Adult Palliative and Supportive Care: Ambulatory Syringe Driver Policy (including Symptom Management Guidelines)

Transcription

1 Adult Palliative and Supportive Care: Ambulatory Syringe Driver Policy (including Symptom Management Guidelines) (CME McKinley T34 (ml/hour)) 2012 Page 1 of 52

2 FAMILY NURSING & HOME CARE RATIFICATION FORM Type i.e. Strategy, Policy, Education Package etc. Name Policy Ambulatory Syringe Driver Policy Category i.e. organisational, clinical, Corporate, Finance etc Clinical Version 1.0 Author H&SS Approved by i.e. Operational Governance Group Julie Gafoor, Chief Executive Officer Date Approved April 2012 Review Date April 2014 Person responsible for review Approved by i.e.sub Committee, H&SS FNHC Operational Governance Group Hospital Care Quality Group/Community Care Quality Group/Medicines Governance Committee, HSS Palliative & Supportive Care Group Policy Amendments Version No. Amendments Copy of this form to be given to Information Governance Officer Page 2 of 52

3 CONTENTS LIST: 1. Introduction Page 4 2. Aim Page 4 3. Roles and Responsibilities Page 5 4. Development and Consultation Process Page 5 5. Training Page 5 6. Indications for Use Page 6 7. Set Up Procedure Page 7 8. Procedure Page 8 9. Monitoring the Infusion Page Safety and Risk Management Page References Page Appendices Page 27 Page 3 of 52

4 1. INTRODUCTION Within the policy document, the terms syringe driver and syringe pump, are synonymous. 1.1 Rationale Palliative and Supportive Care is defined as: an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, an impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. (World Health Organisation 2002). Adult Palliative and Supportive Care is an important area of clinical practice that requires specialist knowledge and skills sets to ensure that the highest standards of practice are applied and best practice principles, based upon the most up to date contemporary evidence. The use of Ambulatory Syringe Drivers assists practitioners in delivering such care. The use of the CME McKinley T34 Ambulatory Syringe Driver addresses the recent medical alert (NPSA, 2011) concerning the use of syringe drivers that deliver medication in mm/24 hours. The T34 only delivers medication in ml/hr which is concurrent with best practice guidelines. The T34 is a small, lightweight, battery powered ambulatory syringe pump. It weighs approximately 210g excluding the battery and measures 169mm x 53mm x 23mm. The syringe driver is used to deliver drugs at a predetermined rate over a 24 hour period in ml per hour. The use of such a device for the delivery of continuous subcutaneous infusion (CSCI) of medications is a well established technique in palliative care (Dickman et al 2005) as it allows for relatively constant levels of medication to be administered, avoiding peaks and troughs which can result in reduced symptom control (Hunt 2002). 1.2 Scope These guidelines have been produced following consultation with practitioners from all areas to support the delivery of consistent, high quality care through best practice principles. This policy and procedural guidelines to be shared between Jersey H&SS, Family Nursing and Home Care and Jersey Hospice Care for adult palliative and supportive care patients. These areas have been identified as it must be acknowledged that differing ambulatory syringe drivers and polices/guidelines are in use in other care settings within Jersey. This guideline concentrates on safe use of the McKinley T34 ambulatory syringe driver in adult palliative care. It may be used to administer drugs in other circumstances but these, as well as the use by parenteral routes other than subcutaneous, are outside the scope of this policy. 2. AIM The aim of the policy is to promote and sustain improved clinical practice and care standards to adult palliative care patients, throughout the aforementioned clinical areas, in the use of the McKinley T34 ambulatory syringe driver. Page 4 of 52

5 3. ROLES AND RESPONSIBILITIES Divisional Managers, Departmental Managers, Ward Managers and Clinical Consultants are responsible for the implementation of these guidelines within their clinical teams. 4. DEVELOPMENT AND CONSULTATION PROCESS 4.1 Consultation Schedule Name of Committee/Group Date of Committee/Group meeting H&SS Palliative and Supportive Care Group December 2011 Medicines Governance Committee February, March 2012 H&SS Care Quality Group February 2012 Primary Care Quality Group March 2012 Documdentation Group March TRAINING 5.1 All staff using a syringe driver must be personally competent and accountable in the use and operation of such devices. Managers should ensure that relevant training takes place (e.g. at induction) and maintain a record of staff who are trained and competent to use such devices. (The Management of Infusion Systems SEHD 1995). Competencies in the use of syringe drivers are available. All staff using a syringe driver, first level nurses and above who are on the NMC register must be personally competent and accountable in the use and operation of such devices 5.2 Initial training will be undertaken by the McKinley Clinical Trainer who will undertake super user training for key staff. These key trainers will cascade the training and any updates to their individual teams. A list of their names will be placed on the Palliative Care page on the HSSD intranet site. 5.3 Once staff have undertaken the initial training all staff must pass a competency based assessment (Appendix 1) 5.4 Additional resources available to staff are an on line tutorial in the use of the McKinley T34 syringe driver on the McKinley website, H&SS intranet palliative care page and jerseyhospicecare.com/palliativecareresources 5.5 The principles behind the training are linked to a practical workshop giving handson experience of handling the equipment and preparing drug mixtures. Participants are expected to follow the training session with a period of personal study and supervised practice 5.6 Training records should be maintained in each clinical area for all staff that may use the ambulatory syringe drivers 5.7 As with all medical devices, operation of the syringe driver should only be undertaken by, or under the supervision of, appropriately trained personnel 6. INDICATIONS FOR USE Page 5 of 52

6 Ambulatory syringe driver care bundle to be implemented in conjunction with ambulatory syringe driver policy. 6.1 The syringe driver can be used to control pain and symptoms in clinical settings when the patient is unable to absorb, tolerate or take oral medications for reasons including: difficulty swallowing intractable nausea and vomiting bowel obstruction head and neck tumours/surgery severe weakness semi-conscious state comatose/moribund patients malabsorption stomatitis patient compliance issues patients requiring regular injections patients struggling with large amounts of oral medications Other alternative routes may be effective for some symptoms. NHS Highland and Highland Hospice (2006) 6.2 Syringe driver will not deliver a better analgesic effect than the oral route unless there is a problem with absorption or administration 6.3 Many patients and relatives associate the use of syringe driver with the end of life. It is of vital importance to reassure them that they are purely an alternative means of delivering medication 6.4 Advantages of using a syringe pump: Delivers drugs at an even rate continuously, maintaining plasma concentration at an optimum therapeutic level therefore improving symptom control Increases patient control, removing the fear and pain of regular injections Allows delivery of drugs through a single site for days/weeks Allows for combination of drugs via a single site Portable and light weight device therefore allows for independence and mobility Accurate infusion timing Multiple symptoms can be managed Potential to increase the quality of life 6.5 Disadvantages of using a syringe pump: Local site reactions from irritant drugs Negative impact upon body image Potential of technical problems Dose titration not possible without renewing whole infusion Potential for psychological dependence on device Page 6 of 52

7 Barrel clamp arm on pump vulnerable to damage with rough handling May cause fear and distress through association with end of life status Potential difficulties in establishing patent infusion site in certain patients e.g. oedematous patients or cachexic patients NHS Highland and Highland Hospice (2006) NB- Transdermal (Fentanyl patches) - SHOULD NOT BE STARTED AS A FORM OF PAIN CONTROL AT THE END OF LIFE, the patches take a long time to titrate and dying patients often have rapidly changing requirements. If a patient is already on a Fentanyl patch then DO NOT REMOVE THE PATCH and if you need to increase the level of pain control add a syringe driver with the equivalent of two prn doses. If you need to increase the dose further please call for advice (see appendix 6 pg 52). If you need to consider an alternative to the Fentanyl patch for reasons such as poorly controlled pain, opioid toxicity, fever (that increases drug absorption) or that your patient s sweating is difficult to control and the patch won t stick, please ask for advice. (Appendix 3 pg 37). 7. SET-UP PROCEDURE Informed consent must to gained prior to commencement of ambulatory syringe driver usage 7.1 Equipment required T34 ambulatory syringe driver and plastic lockbox/key/holster 9V alkaline battery (recommended Duracell MN1604) Luer lock syringe 20 or 30ml (recommended BD Plastipak) Subcutaneous infusion set ( S Gauge Butterfly needle Syringe Set). Teflon cannula sets (e.g. MiniMed Silhouette priming volume 0.15ml) are particularly suitable for use with cachetic patients or where a metal allergy already exists. Antiseptic wipe (2% Chlorhexidine 70% alcohol) Transparent surgical dressing (IV 3000) or local equivalent Syringes and needles (filter needles) to prepare medication Prescribed medications and diluents Sharps bin Medications additive label McKinley T34 Subcutaneous Infusion Prescription (HSS), or local Subcutaneous Infusion Prescription (Hospice & FNHC) Monitoring Chart Clean tray or surface for preparation Page 7 of 52

8 7.2 Prescription The prescription should contain the following: Date Patient details full name, date of birth, URN Generic name of the medicine(s) preferably in capital letters Route and time of administration. i.e. subcutaneous infusion by syringe driver over 24 hours Signature of prescriber and bleep/contact number Prescriber has fluently communicated prescription and management plan with the administrator Medications used within palliative care are frequently used off-license and therefore both prescriber and administrator of these medications must be fully understanding of this situation please refer to the Health and Social Services policy on unlicensed medication and/or contact Specialist Palliative Care Professional for advice Label the syringe with patients name, number, D.O.B, medication name and dose, diluent and total volume in ml, date and time prepared and initials of those individuals preparing the syringe Apply the label to the syringe barrel in such a way as not to obscure the measuring gauge on the syringe or the sensors on the syringe driver 8. PROCEDURE Action 1 Discuss the use of the syringe driver and explain the procedure to the patient and if appropriate the family. PRN medication will be required to control symptoms in addition to the syringe driver medications and until the infusion by syringe driver takes effect. 2 Assemble equipment. Check all packaging before opening and prepare the equipment on a clinically clean receptacle or surface. Rationale To obtain informed consent and care concordance Due to the slow rate of infusion there can be up to a 4 hour lag period until optimal levels of medication are reached. (Twycross and Wilcock 2007) To reduce the transmission of microorganisms and to ensure that no equipment is damaged. Page 8 of 52

9 3 To fill syringe: (using filter needle) Draw up first if this is being used with at least 1ml of the diluent, then add the second drug where required, adding more diluent to the total volume. 20ml syringe fill to 18 ml 30ml syringe fill to 23.5 ml 50ml syringe fill to 34.5 ml (following Specialist Palliative Care advice only). Only Luer lock syringes should be used. To reduce the risk of precipitation and particulate spyphonage (Greater Glasgow and Clyde NHS 2009). A 20ml syringe is the recommended minimum: -Diluting the mixture reduces risk of adverse site reactions and incompatibility. (Dickman et al 2005). The needle syringe set only needs 0.2ml to prime so does not need to be taken into consideration when filling the syringe. (McKinley Medical UK Ltd 2006). Teflon cannula sets (e.g. MiniMed Silhouette priming volume 0.15ml) are particularly suitable for use with cachetic patients or where a metal allergy exists. (NHS Highland, NHS Greater Glasgow & Clyde 2007). To prevent the syringe becoming dislodged from the line. Ensure the correct dosage is withdraw from the medication ampoules certain ampoules contain medication overage which could lead to incorrect doseaging. 4 Invert the syringe to mix medications observing for cloudiness or crystallisation. 5 Attach a completed syringe driver additive label to the Luer lock syringe, taking care not to obscure the numbering on the syringe or interfere with the mechanism of the infusion device, i.e. the barrel clamp arm. To ensure correct medication dosages are used as per prescription. This could indicate incompatibility of medications and/or solution. Discard if this occurs. Contact the Prescriber, the Specialist Palliative Care Team and/or Hospital Pharmacy Department. (Twycross and Wilcock 2007). In the instance of a change in prescribed medication ensure a new 25 gauge butterfly needle syringe set is used. The scale on the Luer lock syringe needs to be visible during the infusion process. 6 If a new infusion set is being used, connect the syringe to the infusion set and prime the line manually. Syringes should be prepared immediately prior to use. The medications within the syringe are stable for 24 hours. Page 9 of 52

10 Action 7 T34 Feature recognition syringe loading Rationale 1. Barrel clamp arm detects syringe size/ width of barrel and secures the syringe 2. Syringe ear / collar sensor detects secure loading of plunger 3. Plunger sensor detects secure loading of syringe plunger 8 T34 Feature recognition keypad. Info key access event log / Set Up (code protected) battery status. Up / down arrow keys increase / decrease parameters / scroll options Yes / Start Key confirms selection / starts infusion. No / stop step back a screen / stops infusion. FF - Forward moves actuator forward. Back moves actuator back. On / Off 9 Install the battery - To fit or change a battery remove battery cover and insert a new 9V alkaline battery into the driver- the recommended battery is a Duracell MN1604 other brands can be slightly larger and may not fit the device properly. Ensure that the +ve/-ve contacts are aligned correctly. To ensure the driver has a correctly fitted battery. Replace battery cover and switch on driver. Before placing the syringe into the Page 10 of 52

11 pump ensure the barrel clamp arm is down then press and hold the On/Off key until the SELF TEST screen appears. During pre-loading the actuator always returns to the start position of the last infused programme. The LCD display will show PRE- LOADING and the actuator will start to move. Wait until it stops moving and the syringe sensor detection screen (syringe graphic) appears. 10 If the actuator is not in the correct position to accommodate the syringe leave the barrel clamp arm down and the FF or BACK buttons on the key pad to move the actuator. Forward movement of the actuator is limited for safety so repeated presses of the FF key may be required. Backwards movement is not restricted. Action 11 Check the battery - Press INFO key repeatedly until the battery level appears on screen and then press YES to confirm. Rationale Discard the battery if less than 40% life remaining in the Community 10% in a hospital setting. Average battery life starting at 100% is approx 3-4 days depending on use. Page 11 of 52

12 12 Fit the syringe to the syringe pump - T34 Feature recognition syringe loading Barrel clamp arm detects syringe size/ width of barrel and secures the syringe 2. Syringe ear / collar sensor detects secure loading of plunger 3. Plunger sensor detects secure loading of syringe plunger Lift the barrel clamp arm. Ensure the line is not connected to the patient. The syringe collar/ear should be vertical To prevent inadvertent medication bolus dose being given.. Seat the filled syringe collar / ear and plunger so the back of the collar / ear sits against the back to the central slot (ensure correct placement). The syringe collar/ear should be vertical. The syringe graphic on the screen ceases to flash when the syringe is correctly seated on all three points. Lower barrel clamp arm. Page 12 of 52

13 13 Confirm that the syringe size and brand match the screen message. Press YES to confirm or scroll with up and down arrows to view other sizes of syringe, press YES to confirm. The McKinley T34 driver are configured to only use BD Plastipak syringes. Action 14 Setting the infusion parameters (New Patient). After the syringe confirmation the first screen displayed is as indicated in the picture below; Rationale All McKinley T34 drivers in HSSD, FNHC & Hospice are configured to infuse over 24 hours. The pump calculates and displays the rate of infusion, press YES to confirm. The pump calculates and displays the deliverable volume, duration of infusion 24 hours and rate of infusion (ml per hour). Press YES to confirm. Pump screen prompts START INFUSION. Page 13 of 52

14 Check the line is connected to the syringe on the pump. 15 Syringe when line is not being primed. After the syringe confirmation, the first screen that appears is as indicated in the picture below; As this is a new infusion press NO FOR NEW PROGRAMME. Connect the line to the syringe on the pump. Page 14 of 52

15 Action 16 Site selection should consider patient preference and care needs: Chest wall anterior, lateral to breast and below the breast in females. Abdominal wall, medial lateral, lower lateral ileal crest. Rationale To promote comfort and concordance. Adequate subcutaneous tissue is required for absorption of prescribed medication. Medication absorption will be affected. Anteriolateral aspects of the thigh Anteriomedial aspects of the thigh Anterior aspects of upper arm Avoid broken/irradiated skin, oedema, bony prominences (Mitten 2001) Avoid the chest wall in cachexic patients. Danger of causing pneumothorax. (Mitten 2001) 17 Insert the needle of the infusion set bevel facing down at an angle of 45 degrees into a pinched skin fold and following the natural curves of the skin. Lay flat and curl tubing once to secure but do not curl over the needle. Place a transparent dressing, such as (Smith & Nephew IV Hand) over the curl of tubing and needle. The butterfly needle must not remain insitu for any longer than 7 days. More frequent changes may be indicated following clinical assessment. To prevent accidental dislodging of the line and allow the fluid to flow into the subcutaneous tissue (Wilson 2000). To allow visualisation of the insertion site and prevent the introduction of infection. To ensure that the butterfly needle does not exceed its maximum time of use and is changed prior to this if required. Action 18 Start the Syringe driver. Pump screen prompts START INFUSION? Rationale Check the line connection to the Page 15 of 52

16 pump and press YES to start infusion. When the pump is running the screen displays: Top line infusion duration time remaining. Main line infusion rate in ml / hour Bottom line alternates between syringe size / brand and the message <<<<pump delivering. Green LED indicator flashes. 19 Lock keypad - With the pump infusing press and hold the INFO key until a chart is displayed showing a progress bar moving from left to right. Hold the key until the bar has moved completely across the screen and a beep is heard to confirm the lock has been activated. To prevent tampering with the device. When keypad is locked the following buttons are still active STOP/NO START/YES and INFORMATION. Unlock keypad - Press and hold the INFO key the bar will move from right (lock) to left (unlock) and a beep will be heard. The pump will still be displaying start infusion Press YES The pump will display the following screen which will remain throughout the infusion. The Green LED indicator will also flash. A breakthrough dose may be required during this initial period. It can take up to 4 hours for drugs to reach therapeutic blood plasma. Page 16 of 52

17 20 Place pump in locked box unless syringe over 30ml. Syringes over 30ml too large to fit in locked box. Each area has been supplied with universal keys. Replacement keys if required are the responsibility of individual teams and staff should contact their line managers. Place in appropriate carrying pouch. To protect medication from light (Dickman et al 2005). Action 21 Complete documentation: Syringe driver monitoring form including asset number of pump (care bundle) Medication chart If used controlled drug book / or medication chart in the Community patient case notes Date and time of administration Name and dosage of medication Record location of infusion site when syringe set up and when line is changed Rationale As per Health & Social Services Department, Jersey Hospice Care, Family Nursing and Homecare policies for the Administration of Medications. Reduces discomfort to patient when monitoring. 22 Do not place the syringe driver more than 75cm above the infusion site. 23 Assess and address the education needs of patient / family. Advise about; Inform them about the name of the syringe driver. how the syringe driver works not putting the pump 75cms above the infusion site checking the driver whilst in use checking the site and reporting if it becomes red / painful Page 17 of 52 Siphonage of medication could occur. (MDA March 2003) This is good practice but butterfly syringe set does have an anti-siphonage device. To gain informed consent and patient/carer concordance.

18 reporting effect of medications/ using PRN medication for breakthrough symptoms. not to get syringe pump wet. Action 24 How to stop the infusion and prime a new line after the infusion has started: Press STOP and disable the keypad lock Disconnect the existing line from the syringe and remove the line from the patient Remove the syringe from the pump. Attach and manually prime a new line Resize the actuator and place the syringe in the pump Confirm the size and make of the syringe Insert the new line / cannula to a new site Press YES to resume the previous programme; the screen will display the volume, duration and rate Press YES to confirm and the screen will display START INFUSION Press YES to confirm 25 How to change the battery when an infusion is running: With the infusion still running, remove the old battery from the pump and replace with a new one Switch the pump back on using the ON/OFF button Confirm the size and make of the syringe. Press YES to resume infusion The screen will display : REMAINING VOLUME, DURATION AND RATE OF INFUSION Press YES to confirm. Rationale DO NOT SWITCH THE PUMP OFF. The time remaining for the infusion will decrease to compensate for the solution that was used to prime the second line. The flow rate will remain the same. Page 18 of 52

19 Screen will display START INFUSION Press YES to confirm. Action 26 Stopping the infusion and removing the syringe pump: When the infusion is nearing completion, a warning will be shown on the LCD display 15 minutes before the end of the infusion. When the infusion is complete and the syringe is empty, the pump will stop automatically and an alarm will sound. If the syringe driver is no longer required for the patient, press yes to confirm the end of the infusion, disable the keypad lock and press and hold the ON/OFF button to switch off the pump. If the infusion is to be stopped before the syringe is empty, disconnect the pump from the patient before the removing the syringe from the pump. Record on the syringe driver monitoring chart the amount of infusion discarded. If the syringe contains controlled medication: Rationale A syringe that is not empty must NEVER be taken off the pump while connected to the patient due to the risk of siphonage of the medication. As per Safe and Secure Handling of Medicine Policy (HSS). As per Safe and Secure Handling of Medicine Policy.local medicines policy (Hospice & FNHC) HSS- destroy the medication in the presence of a qualified witness (e.g. Nurse, Pharmacist). The destruction must be recorded in the organisation s Controlled Drug Register Hospice & FNHC- follow local policy for the destruction and recording of medication/controlled drugs. - In all care settings a suitably absorbent material e.g. swabs should be placed in the Sharps Bin and the medication disposed of onto Page 19 of 52

20 this, as per local policy (HSS, Hospice & FNHC). Clean the pump and the lockbox as detailed on page 22 (do not immerse pump in water). Dry and replace in box if no longer required for use. Action 27 How to temporarily stop the infusion Press STOP, disable the keypad lock and press and hold the ON/OFF button. Do NOT remove syringe from pump. Resuming the Infusion: Check that the prescription, syringe label and patient details match, to ensure that this is the correct syringe for this patient. Reconnect the line to the syringe on the pump if it has been disconnected. Press and hold the ON button until a beep is heard. The screen will request confirmation of syringe size and syringe brand. Press YES to confirm. The screen will display: Remaining volume, duration and rate of infusion. Press YES to confirm. Screen will display: Start Infusion. Press YES to confirm. Rationale This should not be used for priming a second line. If you press NO the pump interprets this as a completely new 24 hour period and the remaining contents of the syringe will be delivered over the next 24 hours from confirming Start Infusion. The patient would not therefore receive the prescribed dose. If NO has been pressed in error, discard the remainder of the syringe contents and prepare and set up a new syringe. Page 20 of 52

21 What to do if the patient dies when the Syringe driver is running: Stop the pump. Press the INFO button and record the date, time and amount of solution remaining to be infused in the syringe (ml). If there are doubts about the circumstances of the death, leave the pump in place and contact your line manager for advice. In a straightforward situation, remove the syringe from the pump, destroy the contents and record the signature(s) of person(s) destroying the remaining solution. Remove the battery from the syringe pump. Remove cannula as soon as possible. 9. MONITORING THE INFUSION Frequency: HSS care settings and Hospice = 4 hourly / FNHC & JHC Community = each visit Action 1. Assess the patients symptoms, monitoring the effect of the medication and any side effects experienced. 2. Check the skin site for erythema, leakage, hardness or swelling. 3. Observe the syringe and infusion set for kinks in the tubing, leakage, precipitation or discolouration of medication. 4. Check the syringe driver: that the rate has not been altered. The green LED light is flashing every 32 seconds and that the bottom line of the LCD display is alternating between <<<< Pump Delivering and make / size of syringe the line is securely attached to the syringe and not leaking. Rationale To promote adequate symptom control. If symptoms are not controlled, breakthrough medication to be given and/or infusion recipe to be reviewed. Absorption of medications will be affected. Abscess formation can occur. Change site as soon as this occurs and document appropriately. Sites can be left intact if satisfactory for up to 7 days. When re-sited the infusion should be placed at least 3cm from previous site (David 1992). To check that the patient is receiving the prescribed medication. If discolouration / precipitation occur stop and discard infusion, check compatibilities and mixing technique, resite butterfly needle and/or seek advice. To assess that medication is being infused at correct rate. Page 21 of 52

22 press the INFO key to check: Single press - VTBI (Volume to be Infused) and volume infused and record. Double press - battery life remaining and record. Visually check fluid remaining in syringe at each check and compare with pump reading. 5. Complete local ambulatory syringe driver monitoring chart documentation. Pilot sites- Ambulatory syringe driver monitoring care bundle 2012 version. (See Appendix 4) As per NMC Record Keeping Guidance (2009) and Health & Social Services Department policy, Family Nursing & Homecare and Jersey Hospice Care. Action 6 Action must be taken and documented in the event of: significant discrepancies in the actual an expected infusion rate Signs of incompatibility Blockage of infusion line Rationale (See Appendix 2)Troubleshooting problems Such as precipitation compatibility of medication in syringe pump needs to be checked. Site needs to be changed. Presence of large amounts of air may indicate cracked syringe syringe needs to be changed. Damage to the syringe barrel or tip Site reaction 10. SAFETY AND RISK MANAGEMENT 10.1 Mixing drugs for administration Even though this policy is for Jersey wide implementation. Reference shall be made to the National Prescribing Centre. The National Prescribing Centre have recently published new guidance on the Mixing of Medicines prior to administration in clinical practice (May 2010).This guidance has been developed Page 22 of 52

23 following consultation by the Medicines and Healthcare Products Regulatory Agency (MHRA) and recommendations by the Commission on Human Medicines (CHM). The key messages are below and are pertinent to Jersey: Mixing is an established practice in many clinical areas Where mixing is undertaken solely for the benefit of patients, the legislative changes enable that practice to continue Potential harm associated with mixing is theoretically possible, though the incidence of serious incidents is not known Individual practitioners are advised to review their own practice and consider their competency and knowledge gaps, and training needs Existing good practice in relation to mixing of controlled drugs should continue in conjunction with the amendments to the Misuse of Drugs Regulations which cover controlled drugs Clinical staff should feel supported to continue the practice of prescribing and administering a mixture of prescribed licensed medication via a single injection or a syringe driver pump in Palliative care when it is carried out in the best interests of patients and within Professional clinical boundaries 10.2 Guidance for the Mixer The mixer is likely to be presented with administration directions in the form of a single patient order (drug chart or similar). The first task is to establish what the prescriber is requesting for the patient and the directions to mix are clear and unambiguous. At this stage the mixer may recognise that this is usual practice or policy (for the clinical area, patient and mixer) and proceed with mixing and administering the product. The mixer should only proceed if they are content to do so. The local formulary and medicines policy should inform this process. If the mixture is not usual practice, then the mixer is advised to assess the appropriateness of the mixing. The mixer must satisfy themselves that they are competent to mix and whether the mixture is essential for patient care. Discussion with the prescriber or the hospital pharmacist would assist in decision making. The mixed products should be labelled and allocated an expiry period where/as appropriate. The mixer should be aware of monitoring requirements, routine or specific to the mixture being used Maintenance and Infection control Cleansing should be carried out with a damp disposable cloth (use warm water and general purpose detergent). Dry thoroughly. If any additional cleansing is needed, e.g. the threads of the screws the actuator moves along, contact infection control team for advice. The pump must not be submerged in water (and if it is accidentally dropped in water, it must be withdrawn from use immediately and sent to Medical Engineering). Do not use chemicals such as Xylene, acetone/similar solvents or Cliniwipes (or similar) as this will cause damage to components and labels. Washable pouches are available for use with the syringe driver. These must be laundered between each patient use and each locality area will need to source appropriate facilities. The pouches should be washed at 30 degrees Centigrade. Page 23 of 52

24 Planned maintenance should be carried out annually. It is the responsibility of the user to ensure that any devices have been serviced during the previous 12 months Incident Reporting What defines an incident? Examples include: Administration of incorrect medication, dose and/or diluent selection Infusions completing ahead of intended time or carrying on beyond intended time of completion Device not alarming Any other incident or near miss which may compromise patient safety or comfort Within all clinical areas across Jersey, if any health professional thinks/or suspects that a patient has had an adverse drug reaction then this would be reported on the 'Yellow Card' system (Back section of the BNF and at and sent to the MHRA. Any device and consumable involved in an adverse incident should be quarantined and sent to H&SS engineering department HSS Any member of staff who is involved in, or witnesses an incident, accident or near miss will ensure that it is properly documented using the Datix incident web based (electronic) form. The completion of Datix report is not a substitute for documenting in patient/clients notes. Incidents and accidents effecting patients or clients must be documented in their record and any action taken or consequence noted. For incidents involving medications and drugs, the patient s/client s doctor must formally review the patient s condition, and the results of any examination and investigations must be documented in the patient s medical notes. Any adverse event involving a medical device should be reported through the Datix incident reporting system. If you believe a medical device incident/adverse event has occurred the equipment should be immediately quarantined without further interference and clearly marked do not use. For further information please refer to Medical Devices Management Procedure and the Incident, Accident and Near Miss Reporting and Management Procedure (section 4 relates specifically to equipment and section 5 to reporting to external agencies) located on the Policy Publishing Centre. If unsure about events which need to be reported to the MHRA, advice may be sought from the Governance Support Team. FNHC Within FNHC the system of reporting is followed utilising their Incident/Near Miss Reporting Procedure. Other relevant procedures would be the 'Reporting Loss or Damage of Equipment Procedure' and the 'Drug Error Procedure'. JERSEY HOSPICE CARE Page 24 of 52

25 Within Jersey Hospice Care a drug incident form is completed and reported to the patient s general practitioner with a copy held in patient notes and a copy sent to the Senior Nurse Hazard Warning Notification HSS and Family Nursing and Home Care operate a cascade system for hazard warning notifications. Individuals with responsibility for managing areas where syringe drivers are in use must ensure relevant notices are acted and reported upon Training All staff using a syringe driver must be personally competent and accountable in the use and operation of such devices. Managers should ensure that relevant training takes place (e.g. at induction and updates as per organisation policy) and maintain a record of staff who are trained and competent to use such devices. (The Management of Infusion Systems SEHD1995) Concordance HSS - Monitoring of concordance with the policy, procedure/guideline will be undertaken through an annual audit of completed Symptom and Syringe Driver Monitoring Forms/Care Bundles (Appendix 3). Family Nursing and Home Care & Jersey Hospice Care Monitoring concordance with this policy document will be undertaken as per local audit plans Review Period This procedure will be reviewed by the multi agency working party at one year intervals and at a frequency of not less than every three years after its implementation. The authors will retain a copy of this policy on file for this purpose. Implementation date: Monday 23rd April REFERENCES Berkshire East Community Health Services (2009) Guideline for Continuous Subcutaneous Syringe Drivers used in Adult Palliative Care. Berkshire, Berkshire East Community Health Service. David, J. (1992) A Survey of the Use of Syringe Drivers in Marie Curie Centres European Journal of Cancer Care. 1:4. Dickman, A., Littlewood, C. and Varga, J. (2005) 2nd EditionThe Syringe Driver- Continuous infusions in palliative care. Oxford: Oxford University Press. Page 25 of 52

26 Greater Glasgow and Clyde NHS Trust (2009) McKinley T34 Syringe Pump: Guidelines for use in Adult Palliative Care Patients Glasgow: Greater Glasgow and Clyde NHS Trust. Hunt, T. (2002) in: Pension, J. Fisher, R. (eds) Palliative care for people with Cancer. London: Arnold. Nursing and Midwifery Council (2009) Record Keeping Guidance for Nurses and Midwives, London: NMC. Nursing and Midwifery Council (2007) Standards for Medicine Management for Nurses and Midwives, London: NMC. Nursing and Midwifery Council (2008) Guidelines for the Code of Professional Conduct, London: NMC. McKinley Medical (March 2006). Ambulatory Syringe Pump Instruction Manual McKinley T34, Medical UK Limited. Medical Devices Agency (March 2003) Graseby MS 26 NHS Web Report Mitten, T., (2001) Subcutaneous Drug Infusions: a review of problems and solutions International Journal of Palliative Nursing 7:2 pp NHS Highland and Highland Hospice (2006) Syringe Pump Guidelines. Inverness: NHS Highland and Highland Hospice. Oxford Radcliffe Hospitals (2004) Clinical Protocol for the use of Syringe Drivers in Palliative Care Patients (Adults) Oxford Radcliffe Hospital NHS Trust. Twycross, R., Wilcock, A (Eds) (2007) Palliative Care Formulary (3rd Ed.)Oxon: Radcliffe Medical Press. Wilson, V. (2000) Guidelines for the use of MS26 Daily Rate Syringe Driver in the Community British Journal of Nursing 5:4 pp World Health Organisation (2002) Palliative Care World Health Organisation. 12. APPENDICES APPENDIX ONE: (draft) competency assessment tool Page 26 of 52

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31 APPENDIX TWO: Trouble Shooting Guide McKinley T34 Driver Alarm Conditions When the pump detects a problem four things occur: The infusion stops. An audible alarm is activated. A message appears on the display screen indicating the cause of the alarm. The LED indicator turns RED. Troubleshooting Problems and Alarm Conditions Common Problems Fault Possible Cause Action The pump will not start Infusion ended early/going too quickly The pump has stopped before emptying syringe. 1. No battery present. 2. Battery inserted incorrectly. 3. Battery is depleted or very low. 4. Pump is faulty. 1. Wrong syringe brand confirmed during set up or incorrect volume measured by pump. 2. Pump faulty or incorrectly calibrated 1. Exhausted battery. 2. Faulty pump. 1. Fit a battery. 2. Re-align battery terminals. 3. Fit a new battery. 4. Service required 1. Stop infusion and discuss with doctor. Set up a fresh infusion using correct syringe brand. 2. Service/calibration required. 1. Fit new battery, turn pump on, confirm syringe size and brand; select to resume infusion. 2. Return for service. Other Problems Syringe driver running fast (i.e. running more than 1 hour ahead of expected time): If major over-infusion, stop infusion, check condition of patient and seek medical advice. Report as a medication incident. Check for disconnection of line or cannula. Check the correct syringe brand or size has been selected. Check syringe securely attached to pump. Check no air present in syringe (solution will siphon in if barrel cracked). Change the entire syringe pump for a new one and send original for servicing. Check that the pump has not been placed above the height of the patient (siphonage could have occurred). Syringe driver running slow (i.e. running more than 1 hour behind expected time): Page 31 of 52

32 Check the syringe driver light is GREEN and flashing. Check the battery level. Check the correct (Luer lock) syringe brand or size has been selected. Check that syringe is inserted correctly into syringe driver (actuator is still against plunger). Ascertain if syringe driver has been stopped and restarted for any reason. Check contents of syringe and line: is there any evidence of crystallisation or kinking of tubing? Check cannula site: is this red, hard, lumpy or sore? Change cannula site if necessary. Consider further dilution of drugs to minimise irritation by setting up a fresh syringe. Consider metal allergy if using nickel needle. If syringe driver continues to run slowly, change entire pump and send for servicing. Check rate of infusion at regular intervals. Precipitation, cloudiness or colour change in syringe contents or line: Stop infusion and inform prescriber. Issues to check and discuss with prescriber include: Compatibility information. Diluent (seek advice from a pharmacist as to when 0.9% sodium chloride might be appropriate). Dilute to a larger volume. Consider separating into two syringe drivers or give one drug as a subcutaneous bolus injection. Keep away from sunlight and heat. Advise patient on keeping syringe driver away from hot pack/heat pad or hot water bottle. Commence new infusion at a different site with new cannula and line. Greater Glasgow and Clyde NHS (2009) Alarm conditions Page 32 of 52

33 The alarms will sound for the following reasons: Problem Alarm type Possible cause Action Occlusion or Syringe empty Syringe displaced Pump paused too long Near end End program Audible and visual alarm. Audible and visual alarm. Intermittent beep. Audible and visual alarm Intermittent beep. Audible and visual alarm. Intermittent beep. Audible and visual alarm. Intermittent Beep. Patient cannula/line blocked, kinked. Occlusion. Infusion has finished Syringe has been removed/ displaced Pump left or no key presses detected for 2 minutes. 15 minutes from end of infusion Infusion complete. Low battery Visual alarm Battery almost depleted (30 mins left) Remove occlusion and restart Change cannula. End of program, switch pump off. Check and confirm syringe seated correctly and resume infusion. Syringe flanges need to be in the vertical 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. Prepare to change battery Page 33 of 52

34 APPENDIX THREE: Prescribing advice for ambulatory syringe drivers in palliative and supportive care in adults Indications Syringe drivers are used to deliver drugs subcutaneously when the oral route is no longer appropriate because the patient: is too weak to swallow oral drugs has a decreased conscious level is vomiting and/or has persistent nausea has dysphagia has poor alimentary absorption (rare) has bowel obstruction In some cases it will be appropriate to use only prn doses and a syringe driver will not be needed. It is normally necessary to give a stat dose of most prescribed drugs before starting a syringe driver as it takes about 4 hours to achieve a steady state. How to calculate the opioid dose Patients who are already taking oral opioids should have their 24 hour dose of oral morphine calculated and then: to convert oral morphine to subcutaneous diamorphine divide by 3 o e.g. a patient taking 30 mg of MST (morphine sulphate modified release) bd would take 60 mg of oral morphine in 24 hours this is equivalent to 20 mg of diamorphine S/C over 24 hours. to convert oral morphine to subcutaneous morphine divide by 2 o e.g. a patient taking 30 mg of MST bd would take 60 mg of oral morphine in 24 hours this is equivalent to 30 mg of morphine S/C over 24 hours. How to calculate the breakthrough (prn) dose To calculate the prn dose of opioid divide the 24 hour dose by 6 and use the same route. e.g. a patient taking 30mg of diamorphine S/C over 24 hours would have a prn dose of 5mg of diamorphine S/C. Increasing the opioid in the syringe driver If the patient s pain persists increase the dose of opioid in the syringe driver by one third. Be aware of signs of opioid toxicity such as drowsiness, reduced respiratory rate, myoclonus, confusion and hallucinations. If a patient needs two or more prn doses of their opioid in 24 hours think about increasing the background dose (i.e. the dose in the syringe driver). The exception to this is when the prn dose is used for incident pain (i.e. pain on movement or dressing change), in this case continue using prn doses and only increase the background dose for an increase in background pain not incident pain. Opioid conversion The table below gives only approximate dosages; due to the risk of toxicity it may be necessary to use lower doses especially in: the elderly patients with renal impairment patients with hepatic impairment patients already on high doses of opioids (there may be incomplete cross tolerance and it is normal practice to reduce the dose by 30%, please ask for help) Page 34 of 52

35 Please regularly review your patient soon after switching to a different opioid, checking for signs of toxicity and to check their level of pain control. You will see the effect of a prn dose within about 15 minutes and the effect of a syringe driver dose change within 2-4 hours. PO Morphine S/C S/C Morphine PO S/C S/C Fentanyl 24h total dose (mg) prn dose (mg) 24h total dose (mg) prn dose (mg) 24h total dose (mg) prn dose (mg) 24h total dose (mg) prn dose (mg) 24h total dose (mg) prn dose (mg) 24h total dose OPIOID DOSE CONVERSION GUIDE Note that dose conversions are approximate only micrograms prn dose micrograms 400 micrograms micrograms If you need to use higher doses please ask for advice to convert to Alfentanil For higher doses the volumes are too big so convert to alternative opioid Fentanyl patches If you have any queries please see Appendix 6 for contact details Page 35 of 52

36 Fentanyl patches should not be started as a form of pain control at the end of life, dying patients often have rapidly changing requirements and the patches take hours to achieve therapeutic blood levels so they should only be used for stable pain. If you remove a fentanyl patch it will take about 18 hours for the blood level to drop by 50% and if you immediately switch to a syringe driver this could result in an overdose. So at the end of life DO NOT REMOVE THE PATCH and if you need to increase the level of pain control add a syringe driver with the equivalent of two prn doses. If you need to increase the dose further please call for advice as below. If you need to consider an alternative to the fentanyl patch for reasons such as poorly controlled pain, opioid toxicity, fever (that increases drug absorption) or that your patient s sweating is difficult to control and the patch won t stick, please ask for advice. Fentanyl patch strength (micrograms/hr) Prn dose range of subcutaneous diamorphine (mg) for breakthrough pain Dose range of diamorphine (mg) subcutaneous over 24 hours to augment the analgesia of a patient on a fentanyl patch When calculating the dose of diamorphine in the syringe driver and the prn dose you may need to use the patient s previous patch strength if not already stabilised for the last 72 hours. If you have any queries please see Appendix 6 for contact details Commonly used drugs in the syringe driver Page 36 of 52

37 SYMPTOM DRUG AND DOSAGE PRN DOSE POSSIBLE SIDE EFFECTS COMMENTS PAIN DIAMORPHINE (for the opioid naive start at 5-10mg over 24 hours, for those already taking opioids please see above) MORPHINE (for the opioid naive please start at 10-15mg over 24 hours) OXYCODONE (Please see conversion chart above) ALFENTANIL (please ask for advice) ONE SIXTH OF THE 24 HOUR DOSE Not suitable for prn doses as has a very short half life Nausea, constipation, dry mouth, sedation, confusion. Nausea, constipation, dry mouth, sedation, confusion. Nausea, constipation, dry mouth, sedation, confusion. Nausea, constipation, dry mouth, sedation, confusion. Used first line for pain but avoid in renal failure Avoid in renal failure Use with caution in renal failure at a lower dose if no alternative available Useful for pain in renal failure. Do not use prn as half life so short, please ask for advice. NAUSEA AND VOMITING HALOPERIDOL (1.5-5mg over 24 hours) METOCLOPRAMIDE (40-80mg over 24 hours) CYCLIZINE (50-150mg over 24 hours) LEVOMEPROMAZINE ( mg over 24 hours) DEXAMETHASONE (4-16mg over 24 hours) 0.5-1mg 10-20mg (max 24hr dose 80mg) 50mg (max 24hr dose 150mg) mg (max 24hr dose 25mg) N/A Extrapyramidal symptoms, dry mouth, sedation, difficulty with micturition. Extrapyramidal symptoms Drowsiness, dry mouth, hypotension Sedation, postural hypotension GI side effects, diabetes Useful in nausea due to metabolic causes or to drugs. Avoid in Parkinson s disease. Useful with delayed gastric emptying and gastric irritation. DO NOT USE in bowel obstruction with colic, avoid with anticholinergic drugs and in Parkinson s disease. Useful in N&V due to intracranial disease and intestinal obstruction. Do not use in heart failure. Careful what you mix it with as precipitates with a few drugs (see Appendix 4). Broad spectrum second line antiemetic. Lowers threshold for convulsions. Do not use in epilepsy and Parkinson s disease. Only use this for N&V due to raised intracranial pressure. There are other indications to use this at the end of life. This needs a separate driver or S/C bolus (see below) SYMPTOM DRUG AND DOSAGE PRN DOSE POSSIBLE SIDE EFFECTS COMMENTS AGITATION AND ANXIETY MIDAZOLAM (5-30mg over 24 hours and up to 100mg for heavy sedation) HALOPERIDOL mg over 24 hours when Start at 2.5-5mg 1.5-5mg (max 24hr dose for Page 37 of 52 Extrapyramidal symptoms This is normally used first line for anxiety. Higher doses are needed if using as an anticonvulsant (e.g. start at mg over 24 hours). Do not use in Parkinson s disease and caution in epilepsy at higher doses.

38 using for delirium) LEVOMEPROMAZINE (25-100mg over 24 hours when using for terminal restlessness) 10mg) Start at 6.25mg Postural hypotension Lowers threshold for convulsions. Do not use in epilepsy and Parkinson s disease. RESPIRATORY SECRETIONS (and colic) GLYCOPYRRONIUM ( mg over 24 hours) HYOSCINE HYDROBROMIDE ( mg over 24 hours) HYOSCINE BUTYLBROMIDE (Usual dose in bowel obstruction is mg over 24 hours) 200 microgram s 400 microgram s 20mg Tachycardia, dry mouth. Sedation, tachycardia, dry mouth. Tachycardia, dry mouth. Does not cross the blood brain barrier so doesn t cause drowsiness. Does cross the blood brain barrier so causes sedation. Does not cross the blood brain barrier. DYSPNOEA Can be helped by opioids, but needs lower doses than we use for pain. In the opioid naive patients start with diamorphine 5 mg S/C over 24 hours. For the anxiety associated with dyspnoea use a benzodiazepine (e.g. midazolam). Although the subcutaneous administration of these drugs in various combinations is common practice in palliative care, prescribers and nursing staff should be aware that this falls outside their product licence. If you have any queries please see Appendix 6 for contact details Page 38 of 52

39 Diluents for syringe driver To avoid confusion, consistency of practice is important. Therefore it has been decided that the diluent of choice is water for injection (WFI). Sodium chloride 0.9% should only be considered for use in the following circumstances: if there is a potential or actual problem with inflammatory reactions at the infusion site levomepromazine is being administered as a single drug subcutaneous infusion (for infusion with drugs in addition to levomepromazine WFI should be used) Syringe driver drug compatibility information See Appendix 4 (Syringe driver drug compatibility charts) for stability information when mixing drugs in a syringe driver. Subcutaneous administration of drugs Infusion site problems may be due to a number of reasons; however the following drugs are known to be irritant when administered subcutaneously. Strongly irritant (do NOT use) Chlorpromazine (can cause local tissue necrosis) Diazepam Prochlorperazine Lorazepam Relatively irritant (precautions may be necessary) Diclofenac Ketamine Ketorolac Levomepromazine Methadone Octreotide (painful if give by SC bolus, reduced if warmed to body temperature beforehand) Ondansetron Phenobarbital Promethazine It should be noted that several drugs with a long duration of action (e.g. dexamethasone and levomepromazine) can be given as a bolus SC or IV injection once or twice daily, this could thus eliminate the need for a syringe driver. References: Watson M, Lucas C, Hoy A, Back I, Armstring P. Palliative Adult Network Guidelines. (3 rd Ed.) Twycross R, Wilcock A. PCF3: Palliative Care Formulary (3 rd Ed.) Oxford: palliativedrugs.com Ltd; If you have any queries please see Appendix 6 for contact details Page 39 of 52

40 APPENDIX FOUR: Syringe driver drug compatibility and stability charts The below charts and tables summarise the compatibility information available for TWO and THREE drug combinations in water for injection (WFI) used as a continuous subcutaneous infusion (CSCI) over a 24 hour period. Please note: the charts and tables should be used to check that drug combinations are appropriate and stable at the doses prescribed. FIGURES STATED IN THE TABLES ARE NOT CLINICAL DOSES TO PRESCRIBE (please refer to Appendix 3 for information on the usual dose ranges for each medication). compatibility of drugs in the syringe driver is concentration dependent, therefore do NOT assume that doses reported as stable for a 23.5ml volume will also apply to a 18ml volume (contact pharmacy for advice). stability data has been obtained from laboratory work and the clinical setting, since a number of factors can affect drug stability and compatibility conflicting reports can occur. If any problems occurs (i.e. precipitation) with a drug combination reported as stable in the below tables please contact pharmacy. For advice on the compatibility of drugs in the following situations please contact pharmacy: drug combinations not listed in the below tables when there is a requirement to use four drugs in the same CSCI When there is a requirement to use diluents other than WFI (i.e. sodium chloride 0.9%) To contact pharmacy for advice either call medicines information (442628) or bleep your ward pharmacist. Outside normal pharmacy hours contact the on-call pharmacist via the hospital switch board (442000). References: Dickman A, Schneider J, Varga J. The Syringe Driver: Continuous subcutaneous infusions in palliative care (2 nd Edition), Palliative Care Guidelines: NHS Scotland. (accessed 1 st February 2012) Palliative Care Matters website: (accessed 1 st February 2012) Twycross R, Wilcock A. Palliative Care Formulary (3 rd Edition), Page 40 of 52

41 If you have any queries please see Appendix 6 for contact details How to use the compatibility charts and tables: Refer to Charts 1-4 to make an initial assessment of the appropriateness of the TWO or THREE drug combination prescribed in the syringe driver, and their likely compatibility and stability in water for injection. If the combination is deemed appropriate refer to the relevant Table (1-6), to confirm the maximum concentration of the drug combination which is physically stable (NOTE: these are NOT recommended doses to prescribe). If the drug combination prescribed is not listed in Tables 1-6 (i.e. it may not include an opiate), or the doses exceed the stated maximum stable concentration contact pharmacy for advice. Key: No data Pharm Reported as compatible. Should be OK to proceed, but refer to Tables 1-6. No compatibility data available. Contact pharmacy for advice. Not applicable or combination not generally recommended. Refer back to prescriber. Compatibility is concentration dependent. Refer to Tables 1-6 or contact pharmacy Do not use, incompatible at usual concentrations. Refer back to prescriber. Compatibility charts for TWO drugs in Water for Injection Cyclizine Glycopyrronium Cyclizine Pharm No data Glycopyrronium Haloperidol Pharm No data Hyoscine butylbromide Pharm Hyoscine hydrobromide Levomepromazine Metoclopramide No data Midazolam Pharm Morphine sulphate Pharm Pharm Pharm Haloperidol Hyoscine butylbromide Hyoscine hydrobromide Levomepromazine Metoclopramide Midazolam Morphine Chart 1. Compatibility chart for TWO drugs in water for injection If you have any queries please see Appendix 6 for contact details Page 41 of 52

42 If you have any queries please see Appendix 6 for contact details Compatibility charts for THREE drugs in Water for Injection + Glycopyrronium + Haloperidol + Hyoscine butylbromide + Hyoscine hydrobromide + Levomepromazine + Metoclopramide + Midazolam Cyclizine No data Pharm Pharm Glycopyrronium Haloperidol Pharm Hyoscine butylbromide Hyoscine hydrobromide Levomepromazine Metoclopramide Chart 2. Compatibility chart for DIAMORPHINE: THREE drugs in water for injection Morphine sulphate + Glycopyrronium No data Morphine sulphate + Haloperidol No data Morphine sulphate + Hyoscine butylbromide Morphine sulphate + Hyoscine hydrobromide No data No data Morphine sulphate + Levomepromazine No data No data Morphine sulphate + Metoclopramide Morphine sulphate + Midazolam Cyclizine Glycopyrronium Haloperidol Hyoscine butylbromide Hyoscine hydrobromide Levomepromazine Metoclopramide Chart 3. Compatibility chart for MORPHINE SULPHATE: THREE drugs in water for injection + Glycopyrronium No data + Haloperidol Pharm No data + Hyoscine butylbromide + Hyoscine hydrobromide No data + Levomepromazine No data + Metoclopramide + Midazolam Pharm Pharm No data Cyclizine Glycopyrronium Haloperidol Hyoscine butylbromide Hyoscine hydrobromide Levomepromazine Metoclopramide Chart 4. Compatibility chart for OXYCODONE: THREE drugs in water for injection If you have any queries please see Appendix 6 for contact details Page 42 of 52

43 Compatibility tables for TWO drugs in Water for Injection FIGURES STATED IN THE TABLES ARE NOT CLINICAL DOSES TO PRESCRIBE. Please see Appendix 3 for information on the usual dose ranges for each medication. Drug combinations Cyclizine Glycopyrronium bromide Haloperidol Hyoscine BUTYLbromide Hyoscine HYDRObromide Levomepromazine Metoclopramide Midazolam MAXIMUM CONCENTRATIONS of TWO drug combinations that are physically stable 18ml in 20ml syringe 23.5ml in 30ml syringe 340mg 440mg 150mg 150mg 425mg 550mg 1.2mg 1.2mg 800mg 1000mg 10mg 10mg 1000mg 1000mg 120mg 120mg 1000mg 1000mg 2.4mg 2.4mg 850mg 1000mg 100mg 100mg 1000mg 1000mg 85mg 110mg 560mg 720mg 80mg 80mg Table 1. Compatibility table for DIAMORPHINE: TWO drugs in water for injection Drug combinations Morphine sulphate Cyclizine Morphine sulphate Glycopyrronium bromide Morphine sulphate Haloperidol Morphine sulphate Hyoscine BUTYLbromide Morphine sulphate Hyoscine HYDRObromide Morphine sulphate Levomepromazine Morphine sulphate Metoclopramide Morphine sulphate Midazolam MAXIMUM CONCENTRATIONS of TWO drug combinations that are physically stable 18ml in 20ml syringe 23.5ml in 30ml syringe 300mg 380mg 150mg 150mg 300mg 380mg 1.2mg 1.2mg 400mg 500mg 10mg 10mg 300mg 380mg 120mg 120mg 450mg 580mg 1.2mg 1.2mg 300mg 380mg 100mg 100mg 120mg 150mg 60mg 70mg 300mg 380mg 30mg 35mg Table 2. Compatibility table for MORPHINE SULPHATE: TWO drugs in water for injection Page 43 of 52

44 Compatibility tables for TWO drugs in Water for Injection FIGURES STATED IN THE TABLES ARE NOT CLINICAL DOSES TO PRESCRIBE. Please see Appendix 3 for information on the usual dose ranges for each medication. Drug combinations Cyclizine Glycopyrronium bromide Haloperidol Hyoscine BUTYLbromide Hyoscine HYDRObromide Levomepromazine Metoclopramide Midazolam MAXIMUM CONCENTRATIONS of TWO drug combinations that are physically stable 18ml in 20ml syringe 23.5ml in 30ml syringe 50mg 200mg 150mg 100mg 40mg 0.6mg 140mg 180mg 10mg 10mg 140mg 180mg 40mg 50mg 130mg 160mg 1.2mg 1.2mg 120mg 150mg 100mg 100mg 80mg 100mg 40mg 50mg 80mg 100mg 40mg 50mg Table 3. Compatibility table for OXYCODONE: TWO drugs in water for injection If you have any queries please see Appendix 6 for contact detail Page 44 of 52

45 Compatibility tables for THREE drugs in Water for Injection FIGURES STATED IN THE TABLES ARE NOT CLINICAL DOSES TO PRESCRIBE. Please see Appendix 3 for information on the usual dose ranges for each medication. Drug combinations MAXIMUM CONCENTRATIONS of THREE drug combinations that are physically stable Cyclizine Glycopyrronium bromide Cyclizine Haloperidol Cyclizine Hyoscine BUTYLbromide Cyclizine Hyoscine HYDRObromide Cyclizine Midazolam Glycopyrronium bromide Haloperidol Glycopyrronium bromide Levomepromazine Glycopyrronium bromide Midazolam Haloperidol Hyoscine BUTYLbromide Haloperidol Hyoscine HYDRObromide Haloperidol Metoclopramide Haloperidol Midazolam Hyoscine BUTYLbromide Levomepromazine Hyoscine BUTYLbromide Midazolam Hyoscine HYDRObromide Levomepromazine Hyoscine HYDRObromide Midazolam Levomepromazine Midazolam Metoclopramide Midazolam 18ml in 20ml syringe 340mg 150mg 10mg Do NOT mix - INCOMPATIBLE 60mg 150mg 1.6mg 630mg 150mg 40mg 130mg 1.6mg 10mg 30mg 1.6mg 100mg 120mg 1.6mg 30mg 60mg 10mg 80mg 230mg 10mg 1.6mg 80mg 10mg 60mg 800mg 7mg 65mg 1900mg 120mg 50mg 120mg 80mg 20mg 450mg 2.4mg 100mg 720mg 1.6mg 40mg 850mg 50mg 30mg 420mg 60mg 20mg Page 45 of ml in 30ml syringe 440mg 150mg 10mg Do NOT mix - INCOMPATIBLE 1000mg 10mg 80mg 150mg 100mg 25mg 1000mg 60mg 40mg Table 4. Compatibility table for DIAMORPHINE: THREE drugs in water for injection

46 Compatibility tables for THREE drugs in Water for Injection FIGURES STATED IN THE TABLES ARE NOT CLINICAL DOSES TO PRESCRIBE. Please see Appendix 3 for information on the usual dose ranges for each medication. Drug combinations MAXIMUM CONCENTRATIONS of THREE drug combinations that are physically stable Morphine sulphate Cyclizine Glycopyrronium bromide Morphine sulphate Cyclizine Haloperidol Morphine sulphate Cyclizine Hyoscine BUTYLbromide Morphine sulphate Cyclizine Hyoscine HYDRObromide Morphine sulphate Cyclizine Midazolam Morphine sulphate Glycopyrronium bromide Haloperidol Morphine sulphate Glycopyrronium bromide Levomepromazine Morphine sulphate Glycopyrronium bromide Midazolam Morphine sulphate Haloperidol Hyoscine BUTYLbromide Morphine sulphate Haloperidol Hyoscine HYDRObromide Morphine sulphate Haloperidol Metoclopramide Morphine sulphate Haloperidol Midazolam Morphine sulphate Hyoscine BUTYLbromide Levomepromazine Morphine sulphate Hyoscine BUTYLbromide Midazolam Morphine sulphate Hyoscine HYDRObromide Levomepromazine Morphine sulphate Hyoscine HYDRObromide Midazolam Morphine sulphate Levomepromazine Midazolam Morphine sulphate Metoclopramide Midazolam 18ml in 20ml syringe 40mg 100mg 2mg Do NOT mix - INCOMPATIBLE 40mg 150mg 5mg 20mg 1.5mg 25mg 100mg 5mg 20mg 70mg 60mg 12.5mg 50mg 40mg 60mg 20mg 0.8mg 20mg 180mg 5mg 10mg 50mg 30mg 7mg Page 46 of ml in 30ml syringe 50mg 100mg 3mg Do NOT mix - INCOMPATIBLE 40mg 150mg 20mg 340mg 15mg 0.6mg 50mg 5mg 80mg 15mg 1.5mg 80mg 130mg 6mg 25mg 40mg 60mg 25mg 60mg 50mg 75mg 30mg 1.2mg 10mg 230mg 5mg 12mg 60mg 40mg 10mg Table 5. Compatibility table for MORPHINE SULPHATE: THREE drugs in water for injection

47 Compatibility tables for THREE drugs in Water for Injection FIGURES STATED IN THE TABLES ARE NOT CLINICAL DOSES TO PRESCRIBE. Please see Appendix 3 for information on the usual dose ranges for each medication. Drug combinations MAXIMUM CONCENTRATIONS of THREE drug combinations that are physically stable Cyclizine Glycopyrronium bromide Cyclizine Haloperidol Cyclizine Hyoscine BUTYLbromide Cyclizine Hyoscine HYDRObromide Cyclizine Midazolam Glycopyrronium bromide Haloperidol Glycopyrronium bromide Levomepromazine Glycopyrronium bromide Midazolam Haloperidol Hyoscine BUTYLbromide Haloperidol Hyoscine HYDRObromide Haloperidol Metoclopramide Haloperidol Midazolam Hyoscine BUTYLbromide Levomepromazine Hyoscine BUTYLbromide Midazolam Hyoscine HYDRObromide Levomepromazine Hyoscine HYDRObromide Midazolam Levomepromazine Midazolam Metoclopramide Midazolam 18ml in 20ml syringe 25mg 150mg 5mg Do NOT mix - INCOMPATIBLE 25mg 1.2mg 25mg 80mg 2mg 100mg 80mg 2mg 1mg 35mg 0.75mg 30mg 80mg 2mg 15mg 80mg 100mg 20mg 25mg 0.8mg 25mg 5mg 6.25mg 10mg 30mg 30mg 10mg 23.5ml in 30ml syringe 55mg 150mg 5mg Do NOT mix - INCOMPATIBLE 5mg 100mg 5mg 100mg 5mg 120mg 100mg 5mg 1.2mg 100mg 5mg 20mg 100mg 120mg 25mg 100mg 1.2mg 25mg 30mg 1.2mg 10mg 130mg 37.5mg 20mg Table 6. Compatibility table for OXYCODONE: THREE drugs in water for injection Page 47 of 52

48 APPENDIX FIVE: AMBULATORY SUBCUTANEOUS SYRINGE DRIVER PRESCRIPTION CHART INFUSIONS TO BE ADMINISTERED ONCE ONLY, UNLESS THE PRESCRIBER SPECIFIES THEY ARE TO BE CONTINUOUS* HOSPITAL: HOSPITAL NO: s SURNAME: WARD: FIRST NAMES: ADDRESS: CONSULTANT: GP: DATE OF BIRTH: DATE DILUENT TOTAL VOLUME ROUTE MEDICINE ADDED TO SYRINGE DRIVER DURATION INFUSION RATE (ml/hour) APPROVED NAME DOSE PRESCRIBER S SIGNATURE PHARM DATE TIME VOLUME START STOP GIVEN GIVEN BY CHECKED BY *Prescriber to initial if continuous bleep No. Diluent: generally use water for injection refer to ambulatory syringe driver policy (appendix 3) for situations when to use sodium chloride 0.9% Syringe driver drug compatibility charts: refer to ambulatory syringe driver policy (appendix 4) for stability information when mixing two or three drug combinations Only prescribe FOUR drugs in a single syringe driver when advised by the specialist palliative care team (tel ) To confirm that this combination is compatible contact pharmacy for advice, either call medicines information (tel ) or bleep your ward pharmacist. Outside normal pharmacy hours contact the on-call pharmacist via the site manager. AMBULATORY SUBCUTANEOUS SYRINGE DRIVER PRESCRIPTION CHART Page 48 of 52