clinical safe use of entonox for short term pain relief

Policy Manager Alan Stirling

Policy Group Pain Team Members, NHS Tayside and

Entonox policy group

CLINICAL

SAFE USE OF ENTONOX FOR SHORT TERM PAIN

RELIEF

Policy Established

2003

Policy Review Period/Expiry

2 years January 2024

Last Updated

January 2022

This policy does apply to Medical/Dental Staff

UNCONTROLLED WHEN PRINTED

Document Control Document: Safe use of Entonox Version:2.3 Version Date: January 2022 Policy Manager: Alan Stirling of 58

Review Date: January 2024

Policy development, review and control policy

Version Control Version Number

Purpose/Change Author Date

1.0

Version Control introduced July 2011 and the previous versions of the policy, prior to this date are available on the Electronic Document Store.

Val. Shepherd/ Pain Team members NHS Tayside and Entonox policy Group

2.0

Annual Policy review Policy updated to include: -Version control - Addition of safety advice re avoiding contamination of gas cylinders and regulators with hand gels, hand creams, moisturizers and grease. - Change to information and advice given to patient re driving after receiving Entonox

Val. Shepherd/ Pain Team members NHS Tayside and Entonox policy Group

October 2012 Ratification process completed December 2013

2.1

Policy due regular review. Minor amendments. - Changes to formatting - Document control footer added. - Completed COSHH assessment and Substance Handling Information Form added. -Updated Rapid Impact Assessment and Policy Approval checklist. -Training plan added.

Val.Shepherd/ Pain Team members, NHS Tayside and Entonox policy group

December 2015

2.2

Policy and rapid impact assessment reviewed. - Updated references

Val.Shepherd Entonox policy review group members.

December 2017

2.3

Policy and rapid impact assessment reviewed in accordance with NHS Tayside process and updated. Updated COSHH section

Val. Shepherd Entonox Policy review group members

January 2020

2.4 Policy and rapid impact assessment reviewed

Alan Stirling Entonox Policy review group members

January 2022



NHS TAYSIDE POLICY: Safe use of Entonox for short t erm pain relief

CONTENTS Section Title Page Number 1 PURPOSE AND SCOPE

4

2 STATEMENT OF POLICY

4

3 RESPONSIBILITIES AND ORGANISATIONAL ARRANGEMENTS

5

4 INCLUSION / EXCLUSION CRITERIA

6

5 RISK MANAGEMENT

7

6 PATIENT MONITORING

8

7 TECHNICAL PROBLEMS

9

8 CLEANING PROCEDURE

9

9 DOCUMENTATION

9

10 KEY CONTACTS

10

11 REFERENCES

10

12

GROUP MEMBERSHIP APPENDICES

10

1. COSHH – Assessment Record and Substance Handling Information Form 12 PLEASE NOTE THAT THE COSHH TEMPLATE IS UNDER REVIEW 2. Adult Patient Group Direction 21

3. Paediatric Patient Group Direction 26

4. Patient group direction Consultation Sheet 32

5. Procedure for administering Entonox 34

6. Side-effects of Entonox and treatment recommenda tions 36

ANNEX

1. Policy approval checklist 37 2. Equality and Diversity Impact Assessment 38 3. Policy training plan 58



1. PURPOSE AND SCOPE 1.1 The purpose of this document is to set out the standards and recommendations for

practice in NHS Tayside which aim to ensure that Health Practitioners are able to comply with local guidance on the safe supervision of patients receiving Entonox for short-term pain relief.

This policy applies to medical staff, registered nurses, midwives and physiotherapists

who care for patients receiving Entonox in NHS Tayside. Nitrous Oxide and oxygen in combination is known as Entonox ®. It is a compressed

medical gas that is a powerful analgesic in sub-anaesthetic concentrations. It is used exclusively for pain relief. It has the special advantage of very rapid onset of analgesia (BOC, Medical Gas Data Sheet, 2019) and is therefore very useful in clinical practice for the management of short term, planned or unexpected episodes of pain (it is used extensively within Maternity and the Ambulance Service).

1.2 Definitions: -

‘Administered’ is a term used throughout this policy document to describe the practitioner’s role in providing and supervising a patient’s self-administration of this drug. For the purpose of this policy document Entonox is the combined, compressed gases 50% Nitrous Oxide and 50% Oxygen A Health Practitioner as used in the policy constitutes a Doctor, Registered Nurse, Registered Midwife or Physiotherapist.

2. STATEMENT OF POLICY

Health Practitioners must have the knowledge of the factors that enhance the risk of complications hence leading to safe and effective evidence based practice. The recommendations for practice contained within this document will:- • Promote and utilise evidence-based practice. • Help staff to manage pain effectively. • Ensure all staff supervising patients receiving Entonox can provide safe care. • Set out actions and treatments, which can help recognise and prevent

complications. • Ensure uniform practice in relation to supervision of patients receiving Entonox

throughout NHS Tayside. • Ensure staff handling Entonox cylinders and equipment are aware of the potential

risks with the gas and equipment and can minimise/avoid harm.



2.1 Entonox can be supplied and administered following a prescription by a medical practitioner, non medical prescriber or via the NHS Tayside Entonox Patient Group Directive. The only exception to this is midwifery practice. Midwives can supply and administer Entonox independent of a medical practitioner (NMC, Standards of proficiency for midwives, 2019) Rationale: Entonox is a prescription only medicine and must therefore be given under the instruction of a prescribing practitioner or provided under the guidance laid out in the NHS Tayside Entonox Patient Group Directive.

2.2 Entonox can only be administered by a competent Health Practitioner who has

successfully completed the NHS Tayside clinical skills pack for Entonox administration or other recognized training such as Midwifery.

Rationale: Staff must be aware of the properties of the gas, precautions to be taken and the correct operating procedures and be able to act appropriately in the event of an emergency.

3. RESPONSIBILITIES AND ORGANISATIONAL ARRANGEMENTS 3.1 The Entonox policy group will review this policy biannually and submit it to the Lead

Officer to implement strategy approval checklist before being placed on the intranet

3.2 Clinical groups who wish to use the Entonox via a PGD will fulfil the responsibilities

associated with PGD use (please see Area Drugs and Therapeutics Committee NHS Tayside website).

3.3 Professionals who wish to change their practice to giving Entonox via a PGD must

negotiate this locally with their multidisciplinary and management team and ensure they practice within the guidance laid out in this policy document and the PGD.

3.4. The health practitioner is responsible for assessing the patient’s suitability for

receiving Entonox as a form of analgesia.

3.5 The health practitioner prescribing Entonox independently (in the case of medical

practitioners, Non-medical prescribers and midwives) is responsible for writing a legible prescription or under the guidance of the patient group directive, the health practitioner administering must keep a legible administration record (see page 25 adult or page 31 paediatric)

3.6 The health practitioner must seek and note the patient’s informed consent prior to

administering this drug and this must be documented on consent and treatment record (see p 25 and 31). A patient information leaflet is available to facilitate this process LN1215.



3.7 The health practitioner must be satisfied that the environment in which Entonox is to be administered is safe as per Control of Substances Hazardous to Health (COSHH) Regulations 2002 as amended. See -COSHH Risk Assessment, Appendix 1.

3.8 The health practitioner is responsible for completing an electronic incident report form

in the event of an adverse incident/near miss and processing this through normal operational procedures.

3.9 Clinical areas which use Entonox must ensure they report all adverse incidents through normal operational procedures for incident reporting, and review all adverse incidents linked to Entonox use at least monthly.

3.10 Criteria for Use of Entonox:

The Criteria for Inclusion is set out in the Patient Group Direction Consultation Sheet (see Appendix 4).

Entonox must only be used to alleviate short term, acute episodes of pain or during childbirth.

Entonox must not be taken constantly by an individual for any longer than 24 hours as prolonged use results in bone marrow depression (BOC Medical Gas Data Sheet 2019).

3.11 Patient Inclusion Criteria :

• Patients who are in acute pain, for example, during a procedure or whilst awaiting other methods of pain relief, women in labour.

• Patients who do not have any of the exclusion criteria listed below. • Patients who are able to hold a mask/mouthpiece by themselves. • Patients who have given their consent. • Patients who have Entonox prescribed or can be given it within the guidance laid

out in the NHS Tayside Entonox Patient Group Directive.

Rationale: Patients must be able to self-administer this drug. This acts, as a safety mechanism in ensuring the patient does not overdose. As the anaesthetic properties affect the patient, the facemask/mouthpiece will automatically fall away from the face.

3.12 Patient Exclusion Criteria: Entonox must not be used with any of the following conditions: -

• Where a patient cannot hold a facemask/mouthpiece. • Impairment of consciousness, head injury, intoxication • Severe respiratory disease, COPD, chest trauma, insertion or removal of chest

drain • Cardiovascular disease, eg mitral valve stenosis • Risk of airway compromise – sleep apnoea, maxillofacial fractures • Gross abdominal distension, bowel obstruction



• Following a recent underwater dive within 48 hours. • Patient receiving Vitamin B12 (hydroxycobalamin) injections. • Recent ear surgery, ear infection, during myringoplasty (repair of the ear drum), • First 16 weeks of viable pregnancy • Patients who have recently received intraocular injection of gas (such as SF6) for

example in retinal detachment surgery.

COMMENT: These exclusion criteria are pertaining to the Patient Group Direction where nursing staff may supply and administer Entonox before seeking medical attention. In some cases Entonox can be administered when prescribed and supervised by medical staff for example chronic obstructive airways disease, mitral valve stenosis, cardiovascular disease and sleep apnoea. Additional monitoring would be required for these patients.

3.13 Risk Management Care must be taken when lifting and carrying smaller cylinders. Larger cylinders are transported using trolleys. Care must be taken when moving cylinders on and off trolleys and between store and clinical area. Entonox is excreted unaltered via the patient’s breath so administration must take place in a well ventilated area to prevent others from inhaling the gas. From staff perspective that must be to a level less than 100ppm (parts per million) over an 8 hour period. In ward areas where a portable Entonox cylinder is used, move the patient to a side room or bed space next to a window. The window should be opened during the procedure. In high use areas where Entonox is used routinely it may be supplied by a fixed pipe system and scavenging systems should be used to ensure that the standards of exposure stated above are not exceeded. Rationale: Ensuring safe manual handling processes. Although very rare, exceptional heavy occupational exposure and addiction have resulted in myeloneuropathy and subacute degeneration. It has been suggested that prolonged exposure to high levels of nitrous oxide may affect a woman’s ability to become pregnant (BOC Medical Data Sheet, 2019).

3.14 All patients self administering this drug must be supervised by a competent

practitioner as outlined in 2.2. Rationale:

Staff must supervise the administration of this drug in order that they are best placed to manage a medical emergency such as loss of consciousness.

3.15 All staff administering Entonox must comply with the guidance in Procedure for

Administering Entonox (see Appendix 5).



3.16 All staff handling the transportation of Entonox cylinders must be aware and competent in the safe handling and transportation of this drug (Health Facilities Scotland 2015, British Compressed Gas Association 2012).

Hand hygiene- immediately prior to handling Entonox cylinders ensure effective hand washing avoid alcohol based hand rubs and hand creams /emollients and the risks associated with these. (Health Facilities Scotland 2015, BOC Medical Gas Data Sheet, 2019) Rationale: Accidents involving gas cylinders can cause serious injury or even death. You have a duty to provide a safe environment and reduce the risks. If medical gas cylinders and regulators are contaminated with oily substances there is a risk of fire or explosion during handling and use.

3.17 Entonox in F size cylinders must be stored vertical at all times.

Entonox in E size cylinders must be stored horizontally at all times. All cylinders must be stored away from combustible materials.

3.18 All staff administering Entonox must assure themselves that the gas has been stored for 24 hours at a temperature above 10ºC, ideally room temperature. Rationale: Nitrous oxide begins to separate out from Entonox if the temperature falls below about -6ºC. A homogenous mixture is again obtained when the temperature is raised above 10ºC and the cylinder agitated (BOC, 2019).

3.19 A microbiological filter must be attached between the Entonox demand valve and the mouthpiece or mask.

Rationale: Although the gas flow is only one way through the expiratory valve, this is close to

the patients mouth and therefore potentially infected debris can contaminate the demand valve. All patients must be protected from potential cross-infection. (Chilvers and Weisz, 2000).

3.20 Patient Information

All patients receiving Entonox must be given verbal and written information regarding the drug. Patient information leaflet LN 1215 available on NHS Tayside staffnet. When Entonox is used as a sole analgesic/sedative agent, driving and use of complex machinery is not recommended until:

• At least 30 minutes has elapsed after the administration of Entonox has ceased

• The healthcare professional has assessed that the patient has returned to normal mental status i.e. orientated to time and place

• The patient feels that they are competent to drive after the relevant procedure is completed. i.e there is no residual drowsiness or light headedness.

(BOC Medical Gas Data sheet, 2019)



Additional care is needed when Entonox is administered to a patient who has been given concomitant medication

4. PATIENT MONITORING 4.1 Maintain verbal contact with the patient throughout the procedure and observe the

patient to determine: • Level of pain • The presence of any side-effects • Whether they are using the Entonox effectively and attaining an adequate level of

analgesia. • If adequate analgesia is not achieved, stop intervention. • If the patient experiences any Entonox side effects, cease inhalation until the

side- effects wear off. (See Appendix 6, Entonox related side effects and treatment recommendations).

4.2 After the procedure:

• Ensure the patient is comfortable • Monitoring should continue until the effects of the Entonox wear off. • Patients should not walk around unaided until any dizziness or disorientation has

gone. • If Entonox is used more than once every 4 days, weekly full blood counts must be

taken for evidence of megaloblastic change in red cells and hypersegmentation of neutrophils.

5. TECHNICAL PROBLEMS

If any of the following technical problems occur they should be reported to a Medical Physics Gas Technician immediately. • Equipment not delivering gas • Leak at the joint between the regulator and cylinder valve (condensation may

appear) The cylinder and equipment interfaces and seals with a washer known as an “O” ring or Bodok seal which can become worn over time).

• Demand valve does not stop flowing after test button is released. 6. CLEANING PROCEDURE / CYLINDER REPLACEMENT 6.1 Filters, masks and mouthpieces are for single patient use only and should be

discarded after each patient use and a fresh component fitted. Entonox tubing should be changed in accordance with the manufacturer’s instructions, and should be used for a maximum of 7 days (this pertains to the labour suite). Changing of the tubing should be documented. For portable cylinders: The external surfaces of the demand valve and tubing must be cleaned with detergent wipes after use.

6.2 Check the cylinder gauge for contents and if less than ¼ full, contact the gas porter for a replacement.



Turn off the cylinder by turning the tap in a clockwise direction. Gas contained in the equipment and regulator should be safely vented to atmosphere before removing from the cylinder (press the button on the demand valve to do this). The gauge will read empty after this process. (Health Facilities Scotland 2015, British Compressed Gas Association 2012). The Entonox cyclinder should be returned to the main storage area after use due to the storage recommendations in the COSHH assessment.

7. DOCUMENTATION Provide a record of the details of Entonox administration, evaluation of its effect and any side effects experienced by the patient in the patients nursing notes.

If using NHS Tayside PGD for Entonox, this document contains an evaluation/monitoring sheet to be completed and kept in the patient’s notes. (p25 or 31)

8. KEY CONTACTS Acute Pain Nurse: Ninewells – 4311 Bleep PRI – 5163 or 5180 Stracathro - 2445

9 REFERENCES

BOC Medical Gas Data Sheet (2019) https://www.bochealthcare.co.uk/en/images/HLC_505605-

MGDS%2520ENTONOX%2520%2528web%2529_tcm409-57640.pdf (accessed 24/01/2020) British Compressed Gas Association –Codes of Practice 44:The storage of gas cylinders 2016. www.bcga.co.uk /publications/codes of practice/ storage of gas cylinders (accessed 24/01/2020)

Chilvers, R.J and Weitsz, M., 2000. Entonox equipment as a potential source of

Cross-infection. Anaesthesia. 55(2). Pp 176 – 179. Health and Safety Executive website. Control of Substances Hazardous to Health (COSHH) www.hse.gov.uk/coshh Accessed 24/01/2020 Health Facilities Scotland SHTM 02_01(2015) Medical Gas Pipeline Systems Part B: Operational Management:section 8 Cylinder Management www.hfs.scot.nhs.uk/publications/guidance-publications Accessed 24/01/2020 NHS Tayside Policy, Control of Substances Hazardous to Health. www.staffnet.tayside/safe and effective working/policies/Risks, Health and Safety policies. Accessed 24/01/2020.

http://www.bcga.co.uk/

http://www.hse.gov.uk/coshh

http://www.hfs.scot.nhs.uk/publications/guidance-publications

http://www.staffnet.tayside/safe



Nursing and Midwifery Council (NMC) 2019. Standards of proficiency for midwives. www.nmc-uk.org Accessed 24/01/2020. Nursing and Midwifery Council (NMC) 2018. The Code: Professional standards of practice and behaviour for nurses and midwives. www.nmc-uk.org Accessed 24/01/2020

10 REVIEW GROUP MEMBERSHIP 2022

Val Shepherd, Senior Pain Specialist Nurse, Ninewells Hospital – facilitator Jennifer Gray, Specialist Clinical Pharmacist, Ninewells. Liz Colquhoun, Senior Pain Specialist Nurse, Ninewells. Dr Calum Grant, Consultant Anaesthetist, Ninewells Margaret Kennedy, Health & Safety Advisor, Chief Executive Dept, Ninewells Paulene Madoc-Jones, Senior Pain Specialist Nurse, Perth Royal Infirmary Lorna Milne, Pain Specialist Nurse, Ninewells Dr Mike Neil, Consultant Anaesthetist, Ninewells Dr Ewan Ritchie, Consultant Anaesthetist, Perth Royal Infirmary Alan Stirling, Pain Specialist Nurse, Ninewells. . CONTRIBUTERS TO PAEDIATRIC PATIENT GROUP DIRECTION Suzie Byers, SCN, Paediatrics, Ninewells Hospital. Dr Phil Lacoux, Consultant Anaesthetist, Chronic Pain and Paediatrics, Ninewells Karen McIntyre, Paediatric Gastroenterology and Rheumatology Nurse

Jonathan Smith, Rotational Pharmacist, Ninewells RATIFICATION The updated policy was ratified by the Quality Clinical Forum in June 2013 Approved by Medicines Policy Group November 2013

Appendix 1 Control of Substances Hazardous to Health Regulation s (COSHH) 2002, as Amended Risk Assessments

http://www.nmc-uk.org/

http://www.nmc-uk.org/



COSHH assessments concentrate on the use and production of hazardous substances. This means in practice looking for the potential within the task for exposure and harm to occur by:

• Inhalation; • Skin contact; • Skin absorption; • Injection via a sharps injury; • Eye contact; • Ingestion.

Grounds for concluding that exposure is not a signi ficant risk to health are:

• quantities or rate of use/production of the substance(s) are too small to constitute any risk to health under foreseeable circumstances of use, even if control measures break down;

OR • There is no available route of exposure

If you are not sure if exposure is significant or not, contact the Health and Safety Team on [email protected], who will be able to give you an opinion or arrange for measurements to be taken to help you decide. A generic risk assessment form is included in this part. You should store your risk assessments in your ward/department along with your staff training records. Substance Handling Information Form

Part of COSHH Assessment Documentation

COSHH Assessment No: Date: 17TH

January, 2020

mailto:[email protected]

Document Control Document: Safe use of Entonox Policy Manager: Alan Stirling

Substance: Oxygen/Nitrous Oxide (Entonox)

Physical State Solid Powder

Exposure

Limits

Long Term Exposure Limit (LTEL)

Nitrous Oxide 100ppm

Hazard Class

Exposure

Route

Inhalation

Possible Effects of Exposure

Long term exposure above the exposure limit could lead to the development of myeloneuropathy

from prolonged or frequent exposure without adequate ventilation.

Reduced fertility has been reported in Healthcare professionals who have been repeatedly exposed

to levels of Nitrous Oxide above the exposure limits but a causal link has not been confirmed

between this.

Safe Handling Information

Ensure patient is suitable recipient of Entonox

Entonox cylinders must be stored above 10 degC for at least 24hrs before use and used within expiry

date

Must be stored in clean, dry and ventilated areas which are secure

Cylinders must not be stored near stocks of combustible materials, exposed to extrem

cold or stored in direct sunlight

Ensure there are no naked flames or smoking near to cylinders

F size and larger sized cylinders must be stored vertically. D sized and smaller may be stored

horizontally

Ensure cylinders switched off when no

Ensure area where cylinders are being stored is appropriately signed to indicate the presence of gas

cylinders; for information in the event of fire

Ensure hands are free from grease, oils or Alcohol Based Hand Rubs before handling cylinders or

associated equipment

Keep out of the reach of children and any other vulnerable individuals

Emergency Procedures

In the event of a fire – warn the emergency services of the presence of Entonox cylinders.

In the event of a leak/suspected leak evacuate

the area is adequately ventilated before any re

Version:2.3 Version Date: January 2022 of 58

Review Date:

: Oxygen/Nitrous Oxide (Entonox) Concentration: Amount50.0% +/- 2.0%Oxygen

50.0% +/- 2.0% Nitrous Oxide Variable amounts

determined by patient

Powder Liquid Vapour Gas

Long Term Exposure Limit (LTEL) Short Term Exposure Limit (STEL)

Nitrous Oxide 100ppm Not indicated on MSDS

� Ingestion Skin Contact Injection


from prolonged or frequent exposure without adequate ventilation.

orted in Healthcare professionals who have been repeatedly exposed


Ensure patient is suitable recipient of Entonox


Must be stored in clean, dry and ventilated areas which are secure

Cylinders must not be stored near stocks of combustible materials, exposed to extrem

Ensure there are no naked flames or smoking near to cylinders


Ensure cylinders switched off when not in use


cylinders; for information in the event of fire


Keep out of the reach of children and any other vulnerable individuals

warn the emergency services of the presence of Entonox cylinders.

In the event of a leak/suspected leak evacuate for the location of the leak/suspected. Ensure that

the area is adequately ventilated before any re-entry to the location.

√

Version Date: January 2022 Review Date: January 2024

Amount:

Variable amounts

determined by patient

√ Fume Aerosol

Short Term Exposure Limit (STEL)

Not indicated on MSDS

Injection Absorption


orted in Healthcare professionals who have been repeatedly exposed



Cylinders must not be stored near stocks of combustible materials, exposed to extremes of heat and




warn the emergency services of the presence of Entonox cylinders.

for the location of the leak/suspected. Ensure that

√



Disposal Procedure

Cylinders should be returned to the supplier with the valves in a closed position.

Cylinders containing Entonox which is no longer required should not be vented but returned to the

supplier for venting.

References

BOC Medical Gas Data Sheet 2019

First Aid Procedures

Lungs: - Remove from exposure and into fresh air as soon as possible. Secure Medical attention.

Where necessary carry out mouth to mouth resuscitation and/or use of oxygen as advised by a

Medical Practitioner.

RECORD OF COSHH ASSESSMENT This is a Generic Risk Assessment for the Use & Storage of Entonox. This must be modified by Clinical staff to reflect the environment where the Entonox is being used.



Identify Hazardous Substances used in the task Substance Handling Information Form should be completed and attached for each substance

Do Substances Present A Risk?

Y | N | N/A

Comments

During preparation Yes Entonox cylinders must be stored at a temperature above 10ºC for at least 24 hours before use.

When stored Yes Cylinders must: - be stored under cover and kept clean and dry. - not be stored near stocks of combustible materials. - not be subjected to extremes of hot or cold. - be stored in a well ventilated location. - be stored out of direct sunlight. - be stored away from reach of children and the public. F size cylinders should be stored vertically, D size cylinders and those of a smaller size should be stored horizontally No smoking or use of naked flames must be allowed near to where cylinders are stored. Warning signage should be displayed where cylinders are stored so that emergency services are made aware of the presence of gas cylinders.

During Transportation Yes Cylinders must be restrained effectively during transportation to prevent damage. Cylinders must be checked to ensure they are not leaking before they are transported. All cylinder valves must be closed prior to transportation. No oils or greases must be allowed to come into

Department

Manager responsible

Risk Assessor(s) Margaret Kennedy Health & Safety Advisor

Assessment Number

Description of Task / Environment / Objectives The safe transport, storage and use of Entonox for short term pain relief.



contact with the gas cylinders

When Performing Task Yes Entonox must only be used in environments which have adequate ventilation. In ward areas, move a patient to a side room or a bed space by the window. The window should be open during the procedure. Patients must not be considered for Entonox if they have any of the following conditions - Where patient is unable to hold a facemask or mouthpiece -Impairment of consciousness, head injury, intoxication -Severe respiratory disease, COPD, chest trauma, insertion or removal of chest drain -Cardiovascular disease, eg mitral valve stenosis -Risk of airway compromise – sleep apnoea, maxillofacial fractures -Following a recent underwater dive within 48 hours -Recent ear surgery, ear infection, during myringoplasty (repair of the ear drum). -Gross abdominal distension -Patient receiving Vitamin B12 (hydroxycobalamin) injections. -First 16 weeks of viable pregnancy -Patients who have recently received intraocular injection of gas (such as SF6) for example retinal detachment surgery

During disposal Yes Cylinders which are no longer required but still contain Entonox should not be vented but returned to the supply company for venting in a safe environment Cylinder valves must always be closed prior to returning to the supplier.

During maintenance operations

N/A

In an emergency Yes Entonox is a compressed gas stored in a pressure cylinder. This could rupture if damaged or heated to high temperatures (e.g. in a fire) Entonox will intensify fire as it is an oxidising agent Entonox may react violently with combustible materials such as oils and grease.

Consider the following

Comments



Elimination Entonox is excreted unaltered via the patient’s breath so administration must take place in a well ventilated area to prevent others from inhaling the gas.

Substitution Entonox will be used as one option with regard to pain relief. Not all patients will be suitable for the use of Entonox to manage their pain (see exclusions). Contact your local Pain Team for alternative analgesia.

Control at Source Entonox will be self –administered by the patient and as it is administered through a demand valve will only provide Entonox when patient inhalation occurs. Entonox will only be used where ventilation is adequate. (e.g. scavenging system, boost ventilation, air changes checked to determine suitability, facility has means of improving general ventilation eg, open window) Signage indicating the presence of gas cylinders should be displayed at locations where Entonox is used/stored.

Detailed Systems of Work Staff complete the Entonox Clinical Skills Pack for safe administration of Entonox. Staff follow the procedures outlined in the NHS Tayside Clinical Policy: Safe use of Entonox for short term pain relief Clinicians assess patients for suitability for use of Entonox. Patients are continuously monitored by staff during procedures

Reduction in quantity The volume of Entonox used during procedures will be determined by pain relief requirement of the patient. The demand valve of the Entonox will close off as soon as the patient ceases to inhale the gas.

Limiting access Only patients who have been clinically assessed as appropriate for the use of Entonox will have access to the gas. Only staff who are viewed as competent will be allowed to access and use the gas in patient treatment.

Limiting exposure time Only clinical staff involved in the procedure will be present during the process when the patient is in receipt of Entonox for pain control. Staff who are pregnant or actively trying to become pregnant should avoid exposure.

Suitable PPE N/A

Workplace monitoring In high use areas where Entonox is used routinely, scavenging systems should be used to ensure that the



standards of exposure (less than 100ppm over an 8 hour period) are not exceeded.

Health surveillance N/A

Information, instruction, training, supervision

Staff complete the Entonox Clinical Skills Package for safe administration of Entonox. Staff follow the procedures outlined in the NHS Tayside Clinical Policy: Safe use of Entonox for short term pain relief Staff will receive regular refresher training Patients receive a Patient Information Leaflet

Decide who might be harmed and how Patients may be harmed if they are offered Entonox while suffering from or having any of the conditions detailed as contra -indicatory to safe use of Entonox. -Where patient is unable to hold a facemask or mouthpiece -Impairment of consciousness, head injury, intoxication -Severe respiratory disease, COPD, chest trauma, insertion or removal of chest drain -Cardiovascular disease, eg mitral valve stenosis -Risk of airway compromise – sleep apnoea, maxillofacial fractures -Following a recent underwater dive within 48 hours -Recent ear surgery, ear infection, during myringoplasty (repair of the ear drum). -Gross abdominal distension -Patient receiving Vitamin B12 (hydroxycobalamin) injections. -First 16 weeks of viable pregnancy -Patients who have recently received intraocular injection of gas (such as SF6) Patients could also be harmed if they have been having Entonox for pain relief over a longer period of time (greater than 24hrs or more recently than in the last 4 days ) for other procedures/ pain episodes Patients may not receive the correct mix of gases if the cylinder has not been stored above 10ºC for 24 hours prior to the treatment occurring. This would lead to ineffective pain relief. Staff could be harmed if long term exposure were to exceed the Long term Exposure Limit of 100ppm. Staff could be at risk of the development of myeloneuropathy from this prolonged or frequent exposure without adequate ventilation. Staff who are pregnant or trying to become pregnant should avoid exposure as although documented evidence is not clear if link between reduced fertility and prolonged exposure to Entonox above the Exposure Limit is proven -care should be taken. Occupants of the building /area could be harmed if the cylinders are handled while grease or oils or residual alcohol hand rubs are present on hands as this could result in combustion. Occupants of the building could be harmed if smoking or naked flames are used near the cylinders which could lead to fire and explosion.



Occupants of the building could be harmed if the cylinders are not handled safely during transfer and become damaged as the cylinder may rupture.

What risk control measures are in place now? Clinicians will determine if patients are suitable for Entonox as a means of pain relief. Clinicians will determine through discussion with the patient and from the patient notes whether the patient has had Entonox for other procedures /pain control in the recent timescales indicated. Clinicians will monitor the patient throughout the procedure and stop the use of Entonox if any problems occur. Patients will be provided with a Patient Information Leaflet LN1215. Staff will be familiar with the NHS Tayside Clinical Policy: Safe Use of Entonox for Short Term Pain Relief. Staff will have completed the Clinical Skills package for the administration of Entonox. Entonox will be stored in a secure designated area in the department away from sources of ignition. Warning signage indicating the presence of gas cylinders is displayed where Entonox is stored. NHS Tayside has a strict No Smoking Policy which is applicable in all NHS Clinics and Departments. Staff will ensure that alcohol hand rubs have evaporated before handling Entonox cylinders. Staff will ensure no greases or oils are contaminating the Entonox cylinders or their hands while using the product. Entonox cylinders will always be transported in appropriate carriers. Equipment is checked prior to use. The use by date of the cylinder is checked prior to use. Cylinders will be suitably secured in clinic rooms and other locations where administered

Severity Likelihood

Negligible 1

Minor 2

Moderate 3

Major 4

Catastrophic 5

Certain 5 Amber 5 Amber 10 Red 15 Red 20 Red 25 Probable 4 Green 4 Amber 8 Red 12 Red 16 Red 20 Possible 3 Green 3 Amber 6 Amber 9 Red 12 Red 15 Unusual 2 Green 2 Green 4 Amber 6 Amber 8 Amber 10 Remote 1 Green 1 Green 2 Green 3 Green 4 Amber 5



Evaluate the risks Risks are determined as Amber 8 based on fire risks as highest likelihood of harm.

What further action is necessary? Record your findings and implement them Action Required Person

Responsible Action Date Action Taken Completed Date

Has the risk assessment been agreed with your line manager?

Yes No

Managers Signature and date

Have the findings of this Risk Assessment been communicated to all relevant staff?

Yes No

Method(s) of communication:

Risk assessment completed by (print name & designat ion): Signature: Date:

How soon should this assessment be reviewed and how regularly afterwards? Review your assessment and update if necessary Review carried out by (print name & designation): Signature: Date:

This assessment should be reviewed immediately foll owing an incident or if there have been significant changes in work



Appendix 2 ADULT

Patient Group Direction For the Supply/Administration of Entonox

Definition of clinical situation/condition

Nitrous Oxide and oxygen in combination is known as Entonox and can be used alone or along with normal, regular analgesia, to manage the pain of intermittent procedures or in patients who are in pain awaiting the attention of a member of medical staff. This directive is to be used to administer patients 12 years of age and above (see paediatric PGD). Entonox must not be taken constantly for any longer than 24 hours as prolonged use results in bone marrow depression. If Entonox is administered more frequently than every 4 days the patient mus t have a weekly full blood count for evidence of megaloblastic changes in red cells and hypersegmentation of neurophils. (BOC Medical Gases Safety Sheet).

Criteria for inclusion Following an assessment and recording of the level of pain. Patients who do not have any exclusion criteria listed below. Patients able to hold a mask/mouthpiece by themselves.

Patients who are requiring:- • Change of dressings, packs, removal of drains, insertion

and removal of sutures. • Invasive procedures e.g. Venepuncture, Venous

Cannulation, Catheterisation, Sigmoidoscopy, Colonoscopy.

• Change to position of limbs, manipulation, splinting, plastering and applying traction.

• Removal of Gynaecological splints, applicators, surgical packing. Gynaecological repair

• Movement of limbs during X-ray. • Physiotherapy. • Renal Colic. • Uterine Contractions. • Biopsy procedures.

This Patient Group Direction (PGD) is a specific written instruction for the supply/ administration of Entonox(BOC), to manage the pain of intermittent procedures during care, for short-lived pain or for patients suffering acute pain, whilst awaiting the attention of a member of medical staff. The PGD only refers to groups of patients who may not be individually identified before presentation for treatment. The PGD will be used for patients in the surgical, orthopaedic, burns and plastic surgery wards and outpatients in Ninewells, orthopaedic and surgical and admission wards, orthopaedic outpatients and A&E in PRI.

This will enable any registered Health Care Professional to supply/administer treatment in accordance with the following protocol and the recommendations of the Department of Health 1998, the NMC, The Code: Professional standards of practice and behaviour for Nurses and Midwives (2018) and the NMC Standards for Medicines Management (2007).

The majority of clinical care should be provided on an individual, patient specific basis. The supply of medicines under Patient Group Directions should be reserved for those limited situations where this offers an advantage for patients care (without compromising patient safety) and where it is consistent with appropriate professional relationships and accountability. Once treatment under the PGD is discontinued then further administration will then have to be prescribed by an appropriate medical prescriber.



Criteria for exclusion Not to be used during the insertion/ removal of chest drains

Contra -indications: - Entonox must not be used in any of the following incidences: -

• Where patient is unable to hold a facemask or mouthpiece

• Impairment of consciousness, head injury, intoxication

• Severe respiratory disease, COPD, chest trauma, insertion or removal of chest drain

• Cardiovascular disease, eg mitral valve stenosis • Risk of airway compromise – sleep apnoea,

maxillofacial fractures • Recent ear surgery, ear infection, during

myringoplasty (repair of the ear drum). • Gross abdominal distension, bowel obstruction • Following a recent underwater dive within 48 hours. • Patient receiving Vitamin B12 (hydroxycobalamin)

injections. • First 16 weeks of viable pregnancy • Patients who have recently received intraocular

injection of gas (such as SF6) for example in retinal detachment surgery.

Action if excluded Record in notes and seek a medical option.

Action if patient declines Record in notes and seek a medical option.

Characteristics of staff authorised to take respons ibility for the supply or administration of medicines under this patient group direction

Qualifications required

Entonox can only be administered by a competent Health Practitioner who has been deemed competent in the administration of medicines and has successfully completed the NHS Tayside clinical skills pack or other recognised training such as midwifery for Entonox administration

Additional Requirements

Successful completion of Clinical Skills pack followed by practical skill training i.e. assessment with Entonox apparatus in order to enable practitioners to safely assist patients in the administration of Entonox.

Continuing Training requirements

Evidence of ongoing updates in the use of Entonox.



Name of Medicine Entonox (50% Nitrous Oxide, 50% Oxygen) is an analgesic gas contained in portable cylinders which are blue with a blue and white yoke. It can be self-administered by the patient through a special demand apparatus. The nitrous oxide acts as an analgesic. The oxygen makes Entonox safe and in many cases beneficial. Entonox has no depressive effects on respiratory or cardiovascular functions and does not mask other symptoms. It is economical, portable; simple to use and trained personnel can supervise treatment. It is a useful analgesic in many situations since the patient can continue to co-operate with medical staff or emergency rescuers (paramedics), nurses and midwifes and when inhalation is stopped the effects of the gas quickly wear off.

POM/P/GSL POM (Prescription Only Medicine)

PGD Ref No

Dose/s As required, until pain is relieved or side effects start to occur.

Route Inhalation.

Total dose number As necessary for procedures but not continuously. If given more than once every 4 days, weekly full blood counts for evidence of megaloblastic change in red cells and hypersegmentation of neutrophils must be taken.

In this event refer to Medical Practitioner.

Entonox must be administered in accordance with procedure identified within the NHS Tayside Policy for ‘Safe use of Entonox for short term pain relief.

Advice to be given to the patient

Maintain verbal contact with the patient throughout the procedure in order to evaluate the effects of Entonox.Check for excess sedation. Intermittent use may be necessary if the sedative effects are too pronounced. After administration, close the valve and vent any pressure in the system by pressing the centre of the demand valve firmly. Use may need to be continued for several weeks’ for in-patients requiring regular changes of dressings etc. Check that the patient understands the purpose of using Entonox. All patients receiving Entonox must be given verbal and written information regarding the drug.

Identification and management of possible adverse effects Procedure for Reporting ADR’s to Doctor:

If excessive sedation or loss of consciousness develops, remove the mouthpiece from the patient and clear the airway. Support respiration if necessary. Administer oxygen and contact medical team. Document all adverse reactions in the notes on the Entonox Administration Sheet, yellow card and complete an electronic incident report form and process through usual incident report procedures. Addiction:

As with some other sedative medications, pleasurable side effects may encourage inappropriate use. The use of Entonox should be reserved for specific short-term procedures but maybe repeated many times in these circumstances. Use between procedures is not permitted.

DESCRIPTION OF TREATMENT AVAILABLE UNDER THIS PATIE NT GROUP DIRECTION



Safety Information:

Patients receiving Entonox must not have additional once-only opiates prescribed for procedure. If the patient requires an additional once-off opiate, a member of medical staff must be present. Make sure that the Entonox cylinder cannot fall when in use. Use in a well ventilated area. Use a new disposable mouthpiece/face mask and heat moisture exchange filter for each patient –this protects the apparatus and the patient from contamination and reduces the effect of dry gases on the respiratory tract. Ensure that the apparatus is properly maintained and has a CE marking as specified in the Medical Devices Regulations. Follow the instructions in the NHS Tayside procedural guidelines (Appendix 5). Ensure patient safety at all times and do not leave patients unattended. Entonox provides strong analgesia with a quick onset, which may make the patient feel drunk though this wears off very quickly. Gases will separate at low temperatures therefore ensure gas is stored in accordance with manufacturers guidelines.

Referral for medical advice Patients who require opiate or additional analgesia should be referred to a doctor. Any adverse event / reaction should be reported to the doctor as soon as possible

Facilities and supplies required Availability of resuscitation equipment (normal hospital procedure)

Treatment Records Record the administration, date, and name of practitioner in the nursing/midwifery/physiotherapy/radiology notes using the NHS Tayside Entonox administration form. (See page 25).

Patients on concurrent medication Regular medication should be administered to patients who require Entonox. Caution is required with drugs with sedative side effects. These include opioids, benzodiazepines, antihistamines, anticonvulsants (including Gabapentin) and sedating antidepressant drugs. Medical advice should be sought if the patient exhibits signs of sedation prior to the administration of Entonox. Regular opioid analgesia with breakthrough opioid can be given whilst the patient is receiving Entonox however if additional opioid is required a doctor must be present.

Patient Consent Prior to receiving Entonox the patient must be given the opportunity to read the patient information leaflet and sign the Consent and Treatment Record.

Audit Trail Administration sufficient to include audit trail.

Adverse Reactions All adverse reactions (actual and suspected) will be reported to the on-call medical practitioner and recorded in the clinical notes. Where appropriate a Yellow Card Report will be forwarded to the Committee on Safety of Medicines. A supply of these forms can be found at the rear of the British National Formulary.



CONSENT AND TREATMENT RECORD - ADULT

This document must only be used when Entonox is administered under the guidance of local P.G.D.)

Information sheet given to patient ______________________ Staff Signature Patient has given informed consent ______________________ Staff Signature ______________________ Patient Signature Date Patient Eligibility Checked_____________ Sign____________________ Reason for administration_______________________________________________

*If Entonox is administered more frequently than every 4 days the patient must have a weekly full blood count for evidence of megaloblastic changes in red cells and hypersegmentation of neutrophils.

Date Time Pain Score (before)

Duration of Entonox administration

Outcome

Successful analgesia Unsuccessful Analgesia

Adverse Event

Yes – detail and Datix report No

*Blood Test

Required

Pain score (After)

Completed by ……………………………….Signature Print Name…………………………………

Patient ID



Appendix 3 PA EDIATRIC

Patient Group Direction For the Supply/Administration of Entonox in the paediatric setting

This Patient Group Direction (PGD) is a specific written instruction for the supply/ administration of Entonox(BOC), to manage the pain of intermittent procedures during care, for short-lived pain or for children and young people suffering acute pain. The PGD will be used for children and young people within the paediatric acute ward and paediatric out patient department in Ninewells hospital. Entonox is the contracted product at time of drafting this PGD.

This will enable any registered Health Care Professional to supply/administer treatment in accordance with the following protocol and the recommendations of the Department of Health 1998, the NMC,The Code: Professional standards of practice and behaviour for nurses and midwives (2018) and the NMC standards for Medicines Management (2007).

The Majority of clinical care should be provided on an individual, patient specific basis. The supply of medicines under Patient Group Directions should be reserved for those limited situations where this offers advantage for patients care (without compromising patient safety) and where it is consistent with appropriate professional relationships and accountability. Once treatment under the PGD is discontinued then further administration will then have to be prescribed by an appropriate medical prescriber.

Definition of clinical situation/condition

Nitrous Oxide and oxygen in combination is known as Entonox and can be used alone or along with normal, regular analgesia, to manage the pain of intermittent procedures or for short-lived pain or for children and young people suffering acute pain. Entonox must not be taken constantly for any longer than 24 hours as prolonged use results in bone marrow depression. If Entonox is administered more frequently than every 4 days the patient mus t have a weekly full blood count for evidence of megaloblastic changes in red cells and hypersegmentation of neurophils. (BOC Medical Gas Data Sheet).

Criteria for inclusion Following an assessment and recording of the level of pain. • Children/young person who do not have any exclusion criteria listed

below. • Children/young person able to hold a mask/mouthpiece by

themselves. Children/young person who are requiring:- • Change of dressings, packs, removing drains, insertion and removal

of sutures. • Invasive procedures e.g. intra-articular joint injection, Venepuncture,

Venous Cannulation, Catheterisation, removal of K wires, insertion of naso-gastric tube, change of gastrostomy button.

• Change to position of limbs, manipulation, splinting, plastering and applying traction.

• Movement of limbs during X-ray. • Physiotherapy. • Renal Colic. • Biopsy procedures



Criteria for exclusion Not to be used during the insertion/removal of ches t drain Contra -indications: -

Entonox must not be used in any of the following incidences: - • Where patient is unable to hold a facemask or

mouthpiece • Impairment of consciousness, head injury,

intoxication • Severe respiratory disease, COPD, chest trauma,

insertion or removal of chest drain • Cardiovascular disease, eg mitral valve stenosis • Risk of airway compromise – sleep apnoea,

maxillofacial fractures • Recent ear surgery, ear infection, during

myringoplasty (repair of the ear drum). • Gross abdominal distension, bowel obstruction • Following a recent underwater dive within 48 hours. • Patient receiving Vitamin B12 (hydroxycobalamin)

injections. • First 16 weeks of viable pregnancy • Patients who have recently received intraocular

injection of gas (such as SF6) for example in retinal detachment surgery.

Action if excluded Record in notes and seek a medical option.

Action if child declines Record in notes and seek a medical option.

Characteristics of staff authorised to take respons ibility for the supply or administration of medicines under this patient grou p direction

Qualifications required

Entonox can only be administered by a competent Health Practitioner who has been deemed competent in the administration of medicines and has successfully completed the NHS Tayside clinical skills pack or other recognised training such as midwifery for Entonox administration

Additional Requirements

Successful completion of Clinical Skills pack followed by practical skill training i.e. assessment with Entonox apparatus in order to enable practitioners to safely assist patients in the administration of Entonox.

Continuing Training requirements

Evidence of ongoing updates in the use of Entonox.



DESCRIPTION OF TREATMENT AVAILABLE UNDER THIS PATIE NT GROUP DIRECTION

Name of Medicine Entonox (50% Nitrous Oxide, 50% Oxygen) is an analgesic gas contained in portable cylinders which are blue with a blue and white yoke. It can be self-administered by the patient through a special demand apparatus. The nitrous oxide acts as an analgesic. The oxygen makes Entonox safe and in many cases beneficial. Entonox has no depressive effects on respiratory or cardiovascular functions and does not mask other symptoms. It is economical, portable; simple to use and trained personnel can supervise treatment. It is a useful analgesic in many situations since the patient can continue to co-operate with medical staff or emergency rescuers (paramedics), nurses and midwifes and when inhalation is stopped the effects of the gas quickly wear off.

POM/P/GSL POM (Prescription Only Medicine)

PGD Ref No

Dose/s As required, until pain is relieved or side effects start to occur.

Route Inhalation.

Total dose number As necessary for procedures but not continuously. If given more than once every 4 days, weekly full blood counts for evidence of megaloblastic change in red cells and hypersegmentation of neutrophils must be taken.

In this event refer to Medical Practitioner.

Entonox must be administered in accordance with procedure identified within the NHS Tayside Policy for ‘Safe use of Entonox for short term pain relief.



Advice to be given to the Child/young person and carers

Maintain verbal contact with the child/young person throughout the procedure in order to evaluate the effects of Entonox. Check for excess sedation. Intermittent use may be necessary if the sedative effects are too pronounced. After administration, close the valve and vent any pressure in the system by pressing the centre of the demand valve firmly. Use may need to be continued for several weeks’ for in-patients requiring regular changes of dressings etc. Check that the patient understands the purpose of using Entonox. All children/young persons and carers receiving Entonox must be given verbal and written information regarding the drug and the need for them to be accompanied home.

Identification and management of possible adverse effects Identification and management of possible adverse effects. Continued…

Procedure for Reporting ADR’s to Doctor: If excessive sedation or loss of consciousness develops, remove the mouthpiece from the patient and clear the airway. Support respiration if necessary. Administer oxygen and contact medical team. Document all adverse reactions in the notes on the Entonox Administration Sheet, yellow card and complete electronic incident report form and process through usual incident report procedures. Addiction:

As with some other sedative medications, pleasurable side effects may encourage inappropriate use. The use of Entonox should be reserved for specific short-term procedures but maybe repeated many times in these circumstances. Use between procedures is not permitted.

Safety Information:

Children/young people receiving Entonox must not have additional once-only opiates prescribed for procedure. If the child/young person requires an additional opiate during the procedure, a Paediatric Anaesthetic must be present. Make sure that the Entonox cylinder cannot fall when in use. Use in a well ventilated area. Use a new disposable mouthpiece/face mask and heat moisture exchange filter for each child/young person –this protects the apparatus and the child/young person from contamination and reduces the effect of dry gases on the respiratory tract. Ensure that the apparatus is properly maintained and has a CE marking as specified in the Medical Devices Regulations. Follow the instructions in the NHS Tayside procedural guidelines (Appendix 5). Ensure patient safety at all times and do not leave child/young person unattended. Gases will separate at low temperatures therefore ensure gas is stored in accordance with manufacturers guidelines.

Referral for medical advice Children/young people who require opiate or additional analgesia should be referred to a Paediatric Anaesthetist. Any adverse event / reaction should be reported to the doctor as soon as possible

Facilities and supplies required Availability of resuscitation equipment (normal hospital procedure)



Treatment Records Record the administration, date, and name of practitioner in the nursing/midwifery/physiotherapy/radiology notes using the NHS Tayside Entonox administration form. (See page 31).

Patients on concurrent medication

Regular medication should be administered to children/young persons who require Entonox. Caution is required with drugs with sedative side effects. These include opioids, benzodiazepines, antihistamines, anticonvulsants (including Gabapentin) and sedating antidepressant drugs. Medical advice should be sought if the child/young person exhibits signs of sedation prior to the administration of Entonox. Regular opioid analgesia with breakthrough opioid can be given whilst the child/young person is receiving Entonox however if additional opioid is required a Paediatric Anaesthetist must be present.

Patient Consent Prior to receiving Entonox the child/young person and carers must be given the opportunity to read the patient information leaflet and sign the Consent and Treatment Record.

Audit Trail Administration sufficient to include audit trail.

Adverse Reactions All adverse reactions (actual and suspected) will be reported to the on-call medical practitioner and recorded in the clinical notes. Where appropriate a Yellow Card Report will be forwarded to the Committee on Safety of Medicines. A supply of these forms can be found at the rear of the British National Formulary.



Consent and Treatment Record - PAEDIATRIC

This document must only be used when Entonox is administered under the guidance of local P.G.D Information sheet given to child/young person/carer______________________ Staff Signature Child/young person has given informed consent ______________________ Staff Signature ______________________ Carer Signature Date child/young person Eligibility Checked_____________ Sign____________________ Reason for administration_______________________________________________

*If Equanox/Entonox is administered more frequently than every 4 days the patient must have a weekly full blood count for evidence of megaloblastic changes in red cells and hypersegmentation of neutrophils.

Date Time Pain

Score (before)

Duration of Entonox

administration

Outcome (Successful analgesia)

Unsuccessful

Analgesia)

Adverse Event

Yes – detail and complete Datix report No

*Blood Test

Required

Pain score (After)

Completed by ……………………………….Signature Print Name…………………………………

Patient ID



Appendix 4 Patient Group Direction Consultation Sheet Proforma for the Administration of Entonox under a PGD PATIENT AND CONSULTATION DETAILS Date of consultation Patient name DOB/CHI Ward PATIENT HISTORY AND CURRENT ANALGESIA Regular opioids PRN opioids Paracetamol NSAIDS Other

Details

CRITERIA FOR INCLUSION

The patient may receive care under this pathway if he/she requires analgesia for one or more of the following Following pain assessment and documentation

YES NO

Patients with no exclusion criteria listed below

YES NO

Patients able hold mouthpiece/ mask by themselves

YES NO

Change of dressings, packs, removing drains, insertion and removal of sutures

YES NO

Invasive procedures e.g. venepuncture, venous cannulation,, catheterisation, sigmoidoscopy, colonoscopy

YES NO

Changing positions of limbs, manipulation, splinting, plastering and applying traction

YES NO

Removal of gynaecological splints, applicators, surgical packing. Gynaecological repair.

YES NO

Movement of limbs during X RAY YES NO Physiotherapy YES NO Renal colic YES NO Uterine contractions YES NO Biopsy procedures YES NO



CRITERIA FOR EXCLUSION The patient must be excluded from receiving treatment under this patient pathway, and referred to a medical practitioner as soon as possible, if one or more of the following criteria apply: Patients who cannot hold a facemask/mouthpiece

YES NO

Impaired conscious level: head injury, intoxication

YES NO

Severe respiratory disease, COPD, Chest trauma, Insertion or removal of chest drain

YES NO

Risk of airway compromise – sleep apnoea, maxillofacial fractures

YES NO

Cardiovascular disease, eg mitral valve stenosis

YES NO

Gross abdominal distension, bowel obstruction

YES NO

Underwater dive within previous 48hours YES NO

Currently receiving vitamin B12 (Hydroxycobalamin) injections

YES NO

First 16 weeks of a viable pregnancy YES NO

Recent ear surgery, ear infection, during myringoplasty (repair of the ear drum).

YES NO

Patients who have recently received intraocular injection of gas (such as SF6) for example retinal detachment surgery

YES NO

Patients who have been using Entonox for 4 consecutive days

YES NO

Action if excluded Record in notes and refer to a medical practitioner

Action if patient declines Record in notes and refer to a medical practitioner



Appendix 5 PROCEDURE FOR ADMINISTERING ENTONOX

Note: You must refer to NHS Tayside Policy and guidelines regarding the Safe Supervision of a Patient Receiving Entonox. If applicable, obtain a copy of the patient group directive and proforma for the administration of Entonox. Patient preparation:

• Check the procedure and the patient’s medical notes against the inclusion and exclusion criteria contained within the policy or the patient group directive.

• Assess the patient’s suitability to use Entonox and obtain consent. • Ensure the area where the procedure is to be carried out is well ventilated. • Ensure the patient has been given any regular analgesia that is prescribed.

Equipment:

• Entonox cylinder (check the cylinder label on the collar) or wall supply. • Cylinder head guage • Disposable mask and /or disposable mouthpiece. • Disposable bacterial filter. • Wide bore tubing and demand valve (stored separately from the cylinder)

Procedure:

• Prepare and explain the procedure to the patient (see PGD).

• Record pain score

• Collect all equipment. Make sure you check the label on the cylinder to ensure you

have the correct gas. Wash hands. If required to use Alcohol Based Rubs ensure that the alcohol is fully evaporated prior to handling the cylinder. Do not apply hand cream prior to assembling the equipment.

• Check that the cylinder has been stored for 24hours above 10 degrees centigrade

(normally stored at room temperature but if the cylinder has been replaced recently it may have been stored outside).If the cylinder has not been stored above 10°C do not use.

• Place cylinder in upright position and ensure it is secure in the transport cage.

• Fit the cylinder head guage to the cylinder by lining up the pin over the hole and

secure in place. Check it is fitted securely before turning on the gas with the key.

• Check the amount of gas in the cylinder by looking at the position of the dial. Change

the cylinder if the dial is in the red area of the guage.

• Fit the tubing to the cylinder. Simply push and twist the tubing into the cylinder head attachment. Before attaching the mouthpiece or mask, push the demand valve button briefly to expel any dust in the system and to ensure the demand valve is working. If



gas continues to escape after pressing the button, switch off the cylinder and collect a new demand valve. Attach the bacterial filter then the mouthpiece or mask.

• Explain to the patient that the Entonox may make him/her feel dizzy or light-headed.

Give the mouthpiece or mask to the patient and instruct him/her to inhale deeply and breathe out normally.

• Instruct the patient to take as necessary prior to and during the procedure. Allow the

patient to practice before the procedure begins. It may take up to 5 minutes to take effect.

• Maintain verbal contact with the patient throughout, assessing their pain and level of

consciousness.

• Continue with the clinical procedure if the pain is well controlled. Discontinue if pain uncontrolled and consider alternative pain relief.

• Patients must always self-administer this drug. This ensures that if they become

drowsy they are unable to take further doses and thus unable to overdose.

• Re-check and document patient’s pain score at regular intervals throughout the procedure and on completion.

• Ensure the patient is comfortable after the procedure and give safety advice.

• Complete the patient group directive documentation to provide a record of evaluation.

• Switch off the cylinder and press the demand valve button to safely dispel any gas from the regulator/equipment. Remove the cylinder from the patient area.

• Remove and discard the bacterial filter and mouthpiece or mask (single use only).

• Remove the tubing /demand valve and cylinder guage when the Entonox is not in use and store separately from the cylinder. Wash the tubing with multi-purpose wipe.

• Ensure the correct storage of the Entonox cylinder after use. Return to the main

storage area if no longer required. .



Appendix 6 SIDE –EFFECTS OF ENTONOX AND TREATMENT RECOMMENDATI ONS If the use of Entonox is unsatisfactory at any stage or the patient is unable to tolerate the delivery device, it may be necessary to stop the procedure until alternative analgesia can be sought. Entonox related side-effects will wear off within a short time. Entonox related side-effect

Action

Dry mouth

This is a common side-effect but is not usually distressing. The patient may take small sips of water and continue to use Entonox

Earache

If the patient complains of earache inhalation should be stopped and alternative analgesia sought.

Dizziness or disorientation

If the patient starts to feel dizzy or disorientated they may cease inhalation for a while. The sensation should start to wear off rapidly. Once recovered the patient may re-commence inhalation if they want to.

Over sedation

If the patient becomes drowsy the seal around the mask or mouthpiece is lost and they will no longer inhale the gas. It is essential that only the patient holds the mask/mouthpiece to prevent the deeper stages of analgesia and sedation.

Generalised muscle rigidity

This may be due to hyperventilation during inhalation. Discontinue Entonox for a while and allow patient to recover. Re-educate the patient stressing deep and regular inspiration.

Nausea

The patient may cease inhalation if they wish. The side-effects wear off quickly. Offer anti-emetic. The patient may re-commence inhalation if they wish.

Vomiting

Remove the mask/mouthpiece immediately. Reassure the patient and clear any obstruction to breathing. Clean and replace the mask/mouthpiece if required. Replace the filter if contaminated by vomit.

Severe pain

Consider alternative analgesia. Do not administer IV Morphine bolus during inhalation of Entonox.

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Document: Safe use of Entonox for short term pain relief Version:2.3 Version Date: December 2019 Policy Manager: Val.Shepherd Page 38 of 59 Review Date: December 2021

Annex 1 NHS TAYSIDE – POLICY APPROVAL CHECKLIST

POLICY AREA: Clinical POLICY TITLE: Safe use of Entonox for short term pain relief POLICY MANAGER: Val.Shepherd

Why has this policy been developed?

To provide healthcare practitioners in NHS Tayside with the ability to make correct decisions regarding supply and supervision of Entonox for short term pain relief

Has the policy been developed in accordance with or related to legislation? – Please give details of applicable legislation.

Control Of Substances Hazardous to Health (COSHH) Regulations 2002 (as amended).

Has a risk control plan been developed and who is the owner of the risk? If not, why not?

YES

Who has been involved/consulted in the development of the policy?

Multidisciplinary health care professionals who currently care for patients requiring Entonox for short term pain relief.

Has the policy been Equality Impact Assessed in relation to:- Has the policy been Equality Impact Assessed not to disadvantage the following groups:-

Age Disability Gender Reassignment Pregnancy/Maternity Race/Ethnicity Religion/Belief Sex (men and women) Sexual Orientation

Please indicate Yes/No for the following YES YES YES YES YES YES YES YES

People with Mental Health Problems Homeless People People involved in the Criminal Justice System Staff Socio Economic Deprivation Groups Carers Literacy Rural Language/Social Origins

Please indicate Yes/No for the following: YES YES YES YES YES YES YES YES YES

Does the policy contain evidence of the Equality Impact Assessment Process?

YES – Rapid impact assessment attached

Is there an implementation plan? YES

Which officers are responsible for implementation?

Pain Team members PRI and Ninewells Hospital

When will the policy take effect?

immediately

Who must comply with the policy/strategy?

Registered nurses, doctors, midwives, physiotherapists

How will they be informed of their responsibilities?

managers

Is any training required?

YES

If yes, attach a template

Are there any cost implications?

NO

If yes, please detail costs and note source of funding

Who is responsible for auditing the implementation of the policy? Pain Team members PRI and Ninewells What is the audit interval? Annually Who will receive the audit reports? Pain Team When will the policy be reviewed and provide details of policy review period (up to 5 years)

Every 2 years. Next review December 2021

POLICY MANAGER:_Val.Shepeherd DATE: 24/01/2020 APPROVAL COMMITTEE TO CONFIRM: Medicines Policy Group November 2013 ADOPTION COMMITTEE TO CONFIRM: Quality Clinical Forum June 2013

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Document: Safe use of Entonox for short term pain relief Version:2.3 Version Date: December 2019 Policy Manager: Val.Shepherd of 59 Review Date: December 2021

Annex 2 EQUALITY IMPACT ASSESSMENT Name of Policy, Service Improvement, Redesign or St rategy: Policy for the Safe use of Entonox for short term pain relief Lead Director of Manager: Director of Nursing What are the main aims of the Policy, Service Impro vement, Redesign or Strategy? To provide healthcare practitioners in NHS Tayside with the ability to make the correct decisions regarding supply and supervision of a patient receiving Entonox for short term pain relief. To assist clinical staff to minimise avoidable/potential risks of Entonox gas and cylinders. Description of the Policy, Service Improvement, Red esign or Strategy – What is it? What does it do? Who does it? And wh o is it for? The policy sets out the standards and recommendations for practice in NHS Tayside in relation to the safe supervision of a patient receiving Entonox for short-term pain relief. The policy applies to medical staff, registered nurses, midwives and physiotherapists who care for patients receiving Entonox. What are the intended outcomes from the proposed Po licy, Service Improvement, Redesign or strategy? – What will happen as a resul t of it?- Who benefits from it and how? The recommendations for practice within the policy will:

• Promote and utilise evidence-based practice • Help staff to manage pain effectively • Ensure staff who supervise patients receiving Entonox can provide safe care • Set out actions and treatments, which can help recognise and prevent complications • Ensure uniform practice in relation to supervision of patients receiving Entonox

throughout NHS Tayside. • Ensure staff who handle Entonox cylinders and equipment are aware of the potential

risks with the gas and equipment and can minimise/avoid harm. Name of the group responsible for assessing or cons idering the equality impact assessment? This should be the Policy Working Grou p or the Project team for Service Improvement, Redesign or Strategy. NHS Tayside Pain Team members and policy group – named within the policy.

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SECTION 1 Part B – Equality and Diversity Impacts Which equality group or Protected Characteristics d o you think will be affected Item Considerations of impact Explain the answer and if

applicable detail the impact Document any Evidence/Research/Data to support the consideration of impact

Further actions required

1.1 Will it impact on the whole population? Yes or No. If yes will it have a differential impact on any of the groups identified in 1.2. If no go to 1.2 to identify which groups

Yes. Positive impact for patients as Entonox can be self administered and rapidly provides effective pain relief with minimal side-effects. Patients can resume normal activities soon after use. Any patient can be considered for the use of Entonox for short term pain relief however, there are some health and safety considerations and the inclusion /exclusion criteria are detailed within the policy. Negative impact on STAFF as they must undergo training and demonstrate competency before being able to offer Entonox to patients. NO

Australian and New Zealand College of Anaesthetists, 2015. Acute Pain Management Scientific Evidence. BOC Medical gas data sheet, 2019. Health and Safety Executive, Website. Control of Substances Hazardous to Health (COSHH) microsite Health Facilities Scotland SHTM 02_01(2015). Medical Gas Pipeline Systems Part B operational Management. British Compressed Gas Association – BCGA Guidance Note 2 (2012) Guidance for the storage of gas cylinders in the workplace.

None

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Item Considerations of impact Explain the answer and if applicable detail the impact

Document any Evidence/Research/Data to support the consideration of impact


1.2 Which of the protected characteristic(s) or groups will be affected?

• Minority ethnic population (including refugees, asylum seekers & gypsies/travellers)

• Women and men • People in

religious/faith groups • Disabled people • Older people, children

and young people • Lesbian, gay, bisexual

and transgender people

• People with mental health problems

• Homeless people • People involved in

criminal justice system

• Staff • Socio- economically

deprived groups

This policy applies to patients attending Ninewells Hospital, PRI or Stracathro Hospital The sole feature of the policy is to determine the appropriateness of Entonox for short term pain relief based on clinical need and health and safety factors, irrespective of protected characteristics. Disabled people, elderly and very young children may not be able to self administer Entonox safely and alternative analgesia will be made available to them.

See exclusion criteria in the policy.

Staff must complete the inclusion/exclusion checklist. Staff must contact the Pain Team on their site if advice on alternative analgesia is required.

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1.3 Will the development of the policy, strategy or service improvement/redesign lead to

• Discrimination • Unequal opportunities • Poor relations

between equality groups and other groups

• Other

NO

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SECTION 2 – Human Rights and Health Impact. Which Human Rights could be affected in relation to article 2, 3, 5, 6, 9 and 11. (ECHR: European Conv ention on Human Rights) Item Considerations of impact Explain the answer and if



2.1

On Life (Article 2, ECHR) • Basic necessities such as

adequate nutrition, and safe drinking water

• Suicide • Risk to life of / from

others • Duties to protect life from

risks by self / others • End of life questions

NO

2.2

On Freedom from ill -treatment (Article 3, ECHR) • Fear, humiliation • Intense physical or

mental suffering or anguish

• Prevention of ill-treatment,

• Investigation of reasonably substantiated allegations of serious ill-treatment

• Dignified living conditions

NO

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Item Considerations of impact Explain the answer and if



2.3 On Liberty (Article 5, ECHR) • Detention under mental

health law • Review of continued

justification of detention • Informing reasons for

detention

NO

2.4 On a Fair Hearing (Article 6, ECHR) • Staff disciplinary

proceedings • Malpractice • Right to be heard • Procedural fairness • Effective participation in

proceedings that determine rights such as employment, damages / compensation

NO

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2.5 On Private and family life (Article 6, ECHR) • Private and Family life • Physical and moral

integrity (e.g. freedom from non-consensual treatment, harassment or abuse

• Personal data, privacy and confidentiality

• Sexual identity • Autonomy and self-

determination • Relations with family,

community • Participation in decisions

that affect rights • Legal capacity in decision

making supported participation and decision making, accessible information and communication to support decision making

• Clean and healthy environment

NO

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2.6 On Freedom of thought, conscience and religion (Article 9, ECHR) • To express opinions and

receive and impart information and ideas without interference

NO

2.7 On Freedom of assembly and association (Article 11, ECHR) • Choosing whether to

belong to a trade union

NO

2.8 On Marriage and founding a family • Capacity • Age

NO

2.9 Protocol 1 (Article 1, 2, 3 ECHR) • Peaceful enjoyment of

possessions

NO

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SECTION 3 – Health Inequalities Impact Which health and lifestyle changes will be affected ? Item Considerations of impact Explain the answer and if



3.1 What impact will the function, policy/strategy or service change have on lifestyles?

For example will the changes affect:

• Diet & nutrition • Exercise & physical

activity • Substance use:

tobacco, alcohol or drugs

• Risk taking behaviours

• Education & learning or skills

• Other

NO negative impact however staff will require to undergo training Clinical skills training pack supports the policy

Staff must access the Clinical skills training package and contact the Pain Team on their site to arrange training. SCN’s/managers of areas where Entonox is used must keep records of staff training and competency.

3.2. Does your function, policy or service change consider the impact on the communities?

Things that might be affected include:

• Social status • Employment

(paid/unpaid) • Social/family support • Stress • Income

No negative impact

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3.3 Will the function, policy or service change have an impact on the physical environment? For example will there be impacts on:

• Living conditions • Working conditions • Pollution or climate

change • Accidental

injuries/public safety • Transmission of

infectious diseases • Other

ENVIRONMENT –The policy recommends an assessment of the environment to ensure adequate ventilation in the area where Entonox is to be used. Negative impact if the safety recommendations regarding storage and handling of the gas cylinder were not followed. Staff must inform their line manager if they believe they may not be able to carry out the task safely.

Health and Safety Executive website Control of Substances Hazardous to Health (COSHH) microsite NHS Tayside Health and Safety policy, Control of Substances Hazardous to Health. BOC Medical gas data sheet, 2019. Health Facilities Scotland SHTM 02_01(2012). Medical Gas Pipeline Systems Part B operational Management British Compressed Gas Association – BCGA Guidance note 2 (2012) Guidance for the storage of gas cylinders in the workplace.

Individual areas must carry out a COSHH assessment. Comply with the policy recommendations with regards the storage and handling of Entonox cylinders.

3.4 Will the function, policy or service change affect access to and experience of services? For example

• Healthcare

No negative impact. Entonox for short-term pain relief can have a positive impact on a patient’s experience of services.

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• Social services • Education • Transport • Housing

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3.5 In relation to the protected characteristics and groups identified:

• What are the potential impacts on health?

• Will the function,

policy or service change impact on access to health care? If yes - in what way?

• Will the function or

policy or service change impact on the experience of health care? If yes – in what way?

No specific impact on the protected groups. Entonox has both analgesic and antianxiolytic properties with very few adverse effects. Improved pain management with minimal side-effects and an element of patient control makes it a more satisfactory experience for the patient. Quick recovery hastens discharge from hospital or clinic.

Patient feedback.

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SECTION 4 – Financial Decisions Impact How will it affect the financial decision or propos al? Item Considerations of impact Explain the answer and if



4.1

• Is the purpose of the financial decision for service improvement/redesign clearly set out

• Has the impact of your financial proposals on equality groups been thoroughly considered before any decisions are arrived at

No financial proposals

4.2 • Is there sufficient information to show that “due regard” has been paid to the equality duties in the financial decision making

• Have you identified methods for mitigating or avoiding any adverse impacts on equality groups

• Have those likely to be affected by the financial proposal been consulted and involved

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5. Involvement, Consultation and Engagement (IEC) 1) What existing IEC data do we have?

• Existing IEC sources • Original IEC • Key learning

2) What further IEC, if any, do you need to undertake?

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6. Have any potential negative impacts been identified?

• If so, what action has been proposed to counteract the negative impacts? (if yes state how)

For example: • Is there any unlawful

discrimination? • Could any community

get an adverse outcome?

• Could any group be excluded from the benefits of the function/policy?

(consider groups outlined in 1.2)

• Does it reinforce negative stereotypes?

(For example, are any of the groups identified in 1.2 being disadvantaged due to perception rather than factual information?)

Risk of non compliance with the policy. Entonox is offered based on clinical need. Patients may not fit the inclusion criteria eg unable to hold the mouthpiece. The procedure may fall into the exclusion criteria – removal of chest drain. A ward/department may not be able to offer Entonox as none of the staff have been trained. The ward/department must provide one nurse to supervise Entonox and another to carry out the procedure/dressing. Staffing numbers may not allow for this . The policy does not reinforce negative stereotypes.

BOC Medical gas data sheet, 2019.

Staff must demonstrate evidence of competency in safe supervision of a patient receiving Entonox. Staff are assessed on their knowledge and practical skills. The Entonox gas cylinder is stored separately from the cylinder head and delivery valve. The Pain nurses will not give staff access to the gas delivery equipment unless the staff can provide evidence of Entonox training. Pain Team regularly offer training to areas that are likely to identify patients who would benefit from Entonox.

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7. Data & Research • Is there need to

gather further evidence/data?

• Are there any apparent gaps in knowledge/skills?

Ongoing policy review process will highlight any new evidence regarding use of Entonox. The Pain Nurses identify areas where staff need training through referrals to the Pain Service to supply Entonox

Ongoing education provided by the Pain Nurses.

8. Monitoring of outcomes • How will the

outcomes be monitored?

• Who will monitor? • What criteria will you

use to measure progress towards the outcomes?

The practitioner who supervises the patient will monitor the patient as per the consent and treatment record which is contained in the policy. This is kept in the patients notes. Adverse events will be Datix reported.

No Datix reports received to-date

9.. Recommendations State the conclusion of the Impact Assessment

The impact of this policy is to provide safe supervision of patients receiving Entonox for short-term pain relief. We recommend that staff access and read this policy. Staff must complete the Clinical Skills Pack, “Supervision of a patient receiving Entonox for short

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term pain relief”. Practical training is provided by the Pain Nurses. The healthcare practitioner will undergo a period of supervision in clinical practice and be assessed on both knowledge and skills related to Entonox using the competency framework in the clinical skills pack. Healthcare practitioners can then integrate this skill in every day practice. Records of training and competency are held locally. Healthcare practitioners are responsible for updating and maintaining their knowledge thereafter. Suitable update would be to access and read the policy and clinical skills pack biannually as they are reviewed and updated. One of the barriers to providing effective pain relief for procedure/trauma pain is waiting for medical staff to prescribe it. Implementation of the policy will raise awareness of Entonox as a safe and effective analgesic. Under a Patient Group Directive, practitioners who have undergone the training

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can supply Entonox independant of a medical practitioner. It is hoped in the future, more patients will be able to experience the benefit of Entonox for short term pain relief.

10. Completed function/policy • Who will sign this off? • When?

Quality Clinical Forum June 2013 and Medicines Policy Group November 2013

11. Publication

Staffnet

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Conclusion Sheet for Equality Impact Assessment

Positive Impacts (Note the groups affected) Patient Groups Entonox has both analgesic and anti-anxiolytic properties. It is self administered by the patient giving them an element of control over pain relief during painful procedures or trauma. Entonox has minimal adverse effects and wears off quickly therefore patients can resume to most activities soon after use. Discharge from hospital or outpatient clinic will not be unduly delayed. Staff Groups Staff can feel stressed and helpless if patients are in severe pain during a procedure or painful dressing. Under a Patient Group Direction, staff who have completed the recommended training can supply Entonox independant of a medical practitioner. This enhances job satisfaction.

Negative Impacts (Note the groups affected) Patient Groups There are few side-effects with short term use of Entonox and they wear off once inhalation ceases. Patients who use Entonox for more than 4 days will require regular blood tests. The policy does not set out to discriminate against any groups or protected characteristics but health and safety reasons may deem Entonox unsuitable for some patients (see inclusion/exclusion criteria). Alternative analgesia will be provided. Staff Groups Staff must undergo the recommended training programme. This will involve an element of self-directed study. Staff must be signed off as competent before supplying Entonox under the Patient Group Direction and supervising the patient receiving Entonox. Staff need to be released to attend the practical workshop. Additional members of staff need to be available for a procedure/dressing – one to supervise the patient receiving Entonox and one to carry out the procedure. Staff may work in an area where Entonox is not used frequently. They are accountable for updating and maintaining their knowledge and competency.

What if any additional information and evidence is required

From the outcome of the Equality Impact Assessment what are your recommendations? (refer to questions 5 - 10) The impact of this policy is to provide safe supervision of patients receiving Entonox for short-term pain relief. We recommend that staff access and read this policy. Staff must complete the Clinical Skills Pack, “Supervision of a patient receiving Entonox for short term pain relief”. Practical training is provided by the Pain Nurses. The healthcare practitioner will undergo a period of supervision in clinical practice and be assessed on both knowledge and skills related to Entonox using the competency framework in the clinical skills pack. Healthcare practitioners can then integrate this skill in every day practice. Records of training and competency are held locally. Healthcare practitioners are responsible for updating and maintaining their knowledge

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thereafter. Suitable update would be to access and read the policy and clinical skills pack biannually as they are reviewed and updated. One of the barriers to providing effective pain relief for procedure/trauma pain is waiting for medical staff to prescribe it. Implementation of the policy will raise awareness of Entonox as a safe and effective analgesic. Under a Patient Group Directive, practitioners who have undergone the training can supply Entonox independent of a medical practitioner. It is hoped in the future, more patients will be ab le to experience the benefit of Entonox for short term pain

Document Control Document: Version:2.3 Version Date: December 2019 Policy Manager: Page 59 of 59 Review Date: December 2021

Annex 3 POLICY TRAINING PLAN

Level of Delivery/ Training Format of Delivery Target Groups

Level 1 eLearning All staff

Level 2 General raising awareness All staff

Level 3 ‘Behavioural skills’ toolkit training / Detailed training programme Line Managers

Level 4 Consultancy/Values based reflective practice / Coaching support from HR / OD Team Identified as required

OPIC Level of

training

Frequency / Dates of Training

Format of Delivery

Target Group

Quantifiable Resources

Links to eKSF Dimensions

Policy for safe use of Entonox for short term pain relief

3

Training or update is provided on request to the Pain Nurse Specialists in Ninewells Hospital or PRI. 3-4 sessions are run each year

a)Self directed study – access and read the policy and complete the activities in the clinical skills workbook. b)Face to face workshop with Pain Specialist Nurse. Practical demonstration and assessment of handling the equipment. c) Supervision in clinical practice and competency sign off using performance indicator tool.

Medical staff, Registered Nurses, Midwives and physiotherapists

Clinical skills packs. Policy for safe use of Entonox.

C1: Communication C2: Personal and people development C3:Health, safety and security C4:Service improvement C5: Quality HWB6: Assessment and treatment planning EF1: Systems, vehicles and equipment

clinical safe use of entonox for short term pain relief

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