Download Syringe_driver_policy_for_PHT_End_of_Life_Care

Continuous Subcutaneous Infusion using the McKinley T34 Syringe Driver
(Palliative/End of Life Setting)
Version
1 (Replace: Continuous Subcutaneous Infusion by
Syringe Driver. Pan Trust)
Name of responsible (ratifying)
committee
Formulary and Medicines Committee
Date ratified
19th September 2014
Document Manager (job title)
PHT Pain Group (Rosy Barnes, Cherilyn MacNee,
Jane Marshall, Ian Cairns, Fiona Wilson)
Date issued
1st October 2014
Review date
30th September 2016
Electronic location
Clinical Policy
Related Procedural Documents
PHT Medical Devices Policy
PHT Medicines Policy
PHT Injectable Medicines Policy.
PHT Drug therapy Guideline: Palliative Care in
Adults-Medicines for use in Syringe Drivers
PHT Controlled Drugs Policy
PHT Pain Management Guideline
Key Words (to aid with searching)
Syringe driver, McKinley T34, Palliative Care, End of
Life
Version Tracking
Version
Date Ratified
1
19/09/2014
Brief Summary of Changes
New Guideline
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
Author
CONTENTS
1. Introduction
2. Purpose
3. Scope
4. Definitions
5. Duties and Responsibilities
6. Process
7. Training
8. References and Supporting Documentation
9. Equality Impact Statement
10. Monitoring Compliance with Procedural Documents
APPENDICES
1. The Perfect Prescription
2. McKinley T34 Instructions
3. Syringe Driver record Sheet.
4. T34 Trouble shooting
5. Pump Discharge Letter
6. McKinley T34 Competency
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
QUICK REFERENCE GUIDE
This policy must be followed in full to ensure that best practice is adhered to in the management
of all patients with subcutaneous in fusion devices.
For quick reference the guide below is a summary of actions required. This does not negate the
need for the document author and others involved in the process to be aware of and follow the
detail of this policy.
1. The Palliative Care Team and/or The End of Life Team should be involved in the
decision to commence a patient on a syringe driver for pain and symptom management
of their palliative condition.
2. Sensitive explanation and inclusion of patient and carers in decision making are
essential prior to initiation of a subcutaneous syringe driver.
3. All staff must ensure that the prescription is legible and correctly prescribed prior to
administration.
4. All staff should ensure that they are competent to set up and commence a subcutaneous
infusion using the T34 McKinley Pump.
5. The syringe driver should be checked one hour after set-up and on each drug round
over a 24 hour period and the check documented on the syringe driver check sheet. In
carrying out a check the following should be reviewed and acted upon if necessary:
6. Within the hospital the settings of the syringe driver should be recorded and a second
signatory obtained on set up and after a syringe change.
7. For patients that transfer to another setting, it is considered best practice that the
infusion remains continuous and that a McKinley T34 pump is transferred with the
patient.
8. Ensure that all processes are put in place to guarantee the timely return of the McKinley
T34 pump from the community to PHT
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish.
They are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its
vision to be the best hospital, providing the best care by the best people and ensure that
our patients are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’
of our Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
1. INTRODUCTION
The aim of this policy is to provide a framework for the management of continuous
subcutaneous infusions with syringe drivers, minimizing hazards and ensuring that everyone
who needs to is able to use them effectively and safely. This policy is only intended to be used
for patients who are in need of symptom and pain management in the palliative/end of life
setting who need a subcutaneous pump.
This policy supports justification of need, clinical use, staff training and equipment
management and should be read in conjunction with local Trust policies on
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Medical Devices Management.
Infection Control.
Medicines Management.
Pain Management Guideline
Palliative care in adults – medications used in subcutaneous syringe drivers.
Controlled Drug Policy
2. PURPOSE
A syringe driver is a portable battery-operated infusion device. In the palliative care setting, it is
used to deliver drugs for pain and symptom management at a predetermined rate
subcutaneously. The syringe driver should be used for patients who are unable to tolerate oral
medication for whatever reason, for example, in nausea and vomiting, dysphagia, intestinal
obstruction, and oral disease. In addition, patients who are weak, agitated or unconscious may
benefit from subcutaneous infusions.
3. SCOPE
This policy applies to all staff involved in the direct care of patients. All staff responsible for
prescribing, issuing and administering/monitoring the infusion must have current appropriate
registration and competency.
Relevant NMC documents
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The Code-Standards of Conduct, Performance and Ethics (May 2008)
Record Keeping: Guidance for Nurses and Midwives (July 2009)
Standards for Medicines Management (April 2010)
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust
recognises that it may not be possible to adhere to all aspects of this document. In
such circumstances, staff should take advice from their manager and all possible
action must be taken to maintain on-going patient and staff safety’
4. DEFINITIONS

Palliative Care - care given to ease symptoms and suffering in an individual with an
incurable condition which it is believed will significantly shorten their life.

End of Life - relates to care of an individual within the last few days, weeks or months of
their life.
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016

Syringe Driver – is a small portable battery powered pump which administers drugs
subcutaneously by continuous infusion. An infusion system may be defined by Policy
for the Management of Infusions with Pumps.
5. DUTIES AND RESPONSIBILITIES
Elements of the process may be delegated to a suitably trained and qualified professional but
the ultimate responsibility for the quality of medical care lies with the Consultant responsible for
the patients.
The nominated clinicians should liaise to discuss common issues such as: assessment, training,
drug regimens, monitoring required, discharge criteria, monitoring of standards and
complications as well as operational implications.
The Trust will ensure provision of appropriate training opportunities with regards to equipment
and drug management training to all professionals involved.
The author of the policy has responsibility and authority to audit compliance with the Policy
among all departments.
6. PROCESS
Subcutaneous drug infusions using a syringe driver are commonly used in palliative and end of
life care. Drugs administered by subcutaneous infusion include opioid analgesics, antiemetics,
anxiolytics and anticholinergic drugs.
(Dickman et al, 2011).Many of these are used ‘off licence’, a common and acceptable practice
in palliative care.
The prescription of the drug/drugs to be infused should be written on the regular section of the
drug chart (Appendix 1), clearly documented with the route reading ‘CSCI’ (Continuous
Subcutaneous Infusion).’24 hours via syringe driver’ should be clearly written in the special
instructions box.
The McKinley T34 syringe driver at Queen Alexandra Hospital will deliver the medication over
24 hours and can be used with most brands of plastic syringe. Currently we use BD Plastipak
syringes with Luer-lock, to avoid leakage or accidental disconnection.
Indications for use
To prevent the need for regular injections when medication cannot be swallowed or absorbed
and to provide effective symptom control e.g.
 Persistent nausea and vomiting
 Impaired consciousness
 Patients preference
 Oral medication not tolerated
 Mal-absorption
 Dysphagia
For further advice on which medication to use for each indication, doses, diluents and
combinations of drugs please refer to the drug therapy guideline- Palliative Care In Adults:
Medications Used in Subcutaneous Syringe Drivers
http://pht/Departments/Pharmacy/Drug%20Therapy%20guidelines/Palliative%20care%20in%20
adults%20-%20Medications%20used%20in%20subcutaneous%20syringe%20drivers.doc
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
and the Palliative care handbook 7th edition 2010 ,
http://pht/Departments/Pharmacy/Drug%20Therapy%20guidelines/Palliative%20care%20in%2
0adults%20-%20Medications%20used%20in%20subcutaneous%20syringe%20drivers.doc
found on the hospital Intranet.
Communicating with patients and carers
Prior to commencing a syringe driver a full explanation about what a syringe driver is, how it
works and why its use is indicated should be discussed with the patients and his/her carers and
informed consent gained. This should be recorded in line with hospital policy. In the event of the
patient who is unable to give consent the nurse will act in their best interests. This should be
carried out in conjunction with the Medical practitioner and in line with the Mental Capacity Act
(2007).Details should be recorded in the medical notes.
Standard Operating procedure for use of McKinley T34 Syringe driver pump.
(Appendix 2)
The McKinley T34 is calibrated in ml/hr. All T34pumps are set up to deliver the syringe contents
by continuous subcutaneous infusion over a 24 hr period only. Within the hospital the settings of
the syringe driver should be recorded, a second signatory obtained and the yellow additive label
signed by both practitioners. This should be another registered nurse who has completed the
medicine management competency. It is good practice that the second signatory witnesses the
whole administration process.
This is a clean procedure:1. Discuss and explain the procedure to the patient, check identification and obtain
consent.
2. Assist patient into comfortable position
3. Check the syringe driver is in working order, serviced within the last year.
4. Consider giving prescribed stat doses prior to setting up the driver. Wash your hands
in accordance with hospital policy
5. Equipment required :
o Syringe driver
o Battery (PP3 size,9 V alkaline)
o Cannula/giving set ( Microflex 25 gauge butterfly with line or BD Saf-TIntima™ needleless system)
o Luer-lock syringe of suitable size ( 20ml is the minimum size recommended
(Dickman 2011)
o Transparent adhesive dressing
o Drugs and diluents
o Needle to draw up drug
o Drug additive label
o Patient’s prescription
o Syringe driver record sheet ( Appendix 3 )
The T34 syringe driver can use different brands and sizes of syringe. At QAH we use 20ml and
30ml Plastipak syringes, making up the volume with the diluent. Diluting the volume reduces risk
of both adverse site reaction and incompatibility (Dickman, 2011). See table below for
suggested fill volumes.
Size of Plastipak
syringe
20ml
30ml
Max fill volume
advised at QAH
17ml
23ml
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
Regardless of the size of syringe the same procedure should be followed:
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Calculate the volume of the drug that needs to be drawn up
Choose the appropriate size of syringe and check that it will fit the pump.
Draw up the required solution, including diluent, in the syringe - refer to the above table
for volume limits.
Prime the line. Ensure there is no air in the syringe/line.
Observe for cloudiness or precipitation. Discard of this occurs and seek advice.
Complete the additive label and attach to syringe. The label should state the patient’s
full name, date, time, drug(s), dose(s) and signatures.
NB If priming, the initial infusion will finish before 24 hours.
Preparing the McKinley T34 Syringe Driver
Sites for Infusion
When siting the infusion consider:
 Skincare needs and access
 Patients preference
 Mobility
 Suggested sites – upper arm, upper chest, thigh for very cachexic patients, scapula
for very restless/agitated patients.
Areas to avoid include:
 Radiotherapy sites
 Tumour sites
 Bony prominences
 Broken, irradiated or oedematous skin
 Lymphoedematous limbs including abdomen with ascites.
1. Insert butterfly needle at 45 degrees.
2. Secure with transparent dressing. Ensure the syringe driver is not
placed greater than 75cms above the infusion site to avoid the risk of
syphonage.
3. Ensure the syringe driver is functioning in accordance with the
manufacturer’s instructions.
4. Complete all documentation as per this policy.
Renewing/replenishing the syringe driver (when the extension line is already primed)
1. Draw up medication for the syringe driver using the correct size syringe that
accommodates the volumes required.
2. Complete the additive label attach to syringe.
3. Ensure the pump has been stopped by pressing the on/off button. Restart the pump
by pressing the on/off button. Ensure the pump has reset for 24hrs – not reading
‘Resume Programme’.
4. Dispose of residual drug according to Controlled Drug Policy.
Monitoring of Infusions
The syringe driver should be checked one hour after set-up and on each drug round over a 24
hr period and the check documented on the syringe driver record sheet. In carrying out a check
the following should be reviewed and acted upon if necessary:
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
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Condition of site. Check insertion site for signs of redness, leakage, hardness, swelling,
pain and blood in the line. Sites can be left intact if satisfactory
Check Volume to be infused (VTBI) - (press blue info button x1)
Infusion rate in ml/hr
Position of needle
Battery Power remaining -(press blue info button x2)
The LED light flashing indicates that the pump is running.
Please change syringe driver record chart with each change of infusion.
To stop the infusion temporarily – in case of re-siting infusion/ occlusion alarm.
Ensure stop button is pressed to use the resume programme. Do Not press Off/On as this will
restart the programme over 24 hours. The alarm will sound if the pump has been paused for 2
minutes. Confirm yes to restart pump or No to pause for a further 2 minutes.
Removal and disposal of the infusion set and syringe driver.
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The infusion set should be removed by a registered nurse.
If there is any medication remaining in the syringe, this should be disposed of as per
destruction guidelines within the PHT Controlled drugs and Medicines Management
policy.
The needle site should be covered by a dry dressing if required.
When the syringe driver is no longer required it should be wiped over with a
detergent wipe and returned to the Medical Equipment Library (MEL).
Alarms – (Appendix 4)
The pump will alarm
 At the completion of the infusion – the message shown will vary depending on
software version.
 If the syringe is displaced.
 If there is an occlusion
 When the pump has been paused for more than 2 minutes.
 When the battery is low
Transfer of patients to the community
For patients that transfer to another setting, it is considered best practice that the infusion
remains continuous and that a McKinley pump is transferred with the patient.
Ideally a pump should be brought in from the community and exchanged before transfer.
However if it is necessary for a PHT pump to leave the hospital the following process should be
followed:
1. Record the following details in the MEL log book – Patients name, Ward, Patient
destination, date.
2. Collect the return envelope and advice sheet from the MEL and send with patient
to ensure return of pump to QAH.
3. Inform either the Specialist Palliative Care Team Ext 6132 or MOPRS EOL Team
Ext 5889/Blp 1384
4. Inform patient’s next of kin/community nurse/nursing home manger re importance
of prompt return.
Reporting of adverse incidents involving McKinley T34 Syringe driver
All adverse incidents or near misses should be reported via Datix and managed as per the
hospital adverse event reporting policy.
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
7.
TRAINING
Queen Alexandra Hospital is responsible for ensuring that training is available for all staff using
medical devices (Managing Medical Devices 2014).
All registered nurses are personally responsible and accountable to ensure they receive training
in the safe use and observation of any medical devices they need to use (MMD 2014)
Only qualified registered nurses will be involved in the setting up and replenishing of a syringe
driver. They must have completed formal training and been assessed as competent in
medicines management the use of syringe drivers. (See Competency check sheet - Appendix 6)
They will work in accordance to local policies and the NMC Code (2009)
8.
REFERENCES AND ASSOCIATED DOCUMENTATION
CME McKinley T34 Ambulatory Syringe Pump Operational Manual: CME McKinley (2007)
The Syringe Driver: Subcutaneous infusions in palliative care: Dickman, A.Scneider, J.and
Varga, J (2011) 2nd ed. Oxford University Press.
The Code – Standards of Conduct, Performance and Ethics: NMC (2008).
Standards for Medicines Management NMC (2010).
The Mental Capacity Act: DOH92007).
PHT
Medical
Devices
Policy:
http://www.porthosp.nhs.uk/Downloads/Policies-AndGuidelines/Management-Policies/Medical_Devices_Management_Policy.doc
MRHA-Devices in practice, a guide for professionals in health and social care: (2008)
http://www.mhra.gov.uk/home/groups/dts-bs/documents/publication/con007424.pdf
Palliative Care Handbook. 7th Edition October 2010
http://pht/Departments/specpalliativecareteam/Useful%20Documents/PC%20Handbook%207th
%20Edition%20Oct%202010%20published.pdf
Palliative Care in Adults: Medications used in Subcutaneous Syringe Drivers. PHT Drug
Therapy Guideline. 2013
http://pht/Departments/Pharmacy/Drug%20Therapy%20guidelines/Palliative%20care%20in%20
adults%20-%20Medications%20used%20in%20subcutaneous%20syringe%20drivers.doc
Record Keeping: Guidance for nurses and midwives: NMC (2009)
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
9.
EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects their
individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly.
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum requirement
to be monitored
Lead
% of patients having a
syringe driver checklist
kept with the drug chart.
PHT Pain Group
Review of Datix incidents
completed
involving
syringe
drivers
for
palliative care patients.
% of syringe drivers
which are being returned
to the Trust.
Tool
Frequency of
Report of
Compliance
Reportin
g
arrangem
ents
Lead(s) for
acting on
Recommenda
tions
Annual audit
Annual
Policy audit
report to:
PHT End
Life Group
PHT Pain Group/
Medication
Safety
Pharmacist
Search
of
Medication Datix
incidents
for
review
Annual
Formulary
and
Medicines
Group.
PHT
Group
PHT End of LIfe
Group.
Audit review of
syringe drivers
Annual
of
Pain
Dr.Ian Cairns
The effectiveness in practice of all procedural documents should be routinely monitored (audited)
to ensure the document objectives are being achieved. The process for how the monitoring will be
performed should be included in the procedural document, using the template above.
The details of the monitoring to be considered include:
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The aspects of the procedural document to be monitored: identify standards or key performance
indicators (KPIs);
The lead for ensuring the audit is undertaken
The tool to be used for monitoring e.g. spot checks, observation audit, data collection;
Frequency of the monitoring e.g. quarterly, annually;
The reporting arrangements i.e. the committee or group who will be responsible for receiving the
results and taking action as required. In most circumstances this will be the committee which
ratified the document. The template for the policy audit report can be found on the Trust Intranet
Trust Intranet -> Policies -> Policy Documentation
The lead(s) for acting on any recommendations necessary
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
APPENDIX 1
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
APPENDIX 2
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
APPENDIX 3:
Syringe Driver Record Chart
Medication and Dosage:
Date and Time:
Place Patient Label Here
Total Volume ml:
Rate ml/hour
Ward:
Setup signature 1.
Pump serial/asset number
Setup signature 2.
Patient name
.................................................................
Hospital No.
.................................................................
DOB.
.................................................................
PLEASE CHANGE SYRINGE DRIVER RECORD CHART WITH EACH CHANGE OF INFUSION
Time
Position of needle
Condition of Infusion Site
Rate
Light flashing Yes / No
Amount Remaining (ml) VTBI
Syringe Secure Yes / No
Connections Secure Yes / No
Is fluid clear Yes / No
Battery Power
Signature of checking Nurse
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
APPENDIX 4
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
APPENDIX 5
Transfer of patients to another setting.
IMPORTANT INFORMATION
McKinley T34 Syringe pump
District Nurse Instructions
Your patient has been discharged from Portsmouth Hospital with a McKinley T34 syringe
pump .At the first syringe change please swap over to a community owned T34 pump
and immediately return the Portsmouth Hospital Pump as detailed below.
•
To unlock keypad, press and HOLD the blue INFO button until alarm sounds.
Press red STOP button and then press and hold the ON/OFF button until device turns off.
•
Lift the clamp up as far as will go and turn 180° remove the syringe and replace
the clamp.
•
Disconnect from patient, remove syringe and dispose of any remaining drugs
according to the community’s local policy.
•
Please clean the pump with supplied wipe
•
Place T34 pump inside supplied Pre-paid jiffy bag
•
Seal
•
Send back via post
•
Please return promptly, these pumps are tracked
Any problems please contact the discharging Ward,
The End of Life Team on 02392286000 bleep 1384, Palliative Care Team Ext: 6132 or
mobile: 07818078876or the Medical Equipment Library on 02392 286977
Syringe driver policy for PHT End of Life Care Issue 1 01/10/2014 Review date 30/09/2016
Medical Device Training
Medical Physics, F Level, QAH
Tel: (7700) x3786
[email protected]
k
Medical Device Training
1. Competency Statement – McKinley T34 Ambulatory Syringe Driver
APPENDIX 6
DO NOT USE THIS DEVICE UNLESS YOU ARE COMPETENT TO DO SO
Name:
Ward/Dept:
Job Title:
Manager:
Date:
Hospital:
Tel & Ext:
Military:  Student:  Non PHT Staff:  (Please tick)
1.1. Self – verification of competence is undertaken by assessment against the following statements:
These statements are designed to help you assess your competency to use this device. Responsibility for safe use remains with you, so if
you are in any doubt regarding your competence to use the device, you should seek guidance.
These questions are designed to help you carry out a self-assessment of your competency. You must be able to answer yes to all the
questions if applicable to you before considering yourself to be competent and then complete section B overleaf. If you are in any doubt
or feel that you are not competent, please complete section A and contact the Medical Device Training Team with dates that you are
available for further training.
Questions to ask yourself:
Are you safe using this device? Can you:
1. State the infusion routes suitable for this pump?
2. Explain the function of the 3 point syringe detection system?
3. State which size syringes can be used and how the brands are identified?
4. Commence an infusion with a new a syringe and explain the importance of choosing new
programme?
5. Explain what information us shown on the working screen?
6. Explain the keypad functions?
7. Lock the keypad?
8. Stop and resume an infusion explaining when this function should be used?
9. Explain the alarm types?
10. Locate and replace the battery? Check the battery life?
11. State the cleaning and maintenance procedures for this device?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Please Turn Over
Medical Device Training
Medical Physics, F Level, QAH
Tel: (7700) x3786
[email protected]
k
Medical Device Training
1. Competency Statement – McKinley T34 Ambulatory Syringe Driver
APPENDIX 6
Complete either section A or B whichever is appropriate to you
Section A
I require further training before I can use this device in a competent manner
Signed:
Print Name:
Date:
Please return this form and contact the Medical Device Training Team within 1 month to arrange this training. Alternatively please provide
dates on return of this form that you are available for additional training.
Section B
Statement: I certify that I am aware of my responsibility for continuing professional development and I understand that I am accountable for my
actions. With this in mind I make the following statement:
I am competent to use this device without further training
Signed:
Print Name:
Date:
On receipt of this the Medical Device Training Team will note that you have made this declaration and issue a competency certificate for a 2
year period.
Please return this form to the Medical Device Training Team, Medical Physics, F Level, QAH. Many thanks