SESLHD GUIDELINE COVER SHEET
SESLHD GUIDELINECOVER SHEETNAME OF DOCUMENTIntramuscular Injection in Mental HealthTYPE OF DOCUMENTGUIDELINEDOCUMENT NUMBERSESLHDGL/076DATE OF PUBLICATIONFebruary 2019RISK RATINGMediumLEVEL OF EVIDENCENational Safety and Quality Health ServiceStandardsStandard 4: Medication Safety (4:13)Standard 1: Clinical Governance (1.29)REVIEW DATEFebruary 2022FORMER REFERENCE(S)SESLHDBR/052 Administration of VentroglutealIntramuscular Injection.EXECUTIVE SPONSOR orDr Peter YoungEXECUTIVE CLINICALSPONSORA/ Clinical DirectorAUTHORBenjamin ChidesterSELSHD Mental HealthWorkplace Capabilities A/Nurse Educator, SESLHDMental Health ServiceBronwyn WalkerWorkplace Capabilities A/Clinical Nurse Educator,SESLHD Mental Health ServicePOSITION RESPONSIBLE FORDOCUMENTBronwyn WalkerKEY TERMSProcess of preparing and administration ofintramuscular injectionsSUMMARYThis guideline offers a framework for mental nursesto practice in line with current research into theprocess of preparing and administration ofintramuscular injections. Applicable to both inpatientand community mental health settings.Workplace Capabilities A/Clinical Nurse Educator,SESLHD Mental Health ServiceBronwyn.Walker@health.nsw.gov.auTHIS DOCUMENT IS A GUIDE FOR BEST PRACTICEThis Guideline is intellectual property of South Eastern Sydney Local Health District.Guideline content cannot be duplicated.Feedback about this document can be sent to seslhd-executiveservices@health.gov.au
Intramuscular Injection in Mental HealthSection 1 - Background . 3Section 2 - Principles . 4Section 3 - Responsibilities . 5Section 4 - Injection Sites . 6Section 5 - Preparation . 95.1 Equipment . 105.2 Procedure . 11Section 6 - Documentation, References, Revisions & Approval History . 12Appendix A: Antipsychotic Long-Acting Injection (LAI) Administration Guide. 12Appendix B: Oil-based Depot Administration . 12REVISION: 1Trim No: T18/53205Date: February 2019THIS DOCUMENT IS A GUIDE FOR BEST PRACTICEThis Guideline is intellectual property of South Eastern Sydney Local Health District.Guideline content cannot be duplicated.Page 2 of 16
Section 1:BackgroundSection 1 – BackgroundIntramuscular (IM) injections have been an integral part of drug administration in nursing practicefor almost half a century. Many medications used in mental health settings require IM route ofadministration and IM injections are often given in circumstances in which there are be risks toboth consumers and staff. Involuntary administration of medications is also a coercive practicethat can be experienced by consumers as traumatic.The purpose of this guideline is to ensure consistent best practice for administration ofmedications by this route in SESLHD mental health services. Areas addressed within this guideinclude appropriate circumstances in which to utilise IM medications, injection sites, appropriateneedle selection and volume administered through IM injections, and injection techniques.An appropriate injection technique reduces discomfort and complications for consumers.Necessary skills for good injection technique include: knowledge of anatomy and physiology,pharmacology, suitable injection sites and injection techniques and effective communicationskills.REVISION: 1Trim No: T18/53205Date: February 2019THIS DOCUMENT IS A GUIDE FOR BEST PRACTICEThis Guideline is intellectual property of South Eastern Sydney Local Health District.Guideline content cannot be duplicated.Page 3 of 16
Section 2:PrinciplesSection 2 – PrinciplesThe correct injection site and volume for the intramuscular injection outlined in this guidelineshould be followed. Decisions regarding the preferred site to use for Intramuscular injections maybe based on clinical judgement of the nurse, aligning to contemporary practices. Consumer’sbody make up and body mass index, needle length available, and types of medication must beconsidered during clinical care. The IMI administration site may variety for rapid tranquilizationand depot medications. See Table 1.The following guideline aligns with SESLHDBR/052 Administration of VentroglutealIntramuscular Injection.REVISION: 1Trim No: T18/53205Date: February 2019THIS DOCUMENT IS A GUIDE FOR BEST PRACTICEThis Guideline is intellectual property of South Eastern Sydney Local Health District.Guideline content cannot be duplicated.Page 4 of 16
Section 3ResponsibilitiesSection 3 – ResponsibilitiesMedical staff are responsible for: Intramuscular injections will be prescribed under the direction of the ConsultantPsychiatrist.Nursing staff are responsible for ensuring: Nursing staff members are trained in the correct administration of Intramuscular injections. The correct safety precautions, preparation and procedure are followed. The Z tracking technique must be used in the administration of the IMI. The 5 Rights: right patient, right drug, right dose, right route and right time are followed ateach administration.Site and Service Managers are responsible for: The Community and Inpatient Unit Service Managers are to ensure adherence to twoperson checking requirements as set out by the NSW Ministry of Health Policy DirectivePD2013 043 - Medication Handling in NSW Public Health Facilities. Clinical Line Managers are responsible for ensuring this guideline is available to all MHSstaff member in their work area. Clinical staff member involved in the administration of intramuscular will follow theseguidelines. Site and Service Managers are responsible for ensuring this guideline is circulated andimplemented locally.REVISION: 1Trim No: T18/53205Date: February 2019THIS DOCUMENT IS A GUIDE FOR BEST PRACTICEThis Guideline is intellectual property of South Eastern Sydney Local Health District.Guideline content cannot be duplicated.Page 5 of 16
Section 4:Injection SiteSection 4 - Injection siteTable 1. Injection site and volume for effective muscle absorptionInjection SiteBackground InformationDeltoid –Suggested indications Test dose Paliperidone –Manufacturersrecommendations When amount is less than 2ml Personal preference Excessive subcutaneous fatthickness is present in othersitesDorsogluteal –Suggested indications For rapid tranquilisation inprone position When amount is up to 3mls Repeated injections Z tracking works effectivelywith this site to trap fluid in thecorrect layer Personal preferenceREVISION: 1Trim No: T18/53205 Injections into the mid deltoid muscle produce aquick uptake of the medicine. The maximum whichcan be safely injected is 2ml and based on clinicalopinion.Common practice is to use this site for smallvolume injections such as vaccinations andmanufacturers recommending site for the smalltest dose of Paliperidone.Volume ofmedication0.5 to 2mlThe dorsogluteal site, colloquially called the ‘upper 1 to 3 mlouter quadrant’, targets the gluteus maximusmuscle.When this site is used, there is a risk that themedicine will not reach the target muscle, butinstead will be injected into subcutaneous fat. As aresult, delayed uptake of the medicine will occurand tissue irritation or the development ofgranulomas may result. The 38mm green and blueneedles are unlikely to reach the gluteal muscles ina considerable number of consumers who areresult in damage to the sciatic nerve or glutealartery, both of which lie a few for those who arevery thin centimetres distal to the dorsoglutealinjection site, causing pain, paralysis orDate: February 2019Page 6 of 16THIS DOCUMENT IS A GUIDE FOR BEST PRACTICEThis Guideline is intellectual property of South Eastern Sydney Local Health District.Guideline content cannot be duplicated.MuscleDeltoidGluteusmaximus
Section 4:Injection SiteVentrogluteal – Suggested indications Clinically indicated forconsumers consenting fordeep IMI Personal preference Elderly consumers withreduced muscle tissues in thedorsogluteal site When the administeringnurses is trained in locatingthe correct Ventrogluteal site.Refer to SESLHDBR/052Administration of VentroglutealIntramuscular Injection. REVISION: 1Trim No: T18/53205haemorrhage. There may also be modesty issuesassociated with the use of this site.Consider injection depth.There are few disadvantages to using this site. It is 1 to 3 mlrelatively free of major nerves and blood vessels,the muscles are large and well defined, and thelandmarks for administration are easy to locate.This site is not preferred in a rapid tranquilisationsituation. There may be modesty issuesassociated with the use of this site.Excessive subcutaneous fat in this area can leadto the risk of a subcutaneous injection, rather thanthe injection reaching the muscle layer. As aresult, delayed uptake of the medicine will occurcan tissue irritation or the development ofgranulomas may result. The 38mm green and blueneedles are unlikely to reach gluteal muscles in aconsiderable number of overweight or obeseconsumers.Consider injection depth for those who are verythin.Clinicians need to be trained in the process ofadministrating and locating the landmarks beforeventrogluteal IMI injection can be given.Date: February 2019Page 7 of 16THIS DOCUMENT IS A GUIDE FOR BEST PRACTICEThis Guideline is intellectual property of South Eastern Sydney Local Health District.Guideline content cannot be duplicated.Gluteusmedius andMinimus
Section 4:Injection SitePlease note: Nurses must use the recommended needles sizes for each injection suppliedinside the packs used for Aripiprazole, Olanzapine, Paliperidone and Risperidone.Only needles supplied in the dose pack should be used. The 22 gauge 38.1mm needle shouldbe used for dorsogluteal/ventrogluteal injection and for deltoid injections in patients over 90kg.The 23 gauge 25.4 mm needle should be used only for deltoid below 90kg.Table 2. Injection site and Needle size guideBodyweightInjection siteNon-obese (BMI - 30)DeltoidGlutealObese (BMI - 30) DeltoidGlutealNeedle size25mm 23gauge38mm 21gauge38mm 21gauge50mm 21gaugeTo ensure an injection reaches the muscle layer a clinician needs to consider the personsBMI, weight and subcutaneous fat thickness when choosing needle length selection.Somatype is one way to assist the clinician to estimate the potential subcutaneous fatthickness. Somatype refers to three categories: the ectomorph (narrow shoulders, torso andhips); mesomorph (broad shoulders & muscle limbs) and endomorph (round body withpredomiance of fat) 1. Consideration of these body shapes has most relevance to the dorsogluteal and ventro gluteal sites.Older females are more likely to receive a subcutaneous injection when comparing gendersand subcutaneous fat thickness. Consideration of a 38mm needle length is a viable optionin the ventrogluteal site but still has limitations.1 In these cases consideration of a 50mmneedle would increase the success of an injection reaching the muscle layer in the eithergluteal site or choosing a different injection site.Other factors to consider is consumers receptivity to intramuscular injections, preferredadministration site and response to treatment and the nurses clinical judgement.1Larkin, Ashcroft, Hickey & Elgellaie (2018). Influence of gender, BMI and body shape on theoretical injection outcome at the ventroglutealand dorsogluteal sites. Journal of Clinical Nursing, 27, 242-250.REVISION: 1Trim No: T18/53205Date: February 2019THIS DOCUMENT IS A GUIDE FOR BEST PRACTICEThis Guideline is intellectual property of South Eastern Sydney Local Health District.Guideline content cannot be duplicated.Page 8 of 16
Section 5:PreparationSection 5 - Preparation5.1 EquipmentThe nurse will need: 2 - 5ml syringe21 gauge 38mm (or 50mm needle if BMI indicates obese 30)Needle for drawing up injection – 18 gauge 40mm needleAripiprazole, Olanzapine, Paliperidone or Risperdone injection kit (syringes, needles /- diluent providedGlovesAlcohol swabNon-woven gauze swabSmall plaster (optional)Prescribed medicationPrescription chart /electronic medication orderDish for equipmentSharps container5.2 Procedure1. Confirm that the injection is due for the identified consumer or has not already beenadministered before assembling the equipment by checking the prescription, theadministration record and whenever possible with the consumer.2. Explain to the consumer the procedure and which site you will be using. Seek confirmationof consumer’s consent. If there are problems with communication offer information inanother format or consider advocacy or interpreter services documenting what action hasbeen taken in the consumer’s notes. Staff should also be mindful of trauma histories whenexplaining procedures. If the consumer does not consent to this site, consider anothersite, being aware of potential licensing implications. Maintain communication with yourconsumer throughout the procedure, offering reassurance and explaining as you proceedwith the procedure (If in restraint, one person talking).3. Prior to preparation of medication, it is vital to identify an area where the qualified nursewill not be disturbed, that provides confidentiality and dignity for the consumer and wherethere is appropriate facility for the disposal of sharps - either a sharps box within a clinicalarea or a portable sharps container.4. The nurse should wash their hands and don gloves before preparing the medication andtouching the consumer, adhering to the 5 points of hand hygiene.5. Check medication expiry date.REVISION: 1Trim No: T18/53205Date: February 2019THIS DOCUMENT IS A GUIDE FOR BEST PRACTICEThis Guideline is intellectual property of South Eastern Sydney Local Health District.Guideline content cannot be duplicated.Page 9 of 16
Section 5:Preparation6. Draw up the prescribed dose of medication immediately prior to the injection, using a widebore needle. Allow refrigerated medications to return to room temperature beforeadministration.7. Change needle and use the relevant gauge and length needle to administer. (Forguidance, see Table 1).8. For Aripiprazole, Olanzapine, Risperdone or Paliperidone Long Acting Injections (LAI’S)the components (needles, syringes diluents etc) provided in the injection kits must beused. Consideration of subcutaneous fat thickness may warrant a review of the contentsof the pre-packaged products and substituting needle lengths for the few that this appliesto. Otherwise outcome will be that the product does not each the intended site andtherefore the consumer is untreated.9. The injection must be administered by a Registered Nurse or Enrolled Nurse withoutnotation and checked by a second person (one of whom must be a registered nurse). Anexception to this is in the community health setting as a second person is not available.10. Check the consumers known allergies against the medication order and with the patient.If an allergy to the medication being administered is identified, do not administer themedication and contact the consumer’s medical officer.11. Choose a site for the injection. In general, not more than 3ml of oily injection should beadministered at any one time in a gluteal site, and no more than 2ml at the deltoid site(For a guide, see Appendix B. NB. Always follow the manufacturer’s guideline).12. Ask the consumer to expose hip, buttock or arm for injection, using the opposite side tothat of the one injected previously.13. Examine site for evidence of lesions and establish that the site is pain free. Seekclarification again that the consumer is happy to have medication given at this site. If theconsumer is not happy with clinically indicated site, further discussion with the multidisciplinary team should be initiated. Avoid using restraints to enforce medicationadministration unless in an emergency situation.14. Wipe the injection site with an alcohol swab and wait 30 seconds until it dries (to avoid thepossibility of alcohol entering the site).15. Administer the injection using the Z-track technique as shown below.Z-Tracking Technique1. Displace the skin by pulling it laterally away from the intended point of injection.2. Insert the needle into the site at a 90 angle, aspirate and if safe continue to inject slowly1ml per 10 seconds.REVISION: 1Trim No: T18/53205Date: February 2019THIS DOCUMENT IS A GUIDE FOR BEST PRACTICEThis Guideline is intellectual property of South Eastern Sydney Local Health District.Guideline content cannot be duplicated.Page 10 of 16
Section 5:Preparation3. Wait 10 seconds then withdraw the needle and release the skin allowing the displacedtissue to seal the needle track.REVISION: 1Trim No: T18/53205Date: February 2019THIS DOCUMENT IS A GUIDE FOR BEST PRACTICEThis Guideline is intellectual property of South Eastern Sydney Local Health District.Guideline content cannot be duplicated.Page 11 of 16
Section 6:Documentation, References & Approval HistorySection 6 – DocumentationDocument the procedure including the time, date and site of insertion in the eMR and in theappropriate medication form/eMEDs.ReferencesSESLHD SESLHDBR/052 Administration of Ventrogluteal Intramuscular Injection SESLHDGL/607 Olanzapine Pamoate Long-Acting Injection (LAI): Administration andManagementOthers Rodger, Michael A. RN; King, RN. (2003). Drawing up and administering intramuscularinjections: a review of the literature Journal of Advanced Nursing Issue: Volume 31(3), pp574-582. National Health Service (NHS) - Guidance on the Administration to Adults of Oil-based andother Long-Acting intramuscular Antipsychotic Injection, May 2016. Feetam C. & White J.Eds. Guidance on the Administration to Adults of oil-based Depot andother Long- Acting Intramuscular Antipsychotic Injections 5th Edition (2016) available atwww.hull.ac.uk/injectionguide accessed 21/11/2017 Larkin, L., Ashcroft, E., Hickey, B.A. & Elgellaie, A (2018). Influence of gender, BMI and bodyshape on theoretical injection outcome at the ventrogluteal and dorsogluteal sites. Journal ofClinical Nursing, 27, 242-250. Summary of licensed routes of administration from Australian Product Information (accessedvia MIMS on 21/11/17), and UK Summary of Product Characteristics (accessed viamedicines.org.uk on 21/11/17)- Product information should be referenced individually for anofficial procedure. Cocoman, A. & Murray, J (2008). Intramuscular injections: A review of best practice for mentalhealth nurses. Journal of Psychiatric and Mental Health Nursing, 15, 424-434.Revision and Approval HistoryDateRevision no:Author and approvalAugust 20180Bronwyn Walker, Clinical Nurse Educator, Workplace Capabilities Team,SESLHD MHS; Benjamin Chidester, Workplace Capabilities NurseA/Educator, SESLHD MHS. Editor: Trinh Huynh, Policy and DocumentDevelopment Officer, SESLHD MHS. Initial consult: Kim Reid, CNC MentalHealth, TSH.September 20180Angela Karooz, Clinical Nurse Manager, SESLHD MHSOctober 20180Reviewed by MHS Therapeutics & Drug Committee. Disseminated for widerconsultation.November 20181Endorsed by DDDCC. Endorsed by SESL
Injections into the mid deltoid muscle produce a quick uptake of the medicine. The maximum which can be safely injected is 2ml and based on clinical opinion. Common practice is to use this site for small volume injections s
SESLHD is building an improvement culture through optimising staff engagement and investment in innovation, organisational development, improvement, and quality and safety. In May 2016, SESLHD launched its Patient Safety Program -Towards Zero Together. This encompassed an Acute Adult Patient Safety Program and a Mental Health Patient
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The Governance and Policy team is responsible for maintaining this Framework, as well as the forms, templates and resources that support the processes outlined in this Framework. The Governance and Policy team also coordinates the process to seek compliance
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