SYRINGE DRIVERS: GUIDANCE FOR THE USE IN THE COMMUNITY and COMMUNITY HOSPITAL SETTING WITHIN WORCESTERSHIRE

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1 Trust Guideline SYRINGE DRIVERS: GUIDANCE FOR THE USE IN THE COMMUNITY and COMMUNITY HOSPITAL SETTING WITHIN WORCESTERSHIRE All healthcare professionals must exercise their own professional judgement when using guidelines. However any decision to vary from the guideline should be documented in the patient records to include the reason for variance and the subsequent action taken. Lead Clinician(s): Chris Freke Designation: Professional Practice Facilitator District Nursing Lead Director Sandra Rote, Director of Clinical Development Ratified by WPCT Quality and Safety Committee: 26 th March 2008 This Policy should not be used after end of: March 2010 Links into Healthcare Standard: Impact Analysis (Race Equality) Impact Analysis (Mental Capacity Act)

2 CONTRIBUTION LIST Key individuals involved in developing the document Name Dr Claire Curtis Glynis Ash Kate Hall Beryl Taylor Alison Glover Julie Taylor Susan Shaw Sue Lunec Designation Consultant in Palliative Medicine Clinical Nurse Specialist Palliative care Clinical Nurse Specialist Palliative Care Clinical Nurse Specialist Palliative Care District Nurse District Nurse Head of Education St Richards Hospice PCT Pharmacy Lead Circulated to the following individuals for comments Name Dr Ian Douglas Sally Knowles Vicky Preece Michael Harper Nicky Wilderspin Deborah Narburgh Maria Wilday Ginny Snape Marjorie Wallace Sue Baker Linda Ingles Della Lewis Jane Freeguard Designation Clinical Director for Palliative Care services Matron St Richards Hospice Associate Director of Nursing Medical Director St Richards Hospice Consultant in Palliative Medicine WRH Sister Wyre Forest Community Unit Matron/ Hospital Manager POWCH Matron Tenbury Wells Community Hospital Service User Matron Evesham Community Hospital Matron Malvern Community Hospital Clinical Governance Co-ordinator Head of Medicines Management & Pharmacy Page 2 of 10

3 Contents Contents Introduction Aim of Guidance Scope Responsibility Education and Training The syringe driver Use of loading / bolus doses Equipment Preparing the infusion Preparing the syringe driver Commencing the infusion Care of the syringe driver Mixing of drugs in the syringe driver Documentation Prescriptions / Directions The administration record should contain: The observation chart should contain: The care plan held with the patient should contain: References...10 Page 3 of 10

4 1.0 Introduction Subcutaneous administration of drugs is common and accepted good practice in palliative care. The syringe driver is a small, portable battery-driven infusion pump used to deliver medication subcutaneously when other routes of drug administration such as oral, buccal, rectal and transdermal are unsuitable. It is intended that this guidance is used in conjunction with the recently revised West Midlands Palliative Care Physicians (WMPCP) Palliative Care Guidelines for the use of drugs in symptom control 4 th edition 2007, the contents of which should meet the needs of most patients and is accepted as current best practice in the West Midlands Region. 2.0 Aim of Guidance The aim of this guidance is to assist the practitioner s decision making whilst caring for patients in the community setting within Worcestershire who require symptom control using drugs delivered by the Graseby MS26 (Green) syringe driver also known as the daily rate syringe driver. It will also facilitate a countywide approach to managing patients with a syringe driver that promotes a safe and consistent method of practice. However, being an advisory document it does allow the practitioner some degree of clinical freedom as long as any deviation from the guidance is documented and justified in the patient s medical and nursing notes. 3.0 Scope This guidance applies to Registered Medical and Nursing staff working within or on behalf of Worcestershire Primary Care Trust who provide palliative care to patients in their own home, Registered Care Homes and Community Hospitals within Worcestershire. 4.0 Responsibility All practitioners who perform this procedure should be aware of the content of this guidance. In addition, all Registered Nurses have an individual responsibility to ensure that they feel confident and competent in the knowledge and skills of practice in line with their Scope of Professional Practice (NMC, 1992) and Code of Professional Conduct (NMC, 2002). They should inform their immediate line manager if they feel they are not competent and discuss their training needs. Practitioners should also use this guidance in conjunction with the Trust s Consent Policy, Infection Control Policy and Procedures, Medicines Policy and Clinical Record Keeping Guidelines. All incidents, including dosing errors etc, should be reported following the PCT Incident Reporting Policy. Page 4 of 10

5 5.0 Education and Training In order for practitioners involved in the setting up and maintaining of treatment via this route to demonstrate the safe and effective use of a syringe driver, education and training that is both theoretical and practical and based on the principles of best practice should be made available. This will be achieved by accessing the website registering on line and successfully completing the e-learning Graseby syringe driver in palliative care package shortly before attending a practical syringe driver workshop provided by the Clinical Nurse Specialists in Palliative Care around the county. This is an essential training requirement that should be undertaken every 2 years. Practitioners will need to evidence their theoretical knowledge by producing their printed e-learning certificate at the practical workshop. 6.0 The syringe driver As syringe bore sizes vary with different manufacturers and syringe volumes, it is the length of the infusion fluid that is important, not the volume in the syringe. It is therefore recommended that the syringe is filled to a standardised length of 48mm for a 24-hour infusion (WMPCP, 2007). This means that whenever there is a need to prime an infusion line it will run through in less than 24hours. If this occurs at a time that is likely to create logistical difficulties for practitioners maintaining treatment via this route, then a more convenient time can be chosen to replenish the syringe driver within that 24 hour period. Equally, if a patient is discharged into the community setting with a different syringe driver in use, the infusion and the device should be removed and replaced with a freshly loaded syringe using the green Graseby MS26 as soon as possible. If doses of drugs need to be changed during the course of a 24-hour infusion then once again, remove and replace with a freshly loaded syringe. Never add medication to an existing syringe or alter the rate of the syringe driver in order to change a drug dose. 7.0 Use of loading / bolus doses When a subcutaneous infusion of drugs is commenced there is a significant time lag before therapeutic levels are achieved. The need for a separate subcutaneous loading dose of drug(s) should therefore be discussed with the prescriber. A loading dose is specifically indicated if the patient has uncontrolled symptoms at the time of initiating a syringe driver infusion. The prescribing of separate as required subcutaneous bolus doses of drugs is also recommended whenever a syringe driver is in use for palliative or terminal care. Never use the syringe driver to administer a loading or bolus dose of drug. Page 5 of 10

6 Ideally, changes in drug doses should be made after combined medical and nursing reassessment. Some General Practitioners may, in conjunction with their District Nursing teams, decide to prescribe a dose range to facilitate titration of medication to achieve timely control of symptoms. This dose range should allow for both the reduction and increase of the drug involved as clinically appropriate and should be made clear by the prescriber on the prescription chart. 8.0 Equipment Graseby MS26 (green) syringe driver 9v battery Luer-lok syringe (usually 10ml but 20ml or 30ml may be used) Infusion or giving set with a volume of 1ml or less Fine gauge needle (23G or 25G butterfly) Clear adhesive film dressing Diluent (usually water for injections) Medication as prescribed. Single use preparations should be used in preference to multi-dose vials Label to be attached to the syringe barrel so that the graduations can still be clearly seen after being completed with the patient s name, name and dose of drug(s), diluent, final length/volume (mm/ml), date and time prepared and signature(s) of preparing nurse(s) Sharps bin 9.0 Preparing the infusion Read all the prescription details carefully and confirm that they relate to the patient to be treated. Check that the prescribed dose has not already been given and that it is appropriate to administer this to the patient under the circumstance. Check that the time elapsed since any long acting preparations is sufficient. Ensure that the area in which the medicine is to be prepared is as clean, uncluttered and free from interruption and distraction as possible. This may mean closing doors on family and patients in the patient's home. Check expiry dates of medications. Check for damage to containers, vials or packaging and for correct storage. Read all labels carefully since some packaging for drugs is identical except for the drug strength. Check the patient has no known allergies to the preparations. Page 6 of 10

7 Make a note of the volume (ml) that measures 48mm in length against the syringe driver. This may vary with different makes and sizes of syringe. Any calculations should be written down in full and a second healthcare professional should independently work the calculation or it should be rechecked by the first individual in circumstances where there is no second healthcare professional available. Prepare the label for the prepared medicine. Dissolve powdered drugs to be used with water for injection using a non-touch technique. Draw up drugs into the syringe and dilute to the volume required with sterile water for injection. Fit a blind hub if available to the administration syringe and invert the syringe several times to ensure good mixing. Remove the blind hub. Tap the syringe lightly to aggregate the air bubbles at the needle end. Expel the air and refit the blind hub. Check the syringe for cracks and leaks and then label. Connect syringe to the infusion line using the luer-lok. The infusion line will need to be primed using some of the contents of the loaded syringe if you are initiating or re-siting the infusion. Keep ampoules and any unused medicine until syringe driver set-up is complete to enable further checking procedures to be undertaken. Any unused solutions should be disposed of by emptying onto a small amount of adsorbent material and dispose in the sharps bin taking care to avoid sharps injury Preparing the syringe driver Set the rate of delivery. For the green Graseby MS26 this will usually be 48mm/day. Insert battery: alarm will sound for a few seconds. Attach loaded syringe to top of syringe driver fitting the flange of the barrel into the slot provided and secure in position with the strap. Press the white release button to slide activator assembly up to the syringe plunger and clamp in place. Page 7 of 10

8 11.0 Commencing the infusion Insert fine gauge butterfly on the end of the infusion line into the skin of the anterior chest wall (or other convenient subcutaneous site) after it has been cleaned with a 70% isopropyl alcohol swab. An angle of 45 degrees to the skin should be used although this may not be possible in very thin patients. Loop the line once to reduce traction and secure using a clear adhesive film dressing. Start the syringe driver by pressing the start/boost button. The operating light will flash every seconds on the MS26. Remember not to use the boost button to administer loading or bolus doses of drugs (see 6.2). Protect the mixture from light by using a holster or covering and place the syringe driver in a convenient place below the level of the insertion site Care of the syringe driver Check the syringe driver and infusion at each visit for: Irritation at the infusion site re-site or seek medical/specialist advice Crystallisation (precipitation) of drugs Light flashing (if not check the battery) Secure connections or kinked tubing Leakage Correct volume remaining 13.0 Mixing of drugs in the syringe driver The current version of the West Midlands Palliative Care Guidelines should be kept with all Clinical Guideline Folders for staff to refer to and at sites where syringe drivers are used for palliative care therapy. Technical information about compatibility, stability and efficacy of drugs mixed in syringes is available in the guide. Try to avoid mixing more than two drugs in a syringe unless there is specific advice at the doses required. Do not leave drugs in a syringe driver for more than 24 hours. Only use unusual combinations of drugs under the guidance of a specialist in Palliative Medicine. Dexamethasone is best given in a separate syringe driver or as a separate subcutaneous bolus dose once daily as its compatibility is unpredictable. Page 8 of 10

9 14.0 Documentation 14.1 Prescriptions / Directions Medication for use in a syringe driver should be clearly written using documentation specifically dedicated for this purpose. It is important that whatever documentation is in use it should contain the following information: The patients name address and date of birth. The name and dose of each drug to be infused over 24 hours. The name, dose, indication, interval between doses and maximum 24hr dose of each drug to be administered as a bolus in anticipation of breakthrough symptoms. The name and range of drug doses that may be titrated to maintain symptom control. The name and signature of the prescriber The administration record should contain: The date and time of each dose given / infusion commenced. The name and dose of the drug(s) given. The route. The drug stock remaining (controlled drug(s) only). The administering practitioners signature The observation chart should contain: The date and time of each observation. The rate in mm that the syringe driver is set at (this should usually be 48mm). The length of infusion (mm) / volume of fluid left in the syringe. The appearance of the fluid in the syringe e.g. cloudy or clear The appearance of the infusion site. Confirmation that the syringe driver light is flashing and the syringe is functioning. The signature of the observing practitioner The care plan held with the patient should contain: The indication for the subcutaneous infusion. An assessment of the efficacy of the drug regimen at each visit. A record of the indication for and subsequent effect of bolus doses of medication when they have been administered. A record of the reason for any dose adjustments. A record of any observed or reported toxicity associated with the infusion e.g. opioid induced hallucinosis and the action and response taken. Page 9 of 10

10 Further information on the use and management of syringe drivers and the use of drugs in symptom control can be found in the Guidelines for the use of drugs in symptom control (WMPCP, 2007) 15.0 References Nursing and Midwifery Council (NMC 2002) Code of Professional Conduct Nursing and Midwifery Council (NMC 1992) Scope of Professional Practice WMPCP (2007) Palliative Care Guidelines for the use of drugs in symptom control 4 th edition Independent Production Promoting safer use of injectable medicines, National Patient Safety Agency Page 10 of 10