Patient Group Direction (PGD) For The Administration of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSOPOTSI

PATIENT GROUP DIRECTION FOR THE ADMINSTRATION/ASPIRATION OF STEROID INJECTIONS AND LOCAL ANAESTHETICS
By:
TENDAYI MUTSOPOTSI BSc. HPT (Hons) MSc. ORTHO-MED MCSP MSOM
Patient Group Directions For The Adminstration Of Steroid Injections Author: Tendayi Mutsopotsi Msc Ortho-Med MCSP 07/11/2012
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PATIENT GROUP DIRECTION FOR THE ADMINSTRATION/ASPIRATION OF STEROID INJECTIONS AND LOCAL ANAESTHETICS Introduction This PGD has been drawn up using the recommendations set out in A Clinical Guideline for the use of Injection Therapy by Physiotherapists by the Association of Chartered Physiotherapists in Orthopaedic Medicine (ACPOM), endorsed by the Chartered Society of Physiotherapy (CSP) 1999, and from injection techniques in Orthopaedic and Sports Medicine by Saunders 2001. Since 1995 injection therapy has fallen within the scope of practice for those physiotherapists who have undertaken appropriate, recognised training. Current practice is restricted to the injection of intra-articular and peri-articular conditions of the upper and lower extremities only. The training courses currently recognised as providing best practice are those which result in a Diploma in Injection Therapy. These are either run by the Association of Chartered Physiotherapists in Orthopaedic Medicine, The Society of Orthopaedic Medicine or in conjunction with institutions of Higher Education. Under certain circumstances, for example where physiotherapists are specialised, training may be provided within the Chelsea and Westminster Hospital Foundation Trust, by the referring Orthopaedic Consultant. This training will identify competency for specific injections. Such training combined with use of this protocol (which is predominantly derived from best practice within physiotherapy ) should ensure safe and effective practice of injection therapy by physiotherapists within the Trust.
Physiotherapists authorised to administer injection therapy
Named therapists within the Trust are authorised to administer injection therapy (see appendix A). This will also include taking responsibility for the supply and administration of medicines (See appendix B). Staff need to have attended the Chelsea and Westminster Hospital Foundation Trust anaphylaxis training programme and be up to-date with mandatory cardio pulmonary resusitation (CPR) training. Rationale/Scope Subject to all conditions and criteria listed below, appropriately trained and authorised physiotherapists will administer an appropriate injection to patients following the clinical procedures within this protocol. This allows the delivery of healthcare provision without the prescription from a named doctor.
ALL PATIENT GROUP DIRECTIONS WILL BE SUBJECT TO REGULAR REVIEW IN LINE WITH CURRENT CLINICAL PRACTICE
Date of overall review of this document- July 2015
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PATIENT GROUP DIRECTIONS FOR THE ADMINSTRATION OF STEROID INJECTIONS
Page Patient Group Direction Epinephrine 1:1000 injection Triamcinolone ecetonide sterile aqueous suspension: Adcortyl 10mg/ml or Kenalog 40mg/ml Hydrocortisone acetate: Hydrocortisab 25mg/ml Depomedrone 40mg/ml Lidocaine Hydrochloride: 0.5% , 1%, 2% without epinephrine Marcaine 0.25% , 0.5% without epinephrine Declaration: Appendices
1. Clinical condition
Clinical condition to be treated Arthritis, Bursitis, Capsulitis, Synovitis, Tendinitis, Tenosynovitis Entrapment neuropathy Ganglia Ligamentous injury For peripheral intra-articular/peri-articular administration in adults (18 years and over) not presenting with any contraindication. Patients with an absolute contraindication are excluded. Medical approval must be sought where a caution exists. Absolute Contraindications Known hypersensitivity to local anaesthetic or steroid Suspicion of infection in the joint or elsewhere Local sepsis over the injection site Acute haemarthrosis Recent trauma Into a prosthetic joint Reluctant patient Pregnancy or breast feeding Tendon bodies Adjacent osteomyelitis Oral antifungal medication (amphotericin and imidazoles) Exposure to chicken pox if previously uninfected Caution Immunosupression, drugs or disease Anticoagulant therapy, increased monitoring required
Criteria for inclusion Criteria for exclusion
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Action if excluded Action if declines Drug Interactions
Bleeding disorder Poorly controlled diabetes, increased monitoring required Anxious/ psychogenic patient Liver disease Unstable joint Ciclosporin treatment, monitoring required Patients who are excluded will be offered alternative appropriate management which may include Physiotherapy. Patients who do not wish to receive injection therapy will be offered alternative appropriate management which may include Physiotherapy. Antibacterials: erythromycin inhibits metabolism of steroid. Anticoagulant effect of warfarin possibly altered. Antidiabetics: antagonism of hypoglycaemic effect. Antiepileptic drugs including barbiturates accelerate metabolism of steroid (reduced effect). Antifungals: increased risk of hypokalaemia with amphotericin, imidazoles inhibit metabolism of steroid. Ciclosporin: plasma ciclosporin concentration increased by high dose methylprednisolone (risk of convulsions)
2. Records The following should be recorded in the patients records. Name of drug Dose given Date given Route given Any advice or warnings given to the patient Any adverse drug reactions occurring after administration Signature of Physiotherapist administering drug Consent form signed by the patient and Physiotherapist
The referring Medical Practitioner will be forwarded a copy of the Injection treatment including drugs used and dose
3. Treatment procedure The following procedure is good practice and based on guidelines from Injection techniques in orthopaedic and sports medicine Saunders 2002. Prepare the patient Injection checklist completed (Appendix D JM and HT checklist) Patient placed in a comfortable, supported position Injection site exposed Allergy to plaster checked
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Prepare equipment Drugs checked for name, dosage an expiry dates Collect syringe and needles for drawing up infiltration Collect alcohol swab, plaster, cotton wool and sharp box Prepare site Position limb to make site accessible Mark skin by applying pressure to injection site Clean site with alcohol Allow to dry
Assemble equipment Wash hands Open vials Draw up drugs, steroid first, using sterile needle Discard needle into sharps box Apply fresh sterile needle of correct size for infiltration
Injection technique Stretch skin and insert needle perpendicular to skin in order to avoid painful skin puncture Angle needle towards site of lesion to obtain correct placement Draw back on plunger to ensure needle tip is not in blood vessel and to check for the presence of sepsis Administer injection as either a bolus into joints/bursa or as a peppering technique for tendons or ligaments Withdraw needle rapidly while applying firm pressure with cotton wool to minimise bleeding and reduce chance of skin de-pigmentation or fat atrophy Discard syringe and needle immediately into sharps box to prevent needle stick injury Apply plaster/alternative to prevent tracking of infection and bleeding onto clothes
Aftercare Injection therapy record to be completed (Appendix D ?) Patient waits for 20 minutes to ensure no adverse reaction Patient advised on home management and follow up appointment arrangement Patient satisfaction form can be given to patient (Appendix E)
Anaphylaxis In the event of an anaphylactic reaction, Chelsea and Westminster Hospital Foundation Trust anaphylaxis procedure should be followed (Appendix F). Physiotherapists therefore need to have undergone the C&W anaphylaxis training programme. 4. Documentation
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All documentation including the injection check list to be added to the patients current physiotherapy or medical records and reference to procedure made within these records sufficient to enable audit trail. Any adverse reaction or patient incident must be reported through the Trust incident reporting procedure and to ACPOM, if the physiotherapist is a member.
5. Professional Responsibility
1. The Physiotherapist will ensure he/she has completed successfully the relevant training (Diploma in Injection Therapy or equivalent) and is competent in all aspects of administration, including cautions and contra-indications. He/she will attend regular training updates including Anaphylaxis management. 2. The Physiotherapist will have due regard for the CSPs Code of Conduct, Scope of Professional Practice, Clinical Guidelines for the use of Injection therapy by Physiotherapists and Safe Systems of work for Injection Therapy. 6. RECOMMENDED MEDICINES 6.1 Name of medicine Legal status Storage Dose Route/method Frequency Total dose number Suggested regime
Epinephrine 1:1000 Prescription only medicine. Store as stock items in a lockable cupboard at room temperature. Epinephrine injection comes as a single-dose pre-filled automatic injection deviceEpi-pen Injected into the thigh intramuscularly using the automatic injection device Used only in the management of an anaphylactic shock Epinephrine injection comes as a single-dose pre-filled automatic injection deviceEpi-pen In the event of an impending or anaphylactic shock. This is a medical emergency with symptoms of an itchy sensation progressing rapidly to facial or glossal swelling. The CSP suggest the following regime: -Stop delivery of drug -Summon Medical Help -Admisnter the adrenaline -Adminster cardiopulmonary resuscitation
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Triamcinolone Acetonide: Name of medicine Legal status Storage Dose Route/method Frequency Triamcinolone Acetonide: Adcortyl 10mg/ml or Kenalog 40mg/ml in 1ml vials or 5ml vials Prescription only medicine. Store as stock items in a lockable cupboard at room temperature. Maximum dose per Consultation is 40mg.
Injection of Steroids with/ without Lidocaine via Intra-articular, Periarticular, Intrabursal, and Tendon Sheaths administration only
Allow at least a two-week interval between repeat injections into the same lesion.
The standard recommendation is for osteoarthritic joints where no other therapy is effective is once every 3 -6 months. Any patient that requires injection as often as once per month should be referred to the appropriate medical or orthopaedic specialists for adequate management and monitoring
Total dose number Advice to Patient
A maximum number of three injections per lesion are acceptable. The patient will be given information about the injection including: Nature of their condition Details of the proposed treatment and alternatives Nature of the drugs to be given Contraindications to injection Possible adverse effects, incidence and management including contacts during and outside working hours Likely benefits Warning about possible post injection pain Plans for follow-up and after care including relative rest The patient will be observed for indications of any immediate post-injection adverse reactions for at least 30 minutes A written information sheet will be given to the patient
6.2 Methylprednisolone (Depo-Medrone): Name of medicine Legal status Storage Dose Route/method Frequency
Methylprednisolone (Depo-Medrone)- 40-120 mg/ml 1 ml, 2 ml, 3ml vials intermediate to long lasting and least soluble
Prescription only medicine. Store as stock items in a lockable cupboard at room temperature. Maximum dose per Consultation is 40mg. with or without Lidocaine Hydrochloride/Marcaine prior to injection. Allow at least a two-week interval between repeat injections into the same
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lesion.
A maximum number of three injections per lesion are acceptable. The patient will be given information about the injection including: Nature of their condition Details of the proposed treatment and alternatives Nature of the drugs to be given Contraindications to injection Possible adverse effects, incidence and management including contacts during and outside working hours Likely benefits Warning about possible post injection pain Plans for follow-up and after care including relative rest The patient will be observed for indications of any immediate post-injection adverse reactions for at least 30 minutes A written information sheet will be given to the patient
6.3 Hydrocortisone: Name of medicine Legal status Storage Dose Route/method Frequency
Hydrocortisone acetate (Hydrocortistab) 25mg/ml - 1 ml AMPOULES. Considered to be more soluble and shorter acting, recommended for tendon sheaths
Prescription only medicine. Store as stock items in a lockable cupboard at room temperature. Maximum dose per Consultation is 25mg. with or without Lidocaine Hydrochloride/Marcaine prior to injection. Allow at least a two-week interval between repeat injections into the same lesion.
A maximum number of three injections per lesion are acceptable. The patient will be given information about the injection including: Nature of their condition Details of the proposed treatment and alternatives Nature of the drugs to be given Contraindications to injection Possible adverse effects, incidence and management including contacts during and outside working hours Likely benefits Warning about possible post injection pain
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Plans for follow-up and after care including relative rest The patient will be observed for indications of any immediate post-injection adverse reactions for at least 30 minutes A written information sheet will be given to the patient
6.4 Local Anaesthetics:

Name of medicine
Lidocaine hydrochloride - AMPOULES of 0.5% (2 ml), 1% (2 ml), or 2% (2 ml or 5ml) - without adrenaline. Marcaine- AMPOULES of 10ml
Legal status Storage Dose
Prescription only medicine. Store as stock items in a lockable cupboard at room temperature. Maximum dose per Consultation
Lidocaine 0.5% solution - 20ml, 1% solution 10ml, 2% solution - 5ml. Marcaine 0.25% solution- 20ml, 0.5% solution- 15ml The doses listed for Lidocaine Hydrochloride are for healthy adult of medium built and should produce only relief of pain and loss of skin sensation for the duration of the half life which is estimated to be between 1 2 hours and for Marcaine is 2.7 hours
Route/method Frequency Total dose number Advice to Patient
Local infiltration with or without steroid Allow at least a two-week interval between repeat injections into the same lesion. A maximum number of three injections per lesion are acceptable. The patient will be given information about the injection including: Nature of their condition Details of the proposed treatment and alternatives Nature of the drugs to be given Contraindications to injection Possible adverse effects, incidence and management including contacts during and outside working hours Likely benefits Warning about possible post injection pain Plans for follow-up and after care including relative rest The patient will be observed for indications of any immediate post-injection adverse reactions for at least 30 minutes A written information sheet will be given to the patient
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This Patient Group Direction for use in
*please tick as appropriate
Chelsea & Westminster Hospital Foundation Trust Management of the patient group direction a. The group direction developed by: Tendayi Mutsopotsi b. Is Authorised by :-
Kensington PCT
Job Title
Orthopeadic Consultant Surgeon Senior Pharmacist (Pharmaceutical Advisor)
Name
Mr. Andrew Sankey
Signed
Date
Executive Nurse
Director/Senior Nurse
The Physiotherapists named below, being employees of the above Organisation are Authorised to administer Depomerone 40mg/ml,Triamcinolone Acetonide ( Adcortyl 10mg/ml, Kenalog 40mg/ml) and Hydrocortisone 25mg/ml
We agree to administer the above drug in accordance with this Patient group Direction
Physiotherapist
Tendayi Mutsopotsi
Job Title
Extended Scope Practitioner
Signed
Date
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Acknowledgement This protocol has been adapted (with permission) from
References CSP (2001). A Clinical Guideline for the use of injection therapy by physiotherapist .
HSC 2000/026 Patient Group Directions British National Formulary (BNF 43 March 2002)
A.C.P.O.M (1999). A Clinical Guide for the use of Injection Therapy by physiotherapists. Genovese, M C (1998) Joint and Soft Tissue Injection: A Useful Adjuvant to Systemic and Local Treatment, Postgraduate Medicine: Symposium: Rheumatologic Diseases, Vol. 103, No 2. Pharmacia Ltd (2001) Drug Information Update: Depo-Medrone with Lidocaine, http://emc.medicine.org.uk/emc Roberts W N (2000) Intraarticular and soft tissue steroid injections: What agent(s) to inject and how frequently? UpToDate Version 8.1. (American Rheumatology CD or on Line) Saunders, S (2002) Patient Group Direction Proforma, The Association of Chartered Physiotherapists in Orthopaedic Medicine (ACPOM). Saunders, S, Cameron, G (1997) Injection Techniques in Orthopaedic and Sports Medicine, Philadelphia (W.B Saunders company Ltd). Kesson,M, Akins,E, Davies, I(2002) Musculoskeletal Injection Skills,Edinburgh (ButterworthHeinemann)
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INJECTION THERAPY PATIENT INFORMATION
What to Expect Post Injection

1. 2. 3. 4. 5. 6. Injected area may ache more for the first 24-48 hours. Your face may become flushed. You may have trouble sleeping the night after injection. If you are diabetic the injection may cause blood sugar to increase. Area injected may become numb and remain numb for 24-48 hours. Injected area may seem more swollen for the first day past injection. CALL THE ME OR THE CLINIC IF THE FOLLOWING SYMPTOMS OCCUR:
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1. 2. 3. 4.
Trouble breathing or swallowing. Skin rash. Develop a fever of 100 o or more. Injected area becomes red or inflamed
Useful Contact Numbers: Physiotherapy Department: Therapist:
Injection Therapy Consent Form

Patient Ref. No: D.O.B: Name: .Gender M/F: ..
Absolute Contraindications: Yes No

Suspicion of infection (anywhere) Hypersensitivity to injections Prosthetic joint Taking oral corticosteroids Unable to rest for 48 hours (including driving) Recent live vaccination (avoid for 2/52 post live vacine) Planned surgical procedure in next 4/52 (including dental) Taking warfarin and no INR (haematology) Damaged / broken skin at site Previous allergic reaction Haemarthrosis < 18 years of age Pregnancy / breast feeding Recent trauma Unstable joint
Yes

No

Precautions: Yes No
Yes No
Yes
No
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Diabetic Taking anticoagulants (eg. warfarin)

INR < 2
Bleeding disorder Needle phobia
Immunosupressed
Warnings of side effects given: Yes

Facial flushing Allergic reaction Infection Diagnosis: Injection site and approach: Menstrual irregularity Post injection flare-up Possible tendon rupture
Yes
Impaired diabetic control (check control) Skin depigmentation / fat atrophy
Yes

Injection composition and prescription: Analgesic: Corticosteroid: Batch: Batch: Expiry: Expiry:
Patient advised to wait 30 minutes post injection? Clinicians name: Patients name: Date of procedure:
Yes Date: Date:
Signature: Signature:
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Patient Group Direction (PGD) For The Administration of Local Anaesthetics and Corticosteroids BY TENDAYI MUTSOPOTSI

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PATIENT GROUP DIRECTION FOR THE ADMINSTRATION/ASPIRATION OF STEROID INJECTIONS AND LOCAL ANAESTHETICS

TENDAYI MUTSOPOTSI BSc. HPT (Hons) MSc. ORTHO-MED MCSP MSOM

Date of overall review of this document- July 2015

PATIENT GROUP DIRECTIONS FOR THE ADMINSTRATION OF STEROID INJECTIONS

Criteria for inclusion Criteria for exclusion

Action if excluded Action if declines Drug Interactions

Total dose number Advice to Patient

Total dose number Advice to Patient

Total dose number Advice to Patient

6.4 Local Anaesthetics:

Legal status Storage Dose

Route/method Frequency Total dose number Advice to Patient

This Patient Group Direction for use in

*please tick as appropriate

Acknowledgement This protocol has been adapted (with permission) from

INJECTION THERAPY PATIENT INFORMATION

What to Expect Post Injection

Useful Contact Numbers: Physiotherapy Department: Therapist:

Injection Therapy Consent Form

Absolute Contraindications: Yes No

Diabetic Taking anticoagulants (eg. warfarin)

Bleeding disorder Needle phobia

Warnings of side effects given: Yes

Yes Date: Date:

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