Suturing Policy for Nurses in Emergency Departments

Transcription

1 This is an official Northern Trust policy and should not be edited in any way Suturing Policy for Nurses in Emergency Departments Reference Number: NHSCT/12/545 Target audience: Registered Nurses Sources of advice in relation to this document: Carolyn Kerr, Deputy Director of Nursing Replaces (if appropriate): N/A Type of Document: Directorate Specific Approved by: Policy, Standards and Guidelines Committee Date Approved: 1 June 2012 Date Issued by Policy Unit: 6 June 2012 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves

2 Suturing Policy for Nurses in Emergency Departments December

3 Contents Page No. 1. Introduction / Purpose 3 2. Roles and Responsibilities 3 3. Linked Policies 3 4. Competence Education and Training Equality, Human Rights and DDA 5 7. Alternative Formats 5 8. Sources of Advice in Relation to this 5 Document Appendix 1 Suturing Protocol 6-7 Infiltration and Suturing of the Skin 8 Achievement of Competence in Infiltration 9 and Suturing of the Skin 2

4 1. Introduction / Purpose Northern Health and Social Care Trust Suturing Policy for Nurses in Emergency Departments, NHSCT This policy provides a framework within which registered nurses may undertake suturing within the Emergency Department (ED), Northern Health and Social Care Trust (NHSCT). Nurses are frequently involved in suturing simple lacerations of the skin that have resulted from soft tissue injuries. Whilst most of these injuries are of a minor nature, significant problems can occur if the management is incorrect or inadequate (Richardson, 2003). 2. Roles and Responsibilities Suturing of a minor wound may be undertaken by a registered nurse who: (i) (ii) (iii) (iv) is willing to undertake this additional role, has the full support of his / her line manager, has undertaken training in wound care and suturing, has been assessed as competent to infiltrate and suture a wound using the correct technique. 3. Linked Policies The policy is based upon, and must be used in conjunction with, the following: The Code : Standards of Conduct, Performance and Ethics, NMC (2008) The Royal Marsden Hospital (2004) Manual of Clinical Nursing Procedures (6 th Edition). Hand Hygiene Policy NHSCT/11/447 (October 2011) Handbook for Emergency Department Doctors (August 2011) 4. Competence 4.1 Wounds will be sutured after a thorough initial assessment and examination by the nurse to ensure that there is no damage to other important structures including tendons, arteries and nerves and that there is no foreign body present (See Appendix 1). 3

5 4.2 The following wounds will not be sutured routinely by the nurse unless he / she has undertaken further training and is competent: Facial wounds and lips. Mouth wounds requiring buccal block. Extensive tissue damage as indicated within the protocol as risk factors where nurse would not suture. 4.3 When patient assessment and examination has been conducted and none of the risk factors have been identified, the nurse will then proceed to clean, infiltrate and suture the wound as per Treatment Protocol in Appendix The nurse will apply local anaesthetic to the wound. Lignocaine with Adrenaline must never be used. 1% or 2% Lignocaine Hydrochloride (plain) 10-20ml, as per Patient Group Directions (PGDs), should be used for simple wounds. The lowest dosage needed to provide anaesthesia should be administered. 4.5 The nurse will document the following information for all patients: Time of injury. Mode of injury. Anatomical site. Immunisation / tetanus status. Relevant past history such as diabetes, asthma, allergies. Relevant drug history e.g. steroids / warfarin. Rationale for suturing, consent, type of suture material, number of sutures inserted, suture set code, use of local anaesthesia under Patient Group Direction. Signature, name and date of nurse performing suturing intervention. Information and advice given to patient regarding care of the wound, arrangements for suture removal. 5. Education and Training 5.1 Training in suturing is provided by: Nursing Education and Development Consortium (NEDC) University of Ulster (UU) Minor Injuries Module University of Ulster (UU) Specialist Nursing Practice Nurse Practitioner Programme Assessment of practice is undertaken by a named assessor / mentor during a period of supervised practice. The named assessor / mentor will be an Emergency Medicine Doctor, Emergency Nurse Practitioner or Emergency Department Sister. 4

6 5.2 The theoretical instruction delivered by NEDC and UU includes: Legal and ethical issues. Local anaesthesia and infiltration techniques. Effects of Lignocaine. Wound assessment. Primary and secondary wound closure. Suture materials. Suturing techniques. Wound closure techniques eg. tissue glue, stapling of skin and suturing. Digital Nerve Block. 5.3 Following theoretical instruction the nurse will practice wound infiltration by local anaesthesia and suturing technique in the classroom setting. The nurse will then undertake wound assessment and examination, local anaesthetic infiltration and suturing in the clinical setting under the guidance of the named assessor / mentor. 5.4 NEDC - achievement of competence will be signed by the nurse and the assessor Emergency Nurse Practitioner, Emergency Medicine Doctor or Emergency Department Sister and filed by the Line Manager. UU assessment of competence is a component of the practice portfolio developed whilst completing the module / specialist practice programme. 5.5 Yearly evidence of competence will be provided at appraisal to the Line Manager professionally responsible. Examples of evidence could include examples such as photographic evidence (with patient consent), reflective practice entry in portfolio and / or copy of symphony notes / documentation. 6. Equality, Human Rights and DDA The policy is purely clinical/technical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. 7. Alternative Formats These documents can be made available on request on disc, larger font, Braille, audio cassette and in other minority languages to meet the needs of those who are not fluent in English. 8. Sources of Advice in Relation to this Document The policy author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. 5

7 Suturing Protocol Appendix 1 RISK FACTORS THE NURSE WOULD NOT NORMALLY SUTURE IF ANY RISK FACTORS PRESENT * Tendon Injury Facial Injury Scarring Deep Tissue involvement Skin Loss Circulatory Compromise Diabetes Peripheral Vascular Disease * Some wounds with these risk factors may require temporary closure before onward referral e.g. to plastics/ortho. This is permitted. Open Fracture Bites Devitalised Tissue Puncture Wounds Hand Injury Dirty Wounds Wound Infection Tetanus Gun Shot Wounds ASSESSMENT Decontaminate hands as per Trust Hand Hygiene Policy. Risk assess need for disposable apron to prevent contamination of uniform by blood/body fluid. Put on disposable gloves. Conduct a thorough history, mechanism of injury and examination of the patient. Within the examination ensure wound is assessed for depth, length, site. Wound assessment undertaken and wound is less than 6 hours old. No foreign body or risk factors present etc. Assess Tetanus status and risk of infection and administer booster vaccine +/- Human Immunoglobulin under PGD if Tetanus prone wound. See BNF Section 14.4 for up to date information. No risk factors present. EXAMINATION Inspect, palpate surrounding structures to ensure full range of movement and no deep tendon / muscle / other tissue involvement. Sensation - blunt / sharp, touch, temperature and 2 point discrimination. Distal Pulses present. 6

8 TREATMENT PROTOCOL Clean wound using aseptic non-touch technique (ANTT) or if aseptic touch technique (ATT), sterile gloves must be worn - irrigation with normal saline / tap water as appropriate. Infiltrate wound area with 1% Lignocaine / 2% Lignocaine as per PGD. DO NOT EXCEED DOSAGE PERMITTED. The lowest dosage needed to provide anaesthesia should be administered. Adult: A maximum dosage of 20ml of 1% in increments of 2-5ml. A maximum of 10ml of 2% in increments of 2ml. Maximum dose is 3mg/kg. Each 1ml of 1% lignocaine contains 10mg of lignocaine, each 1ml of 2% lignocaine contains 20mg lignocaine.) Child: Usual dosage should not exceed 3mg / kg. (Each 1ml of 1% lignocaine contains 10mg of lignocaine, each 1ml of 2% lignocaine contains 20mg lignocaine). Suture wound area ensuring minimum number of sutures use nonabsorbable suture material only. Remove PPE, dispose of in clinical waste bin and decontaminate hands as per Trust Hand Hygiene Policy. Document care provided including the type suture material, grade of suture material used, how many sutures, suture code / CSSD code of instruments. Advice re removal of sutures as per Ethicon guidelines, when to return etc. NB If patient consent is not obtained then the patient must not be sutured. The nurse must have previous proof of competence in the technique of suturing. DISCHARGE ARRANGEMENTS Ensure patient is safe to be discharged or appropriate transfer arrangements made. The individual practitioner must justify all deviations from protocols and ensure that the rationale is clearly documented. 7

9 INFILTRATION AND SUTURING OF THE SKIN Assessment Criteria (NEDC) Name of Nurse: Staff No.: NMC PIN: Criteria Infiltration Suturing Comments 1 Explain choice of equipment assembled for carrying out procedure. (e.g. local anaesthetic drug / choice of suture material) 2 Obtain Consent for Procedure 3 Apply Standard precautions for infection control and other relevant health and safety measures 4 Explain the importance of checking drug to be used prior to administration and suture material / needle selected for use 5 Demonstrate safe administration of local anaesthetic drug 6 Wound will be sutured after a thorough and initial examination to ensure that there is no damage to other important structures including tendons, arteries, nerves and there is no foreign body present 7 Assess the patients physical and emotional condition prior to, during and after procedure 8 Adhere to the relevant Trust policies 9 Advice to patient re: any complications which may arise / care of wound / when to return / removal of sutures 10 Complete relevant documentation The Assessor will sign and date when the criteria has been successfully achieved during the assessment. The nurse must demonstrate her/his ability to safely and effectively undertake all of the criteria. Reassessment If competence is not achieved, reassessment will occur after a further 2 weeks of supervised practice. Further failure to meet the criteria for success will result in discussion between the Line Manager and Lead Nurse to decide upon further action. June

10 Achievement of Competence in: INFILTRATION AND SUTURING OF THE SKIN Name of Nurse: Ward/Work Base: The above nurse has attended an education programme held by NEDC, North & West Title/Date of Programme: Signature of NEDC Teacher: The education programme has been followed by a period of observation and supervised practice of the procedure(s) outlined below, and COMPETENCE HAS BEEN ASSESSED BY: Signature of Assessor: Date: Assessment Component(s) Infiltration of the skin Suturing of the skin Criteria for Success (delete as appropriate) Achieved / Not Achieved Achieved / Not Achieved STATEMENT OF COMPETENCE I am competent in carrying out procedures, as indicated, and agree to undertake such in accordance with relevant Trust Policies / Guidelines. Name of Nurse (Print): Signature: Date: The assessor will be a registered nurse or other professional who is competent in this procedure. Supervised practice may be provided by the assessor or delegated to other staff who are competent in this procedure. The assessment should normally be successfully completed within 8 weeks of attendance at the educational programme. This completed form is to be retained by the Line Manger in the training records. The assessment booklet and copy of this form should be retained in the personal portfolio of learning. June