This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form.

Part A – Information about this Document

Policy Name Syringe Driver Policy

Policy Type Board Approved (Trust-wide) ☐ Trust-wide ☐ Divisional / Team / Locality ☐

Action No Change ☐ Minor

Change ☐ Major Change ☐ New

Policy ☒ No Longer Needed ☐

Approval

As Mersey Care’s Executive Director / Lead for this document, I confirm that this document: a) complies with the latest statutory / regulatory requirements, b) complies with the latest national guidance, c) has been updated to reflect the requirements of clinicians and officers, and d) has been updated to reflect any local contractual requirements

Signature: Date:

Part B – Changes in Terminology (used with ‘Minor Change’, ‘Major Changes’ & ‘New Policy’ only)

Terminology used in this Document New terminology when reading this Document

Part C – Additional Information Added (to be used with ‘Major Changes’ only)

Section /

Paragraph No Outline of the information that has been added to this document – especially where it may

change what staff need to do

Part D – Rationale (to be used with ‘New Policy’ & ‘Policy No Longer Required’ only)

Please explain why this new document needs to be adopted or why this document is no longer required

Part E – Oversight Arrangements (to be used with ‘New Policy’ only)

Accountable Director

Recommending Committee

Approving Committee

Next Review Date

LCH Policy Alignment Process – Form 1

SUPPORTING STATEMENTS

This document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS

All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including:

• being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child / adult;

• knowing how to deal with a disclosure or allegation of child / adult abuse;

• undertaking training as appropriate for their role and keeping themselves updated;

• being aware of and following the local policies and procedures they need to follow if they have a child / adult concern;

• ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust’s safeguarding team;

• participating in multi-agency working to safeguard the child or adult (if appropriate to your role);

• ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

• ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTS

Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy

Clinical Policy and Procedure for the Subcutaneous Administration of Drugs via a Syringe Driver

Policy Reference Number: 84

Title Clinical Policy and Procedure for the Subcutaneous Administration of Drugs via a Syringe Driver

Guideline reference number: 84

Aim and purpose of clinical document:

To provide guidance on the subcutaneous administration of drugs via a syringe driver by clinical staff within Mersey Care NHS Foundation Trust

Author: Specialist Palliative Care Team

Type: New Document Reviewed Document

X Review Date: 31 June 2020

Person / Group accountable for review:

End of life group

Type of Evidence base used: C. Evidence which includes published and/or unpublished studies and expert opinion (limited scientific evidence)

Issue Date: 26 June 2018

Authorised by Clinical Standards Group:

June 2018

Impact Assessment undertaken:

Yes X Evidence Collated

No

Version Number: 7

Ratified by:

Clinical Standards Group

Date of Approval:

26/06/18

Name of originator/author:

Specialist Palliative Care Team Leaders Victoria Ali and Suzanne Doolan. EOL Group

s Approving Body / Committee:

Clinical Standards Group

Date Issued:

June 2018

Review Date:

June 2020

Target Audience:

Organisation wide

Accountable Executive:

Medical Director

Changes to previous version

Section 6 - Added in that two nurse checks should be present when syringe driver is being commenced.

Section 7 Brand of Battery added in as per MHRA alert 2018

Section 7 Authorisation sheet now requiring review every 28 days rather than valid. Changes to the drug authorisation form should be completed on a new form and the previous form crossed through and filed.

Section 7 Faxed forms are valid for 48 hours (excluding weekends and bank holiday) increased from 24 hours including weekend and bank holidays

Section 8 Updated to reflect new training package and frequency of training

Contents

1. Introduction ............................................................................................................................ 6 2. Purpose ................................................................................................................................. 6 3. Scope .................................................................................................................................... 6 4. Definitions .............................................................................................................................. 6 5. Duties and Responsibilities ..................................................................................................... 7 6. Process and Documentation ................................................................................................... 7 7. Setting up of a Syringe Driver ................................................................................................. 9 Equipment Required .................................................................................................................. 9 Preparation required for the Administration of Subcutaneous drugs via a syringe driver ... 10 Nursing Procedure ................................................................................................................... 11

Documentation ........................................................................................................................ 13 Instruction for the return of McKinley Syringe Drivers to Acute Trusts and Hospices and

Community. ..................................................................................................................................... 14

Taking down/discontinuing a syringe driver ..............................................................................14

8. Training ................................................................................................................................ 14 9. Implementation, Monitoring and Review ............................................................................... 15 Impact Assessment ................................................................................................................. 15 Linked areas/information .......................................................................................................... 15

10. References ....................................................................................................................... 17 11. Appendices ...................................................................................................................... 16

Appendix 1 Syringe Driver Checklist .................................................................. 19 Appendix 2 Drug Authorisation Sheet ................................................................ 20 Appendix 3 Setting up of Syringe Driver Notification ........................................... 22 Appendix 4 Risk Assessment Pathway for Controlled Drugs in Patient Homes . 23 Appendix 5 Competency framework …………………….24

1.0 Introduction

This policy is designed to support the administration of subcutaneous drugs, using a syringe driver by Registered Nurses working in the community setting. The procedure is designed to ensure that all Registered Nurses working for, or on behalf of the Trust, provide the optimal level of care to this patient group. Syringe drivers are used for the continuous delivery of drugs into the subcutaneous tissue of patients for whom oral administration would be difficult or problematic. The practice of using syringe drivers in the care of patients with terminal illnesses and/or with palliative care need is well established in the hospital, hospice and community settings. The effective use of syringe drivers can enhance the patient’s quality of life and allow them to remain in their own homes with their symptoms well controlled.

2.0 Purpose

This clinical policy and procedure aims to provide for the patient, a standard level of care and competence from Registered Nursing staff, when they require the administration of drugs sub-cutaneously using a syringe driver.

3.0 Scope

This clinical policy and procedure applies to all Mersey Care NHS Foundation Trust employed Registered Nursing Staff. As such these guidelines must be used in conjunction with Code: professional standards of practice and behaviour for Nurses and Midwives of Professional Conduct (NMC 2015).

Nursing staff within Mersey Care NHS Foundation Trust devised this clinical policy and procedure to fulfil the requirements of patients receiving medication subcutaneously via a syringe driver, in the community setting. Mersey Care NHS Foundation Trust is committed to ensuring that all staff are trained and equipped to perform their role effectively and a competency framework is included within the policy and procedure.

4.0 Definitions Definitions of specialist terms/ abbreviations used in the document are

4.1 Subcutaneous – below the surface of the skin

4.2 Syringe Driver - a small infusion pump, used to administer infusion fluid containing medication, sometimes in combination, to a patient usually over a 24 hour period.

5.0 Duties and Responsibilities

The following (general) statutory duties apply All Mersey Care NHS Foundation Trust staff are responsible for co-operating with the development and implementation of Mersey Care NHS Foundation Trust policies as part of their normal duties and responsibilities. All other personnel will be expected to comply with the requirements of all relevant Mersey Care NHS Foundation Trust policies applicable to their area of operation.

All incidents including near misses should be reported using the Datix system and in line with the Being Open Policy.

6.1 Process and Documentation

A R egi s t e r ed Nurse can undertake the setting up, reloading and or re-siting of a syringe driver on his/her own, provided that they have achieved the appropriate competencies and have been supported in practice for 6 months after commencing in the role. However where possible within service limitations, two Nurses should attend. The justification of this is not patient safety, but to prevent the diversion of controlled drugs as advised following the Shipman Enquiry. As soon as controlled drugs are prescribed, either by the GP or NMP, the risk assessment pathway for controlled drugs in a patient’s home (appendix 4) must be followed and outcome documented on the core care plan. This is a dynamic process and reassessment should occur if any new concerns are raised

W hen a Nurse has not yet achieved the syringe driver competencies, a Nurse who has achieved the competencies must supervise him/her. Student Nurses are able to act as second signatories for medication administration although the appropriateness of delegating this task must be assessed based on the complexity of the procedure. Responsibility of the delegation of this task lies with the Registered Nurse.

There are other situations when it may be necessary for two nurses to undertake the procedure. These are listed below.

• When a syringe driver is being commenced

• More than one syringe driver is being used

• Four or more drugs in any one syringe driver

• W hen the drugs prescribed for the syringe driver are outside the Merseyside and Cheshire Guidelines. Advice can be sought from the specialist palliative care

team and www.palliativedrugs.com

• Witnessed destruction of controlled drugs. Before undertaking the subcutaneous administration of drugs via a syringe driver nurses must be competent in the following areas:

• Reasons for use of a syringe driver: including nausea and vomiting not controllable by other means, dysphagia and the inability to swallow oral medication, intestinal obstruction, oesophageal obstruction both due to internal and external compression and malabsorption of drugs: although this list is not exhaustive

• Knowledge of the drugs that can be used and their possible side effects

and drug compatibilities

• Safe monitoring of the patient and the response to drugs

• Correct procedure for setting up, maintaining and discontinuation of equipment

• Recording and monitoring quantity of patients drugs

• Recording of drugs administered

• Issues of consent as per Mersey Care NHS Foundation Trust policy.

Under no circumstances should a nurse undertake the subcutaneous administration of drugs via a syringe driver unless they are competent to do so.

Residential Care Homes

In the event that a patient situated in a residential care bed requires a syringe driver, it is the responsibility of the District Nursing team responsible for that resident to undertake the management of the syringe driver. This includes the setting up and reloading of the syringe driver as per Mersey Care NHS Foundation Trust Clinical Policy and Procedure.

Other care settings including Nursing homes

Occasionally patients may need to be supported to remain in their primary place of residence, such as a nursing home or hostel. If the care team is unable to support the patient with delivering medication via a syringe driver then Mersey Care NHS Foundation Trust staff may be asked to support this. In which case it is the

responsibility of the District Nursing team for that patient (GP attached) to undertake the management of the syringe driver. This includes the setting up and reloading of the syringe driver as per Mersey Care NHS Foundation Trust Clinical Policy and Procedure. Each individual situation will require its own dynamic and/or formal risk assessment.

7.1 Setting up of a Syringe Driver

Equipment Required

• Syringe Driver – T34 McKinley

• Battery (9v) and spare.- Varta Brand

• Small transparent dressing

• Saf-T-intima (yellow) for medication via syringe driver, and Saf-T-intima (blue) for administration of stat doses and giving set if appropriate. The use of multiple extension lines should be avoided

• Luerlok syringe - 20ml syringe is the recommended minimum size

• Lockable transparent box

• Prescribed drugs

• Drug additive label

• Administration sheet

• Syringe Driver documentation

• Good source of light

• Socially clean work surface

• Soap, water and paper towels/ alcohol hand gel rubs. (as per Infection Control policy)

• Sharps box

• CD denaturing kit (if applicable).

Preparation required for the Administration of Subcutaneous drugs via a syringe driver

• Obtain consent as per Mersey Care NHS Foundation Trust policy

• Complete the risk assessment pathway for controlled drugs in a patients home

(Appendix 4) and document in the core care plan • Ensure maintenance of patient privacy and dignity

• Explain the nursing procedure

• Check the drug authorisation sheet (appendix 2) drug name, specific

directions, time due, dosage, f r eq ue nc y , route of administration, the prescriber’s signature and date prescribed. The drug authorisation sheet should be reviewed every 28 days, check that this is in date. The review should be documented on the authorisation sheet. Any changes to the drug authorisation sheet should be completed on a new form and the previous sheet crossed through and filed in the patients notes. Faxed drug authorisation sheets not on Mersey Care NHS Foundation Trust documentation (i.e. from Hospice or Hospital) are valid for 48 hours (not including weekends and Bank Holidays)

• Verify patient details against drug authorisation sheet

• Check that the drug and dose are appropriate to the patient’s condition, age and

previous exposure to drugs/medication. If in doubt contact the Palliative Care Specialist Nurse for advice and also refer to the current British National Formulary, Palliative Care Formulary, Prescriber, or Pharmacist

• Carry out any necessary calculations relating to dosage

• Check if the patient has any allergies or contraindications to the syringe

driver being commenced • Ensure dose has not already been given by checking, patient notes and

referencing against quantity of patients drugs on stock check • Make sure all products are in date and sterile

• Check the maintenance date of the syringe driver. (Syringe Drivers should be

serviced annually and dated). If the syringe driver is past its due maintenance date, do not use and send for servicing, as per Medical Device Policy

• If applicable, ask the patient to position his/herself in an appropriate comfortable position.

Nursing Procedure

• Nurse is to wash his/her hands (clean procedure)

• Wear PPE (apron and gloves)

• The patient should be given choice, where possible, in the site of the infusion. W hen setting up or re-siting the syringe driver, choose an appropriate infusion site. It is usual to use the anterior chest wall, abdomen, upper arm, thigh or occasionally the back for subcutaneous administration of drugs via a syringe driver

• If it is necessary, excess hair can be cut at the site

• Areas to be avoided include areas of lymphoedema or ascites as

absorption will be restricted and breaches of skin integrity may increase the risk of infection, bony prominences, recently irradiated skin sites, joints and skin folds, tumour sites, areas of broken skin and areas of inflammation or infection

• Expose the chosen site for infusion

• Cleanse site with ChloraPrep Sepp 0.67ml. Allow to dry for 30 seconds.

• Use aseptic non-touch technique of key parts of the saf-T-intima cannula during insertion. Insert the saf-T- intima (yellow) for the syringe driver (blue for stats) with t he bevel side up. Remove the introducer and secure with a transparent dressing

• 2% Alcohol Chlorhexidine wipes are to be used to disinfect the blue cannula prior to administration of stat doses of medication

• Draw up the drug into the syringe, complying with the manufacturers and prescriber’s instructions. Check compatibility before mixing drugs in a syringe driver

• Check infusion clarity. If the drugs were clear before mixing any precipitation or clouding is an indication that the drugs or the concentration are incompatible and the infusion should be discarded. Speak to Specialist Palliative Care Team for advice

• Connect the syringe to the giving set

• W hen setting up a new infusion the infusion tube should be primed before connecting to the Syringe Driver

• Ensure that a label is correctly completed with patient name, date of birth, drug(s)

and dose in the syringe, diluent, length of fluid in syringe at commencement and the date and time of commencement. This must be attached to the syringe before placing the syringe in the syringe driver. Ensure the fluid in the barrel remains visible for measuring and monitoring purposes

• Mersey Care NHS Foundation Trust utilise the McKinley T34 Syringe pump

for all patients requiring 24 hour infusion. Ensure the McKinley T34 is set the appropriate brand of syringe in use. The pump should be loaded as per manufacturer’s guidelines

• Syringe Driver must be placed in the transparent locked box and patients are

to be provided with a fabric holster if they are mobile. Position syringe driver out of the light (if not placed in a holster) to prevent reaction of light sensitive drugs such as Levomepromazine

• Complete Appendix 1, Syringe Driver Checklist, for monitoring

of the infusion site at each visit, checking pump, cannula, site and tubing at each visit, and prior to each administration

• The site must be changed if there is any redness, swelling, tenderness,

leakage or precipitation within line. If the site has ‘tissued’ a new infusion MUST be reconstituted up before it is re-sited, using a new giving set and syringe, drawing up new drugs as per the drug authorisation sheet (Appendix 2)

• This infusion will then last for the prescribed infusion period, usually 24

hours. The reloading time of the syringe driver should then be altered accordingly to avoid wastage. If due to service limitations this is not possible the syringe driver should be reloaded at the planned time

• T34 syringe drivers are fitted with a ‘stop function’ which is outside of the locked

box. This is a safety requirement which enables the pump to be stopped even if the keypad lock is on. When pressed the stop function will cease delivery of the infusion for two minutes. It is possible for anyone to pause the infusion when in lockable mode but the syringe driver will alarm every two minutes until the infusion has been restarted. This is a safety feature and is designed for clinicians and carers to stop the infusion in mid flow to allow for alterations. It is important to advise the patient and their carers regarding this function whilst reinforcing correct reporting and escalation procedure. It would not be appropriate or carers/relatives to be advised to use any other function within the McKinley T34.

Documentation

The Nurse should document the following

Within the syringe driver checklist (Appendix 1):

• Presence or absence of site reactions

• Length of fluid remaining in the syringe

• Clarity of solution in syringe

• Names of drug(s) in syringe, dose(s) of each drug, name of diluents, length of

total fluid in syringe at time syringe driver commenced, date and time syringe driver commenced

• Signature of nurses responsible for undertaking the procedure.

Other documentation:

• Completion of “Personalised Care Plan for the Last Days of Life” where appropriate

• All syringes should be labelled with the patients name, drug(s) and dose in

syringe, name and amount of diluent, length of total fluid in syringe at time syringe driver commenced, date and time syringe driver commenced

• Faxed authorisation sheets are valid for 48 hours, (not including weekends and

bank holidays) then the original should be collected or rewritten and put in the patient’s notes)

• Notification of setting up of syringe driver form should be completed and faxed to

both the patient’s GP Surgery and District Nursing Out of Hours service. This should then also be tasked over to the District Nursing Out of Hours for their reference. This will then be scanned onto the patients EMIS record

• Completed documentation must be placed and scanned in the patient’s clinical

record.

Instruction for the return of McKinley Syringe Drivers to Acute Trusts and Hospices from the Community setting.

For patient discharged from Hospital/Hospice with a syringe driver in situ they should be transferred to a Mersey Care NHS Foundation Trust Syringe Driver as soon as is feasibly possible. The Hospital/Hospice Syringe Driver and locked box (if present) should then be cleaned using a detergent wipe (e.g Tuffie Wipes), this should be followed by an antiseptic wipe if the equipment has been in contact with

bodily fluids. Then attach a label to confirm the equipment has been checked and cleaned. The syringe driver should then be returned to the appropriate Acute Trust/Hospice clearly marking which patient it has come from and annotating in the patient notes where you have sent it. If the patient has been discharged from either Woodlands Hospice or Aintree Hospital the syringe driver can be returned to the Community Specialist Palliative Care team who will return it.

Taking down/ discontinuing a Syringe Driver.

Do not disconnect a syringe driver until death has been verified. The need for sensitivity when disconnecting the syringe driver is essential and should be completed as part of last offices. If there are controlled drugs to be destroyed in line with the Controlled Drugs Policy and Standard Operating Procedure for the Denaturing of Controlled Drug in the Community by Registered Community Nurses, this again needs to be performed with the upmost sensitivity. If possible this could be done in private in an alternative room within the patient’s home.

8.1 Training

It is the responsibility of the Registered Nurse to ensure they have received training in the safe administration of drugs via a syringe driver. This procedure must not be undertaken until training has been completed and signed off as competent in the skill. Training will be in the form of an initial half day classroom based session. Syringe driver training is embedded into classroom training however the practical T34 syringe driver and competency/self-assessment sign off will be completed with the DN Team Leader or Caseload Holder at base. This is then followed by an e-learning package which must be done on a yearly basis. The individual nurse is then responsible for identifying any further development and learning needs.

The nurse‘s competence will be assessed against the competency framework and competency certified on the Syringe Driver competency document and will be signed by the Team Leader or Caseload Holder (Appendix 5). An annual review of competency is required as part of the appraisal/PDR process, as stated in the Medical Device Policy, where any learning needs/competencies should be identified and documented.

Nursing staff from Mersey Care NHS Foundation Trust devised this clinical policy and procedure to fulfil the requirements of patients receiving subcutaneous drugs via a syringe driver, in the community setting. Mersey Care NHS Foundation Trust is committed to ensuring that all staff are trained and equipped to perform their role effectively.

This training can be accessed via the Learning and Development Bureau.

9.1 Implementation, Monitoring and Review

The Medical Director of the organisation is responsible for implementing this policy. This process has been delegated to the Specialist Palliative Care Team Leader.

The Director of Operations/Executive Nurse is responsible for ensuring that this document is reviewed and, if required revised in the light of legislative guidance and organisational change. This process has been delegated to the author of the policy.

This policy will be reviewed within the next two years unless practice or the organisation changes in the interim.

This policy will be monitored via Datix reporting incident system. This will be undertaken by the Leads for each service. Findings and lessons learned will be disseminated via relevant local governance groups.

Practice will be audited against the policy in the 2018/19 Audit cycle.

Impact Assessment

This has been undertaken and the evidence has been retained by the authors and the Equality and Diversity Lead of Mersey Care NHS Foundation Trust.

Linked areas/information

Other related policies, procedures or work instructions:

• Infection Control Policy http://opera.liverpooMersey Care NHS Foundation Trust.nhs.uk/SIRS/Policies-and- Procedures/Clinical%20Policies/Infection%20Prevention%20Control%20Manua l.pdf

• Verification of Death Policy http://opera.liverpooMersey Care NHS Foundation

Trust.nhs.uk/SIRS/Policies-and- Procedures/Clinical%20Policies/Verification%20of%20Death%20Policy.pdf

• Consent to Treatment Policy http://opera.liverpooMersey Care NHS Foundation

Trust.nhs.uk/SIRS/Policies-and- Procedures/Clinical%20Policies/Consent%20to%20Treatment%20Policy.pdf

• Standard of Health Recordkeepinghttp://opera.liverpooMersey Care NHS

Foundation Trust.nhs.uk/SIRS/Policies-and- Procedures/Corporate%20Policies/Records%20Manual%20Policy.pdf

• Policy for the Management of and Training Needs for Medical devices and Equipment http://opera.liverpooMersey Care NHS Foundation Trust.nhs.uk/SIRS/Policies-and- Procedures/Clinical%20Policies/Medical%20Device%20Guidelines.pdf

• Cardiopulmonary Resuscitation Policy http://opera.liverpooMersey Care NHS

Foundation Trust.nhs.uk/SIRS/Policies-and- Procedures/Clinical%20Policies/Resuscitation%20Incorporating%20Anaphylaxi s%20And%20Deteriorating%20Patient%20Policy.pdf

• UDNACPR policy http://opera.liverpooMersey Care NHS Foundation

Trust.nhs.uk/SIRS/Policies-and- Procedures/Clinical%20Policies/DNACPR%20Adult%20Policy.pdf

• Policy for the management of controlled drugs http://opera.liverpooMersey Care NHS Foundation Trust.nhs.uk/SIRS/Policies-and- Procedures/Clinical%20Policies/Controlled%20Drugs%20Policy.pdf

• The Denaturing of Controlled Drugs (CDs) in the Community by Registered Community Nurses SOP http://opera.liverpooMersey Care NHS Foundation Trust.nhs.uk/SIRS/Policies-and- Procedures/Standard%20Operating%20Procedures/SOP%20CNAll01Den aturing%20of%20CDs%20V6.pdf

• North West Coast Strategic Clinical Network – Clinical Standards and Guidelines – accessible at http://www.nwcscnsenate.nhs.uk/strategic- clinical-network/our-networks/palliative-and-end-life-care/audit- group/clinical_standards_and_guidelines/

• End of Life Policy http://opera.liverpooMersey Care NHS Foundation Trust.nhs.uk/SIRS/Policies-and- Procedures/Clinical%20Policies/End%20of%20life%20Policy.pdf

12. References

• Department of Health (1995) Infusion Systems Device Bulletin MDA DB 9503. Medical Devices Agency.

• http://www.nwcscnsenate.nhs.uk/strategic-clinical-network/our-

networks/palliative-and-end-life-care/audit- group/clinical_standards_and_guidelines/

• MHRA Alert – 2018 https://www.gov.uk/drug-device-alerts/all-t34-ambulatory- syringe-pumps-risk-of-unintended-pump-shutdown-and-delay-to-treatment

• Nursing and Midwifery Council (2015) The Code – Professional standards of practice and behavior for nurses and Midwives. NMC. London

• Nursing and Midwifery Council (2007) Standards for Medicines Management. NMC. London

13. Appendices

Appendix 1 Syringe Driver Checklist

Appendix 2 Drug Authorisation Sheet

Appendix 3 Setting up of Syringe Driver Notification Sheet

Appendix 4 Risk Assessment Pathway for Controlled Drugs in Patient Homes

Appendix 5 Competency framework

Appendix 1

SYRINGE DRIVER CHECKLIST

Patient Name: D.O.B: Trust: NHS No: Assess the patient and complete this record on every clinical visit.

Date

Time Syringe Checked

Label Checked (tick)

Rate (mm)

Fluid Volume (mls)

Solution

• Clear • Cloudy • Crystallised

Site Condition 1) Good 2)Change

Key Lock

On

Site

Battery Level %

Actio n Taken

Name Signatur e 1st

Name Signature 2nd

Guideline for Completion

ACTION TAKEN 0. No Action Taken 1. Site Changed 2. Battery Changed 3. Syringe / Contents Change

PATIENT DETAILS NHS NUMBER: SURNAME: FORENAME: DATE OF BIRTH:

DRUG AUTHORISATION SHEET (In Conjunction with FP10 for Legal Supply) Drugs to be administered according to patient’s symptoms

ALLERGIES: PRESCRIBER REVIEW REQUIRED EVERY 28 DAYS (SEE OVERLEAF)

DRUGS TO BE GIVEN SUBCUTANEOUSLY VIA SYRINGE DRIVER DRUGS TO BE GIVEN AS REQUIRED (PRN) Symptom

Drug dosage Range over 24 Hours Prescribers Name,

Sig. and Date

Drug and Dose

Route

Frequency Prescribers Name;

Sig. and Date

Pain (For advice on dose or conversion from oral to s/c, see overleaf)

Fentanyl/Buprenorphine patch in place? YES NO Is the patient opioid naïve? YES NO

(ensure long acting opiates are discontinued)

S/C

1 – 4

hourly/ PRN

Nausea and /or Vomiting

Levomepromazine 6.25mg – 25mg

Levomepromazine 6.25mg

S/C

PRN Max total daily

dose 25mg

Agitation/ Restlessness

Midazolam 5mg – 30mg (Seek specialist advice if above 30mg)

Midazolam 2.5mg – 5mg (Max dose 10mg/4 hours)

S/C

1–4 hourly / PRN

Respiratory Tract Secretions

Hyoscine Hydrobromide 1200 – 2400 micrograms (Seek specialist advice if above 2.4mg) OR

Hyoscine Hydrobromide 400 micrograms

S/C

PRN Max

total daily dose

2.4mg

Glycopyrronium 600 – 1200micrograms (Seek specialist advice if above 1200micrograms)

Glycopyrronium 200 micrograms

S/C

PRN Max total

daily dose 1.2mg

Other Medication

PRESCRIBER REVIEW (To be completed every 28 days)

Date Reviewer

(Name and Signature) Continue YES/NO

Next Review Date

A guide to Drugs commonly used in Syringe Drivers over 24 hours

INDICATION DRUG COMMON DOSES Pain Diamorphine Dependent on titration of oral and

sub-cut doses received (see below) Oxycodone Alfentanil Use in renal failure – Refer to Specialist

Palliative Care Nausea and / or vomiting

Levomepromazine 6.25 - 25mgs

Haloperidol 1.5 - 5mgs Cyclizine 100 - 150mgs (Vestibular induced vomiting) Metoclopramide 30 - 60mgs (Increased gastric emptying) Agitation and / or restlessness

Midazolam 5 mgs upwards (dose above 30mg seek specialist advice)

Levomepromazine 25 - 150mgs Dry up bronchial secretions

Hyoscine Hydrobromide 1200 - 2400 micrograms

Glycopyrronium bromide 600 - 1200 micrograms (and intestinal colic) Intestinal Colic Hyoscine Butylbromide 60 - 120mgs

Diluent Use 0.9% Sodium Chloride as the standard diluent. If the syringe driver contains Cyclizine or if the Diamorphine dose is greater than 40mg/ml use Water for Injection. Ensure all drugs to be added to syringe driver are compatible. Any queries re compatibility of drugs seek specialist advice for e.g. Dexamethasone dose above 1mg needs to have separate syringe driver.

Conversions Oral morphine to subcutaneous (s/c) Diamorphine Add total intake of slow release (S/R) morphine and liquid Oramorph over past 24 hours. Divide total by 3 to give s/c Diamorphine dose over 24 hours. E.g. S/R Morphine 120mgs twice daily = 80 mgs s/c Diamorphine over 24 hours.

Oral Oxycodone to s/c Oxycodone Add total of oral modified release (M/R) Oxycodone and oral immediate release Oxycodone over past 24 hours. Divide total by 2 to give s/c Oxycodone over 24 hours. E.g. M/R Oxycodone 30mg twice daily = 30mg s/c Oxycodone over 24 hours.

FentanylBuprenorphine patch These patches should be left in place upon commencement of syringe driver and renewed as prescribed. Contact Palliative Care Team for advice on calculating dose of s/c when required (PRN) Diamorphine or Oxycodone.

To be read in conjunction with Mersey Care NHS Foundation Trust Clinical Policy and Procedure for the Subcutaneous Administration of Drugs via a Syringe Driver Merseyside and Cheshire Palliative Care Network Audit Group (2009) Guidelines for use of syringe drivers in palliative care.

If further advice is required regarding drug regimes or to check compatibility contact your Clinical Nurse Specialist in Palliative Care. Out of hours contact the 24hr Palliative Care Help Line Marie Curie: 0845 223 2900 or Woodlands: 0151 529 2299

ent

Setting up a Syringe Driver Notification

Appendix 3 Syringe Driver Notification Sheet

Patient Details: Surname: First Name:

NHS Number: Date of Birth:

Address:

Postcode:

Registered GP – Please ensure patient ‘special note’ has been sent to UC24 Doctor: Surgery

GP Tel No: GP Fax No:

Diagnosis:

Reason for Continuous Subcutaneous Infusion (CSCI) End of life

Symptom managem

EOL Care Plan in place: Yes/No PPC - please state: Completed by Name: (Print Name) Signature: Designation: Date & Time:

Complete & fax to:

• GP and OOH DN services. • Scan onto patients EMIS record

Appendix 4

Risk Assessment Pathway for Controlled Drugs in Patient Homes

For use where any Controlled Drugs or syringe driver medication will be administered in a patient home. Consider as part of anticipatory care.

This includes both administration of non-parenteral medicines by a nurse, carer or patient.

Or medicines administered via a syringe driver by nurse or patient

Possible Risk Identified Possible Control Measures

Risk 1

There may be contact with children within the house

• Drugs to be kept out of reach of children, ideally high up

• Drugs to be kept ideally locked away

• Consider tamper evident box if appropriate for safety

• Document in the Core Care plan

Risk 2

There is potential for inappropriate access to the patients drugs by person(s) with a history of substance abuse

Risk 3

There is no one with capacity to take responsibility for the collection/receipt/storage of medication

• Inform GP • MDT meeting if needed • Consider daily supply of

medication from pharmacy (including collection by family or delivery by pharmacy as arranged)

• Tamper evident box for safety • Document in the Core Care

Plan

Multidisciplinary Team Meeting may compromise of GP, DN or other healthcare professional as appropriate

Management plan should be developed taking into account individual situation and circumstances. Safe storage of medicines should be discussed with the patient and patient information leaflet issued. Where there are any concerns the above measures should be considered. Controlled Drugs should be managed in accordance with The Safer Management of Controlled Drugs Policy. Contact the Palliative Care Team or Medicines Management Team for advice.

Appendix 5 Syringe Driver Competency Framework

Competency Competency Indicator Supporting Evidence Assessment

Date Assessors Signature

Practitioner Signature

1. Demonstrates a clear knowledge and understanding of trust policies and NMC standards associated with the administration of drugs via a syringe driver

Demonstrate knowledge of the following policies/standards:

• Subcutaneous administration of drugs via a syringe driver

• Controlled drugs policy • Medicines overarching

policy • NMC standards for the

administration of medication

• Understanding of when appropriate for 1 or 2 nurses to administer drugs via syringe driver

Formative Summative Assessor Comments:

2. Demonstrates the ability to recognise the indications for use of a syringe driver in accordance with the end of life care plan / symptom management care plan

Demonstrate knowledge of the reasons for use of a syringe driver

Assessment Date Assessors Signature

Practitioner Signature

Formative Summative Assessor Comments:

Competency Competency Indicator Supporting Evidence Assessment

Date Assessors Signature

Practitioner Signature

3. Demonstrates the ability to select and administer appropriately prescribed drugs in accordance with the patient’s symptoms and trust guidelines

Demonstrates knowledge and ability in the following:

• Identification of appropriate sites and areas to be avoided

• Identification/ correct calculation of drug dosages and knowledge of compatibilities

• Checking of prescription sheet

• Checking of site • Drawing up of drugs and

checking infusion clarity • Connecting of syringe to

giving set and priming of line

• Correct completion of label

• Use of syringe driver locked box

Formative Summative Assessor Comments:

4. Demonstrates appropriate use of trust documentation in accordance with NMC guidelines

Demonstrates ability to complete documentation as per trust policy and NMC guidelines to include:

• Care plans • Syringe driver checklist • EOL documentation (as

appropriate) • Syringe driver

notification sheet

Assessment Date Assessors Signature

Practitioner Signature

Formative Summative Assessor Comments:

McKinley T34 Syringe Driver

STOP: Do not use the device unsupervised unless you are competent to do so.

Competency Statement – Self Assessment

Surname: Forenames:

Title (Mr/Mrs/Miss/Dr etc): Job Title, Designation: Personal No. (payslip):

Department: Manager/Team Leader: Telephone Extension No.

Self-verification of competence is undertaken by assessment against the following statements, specific to this device. Responsibility for use remains with the user, so if you are in any doubt regarding your competence to use this device, you should seek training. This might include self-directed learning, coaching or formal training. Resources include the product operating manual, colleagues, the intranet link for this device, or the designated Trust Lead for this device – Clinical Skills Department.

Carry out an initial assessment. You must be able to answer “yes” to all the questions before considering yourself to be competent.

Ask yourself are you safe using this device?

Have you been assessed for competency level, please provide your answer and your required review date?

Can you:

1. Define the features of the T34 McKinley Pump. 2. Demonstrate the correct operation of the T34 McKinley Pump. 3. Explain how to correctly programme the T34 Pump. 4. Distinguish between the different alarms and alerts and explain the actions required to rectify

these. 5. State the required accessories for safe use of the T34 in clinical practice. 6. Confidently explain the procedure for cleaning the device and when it should be cleaned 7. Demonstrate how you would check the pump is deemed fit for purpose by the medical devices

team. 8. Demonstrate the procedure for documenting the device prior to use in the community 9. Do you know to keep the McKinley Pump in its clear plastic case & ensure it is locked when in

use in the community.

1. UPDATE TRAINING IS AVAILABLE AS AN E-LEARNING PACKAGE. TO ACCESS THE COURSE YOU WILL NEED TO GO TO: www.cmemedical.co.uk REGISTER ON THE FIRST OCCASION USING THE FOLLOWING PASSWORD - MERSEY CARE NHS FOUNDATION TRUSTtraining

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 the device without supervision.

Signature: Date:

Signature of Manager: Date: