Department Policy. Code: D: MM Entity: Fairview Pharmacy Services. Department: Fairview Home Infusion. Manual: Policy and Procedure Manual

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1 Department Policy Entity: Fairview Pharmacy Services Department: Fairview Home Infusion Manual: Policy and Procedure Manual Category: Home Infusion Subject: Management of Intravenous, Intraspinal or Subcutaneous Narcotic Medications Policy: Provide safe and appropriate methods of preparation, dispensing, administration and monitoring of intravenous, intraspinal or subcutaneous narcotic s pain management therapies in the home setting. Procedure: I. All patients shall meet admission criteria and have an appropriate indication for pain management therapy. II. III. IV. Follow guidelines for assessment and management of patients who are experiencing acute or chronic pain - refer to System Pain Management Policy. Initial orders shall include, dose, route, and frequency of administration; A. For a continuous, the order must include the basal rate (dose/hour); bolus dose orders must include dose and frequency (doses/hour) B. If the order is written as a range, verify the current dose with the discharging facility and use that dose as the starting dose. Initial administration of home IV by FHI nursing in the hospital will include: A. Verification that the and concentration compounded by the FHI pharmacy matches the and concentration compounded by the hospital pharmacy. 1. Medication compounded by FHI is the same as the current hospital :, loading dose, rate, concentration, dose and frequency of bolus dose. 2. Discrepancies must be clarified (Prescriber, FHI pharmacist, and hospital RN) prior to initiating the provided by FHI. V. Use of IV naloxone in the home is not recommended. Page 1 of 6

2 VI. VII. VIII. IX. Central venous access is recommended for intravenous administration to maintain uninterrupted level of analgesic in the home. The Patient must have an alternate mode of pain management (oral, sublingual, or rectal analgesia) in the home to be used in the event of an interruption in the administration of therapy (i.e., pump malfunction, loss of access device). A. Back up bags of pain may be provided to patients on a continuous B. Back up pumps will only be made available for patients with intraspinal s or when assessed as necessary on a case by case basis. All electronic ambulatory pumps dispensed by FHI must be verified for correct programming by two clinicians. A. The administering nurse will verify the pump program label with the pump. B. Documentation should appear in the chart that such verification was done and by whom. 1. The pump label with the program instructions will be printed and initialed by two clinicians. a. One copy will be dispensed with the pump and one copy will be archived in the medical record. 2. Nurses in the field will verify the pump program and document in electronic medical record. C. If the pump program is changed in the home after initiation of therapy, the nurse must verify the pump program over the telephone with a pharmacist. Documentation of this activity in the patient s electronic medical record should occur by one or both of the clinicians. Patients and/or caregivers shall be taught: A. To recognize pump alarms and be familiar with appropriate intervention. B. Use, storage and disposal of controlled substances 1. The patient or caregiver is responsible for disposal of controlled substances. 2. Controlled substances may not be returned to the Fairview Home Infusion Pharmacy. C. Common side effects of opioid s include: 1. Respiratory depression 2. Sedation 3. Nausea, vomiting Page 2 of 6

3 4. Constipation 5. Changes in sensorium 6. Altered mental status 7. Side effects associated with intraspinal administration of opioids: pruritus, urinary retention, tolerance, catheter migration, or meningitis D. Care management and observation of access device and management of problems as appropriate should be performed, (see appropriate Access Device Policy and Procedure). 1. The vascular access device is ed to ensure and maintain patency of the catheter and to prevent mixing of incompatible s. 2. If s need to be infused through the same catheter lumen as a continuous of pain, the access device is to be ed as close to the hub of the catheter as possible to prevent mixing of the s. 3. Before ing the lumen of a catheter of a continuous narcotic : a. Assure the patient s pain is under control. b. If ordered by the provider and the patient does not have relief from pain, administer a bolus prior to interrupting the. c. See Addendum A for ing guidelines with continuous s. d. Subcutaneous administration should be according to FHI policy (see FHI Policy Subcutaneous Infusion Access). X. When pain management is administered via a programmable pump, an RN will be responsible for changing the bag or cassette containing the narcotic. XI. XII. XIII. With a provider order, the patient and caregivers may be taught the following procedures if they are able to learn and demonstrate competence and compliance: A. Cassette or IV bag and tubing change B. Subcutaneous needle removal and insertion Pain pumps will be programmed and locked before dispensing. A. With a provider order, an RN may assess the patient and change the pump in consultation with the FHI pharmacist. Administration of intravenous, subcutaneous, or intraspinal opioid therapy shall be initiated whenever possible in the Page 3 of 6

4 XIV. XV. hospital setting. The patient shall preferably be on a controlled dose for 24 hours prior to hospital discharge. The provider must be notified under the following circumstances: A. The patient/caregiver is determined to be incapable of ensuring the safe administration of intravenous, subcutaneous, or intraspinal narcotics. B. When a dose change seems appropriate. C. An adverse reaction is suspected (i.e. sudden, unexpected, acute, clinically significant changes such as cyanosis, decreased respiration, changes in mental status, drop in blood pressure, cardiac irregularities). D. Opioid toxicity is suspected (i.e., sudden, unexpected, acute, clinically significant changes such as coma, severe respiratory depression, skeletal muscle flaccidity, hypertension or bradycardia.) Considerations in assessment of patient: A. Pain including, but not limited to, characteristics, location, intensity. B. Level of consciousness. C. Respiratory including rate, depth, quality, and effort. D. Patient s response and pain intensity with intervention. External Ref: Internal Ref: Joint Commission applicable standards Source: FHI clinical managers and staff pharmacist Approved by: Director of Operations; Medical Directors Date Effective: 02/22/1993 Date Revised: 02/26/1996, 03/19/1999, 10/2000, 1/1/2002, 6/4/2002, 4/04, 3/05, 5/07, 7/10, 7/2011, 12/2014, 12/2017 Date Reviewed: 12/2014, 12/2017 Page 4 of 6

5 Addendum A Flushing Guidelines with Continuous Opioid Infusions Access/Initiation Narcotic Bag Change Only Lab Draw Medication Administration Other PICC Flush with 0.9% NaCl 10ml to verify patency Do not Draw waste of 4- Obtain lab sample Flush with 0.9% NaCl 10ml Resume Draw waste, of 4- Flush with 0.9% NaCl 10ml Administer Flush with 0.9% NaCl 10ml Resume continuous after lab draw and Change extension set weekly or PRN Prime extension set with 0.9% NaCl (approx. 0.5 ml) and resume Change injection cap after blood draw if not done at time of extension set change Port Aspirate for blood return to verify needle placement Flush with 0.9% NaCl (10-20ml) Do not Draw waste of 4- Obtain lab sample Flush with 0.9% NaCl (10-20ml) Resume Draw waste of 4- Flush with 0.9% NaCl (10ml) Administer Flush with 0.9% NaCl (10ml) Resume continuous after lab draw and Change port needle every 7 days or PRN Change injection cap after blood draw if not done at time of needle change Page 5 of 6

6 Access/Initiation Narcotic Bag Change Only Lab Draw Medication Administration Other Sub-Q Sub-Q set directly connected to administration set should be primed to avoid interruption in therapy Do not Consider performing Sub-Q site change with bag change if due within 72 hours N/A N/A Site change performed every 3 days or PRN Tunneled/Non- Tunneled Chest Catheter (i.e., Hickman, Subclavian) Flush with 0.9% NaCl 5 ml to verify patency Do not Draw waste of 4- Obtain lab sample Flush with 0.9% NaCl 10-20ml Resume Draw waste of 4- Flush with 0.9% NaCl 5ml Administer Flush with 0.9% NaCl 5ml Change injection cap weekly, after blood draw or PRN clinician bolus after lab draw and Resume continuous after lab draw and Page 6 of 6