outpatient parenteral antimicrobial therapy (opat ... · outpatient parenteral antibiotic therapy...
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If you are admitted to another hospital or need to see another healthprofessional, please show them page 4 of this patient held record.
Outpatient parenteral
antiMiCrOBial therapy (Opat)
Integrated Care Pathway
The OPAT team consists ofConsultant microbiologists
OPAT Clinical Nurse Specialists
OPAT pharmacist
Contact numbers for OPAT team
Monday to Friday (excluding bank holidays)
09.00 - 17.00
020 8385 3046
Or ring Switchboard: 020 8954 2300and ask for Bleep 815
Opat pharmacists Bleep 788
All other timesContact the out of hours site manager viaSwitchboard by asking for Bleep 741
Contents
Contacts at RNOH 2
Information if admitted to hospital 4
Patient assessment 5
PICC line details 6
Blood testing schedule and results 7
Patient Consent for IV Antibiotics in the community 8
VIP score 10
Self-administration record 11
Information for Community nurses 16
FAQ 20
Line problems, possible causes and action points 24
Emergency advice 28
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is under the care of the royal national Orthopaedic hospitals Outpatientparental antimicrobial therapy team. as part of their treatment plan the
microbiology Consultant has prescribed a course of:
if you would like to discuss this patient’s treatment plan please contact ususing the Opat team contact numbers at the front or the microbiology
registrar can be contacted on 07887 650795.
Medicationand dose
Condition (date of surgery)
Management plan
Organisms
Start date
planned end dateof iV’s and
outpatient appt.
planned oralantibiotic follow on
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Dear colleague
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past medical history:
Current medication:
Suitable for self-administration or carer administration?
Does the patient consent to discharge on the Opatpathway and agree to return to the rnOh as required?
this section should be completed by Opat nurse
Discharge planning & monitoring reviewarrangements
Allergies
nature of reaction
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INSERTION
Veinutlised:
Median-cubitalCephalicBasilicrightleft
name of operator
LINE REMOVAL
total length ofcatheter
product code
Brand of line
Confirmation tiplocation:
Document any linecomplications
reasonfor
removal
length of catheterfrom exit side to hub
Date
name
role
Designation: Date
PICC & mid line record
cm
cm
Weekly blood tests required every Friday
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Full blood count FBC
urea and electrolytes u+e
liver function test lFt
C reactive protein Crp
ANTIBIOTIC SPECIFIC TESTS
teicoplanin level (red top )
CK for Daptomycin patients
Vancomycin levels Mon & thurs
Outpatient Parenteral Antibiotic Therapy (OPAT) is a safe, convenientway of treating infection in the comfort of the patient’s own home.However, for safety reasons, certain ground rules must be respectedby the patient for OPAT to be successful.
the following conditions must be met for a patient to be treated safely onOpat:
• you must have a fixed address to which each delivery is made. ifnecessary, a fridge should be available to store medication.
• you must have a working telephone.
• We will dispense your antibiotics on a fortnightly basis. Wherepossible we will try to tie this in with clinic and therapy appointments,therefore please inform us of any appointments in advance.you or arelative must be at home to accept deliveries.
• For your safety, all equipment (especially the sharps bin) must be keptsafe and out of reach of small children.
• unless you have been trained by the Opat team, you must not selfadminister the drug at any time during the course of treatment, andmust not interfere with the piCC line under any circumstances.
• if you are not self-administering the intravenous drug, you must beat your address each day to allow the district nurse to assess you andadminister the intravenous antibiotic. it is not possible for a nurse torevisit you should you not be at home. please contact the Opat nursein advance if you have any practical queries.
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Patient Consent for IV Antibiotics in the community
please note the following patient warning regarding continued provisionof the Opat service:
• any preventable missed intravenous antibiotic doses and/or suspectedepisodes of alcohol or substance abuse will be reported to the Opatconsultant. Missed doses are likely to lead to the Opat service beingwithdrawn and the piCC line removed. hospital readmission may berequired to complete antibiotic treatment.
• in order to review the safety and efficacy of your treatment we needto review your blood results on a weekly basis. We may be unable tocontinue prescribing without this information.
• We try to minimise your number of appointments at the rnOh butfor your treatment to be effective and safe you must be able to attendboth routine and unscheduled hospital appointments, as necessary,at the request of the Opat team. if you have any concerns regardingyour Opat treatment or the piCC line, please contact the royalnational Orthopaedic hospital’s Opat team. please note that anyconcerns regarding piCC lines should be raised immediately.
your antibiotic regimen has been specifically tailored to cover the organismsthat you have grown. it should not be changed without discussion withthe Opat team.
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Patient Name: Hospital No:
OPAT Nurse: Signature:
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Visual inspection of phlebitis score (VIP)
Osbervation Action
i.V. site appears healthyno signs of phlebitisObserve PICC line each timemedication given
One of the following is evident:Slight pain near i.V. site o
Slight redness near i.V. site o
possible first signs of phlebitisContact OPAT team for advice
two of the following are evident:pain near i.V. site o
erythema (redness) o
Swelling o
early stage of phlebitisContact OPAT team for advice
all of the following are evident:pain along path of piCC line o
erythema (redness) o
hardening of tissue o(tissue feeling firm and swollen)
Medium stage of phlebitisContact OPAT team for advice
all of the following are evidentand extensive:pain along path of piCC line o
erythema (redness) o
hardening of tissue o
palpable venous cord o
advanced stage of phlebitis orstart of thrombophlebitisContact OPAT team for adviceor attend local hospital
all of the following are evidentand extensive:pain along path of piCC line o
erythema (redness) o
hardening of tissue o
palpable venous cord o
pyrexia o
advanced stage ofthrombophlebitisAttend local hospital fortreatment
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2
3
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Administration record
Date Drug Initials VIP Score
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Administration record
Date Drug Initials VIP Score
13
Date Drug Initials VIP Score
Outpatient Parenteral Antimicrobial Therapy (OPAT)Communication sheet between hospital and community staff
Date time CommentsSigned/
designation
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Date time CommentsSigned/
designation
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for patients, Carers, District nurses
Informationfor Patients, Carers,
District NursesInformation forPatients, Carers,District Nurses
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Please treat each lumen
separately, using a different
syringe for each lumen.
CommunityNurses
Our piCCs are fitted withneedle free devices rather
than bungs. YOU SHOULD NEVERSTICK NEEDLES INTO THEM, the
needle free device, piCC line securement and transparent dressing
must be changed weeklyor when soiled.
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Accessing/flushing line
1 Wash hands. Draw up saline into
syringes.
2 Clean end of needle free device with
an alcohol swab. allow to dry fully
or if needle free device change is due,
remove device, clean end of lumen
with alcohol swab; allow to dry; apply
a new needle free device and proceed).
3 remove needle from saline syringe.
push the syringe into the needle free
device and twist clockwise. unclamp line the syringe should now 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 or you may split the piCC.
If you meet resistance, ask the patient to look away from the
PICC line, change position, move their arm, take some deep
breaths as PICC lines can rest on the vessel wall then try and
flush the line again.
never use a smaller
syringe to try to
unblock the piCC.
5 re clamp the line
and remove syringe
by twisting anti-
clockwise. leave
needle-free device
in place.
Equipment needed
per lumen
• 10 mls 0.9% Saline iV
• 1 x 10 ml syringe
(no smaller)
• isopropyl alcohol swabs
• Sterile towel
• Spare needle-free
device if change due
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Equipment needed
as for routine flush
(above) but add:
• two extra syringes
(or one extra syringe
plus Vacutainer
connector)
• spare 10ml syringe
of saline in case piCC
needs flushing before
it will bleed back
Taking blood from a PICC
1 access the piCC using aseptic
technique as for flushing.
2 Withdraw & discard first 4mls of
blood from piCC. (if it won’t bleed
back try flushing the line first or ask
patient to take deep breaths).
3 take the blood sample.
4 Flush immediately with 10mls 0.9%
saline to prevent occlusion
then fill blood bottles
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Your Hickman line, Peripherally Inserted CentralCatheter (PICC) or Mid Line
Frequently askedquestions:
What is a Hickman line?
a hickman line is a long, very thin,
flexible tube that is tunnelled through
the skin normally in the chest region
then usually placed into one of the
large veins in the neck, below the skin
and not seen. this tube once in the
large vein is threaded through the vein
stopping above the right side of the
heart.
What is a PICC line?
a piCC line is a long, very thin, flexible
tube that is usually placed into one of
the large veins in the arm, often just
above or just below the elbow. this
tube is threaded into a large vein above
the right side of the heart, the same
place as the hickman line.
Superiorvena cava
Subclaviarvein
Tip ofcentral
catheter
Heart
Insertionsite
Cathetertunnelledunder skin
BungClamp
PICCPICC line
enters bodyhere
Heart
Exitsite
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What are they used for?
these lines are used to give iV (intravenous) medications or fluids. the
tubes are small and flexible, this allows the lines to stay in position several
weeks or months, which means fewer needles and less pain. they can be
used to take blood samples in most cases, although occasionally the
team may wish to use an alternative vein or the line may not allow blood
sampling.
Does my Hickman or PICC ever need to be replaced?
the lines can last up to several weeks and even months, they do not
need to be replaced. however, they may need to be repaired if there is a
leakage from the hub (small connector to the line outside). if infection is
suspected, the line will be removed and another may be required.
How is the Hickman line held in?
at insertion a stitch will be used at the exit site to secure the line. after
10-21 days (depending on your rate of healing) the stitch will be
removed by a nurse or doctor. the body will then hold the line in by
itself.
How will my PICC line be held in place?
the piCC line is not stitched in place. it is kept in place by a line
securement device which is a sticky dressing that is placed onto the skin
and the piCC is then clipped (plastic device) or gripped (Velcro) into it.
the whole site will be fixed to your skin with a special “see- through”
dressing. this dressing will be changed once a week or if it becomes
loose. the nurse administering your medication will do this for you. if you
are self-administering you will be consulted on who will do this for you.
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Can I do the dressing myself?
no, your designated community nurse will clean and dress your line exit
site.
When can my line be removed?
your line will be removed when there is no longer a need for it. your
nurse will remove the piCC ; this comes out easily, creating an exit site.
the exit site will be cleaned and a dry dressing will be placed over the
site. this dressing can be removed after 24hrs. the medical team will
arrange for you to come in to the planned procedures unit for the
hickman line to be taken out. neither of these normally require an
overnight stay.
Can I exercise with my line in?
yes although there are some limitations, some of these are outlined in
the accompanying section “how you can help care for your hickman,
piCC or mid line at home”. if you feel there is something that is not
covered here please discuss the form of exercise with your doctor,
pharmacist or nurse.
Are there any risks or side effects?
the insertion of a line is usually a safe procedure. however, as with all
invasive procedures, there are some risks. your doctor, nurse or
pharmacist will discuss in detail possible complications. this will be before
you sign your consent form agreeing for a line to be placed.
Some of the possible risks / complications with piCC lines and what to do
are outlined in the table on the next page:
Frequently askedquestions:
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Problem Possible cause of problem
If you have troublebreathing or chest pain
Fever, chills. Soreness,redness, or pus at the lineinsertion site. Swollen arm
possible infection
Flushing problems.unable to push medicine
or fluids intohickman/piCC/mid line
line may be kinked.line may be blocked
hickman/piCC/mid lineaccidentally comes out
redness of skin wheredressings have been used
Sensitivity, reactionto dressings glue
redness and/or tendernesof upper arm
Mechanical phlebitis (veinirritation from line) which mayoccur within the first few days
after line placement
length of exposed lineis increased
line has been pulled outpartially or completely
Whooshing sound in ear.numbness/tingling in arm.
Discomfort in jaw, ear, teethor face on line side of body
line may have moved.line causing nerve irritation
leaking from the lineCap/bung on line is not screwed
on tight. a hole in the line.
Line problems, possible causesand action points
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What to do
lie on your left side and call 999
take your temperature if you feel unwell & make anote of the reading. inform Opat team on numbers at the front.
ensure arm is straightened. if not kinked, do not force the solutioninto the tube. Contact Opat team using numbers on the front page
of these instructions.
press down on the site for at least 5 minutes.apply gauze and secure with bandage.
Contact Opat team using numbers on the front page.
May need to have dressing changed and the type of dressingused may be changed.
Contact Opat team using numbers on the front page.
this is not an infection. apply warm packs.Contact Opat team using numbers on the front page.
Do not push line back in. Cover with gauzeContact Opat team using numbers on the front page.
Stop medication.Contact Opat team using numbers on the front page.
tighten the cap/bung. Check the line for a tear.if you see a leak in the line, clamp it or fold it over, pinch it between the
leak and the skin and call your nurse specialist immediately.Contact Opat team using numbers on the front page.
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• Do not engage in any strenuous activity or heavy lifting for the first 48
hours after line insertion
• never use scissors to remove tape/dressing from around the line
• always tape your piCC/mid line to your arm or cover with an
elasticated dressing like a tubegrip® to prevent it from snagging on
objects
• hickman lines can be left loose or “rested” in a neck loop or secured
using a sticky spot dressing
• Cover piCC with plastic sleeves provided when showering so the
dressing does not get wet
• Showering is preferred to bathing, Do not let end of line/cap/bung
hang in bath water
• Swimming, paddling and other water sports are not recommended as
submersion of lines is not advised as it could increase the risk of you
acquiring water born infection
• avoid rough contact sports, e.g. football & rugby. Some martial arts
may be continued but “no contact” sparring and full contact sparring
should be avoided as line may move or be damaged
• Body building and weight training at the gym can over-tense muscles
around lines making them hard to use and should therefore be
avoided
• routine dental appointments should be rescheduled for when your
treatment is finished, if your treatment is for longer than 3 months
discuss the need for dental hygiene with your infection doctor they
will advise you
How you can help care for your Hickman,PICC or mid line at home
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• avoid having emergency dental work done while the line is in place as
bacteria can be released from your mouth into the bloodstream and
attach onto the end of the line causing possible infection risk. if dental
work is necessary, inform the dentist and your infection doctor about
the piCC line and your requirement for treatment about 5 days before
the dental work, they may wish to alter your antibiotic therapy or
increase your antibiotic “cover” for the procedure.
• in the event of a dental emergency ask your dentist to contact the
infection doctor for advice on antibiotic cover
• if you see any medical professional, general practitioner (Gp doctor),
district nurse, dentist, physiotherapist/occupational therapists,
osteopaths or chiropractors please tell them about your
line it may affect the treatment they wish to give you.
they may wish to contact the Opat team
for advice prior to your treatment.
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In an Emergency:although it is unlikely that you will become unwell, this can happen
because of a reaction to the drug or an infection.
• Stop giving the drug, clamp the line if applicable
• Do not flush the line
• if you feel breathless, sit up. if you are alone call someone for support
• Dial 999 for an ambulance
• if you feel drowsy or you feel you are losing consciousness, lie on your
side
• please ensure you take all the drugs you are taking with you into
hospital
• Feeling shivery or faint during or after the venous access device has
been accessed may imply the device has become infected. if you do
not have any other symptoms then please contact the nurse who
helps care for the line for advice
royal national Orthopaedic hospital nhS trustBrockley hill, Stanmore, Middlesex ha7 4lp
Switchboard: 020 8954 2300www.rnoh.nhs.uktwitter: @rnOhnhs
17-140 © rnOhpublication date: april 2017Date of next review: april 2019author: Katy Crick