Guidance for Teaching Patients and Carers Self Administration of Low Molecular Weight Heparin - Enoxaparin ( Inhixa brand) 

• Introduction
• Principles of Protocol for the Administration of LMWH
• Principles for District Nurse referral
• Practice Nurse Referral Process

Introduction

Low Molecular Weight Heparin (LMWH) is widely used across the trust for the prevention and treatment of Venous Thromboembolism (VTE) and for bridging therapy for patients on warfarin who are undergoing surgery. In many cases patients are required to continue with LMWH therapy after discharge. 

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Principles of Protocol for the Administration of LMWH

1. Target Patient Groups
   The target patient group is any patient (adult or child) who requires LMWH administration at home.
   
   
2. Initial Prescription
   Prior to prescription of LMWH patients should have baseline bloods sent to check their FBC, U&E’s, LFT’s and clotting screen. If bloods are satisfactory and a decision is made to commence LMWH the initial prescription of LMWH should be discussed with the patient to ensure they understand why they are being prescribed the drug. They should also be informed that Enoxaparin (Inhixa) is a porcine based product. Patients should be given a VTE prevention information leaflet (this should be given as soon as LMWH treatment commences), a sharps disposal bin, tear off leaflet detailing injection technique, and a supply of the drug.
   
   
3. Supply of LMWH
   Leeds Teaching Hospitals Trust will supply the whole course of LMWH for patients who require the drug for a short period of time (approximately 6 weeks). General Practitioners will be asked to supply LMWH for patients who require the drug for a prolonged period of time.
   
   
4. Administration
   LTHT nursing staff should encourage all patients who require administration of LMWH at home to self-administer the drug. If this is not appropriate staff should attempt to encourage a carer to administer the LMWH. It is anticipated that the vast majority of patients or carers will be able to self/carer administer LMWH confidently and competently at the point of discharge. We recognise that some patients/carers will require additional support on discharge and we will arrange for the community nursing teams to visit this group of patients until they feel confident and competent at self/carer administration. It should however be explained to patients and carers that additional support will be discontinued when they are able to self-administer.
   
   If self/carer administration of LMWH is appropriate LTHT nursing staff should provide training on appropriate injection technique (detailed below), information about side effects and details of who to contact if side effects occur. Supervised self/carer administration of LMWH should be initiated soon as possible.
   
   If self/carer administration of LMWH is not appropriate/possible (see principles for district nurse referral section) consider whether it would be possible for them to visit their practice nurse for administration Monday - Friday with district nurse administration Saturday and Sunday.
   
   Patients should only be referred to district nurses for administration of LMWH when all other options have been discounted.

Instructions for teaching patients/carers to self-administer LMWH

• Explain that LMWH should be administered at approximately the same time each day clarifying that if necessary the time of administration can be moved backwards or forwards by two hours per day.
• Wash hands thoroughly with soap and water.
• Choose an appropriate site on the abdomen for injection.
• Use a different injection site each day.
• Avoid injecting 5cm (2 in) around the belly button and do not inject near to any bruising or scars.
• When you are ready to inject remove the grey needle cap from the syringe.
• Hold the syringe in your writing hand like a pen, with the other hand gently pinch a fold of skin (approximately an inch) between your thumb and index finger.
• Gently but firmly insert the needle at a 90 degree angle and continue to hold the skin.
• Push the plunger down slowly to inject the LMWH over 10 - 15 seconds.
• Keep the plunger pressed down and remove the needle from your skin keeping it at a 90 degree angle and then release the skin fold but keep hold of the plunger.
• Do not rub or massage the area as this can cause bruising.
• Push the plunger down further. This will activate the protective needle cover.
• Put the used syringe into the sharps bin.

Disposal instructions
Option 1 - Carefully place the syringe needle first directly into a sharps bin. The used sharps bin should be closed and locked as directed. Locked sharps bins should be returned to LTHT for disposal.

Side effects:
Instruct patients to contact their doctor, pharmacist or nurse if they experience side effects. This includes any possible side effects not listed in the patient information leaflet (PILS) which comes with the drug. They can also report side effects directly via the yellow card scheme at www.mhra.gov.uk/yellowcard.

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Principles for District Nurse referral

District/practice nurse referral criteria
Patients who are unable to self-administer LMWH and do not have a relative or carer who is able to administer LMWH should be referred to the district/practice nursing team for administration.

Reasons for referral to District/practice nurses

• Capability issues
• Dexterity issues
• Vision issues
• Needle phobia
• Patients who are unable to self-administer LMWH and do not have a carer who is able to administer it for them
• Patients or carers who lack confidence/competence at self/carer administration should be referred to the district/practice nurses for additional support

General points to remember when referring to the District Nursing Team for LMWH administration

• Prior to referral please ensure that all other options for LMWH administration have been considered
• If all other administration options have been discounted consider whether the patient would be able to visit their practice nurse for administration Monday - Friday with district nurse administration Saturday and Sunday.
• All referrals to district nursing/intermediate care teams (ICT) should go through Single Point Of Referral (SPUR)
• Complete all sections of the district nursing referral form (see below) and fax to SPUR
• If Friday or weekend discharges are necessary please ensure that District nurses are able to initiate visits at the point of discharge
• If a timed visit is required please liaise with the appropriate District Nursing team prior to informing the patient
• If you are aware of any potential or actual risks to either patient or staff, for example violent or aggressive behaviour, please contact the appropriate District Nursing team to discuss
• Please remember to cancel the district nursing visit if it is no longer required, for example, the patient has died or the discharge is delayed
• Ensure SPUR receive the electronic discharge note detailing the LMWH prescription
• Ensure DN’s/ICT receive details of the time the last dose of LMWH was given
• If a patient is being discharged and LMWH is due in the next two hours it needs to be given prior to discharge
• Ensure that the patient is discharged with the appropriate equipment - supply of LMWH, a tear off leaflet detailing injection technique, patient information leaflet, a sharps bin and details of who to contact if they experience any adverse effects.

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Practice Nurse Referral Process

General points to remember when referring to the Practice Nursing Team for LMWH administration

• Prior to referral please ensure that all other options for LMWH administration have been considered
• All referrals to practice nursing teams should be booked at the earliest opportunity to ensure that an appointment is available.
• Inform the practice nurse team that the referral is for Enoxaparin (Inhixa) administration and training, clarify the time the injection needs to be given and reinforce that it should be given at the same time each day (it can be moved by 2 hours if required).
• Ensure that a copy of the electronic discharge note is sent to the practice nurse team, this needs to include details of the LMWH prescription, a clear plan for on-going treatment, any monitoring and prescribing requirements (if course exceeds 6 weeks).
• Ensure that the patient has an adequate supply of LMWH and understands that they need to take it with them to their practice nurse appointment.
• Complete all sections of the district nursing referral form (see below) and fax to SPUR
• If Friday or weekend discharges are necessary please ensure that District nurses are able to initiate visits at the point of discharge
• If a timed visit is required please liaise with the appropriate District Nursing team prior to informing the patient
• Please remember to cancel the practice nurse appointment if it is no longer required, for example, the patient has died or the discharge is delayed
• Ensure that the patient is discharged with the appropriate equipment - supply of LMWH, a tear off leaflet detailing injection technique, patient information leaflet, a sharps bin and details of who to contact if they experience any adverse effects.