Inability to recall the drug, reversal agents may not exist. 13. Psychological considerations o Altered body image, especially with central venous access devices & needle phobia. The CINS guidelines and supplementary care plans have been developed as an evidence based guide to minimise the potential disadvantages and risk of complications. The guidelines should be read in conjunction with the workbook and competency framework. Before commencing IV therapy, it is important that the professional is aware of the potential risks and how to minimise them, their professional and legal responsibilities. The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 13

16 1. LEGAL, PROFESSIONAL AND ETHICAL ISSUES Professional guidance in care delivery Healthcare professionals have a duty of care to provide safe and competent care to their patients and clients. In addition to this the Nursing and Midwifery Council [NMC] Code (2008) states that you must provide a high standard of practice and care at all times by undertaking the following: Use the best available evidence You must deliver care based on the best available evidence or best practice You must ensure any advice you give is evidence based if you are suggesting healthcare products or services You must ensure that the use of complementary or alternative therapies is safe and in the best interests of those in your care Keep your skills and knowledge up to date You must have the knowledge and skills for safe and effective practice when working without direct supervision You must recognise and work within the limits of your competence You must keep your knowledge and skills up to date throughout your working life You must take part in appropriate learning and practice activities that maintain and develop your competence and performance Keep clear and accurate records You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been. You must complete records as soon as possible after an event has occurred You must not tamper with original records in any way You must ensure any entries you make in someone's paper records are clearly and legibly signed, dated and timed The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 14

17 The workbook is a resource to use to protect both professional and public interests. The law and accountability in relation to IV drug administration The law requires that medicines be given to the right person, in the correct form, using the correct dose and via the correct route. It is essential that administration practice be informed both in relation to the law and each area of accountability: The legal framework protects patients from the harmful effects of medicines whilst allowing them to benefit from their therapeutic properties by drawing together four separate areas of accountability. 1. To the public, via criminal law 2. To the patient, via civil law 3. To the employer, via contractual law 4. To the profession, via the regulating professional body Criminal law: Usually seeks to establish guilt and determine punishment and will follow if a criminal act has taken place e.g. The Beverly Allitt case. Civil law: May be pursued by an individual or relative if negligence is implicated in the death or injury of a patient. Civil law usually seeks to establish accountability and award damages. Contractual law: Based upon practitioners contract of employment, and the terms within it. Failure to comply with terms and conditions of contract may result in disciplinary action against the employee. Professional Accountability: Through registration with the professional regulating body. Following successful prosecution of a civil or criminal law suit the professional body will review possible misconduct charges and any action, which should be taken. The NMC has produced standards on your responsibilities for the safe administration of medication. In Standards for medicine management the NMC (2008) states; In exercising your professional accountability during administration of IV therapy in the best interests of your patients, you must: The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 15

18 be certain of the identity of the patient to whom the medicine is to be administered. check that the patient is not allergic to the medicine before administering it. You must know the therapeutic uses of the medicine to be administered, its normal dosage, side effects, precautions and contra-indications. You must be aware of the patient s plan of care (care plan/pathway) You must check that the prescription or the label on medicine dispensed is clearly written and unambiguous. You must check the expiry date (where it exists) of the medicine to be administered. You must have considered the dosage, weight where appropriate, method of administration, route and timing. You must administer or withhold in the context of the patient s condition (e.g. digoxin not usually to be given if pulse below 60) and co-existing therapies e.g. physiotherapy. You must contact the prescriber or another authorised prescriber without delay where contra-indications to the prescribed medicine are discovered, where the patient develops a reaction to the medicine, or where assessment of the patient indicates that the medicine is no longer suitable (See Standard 25). You must make a clear, accurate and immediate record of all medicine administered, intentionally withheld or refused by the patient, ensuring the signature is clear and legible; it is also your responsibility to ensure that a record is made when delegating the task of administering medicine. In addition: Where medication is not given the reason for not doing so must be recorded. NMC (2008) The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 16

19 Legal requirements in relation to transfusion of blood products Blood Transfusion: European Directive (2002/98/EC) and the UK Blood Safety regulations 2005 came into force in November Vein- to-vein traceability of all blood products shall be maintained for the Trust to be compliant with this law. The transfusion of blood and blood products remains a highly effective and potentially life saving treatment for many patients. However, blood is a living tissue and it s transfusion, from one individual to another, is not without risk. One of the most common is the potential for human error that may then lead to the transfusion of incorrect blood products (Higgins, 2000). The decision to transfuse a patient with blood or blood products should only be considered following careful examination of the patient, the patient s condition and the patient s blood results i.e. full blood count. The doctor should take careful consideration and gain the patients verbal consent where possible before requesting blood or blood products. Any blood transfusion incidents shall be reported to the Transfusion Practitioner or the Blood Transfusion laboratory, to be reported to the appropriate authorities. Responsibilities: Collection of Blood Products (Providing they have been previously shown how): Registered nurse, Healthcare Assistant, Operating Department Practitioner or Student Nurse. 1 st Checker: RGN/M, ODP, Medic 2 nd Checker: RGN/M, ODP, 2 nd / 3 rd Year Student Please contact the Transfusion Practitioner for more details or training in relation to Trust policy. Vicarious Liability When a practitioner works for an employer within the policies, procedures and guidelines laid down by that employer, the practitioner will be covered by the Trust via vicarious liability. Should the employee act outside of these guidelines / protocols then they are liable themselves. If Mr A is receiving IV therapy the practitioners involved The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 17

20 have a duty of care to provide that therapy to a reasonable standard. See example below; Case Study Example If Mr A is receiving IV therapy:- During the administration of an IV drug, he complains of pain. The nurse stops the administration of both the drug and the IV fluids, reassesses the venous access removes the device and arranges for another to be inserted. Mr A wants to sue because of his painful arm. If documented at the time, subsequent inquiry will demonstrate that there was no breach in the duty of care because the practitioner took appropriate action as soon as the pain was known (Scales 1996). Although the subject of Law seems daunting, it is essential to have an awareness of the implications for practice. If any patient or relative is dissatisfied with his/her care, they can sue for negligence. For this action to be successful, there are three main criteria, which must be established: A duty of care must be proven between the health authority or individual professional and patient A breach in the duty of care must be proven There must be evidence of damage caused by that breach. This may be physical, psychological or financial. You must keep clear records of drugs that you have given or withheld, the time administered and document any deviations. Well-written records do not simply convey information but they provide evidence of your actions and can protect you from liability. It is your responsibility when administering medication to be aware of all areas of accountability and that these are met. It is your responsibility to ensure that the patient has taken medication given by you to them. The CINS group hereby assert their right to the works here in accordance with the data protection act 1988 CINS workbook draft 9.1 (adult) 18