USE OF MCKINLEY T34 SYRINGE DRIVER

Transcription

1 USE OF MCKINLEY T34 SYRINGE DRIVER Full Title of Guideline: Author (include and role): Division & Speciality: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Nursing Guidelines for a Continuous Subcutaneous Infusion using a McKinley T34 syringe driver Version 4 Alison Freemantle and Lindsay Hall Amended January 2018 by Nicola Jones Nicola.jones3@nuh.nhs.uk Hospital Palliative Care Team Palliative Care, CAS Clinical registered staff trust wide December 2020 Patients requiring medication via a T34 syringe driver Total volume of prescribed medication and diluent. Contact numbers. Safety alert advice re batteries. Advice re set up of T34 pump. Discharge guidance. Troubleshooting guide. Summary of evidence base this NICE Guidance, NMC standards guideline has been created from: Expert committee reports or opinions and / or clinical experiences of respected authorities Recommended best practise based on the clinical experience of the guideline developer This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust. Page 1 of 29

2 Contents Introduction 3 Prescription/ compatibilities 5 Syringe selection 6 Diluent 6 Administration and preparation 6 Commencing a McKinley T34 syringe driver 7 Subcutaneous cannula 14 Documentation of administration and monitoring 15 Disconnecting the infusion 16 Discharge into the community 17 Risk management 18 Appendix 1- Guidelines for disconnecting a McKinley T34 syringe 21 driver (Advice for community nurses) Appendix 2- Discharge Flow Chart for a patient with a McKinley 22 T34 syringe driver Appendix 3- Trouble shooting guide 24 Appendix 4- Choice of subcutaneous cannula 27 Audit points 29 Page 2 of 29

3 Introduction The use of an ambulatory battery operated syringe driver for subcutaneous medications is an established technique in palliative care. The syringe driver provides a minimally invasive route of drug administration to administer the continuous delivery of a range of medications to aid patient comfort. The McKinley T34 battery syringe pump is used at Nottingham University Hospital (NUH) NHS Trust predominantly for palliative care patients who often present with multiple symptoms that can necessitate the need to use several drug treatments. Syringe drivers should not be considered as a last resort but as an important alternative route of drug administration in certain circumstances. A McKinley T34 syringe pump is an ambulatory battery operated infusion pump weighing approximately 210g. This pump is small in size, and has a large LCD display which provides error messages and context sensitive instructions. The device includes a rolling 512 date and time stamped event log, mechanical syringe sensors that interlock with the syringe and provision of alarms during incorrect operation thus complying with IEC standards. The McKinley T34 is calibrated in ml/hour. Figure 1- McKinley T43 syringe pump. When the oral route is unavailable to patients, the subcutaneous (SC) route is an option and is the preferred route in the last days of life. However, the SC route should not only be reserved for use in a dying patient. Consider this route for the treatment of pain and / or other symptoms when other routes of administration are inappropriate. For example: Page 3 of 29

4 inability to take medications orally dysphagia nausea and vomiting poor absorption e.g. ileostomy. The SC route will not give better analgesia than the oral route unless there is a problem with absorption or administration. For patients in the last days of life intravenous injections (IV) should be avoided because they are invasive and no more effective than the subcutaneous route. Intramuscular injections (IM) should be avoided, as they are painful, particularly in the cachexic patient. Advantages and disadvantages of continuous SC administration Advantages: can be used when patients can no longer tolerate oral therapy due to nausea, vomiting, dysphagia or reduced level of consciousness increased patient comfort, avoiding the need for repeated injections avoids the administration of excessive tablets control of multiple symptoms with a combination of drugs round the clock comfort because plasma drug concentrations are maintained without peaks and troughs mobility and independence can be maintained as device is lightweight and can be carried in a holster either under or over clothes (Dickman et al, 2005) delivered over 24 hours, this reduces the number of times drugs are administered. As a consequence opportunities for drug errors are reduced; it is also less time consuming and more cost effective for nursing staff. N.B. The McKinley T34 is pre-configured to administer drugs over a 24 hour period. This cannot be changed. If the total volume of drug to be administered is an issue please contact Hospital Palliative Care Team (HPCT) (Monday Friday 8am-4pm) ext /68402 or Hayward House ext (out of hours). Page 4 of 29

5 Disadvantages: possible inflammation or irritation at infusion site possible leakage of SC site possible allergic reaction (rare occurrence) fears that a syringe driver may hasten death ( Thomas and Barclay 2015) lack of reliable compatible data for some mixtures (Twycross and Wilcock, 2009). Best Practice If symptoms are controlled, start the syringe driver 2-4 hours before the effect of the medication is due to wear off (following initial set-up of the driver it takes several hours for drugs to reach therapeutic blood levels). If symptoms are uncontrolled set up the syringe driver immediately with stat doses of the same drugs. Prescription/compatibilities All prescriptions must be written to be administered over a 24-hour period. The dose of any controlled drugs must be written in words and figures for clarity. The McKinley T34 is configured to run over 24 hours ONLY; this cannot be changed. Only a luer lock BD syringe should be used. The medications advised in the End of Life Medical Documentation can be mixed together for infusion over 24 hours with no reported compatibility problems. For up to date clinical data please refer to and click on SDSD (Syringe Driver Survey Database). Alternatively, consult booklet Syringe Driver Drug Compatibility Charts (available in Blue Box). If there appears to be any problem with the prescription/ mixture please contact the following for advice: Hospital Palliative Care Team (Monday Friday 8am-4pm) ext /68402 or Hayward House ext (out of hours) Page 5 of 29

6 Syringe selection The McKinley T34 pump has been designed to be used with 2mL to 50mL syringes. However, at NUH the procedure is to use a 20mL or 30mL BD Plastipak luer lock syringe; no other make of syringe should be used. This provides sufficient dilution to reduce the risk of adverse site reactions and incompatibility, without providing too large a volume for uncomfortable administration. (See Table 1 for choice of syringe size). Pumps at NUH will be set to recognise BD Plastipak syringes only. Diluent Water for injection is the diluent of choice. Syringes should be made up immediately before use, using a non-touch technique. Ensure adequate mixing has occurred. The solution should be clear and free from crystals or precipitate. Volume of prescribed medication (undiluted) Size of BD Plastipak Syringe Total volume of prescribed medication and diluent Less than 10mL 20mL syringe Make up to 17mL with water for injection More than 10mL 30mL syringe Make up to 22mL with water for injection Table 1 Syringe size, volumes and diluent If there is doubt about compatibility of a mixture, patient develops a site reaction or contents of the syringe/line appear cloudy please contact the Hospital Palliative Care Team (Monday Friday 8am-4pm) ext /68402 or Hayward House ext for advice. Administration and preparation Refer to policy for administration of medicines All syringes containing drug additives must be fully labelled. If there is any doubt as to the contents of a syringe, the contents should be discarded. This is particularly important for continuity of care, especially where patients transfer from one care setting to another. Page 6 of 29

7 Complete the label details in black ink stating the following: name of the patient for whom it is intended and hospital number date and time of preparation initials of the persons preparing and checking the contents name and dose of all the drugs name of the diluent total visual volume of the contents. Attach label to the tip end of the syringe taking care not to obscure the solution or the syringe leaving the scale visible so that it can still be read. Keep the label flat and unfolded to avoid obstructing the pump mechanism. Commencing a McKinley T34 syringe driver Only staff who have received the training and are deemed competent or under the direct supervision of a member of staff competent in the use of a McKinley T34 syringe driver should use the device. Information on training in the use of the McKinley T34 syringe driver can be obtained from the Medical Devices Training Team on: City ext QMC ext McKinley T34 syringe pumps are available from the equipment library on both campuses. The pumps will arrive in a Blue Box containing all of the necessary equipment to set up the pump. Devices must be returned promptly to the equipment library following use. The NUH equipment library can be contacted via the response centre on the following telephone numbers: ext Out of working hours the equipment library can be accessed at: City campus by contacting Helpdesk on QMC campus by contacting Attempts will be made to ensure that devices will be available at both sites over a week-end: in the rare event that there is no device available at the equipment library please contact neighbouring wards to establish if a T34 is awaiting collection and can be used, following appropriate infection control procedures, for your patient. In the event of syringe driver unavailability prn medications should be used to ensure symptom control until a T34 can be obtained. If optimal symptom control is compromised please complete a Datix to this effect. Page 7 of 29

8 Equipment list: injection tray syringe pump prescription prescribed medicines / diluent label. In Blue Box: McKinley T34 syringe pump battery, PP3: 9V showing code 6LR61 Alkaline/Lithium, plus a spare battery (a new battery will last for approximately 3-4 days depending on use) As batteries can vary slightly in shape and size, equipment library will advise on the current appropriate brand of battery in use 20 ml and 30 ml luer lock BD Plastipak syringes subcutaneous infusion cannula e.g. Saf-T-Intima cannula 22G (blue) 100 cm McKinley extension sets with integrated anti-siphon valve bionector lockbox and key transparent adhesive dressing Syringe Driver Drug Compatibility Chart Subcutaneous Syringe Driver Administration Record and Monitoring Form. Page 8 of 29

9 Principles of Care: see General Principles for all procedures. PRINCIPLE 1 Draw up the drug (s) in the diluent as prescribed. See Table 1 for volume guidance. 2 Attach syringe to the extension set and prime the set manually. 3 Insert the 9V alkaline battery into the McKinley T34 syringe pump. Ensure that the plastic terminal cover on the battery (if fitted) is removed prior to inserting the battery as this can cause damage to the devices battery terminals. Also ensure that the battery fits tightly and is not loose. 4 Ensure the barrel clamp is DOWN and the syringe is not connected 5 Press and hold the dark grey ON/OFF key until PRE-LOAD screen appears 6 Wait until pre-loading has finished (actuator stops moving) RATIONALE If the battery terminals are damaged this can cause intermittent failure of the pump. 7 Check the battery life by pressing the blue INFO key and YES key to view battery status. - If shows 10% or less power, change the battery- switch off by holding down the ON/OFF key until the screen goes blank, discard the battery, insert a new one and start up again as above and check the life of the new battery. - If discharging a patient home, please see Appendix 2 regarding the power level at which to change the battery. Page 9 of 29

10 PRINCIPLE 8 The actuator will move automatically to the start point of the last syringe loaded. PRIOR TO LOADING NEW SYRINGE- measurement of the new syringe must take place with the pump on a flat surface and the barrel clamp DOWN to check the syringe will fit into the three syringe detection points on top of the pumps. Rest the plunger end of the syringe gently between the two sets of prongs in the actuator, visibly check that the flange of the syringe lines up with the collar sensor. If adjustment is required use the FF or BACK keys to move the actuator into the correct position. RATIONALE 9 Once the correct position has been ascertained, lift and rotate barrel clamp arm, load the syringe, inserting the plunger and syringe flange in the correct slots, rotate and replace barrel clamp arm. The pump display screen will show if any of the three detection points are not aligned correctly. If this is the case, remove the syringe and re-insert as described above. 10 Ensure the pump has detected the correct syringe type (only BD Plastipak syringes should be used) and size, press YES to confirm or use +/- keys to scroll and select the correct option. To ensure that the medication is delivered at the correct rate Page 10 of 29

11 PRINCIPLE 11 In the event that the pump gives the option of resuming a previous programme, this option must not be taken (i.e. select NO). Turn off the pump, remove the syringe and start again. 12 Check the correct infusion volume (as documented after priming) and duration (24 hours) is shown on the display summary. Press YES if settings are correct. Record this volume on Subcutaneous Syringe Driver Administration Record and Monitoring Form. RATIONALE This would indicate that the pump had been set up incorrectly. A new programme must be set up for each new syringe Priming uses about 0.4mL. The volume remaining will be detected automatically by the pump and the rate calculated automatically so that the infusion lasts for 24 hours. The rate is automatically calculated but should be double checked as good practice by dividing the volume by the time 13 Insert the subcutaneous infusion cannula e.g. Saf-T-Intima in the patient in a suitable position (see page 15) and attach the syringe and extension set to the cannula. 14 Press YES to start the infusion. A screen displaying the time remaining for the infusion, the rate in (ml/h) and the syringe selected will be shown continuously throughout the infusion. 15 Press and hold the blue INFO key until the display shows Keypad LOCK ON, this will lock the ON/OFF button, but other buttons will still work. To prevent the pump being inadvertently switched off. Page 11 of 29

12 PRINCIPLE 16 Secure the syringe pump in the lock box provided. It is advised that the key to the locked box be kept safely either with the ward drug keys or in the patient s own drug pods. RATIONALE This will protect the syringe from accidental knocks. Insert the pump into the cloth bag provided (single patient use) to protect from sunlight and heat. Also protect from excessive heat such as electric blankets. The pump should NEVER be tucked under pillows or bed covers hourly checks on the progress, the visual appearance of the infusion and administration site should be performed and documented during the infusion on the Subcutaneous Syringe Driver Administration Record and Monitoring Form. This can alter the functioning of the syringe driver. Alarm is not very loud and may not be heard. The pump could be exposed to moisture and heat. To ensure that the device is working effectively and the patient is receiving the prescribed medication. The LCD display will indicate rate of administration and time remaining. Press blue INFO key once to check volume to be infused (VTBI) and volume infused (VI). Press again to check battery level. Do not remove the syringe from the pump to perform these checks. If checking indicates a problem, action should be taken and then documented - see Trouble Shooting Guide (Appendix 3) available in Blue Box. Page 12 of 29

13 PRINCIPLE 18 When the infusion has completed, the alarm will sound and the infusion will stop. Unlock the keypad by pressing and holding the blue INFO key until the display shows Keypad LOCK OFF. Press red STOP key, then press and hold the dark grey ON/OFF key to switch the pump off. RATIONALE If a new infusion is to be commenced, with the pump switched OFF, remove the pump from the lock box and remove the syringe from the pump. If the current infusion set can continue to be used, leave this line attached to the now empty syringe. Take the new syringe, switch the pump back on, allow it to PRE- LOAD and when the actuator stops moving, with the barrel clamp down, check the new syringe will fit into the three syringe detection points (see point 8 above). Adjust the actuator as required. Load the syringe and THEN remove the line from the old syringe and attach to the new syringe now fitted into the pump. Place the pump back into the lock box. When the McKinley T34 is no longer in use it must be returned to the equipment library ASAP. Prevents bolus being administered to the patient while squeezing the syringe into the detection points. Prevents any fluid from dripping into the lock box which will cause rust and crust, which cannot be cleaned, becoming an infection risk and the box will need to be replaced. Page 13 of 29

14 Subcutaneous cannula Insertion sites (see Figure 2) There are a number of sites that are suitable for the insertion of a subcutaneous cannula. They include: anterior aspect of the upper arms or anterior abdominal wall anterior aspect of the thigh the scapula if the patient is distressed and or/agitated anterior chest wall (least common). Figure 2. Absorption from these sites through the capillary network is slower then that of the intramuscular route. It is advisable to rotate the site for placement of the subcutaneous cannula to decrease the likelihood of irritation (Dougherty and Lister 2008). Sites not suitable for placement of subcutaneous cannulae for continuous infusion: skin folds and breast tissue directly over a tumour site lymphoedematous limb, any area where oedema or ascitic fluid is present bony prominences - there is little subcutaneous tissue and absorption reduced previously irradiated skin - the skin may be sclerosed and therefore have a poor blood supply Page 14 of 29

15 sites near a joint - this can be uncomfortable for the patient and there is an increased risk of displacement of the cannula. infected, broken, or bruised skin Choice of cannula (Appendix 4) Best Practice As required bolus medication Break through analgesia should be prescribed subcutaneously. If a breakthrough dose of medication is required, this bolus dose should be given through a separate subcutaneous cannula secured by a dressing. The medication should be flushed with at least 0.2 ml of Water for Injection to accommodate the dead space after administration of the drug. Documentation of administration and monitoring The Subcutaneous Syringe Driver Administration Record and Monitoring Form must be used to record details of preparation and subsequent administration and monitoring. The following must be documented: details of preparation and commencement. Checks at 4 hourly intervals: site appearance (no redness). Subcutaneous cannula can be left in situ for 7 days if no issues. syringe/line contents appearance (absence of clouding, crystallisation or colour change) infusion rate setting volume remaining ( remember to correlate the volume remaining with the time remaining) volume infused battery status (shown as a percentage on the display panel on the front of the syringe pump) any problem noted and action taken disposal of any remaining syringe contents. Page 15 of 29

16 Disconnecting the infusion The T34 syringe driver MUST NOT be left in situ when the patient bathes / takes a shower. In this situation or for any other occasions where it is necessary to temporarily disconnect or stop the infusion e.g. to change the battery: PRINCIPLE 1 Wash hands as per infection prevention and control policy 2 Unlock the keypad by pressing and holding down the blue INFO key until the display shows LOCK OFF. Wait to hear a confirmation beep RATIONALE To minimise the risk of cross infection (DH 2008). 3 Press red STOP key This will stop the infusion 4 Press and hold dark grey ON/OFF To switch pump off key 5 Leave the syringe attached to the pump. Disconnect the extension set from the patient. Ensure bionector is in situ to make a closed system. 6 Store syringe and extension set safely; lock in a Controlled Drug (CD) cupboard if it contains a CD. To ensure infusion is kept locked and secured. Page 16 of 29

17 PRINCIPLE 7 After interruption: Reconnect the extension set to the cannula (ensuring the patient details and prescription are still correct on the label) Turn on the pump by pressing and holding the ON/OFF key Confirm the syringe size and brand Select YES to resume the infusion Check and confirm the volume, duration and rate Select YES to start the infusion 8 If the infusion is to be disconnected permanently and contains a CD, record on the Subcutaneous Syringe Driver Administration Record and Monitoring Chart the date, time, and the amount of solution remaining. The signature of the persons present should also be documented. Dispose of the controlled drug. RATIONALE To dispose of any remaining drug securely Discharge into the community The Discharge Flow Chart, (Appendix 2), should be followed and complete the Equipment Library Returns Form which is available in the Blue Box. (This provides information to the equipment library if the pump is not returned from the community to MESU). It is essential to contact the District Nursing Team as soon as the discharge date is known and inform them of plan to discharge a patient with a McKinley T34 syringe driver. Agree with community team that they will stop and disconnect the T34 and replace the syringe driver with the appropriate device used in their area. The McKinley T34 pump must be returned to NUH in a labelled red envopak bag obtained by contacting equipment library ext Page 17 of 29

18 Instructions for disconnecting the McKinley T34 and a key to the lock box are attached to each red envopak bag. For patients in Nottingham/Nottinghamshire, devices can be returned via the pathology collection service at the local health centre. For patients outside Nottingham/Nottinghamshire it is essential to talk to the family and the medical equipment library agreeing a system of returning the device to NUH. A community syringe driver MUST NOT be connected to the patient prior to discharge. Give and discuss with the patient the You and your syringe pump leaflet. Complete the Medical Device Discharge Agreement Form and file in medical notes. If a patient comes into Nottingham University Hospitals NHS Trust with a community T34 device this is to be removed and replaced with an NUH T34 and the community device sent to the equipment library for return to the appropriate community team Risk management Care must be taken to ensure that the McKinley T34 is NOT immersed in water. Maintenance and cleaning should be in accordance with those listed in the Infusion Device Policy. In the event of an incident, a Datix must be completed and the device returned to MESU informing them of this. What defines an incident? o administration of incorrect medication, dose and /or diluent o infusions completing ahead of time or carrying on beyond intended time of completion o device not alarming o any other incident or near miss which may compromise patient safety or comfort. Page 18 of 29

19 Syringe Pump Maintenance All pumps are serviced regularly by MESU according to a defined schedule and at least annually. Syringe pumps should be sent for maintenance checks when they have been dropped, submerged in fluid, if there is any doubt as to their handling operation whilst in use or the service sticker date is overdue. Cleaning and Decontamination Following use, cleaning should be carried out using Clinell green wipes as per policy. Dry thoroughly. If any additional cleaning is required e.g. the treads of the screws the actuator moves along, contact MESU. Do Not attempt to submerge the pump. Training All staff using the McKinley T34 syringe driver must be personally competent and accountable in the use and operation of this device. Staff must have attended a McKinley T34 pump training session; this must include the use of the McKinley T34 as an infusion device and information on the clinical implications for use. Staff must also have been assessed and verified as competent using the NUH T34 Ambulatory Syringe Driver Competencies (obtained from your trainer or the Medical Devices Training Team ) City ext QMC ext A record of trained and competent staff must be kept, in line with NUH guidelines. A three yearly update is required to maintain competence. Page 19 of 29

20 References: DH (2008) Clean, Safe Care: Reducing infections and Saving Lives. London, DH. Dickman, A. Schneider, J. and Varga, J. (2005) The Syringe Driver (2 nd ed) Oxford University Press: Oxford Dougherty, L. and Lister, S. (2008) The Royal Marsden Manual of Clinical Nursing Procedures. Wiley Blackwell. Oxford. Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. London, Nursing and Midwifery Council. Thomas, T. and Barclay, S. (2015) Continuous subcutaneous infusion in palliative care: a review of current practice. International Journal of Palliative Nursing 21(2) Twycross, R. Wilcock, A. and Stark Toller, C. (2009) Symptom management in Advanced cancer (4th ed) palliativedrugs.com Ltd: Nottingham Twycross, R. and Wilcock, A. and Howard P (2011) Palliative Care Formulary (5th ed) palliativedrugs.com Ltd: Nottingham Page 20 of 29

21 (Appendix 1) Guidelines for disconnecting a McKinley T34 syringe driver (Advice for community nurses attached to red envopak bag with key to lock box) To discontinue the McKinley T34 pump: 1. Remove keypad lock by pressing and continually holding down the blue INFO key. Wait to hear a confirmation beep. 2. Press red NO key, this will stop the infusion. 3. Press dark grey ON/OFF key to switch off. 4. Lift barrel clamp up, and rotate anti-clockwise. 5. Remove syringe from pump, remove subcutaneous cannula and discard, recording the disposal of any remaining syringe contents 6. Recommence syringe driver using local procedure 7. Remove battery 8. Return the T34 pump to the equipment library, at Nottingham University Hospitals in labelled, zipped red envopak bag (provided). For queries about clinical issues e.g. compatibility or volumes contact: The Hospital Palliative Care Team: (Mon-Fri 8am-4pm) QMC Campus: internal ext City Campus: internal ext For queries about technical issues contact: Clinical Engineering Response Centre, QMC Tel ext For queries out of hours: Hayward House Direct line Or ext: Page 21 of 29

22 (Appendix 2) Discharge Flow Chart for a patient with a McKinley T34 syringe driver Communication Contact DN/GP/NH Manager. Inform McKinley T34 syringe driver in progress. Patient will be leaving NUH with T34 in situ. Syringe driver to be returned to NUH equipment library within 24 hours of discharge via the pathology collection service at local health centre (Nottingham only *) Equipment Library Patient Family Medication Point of discharge Contact equipment library ext 64287: request red envopak bag and provide details of patient name, NHS number and discharge destination so that the device can be tracked and returned to NUH. Complete Equipment Library Returns Form (in blue box) Educate patient and family on care of syringe driver and provide general instructions booklet You and your syringe pump (in blue box). Complete Medical Device Discharge Agreement Form (in blue box) and file this in the patient s medical notes. When in the community if patient and/or family have concerns about medication use or sideeffects to contact G.P. and /or district nurse. Obtain TTO s Fax ETTO form to DN and / or GP 24 hours prior to discharge Ensure the patient has sufficient medication in the syringe driver to cover the next 24 hour period. Check the battery life, if less than 40% replace with a new battery. Discharge patient with the red envopak, check key and disconnection guidelines are attached. Return the blue box to the equipment library with the Equipment Library Returns Form ASAP Page 22 of 29

23 *If outside Nottingham liaise with the community team and family regarding returning the pump directly to NUH equipment library. Discharge documentation in Blue Box: You and your syringe pump leaflet give to patient/family Medical Device Discharge Agreement Form file in medical notes. Equipment Library Returns Form return to equipment library Page 23 of 29

24 (Appendix 3) McKinley T34 Trouble Shooting Guide McKinley T34 pump alarm conditions When the pump detects a problem four things occur: 1. the infusion stops 2. an audible alarm is activated 3. a message appears on the display screen indicating the cause of the alarm 4. the LED indicator turns RED. The alarm will sound for the following reasons LCD Display Alarm type Possible cause Action Occlusion or Syringe Empty Audible and visual alarm Patient cannula / line blocked, kinked. Occlusion Infusion has finished Press YES to silence alarm Remove occlusion and restart If two occlusions occur change cannula record all actions on the Subcutaneous Syringe Driver Administration Record and Monitoring Form. End of program, switch Syringe Displaced Pump paused too long Near end End program Audible and visual alarm Intermittent beep the alarm is insistent Audible and visual alarm Intermittent beep Audible and visual alarm Intermittent beep 3 beeps/3 min silence Audible and visual alarm Intermittent beep Syringe has been removed or displaced Pump left or no key presses detected for 2 minutes 15 minutes from end of infusion Infusion complete pump off Check and confirm syringe is seated correctly and resume infusion Syringes need to be in the horizontal position at all times Start infusion, continue programming or switch off Prepare to change syringe or switch off Pump will alarm. Press YES to confirm end of program and OFF to switch pump off Page 24 of 29

25 Low battery End battery Audible and visual alarm 2 beeps 3min silence Audible and visual alarm Battery is almost depleted (30 minutes left) Battery is depleted Prepare to change battery and resume infusion Change battery and resume infusion N.B. With pump running, occlusion may take more than 2 hours to alarm. The T34 operates an anti-bolus back-off system, consequently approximately 38 minutes is added to the infusion time following an occlusion. Other problems: Pump running fast (i.e. running more than 1 hour ahead of expected time) If major over-infusion, stop infusion, check condition of the patient and seek medical advice. Report as a medication incident. Check that neither the line nor cannula have become disconnected. Check correct syringe size has been selected. Check syringe securely attached to the pump. Check there is no air present in syringe. Check that the pump has not been placed above the height of the patient (risk of siphonage). Action: change the entire syringe pump for a new one and send original to MESU for servicing stating the nature of the problem and include the syringe used and administration line. Complete Datix. Pump running slow (i.e. running more than 1 hour behind expected time) Check the syringe pump light is GREEN and flashing once every 32 seconds. Check the battery level. Check the correct syringe size has been selected. Check the syringe is inserted correctly into the syringe pump (actuator is against the plunger). Establish if syringe pump has been stopped and restarted for any reason (i.e. disconnected whilst patient in shower, or occlusion). Check contents of syringe and line for crystallisation/ kinking of tube. Check cannula site is it red, hard, lumpy, sore? Page 25 of 29

26 Action: change cannula site if necessary. Consider further dilution of drugs to minimise irritation contact Hospital Palliative Care Team (HPCT) (Monday Friday 8am-4pm) ext /68402 or Hayward House ext for advice. If syringe pump continues to run slowly at the next check, change the entire pump and send to MESU for servicing stating the nature of the problem. Complete Datix. Site irritation Change site, use new cannula. Dilute drugs to a larger volume in new syringe contact HPCT or Hayward House for advice (numbers above) Discuss possible drug changes with doctor (Cyclizine = most common cause). Consider separating into 2 syringe pumps. Consider other possible routes of drug administration e.g. rectal. Precipitation, cloudiness or colour change in syringe contents or line Stop infusion and inform prescriber. Things to check and discuss with prescriber include: o compatibility information SDSD site, most up to date Palliative Care Formulary or Syringe Driver Drug Compatibility Charts in Blue box o dilute to larger volume contact HPCT or Hayward House (numbers above) for advice o consider separating into 2 syringe pumps o consider giving one drug by bolus administration o keep away from sunlight and heat. Action: following discussions as above, commence new infusion at a different site with new cannula and extension line. Page 26 of 29

27 (Appendix 4) Choice of subcutaneous cannula The BD Saf-T-Intima cannula is the choice of cannula for subcutaneous medications at NUH. The rationale behind this preference is: site reactions are less common insertion is less traumatic needle stick injury is reduced to patient and staff. BD Saf-T-Intima 22 Gauge cannula (blue -stores code number L003052) Figure 3- an example of a Saf-T-Intima cannula Best Practice The BD Saf-T-Intima cannula has a dead space of 0.2mL. It is not primed before or after insertion. If a patient is started on a continuous subcutaneous infusion they will require a separate BD Saf-T-Intima cannula for bolus medications Equipment list: BD Saf-T-Intima 22 gauge cannula (blue, L003052) 24 gauge (yellow) can be used occlusive dressing non sterile gloves bionector Page 27 of 29

28 Principles of care See General Principles for All Procedures. PRINCIPLE 1 Explain the procedure to the patient and gain consent (if patient is able to give consent) RATIONALE Gain co-operation, reassure and minimise anxiety. Obtain permission from the patient (NMC 2015) To minimise the risk of cross infection (NUH 2013). To prevent the introduction of infection 2 Wash hands as per infection prevention and control policy 3 Ensure that the skin is socially clean. Wash with soap and water if visibly soiled 4 Apply gloves 5 Pinch the patients skin between the To ensure subcutaneous tissue is thumb and forefinger identified 6 Insert the cannula at a 45 degree angle with the bubble surface of the wings face down. 7 Secure the cannula at the insertion To ensure it remains in place site with the occlusive dressing 8 Pull the needle safe system down in one smooth single movement 9 If this movement is unsuccessful or Rotation of the site prevents if blood appears in the cannula discomfort for the patient. choose a fresh cannula at a different site and repeat points Dispose of the needle in a sharps To prevent a sharps injury to container as per NUH policy patient or a member of staff 11 Remove and dispose of the clamp To avoid accidental occlusion on the BD Sat-T-Intima 12 Replace the bung with a bionector. To enable the administration of medications via a needless system 13 Document in the nursing notes the date, time and place of cannula insertion. 14 Remove gloves and wash hands as per NUH Hand hygiene policy To identify when the cannula requires removal. To minimise the risk of cross infection (NUH 2013). Page 28 of 29

29 Audit Points currently obtained Number of staff deemed competent within a clinical area Number and type of incidences involving a McKinley T 34 syringe driver New audit points to be considered Documentation of syringe driver checks Authors: Alison Freemantle and Lindsay Hall Amended: 9 January 2018 Nicola Jones Ratified by EBPC: 20 th June 2018 For Review: December 2020 Page 29 of 29