GUIDELINE FOR THE USE OF THE McKINLEY T34 SYRINGE PUMP. Version No: 3.0

GUIDELINE FOR THE USE OF THE McKINLEY T34 SYRINGE PUMP Document Reference No: 1693/ CP38 Type: Clinical policy Version No: 3.0 Status: Approved Document applies to (staff group): All staff employed by the Suffolk Community Healthcare Consortium Where the procedural documents refer to Suffolk Community Healthcare (SCH) this is referring to those staff employed by the Suffolk Community Healthcare Consortium; a service delivered by West Suffolk NHS Foundation Trust (WSHFT) with The Ipswich Hospital NHS Trust (IHT) and Norfolk Community Healthcare and Care Trust (NCH&C) Date adopted/ ratified: March 2017 Review date: March 2020 Signature of Director: S/Internal/McKinleySyringePumpGuidelines/Feb2017/V3.0

GUIDELINE FOR THE USE OF THE McKINLEY T34 SYRINGE PUMP Policy Reference: SCH CP38 Version: 3.0 Status: Approved Document applies to: All community adult and children s services and community in-patient units Required compliance: This policy must be complied with fully at all times by the appropriate staff. Where it is found that this policy cannot be complied with fully, this must be notified immediately to the owner through the waiver process Document owner: Executive Chief Nurse, WSFT Document author: St Nicholas Hospice (adapted), Senior Modern Matron Other contact: Quality Patient & Safety Assurance Group Date this version adopted March 2017 Reviewer Practice Development Team Last review date January 2017 Next review date March 2020 Location of electronic master SCH S Drive Location of staff accessible copy SCH Intranet AGREED POLICY/GUIDELINE REVIEW / RATIFICATION / ADOPTION PATH: Level 1: Agreed by: Practice Development Team Date: January 2017 Level 3: Agreed by: Quality Patient & Safety Assurance Group Date: 28/3/17 Name and Title of people who carried out the EQIA: Sarah Miller, Clinical Effectiveness Manager Date EQIA completed: 28/2/17 Level 2: Agreed by: Integrated Policy & Documentation Group Date: February 2017 Name of Director who signed EQIA: Rowan Procter Signature of Director: Date EQIA signed: 29/3/17 S/Internal/McKinleySyringePumpGuidelines/Feb2017/V3.0

CONTENTS 1 Introduction... 5 2 Obtaining Consent... 5 3 Scope of Guidelines... 5 4 Policy agreement path... 5 5 Training Needs... 5 6 Syringe Pump Competencies... 6 7 Definition... 6 8 Benefits of Use... 6 9 Indications for Use... 6 10 Contraindications for Use... 6 11 Equipment Needed... 6 12 Setting up the Pump... 7 13 Priming of Lines... 7 14 Disconnecting the pump for personal care... 8 15 Drug Administration Chart... 8 16 Syringe Pump Location Record... 8 17 Transfer Into Different Care Setting... 8 18 Drugs commonly used in syringe pumps... 8 19 Drug Combinations and Compatibilities... 8 20 General Principles of Combining Drugs in a Syringe Pump... 9 21 Using licensed drugs for unlicensed purposes... 9 22 Prescribing... 9 23 Care & Maintenance of Syringe Pumps... 9 24 References and Further Reading... 10 25 Cross-reference to other related SCH policies... 11 Appendix 1: Instructions on setting up the McKinley Syringe Pump... 12 Appendix 2: Drugs commonly used in syringe pumps (ADULTS ONLY)... 18 Appendix 3: Syringe Pump Compatibilities... 21 Appendix 4: Selecting Suitable Infusion Sites... 24 Appendix 5: Daily Stock Check of Drugs Form... 25 Appendix 6: Record of continuous subcutaneous infusion using the McKinley T34 Syringe Pump... 26 Appendix 7: Syringe Pump Drug Chart (A4) (new chart must be commenced for continued administration)... 27 Appendix 8: Troubleshooting... 29 S/Internal/McKinleySyringePumpGuidelines/Feb2017/V3.0

Appendix 9: Physical Features & Function... 30 Appendix 10: Use of drugs beyond licence in palliative care... 31 Appendix 11: Syringe Pump Tool Box... 32 Appendix 12: Assessment of Current Competence Pack... 33 Appendix 12: McKinley E-Learning Access Instructions... 41 Equality Impact Assessment Tool... 42 S/Internal/McKinleySyringePumpGuidelines/Feb2017/V3.0

EQUALITY and DIVERSITY IMPACT STATEMENT All policies, procedures, guidelines and other approved documents of SCH are formulated to comply with the overarching requirements of legislation, policies or other overarching standards relating to equality and diversity SCH welcomes feedback on this document and the way it operates and needs to be informed of any possible or actual adverse impact that it may have on any groups listed below. This document has been screened to determine equality relevance for the following dimensions: * Age * Gender * Disability * Race * Religion/ belief * Sexual Orientation * Transgender/ transsexual * Other characteristics 1 Introduction 1.1. This guideline is intended to minimise risk and maximise good practice when using the McKinley T34 syringe pump. The pumps will be set to lock on mode. 2 Obtaining Consent 2.1. This will be in line with the SCH Consent to Treatment Policy. 3 Scope of Guidelines 3.1. These guidelines only cover the use of the McKinley T34 for subcutaneous infusion. 3.2. Please note that the Graseby Syringe Drivers have been phased out and have been replaced by the McKinley T34. 4 Policy agreement path 4.1. See front sheet 5 Training Needs 5.1. You must have the knowledge and skills for safe and effective practice you must take part in appropriate learning and practice activities that maintain and develop your competence and performance (Nursing & Midwifery Council. The Code for Nurse & Midwives 2015) 5.2. Only registered nurses competent in the operation of McKinley T34 syringe pumps must operate these devices. 5.3. Existing practitioners already competent in use of these pumps must ensure they maintain their knowledge and skills. 5.4. Practitioners newly gaining skills, must attend a relevant, approved training programme and successfully demonstrate competency of setting up and operating the T34 in clinical practice with an approved assessor. CME McKinley also provide an online training programme for registered nurses (see http://www.mckinleymed.co.uk/online-training) which is approved by the organisation and which staff are encouraged to complete as best practice (see appendix 12). S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 5

These competencies are used by Marie Curie as part of their quality assurance and clinical governance process. 6 Syringe Pump Competencies 6.1. The use of syringe pumps must only be carried out by staff who can demonstrate they are competent and confident. 6.2. All staff who involved in the use of syringe pumps must complete the SCH training, Syringe Pump training pack and Assessment of Current Competence every 2 years and have it recorded on the PDP documentation as complete. 6.3. If you are in any doubt regarding use of the pumps, you must inform your line manager and discuss your training/educational needs. 7 Definition 7.1. The McKinley T34 syringe pump is a small battery operated continuous infusion pump. It meets the requirements of the MHRA (Medicines and Healthcare products Regulatory Agency) and the International Electro-technical Standard (IEC) 60601-2-24. 7.2. An on-line e-training programme is available to support the training. However this must NOT be used alone as the only training given. It must be supported with a practical assessment. 8 Benefits of Use 8.1. More control of dose administration, especially if gut malabsorption is suspected. 8.2. Certainty of drug absorption avoiding peaks and troughs in drug levels. 8.3. Constant blood level of medication administered. 8.4. Comfort decreases need for repeated injection, if oral route is not available. 8.5. Mobility and independence can be maintained, as compared to intravenous administration. 9 Indications for Use 9.1. Inability to swallow 9.2. Persistent nausea and vomiting 9.3. Malabsorption 9.4. Intestinal obstruction 9.5. Semi or unconscious 9.6. Rectal route is not appropriate 10 Contraindications for Use 10.1. Restless patient who may dislodge the needle (NB May need sedation first) 10.2. Lack of sites e.g. because of oedema 11 Equipment Needed 11.1. A copy of the syringe pump policy must be kept in every palliative care box in the community, or readily available on In-Patient units 11.2. All pumps will be set in PROGRAM LOCK ON MODE (volume over fixed duration) S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 6

11.3. The pump will deliver the full contents of the syringe fitted over the duration set on the pump. This mode is ideal where the entire contents of a syringe are always required to be delivered over the same duration. The duration is locked on 24hrs so the user cannot change it. This prevents programming errors and makes setting up an infusion very simple. The user cannot change the volume to be infused or the default duration time (24hrs). Pump calculates the volume, applies the pre-set duration and calculates the appropriate rate for the infusion. The user checks and confirms the infusion summary on the display screen before starting the infusion. 11.4. Other items as follows: a) A copy of the syringe pump policy must be kept in every palliative care box in the community, or readily available on In-Patient units b) 2 x 9 Volt Duracell Alkaline Battery (1 for use, 1 for spare) [Duracell Procell MN1604 ] c) Carrying pouch if required d) Sharps box and powder free gloves e) Plastic lock box with key. f) BD PLASTIPAK 30ML syringe with Luer Lock connection. g) Drug additive label. h) Operation manual. i) Filter needle for drawing up medications j) Vapour permeable, transparent dressing. k) Infusion cannula: Saf-T-Intima. l) 0.5ml infusion giving set. m) Lockable cover: the key for this should be kept in an unobtrusive location in the patient s house (e.g. within the drug box). If there are security concerns then the team must make local arrangements for storage of, and access to, the key n) Subcutaneous syringe pump check chart (see Appendix 1). o) Prescribed drug and appropriate prescribed diluent (Sterile Sodium Chloride 0.9% for injection or sterile water for injection). 11.5. NB: Some plastic cannulae may not currently be licensed for subcutaneous use but research has demonstrated that there is less phlebitis associated with the use of peripheral cannulae when compared with steel winged infusion devices (Dawkins et al 2000; Ross et al 2002) Therefore the administration of subcutaneous infusions is recommended via a plastic cannula (Cited in Dougherty and Lister 2004 Ch9 p195). 11.6. Physical features chart of the McKinley Syringe Pump can be found at Appendix 7. 12 Setting up the Pump 12.1. For instructions on setting up the McKinley Syringe Pump please see appendix 1 13 Priming of Lines 13.1. The line must be no greater than 0.5mls in order for the amount used to purge/ prime the line to be negligible. 13.2. Under no circumstances should the follows practices be undertaken: a) Prime line with saline S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 7

b) Add additional fluid to the prescribed dose to prime line 14 Disconnecting the pump for personal care 14.1. The McKinley pump can be stopped to allow for personal care by holding down the info key to release the key lock, press STOP followed by OFF. 14.2. Once care has been performed turn the pump on using the ON/OFF button; confirm syringe by using the up down arrows as mentioned above, the pump will then ask press YES to resume NO if for new syringe, press YES as this will continue with the current volume to be infused and flow rate. 14.3. NOTE: if NO is pressed the current programme is deleted and the remaining syringe volume will be recalculated over 24hours, if this happens a new syringe should be made up to ensure the patient continues to receive the same volume and dilution of medication. 15 Drug Administration Chart 15.1. All drugs used within Syringe Pumps must be written up by the prescriber on SCH Syringe Pump Medication sheet (see appendix 7). 15.2. If the patient has EPRO form on discharge from hospital, this can be attached to the sheet until the patients General Practitioner completes the Drug administration chart. The serial number of the syringe pump must be written in the patient s record to enable data matching with the patient 16 Syringe Pump Location Record 16.1. All syringe pumps should be recorded on equipment list and record kept of who and where they have been allocated to. 17 Transfer Into Different Care Setting 17.1. For patients with a T34 who are being transferred for care in another setting, please provide a Jiffy bag with a return address written for the SCH community team on the front. 17.2. Please ensure that record is kept of where syringe pump has been sent to in order to ensure that pump is returned. 18 Drugs commonly used in syringe pumps 18.1. Please see table in appendix 2 for list of common drugs 19 Drug Combinations and Compatibilities 19.1. Although multiple drugs are often used in syringe pumps, it is essential that any combination of drugs used together, are checked for physical compatibility. Drugs may be physically incompatible in solution together causing them to precipitate or discolour. 19.2. Drug combinations are defined as physically compatible where there is evidence that they do not discolour, remain free from precipitation over the specified infusion time and achieve the desired clinical effect. 19.3. There is growing evidence for the physical compatibility of drug combinations but often the data is limited to specific concentrations. The compatibility date provided is for commonly used drug combinations for which there is clear laboratory evidence of compatibility at usual concentrations. S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 8

20 General Principles of Combining Drugs in a Syringe Pump 20.1. It is recommended to use water for injection as diluent unless otherwise specified in local policy 20.2. Some local palliative care teams may decide to use Sodium chloride 0.9% (sodium chloride 0.9% rather than water should be used for octreotide, ketamine and ketorolac) 20.3. Commonly used combinations of drugs are specified in this guideline. If another combination is required please refer to your local specialist palliative care team/pharmacist for further advice 20.4. Inspect the contents of all syringe pumps and tubing for discolouration and precipitation (according to guideline). 20.5. More detailed of compatibility and charts can be found in appendix 2 21 Using licensed drugs for unlicensed purposes 21.1. In palliative care up to a quarter of all prescriptions are licensed drugs given for unlicensed indications and/or via an unlicensed route. Often it is simply a matter of the route or dose being different from the manufacturer s licence. 21.2. The Medicines Act 1968 specifically safeguards a doctors clinical freedom. Drugs prescribed outside licence can be dispensed by a pharmacist and administered by a nurse. 21.3. See appendix 10 for more detailed information. 22 Prescribing 22.1. All prescriptions for syringe pumps should be formatted in the same way to avoid confusion and error. Points of good practice to follow: 22.2. All prescriptions for syringe pumps should be written on the local Subcutaneous Syringe Pump Prescription Chart. 22.3. All handwriting should be clearly legible 22.4. An existing prescription should not be altered but rewritten again. 23 Care & Maintenance of Syringe Pumps 23.1. Cleaning: a) The outside surface of the syringe pump can be cleaned by wiping with a lint-free cloth lightly dampened with warm water and a mild detergent, disinfectant or 10% bleach solution. b) The threads the actuator moves along can be cleaned with a small stiff bristled brush e.g. toothbrush. c) It is recommended that these cleaning procedures are undertaken after use with each individual patient to prevent cross infection. d) Avoid cleaning with organic solvents e.g. spirit based cleansers or abrasive cleaners, as they may damage some of the plastic parts. e) N.B. Never dip or immerse the syringe pump in any liquid or try to sterilize it in gas or steam. It is not completely sealed and there is a risk of change in device performance. f) Cloth dampened with a solution of mild detergent. g) Always turn pump off and remove battery before cleaning. h) Refer to operation manual for further advice. S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 9

i) The plastic lock box should always be cleaned with mild detergent and water to avoid degradation of the plastic. Do not use Sani wipes. 23.2. Storage: a) It is important to remove the battery before storing the syringe in a dry warm place. 23.3. Syringe pump box and storage of Security Key: a) The syringe pump box MUST be kept locked at all times. Each syringe pump is provided with two keys to unlock the unit. b) One key is to be kept with the District Nurse Team caring for the patient, the other one is either kept in the home in a safe place (this could be the key-safe if there is one installed) or with the appropriate out-of-hours service. c) See appendix 10 for recommended contents of syringe pump box. 23.4. Servicing: a) It is recommended by CME McKinley that the performance of the syringe pumps be checked annually. Send to EBME annually. b) If the syringe pump is damaged in any way, the performance must always be checked by EBME before it is used again. c) The syringe pump must be repaired by its appointed representative EBME. d) It is the responsibility of the District Nursing Team to maintain a list of syringe pumps (and other equipment) with their ID code, and ensure that they are sent for servicing on a rotational basis. e) All practitioners must ensure they check the last service is in date, before use. 23.5. Faults and incident reporting: a) All incidents and / or faults associated with patient connected medical equipment must be reported and the appropriate action taken according to SCH procedure. 24 References and Further Reading 24.1. DAWKINS L, BRITTON D, and JOHNSON I, HIGGINS B, DEAN T (2000) A randomised trial of Winged Vialon cannulae and metal butterfly needles: International Journal of Palliative Nursing: Vol 6 No 3. pp 110-116. 24.2. DICKMAN A, SCHNEIDER J, VARGA J (2005) The Syringe Pump Continuous subcutaneous infusions in palliative care (second edition) Oxford University Press, Oxon 24.3. DOUGHERTY L, LISTER S (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures: 6TH ed: Blackwell. Oxford 24.4. EVANS N, PALMER A, (1998) Controlling breakthrough pain in palliative care: Nursing Standard Vol 13, No7, Nov 4, p53-54 24.5. REYNOLDS, A (2004) Changing practice in the subcutaneous infusion of fluids to improve safety: Professional Nurse. Vol 20, No 3. 24.6. TWYCROSS R, WILCOCK A, CHARLESWORTH S, DICKMAN A (2002) Palliative Care Formulary (PCF2) (SE) (Second edition) Radcliff Medical Press Ltd 24.7. DICKMAN (2007) Devices for continuous subcutaneous infusions: Hospital pharmacy Europe, Vol. November/December 2007 24.8. BRENNEIS, C. ET AL (1987) Local toxicity during subcutaneous infusion of narcotics (SCIN); a prospective study: Cancer Nursing, Vol. 10, Pages 172-176 S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 10

24.9. MACMILLAN, K. ET AL (1994) A prospective comparison study between a butterfly needle and a teflon cannula for subcutaneous narcotic administration, Journal of Pain and Symptom Management, Vol. 9, No. 2 Pages 82-84 24.10. MHRA (2008) Infusion systems and pumps: www.mhra.gov.uk/safetyinformation/generalsafetyinformation Accessed 04/03/08 24.11. MHRA (2008) Medicines and Medical devices regulation: What you need to know. www.mhra.govt.uk/aboutus/index Accessed 04/03/08 24.12. NHS PURCHASING AND SUPPLY AGENCY (MARCH 2006). Report 05076. McKinley T34 syringe pump evaluation: www.pasa.nhs.uk/cep Accessed 04/03/08 24.13. SHVARTZMAN, P & BONNEH, D. (1994) Case report - local skin irritation in the course of subcutaneous morphine infusion: A challenge. Journal of Palliative Care, Vol. 10, No. 1 Pages 44-45 24.14. Anglia Cancer Network Guidelines for the use of Graseby Syringe Drivers & McKinley Syringe Pumps for subcutaneous route in palliative care (2011) 24.15. Ipswich Hospital Syringe Driver Policy 25 Cross-reference to other related SCH policies 25.1. Safe & Secure Handling of Medicines Policy 25.2. Controlled Drugs Policy 25.3. End of Life Guidelines 25.4. Record Keeping Policy 25.5. Consent to Treatment Policy 25.6. Controlled Drugs Standard Operating Procedures (Community Health Teams & Inpatients) S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 11

Appendix 1: Instructions on setting up the McKinley Syringe Pump ACTION 1. Discuss with patient and carer the reason for use and where the infusion is to be sited. Ensure consent is gained and documented. 2. Check the prescription according to the medicines policy and ensure it is written clearly and accurately. Review the patient s notes and identify any individual instructions or allergies. 3. Assemble all equipment and check the pump is clean, the last service is in date, and there is no visual damage. Ensure the previous programme has been deleted before starting/ entering a new one 4. Wash hands thoroughly. RATIONALE/ NOTES To gain patient s consent where possible To dispel any fears or anxieties and support patient to make an informed choice. To ensure safe practice in line with trust policy for drug administration To ensure the pump is fit for use To remove transient organisms. Check, prepare and draw up drugs according to the trust s medicines policy. Consider using plastic cannulae which have been shown to cause less skin reactions (see equipment list) if frequent problems encountered with steel winged infusion set. 5. Always ensure compatibility of medicines and do not mix unless specific information regarding the safety/ compatibility of this has been obtained 6. A 30ml Luer Lock syringe is recommended. NB Always choose a syringe brand and size that fits properly onto the syringe pump 7. When using a 30ml syringe, the maximum volume of fluid should be 22mls to accommodate expansion of the actuator 8. Use water for injections diluent unless otherwise specified on compatibility chart Section 5.6 5.8. Measure first, then prime line. May reduce the frequency of site changes as less irritant to the skin. To ensure safe practice in line with trust policy for drug administration The manufacturers have pre-set pump to recognise commonly used Luer Lock syringes (see appendix). Luer Lock syringes minimise risk of disconnection (Dickman et al 2005). Greater volume of diluent (i.e. a 30ml syringe) reduces risk of skin irritation, precipitation and discolouration of syringe content (Dickman et al 2005) Larger volumes will not fit into the syringe pump NB Be aware that using normal saline will give a more isotonic solution which is less irritant to the site if there are issues with irritation. (Dickman et al 2005) 9. Invert the syringe several times. To thoroughly mix the contents of the syringe 10. Purge the syringe of air. Attach giving set and prime the infusion line. Do not use more than 0.5ml to prime/ purge To ensure safe practice and safety of patient S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 12

or the amount of the drug administered will be reduced. 11. Ensure the SCH Policy for drug administration is followed. 12. Attach completed drug additive label to the syringe itself. Do not attach label to the McKinley pump itself and do not put the label under the clamp as this will cause the machine to identify an incorrect syringe. 13. When two pumps are running concurrently then each should be given an identifying number as (1) and (2) which is used both on the additives label and on the medicines record card. 14. Insert battery into pump. Press and hold the ON button until pump identification is displayed. Battery must have minimum of 40% battery life at commencement and / or renewing of syringe contents. 15. The following screens will be displayed in quick succession. Please note that the graphics and information displayed within are for guidance only. The information on your T34 will differ depending on syringe used and individual rates/settings. Please note that at this point the actuator will move backwards and forwards DO NOT interrupt it at this stage as the process deletes the previous instructions programmed into the pump. If it is interrupted there is a chance that previous instructions will be delivered to a new patient 16. When flashing syringe is displayed, the pump has finished its start-up procedure. Press INFO button. To ensure safe practice in line with SCH policy for drug administration. To ensure there is a record of drugs used in the syringe. To avoid build-up of adhesive. If pump and syringe become detached, there is still a record of what is in the syringe. To promote safe drug administration. Self-testing to ensure working properly. 17. Select battery level Press YES to view battery level. If % displayed 40% or more continue with set up. If below 40% replace battery. Confirmation of sufficient battery life for minimum of one infusion. In hospital setting it may be agreed with site manager to use battery until low battery alert is triggered. 18. With the barrel clamp arm down (1), position the syringe over it and line up the syringe collar with the collar sensor (2). If the Ensures secure fitting of syringe. S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 13

actuator (3) is not in the required position to fit the syringe plunger use the forward or back keys to move actuator to correct position. Hold the syringe above device to establish correct position. 19. The display screen prompts user to load syringe, flashing in three places. Lift the barrel clamp arm and twist 45 degrees. 20. Position the collar (vertically) and plunger simultaneously. 21. Lower the barrel clamp arm over syringe. If syringe is fitted correctly the screen graphic will appear solid. 22. If not fitted correctly the display will flash at the affected area until problem remedied. 23. The pump will now display size and brand of syringe detected. Press yes to confirm or scroll using up/down keys, then press yes to confirm when 30ml Plastipak syringe is displayed 24. NB. If pump was turned off before last program reached end program, e.g. to change a battery, the Resume prompt screen will appear. Press NO to continue setting new program. Press YES if you have changed the battery. If there is an occlusion the problem must be resolved before pressing the Resume key 25. There is now a different step to finalising the settings depending on which mode the T34 is being used in: Lock -on mode (volume over 24hrs duration) cannot be changed. The screen summary displays volume, duration and infusion rate. Press yes/start button to confirm settings. 26. Pump prompts START INFUSION? To enable T34 to calculate to make correct volume and rate calculation Check screen details match prescription before proceeding. 27. If line in position and patent go to 29 See Appendix 4 for infusion site selection. 28. Wash hands thoroughly. Put on non-latex, powder-free gloves. Clean the chosen site with a Chlorasept swab. To remove transient organisms Standard Precautions. To remove surface grease which help prevent the dressing from adhering. S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 14

Wait until solution evaporates. 29. Press YES to start infusion. The information screen will be display the following during infusion. Allowing time to evaporate reduces pain on insertion, which may be caused by introducing alcohol. Commences infusion. Pump delivering will alternate with the type of syringe you have selected 30. Commence the syringe pump check chart (appendix 1). 31. Monitor and observe the patient and the infusion. (appendix 1) Observe: The patient The site for redness, swelling and tenderness, leakage or bleeding. The syringe and the syringe pump. The contents of the tubing and syringe. The rate set and volume being delivered The green indicator light is flashing. 32. Press INFO key once: Volume to be infused (VTBI). Volume infused (VI). To document and support monitoring of the patient and infusion. To ensure any problems are identified and acted upon as soon possible. To detect early signs of precipitation, discolouration or crystallisation of the medicines. To check the delivery is running to correct time. Indicates device is infusing. Press INFO key twice: Battery life remaining. 33. The keypad should be locked at all times this is especially if there is concern about patients/ relatives tampering with the pump. N.B. you should always be able to operate the STOP key even when the keypad is locked. Press and hold the INFO key during infusion. Press and hold key until shaded bar is S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 15

complete and a beep is heard. This confirms activation. To unlock the keypad follow same procedure. N.B. Do not confuse keypad lock with lock on/off duration setting. 34. Ensure all documentation is completed including actions/observations/patient responses and evaluation. If there is evidence of inflammation, leakage or pain at the site, the infusion site should be renewed immediately to prevent discomfort to the patient and to ensure the effective delivery of drugs. (The cannula/winged infusion set only need to be re-sited if there is evidence of inflammation, pain or leakage). 35. Ensure the syringe pump is: Kept dry at all times. Protected from light. (A holster bag can be used, or the pump tucked under the bedclothes of a bed bound patient.) Protected from heat, including body heat Never take a syringe that is not empty off the syringe pump and leave it connected to the patient unless the infusion line is clamped off. If placing into a fabric holster, keep the syringe nozzle uppermost; slide the syringe pump with its cover into the holster. Fasten the tape across the top. If using a lock box ensure key is removed as box is not secure otherwise. Individual team/unit managers to decide on arrangements for storage of keys. Ensure syringe pump is always below level of infusion site 36. Ensure information is given to patients/ carers as appropriate for the situation / environment and document this. e.g. Tubing kept as straight as possible Check the clamp Encourage patients/carers to report any change in symptoms or pain. Provide contact telephone numbers (community). 37. To ensure the patient has appropriate information and knows where and who to contact. To ensure effective communication and evaluation. The time taken for this to occur can vary from hours to over 3 weeks, dependent on the patient and the drug(s) being infused. There would appear to be a relationship between the concentration of drug(s) being infused and the duration of a skin site (Twycross et al. 1998 in Dougherty and Lister 2004 Ch9 p 196). The syringe pump is not waterproof and the performance will be severely affected if it becomes wet. Some drugs can degrade in the sunlight. Heat can degrade the drugs and reduce effectiveness. To prevent risk of siphonage of medication flowing into the patient. To reduce risk of kinking infusion line. To prevent siphonage To ensure the patient has appropriate information and knows where and who to contact. To ensure effective communication and evaluation. S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 16

38. Removing the winged infusion set/ plastic cannula. a. Discuss with the patient. b. Collect equipment required and wash hands thoroughly. Put on powder free gloves. c. Take a small sharps box to patient s bedside or chair-side. d. Press stop key or turn off T34 syringe pump e. Remove tape that is securing tubing to the skin. f. Partially remove dressing and remove the giving set taking care that the needle/cannula is not dislodged. g. Remove needle / cannula. Immediately dispose into a sharps box. h. Apply sterile dressing to puncture site / tape. i. Remove syringe from syringe pump. j. Dispose of syringe contents (as per controlled drug standard operating procedure), line and old dressing appropriately. Ensure all appropriate documentation is completed. 39. Ensure battery is disposed of appropriately. Ensure the pump is cleaned with alcohol or detergent wipe before storage. To gain patient s consent where possible and dispel any fears To remove transient organisms To stop the syringe pump To minimise risk of sharps injury. N.B. Any remaining contents of the syringe should be squirted into sharps box The hospices will take old batteries as they can utilise the remaining 39% of power S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 17

Appendix 2: Drugs commonly used in syringe pumps (ADULTS ONLY) Available Drug Strengths Action Usual 24 hour dose range Cyclizine 50mg in 1ml Antiemetic 100 150mg (rarely 200mg) Indications General antiemetic Gastro-intestinal obstruction (N.B Metoclopromide) Raised intra-cranial pressure Contraindications No absolute contra-indications but physical interaction with higher doses of diamorphine (over 300mg, depends on volume in syringe Precipitates in saline, use water for injections Precipitates with Buscopan Avoid with Metoclopromide (antagonistic effect) Dexamethasone Sodium Phosphate 4mg in 1ml 8mg in 2ml Corticosteroid 1mg to prevent site reactions with specialist advice 2-16mg for other indications Brain tumours Spinal cord compression SVCO Sickness Numerous others Huge range of side-effects including: Cushingoid appearance Hyperglycaemia Peptic ulceration Oedema Agitation Proximal myopathy Infections Poor wound healing Keep to minimum effective dose where possible Incompatible with most drugs in doses of over 1-2mg (need 2 drivers) Diamorphine 5, 10, 30, 100, 500mg ampoules in powder form (5 per Packet) Or follow local guidelines Analgesic 5mg no specific upper dose limit Pain Dyspnoea (Diarrhoea) (Cough) Opioid of choice for s/c route Highly soluble Patient may need s/c stat injection before starting the continuous infusion, but there is usually no significant delay in onset of action Caution when used with patients with hepatic or renal failure Dose may need to be adjusted S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 18

Hyoscine Butylbromide (Buscopan) 20mg in 1ml Hyoscine Hydrobromide 0.4mg in 1ml 0.6mg in 1ml Haloperidol 5mg in 1ml Anticholinergic 60 120mg+ Anticholinergic (Centrally acting) Antiemetic Anxiolytic or Antipsychotic 0.8 2.4mg+ 2.5-7.5mg Not Higher than 10mg 5-10mg Contact Specialist Pall Care Colic Terminal secretions Non-sedative Terminal secretions Antiemetic Drug induced, chemical or toxic causes of vomiting. Psychosis Avoid with cyclizine (precipitates) Sedative Can sometimes cause severe agitation Little sedation Can cause hypotension Extrapyramidal effects In antipsychotic doses can precipitate with diamorphine Levomepromazine (Nozinan) 25mg in 1ml Antiemetic Anxiolytic /Antipsychotic 6.25-25mg+ 25-100mg+ Broad spectrum antiemetic (usually 6.25-12.5mg/24hr) Terminal restlessness 50-200mg/24hr Protect from light Site reactions Can cause hypotension Sedative at moderate to high doses S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 19

Metoclopramide 10mg in 2ml Antiemetic 30-80mg Delayed gastric emptying Partial bowel obstruction Oesophageal reflux Avoid in complete gastro-intestinal obstruction. Caution in young adults/elderly (greater chance of extra-pyramidal effects) Avoid with cyclizine (antagonistic effects) Midazolam 10mg in 2ml 10mg in 5ml Anxiolytic Antiepileptic 5-60mg+ (Higher doses for epilepsy) Terminal agitation To sedate patient Anticonvulsant in terminal care Dyspnoea Larger does (60mg or more in 24 hrs) NB may require larger volume syringe. 2-3 times more potent than diazepam Anti-convulsant equipotent to diazepam Oxycodone 10mg in 1ml 20mg in 2ml Use under specialist advice Analgesic 5mg upward Maximum dose usually determined by volumes Pain More expensive than diamorphine Doses can be restricted by volumes Used where side- effects with other opioids or in case of diamorphine shortage N.B. Where a small dose of morphine has been stated and morphine has been supplied; this should be used and need not be converted to diamorphine. Conversion is only needed if dose increase means volume becomes an issue. S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 20

Appendix 3: Syringe Pump Compatibilities Codes:. Compatible at usual doses. Cyclizine and Metoclopramide may precipitate with Diamorphine in doses of over 300mg. CNA Clinically not advised. Metoclopramide s prokinetic effect is blocked by anticholinergics,eg cyclizine and hyoscine Avoid combining drugs with extrapyramidal side-effects, eg haloperidol, levomepromazine and metoclopramide X Incompatible Syringe Pump Two Drug Compatibility (For other drugs, see The Syringe Driver [Dickman et al] or Palliative Care Formulary (PCF2) [Twycross et al]) Diamorphine Cyclizine Haloperidol Midazolam Levomepromazine Hyoscine Butylbromide Metoclopramide Oxycodone Diamorphine...... CNA Cyclizine..... X CNA Haloperidol... CNA.. CNA Midazolam...... Levomepromazine... CNA. CNA Hyoscine.... Butylbromide X CNA Metoclopramide.. CNA CNA CNA CNA Oxycodone...... CNA... Dexamethasone is incompatible with most drugs in doses of over 1-2mg (need 2 drivers). 1mg dose often used to prevent site reactions: discuss with palliative care team Diluent to be used is water for all above drugs (Saline must be used for Octreotide and Ketamine) S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 21

Syringe Pump Three Drug Compatibility with Oxycodone (For other drugs, see The Syringe Driver [Dickman et al] or Palliative Care Formulary (PCF2) [Twycross et al]) Cyclizine Haloperidol Midazolam Levomepromazine Hyoscine Butylbromide Metoclopramide Oxycodone & Cyclizine.... X CNA Oxycodone & Haloperidol... CNA Oxycodone & Midazolam... CNA... Oxycodone & Levomepromazine. CNA.. CNA Oxycodone & Hyoscine X... CNA Butylbromide Oxycodone & Metoclopramide CNA CNA. CNA CNA Dexamethasone is incompatible with most drugs in doses of over 1-2mg (need 2 drivers). 1mg dose often used to prevent site reactions. Discuss with palliative care team Diluent to be used is water for all above drugs (Saline must be used for Octreotide and Ketamine) S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 22

Syringe Pump Three Drug Compatibility with Diamorphine (For other drugs, see The Syringe Driver [Dickman et al] or Palliative Care Formulary (PCF2) [Twycross et al]) Cyclizine Haloperidol Midazolam Levomepromazine Hyoscine Butylbromide Metoclopramide Diamorphine & Cyclizine.... X CNA Diamorphine & Haloperidol... CNA. CNA Diamorphine & Midazolam..... Diamorphine & Levomepromazine. CNA.. CNA Diamorphine & Hyoscine X... CNA Butylbromide Diamorphine &. Metoclopramide CNA CNA CNA CNA Dexamethasone is incompatible with most drugs in doses of over 1-2mg (need 2 drivers). 1mg dose often used to prevent site reactions: discuss with palliative care team Diluent to be used is water for all above drugs (Saline must be used for Octreotide and Ketamine) S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 23

Appendix 4: Selecting Suitable Infusion Sites If possible discuss with patient first. Suitable sites:- 1. Upper chest wall below the clavicle. 2. Outer aspect of upper arms. 3. Abdomen. 4. The back scapula (occasionally). 5. Upper outer aspect of thighs. Contra indicated sites:- 1. Areas of oedema, swelling or redness; the tissues will be ineffective for absorbing medication at the predictable rate. 2. Avoid putting near bony prominences or any joints. 3. Recently irradiated skin (within previous 8 weeks). 4. Avoid arm with long lines or intravenous infusions already in situ. 5. Avoid damaged skin, i.e. broken, reddened or bruised skin. 6. Fractured bones or bruised areas. S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 24

Appendix 5: Daily Stock Check of Drugs Form S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 25

Appendix 6: Record of continuous subcutaneous infusion using the McKinley T34 Syringe Pump S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 26

Appendix 7: Syringe Pump Drug Chart (A4) (new chart must be commenced for continued administration) SYRINGE DRIVER/ PUMP NO: 1 or 2 : Serial No: Patients Name: Address: MCKINLEY SYRINGE DRIVER MEDICATION PRESCRIBER ADMINISTRATION SHEET NHS No: DoB: GP: Continuation No: PRESCRIPTION INFORMATION Please consider sliding scale/ dose adjustment to maximum symptom control Date Drug Dose Route Frequency Prescribers Signature Diluent: Drug (mg/24hrs): Dose Batch No. Expiry date: Infusion site: Line primed Y/ N: Rate: Battery life left (%) Length of contents (ml): Duration left (in hours): Diluent used: Amount remaining in syringe discarded: Time changed: Signed: Date: Drug (mg/24hrs): Dose Batch No. Expiry date: Infusion site: Line primed Y/ N: Rate: Battery life left (%) Length of contents (ml): Duration left (in hours): Diluent used: Amount remaining in syringe discarded: Time changed: Signed: Date: Drug (mg/24hrs): Dose Batch No. Expiry date: Infusion site: Line primed Y/ N: Rate: Battery life left (%) Length of contents (ml): Duration left (in hours): Diluent used: Amount remaining in syringe discarded: Time changed: Signed: Date: S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 27

Patient Name: NHS No: DOB: Drug (mg/24hrs): Dose Batch No. Expiry date: Infusion site: Line primed Y/ N: Rate: Battery life left (%) Length of contents (ml): Duration left (in hours): Diluent used: Amount remaining in syringe discarded: Time changed: Signed: Date: Drug (mg/24hrs): Dose Batch No. Expiry date: Infusion site: Line primed Y/ N: Rate: Battery life left (%) Length of contents (ml): Duration left (in hours): Diluent used: Amount remaining in syringe discarded: Time changed: Signed: Date: Drug (mg/24hrs): Dose Batch No. Expiry date: Infusion site: Line primed Y/ N: Rate: Battery life left (%) Length of contents (ml): Duration left (in hours): Diluent used: Amount remaining in syringe discarded: Time changed: Signed: Date: Drug (mg/24hrs): Dose Batch No. Expiry date: Infusion site: Line primed Y/ N: Rate: Battery life left (%) Length of contents (ml): Duration left (in hours): Diluent used: Amount remaining in syringe discarded: Time changed: Signed: Date: S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 28

Appendix 8: Troubleshooting Screen Description Implication/ Action Low Battery Alert: Battery almost depleted Prepare to change battery Program Nearly Complete Alert: Infusion will end soon Prepare to change syringe or turn pump off Pump Paused Too Long Alarm: Pump has been left in STOP mode (on hold) for 2 minutes End battery Alarm: Battery is depleted Change battery Press on/ off button once quickly to either start the infusion, continue pause mode or turn pump off End Program/ Syringe Syringe Displaced, Check Syringe Occlusion Check Line & Syringe Alarm: Infusion is complete Alarm: One or more of the syringe detection sensors is not detecting Alarm: Patient access device is either blocked, occluded, clamped or kinked Close down or start new infusion Check screen messages for assistance Check the syringe and re-seat in necessary Flush/ replace access device, release the clamp or un-kink the set S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 29

Appendix 9: Physical Features & Function S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 30

Appendix 10: Use of drugs beyond licence in palliative care In palliative care up to a quarter of all prescriptions are for licensed drugs given for unlicensed indications and/or via an unlicensed route. Often it is simply a matter of the route i.e. dose being different from the manufacturers' licence. The Medicines Act 1968 specifically safeguards a doctors' clinical freedom. Drugs prescribed outside licence can be dispensed by a pharmacist and administered by a nurse. The Association for Palliative Medicine and the Pain Society state: 1. This statement should be seen as reflecting the view of a responsible body of opinion within the clinical specialties of palliative care and pain management. 2. The use of drugs beyond licence should be seen as a legitimate aspect of clinical practice. 3. The use of drugs beyond licence in palliative care and pain management practice is currently both necessary and common. 4. Choice of treatment requires partnership between patients and healthcare professionals and informed consent should be obtained, whenever possible, when prescribing any drug. Patients should be informed of any identifiable risks and details of any information given should be recorded. It is often necessary to take additional steps when recommending drugs beyond licence. 5. Patients, carers and healthcare professionals need accurate, clear and specific information that meets their needs. The Association for Palliative Medicine and the Pain Society should work in conjunction with pharmaceutical companies to design accurate information for patients and their carers about the use of drugs beyond licence. 6. Health professionals involved in prescribing, dispensing and administering drugs beyond licence should select those drugs that offer the best balance of benefit against harm for any given patient. 7. Health professionals should inform, change and monitor their practice with regard to drugs used beyond licence in the light of evidence from audit and published research. 8. The Department of Health should work with health professionals and the pharmaceutical industry to enable and encourage the extension of product licences where there is evidence of benefit in circumstances of defined clinical need. 9. Organisations providing palliative care and pain management services should support therapeutic practices that are underpinned by evidence and advocated by a responsible body of professional opinion. 10. There is urgent need for the Department of Health to assist healthcare professionals to formulate national frameworks, guidelines and standards for the use of drugs beyond licence. The Pain Society and the Association for Palliative Medicine should work with the Department of Health, NHS Trusts, voluntary organisations and the pharmaceutical industry to design accurate information for staff, patients and their carers in clinical areas where drugs are used off label. Practical support is necessary to facilitate and expedite surveillance and audit which are essential to develop this initiative. S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 31

Appendix 11: Syringe Pump Tool Box Easily identifiable box containing: It is recommended that a tool box with the items identified below be available within the settings where syringe pumps are in use. This has particular relevance in the community where it is essential that equipment/replacements are readily available within the patient s home: Syringe pump Two batteries Duracell (alkaline 9v recommended) Infusion set 30 ml (Luer lock) syringes (recommended) 2 ml and 5 ml syringes and needles Labels for additives Transparent fixative (op-site or similar) Adhesive tape Patient information guide Copy of syringe pump guideline Troubleshooting guide McKinley Instruction Manual McKinley Syringe Pump Guideline Metric ruler S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 32

Appendix 12: Assessment of Current Competence Pack Registered Nurse Assessment of Current Competence In Caring for Individuals Requiring Subcutaneous Infusions via a Syringe Pump Supported by S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 33

Index Content Page Introduction 3 Guidance for Completion 3 Rating Score 4 Section 1 (Self-Assessment of Current Competence) 5 Section 2 (McKinley Competencies) 7 Section 3 (Role Development and Declaration) 8 Resources 10 S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 34

Introduction This document is for use by Registered Nurses to assess their competence to set up, monitor and discontinue continuous subcutaneous infusions delivered via a Syringe Pump (McKinley T34). You must have the knowledge and skills for safe and effective practice..you must take part in appropriate learning and practice activities that maintain and develop your competence and performance (Nursing & Midwifery Council. The Code 2015) If you are in any doubt regarding use of the drivers, you must inform your line manager and discuss your training/educational needs. This Assessment and Declaration must be completed two yearly and recorded in your Personal Performance Review and Development (PPRD) meeting. Please ensure that you take the completed documentation to your PPRD and discuss your selfassessment and any identified training needs with your line manager. Guidance for completion Read through each competency and with your line manager assess your confidence and competence re this action/knowledge. Use the Self-Assessment Rating (Table 1) to enter your score for each competency 1. Section 1 MUST be completed. 2. You must now complete Section 2 (McKinley T34) 3. Complete Section 3 Role Development Review & Declaration of Competence. This must also be signed by your Line Manager. 4. If you score below 3 for any competency, this has identified a training or education need which you must discuss with your Line Manager before you are able to complete the Declaration. S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 35

Table 1 Rating Score for use with assessments Level of performance Cannot perform this activity satisfactorily to participate in practice AND Doesn t have any knowledge/ understanding to support their practice 0 Can perform this activity but not without constant supervision and some assistance AND Has a limited level of knowledge/ understanding but insufficient to support practice 1 Can usually perform this activity satisfactorily but sometimes requires some supervision and assistance AND Has basic level of knowledge/ understanding but insufficient to support practice 2 Can perform this activity satisfactorily without assistance and / or supervision AND Has adequate knowledge and understanding to support practice 3 Can perform this activity satisfactorily without assistance and / or supervision and feels able to teach/ supervise others AND Has a good knowledge and understanding and feels able to teach / supervise others 4 Level of performance 3 required. S/Internal/McKinleySyringePumpGuidelines/Feb17/V3.0 36