NHS Tayside CLINICAL

NHS Tayside

CLINICAL

Policy for Subcutaneous Administration of Medicines by the T34 Ambulatory Syringe Pump

for Adults Requiring Symptom Management

Policy Manager Marion McLagan Macmillan SCN/

T34 Syringe Pump Policy Group

Poli cy Group Medicines Policy Group

Tayside Improvement Panel

Policy Established 2011

Last Updated AUGUST 2017

Policy Review Period/Expiry

2 years/AUGUST 2019

UNCONTROLLED WHEN PRINTED

This poli cy does apply to Medical/Dental Staff

Document Control Document: Policy for Subcutaneous Administration of Medicines by the T34 Ambulatory Syringe Pump for Adults Requiring Symptom Management

Version: 3.0 Version Date: August 2017

Policy Manager: Marion McLagan Page 1 of 55 Review Date: August 2019

Policy for Subcutaneous Administration of Medicines by the T34 Ambulatory Syringe Pump for Adults Requiring Symptom Managemen t

Version Control

Version Number

Purpose/Change Author Date

1.0

Version Control was introduced in July 2011 and the previous versions of this policy, prior to this date, are available in the Electronic Document Store.

Liz Murray

2.0

Policy Review: Policy previously known as NHS Tayside Policy For Subcutaneous Administration Of Medicines by the McKinley T34 Syringe Driver CME T34 Syringe pump previously known as the McKinley T34 Syringe driver Staff training recommendations have been revised. Supporting Guidelines review: To improve access to any update The previous Medication Guidance has been replaced with direct links to NHS Scottish Palliative Care Guidelines – T34 syringe pumps ( NHS Scotland 2014 ) To comply with recommendations within Scottish Palliative Care Guidelines (NHS Scotland 2014) Maximum Volumes have been amended Change to use of BD Saf-T-Intima™ Cannula in line with NHS Tayside sharps injury prevention strategy (2014)

Marion McLagan

09/03/2015

3.0 Revised links to NHS Scotland Palliative

care guidelines ( 2014) Revised access details to online training for CME T34 syringe pump Revised Reference list

Marion McLagan 08/08/2017




Table of Contents

Contents Page number

1. Purpose and Scope 4

2. Statement of Policy 4

3. Responsibilities and Organisational Arrangements 4

4. T34 Syringe Pump Maintenance 5

5. Safety and Risk 5

5.1. Reporting Suspected Incidents or Defects 5

6. Other Relevant Information 6

6.1. Patient Admission, Discharge and Inter Hospital Transfer 6

7. Key Contacts 7

8. Supporting Guidelines For The Subcutaneous Administration Of

Medicines By T34 Syringe Pump

8

8.1. Administration of Subcutaneous Infusions Using The T34 Syringe

Pump

8

8.2. Indications For Use 8

8.3. Equipment Required For Setting Up A T34 Syringe Pump 9

8.4. Preparing the Subcutaneous Infusion 9

8.5. Connecting the Infusion Set to the Syringe 11

8.6. Choice of Infusion Sites For Placement Of Cannula For T34 Syringe

Pump Administration

11

8.7. T34 Syringe Pump Feature Recognition 12

8.8.

8.9.

8.10.

8.11.

8.12.

8.13.

8.14.

Preparing The T34 Syringe Pump

Connecting The Infusion To The Patient

Commencing the infusion

Key Pad lock Function

Discontinuing an Infusion

Temporary interruption and Resuming the Infusion

What To Do If The patient Dies With The Infusion Insitu

13

14

15 16 17 18 18

8.15. Monitoring The T34 Syringe Pump While In Use 19

8.16. Troubleshooting 19

8.17. T34 Syringe Pump Alarm Conditions 20

8.18. Cleansing And Decontamination 21




Appendices

Appe ndix 1 – Scottish Palliative Care Guidelines NHS Scotla nd

2014 Copyright © 2014 NHS Scotland.

Syringe Pump information including:

• Direct links to compatibility and stability tables for

subcutaneous infusion

• Drug administration Table: Unlicensed Routes

22

Appendix 2 –Inpatient documentation

• THB (MR)48 Version 2 McKinley T34 syringe pump administration

Record (in patients)

26

Appendix 3 – Community Nursing Service documentation

• i) AS1 Version 2 McKinley T34 Syringe Pump Prescription Record

• ii) AS2 Version 2 McKinley T34 Syringe Pump Administration

Record

• iii) CD1 Version 2 Community Nursing Service Controlled Drug +/

- Adjuvant Prescription Record

• iv) CD2 Version 2 Community Nursing Service Controlled Drug

+/- adjuvant Administration Record

• v) Community Nursing Services Controlled Drug Stock Balance

Sheet

27

Appendix 4 – Training - Online CME Medical T34 Syringe Pump

training instructions and access

32

Appendix 5 - References

34

Appendix 6A: NHS Tayside Policy Approval Checklist

35

Appendix 6B: Equality Impact Assessment

37

Appendix 6C: NHS Tayside Training Plan 55




1. Purpose and Scope The purpose of this policy is to provide a framework for the use of CME Medical T34 Ambulatory Syringe Pump to deliver medicines to meet the needs of Adults requiring symptom management in NHS Tayside. This document applies to all practitioners within NHS Tayside when using CME Medical T34 Ambulatory Syringe Pump, be it in the hospital, community or hospice setting. (NB For the rest of this document CME Medical T34 Ambulatory Syringe Pump will be referred to as the T34 Syringe Pump) Using the T34 syringe pump to administer medicines via other routes and to other patient groups e.g paediatrics are out with the scope of these guidelines, therefore it is recommended that other specialist reference sources be accessed. General guidance on the safe use of medicines can be found in the NHS Tayside Safe and Secure Handling of Medicines Manual (link below) http://www.nhstaysideadtc.scot.nhs.uk/SSHM/MAIN/Front%20page.htm Guidelines are also included with this policy in relation to setting up the T34 syringe pump and the symptom management for adults with palliative care requirements 2. Statement of Policy The aims of this policy are to:

• Promote procedural uniformity and assist practitioners when using the T34 Syringe Pump within NHS Tayside.

• To support safe and accountable practice when providing symptom relief for those patients where a T34 syringe pump is the preferred method of the administration of prescribed medicines.

• To clarify roles and responsibilities. 3. Responsibilities and organisational arrangements The Medical Physics department will maintain a register of all T34 syringe pumps and will respond to repair requests from all areas. Line managers must ensure that all practitioners who are required to administer medications using the T34 Syringe Pump are competent in its safe set up and use. Line managers in all clinical areas where staff will use theT34 syringe pump are recommended to identify appropriate individuals within their areas of responsibility who can undertake the advanced user training provided by CME Medical in NHS Tayside. to support clinical staff in their areas on the safe use of the T34 syringe pump. CME Medical Limited to date has supported advanced user education to promote a consistent approach to staff education on this device.

http://www.nhstaysideadtc.scot.nhs.uk/SSHM/MAIN/Front page.htm




A register within each department of all advanced trainers and assessments should be maintained and made available to the responsible Senior Charge Nurses and or Heads of Nursing All practitioners using the T34 syringe pump must:

• Have successfully completed the on-line T34 syringe pump training programme by visiting http://www.cmemedical.co.uk/training/clinical-training/clinical-elearning/ (To access online training see Appendix 4)

• Demonstrate to their line manager and or identified advanced users within each clinical area that they have completed the recommended online training annually as a minimum and that this and other evidence of competency is provided within each individuals e-KSF/PDP

• Maintain clear, legible and accurate records for medicine administration and the use of the T34 syringe pump (NMC 2010 (updates made in 2015).

• Ensure that prior to, and during use the equipment is maintained in line with NHS Tayside Policy and that the service history is current.

• Follow the procedures set out within NHS Tayside Safe and Secure Handling of Medicines Manual when prescribing and administering medicines via the T34 syringe pump.

4. T34 Syringe Pump Maintenance All T34 syringe pumps must be serviced regularly and at least annually, whether used or not, to ensure their function is maintained. T34 syringe pumps should be sent for maintenance checks immediately if they have been dropped, suffered fluid ingress (e.g. had fluid spilt over them or dropped in a bath) or if there is any doubt as to their functional operation whilst in use. 5. Safety and Risk

5.1. - Reporting suspected incidents or defects Any errors or incidents in relation to the use of a T34 syringe pump must be recorded and reported. This should be done via the practitioner’s line manager and documented on the Datix system. Any further documentation must be completed as per local policy. In the case of an adverse incident occurring, practitioners are reminded that ALL equipment, including the whole giving set being used at the time must be quarantined for investigation. The incident should also be reported to the Medical Physics Department directly to speed the investigation. Medical Physics should be informed of the incident reference number and the following should be recorded on the Datix system:

• A clear description of the incident. • The T34 syringe pump asset number • The patient’s name and CHI. • The name and dose of each medicine prescribed. • The name of the diluent.

http://www.cmemedical.co.uk/training/clinical-training/clinical-elearning/




• The total volume in the syringe at the start of the infusion. • The date and time the infusion started. • Where the T34 syringe pump is to be returned to.

6. Other Relevant Information 6.1 Patient admission, discharge and Inter Hospital Transfer When patients are being admitted to hospital, transferred to another hospital or discharged home with a T34 syringe pump in situ, the following details must accompany the patient:

• The time the infusion was set up. • The rate of the infusion. • The name and dose of the medicine(s) prescribed. • The name of the diluent. • The time the syringe is due to empty, and requires renewal. • The asset number of the T34 syringe pump insitu

If the patient has been transferred to another hospital or discharged home from any ward or department in Ninewells, then theT34 syringe pump in situ should be changed to a T34 syringe pump from the local area, and the original T34 syringe pump returned to the Medical Physics Department, Ninewells for return to the equipment library If the patient has been transferred to another hospital or discharged home from any ward or department in PRI, then the T34 syringe pump in situ should be changed to a T34 syringe pump from the local area, and the original T34 syringe pump returned to the Medical Physics Department, PRI If the patient has been transferred to another hospital or discharged home from any ward or department from any other hospital (eg local Community Hospital, Royal Victoria Hospital) then the T34 syringe pump in situ should be changed to a T34 syringe pump from the local area, and the original T34 syringe pump returned to the hospital the patient has been transferred/discharged from. If the patient has been admitted to any hospital with a T34 syringe pump in situ, then the T34 syringe pump should be changed to a T34 syringe pump from the hospital/ward/department and the original T34 syringe pump should be returned to the local area.




7. Key Contacts Jean Ngoie Head of Instrumentation

Medical Physics Department Ninewells Hospital DD1 9SY Tel: 01382 632797

Marnie Ferguson Senior Charge Nurse Roxburghe House

Jedburgh Road Dundee DD2 1SP Tel: 01382 423133

Shirley Kelly Macmillan Lead Clinical Pharmacist (Palliative Care)

Roxburghe House Jedburgh Road Dundee DD2 1SP Tel: 01382 423130

Marion McLagan

Macmillan Senior Charge Nurse Cornhill Macmillan Centre Perth Royal Infirmary Perth PH1 1NX Tel: 01738 413001

Libby Cachir Macmillan Palliative Care Practice Educator

Roxburghe House Jedburgh Road Dundee DD2 1SP Tel: 01382 423100




Supporting Guidelines for the Subcutaneous Administ ration of Medicines by CME Medical T34 Ambulatory Syringe Pump for adul ts requiring symptom management. 8. These guidelines have been developed with the fo llowing aims:

• To improve the standard of care provided to the patient. • To increase confidence and raise awareness amongst nursing staff in the use of

equipment. • To ensure efficient and safe practice when using the T34 syringe pump. • To optimise the use of resources through improved equipment management.

It is recommended that these guidelines are easily accessible for staff reference at all times. These guidelines do not replace any training in the use of the T34 syringe pump or the need for regular updates. 8.1. Administration of continuous subcutaneous infu sions using the T34 Syringe

Pump A continuous subcutaneous infusion achieves a steady plasma concentration of medicines that is equivalent to an intravenous infusion. It removes the need for regular suppositories or injections. The T34 syringe pump meets all the safety features recommended by the Medical Devices Agency. It is a portable battery-operated infusion pump, which uses a PPS 9V alkaline battery. The battery should last approximately 2 - 3 days depending on use (CME Medical) DO NOT USE RECHARGEABLE BATERIES It is recommended that FOUR (4) new spare batteries should always be available and kept with the T34 syringe pump for replacement as necessary. The practitioner who replaces a battery is responsible for replenishing the stock of spare batteries. (Please note - battery terminals must be taped prior to disposal.) In NHS Tayside the T34 syringe pump is pre-set by the medical physics department:

• To deliver over a 24 hour period only • For use with BD Plastipak syringes only • And is calibrated in millilitres (ml) per hour.

8.2. Indications for Use Administering medication via a subcutaneous route to control pain and other symptoms

when the oral route is not possible due to:

• Persistent nausea and vomiting. • Intestinal obstruction. • Dysphagia eg mouth, throat or oesophageal lesions. • Drowsy, semi-comatose or comatose patient. • Poor absorption of oral medicines (rare).




8.3. Equipment required for setting up a T34 Syring e Pump

• T34 ambulatory syringe pump™ and protective box. • Luer lock BD Plastipak syringe (20ml, 30ml or 50ml). • BD Saf-T-Intima™ 24 Gauge cannula (as below)

Please note: The larger gauge BD Saf-T-Intima 22 gauge cannula (blue wings) can be used for medications that may be more viscous There is no requirement to prime the Saf T intima when using as a sub cut device)

All Staff should be familiar with the safe inserti on and use of the BD Saf-T-Intima™ with the T34 Syringe pump before commencing this procedure

(Product description Becton Dickson Cannula I.V saf ety Saf-T-Intima (24G x 19mm) up to date codes available from PECOS

• CME medical giving set with integrated anti-syphon valve. Product description: CME Medical UK. T34 SET INTEG ANTI SYPH VALVE 100CM. order codes available from PECOS

• A good quality alkaline battery (9 volt PP3 size – (NOT RECHARGEABLE) battery life approximately 2 - 3 days). A battery should have at least 40% life left when used in the community to ensure the infusion will last for 24 hours.

• Prescribed medication. • Needles to draw up medication and diluent. • Water for injections as diluent. It should be noted that some drugs require to be

diluted using sodium chloride intravenous infusion 0.9% – the practitioner preparing the infusion must check the diluent required (ref materials Appendix 1)

• Transparent dressing eg Tegaderm. • Swab saturated with isopropyl alcohol 70%. • NHS Tayside Prescription and Administration Record (TPAR) or community

prescription sheet (AS1 Version 2 - appendix 3) i ) • Drug additive label • T34 syringe pump recording chart (Appendices 2 and 3) ii ) • Appropriate holder if necessary eg T34 disposable bag. ( available through

Procurement as Non Stock purchase order and CME Medical) 8.4. Preparing the subcutaneous infusion Before setting up the T34 syringe pump, how it works and the reasons for its use should be discussed with the patient and family/carer. In the community setting, the patient and/or carer must also be given clear guidance on what to do, and who to contact, in the event of a problem arising




Any reported incident from patients in the community must be followed up by a visit to the patient’s home. Staff should be mindful of the fact that English may not be the patient’s first language. There may be a need to use an interpreter to explain the procedure to the patient.

Ideally two qualified practitioners should prepare and check the infusion and set up the T34 syringe pump. However it is acknowledged that in the community this is not always possible due to staffing constraints. (Ref: NHS Tayside Safe & Secure Handling of Medicines Manual). For ease of reference these guidelines will assume two practitioners are preparing the syringe driver.

a) Although it is the responsibility of the prescriber to provide a prescription appropriate to the needs of the patient, the practitioners preparing and administering the infusion should ensure the medicine combination to be infused is compatible. It is the responsibility of the practitioners involved to ensure that they have up to date knowledge regarding the various medicines prescribed and to ensure the prescription is appropriate for the patient. ( see appendix1). If in doubt CHECK! Check the patient’s name, date of birth and CHI number and the signed prescription and for any allergies the patient may have

b) Prescribed medicines must be checked prior to drawing up and a second check

made once drawn up. Batch numbers should be recorded on the T34 syringe pump recording sheet and the label on the syringe.

c) For multiple medicine mixtures, water for injections is the preferred diluent. However some admixtures recommend the use of sodium chloride intravenous infusion 0.9% (ref available within Appendix 1)

d) The ONLY syringes to be used are BD Plastipak Luer lock 20ml, 30ml or 50/60ml.

When using a 50/60ml syringe the protective box will not fit with this size of syringe. Choose the appropriate size of syringe to accommodate the volume to be infused. As a guide approximately:

• 33ml can be delivered from a 50ml syringe, • 22ml from a 30ml syringe • 17ml from a 20ml syringe.

e) Draw up the prescribed medicine(s) into the syringe and draw up the required

amount of diluent. Observe for cloudiness, discolouration or precipitation. Discard if this occurs and seek advice. Expel any air from the syringe.

f) Complete the details on the drug additive label and attach to the syringe taking care not to occlude the contents.




8.5. Connecting the infusion set to the syringe

a. Use the CME extension tubing with integrated anti-syphon valve b. Connect it securely to the syringe. c. If it is a new infusion set, gently depress the syringe plunger until the line is

primed fully (Approximate Volume to prime is 0.5 ml CME) 8.6. Choosing a suitable site for placement of cann ula for T34 syringe pump

administration

a. Commonly used subcutaneous sites: i. Anterior chest wall (Avoid using this site in cachexic patients as there is a risk

of causing pneumothorax) ii. Abdomen. iii. Lateral aspects of upper arms and thighs. iv. Back (scapula) – particularly suitable for patients who may try to pull the

cannula out.

NB: The BD Saf-T Intima™ can remain in situ for up t o seven days if there is no signs of irritation, inflammation, pain or infectio n and the site remains viable. (NSW South Eastern Sydney Local health network 2011 ). In many circumstances eg extreme cachexia it may be appropr iate to leave the cannula in place longer provided the integrity of the site remains.

b. Areas, which should not be used for subcutaneous si tes:

i. Lymphoedematous limbs or trunk (Poor drug absorption and increased risk of infection/exacerbation of oedema)

ii. Sites over bony prominences (poor absorption and discomfort) iii. Sites near a joint. iv. Previously irradiated skin. v. Infected skin/skin lesions.

c. Causes of infusion site problems:

i. Irritant medicines. ii. Tonicity of the infusion. iii. PH of the infusion. iv. Incompatible medicine/diluent mixture. v. Infection. vi. Sterile abscess.

d. How to deal with infusion site problems: i. When local reaction occurs, a new cannula and SC infusion line should be re-

sited. ii. If this recurs then consider diluting the medicine(s) further. iii. Check the compatibility of the medicines being used and use less irritant

medicines if possible. Check that the patient is not reacting to the dressing that secures the infusion set.




iv. N.B. Other infusion sets may not have an integrated anti-syphon valve. Document the reason for using a cannula and giving set other than the recommended Saf T Intima cannula and CME infusion set with integrated anti-syphon valve in the patient’s record.

8.7. T34 Syringe Pump Feature Recognition

a. Syringe Loading

Figure 1.T34 Syringe Pump

1. Barrel Clamp Arm & Sensor – detects syringe size or width of barrel, secures

syringe. 2. Syringe Flange/Collar Sensor - detects secure loading of syringe collar. 3. Plunger Sensor - detects secure loading of syringe plunger. 4. Actuator.

b. Keypad

Figure 2. Keypad

i. “INFO” key – Infusion summary info/battery status access event log/keypad lock/unlock. (NB the battery must have a minimum of 40% power remaining when used in the community setting to ensure it will deliver for 24 hours).

ii. “Up/Down” arrow keys – scroll up/down.

1. Barrel Clamp Arm & Sensor

2. Syringe Flange/Collar Sensor

3. Plunger Sensor

4. Actuator

Infusion light status indicator. Green (running). Red (stopped).




iii. “YES/START” key – confirms selection/starts infusion. iv. “NO/STOP” key – respond no to selection/stops infusion. v. “FF” (forward) key – moves actuator forward. vi. “BACK” key – moves actuator back. vii. “ON/OFF” key – power on/off.

8.8. Preparing the T34 Syringe pump

a. Preloading and syringe placement i. Install battery

Figure 3. Battery Compartment

ii. Before placing the syringe onto the T34 syringe pump ensure the barrel clamp arm is DOWN then press and hold the “ON/OFF” key until the screen illuminates and T34 is displayed with ID (Hospital name) appearing on the screen.

iii. The LCD display will then show “Pre-Loading” and the actuator will start to move.

Wait until it stops moving and the syringe sensor detection screen (syringe graphic) appears.

Figure 4. Preloading Indication Display NOTE: During Pre-Loading the actuator always returns to the start position of the last infusion programmed. iv. If the actuator is not in the correct position to accommodate the syringe, leave the

barrel clamp arm down and use the “FF” or “BACK” buttons on the keypad to move the actuator. Warning: Do not use force to move the actuator manually, this could cause damage to the device and/or affect calibration of the device




v. Check the battery by pressing the “INFO” key until the battery level appears on the screen and then press “YES” to confirm. Verify there is sufficient battery power for the programme. (In the community, discard the battery if there is less than 40% power remaining. Replace with a new battery to ensure the T34 syringe pump will deliver for 24 hours).

Figure 5. Battery Level Indicator Display b. Fitting the syringe to the T34 Syringe Pump Ensure the line is not connected to the patient at this point.

i. Lift the barrel clamp arm fully and turn the arm 90 degrees. Place the syringe collar vertically into the pump collar slot and the syringe plunger end into the pump plunger slot. The syringe should click into place. The syringe collar should be vertical.

ii. Turn and lower the barrel clamp arm onto the syringe. If all points are loaded correctly the screen will display a syringe brand and size.

iii. Ensure the syringe label does not interfere with the mechanism of the infusion device eg if there is contact with the barrel clamp arm and sensor. The syringe graphic on the screen ceases to flash at each point as the syringe is correctly seated.

iv. Confirm that the syringe size and brand match the screen message. Press the “YES” key to confirm or scroll with up (+) or down (-) keys to view other syringe sizes, select correct syringe and size and press the “YES” key to confirm (Figure 6). The T34 syringe pumps are all pre-set to the recommended brand of BD Plastipak. This still requires a visual check and confirmation of correct brand and syringe volume

8.9. Connecting the infusion to the patient.

i. Identify appropriate site. It is preferred that sites are as hair free as possible - if excessive hair please trim or shave

ii. Remove and dispose of clamp on the BD Saf-T-Intima™ to avoid accidental occlusion.

iii. Rotate white safety barrel to loosen needle. iv. Remove clear needle cover. v. Grasp pebbled side wings, pinching firmly. vi. Pinch skin between thumb and forefinger to ensure SC tissue is identified. vii. Insert cannula at a 45-degree angle.




viii. Hold wings of the cannula firmly and remove introducer (needle) by pulling back in a smooth single movement. This should leave an injectable bung in-situ.

ix. Remove this injectable bung and securely connect the infusion line directly to the cannula end

x. Dispose of needle in sharps container as per local policy. xi. Secure the needle and infusion line by making a small loop to ensure there is no

pull on the needle. Cover with a transparent semi-permeable dressing eg Tegaderm.

xii. Record in the appropriate documents; all required information including the medicines, details of the diluent administered and the time the infusion commenced.

8.10. Commencing the infusion

Figure 6. Syringe Confirmation Display

i. When a syringe has been confirmed (Fig 6) the pump calculates the ml/hr rate from the syringe volume and fixed infusion duration (Example screen Figure 7).

Figure 7. Volume, Duration and Rate Display




ii. The T34 syringe pump calculates and displays the deliverable volume, the duration of the infusion (24 hours) and the rate of the infusion (ml per hour). Press the “YES” key to confirm the details. The display screen prompts “Start Infusion?” (Figure 8).

Figure 8. Start Infusion Screen Prompt

iii. Start the infusion by pressing the “YES” key. iv. When the T34 Ambulatory T34 syringe pump is running the screen displays

(Figure 9):

• Top line –the time remaining for the current infusion. • Main line – the infusion rate is displayed in ml/hour. • Bottom line – alternates between syringe size and brand and the

message “<<<< Pump Delivering” . • The Infusion Light Status Indicator flashes green (Figure 2).

Figure 9. Pump Running Display

8.11. Keypad lock The T34 syringe pump allows all users to lock the operation of the keypad during infusion. It is strongly recommended that this function is routinely used to prevent tampering and or inadvertent key presses or power off (Figure 10). NB The key pad lock function does not prevent the info key being accessed for routine infusion checks or the device being stopped urgently




Figure 10. Keypad Lock Display

i. To activate the keypad lock when the pump is infusing press and hold the “INFO” key until a chart is displayed showing a ‘progress’ bar moving from left to right.

ii. Hold the key until the bar has moved completely across the screen and a beep is heard to confirm the lock has been activated.

iii. To turn the lock off, repeat the above procedure. The bar will now move from right (lock) to left (unlock) and a beep will be heard.

Place the T34 Syringe pump in the hard clear protective box supplied and secure lock. Disposable bags are available for ambulatory patients. These are for individual patient use. NB: The T34 Syringe pump should be powered down and restarted prior to reloading a new infusion. 8.12. Discontinuing the infusion and removing the syringe pump

i. Removal of the cannula and/or discontinuation of the infusion should only be carried out by appropriately trained staff.

ii. When the infusion is complete and the syringe is empty, it will stop automatically and the alarm will sound.

iii. If the T34 syringe pump is no longer required for the patient, press the “ON/OFF” key and then remove the battery from the T34 syringe pump.

iv. If the infusion is to be discontinued before the syringe is empty the syringe and pump should be disconnected from the patient before the syringe is taken off the T34 syringe pump.

v. Clean the T34 syringe pump vi. (See Section 6.12) and the cover (do not immerse the T34 syringe pump in

water or use product with alcohol content). Dry and store if no longer required for use.

vii. Always ensure that FOUR (4) new batteries are stored with the T34 syringe pump.




8.13. a. Temporary interruption of infusion. This is not normal practice and should only be used in exceptional circumstances eg some radiological procedures cannot be carried out with a syringe pump in situ (this should not be used for priming a second line):

i. Press the “STOP” key. ii. Press and hold “ON/OFF” key until a beep is heard. The screen will go

blank. iii. Do not remove the syringe from the T34 syringe pump. iv. Disconnect the line from the syringe and cap the end of the line and the

syringe tip. v. Record on the monitoring chart, the length of time the infusion is stopped for.

8.13.b. Resuming the infusion

Figure 11. Resume Program Display i. Check that the prescription, syringe label and patient details match, to ensure that

this is the correct syringe for this patient. ii. Reconnect the line to the syringe on the T34 syringe pump. iii. Press and hold the “ON/OFF” key until a beep is heard. The screen will request

confirmation of syringe size and the syringe brand. iv. Press the “YES” key to resume (Figure 11). The screen will display “Remaining

volume, duration and the rate of infusion”. Press the “YES” key to confirm.

WARNING: The screen will also give the option to se lect “NO for New Program”. If the NO key is pressed, the T34 syring e pump will calculate a new programme based on the current volume. The patient would not therefore receive the prescribed dose. If the NO key has bee n pressed in error, discard the remainder of the syringe contents and prepare a nd set up a new syringe.

8.14. What to do if the patient dies whilst the T3 4 syringe pump is in situ

i. Stop the syringe driver. ii. Press the “INFO” key and record the date, time and amount of solution remaining

to be infused in the syringe (in ml). If there are doubts about the circumstances of the death, leave the T34 syringe pump in situ and contact your Line Manager for advice.

iii. In an expected death situation, remove the syringe from the syringe driver, record the amount being discarded then destroy the contents. The person(s) (ideally two nurses) destroying the remaining solution must sign the administration record to




confirm the amount destroyed. Remove the battery from the driver and the cannula as soon as possible and dispose.

iv. Clean the T34 syringe pump as detailed in Section 6.12. v. Always ensure that FOUR (4) new batteries are stored with the syringe driver.

8.15. Monitoring the T34 syringe pump while in use It is recommended best practice in both the hospital and the community setting when a T34 syringe pump is set-up, reloaded or re-sited to observe the T34 syringe pump for the first 15 minutes to check that it is working correctly. Thereafter the T34 syringe pump should be checked for correct delivery of the medication in the syringe a minimum of every 4 hours in the hospital setting or on visitin g in the community (at least once daily). The essential checks to include when monitoring:

i. Check the battery daily. (Must have at least 40% battery power left on commencement in the community setting).Check this by pressing the “INFO” key twice.

ii. Check the LCD display to ensure the T34 syringe pump is delivering correctly. This will display the time remaining and the infusion rate.

iii. The volume to be infused (VTBI) and the volume infused (VI) can be checked by pressing the “INFO” key once.

iv. Visually check the fluid remaining in the syringe at each check and compare this with the T34 syringe pump display.

v. Check the contents of the syringe and infusion line for crystallisation, precipitation, cloudiness or colour change.

vi. Inspect the cannula site for evidence of redness, swelling or discomfort and any evidence of poor absorption. Re-site if necessary. This will require a new infusion to be prepared using a new cannula and giving set.

vii. Check the medication is adequately controlling the patient’s symptoms. viii. Inspect for leakage at the cannula site and the connection sites. The giving set

should only be changed if there are site problems. ix. Record the monitoring checks as required within the documentation.

8.16. Troubleshooting

a. If the infusion is running too fast (ie running more than 1 hour ahead of expected time):

i. Check the rate setting is correct. ii. Check the syringe is the recommended brand and correct volume size and is

inserted correctly onto the syringe driver. iii. Change the entire T34 syringe pump for a new one and send the original pump

back to Medical Physics for servicing.

b. If the infusion is running too slow (ie running more than 1 hour behind the expected time):

i. Check the rate setting is correct. ii. Check the Infusion Light Status Indicator is green and flashing. iii. Check the battery level. iv. Ascertain if the T34 syringe pump has been stopped and restarted for any

reason.




v. Check the contents of the syringe and line. Is there any evidence of crystallisation or kinking of the tubing?

vi. Check the cannula site. Is this red/hard/lumpy/sore? vii. Consider changing the site or further dilution of the drugs to minimise irritation by

setting up a fresh syringe. NB: If the infusion continues to run through too slowly, change the entire T34 syringe pump and send to Medical Physics for servicing.

c. If the infusion has to be stopped due to the can nula falling out/line disconnection etc the contents should be checked by two people then discarded with the amount discarded recorded and signed. A new infusion with a new giving set should then be made up.

8:17. T34 Syringe Pump Alarm Conditions When the T34 syringe pump detects a problem four things occur:

• The infusion stops. • An audible alarm is activated. • A message appears on the display screen indicating the cause of the alarm. • The Infusion Light Status Indicator turns red .

The following table indicates the appropriate actio ns should the T34 syringe pump alarm.

Alarm Possible cause Action Occlusion: Check line and syringe empty.

Patient access device is blocked, kinked, clamped, or occluded.

• Unclamp/un-kink and restart.

• Replace access device.

• Release clamp (should be removed when cannula inserted)

Syringe displaced, check syringe

Syringe has been removed or displaced. One or more of the syringe detection sensors is not detecting

Check and confirm syringe seated correctly and resume.

Pump paused for too long Pump has been left in stop mode (on hold) for 2 minutes.

Start infusion, continue pause or turn the pump off.

Programme nearly complete Infusion will end soon Prepare to change syringe or switch pump off.

End program/syringe Infusion complete. Commence new infusion/or close down

Low battery. Battery is almost depleted (30 minutes left).

Prepare to change battery.

End battery.

Battery is depleted. Change battery.




8:18 Cleansing and decontamination Cleansing should be carried out with a damp disposable cloth (use warm water and general purpose detergent). Dry thoroughly. If any additional cleansing is needed, e.g. the threads of the screws the actuator moves along refer to local infection control procedures or contact the Infection Control Team for advice. Do not use alcohol based products as this will damage the device. The T34 syringe pump must not be submerged in water and if accidentally dropped in water, must be withdrawn from use immediately and returned to Medical Physics for checking.

Scottish Palliative Care Guidelines NHS Scotland 20 14 Appendix1




Copyright © 2014 NHSScotland

Syringe Pumps

Introduction

Portable infusion pumps are used in palliative care to deliver a continuous subcutaneous infusion of medication over 24 hours. Mixing of medications in this manner is unlicensed but is supported by practice.

Some acute areas will use non-ambulatory pumps eg A laris pump. Check which device is used in your area.

Indications

A patient is unable to take medication orally due t o:

• Persistent nausea and/ or vomiting. • Dysphagia. • Bowel obstruction or malabsorption.

• Reduced level of consciousness, such as in the last days of life.

General information

• Use the current local protocols for setting up and monitoring the syringe pump you are using.

• The tables in this guideline contain information a bout preparations, dose ranges, diluents and indications for single drugs t hat can be given by subcutaneous infusion for symptom control in palliative and end of life care.

Assessment

The figures in these tables are NOT clinical doses to prescribe. Most patients will require much lower doses.

• Refer to relevant guidelines to obtain usual dose range for each medication

• Use minimum effective dose and titrate according t o response

• Concentrations equivalent to or less than those st ated in table are physically stable for 24 hours

• For doses greater than those stated in the tables seek specialist advice

http://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/nausea-and-vomiting.aspx

http://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/bowel-obstruction.aspx

http://www.palliativecareguidelines.scot.nhs.uk/guidelines/end-of-life-care/care-in-the-last-days-of-life.aspx





The tables contain information about the stability and compatibilities of drug combinations for use in a subcutaneous infusion in palliative care.

• The compatibility tables contain information for a subcutaneous infusion using a CME T34 syringe pump or a non-ambulatory pump conta ining:

Copyright © 2014 NHS Scotland

o Alfentanil and one or two other drugs (see: Alfentanil guideline & seek specialist advice

o Diamorphine and one or two other drugs

o Hydromorphone and one or two other drugs (seek sp ecialist advice)

o Ketamine and one or two other drugs (see: Ketamine guideline & seek specialist advice)

o Morphine and one or two other drugs

o Oxycodone and one or two other drugs (using 10mg/ ml and 50mg/ml preparations)

o Drug combinations, diluents or doses other than t hose listed in the compatibility tables are used occasionally on the recommendation of a palliative care specialist. Stability data to support this combination should b e checked with a clinical pharmacist before infusion. Any recommendation given by the pa lliative care specialist should be documented clearly in the patient’s notes.

Compatibility and stability tables for subcutaneous infusion

Drug Route

Table 0 (a-f)

Single drugs used in a subcutaneous infusion over 24 hours in Palliative Care

a Opioids b Anti-emetics c Anticholinergics d Non-steroidals e Sedatives f Other Medications

Table 1a Subcutaneous Morphine infusion in a syringe pump (2 Drug Combinations)

Table 1b Subcutaneous Morphine infusion in a syringe pump (3 Drug Combinations)

Table 2a Subcutaneous Diamorphine Infusion (2 Drug Combinations)

http://www.palliativecareguidelines.scot.nhs.uk/guidelines/medicine-information-sheets/alfentanil.aspx

http://www.palliativecareguidelines.scot.nhs.uk/guidelines/medicine-information-sheets/ketamine.aspx

http://www.palliativecareguidelines.scot.nhs.uk/media/1055/table-0a-subcutsingleagents_opioids.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1056/table-0b-subcutsingleagents_antiemetics.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1057/table-0c-subcutsingleagents_anticholinergics.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1058/table-0d-subcutsingleagents_nonsteroidals.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1059/table-0e-subcutsingleagents_sedatives.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1148/table-0f-subcutsingleagents_othermeds.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1251/table-1a-subcutaneous-morphine-infusion-2-drug-combinations.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1252/table-1b-subcutaneous-morphine-infusion-3-drug-combinations.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1253/subcuttable2a-diamorphine-2-drugs-in-combination.png





Compatibility and stability tables for subcutaneous infusion

Drug Route

Table 2b Subcutaneous Diamorphine Infusion (3 Drug Combinations)

Table 3a Subcutaneous Oxycodone Infusion using 10mg/ml and 20mg/2ml injection (2 Drug Combinations)

Table 3b Subcutaneous Oxycodone Infusion using 50mg/ml injection (2 Drug Combinations)

Table 3c Subcutaneous Oxycodone infusion using 10mg/ml or 20mg/2ml injection (3 Drug Combinations)

Table 4a Subcutaneous Alfentanil infusion (2 Drug Combinations)

Table 4b Subcutaneous Alfentanil infusion (3 Drug Combinations)

Table 5a Subcutaneous Hydromorphone infusion (2 Drug Combinations)

Table 5b Subcutaneous Hydromorphone infusion (3 Drug Combinations)

Table 6 Subcutaneous Ketamine infusion in a syringe pump (2 Drug Combinations)

Stability Tables - Subcutaneous Infusion over 24 hours - Version 1 May 2014

PRACTICE POINTS • A continuous subcutaneous infusion of medication aims to maintain symptom control. If the patient has uncontrolled symptoms before the infusion is started or during the infusion period, give breakthrough doses of medication as required. • Prescribe the medication(s) for subcutaneous infusion and the diluent, calculating appropriate dose when converting from oral to subcutaneous route. The infusion is given over 24 hours. • Prescribe the correct breakthrough dose, as required, for each medication in the infusion, a maximum volume of 2ml can be used for SC bolus but consider your patient and avoid a volume over 1ml for patients with little subcutaneous tissue. These should be administered via a separate SC site. • Cannula does not need to be flushed prior to administering medicines, but should be flushed after with sterile water for injection and between any incompatible medications (see local guidelines for more information on SC administration of as required medication) • Prepare a new syringe every 24 hours. • Protect the syringe from direct light and heat. • Check the syringe after set up and within acute setting every 4 hours for precipitation, cloudiness, particles, colour change. Make sure the pump is running to time. Check the line, connection and cannula regularly.

http://www.palliativecareguidelines.scot.nhs.uk/media/1254/subcuttable2b-diamorphine-3-drugs-in-combination.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1255/table-3a-subcutaneous-oxycodone-infusion-10mgml-20mg2ml-2-drug-combinations.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1255/table-3a-subcutaneous-oxycodone-infusion-10mgml-20mg2ml-2-drug-combinations.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1256/table-3b-subcutaneous-oxycodone-infusion-50mgml-2-drug-combinations.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1257/table-3c-subcutaneous-oxycodone-infusion-10mgml-20mg2ml-3-drug-combinations.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1257/table-3c-subcutaneous-oxycodone-infusion-10mgml-20mg2ml-3-drug-combinations.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1258/table-4a-subcutaneous-alfentanil-in-2-drug-combinations.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1259/table-4b-subcutaneous-alfentanil-in-3-drug-combinations.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1260/table-5a-subcutaneous-hydromorphone-infusion-2-drug-combinations.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1261/table-5b-subcutaneous-hydromorphone-infusion-3-drug-combinations.png

http://www.palliativecareguidelines.scot.nhs.uk/media/1262/ketamine-alone-and-in-combination-2-drugs-in-a-subcutaneous-infusion-over-24-hours-in-palliative-care.png





Appendices References

• References

Copyright © 2014 NHSScotland

Last Updated: 06 Feb 2017

Created: 03 Jun 2014

† Indicates this use is off licence

QT Indicates this medication is associated with QT prolongation

Colour codes: See note if colour vision is an issue

Red – For medicines normally initiated and used under specialist guidance

Amber – For medicines normally initiated by a specialist but may be used by generalists

Green – For medicines routinely initiated and used by generalists References: 1) Dickman A: The syringe driver; continuous subcutaneous infusion in palliative care. 3rd Edition

2011. OUP 2) The Syringe Driver Survey Database available online at Palliative care drug information on-line: http://www.palliativedrugs.com/ Further reading: http://www.palliativecareguidelines.scot.nhs.uk

http://www.palliativecareguidelines.scot.nhs.uk/guidelines/end-of-life-care/syringe-pumps/references.aspx

http://www.palliativecareguidelines.scot.nhs.uk/guidelines/about-the-guidelines/Pharmacological-Considerations.aspx#OffLabel

http://www.palliativecareguidelines.scot.nhs.uk/guidelines/about-the-guidelines/Pharmacological-Considerations.aspx#QTProlongingMedicines

http://www.palliativecareguidelines.scot.nhs.uk/guidelines/notes-on-colour-codes.aspx

http://www.palliativedrugs.com/

http://www.palliativecareguidelines.scot.nhs.uk/

THB(MR)48 Version 2 INPATIENT RECORD

Appendix 2




AS1 Version 2 COMMUNITY NURSING SERVICES RECORD

Appendix 3i




Medica l Physics No: ……………………… NHS Tayside

COMMUNITY NURSING SERVICES MCKINLEY T34 SYRINGE PUMP PRESCRIPTION RECORD – AS1 (Version 2)

(CONTROLLED DRUG AND/OR ADJUVANT) Patients Name: C.H.I. G.P. G.P.Tel No DN Team Allergies

DN Team Tel No

ONLY TO BE USED WHEN AUTHORISING SUBCUTANEOUS ADMINISTRATION OF M EDICINES BY AUTOMATED T34 SYRINGE PUMP

Date

Medicine(s) Diluent Dose per 24 hours Prescriber ’s Signature

Date Discontinued

Comments

AS2 Version 2 COMMUNITY NURSING SERVICES RECORD Appendix 3ii




Medical Physics No: ……………………… NHS Tayside COMMUNITY NURSING SERVICES

MCKINLEY T34 SYRINGE PUMP ADMINISTRATION RECORD – AS2 (Version 2) Patient's Name C.H.I. G.P. G.P.Tel No DN Team Allergies

DN Team Tel

ONLY TO BE USED WHEN ADMINISTERING MEDICINES SUBCUT ANEOUSLY BY AUTOMATED T34 SYRINGE PUMP

Date & time of loading

15 min

check

Medicine(s) + Batch Number(s)

Dose per 24 hours Diluent

Total Volume

(mls)

Prepared By

Checked

By

Infusion

Site Check

Rate (ml per hour)

Battery

level (%)

Comments

CD1 Version 2 COMMUNITY NURSING SERVICES RECORD Appendix 3iii




COMMUNITY NURSING SERVICES CONTROLLED DRUG+/- ADJUVANT PRESCRIPTION RECORD – C D1 (Version 2)

Patient's Name C.H.I. G.P. G.P.Tel No DN Team Allergies

DN Team Tel

Date

Medicine

Dose/ Frequency

Method of Administration

Signature of Prescriber

Discontinuation Date

CD2 Version 2 COMMUNITY NURSING SERVICES RECORD Appendix 3iv




COMMUNITY NURSING SERVICES CONTROLLED DRUG+/- ADJUVANT ADMINISTRATION RECORD - CD2 (Version 2 )

Patient's Name C.H.I. G.P. G.P.Tel No DN Team Allergies

DN Team Tel

Date

Time

Medicine Method of

Administration

Batch Number Dose

Site

Signature

COMMUNITY NURSING SERVICES CONTROLLED DRUG STOCK BALANCE SHEET Appendix 3v




COMMUNITY NURSING SERVICES STOCK BA LANCE SHEET Patien t's Name C.H.I. G.P. G.P.Tel No DN Team Allergies

DN Team Tel

Drug Name/ Strength and Form ……………………………………………….

Date Time Quantity received

Quantity administered

Signature Signature Stock Balance

CME Medical T34 Training Access Appendix 4




CME McKinley Online Learning System

How to register a training account

Please access the CME web site by searching http://www.cmemedical.co.uk/online-training through either the Google Chrome Browser (newly installed on our NHS computers on our desktops following NHS mail 2 upgrades

Or Fire Fox browser

If these are not installed on your NHS computer please log a call with IT – Tel 01382 42444.

To access the site

Click on the Training Tab embedded on the horizontal line at the top of the page

1. Two additional tabs appear – clinical training or technical training – hover over the clinical training tab and click clinical e- learning tab

2. On this page underneath the clinical e-learning picture that is displayed two tabs appear –click the darker blue one that states click here to access our learning portal

3. A new device user registration box should appear. Within this box enter the ‘Company Password’ (DD21SP) and click on ‘submit’. The following screen shot should be displayed. Please note: password in capital letters no space

https://web.nhs.net/owa/redir.aspx?C=AEX6Ufq-xEGwNeKrYcwteq2Uvzhf6c9IoyvNV2pmfiTQtZwDPE-WgoizUGdzhp2y4DQ-02O3BQA%2E&URL=http%3a%2f%2fwww%2Ecmemedical%2Eco%2Euk%2fonline-training

https://web.nhs.net/owa/redir.aspx?C=AEX6Ufq-xEGwNeKrYcwteq2Uvzhf6c9IoyvNV2pmfiTQtZwDPE-WgoizUGdzhp2y4DQ-02O3BQA%2E&URL=http%3a%2f%2fwww%2Ecmemedical%2Eco%2Euk%2fonline-training

http://www.google.co.uk/url?url=http://www%2Eappsforpcmero%2Ecom/google-chrome-free-download-for-windows-and-mac/&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjf2v78qtzOAhWrKMAKHbmLAuoQwW4IHjAE&usg=AFQjCNEkxROA4kL2aYnJylveZVbIdElKdw

https://www.google.co.uk/url?url=https://www%2Emozilla%2Eorg/en-US/firefox/new/&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwjYt96Zq9zOAhVnK8AKHS_eDl8QwW4IFjAA&usg=AFQjCNH6ZagiwbnI-KSj_Wlk-1kUceqHNw

CME Medical T34 Training Access Appendix 4




Important following submission of the password You should visualise Libby Cahir’s name - displayed within the dialogue text. Libby is NHS Tayside on-line account manager – below this script you will be able to submit your registration details

3 boxes appear:

• Please enter your name: • Please enter user name: • Please enter user email:

Press submit registration. Once submitted login as returning device user

Login using the Username / email created. Remember password is the Organisational password – DD21SP

Start your on line training

IMPORTANT

Some practitioners are able to register an account with ease but when it comes to commencing the e-learning materials a dialogue box appears that states you need to install a “plug in”.

I have contacted IT and this means that if you are accessing the training from an NHS computer you need to log a call with IT as they need to rectify the problem for you as additional software is required to be downloaded to support this

Accessing the online training

Please note when a trainee wishes to close the learning interface it is very important that they click on the ‘Log Out’ link below your name on the left hand side of the screen. This will ensure the training session ends the correct way.

The training session will ask you to tick you have read your local policy NHS Tayside and NES have been sent with these instructions The T34 McKinley syringe pumps in this area are locked on 24 hours per day and cannot be altered. There is no purge facility, and can use 20, 30 or 50 ml BD Plastipak syringes. The video to watch for setting up is Prime and Load. You must pass the online assessment training before coming to the update session Please Note If you still do not manage to log in please contact Libby Cahir: [email protected] Macmillan Palliative Care Practice Educator

Specialist Palliative Care Services Dundee Health and Social Care partnership Royal Victoria Hospital Jedburgh Road Dundee DD21SP Tel: 01382 423000 / Ext 26266

mailto:[email protected]




References Appendix 5 CME Medical T34 Ambulatory Syringe Pump Operation Manual. Scottish Government (2002) ‘”Good practice statement for the preparation of injections in near-patient areas, including clinical and home environments” Dickman A, Schneider,J (2011)The syringe driver: Continuous subcutaneous infusions in palliative care.3nd Edition, OUP NHS Scotland (2011) Guidelines for the use of the CME McKinley T34 Syringe Pump for Adults in Palliative Care NHS Tayside Safe and Secure Handling of Medicines Manual – Please note this manual will be regularly updated electronically, and can be accessed by the following link http://www.nhstaysideadtc.scot.nhs.uk/SSHM/MAIN/Front%20page.htm Nursing and Midwifery Council (NMC) (March 2015) The Code: Professional standards for practice and behaviours for nurses and midwives Nursing and Midwifery Council (NMC) (2010- updates 2015) Standards for Medicines Management Scottish Intercollegiate Guideline Network (SIGN) (2008) Guideline 106: Control of pain in adults with cancer Twycross R and Wilcock A. (2014) Palliative Care Formulary (Fifth ed). NHS Greater Glasgow and Clyde. (2011) Guidelines for the Use of Subcutaneous Medications in palliative Care for Adults – Primary Care and Hospices Subcutaneous Needle Insertion and Management (2011) NSW South Eastern Sydney Local health network http://www.cmemedical.co.uk

http://www.nhstaysideadtc.scot.nhs.uk/SSHM/MAIN/Front page.htm




NHS TAYSIDE – POLICY APPROVAL CHECKL IST Appendix 6A

This form must be completed by the Policy Manager a nd this checklist must be completed and forwarded with the policy to the E xecutive Team, Clinical

Quality Forum or Area Partnership Forum for approva l and to the appropriate Committee for adoption.

POLICY AREA: CLINICAL (all staff) POLICY TITLE: Subcutaneous Administration of Medicines by the T34 Ambulatory Syringe Pump for Adults Requiring Symptom Management POLICY MANAGER: Marion McLagan Head of Nursing/T34 ambulatory syringe pump policy group

Why has this policy been developed?

Review of current policy and guidelines To promote safe and effective delivery of medications via the T34 ambulatory syringe pump

Has the policy been developed in accordance with or related to legislation? – Please give details of applicable legislation.

Has a risk control plan been developed and who is the owner of the risk? If not, why not?

No

Who has been involved/consulted in the development of the policy?

T34 ambulatory syringe pump policy group

Has the policy been Equality Impact Assessed in relation to:- Has the policy been Equality Impact Assessed not to disadvantage the following groups:-

Age Disability Gender Reassignment Pregnancy/Maternity Race/Ethnicity Religion/Belief Sex (men and women) Sexual Orientation

Please indicate Yes/No for the following: Yes Yes Yes Yes Yes Yes Yes Yes

People with Mental Health Problems Homeless People People involved in the Criminal Justice System Staff Socio Economic Deprivation Groups Carers Literacy Rural Language/Social Origins

Please indicate Yes/No for the following: Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Does the policy contain evidence of the Equality Impact Assessment Process?

Yes

Is there an implementation plan? This is existing policy implementation of review document through policy review process including staff net

Which officers are responsible for implementation?

CHP/Directorate/Heads of department/clinical areas will be responsible for ensuring implementation of any change to policy

When will the policy take effect?

As soon as placement on staff net

Who must comply with the policy/strategy?

All clinicians delivering medication using this equipment

How will they be informed of their responsibilities?

CHP/Directorate/Heads of department/clinical areas will be responsible for ensuring implementation of any change to policy

Is any training required?

Current training is in place some amendments made to access process




If yes, attach a training plan

as above

Are there any cost implications?

Staff training although much is accommodate in the clinical area and on line. CME medical have agreed to provide advanced trainer session for NHS Tayside free of charge at this time

If yes, please detail costs and note source of funding

Resource costs are not changed to previous policy

Who is responsible for auditing the implementation of the policy? Departmental Leads

What is the audit interval? Recommended that audit is undertaken yearly

Who will receive the audit reports? Departmental Leads

When will the policy be reviewed and provide details of policy review period (up to 5 years)

2 years – review date August 2019

POLICY MANAGER: Marion Mclagan, Macmillan SCN on behalf of the T34 ambulatory syringe pump policy group DATE: 15/08/2017 APPROVAL COMMITTEE TO CONFIRM: Clinical Quality Forum ADOPTION COMMITTEE TO CONFIRM: Improvement and Quality Committee




EQUALITY IMPACT ASSESSMENT Appendix 6B Section 1 (This is mandatory and should be completed in all cases) Part A – Overview Name of Policy, Service Improvement, Redesign or St rategy: Review of current : Policy for Subcutaneous Administration of Medicine s by the T34 Ambulatory Syringe Pump for adults requiring symptom managemen t Lead Director of Manager: Marion McLagan Macmillan SCN /lead for the NHS Tayside T34 Ambulatory Syringe Pump Policy Group What are the main aims of the Policy, Service Impro vement, Redesign or Strategy? •Promote procedural uniformity and assist practitioners when using the T34 Syringe Pump within NHS Tayside. •To support safe and accountable practice when providing symptom relief for those patients where a T34 syringe pump is the preferred method of the administration of prescribed medicines. •To clarify roles and responsibilities. Description of the Policy, Service Improvement, Red esign or Strategy – What is it? What does it do? Who does it? And wh o is it for? The purpose of this policy is to provide a framework for the use of the T34 Ambulatory Syringe Pump to deliver medicines to meet the needs of Adults requiring symptom management in NHS Tayside. This document applies to all practitioners within NHS Tayside when using the T34 Ambulatory Syringe Pump, be it in the hospital, community or hospice setting. What are the intended outcomes from the proposed Po licy, Service Improvement, Redesign or strategy? – What will happen as a result of it?- Who benefit s from it and how? To ensure all clinicians who are required to use the T34 syringe pump feel confident to deliver safe and effective care to the patient Name of the group responsible for assessing or cons idering the equality impact assessment? This should be the Policy Working Group or the Proj ect team for Service Improvement, Redesign or Strategy. Marion Mclagan Macmillan SCN /NHS Tayside T34 Ambulatory Syringe Pump Policy Group




SECTION 1 Part B – Equality and Diversity Impacts Which equality group or Protected Characteristics d o you think will be affected? Item Considerations of impact Explain the answer and if

applicable detail the Impact Document any Evidence/Research/Data to support the consideration of impact

Further Actions required

1.2 Which of the protected characteristic(s) or groups will be affected?

• Minority ethnic population (including refugees, asylum seekers & gypsies/travellers)

• Women and men • People in religious/faith

groups • Disabled people • Older people, children

and young people • Lesbian, gay, bisexual

and transgender people • People with mental

health problems • Homeless people • People involved in

criminal justice system • Staff • Socio- economically

Due to some religious beliefs The use of syringe drivers needs careful discussion withal individuals




deprived groups




Item Considerations of impact Explain the answer and if



1.3 Will the development of the policy, strategy or service improvement/redesign lead to

• Discrimination • Unequal opportunities • Poor relations between

equality groups and other groups

• Other

No




SECTION 2 – Human Rights and Health Impact. Which Human Rights could be affected in relation to article 2, 3, 5, 6, 9 and 11. (ECHR: European Conv ention on Human Rights)

Item Considerations of impact Explain the answer and if applicable detail the Impact

Document any Evidence/Research/Data to support the consideration of impact


2.1

On Life (Article 2, ECHR) • Basic necessities such as

adequate nutrition, and safe drinking water

• Suicide • Risk to life of / from others • Duties to protect life from

risks by self / others • End of life questions

Risk to life of others needs to be considered particularly when delivery of medication via the T34 is undertaken at home End of life may be the purpose of the symptom management but is not the case for all uses this often raises concerns of individuals who think this mode of delivery is only used at end of life

Risk assessment is required in all cases and actions determined by this and local policy

2.2

On Freedom from ill -treatment (Article 3, ECHR) • Fear, humiliation • Intense physical or mental

suffering or anguish • Prevention of ill-treatment, • Investigation of reasonably

substantiated allegations of serious ill-treatment

• Dignified living conditions

To provide this treatment inpatients homes or various clinical settings promotes prevention of suffering in preferred place of care







2.3 On Liberty (Article 5, ECHR) • Detention under mental

health law • Review of continued

justification of detention • Informing reasons for

detention

N/A

2.4 On a Fair Hearing (Article 6, ECHR) • Staff disciplinary

proceedings • Malpractice • Right to be heard • Procedural fairness • Effective participation in

proceedings that determine rights such as employment, damages / compensation

N/A




Item Considerations of imp act Explain the answer and if



2.5 On Private and family life (Article 6, ECHR) • Private and Family life • Physical and moral integrity

(e.g. freedom from non-consensual treatment, harassment or abuse

• Personal data, privacy and confidentiality

• Sexual identity • Autonomy and self-

determination • Relations with family,

community • Participation in decisions

that affect rights • Legal capacity in decision

making supported participation and decision making, accessible information and communication to support decision making

• Clean and healthy

All capacity issues will be addressed through local policy and procedure and would not exclude individuals from receiving this symptom management




environment




2.6 On Freedom of thought, conscience and religion (Article 9, ECHR) • To express opinions and

receive and impart information and ideas without interference

All individuals have the right to refuse any intervention Informed consent must be sought for the use of any clinical procedures

2.7 On Freedom of assembly and association (Article 11, ECHR) • Choosing whether to belong

to a trade union

N/A

2.8 On Marriage and founding a family • Capacity • Age

N/A

2.9 Protocol 1 (Article 1, 2, 3 ECHR) • Peaceful enjoyment of

possessions

N/A




SECTION 3 – Health Inequalities Impact Which health and lifestyle changes will be affected ?




3.1 What impact will the function, policy/strategy or service change have on lifestyles?

For example will the changes affect:

• Diet & nutrition • Exercise & physical activity • Substance use: tobacco,

alcohol or drugs • Risk taking behaviours • Education & learning or

skills • Other

In some cases may improve lifestyle with use of good symptom management ( even if only for a short time in some instances)

NHS Scotland Palliative care guidelines ( 2014)

3.2. Does your function, policy or service change consider the impact on the communities?

Things that might be affected include:

• Social status • Employment (paid/unpaid) • Social/family support • Stress • Income

It may impact positively on individuals who require symptom management potentially promoting independence in some individuals End of life care impacts on stress for individuals and families







3.3 Will the function, policy or service change have an impact on the physical environment? For example will there be impacts on:

• Living conditions • Working conditions • Pollution or climate change • Accidental injuries/public

safety • Transmission of infectious

diseases • Other

No

3.4 Will the function, policy or service change affect access to and experience of services? For example

• Healthcare • Social services • Education • Transport • Housing

No change in policy function at this review




Item Considerations of impact Explain the answer and if



3.5 In relation to the protected characteristics and groups identified:

• What are the potential impacts on health?

• Will the function, policy or

service change impact on access to health care? If yes - in what way?

• Will the function or policy

or service change impact on the experience of health care? If yes – in what way?

This is an existing policy and has no impact on access to healthcare




SECTION 4 – Financial Decisions Impact How will it affect the financial decision or propos al? Item

Considerations of impact Explain the answer and if applicable detail the Impact



4.1

• Is the purpose of the financial decision for service improvement/redesign clearly set out

• Has the impact of your financial proposals on equality groups been thoroughly considered before any decisions are arrived at

N/A

4.2 • Is there sufficient information to show that “due regard” has been paid to the equality duties in the financial decision making

• Have you identified methods for mitigating or avoiding any adverse impacts on equality groups

• Have those likely to be affected by the financial proposal been consulted and involved

N/A




Item Considerations of impact Explain the a nswer and if



5. Involvement, Consultation and Engagement (IEC) 1) What existing IEC data do we have?

• Existing IEC sources • Original IEC • Key learning

2) What further IEC, if any, do you need to undertake?

N/A







6. Have any potential negative impacts been identified?

• If so, what action has been proposed to counteract the negative impacts? (if yes state how)

For example: • Is there any unlawful

discrimination? • Could any community get

an adverse outcome? • Could any group be

excluded from the benefits of the function/policy?

(consider groups outlined in 1.2) • Does it reinforce

negative stereotypes? (For example, are any of the groups identified in 1.2 being disadvantaged due to perception rather than factual information?)

N/A







7. Data & Research • Is there need to gather

further evidence/data? • Are there any apparent

gaps in knowledge/skills?

The policy defines and supports the education required and how this should be achieved and monitored at local level

8. Monitoring of outcomes • How will the outcomes

be monitored? • Who will monitor? • What criteria will you use

to measure progress towards the outcomes?

• Numbers of staff trained • Number of Datix raised • All monitored at local

level through training figures and datix

9.. Recommendations State the conclusion of the Impact Assessment

The changes made under this policy review aim to improve delivery of safe and effective patient care.







10. Completed function/policy • Who will sign this off? • When?

Policy review only with some revision of practice due to current changes in NHS Tayside Policy :

• Clinical Quality Forum • Improvement quality

Committee • Nursing and midwifery

Directorate

11. Publication




Conclusion Sheet for Equality Impact Assessment

Positive Impacts (Note the groups affected)

All groups.

Improved quality of life and effective

symptom management.

Could allow participation in social aspects.

Job satisfaction, training, knowledge

and skills for staff.

Can reduce stress for individual and families if symptoms controlled

Negative Impacts (Note the groups affected)

Can increase stress for individual and

their family.

May be associated stigma/body image.

Issues of informed consent.

Resources to provide ongoing staff training

What if any additional information and evidence is required

From the outcome of the Equality Impact Assessment what are your recommendations? (refer to questions 5 - 10) Raising awareness of the Equality and Diversity issues associated with T34 syringe pump use

This conclusion sheet should be attached to the relevant committee report. MUST BE COMPLETED IN ALL CASES Manager’s Signature: Marion McLagan Date 09/03/2015




POLICY TRAINING PLAN

Level of Delivery/ Training Format of Delivery Target Groups

Level 1 eLearning All staff

Level 2 General raising awareness All staff

Level 3 ‘Behavioural skills’ toolkit training / Detailed training programme Line Managers

Level 4 Consultancy/Values based reflective practice / Coaching support from HR / OD Team Identified as required

Future course dates and availability are distributed through the nursing and midwifery directorate e-mail distribution lists published on the clinical skills web pages , both accessed via Staffnet.

Appendix 6C




TOPIC Level of

training

Frequency / Dates of Training

Format of Delivery

Target Group

Quantifiable Resources

Links to eKSF Dimensions

1

2

2

Available to staff at all times / Mandatory requirement to undertake if not used this device before. Recommended for staff who use infrequently to complete yearly as a minimum Educational opportunities at sites across Dundee/Angus and Perth on the use of Syringe drivers in palliative care context Available yearly/ Advanced user training for identified leads in clinical areas to deliver face to face education for all staff required to use the T34

Online/e-learning face to face Face to face

Any trained staff from NHS and care homes Any trained staff from NHS and care homes Identified advanced users from NHS and care homes to attend one of advanced user training

Staff time Access to computer Staff time Staff time

C2 C3 C6 HWB7 for 1,2,and 3 below

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