This protocol concerns the aspiration of synovial fluid and administration of
intra-articular or soft tissue cortico-steroid injection for patients with
musculoskeletal disease by registered health care practitioners working in line
with patient group directions or as independent prescribers. For the purposes
of this protocol, the term “healthcare practitioners” includes registered nurses,
physiotherapists and podiatrists who have demonstrated competence.
DATE PROTOCOL VERIFIED: October 2006 DATE PROTOCOL REVIEW DUE: July 2010 ema Rheumatology helpline 07595552782
Patients with rheumatic disease often require joint aspiration, intra-articular
injection or soft tissue injection as part of their ongoing management (Dixon A
and Emery 1992). These procedures are largely undertaken only by doctors
within rheumatology departments and are often needed at short notice for
symptom relief. The implications of this are health professionals with the skills
and competence to provide joint injections are able to provide timely care to
patients. Registered nurses and allied health professionals have developed
skills and competence to provide joint injections in rheumatology and the
implementation of joint injection services has enhanced the patient experience
(Edwards et al 2000). Registered health care practitioners who are trained to
give joint injections can also provide support and training for junior doctors
and other rheumatology health professionals.
Patient Group Directions (DOH Crown 1998) set out the legal framework by
which health professionals working in a specific specialty can supply and
administer specified medications to a particular group of patients. The patient
group directions for the administration of lidocaine hydrochloride (PGD
number 004/0902) and methylprednisolone acetate (PGD number 005/0902)
are central to the protocol for joint aspiration and injection of cortico-steroid
into the intra-articular space or soft tissues. Other drugs may be injected
using this protocol but they must be prescribed by an independent prescriber
prior to administration.
Audits carried out by the UHB rheumatology department demonstrate that
registered health care practitioners are competent, prepared to abide by the
protocol, the protocol remains relevant, the documentation is fit for practice
and there is a minimal risk of infection (Homer, 2005).
Patients are referred for joint aspiration and injection of cortico-steriod into an
intra-articular space or soft tissues by General Practitioners and
Rheumatology Consultants. They are then assessed by the registered
healthcare practitioner.
They are referred for:
Relief of pain from inflammation in or near a joint when there are signs of synovitis, effusion, crepitus or capsulitis. The patient must have a full clinical assessment (Appendix 3) and the opportunity to provide verbal informed consent before the procedure takes place. The patient is provided with an information leaflet (Appendix 4) CONTRAINDICATIONS
In the following circumstances the procedure will not be performed:
1. The patient is under the age of 16
2. The patient refuses treatment. If a patient declines treatment the reasons
should be documented and if their preference is for a doctor to do the injection a medical opinion should be requested or an appointment booked with the relevant doctor 3. The proposed injection site is a joint replacement/prosthesis 4. Septic arthritis is suspected 5. Infection, cellulitis or active psoriatic plaque overlying the site to be 6. Planned joint replacement within the next six months 7. The patient is receiving anticoagulant therapy eg. Warfarin or Heparin 8. The patient has a bleeding disorder eg. Haemophillia, Von Willebrand’s 9. The patient is receiving antibiotic therapy for a current infection 10. The patient assessment suggests they may have an intra-articular fracture 11. The patient is pregnant or breastfeeding 12. The patient has a known allergy to the drugs to be injected 13. If the registered health care practitioner considers that an attempt to perform joint aspiration and injection would cause the patient unnecessary discomfort/trauma it should not be given i.e. when sepsis is suspected, in a badly deformed joint or when previous injections to the same joint have been traumatic. The patient will be referred for a medical assessment.
If, in the registered health care practitioner’s clinical opinion, an injection is not
warranted the patient will be referred for a medical assessment.
1. Resuscitation facilities must be available before the aspiration or injection
Under the following circumstances advice from a doctor should be
sought prior to aspiration or injection

1. Patient has had more than 5 injections to the same site in the past 12 2. Previously infected joint <6 months 3. Active bleeding gastric/duodenal ulcers 4. Planned dental extraction within the following 2-3 weeks 5. The patient has unstable blood sugars 6. Lack of success in previous attempts at injection in the proposed site 7. No evidence of active disease process at the site 8. Live vaccination <2 weeks 9. Unstable Angina 10. Active chickenpox, shingles or tuberculosis CRITERIA FOR COMPETENCE
1. The registered healthcare practitioner must be a registered nurse, a physiotherapist or a podiatrist. They must have completed relevant education and training in joint aspiration and injection of corticosteroid into an intra-articular space or soft tissue, as recognised by this protocol 2. The registered health care practitioners will have a working knowledge of and be competent in the administration of lidocaine hydrochloride and methylprednisolone acetate using PGDs or be an independent prescriber 3. Evidence of competence must be provided and a copy kept in the registered health care practitioner’s personal file and in the health centres where the skill is practiced. A copy must also be sent to the Consultant Nurse for Rheumatology (Appendix 1) 4. Evidence of satisfactory supervised practice must be provided by the registered health care practitioner as witnessed by a practitioner who is already competent in providing joint injections (Appendix 2) 5. The number of supervised practices required will reflect the individual registered health care practitioner’s learning needs and they will undertake a final assessment with a practitioner who is already competent in providing joint injections 6. Evidence of continuing professional development and maintenance of 7. Registered health care practitioners new to The community rheumatology service, who have been performing the skill elsewhere, must familiarise themselves with this protocol. Evidence of appropriate education and competence must be provided before undertaking this expanded practice and competence will be assessed formally and informally by a practitioner competent in joint injection practicing in the service
The Rheumatology Nurse Consultant will lead audit of the protocol. The audit
will include:
• Adherence to the protocol and the patient group directions • Any untoward incidents and adverse events arising from the aspiration or injection of joints and soft tissues by registered health care practitioners. Eg. Allergy, inoculation injury etc. All patients receiving injections by trained health professionals will be encouraged to call the rheumatology helpline with regard to post injection problems or adverse events. Records of any helpline calls pertaining to injections administered by rheumatology practitioners will be kept with the audit documentation • Details of those patients declining treatment and those referred for a • Patient satisfaction with the procedure • Any untoward incidents and complaints

An incident form must be completed for any untoward incidents and near
misses. A risk assessment must be completed.

A list of registered health care practitioners competent to perform this skill will
be kept by the rheumatology nurse consultant.

Dixon A St J, Emery P (1992) Local Injection Therapy in Rheumatic
Eular Publishing
Edwards J, Hannah B, Brailsford-Atkinson K, Sheeran T, Price T and Mulherin
D J (2000) Intra-articular and soft tissue corticosteroid injections: Assessment
of a nurse provider service. Rheumatology Abstract supplement 1:39;
Homer, D. (2005) Audit of the CP 60 Protocol for the joint aspiration and
injection of corticosteroid into an intra-articular space or soft tissues by
trained health professionals
. University Hospital Birmingham NHS
Foundation Trust. Unpublished.
Department of Health. The Crown Report (1998) Department of Health

Department of Health (2001) Reference Guide to Consent for Examination
or Treatment.

Dieppe P et al (1991) Arthritis and Rheumatism in Practice Gower Medical
Dougherty, L. Lister, S. (2004) (Eds) The Royal Marsden NHS Trust Manual
of Clinical Nursing Procedures.
Sixth Edition Blackwell Science, London
Nursing and Midwifery Council (2002) Code of Professional Conduct.
Nursing and Midwifery Council, London
Nursing and Midwifery Council (2004). Guidelines for the Administration of
. Nursing and Midwifery Council, London
Price R, Sinclair H, Heinrich I, Gibson T (1991) Local injection treatment of
tennis elbow - hydrocortisone, triamcinolone and lignocaine compared.
British Journal of Rheumatology; 30: pp39-44.
HOBTPCT Guidelines on the management of inoculation
accidents/injuries to staff

HOBTPCT Hand Hygiene Trust Infection Control Policy Manual 2: B 1-3
University Hospital Birmingham NHS Trust, Unpublished
HOBTPCT Handling, disposal and training in the use of sharps staff

HOBTPCT Waste Disposal
HOBTPCT Medicines Policy
Protocol prepared by:
Dawn Homer

Education Package reviewed by
: Dawn Homer

Protocol submitted to and approved by:
To be reviewed by:
Date(s) of Education and supervised practice:

Name of Registered Health Care Practitioner:
Name of Supervisor:
Element of Competence To Be Achieved
Date Achieved
Registered Health
Supervisor Sign
Care Practitioner
Discuss the relevance of clinical assessment of the patient and the evidence on which you would base your judgment for or against performing joint aspiration and injection. Discuss the circumstances when you would decline treating the patient and seek advice from medical staff. Discuss indications for joint aspiration and injection. Discuss potential complications of joint aspiration and injection. Discuss contra indications and cautions for joint aspiration and injection. Discuss limitations to practice as stated in the protocol. Discuss accountability in relation to joint aspiration and injection. Provide patients with correct information, education and aftercare instructions. (Appendix 4) Demonstrate accurate record keeping relating to joint aspiration and injection. Discuss the complications of the drug therapy as stated in the protocol. Correctly interpret and apply the Patient Group Directions for administering Lidocaine Hydrochloride 2% (PGD Number 004/0902)and Methylprednisolone Acetate(PGD number 005/0902). Demonstrate accurate and safe joint aspiration into an intra- articular space or soft tissue Demonstrate correct infection control precautions throughout the procedure Discuss clinical governance and risk adverse event reporting I declare that I have expanded my knowledge and skills and undertake to practice with accountability for my decisions and actions.
Signature of Registered Health Care Practitioner: ………………………………………………
Print name:

I declare that I have supervised this registered healthcare practitioner and found her/him to be competent as judged by the above
Signature of Supervisor:
……………………………………………. Print name:……………………………….
A copy of this record should be placed in the registered healthcare practitioner’s personal file, a copy must be stored in the clinical area by the line manager and a copy can be retained by the individual for their Professional Portfolio. A copy must be sent to the COMMUNITY RHEUMATOLOGY SERVICE
To become a competent practitioner, it is the responsibility of each practitioner to undertake supervised practice in order to perform JOINT ASPIRATION AND ADMINISTRATION OF CORTICOSTEROID INJECTIONS INTO AN INTRA-ARTICULAR SPACE OR SOFT TISSUES in a safe and skilled manner. Name of registered health care practitioner: …………………………………………………. DETAILS OF PROCEDURE
Patient Assessment Checklist for Intra-articular aspiration and injection Patient assessment, indications and procedure planned:
Procedure carried out: (state joint/s injected)
Needle size(s) used:

Problems encountered (include allergies):

Amount of aspirate: mls

Medical opinion: (Give reasons)

Drs Signature:

List Drugs administered:

Name of Injector: (Please Print)
If all listed
injection can
take place
Patient is receiving a course of antibiotics Evidence of infection (e.g, fever, coloured YES: do not give injection
YES: do not give injection
and consult medical staff
Anticoagulation therapy (eg, Warfarin or YES: do not give injection
Planned procedure within next 2 weeks: i.e. endoscopy, surgery, dental treatment etc. Unstable Angina. Previous infection in target joint < 6 months. Injection into target joint < 3 months. Previous difficulties or allergy to injection Patient information and aftercare advice. administer according to appropriate patient group directions given their verbal consent for the procedure to go ahead. Diabetic well controlled (warn patient of YES: do not give injection
and consult medical staff
YES: do not give injection
and consult medical staff
Written and verbal after care instructions
Appendix 4

Laurie Pike Health Centre Community Rheumatology
Rheumatology Helpline Number 07595552782
Information for Patients – Joint injections
What is a Joint injection ?

Cortisone (steroid) is a powerful anti-inflammatory drug. When injected into an
inflamed/painful joint or area of soft tissue, it can quickly reduce inflammation and
as a result in reduced pain and stiffness. It is usually injected along with some local

Does it always work?
A joint injection is not always helpful. And if it does reduce the pain and stiffness
we cannot predict how long it will work for. But it is often very beneficial and those
benefits can last for many months in some people.
What happens?
You will be sitting or lying in a comfortable position. The site to be injected will be
cleaned and may be sprayed with a freezing spray. The site is then injected.
Is it Painful?

No injection is painless. The amount of discomfort can depend on the site injected.
But most people who need to have a joint injection are often pleasantly surprised
and find it was much better than they expected it to be.
What about after the injection?
You may have some discomfort in the injected area for 24 – 48 hours. During this period it
is advisable to rest the area injected as much as possible. We appreciate that some people
with find it difficult to follow this advice. Nevertheless it is the best advice.

Are there any side effects?
All treatments and procedures have the potential for unwanted effects. However there are
very few problems associated with joint or soft tissue injections. We will have discussed these
with you already. However the most commonly occurring side effects are:
• Pain for a day or two at the site of the injection • Slight thinning of the skin or a small patient of scarring over the injection site • Alteration on blood sugar levels. If you have diabetes you will need to monitor your blood sugar more regularly for up to 48 hours after the injection. And if you are on insulin you may need to adjust your dose accordingly • Adverse reaction to either the steroid or local anaesthetic used If you have concerns prior to your injection please discuss them with the clinician concerned. If you have any concerns following the injection please contact the clinic where the injection took place during normal working hours (The contact number is at the top of this leaflet). If the joint injected becomes more hot, red or is extremely painful 72 hours after the injection was administered please contact the clinic or out of hours your GP and or Accident and Emergency Department. Don’t forget?

√ If you have had an injection, please do not drive home. Arrange alternative transport.
√ It is best to rest the injected joint/area as much as possible for the next 48 hours. Then
gradually return to your normal activities.
√ You may notice some discomfort/pain around the injected area for 24 – 48 hours after the
injection has been given, but this should not usually be severe. Use your usually pain killers
more regularly as required. Follow the instructions on the label. If you are taking anti-
inflammatory tablets these may also help.
√ The benefits of the injection can often be felt quickly but may take several day or
even weeks


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