Our Policies

Author: W MELTON  (based on First Practice Management Format)
Version:  1.2
Date Issued: 01/12/2020
Reviewed: 12/12/2024
Review: 12/12/2025
Classification: Public

The on-line version of this document is the only version that is maintained.  Any printed copies should, therefore, be viewed as ‘uncontrolled’ and as such may not necessarily contain the latest updates and amendments.

1  INTRODUCTION

1.1. Wolds Medical has a statutory duty to safeguard the confidential information it holds. The principle of this policy is that no individual or company working for or with the organisation shall misuse any information it processes or comes into contact with, or allow others to do so. It is also required that all individuals or companies working for or on behalf of the organisation implements appropriate information security to protect the information they process and hold in line with legal obligations.

1.2. During the course of their day to day work, many individuals working within or for the organisation will often handle or be exposed to information which is deemed personal, sensitive or confidential, (including commercially confidential) information. It is a requirement that any individual, company and firm to which this policy applies shall not at any time during the period they work for or provide services to the organisation or at any time after its termination, disclose confidential information that is held or processed by or on behalf of the organisation.

1.3 All staff working in the organisation are bound by a legal duty of confidence to protect personal information they may come into contact with during the course of their work. This is not just a requirement of their contractual responsibilities but also a requirement within the Data Protection Act 1998/2018 and, for health and other professionals, through their own professions Codes of Conduct.

1.4. The organisation places great emphasis on the need for the strictest confidentiality in respect of person identifiable and sensitive data. This applies to manual and computer records and conversations about service user’s treatments. Everyone working for the organisation is under a legal duty to keep service user’s information, held in whatever form, confidential. Service users who feel that confidence has been breached may issue a complaint under the organisations complaints procedure or they could take legal action.

1.5. Confidentiality should only be breached in exceptional circumstances and with appropriate justification and this must be fully documented.

1.6. The organisation is committed to the delivery of a first class confidential service. This means ensuring that all personal service user and staff information is processed fairly, lawfully and as transparently as possible so that the public can:

• understand the reasons for processing personal information;
• give their consent for the disclosure and use of their personal information where necessary;
• gain trust in the way the organisation handles information; and
• understand their rights to access information held about them.

2 ENGAGEMENT

This policy has been developed based on the knowledge and experience of the Information Governance team. It is derived from a number of national codes and policies which are considered as best practice and have been used across many public sector organisations.

3 IMPACT ANALYSES

3.1 Equality

An equality impact screening analysis has been carried out on this policy.

As a result of performing the analysis, the policy, project or function does not appear to have any adverse effects on people who share Protected Characteristics and no further actions are recommended at this stage.

3.2 Sustainability

A sustainability assessment has been completed and is attached at Appendix 2. The assessment does not identify and benefits or negative effects of implementing this document.

4 SCOPE

This policy applies to all Wolds Medical staff, members, temporary staff, seconded staff, contractors and others undertaking work on behalf of the organisation etc.

4.1. For those staff covered by a letter of authority/honorary contract or work experience the organisations policies are also applicable whilst undertaking duties for or on behalf of the organisation. Further, this policy applies to all third parties and others authorised to undertake work on behalf of the organisation.

4.2. For the purposes of this policy, confidential information shall include any confidential information relating to the organisation and/or its agents, customers, prospective customers, service users, suppliers or any other third parties connected with the organisation and in particular shall include, without limitation:

• service user information;
• ideas/programme plans/forecasts/risks/issues;
• finance/budget planning/business cases;
• sources of supply and costs of equipment and/or software;
• prospective business opportunities in general;
• computer programs and/or software adapted or used;
• corporate or personnel information; and
• contractual and confidential supplier information. This is irrespective of whether the material is marked as confidential or not.

5 POLICY PURPOSE & AIMS

The aims of this policy are:

• to safeguard all confidential information held and processed by Wolds Medical;
• to provide guidelines for all individuals working within the organisation;
• to ensure a consistent approach to confidentiality across Wolds Medical;
• to ensure all staff are aware of their responsibilities with regards to confidential information;
• to provide all individuals working within the organisation access to the documents which set out the laws, codes of practice and procedures relating to confidentiality and which apply to them. These include:
• the common law duty of confidentiality;
• Caldicott principles;
• Human Rights Act 1998;
• the Department of Health Publication: Confidentiality: NHS Code of Practice November 2003;
• the Department of Health Publication Confidentiality: NHS Code of Practice – Supplementary Guidance: Public Interest Disclosures November 2010;
• Data Protection Act 1998 and 2018
• The Public Interest Disclosure Act 1998;
• The Computer Misuse Act 1990;
• Care Record Guarantee.
• The EU General Data Protection Regulation (GDPR) 2018;

It must also be recognised that under the Data Protection Act 1998/2018 that individuals have the right to request access to their information, regardless of the media and format in which the information is held. The organisation must therefore put processes and procedures in place to respond to subject access requests in line with the Data Protection Act 1998/2018.

5.1. Conduct

Individuals shall not be restrained from using or disclosing any confidential information which:

• they are authorised to use or disclose by the organisation; and/or
• has entered the public domain unless it enters the public domain as a result of an unauthorised disclosure by the individual; and/or
• has entered the public domain by an authorised disclosure for an authorised purpose by the individual or anyone else employed or engaged by the organisation; and/or
• they are required to disclose by law; and/or
• they are entitled to disclose under the Public Interest Disclosure Act 1998 provided that the disclosure is made in an appropriate way to an appropriate person having regard to the provisions of that Act.

All individuals must:

• exercise all due care and diligence to prevent unauthorised disclosure of confidential information;
• ensure the physical security of all confidential documents and/or media, including storage of files on PCs and any mobile equipment. Confidential information must never be left unattended and should be secure when not in use, this is incredibly important when in a public place and work containing confidential information should only be done in public places when absolutely necessary and all information must be kept in the strictest confidence;
• password protect all magnetic media
• passwords must not be disclosed to anyone including colleagues.
• Only use officially issued and fully encrypted mobile equipment in line with the mobile/agile working standard.
• Individuals must implement appropriate information security and safe haven procedures to protect the information they hold and process

All individuals will be required to comply with this policy whilst working within Wolds Medical and thereafter for as long as the information remains confidential information. It is only when the information has entered the public domain that the information can be classed as no longer confidential.

If an individual is unclear if information should be classified as confidential, they must discuss the issue with their manager who will offer advice.

5.2. The duty of confidence

• All NHS bodies and those carrying out functions on behalf of the NHS have a duty of confidence to service users and a duty to support professional ethical standards of confidentiality and any service providing any healthcare related activity.
• Everyone working for or with the NHS records that handles, stores or otherwise comes across information that is capable of identifying individual service users has a personal duty of confidence to the service user and to his/her employer.
• The duty of confidence is conferred by common law, statute, contract of employment, disciplinary codes and policies and professional registration.
• Service users expect that information given by them to their doctors, nurses and other members of the healthcare team is treated in confidence and not passed to others without their permission. Similar considerations apply to personal information concerning other individuals, such as staff. Particular care must be taken to avoid inadvertent or accidental disclosure. The underlying principle is that all information that can be related to an individual must be treated as confidential and it must not be communicated to anyone who is unauthorised to receive it. Unauthorised staff includes those who are not involved in either the clinical care of the service user or the associated administration processes.
• No personal information, given or received in confidence, may be passed to anyone else without the consent of the provider of the information. This is usually the service user but sometimes another person may be the source (e.g. relative or carer).
• No personal information, given or received in confidence for one purpose, may be used for a different purpose without the consent of the provider of the information.
• Service users are entitled to object to the use of their personal health data for purposes other than their immediate care.
• The duty of confidentiality owed to a deceased service user should be viewed as being consistent with the rights of living individuals.

5.3 What is personal information

• Person-identifiable information is anything that contains the means to identify a person, e.g. name, address, postcode, date of birth, NHS number, National Insurance number etc. Any data or combination of data and other information, which can indirectly identify the person, will also fall into this definition.
• Information that identifies individuals personally must be regarded as confidential, and should not be used unless absolutely necessary.
• Whenever possible, anonymised data, that is data where all personal details have been removed and which therefore cannot identify the individual, should be used. Note however that even anonymised information can only be used for justified purposes.
• Confidential information is information entrusted by an individual in confidence where there is a general obligation not to disclose that information without consent.
• Confidential information may include personal information such as name, age, address, and personal circumstances, as well as sensitive personal information regarding race, health, sexuality, etc.
• Confidential information may be known, or stored on any medium. Photographs, videos, etc. are subject to the same requirements as information stored in health records, on a computer, or given verbally.

Further information on what constitutes personal information:

https://ico.org.uk

5.4 Disclosing Information

• The NHS Confidentiality Code of Practice provides advice on using and disclosing confidential service user information and has models for confidentiality decisions and all Wolds Medical staff should adhere to this guidance.
• Personal information may be disclosed on the basis of informed consent where the disclosure is necessary for healthcare purposes and is undertaken by a health professional or a person owing an equivalent duty of confidentiality.
• The organisation will inform service users, staff and any other data subject why, how and for what purpose personal information is collected, recorded and processed.
• Consent of the data subject will be required where a disclosure of personal information is not directly concerned with the healthcare / treatment of a service user e.g. medical research, health service management, financial audit, personnel data or where disclosure is to a non-health care professional.
• Under common law, personal information may be disclosed without consent for example:
  • in order to prevent abuse or serious harm to others
  • where the public good that would be achieved by the disclosure outweighs both the obligation of confidentiality to the service user concerned and the broader public interest in the provision of a confidential service.
• Where information is required by the police, this must be in line with the Data Protection Act section 29, and staff should consult the Information Governance, Security and Compliance Manager. Decisions on whether to disclose information or not must be recorded.

5.5 Personnel information

In keeping with good Human Resources practice, the organisation retains and processes personal data on its employees. In addition, the organisation may from time to time, retain and process “sensitive personal data” (as defined by the Data Protection Act 1998(DPA)), for example in relation to sickness and occupational health records, performance reviews, equal opportunities monitoring for the prevention of fraud or other illegal activities.

The organisation may process such data and such data may be legitimately disclosed to appropriate employees and to the organisations professional advisors, in accordance with the principles of the DPA.

The organisation takes all reasonable steps to ensure that the data it holds is accurate, complete, current and relevant. If a member of staff considers that data held on him/ her is or may be inaccurate, or if he/she wishes to have access to such data, then contact should be made with the Head of Human Resources.

5.6 Media Enquiries

All requests for information by the media, other than those made under the Freedom of

Information (FOI) Act, must be referred to the Business Manager.

5.7. Termination or expiry of a contract with Wolds Medical

On leaving or termination of a contract with the organisation any copies of software, documents or correspondence, diaries, documents, plans, specifications or any other information relevant to the organisation (whether or not prepared or produced by the individual) must be returned to the organisation’s possession and under no circumstances must the leaver take this information with them. All individuals that have left the organisation are bound by the Confidentiality Policy that was in publication at the time of their departure.

5.8. Awareness and compliance

It is important to the organisation to protect its legitimate business interests and in particular it’s confidential information. Breaches of confidentiality, of any sort, including breach of this policy will be regarded as serious misconduct and may result in:

• dismissal;
• termination of secondment for secondees and a request for their employer to apply their internal disciplinary procedures;
• termination of contracts for interim resources, temporary workers, agency workers and/or contractors; and
• legal action being taken against the discloser and/or any other third party.

If an individual unintentionally divulges confidential information, or they are aware of any individual doing so, he or she must report it immediately to their line manager.

Everyone in the organisation must be aware of the importance of confidentiality. All staff need to be aware of their responsibilities for safeguarding service user confidentiality and keeping information secure.

The duty of confidentiality is written into employment contracts. Breaches of confidentiality are a serious matter. A breach of confidentiality of information gained, whether directly or indirectly, in the course of duty is a disciplinary offence which could result in dismissal and/ or prosecution. No employee shall knowingly misuse any information or allow others to do so.

It is a disciplinary offence to access records/ information that you have no legitimate reason to view this includes, records about yourself, your family, friends, neighbours, acquaintances. If you do not have a legitimate reason to access, do not browse. Remember all transactions are auditable.

6 Roles / Responsibilities / DUTIES

6.1. Overall accountability for procedural documents across the organisation lies with the Business Manager who has overall responsibility for establishing and maintaining an effective Information Governance Framework, for meeting all statutory requirements and adhering to guidance issued in respect of procedural documents.

6.2. Overall responsibility for the confidentiality policy lies with Business manager who has delegated responsibility for managing the development and implementation of Confidentiality policy procedural documents.

6.3. The Caldicott Guardian is responsible for overseeing and advising on issues of service user confidentiality for the organisation.

6.4. Line managers are responsible for ensuring that all staff, particularly new staff, temporary staff, contractors and volunteers, know what is expected of them with respect to confidentiality and protecting information. They are also responsible for monitoring compliance with this guideline e.g. undertake ad hoc audits to check for inappropriate disclosures, records left out, abuse of passwords etc.

6.5. Staff are responsible for maintaining the confidentiality of all personal and corporate information gained during their employment with the organisation and this extends after they have left the employ of the organisation.

6.6. Individual staff members are personally responsible for any decision to pass on information that they may make.

6.7. All staff are responsible for adhering to the Caldicott principles, the Data Protection Act, and the Confidentiality Code of Conduct.

6.8.  Staff will receive instruction and direction regarding the policy from a number of sources:

• policy/strategy and procedure manuals;
• line manager;
• specific training course;
• other communication methods (e.g. team brief/team meetings);
• staff Intranet;

6.9. All staff are mandated to undertake Information Governance training on an annual basis. This training should be provided within the first year of employment and then updated as appropriate in accordance with the Statutory and Mandatory Training Standard and Information Governance Training Needs Analysis.

6.10. The organisation must ensure that all contractors and supporting organisations are working to documented contracts or service level agreements that detail their responsibilities in respect of information governance and security, and confidentiality and data protection. This includes the completion of the Information Governance Toolkit to a minimum of level 2 compliance.

7  IMPLEMENTATION

The policy will be disseminated by being made available on the intranet and highlighted to staff through newsletters, team briefings and by managers.

‘Breaches of this policy may be investigated and may result in the matter being treated as a disciplinary offence under Wolds Medical’ disciplinary procedure’.

8 TRAINING & AWARENESS

Staff will be made aware of the policy on induction.

9  MONITORING & AUDIT

9.1. Performance against the Information Governance Toolkit will be reviewed on an annual basis and used to inform the development of future procedural documents.

9.2. This policy will be reviewed every year, and in accordance with the following on an as and when required basis:

• legislative changes;
• good practice guidance;
• case law;
• significant incidents reported;
• new vulnerabilities; and
• changes to organisational infrastructure.

9.3. Equality Impact Assessment

9.3.1. The organisation aims to design and implement services, policies and measures that are fair and equitable. As part of its development, this policy and its impact on staff, service users and the public have been reviewed in line with the organisation‘s Legal Equality Duties. The purpose of the assessment is to improve service delivery by minimising and if possible removing any disproportionate adverse impact on employees, service users and the public on the grounds of race, socially excluded groups, gender, disability, age, sexual orientation or religion/ belief.

9.3.2.  The Equality Impact Assessment has been completed and has identified impact or potential impact as “no impact”

9.4. Records Management, Retention and Disposal

9.4.1. A records management system must be implemented to ensure that all records are maintained in accordance with the Data Protection Act and Caldicott Principles (See Annexes A&B), and the NHS Records Management, Code of Practice.

9.4.2  The records management systems must include appropriate controls to protect information from unauthorised access, theft or loss, and inappropriate disclosure of person identifiable or corporately confidential information.

9.4.3 A system of timely housekeeping must be implemented and include secure methods of destruction for records that have reached their retention period and been assessed as not to be retained for permanent preservation.

9.5. Complaints

9.5.1 The organisation will implement a complaints procedure to deal with complaints in connection with the Data Protection Act and breaches of confidentiality. If the complainant is not satisfied with the investigation and outcome of their complaint they should be advised of their right to contact the Information Commissioners Office.

10 POLICY REVIEW

This policy will be reviewed in 1 year.  Earlier review may be required in response to exceptional circumstances, organisational change or relevant changes in legislation/guidance, as instructed by the senior manager responsible for this policy.

Version: 3.0

Author: Carol Melton, Lead Sonographer Elizabeth Bowles, Senior Sonographer, Rob Tew, Senior Sonographer.

Date: 11/12/2024
Review Date: 11/12/2025

The on-line version of this document is the only version that is maintained.  Any printed copies should, therefore, be viewed as ‘uncontrolled’ and as such may not necessarily contain the latest updates and amendments.

The ultrasound machines, carts, transducers, patient examination couches and examination counter tops should be cleaned / or disinfected as per the protocol stated in this policy in order to provide infection control for the safety of patients and staff.

Procedure

A clean paper sheet covers the examination couch and integral headrest for every patient.  If the patient is required to void during the examination replace the sheet again if stained with gel.

The ultrasound unit, utilised transducers, any equipment which is directly involved in skin contact are cleaned after every patient with multi-surface disinfectant wipes.  Any excess gel is initially wiped off the probes with a paper towel. If any of the equipment comes into contact with blood or bodily fluid, it is cleaned as soon as the examination has finished with Tristel duo cleaning system.  Please refer to the specific Tristel policy on the T-drive.

If an endo-cavity examination is performed, the transducer is firstly covered by a sheath or cover containing sterile gel for acoustic coupling, then a sachet of sterile gel is applied.  Non-latex probe covers are always used. The sonographer must wear non-latex gloves and must ensure personal responsibility for good hand hygiene at all times.

Once the examination is completed the probe cover is carefully removed from the transducer to avoid cross contamination and the sheath placed in the clinical waste bin along with the clincians gloves. Any gel remaining on the endo- cavity transducer is removed by a paper towel and the probe is routinely cleaned with Tristel duo including the cable.

For non endo-cavity probes, the excess gel is removed with paper towels and then cleaned with a disinfectant wipe.

When scanning a patient with an open wound or sore, a transducer cover and sterile gel may be required.  The probe will be cleaned thoroughly using the Tristel cleaning system following the initial clean.

At the end of the afternoon / evening session the removal of clinical waste is performed by the clinician and a fresh bag placed in the clinical bin ready for the next day. Place, date and time are written on the waste bag and the bag taken to the clinical waste room for safe disposal.

The counter tops, floors and general environmental cleaning is provided by the housekeeping staff at the end of the working day.

A “deep” clean of the ultrasound scan room is carried out by housekeeping staff on a monthly basis.

Good Practice Guidance Re Intimate Ultrasound Examinations and Use of Chaperone within the Community Setting

Intimate examinations, including but not limited to examinations of pelvis, genitalia, axilla/chest, upper thigh and groin, may be stressful and embarrassing for patients.

• Every person assigned female at birth, aged 16 years or older for a gynaecological examination, is eligible to be offered TVUS. Eligibility is extended to transgender men, transgender women and people who identify as asexual, intersex or non-binary. In some circumstances minors may be offered TVUS. There is no upper age limit for TVUS. The age, sexual status, sexuality, religious or personal beliefs of the person or the ultrasound practitioner should not be barriers to offering TVUS.
• Patients who have not had penetrative sex are still entitled to be offered a TVUS in the same way that cervical screening is offered to all eligible patients. Cultural and religious factors may influence a patient’s wish to consent to TVUS, however religious mandate should not prevent an individual being offered TVUS.
• Explain to the patient why an examination is necessary, give the patient an opportunity for questions and encourage discussion.
• Explain what the examination will involve, in a way the patient can understand, so that the patient has a clear idea of what to expect, including any potential pain or discomfort. If during the examination this differs from what you have told the patient, explain why and seek the patient’s permission.
• Obtain the patients verbal and written consent. Ascertain that the patient has received the information/consent form (See Appendix 1), has read and understood it and signs the form declaring their informed consent. The sonographer performing the examination must then also sign the consent form.
• The signed and dated consent form should then be scanned in and attached to the patient’s record.
• Offer a trained chaperone. The patient may have a relative or friend present for support, however a trained chaperone is still required in addition to this. If a chaperone is present, you should record this and make a note of the chaperone’s identity within the report.

A chaperone should usually be a health care professional or a member of the Ultrasound

Team and they should be:

• Sensitive and respect the patients dignity and confidentiality.
• Reassure the patient if they show signs of distress or discomfort.
• Be familiar with the procedures involved in a routine intimate examination.
• Stay for the entire examination and be able to see the procedure.
• Be prepared to flag any issues regarding the scan.
• Patients are within their rights to request either a Male or Female sonographer.
• All male sonographers should have a trained female chaperone present whilst performing a transvaginal ultrasound.
• If for justifiable reasons you cannot offer a chaperone or if either of you are uncomfortable with the choice of chaperone, you should explain that to the patient and, if necessary, offer to delay the examination to a later date. You should record the discussion and its outcome.
• If the patient declines a chaperone, but the sonographer would prefer one to be present then the importance of a chaperone should be explained to the patient.
• Ultimately the patient’s clinical needs must take precedence. You may wish to consider referring the patient to a colleague who would be willing to examine the patient without a chaperone, as long as a delay would not adversely affect the patient’s health.
• Please note that a non-latex probe cover and hypoallergenic lubricant should be utilised where applicable.
• Give the patient privacy to undress and dress in a warm and comfortable setting using drapes to maintain the patient’s dignity.

Do not assist the patient in removing clothing unless they have asked you to or you have clarified with them that your assistance is required.

The above provides guidance for intimate examinations.  All physical examinations should be approached in a similar professional manner.  Where patients appear nervous, the offer of a chaperone may be professionally appropriate.

This policy has been adopted from the NE Lincs CCG/ HNYICB Guidelines for chaperone policy during intimate examinations and used in conjunction with the GMC Intimate examinations and chaperones guide and Society of Radiographers Intimate Examinations and Chaperone Policy.

Patient Information

Gynaecological ultrasound scans are routinely performed both transabdominally (on the tummy) and transvaginally (internally). This technique is a high resolution examination of the pelvic organs and is often the best technique for achieving high quality diagnostic images.

There are no known risks associated with ultrasound when performing a transvaginal scan. Transvaginal ultrasound scans can safely be performed during menstruation and episodes of vaginal bleeding.

You have the right to decline this examination.

A transvaginal scan will be offered to you if you are aged 16 or over as these are the British Medical Ultrasound Society guidelines.

Please note that we use a non-latex probe cover and sterile Pasante lubrication for transvaginal ultrasound scans. This is to meet with our risk assessment procedures and protocols for infection control.

If you have any concerns regarding the scan, please discuss with the health professional before giving written consent.

So what does a Transvaginal Ultrasound involve?

• The transducer will be prepared with a non-latex probe covering and sterile ultrasound gel.
• The transducer will then be gently placed into the vagina.
• It will be necessary to move the transducer from side to side, up and down and may be swivelled to obtain the required images of your pelvic anatomy.
• A third person may be present during the examination acting as a chaperone, if required by the sonographer or yourself.
• If you would like a chaperone to be present you may ask for one before your appointment or during it.
• You may request the examination to be stopped at any time during the procedure.
• The scan can take up to 10 minutes to perform.
• The probe is then gently removed and you will be given privacy and wipes to clean and get dressed.
• Once the scan is finished the probe is cleaned using high grade medical disinfectant.

Contraindications

• Patient Choice
• Vaginal obstruction
• Recent vaginal surgery
• Premature ruptured membranes during pregnancy
• Gellhorn or shelf pessary where self-management is not possible

Version:	1.0
Name of originator/author:	William Melton (consulted with GPs, Pharmacist and Physiotherapist)
Date issued:	11.08.2024
Review date:	11.08.2025

Policy for Administration of Steroid, 0.9%NaCL and Local Anaesthetic Injections by Registered Allied Health Professionals

Independent Prescribers – professionals who are responsible for the initial assessment of the patient and for devising the broad treatment plan, with the authority to prescribe the medicines required as part of that plan. This includes medical staff, dentists and authorised nurse and pharmacist prescribers who have successfully completed an independent prescribing course. A qualified independent prescribing physiotherapist or allied health professional can prescribe the drugs contained within this policy, adhering to the Standards for Independent Prescribers from the Health and Care Professions council (HCPC). Mixing of steroid, local anaesthetic and/or 0.9%NaCL prior to administration is permissible using this mechanism.

Drugs and Injection

An injection may only be carried out if informed consent is given and in the absence of exclusions e.g. Hypersensitivity to any of the ingredients; Systemic infections unless specific anti-infective therapy is employed.

Triamcinolone Acetonide e.g. Kenalog can be administered via injection for the management of pain, stiffness and inflammation associated peripheral neuro-musculoskeletal lesions. Injections are limited to neuro-musculoskeletal conditions and do not include spinal/vertebral injections. Injection is only offered after an assessment of the patient, including medical history, list of medications/sensitivities, history of presenting problem and discussion of alternative treatment options

Where a caution to injection is present, alternative management should be discussed with the patient in addition to the effects and side effects of injection including the possible effects on their medical condition. If necessary, the allied health professional should consult further with the patient’s medical practitioner to discuss the individual case. If the medical practitioner agrees that it is acceptable to continue with injection therapy, record of this decision should be documented in patient’s notes. If the medical practitioner feels it is unsuitable to continue with injection therapy, this too is documented and patient informed of decision and alternative management agreed.

Administration of Medicines

It is unacceptable to prepare medicines in advance of their immediate use or to prepare medicines for administration by others. It is unacceptable to administer medicines prepared by another practitioner if this practitioner is not present.

Allied health professional supplementary prescribers are not allowed to prescribe controlled drugs.

Preparation

Skin cleaning prior to injection must be undertaken using a disposable disinfection wipe or Chlorhexidine Gluconate 0.5% w/v in 70% v/v DEB. Steroid injection is carried out following a ‘no touch’ technique and in keeping with infection control and hand hygiene policies.

Reporting

The following will be recorded in the patient’s clinical records:

• Record patient consent
• The diagnosis and treatment
• The dose administered
• Batch number and expiry date
• The route and site of administration
• The signature and name of the person administering the medication

Side effects and post injection

All qualified clinicians caring for patients are responsible for monitoring patients for side effects during the consultation. Patients should be asked about any adverse reactions to medications. Post procedure the patient is reminded of potential side-effects and that they are most likely to occur within 20 minutes. They are encouraged again to remain in the surgery for this time and tell a member of staff if they feel unwell. (This is included in the information leaflet sent with the initial appointment). Patients are advised of problems to look out for following the injection and signposted to their GP or 111 for advice.

Patients are advised to avoid heavy loading of tendons that have been injected around for up to 2 weeks, due to the potential for transient weakening.

Training and Qualifications Required

In order to work under this guideline, therapists must be; HCPC registered allied health professional who have specific, appropriate supervised training and have been assessed as competent to administer injections or HCPC registered allied health professional undertaking the appropriate training and working under the supervision of an allied health professional qualified in injection therapy.

Additional requirements

• Immediate access to Adrenaline 1 in 1000 for anaphylaxis
• Up to date Hepatitis B vaccination
• Emergency cardiopulmonary resuscitation and anaphylaxis training
• Working knowledge of Wolds Medicals Medicines Policy and associated Standard Operating Procedure; Anaphylaxis Policy and Consent policy
• An up to date risk assessment of the Injectable Medicines
• Evidence of continuing professional development, training and competence in intra-articular and soft tissue injection and the management of musculoskeletal lesions

Allied health professionals training must also comply with the above.

Clinical governance will be ensured by:

• All staff undertaking injections must perform 2 audits per year with an Orthopaedic Consultant, which will be written up and fed back.
• New staff within Wolds Medical must undertake 2 injections prior to practicing, observed by a senior clinician qualified in injection therapy.

Policy for Administration of Steroid and Local Anaesthetic Injections by Registered Allied Health Professionals

Version:	1.0
Name of originator/author:	William Melton (consulted with GPs, Pharmacist and Physiotherapist)
Date issued:	11.08.2022
Reviewed:	01.05.2024
Review Date:	01.05.2025

Independent Prescribers – professionals who are responsible for the initial assessment of the patient and for devising the broad treatment plan, with the authority to prescribe the medicines required as part of that plan. This includes medical staff, dentists and authorised nurse and pharmacist prescribers who have successfully completed an independent prescribing course. A qualified independent prescribing physiotherapist or allied health professional can prescribe the drugs contained within this policy, adhering to the Standards for Independent Prescribers from the Health and Care Professions council (HCPC). Mixing of steroid and local anaesthetic prior to administration is permissible using this mechanism.

Drugs and Injection

An injection may only be carried out if informed consent is given and in the absence of exclusions. Glucocorticoids e.g. Kenalog/Depomedrone can be administered via injection for the management of pain, stiffness and inflammation associated peripheral neuro-musculoskeletal lesions. Hyaluronic Injections may also be administered as required. Injections are limited to peri-articular and intra-articular lesions of the upper and lower extremities only. Injection is only offered after a full assessment of the patient, including medical history, list of medications/sensitivities, history of presenting problem and discussion of alternative treatment options.

Where a caution to injection is present, alternative management should be discussed with the patient in addition to the effects and side effects of injection including the possible effects on their medical condition. If necessary, the allied health professional should consult further with the patient’s medical practitioner to discuss the individual case. If the medical practitioner agrees that it is acceptable to continue with injection therapy, record of this decision should be documented in patient’s notes. If the medical practitioner feels it is unsuitable to continue with injection therapy, this too is documented and patient informed of decision and alternative management agreed.

Administration of Medicines

It is unacceptable to prepare medicines in advance of their immediate use or to prepare medicines for administration by others. It is unacceptable to administer medicines prepared by another practitioner if this practitioner is not present.

Allied health professional supplementary prescribers are not allowed to prescribe controlled drugs.

Preparation

Skin cleaning prior to injection must be undertaken using a disposable disinfection wipe. Steroid injection is carried out following a ‘no touch’ technique and in keeping with trust infection control and hand hygiene policies.

Reporting

The following will be recorded in the patient’s clinical records:

• Record patient consent
• The diagnosis and treatment
• The dose administered
• Batch number and expiry date
• The route and site of administration
• The signature and name of the person administering the medication

Side Effects and Post Injection

All qualified clinicians caring for patients are responsible for monitoring patients for side effects. Patients should be asked about any adverse reactions to medications. Post procedure the patient is reminded of potential side-effects and that they are most likely to occur within 20 minutes. They are encouraged again to remain in the surgery for this time and tell a member of staff if they feel unwell. (This is included in the information leaflet sent with the initial appointment). If side-effects are observed or reported the administering allied health professional should be informed immediately who may in turn choose to escalate to a GP.

Patients are advised to avoid heavy loading of tendons that have been injected around for up to 2 weeks, due to the potential for transient weakening.

Self-referrals Following Initial GP Referral and 1^st Appointment

Patients may only receive a maximum of 3 ultrasound guided steroid injections per year as long as there are no side effects/ complications and the patient is properly consented. This may only be appropriate when:

• the patient cannot have surgery
• patients are in severe pain and there are no other treatment options
• the patient declines surgery

If the ultrasound guided steroid injection is used for pain management which the patient is requesting, one of the above criteria is met and it is easing the patients pain and quality of life they may self-refer as long as the procedure is effective in providing pain relief for a sustained period of time.

Training and Qualifications Required

In order to work under this guideline, therapists must be; HCPC registered allied health professional who have specific, appropriate supervised training and have been assessed as competent to administer injections or HCPC registered allied health professional undertaking the appropriate training and working under the supervision of an allied health professional qualified in injection therapy.

Additional requirements

• Immediate access to Adrenaline 1 in 1000 for anaphylaxis
• Up to date Hepatitis B vaccination
• Emergency cardiopulmonary resuscitation and anaphylaxis training
• Working knowledge of Wolds Medical Medicines Policy and associated Standard
• Operating Procedure; Anaphylaxis Policy and Consent policy
• An up to date risk assessment of the Injectable Medicines
• Annual training in emergency cardiopulmonary resuscitation (CPR) and anaphylaxis procedures
• Evidence of continuing professional development, training and competence in intra-articular and soft tissue injection and the management of musculoskeletal lesions

Allied health professionals training must also comply with the above.

Clinical governance will be ensured by:

• All staff undertaking injections must perform 2 audits per year with an Orthopaedic Consultant, which will be written up and fed back.
• New staff within Wolds Medical must undertake 2 injections prior to practicing, observed by a senior clinician qualified in injection therapy.