ID Badges & Secure Wards/ Departments

1. ID Badges & Secure Wards/ Departments • ID badges must be worn at all times whilst on Trust property. • It is important to challenge individuals in secure areas who you do not recognise. It is important to be vigilant and security aware at all times; “when in doubt” IMMEDIATLEY make the 2222 call and ask for assistance. • When entering a secure ward it is vital to ensure that individuals do not “tailgate” you onto/ off the ward. Always make sure that you check behind you, and should there be someone trying to follow you into/out of the secure area, ask whether you are able to assist the person: your response must be “Sorry, I am unable to let you in/out, however if you press the contact button a member of staff will assist you”. • Any adverse reaction to this request must be reported immediately to the security department via the 2222 number.

2. Trust & Personal Property • The Trust does not have a security guard presence, it is therefore vital that we all keep alert and vigilant. The Trust requires all staff to report any security breach or suspicious activities; should your suspicions be raised, do not hesitate, challenge and immediately call for assistance via 2222. • Do not bring personal items of value or large amounts of cash into the work place unless you have somewhere safe and secure to keep them. Should you choose to do so, this will be entirely at your own risk. • At the end of the day remember to lock items of value away and ensure that your office windows are shut and that the door is locked • All incidents of theft must be recorded on a “Trust Incident reporting system” and reported to the Police via 101, the Police will issue an Event Number and Crime Number relevant to the incident, both to be included on the incident report.

3. The Management of Violence and Aggression • In line with the Secretary of State for Health's 2003 Directions, the Trust is required to provide “Conflict Resolution Training” to all staff who deal directly with patients, visitors and the public. This training, which is mandatory, will help you to identify possible situations that may escalate into serious incidents and will assist you in preventing this happening. • It is surprising how easily conflict can be avoided; for example a simple question such as “How can I help you” accompanied by a smile, can work wonders. Try to maintain eye contact and invite the individual to sit down these are proven de-escalation techniques. • Always try to solve the problem and never make promises that you cannot keep. • Please remember that the WSH Trust operates a Zero Tolerance policy (see The Management of Violence and Aggression Policy PP(12)183), and if “Talk Down” fails call for assistance via 2222.

4. Restrictive Physical Intervention Team • Physical intervention should be seen as one in a range of strategies and actions to help staff address the needs of individuals who behaviour posses a serious challenge too provided services. • Safer Physical intervention techniques are a skilled hands-on method of physical restraint. Its purpose is to safely immobilise or restrict the individual involved. • The Trusts RPI team will comprise of pager holders to form a rapid response unit which will operate 24/7. • The Team will consist of a minimum of three persons; all trained in conflict resolution, breakaway skills and restrictive physical intervention techniques. An RPI team attendance can be requested via the trusts emergency 2222 number.

5. Blood Borne Viruses Jenny Saunders Occupational Health Manager Ext. 3423

6. Blood Borne Viruses Blood Borne Viruses (BBV’s) can be carried by some people in their blood and can cause severe disease in certain people and few or no symptoms in others. The Virus can spread to another person, whether or not the carrier of the virus is ill or notThese viruses can be found in body fluids as well as blood e.g. semen, vaginal secretions and breast milk.Other body fluids such as urine, sputum, sweat, tears or vomit carry a minimal risk of BBV’s unless contaminated with blood

7. How can BBV’s be spread in the workplace? • Needlestick Injury • Carrying out surgery (EPP) • During delivery of baby • Splashes of bloodstained fluids in mucous membrane of eyes or mouth • Human bites

8. E.P.P. • Exposure Prone Procedures are those in which there is a risk that injury to the Health Care Worker could result in exposure of the patient’s open tissue to the blood of the Health Care Worker placing the patient at risk. • Such procedures occur mainly in surgery, obstetrics and gynaecology, midwifery and dentistry

9. Action following exposure (needlestick/sharps injury/splash) • Bleed injury by squeezing • Wash wound • Cover wound • Report immediately to senior member of staff • Attend Occupational Health Department (or A & E between 16.30 and 08.30 hrs and weekends) immediately • Complete Incident Form

10. Antimicrobial Prescribing Gemma Kerridge Antimicrobial Pharmacist Ext. 3232 (bleep 514)

11. Appropriate antimicrobial prescribing Antibiotics are a finite & vulnerable resource that need protecting Threatened by increasingly diverse antibiotic resistance among pathogens Limited by a shrinking development pipeline (i.e. too few new antibiotics) Poor prescribing causes immediate and long-term problems Clostridium difficile MRSA VRE (Vancomycin-resistant Enterococci) ESBL (extended-spectrum β-lactamase) - producing coliforms Penicillin resistant Strep. pneumoniae Multi-resistant Pseudomonas & Acinetobacter Drug-resistant TB Financial cost (Drug costs, Bed-days, Fines etc.) Check compliance with Antibiotic Guidelines (see intranet Pink Book) and ensure that justification of any variation has been documented Consultants are ultimately responsible for the prescribing for their patients and should provide leadership for their team. Additional advice is available via the duty Consultant Microbiologist on Ext 2579 • Prepared by Gemma Kerridge, Antimicrobial Pharmacist Bleep 514 and Dr Robert Sue-Ho, Consultant Microbiologist

13. Indication(s) - confirm by clinical assessment and document in medical notes Previous microbiology – check for resistant organisms Allergy Details – check on the front of the drug chart Interactions with other medication? Compliance with Antibiotic Guidelines according to indication? Is the Dose appropriate? (weight, renal function, liver function) Follow-on therapy check list: Clinical Indication -still current? Review antibiotics daily with Micro Results and clinical response Switch to narrowspectrum as soon as possible Switch IV to oral as soon as practical Maximum of 48-72 hours IV needed in most cases after clinical review Set a duration 5-7 days duration is usually sufficient (See exceptions in guidelines) Are antibiotics appropriate for your patient?A check list:

14. Colonisation(N.B Infection is assessed clinically NOT by micro report) e.g. leg ulcers (No surrounding cellulitis) catheter urine (No systemic signs of infection) asymptomatic bacteriuria (No urinary symptoms in elderly) Contamination e.g. skin flora in blood culture Viral infections e.g. colds, sore throats and acute bronchitis Mild or Improving self-limiting infections e.g. gastroenteritis When NOT to use antibiotics Also Consider: Specific dressings for wounds instead of antibiotics, debride wounds/drain abscesses where possible, remove/change catheters, serial observation and appropriate investigations rather than antibiotics that are just in case.

15. DO be aware of possible druginteractions • Methotrexate: NEVER prescribe trimethoprim, not even a short course or a low dose, to patients receiving methotrexate. Note: Co-trimoxazole (Septrin®) contains trimethoprim. This is a POTENTIALLY FATAL interaction. • Warfarin:While almost all antibiotics can ‘potentiate warfarin’ but this effect can be amplified in those antibiotics that inhibit warfarin's metabolism such as: ciprofloxacin, clarithromycin, erythromycin, metronidazole and co-trimoxazole (Septrin®)especially in elderly patients. (Arch. Intern. Med. 2010, 170 p.617). • Statins:should NOT be used with fusidic acid (Fucidin) because of the risk of (potentially fatal) rhabdomyolysis. The statin should not be restarted until 7 days after the last dose of fusidic acid. (MHRA Drug Safety Update Sept 2011, Vol 5, issue 2) The plasma concentration of statins can be increased by macrolides.Avoid concomitant use of clarithromycin or erythromycin with simvastatin. See the current BNF for other statin-macrolide interactions. • Macrolides:(e.g. erythromycin, clarithromycin, azithromycin) and many other drugsthat inhibit or are metabolized through Cytochrome P450 Pathways Macrolides can increase the level of digoxin and lead to toxicity – monitor digoxin levels if this combination is required. Avoid macrolides in certain disorders: e.g. Porphyria, certain Heart rhythm disorders • Rifampicin:Rifampicin is a potent inducer of certain cytochrome P-450 enzymes and interacts with many drugs that are metabolised by this route. • Gentamicin: Carefully monitor patients renal function and review any concomitant nephrotoxic medication. E.g. NSAIDs may not be necessary during treatment with gentamicin. Monitor patients auditory function – ototoxicity can be a delayed event. • THIS IS A SMALL SUMMARISED SELECTION. PLEASE CHECK CAREFULLY BEFORE INITIATING ANTIBIOTICS IN PATIENTS WHO ARE ALREADY TAKING MEDICATIONS.

16. Preventing falls in hospital Shubhada Sinha Consultant Geriatrician Ext. 3890 (bleep 479)

17. What puts patients at risk of falling? • Medical conditions affecting mobility • Multiple medications • Poor vision • Dehydration and malnutrition • Incontinence • Dementia and “acute confusion/agitation” • Postural hypotension

18. What can you do to prevent falls • Ask all patients about falls in previous year • All patients who have fallen should have a multidisciplinary assessment including physio, OT, nurse and doctor • Patients who are confused or agitated should have enhanced supervision

19. Medical Assessment • Is it syncope? • Is there undiagnosed neurological or cardiovascular disease • Check for postural hypotension • Consider whether medication can be reduced or stopped, especially antidepressants, sedatives, opiate analgesics or anti-psychotics • Prescribe calcium & vitamin D if frail or housebound

20. Onward Referral • Patients with recurrent falls or a single fall with abnormal gait or balance should be referred to community teams for follow-up • This is done by faxing a “single point of access” form to the team covering the patient’s locality

21. Medications Management Jenny Hannah Pharmacy Ext. 2813 (bleep 969)

22. Prescribing errors at West Suffolk Hospital Insulin dose changed on existing prescription and dose prescribed with abbreviated U instead of units. Ramipril prescribed, patient allergic to this, nothing written in allergy box at the time of prescribing, one dose given Actrapid insulin written as 4U instead of 4units These significant errors have all been reported in the last 12 months: Insulin prescribed with abbreviation "u" instead of word "units" and not signed by the doctor Patient prescribed wrong dose of perindopril,80mg instead of 8mg. Patient takes weekly methotrexate (25mg on Mondays s/c) and has been prescribed trimethoprim. He has received one dose of 200mg trimethoprim. Outpatient prescription for 'methotrexate 10mg PO daily' prescribed. The prescriber was not aware that methotrexate is given once weekly Patient allergic to penicillin – prescribed penicillin Trimethoprim prescribed for patient on Methotrexate (also Methotrexate prescribed by Dr not authorised to prescribe Methotrexate) Do you check the patient’s drug chart during your ward rounds? Do you encourage good prescribing by your team? Do you lead by example?

23. Prescribers of unlicensed medicines have a personal responsibility for their use, which cannot be transferred to the drug company producing or importing the product. • Trust policy is only to use unlicensed medicines when no licensed alternative exists. It is also Trust policy to require evidence that the use of unlicensed medicines, or the unlicensed use of a licensed medicine, is evidence based and peer supported. • Patients must be provided with a suitable information leaflet to aid them in making an informed decision regarding the risks and benefits of the unlicensed treatment – this is the responsibility of the prescriber • It is vital that the patient's GP is also informed of the decision to treat using an unlicensed preparation, particularly if the patient is to be discharged to the care of the GP.

24. Update on anticoagulants • Is your patient currently receiving an anticoagulant? This may be extended VTE prophylaxis post-surgery. The patient may be on rivaroxaban, tinzaparin or unfractionated heparin and will fulfil one of the following criteria: • Patients who have undergone elective total hip replacement (THR) in last 28 days • Patients who have undergone elective total knee replacement (TKR) in last 14 days • Patients with fracture neck of femur in last 28 days • Patients with lower limb casts • Patients who have had major cancer surgery in the abdomen or pelvis within last 28 days • These anticoagulants should be continued for the specified time unless there are new contra-indications. See CG10211-1 Extended Venous Thromboembolism (VTE) Prophylaxis In Adult Non-Pregnant Patients for more details • As well as the vitamin K antagonist oral anticoagulants i.e. warfarin, phenindione, and acenocoumarol (also known as nicoumalone), watch out for the new oral anticoagulants : apixaban, dabigatran, rivaroxaban. All of the new oral anticoagulants: • Can be given without therapeutic monitoring. • Are either contra-indicated or require a decrease in dose in renal impairment • Have haemorrhage as a common side-effect hence patients should be monitored for signs of bleeding or anaemia; treatment should be stopped if severe bleeding occurs. • Should be avoided in severe hepatic impairment associated with coagulopathy. • Have no specific antidote.

25. Medicines Alert • IV paracetamol – reduce dose in: • Low body weight (<50kg) • Patients with/at risk of hepatocellular insufficiency • Renal impairment (CrCl<30ml/min) • Long term PPIs: • Risk of hypomagnasaemia • Increased risk of Clostridium difficile infection • Increased risk of bone fractures • QT prolongation with citalopram/escitalopram – review dose, check for drug • interactions & contra-indications • Strontium – increased VTE risk; review in immobilised patients Our Medicines Information Department produce regular medicines alerts. Did you catch all the 2012 updates? For more information please see our pages on the Pink Book: https://www.wsh.nhs.uk/Extranet/SupportServices/Pharmacy/GuidelinesandInformation/ClinicalGuidelinesandInformationIndex.aspx (in the relevant BNF section) or contact Medicines Information on ext 3109

26. All transfusion guidelines are under the pathology handbook on the intranet. See also information on pink prescription chart. For specific transfusion advice contact duty haematologist via switch or BMS in blood bank (3316) or Transfusion Nurse Specialists (TNS) Gilda Bass or Joanne Hoyle via TNS@wsh.nhs.uk Ext 3089 Bleep 455/262 Mandatory Blood Transfusion Update for Medical Staff 2012/2013 (focussing on new guidance) Title slide

27. Consent(* specified in new guidance from SaBTO) • Written consent is not currently required • A discussion between the doctor and patient needs to take place and be documented in the patient notes. The discussion should cover : the risks, benefits and alternatives to transfusion and the patient’s right to refuse transfusion*. • The NHS patient information leaflet should be offered to patients. The leaflet gives a summary of the risks and includes the unknown risk of vCJD which we are required to tell patients about. • For patients having multiple transfusions this discussion can cover the series of transfusions as long as that is made clear in the notes*. • For patients who refuse blood and blood products for whatever reason refer to Trust policy for treatment of Jehovah’s Witnesses CG10013 • Patients who may not have been aware they were transfused (e.g if transfused in theatre or on ITU) need to be informed prior to discharge so they have a chance to ask any questions they may have*. • Patients who have received blood may not be blood donors.

28. Specific Blood requirements • Some patients require specific products e.g. CMV negative or irradiated products: • Irradiated products: • In general significantly immunocompromised patients e.g those having drugs such as purine analogues or antagonists for CLL, lymphoma etc (e.g. fludarabine, cladrabine, deoxycoformycin, bendamustine, clofarabine) or atemtuzumab (Campath) for any indication (new British Committee for Standards in Haematology (BCSH) guideline) or any patient who has had Hodgkins lymphoma should have irradiated products to avoid risk of fatal transfusion associated graft versus host disease. • See prescription form for summary and ‘Indications for Irradiated blood products’ Guideline CG 10094 for more details. • CMV negative products (new guidance from SaBTO): • Some patients need CMV negative blood. These are mainly neonates or pregnant women to avoid transmission to the fetus. See ‘Use of CMV negative blood components’ guideline CG 10208 for more details

29. Transfusion Reactions New reactions algorithm • Stop the transfusion • If called to a potential transfusion reaction patient should be assessed immediately. • Refer to Transfusion Reactions guideline CG10126 and use algorithm (new algorithm from updated BCSH guideline) • Inform blood bank • If a major reaction obtain all samples and discuss further management with duty haematologist • Complete transfusion reactions form and send to blood bank with samples required • Complete Trust incident form on Datix for all major reactions • Consider potential impact on patients receiving blood products from the same donor in other hospitals • Follow up on results from transfusion reaction

30. Blood in an Emergency • O negative emergency blood is kept in the blood fridge in Blood bank. Send a runner or porter to collect. If no-one is BARs trained ask a member of the lab staff to release the blood. • If the patient has a valid group and save sample ‘group specific blood’ should be requested and can be ready in 5 mins – phone blood bank. • If a new sample is sent group specific blood will take approx 10 - 20 mins. • NB group specific or O neg blood does carry of small risk of causing reactions if a patient has developed red cell antibodies. Fully crossmatched compatible blood which is safe will be available in approx 30-40 minutes. • If the patient is likely to require a significant amount of blood – approx one blood volume then the ‘Massive Haemorrhage policy’ should be triggered by calling the blood bank – see algorithm on next slide.

31. Massive Blood Loss Algorithm

32. Acute oncology service (AOS) Dr Dan Patterson Consultant Medical Oncologist

33. ‘Acute oncology’ • The management of patients who develop severe complications following chemotherapy or as a consequence of their previously diagnosed cancer, as well as the management of patients who present as emergencies with previously undiagnosed cancer.

34. WSH Acute Oncology Service Chemo pts: dedicated phone no. for advice (24/7) AOS available to see patients Mon-Fri 9-5 Out of hours: Addenbrookes Onc SpR/Cons on call Daily cancer patient email alerts Assessment beds on Macmillan Day Unit Commenced Sept 2011 – ran by CNS & Consultant

36. Please use the pink book for emergency treatment guidelines and contact numbers

37. Basic Fire Precautions Please Note: Staff MUST undertake a face to face classroom session with the Trust Fire Safety Advisor every alternate year

38. In your place of work You should ensure you are familiar with: • How to raise the alarm • The location of break-glass call points • Means of escape routes • Evacuation procedure & fire assembly point • Location of first aid fire fighting equipment

39. Fire prevention • Do not leave machinery switched on overnight unless it is designed for that purpose • Close all doors and windows at the end of the working day • Ensure all electrical appliances are switched off at the wall socket, with the exception of computers which are in use 24/7. • Switch off any portable heaters • Ensure that nothing flammable is kept too near any heat source • All containers of flammable liquids or medical gases are returned to their proper storage area when not in use • Any faulty equipment should immediately be taken out of use and reported on the Helpdesk service ext 5555

40. What not to do • Do not wedge fire doors open • Do not remove first aid fire fighting equipment from its designated position or use as a door stop • Do not restrict width of fire exit routes or store any flammables on fire exit routes

41. The Fire Triangle • Fire relies on all 3 aspects to remain combustion • Ignition Source – Naked flame, spark, welding. Method of extinction: remove or isolate • Oxygen – all around us – method of extinction smothering • Fuel – anything which will burn. Method of extinction: remove fuel • Remove any 1 of the 3 to extinguish the fire

42. Action in the event of a fire If you see, suspect or smell smoke/flame, carry out the following actions:- • Raise the alarm – use the nearest break glass call point, or shout FIRE FIRE FIRE. • Evacuate the immediate vicinity, closing all doors and windows (if safe to do so) • Call the switchboard on 2222 and report fire and its location • Make your way to a Fire Assembly Point • Try to account for everyone in your department • The Trust Fire response team will investigate and take control. • Only attempt to fight the fire if safe to do so, you’re confident, you’re trained and always take someone with you for safety In a real fire situation, the Senior fire officer (Suffolk Fire Service) is in charge and only that officer can tell you when it is safe to re-enter the building or area

43. Fire Fighting Equipment • Carbon Dioxide Fire extinguisher - Used on Flammable liquids & Electrical fires. Hazard – Do not hold the horn or the bottom of the cylinder • Foam (AFFF) Fire extinguisher – Used on paper, cardboard, wood & contained flammable liquid fires. Hazard – Do not use on electrical fires • Fire Blanket – Ensure you protect your hands before attempting to smother the fire or object

44. Evacuation policy • On hearing an alarm • All non clinical areas to evacuate totally to a designated fire assembly point • All clinical areas are to horizontal evacuate to either an intermittent zone or a clear zone • Evacuation methods: • Walk • Wheelchairs • Beds

45. Safeguarding Adults Jayne Holmes Deputy Chief Nurse Ext. 2746

46. Safeguarding vulnerable adults A vulnerable adult is any person aged 18 or over who: • Is or may be in need of community services by reason of mental, physical, or learning disability, age or illness and who: • Is or may be unable to take care of himself or herself or unable to protect him or herself against significant harm or serious exploitation which may be occasioned by the actions or in-actions of other people.

47. Responsibilities • If you suspect that, a vulnerable adult is at risk of, or is actually suffering harm, you should: • In working hours, contact the hospital social care department for Suffolk patients or relevant county’s on-call social worker. • Outside of normal working hours, contact “Customer First” via switchboard. • The “Cause for Concern Communication Form” should be used to record the concern and action taken. A copy should be sent to Jayne Holmes, Safeguarding Lead and the form put into the patients notes

48. What information do I need? Social services will require information about: • The nature of the problem • General background about the people concerned • The name of the G.P. and other agencies in contact with the person • The level and nature of the immediate risk (and why) • Whether the person concerned is aware of/consenting to the referral • Previous occurrences • Who has been informed • Any actions taken or requested

49. Mental Capacity Act 2005 • The Mental Capacity Act protects people who can't make decisions for themselves or lack the mental capacity to do so. This could be due to: • a mental health condition • a severe learning difficulty • a brain injury, such as a stroke • or unconsciousness due to an anaesthetic or sudden accident.

50. Assessing Capacity This is a 2 stage assessment: Does the person have: • an impairment or disturbance in the functioning of the mind or brain, and • an inability to make decisions. A person is unable to make a decision if they cannot: • understand the information relevant to the decision, • retain that information, • use or weigh that information as part of the process of making the decision, or • communicate the decision. The final decision about a person’s capacity must be made by the person intending to make the decision or carry out the action on behalf of the person who lacks capacity