PROTOCOL FOR JOINT ASPIRATION AND INJECTION OF CORTICO-STEROID INTO AN INTRA-ARTICULAR SPACE OR SOFT TISSUES BY REGISTERED HEALTH CARE PRACTITIONERS
Definition: 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
EVIDENCE FOR PRACTICE 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). INDICATIONS 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: 1.
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.
LIMITATIONS TO PRACTICE 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
PROTOCOL AND SKILLS AUDIT 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
CLINICAL INCIDENT REPORTING AND MANAGEMENT
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. REFERENCES
Dixon A St J, Emery P (1992) Local Injection Therapy in Rheumatic Diseases 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; pp167 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 London BIBLIOGRAPHY
Department of Health (2001) Reference Guide to Consent for Examination or Treatment. Dieppe P et al (1991) Arthritis and Rheumatism in Practice Gower Medical Publishing 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 Medicines. 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 health HOBTPCT Waste Disposal HOBTPCT Medicines Policy PROTOCOL SUBMISSION DETAILS Protocol prepared by: Dawn Homer Education Package reviewed by: Dawn Homer Protocol submitted to and approved by: To be reviewed by: COMMUNITY RHEUMATOLOGY SERVICE END COMPETENCE: PROTOCOL FOR JOINT ASPIRATION AND ADMINISTRATION OF CORTICOSTEROID INJECTIONS INTO AN INTRA-ARTICULAR SPACE OR SOFT TISSUES BY REGISTERED HEALTH CARE PRACTITIONERS 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. I have read and understood the PROTOCOL FOR JOINT ASPIRATION AND ADMINISTRATION OF CORTICOSTEROID INJECTIONS INTO AN INTRA-ARTICULAR SPACE OR SOFT TISSUES BY REGISTERED HEALTH CARE PRACTITIONERS 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 criteria. 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 COMMENTS OBSERVED BY SIGNATURE DESIGNATION COMMUNITY RHEUMATOLOGY SERVICE
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) Outcome:
List Drugs administered:
Name of Injector: (Please Print) Signature: If all listed criteria 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 Service 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 anaesthetic. 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.
√ 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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