Integrated Care Pathway

Transcription

1 Outpatient parenteral antimicrobial therapy (Opat) Integrated Care Pathway If yu are admitted t anther hspital r need t see anther health prfessinal, please shw them page 4 f this patient held recrd.

2 2 The OPAT team cnsists f Cnsultant micrbilgists OPAT Clinical Nurse Specialists OPAT pharmacist Cntact numbers fr OPAT team Mnday t Friday (excluding bank hlidays) Or ring Switchbard: and ask fr Bleep 815 Opat pharmacists Bleep 788 All ther times Cntact the ut f hurs site manager via Switchbard by asking fr Bleep 741 rn-tr.opat@nhs.net

3 Cntents Cntacts at RNOH 2 Infrmatin if admitted t hspital 4 Patient assessment 5 PICC line details 6 Bld testing schedule and results 7 Patient Cnsent fr IV Antibitics in the cmmunity 8 VIP scre 10 Self-administratin recrd 11 Infrmatin fr Cmmunity nurses 16 FAQ 20 Line prblems, pssible causes and actin pints 24 Emergency advice 28 3

4 Dear clleague is under the care f the ryal natinal Orthpaedic hspitals Outpatient parental antimicrbial therapy team. as part f their treatment plan the micrbilgy Cnsultant has prescribed a curse f: Medicatin and dse Cnditin (date f surgery) Management plan Organisms Start date planned end date f iv s and utpatient appt. planned ral antibitic fllw n if yu wuld like t discuss this patient s treatment plan please cntact us using the Opat team cntact numbers at the frnt r the micrbilgy registrar can be cntacted n

5 this sectin shuld be cmpleted by Opat nurse Discharge planning & mnitring review arrangements past medical histry: Current medicatin: Allergies nature f reactin Suitable fr self-administratin r carer administratin? Des the patient cnsent t discharge n the Opat pathway and agree t return t the rnoh as required? 5

6 PICC & mid line recrd INSERTION name f peratr Designatin: Date Vein utlised: left right Basilic Cephalic Mediancubital ttal length f catheter cm length f catheter frm exit side t hub cm Brand f line prduct cde Cnfirmatin tip lcatin: Dcument any line cmplicatins LINE REMOVAL Date reasn fr remval name rle 6

7 Weekly bld tests required every Friday Full bld cunt FBC urea and electrlytes u+e liver functin test lft C reactive prtein Crp ANTIBIOTIC SPECIFIC TESTS teicplanin level (red tp ) CK fr Daptmycin patients Vancmycin levels Mn & thurs 7

8 Patient Cnsent fr IV Antibitics in the cmmunity Outpatient Parenteral Antibitic Therapy (OPAT) is a safe, cnvenient way f treating infectin in the cmfrt f the patient s wn hme. Hwever, fr safety reasns, certain grund rules must be respected by the patient fr OPAT t be successful. the fllwing cnditins must be met fr a patient t be treated safely n Opat: yu must have a fixed address t which each delivery is made. if necessary, a fridge shuld be available t stre medicatin. yu must have a wrking telephne. We will dispense yur antibitics n a frtnightly basis. Where pssible we will try t tie this in with clinic and therapy appintments, therefre please infrm us f any appintments in advance.yu r a relative must be at hme t accept deliveries. Fr yur safety, all equipment (especially the sharps bin) must be kept safe and ut f reach f small children. unless yu have been trained by the Opat team, yu must nt self administer the drug at any time during the curse f treatment, and must nt interfere with the picc line under any circumstances. if yu are nt self-administering the intravenus drug, yu must be at yur address each day t allw the district nurse t assess yu and administer the intravenus antibitic. it is nt pssible fr a nurse t revisit yu shuld yu nt be at hme. please cntact the Opat nurse in advance if yu have any practical queries. 8

9 please nte the fllwing patient warning regarding cntinued prvisin f the Opat service: any preventable missed intravenus antibitic dses and/r suspected episdes f alchl r substance abuse will be reprted t the Opat cnsultant. Missed dses are likely t lead t the Opat service being withdrawn and the picc line remved. hspital readmissin may be required t cmplete antibitic treatment. in rder t review the safety and efficacy f yur treatment we need t review yur bld results n a weekly basis. We may be unable t cntinue prescribing withut this infrmatin. We try t minimise yur number f appintments at the rnoh but fr yur treatment t be effective and safe yu must be able t attend bth rutine and unscheduled hspital appintments, as necessary, at the request f the Opat team. if yu have any cncerns regarding yur Opat treatment r the picc line, please cntact the ryal natinal Orthpaedic hspital s Opat team. please nte that any cncerns regarding picc lines shuld be raised immediately. yur antibitic regimen has been specifically tailred t cver the rganisms that yu have grwn. it shuld nt be changed withut discussin with the Opat team. Patient Name: Hspital N: OPAT Nurse: Signature: 9

10 Visual inspectin f phlebitis scre (VIP) Osbervatin i.v. site appears healthy One f the fllwing is evident: Slight pain near i.v. site Slight redness near i.v. site tw f the fllwing are evident: pain near i.v. site erythema (redness) Swelling all f the fllwing are evident: pain alng path f picc line erythema (redness) hardening f tissue (tissue feeling firm and swllen) all f the fllwing are evident and extensive: pain alng path f picc line erythema (redness) hardening f tissue palpable venus crd all f the fllwing are evident and extensive: pain alng path f picc line erythema (redness) hardening f tissue palpable venus crd pyrexia Actin n signs f phlebitis Observe PICC line each time medicatin given pssible first signs f phlebitis Cntact OPAT team fr advice early stage f phlebitis Cntact OPAT team fr advice Medium stage f phlebitis Cntact OPAT team fr advice advanced stage f phlebitis r start f thrmbphlebitis Cntact OPAT team fr advice r attend lcal hspital advanced stage f thrmbphlebitis Attend lcal hspital fr treatment

11 Administratin recrd Date Drug Initials VIP Scre 11

12 Administratin recrd Date Drug Initials VIP Scre 12

13 Date Drug Initials VIP Scre 13

14 Outpatient Parenteral Antimicrbial Therapy (OPAT) Cmmunicatin sheet between hspital and cmmunity staff Date time Cmments Signed/ designatin 14

15 Date time Cmments Signed/ designatin 15

16 Infrmatin fr Patients, Carers, District Nurses Infrmatin fr Patients, Carers, District Nurses fr patients, Carers, District nurses 16

17 Cmmunity Nurses Our piccs are fitted with needle free devices rather than bungs. YOU SHOULD NEVER STICK NEEDLES INTO THEM, the needle free device, picc line securement and transparent dressing must be changed weekly r when siled. Please treat each lumen separately, using a different syringe fr each lumen. 17

18 Accessing/flushing line 1 Wash hands. Draw up saline int syringes. 2 Clean end f needle free device with an alchl swab. allw t dry fully r if needle free device change is due, remve device, clean end f lumen with alchl swab; allw t dry; apply a new needle free device and prceed). 3 remve needle frm saline syringe. push the syringe int the needle free device and twist clckwise. unclamp line the syringe shuld nw stay in place. 4 Flush the line using a brisk push-pause technique (i.e. pause after each ml. this creates turbulence in the line and helps clear any tiny debris). DO not FOrCe the FluSh r yu may split the picc. If yu meet resistance, ask the patient t lk away frm the PICC line, change psitin, mve their arm, take sme deep breaths as PICC lines can rest n the vessel wall then try and flush the line again. never use a smaller syringe t try t unblck the picc. 5 re clamp the line and remve syringe by twisting anticlckwise. leave needle-free device in place. Equipment needed per lumen 10 mls 0.9% Saline iv 1 x 10 ml syringe (n smaller) isprpyl alchl swabs Sterile twel Spare needle-free device if change due 18

19 Taking bld frm a PICC 1 access the picc using aseptic technique as fr flushing. 2 Withdraw & discard first 4mls f bld frm picc. (if it wn t bleed back try flushing the line first r ask patient t take deep breaths). 3 take the bld sample. 4 Flush immediately with 10mls 0.9% saline t prevent cclusin then fill bld bttles Equipment needed as fr rutine flush (abve) but add: tw extra syringes (r ne extra syringe plus Vacutainer cnnectr) spare 10ml syringe f saline in case picc needs flushing befre it will bleed back 19

20 Yur Hickman line, Peripherally Inserted Central Catheter (PICC) r Mid Line Frequently asked questins: Superir vena cava Insertin site Subclaviar vein Tip f central catheter What is a Hickman line? a hickman line is a lng, very thin, flexible tube that is tunnelled thrugh the skin nrmally in the chest regin then usually placed int ne f the large veins in the neck, belw the skin and nt seen. this tube nce in the large vein is threaded thrugh the vein stpping abve the right side f the heart. Catheter tunnelled under skin Exit site Clamp Heart Bung What is a PICC line? a picc line is a lng, very thin, flexible tube that is usually placed int ne f the large veins in the arm, ften just abve r just belw the elbw. this tube is threaded int a large vein abve the right side f the heart, the same place as the hickman line. PICC PICC line enters bdy here Heart 20

21 What are they used fr? these lines are used t give iv (intravenus) medicatins r fluids. the tubes are small and flexible, this allws the lines t stay in psitin several weeks r mnths, which means fewer needles and less pain. they can be used t take bld samples in mst cases, althugh ccasinally the team may wish t use an alternative vein r the line may nt allw bld sampling. Des my Hickman r PICC ever need t be replaced? the lines can last up t several weeks and even mnths, they d nt need t be replaced. hwever, they may need t be repaired if there is a leakage frm the hub (small cnnectr t the line utside). if infectin is suspected, the line will be remved and anther may be required. Hw is the Hickman line held in? at insertin a stitch will be used at the exit site t secure the line. after days (depending n yur rate f healing) the stitch will be remved by a nurse r dctr. the bdy will then hld the line in by itself. Hw will my PICC line be held in place? the picc line is nt stitched in place. it is kept in place by a line securement device which is a sticky dressing that is placed nt the skin and the picc is then clipped (plastic device) r gripped (Velcr) int it. the whle site will be fixed t yur skin with a special see- thrugh dressing. this dressing will be changed nce a week r if it becmes lse. the nurse administering yur medicatin will d this fr yu. if yu are self-administering yu will be cnsulted n wh will d this fr yu. 21

22 Frequently asked questins: Can I d the dressing myself? n, yur designated cmmunity nurse will clean and dress yur line exit site. When can my line be remved? yur line will be remved when there is n lnger a need fr it. yur nurse will remve the picc ; this cmes ut easily, creating an exit site. the exit site will be cleaned and a dry dressing will be placed ver the site. this dressing can be remved after 24hrs. the medical team will arrange fr yu t cme in t the planned prcedures unit fr the hickman line t be taken ut. neither f these nrmally require an vernight stay. Can I exercise with my line in? yes althugh there are sme limitatins, sme f these are utlined in the accmpanying sectin hw yu can help care fr yur hickman, picc r mid line at hme. if yu feel there is smething that is nt cvered here please discuss the frm f exercise with yur dctr, pharmacist r nurse. Are there any risks r side effects? the insertin f a line is usually a safe prcedure. hwever, as with all invasive prcedures, there are sme risks. yur dctr, nurse r pharmacist will discuss in detail pssible cmplicatins. this will be befre yu sign yur cnsent frm agreeing fr a line t be placed. Sme f the pssible risks / cmplicatins with picc lines and what t d are utlined in the table n the next page: 22

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24 Line prblems, pssible causes and actin pints Prblem Pssible cause f prblem If yu have truble breathing r chest pain Fever, chills. Sreness, redness, r pus at the line insertin site. Swllen arm Flushing prblems. unable t push medicine r fluids int hickman/picc/mid line pssible infectin line may be kinked. line may be blcked leaking frm the line Cap/bung n line is nt screwed n tight. a hle in the line. hickman/picc/mid line accidentally cmes ut redness f skin where dressings have been used redness and/r tendernes f upper arm length f expsed line is increased Whshing sund in ear. numbness/tingling in arm. Discmfrt in jaw, ear, teeth r face n line side f bdy Sensitivity, reactin t dressings glue Mechanical phlebitis (vein irritatin frm line) which may ccur within the first few days after line placement line has been pulled ut partially r cmpletely line may have mved. line causing nerve irritatin 24

25 What t d lie n yur left side and call 999 take yur temperature if yu feel unwell & make a nte f the reading. infrm Opat team n numbers at the frnt. ensure arm is straightened. if nt kinked, d nt frce the slutin int the tube. Cntact Opat team using numbers n the frnt page f these instructins. tighten the cap/bung. Check the line fr a tear. if yu see a leak in the line, clamp it r fld it ver, pinch it between the leak and the skin and call yur nurse specialist immediately. Cntact Opat team using numbers n the frnt page. press dwn n the site fr at least 5 minutes. apply gauze and secure with bandage. Cntact Opat team using numbers n the frnt page. May need t have dressing changed and the type f dressing used may be changed. Cntact Opat team using numbers n the frnt page. this is nt an infectin. apply warm packs. Cntact Opat team using numbers n the frnt page. D nt push line back in. Cver with gauze Cntact Opat team using numbers n the frnt page. Stp medicatin. Cntact Opat team using numbers n the frnt page. 25

26 Hw yu can help care fr yur Hickman, PICC r mid line at hme D nt engage in any strenuus activity r heavy lifting fr the first 48 hurs after line insertin never use scissrs t remve tape/dressing frm arund the line always tape yur picc/mid line t yur arm r cver with an elasticated dressing like a tubegrip t prevent it frm snagging n bjects hickman lines can be left lse r rested in a neck lp r secured using a sticky spt dressing Cver picc with plastic sleeves prvided when shwering s the dressing des nt get wet Shwering is preferred t bathing, D nt let end f line/cap/bung hang in bath water Swimming, paddling and ther water sprts are nt recmmended as submersin f lines is nt advised as it culd increase the risk f yu acquiring water brn infectin avid rugh cntact sprts, e.g. ftball & rugby. Sme martial arts may be cntinued but n cntact sparring and full cntact sparring shuld be avided as line may mve r be damaged Bdy building and weight training at the gym can ver-tense muscles arund lines making them hard t use and shuld therefre be avided rutine dental appintments shuld be rescheduled fr when yur treatment is finished, if yur treatment is fr lnger than 3 mnths discuss the need fr dental hygiene with yur infectin dctr they will advise yu 26

27 avid having emergency dental wrk dne while the line is in place as bacteria can be released frm yur muth int the bldstream and attach nt the end f the line causing pssible infectin risk. if dental wrk is necessary, infrm the dentist and yur infectin dctr abut the picc line and yur requirement fr treatment abut 5 days befre the dental wrk, they may wish t alter yur antibitic therapy r increase yur antibitic cver fr the prcedure. in the event f a dental emergency ask yur dentist t cntact the infectin dctr fr advice n antibitic cver if yu see any medical prfessinal, general practitiner (Gp dctr), district nurse, dentist, physitherapist/ccupatinal therapists, stepaths r chirpractrs please tell them abut yur line it may affect the treatment they wish t give yu. they may wish t cntact the Opat team fr advice prir t yur treatment. 27

28 In an Emergency: althugh it is unlikely that yu will becme unwell, this can happen because f a reactin t the drug r an infectin. Stp giving the drug, clamp the line if applicable D nt flush the line if yu feel breathless, sit up. if yu are alne call smene fr supprt Dial 999 fr an ambulance if yu feel drwsy r yu feel yu are lsing cnsciusness, lie n yur side please ensure yu take all the drugs yu are taking with yu int hspital Feeling shivery r faint during r after the venus access device has been accessed may imply the device has becme infected. if yu d nt have any ther symptms then please cntact the nurse wh helps care fr the line fr advice ryal natinal Orthpaedic hspital nhs trust Brckley hill, Stanmre, Middlesex ha7 4lp Switchbard: rnoh publicatin date: april 2017 Date f next review: april 2019 authr: Katy Crick