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Canberra Hospital and Health ServicesClinical Procedure Administration of Antibiotics by Community Nurses – Adults Only Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – General Information...............................................................................................2

Section 2 – Administration of IV Antibiotics by Push Dose via a CVAD.....................................3

Section 3 – Administration of IV Antibiotics by Freeflex® mini infusion bag via a CVAD...........4

Section 4 – Administration of IV Antibiotics by a non-electronic medication pump via a CVAD.................................................................................................................................................. 6

Section 5 – Administration of Intramuscular Injection IMI Site Antibiotics...............................8

Implementation...................................................................................................................... 10

Related Policies, Procedures, Guidelines and Legislation.......................................................10

References.............................................................................................................................. 11

Definition of Terms................................................................................................................. 13

Search Terms.......................................................................................................................... 13

Attachments............................................................................................................................13

Attachment 1 - Intramuscular Injection Technique.............................................................14

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Purpose

The purpose of this procedure is to provide Community Care Program (CCP) Registered Nurses (RNs) with information on the safe and effective management of an adult patient receiving antibiotics via a Central Venous Access Device (CVAD) or intramuscular (IM) route in the community.

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RNs do not administer the first dose of each course of intravenous (IV) or IM antibiotics, the first dose is to be given by a Medical Officer (MO).

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This document applies to the following CCP staff working within their scope of practice: Nurses and Midwives Student Nurses under direct supervision.

This document is to be read in conjunction with: Clinical Guideline Management of Anaphylaxis in Adults and Children Clinical Procedure Central Venous Access Device (CVAD) Management – Children,

Adolescents and Adults (NOT Neonates) Healthcare Associated Infections Procedure.

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Admission Criteria If referral requests for administration of IV antibiotics occur more frequently than twice

daily, community nursing capacity needs to be discussed with the CCP Assistant Director of Nursing before acceptance of the referral.

The patient must: Be 18 years old or above. Have a General Practitioner (GP) in the ACT region who is willing to be responsible for

the medical care for this episode of care. Have an Infectious Diseases Specialist in the ACT if the administration of IV or IMI

antibiotics is required for more than 10 days. The referral source is to provide the name of the ACT Infectious Diseases Specialist and date of the referral.

Provide their own medication (antibiotics, Adrenaline x 2 ampoules). Have received the first dose of each course of medication by a MO.

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This Standard Operating Procedure (SOP) describes for staff the process to

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Have a medical order on the ‘Medical Officers Orders For Medication Administration’ form which is filed in the clinical record for:o Antibiotico Normal saline flush (sodium chloride 0.9% 10mL)o Pro re nata (PRN) Adrenaline

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Section 2 – Administration of IV Antibiotics by Push Dose via a CVAD

Equipment Medical order Medication with reconstituting /diluting fluid as prescribed Adrenaline x 2 ampoules (access to 1mL syringes, drawing up needles and 23 gauge

needles) Injection tray / container / kidney dish Soft pre-moistened cloths Alcohol Based Hand Rub (ABHR) Clean gloves Safety eyewear Luer lock syringes 10mL Luer lock syringe 20mL (if a larger than 10mL syringe is required for medication

reconstituting) 10mL sodium chloride 0.9% for flushes Drawing up needles Chlorhexidine 2% alcohol 70% swabs Sharps disposal container Clinical waste receptacle

Procedure1. Attend to hand hygiene using soft pre-moistened cloths and ABHR.2. Set up equipment.3. Attend to hand hygiene.4. Don safety eyewear and clean gloves - Standard Aseptic Non Touch Technique (ANTT).5. Prepare the medication for use according to MIMS, or the Australian Injectable Drugs

Handbook or the manufacturer’s product information.6. Remove gloves and attend to hand hygiene.7. Don clean gloves.8. Draw up sodium chloride into syringes using a drawing up needle.9. Inspect the CVAD for signs of inflammation or infection.10. Swab the needleless injection cap firmly with chlorhexidine 2% alcohol 70% swab for 10

seconds. Allow to dry for 30 seconds. 11. Attach the syringe 10mL and withdraw 5mL of blood to establish patency by observing

blood return, disconnect and discard the syringe.12. Swab the needleless injection cap firmly with chlorhexidine 2% alcohol 70% swab for 10

seconds. Allow to dry for 30 seconds

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13. Attach the sodium chloride 0.9% syringe 10mL flush in pulsatile motion, as per Positive Pressure Flushing Method. DO NOT CLAMP if using the Caresite™ Luer Lock Access device (Positive Pressure). Disconnect the syringe.

14. Swab needleless injection cap firmly with chlorhexidine 2% alcohol 70% swab for 10 seconds. Allow to dry for 30 seconds.

15. Attach the syringe with medication and inject medication at the recommended rate.Disconnect the syringe.

16. Swab needleless injection cap firmly with chlorhexidine 2% alcohol 70% swab for 10 seconds. Allow to dry for 30 seconds.

17. Attach the sodium chloride 0.9% syringe 10mL and flush in pulsatile motion. DO NOT CLAMP if using the Caresite™ Luer Lock Access device (Positive Pressure). Disconnect the syringe.

18. Discard equipment appropriately, including use of sharps container.19. Remove gloves and safety eyewear.20. Attend to hand hygiene. 21. Document in clinical record.22. No post antibiotic administration observation period is required if the patient remains

stable. If concerned refer to the Clinical Guideline Management of Anaphylaxis in Adults and Children and follow procedures within this document.

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Section 3 – Administration of IV Antibiotics by Freeflex® mini infusion bag via a CVAD

An IV pole may need to be organised through the Equipment Loan Scheme (ELS) prior to admission to the CCP. An ‘ELS Referral Checklist’ form must be completed by the requesting RN and emailed or faxed to ELS to organise the loan of the IV pole if required (see ACT Equipment Loan Service Policy).

Alert:Check that the prescribed medication is compatible with sodium chloride 0.9% in MIMS, the Australian Injectable Drugs Handbook or the manufacturer’s product information before preparing the medication for use.

Equipment Medical order Medication as prescribed Adrenaline x 2 ampoules (access to a 1mL syringes, drawing up needles and 23 gauge

needles) Injection tray / container / kidney dish Soft pre-moistened cloths Alcohol Based Hand Rub (ABHR) Clean gloves Safety eyewear

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Freeflex® sodium chloride 0.9% injection solution for intravenous infusion mini bag 50mL or 100mL x 1 (e.g. PICS: 27383 or 70063)

Freeflex® transfer device (e.g. PICS: 111089) IV gravity administration set (e.g. PICS: 79796) Luer lock syringes 10mL x 2 Sodium chloride 0.9% 10mL for flushes Drawing up needles Chlorhexidine 2% alcohol 70% swabs IV pole Sharps disposal container Non transparent rubbish bag

Procedure1. Attend to hand hygiene using soft pre-moistened cloths and ABHR.2. Set up equipment.3. Attend to hand hygiene.4. Don safety eyewear and gloves - Standard ANTT.5. Draw up sodium chloride into syringes using a drawing up needle.6. Reconstitution using the Freeflex® sodium chloride 0.9% mini bag and Freeflex® transfer

device: Identify the white injection port on the Freeflex® mini bag Break off the white cover from the Freeflex® mini bag injection port. Push the narrow end of the Freeflex® transfer device over the white injection port to

the first notch. The tip of the needle is now in the sterile chamber. Prepare the antibiotic vial and connect it to the open end of the Freeflex® transfer

device. Push the Freeflex® transfer device with the vial towards the mini bag to pierce the

inner membrane. Press the solution into the vial from the mini bag to dissolve the powder. Turn the vial upside down and press air into the vial to transfer the solution from the

vial into the Freeflex® minibag. Repeat until all liquid is transferred. If a second vial of the same prescribed medication is required to make up the full

dose, remove the vial from the Freeflex® transfer device and repeat the above steps Remove the vial and Freeflex® transfer device from the white injection port and

discard into the sharps container.7. Break off the blue cover from the Freeflex® minibag blue infusion port.8. Spike the Freeflex® minibag via the blue infusion port with the IV administration set and

prime the line. Hang the Freeflex® mini bag on the IV pole.9. Remove gloves and attend to hand hygiene.10. Don clean gloves.11. Inspect the CVAD for signs of inflammation or infection. 12. Swab the needleless injection cap on the CVAD firmly with chlorhexidine 2% alcohol 70%

swab for 10 seconds. Allow to dry for 30 seconds. 13. Attach the syringe 10mL and withdraw 5mL of blood to establish patency by observing

blood return, disconnect and discard the syringe.

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14. Swab the needleless injection cap firmly with chlorhexidine 2% alcohol 70% swab for 10 seconds. Allow to dry for 30 seconds

15. Attach the sodium chloride 0.9% syringe 10mL flush in pulsatile motion, as per Positive Pressure Flushing Method. DO NOT CLAMP if using the Caresite™ Luer Lock Access device (Positive Pressure). Disconnect the syringe.

16. Swab needleless injection cap firmly with chlorhexidine 2% alcohol 70% swab for 10 seconds. Allow to dry for 30 seconds.

17. Pick up the IV administration set with the Freeflex® mini bag attached and carefully remove the cap from the end of the line without touching the end of the line. Connect the line to the CVAD with a clockwise turn. Administer medication at the recommended rate.

18. Remove gloves and attend to hand hygiene if attending to other tasks during infusion.19. Attend to hand hygiene and don clean gloves.20. At completion of the infusion close the roller clamp on the IV administration set.21. Disconnect the IV administration set from the CVAD with an anticlockwise turn.22. Swab the needleless injection cap firmly with chlorhexidine 2% alcohol 70% swab for 10

seconds. Allow to dry for 30 seconds. 23. Connect the sodium chloride 0.9% syringe 10mL, flush in pulsatile motion, as per Positive

Pressure Flushing Method. DO NOT CLAMP if using the Caresite™ Luer Lock Access device (Positive Pressure). Disconnect the syringe

24. Discard equipment appropriately, including use of sharps container.25. Remove gloves and safety eyewear.26. Attend to hand hygiene. 27. Document in the clinical record.28. No post antibiotic administration observation period is required if the patient remains

stable. If concerned refer to the Clinical Guideline Management of Anaphylaxis in Adults and Children and follow procedures within this document.

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Section 4 – Administration of IV Antibiotics by a non-electronic medication pump via a CVAD

An example of a non-electronic medication pump is a Baxter or Mobifuser Elastomeric Infusion Pump.

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Note:If the Elastomeric Pump is refrigerated ask the patient/ carer to remove the pump from the refrigerator and allow the device to reach room temperature prior to use.

Monitoring Infusion Progress Since the pump delivers medication at a slow rate (e.g. 10mLs per hour) the elastomeric

‘balloon’ reservoir will appear to be shrinking over several hours. Ensure the IV tubing is not clamped or kinked. Educate the patient to check the progress of the infusion three times per day. Mobifuser: as the balloon deflates the black line (volume indicator) slowly moves

downwards. Check how much of the medication has infused by lining up the black line with the amounts in the outer case.

Baxter: utilise progression lines on the pump housing to monitor infusion progress over time. The infusion is complete when all eight indicator bumps (four on either side of the balloon) on the inside of the device are clearly visible.

Infusion progress is complete when the ‘balloon’ is completely deflated.

Equipment Medical order Elastomeric infusion pump for IV Administration as prescribed Adrenaline x 2 ampoules (access to a 1ml syringes, drawing up needles and 23 gauge

needles) Soft pre-moistened cloths Alcohol Based Hand Rub (ABHR) Clean gloves Safety eyewear Dressing pack Tape Luer lock syringes 10mL x 2 Sodium chloride 0.9% 10mL for flushes Drawing up needles Chlorhexidine 2% alcohol 70% swabs Scissors Sharps container Non transparent rubbish bag

Procedure1. Attend to hand hygiene using soft pre-moistened cloths and ABHR.2. Set up equipment.3. Remove tape securing the pump line to the skin.4. Remove the old pump from the belt/mesh bag or carry case.5. Attend to hand hygiene and don safety eyewear and clean gloves - Standard ANTT.6. Draw up sodium chloride into syringes using a drawing up needle.7. Carefully open the new infusion pump plastic overpouch using scissors.

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8. Remove the luer cap for the end of the new infusion pump line. Check to make sure that the fluid has moved to the end of the tubing.

9. Replace the luer cap and position the new line within easy reach in the opened dressing pack.

10. Remove gloves.11. Attend to hand hygiene using ABHR and don clean gloves.12. Inspect the CVAD for signs of inflammation or infection.13. Disconnect the old pump line, from the CVAD with an anticlockwise turn and discard.14. Swab the needleless injection cap on the CVAD firmly with chlorhexidine 2% alcohol 70%

swab for 10 seconds. Allow to dry for 30 seconds. 15. Attach the sodium chloride 0.9% syringe 10mL flush in pulsatile motion, as per Positive

Pressure Flushing Method. DO NOT CLAMP if using the Caresite™ Luer Lock Access device (Positive Pressure). Disconnect the syringe.

16. Swab the needleless injection cap on the CVAD firmly with chlorhexidine 2% alcohol 70% swab for 10 seconds. Allow to dry for 30 seconds.

17. Pick up the new infusion pump line and carefully remove the luer cap from the end of the line without touching the end of the line and connect the new pump line to the CVAD with a clockwise turn.

18. Mobifuser: secure the new mobifuser line to the skin with tape placed between the air filter and flow rate controlled tubing. Baxter: tape the new luer lock connector to the patient’s skin at approximately the same level as the top of the pump.Ensure that the top of the pump is carried as close to the connector as possible (e.g. maximum of approximately 10cm distance). The flow rate is most accurate when the top of the pump and the connector are at the same height.

19. Place the new pump in the belt/mesh bag or carry case.20. Discard equipment appropriately, including use of sharps container.21. Remove gloves, safety eyewear.22. Attend to hand hygiene. 23. Document in clinical record 24. No post antibiotic administration observation period is required if the patient remains

stable. If concerned refer to the Clinical Guideline Management of Anaphylaxis in Adults and Children and follow procedures within this document.

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Section 5 – Administration of Intramuscular Injection IMI Site Antibiotics

General Information Prepare the medication for use according to MIMS, or the Australian Injectable Drugs

Handbook or the manufacturer’s product information Medications are not mixed in a single syringe unless specifically prescribed by a MO and

checked for compatibility. The site for IMI must be chosen carefully, taking into account the patients' general

physical status, patient preference and the purpose of the injection. Attachment 1 describes and illustrates the process for locating intramuscular injection (IMI) sites.

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When medications are to be repeatedly given by IMI, the site must be varied, rotate the injection site from right side to left.

Needle length depends on the chosen injection site, the patient's size and the amount of subcutaneous fat covering the tissue.

Equipment Medical order Prescribed medication Adrenaline x 2 ampoules (access to 1ml syringes, drawing up needles & 23 gauge

needles) Soft pre-moistened cloths Alcohol Based Hand Rub (ABHR) Clean gloves Injection tray / container / kidney dish Syringe-size as required Drawing up needle Needle for injection: 23 gauge (32mm) to 21 gauge (40mm) Alcohol swabs Gauze Small dressing for injection site if required (e.g. PICS: 10251 Dressing Spot Bandaid) Sharps container Non transparent rubbish bag

Procedure1. Attend to hand hygiene using soft pre-moistened cloths and ABHR.2. Don clean gloves - Standard ANTT.3. Use a drawing up needle to draw up the antibiotic.4. Change the needle to administer the antibiotic. 5. Position the patient according to the site to be chosen.6. Select an appropriate injection site. The Ventrogluteal IM Injection site is recommended

for antibiotics (see Attachment 1). 7. Clean the injection site with an alcohol swab in a circular motion of approximately 5-8 cm

for 30 seconds. Allow to dry.8. Remove the sheath from the needle.9. The recommended Z-track technique involves pulling the skin and subcutaneous tissue

with the non dominant hand 2 to 3 cm to the side or down from the injection site. Alternatively gently stretch the skin of the injection site taut with the non dominant hand. Hold the syringe like a pencil or dart, and insert the needle at a 90° angle, leaving 0.5 cm of the needle exposed.

10. Withdraw plunger gently to aspirate for blood for 5 – 10 seconds. If blood is returned discard the syringe, medication and needle into the sharps bin and start again at a different site.

11. If no blood is apparent, slowly inject the medication (1mL per 10 seconds) until the full dose is administered.

12. Quickly withdraw the needle, then release the skin.

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13. Apply gentle pressure with dry gauze, do not massage the site. Apply a small dressing over the site if required.

14. Dispose of equipment directly into sharps container. 15. Remove gloves.16. Attend to hand hygiene. 17. Document in clinical record including injection site and the location either the right or

left side.18. No post antibiotic administration observation period is required if the patient remains

stable. If concerned refer to the Clinical Guideline Management of Anaphylaxis in Adults and Children and follow procedures within this document.

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Implementation

This procedure will be communicated to community nurses via team meetings. It will be incorporated into existing education and orientation programs.

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Related Policies, Procedures, Guidelines and Legislation

Legislation ACT Medicines, Poisons and Therapeutic Goods Act 2008 ACT Medicines, Poisons and Therapeutic Goods Regulation 2008 Health Practitioner Regulation Law (ACT) Act 2010 Work Health and Safety Act 2011

Policies ACT Equipment Loan Service Policy Nursing and Midwifery Continuing Competence Policy and SOP Medication Handling Policy

Procedures Antimicrobial Stewardship Healthcare Associated Infections Aseptic Non Touch Technique Community Care Program Referral Management Central Venous Access Device (CVAD) Management – Children, Adolescents and Adults

(NOT Neonates)

Guidelines Management of Anaphylaxis in Adults and Children

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References

1. Baxter Healthcare. Baxter Elastomeric Pumps. Contacted 2016 October 24. Clinician Guide. 2010. Patient Guide. 2010. Patient Pocket Guide. Baxter Infusor Range. n.d. Professional Guide. 2012.

2. Brown J, Gillespie M, Chard S. The dorso-ventro debate: in search of the empirical evidence. British Journal of Nursing. 2015; 24(22):1132-1139.

3. Cocoman A, Murray J. Recognizing the evidence and changing practice on injection sites. British Journal of Nursing. 2010; 19(18):1170-1174.

4. Cocoman A, Murray J. Intramuscular injections: a review of best practice for5. mental health nurses. Journal of Psychiatric and Mental Health Nursing. 2008;15(5):424-

434. 6. Coskun H, Kilic C, Senture C. The evaluation of the dorsogluteal and ventrogluteal

injection sites: a cadaver study. Journal of Clinical Nursing. [Internet]. 2016 Apr [cited 2016 Nov 30];25(7-8):1112-1119. Available from: http://onlinelibrary.wiley.com/doi/10.1111/jocn.13171/epdf DOI: 10.1111/jocn.13171.

7. Fresenius Kabi. Medical Devices. Reconstitution Using the Freeflex® Transfer Device. Contacted 2016 November 10.

8. Joanna Briggs Institute. Injection: Intramuscular. 2016. Mann E. Injection (Intramuscular): Clinical Information. 2016. Mann E. Intramuscular Injection: Aspiration. 2016. Mann E. Evidence Summary: Injection (Intramuscular). 2016.

9. Hamilton S. Chapter 6. Intravenous Therapy. Nettina SM. (Ed.). Lippincott Manual of Nursing Practice. 10th ed. Philadelphia. Wolters Kluwer Health Lippincott Williams & Wilkins. 2014. p. 82-101.

10. HealDove. [Internet]. Ventrogluteal Injection. Last updated 2015 June 12 [cited 2016 December 1]. Figure 2 Locating the Ventrogluteal Injection Site According to the V Method. In Kaya N, Salmaslıoğlu A, Terzi B, Turan N, Acunaş B. The reliability of site determination methods in ventrogluteal area injection: A cross-sectional study. International Journal of Nursing Studies. 2015 Jan;52(1):356. Available from: https://healdove.com/health-care-industry/Ventrogluteal-Injection

11. Hopkins U, Arias CY. Large-volume IM Injections: A review of best practices. Oncology Nurse Advisor. [Internet]. 2013 Jan/Feb. [cited 2016 Nov 25]:32-37. Figure 1, Sites for Intramuscular Injection; p. 33. Available from: http://media.oncologynurseadvisor.com/documents/44/ona_feature0213_injections_10767.pdf

12. Hunter J. Intramuscular injection techniques. Nursing Standard. 2008;22(24):35-40.13. Kara D, Uzelli D, Karaman D. Using the ventrogluteal site in intramuscular injections is a

priority or an alternative? International Journal of Caring Sciences. 2015;8(2):507-513.14. Kaya N, Salmaslıoğlu A, Terzi B, Turan N, Acunaş B.The reliability of site determination

methods in ventrogluteal area injection: A cross-sectional study. International Journal of Nursing Studies. 2015 Jan;52(1):355-60.

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15. MIMS Online. MIMS Australia 2017. [Internet]. [cited 2017 March 07]. Available from ACT Health Library: http://tch.anu.edu.au/ https://www.mimsonline.com.au/Search/Search.aspx

16. Mobilife. Mobifuser Home Care Infusion Pump. [Internet]. [cited 2017 March 07]. Available from: http://mobilifemedical.com/ Instructions for Use Medical Professional Information

17. MIMS Online. March 2017. [Internet]. ACT Health Library. http://tch.anu.edu.au/ [cited 2017 March 08]. Available from: https://www.mimsonline.com.au/Search/Search.aspx

18. Ogston-Tuck S. Intramuscular injection technique: an evidence-based approach. Nursing Standard. 2014;29(4):52-59. Table 1 Intramuscular injection sites; p. 55.

19. Sisson H. Aspirating during the intramuscular injection procedure: a systematic literature review. Journal of Clinical Nursing. 2015;24(17-18):2368-2375. The Society of Hospital Pharmacists of Australia. The Australian Injectable Drugs Handbook. 7th ed. Melbourne. 2016.

20. Tufanaru C. Mental Health: Intramuscular Injections (Ventrogluteal Site). 2016.[cited 2016 November 16]. ACT Health Library. http://tch.anu.edu.au/ Available from: http://access.ovid.com/custom/can999/update/

21. Wynaden D, Tohotoa J, AL Omari O, Happell B, Heslop K, Barr L, Sourinathan V. Administering intramuscular injections: How does research translate into practice over time in mental health setting? Nurse Education Today. 2015 Apr; 35(4):620-624.

Contacts for further information 1. Calvary Health Care, Care at Home HITH T: 6201 6604

7am-6pm 7 days per week2. Canberra Hospital, Hospital In the Home (HITH) T: 6174 8260 / 6244 2818

Monday-Friday 8am-5pm including public holidays3. Canberra Hospital Infectious Diseases Unit T: 6244 2105

Monday-Friday: 9am–5pm. After Hours contact the Infectious Diseases Registrar on call through Canberra Hospital Switch T: 6244 2222

4. Canberra Hospital Pharmacy T: 6244 2121Monday-Friday: 8.30am–5pm, Weekends and Public Holidays: 9am-5pm

5. ACT Equipment Loan Service T: 6207 0658 F: 6205 2604 E: ELS@act.gov.au Address: 37 Kingsmill Street Kambah ACT 2902Office hours for collection and return of equipment are Monday to Friday 08:30am – 5.00pm, Saturday and Sunday 11:00am – 12:00pm. Collection is subject to prior confirmation by ELS Staff that the requested equipment is available.

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Definition of Terms

Baxter Elastomeric Pump: a non-electronic medication pump designed to provide ambulatory infusion therapy. Medication is delivered to the patient as the elastomeric ‘balloon’ consistently deflates and gently pushes solution through the IV tubing and into the CVAD.

Mobifuser Elastomeric Infusion Device: is a delivery device which is driven by a balanced contraction of an elastic reservoir, with infusion rate controlled by flow rate controlled tubing. The mobifuser delivers medication on a continuous basis over a specified period of time

Z Track Technique: is an IM injection manoeuvre that creates a disjoint perforation or broken injection pathway that locks the medication into the targeted muscle preventing leakage into the subcutaneous tissue and decreases the chance of local irritation.

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Search Terms

Antibiotic, CVAD, IV, IMI, home, care, infusion, medication, pump

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Attachments

Attachment 1 - Intramuscular Injection Technique

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved By

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Attachment 1 - Intramuscular Injection Technique

Injection SiteThere are three muscle groups indentified for IM injections: the deltoid muscle of the upper arm, gluteal muscle of the buttocks and the quadriceps muscle; the rectus femoris and vastus lateralis of the thigh (Ogston-Tuck 2014 p 53 see Attachment 1, Figure 1 and Table 1).

Ventrogluteal IM Injection SiteThe ventrogluteal IM injection site, located in the hip (see attachment 1 Figure 2) is preferred rather than the dorsogluteal (located in the buttocks ‘upper outer quadrant’) site.

Advantages for the ventrogluteal site include: Thickness of the gluteal muscle Freedom from penetrating nerves and blood vessels Narrow layer of adipose tissue overlying the site The patient does not need to be rolled to be given the injection and may lie on their

back, abdomen or side for the injection.

1. Landmarking instructions:Locate the landmarks of the greater trochanter (bony prominence of the hip joint) and the iliac crest (the thick curved upper border of the ileum, the most prominent bone on the pelvis. You can feel the iliac crest by pushing your hand on your sides at your waist, feeling the bone and following it down and to the front).

2. Positioning:Position your right hand to the patient’s left side if using the left ventrogluteal site, or place your left hand to the patient’s right side for the right ventrogluteal site. Place the palm of your hand over the greater trochanter. Point your index finger toward the anterior iliac crest. Spread the second or middle finger toward the back of the iliac crest, making a V with your fingers. The injection site is in the middle of this V, level with the knuckles of your fingers. Your thumb should always be pointed towards the front of the patient’s body.

3. AdministrationRemove your hand to one side of the injection site to assist with preparing to administer the injection in the targeted area you have just landmarked.

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Figure 1 Sites for Intramuscular Injection

Note: Sites for Intramuscular Injection. Reprinted from Hopkins U, Arias CY. Large-volume IM injections: A review of best practices. Oncology Nurse Advisor. 2013. p. 33. Available from: http://media.oncologynurseadvisor.com/documents/44/ona_feature0213_injections_10767.pdf

Table 1 Intramuscular Injection SitesInjection site Recommended

volumePatient Positioning Site selection/landmarking

Deltoid 1-2mL Standing or sitting, with arm placed on the waist to relax the muscle

Identify the acromial process. Place two fingers or measure 2.5cm, from this location along the lateral aspect of the humerus.Alternatively, draw an imaginary line from the axilla across to the humerus and inject just above this.

Ventrogluteal 2.5-3mL Lying on the side in the prone position facing away. Bend the knee or gently point the toe outward to relax the muscle.

Identify the greater trochanter of the femur and place the base of the hand over this. Reaching toward the iliac crest, so the index finger is toward or touching the iliac crest, spread the fingers apart. The injection should be placed in the ‘V’ when the index finger and second finger are splayed.

Rectus femoris and vastus lateralis

Up to 5mL Sitting or lying, with the toes gently pointed away to relax the muscle.

Place the base of one hand over the greater trochanter of the femur and the base of the other hand over the kneecap. In the space between fingertips, the injection should be placed on the lateral or anterior surface, in the upper two-thirds of the thigh.

Note: Adapted from Intramuscular injection sites and useful anatomical landmarks. Ogston-Tuck S. Intramuscular injection technique: an evidence-based approach. Nursing Standard. 2014;29(4):55.Figure 2 Locating the Ventrogluteal Injection Site According to the V MethodDoc Number Version Issued Review Date Area Responsible PageCHHS17/195 1 10/08/2017 01/08/2022 RACC 15 of 16

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS17/195

Note: Locating the Ventrogluteal Injection Site According to the V method. Reprinted from HealDove [Internet]. Last updated 2015 June 12 [cited 2016 December 1] Available from: https://healdove.com/health-care-industry/Ventrogluteal-Injection

Doc Number Version Issued Review Date Area Responsible PageCHHS17/195 1 10/08/2017 01/08/2022 RACC 16 of 16

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register