PROCESS FOR INITIATING A SYRINGE DRIVER FOR COMMUNITY NURSE PATIENTS OUT OF HOURS

Transcription

1 STANDARD OPERATING PROCEDURE PROCESS FOR INITIATING A SYRINGE DRIVER FOR COMMUNITY NURSE PATIENTS OUT OF HOURS Issue History Issue Version one Purpose of Issue/Description of Change To facilitate patients receiving safe and timely palliative care treatment, via a syringe driver out of hours Planned Review Date 2013 Named Responsible Officer:- Approved by Date Medicines Governance Pharmacist Risk and Governance Group February 2012 Section:- Medicines Management MMSOP22 Target Audience Doctors working for Unplanned Care Services UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

2 CONTROL RECORD Title Process for commencing a syringe driver for community nursing patients out of hours Purpose To facilitate patients receiving safe and timely palliative care treatment, via a syringe driver out of hours Author Quality and Governance Service (QGS) and L Knight Impact Assessment Incorporated into procedure Yes No Subject Experts Dr Kathy Ryan, Clinical Director Unplanned Care Services Lisa Knight, Medicines Governance Pharmacist Document Librarian QGS Groups consulted with :- Medicines Management Group Infection Control Approved Not applicable Date formally approved by 1 st Dec 2011 Risk and Governance Group Method of distribution Intranet Archived Date Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 New To outline best practice for Doctors to initiate the setting up of a syringe driver in community nursing Status New / Revised / Trust Change 2/9

3 NAME OF DISCIPLINE: GP OUT OF HOURS, UNPLANNED CARE OBJECTIVES To inform doctors working within Unplanned Care, the correct procedure for initiating syringe drivers for palliative care, during the out of hours period SCOPE To highlight the Wirral Care of the Dying Clinical Guidelines To outline the requirements for completing Patient Medicines Administration Charts (PMACS) To detail the importance of prescribing for pain, breathlessness, agitation, secretions, nausea and vomiting whether currently an issue or not To explain the mechanisms for obtaining stock medication out of hours To inform doctors, where to obtain out of hours advice. To give details on the community nursing service facilitating seamless care TARGET GROUP (Staff authorised to follow this SOP) EVIDENCE TO SUPPORT PROCEDURE Doctors working within GP Out of Hours National Patient Safety Agency (NPSA) Rapid Response Report. Reducing Dosing Errors with Opioid Medicines 4 July 2008 NPSA Safer Practice Notice 12 Ensuring Safer Practice with High dose Ampoules of Diamorphine and Morphine 25 May 2006 Dose Conversion Chart for Strong Opioids, (Wirral Drug and Therapeutics Committee: Approved March 2010) Care of the Dying, Clinical Guideline, (Wirral Drug and Therapeutics Committee: Approved May 2010) Care of the Dying, Management in Severe Renal Failure, Clinical Guideline: (Wirral Drug and Therapeutics Committee: Approved May 2010) Trust Procedure for Graseby MS26 Syringe Driver Standard Operating Procedure For: The Provision of Patient Medicines Administration Charts (PMAC) for Community Nurses IT IS THE RESPONSIBITITY OF ALL STAFF TO COMPLY WITH RELEVANT TRUST POLICIES, PROCEDURES AND PROTOCOLS IN CONJUNCTION WITH THIS PROCEDURE 3/9

4 PROCEDURE ACTIVITY RATIONALE RESPONSIBILITY 1. Indications For Using a Syringe Driver in Palliative Care Following assessment of the patient, the practitioner may be satisfied that it is in the best interest of the patient to receive medication subcutaneously via a syringe driver. This may be for one or more of the following reasons: Persistent nausea and vomiting Dysphagia; intermittent or continuous Oral or pharyngeal lesions Intestinal obstruction Patient too weak to swallow oral medication Diminishing level of consciousness Malabsorption of oral medication Rectal route inappropriate or unavailable The use of syringe drivers avoids the need for four hourly injections and provides stable plasma levels of analgesics/medication that may be required for symptom management 2. Prescribing for Patients who require Syringe Drivers in Palliative Care The Wirral Health economy follow the Care of the Dying Clinical Guidelines for both non renal and severe renal failure patients (approved by Wirral Drugs and Therapeutics Committee) Following the same guidelines promotes seamless continuation of care These documents can all be found on the Trusts website Prescribers should anticipate the patient s clinical needs and prescribe for symptoms that the patient may not currently be suffering from including: Pain, dyspnoea, agitation, secretions, nausea and vomiting Refer to Care of the Dying Clinical Guidelines for full details First line medications for patients following the non renal guidelines are as follows: morphine sulphate for pain morphine sulphate (and haloperidol if Any deviation from the guidelines needs a rationale recorded in the patient s health records It is essential to anticipate the changing needs of the dying patient Guidelines have been developed by subject experts Medical Practitioner in conjunction with community nurse were appropriate Medical Practitioners Medical Practitioners 4/9

5 required see Clinical Guideline) for dyspnoea glycopyrronium for excessive secretions midazolam for agitation levomepromazine for nausea and vomiting The medication prescribed will then be adjusted to meet the clinical needs of the patient. Best practice emphasises the need to prescribe a sliding scale to facilitate dose adjustments to meet patients changing clinical needs The Nursing and Midwifery Council states nurses can titrate dosages according to patient response and symptom control, and administer within a prescribed range ( Standard 13, 2010) It is essential to seek specialist palliative care advice before prescribing Alfentanil For patients who are prescribed Alfentanil in a syringe driver, Alfentanil must NOT be used for breakthrough pain 3. Documentation required Medication administered by the Community Nursing Service needs to be authorised by the prescriber by completing a Patient Medicines Administration Chart (PMAC) There are two types of PMACs: A PMAC for Subcutaneous Palliative Care Medicines via a syringe driver should be completed for medication administered via a syringe driver. For medication via all other routes a general PMAC should be completed. This chart must therefore be completed to authorise the administration of medication for break though symptom management It is highly recommended to authorise the administration of a range of doses, i.e. a Alfentanil should be reserved for use only in patients with severe renal impairment. Due to its short half life, Alfentanil is inappropriate for use as stat or PRN doses Trust procedure and in line with Nursing and Midwifery Council Standards (2010) Copies of PMACs are kept in the Doctors home visiting bag for ease of access This allows community nurses to increase medication in Medical Practitioners Medical Practitioners 5/9

6 sliding scale for symptom management, as outlined in the Care of the Dying Clinical Guidelines. response to the patient s changing needs and to manage symptoms appropriately. Nurses are trained to administer the lowest dose and titrate upwards appropriately unless otherwise directed by the prescriber. The PMAC must be clearly written in black ink and be indelible Refer to appendix 1 for full details of what needs to be included on a PMAC Include a date and signature for each medication authorised To reduce error Black can be photocopied in case of later query or root cause analysis Medical Practitioner When writing PMACs for syringe drivers, the diluent must be included This is usually sodium chloride 0.9%, water for injection should be used for diamorphine in concentrations above 40mg per ml and for cyclizine Most injections are isotonic and diluting with sodium chloride 0.9% does not change this. Also prescribe all medication required on an FP10. Order sufficient supplies of medication to comfortably cover the out of hour s period, until the patient is reviewed by their own registered practice. It is also important to anticipate any need to increase the doses of medication to manage uncontrolled symptoms Include any necessary diluents For controlled drugs, remember to write the total quantity required in both words and figures. 6/9

7 4. Where to obtain advice Information relating to starting dose, dose conversions and formulations may be found in the following texts:- Patient information leaflet that should be supplied by the pharmacist British National Formulary (BNF) BNF for Children Palliative Care Formulary or Summary of Product Characteristics of Individual products are available at Merseyside and Cheshire Palliative Care Network Guidelines (copy available for reference in GP Out of Hours) Care of the Dying Non-Renal Clinical Guidelines on Trust intranet Care of the Dying Severe Renal Failure Clinical Guidelines on Trust intranet Medicines Information Lines Community Specialist Palliative Advice and Information Line hours days a week Contact Palliative Advice and Information Line (P.A.I.L ) Evenings only hours How to contact the community nursing service Via GP OOH s Service Monday Friday Relevant teams are geographical to support timely patient care Weekends & Bank Holidays It the whole 24hrs 6. Where to obtain stocks of medication If appropriate, such as late at night, provide enough medication and diluent to start the driver from home visiting supplies There is also a limited number of palliative care medicines, kept at Riverside and Arrowe Park sites Lloyds Pharmacy, Arrowe Park Hospital site keep an agreed list of palliative care medicines and are usually open until 10pm at night. It is advisable to telephone prior to writing an FP10, to check on availability of stock medication on To obtain palliative care medication Medical Practitioner 7/9

8 Carers and relatives need to be advised to take some form of identity card if collecting controlled drugs 7. Incident and near miss reporting Any related incidents arising from this SOP which may involve a clinical error or near miss must be reported following the Trust s Incident Reporting policy For feedback and trend analysis and compliance with Trust Policy Medical Practitioner EQUALITY ASSESSMENT CLINICAL GOVERNANCE PROFESSIONAL STANDARDS RISK ASSESSMENTS ORGANISATION DEPARTMENT (IF APPLICABLE) During the development of this procedure the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no clinical evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place All medical staff will have had their current General Medical Council registration verified. All medical staff will have had a local induction, outlining Trust Policies and Procedures and best practice for End of Life Care Generic risks assessments need to be completed if required e.g.. know drug misuser in the home Wirral Community NHS Trust GP Out of Hours Unplanned Care Peer Review Forum Trust Formal Approval Medicines Management Group Risk and Governance Group 8/9

9 Appendix 1 Essential Information to be included on the current Patient Medicines Administration Chart The prescribed medication should be written on the PMAC and includes the following:- Patient s full name and address Date of birth (DOB) Prescriber s signature The approved medicines name The dose including units (in the case of insulin the word units must be written in full Frequency of administration and time if relevant The date and route of administration The date prescribed The allergy status of the patient It is also recommended that the patient s NHS number is recorded on the Patient Medicines Administration Chart. Where relevant the age and weight of the patient In the case of injectable medicine, where relevant, the PMAC must also specify the following: Brand name and formulation of the medicine, Concentration or total quantity of medicine in the final container or syringe The name and volume of diluent The rate and duration of administration The date on which treatment should be reviewed The age and weight of the patient 9/9