C-06-16-60839 Published Date: 23-Oct-2020 Page 1 of 6 Review Date: 23-Oct-2023

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

Standard Work

HIV MEDICATION ADMINISTRATION & LABS DOCUMENTATION

Document Owner(s): PM (UCC/TECK ACC LDR) / PM (PP) Department: Maternal Newborn

Created: AUG 31 2020 Last Revised: SEPT 22, 2020

Date Approved: September 22, 2020 Launch October 19, 2020

Performed By (Primary): UCC RN, UCC UC, MRP (OB), PHLEBOTOMIST, DELIVERY RN, PEDIATRICIAN

Other Roles Involved: PORTER, OAK TREE, NICU, CW PHARMACY

Process Summary:

Objective: To ensure a consistent process for each patient that required HIV medication/bloodwork during their time at BCW hospital. To communicate the key updates / changes to the process.

# Major Steps Details/Pictures/Visuals Rationale, Quality

or Safety Considerations

1

PATIENT:

C-Section or Labouring patient aarrives in UCC

Prenatals indicate HIV risk factors or positive status

2

UCC RN: Obtain applicable

Chart Pack for:

A) Known HIV Positive Mother or

B) Mother with HIV Infection Not Ruled out

Notify MRP of arrival

(NEW) Chart Packs (obtained at team station) includes these key items:

o Resource tools and algorithms o Order sets for mother and infant o Pre-filled requisitions o MARs for mother / infant

Chart Packs are now found in UCC and TECK ACC LDR

C-06-16-60839 Published Date: 23-Oct-2020 Page 2 of 6 Review Date: 23-Oct-2023

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

3

MRP: Discuss proposed

treatment plan with patient

Sign PPO for medication & labs

Obtain informed consent from patient

(NEW) Updated Pre Printed Orders for Mother / Infant

4

UCC RN:

Obtain HIV medications from Omnicell

(NEW) Previous documents (such as Algorithms etc) has been removed from HIV Med Kit Packs and are now found in the Chart Packs

Medication bag to remain in medication room throughout patient stay at current unit with Patient ID Sticker attached.

Medication to be prepared in med room and meds taken into room as needed.

Attached Patient ID Sticker to Replacement Kit Order Form on front pouch of med bag.

5

UCC UC:

Compile the inpatient chart

Obtain PRE-PRINTED requisitions from chart pack

Complete requisitions as per eLAB handbook instructions.

Place Newborn Orders & Requisitions into the baby chart (back)

(NEW) If Pre-filled lab requisitions are NOT available in chart pack, you can obtain them at eLAB handbook website (http://www.elabhandbook.info/)

Search for ‘HIV’ in search bar of eLAB handbook

Click on links at bottom of page of the next

screen on eLAB handbook for the requisition package

UCC: Use OUTPATIENT requisitions for bloodwork

(NEW) Pre-

filled requisitions are available

for women who have had no prenatal care (Package E)

C-06-16-60839 Published Date: 23-Oct-2020 Page 3 of 6 Review Date: 23-Oct-2023

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

6

LAB PHLEBOTOMIST / UCC RN: Collect bloodwork

See (NEW) Lab Sample Collection instructions for blood tubes / volume of blood (found on ePOPS)

7

UCC RN/LDR RN: (depending on where pt is located): Administer Oral Anti-

retrovirals (as applicable)

Administer AZT Bolus at ROM or at initiation of labour or 2 hrs prior to c-section

Administer Nevirapine

Administer AZT maintenance dose (continuous infusion)

Only for Moms who are Known HIV Positive and on Oral Anti-Retrovirals:

Send patient own meds to pharmacy and administer oral anti-retrovirals throughout labour

Nevirapine:

Administer to all moms at risk for HIV or if sub-optimal/no antenatal antiretroviral therapy for HIV positive moms

8

UCC RN/HIGH RISK L&R RN:

Document all meds on MAR

(NEW) MARs for Mother (Known HIV Positive or Infection Not Ruled out) are contained in chart pak (MAR obtainable on ePOPS)

C-06-16-60839 Published Date: 23-Oct-2020 Page 4 of 6 Review Date: 23-Oct-2023

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

9 PORTER / RN: Patient transferred to

delivery area

Bag of HIV meds to be transferred with patient

Continue AZT infusion until cord is clamped

10 DELIVERY OCCURS

11

HIGH RISK L&D RN: Stop Maternal IV AZT

after cord is cut

Send placenta to pathology and flag if in research study

Send cord gases and collect maternal and cord blood samples for research if enrolled in research study

12

MRP:

Re-order Ante-natal oral anti-retroviral therapy as appropriate

Order Combivir

If woman received Nevirapine in labour give Combivir 1 tablet PO BID for 7 days

13

HIGH RISK L&D RN: Complete

Replacement Kit Order Form

Send completed form and any unused maternal meds to Pharmacy

Administer Ante-natal oral anti-retroviral therapy

(NEW) Visual Cue (sticker) to trigger completion of kit order form

Breastfeeding is contraindicated if known

HIV positive and offer treatment for lactation suppression within first 24 to 48 hours

Document meds on MARs (mother)

14

PEDIATRICIAN:

Assess &Weigh baby

Sign PPO for medication & labs

For infant of mother with HIV infection not ruled out:

Assess Newborn to determine if baby is LOW Risk or High Risk for HIV

All infants:

Weigh the baby (for order set)

C-06-16-60839 Published Date: 23-Oct-2020 Page 5 of 6 Review Date: 23-Oct-2023

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

Related Documents: Chart Packs (and list) for Known HIV Positive and High Risk/Unknown HIV Status

Lab Sample Collection Instructions for HIV intrapartum orders for Woman who is KNOWN HIV Positive and Infant of Mother who is KNOWN HIV Positive

Lab Sample Collection Instructions for HIV intrapartum orders for Woman who is at HIGH RISK for HIV or Unknown HIV status and Infant of Mother with HIV infection not ruled out

15

LAB PHLEBOTOMIST: Collect infant

bloodwork

See relevant (NEW) job aid easy reference for blood tubes / volume of blood (also on ePOPS)

(NEW) Standardized blood collection time

(90 min)

16

HIGH RISK L&D RN / PP RN: (depending on where pt is located)

Obtain medications from med pack

Document medications on (NEW) Infant MAR

Administer first dose of infant meds prior to sending meds to Pharmacy for labelling

For infants of mothers who are known HIV Positive:

LOW RISK BABY: Start MONO therapy within 6 hours of birth

HIGH RISK BABY: Start TRIPLE anti-retroviral therapy within 90 min of birth

For infants of mothers with HIV infection not ruled out:

Start TRIPLE anti-retroviral therapy within 90 min of birth

(NEW) MAR for infants in chart pak

These MARs are NOT utilized on EVE / FIR (these units have Pharmacy generated MARs)

17

HIGH RISK L&D RN / PP RN: Send infant

medications and PPOs to Pharmacy for labelling

Ensure labelled medications (from Pharmacy) stay with patient (and to next unit)

18

POST PARTUM RN: Acquire CMV swab

sample from infant at about time of newborn screen (~24 hours)

(NEW) Standard time for CMV swab collection to occur at the time of Newborn Screen (~24 hrs)

C-06-16-60839 Published Date: 23-Oct-2020 Page 6 of 6 Review Date: 23-Oct-2023

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

Medication Administration Record (mother / infant)

AZT Replace Kit Order forms

Pre-Printed Orders

Developed By BCW HIV Working Group

Version History DATE DOCUMENT NUMBER and TITLE ACTION TAKEN

22-Sept-2020 C-06-16-60839 Standard Work: HIV Medication Administration & Labs Documentation

Approved at: Perinatal Best Practice Committee

DISCLAIMER This document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.