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OXYCODONE – Policy for Oxycodone Intravenous Patient Controlled
Analgesia – Adult Patients
Page 1 of 14 Date Issued: 31st October 2017
Review Date: April 2021 (ext1)
OXYCODONE – Policy for Oxycodone Intravenous Patient
Controlled
Analgesia – Adult Patients
Issue Date: 31st
October 2017
Disclaimer
Overarching policy statements must be adhered to in
practice.
Clinical guidelines are for guidance only. The interpretation
and application of them remains the responsibility of the
individual clinician. If in doubt contact a senior colleague or
expert.
The Author of this clinical document has ultimate responsibility
for the information within it.
This clinical document is not controlled once printed. Please
refer to the most up-to-date version on the intranet.
Caution is advised when using clinical documents once the review
date has passed. Clinical Document Template: v4.1 / 04-01-2016
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OXYCODONE – Policy for Oxycodone Intravenous Patient Controlled
Analgesia – Adult Patients
Page 2 of 14 Date Issued: 31st October 2017
Review Date: April 2021 (ext1)
CONTENTS
SECTION DESCRIPTION PAGE
1 INTRODUCTION 2
2 SCOPE OF DOCUMENT 3 3 DEFINITIONS AND/ OR ABBREVIATIONS 4
4 ROLES AND RESPONSIBILITIES 4
5 NARRATIVE 5-9
6 EVIDENCE BASE / REFERENCES 9
7 EDUCATION AND TRAINING 10
8 MONITORING COMPLIANCE 10
9 CONSULTATION 11
10 EQUALITY IMPACT ASSESSMENT (EIA) 11
11 KEYWORDS 11
12
APPENDICES
Appendix A – Equality Impact Assessment Form
11 12-13
DOCUMENT CONTROL (Last page) 14
ASSOCIATED DOCUMENTS
CADD® Solis Quick Guide
CADD® Solis Operator's Manual
Hyperlinked
to Pain Management Intranet Site
1. INTRODUCTION
This policy is issued and maintained by the Chief Nurse on
behalf of The Trust, at the issue
defined on the front sheet.
“The complexities associated with prescribing, preparing and
administrating injectable
medicines mean that there are greater potential risks for
patients than for other routes of
administration. Weak operating systems increase the potential
risk of harm and a safe
system of work is needed to minimise these risks.”
(NPSA, 2008)
This policy aims to establish standards of safe practice for
adult patients using oxycodone IV
PCA post operatively or for the management of pain following
trauma or during acute flare of
disease.
This policy is written in accordance with and reflects standards
set out in the Trust’s policy
for ‘The Care of the Patient Undergoing Intravenous Therapy
(Bolus, Continuous and
Intermittent)’, (version 2, 2017).
All registered healthcare professionals as defined in this
policy can check IV oxycodone in
accordance with their professional registration, but they are
prevented from administering
this medication unless they have received the Trust’s IV
medicines administration training
relevant to their area of practice (RD04/RD04.4/RD05).
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Analgesia – Adult Patients
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Review Date: April 2021 (ext1)
This policy identifies which members of staff can prescribe
oxycodone IV PCA and use this
equipment. It also specifies the level of training the
practitioner must complete: its place is to
ensure the highest standard of care delivery to patients.
Failure to comply with this policy
may be regarded as misconduct and dealt with in accordance with
the Trust’s disciplinary
procedures and potentially the practitioner’s regulatory
body.
2. SCOPE OF DOCUMENT
This clinical document applies to:
Staff group(s)
Appropriately trained registered nurses
Appropriately trained registered midwives
HCPC registered operating department practitioners
Anaesthetists
Clinical area(s)
ICCU
Main & Day Case Theatres/ Theatre Recovery (Kings Mill
only)
Wards 11,12,14,31 & 32
Sherwood Birthing Unit & Maternity Ward
Patient group(s)
Adult patients following major surgery, or surgery that has
resulted in severe
symptoms of pain.
Adult patients with severe acute pain following traumatic injury
or disease.
Maternity patients post Caesarean section with severe symptoms
of pain.
Exclusions
Patients under the age of 16 years old.
Patients who lack mental or physical capacity needed to use the
equipment (self -
administration button).
Related Trust policies and guidelines and/or other Trust
documents
Standard Operating Procedure Infection Prevention and Control
ICP 1
Policy for the Care of the Patient Undergoing Intravenous
Therapy (Bolus, Continuous
and Intermittent)
The Observations and Escalation Policy for Adult Patients
Medicines Policy
Medical Equipment User Training Policy
Medical Device Management Policy
Policy for Consent to Examination, Treatment and Care
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Analgesia – Adult Patients
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Review Date: April 2021 (ext1)
3. DEFINITIONS AND/OR ABBREVIATIONS
Trust Sherwood Forest Hospitals NHS Foundation Trust
Staff All employers of the Trust including those managed by a
third
party on behalf of the Trust
L Litres
TDS Three times a day
QDS Four times a day
PRN As required
IV Intravenous
PR Per rectum
PO Per oral
NG Nasogastric tube
IV PCA Intravenous patient controlled analgesia
NEWS National Early Warning Score
APPC Acute Pain Prescription Chart
SOC Specialist Observation Chart
ICCU Integrated Critical Care Unit
NSAID Non-steroidal anti-inflammatory drug
VIP Visual inflammatory phlebitis
EIA Equality Impact Assessment
EOS Electronic Observation System
4. ROLES AND RESPONSIBILITIES
4.1 RESPONSIBILITIES OF THE ANAESTHETIST:
Be conversant with this policy and access informal pump training
if required via the
Pain Team, Theatre Recovery Team or medical equipment training
facilitator;
ensuring competent use of the equipment.
Discuss the IV PCA with the patient to establish patient
compliance, physical and
mental capacity to use the system and any sensitivity to
oxycodone.
Ensure prescription of the correct opioid drug for the IV PCA on
the Trust APPC.
Ensure awareness of their patient’s post-operative progress.
4.2 RESPONSIBILITIES FOR THE REGISTERED NURSE/ODP:
Be conversant with this policy.
Access formal training and be assessed as competent in the use
of the grey
CADD®Solis IV PCA pump and associated equipment.
Ensure required patient observations are carried out as dictated
in this policy.
Appropriately respond to untoward events.
Ensure correct preparation of opioid drug as per
prescription.
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Analgesia – Adult Patients
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4.3 RESPONSIBILITIES FOR WARD SISTER/CHARGE NURSES:
To act as excellent role models and be responsible and
accountable for the policy
implementation among staff in practice, and the monitoring of
standards and best
practice associated with it.
Ensure that all staff in the sphere of their responsibility have
access to training
required to develop the skills and competence. This includes the
completion of the
associated work books, medical equipment competency documents
and study
sessions in a timely manner.
Ensure that all staff accountable to them are aware of this
policy and adhere to its
statement.
4.4 RESPONSIBILITY OF PHARMACISTS:
To monitor prescribing and oversee the administration of
medicinal therapies.
To alert prescribers and other health care professionals to
potential or actual
problems.
4.5 RESPONSIBILITY OF ALL ABOVE:
Report incidents or near misses relating to IV medicines using
the Trust incident
reporting system (Datix).
To gain valid consent. Patients have the legal and ethical right
to determine what
happens to them. Valid consent to treatment is essential to all
forms of healthcare and
paramount when considering invasive techniques. Obtaining
consent is also a matter
of common courtesy between the healthcare provider and
recipient.
5. NARRATIVE
IV PCA is suitable for pre and post-operative pain management
and/or the management
of pain caused by traumatic injury or acute flare of disease.
PCA allows the patient to
have more control over their analgesia and often avoids peaks
and troughs in plasma
concentration which can occur with the IM or SC route. IV PCA
has also been found to
save on nursing time and empowers patients to self- manage pain.
Caring for patients
with IV PCA requires specialist knowledge and training of the
bolus only infusion pumps
and awareness of potential side effects or complications. All
clinicians involved in the care of patients with IV PCA must be
trained and assessed as competent to do so.
In the interest of patient safety- IV PCA should not be used
concomitantly with
PCEA unless in a critical care environment.
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Analgesia – Adult Patients
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Review Date: April 2021 (ext1)
5.1 THE PRESCRIPTION/ OXYCODONE INFUSION BAG
IV PCA (oxycodone) standard prescription:
Oxycodone 0.5mg bolus with a 5 minute lockout interval (standard
dose) - no
background infusion.
The initial prescribed dose will be determined by the
prescribing anaesthetist and
may differ from the standard dose.
Changes from the initial prescription MUST be agreed by the Pain
Team or on-call
anaesthetist and the reason for the change documented in the
patient’s medical
notes. Any changes to the original prescription must be
documented and
prescribed on the APPC chart by a doctor.
Infusion bags are to be mixed by a registered practitioner under
the direct
observation of a second registered practitioner. The infusion
bag will contain
oxycodone 50mg (5 x 10mg ampules) in 100ml of 0.9% sodium
chloride;
concentration = 0.5mg per ml. The bag will clearly display a
yellow drug additive
label, which is dated and signed as per Medicines Policy. When
mixed, the
oxycodone infusion bag will have a life of 24 hours.
If commenced in Theatre Recovery, prior to discharge from this
area the RN will
inform the patients residing ward/ICCU that an oxycodone PCA is
insitu: this is to
allow time for injectable oxycodone ampule stock to be ordered
from Pharmacy
(injectable oxycodone will not be routine ward stock).
5.2 SETTING UP AN IV Oxycodone PCA (See CADD® Solis Quick Guide
for full
guidance).
Dedicated grey CADD®-Solis pump with a lock box, marked for
‘intravenous use
only’ and specifically configured for IV PCA must be used.
Dedicated CADD®-Solis giving sets must have anti-siphon and
anti-reflux valves
and “Y”- extension.
The pump programme and opioid infusion bag MUST be checked by
two qualified
practitioners who are appropriately trained as per Medicines
Policy.
The process for priming the line and preparing the pump is
described in:
o CADD® Solis Quick Guide
o CADD® Solis Operator's Manual
Ensure the ‘oxycodone’ programme is selected (morphine and
fentanyl
programme options are also available on these pumps).
The pump is automatically programmed to deliver a 0.5mg bolus
dose of
oxycodone with a 5-minute lockout as standard, but this
programme may need to
be changed on occasion due to higher / lower prescribed dose
based on individual
patient need.
The pump will only allow for bolus delivery and will not allow a
background
infusion.
All patients with an oxycodone IV PCA must be referred to the
Pain Team for daily
monitoring.
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Analgesia – Adult Patients
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5.3 SUPPORTIVE ANALGESIA
These are an essential part of PCA management. The requirement
for opioids and
severity of side effects can be effectively minimised with
additional analgesia-
supportive analgesia includes:
Paracetamol 1g QDS - PO/PR/NG/IV (if appropriate consider nature
of surgery
when selecting route for administration.
NSAID (unless contra-indicated) - oral ibuprofen 200mg-400mg TDS
or IV
Parecoxib 40mg (Theatre Recovery only).
Weak opioids e.g. tramadol 50-100mg QDS or codeine phosphate
/
dihydrocodeine 30-60mg QDS. This provides background analgesia
and may
reduce the amount of oxycodone required.
5.4 ANTIEMETICS
Follow Trust post-operative nausea and vomiting guidance:
First line: IV/PO ondansetron 4mg 6 hourly either PRN or QDS
Second line: IV/PO cyclizine 50mg 8 hourly either PRN or TDS
5.5 ITCHING
Opioids can cause itching:
Explain to the patient that this can be an effect of intravenous
opioids.
Consider administering ondansetron 4mg IV or an antihistamine
such as
chlorphenamine (chlorphenamine is a sedating anti-histamine
which could
potentially lead to increased levels of sedation when used
alongside oxycodone).
5.6 PATIENT MONITORING
Ensure the patient is monitored as stipulated below as oxycodone
has a significant
side effect profile…
Document via:
Observation
First 2
hours
Next 4
hours
Then 2 – 4 hourly for:
(patient’s condition
determines)
EOS /SOC Blood pressure 30 mins Hourly Duration of IV PCA
EOS /SOC Pulse 30 mins Hourly Duration of IV PCA
EOS /SOC & APPC Respirations 30 mins Hourly Duration of IV
PCA
EOS /SOC & APPC AVPU 30 mins Hourly Duration of IV PCA
EOS /SOC Oxygen saturation 30 mins Hourly Duration of IV PCA
EOS/SOC Temperature 30mins Hourly Duration of IV PCA
EOS /SOC & APPC Pain 30 mins Hourly Duration of IV PCA
APPC Itching 30 mins Hourly Duration of IV PCA
EOS / SOC Nausea & Vomiting 30 mins Hourly Duration of IV
PCA
EOS NEWS 30 mins Hourly Duration of IV PCA
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Analgesia – Adult Patients
Page 8 of 14 Date Issued: 31st October 2017
Review Date: April 2021 (ext1)
The table above demonstrates standard requirements for patient
monitoring with IV
PCA. Observations may need to be increased if a patient’s
condition deteriorates as
per guidelines set out in the Trust’s Observations and
Escalation Policy for Adult
Patients.
5.7 PUMP AND SYSTEM
Pump settings MUST be checked against the prescription by
performing a
programme review:
On hand over from the Theatre Recovery RN/ODP to the ward RN
and
documented on the APPC
At every shift change with two qualified nurses/midwives, one
from either shift to
ensure programming is correct.
Also ensure that:
The pump screen is displaying the oxycodone programme on a
purple
background (not the morphine programme on a blue background /
fentanyl
programme on a green background)
You document the PCA bolus dose, lockout period and PCA demands
on the
APPC at the observation times stated above.
5.8 CANNULA
The cannula must be checked as per VIP Trust Protocol
This is to be recorded on the Cannulation Documentation
Chart.
5.9 TROUBLESHOOTING PROBLEMS
5.9.1 Unrelieved pain:
Should be reviewed by a surgical F2 doctor/registrar to
eliminate underlying
causes.
Inform the pain nurse specialist or on call anaesthetist.
Check the pump is functioning correctly.
5.9.2 De-functioning pump:
Follow CADD® Solis Quick Guide
Contact the pain nurse specialists via Vocera
If pain nurse unavailable contact the Theatre Recovery Team for
advice on
ext.3704
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Analgesia – Adult Patients
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Review Date: April 2021 (ext1)
5.9.3 Sedation and respiratory depression:
If the patient is drowsy or difficult to rouse (AVPU – P or U)
and/or respiratory rate is
less than 8 breaths per minute:
The handset MUST be taken away from the patient and pump
stopped.
Administer oxygen at 4L/min via face mask.
Prepare Naloxone 200mcg IV and contact the ward doctor
immediately
Inform on call anaesthetist and or the pain nurse specialist and
record event on
the APPC
The IV PCA must not be recommenced without prior advice from the
on call
anaesthetist or pain nurse specialist.
5.10 CAUTIONS
Only the patient must press the PCA button.
Ensure the bolus demand button is visible at all times.
5.11 DISCONTINUATION
Ensure adequate step-down analgesia is prescribed prior to
discontinuation of
the IV PCA.
Please return the pump / power cable to Theatre Recovery
promptly following
discontinuation and cleaning (Clinell wipe).
6. EVIDENCE BASE / REFERENCES
Australia and New Zealand College of Anaesthetists (ANZCA)
(2015) Acute Pain
Management: Scientific Evidence: 4th Edition. ANZCA.
Melbourne.
Lee A, O’Loughlin E, Roberts LJ (2013) A double-blinded
randomized
evaluation of alfentanil and morphine PCA versus fentanyl PCA:
analgesia
and sleep trial. BJA 110 (2): 293 – 298
Macintyre PE (2001) Safety and efficacy of patient controlled
analgesia. BJA
87 (1): 36-46
Smiths Medical (2011) CADD®-Solis 2100, 2110 Ambulatory Infusion
Pumps-
Operator’s Manual. Smiths Medical. Watford.
Smiths Medical (2009) Quick Guide for the CADD®-Solis. Smiths
Medical.
Watford.
The Royal Marsden Hospital (2015) Manual of Clinical Nursing
Procedures:
9th Edition. Royal Marsden Hospital. London.
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Analgesia – Adult Patients
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Review Date: April 2021 (ext1)
7. EDUCATION AND TRAINING
7.1 For Anaesthetists:
Be conversant with this policy and access informal training
available via Pain or
Theatre Recovery Teams.
Ensure competent to use the equipment.
7.2 For Nurses/ODP:
To be conversant with this policy. This policy will be promoted
by a pain nurse
specialist during Trust Induction Programme and the Pain
Management Study
Day.
To have completed the IV PCA training package and have been
assessed as
competent by a senior member of staff or a member of the Pain
Team.
8. MONITORING COMPLIANCE
Monitoring of compliance and competencies will be achieved via
the database on the
register of training retained in the Training and Development
Department.
WHO is going to monitor
this element (job title
of person/ group
responsible)
WHAT element of compliance
or effectiveness within
the procedural
document will be
monitored
HOW will this element be
monitored (method
used)
WHEN will this element be
monitored
(frequency/ how
often)
REPORTING Which committee/ group
will the resultant report
and action plan be
reported to and
monitored by (report
should include any
areas of good practice/
organisational learning)
Ward Leaders Competency
packs are
complete
Appraisals,
Induction
On going Department
leaders/ ward
leaders
Training and
Development
Training
completion packs
Register of training On going Practice
Development
Forum
Pain nurse
consultant
Reported
incidents
Datix Following each
incident
Anaesthetic
Governance Group
Pain nurse
specialists
Daily audit trail Recorded onto
pain management
database via Orion
For each patient
with oxycodone
IV PCA
Anaesthetic
Governance Group
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Analgesia – Adult Patients
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9. CONSULTATION
The following individuals, groups of staff and Trust group(s)/
committee(s) have been
consulted in the development/ update of this document:
Contributors: Communication
Channel: e.g.
Email
1:1 meeting/ phone
Group/ committee
meeting
Date:
Anaesthetic Lead in Acute Pain- Dr Hasan Pathan email 9/8/17
Divisional Head of Midwifery / Nursing – Alison Whitham email
9/8/17
Matron for Surgery – Marie Sissons email 9/8/17
Matron for Theatres & ICCU – Sharon Baxter email 9/8/17
Lead Pharmacist- Thomas Bell email 9/8/17
Theatre Recovery Lead Nurse- Claire Wythes-Liddle email
9/8/17
Practice Development Lead Nurse – Claire Madon email 9/8/17
Drugs and Therapeutics Committee meeting
Speciality Anaesthetic Clinical Governance Group meeting
18/10/2017
10. EQUALITY IMPACT ASSESSMENT (EIA)
The Trust is committed to ensuring that none of its policies,
procedures and guidelines
discriminate against individuals directly or indirectly on the
basis of gender, colour, race,
nationality, ethnic or national origins, age, sexual
orientation, marital status, disability,
religion, beliefs, political affiliation, trade union
membership, and social and employment
status. An EIA of this policy/guideline has been conducted by
the author using the EIA
tool developed by the Diversity and Inclusivity Committee. See
Appendix A for
completed form.
11. KEYWORDS
IV; PCA; IVPCA; Programming; Grey; CADD®-Solis; pump;
oxycodone
12. APPENDICES
Appendix A – Equality Impact Assessment Form
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Analgesia – Adult Patients
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Review Date: April 2021 (ext1)
Appendix A – Equality Impact Assessment (EqIA) Form (please
complete all sections)
Guidance on how to complete an EIA Sample completed form
Name of service/policy/procedure being reviewed: Policy for
Oxycodone Intravenous Patient Controlled Analgesia – Adult
Patients
New or existing service/policy/procedure: Existing
Date of Assessment: 1st November 2017
For the service/policy/procedure and its implementation answer
the questions a – c below against each characteristic (if relevant
consider breaking the policy or implementation down into areas)
Protected
Characteristic
a) Using data and supporting information, what issues, needs or
barriers could the protected characteristic groups’ experience? For
example, are there any known health inequality or access issues to
consider?
b) What is already in place in the policy or its implementation
to address any inequalities or barriers to access including under
representation at clinics, screening?
c) Please state any barriers that still need to be addressed and
any proposed actions to eliminate inequality
The area of policy or its implementation being assessed:
Race and Ethnicity: Non-English speaking patients may face
potential issues on understanding the explanation given on how to
use the bolus button and rationale behind patient controlled
analgesia (PCA).
Verbal translation will be required via a Trust appointed
language translator or via use of ‘big word’ telephone
translation.
None
Gender:
None None None
Age:
None None None
Religion: None None None
Disability:
Patients with physical disabilities affecting use of hands will
not be able to operate this equipment. Patients who lack the mental
capacity to effectively uses this device will not be offered this
analgesic technique
Alternative analgesic techniques / plans will be available /
prescribed for patients who cannot physically operate the
self-administration (bolus) button or for patients who lack the
mental capacity understand or use the device
None
Sexuality:
None None None
Pregnancy and Maternity:
None None None
Gender Reassignment:
None None None
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Marriage and Civil Partnership:
None None None
Socio-Economic Factors (i.e. living in
a poorer neighbourhood /
social deprivation):
None None None
What consultation with protected characteristic groups including
patient groups have you carried out? Consultation for this policy
via speciality (anaesthetics) governance and key clinicians /
pharmacists associated with the use of IV PCA in approved clinical
areas
What data or information did you use in support of this EqIA?
None
As far as you are aware are there any Human Rights issues be
taken into account such as arising from surveys, questionnaires,
comments, concerns, complaints or compliments? No
Level of impact From the information provided above and
following EqIA guidance document, please indicate the perceived
level of impact: Low Level of Impact For high or medium levels of
impact, please forward a copy of this form to the HR Secretaries
for inclusion at the next Diversity and Inclusivity meeting.
Name of Responsible Person undertaking this assessment:
Signature: Clare Burton
Date: 01/11/2017
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Analgesia – Adult Patients
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Document control/ supporting information for this clinical
document
Title:
OXYCODONE – Policy for Oxycodone Intravenous Patient Controlled
Analgesia – Adult Patients
Document category: Clinical Policies and Guidelines
Reference:
CPG-TW-IVPCA(Fentanyl)
Version number:
1.0
Approval:
v. Approved by:
Approval Date:
1.0 Anaesthetic Clinical Governance Group 18-10-2017
Issue date:
31st October 2017
Review date: April 2021 (ext1)
Job title of author responsible for the document/ author
name:
Pain Management Nurse Consultant/ Clare Burton
Division & Specialty/ Department/ Service responsible for
reporting the status of the document
Surgery
Anaesthetics, Critical Care & CSSD – Anaesthetics/ Pain
Management
Document Sponsor:
Chief Nurse
Date Equality Impact Assessment completed/ updated:
Date Month Year
Superseded document(s): (Ref No., Version number, previous title
if changed, date issued – review date)
Not Applicable – NEW
Distribution (Circulation):
This document will be accessible via the Trust’s intranet.
Communication:
Information regarding the initiation and subsequent updates of
this document will be communicated via the earliest weekly Trust
staff bulletin/ nursing bulletin and/ or other agreed communication
method.