TRAINED STAFF ORIENTATION PACK
ACCIDENT AND EMERGENCY DEPARTMENT QUEEN ALEXANDRA HOSPITAL
INDUCTION PROGRAMME & SUTURE PLAN
Updated August 04 by Teresa Cohen & Anita Fisher
JS/ QSF TRAINED STAFF ORIENTATION PROGRAMME
Philosophy of Care Patient should be treated effectively and/or referred to the appropriate specialty. Patients should be seen as quickly as possible according to the seriousness of their condition. Symptoms should be relieved and the patient kept as comfortable as possible. The work of the department should be based on the following principles. Respect for the individuals' personality and culture, Recognition of each persons needs and abilities, Care and compassion for patients and relatives, Provision of support and information, Effective communication both within the hospital and with outside agencies, Maintenance of a safe working environment for patients and staff, provision of effective working relationships among staff of different disciplines.
TRAINED STAFF ORIENTATION PROGRAMME
Welcome to the Accident and Emergency Department ACCIDENT AND EMERGENCY DEPARTMENT THE PATIENT The routine in the department is very different from the wards and other departments. Nevertheless, there is a routine that you will find helpful. Our patients are not conditioned to a ward routine. Every one of them is in a stressful situation, not knowing quite what to expect. Minor problems may be magnified out of all proportion, when all that is really necessary may be counselling or advice. NEVER turn a patient away without seeking the opinion of the Senior Nurse, Sister or Doctor. We see well over 150 patients a day and this can easily double during busy times e.g. summer, evenings and bank holidays. For many, their contact with the nurse and doctor is very short, therefore it is important to develop a good relationship. Never let the patient feel he/she is wasting your time. Remember that A&E is the „window‟ of the hospital. It is important; therefore, to create an impression of quiet efficiency and professionalism at all times. A system of streaming and Nurse Practitioning is in operation and a waiting time board displayed during busy periods.
THE DEPARTMENT The department is divided into four main areas: 1. Major Treatment Area, High Dependency unit and Room 1 Room 1 - For very seriously ill or injured patients requiring immediate medical attention, unconscious patients, cardiac arrests, and on occasion patients requiring gastric lavage. Major Treatment Area - For patients whose illness or condition requires intensive treatment and/or close observation e.g. chest pain, post-ictal patients, severe abdominal pain, 'major' head injuries etc. These patients should be undressed, put into a gown, placed on a trolley and all relevant observations recorded. They are assessed using Manchester triage as a guide to prioritise care. High Dependency Unit - Cubicles 1 and 2 in the major treatment area are 'observation' bays and should be used for those patients requiring constant observation e.g. unwell chest pain, unconscious patient‟s etc. 2. Minor Treatment Area - Intended as a fast flow area for minor injuries and conditions that generally require less intensive treatment or observation. Accident Beds Accident Observation Beds - two 4-bedded wards plus a single room. Patients admitted are intended as short stay, (usually 24 hours max). Most commonly used for minor head injuries/some overdoses, but may be utilised in many other ways, e.g. patients with fractures returning to fracture clinic next morning, those requiring social care, occupational therapy and mental health assessment. Responsibility for admission and discharge of these patients is with the Senior Doctor on duty, in consultation with the nurse in charge. ALWAYS INFORM THE PERSON IN CHARGE OF ALL ADMISSIONS. 5
Relatives Room - for anyone who is distressed or bereaved. designated nurse cares for these people.
Interview rooms – Used by mental health team for the assessments of patients following deliberate self-harm. Also can be used, as a secondary relative‟s room. 4. Paediatric Area - Separate clinical area and play facility for children. Designed for the majority of children with minor injuries and those returning for clinic appointments. Also: Clinic Room - To be utilised by any departmental area eg for patients requiring suturing, dressings, and examinations. Returns clinic is usually carried out in this area as well as any patient requiring procedures carried out under intravenous drugs i.e. sedation. X-ray - Between major and minor treatment areas. Streaming and „see and treat‟ rooms - Next to reception. Equipped with intercom, phone, first aid, dressings, basic obs and hand washing facilities. The designated nurse will be identified to assess and stream patients. Streaming is based on the Manchester Emergency Triage System (see protocol). Aims - Streaming will be practised at all times and all patients will be seen within 15 minutes. Priority of care decided. Appropriate first aid given. Recognise change of priority. Objectives 1. 2. 3. 4. 5. 6. Patients and relatives anxiety should be allayed. Improved communication between relatives and patients in all areas of the department. Reduce hostility by communication. Monitor patient flow via telephone or the intercom. Effective liaison with all disciplines within the department and the hospital. Effective liaison with all disciplines in the community, e.g. GPs, Health Centre, etc. 6
Re-direct inappropriate attenders.
Nurse Practitioning - A specified nurse may assess and treat: 1. 2. Minor injuries without reference to a doctor with the patient‟s consent. Refer inappropriate attenders to other agencies, remembering a record must be kept. Arrange appointments with GPs. Arrange appropriate follow-up appointments. Refer patients to other departments within the hospital. Prescribe medication within department protocols.
BENEFITS OF THE ENP ROLE TO NURSE, DOCTOR AND PATIENT
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Decreases hostility Reduces waiting time Efficient use of staff skills Customer satisfaction (audited annually by Customer Satisfaction Surveys) Allows medical staff more time to deal with more serious cases Enhances patient flow through department Encourages nurses to develop skills in assessment and management of minor injuries Increases public awareness of potential for nurses role Encourages communication between the multidisciplinary team Improves communication with the department attenders Encourages and facilitates the role of the A&E nurse as a health promoter/educator Regular audit activity promotes quality care and service Attenders can be educated about the correct use of the A&E service
EMERGENCY NURSE PRACTITIONER A specific nurse may assess and treat: *** *** *** *** *** Minor injuries and condition, following department guidelines Refer inappropriate attenders to other agencies, recording these referrals Arrange departmental clinic appointments in A&E or Fracture Clinic, where this is appropriate Administer once only analgesia, tetanus immunoglobin, following written policy toxoid and anti-tetanus
ENP may treat minor injuries to the head, face and forehead, providing there are no central nervous system signs, bony tenderness or significant swelling LIST OF CONDITIONS NOT TO BE TREATED BY THE NURSE PRACTITIONER
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Abdominal and chest pain Headache Children with raised temperatures, earache or non-specific illnesses Diarrhoea and/or vomiting Loss of consciousness for any reason Suspected non-accidental injury
GENERAL INFORMATION WHO’S WHO General Manager Tim Robinson
Senior Nurse Modern Matron Isabel Gaylard Nurse Consultant G Senior Sister Senior Sister Senior Sister Senior Sister Senior Sister Charge Nurse Senior Sister Charge Nurse Senior Sister Senior Sister F Sister Sister Sister Sister Sister Sister Sister Sister Sister Charge nurse Consultants Mr Sandy Carss Clinical Director Mr Chris Cahill Mr Simon Mullett Lieutenant Colonel Catherine Hartington Major Simon Hunter Anita Fisher Janice Goatley Julie Hamilton Julie Mac Donald Emma Mc Lochlan Ali Portsmore Lisa Rees Jane Sampson Toni Williams Graeme Wilson Tricia Breach Emma Chase Teresa Cohen Andrea Edwards Sue Lindsay Peter Manson Ann Miles Chris Walker Sally Wiseman Sharon Voller Alan Charters
Associate Clinical Specialist 10
Mr A Okonkwo Specialist Registrar Miss Sarah Assherton Mr Chris Busutill Mr Simon Hunter Dr Jacqueline Lynch Dr Fiona Rae Staff Grades Dr C Hargreaves Mr N Karkee Dr F D‟Souza Clinical Fellows Dr Grant Hamlett Dr Franco Shreve 15 SHOs - rotate every 3-6 months, usually February/August.
Key Responsibilities Tricia Breach Emma Chase Teresa Cohen Andrea Edwards Anita Fisher Janice Goately Julie Hamilton Sue Lindsay Emma Mc Lochlan Major nurse practitioner Clinical Governance, Recruitment/Retention, health and safety Representative Training & Development, Paediatrics Major Incident Training and development, paediatrics Off duty issues Training and development, Recruitment/Retention Military 11
Ann Miles Alison Portsmore Lisa Rees Sharon Voller Chris Walker Graeame Wilson Sally Wiseman SUPPORT NETWORKS
Care of the Elderly Wound Care Health and safety Off duty issues, Thankyou‟s Major Nurse practitioner, training and development MTOS Paediatrics / Child Protection Co-ordinator
Systems and definitions of support can be confusing. Out lined below are the definitions of systems used in this A&E department. During your first two weeks you will work with a 'buddy'. This person may by your clinical supervisor or may be someone different. Managerial Assessor You will be allocated to a group headed by a G grade Sister. They will be your managerial assessors. The group will also contain an F grade Sister, who may carry out your IPR. INDIVIDUAL PERFORMANCE REVIEW The Individual Performance Review (IPR) system is designed to be a critical appraisal of your work. It is a two-way process aimed at reinforcing good work practices, clarifying objectives and identifying skills not currently utilised. It also involves the identification of training needs and how to meet them, from a departmental requirement aspect as well as for individual development. You should have an IPR at least annually, more often if either you or your managerial assessor feel it necessary. The general idea is that you should know what you are supposed to be doing and how well you are doing it. Your Managerial Assessor‟s Name: ....................................................
CLINICAL SUPERVISION 12
Definition “... An exchange between practising professionals to assist the development of professional skills." Butterworth C A & Faugier J Clinical Supervision & Mentorship in Nursing London: Chapman and Hall "The process whereby a practitioner reviews with another person their ongoing clinical work and relevant aspects of their reactions to it." Minot S R & Adamski T J 1989 Elements of Effective Clinical Supervision Perspect: Psych Care 25 22-26 "A practice-focused professional relationship involving a practitioner reflecting on practice, guides by a skilled supervisor." UKCC 1999 Position Statement on Clinical Supervision for Nursing and Health Visiting London: UKCC You will be allocated a clinical supervisor for your arrival to the department and a booklet explaining it to you. Please ensure you introduce yourself to your supervisor as soon as possible. The essence of supervision is to allow you „protected‟ time on a regular basis, to discuss clinical issues with an experienced member of the nursing team in complete confidence. You should discuss and establish ground rules in your first meeting and you will be expected to keep reflective notes on supervision sessions for your professional profile. If at any time you feel your supervisor is not the person you are able to talk frankly to, you may suggest a more suitable person through the clinical supervision co-ordinators, Staff nurses Rebecca Limer or Claire Bailey. This also applies to your supervisor. Any questions or problems please speak to Staff nurses Rebecca Limer or Claire Bailey. Your Clinical Supervisor‟s Name: ................................................................... MENTORSHIP Definition “An experienced and admired person who extends support, knowledge and counsel over a long period.” 13
“They welcome the protege into their world and share personal and professional knowledge and experience.” Norman E 1997 Boosting Your Career with a Mentor Orthopaedic Nursing Vol. 16 No. 4 p. 13 - 16 This term is difficult to define as it can be used to describe different things in different situations. It is often confused with other terms like supervision, assessing or role model. The term is usually associated with student assessment, but more specifically, relates to an individual guiding, supporting and advising another individual using their experience, knowledge and skills. A mentor cannot be allocated. They are chosen or more specifically, seem to „emerge‟ as a respected and approachable advisor. Whilst continuing to fulfil this traditional, supportive, friendly, guiding definition, mentoring is changing to incorporate a more challenging approach. Consequently, mentors are not allocated in this department (although you may still hear the term used). Preceptor This is the supportive and educative role of the experienced, qualified nurse with newly qualified nurses. This A&E department does occasionally take newly qualified nurses. With the „Buddy‟ system and through clinical supervision the department endeavours to support new staff and give guidance and support as needed. Clinical Assessor This is a role that you may be expected to take on following completion of an assessor‟s course. It involves the observing, supporting, teaching, guiding and assessing of student nurses within their placement in A&E. Initially you may act as a secondary assessor supporting an assessor, as your experience and confidence grows. Nursing Standards
The purpose of written standards is to guide nurses (especially new practitioners) in their activities. To ensure information is passed on to managers and members of other disciplines about what can reasonably be expected of the nursing services in the department. To provide means of monitoring and assessment so that problems which adversely affect the care of patients can be rectified. The A&E department currently has 9 nursing standards, more are being developed. 1. 2. 3. 4. 5. 6. 7. 8. 9. Emergency treatment Pain control Communication Bereavement Patient safety Staff safety Management of violence or aggression Discharges Paediatric pain control .
DURING YOUR FIRST DAY in the department, someone will guide and instruct you through the following: 1. 2. A detailed guided tour of the department with introduction to key members of staff, Use of: Intercoms BLUE alert for C.A.
Telephones including MEDIC 5 and CALL OUT procedures Emergency buzzers, bleep systems, 2222, 3. Fire procedure and location of: Hose reels Extinguishers Assembly point,
Personal details cards Telephone numbers etc, Salary claims forms Official hours, breaks Night duty rotation Annual leave Self-Rostering. SICKNESS inform bleep 170 on first day please,
Question and answer session.
DURING YOUR FIRST WEEK 1. Orientation to the normal daily routine of the department, which will include the importance of cleaning and stocking key areas Location of essential equipment DEFIB/monitors BP etc. AMBU BAG C/A drugs Clean utility drugs.
A teaching session will be set up with M. Phillips to cover equipment cleaning and maintenance. 2. Procedure books: to avoid misunderstanding and confusion, Please use the procedure books provided for all A&E procedures.
There are alternative procedures BUT it is better to follow one or two rather than several. REMEMBER A&E IS TEAMWORK. 3. Importance of communication and documentation a. b. c. d. 4. Administration With staff. With patients With doctors. With other health care professionals
Property - valuables, patient‟s affairs, lost property. Managing actual/potential aggression and violence Complaints procedure, Risk assessment forms Amenity fund, taxis etc. A B C airway breathing circulation
Orientated with the procedure of
Hopefully you will work alongside your mentor/clinical supervisor for most of the first two weeks of duty. If you have not attended a Trust induction programme statutory training course or have not received notification of attendance, inform your mentor.
WITHIN THE FIRST MONTH You will learn how to: Take observations and record them correctly, Care for the airway, Become a member of the arrest team, Use documentation for receiving, admitting and discharging of patients. Pressure infusers, Warmers, Filters. Children under 16, Relatives, N.A.I.s. Child protection procedures B.I.D., Last offices D.I.C., Care of the relatives, relative‟s room and bereavement follow up etc.
Use of blood and plasma:
Care of children:
Care of the deceased:
Procedures for: Receiving of patients into any area. Major incident plan. Attending cardiac arrests in hospital, non-clinical areas. Importance of pain control. Read department‟s standards. Arrange a morning in fracture clinic and a day with ambulance personnel, if you wish to. Have your first clinical supervision session (to be arranged with your supervisor). Complete the self-assessment and objective forms to be discussed either in clinical supervision or with your mentor.
YOUR 1st 4 WEEKS REFLECTION. This self-assessment is to enable you to reflect on the last month and identify your strengths and areas where you need to gain further experience.
Through your reflection, identify your objectives to be met after 8 weeks in A and E. Discuss how to achieve these with your mentor.
Within the first 3 months Ensure your suture plan has commenced and continue to work through it steadily. Ensure that you are aware of the treatment guidelines for the following procedures: ALS. ASTHMA. ANAPHYLAXIS. CARDIAC ARRYTHMIAS ROLE OF THE CARDIAC TRIAGE NURSE. Gain knowledge/competence in the following:-
DATE/SIG BANDAGING DRUGS BURNS FRACTURES MAJOR INCIDENT ECGs NEUROLOGICAL OBSERVATIONS CARE OF THE CRITICALLY ILL THOMAS SPLINT STERISTRIPS GLUE TREPHINING BACKSLABS
TUBIGRIPS GENERAL OBSERVATIONS USE OF MONITORING EQUIPMENT
Within the first 6 months Aim to have completed your suture plan. Arrange your first IPR with your mentor, complete preparatory checklist before you meet. Ensure you are up to date with statutory training and complete the form below. This will be monitored at the post induction study day.
STATUTORY TRAINING REQUIREMENTS DATE LAST FORMAL TRAINING LIFTING (2 yearly) RESUSCITATION (yearly) CONTROL OF INFECTION FOOD HYGIENE FIRE (yearly) SECURITY CHILD PROTECTION (yearly) DATE OF ACCIDENT/ ILLNESS COMPETENCE (satisfactory/ needs refresher) DATE OF NEXT TRAINING COMPLETED (initialled by manager)
PREPARATORY CHECKLIST Staff development and performance reviews Checklist for the reviewee: Please comment 1. What objectives have you achieved with the last 6 months and how well did you do? COMMENT: -
What aspects of your job do you feel confident in? COMMENT: -
What aspects of your job do you feel you need more support/training with? COMMENT:-
Do you think you have a complete understanding of the requirements of your job? If not, what are you unsure about? COMMENT:-
Do you have any skills that are not being used to the full in your present role? COMMENT:-
Are their any problems outside your control that have reduced your ability to perform your job? COMMENT:-
What training and development do you feel would help you to perform your job more effectively? COMMENT:-
Is there any particular career path in the organisation you would like to follow given the chance? COMMENT:-
Is there anything that you feel your manager could do to help you to achieve your goals? COMMENT:-
Could communication between you and the management structure be improved? Is so, how? COMMENT: -
STAFF NURSE INDUCTION PERIOD EVALUATION SHEET 1. Do you feel your needs were met during this time? YES/NO ________________________________________________________ ________________________________________________________________ 2. Were the teaching sessions aimed at the correct level? YES/NO ________________________________________________________ ________________________________________________________________ 3. Is there any additional subject material you think should be included? YES/NO _______________________________________________________ _______________________________________________________________ 4. Are there any additional practical sessions you require? YES/NO _______________________________________________________ _______________________________________________________________ 5. Have you experience any similar induction programme? YES/NO ________________________________________________________ ________________________________________________________________ 6. Should this induction continue in its present form? YES/NO ________________________________________________________ ________________________________________________________________ ADDITIONAL COMMENTS: Thank you for your co-operation in completing this form. Senior Sister Teresa Cohen and Sister Anita Fisher
Reflective Learning Reflective learning assists us to identify what we have learnt from a specific episode. This form is can be removed from this package and placed within your portfolio. This is a requirement for nursing staff, but may also assist other staff groups to learn (to be photocopied if more required). Description of event
Why the event was important
What was satisfactory/troubling about event
What you might have done differently
What action you will take as a result of this
SUTURING A TRAINING PROGRAMME FOR REGISTERED NURSES RULES 1. 2. All wounds for suturing will be seen by a doctor or Nurse Practitioner before treatment. Nurses may not suture wounds: a) Involving tendons, nerves, muscle, fascia or joint capsule, b) Involving puncture injuries with possible damage to underlying tissues and structures, i.e. stab wounds, c) With profuse bleeding or requiring ligation of blood vessels, d) Requiring debridement of tissues, e) Which require subcutaneous catgut sutures, f) Involving sites where undue scarring may result. g) Over a fracture. 3. 4. 5. 6. Nursing staff SHOULD NEVER use LIGNOCAINE WITH ADRENALINE. Nursing staff must not carry out ring blocks. Nursing staff must not use dental syringes. Choice of type and strength of local anaesthetic and type of suture material will be in line with current A&E policy. 2% lignocaine plain max 5 mls 1% lignocaine plain max 10 mls THIS IS THE PREFFERED LOCAL ANAESTHETIC 7. In the case of Hepatitis and AIDS risk patients all contaminated linen disposal; see guidelines in control of infection book. All instruments used for suturing are disposable and should be placed in sharps bin. 8. Any suturing request which nurses are not happy to carry out should be referred back to the requesting doctor or nurse in charge.
SUTURE PLAN 1. Each nurse, following discussion with mentor will commence a Suture Plan. Each section of the plan must be completed before the next section is commenced. The nurse countersigning the procedure must only do so if she is sure the procedure was carried out in a competent manner, and must witness the whole procedure. The sister in charge will be responsible for the selection of patients for the Suture Plan. Children will not normally be included in the selection. The Suture Plan only applies to trained nurses. An experienced member of staff must supervise the nurse with at least one year’s experience after completing their own plan. PROCEDURE 1. 2. 3. 4. 5. 6. 7. 8. Place patient in the most comfortable position on the trolley, flat if possible. This will prevent nausea and fainting. Explain the procedure and obtain verbal consent. Prepare equipment in accordance with A&E procedure. Remove appropriate clothing to expose area to be sutured. Place protective sheet under the area to be sutured. Adjust light and stool to appropriate positions. Ensure your own comfort as well as the patients. Wash your hands. Put on appropriate size gloves; place sterile field surrounding wound. Using a clean swab, wash the top of local anaesthetic bottle and draw up local anaesthetic, using a 2ml syringe and a green needle. Change to orange needle to infiltrate the wound. DO NOT BEND NEEDLE.
3. 4. 5.
Clean area around wound, infiltrate with Local Anaesthetic. Continue to clean area while waiting for anaesthetic to become effective. Test with point of needle to ensure area around wound is anaesthetised. CLEAN AND EXAMINE the wound carefully observing for foreign bodies, tendon or nerve damage, arterial bleeding. Any damage to underlying vessels, or if any doubt about a wound, refer back to the doctor or nurse practitioner. Using forceps and a needle holder, insert suture bringing skin edges together avoiding overlapping. Tie knot by wrapping thread around needle holder as shown. Write number of sutures and type of suture, in A&E notes and sign your name. General Instructions to Patient a) Explain that a letter will be sent to GP, and give patient a care of suture advice sheet. Advise patient to ring and make an appointment for practise nurse to remove sutures.
Current Policy Suture material generally used: NYLON (Dermalon) Location Faces, Scalp wounds, Hands Small wounds Large wounds or over joints b) c) Gauge 5/0 (6/0) 3/0 4/0 4/0 3/0 or 4/0 Removal 5-6 days 7 days 7 days 7 days 10-12 days
Max Fax may suture (some more complicated facial wounds)
Tegaderm pad dressing to be applied, patients should be advised to keep wounds clean and dry, until sutures are removed. Elevate wounds, especially hands in a sling for 48 hours. Encourage gentle mobilisation/movement.
PORTSMOUTH HOSPITALS NHS TRUST ACCIDENT AND EMERGENCY SERVICES
1. 2. 3.
Begin suture plan when you have worked in the department for 1-2 months. The nurse will commence a suture plan. Each section of the plan must be completed before the next section is commenced. Countersigning of each procedure must be done by an experienced nurse and only if the procedure is carried out in a competent manner.
OBJECT TO ACHIEVE A HIGH STANDARD OF COMPETENCE IN THE SKILL OF SUTURING. DEFINITION Suturing is the art of stitching two cut edges of skin together in order to promote good healing with a minimal amount of scarring.
NAME: _____________________________________________ SECTION 1 Observe the suturing procedure in a minimum of ten individual patients.
NAME OF PATIENT
NUMBER OF SUTURES
SECTION 2 Practise the technique of suturing on a felt pad using black silk, needle holder and forceps. An experienced nurse must sign this, before continuing the suture plan. Permission to progress to Section 3. DATE: _____________________ SECTION 3 Has carried out competently procedures involving lacerations to the scalp under observation. NOT to include infiltration of LOCAL ANAESTHETIC. SIGNED BY SISTER: ______________________
NAME OF PATIENT
NUMBER OF SUTURES
SECTION 4 Infiltration of local anaesthetic and suturing minimum of five scalp wounds under observation.
NAME OF PATIENT
NUMBER OF SUTURES
SECTION 5 Infiltration of local anaesthetic and suturing of small wounds other than on the scalp. PROCEDURE NAME OF PATIENT DATE NUMBER OF SUTURES OBSERVED BY
On completion of Stages 1 - 5, approval of competence to suture will be given by a department sister. Approval is given on the understanding that the nurse: 1. 2. 3. 4. Has completed sections 1 - 5 of the suture plan, Demonstrates a good knowledge of suturing procedures, Is aware of the limitation imposed by the procedure, The nurse will comply with the plan.
APPROVAL TO SUTURE WITHIN THE ACCIDENT AND EMERGENCY UNIT Name of Nurse: __________________________________ Signed: __________________________________________ Date: ____________________________________________ Please allow 4 weeks before final approval When the nurse has completed sections 1-5 and has been signed for competency for suturing, a further 5 more difficult wounds will be observed by an experienced nurse. This is done so that you can gain more confidence and knowledge in the suturing of more complicated wounds. (Sister)
SECTION 6 Suturing of more complicated wounds.
NAME OF PATIENT
NUMBER OF SUTURES
On completion of stages 1-6, approval of competence to suture will be given by a consultant or senior registrar working within the department. Approval is given on the understanding that the nurse; 1.has completed sections 1-6 of the suture plan, 2. Demonstrates a good knowledge of suturing procedures, 3. Is aware of the limitation imposed by the procedure, 4.the nurse will comply with the plan. APPROVAL TO SUTURE WITHIN THE ACCIDENT AND EMERGENCY UNIT Name of Nurse: __________________________________________________ Consultant/Specialist registrar signature: _____________________________