Download Clinical Protocol: Management of Continuous

CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 1 of 42
May 9, 2011
PURPOSE:
This protocol supports the practice of administering one or more medications via Continuous
Subcutaneous Infusion (CSCI) delivered by Computerized Ambulatory Drug Delivery (CADD®) pump to
Registered Hospice Palliative Care (HPC) patients/clients who are receiving services in Tertiary Hospice
Palliative Care Units (THPCU), Hospice Residences, and Home Health in Fraser Health (FH). It is
intended to guide the practice of physicians, nurses and pharmacists in the use of CSCI.
1.0 BACKGROUND
Hospice Palliative Care patients /clients who are registered with the End of Life Care Program in Fraser
Health (FH) are considered to be in the final stages of a life-limiting illness, with a prognosis of weeks to
months (but not years). Many of these people have a cancer diagnosis and some of them have major
organ failure (heart, lung, liver, or kidney) as the terminal outcome of a chronic illness. Pain and dyspnea
are common at the end of life for patients with non-cancer illnesses as well as those with terminal cancer;
for both of those symptoms an opioid analgesic is often considered an appropriate and effective
medication. 1- 6 The oral route of administration is usually preferred 2, 7, 8 but parenteral routes need to be
considered in the following instances: impaired swallowing; gastro-intestinal obstruction; when very high
doses of analgesic are required and the oral dose would be unmanageable, and when standard oral opiate
therapy may be limited.2, 5, 9, 10, 11 Administration of medications by intermittent subcutaneous (SC)
injection is limited by dose volume (patient discomfort) and "bolus effect" (toxicity at peak concentration
and/or pain breakthrough at trough).2, 8, 12 There is evidence of no significant differences between the
intravenous (IV) and the subcutaneous (SC) routes for most patients, especially when administered by
subcutaneous infusion 6, 13, 14, but the IV route is not feasible for patients at home or in Hospice Residences.
The use of continuous subcutaneous infusion of opioids is effective and safe in terminal illness and has a
proven role in pain management at end of life.2, 9, 15 The advantages of using CSCI include providing a
steady state of analgesia, simplicity of medication administration, possibly fewer gastrointestinal side
effects, and portability that allows for maintenance of functional ability and for management at home; the
disadvantages include local irritation at the infusion site, poor absorption at higher infused volumes, the
relatively high cost of purchasing or renting CADD® pumps, and the cost of preparing and delivering
medication and supplies to people at home.8, 12, 16 Still, use of CSCI can lower costs by replacing IV
infusions and allowing for discharge home or to a Hospice Residence.13, 15, 17
It is not uncommon for other medications to be added to the opioid in an infusion. The administration of
analgesics, antiemetics, anxiolytic sedatives, and dexamethasone by continuous subcutaneous infusions is
well-established in palliative care, but the stability and compatibility of many of these combinations is not
known.2, 18, 19 In the United Kingdom laboratory, physical, and chemical data are available for less than
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 2 of 42
May 9, 2011
half of the most frequently used combinations.20 Relying on observational data such as the absence of
discoloration, crystallization, or precipitation is subjective and imprecise, and generally only major
incompatibilities will be detected in this way.2, 18, 20 There are a few studies of specific drug combinations
21- 24
and there is need for much more research; without compatibility data optimal symptom control could
be compromised.17, 25 It has been suggested that the number of drugs in an infusion mixture be limited to
three or less2 . Information about compatibility is available in texts such as The Syringe Driver 18 and
through internet databases of compatible drug combinations, such as www.pallmed.net and
www.palliativedrugs.com.
It has been estimated that up to a quarter of all prescriptions in palliative medicine are for licensed drugs
that are used for unlicensed indications or that are given by an unlicensed route (7, 26), and this is termed
"off-label" use. "Off-label" is the use outside the specifications of its marketing authorization, including
prescription for an unlicensed indication and/or by an unlicensed route 27 ( p. .365) . The lack of strong
evidence for the use of off-label medications is probably related to the difficulties in attracting research
funding from pharmaceutical companies, who may not see much benefit in supporting studies for
symptom management at end of life, and the difficulty of recruiting palliative patients into clinical trials.5,
27- 29
Despite this, off-label prescription is very often grounded in pharmacological principles and on
clinical outcomes. A study looking at the unlicensed uses of medication in a palliative care unit found that
68% of the drug prescriptions were supported by license (45% of those given SC were licensed for the
given indication), 17% were licensed for the given indication in a different clinical situation, and 15%
were for indications not supported in the product license, although their use was supported in the
literature: most of the drugs in this category were given subcutaneously.28
2.0 DEFINITIONS
CADD® Pump
 A Computerized Ambulatory Drug Delivery (CADD®) pump is a delivery system for providing one
or more medications subcutaneously at a continuous rate of infusion and may also have patient
controlled demand doses(breakthrough doses).
Caregiver
 The caregiver may be a professional or a non-professional care-provider.
 A professional caregiver is a nurse, (RN/LPN) working in THPCU, Hospice Residences and Home
Health.
 A non-professional caregiver is a person 19 years or older who agrees to provide the support needed
to enable CSCI at home. This is usually a relative but can be a friend of the person who will receive
CSCI.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 3 of 42
May 9, 2011
Chemical Compatibility Data
 Evidence from a laboratory study of the drug mixture that verifies medications maintained their
chemical integrity without degradation or decomposition, and without forming potentially toxic
compounds.18, 25
Clinical Compatibility Data
 Evidence from a clinical setting that verifies expected outcomes were achieved, meaning symptoms
were adequately managed.18
 It is assumed that the drugs in the mixture are compatible if clinical outcomes are met.
Community Pharmacy Designate (CPD)
 A community pharmacy designate is one that meets the criteria established by the College of
Pharmacists of BC, Fraser Health Pharmacy Standards, or the accepted Standards in HPC Clinical
References, related to the preparation of medications for CSCI, and that will deliver medications to
the home.
 Some CPD may also supply the CADD® pumps.
Compounded Sterile Preparations (CSP)
 A preparation compounded in a controlled environment employing aseptic technique, prepared in a
licensed pharmacy or other health care related facility, and intended for parenteral administration.
Continuous Subcutaneous Infusion (CSCI)
 A route of medication administration characterized by the continuous controlled delivery of
medication(s) into the subcutaneous tissue via an infusion pump.
Laboratory Compatibility Data

Evidence from a laboratory study that verifies solutions of two or more drugs are compatible over a
given time period. 18

Laboratory physical and chemical compatibility data are available for less than half the most
frequently used combinations.20
Off Label Use

"Off-label" is the use outside the specifications of its marketing authorization, including prescription
for an unlicensed indication and/or by an unlicensed route 27 (p.365) or in other words a licensed
medication prescribed for a purpose outside its product license as defined by the pharmaceutical
company, for an unlicensed indication and/or for administration by an unlicensed route.
 In some cases off- label use is referred to as unlicensed use
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program



Patient

Date Released:
Page 4 of 42
May 9, 2011
Off-label prescription is very often grounded in pharmacological principles and on clinical
outcomes.
It is meant to benefit an individual patient, and is usually well-supported by some scientific evidence
as well as clinical practice in palliative medicine.7
Clinical pharmacists can provide information and advice about use of off-label medications 30
For the purposes of this protocol, the term ‘patient’ includes ‘client’.
Patient Controlled Analgesia (PCA)
 The patient is able to titrate the opioid dose to his or her individual needs by controlling a pump that
delivers bolus doses of an analgesic according to parameters set by a physician; the option for bolus
dosing can be included for patients receiving continuous opioid infusion as appropriate 2.
Physical Compatibility Data
 Physical compatibility means that two or more drugs in a mixture do not react with one another to
produce a new compound or a precipitate.
 Often based on visual evidence that the drug mixture remains colorless, clear, and free of particulate
matter or crystallization over a specified time. 18, 20, 25
Required Competency in Management of CSCI and the CADD pump
 A Registered Nurse (RN) who has reviewed this Clinical Protocol and completed the CADD®
Learning Module, successfully passing the Quiz and the Performance Skills Checklist, is considered
to have the required competency to manage CSCI including programming of the CADD® pump. The
RN who has the required competency is responsible for all duties related to management of the
infusion pump.
 A Licensed Practical Nurse (LPN) would not be expected to acquire this competency, but would be
able to provide limited care to a patient receiving CSCI as long as an RN with the required
competency is available on site. The LPN would never be required to program the pump, change
cassette/mini-bag, but could be taught to perform simple functions such as reviewing programmed
parameters. The LPN may be responsible for assessing and identifying the status of the patient,
symptom assessment, SC site and infusion pump functioning to the RN.
Stability Data
 Evidence that the drug or drugs in a mixture retain their dose strength and composition over a given
period of time at a given temperature. 18
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program

Date Released:
Page 5 of 42
May 9, 2011
Ideally this would be based on lab data but often visual inspection is relied on to determine that
degradation has not occurred.
3.0 RELATED RESOURCES
Edmonton Symptom Assessment System (ESAS) (Will be available on FH Intranet>Clinical Programs>End
of Life>Documents; or contact the Hospice Palliative Care team in your area)
FH- Learning Module for CADD-Prizm® Pump. Model 6100 and 6101 (2010) (Will be available FH
Intranet>Clinical Programs>End of Life>Documents or contact the Hospice Palliative Care team in your
area)
FH Parenteral Drug Therapy Manual.
http://fhaweb/Programs+and+Services/Strategic+Services/Pharmacy+Services/IV+Manual/default/htm
LPN Scope of Practice Regulation, Health Professions Act 1996
http://www.health.gov.bc.ca/leg/pdfs/Oct15_NursesLicensedPracticalReg.pdf
Mosby's Nursing Skills , Subcutaneous Catheter Initiation
RN Scope of Practice Regulation, HPA 2005
http://www.healthgov.bc.ca/leg/pdfs/
Smiths-Medical online Operator’s Manual for CADD-Prizm® PCS/ Model 6100 and 6101 Ambulatory
Infusion Pump, and other Resources, www.smiths-medical.com
Site-specific Nursing Policies and Procedures for Establishing and Maintaining a Subcutaneous Site
Guidelines to Facilitate the Transfer of Complex Patients (when approved will be available on FH
Intranet>Clinical Programs>End of Life>Documents or contact the Hospice Palliative Care team in your
area)
4.0 APPLICATION PARAMETERS
When to Initiate

The decision to implement CSCI is based on:
o Need for effective symptom management;
o Loss of or unfeasibility to use other routes of administration;
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 6 of 42
May 9, 2011
o Capacity of professional and non-professional caregivers to manage and monitor the infusion and
to provide ongoing monitoring and assessment of the patient receiving the infusion, and
o Availability of the necessary equipment and supplies, including medication(s) provided in a
cassette reservoir or mini-bag and a CADD® pump.
Decision Making Process
The decision to implement CSCI must be based on consultation and collaboration with all care providers
who will be involved, each of whom has a role to play in reaching a decision.
Physician's Role (usually a HPC specialist physician)
 Assesses the patient's condition and determines that use of CSCI is the best therapeutic option for
effective symptom management.
 Consults with Nursing Unit Team and/or HPC Clinical Resource Nurse (CRN) re: capacity to
manage and monitor CSCI.
 Consults with the pharmacist about the specific medication(s) to be included in the infusion.
 Discusses plan to use CSCI with the patient and/or family.
HPC CRN Role
 HPC CRN engages with the Hospice, Nursing Unit or Home Health Nursing Team to establish
capacity to; manage CSCI, identify, support and problem solve any real or potential barriers to
implementation.
 Plans for and supports staff nurses in obtaining and maintaining required competency in
management of CSCI and the CADD® Pump.
 Assists as necessary with information about how to obtain a CADD® pump.
 As necessary, facilitates transfers between care settings (home to hospital, hospital to hospice
residence, for example) of patients receiving CSCI.
 Ensures that the patient is enrolled in the BC Palliative Care Drug Benefits Program BC
Palliative Care Benefits Program.
Nursing Unit Team Role (THPCU, Hospice Residence)
 Patient Care Coordinator (PCC) or charge nurse identifies that staff mix (RN/LPN) can
accommodate a patient receiving CSCI, and whether the staff have the knowledge and skills to
manage CSCI.
 Each unit should keep a record of nurses with the required competency in management of CSCI
and the CADD® Pump if CSCI is a common practice on those units (THPCU, Hospice
Residences).
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program




Date Released:
Page 7 of 42
May 9, 2011
Implementation may have to be delayed until sufficient numbers of RNs have the required
competency.
Identifies source for obtaining a CADD® pump or seeks assistance from HPC CRN in obtaining
a pump.
Ensures Discharge Planning begins as soon as decision is made to initiate CSCI, when patient
goal is to transfer to another care setting.
Assessment and initial teaching of the non-professional (family) caregiver will be done by an RN
with the required competency prior to discharge home.
Home Health Nursing Team Role
 Home Health Liaison refers patient to Home Health Service if not already receiving care.
 Team Leader in Home Health identifies that there is sufficient staffing by RNs with the required
competency to accommodate care at home of patient receiving CSCI.
 The Nurse Educator in Home Health will liaise with the HPC CRN as necessary to provide
education and skills training to RNs in order for them to achieve and maintain required
competency in management of patients receiving CSCI via CADD® pump.
 The role of the LPN in caring for the patient at home with CSCI will be made explicit by the
Team Leader or Nurse Educator; however the LPN role will always adhere to their scope of
practice with regards to CSCI which includes assessment of the CSCI, symptoms and S/C site
and working in collaboration with RN HCN staff.
 Verifies that there is a non-professional caregiver in the home who is potentially able to monitor
and maintain the CSCI.
 Identifies source for obtaining a CADD® pump and the pharmacy (CPD) that will be supplying
and delivering the medication, or seeks advice from HPC CRN on how to do this.
 Identifies the resources needed to assess and teach the non-professional (family) caregiver how
to monitor and manage the infusion.
 Seeks the assistance of the HPC Consultation Team as needed.
Patient/Family Role
 Seeks further information as desired about the reasons for using CSCI; capable patients have the
right to refuse.
 Non-professional family caregiver understands what will be expected of him or her, and agrees
to participate in care.
 The patient agrees to have the non-professional caregiver (family member or friend) participate
in the monitoring and management of the CSCI at home.
Pharmacist Role (Hospital or Community pharmacist at a CPD or HPC Clinical Pharmacist Consultant)
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program


Date Released:
Page 8 of 42
May 9, 2011
Discusses concerns about compatibility, solubility and stability with the ordering physician as
necessary, when more than one medication is to be mixed in the cassette reservoir or mini-bag.
Where information is not readily available regarding compatibility and stability, the pharmacist
will notify the physician which may delay medication dispensing.
Provides compatibility and stability information on medications provided by cassette or minibag, to nursing staff upon request. When no other compatibility or stability information exists
the pharmacist will refer to BUNABY HOSPITAL THPCU 24 hour visual and clinical
COMPATIBLE INFUSIONS JULY 4, 2004 – July 4, 2006 for previously administered
infusion mixtures that were considered to be safe and effective or see the following link.
http://fhpulse/clinical_support_services/pharmacy/policies_pdtm_ppos_forms/Pages/ParenteralDrugThe
rapyManual(PDTM).aspx





The pharmacist will consider that lower concentrations of combinations are generally
compatible if higher concentrations of same combination are compatible, unless alcohol or
other solvents have been used in formulation to keep medication in solution. 31
If there is no research literature to support stability or compatibility of medications, the
physician and pharmacist will engage in collaborative decision-making. The collaborative
decision making process could include further investigations and may mean a delay in
initiation of CSCI.
To deliver the medications to the patient’s home (if pt at home) when needed, in collaboration
with patient/caregiver and nursing staff.
HPC Pharmacist can consult with the ordering physician, community/hospital pharmacist or
nursing staff as necessary to support the process of ordering medications and compatibility or
stability of medications.
For further Pharmaceutical Information see the Bibliography for Pharmaceutical References
(Appendix I).
Participants in Care of the Patient Receiving CSCI
Those who participate directly in caring for the patient are primarily the professional and nonprofessional caregivers: nursing staff (RN and LPN) and the family member or friend who has agreed to
be involved in care. The physician ordering CSCI and the pharmacist who prepares the medication
cassette/mini-bag are also directly involved in care.
5.0 ASSESSMENT and CONDITION/DIAGNOSIS
Initial Patient Assessment
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program



Date Released:
Page 9 of 42
May 9, 2011
Meets criteria for choosing CSCI
o Oral route is not feasible,
o Intermittent SC dosing is not practical or causes too much discomfort to the patient,
o IV route is not available or desired,
o Medication protocol necessitates CSCI. 32
Does not have a condition that would make CSCI inadvisable
o Insufficient subcutaneous tissue (e.g. extreme cachexia),
o Coagulation disorder,
o Gross edema,
o Unusual skin disorders.
Symptom(s) of concern; intensity/severity of symptom(s)
o Patient completes the ESAS Numerical Scale, assigning score /10 to the symptoms listed on the
scale.
o If patient is unable to provide scores the physician or nurse should document the behavioral
indicators indicating distress; collateral information about the patient’s distress from a caregiver
who knows the patient well should also be documented in the patient chart.
Ongoing Patient Assessment and Monitoring
 Symptom (s) of concern will be assessed using the ESAS Numerical Scale or behavioral indicators to
determine that the medication therapy is effective, until the target comfort goals are met
o At least once every 24 hours in THPCU or Hospice Residence (RN),
o On each home visit by Home Health RN,
o Daily by the non-professional caregiver, and
o Once the target comfort goals have been achieved, the ESAS can be done weekly unless a new
symptom arises.
 The physician will assess patient response and make adjustments to the dose or mix of medications as
needed.
 The patient will be observed for the presence of unwanted side effects, such as a new symptom of
confusion, increased agitation, myoclonus or increased sedation/drowsiness; these will be reported to the
physician by the nurse (RN/LPN) or by the non-professional caregiver.
 The SC infusion site will be assessed at least once per shift (RN/LPN), on each home nursing visit (RN),
and every 6-12 hours by the non-professional caregiver at home (as instructed by the RN) for:
o Signs of inflammation (redness, tenderness),
o Swelling/firmness, indicating decreased absorption, or
o Leaking from the site.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 10 of 42
May 9, 2011
NOTE: If a suspected allergic reaction occurs stop the infusion and notify the physician, who will assess and
determine that this is a true allergy. If it is a true allergy, the pharmacist should be informed and a special
medication incident report should be completed. The incident report can be completed online or downloaded
from https://fha.bcpsls.ca/patient.
Signs and symptoms of a true allergy may include intense irritation or pain /tenderness at the site, and systemic
reactions such as hives, oral numbness, swelling of tongue, and breathing difficulties.

The infusion solution will be inspected by looking carefully at the fluid in the tubing or
in the mini bag at least once per shift (RN/LPN), on each home visit (RN), and every 6 – 12 hours by the
non-professional caregiver at home (as instructed by the nurse) for:
o Clarity and colorlessness,
o Absence of crystals or precipitate.
NOTE: If the solution becomes cloudy or takes on coloration, or if crystals or precipitate are observed stop the
infusion immediately and contact the physician and the pharmacist. An incident report should also be
completed. It can be completed online or downloaded from https://fha.bcpsls.ca/patient.
Non-Professional Caregiver Assessment
 Initial assessment – before deciding to use CSCI at home the caregiver will be assessed for:
o Willingness and ability to learn how to monitor and manage the infusion,
o Availability to be present in the home around the clock,
o Physical ability (vision, hearing, and manual dexterity) to assess and monitor the infusion site,
hear the alarms, perform simple tasks, such: as turning the pump off and on, changing the
battery, determining that the pump is running, and trouble-shooting the error or alarm messages
on the display screen on the pump.
 The lack of a willing and capable non-professional caregiver may disqualify a patient from receiving
CSCI at home.
 Ongoing assessment – at each home visit the home health nurse will assess caregivers:
o The willingness and ability of the caregiver to continue to monitor and manage the CSCI,
o The need for reinforcement of the teaching related to providing the necessary care,
o If it appears that the caregiver does not have the ability to manage, or is no longer willing to
support the patient to receive CSCI at home, the nurse will communicate that to the Home Health
team leader, or the HPC CRN/CNS, and to the ordering physician.
6.0 INTERVENTIONS
Obtaining
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
CADD Pump and Medication Cassette, or Mini-bag with CADD®
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Equipment and
Medication
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Date Released:
Page 11 of 42
May 9, 2011
Administration Set
 The FH Standard is to order the pump and other supplies from
Calea Pharmacy for people receiving CSCI at home and in Hospice
Residences (Appendix II).
 Calea requires 24 hours notice to prepare and deliver the
medication and equipment,
 Calea is not able to fill prescriptions over the weekend, so
enough medication must be ordered to cover weekend and
stat holidays.
 Some sites own their own CADD® pumps which may be a different
type than noted in this document.
 Sites that own CADD® pumps are responsible for ensuring that they
are inspected regularly by a biomedical professional to ensure safe
and reliable functioning.
 Medications not provided by Calea must be prepared by a hospital
pharmacy or community pharmacy designate (CPD), and must be
supplied in a medication cassette or a mini-bag.
 A CADD® Administration set must be used with a mini-bag.
Components of a Physician Order
 Name of the drug or drugs,
* A duplicate prescription form must be used when an opioid is
used in an infusion for patients at home.
 Concentration of the drug or drugs,
* Choose a higher concentration in order to keep the volume
infused as low as possible.
 Rate of administration, in mg, mcg, (or mL per hour, if more than
one medication is in the infusion),
* The volume infused /hr should be as low as possible to preserve
the SC site as long as possible. The usual rate is 0.1 – 5 mL per
hour, but some patients may require higher volumes.
* Care should be taken when a range in volume is ordered, as
increasing or decreasing mL/hr can have a large effect on the dose;
upward titration should not generally occur more frequently than
q8h.(8)
 Demand dose, lockout time, and number of doses per time period if
ordering a breakthrough dose.
 Clinician bolus dose – suggested when increasing the base rate, and
given at the same time so as to more quickly reach steady state of
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 12 of 42
May 9, 2011
drug concentration in the blood.(9, 12)
The preferred diluent is normal saline, unless otherwise indicated by the
particular drug or drugs chosen. (18)
Establishing SC
site(s)
Visual Inspection
Possible sites:
 Preferred sites: abdomen, upper or outer aspect of thigh,
 Other possible sites: sub-clavicular area, anterior chest wall, upper
outer aspect of the arms,
 Rotate sites,
 Avoid areas that are swollen, hard, or bruised /tender,
 Sites can last up to 7 days, and should be changed when the site
appears inflamed, is leaking, or becomes firm/hard.
Equipment and Procedure:
 See Mosby's Nursing Skills (on-line through FH Intranet) –
Subcutaneous Catheter Initiation (or Site Specific Policies and
Procedures).
Visually inspect the cassette or mini-bag and tubing to ensure the fluid is
colorless, clear, and free of crystals or particulate matter. Do not use the
medication solution if it is not clear, colorless, and free of particulate
matter.
 This should be done whenever a cassette or mini-bag is changed,
 Tubing should be inspected at least once every 12 hours, no matter
where the patient is located,
 NOTE: If the solution changes color, becomes cloudy, or if
particulate matter forms, stop the infusion immediately; notify the
physician and the pharmacy that prepared the medication. A
special medication incident report should be completed.
Stability
In FH, drug mixtures in mini bags or medication cassettes are considered to
be stable at room temperature for 24 hours. Where a community pharmacy
(CPD) is able to prepare infusions DAILY, they are supplied daily,
otherwise stability may vary depending on the drug combinations and the
conditions under which the individual pharmacy prepares the infusions.
The CPD will determine length of stability for each medication or
combination of medications they prepare. Single drug solutions are usually
considered stable for up to several days at room temperature.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Reviewing the
Programmed
Parameters
Date Released:
Page 13 of 42
May 9, 2011
Pumps that are provided by Calea Pharmacy will be programmed
according to the physician’s order prior to being delivered to the home or
hospice residence.
The parameters must be reviewed by the nurse before connecting the pump
and medication to the patient, and whenever the cassette or mini-bag is
changed.
See the FH CADD Learning Module for direction on using a CADD®
pump.
Changing the
Tubing
Cassette – tubing is attached to the cassette, and is new each time a cassette
is changed.
Mini-bag – CADD® Administration set/tubing is changed every three days.
Frequency of
Nursing
Assessments
Home
 RN should visit daily until the patient and caregiver have
demonstrated ability to manage the infusion between nursing visits,
which should be at least once a week.
 Review of the programmed parameters should be done at each visit.
 Condition of the infusion site and appearance of the medication
solution should be assessed on each visit.
 Review the Specifics for Home Care Nurses Checklist (Appendix
III).
THPCU or Hospice Residence
 Review of programmed parameters should be done at the start of
each shift.
 Condition of the infusion site and appearance of the medication
solution should be done at least once per shift.
Responding to
Alarms
See Quick Reference Sheet or CADD-Prizm® PCS Model 6100 and 6101
Operator’s Manual at www.smiths-medical.com (Appendix IV).
Non-professional caregiver will be instructed on how to use the CADD®
pump and given a Patient Information booklet from CADD Prizm VIP®
for models 6100 and 6101 www.smiths-medical.com.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Troubleshooting
Date Released:
Page 14 of 42
May 9, 2011
See Quick Reference Sheet or CADD® Operator’s manual at www.smithsmedical.com (Appendix IV).
Non-professional caregiver will be instructed on how to trouble shoot and
given a Patient Information booklet from CADD Prizm VIP® for models
6100 and 6101 www.smiths-medical.com.
When to refer to
a consultant
Patient / Symptom Issues
 Symptoms are not well-controlled; new symptoms arise; adverse
reaction at infusion site - consult with physician and pharmacist.
Infusion Issues
 S/C site reaction (allergic reaction, not expected deterioration of the
site over time) – it is recommended an incident report be filled out
(https://fha.bcpsls.ca/patient).
 Solution is cloudy, discolored, and/or contains particulate matter –
consult with pharmacist, notify physician, and complete PSLS
incident report (https://fha.bcpsls.ca/patient).
 There is a discrepancy between the expected volume and the actual
volume remaining – consult with pharmacist and physician.
Equipment Issues
 Consult with Calea Pharmacy, or with the hospital biomedical
department for concerns about equipment functioning.
 Consult with local HPC CRN or Clinical Nurse Specialist for
questions or concerns about obtaining the correct equipment.
Transition points: Ensure that there is clear communication, both verbal and written or faxed,
between caregivers in both settings prior to transfer.
Patient transfers
 Medication orders, CADD® Medication Record/ CADD®
from one setting
Flow Sheet.
to another
 CSCI Care Plan and CSCI Caregiver Teaching Checklist.
(Complex patient)
 Tracking of Equipment – who supplied the CADD® pump
and whether it needs to be returned.
Patient's who are receiving medication via CSCI are considered to be
"complex". Care providers in both the sending and receiving settings
should refer to the document Guidelines to Facilitate Transfer of Complex
Patients.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 15 of 42
May 9, 2011
7.0 PATIENT /CAREGIVER EDUCATION and DISCHARGE INFORMATION
 RN or physician will explain rationale for using CSCI and the plan for managing the infusion at home to
the patient and / non-professional caregiver.
 If patient is going to be discharged home from THPCU or a Hospice Residence:
o PCC or HPC CRN to perform initial assessment and teaching of non-professional caregiver as
per the Caregiver Teaching Checklist (Appendix V),
o Ensure that there is a back up plan in place in case of a SC site or CADD® pump failure. The
back up plan may include orders for an alternate route (i.e. having a back up s/c site, using
intermittent SC injections, or taking medications buccally or rectally) until issue can be resolved.
 When patient is at home:
o Prior to decision to implement CSCI, home care nurse (RN) will perform initial assessment of
non-professional caregiver,
o Home care nurse (RN) with the required competency will teach the non-professional caregiver
to monitor and manage the CSCI as per the CSCI Caregiver Teaching Checklist,
o Non-professional caregiver will be supported by ongoing assessment and monitoring by Home
Care nurses and will have access to After Hours support through the BC Nurse Line.
 The Patient Information booklet available from the Smiths-Medical website should be given to the
patient and the non-professional caregiver on discharge. A one-page information sheet about CSCI and
using the Patient Controlled Analgesia (PCA) mode should be provided as well (Appendix VI).
8.0 DOCUMENTATION
 THPCU, Hospice Residences:
o Medication Record for CADD/PCA Pump to be completed at least once per shift. CSCI
Medication Record to be used by THPCU staff and Hospice staff (Appendix VII);
o CSCI CADD Care Plan (Appendix VIII) will be filled out and updated and kept with the
Kardex;
o Location and condition of SC site to be documented in Progress Notes;
o Symptom response: ESAS Numeric Scale to be completed by patient (with assistance from the
nurse if necessary) once every 24 hours in THPCU and Hospice Residence and the scores to be
transferred to the ESAS Graph; on each home visit by a Home Health RN, and daily by the nonprofessional caregiver, until target comfort goals have been achieved;
o When appropriate, caregiver teaching to be documented on the Caregiver Teaching Checklist.

Home Care:
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 16 of 42
May 9, 2011
o CSCI CADD Care Plan will be completed on admission and updated as often as necessary
(Appendix VIII);
o CADD Continuous or PCA Infusion Flow Sheet will be used to document the infusion and are to
be completed at each nursing visit (Appendix IX);
o Location and condition of SC sites, symptom response, and caregiver assessment to be
documented in the Progress Notes;
o Document teaching on Caregiver Teaching Checklist (Appendix V).
9.0 CLINICAL OUTCOMES
 Improved symptom relief according to patient self-report (ESAS) and /or behavioral indicators of
comfort.
 Improved quality of life because of better symptom control and opportunity for patient to engage in
valued activities with loved ones, due to portability of CADD® pump.
10.0 REFERENCES
1. Foley KM. Acute and chronic cancer pain syndromes. In Doyle D, Hanks G, Cherny NI, Calman K,
editors. Oxford textbook of palliative medicine, 3rd ed. Oxford: Oxford University Press; 2005. p. 298316.
2. Hanks G, Cherny NI, Fallon M. Opioid analgesic therapy. In Doyle D, Hanks G, Cherny NI, Calman
K, editors. Oxford textbook of palliative medicine, 3rd ed. Oxford: Oxford University Press; 2005. p.
316-342.
3. Janssens J-P, de Muralt B, Titelion V. Management of dyspnea in severe chronic obstructive pulmonary
disease. J Pain Symptom Manage. 2000 May; 19(5): 378-392.
4. Paice JA, Fine PG. Pain at the end of life. In Ferrel BR, Coyle N, editors. Textbook of palliative
nursing, 2nd ed. New York: Oxford University Press; 2006. p. 131-153.
5. Watanabe S, Pereira J, Tarumi Y, Hanson J, Bruera E. A randomized double-blind crossover
comparison of continuous and intermittent subcutaneous administration of opioid for cancer pain. J
Palliat Med. 2008; 11(4): 570-574.
6. Zyczkowska J, Wordliczek J. Subcutaneous and intravenous administration of analgesics in palliative
medicine. Adv Pall Med. 2009; 8: 153-160.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 17 of 42
May 9, 2011
7. Hanks G, Roberts CJC, Davies AN. Principles of drug use in palliative medicine. In Doyle D, Hanks G,
Cherny NI, Calman K, editors. Oxford textbook of palliative medicine, 3rd ed. Oxford: Oxford
University Press; 2005: p. 213-225.
8. Black F, Downing M. Pain - analgesics. In Downing, GM, Wainwright W, editors. Medical care of the
dying, 4th ed. Victoria: Victoria Hospice Society, Learning Centre for Palliative Care; 2006. p. 189251.
9. Anderson SL, Shreve ST. Continuous subcutaneous infusion of opiates at end-of-life. Ann Pharm. 2004;
38(6): 1015-1023.
10. Furst CJ, Doyle D. The terminal phase. In Doyle D, Hanks G, Cherny NI, Calman K, editors. Oxford
textbook of palliative medicine, 3rd ed. Oxford: Oxford University Press; 2005: p. 1119-1133.
11. Enting RH, Oldenmenger WH, van der Rijt CC, Wilms EB, Elfrink EJ, Elswijk I, Sillevis PA. A
prospective study evaluating the response of patients with unrelieved cancer pain to parenteral opioids.
Cancer. 2002 June 1; 94(11): 3049-3056.
12. Pharmacy Specialty Group on Palliative Care, Neron A, editor. Care beyond cure: a
pharmacotherapeutic guide to palliative care. Montreal: A.P.E.S. and Sabex, Inc.; 2000: p. 29.
13. Justad M. Continuous subcutaneous infusion: an efficacious, cost-effective analgesia alternative at the
end of life. Home Healthcare Nurse. 2009 March; 27(3): 140-147.
14. Nelson KA, Glare PA, Walsh D, Groh ES. A prospective, within-patient, crossover study of continuous
intravenous and subcutaneous morphine for chronic cancer pain. J Pain Symptom Manage. 1997 May;
13(5): 262-267.
15. Bruera E, Brenneis C, Michaud M, Bacovsky R, Chadwick S, Emeno A, MacDonald N. Use of the
subcutaneous route for the administration of narcotics in patients with cancer pain. Cancer. 1988 July
15; 62(2): 407-11.
16. Costello J, Nyatanga B, Mula C, Hull J. The benefits and drawbacks of syringe drives in palliative care.
Int J Palliat Nurs. 2008; 14(3): 139-144.
17. Herndon CM, Fike DS. Continuous subcutaneous infusion practices of United States hospices. J Pain
Symptom Manage. 2001 December 6; 22(6): 1027-1034.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 18 of 42
May 9, 2011
18. Dickman A, Schneider J, Varga, J. The syringe driver: continuous subcutaneous infusions in palliative
care, 2nd ed. Oxford: Oxford University Press; 2005: p. v, Preface.
19. O'Doherty CA, Hall EJ, Schofield L, Zeppetella G. Drugs and syringe drivers: a survey of adult
specialist palliative care practice in the United Kingdom and Eire. Palliat Med. 2001; 15: 149-154.
20. Wilcock A, Jacob JK, Charlesworth S, Harris E, Gibbs M, Allsop H. Drugs given by a syringe driver: a
prospective multi-centre survey of palliative care services in the UK. Palliat Med. 2006; 20: 661-664.
21. Good PD, Schneider JJ, Ravenscroft PJ. The compatibility and stability of midazolam and
dexamethasone in infusion solutions. J Pain Symptom Manage. 2004 May; 27(5): 471-475.
22. Moselli NM, Cruto M, Massucco P, Savojardo M, Debernardi F. Long-term continuous subcutaneou
infusion of ketoprofen combined with morphine: a safe and effective approach to cancer pain. Clin J
Pain. 2010 May; 26(4): 267-274.
23. Negro S, Martin A, Azuara ML, Sanchez Y, Barcia E. Stability of tramadol and haloperidol for
continuous subcutaneous infusion at home. J Pain Symptom Manage. 2005 August; 30(2): 192-199.
24. Watson DG, Lin M, Morton A, Gable CG, McArthur DA. Compatibility and stability of dexamethasone
sodium phosphate and ketamine hydrochloride subcutaneous infusions in polypropylene syringes. J
Pain Symptom Manage. 2005 July; 30(1): 80-86.
25. Rose M, Currow DC. The need for chemical compatibility studies of subcutaneous medication
combinations used in palliative care. J Pain Palliat Care Pharm. 2009; 23(3): 223-230.
26. Pavis H, Wilcock A. Prescribing of drugs outside their licence in palliative care: survey of specialists in
the United Kingdom. BMJ 2001 September 1; 323(7311): 484-485.
27. Toscani F, Di Giulio P, Campi R, Pellerin I, De Luca A, Casale G. Off-label prescriptions in Italian
hospices: a national survey. J Pain Symptom Manage. 2009 September; 38(3): 365-371.
28. Atkinson CV, Kirkham SR. Unlicensed uses for medication in a palliative care unit. Palliat Med. 1999;
13: 145-152.
29. MacDonald N., Weijer C. Ethical issues in palliative care research.. In Doyle D, Hanks G, Cherny NI,
Calman K, editors. Oxford textbook of palliative medicine, 3rd ed. Oxford: Oxford University Press;
2005: p. 76-83.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 19 of 42
May 9, 2011
30. Fielding H, McArthur D. The contribution of the clinical pharmacist to palliative medicine. In Doyle
D, Hanks G, Cherny NI, Calman K, editors. Oxford textbook of palliative medicine, 3rd ed. Oxford:
Oxford University Press; 2005: 1079-1084.
31. Walker, Scott. Personal communication, April 5, 2006.
32. Twycross R, Wilcock A, Charlesworth S, Dickman A. Palliative care formulary, 2nd ed.
Oxon: Radcliffe Medical Press; 2002.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 20 of 42
May 9, 2011
APPENDIX LIST
Appendix I
Bibliography of Pharmaceutical References ----------------------------------------- 21
Appendix II
Calea Contact Information and Order Form ---------------------------------------- 25
Appendix III
Specifics for Home Care Nurses ------------------------------------------------ 27
Appendix IV
Quick Reference Sheet, CADD – Prizm® VIP --------------------------------------- 28
Appendix V
CSCI Caregiver Teaching Checklist --------------------------------------------------- 29
Appendix VI
Patient Information Sheet on CADD Pump ------------------------------------------ 31
Appendix VII Medication Record for CADD Pump for THPCU and Hospice Residence ---- 32
Appendix VIII CSCI CADD Care Plan and Guideline ------------------------------------------------ 34
Appendix IX
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
CADD Continuous Infusion and PCA Flow sheets and Guidelines for HCN --37
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 21 of 42
May 9, 2011
APPENDIX I
BIBLIOGRAPHY – Pharmaceutical References
Agar M, Webster R, Lacey J, Donovan B, Walker A. The use of subcutaneous omeprazole in the treatment
of dyspepsia in Palliative Care Patients. J Pain Symptom Manage 2004 Dec;6:529-531.
Bamigbade T, Langford R. The clinical use of tramadol hydrochloride. Pain Reviews 1998;5:155-182.
BIAM. Amikacine monograph Methods of administration [Online] [cited 2010 Oct 18] Available from:
http://www.biam2.org/www/Sub1609.html
Borker K, Lode H, Hampel B, Pfeuffer M, Koeppe P. Comparative pharmacokinetics of ceftriaxone after
subcutaneous and intravenous administration. Chemotherapy 1985;31 (4):237-45.
Caderio B, Leathem A. editors. Drug Information Reference 4th edition. Vancouver: B.C. Drug and Poison
Information Centre; 1996.
CommentGuerir.com Amikacine Merck 500 mg Mode of Administration. [Online] [cited 2010 Oct 18]
Available from: http://www.commentguerir.com/medicaments/amikacine-merck-500-mg.
Commission de la Transparence Republic of France. Amikacine modes of administration 10 July 2002.
Capital Health Regional Health Services. Palliative Care Medications commonly used Subcutaneously.
[Online] 2005 Feb 22 [cited 2010 Oct 4] Available from:
http://www.palliative.org/PC/ClinicalInfo/scchartFeb05.pdf
De Conno F, Saita L, Ripamonti C, Ventafridda V. Subcutaneous octreotide in the treatment of pain in
advanced cancer patients. J Pain Symptom Manage 1994; 9(1):34-8.
Delgado-Guay M, Currry E, Bruera E, Paraskevopoulus T, Munsel M, Elsayem A, et al. Cognitive
symptoms and delirium: subcutaneous olanzapine for hyperactive or mixed delirium in a comprehensive
cancer center; European Association of Palliative Care Abstracts of the 5th Research Forum of the European
Association for Palliative Care (EAPC) Trondheim, Norway, Scientific Committee Poster N°: 191 [Online]
2008 May 28-31 [cited 2010 Oct 21] Available from:
http://www.eapcnet.eu/LinkClick.aspx?fileticket=kKNT2aOl9pM%3d&tabid=618
Desmidt T. Subcutaneous infusion of esomeprazole in elderly patients in palliative care: a report of two
cases. J Am Geriatr Soc 2009 Sep;57(9):1724-5.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 22 of 42
May 9, 2011
Duncan A. The use of subcutaneous pamidronate J Pain Symptom Manage. 2003 Jul;26 (1):592-3.
Elsayem A, Bush S, Munsell M, Curry E, Calderon B, Paraskevopoulos T, Fadul N, Bruera E. Subcutaneous
olanzapine for hyperactive or mixed delirium in patients with advanced cancer: a preliminary study. J Pain
Symptom Manage 2010 Nov;40(5):774-82.
Flowers C, McLeod F. Diluent choice for subcutaneous infusions: a survey of the literature and Australian
practice. Int J Palliat Nurs 2001 Feb;11(2):54-60.
Fonzo-Christe C, Vukasovic C, Wasilewski-Raska A, Bonnabry P. Subcutaneous administration of drugs in
the elderly: survey of practice a systematic literature review. Palliative Medicine 2005;19:208-19.
Gagnon B, Bielech M, Watanabe S, Walker P, Hanson J, Bruera E. The use of intermittent subcutaneous
oxycodone for opioid rotation in patients with cancer pain. Supportive Care Cancer 1999;7:265-70.
Gilbar P. The role of octreotide in symptom management in oncology and palliative care. J Oncol Pharm
Practice 2000;6(3):81-91.
Goenada M, Millet M, Sanchez E, Garde C, Carrera J, Arzellus E. Subcutaneous furosemide. The Annals of
Pharmacotherapy 2004 Oct;38:1751.
Hospital Information Amikacin Winthrop Modes of administration [Online] [cited 2010 Oct 18] Accessed
from; http://www.informationhospitaliere.com/medicament_4-8888-amikacine-winthrop-500-m
HUG –Hospital of University of Geneva Department of rehabilitation and geriatrics HUG Pharmacy
Administration of medications and rehydration via subcutaneous route CAPP-INFO No 23 [Online] 2003
August [cited 2010 Oct 18] Available from: http://www.hcuge.ch/Pharmacie/infomedic/cappinfo.htm
Hum A, Fainsinger R, Subcutaneous methadone-an issue revisited. J Pain Symptom Manage 2007
Dec;34(6):5735.
Mathew P. Storey P. Subcutaneous methadone in terminally ill patients:manageable local toxicity. J Pain
Symptom Manage 1999 Jul;18(1):49-52.
McQuay H. The Logic of Alternative Routes. J Pain Symptom Manage 1990 Apr;5(2):75-7.
Mercandante S. Tolerability of continuous subcutaneous octreotide used in combination with other drugs. J
Palliative Care 1995 Jan;11(4):14-16.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 23 of 42
May 9, 2011
Moulin D, Kreeft J, Murray-Parsons N, Bouquillon A. Comparison of continuous subcutaneous and
intravenous hydromorphone infusions for management of cancer pain. The Lancet 1991 Feb:337:465-8.
Mulvenna P, Regnard C. Subcutaneous ondansetron. The Lancet 1992 Apr 25;339:1059.
Canadian Pharmacists Association Opioids monograph. Compendium of Pharmaceuticals and Specialties,
[online version (e-CPS)] 2009.
Canadian Pharmacists Association. Meperidine monograph. Compendium of Pharmaceuticals and
Specialties, [online version (e-CPS)] 2008.
Parsons H, Shukkoor A, Quan H, Delgado-Guay, M. Palmer J, Fainsinger R, Bruera E. Intermittent
subcutaneous opioids in the management of cancer pain. Journal of Palliative Medicine 2008;11(10):131924.
Personal communication Gail Saiger and Bruce Kennedy Proton-Pump Inhibitors by the Subcutaneous
Route Draft. August 11, 2008.
Personal Communication Eve Sample and Mike Harlos St Boniface General Hospital Subcutaneous
Medication Table. Pharmacy Dept. May 2008.
Personal communication between Eve Sample and Lawrence Jackson Pharmacist Sunnybrook Medical
Centre Sept 21, 2010.
Roemer-Becuwe C, Vigano A, Romano F, Neumann C, Hanson J, Quan H. Safety of subcutaneous
clodronate and efficacy in hypercalcemia of malignancy: A novel route of administration. J Pain Symptom
Manage 2003 Sep;26(3):843-8.
Sandoz Canada. Prescribing information Promethazine Hydrochloride. March 8, 2010.
Schneider J, Good P, Ravenscroft P. Effect of tubing on loss of clonazepam administered by continuous
subcutaneous infusion. J Pain Symptom Manage 2006 Jun;31(6):563-7.
Scotland National Health Service. Lothian Palliative Care Guidelines subcutaneous medication.[Online]
2009 [cited 2010 Oct 6] Available from: www.palliativecareguidelines.scot.nhs.uk
Vancouver Acute Parenteral Drug Therapy Manual - Subcutaneous Medication Compatibility Chart. 2010.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 24 of 42
May 9, 2011
Verma A, Da Silva J, Kuhl D. Diuretic effects of subcutaneous furosemide in human volunteers: a
randomized pilot study. Ann Pharmacother 2004;38:544-9.
Vielvoye-Kerkmeer P, van Mansom I. Re: subcutaneous methadone- An issue revisited. J Pain Symptom
Manage 2008 Jun;35(6):572.
Walker P, Neuhauser M, Tam V, Willey J, Palmer J, Bruera E, Prince R. Subcutaneous administration of
cefepime. J Pain Symptom Manage 2005 Aug;30(2):170-182.
Walker P, Watanabe S, Lawlor P, Bruera E. Subcutaneous clodronate. The Lancet 1996 Aug 3;348:345-6.
Walker P, Watanabe S, Lawlor P, Hanson J, Periera J, Bruera E. Subcutaneous clodronate: A study
evaluating efficacy in hypercalcemia of malignancy and local toxicity. Annals of Oncology 1997;8:915-6.
White C. Subcutaneous sufentanil for palliative care patients in a hospital setting. Palliative Medicine
2008;22:89-90.
www.palliativedrugs.comAgar M. Webster R. Lacey J. Donovan B. Walker A. The Use of Subcutaneous
Omeprazole in the Treatment of Dyspepsia in Palliative Care Patients JPSM 28 (6) 529-531 December 2004
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 25 of 42
May 9, 2011
APPENDIX II
B.C. PALLIATIVE CARE
BENEFITS SUPPLY ORDER FORM
Tel: 604-294-1500 ext: 6
Fax: 604-299-3940
FORMS MUST BE FAXED TO CALEA – VOICE MESSAGES WILL NOT BE ACCEPTED
HEALTH UNIT:
Abbotsford
Burnaby
Chilliwack
Delta
Langley
Maple Ridge
Mission
New West
Surrey (Gateway)
Surrey (Newton)
White Rock
Nurse ordering: _______________________
Please Print Name
Phone: ______________________________
Pager/cell:____________________________
Pt. Name: _____________________________
PHN: _______________________________
Address:______________________________
___________________________________
___________________________________
_______________________________
Special Instructions:_____________________
_______________________________
_______________________________
MRSA/VRE POSITIVE (please circle) YES NO
Qty
Code
PV447X
PV446X
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Tri-Cities
*Clients must be registered on BC
Palliative Benefits Program to be
eligible for supplies*
Description
EQUIPMENT & SUPPLIES CADD PUMP
Cassette 100ml
Cassette 50ml
Mini-Bag ___________CCs
CADD PRIZM 6100 PCA PUMP/KEY – weekly rental
Fraser Health
CDST# :
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electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
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AUTHORIZATION: Practice
Council, End of Life Care
Program
PV2170X
PV2171X
PV7009X
MN1604
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Date Released:
Page 26 of 42
May 9, 2011
CADD Fanny Pack (with rental) S M L
CADD Admin Set
Ext. Set male/male 30”
Ext. Set male/male 60”
Air Detector – not required for subcutaneous infusion, only used for
intrathecal or IV
9 Volt Battery
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 27 of 42
May 9, 2011
APPENDIX III
SPECIFICS FOR HOME CARE NURSING
In General:
1. Change battery daily, unless the physician order indicates to change it only when the pump
signals that the battery is low. Always ensure there is a spare battery in the home. Make sure
the patient or the caregiver know how to change the battery if necessary.
2. Review the screens each visit by pressing the Next key repeatedly.
3. Clear these screens each visit: Dose counters; Mg given; Total med given since last visit.
4. Analyze doses Given/Attempted. Liaise with MD if > 3 doses in 24 hr re: need for dose
adjustment.
5. Notify Calea of any changes to the Continuous Rate of Demand Doses.
6. Ensure extra SC supplies are in the home.
7. Have an extra SC site available; backup plan should include pre-filled syringes and/or oral
medication that could be given orally or by rectum, in the home.
8. If the extension tubing is not attached to a new cassette: connect the purple end of the
cassette tubing to the purple end of the extension tubing; prime the extension tubing; ensure
pump is returned to LL2 after priming all tubing.
9. Disposal of Unused portion of cassettes/ mini bags: Return to Calea, or to the pharmacy that
supplied the medication infusion.
10. For Clinicians only: Call 1-800-426-2448 (Calea) for assistance with the CADD-Prizm pump.
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 28 of 42
May 9, 2011
APPENDIX IV
Quick Reference Sheet, CADD – Prizm® VIP link
http://www.smiths-medical.com/Upload/products/product_relateddocs/infusion/CADD-PrizmVIP-6100-6101/40-3744-01(19813).pdf
APPENDIX V
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 29 of 42
May 9, 2011
Hospice Palliative Care
CSCI via CADD Pump Caregivers Teaching Checklist
Prior to discharge home of a patient with a CSCI via a CADD pump the patient/client must be assessed to
have a caregiver who is able to manage the infusion pump both mentally and physically.
Assessment:
Caregiver(s)






must be able and available 24/7 to monitor the infusion device.
must have the manual dexterity to operate a continuous infusion device.
must be able to learn how to trouble-shoot the infusion device and support basic functions to keep it running
(i.e. change battery, change medication infusion from one s/c site to another, assess s/c sites).
must have the visual acuity to see signs of cloudiness or change in colour of the medication solution.
must be able to act in the best interests of, and be in agreement with, the patient’s wishes in the administration
of the medications and breakthrough doses.
must be willing to participate in managing the CSCI via CADD
Patient


willingness to try CSCI via CADD infusion pump
must be assessed for risk of misusing the medications given via the pump, or of anyone in the home misusing
the medications
Skill
Changing Battery
Caregiver
Date
Taught by
Changing infusion from
one s/c site to another
s/c site assessment
(redness, leaking,
infusion not infusing)
Trouble-shooting Alarms
Trouble-shoot problems
with the pump and have a
back up plan
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 30 of 42
May 9, 2011
Assessment of
stability/compatibility of
mediations (fluid in
tubing remains clear and
colourless)
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 31 of 42
May 9, 2011
APPENDIX VI
CONTINUOUS SUBCUTANEOUS INFUSION WITH CADD-PRIZM (R) PUMP
PATIENT AND FAMILY CAREGIVER INFORMATION
Your doctor has recommended that you receive medications through a small needle placed on your upper chest,
upper arms, or upper part of the legs, and delivered by the CADD-Prizm (R) pump. The pump contains a
computer which is programmed to provide medications slowly and continuously. In some cases it can also be
programmed to allow you, the patient, to receive a booster dose when a special button is pressed. You, and/or a
family member or friend who has agreed to help manage the pump and care for you, will be taught what to look
for and how to give the booster dose if the doctor has ordered it.
The pump will come in a small soft case like a fanny pack, with a strap that makes it easy to carry around.
When you are in bed the pump in its case can lie beside you or go under the pillow. If you want to have a
shower, either wait till the needle needs to be re-positioned (it can be removed and the pump turned off briefly),
or put the pump in a plastic shopping bag and use a coat hanger to hang it on a hook or towel rack outside the
shower stall.
If the pump is dropped in water:
Take the pump out of the water quickly, dry it off with a towel, and call the nurse.
If the pump is hit or dropped on a hard surface:
Check that the pump is still running. If it has stopped – restart it by pressing and holding down the
STOP/START button until the three dashes --- --- --- disappear.
Look to see if the battery door is broken or damaged, or if the hard casing of the pump is cracked.
If you can’t get the pump to work or if you are worried about it, call the nurse.
You (or the person who is helping to manage the pump and care for you) will need to watch for the
following things:
 redness, soreness, or hardness around where the needle is placed;
 leaking of fluid from where the needle is placed, or from any of the connections in the tubing;
 that the fluid in the tubing is clear (like water), not cloudy;
 there are no crystals and no fine sediment in the fluid in the tubing.
If you have questions or are concerned or worried about anything to do with the pump,
the fluid, or the area around where the needle is placed, please call your nurse at:
_______________________________________
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 32 of 42
May 9, 2011
APPENDIX VII
Medication Record for CADD Pump for THPCU and Hospice Residence
KEY:
Tasks
OV = Order verification at start of each shift
CADD PUMP FLOW SHEET
CL = Clearing pump at end of shift
I
Medication(s):
= Infusion Initiation
DA = Dosage Adjustment
C = Casssette / IV Bag Charge q72h or
less**
**
**
g change q72h or
less**
T = Tubing change in q72 hours
B = Battery change
Type of Infusion:
SC
Please complete Patient Assessment Flow Sheet as
well
Patient Monitoring Flow Sheet for Lidocaine, Ketamine, Midazolam, and Intrathecal Infusions
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
IV
IT
** needs to be verified & signed by 2 RNs
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The electronic version of this document in the Clinical Policy Office is the current version - any print versions should be
checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
DATE
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
TIME
Fraser Health
Date Released:
Page 33 of 42
May 9, 2011
TASK
RESIDUAL
VOLUME ml
Concentration
Please check:
 mg/ml
 mcg/ml
Continuous
Rate
Demand Dose (amount)
Dose Lockout
(minutes)
DEMAND DOSES
attempted
given
Total
amount of
drug given
(cont. + DD)
Integrity of
Solution
LL
RN Signature
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The electronic version of this document in the Clinical Policy Office is the current version - any print versions should be
checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 34 of 42
May 9, 2011
APPENDIX VIII
Continuous SubCutaneous Infusion CADD CARE PLAN
Continuous Infusion +/- Patient Controlled Analgesia (PCA)
Patient Label
Description of Problem
(Write in Ink)
#1 Management of
Medication via subcutaneous
infusion
 S.C. Intima
 B.D. Saf-T-Intima
 Other type
_______________
Expected Outcome and
Assessment (Write in Ink)
SC medication will be administered
as prescribed
CSCI therapy will be effective as
symptom will be assessed regularly
and documented on CADD flow
sheet
SC site will remain patent and
intact as assessed regularly by
hospice staff/HCN/client/caregiver
Medication:
Name:_______________
Purpose:________________
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
Teaching if Pt at home:
Client/Caregiver will manage basic
trouble-shooting functions of CSCI
 Is able to monitor SC site for
Nursing Intervention
(Write in Pencil)
CADD PUMP
 Battery will be changed daily or __________
 Monitor and document on CADD Flow Sheet Q
shift/visit and with any changes to infusion.
 Tubing will be changed when the cassette is
changed, or Q 3 days if using a mini-bag
 SC Tubing and Mini-bag/Cassette changed Q ___
Days
SC SITE
 SC site changed prn/max 7 days.
# of sites _______(minimum of 2 sites if pt at home)
Location of Sites and date of insertion:
1.
2.
3.
4.
Worksheet
(Write in Pencil)
Due: ___________
Due: ___________
Due: ___________
Due: ___________
Due: ___________
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The electronic version of this document in the Clinical
Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Name:_______________
Purpose:________________
Name:_______________
Purpose:________________
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
Date Released:
Page 35 of 42
May 9, 2011
signs of infection or leaking
 Is able to change CADD pump
battery daily
 Is able to change infusion from
one S/C site to another
 Is able to change cassette (not
mandatory)
Pump Information:
Reserve Volume:__________
Concentration: ____________
Units (mcg or mg or ml): ____________
Rate of Infusion: ___________
Demand Dose: _____________
Demand Dose Lock out:______(min)
Number of demand doses allowed/hr_______
Lock level: ___________Code________
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The electronic version of this document in the Clinical
Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 36 of 42
May 9, 2011
APPENDIX VII
CONTINUOUS +/- PCA Care Plan
GUIDELINE
1.0 Purpose: to ensure patient/client’s receive appropriate, standardized care when they are receiving
medications from a Continuous Sub-Cutaneous Infusion (CSCI) via a CADD pump infusion device. This careplan also supports RNs working in Home Health, Hospice Residence and Tertiary Hospice Palliative Care units
to be able to documentation appropriately when caring for a patient/client with a CSCI. This guideline supports
the use of a Continuous Infusion +/- Patient Controlled Analgesia.
2.0 Definitions:
 Continuous Subcutaneous Infusion (CSCI): patient/client receives a continuous subcutaneous
infusion of one or more medications
 Patient Controlled Analgesia (PCA): patient/client receives self-administered bolus doses of
medications on demand, it is usually combined with a continuous infusion
 CADD infusion device: Computerized Automatic Drug Delivery device that delivers medications to
a patient/client continuously +/- bolus doses. See CADD pump Learning Module for more
information on the pump
3.0 Patient Population: all patients/clients who are receiving care through the end of life program (i.e. in a
hospice residence, or THPCU or at home), are register on the HPC program and who have a CSCI infused via a
CADD pump infusion device
4.0 Responsible Person: The RN providing care to the patient
5.0 Form Placement: In the section of the chart section where care plans are kept according to unit policy
6.0 Detailed Instructions:
 To be filled out at the initiation of CSCI via a CADD pump
 to be updated after any changes to the infusion parameters
 to be updated when the mini-bag/cassette, tubing or s/c site has been changed.
 If patient/client is not at home the Teaching section can be crossed out as the patient/client /family is
not responsible for this care when care is provided in a FH facility (hospice residence or THPCU)
7.0 Source: Created by Shelley Briggs
8.0 Revision/Review: Every 5 years by the HPC PAC
Created on 10/29/2010 9:39:00 AM
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
May 9, 2011
APPENDIX IX
CADD CONTINUOUS INFUSION
FLOW SHEET – PCA
Assmt
Category
Number
PROBLEM NAME
AND PARAMETERS
#1
Medication:
Subcutaneous Tx via
CADD PCA
pump
INFUSION MED(s). SEE
DOCTOR’S ORDER FOR
DOSE
Page 37 of 42
Client Label
Date
Time
#1 – RESERVOIR VOLUME
#2 – CONCENTRATION
MCG or MG/ML
If multiple medication infusing do
not use this box
#3 – RATE OF INFUSION
MCG/HR or MG/HR or
ML/HR
(circle one)
#4 - TOTAL MG. GIVEN
CLEARED? Y
N
#5 - LOCK LEVEL
#6 – CASSETTE/MINI-BAG
CHANGED
Y N
# 7 BATTERY CHANGED
(DAILY) Y N
#8 – CASSETTE/MINI-BAG
AND TUBING CHANGED
Y
N
# 9 – INTEGRITY OF
SOLUTION
CLEAR/NOT CLOUDY
COLORLESS
NO PRECIPITATE
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 38 of 42
May 9, 2011
PROBLEMS/COMMENTS
SIGNATURE
Created on February 15, 2011
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 39 of 42
May 9, 2011
APPENDIX IX
CADD CONTINUOUS INFUSION FLOW SHEET
Assmt
Category
Number
PROBLEM NAME
AND PARAMETERS
#1
Medication:
Subcutaneous Tx via
CADD PCA
pump
INFUSION MED(s). SEE
DOCTOR’S ORDER FOR
DOSE
Date
Time
#1 – RESERVOIR VOLUME
#2 – CONCENTRATION
MCG or MG/ML
If multiple medication infusing
do not use this box
#3 – RATE OF INFUSION
MCG/HR or MG/HR or
ML/HR
(circle one)
#4 - TOTAL MG. GIVEN
CLEARED? Y
N
#5 - LOCK LEVEL
#6 - CASSETTE CHANGE
Y N
# 7 BATTERY CHANGED
(DAILY)? Y N
#8 – CASSETTE AND
TUBING CHANGED
Y
N
# 9 - MEDICATION CLEAR
IN CASSETTE/
TUBING
PROBLEMS/COMMENTS
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 40 of 42
May 9, 2011
SIGNATURE
rev 11/17/2011
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program
Date Released:
Page 41 of 42
May 9, 2011
APPENDIX IX
CADD CONTINUOUS AND PCA FLOW SHEET
GUIDELINES
1.0 Purpose: to ensure patient/client’s receive appropriate, standardized care when they are receiving
medications from a Continuous Sub-Cutaneous Infusion (CSCI) via a CADD pump infusion device. These flow
sheets are to support RNs with appropriate documentation when caring for a patient/client with a CSCI via
CADD infusion device. These guidelines support the use of both the Continuous Infusion Flow sheet and the
Patient Controlled Analgesia Flow sheet
2.0 Definitions:
 Continuous Infusion: patient receives a continuous subcutaneous infusion of medications
 Patient Controlled Analgesia: patient receives a self-administered bolus dose of medications on
demand
 CADD infusion device: Computerized Automatic Drug Delivery device that delivers medications to
a patient/client continuously +/- bolus doses. See CADD pump Learning Module for more
information on the pump
3.0 Patient Population: all patients/clients who are receiving care through the end of life program (i.e. in a
hospice residence, or THPCU or at home), are register on the HPC program and who have a CSCI infused via a
CADD pump infusion device
4.0 Responsible Person: The RN providing care to the patient/client
5.0 Form Placement: In the section of the chart section where daily documentation is kept according to unit
policy
6.0 Detailed Instructions:
 To be filled out by RN at the initiation of CSCI via a CADD pump
 To be filled out once per shift or at each HCN visit, and after any cassette/mini-bag change, or
changes to the infusion parameters
 Under # 2 if there are multiple medications being infused cross out this row
 on initiation of CSCI under # 3 circle the current unit being used by this patient/client (i.e. either ml,
mg, mcg)
 For the PCA flow sheet # 7 + # 8 write in the number of demand doses given or attempted
according to CADD devise. Then write Y if you have cleared the number of demand doses given or
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011
CLINICAL PROTOCOL: Management of Continuous Subcutaneous Infusions
(CSCI) in Adult Hospice Palliative Care Patients
AUTHORIZATION: Practice
Council, End of Life Care
Program




Date Released:
Page 42 of 42
May 9, 2011
attempted, or N if you have not cleared the demand doses given or attempted. The demand doses
should be cleared every 24 hours at least.
# 9 write in the total mgs given according to the CADD pump devise. Write in Y if you clear this
number or N if you have not cleared it. You should only clear the total mgs given when you are
replacing the cassette/mini-bag.
# 11 & # 12 write Y if you have changed the battery, cassette/mini-bag or tubing and then indicate
the date of the next change on the care plan.
# 13 if the medication is not clear and colourless in the tubing or cassette/mini-bag write N and then
what colour it is or indicate it is cloudy. If it is not clear you must stop the infusion and contact the
physicians and pharmacist.
For the Continuous Infusion Flowsheet without PCA there are three blank rows which may be
used to monitor patient specific criteria at the determination of the RN or MD.
7.0 Source: Created by Shelley Briggs on February 21, 2011
8.0 Revision/Review: Every 5 years by the EOLC PC
Author(s): Shelley
Briggs, CNS
Dr. Lynne Potter
Eve Sample,
Clinical Pharmacist
Lucille Taylor, CNS
Fraser Health
CDST# :
NOTE: This is a controlled document for Fraser Health (FH) internal use only. FH accepts no responsibility for use outside of this health authority. The
electronic version of this document in the Clinical Policy Office is the current version - any print versions should be checked against the electronic copy.
May 9 2011