St John Cymru-Wales Blood Pressure Measurement Standard Operating Procedure Date Approved: February 2015 Date Implemented: February 2015 Date of Review: February 2016 Version: 1.3 1
Document Control Version: 1.3 Title: Blood Pressure Measurement SOP SOP Category: Clinical / Operations Date Approved: February 2015 Date Implemented: February 2015 Supersedes: None Date of Review: February 2016 SOP Owner: SOP Approval: Healthcare Governance Committee Healthcare Governance Committee Supporting Documents Document Name: Medical Devices Policy Infection Prevention Control Policy Approved Equipment Guide On Duty Guide Version Date Author Comment 1.0 November 2012 Paramedic Advisor SOP Developed 1.1 January 2013 Paramedic Advisor Change of Product 1.2 February 2014 Paramedic Advisor Supplier Amendment 1.3 February 2015 Paramedic Advisor Review Date change of Supplier Information Blood Pressure Standard Operating Procedure Page 2
1. Introduction St. John Cymru Wales (hereafter referred to as St John) acknowledges the benefit of blood pressure (BP) measurement by approved, appropriately trained members to diagnose and monitor a wide range of clinical conditions. St John is also aware of the recent review into the reliability of the wide range of blood pressure devices and of the potential Health and Safety and Patient Safety impacts of mercury-based blood pressure devices, identified by the Medicines and Healthcare Regulatory Agency (MHRA), and will seek to limit these through the use of robust policies and procedures. 2. Purpose 3. Scope 2.1. St John requires that all parts of its activities and operations have an understanding of their responsibilities for BP Measurement. The purpose of this procedure is to: a) ensure compliance with all relevant legislation b) outline minimum training requirements for all personnel c) identify specific responsibilities d) provide all personnel with explicit guidance in the correct procedure for obtaining a BP, and appropriate calibration and maintenance of the equipment they hold in line with both Health & Safety and Control of Infection requirements 3.1. This procedure will apply to all personnel who have achieved the Enhanced First Aider or Patient or Emergency Transport Attendant qualification. Due to the potential for error and adverse events, BP monitoring will be restricted to the aforementioned skill levels and a thorough training and assessment package will be in place with annual recertification. Healthcare Professionals (HCPs) are reminded that national clinical guidelines should be followed at all times and that they are accountable to their own professional registering body. 4. Responsibilities 4.1. Healthcare Governance Committee The Healthcare Governance Committee is responsible for the development of this blood pressure measurement procedure and its review. It has overall control over this document and is responsible for regularly updating it to ensure this procedure reflects legislation and recognised best practice. The Clinical Advisors will be responsible for promoting best practice in BP measurement, including advice, support and guidance. Blood Pressure Standard Operating Procedure Page 3
Particular responsibilities include: a) Reporting and investigating adverse incidents b) Creating suitable training sessions which can be delivered to personnel c) Being available for clinical advice at all times of activity within St John d) Ensuring personnel are aware of their requirements under the scope of this procedure e) Being up-to-date on legislation pertaining to BP measurements County Staff Officers / Line Managers County Staff Officers / Line Managers hold delegated authority to carry out inspections on behalf of the Healthcare Governance Committee; of all members, including HCPs within St John. Particular responsibilities include: a) Reporting adverse incidents involving BP measurements so that these can be investigated in a timely manner b) Ensuring that this procedure is followed and BP monitoring is only carried out by approved personnel who hold the following qualifications: Enhanced First Aider (EFA), Patient Transport Attendant (PTA) Emergency Transport Attendant (ETA) Healthcare Professional (HCP). c) Ensuring correct implementation and development of the approved training package d) Ensuring that personal protection and basic hygiene precautions are adhered to e) Ensuring risk assessments are in place f) Keeping accurate records to assist in the preparation of reports to the Healthcare Governance Committee. Blood Pressure Standard Operating Procedure Page 4
All personnel All personnel (including volunteers and employees) have the following responsibilities under this procedure: a) Making themselves familiar with this procedure b) Adhering to and observing the requirements of this Standard Operating Procedure, ensuring they have been approved to undertake this extended role c) Participating in BP measurement training and attend / complete updates as change in procedure or equipment dictates d) Reporting dangerous or untoward incidents and situations as soon as they are identified, take action to prevent others being affected and assist with any resulting investigation. e) Ensuring that only approved and correctly maintained equipment is used. f) Ensuring personnel know what action to take should equipment become damaged, contaminated, or produces erroneous results. g) Wearing protective clothing and equipment in accordance with relevant working procedures applicable to the task being undertaken, ensuring that sharps waste is disposed of safely and in line with national and local guidance h) Observing personal protection and basic hygiene precautions 5. Indications for Blood Pressure Measurement 5.1. Blood pressure measurement gives an indication of the body s cardiac output and any resistance met when the blood is expelled from the heart through the blood vessels. Within the scope of St John practice, its primary function would be in the monitoring of patients; however it also has a place in the management of any acutely unwell patient. 5.2. To ensure continuity of care and to prevent adverse incidents, all BP results are displayed and interpreted in mmhg ONLY. This is current best practice in the United Kingdom for healthcare organisations. Blood Pressure Standard Operating Procedure Page 5
6. Blood Pressure Measurement Equipment 6.1. The information below highlights the Blood Pressure Monitoring Equipment for use by St John personnel. No personal devices are to be used at any time. All of the equipment listed is required. a) Approved Blood Pressure Device: Model : Supplier: Notes: Sapphire Sphygmomanometer St John Wales Supplies b) Approved Stethoscope: Model : Sprague Rappaport Stethoscope Supplier: St John Wales Supplies Notes: 6.2. The MHRA conducted a study in 2006 and established a committee on Blood Pressure Monitoring in Clinical Practice; following concerns regarding the use of mercury based sphygmomanometers. These concerns were based around environmental and health and safety issues. The committee concluded that if utilised, recommendations are made for mercury spillage kits to be available (Recommendation 1, MHRA, 2005). 6.3. With this recommendation in mind, coupled with potential cost implications; St John will prohibit the use of mercury sphygmomanometers and therefore only aneroid sphygmomanometers and automatic cycling non-invasive blood pressure (NIBP) monitors will be used on approved devices. 6.4. Manual Blood Pressure Devices When undertaking manual blood pressure measurements, there may be differences between the auditory acuity of personnel and digit preference is a common occurrence; particularly with personnel recording a disproportionate number of readings ending in five or zero (MHRA, 2006). To minimise this risk, formal blood pressure training will be undertaken and personnel instructed that additional information about the patient must be Blood Pressure Standard Operating Procedure Page 6
obtained; such as the regularity and strength of the pulse, skin condition and any tremors. 6.5. Automated Blood Pressure Devices Personnel should be aware that for patients suffering muscle tremors, abnormal heart rhythms, weak pulse or very low blood pressure due to shock some automated blood pressure devices may fail to obtain a reading and will either indicate an error code or give unreliable results. Some automated non-invasive blood pressure devices may produce different readings to those by manual devices due to the configuration of the devices. Only approved automatic blood pressure devices are permitted within St John. Details are available in the Approved Equipment Guide. 6.6. Cuff Size Incorrect cuff size is a major source of error for both manual and automated devices. An under-sized cuff tends to over-estimate blood pressure, while an over-sized cuff may under-estimate (MHRA, 2006). Incorrect cuff placement can also be a contributing factor. A range of blood pressure cuff sizes should be made available. Cuffs should also be regularly inspected for damage and replaced as required. 6.7. Supply & Purchase Only approved blood pressure devices that are CE marked to show compliance with the Medical Devices Policy and included in the Approved Equipment Guide should be used. 6.8. Manual Defibrillators / AEDs with BP Monitoring Capability Manual defibrillators or AED s with manual override shall only be used by Healthcare Professionals who regularly operate manual defibrillators in their clinical practice. Non-Healthcare Professionals are prohibited to use this equipment or any functions within it unless under the direct supervision of a Healthcare Professional. 7. Blood Pressure Measurement Equipment Procedure 7.1. After ensuring the blood pressure machine has been appropriately calibrated, the following procedure is carried out 1. Explain and ask the patient for their consent to carry out the procedure Blood Pressure Standard Operating Procedure Page 7
2. Adopt appropriate Infection Control methods 3. Ensure that the patients arm is free of restrictive clothing 4. Apply the cuff around the arm firmly with the bladder centered over the brachial artery 5. Advise the patient that the cuff will temporarily tighten 6. Palpate the radial artery whilst inflating the cuff until the pulse is no longer palpable. Note pressure and deflate the cuff rapidly 7. Position stethoscope over the brachial artery and inflate cuff to predetermined pressure 8. Deflate the cuff at a suitable rate and note the pressure when the first two consecutive heart beats are heard = Systolic Pressure 9. Continue to deflate the cuff and note the pressure when the heart beat can no longer be heard = Diastolic Pressure 10. Remove the cuff from the patients arm 11. Equipment cleaned and prepared for next patient 12. Remove gloves and wash hands Please note that patients must receive a manual blood pressure (using a sphygmomanometer) if automatic blood pressures provide abnormal readings. 8. Calibrating blood pressure equipment 8.1. All blood pressure equipment should be calibrated at least every six months or if the integrity or reliability is questioned when the result is not in keeping with the clinical condition of the patient. 8.2. For the procedure of calibrating the blood pressure devices, refer to the manufacturer s guideline. 9. Training 9.1. MHRA, 2005 (Recommendation 7), states that the method of auscultation as a way of determining blood pressure should continue to be taught. Due to this, the skill of auscultation is incorporated in the BP measurement training by St John (see section 8.1). 9.2. All personnel undertaking the EFA, PTA or ETA course will receive training on how to correctly carry out the blood pressure measurement procedure. All Blood Pressure Standard Operating Procedure Page 8
personnel already holding this qualification will receive an additional, mandatory training course. 9.3. Monitored training will take place in the form of formative assessments and completion of the OSCE Record Sheet (Appendix I). 9.4. Assessments will take place in the form of an Objective Structured Clinical Examination (OSCE) with a Skills Test 25A (assessment criteria) undertaken by an NHS Paramedic or IHCD Technician. 9.5. It is a requirement that all personnel undergo an OSCE on an annual basis to ensure the required standards are still being met. 9.6. Assessment and Management of patients undergoing a blood pressure measurement will be used in conjunction with the National Institute for Health and Clinical Excellence (NICE) Hypertension Guidelines, Blood Pressure Association Guidelines and those contained within the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) UK Ambulance Service; Clinical Guidelines. 10. Reporting incidents, injuries and accidents 10.1. All personnel should be aware that there is a potential for error with BP measurement and they should familiarise themselves with the training materials and practice the skill regularly. 10.2. All potential and actual adverse incidents concerning BP measurements as a result of device malfunction should result in the device being withdrawn from service, pending investigation. Personnel should be mindful that their first priority should be the care of their patients; BP measurements should not delay patients being removed to an Emergency Department for further management if required. 10.3. Any incident involving BP measurement devices or skills should be reported immediately to a member of County Staff. 10.4. In addition to the above procedure, an Adverse Incident / AC 3 Form must be completed and if applicable, a RIDDOR notification may need to be completed at the earliest opportunity and submitted without delay. 11. Monitoring of Compliance 11.1. This procedure will be monitored by the Healthcare Governance Committee and updated accordingly. 11.2. Compliance to this procedure will be regularly checked through local audits including PRF audits and monitoring. Blood Pressure Standard Operating Procedure Page 9
11.3. Reported breaches of this procedure will be discussed with those concerned and maybe dealt with under other polices, regulations or legislation. 12. References Blood Pressure Measurement (2006), Medical Device Bulletin, Medicine and Healthcare Regulatory Agency, London National Institute for Clinical Excellence (2011) Hypertension, Clinical Management of Primary Hypertension in Adults, National Institute for Clinical Excellence, London Report of the Independent Advisory Group on Blood Pressure Monitoring in Clinical Practice (2005) Medicine and Healthcare Regulatory Agency, London Blood Pressure Standard Operating Procedure Page 10
Appendix I Blood Glucose & Blood Pressure Measurement Objective Structured Clinical Examination (OSCE) To prepare you for the final OSCE assessment in Blood Pressure and Blood Glucose Measurement, please ensure that you allow ample time to practice these skills. Your trainer must witness measurements and complete all elements below prior to your final assessment. It is not necessary to take blood samples for Blood Glucose during each practice. It is acceptable for this to be demonstrated in the initial practice and final assessment, with simulation during other attempts. Blood Pressure Measurement Trainer Initial Blood Glucose Measurement Trainer Initial Procedure 1 2 3 Procedure 1 2 3 1. Explain and ask the patient for their consent to carry out the procedure 2. Adopt appropriate Infection Control methods 3. Ensure that the patients arm is free of restrictive clothing 4. Apply the cuff around the arm firmly with the bladder centred over the brachial artery 5. Advise the patient that the cuff will temporarily tighten 6. Palpate the radial artery whilst inflating the cuff until the pulse is no longer palpable. Note pressure and deflate the cuff rapidly 7. Position stethoscope over the brachial artery and inflate cuff to pre-determined pressure 8. Deflate the cuff at a suitable rate and note the pressure when the first two consecutive heart beats are heard = Systolic Pressure 9. Continue to deflate the cuff and note the pressure when the heart beat can no longer be heard = Diastolic Pressure 10. Remove the cuff from the patients arm 11. Equipment cleaned and prepared for next patient 12. Blood Pressure Reading diagnosed as Normal or Hyper/Hypotension correctly 1. Explain and ask the patient for their consent to carry out the procedure 2. Adopt appropriate Infection Control methods 3. Prepare equipment and ensure the glucose monitor is fully calibrated 4. Clean the tip of the selected finger with wipe and allow to dry 5. Prepare the test strip, ensuring that it is still in date and load into glucose monitor 6. Prick the side of the finger with the lancet and squeeze the finger to draw blood 7. Dispose of the lancet into a Sharps Box 8. Place the drop of blood onto the test strip so that the strip is covered 9. Give the patient a gauze swab and advise them to apply pressure to stop bleeding 10. Record the reading from the glucose monitor display 11. Dispose of the test strip into a clinical waste bag 12. Blood Glucose Reading diagnosed as Normal or Hyper/Hypoglycaemia correctly Blood Pressure Standard Operating Procedure Page 11