administration of drugs via the cme - rdash.nhs.uk · syringe driver standard operating procedure....

DOCUMENT CONTROL:

Version: 3

Ratified by: Quality and Safety Sub Committee Date ratified: 30 May 2017 Name of originator/author:

Community Practice Educator Current version reviewed by Pharmacy Team

Name of responsible committee/individual:

Medicines Management Committee

Date issued: 6 December 2017

Review date: May 2020 Target Audience Community Nursing Staff

Administration of Drugs via the CME Medical T34

Syringe Driver

Standard Operating Procedure

http://nww.intranet.rdash.nhs.uk/home/corporate-templates/rotherham-doncaster-and-south-humber-nhs-foundation-trust-rgb-blue/

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1. Aim

This Standard Operating Procedure (SOP) represents current recommended good practice and will ensure the proper action to take regarding the setting up and management of the CME Medical T34 Syringe driver by clinical staff in the Community setting.

2. Scope

All registered nurses using the CME T34 Syringe Driver must be personally competent and accountable in the use and operation of the device by attending bespoke training. Evidence of training will be recorded on each staff member’s training record. Mandatory annual updates will be provided.

3. Link to overarching policy and/or procedure

This SOP is to be used in conjunction with the RDaSH Policy Safe and Secure Handling of Medicines.

4. Procedure

4.1 General Information

The McKinley T34 Syringe Driver is used across Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) in line with the requirements of the National Patient Safety Alert entitled ‘Safer Ambulatory Syringe Drivers’ (NPSA/2010/RRR019) (2010). .

4.2 Safety

The McKinley T34 is a small battery operated machine, designed to give a continuous subcutaneous infusion in milliliters (ml) per hour over a given period. This method of symptom control, used predominantly in palliative and end of life care provides relief of multiple symptoms e.g. pain, nausea and agitation via a single route. The safe use of the syringe driver requires comprehensive knowledge in order to maintain patient safety.

Caution: If a patient is discharged home with a different make of syringe driver, this should be changed to a McKinley T34 device as soon as possible.

Lock boxes will fit syringes up to 30ml and should always be used with the CME Medical T34. Lock boxes reduce the risk of accidental or intentional interference with the syringe driver and protect from damage caused by normal daily use or drops within the range of one metre.

4.3 Cleansing, Decontamination and Maintenance

All staff must follow standard infection prevention and control precautions including hand hygiene, use of personal protective equipment, decontamination of reusable medical devices, sharps management and

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disposal of healthcare waste.

The device must be decontaminated between patients, daily when in use and as and when it becomes dirty or contaminated.

Always turn the syringe driver off before cleaning.

After patient use decontaminate the unit using lint free cloth such as Tuffi 5. Also clean actuator screw thread and guiding rods to remove debris or other particles.

Do not clean the syringe pump with chemicals such as xylene, acetone, or similar solvents. These chemicals can cause damage to components and labels.

Do not soak or immerse any part of the syringe driver in any solution. Immersing the pump in liquid will cause damage to components and this will void the guarantee.

It is recommended that Tuffi 5 wipes are also used to decontaminate the lock box.

All Syringe Drivers will require routine annual maintenance and service as a minimum or when syringe driver warning is indicated on individual syringe drivers. Key Health Solutions will provide maintenance work. Devices due for maintenance can be returned to the designated person for the clinical area, who will then forward the devices onto Key Health Solutions. A declaration of decontamination status for will need completing and attaching to the device prior to sending it for repair or service.

4.4 Storage

It is essential that all syringe drivers are accounted for at all times. Hospice Syringe drivers and locked boxes will be stored in a designated place within the hospice. Each syringe driver will have its’ own case. It will be the responsibility of the nurse who last used the device to clean the syringe driver and lock box adhering to the Standard Infection Prevention and Control Precautions Policy. Community All Community Nursing Teams (Planned and Unplanned) are required to keep an up to date list of the exact location of the Syringe Drivers. (See appendix 1)

Syringe Drivers will be stored at the four planned locality bases and a

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designated place for Unplanned. They will be stored in lockable cases and each device will have its’ own case. It will be the responsibility of the nurse who last used the device to clean the syringe driver and lock box adhering to the Standard Infection Prevention and Control Precautions Policy.

The case will be refilled ready for further use and stored in a safe place within the base point. There will be 1 case for each device and these cases will be stored at each base point in the Community.

4.5 Equipment Required

4.5.1 Syringe driver McKinley T34 and Lock Box. Ensure within maintenance date. Obtain a new syringe driver if out of date.

4.5.2 9-volt alkaline battery Duracell Procell. The average battery life is 3-5

days depending on usage e.g. key presses or backlight use.

4.5.3 Winged infusion set Saf-T-Intima24Gx0.75 FSP318Yellow.

4.5.4 Administration set CME McKinley Micro set 100-172S (Anti-siphon valve

and female luer lock. Length approx. 100cm, priming volume approx. 0.5ml).

4.5.5 BD Plastipak luer lock syringe 20ml or 30ml. N.B. luer lock syringes

must always be used to ensure secure connection of the infusion set. The pump is calibrated to luer lock and failure to use may result in under or over infusion due to variation in syringe dimensions.

4.5.6 Combi-stopper to cap the syringe or administration set

4.5.7 Transparent adhesive dressing

4.5.8 Drugs and diluent prescribed

4.5.9 Needle (to draw up drug)

4.5.10 Drug additive label

4.5.11 Patient’s Syringe Driver Prescription and Observation Chart.

4.5.12 Sharps receptacle

4.5.13 Disposable carrying pouch (only if patient is mobile)

4.5.14 Instruction procedure manual and equipment, as documented on syringe

driver check list.

4.5.15 Signing in and out sheet completed with the syringe driver serial number

date, time, patient name and address (see appendix 2)

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4.5.16 Battery will be removed when device not in use. Syringe driver to be stored in cases provided by Trust.

A reciprocal agreement is in place between RDaSH and Doncaster and Bassetlaw Hospital NHS Foundation Trust (DBHFT) for the safe return of syringe drivers to their respective bases. The syringe driver must be returned to base after use. If the patient is admitted to hospital, then it is the responsibility of the nurse who is allocated to the visit to ensure that they retrieve the syringe driver. The responsible nurse will contact the Community Support Manager via e-mail using the relevant form. (See appendix 2) An agreement is in place with Doncaster Royal Infirmary (DRI) for devices that turn up with patients that have been admitted to hospital. These devices will be returned to the medical devices unit at DRI. The medical devices unit will then return the device to the Community Support Manager. If devices from DRI are sent home with patients in the community, these will be returned by the Community Support Manager to the medical devices unit at DRI. Admission to the Hospice If a patient is admitted to the hospice with a community syringe driver, the device is swapped to a hospice device within 24 hours and returned to the designated base via the RDASH shuttle. If a patient is discharged from the hospice with a syringe driver, the device should be swapped to a community device within 24 hours and returned to the hospice ASAP. All Hospice device serial numbers are recorded on a database and tracked by the Hospice Ward Clerk.

Transferred out of RDaSH

The registered nurse must:

• Record the details and serial number of the syringe driver on the

district nurse referral form or on the transfer letter if the patient is discharged to a care home, other hospital or hospice

• Place a copy of the form in the patient’s notes • Request that care home, hospital or hospice return the syringe

driver to Medical Technical Services • Inform Medical Technical Services of the transfer

Caution: If a patient is discharged home from a neighbouring hospital (other than Doncaster Royal Infirmary) with a different make of syringe driver, this should be changed over to the McKinley T34 and the other syringe driver returned to the hospital in question as soon as possible.

4.6 Administration Procedure

It is good practice for two staff members, one of which must be qualified, to

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undertake the procedure; however, in community settings where there may not be another health professional available, the patient’s relative may act as a second signatory to check relevant aspects of the procedure. e.g. Stock levels. See Appendix 3 for indications, advantages and disadvantages of syringe driver

4.7 Involving the patient and family

Communication and consultation with the patient and family is essential. Before starting a subcutaneous infusion, the reasons for using this method of administration should be explained to the patient and family. Informed consent for administration should be obtained, in accordance with the Mental Capacity Act 2005 Policy. The discussion is then to be recorded in the nursing care plan. Attention should be paid to both the physical and psychological aspects involved in accepting a new way of receiving medication. Some patients feel that this method of drug delivery is a last resort that their activities will be restricted and that death may be imminent. It is necessary to listen to and answer the patient’s questions, acknowledge their concerns and then give explanations and reassurance as appropriate. Community only - The patient and family will be informed that the syringe driver device is on loan to them and must be returned as delivered after use. A signature will be required from the patient or family after discussion. (See appendix 7) The explanation should include the following: The reasons for using a syringe driver

How the syringe driver works

The siting procedure and site care

How the dose of medication can be adjusted to manage symptoms Encouragement to describe symptoms

4.8 Procedure for setting up the syringe driver

A registered nurse must calculate the volume of drug that needs to be drawn up from the concentration of the preparation to be used and the prescribed dose.

When preparing medicines and disposing of waste materials, the registered nurse must adhere to the following guidance:-

Safe and Secure Handling of Medicines Policy SOP for Controlled

Drugs

Standard Infection Prevention and Control Precautions Policy

Sharps Policy Safe Use and Disposal of Sharps and Management of Contamination Injuries

Hand Hygiene policy

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NMC Standards of Medicines Management The Medicines Act (1986)

Waste Policy

A registered nurse must ensure:-

The prescription has been completed correctly, perform the

calculation and check the medication.

Confirm the previous opioid dose, formulation and frequency.

Ensure the medication prescribed and the doses are clinically appropriate based on the patient’s previous requirements (NPSA, 2008).

The diluent will be prescribed on the patient’s Syringe Driver Prescription (Syringe Driver prescription chart). For McKinley T34 feature recognition please see appendix 4

Sterile water for injection Advantages • Recommended because of its use in reconstituting lyophilized

(freeze-dried) Morphine Sulphate • More supporting compatibility data • Reduces the risk of precipitation with cyclizine lactate

Disadvantages • Large volumes are hypotonic and can cause infusion site pain

Sterile 0.9% Sodium chloride Advantages • Recommended with certain drugs e.g. octreotide • Less infusion site pain and fewer skin reactions Disadvantages

Disadvantages • Incompatible with cyclizine • Increases likelihood of precipitation when more than one drug is used

There is a potential for interaction between drugs in a syringe driver. The compatibility of the drugs and the diluent to be drawn up must be checked prior to mixing. The Palliative Care Formulary (Twycross et al, 2014), The Syringe Driver, Continuous subcutaneous infusions in palliative care (Dickman A and Schneider J, 2011) suggest suitable combinations of drugs. If there are any concerns regarding compatibility:

Firstly refer to the compatibility and stability tables for a subcutaneous infusion in a McKinley T34 Syringe pump (appendix 5)

Contact the prescriber

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Contact the Specialist Palliative Care Triage or pharmacy

If any further concerns out of hours (after doing all of the above) call the on-call Consultant in Palliative Medicine or on-call Pharmacist via DRI switchboard.

Ideally syringe driver prescription reviews should take place in working hours only.

In Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) a combination of no more than 3 dugs should be prescribed on the prescription form or drawn up into a syringe. If more than 3 drugs are required, 2 prescription forms and 2 syringe drivers will be needed. Please seek advice from the Specialist Palliative Care Team. Hospice only – 4 drug combinations may be appropriate on an individualised basis only and rationale clearly documented in the medical notes.

N.B. Ampules containing a liquid solution may contain an amount in excess of the volume stated on the label. Therefore, measure the volume of liquid as it is drawn up to ensure accuracy of the dose.

Select the appropriate syringe size 20ml or 30ml

Draw up the prescribed medication

Add the diluent up to the required volume

Complete the label, including: - Patient name and NHS number - Medicine name and dose - Batch numbers - Diluent used - Route of infusion - Date and time prepared - Initials of the registered nurses preparing the syringe

Attach the label to the syringe ensuring that it is flat and not folded. Leave the scale visible so that it can still be read.

Skin Site Selection for Subcutaneous Infusions. Where possible involve the patient in the choice of a suitable site. Areas suitable for subcutaneous infusion include those with a good depth of subcutaneous fat, towards the trunk of the body, particularly if the patient’s peripheral circulation is compromised

Following completion of the procedure document the following in the patient’s electronic records -the prescribed medication, dose, dilutant and site of the syringe driver alongside the amount of prescribed medication remaining. (See appendix 2). Note when using Appendix 2:-

The CME Medical T34 ambulatory syringe pump is calibrated to operate with BD Plastipak Luer lock syringe brands and sizes. It is programmed to recognise both the brand and the size of syringe being used (commonly 20ml. and 30ml).It will be defaulted using a Prime and Load (Lock – on) Programme of a 24 hour delivery system.

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Fill volume Medication and diluents should always be drawn up to the following volumes 20ml syringe draw up to 17ml 30ml syringe draw up to 22ml Acceptable sites

Sites to avoid

Oedematous areas, including areas affected by lymphedema or ascites. (poor absorption, increased risk of infection)

Sites over bony prominences (discomfort and poor absorption)

Joints or skin folds (discomfort and movement may displace cannula) Previously irradiated skin (may have poor perfusion - affects drug absorption)

Upper abdomen in a patient with an enlarged liver (risk of puncturing the liver capsule)

Upper chest wall in a very cachectic patient (risk of pneumothorax) Infected, broken, inflamed or bruised skin

Sites of tumour

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Inserting BD Saf-T- Intima Venflon

Please note PPE and hand hygiene principles should be adhered to for all procedures.

Clean the site with soap and water if the skin is dirty otherwise there is no need to swab the skin

Apply the clamp to the line

Grasp the “pebbled” side of the wings of the cannula, pinching the wings firmly together. This “locks” the needle and prevents it from retracting during insertion

Ensure that the needle is point down and bevel uppermost, to guide the cannula through the tissues. This prevents kinking of the cannula. If the needle is not already orientated with the point down open the wings and gently twist the white shield until the needle is correctly positioned

Insert the cannula subcutaneously at an angle of less than 45 degrees, lowering the initial angle of the cannula to a level more parallel to the skin (caution on the chest wall) and advance to the hilt of the cannula

Open the wings (pebbled side down) flat against the skin

Apply transparent adhesive dressing over the insertion site and the cannula wings

Apply firm finger- tip pressure over the wings of the cannula (avoiding the centre where the needle retracts) simultaneously grasp the pebbled end of the coloured/white cylinder shield and pull in a straight continuous motion until the needle has fully with drawn into the cylinder and pops off

Gently remove cylinder from the cannula port, if it has not released spontaneously, exposing the adapter with the rubber bung

Place the needle shield in the sharps bin

Change the site every 7 days or as necessary depending on the condition of the skin

N.B. Te Saf-T-Intima cannot be primed when using the McKinley T34. When setting up the syringe driver the primed extension line is connected directly to the un-primed Saf-T-Intima

The registered nurse must prepare the syringe and confirm the patient’s identity as on prescription

• Check the battery life by pressing the INFO Key twice *** • Prepare syringe and contents and cap the syringe. • Press STOP • Press and hold INFO key to deactivate keypad lock • If the infusion complete alarm has activated, press YES to confirm end

of infusion • Switch syringe driver OFF • Clamp Saf-T-Intima • Raise the barrel clamp arm • Remove old syringe

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• Follow instructions on page 18 Power on and pre-loading • When “Start infusion?” screen displays, connect the infusion line to the

syringe, release the clamp on the Saf-t- Intima and press YES

*** For community use the battery will need changing when the device registers at 40% battery life left. Bolus dose of medication

If the patient has uncontrolled symptoms prior to setting up the McKinley T34, it may be necessary to give a PRN dose of medication.

A separate Saf-T- Intima 24Gx0.75 FSP318 Yellow should be inserted for the purpose of giving PRN doses. A Swan Lock needle free device should be attached to the Saf-T- Intima port.

Temporary interruption to the infusion - Hospice

This is not normal practice in a community setting and should only be used in exceptional circumstances e.g. showering or bathing. N.B. Topping the infusion will delay the end time of the infusion

Stopping the Infusion • Press STOP – unlock the keypad and turn the syringe driver OFF. • Clamp the Saf-T- Intima • Disconnect the syringe driver. DO NOT REMOVE THE SYRINGE FROM

THE PUMP • Cap the Saf-T-Intima and infusion line to minimize cross infection. • Record time and reason why infusion stopped on Syringe Driver

Observation Chart Resuming the Infusion • Check that the prescription, syringe label and patient details are correct • Reconnect the line to the syringe on the pump maintaining asepsis • Press and hold ON button • The screen will request confirmation of size and brand of syringe • Press YES to confirm • The screen will display “Press YES to Resume” “NO for New Syringe” • Press YES to resume • The screen will display remaining volume/ duration/ rate of infusion • Ensure information is correct as prescribed • Press YES to confirm • Unclamp Saf-T-Intima • Screen will display “Start Infusion?” • Press YES to start infusion • Press and hold INFO key to lock the keypad • Replace the Lock Box

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• Record on the Syringe Driver Observation chart the time the infusion was recommenced

N.B. If “NO for New Syringe” is pressed the remaining infusion will be reset to deliver over the next 24hrs at a different rate, and the infusion will be incorrect.

If “NO for New Syringe” has been pressed in error. Discard the remainder of the syringe contents, prepare, and set up a new syringe. In a community setting the following procedure should not be applicable as staff will check the battery status before commencing each 24 hour regime.

Changing the battery during an infusion

When near the end of the battery alert sounds, it indicates that the battery should be changed within the next half hour

Press STOP and apply clamp to Saf-T-Intima

Insert new battery

Restart the syringe driver

Reconfirm syringe size and brand

Press YES to resume

Reconfirm volume and duration and rate of infusion

Press YES to recommence the infusion

Lock the keypad

Following completion of the procedure all patient records will be updated and signed by the registered nurse. (For paper documentation see appendix 2). Records will also include those accessed on System One.

What to do if there is an occlusion in the extension line

Check that the Saf-t-Intima is not clamped

Check the extension line and Saf-t-Intima for any kinking – straighten if kinked

Check the syringe, extension line and Saf-t-Intima for any signs of crystallization of the solution.

If crystallization detected – prepare and fit new syringe, extension line and change Saf-t-Intima site

If no physical reason for the occlusion is detected – resite the Saf-t-Intima

If occlusion is still present – change the site, extension line and syringe

N.B. During an occlusion the pump’s Post Occlusion Reduction System will reverse the operation of the motor and drive the actuator backwards, otherwise the pressure build up could cause a surge of fluid into the patient on release of the occlusion. When the pump is resumed/restarted following the backward movement of the actuator, time will be added to the time remaining to protect the original calculated rate.

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Procedure for releasing a trapped foreign object from the actuator (See appendix 6)

WARNING: IF A FOREIGN OBJECT IS TRAPPED IN FRONT OF OR BEHIND THE ACTUATOR DURING PRE-LOADING (AUTOMATIC ACTUATOR MOVEMENT) OR WHEN MANUALLY ADJUSTING THE ACTUATOR, THE USER SHOULD:

Ignore screen prompts as the prompt that may display will be in

relation to alarm activation and NOT the trapped object

Turn the syringe driver OFF

Raise the barrel clamp arm and turn it to the left or right to keep it in the raised position

Turn the syringe driver ON

Turn and lower the barrel clamp arm

Use the FF key (or BACK key) to move the actuator in order to release the object

4.9 Incident Reporting

Systems are in place within Rotherham Doncaster and South Humber NHS Foundation Trust to report and manage incidents, near misses and serious untoward incidents involving syringe pumps. Staff should be familiar with the reporting process and the Incident Reporting Policy.

Acknowledgements McKinley T34 Ambulatory Syringe Pump Operations Manual (2011)

Illustrations courtesy of CME McKinley Medical CME McKinley UK Ltd Kincraig Business Park, Kincraig Road, Blackpool, FY2 0PJ Tel: 01253 894646 www.cme-mckinley.co.uk

5. Links to Associated Documents

Aseptic technique and Aseptic Non Touch Technique Policy Lifecycle of Clinical & Corporate Records Policy

Medical Devices Policy The Medicines Act (1986)

Mental Capacity Act 2005 Policy Incident Reporting Policy

Policy for Consent to Examination and Treatment. SOP for Controlled Drugs

Standard Infection Prevention and Control Precautions Policy

Sharps Policy Safe Use and Disposal of Sharps and Management of Contamination Injuries

http://www.cme-mckinley.co.uk/

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Hand Hygiene Policy

NMC Standards of Medicines Management Waste Policy 6. References and Literature review

British Medical Association and the Royal Pharmacological Society of Great Britain. (2013) British National Formulary No 64 London. BMA and RPSGB.

Dickman A and Schneider J (2011) The Syringe Driver. Continuous subcutaneous infusions in palliative care 3rd edition, Oxford University Press, Oxford

Perdue, C. (2004) The syringe driver – an aid to delivering symptom control. Nursing Times, 100, 13. pp32-35.

Medicines Act 1986. HMSO: London Mental Capacity Act (2005) DOH: London Mitten, T. (2001) Subcutaneous drug infusions: a review of problems and solutions. International Journal of Palliative Nursing, 7,2. pp.75-85.

National Patient Safety Agency (2008) Reducing dosing errors with Opioid Medicines Rapid Response Report 05

National Patient Safety Agency (2010) Safer ambulatory syringe drivers Rapid Response Report 019

NMC (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives, Nursing and Midwifery council, London

NMC (2008) Standards for medicines management, Nursing and Midwifery Council, London

Twycross, R , Howard ,P and Wilcock A (2014) (eds) Palliative Care Formulary 5th edition, Nottingham, palliativedrugs.com Ltd.

Wilson J. (2001) Infection Control in Clinical Practice. Bailliere Tindall. London pp138

7. Appendices

Appendix 1 Syringe Driver base information Appendix 2 Subcutaneous syringe driver instruction and observation

chart for McKinley T34 and continuation sheet Appendix 3 Indications, Advantages and Disadvantages for use of

Syringe Driver

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Appendix 4 McKinley T34 Feature Recognition Appendix 5 McKinley Syringe pump compatibility tables Appendix 6 Procedure for releasing a trapped object from the actuator Appendix 7 Form for the patient regarding loan of syringe driver

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Appendix 1

SYRINGE DRIVE BASE INFORMATION

SYRINGE DRIVER IDENTIFICATION CODE

CLUSTER AREA IN USE/NOT IN USE nb. IF IN USE PLEASE REFER TO THE RECORD SHEET

STAFF SIGNATURE

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ADMINISTRATION & OBSERVATION DETAILS [for completion by administering clinician] WARD OR BASEPOINT NAME

The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary treatment changes or need for review.

ADMINISTRATION1 Day and Date OBSERVATIONS2

Time [HH:MM]

DA

ILY

SET

UP

Start time of infusion:

MO

NIT

OR

ING

PR

OG

RES

S

Site appearance6 :

Syringe size used 20ml or 30ml

17ml infusion in 20ml syringe 22ml infusion in 30ml syringe

Syringe/line contents clear3 - OK to continue? [Y/N]

Infusion rate setting – as at set up? [Y/N]

Syringe Driver serial No.: Battery Status [%]: Infusion time remaining [HH:MM]

Infusion rate [ml/hr]: Volume still to be infused (vtbi) [ml]

Site used5: Site Appearance6: Is the VTBI correct for time remaining [Y/N]

Drawn up by: Checked by: Volume infused [ml]

Details of any problems & actions taken:

If syringe contents discarded: Volume discarded: Date & time: Discharged by: Checked:

Battery status [%]4

Is the key pad locked? [Y/N]

Observer’s initials

1. To be completed each time syringe driver is loaded 4. Change battery when less than 10% (ward ) or 40% (community) 2. WARD - Completed 30 minutes after loading and then every 4 hours 5. Document insertion site of winged

infusion COMMUNITY – Complete at set up, at each subsequent visit and at syringe change 6. Appearance: Use code below 3. If contents of syringe look cloudy, precipitation has occurred. STOP infusing and contact NP (no problem) P (pain) I

(inflammation) prescriber. Refer to policy for guidance on checking compatibility SW (swelling) B (bleeding) H (hardening)

Page 1

Appendix 2

SUBCUTANEOUS SYRINGE DRIVER INSTRUCTION AND OBSERVATION CHART FOR MCKINLEY T34 PRESCRIPTION DETAILS [for completion by the prescriber] – a separate form must be completed for each syringe driver

DRUG DOSE DILUENT PHARMACYa ALLERGY

STATUS PATIENT DETAILS [Affix label if available]

Date 1. Please circle

Water for injection

or Normal Saline

NHS Number: ……………………………………………….. Surname: ……………………………………………………… Forename(s): ………………………………………………… Address: ………………………………………………………..

………………………………………………………. DOB: ……………………..

Route SC 2.

Duration of flow

Please circle 12 hours 24 hours

3.

4.

The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary treatment changes or need for review. If, as the prescriber, you wish to review the patient on a particular date, please stipulate below -

Review date: ………………………..

Prescriber name: ………………………………………… Signature: ………………………………………………… Practice: ……………………………………………..

a. Pharmacy: Only complete if this form is used on a ward. NOT required for community use.



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SUBCUTANEOUS SYRINGE DRIVER CONTINUATION SHEET

ADMINISTRATION & OBSERVATION DETAILS WARD OR BASEPOINT NAME



Time [HH:MM]

DA

ILY

SET

UP


MO

NIT

OR

ING

PR

OG

RES

S

Site appearance6 :



Syringe/line contents clear3- OK to continue? [Y/N]








Battery status [%]4




The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary treatment changes or need for review. ADMINISTRATION1

Day and Date OBSERVATIONS2 Time

[HH:MM]

DA

ILY

SET

UP


MO

NIT

OR

ING

PR

OG

RES

S

Site appearance6 :











Battery status [%]5



1. To be completed each time syringe driver is loaded 2. WARD - Completed 30 minutes after loading and then every 4 hours

COMMUNITY – Complete at set up, at each subsequent visit and at syringe change 3. If contents of syringe look cloudy, precipitation has occurred. STOP infusing and

contact prescriber. Refer to policy for guidance on checking compatibility 4. Change batter when less than 10% (ward ) or 40% (community) 5. Document insertion site of winged infusion 6. Appearance: use code below

NP (no problem) P (pain) I (inflammation)

SW (swelling) B (bleeding) H (hardening) Page …

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SUBCUTANEOUS SYRINGE DRIVER CONTINUATION SHEET


The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary treatment changes or need for review. ADMINISTRATION1

Day and Date OBSERVATIONS2 Time [HH:MM]

DA

ILY

SET

UP


MO

NIT

OR

ING

PR

OG

RES

S

Site appearance6 :



Syringe/line contents clear3- OK to continue? [Y/N]








Battery status [%]4






Time [HH:MM]

DA

ILY

SET

UP


MO

NIT

OR

ING

PR

OG

RES

S

Site appearance6 :











Battery status [%]5



4. To be completed each time syringe driver is loaded 5. WARD - Completed 30 minutes after loading and then every 4 hours

COMMUNITY – Complete at set up, at each subsequent visit and at syringe change

6. If contents of syringe look cloudy, precipitation has occurred. STOP infusing and contact prescriber. Refer to policy for guidance on checking compatibility

4. Change batter when less than 10% (ward ) or 40% (community) 5. Document insertion site of winged infusion 6. Appearance: use code below

NP (no problem) P (pain) I (inflammation)

SW (swelling) B (bleeding) H (hardening)= Page ……..


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Appendix 3

Indications for the use of a syringe driver

The inability of the patient to swallow or absorb oral drugs because of:

Intestinal Obstruction Persistent Vomiting Dysphagia Mouth Throat or Oesophageal Tumour Altered Level of Consciousness Malabsorption Profound Weakness Advantages

Plasma drug levels are maintained preventing peaks and troughs Effective symptom control without repeated injections Control of multiple symptoms with a combination of drugs Mobility and independence maintained for some patients Disadvantages/Risks Medication errors relating to drug or dose Inflammation or infection may occur at skin site Drug/patient and drug/diluent incompatibility

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Appendix 4

McKinley T34 Feature Recognition

Barrel clamp arm….secures syringe and detects brand and size Collar sensor……… detects correct loading of syringe collar Plunger sensor…… detects correct loading of the syringe plunger Actuator drives the syringe plunger to deliver the syringe contents Info key (a) shows infusion summary, protocol parameters, battery

level (b) when pump is paused, access the main menu

(c) activates/deactivates keypad lock UP arrow key (a) scrolls between options

(b) increases infusion parameters Down arrow Key (a) scrolls between options

(b) decreases infusion parameters during programming/ titration

Yes/Start Confirms selection and starts infusion No/Stop (a) stops infusion

(b) takes the user back a step during programming FF (Forward) (a) moves actuator forward when no syringe in place and

barrel clamp arm is down (b) accesses purge function (if enabled)

Back (Reverse) moves actuator backward when no syringe is in place and barrel clamp arm is down

On/Off key Switches the pump on and off Infusion LED light. A green indicator lights: (a) during system self-test (b) intermittently to indicate infusion delivery A red indicator light: (a) continuously to indicate an alarm state (b) when pump paused/on stand-by mode

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Appendix 5

Compatibility and stability tables for a subcutaneous infusion in a McKinley T34 Syringe Pump

Table 1: Subcutaneous Morphine Infusion Diluent: Water for injections The figures in these tables are not clinical doses to prescribe. Most patients do not need

such large amounts of medication.

Refer to the relevant guidelines to obtain the usual dose range for each of the medications.

Use the minimum effective dose and titrate according to response.

Use the table to check for concentrations that are stable for 24 hours; their use is unlicensed.

Drug Combination Concentrations of two drug combinations that are

physically stable for 24 hours

17ml in 20ml syringe 22ml in 30ml syringe

Morphine Sulphate Cyclizine 300mg 150mg

380mg 150mg

Morphine Sulphate Glycopyrronium bromide

300mg 1200 micrograms


Morphine Sulphate Haloperidol 400mg 10mg

500mg 10mg

Morphine Sulphate Hyoscine butylbromide

300mg 120mg

380mg 120mg

Morphine Sulphate Hyoscine hydrobromide



Morphine Sulphate Levomepromazine

300mg 100mg

380mg 100mg

Morphine Sulphate Metoclopramide 120mg 60mg

150mg 70mg

Morphine Sulphate Midazolam 300mg 30mg

380mg 35mg

Morphine Sulphate Octreotide 400mg 400 micrograms


Drug Combination Concentrations of three drug combinations that are physically stable for 24 hours


Morphine Sulphate Cyclizine Haloperidol

40mg 100mg 2mg

50mg 100mg 3mg

Morphine Sulphate Haloperidol Midazolam

100mg 5mg 20mg

130mg 6mg 25mg

Morphine Sulphate Hyoscine butylbromide Midazolam

50mg 40mg 60mg

60mg 50mg 75mg

Morphine Sulphate Metoclopramide Midazolam

50mg 30mg 7mg

60mg 40mg 10mg

Morphine Sulphate Midazolam Levomepromazine

180mg 10mg 5mg

230mg 12mg 5mg

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Table 2: Subcutaneous Diamorphine infusion in a McKinley T34 Syringe Pump Diluent: Water for injections

The figures in these tables are not clinical doses to prescribe. Most patients do not

need such large amounts of medication.




Drug Combination Concentrations of two drug combinations that are physically stable for 24 hours


Diamorphine Cyclizine 340mg 150mg

440mg 150mg

Diamorphine Glycopyrronium bromide 425mg 1200 micrograms


Diamorphine Haloperidol 800mg 10mg

1000mg 10mg

Diamorphine Hyoscine butylbromide

1000mg 120mg

1000mg 120mg

Diamorphine Hyoscine hydrobromide



Diamorphine Levomepromazine 850mg 100mg

1000mg 100mg

Diamorphine Metoclopramide 1000mg 85mg

1000mg 110mg

Diamorphine Midazolam 560mg 80mg

720mg 80mg

Diamorphine Octreotide 425mg 900 micrograms




Diamorphine Cyclizine Haloperidol 340mg 150mg 10mg

440mg 150mg 10mg

Diamorphine Haloperidol Midazolam 800mg 7mg 65mg

1000mg 10mg 80mg

Diamorphine Hyoscine butylbromide Midazolam

120mg 80mg 20mg

150mg 100mg 25mg

Diamorphine Levomepromazine Metoclopramide

850mg 100mg 50mg

1000mg 100mg 60mg

Diamorphine Levomepromazine Midazolam

850mg 50mg 30mg

1000mg 60mg 40mg

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Table 3: Subcutaneous Oxycodone infusion in a McKinley T34 Syringe Pump Diluent: Water for injections






If the 10mg/ml preparation of oxycodone injection is used, and the 24 hour dose of

oxycodone exceeds 60mg, an alternative opioid may be needed for breakthough pain.

Drug Combination Concentrations of two drug combinations that are physically

stable for 24 hours


Oxycodone Cyclizine

Do not mix - Incompatible Do not mix - Incompatible

Oxycodone Haloperidol

140mg 10mg

180mg 10mg

Oxycodone Hyoscine butylbromide

140mg 40mg

180mg 50mg

Oxycodone Hyoscine hydrobromide



Oxycodone Levomepromazine

120mg 100mg

150mg 100mg

Oxycodone Metoclopramide

80mg 40mg

100mg 50mg

Oxycodone Midazolam

80mg 40mg

100mg 50mg

Oxycodone Octreotide

80mg 400 micrograms


Drug Combination Concentrations of three drug combinations that are physically

stable for 24 hours


Oxycodone Haloperidol Hyoscine butylbromide

80mg 2mg 100mg

100mg 5mg 120mg

Oxycodone Haloperidol Hyoscine hydrobromide

80mg 2mg 1000 micrograms

100mg 5mg 1200 micrograms

Oxycodone Haloperidol Midazolam

80mg 2mg 15mg

100mg 5mg 20mg

Oxycodone Levomepromazine Hyoscine butylbromide

80mg 20mg 100mg

100mg 25mg 120mg

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Table 4: Subcutaneous Alfentanil infusion in a McKinley T34 Syringe Pump Diluent: Water for injections






Drug Combination Concentrations of two drug combinations that are physically stable for 24 hours


Alfentanil Cyclizine

4mg 150mg

5mg 150mg

Alfentanil Glycopyrronium bromide

5mg 1200 micrograms

8mg 1200 micrograms

Alfentanil Haloperidol

7mg 10mg

10mg 10mg

Alfentanil Hyoscine butylbromide

5mg 120mg

8mg 120mg

Alfentanil Hyoscine hydrobromide

7mg 1200 micrograms


Alfentanil Levomepromazine

7mg 40mg

10mg 50mg

Alfentanil Metoclopramide

2mg 60mg

3mg 80mg

Alfentanil Midazolam 3mg 50mg

5mg 60mg

Alfentanil Octreotide

6mg 800 micrograms

8mg 900 micrograms



Alfentanil Haloperidol Midazolam

4mg 5mg 35mg

6mg 5mg 45mg

Alfentanil Hyoscine butylbromide Levomepromazine

5mg 120mg 25mg

7mg 120mg 25mg

Alfentanil Metoclopramide Midazolam

3mg 35mg 20mg

3mg 45mg 30mg

Alfentanil Levomepromazine Midazolam

3mg 80mg 30mg

5mg 100mg 40mg

1. Dickman A: The syringe driver: continuous subcutaneous infusions in palliative care. 2nd Edition, 2005. OUP.

2. Palliative care drug information online http://www.palliativedrugs.com/

http://www.palliativedrugs.com/

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Appendix 6

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You have been loaned a syringe driver by Rotherham Doncaster and South Humber NHS Foundation Trust.

Make and Model...........................................................................................................

Serial Number...............................................................................................................

This syringe driver will be cleaned, maintained and tested to ensure it is, and remains fit for purpose by the Nursing team.

We have included an instruction manual for the unit that you have been given.

Please ensure that;

• The driver is kept dry

• It is handled with care

Delivered by (Print name)................................................................RDaSH Employee

Instruction given - Date.............................Signature.....................................................

Syringe driver accepted by (print name)...................................................Patient/carer

Date accepted..................................................................

By accepting this machine I agree to the above.

Signature..........................................................................................

.........Patient/carer Advice available

from............................................................

Please contact .............................................................................. for any issues or to return the unit.

The equipment specified remains the property of Rotherham Doncaster and South Humber NHS Foundation Trust and must be returned to the contact above in the condition it was received in when no longer required.

Appendix 7