Administration of Drugs via the CME Medical T34 Syringe Driver Standard Operating Procedure

Administration of Drugs via the CME Medical T34 Syringe Driver Standard Operating Procedure DOCUMENT CONTROL: Version: 3 Ratified by: Quality and Safety Sub Committee Date ratified: 30 May 2017 Name of originator/author: Community Practice Educator Current version reviewed by Pharmacy Team Name of responsible Medicines Management Committee committee/individual: Date issued: 6 December 2017 Review date: May 2020 Target Audience Community Nursing Staff

1. Aim 2. Scope This Standard Operating Procedure (SOP) represents current recommended good practice and will ensure the proper action to take regarding the setting up and management of the CME Medical T34 Syringe driver by clinical staff in the Community setting. All registered nurses using the CME T34 Syringe Driver must be personally competent and accountable in the use and operation of the device by attending bespoke training. Evidence of training will be recorded on each staff member s training record. Mandatory annual updates will be provided. 3. Link to overarching policy and/or procedure This SOP is to be used in conjunction with the RDaSH Policy Safe and Secure Handling of Medicines. 4. Procedure 4.1 General Information 4.2 Safety The McKinley T34 Syringe Driver is used across Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) in line with the requirements of the National Patient Safety Alert entitled Safer Ambulatory Syringe Drivers (NPSA/2010/RRR019) (2010).. The McKinley T34 is a small battery operated machine, designed to give a continuous subcutaneous infusion in milliliters (ml) per hour over a given period. This method of symptom control, used predominantly in palliative and end of life care provides relief of multiple symptoms e.g. pain, nausea and agitation via a single route. The safe use of the syringe driver requires comprehensive knowledge in order to maintain patient safety. Caution: If a patient is discharged home with a different make of syringe driver, this should be changed to a McKinley T34 device as soon as possible. Lock boxes will fit syringes up to 30ml and should always be used with the CME Medical T34. Lock boxes reduce the risk of accidental or intentional interference with the syringe driver and protect from damage caused by normal daily use or drops within the range of one metre. 4.3 Cleansing, Decontamination and Maintenance All staff must follow standard infection prevention and control precautions including hand hygiene, use of personal protective equipment, decontamination of reusable medical devices, sharps management and Page 2 of 27

disposal of healthcare waste. The device must be decontaminated between patients, daily when in use and as and when it becomes dirty or contaminated. Always turn the syringe driver off before cleaning. After patient use decontaminate the unit using lint free cloth such as Tuffi 5. Also clean actuator screw thread and guiding rods to remove debris or other particles. Do not clean the syringe pump with chemicals such as xylene, acetone, or similar solvents. These chemicals can cause damage to components and labels. Do not soak or immerse any part of the syringe driver in any solution. Immersing the pump in liquid will cause damage to components and this will void the guarantee. It is recommended that Tuffi 5 wipes are also used to decontaminate the lock box. All Syringe Drivers will require routine annual maintenance and service as a minimum or when syringe driver warning is indicated on individual syringe drivers. Key Health Solutions will provide maintenance work. Devices due for maintenance can be returned to the designated person for the clinical area, who will then forward the devices onto Key Health Solutions. A declaration of decontamination status for will need completing and attaching to the device prior to sending it for repair or service. 4.4 Storage It is essential that all syringe drivers are accounted for at all times. Hospice Syringe drivers and locked boxes will be stored in a designated place within the hospice. Each syringe driver will have its own case. It will be the responsibility of the nurse who last used the device to clean the syringe driver and lock box adhering to the Standard Infection Prevention and Control Precautions Policy. Community All Community Nursing Teams (Planned and Unplanned) are required to keep an up to date list of the exact location of the Syringe Drivers. (See appendix 1) Syringe Drivers will be stored at the four planned locality bases and a Page 3 of 27

designated place for Unplanned. They will be stored in lockable cases and each device will have its own case. It will be the responsibility of the nurse who last used the device to clean the syringe driver and lock box adhering to the Standard Infection Prevention and Control Precautions Policy. The case will be refilled ready for further use and stored in a safe place within the base point. There will be 1 case for each device and these cases will be stored at each base point in the Community. 4.5 Equipment Required 4.5.1 Syringe driver McKinley T34 and Lock Box. Ensure within maintenance date. Obtain a new syringe driver if out of date. 4.5.2 9-volt alkaline battery Duracell Procell. The average battery life is 3-5 days depending on usage e.g. key presses or backlight use. 4.5.3 Winged infusion set Saf-T-Intima24Gx0.75 FSP318Yellow. 4.5.4 Administration set CME McKinley Micro set 100-172S (Anti-siphon valve and female luer lock. Length approx. 100cm, priming volume approx. 0.5ml). 4.5.5 BD Plastipak luer lock syringe 20ml or 30ml. N.B. luer lock syringes must always be used to ensure secure connection of the infusion set. The pump is calibrated to luer lock and failure to use may result in under or over infusion due to variation in syringe dimensions. 4.5.6 Combi-stopper to cap the syringe or administration set 4.5.7 Transparent adhesive dressing 4.5.8 Drugs and diluent prescribed 4.5.9 Needle (to draw up drug) 4.5.10 Drug additive label 4.5.11 Patient s Syringe Driver Prescription and Observation Chart. 4.5.12 Sharps receptacle 4.5.13 Disposable carrying pouch (only if patient is mobile) 4.5.14 Instruction procedure manual and equipment, as documented on syringe driver check list. 4.5.15 Signing in and out sheet completed with the syringe driver serial number date, time, patient name and address (see appendix 2) Page 4 of 27

4.5.16 Battery will be removed when device not in use. Syringe driver to be stored in cases provided by Trust. A reciprocal agreement is in place between RDaSH and Doncaster and Bassetlaw Hospital NHS Foundation Trust (DBHFT) for the safe return of syringe drivers to their respective bases. The syringe driver must be returned to base after use. If the patient is admitted to hospital, then it is the responsibility of the nurse who is allocated to the visit to ensure that they retrieve the syringe driver. The responsible nurse will contact the Community Support Manager via e-mail using the relevant form. (See appendix 2) An agreement is in place with Doncaster Royal Infirmary (DRI) for devices that turn up with patients that have been admitted to hospital. These devices will be returned to the medical devices unit at DRI. The medical devices unit will then return the device to the Community Support Manager. If devices from DRI are sent home with patients in the community, these will be returned by the Community Support Manager to the medical devices unit at DRI. Admission to the Hospice If a patient is admitted to the hospice with a community syringe driver, the device is swapped to a hospice device within 24 hours and returned to the designated base via the RDASH shuttle. If a patient is discharged from the hospice with a syringe driver, the device should be swapped to a community device within 24 hours and returned to the hospice ASAP. All Hospice device serial numbers are recorded on a database and tracked by the Hospice Ward Clerk. Transferred out of RDaSH The registered nurse must: Record the details and serial number of the syringe driver on the district nurse referral form or on the transfer letter if the patient is discharged to a care home, other hospital or hospice Place a copy of the form in the patient s notes Request that care home, hospital or hospice return the syringe driver to Medical Technical Services Inform Medical Technical Services of the transfer Caution: If a patient is discharged home from a neighbouring hospital (other than Doncaster Royal Infirmary) with a different make of syringe driver, this should be changed over to the McKinley T34 and the other syringe driver returned to the hospital in question as soon as possible. 4.6 Administration Procedure It is good practice for two staff members, one of which must be qualified, to Page 5 of 27

undertake the procedure; however, in community settings where there may not be another health professional available, the patient s relative may act as a second signatory to check relevant aspects of the procedure. e.g. Stock levels. See Appendix 3 for indications, advantages and disadvantages of syringe driver 4.7 Involving the patient and family Communication and consultation with the patient and family is essential. Before starting a subcutaneous infusion, the reasons for using this method of administration should be explained to the patient and family. Informed consent for administration should be obtained, in accordance with the Mental Capacity Act 2005 Policy. The discussion is then to be recorded in the nursing care plan. Attention should be paid to both the physical and psychological aspects involved in accepting a new way of receiving medication. Some patients feel that this method of drug delivery is a last resort that their activities will be restricted and that death may be imminent. It is necessary to listen to and answer the patient s questions, acknowledge their concerns and then give explanations and reassurance as appropriate. Community only - The patient and family will be informed that the syringe driver device is on loan to them and must be returned as delivered after use. A signature will be required from the patient or family after discussion. (See appendix 7) The explanation should include the following: The reasons for using a syringe driver How the syringe driver works The siting procedure and site care How the dose of medication can be adjusted to manage symptoms Encouragement to describe symptoms 4.8 Procedure for setting up the syringe driver A registered nurse must calculate the volume of drug that needs to be drawn up from the concentration of the preparation to be used and the prescribed dose. When preparing medicines and disposing of waste materials, the registered nurse must adhere to the following guidance:- Safe and Secure Handling of Medicines Policy SOP for Controlled Drugs Standard Infection Prevention and Control Precautions Policy Sharps Policy Safe Use and Disposal of Sharps and Management of Contamination Injuries Hand Hygiene policy Page 6 of 27

NMC Standards of Medicines Management The Medicines Act (1986) Waste Policy A registered nurse must ensure:- The prescription has been completed correctly, perform the calculation and check the medication. Confirm the previous opioid dose, formulation and frequency. Ensure the medication prescribed and the doses are clinically appropriate based on the patient s previous requirements (NPSA, 2008). The diluent will be prescribed on the patient s Syringe Driver Prescription (Syringe Driver prescription chart). For McKinley T34 feature recognition please see appendix 4 Sterile water for injection Advantages Recommended because of its use in reconstituting lyophilized (freeze-dried) Morphine Sulphate More supporting compatibility data Reduces the risk of precipitation with cyclizine lactate Disadvantages Large volumes are hypotonic and can cause infusion site pain Sterile 0.9% Sodium chloride Advantages Recommended with certain drugs e.g. octreotide Less infusion site pain and fewer skin reactions Disadvantages Disadvantages Incompatible with cyclizine Increases likelihood of precipitation when more than one drug is used There is a potential for interaction between drugs in a syringe driver. The compatibility of the drugs and the diluent to be drawn up must be checked prior to mixing. The Palliative Care Formulary (Twycross et al, 2014), The Syringe Driver, Continuous subcutaneous infusions in palliative care (Dickman A and Schneider J, 2011) suggest suitable combinations of drugs. If there are any concerns regarding compatibility: Firstly refer to the compatibility and stability tables for a subcutaneous infusion in a McKinley T34 Syringe pump (appendix 5) Contact the prescriber Page 7 of 27

Contact the Specialist Palliative Care Triage or pharmacy If any further concerns out of hours (after doing all of the above) call the on-call Consultant in Palliative Medicine or on-call Pharmacist via DRI switchboard. Ideally syringe driver prescription reviews should take place in working hours only. In Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) a combination of no more than 3 dugs should be prescribed on the prescription form or drawn up into a syringe. If more than 3 drugs are required, 2 prescription forms and 2 syringe drivers will be needed. Please seek advice from the Specialist Palliative Care Team. Hospice only 4 drug combinations may be appropriate on an individualised basis only and rationale clearly documented in the medical notes. N.B. Ampules containing a liquid solution may contain an amount in excess of the volume stated on the label. Therefore, measure the volume of liquid as it is drawn up to ensure accuracy of the dose. Select the appropriate syringe size 20ml or 30ml Draw up the prescribed medication Add the diluent up to the required volume Complete the label, including: - Patient name and NHS number - Medicine name and dose - Batch numbers - Diluent used - Route of infusion - Date and time prepared - Initials of the registered nurses preparing the syringe Attach the label to the syringe ensuring that it is flat and not folded. Leave the scale visible so that it can still be read. Skin Site Selection for Subcutaneous Infusions. Where possible involve the patient in the choice of a suitable site. Areas suitable for subcutaneous infusion include those with a good depth of subcutaneous fat, towards the trunk of the body, particularly if the patient s peripheral circulation is compromised Following completion of the procedure document the following in the patient s electronic records -the prescribed medication, dose, dilutant and site of the syringe driver alongside the amount of prescribed medication remaining. (See appendix 2). Note when using Appendix 2:- The CME Medical T34 ambulatory syringe pump is calibrated to operate with BD Plastipak Luer lock syringe brands and sizes. It is programmed to recognise both the brand and the size of syringe being used (commonly 20ml. and 30ml).It will be defaulted using a Prime and Load (Lock on) Programme of a 24 hour delivery system. Page 8 of 27

Fill volume Medication and diluents should always be drawn up to the following volumes 20ml syringe draw up to 17ml 30ml syringe draw up to 22ml Acceptable sites Sites to avoid Oedematous areas, including areas affected by lymphedema or ascites. (poor absorption, increased risk of infection) Sites over bony prominences (discomfort and poor absorption) Joints or skin folds (discomfort and movement may displace cannula) Previously irradiated skin (may have poor perfusion - affects drug absorption) Upper abdomen in a patient with an enlarged liver (risk of puncturing the liver capsule) Upper chest wall in a very cachectic patient (risk of pneumothorax) Infected, broken, inflamed or bruised skin Sites of tumour Page 9 of 27

Inserting BD Saf-T- Intima Venflon Please note PPE and hand hygiene principles should be adhered to for all procedures. Clean the site with soap and water if the skin is dirty otherwise there is no need to swab the skin Apply the clamp to the line Grasp the pebbled side of the wings of the cannula, pinching the wings firmly together. This locks the needle and prevents it from retracting during insertion Ensure that the needle is point down and bevel uppermost, to guide the cannula through the tissues. This prevents kinking of the cannula. If the needle is not already orientated with the point down open the wings and gently twist the white shield until the needle is correctly positioned Insert the cannula subcutaneously at an angle of less than 45 degrees, lowering the initial angle of the cannula to a level more parallel to the skin (caution on the chest wall) and advance to the hilt of the cannula Open the wings (pebbled side down) flat against the skin Apply transparent adhesive dressing over the insertion site and the cannula wings Apply firm finger- tip pressure over the wings of the cannula (avoiding the centre where the needle retracts) simultaneously grasp the pebbled end of the coloured/white cylinder shield and pull in a straight continuous motion until the needle has fully with drawn into the cylinder and pops off Gently remove cylinder from the cannula port, if it has not released spontaneously, exposing the adapter with the rubber bung Place the needle shield in the sharps bin Change the site every 7 days or as necessary depending on the condition of the skin N.B. Te Saf-T-Intima cannot be primed when using the McKinley T34. When setting up the syringe driver the primed extension line is connected directly to the un-primed Saf-T-Intima The registered nurse must prepare the syringe and confirm the patient s identity as on prescription Check the battery life by pressing the INFO Key twice *** Prepare syringe and contents and cap the syringe. Press STOP Press and hold INFO key to deactivate keypad lock If the infusion complete alarm has activated, press YES to confirm end of infusion Switch syringe driver OFF Clamp Saf-T-Intima Raise the barrel clamp arm Remove old syringe Page 10 of 27

Follow instructions on page 18 Power on and pre-loading When Start infusion? screen displays, connect the infusion line to the syringe, release the clamp on the Saf-t- Intima and press YES *** For community use the battery will need changing when the device registers at 40% battery life left. Bolus dose of medication If the patient has uncontrolled symptoms prior to setting up the McKinley T34, it may be necessary to give a PRN dose of medication. A separate Saf-T- Intima 24Gx0.75 FSP318 Yellow should be inserted for the purpose of giving PRN doses. A Swan Lock needle free device should be attached to the Saf-T- Intima port. Temporary interruption to the infusion - Hospice This is not normal practice in a community setting and should only be used in exceptional circumstances e.g. showering or bathing. N.B. Topping the infusion will delay the end time of the infusion Stopping the Infusion Press STOP unlock the keypad and turn the syringe driver OFF. Clamp the Saf-T- Intima Disconnect the syringe driver. DO NOT REMOVE THE SYRINGE FROM THE PUMP Cap the Saf-T-Intima and infusion line to minimize cross infection. Record time and reason why infusion stopped on Syringe Driver Observation Chart Resuming the Infusion Check that the prescription, syringe label and patient details are correct Reconnect the line to the syringe on the pump maintaining asepsis Press and hold ON button The screen will request confirmation of size and brand of syringe Press YES to confirm The screen will display Press YES to Resume NO for New Syringe Press YES to resume The screen will display remaining volume/ duration/ rate of infusion Ensure information is correct as prescribed Press YES to confirm Unclamp Saf-T-Intima Screen will display Start Infusion? Press YES to start infusion Press and hold INFO key to lock the keypad Replace the Lock Box Page 11 of 27

Record on the Syringe Driver Observation chart the time the infusion was recommenced N.B. If NO for New Syringe is pressed the remaining infusion will be reset to deliver over the next 24hrs at a different rate, and the infusion will be incorrect. If NO for New Syringe has been pressed in error. Discard the remainder of the syringe contents, prepare, and set up a new syringe. In a community setting the following procedure should not be applicable as staff will check the battery status before commencing each 24 hour regime. Changing the battery during an infusion When near the end of the battery alert sounds, it indicates that the battery should be changed within the next half hour Press STOP and apply clamp to Saf-T-Intima Insert new battery Restart the syringe driver Reconfirm syringe size and brand Press YES to resume Reconfirm volume and duration and rate of infusion Press YES to recommence the infusion Lock the keypad Following completion of the procedure all patient records will be updated and signed by the registered nurse. (For paper documentation see appendix 2). Records will also include those accessed on System One. What to do if there is an occlusion in the extension line Check that the Saf-t-Intima is not clamped Check the extension line and Saf-t-Intima for any kinking straighten if kinked Check the syringe, extension line and Saf-t-Intima for any signs of crystallization of the solution. If crystallization detected prepare and fit new syringe, extension line and change Saf-t-Intima site If no physical reason for the occlusion is detected resite the Saf-t- Intima If occlusion is still present change the site, extension line and syringe N.B. During an occlusion the pump s Post Occlusion Reduction System will reverse the operation of the motor and drive the actuator backwards, otherwise the pressure build up could cause a surge of fluid into the patient on release of the occlusion. When the pump is resumed/restarted following the backward movement of the actuator, time will be added to the time remaining to protect the original calculated rate. Page 12 of 27

Procedure for releasing a trapped foreign object from the actuator (See appendix 6) WARNING: IF A FOREIGN OBJECT IS TRAPPED IN FRONT OF OR BEHIND THE ACTUATOR DURING PRE-LOADING (AUTOMATIC ACTUATOR MOVEMENT) OR WHEN MANUALLY ADJUSTING THE ACTUATOR, THE USER SHOULD: Ignore screen prompts as the prompt that may display will be in relation to alarm activation and NOT the trapped object Turn the syringe driver OFF Raise the barrel clamp arm and turn it to the left or right to keep it in the raised position Turn the syringe driver ON Turn and lower the barrel clamp arm Use the FF key (or BACK key) to move the actuator in order to release the object 4.9 Incident Reporting Systems are in place within Rotherham Doncaster and South Humber NHS Foundation Trust to report and manage incidents, near misses and serious untoward incidents involving syringe pumps. Staff should be familiar with the reporting process and the Incident Reporting Policy. Acknowledgements McKinley T34 Ambulatory Syringe Pump Operations Manual (2011) Illustrations courtesy of CME McKinley Medical CME McKinley UK Ltd Kincraig Business Park, Kincraig Road, Blackpool, FY2 0PJ Tel: 01253 894646 www.cme-mckinley.co.uk 5. Links to Associated Documents Aseptic technique and Aseptic Non Touch Technique Policy Lifecycle of Clinical & Corporate Records Policy Medical Devices Policy The Medicines Act (1986) Mental Capacity Act 2005 Policy Incident Reporting Policy Policy for Consent to Examination and Treatment. SOP for Controlled Drugs Standard Infection Prevention and Control Precautions Policy Sharps Policy Safe Use and Disposal of Sharps and Management of Contamination Injuries Page 13 of 27

Hand Hygiene Policy NMC Standards of Medicines Management Waste Policy 6. References and Literature review British Medical Association and the Royal Pharmacological Society of Great Britain. (2013) British National Formulary No 64 London. BMA and RPSGB. Dickman A and Schneider J (2011) The Syringe Driver. Continuous subcutaneous infusions in palliative care 3rd edition, Oxford University Press, Oxford Perdue, C. (2004) The syringe driver an aid to delivering symptom control. Nursing Times, 100, 13. pp32-35. Medicines Act 1986. HMSO: London Mental Capacity Act (2005) DOH: London Mitten, T. (2001) Subcutaneous drug infusions: a review of problems and solutions. International Journal of Palliative Nursing, 7,2. pp.75-85. National Patient Safety Agency (2008) Reducing dosing errors with Opioid Medicines Rapid Response Report 05 National Patient Safety Agency (2010) Safer ambulatory syringe drivers Rapid Response Report 019 NMC (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives, Nursing and Midwifery council, London NMC (2008) Standards for medicines management, Nursing and Midwifery Council, London Twycross, R, Howard,P and Wilcock A (2014) (eds) Palliative Care Formulary 5th edition, Nottingham, palliativedrugs.com Ltd. Wilson J. (2001) Infection Control in Clinical Practice. Bailliere Tindall. London pp138 7. Appendices Appendix 1 Appendix 2 Appendix 3 Syringe Driver base information Subcutaneous syringe driver instruction and observation chart for McKinley T34 and continuation sheet Indications, Advantages and Disadvantages for use of Syringe Driver Page 14 of 27

Appendix 4 Appendix 5 Appendix 6 Appendix 7 McKinley T34 Feature Recognition McKinley Syringe pump compatibility tables Procedure for releasing a trapped object from the actuator Form for the patient regarding loan of syringe driver Page 15 of 27

SYRINGE DRIVE BASE INFORMATION Appendix 1 SYRINGE DRIVER IDENTIFICATION CODE CLUSTER AREA IN USE/NOT IN USE nb. IF IN USE PLEASE REFER TO THE RECORD SHEET STAFF SIGNATURE Page 16 of 27

DAILY SET UP MONITORING PROGRESS Appendix 2 SUBCUTANEOUS SYRINGE DRIVER INSTRUCTION AND OBSERVATION CHART FOR MCKINLEY T34 PRESCRIPTION DETAILS [for completion by the prescriber] a separate form must be completed for each syringe driver DRUG DOSE DILUENT PHARMACY a ALLERGY STATUS Date 1. Please circle Route SC 2. Duration 3. of flow 4. Please circle 12 hours 24 hours Water for injection or Normal Saline The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary treatment changes or need for review. If, as the prescriber, you wish to review the patient on a particular date, please stipulate below - Review date:.. Prescriber name: Signature: Practice:.. ADMINISTRATION & OBSERVATION DETAILS [for completion by administering clinician] WARD OR BASEPOINT The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary treatment changes or need for review. ADMINISTRATION 1 Day and Date OBSERVATIONS 2 Time Start time of infusion: Site appearance 6 : Syringe size used 17ml infusion in 20ml syringe Syringe/line contents clear 3 - OK to continue? 20ml or 30ml 22ml infusion in 30ml syringe Infusion rate setting as at set up? [Y/N] Syringe Driver serial No.: Battery Status [%]: Infusion time remaining [HH:MM] Infusion rate [ml/hr]: Volume still to be infused (vtbi) [ml] Site used 5 : Site Appearance 6 : Is the VTBI correct for time remaining [Y/N] Drawn up by: Checked by: Volume infused [ml] Details of any problems & actions taken: Battery status [%] 4 Is the key pad locked? [Y/N] Observer s initials If syringe contents discarded: Volume discarded: Date & time: Discharged by: Checked: 1. To be completed each time syringe driver is loaded 4. Change battery when less than 10% (ward ) or 40% (community) 2. WARD - Completed 30 minutes after loading and then every 4 hours 5. Document insertion site of winged infusion COMMUNITY Complete at set up, at each subsequent visit and at syringe change 6. Appearance: Use code below 3. If contents of syringe look cloudy, precipitation has occurred. STOP infusing and contact NP (no problem) P (pain) I (inflammation) prescriber. Refer to policy for guidance on checking compatibility SW (swelling) B (bleeding) H (hardening) PATIENT DETAILS [Affix label if available] NHS Number:.. Surname: Forename(s): Address:... DOB:.. a. Pharmacy: Only complete if this form is used on a ward. NOT required for community use. Page 1 Page 17 of 27

DAILY SET UP MONITORING PROGRESS DAILY SET UP MONITORING PROGRESS SUBCUTANEOUS SYRINGE DRIVER CONTINUATION SHEET ADMINISTRATION & OBSERVATION DETAILS WARD OR BASEPOINT NAME The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary treatment changes or need for review. ADMINISTRATION 1 Day and Date OBSERVATIONS 2 Time [HH:MM] Start time of infusion: Site appearance 6 : Syringe size used 17ml infusion in 20ml syringe Syringe/line contents clear 3 - OK to continue? [Y/N] 20ml or 30ml 22ml infusion in 30ml syringe Infusion rate setting as at set up? [Y/N] Syringe Driver serial No.: Battery Status [%]: Infusion time remaining [HH:MM] Infusion rate [ml/hr]: Volume still to be infused (vtbi) [ml] Site used 5 : Site Appearance 6 : Is the VTBI correct for time remaining [Y/N] Drawn up by: Checked by: Volume infused [ml] Details of any problems & actions taken: Battery status [%] 4 Is the key pad locked? [Y/N] If syringe contents discarded: Volume discarded: Observer s initials Date & time: Discharged by: Checked: ADMINISTRATION & OBSERVATION DETAILS WARD OR BASEPOINT NAME The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary treatment changes or need for review. ADMINISTRATION 1 Day and Date OBSERVATIONS 2 Time [HH:MM] Start time of infusion: Site appearance 6 : Syringe size used 17ml infusion in 20ml syringe Syringe/line contents clear 3 - OK to continue? [Y/N] 20ml or 30ml 22ml infusion in 30ml syringe Infusion rate setting as at set up? [Y/N] Syringe Driver serial No.: Battery Status [%]: Infusion time remaining [HH:MM] Infusion rate [ml/hr]: Volume still to be infused (vtbi) [ml] Site used 5 : Site Appearance 6 : Is the VTBI correct for time remaining [Y/N] Drawn up by: Checked by: Volume infused [ml] Details of any problems & actions taken: Battery status [%] 5 Is the key pad locked? [Y/N] If syringe contents discarded: Volume discarded: Observer s initials Date & time: Discharged by: Checked: 1. To be completed each time syringe driver is loaded 2. WARD - Completed 30 minutes after loading and then every 4 hours COMMUNITY Complete at set up, at each subsequent visit and at syringe change 3. If contents of syringe look cloudy, precipitation has occurred. STOP infusing and contact prescriber. Refer to policy for guidance on checking compatibility 4. Change batter when less than 10% (ward ) or 40% (community) 5. Document insertion site of winged infusion 6. Appearance: use code below NP (no problem) P (pain) I (inflammation) SW (swelling) B (bleeding) H (hardening) Page 18 of 27 Page

DAILY SET UP MONITORING PROGRESS DAILY SET UP MONITORING PROGRESS SUBCUTANEOUS SYRINGE DRIVER CONTINUATION SHEET ADMINISTRATION & OBSERVATION DETAILS WARD OR BASEPOINT NAME The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary treatment changes or need for review. ADMINISTRATION 1 Day and Date OBSERVATIONS 2 Time [HH:MM] Start time of infusion: Site appearance 6 : Syringe size used 17ml infusion in 20ml syringe Syringe/line contents clear 3 - OK to continue? 20ml or 30ml 22ml infusion in 30ml syringe [Y/N] Infusion rate setting as at set up? [Y/N] Syringe Driver serial No.: Battery Status [%]: Infusion time remaining [HH:MM] Infusion rate [ml/hr]: Volume still to be infused (vtbi) [ml] Site used 5 : Site Appearance 6 : Is the VTBI correct for time remaining [Y/N] Drawn up by: Checked by: Volume infused [ml] Details of any problems & actions taken: If syringe contents discarded: Volume discarded: Date & time: Discharged by: Checked: Battery status [%] 4 Is the key pad locked? [Y/N] Observer s initials ADMINISTRATION & OBSERVATION DETAILS WARD OR BASEPOINT NAME The patient will be reviewed by the attending clinician at each attendance and, where there has been a change of circumstances, will refer to the prescriber for any necessary treatment changes or need for review. ADMINISTRATION 1 Day and Date OBSERVATIONS 2 Time [HH:MM] Start time of infusion: Site appearance 6 : Syringe size used 17ml infusion in 20ml syringe Syringe/line contents clear 3 - OK to continue? [Y/N] 20ml or 30ml 22ml infusion in 30ml syringe Infusion rate setting as at set up? [Y/N] Syringe Driver serial No.: Battery Status [%]: Infusion time remaining [HH:MM] Infusion rate [ml/hr]: Volume still to be infused (vtbi) [ml] Site used 5 : Site Appearance 6 : Is the VTBI correct for time remaining [Y/N] Drawn up by: Checked by: Volume infused [ml] Details of any problems & actions taken: Battery status [%] 5 Is the key pad locked? [Y/N] If syringe contents discarded: Volume discarded: Observer s initials Date & time: Discharged by: Checked: 4. Change batter when less than 10% (ward ) or 40% (community) 5. Document insertion site of winged infusion 6. Appearance: use code below NP (no problem) P (pain) I (inflammation) SW (swelling) B (bleeding) H (hardening)= Page.. 4. To be completed each time syringe driver is loaded 5. WARD - Completed 30 minutes after loading and then every 4 hours COMMUNITY Complete at set up, at each subsequent visit and at syringe change 6. If contents of syringe look cloudy, precipitation has occurred. STOP infusing and contact prescriber. Refer to policy for guidance on checking compatibility Page 19 of 27

Appendix 3 Indications for the use of a syringe driver The inability of the patient to swallow or absorb oral drugs because of: Intestinal Obstruction Persistent Vomiting Dysphagia Mouth Throat or Oesophageal Tumour Altered Level of Consciousness Malabsorption Profound Weakness Advantages Plasma drug levels are maintained preventing peaks and troughs Effective symptom control without repeated injections Control of multiple symptoms with a combination of drugs Mobility and independence maintained for some patients Disadvantages/Risks Medication errors relating to drug or dose Inflammation or infection may occur at skin site Drug/patient and drug/diluent incompatibility Page 20 of 27

McKinley T34 Feature Recognition Appendix 4 Barrel clamp arm.secures syringe and detects brand and size Collar sensor detects correct loading of syringe collar Plunger sensor detects correct loading of the syringe plunger Actuator Info key (c) key Key Yes/Start No/Stop FF (Forward) Back (Reverse) On/Off key drives the syringe plunger to deliver the syringe contents (a) shows infusion summary, protocol parameters, battery level (b) when pump is paused, access the main menu activates/deactivates keypad lock UP arrow (a) scrolls between options (b) increases infusion parameters Down arrow (a) scrolls between options (b) decreases infusion parameters during programming/ titration Confirms selection and starts infusion (a) stops infusion (b) takes the user back a step during programming (a) moves actuator forward when no syringe in place and barrel clamp arm is down (b) accesses purge function (if enabled) moves actuator backward when no syringe is in place and barrel clamp arm is down Switches the pump on and off Infusion LED light. A green indicator lights: (a) during system self-test (b) intermittently to indicate infusion delivery A red indicator light: (a) continuously to indicate an alarm state (b) when pump paused/on stand-by mode Page 21 of 27

Appendix 5 Compatibility and stability tables for a subcutaneous infusion in a McKinley T34 Syringe Pump Table 1: Subcutaneous Morphine Infusion Diluent: Water for injections The figures in these tables are not clinical doses to prescribe. Most patients do not need such large amounts of medication. Refer to the relevant guidelines to obtain the usual dose range for each of the medications. Use the minimum effective dose and titrate according to response. Use the table to check for concentrations that are stable for 24 hours; their use is unlicensed. Drug Combination Concentrations of two drug combinations that are physically stable for 24 hours 17ml in 20ml syringe 22ml in 30ml syringe Morphine Sulphate Cyclizine 300mg 150mg 380mg 150mg Morphine Sulphate Glycopyrronium bromide 300mg 380mg Morphine Sulphate Haloperidol 400mg 500mg Morphine Sulphate Hyoscine butylbromide 300mg 120mg 380mg 120mg Morphine Sulphate Hyoscine hydrobromide 450mg 580mg Morphine Sulphate Levomepromazine 300mg 380mg Morphine Sulphate Metoclopramide 120mg 60mg 150mg 70mg Morphine Sulphate Midazolam 300mg 30mg 380mg 3 Morphine Sulphate Octreotide 400mg 400 micrograms 500mg 500 micrograms Drug Combination Concentrations of three drug combinations that are physically stable for 24 hours 17ml in 20ml syringe 22ml in 30ml syringe Morphine Sulphate Cyclizine Haloperidol 40mg 50mg Morphine Sulphate Haloperidol Midazolam Morphine Sulphate Hyoscine butylbromide Midazolam Morphine Sulphate Metoclopramide Midazolam Morphine Sulphate Midazolam Levomepromazine 2mg 20mg 50mg 40mg 60mg 50mg 30mg 7mg 180mg 3mg 130mg 6mg 2 60mg 50mg 7 60mg 40mg 230mg 12mg Page 22 of 27

Table 2: Subcutaneous Diamorphine infusion in a McKinley T34 Syringe Pump Diluent: Water for injections The figures in these tables are not clinical doses to prescribe. Most patients do not need such large amounts of medication. Refer to the relevant guidelines to obtain the usual dose range for each of the medications. Use the minimum effective dose and titrate according to response. Use the table to check for concentrations that are stable for 24 hours; their use is unlicensed. Drug Combination Diamorphine Cyclizine Diamorphine Glycopyrronium bromide Diamorphine Haloperidol Diamorphine Hyoscine butylbromide Diamorphine Hyoscine hydrobromide Diamorphine Levomepromazine Diamorphine Metoclopramide Diamorphine Midazolam Diamorphine Octreotide Drug Combination Diamorphine Cyclizine Haloperidol Diamorphine Haloperidol Midazolam Diamorphine Hyoscine butylbromide Midazolam Diamorphine Levomepromazine Metoclopramide Diamorphine Levomepromazine Midazolam Concentrations of two drug combinations that are physically stable for 24 hours 17ml in 20ml syringe 22ml in 30ml syringe 340mg 150mg 42 800mg 1000mg 120mg 1000mg 850mg 1000mg 8 560mg 80mg 42 900 micrograms 440mg 150mg 550mg 1000mg 1000mg 120mg 1000mg 1000mg 1000mg 1 720mg 80mg 550mg 900 micrograms Concentrations of three drug combinations that are physically stable for 24 hours 17ml in 20ml syringe 340mg 150mg 800mg 7mg 6 120mg 80mg 20mg 850mg 50mg 850mg 50mg 30mg 22ml in 30ml syringe 440mg 150mg 1000mg 80mg 150mg 2 1000mg 60mg 1000mg 60mg 40mg Page 23 of 27

Table 3: Subcutaneous Oxycodone infusion in a McKinley T34 Syringe Pump Diluent: Water for injections The figures in these tables are not clinical doses to prescribe. Most patients do not need such large amounts of medication. Refer to the relevant guidelines to obtain the usual dose range for each of the medications. Use the minimum effective dose and titrate according to response. Use the table to check for concentrations that are stable for 24 hours; their use is unlicensed. If the /ml preparation of oxycodone injection is used, and the 24 hour dose of oxycodone exceeds 60mg, an alternative opioid may be needed for breakthough pain. Drug Combination Oxycodone Cyclizine Concentrations of two drug combinations that are physically stable for 24 hours 17ml in 20ml syringe Do not mix - Incompatible 22ml in 30ml syringe Do not mix - Incompatible Oxycodone Haloperidol Oxycodone Hyoscine butylbromide Oxycodone Hyoscine hydrobromide Oxycodone Levomepromazine Oxycodone Metoclopramide Oxycodone Midazolam Oxycodone Octreotide 140mg 140mg 40mg 130mg 120mg 80mg 40mg 80mg 40mg 80mg 400 micrograms 180mg 180mg 50mg 160mg 150mg 50mg 50mg 500 micrograms Drug Combination Oxycodone Haloperidol Hyoscine butylbromide Concentrations of three drug combinations that are physically stable for 24 hours 17ml in 20ml syringe 80mg 2mg 22ml in 30ml syringe 120mg Oxycodone Haloperidol Hyoscine hydrobromide Oxycodone Haloperidol Midazolam Oxycodone Levomepromazine Hyoscine butylbromide 80mg 2mg 1000 micrograms 80mg 2mg 1 80mg 20mg 20mg 2 120mg Page 24 of 27

Table 4: Subcutaneous Alfentanil infusion in a McKinley T34 Syringe Pump Diluent: Water for injections The figures in these tables are not clinical doses to prescribe. Most patients do not need such large amounts of medication. Refer to the relevant guidelines to obtain the usual dose range for each of the medications. Use the minimum effective dose and titrate according to response. Use the table to check for concentrations that are stable for 24 hours; their use is unlicensed. Drug Combination Alfentanil Cyclizine Alfentanil Glycopyrronium bromide Alfentanil Haloperidol Alfentanil Hyoscine butylbromide Alfentanil Hyoscine hydrobromide Alfentanil Levomepromazine Alfentanil Metoclopramide Alfentanil Midazolam Alfentanil Octreotide Drug Combination Concentrations of two drug combinations that are physically stable for 24 hours 17ml in 20ml syringe 4mg 150mg 7mg 120mg 7mg 7mg 40mg 2mg 60mg 3mg 50mg 6mg 800 micrograms 22ml in 30ml syringe 150mg 8mg 8mg 120mg 50mg 3mg 80mg 60mg 8mg 900 micrograms Concentrations of three drug combinations that are physically stable for 24 hours Alfentanil Haloperidol Midazolam Alfentanil Hyoscine butylbromide Levomepromazine Alfentanil Metoclopramide Midazolam Alfentanil Levomepromazine Midazolam 17ml in 20ml syringe 4mg 3 120mg 2 3mg 3 20mg 3mg 80mg 30mg 22ml in 30ml syringe 6mg 4 7mg 120mg 2 3mg 4 30mg 40mg 1. Dickman A: The syringe driver: continuous subcutaneous infusions in palliative care. 2nd Edition, 2005. OUP. 2. Palliative care drug information online http://www.palliativedrugs.com/ Page 25 of 27

Page 26 of 27 Appendix 6

Appendix 7 You have been loaned a syringe driver by Rotherham Doncaster and South Humber NHS Foundation Trust. Make and Model... Serial Number... This syringe driver will be cleaned, maintained and tested to ensure it is, and remains fit for purpose by the Nursing team. We have included an instruction manual for the unit that you have been given. Please ensure that; The driver is kept dry It is handled with care Delivered by (Print name)...rdash Employee Instruction given - Date...Signature... Syringe driver accepted by (print name)...patient/carer Date accepted... By accepting this machine I agree to the above. Signature......Patient/carer Advice available from... Please contact... for any issues or to return the unit. The equipment specified remains the property of Rotherham Doncaster and South Humber NHS Foundation Trust and must be returned to the contact above in the condition it was received in when no longer required. Page 27 of 27