Document Type: Protocol 1719 4 22 May 2023 McKinley T34

Collated by Clinical Effectiveness McKinley T34 Syringe Pump Device, administration of medicationVersion 4 (May 2020) Page 1 of 11

Contents

1 Introduction ..................................................................................................................12 Policy Statement/Objective ..........................................................................................13 Roles & Responsibilities............................................................................................... 24 Indications for use …………....................................................................................... 25 Training........................................................................................................................ 86 Monitoring, Auditing, Reviewing & Evaluation........................................................... 97. Safe Practice …………………………………………………………………………….. 98. References ................................................................................................................ 108 Distribution ................................................................................................................ 109 Appendices ............................................................................................................... 10

1 Introduction

1.1 A syringe pump is a portable battery operated infusion pump, which delivers ameasured volume of drug at a pre-determined rate via a subcutaneous route to clientsfor whom oral administration would be problematic. Use of syringe pumps is a well-established practice in the care of clients with terminal illness, and /or with palliativecare needs in the inpatient and home setting.

2 Policy Statement/Objective

2.1 The aim of this policy is to provide a consistent and evidence based framework forthe management of battery operated syringe pumps used by Torbay & South DevonNHS Foundation Trust (TSDFT) staff, minimizing hazards to clients and ensuring thatall staff required to use them are able to do so effectively and safely. This policycovers the principles of management of the McKinley syringe pump.

2.2 Safe Transfer of Care guidelines support the transfer of patients acrossorganisations ensuring safe and effective treatment continuity (appendix 8).

2.3 This policy is directed for adults with syringe pumps. For any TSDFT staff involvedwith setting up or managing syringe pumps for children this should be done underthe direction of the palliative care specialist team with exception reporting throughtheir line management, to operate outside this policy.

2.4 This policy should be read in conjunction with other TSDFT Policies includingMedicines Policy for Registered Staff & Injectable Medicines Policy for RegisteredStaff.

Document Type: ProtocolReferenceNumber : 1719

VersionNumber: 4

NextReview Date: 22 May 2023

Title: McKinley T34 syringe Pump Device, Administration ofmedication using

Document Author: Consultant in Palliative Care

Applicability: All patients and staff as indicated


3 Roles & Responsibilities

3.1 TSDFT heads of Professional Services are responsible for the implementation ofthis policy across the Community Service Delivery Unit.

3.2 TSDFT Communications and Information Governance teams will assist in thedistribution of the policy and ensure that ratified document is accessed via therelevant site on the intranet.

3.3 TSDFT are responsible for providing and ensuring that all staff required to use medicaldevices are appropriately trained (Medical Devices Agency (MDA) .

3.4 TSDFT – The Accountable Officer is responsible for ensuring the safe and effectiveuse and management of controlled drugs within the organization (DH 2006).

3.5 TSDFT is responsible for working in partnership with the medical electronics team toensure that all syringe pumps are serviced annually and an audit trail is available.

3.6 All Registered Nursing Staff administering medication via a syringe pump must havecurrent effective Nursing and Midwifery Council (NMC) registration

3.7 Registered Nurses must use this policy in conjunction with The Code, Nursing &Midwifery Council (NMC), and Standards for Medicines Management (NMC 2010),Record Keeping: Guidance for Nurses and Midwives (NMC) and TSDFT RecordsManagement Policy.

3.8 All Registered Nursing Staff are personally responsible and accountable to ensurethey receive training in the safe use and observation of medical devices they arerequired to use in the course of their duties.

3.9 All support staff, including assistant practitioners, involved in the care of a client witha syringe pump must have received appropriate training relevant to their role, and beable to demonstrate the required competencies in monitoring the patient and pumpdevice.

4: Indications for use

4:1 For symptom control and medication administration where other routes areinappropriate due to:

1. Altered level of consciousness in a dying patient2. Persistent nausea and vomiting e.g. in bowel obstruction3. Inability to swallow4. Poor compliance with oral medication

The syringe pump is simply another method of administration of medication for patientswho are symptomatic.

4.2 Communication and consent

Prior to commencing a syringe pump a full explanation and discussion about what a syringepump is, how it works and why it is indicated should occur between the nurse and the clientand his/her carers. Informed consent should be obtained. In the event of a client beingunable to give consent the nurse will act in the best interests of the client in conjunctionwith a medical practitioner and in accordance with the Mental Capacity Act (2007). For


clients unable to give consent, appropriate assessment and documentation to demonstratebest interest actions should be completed. Informed consent should be recorded in linewith local policy. Written information should also be made available for the client andcarers.

4.3 Prescribing the Drugs

· Reference should be made to the TSDFT Medicines Policy, the TSDFTInjectable Medicines Policy and related SOP’s for further guidance. All injectablemedicines should be risk assessed and guidance is given in the injectablemedicines policy

· Non-Medical Independent/Supplementary Prescribers may only prescribecontrolled drugs according to their level of prescribing status and within their areaof expertise and level of competence.

· All prescriptions for Controlled Drugs must comply with the requirements of theMisuse of Drugs Act 1971 (see BNF Guidance on Prescribing)

· Verbal orders must not be taken for injectable medication or controlled drugs. Theuse of faxes and e-mails are regarded as a verbal order in this context. However forcommunity patients during COVID-19 pandemic 2020, transfer of the communityprescription for continuous subcutaneous syringe pump infusions and PRN doses,can take place electronically from general practice to the local community nursingteam.

· In the community setting a stated start dose and an incremental range may beprescribed to facilitate adequate symptom control.

· Prescribing of bolus as required medication should be completed forbreakthrough pain and symptom control.

· Amendments to the Home Office Misuse of Drugs Regulations 2001: changes tonurse and pharmacist independent prescribing of controlled drugs in the UK takeeffect 23 April 2012.


Home Office circular 009/2012Nurse and pharmacist independent prescribing, 'mixing of medicines', possessionauthorities under patient group directions and personal exemption provisions forSchedule 4 Part II drugs

The Misuse of Drugs (Amendment No. 2) Regulations 2012 amends the Misuse of DrugsRegulations 2001 (as amended) (the 2001 Regulations) (SI 2001/3998) as follows:

-removes the restrictions on the prescribing of Schedules 2-5 controlled drugsby nurse independent prescribers

-introduces pharmacist independent prescribing for Schedules 2-5 controlled drugs

-authorises the supply of morphine and diamorphine by registered nurses andpharmacists underPGDs in any setting

-regularises the compounding of medicines that include controlled drugs prior toadministration

-authorises the possession of specific controlled drugs – such as ketamine andmidazolam – by healthcare professionals, including paramedics, under PGDs

-makes legislative provisions relating to drugs listed in Part II of Schedule 4 to 2001Regulationsby restricting importation and exportation of these drugs to circumstances where it iscarried out in person and removing the term 'medicinal product'

For clients in the acute/ community hospital: The medical practitioner, or non-medicalindependent prescriber, should prescribe the required syringe pump medication on theregular injection section of the hospital Drug Prescription and Administration Record,using guidelines recommended in the Joint Formulary relevant to the local area.If a patient is being discharged to their home or care home, the Community Prescription forSyringe Pump Infusions and PRN doses form (Appendix 1) should be completed. Themedications to be ordered from the hospital pharmacy using the usual procedures for CDand non-CD TTA's.

For clients in the community/home setting: The medical practitioner, or non-medicalindependent prescriber, should prescribe the required medication on a prescription (FP10)using guidelines recommended in the Joint Formulary relevant to the local area. Requiredmedication, including ‘as required’ drugs must also be recorded by the medical practitioneror non-medical independent prescriber on the Community Prescription for Syringe PumpInfusions and PRN doses form (Appendix 1).


The prescription should contain the following

· Date· Patient full name, address, date of birth, hospital number (where relevant) and NHS

number· Full generic name of the medicine(s) to be used in the syringe pump which should be

legible and in capital letters· The appropriate diluents, name, volume and number of ampoules required· Route and duration of administration i.e. subcutaneous infusion by syringe pump· As required doses for anticipated symptom control· Signature of prescriber.

All prescriptions for Controlled Drugs must comply with the requirements of the Misuse ofDrugs Act 1971 (see British National Formulary Guidance on Prescribing).

Practice Standard 9.1 (NMC Standards of Proficiency for Nurse & Midwife Prescribers2008) recommends that the practitioner must ensure separation of the prescribing andadministering activities wherever possible.Practice standard 9.2 (NMC Standards of Proficiency for Nurse & Midwife Prescribers2008) states that in exceptional circumstances where you are involved in both prescribingand administering a patient/client controlled drugs, a second, suitably competent personshould be involved in checking the accuracy of the medication provided.

‘As required’ doses

Must be included on the FP10 and the Community Syringe Pump Medication PrescriptionChart (Appendix 1) or the Hospital ‘Drug Prescription and Administration Record’.

Dose RangesIn the community setting only, a dose range may be prescribed but must includedocumentation by the medical practitioner/prescriber, to direct incrementalincrease/decrease amount and the symptom against which any change should beadministered. It should also include a review date.

Commencing a patient on a syringe pump previously treated with opioid patchtherapy

· If a patient is started on a syringe pump after previously receiving opioid patchtherapy, appropriate measures must be taken by the prescriber to ensure thistreatment is taken into account when prescribing the initial dose of the opioidcontained within the subcutaneous infusion and any prn doses.

· In most cases it is appropriate to continue with an opioid patch but this should beinstructed by the prescriber. Established dose conversions are available withinAppendix 1.

· If the patches are removed when the syringe pump is started or, after an agreed time


period as instructed by the prescriber or specialist palliative care nurse carefulattention should be paid to the calculation of opioid in the syringe pump and any prndoses.

· In order to ensure that inadvertent dual administration of opioid patches andsubcutaneous therapy is avoided, registered practitioners must routinely ask thepatient or carer if they have knowledge of patches being used in the period of timeleading up to the syringe pump starting. If there is any doubt the prescriber should becontacted.

· If a patch is found on a patient after a subcutaneous infusion has been started, andthis has not been agreed by the prescriber, the prescriber should be contactedimmediately for advice, or if out of hours from Devon Doctors. The outcome shouldbe fully documented in the patients care notes.

Non–licensed drug indications/routes of administration

The treatment of many symptoms in palliative care often requires the use of medicines forunlicensed routes or doses. The Medicines Act 1968 preserves the clinical freedom ofprescribers to prescribe in such circumstances and these prescriptions can be legallydispensed and administered in accordance with the prescribers written instructions. TheTSDFT Medicines Policy for Registered Professionals provides guidance.

Guidance Points on Prescribing and Administration of Medicines intended to bemixed prior to administration

Following detailed discussion by the Department of Health with the Commission on HumanMedicines (CHM) and recommendations by the MHRA, the following points should becarefully considered when prescribing and administering medicines which are intended tobe mixed prior to administration. In some settings, including End-of-Life Care and intensivecare, it will be in the patient’s best interests for medicines to be mixed, for instance througha syringe drive or single line. The legal changes also define mixing as “the combination oftwo or more medicinal products together for the purposes of administering them to meet theneeds of a particular patient.”

Parameters

The mixing of medicines should:· Only be undertaken in the best interests of the patient· Be avoided where possible· Only be done by a person competent and willing to do so· Take place in a pharmacy, where possible


Principles

The CHM has agreed that the following principles on mixing of medicines should apply:

· Mixing of medicines should be avoided where possible. It must only beundertaken when clinically appropriate and essential to meet the needs of thepatient. It should not be undertaken for the convenience of a health professional.The instruction/ direction to mix must be in writing.

· The prescriber takes responsibility for satisfying himself or herself that clinicalgovernance arrangements are in place to ensure that the “mixer” is competent toundertake the task safely and effectively - especially within a non-hospitalenvironment.

· The person mixing the medicines must be competent.

· No-one should be obliged to mix and administer medicines if they do not feelcompetent or confident to do so.

Key points - Prescribing and administration of medicines intended to be mixed

· Medicines should not be prescribed for mixing (whether for parenteral or oraladministration) unless essential to meet the needs of the patient. Licensed productsshould be used for reference

· If mixing is necessary, the product should, as a preference and where possible, beprepared in a pharmacy by or under the supervision of a pharmacist or ordered froma person holding a manufacturer’s license.

· Prescribers should seek advice from a pharmacist in deciding whether there arealternatives to administering mixed medicines for individual patients or, if this is notpossible, from an authoritative source of guidance on the combination of medicines.

· Prescribers should seek advice from a pharmacist in determining whichsubstance(s) can be mixed and in what dosages or, if not possible, from anauthoritative source of guidance on the combination of medicines.

· If mixing must be undertaken in a “near-patient” situation, prescribers shouldclearly identify which substance(s) should be mixed and in what dosages.

· It is recognised that there are particular circumstances, for example for a patient atthe end of life and intensive care, where mixing will be in the patient’s best interestsas it will provide the simplest and most efficient way of managing the patient’ssymptoms.

· Injections and sterile medicines prepared in near-patient areas shouldnormally be administered immediately.


· A medicine mixed in a near-patient area should be prepared only for individualpatients and be clearly labelled with the direction that it is to be used immediatelyand, if not, labelled with an expiry period.

· Medicines should only be prescribed for administration by injection when no otherroute is suitable [NB: refer to NICE guidance on risk assessments for IV”general”injections].

· The Commission on Human Medicines recommends prescribers should satisfythemselves that clinical governance arrangements are in place, to ensure thatthose undertaking the mixing of medicines they have prescribed areprofessionally competent and will take full professional and clinical responsibilityfor their decisions and actions.

· Prescribers need to take account of their local employer’s policy and guidance onmixing of medicines and the prescribing of unlicensed medicines, eg NHS Trust orPCT (Department of Health 2010).

Best practice points

· The syringe pump should be commenced within 4 hours of prescribing.· A syringe pump may take 4 hours to deliver medication to the optimum therapeutic

level and it is considered best practice to have stat doses prescribed to providesymptom relief until optimum level is achieved.

· Within the community/home setting a stated start dose and an incremental range maybe prescribed to facilitate adequate symptom control i.e. Morphine 30mg to 60mgmay be increased in 10mg increments if necessary following each 24 hour period.This must include a written review date.

· Practitioner should seek advice from a medical practitioner, pharmacy dept. orspecialist palliative care team for support and advice if concerned around unresolvedsymptoms or if more than 3 drugs have been prescribed for administration in a singlepump device.

· When drawing up the drugs, doses must be measured against the syringemarkings.

5 Training

5.1 TSDFT is responsible for providing and ensuring that all staff required to usemedical devices are appropriately trained (Medical Devices Agency (MDA).

5.2 For all Registered Nurses required to set up and manage clients who have syringedrivers the following training is also required;

· Attendance at annual mandatory resuscitation training· Anaphylaxis training within previous 2 yrs.· Attendance at McKinley T34 syringe pump training session every 3 years, with

yearly update via HIVE ‘T34 Syringe Pump (2nd and 3rd Editions)’ videos.· Attendance at Medicines Policy Training for Registered Staff.


· Successful completion and evidence of competency assessment including drugcalculations.

5.3 Records of training and competency assessment will be held within the individuals’portfolio and reviewed as part of annual appraisal process. The records will also berecorded within TSDFT staff records.

5.4 Where patients or unpaid carers wish to undertake the procedure a suitably trainedRegistered Nurse must ensure consent is obtained, a risk assessment is completed,adequate training and support is provided and that all training and supervisionprovided is recorded.

6 Monitoring, Auditing, Reviewing & Evaluation

6.1 Monitoring: Torbay and South Devon NHS Foundation Trust, through the clinicalgovernance framework, will ensure a process for monitoring the compliance andeffectiveness of this document. This process will include reviewing incidents reported,through the incident reporting process and be part of the process relating to themaintenance of medical devices.

6.2 All syringe pump incidents will be treated as controlled drug incidents and reviewed by the Accountable Officer.

7 Safe Practice

7.1 The Registered Practitioner will ensure the use of the syringe pump is in line withCare Quality Commission Guidance Essential standards of quality and safety March2010

7.2 Outcome 9: Safe Management of Medicines

The registered person must protect service users against the risks associated with theunsafe use and management of medicines, by means of the making of appropriatearrangements for obtaining, recording, handling, using, safe keeping, dispensing, safeadministration and disposal of medicines used for the purposes of the regulated activity.Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations20107.3

Outcome 11: Safety, availability and suitability of equipment

1: The registered person must make suitable arrangements to protect service users andothers who may be at risk from the use of unsafe equipment by ensuring that equipmentprovided for the purposes of the carrying on of a regulated activity is:-(a) Properly maintained and suitable for its purpose;(b) Used correctly.


(c) The correct edition of the T34 for their practice area. 2nd Edition for communitybased patients, to include community hospitals. 3rd Edition only to be used inthe acute areas of Torbay Hospital.

2: The registered person must ensure that equipment is available in sufficient quantities inorder to ensure the safety of service users and meet their assessed needs.

3: Where equipment is provided to support service users in their day to day living, theregistered person must ensure that, as far as reasonably practicable, such equipmentpromotes the independence and comfort of service users.

4: For the purposes of this regulation—(a) “Equipment” includes a medical device; and(b) “Medical device” has the same meaning as in the Medical Devices Regulations 2002.

Regulation 16 of the Health and Social Care Act 2008.

8. ReferencesDepartment of Health (2010) Mixing of Medicines prior to administration in clinicalpractice: medical and non-medical prescribing.

Department of Health (2006) Safer Management of Controlled Drugs: (1) Guidanceof Strengthened Governance Arrangements.Home Office circular 009/2012 - Nurse and pharmacist independent prescribing,'mixing of medicines', possession authorities under patient group directions andpersonal exemption provisions for Schedule 4 Part II drugs

Nursing and Midwifery Council (2009) Record Keeping: Guidance for Nurses andMidwives. London. NMC.

Nursing and Midwifery Council (2007) Standards for Medicines Management.London. NMC. Nursing and Midwifery Council (2008) The Code. London. NMC.

South Devon Joint Formulary (2006) Chapter 16. South Devon Palliative CareGuidelines.

Nursing and Midwifery Council (2008) Standards of Proficiency for Nurse & MidwifePrescribers.

9 Distribution

9.1 TSDFT will ensure dissemination of this policy across senior managers, ProfessionalNursing Leads and cascaded through nursing teams.

9.2 Access to this policy will be ensured using local intranet.

10 Appendices

Appendix 1 – Syringe Pump Prescription FormAppendix 2 – Community Prescription Medication Administration record (PMAR)Subcutaneous routeAppendix 3 – Community Prescription Medication Administration record (PMAR)bolus injection


Appendix 4 – Community Hospital Prescription Medication Administration record(PMAR)subcutaneous routeAppendix 5 – Acute (TBH) T34 Syringe Pump Observation ChartAppendix 6 – Community Medication Stock RecordAppendix 7 – Competency assessment for delivery & close down ofsubcutaneous treatments using the McKinley T34 device.Appendix 8 – Safe Transfer of Care Guidelines.Appendix 9 - Patient Information Leaflet. 25162 – The McKinley T34 Syringe PumpAppendix 10 - Guidance outlining the procedure for obtaining and returning theCME McKinley T34 Syringe pump and accompanying consumables to NRSAppendix 11 – Standard Operating Procedure

Appendix 1PRESCRIBER MUST COMPLETE PARTS 1 & 2 OF THIS FORM

DURING COVID PANDEMIC 2020 TRANSFER OF THIS Prescription IS TO TAKE PLACE ELECTRONICALLYFROM GENERAL PRACTICE TO THE LOCALITY COMMUNITY NURSING TEAM

Patient Name Date of Birth GP

NHS /Unique Identification number Allergies

Part 1: COMMUNITY PRESCRIPTION FOR CONTINUOUS SUBCUTANEOUS SYRINGE PUMP INFUSIONSFor prescribing guidance see overleaf

DATE/TIMEGeneric NAME of DRUG and

DILUENTBlank rows are provided for

prescribing of drugs not listed

24 HOURDOSE mg/24hrs

Consider prescribingdose ranges

PRESCRIBER NAME & SIGNATURE(IN FULL)

MORPHINE sulfate- max of30mg/ml due to solubilityMetoclopramide HydrochlorideLevomepromazineMidazolam

Hyoscine BUTYLbromideHyoscine HYDRObromideHaloperidol

Water for injection

Part 2: PRESCRIPTION FOR AS REQUIRED (PRN) DOSESFor prescribing guidance see overleaf

DATE/TIMEGENERIC NAME OFMEDICATION & ANY

DILUENT

DOSEConsider prescribing

dose ranges

FREQUENCYROUTE PRESCRIBER NAME & SIGNATURE

IN FULLMORPHINE sulfateMetoclopramideHydrochlorideLevomepromazineMidazolamHyoscineBUTYLbromideHyoscineHYDRObromideHaloperidol

Collated by Clinical Effectiveness Instructions for use of Subcutaneous Syringe PumpsVersion 4 (May 2020) Page 2 of 9

TORBAY & SOUTH DEVON SPECIALIST PALLIATIVE CARE SERVICEINSTRUCTIONS FOR USE OF SUBCUTANEOUS SYRINGE PUMPS

Indications for using a subcutaneous syringe pump [SCSP]:1. Altered level of consciousness in a dying patient2. Persistent nausea and vomiting e.g. in bowel obstruction3. Inability to swallow4. Poor compliance with oral medication

The syringe pump is simply another method of administration of medication for patients who are symptomatic.

ANALGESICSMorphine – dose per 24 hours: no ceiling dose but:1. Start at 10-15mg/24 hours in opioid naïve patients (less in very elderly/frail)2. See conversion table for calculating doses, changing from oral to SCSP use and using other opioids e.g. converting the total dailydose of oral morphine to the total daily dose of subcutaneous morphine by dividing by 2, e.g. MST 60mg bd=120mg/day =morphine60mg/24 hours by SCSP.3. Caution: in patients with significant renal impairment (suspected eGFR <30) aim to avoid morphine because of significant risk ofopioid accumulation/toxicity. Alternative opioids such as oxycodone/fentanyl/alfentanil may be more appropriate. Please seek advicefrom Specialist Palliative Care team (see guidance on prescribing at end of life in renal failure)4. Patches - Transdermal opioid patches should not be started in the terminal stage since it takes too long to titrate against a patient’spain. If the patient is already established on a patch it may be appropriate to continue with it and add in additional medications via theSCSP.

ANTIEMETICS1. Metoclopramide useful for gastric stasis and upper gastrointestinal obstruction. Avoid in patients with colic. Non-sedating.Dose per 24 hours: 30-60mg (BNF dose range is 30-100mg/24h)Dose per prn injection: 10mg 6-8 hourly2. Haloperidol useful in chemically induced vomiting (e.g. hypercalcaemia, renal failure), and/or in patients with psychotic features.Sedating at higher doses. Use lower dose in the elderly.Dose per 24 hours: 2.5-5mg (up to 10mg if being used for sedation as well)Dose per prn injection: 1-3mg od-bd3. Levomepromazine good antiemetic especially with co-existing anxiety, very sedating at higher doses.Dose per 24 hours: 6.25-25mg (BNF dose range 5-25mg/24h)Dose per prn injection: 6.25mg 6-8 hourly


4. Cyclizine relatively non-sedating, useful in mechanical bowel obstruction or raised intracranial pressure, but precipitates out whenmixed with Hyoscine Butylbromide.Dose per 24 hours: 50-150mg Dose per prn injection: 50mg 8 hourly (max. 150mg/24hours)

ANTISPASMODICSHyoscine butylbromide (Buscopan)Dose per 24 hrs: 60-120mg (BNF dose range 60-300mg/24h)Dose per PRN injection 20mg 4 hourlySEDATIVES1. Midazolam useful for anxiety, breathlessness, restlessness and muscle stiffness in terminal phase. Also used as ananticonvulsant.Dose per 24 hours: 10-60mg. Higher doses occasionally required. (BNF start 10-20mg/24h usual dose 20-60mg/24h)Dose per prn injection: 2.5-10mg 4 hourly

Caution: respiratory depression is more likely when midazolam is given parenterally with morphine.2. Levomepromazine useful as sedative but can lower fitting thresholdDose per 24 hours: 12.5-50mg (higher doses occasionally required)Dose per prn injection: 12.5-25mg 4 hourlyTERMINAL SECRETIONS1. Hyoscine butylbromide (Buscopan) useful in respiratory secretions when sedation not desiredDose per 24 hours: 60-120mg (BNF dose range 20-120mg/24h)Dose per prn injection: 20mg 4 hourlySuitable for use if suspected eGFR <302. Hyoscine hydrobromide useful in terminal stages when sedation required but can cause paradoxical agitation; usually given witha sedative, e.g. Levomepromazine or Midazolam. Caution: avoid if suspected eGFR <30.Dose per 24 hours: 1.2-2.4mg (BNF dose range 1.2-2mg/24h)Dose per prn injection: 0.4-0.6mg 4 hourly (max. 2.4mg/24 hours)AS REQUIRED (PRN) DOSES MUST BE PRESCRIBED· Always ensure that adequate prn doses are clearly written on the syringe pump prescription sheet so that any trained healthcare

professional visiting the home who does not know the patient can give extra medication when indicated. These prn medicationsare not the same as Just In Case Bag (JICB) medication


· JICB medication should be prescribed when a clinical deterioration is anticipated but the patient does not yet need a syringepump for current symptom control.

· A syringe pump should be started when clinically indicated and should not be delayed because JICB medications are alreadyavailable. There is no requirement to use JICB medication prior to setting up a syringe pump.

· Ideally there should be no more than a 4 hour delay between the request for starting a syringe pump and it being set up for thepatient.

24 hour advice line (Rowcroft Hospice) tel no: 01803 210800. Calls go through to the hospice. The senior nurse will be able toanswer queries or ask the doctor on call to ring you back.Rowcroft Community Specialist Palliative Care Team - Mon – Fri 9-5 tel no: 01803 210811 Sat – Sun, bank holidays 9-1 (teladvice) tel no: 01803 210812Consultants in Palliative Medicine, Torbay and South Devon NHS Foundation Trust/Rowcroft HospiceGP Facilitators in Palliative Care, South Devon and Torbay.Updated November 2018 Review November 2021


PRESCRIBING IN PALLIATIVE CARE: A GUIDE TO EQUIVALENT DOSES FOR OPIOID DRUGS

This is to be used as a guide rather than a set of definitive equivalences. It is crucial to appreciate that conversion ratios arenever more than an approximate guide (comprehensive data are lacking, inter-individual variation). The advice is always tocalculate doses using morphine as standard and to adjust them to suit the patient and the situation. Some of these doses haveby necessity been rounded up or down to fit in with the preparations available, including adjustment of doses for liquid andinjectable medications in order to optimise ability to dispense accurately.

Oral Morphine SubcutaneousMorphine

SubcutaneousDiamorphine

Oral Oxycodone SubcutaneousOxycodone

ApproximateTD Fentanyl

patchmicrograms/hr

SubcutaneousAlfentanil

SubcutaneousFentanyl

4 hrdose(mg)

12hrSR

dose(mg)

24hrTotaldose(mg)

4 hrdose(mg)

24 hrtotaldose(mg)

4 hrdose(mg)

24 hrtotaldose(mg)

4hrdose

(mg)

12hrSR

dose(mg)

24hrtotaldose(mg)

4 hrdose(mg)

24 hrtotaldose(mg)

Please seeadditional chartbelow for dose

conversionranges

4 hrdose(mg)

24hrtotaldose(mg)

4 hrdose(mcg)

24hrtotaldose(mcg)

5 15 30 2.5 15 1 10 2.5 7.5 15 1 7.5 12mcg 0.1 1 25 200-25010 30 60 5 30 2.5-5 20 5 15 30 2.5 15 25mcg 0.2 2 50 400-50015 45 90 7.5 45 5 30 7.5 25 50 4 25 25-37mcg 0.5 3 100 600-75020 60 120 10 60 7.5 40 10 30 60 5 30 37-50mcg 0.7 4 Syringe pump

volume issues likelyabove500mcg/24hoursbecause fentanylinjection availableas 50micrograms/ml

30 90 180 15 90 10 60 15 45 90 7.5 45 50-75mcg 1 640 120 240 20 120 12.5 80 20 60 120 10 60 75-100mcg 1 850 150 300 25 150 15 100 25 75 150 12.5 75 100-150mcg 1.5 1060 180 360 30 180 20 120 30 90 180 15 90 100-150mcg 2 1270 210 420 35 210 25 140 35 105 210 17.5 100 125-175mcg 2.5 1480 240 480 40 240 27.5 160 40 120 240 20 120 125-200mcg 2.5 16


PLEASE SEEK SPECIALIST ADVICE IF YOU ARE UNCERTAIN ABOUT WHAT TO PRESCRIBE AND / OR PATIENTNEEDING ESCALATNG OPIOID DOSES

· Two thirds of palliative care patients need <180mg/24hrs of oral morphine· The dose conversion ratio of morphine to oxycodone is approximately 1.5-2:1.For the purposes of this guidance we have

adopted a 2:1 ratio· The dose conversion ratio of SC diamorphine: SC Alfentanil is from 6-10:1. It is prudent to use the more conservative ratio

when switching from one to the other e.g. if switching from diamorphine to Alfentanil, use dose conversion ratio 10:1 sothat 10mg diamorphine = 1mg Alfentanil. If switching from Alfentanil to diamorphine use dose conversion ratio 6:1 so that1mg Alfentanil = 6mg diamorphine.

· The dose conversion ratio of SC Alfentanil: SC fentanyl is approximately 4-5:1

TRANSDERMAL (TD) OPIOID PATCHES

Fentanyl TD patchmicrograms/hr

Approximate oralMorphine mg/24hours

12 30-4525 60-9037 90-13550 120-18062 150-22575 180-270100 240-360125 300-450150 360-540175 420-630200 480-720

Buprenorphine TDmicrograms/hr

Approximateoral Morphine mg/24hrs

5 10-2010 20-3015 30-4020 40-50

35.5 80-9052.5 120-13070 160-180

Maximum authorised dose istwo 70micrograms/hr patches


· A PO morphine:transdermal fentanyl dose conversion ratio of 100-150:1 is used (PCF5& BNF 100:1, Public Health Education Opioids Aware Resource 150:1) resulting in adose range of oral morphine per patch strength e.g. Fentanyl TD 25mcg/hr patchapproximately= 60-90mg oral morphine/24hrs

· It is suggested that for conversions from oral morphine to fentanyl patches, the lowerdoses of fentanyl should be used for patients who have been on oral opioids for justweeks and the higher doses for people who have been on a stable and well toleratedoral opioid regimen for a longer period.

· Transdermal fentanyl patches are changed every 3 days (72 hours)· A PO morphine: transdermal buprenorphine dose conversion of 100:1 is used (PCF5)· A variety of transdermal buprenorphine patches are available, changed either every 3, 4

days or 7 days. Check carefully before prescribing & instructing the patient.

Resources: Palliative Care Formulary 6th Edition (PCF6)BNFUK Medicines Information: How should conversion from oral morphine to fentanyl patches becarried out?https://www.sps.nhs.uk/wp-content/uploads/2017/12/UKMI_QA_Conversion-from-oral-morphine-to-fentanyl-patches_November-2017_Final.docx.Updated November 2018 / Review November 2021Dr Sarah Human, Dr Jo Sykes and Dr George Walker, Consultants in Palliative Medicine,Rowcroft Hospice, South Devon in collaboration with Hospiscare, Exeter, St Luke’s Hospice,Plymouth and North Devon Hospice, Barnstaple.

https://www.sps.nhs.uk/wp-content/uploads/2017/12/UKMI_QA_Conversion-from-oral-morphine-to-fentanyl-patches_November-2017_Final.docx

https://www.sps.nhs.uk/wp-content/uploads/2017/12/UKMI_QA_Conversion-from-oral-morphine-to-fentanyl-patches_November-2017_Final.docx


TOP TIPS for prescribing opioids at end of life

· Use the lowest dose needed to achieve symptom control. Be prepared to adjust thedose up or down according to symptom relief and side effects. Review the patientregularly.

· Opioids are good for relief of pain and breathlessness, but should not be used forsedation.

· Always check conversion doses, especially when using unfamiliar opioids. It is usuallyhelpful to calculate the equivalent oral morphine dose and continue from there.

· In opioid naïve patients, start with a subcutaneous syringe pump (SCSP) dose ofmorphine 10-15mg/24hrs (use lower doses for elderly, frail patients).

· In opioid naïve patients, consider adding in an antiemetic to the SCSP regime. Nauseaand vomiting is a common initial undesirable effect of opioids.

· For patients already using opioids calculate their equivalent SCSP opioid dose.Consider factoring in an increase if the patient’s pain is not controlled.

· It is usual to continue with transdermal Fentanyl/Buprenorphine patches using theSCSP to add easily adjustable doses of opioids/medications.

· When adjusting the 24-hour dose of opioid, PRN use should be taken into account;dose increases should not exceed 1/3rd - 1/2 of total dose every 24hrs.

· Prescribe a PRN SC dose equivalent up to 1/6th of the 24hr dose. It may be helpful toprescribe a range:

e.g. morphine 60mg/24hrs via SCSP, morphine 5-10mg SC PRN

Clarify permitted frequency (generally 2-4 hourly PRN but can be 1 hourly PRN when painsevere, or in the last few days of life).

· Do not forget to include the equivalent dose of transdermal patch PLUS the SCSPopioid dose when calculating PRN SC opioid dose:

· For patients in the community setting, it may be helpful to prescribe a dose range for the24hr SCSP regime. Provide clear instructions on indication(s) for increasing the dosewith suitable dose increments:

E.g. Morphine 60-100mg/24hrs. “Increase in increments of 10-20mg, depending on PRN use, ifpain not controlled. Do not increase more frequently than every 24hrs”.

E.g. fentanyl patch 25mcg/hour (approx. 60-90mg oral morphine/24hrs) + SCSP morphine15mg/24hrs (approx. 30mg oral morphine/24hrs)

=total oral morphine 90-120mg/24hrs = total SC morphine 45-60mg/24hrs.

Therefore, PRN SC morphine dose range = 5-10mg


· For patients with renal failure please see your local prescribing guidance and/or seekspecialist advice (See guideline Ref G1612 Prescribing at the End of Life for Patientswith Renal Impairment)

For more detailed guidance refer to Torbay and South Devon Care of the DyingResources (includes information about symptom control, use of syringe pumps,

prescribing in renal impairment and patient information):

https://www.rowcrofthospice.org.uk/how-we-can-help/referrals-access-services/clinical-resources/

Consultants in Palliative Medicine, Torbay and South Devon NHS Foundation Trust/Rowcroft HospiceGP Facilitators in Palliative Care, South Devon and Torbay.

Updated November 2018 / Review November 2021

https://icon.torbayandsouthdevon.nhs.uk/corp_doc_mgmt/Clinical%20Effectiveness/G1612.pdf

https://icon.torbayandsouthdevon.nhs.uk/corp_doc_mgmt/Clinical%20Effectiveness/G1612.pdf



CC

Collated by Clinical Effectiveness Prescription Medication administration record for Subcutaneous Route – Community Use OnlyVersion 4 (May 2020) Page 1 of 1

Date Time Drugs(including batch no. &expiry date)

Made up to(ml)

Dilutedwith

Set at (ml/hr)(from LCD

screen)

Checks Linechange(72hrly)Yes/No

Cannulachange

Yes/No

Sign & Printname in fullSite

check

Lightflashing/

pumpdelivering

Batterylevel

%

Appendix 2

Patient Name Address Date of Birth NHS or UniqueIdentification Number

Syringe Pump MedicalElectronic Asset Number

PRESCRIPTION MEDICATION ADMINISTRATION RECORD FOR SUBCUTANEOUS ROUTE – community use only

Collated by Clinical Effectiveness Community Prescription for Continuous Subcutaneous Syringe Pump InfusionsVersion 4 (May 2020) Page 1 of 1

Appendix 3

MEDICATION ADMINISTRATION FOR BOLUS INJECTION – community use only

NB. When more than one stat dose has been necessary in a 24 hour period please contact prescriber atearliest opportunity fo r review of symptom control

Patient Name Address Date of Birth NHS or Unique Identification Number

Date Time Medication & Diluents Dose Batch No. Expiry Date Route Sign & Print name in full

CC

Collated by Clinical Effectiveness Syringe Pump Subcutaneous Medication Administration RecordVersion 4 (May 2020) Page 1 of 1

Appendix 4

Syringe Pump Subcutaneous Medication Administration RecordFor Daily use in Community Hospital

Patient Name Syringe Pump Medical Electronic Asset Number

Date serviced:NHS number/unique identification number Date of birth 4 Hourly checks

Date & Time Medication &Diluents

Dose Volume Batch number & Expiry date Time Timeremaining

Site checkY / N

Comments Full signature

Final volume in syringe: Site:

Amount left in discarded syringe: Site changed:

Battery level % New battery Y / N Line changed:

Full Signature Print Name

Collated by Clinical Effectiveness McKinley T34 Syringe Pump Observation Chart (Inpatients)

Appendix 5McKinley T 34 Syringe Pump Observation Chart (Inpatients)

Name of Ward _________________________ Check Syringe Pump 4 hourly

PLEASE GIVE LOADING PRN DOSE WHEN SETTING UP (assess first)

Dat

e/Ti

me

rene

wed Drugs in 24

hours

DES

CR

IBE

SITE

WH

ERE?

HA

S IT

BEE

N C

HA

NG

ED?

SITE

CH

ECK

ED

CR

YSTA

LLIS

ATI

ON

LIG

HT

FLA

SHIN

G

TIM

E C

HEC

KED

BA

TTER

Y LE

VEL

%

SYR

ING

E FL

UID

REM

AIN

ING

IN m

ls

INFU

SIO

N R

ATE

ml/h

r

TIM

E R

EMA

ININ

G

RU

NN

ING

TO

TIM

E

SYM

PTO

MS

CO

NTR

OLL

ED

SIGNATURE

01/01/17 EXAMPLEMORPHINE 20mg

NADL abdo Y N Y 0800 33 8 0.41

ml/hr 19.5 hrs Y Y A Another

060010001400180022000200060010001400180022000200060010001400180022000200060010001400180022000200

Syringe Size Syringe Volume10 ml 10 ml20ml 17 ml30 ml 22 ml

LABELName:

Hospital no:

T34 2nd edition 9v battery will last 3-4 daysT34 3rd edition 9v battery to be changed every 24 hours

CC

Collated by Clinical Effectiveness McKinley T34 Syringe Pump Observation Chart (Inpatients)

Check Syringe Pump 4 hourlyD

ate/

Tim

ere

new

ed Drugs in 24hours

DES

CR

IBE

SITE

WH

ERE?

HA

S IT

BEE

N C

HA

NG

ED?

SITE

CH

ECK

ED

CR

YSTA

LLIS

ATI

ON

LIG

HT

FLA

SHIN

G

TIM

E C

HEC

KED

BA

TTER

Y LE

VEL

%

SYR

ING

E FL

UID

REM

AIN

ING

IN m

ls

INFU

SIO

N R

ATE

ml/h

r

TIM

E R

EMA

ININ

G

RU

NN

ING

TO

TIM

E

SYM

PTO

MS

CO

NTR

OLL

ED

SIGNATURE

01/01/17 EXAMPLEMORPHINE 20mg

NADL abdo Y N Y 0800 33 8 0.41

ml/hr 19.5 hrs Y Y A Another

060010001400180022000200060010001400180022000200060010001400180022000200060010001400180022000200

Collated by Clinical Effectiveness Community Medication Stock Record

Appendix6Community Medication Stock Record

All controlled drugmedication must be

recordedSeparate sheet must be used for each

medication and strengthPatient Name Date of Birth NHS or Unique Identification Number

Medication Strength

Receipt ofMedication

Administration ofMedicationDate & Time Remaining

stockbalance

Number ofampoulesreceived

Totalstockbalance

Full Signature Date & Time TotalStockbalance

Number ofampoulesused

Remainingstockbalance

Full Signature

Collated by Clinical Effectiveness Prepare & deliver subcutaneous treatments using the McKinley T34 Syringe PumpVersion 4 (May 2020) Page 1 of 5

Appendix 7Prepare & deliver subcutaneous treatments using the T34 syringe pumpdevice 2nd and 3rd Editions.

Competency Framework Achieved Not Achieved AssessorInitials

1. Apply standard precautions for infection control andany other relevant health and safety measures

2. Accurately identify the patient and introduce yourselfand any colleagues present

3. Assess the patient fully, including fitness for theprocedure combined with review of the patient's notesand prescription to identify any special instructions (e.g.allergies), investigations or items for which you need toseek advice

4. Confirm the identity of the patient against theprescription authorisation chart and determine whetherthe prescription is clinically appropriate for the patientand medication compatible

5. Assess the patient's psychological and emotional stateand respond appropriately

6. Inform the patient and/or key person of the procedureand where appropriate, how to manage the syringepump or infusion device, the treatment and potentialreactions

7. Obtain informed consent for all interventions,accurately answering any questions that arise at anappropriate level and pace. Agree the appropriateinfusion site with the patient, position the patientappropriately and comfortably

8. Ensure that the area in which the medicine is to beprepared is as clean, uncluttered and free frominterruption and distraction as possible. Ideally,preparation should take place in an area dedicated tothis process.Prepare medication in accordance with T&SDFT InjectableMedicines For Registered Professionals


9. Prepare Equipment· Check that the device is clean, intact and has

relevant electronic test date visible· Check the device is the correct edition of the

T34 for the practice area· Correctly prepare the infusion equipment

10. Turn on device· Check that a syringe is not loaded, that the

barrel clamp arm is down on the device andinstall the correct battery

· Turn the device on and observe completion ofthe pre-programmed start up sequence (actuatormovement)· During pre-programming, check the LCD

display to confirm the default settings of thedevice

· On completion of the pre-programme sequence,checked the battery power available is sufficient torun the device for the prescribed duration

· For 3rd Edition T34 a new battery Must be used foreach syringe change due to its battery life of only24 hours

11. 2nd Edition T34Ensured syringe placement & detection:

· Visually align the 3 syringe sensors to syringe andused the FF/back keys to adjust

· Correctly load the syringe: ensured the syringeis placed in the 3 detection areas fully andobserved LCD screen to confirm correctplacement

· Check the device has correctly identified thesyringe brand and size and take appropriateaction if necessary.

12 2nd Edition T34Review programme, remove syringe, prime line,reload, resume programme and start infusion:

· Review the summary screen and checked theLCD screen for correct duration of infusion(volume, duration, rate)

· Remove syringe and primed line· Reload syringe as in 13. and observe

“resume/new programme” screen and press“Yes” to resume programme

· Observe and review infusion summary screen –noted that syringe volume and infusion durationhave changed

· Observe “start infusion” screen, check theadministration set is connected to the patientaccess port and the clamp released

· Observe the “running screen”, check greenlight on

CC


13. 3rd Edition T34Ensured syringe placement & detection:

· Load the syringe as in 11, but prime the linebefore loading for this edition of the T34

Review programme and start Infusion· Review the summary screen and check the

LCD screen for correct duration of infusion(volume, duration, rate)

· ‘Start Infusion’ displayed on screen, press ‘yes’to start

· Observe the “running screen”, check greenlight on


14.Monitoring:· Correctly accessed and explained the info keys

in relation to the current infusion· Single press to view volume infused and volume

to be infused· Double press to view battery status· Observed the screens reverting to the default

running screen· Activated/deactivated the keypad lock function· Demonstrated awareness/performed checks/or

action taken in relation to audible/visual alert:near end of infusion & low battery

· Demonstrated awareness/performed checks/oraction taken in relation to audible/visual alarms:occlusion, end of infusion, syringe displaced, pumppaused too long and end of battery

15.Close down:· Correctly closed down and dismantled the device

(assuming duration completed)· Checked device/tubing disconnected from

access device· Removed syringe from device and returned barrel

clamp to down position, turned the device off· Demonstrated safe removal of disposables and

all contaminated waste· Correctly removed the batteries ready for

storage· Cleaned and stored the device as per local

policy/manufacturer instructions

16. Recognise when you need help and/or advice andseek this from appropriate sources – understands limitsof own competence/knowledge

17. Advise the patient and/or key person on specificnecessary precautions related to the attached syringepump or infusion device and who to contact if problemsarise, provided written information

18. Record details of the procedure and treatment in thepatient's notes, medication administration chart and anyother relevant documentation ensuring team membersare aware of these details

19. Assess both the efficacy and effect on the patient ofthe medication using the patient's physical, psychologicaland emotional condition, their response to the treatmentand any reactions or allergies which may have becomeapparent, seeking advice from an appropriate teammember/specialist if required


ASSESSORS COMMENTS: Use this space to add any additional comments.Ensure that each comment is linked clearly to a numbered performance criterion.

Though not part of the assessment process the user must be aware of otherfeatures available, the prompts that can appear and action to be taken in certaincircumstances:

Feature: Purge operationThis option is not used within Torbay & South Devon NHS Foundation Trust ProviderServices

Prompt: Pump paused too longActivated after 2 minutes if the device remains paused. Pause can be continued bypressing the “Yes” key.Options available: repause, restart the infusion or turn the device off

Prompt: Resume/New programme screenIf the pump was stopped and turned off before the last programme reached “endprogramme”, the resume prompt screen will appear (e.g., if, during an infusion, thepump was powered off to change the battery). Press “No” to continue programming thenew regime. Press “Yes” to resume current programme.

Action To: Silence the alert/alarm noise before troubleshootingPress “Yes” key to silence the alert/alarm noise for 2 minutes (device is paused). Observescreen to indicate the reason for the alert/alarm

Collated by Clinical Effectiveness Safe Transfer of Care for Patients (T34 McKinley Device)Version 4 (May 2020) Page 1 of 2

Appendix 8

Safe Transfer of Care for Patients (T34 McKinley Device)

The T34 McKinley syringe pump device Editions 2 and 3 will be in use within someorganisations from 2020. The guidance set out below should be followed when patientsare transferred in or out of different organisations to ensure safe and effective treatmentcontinuity and minimize risks.

Transfer of patients with a T34 McKinley syringe pump from any care settingoutside of Torbay & South Devon NHS Foundation Trust.

· When a patient is transferred to a Torbay & South Devon NHS F o u n d a t i o nT rust setting from another organization with a T34 McKinley syringe pump, theSafe Transfer of Care for Patients with a Syringe Pump form (Appendix 7) mustbe requested, completed and forwarded to the receiving nursing team to facilitatesafe patient transfer between care settings.

· When a patient is transferred with a T34 syringe pump this must be changed to aT34 syringe pump of the Edition agreed for safe practice in the area where thepatient is to be cared in, within 24hours and arrangements made to return the T34device to the transferring organization/team.

Transfer of patients with a T34 McKinley syringe pump to any care setting outsideof Torbay & South Devon NHS Foundation Trust.

· When a patient is transferred from Torbay & South Devon NHS Foundation Trustto another organization, the Safe Transfer of Care for Patients with a SyringePump form should be completed by the transferring team/organization. Thiscould be by Email, fax or sent with the patient. A copy should be retained by thesending team

Collated by Clinical Effectiveness Safe Transfer of Care for Patients (T34 McKinley Device)Version 4 (May 2020) Page 2 of 2

Safe Transfer of Care for Patients with a Syringe Pump

Patient Name:

NHS Number:

Date of transfer

Transferred from

Tel:

Transferred to:

Tel:

Date Signature

Telephone referral to the area the patient is beingtransferred to providing the following information.

1) Type of syringe pump (2nd or 3rd edition T34)

2) The prescribed medication

3) The date and time the syringe pump is due to bechanged

4) 7 days supply of medication for the syringe pump ondischarge from inpatient settings.

5) A signed syringe pump prescription sheet including statdoses to be sent with the patient

6) Are the family aware of planned transfer/discharge

7) Written information on how to stop/disconnect thesyringe pump to be sent with patient. For T34 McKinleypumps; the pump lock box will be unlocked prior to transfer

Other information

Return of the syringe pump sent with patient on transfer

Model and asset number of syringe pump

Syringe pump to be returned to

* Name and signature of staff member returningthe syringe pump

* Date

* To be completed by person returning the syringe pump

Collated by Clinical Effectiveness G1719 - Linked to Patient Information Leaflet 25162 The McKinley T34 Syringe PumpVersion 4 (May 2020) Page 1 of 1

Appendix 9

Linked to Patient Information Leaflet;25162 – The McKinley T34 Syringe Pump, a guide for Patients and Carers

http://www.torbayandsouthdevon.nhs.uk/uploads/25162.pdf

Collated by Clinical Effectiveness SOP No 1 Use of the McKinley T34 Syring PumpVersion 4 (May 2020) Page 1 of 3

Appendix 10

Guidance outlining the procedure for obtaining and returning the CMEMcKinley T34 Syringe pump and accompanying consumables to NRS

FOR TORBAY AREA ONLY

Scope of the information

This document applies only for the use of the McKinley T34 syringe pump device andis applicable to Registered Nursing staff employed by Torbay & South Devon NHSFoundation Trust (TSDFT) within the community/home setting. (Currently this does notapply to TSDFT staff working in Southern Devon areas)

Competencies required

Registered Nurse employed by Torbay and South Devon NHS Foundation Trust(T&SDFT) within the community hospital/unit or community/home setting, evidence ofattendance at annual mandatory training and anaphylaxis training and successfulcompletion of a drug calculation test annually. Evidence of attendance at syringe pumpstraining session (yearly community staff, 2yrly acute hospital staff) Attendance atMedicines Policy Training for Registered Staff. Successful completion and evidence ofcompetency assessment.

Process for use

On receipt of a request for a syringe pump to be set up telephone NRS to initiate syringepump start up box. Only T&SDFT Staff who are listed on the NRSPrescriber list canplace requests for syringe pumps.

The first request can be made by telephone, ensure all correct patient details are available:- name, address, telephone number and confirmation that there will be a personavailable to accept the equipment (this does not have to be a member of the nursingteam)

· The start-up box will be delivered to the patient within 2 hours of receipt of therequest.

· A N R S requisition request form must be completed and submitted within 24hours.

The start-up kit box will contain, along with the relevant consumables:

· 1 CME McKinley T34 Syringe pump 2nd Edition (this will not be in the resupplybox). NB Ensure the S/D is returned in the bag provided when it is no longer requiredfor the prescribed patient.


· 1 Slide sheet (this will not be in the resupply box). NB Ensure the slide sheetis returned with the box in the bag provided when it is no longer required for theprescribed patient.

· 2 polythene ‘dirty’ equipment bags labelled syringe pump and slide sheet fortheir return after use.

· Every box will contain 1 key. NB Ensure the key is not kept butreturned each time the box is requested to be picked up.

· Adhesive labels for the syringes to identify medication in use.· Patient information leaflet.· Ensure that the syringe pump and the slide sheet are only returned when none

of the equipment is required for the prescribed patient as they will not be in theresupply box.

· On the first visit to setup the syringe pump, record in the patient’s care record thedate and time the request was initiated and the time the equipment is delivered, ifunknown the approximate time

· Once the box is in use any equipment removed from the box and not used mustnot be returned to the box this will cause contamination of remaining stock. If thisoccurs the remaining consumables will become non-returnable and the Trust will becharged.

· The drugs for use with the pump must not be stored in the kit box.· If more stock is required for longer than 14 days contact NRS before or on the 12th

day making certain it is clear that a resupply box is required. The resupply boxwill contain everything as above with the exception of the syringe pump and slidesheet. There is no 2hour delivery agreement for this box 24 hour notice mustbe given.

· A NRS requisition form will need to be completed clearly marked “Resupply Box”.Each time a new box is delivered there will be 14days supply.

· Continue to follow this procedure until there is no longer a requirement for theequipment.

The start-up box or the resupply box will not contain the following:

Patient documentation this must be supplied by the nurse on the first visit and removedand stored in accordance with Trust policy when no longer required.

No sharps disposal box this will have to be taken by the visiting nurse and removed bythe visiting nurse when no longer required. No drugs will be available, arrangements forhow the medication is to be delivered and removed is the responsibility of the visiting nurse.

NB. If a syringe pump is required for long term use, that is longer than 49 days, it isvery important that NRS are notified of this as it will require a different rental system,e.g. for apomorphine use

Procedure for returning equipment

· When the syringe pump is no longer required, initially, a request via telephone toNRS for the collection of the kit box and syringe pump is acceptable.


· The verbal request must be followed up with the NRS collection request form within24hours the N R S premises therefore it is vital that the return of the pump isrequested as soon as it is no longer needed.

· Manager (NRS) will monitor their information and any pump that is outstanding formore than 3days with no request for further resupply boxes will contact the relevantZone Lead to notify and confirm that the situation is acceptable.

· Manager (NRS) will provide the Zone Leads with a monthly print out of syringe pumpusage.

· Document in the patient care record the date & time the request for collection w a sm a d e a n d w h e n a l l t h e e q u i p m e n t w a s a c t u a l l y collected. This isimportant to ensure all charges incurred are correct.

· If it is not possible to collect the equipment from the patient’s residence then ensurean appropriate alternative address is agreed to prevent any hold ups in thecollection process

Syringe pumps being sent out of area:

NB. Please do not allow the syringe pump to leave the area without notifying NRS as theequipment is their property it does not belong to Torbay & South Devon and permissionmust be obtained from them.

Please remember that the equipment is being rented and therefore charging for this willcontinue until the syringe pump is returned.

If permission is given for the syringe pump to leave the area please ensure all relevantpatient details are obtained along with the District Nurse Team managing the patientcare.

Before returning the syringe pump to NRS the syringe, cannula and line and any drugsremaining in this equipment must be removed in line with TSDFT policy.

Do not return any drugs with the syringe pump or in the consumables box they must bedisposed of in accordance with TSDFT policy.

For returning ‘dirty’ equipment please ensure the labelled polythene bags provided areused for this purpose; do not replace in the consumables box.

Stock supplied in the box is for use with the named patient only and should not be removedfor use with another patient.

Standard operating procedure for use of the McKinley T34 Syringe Pump (section 11) -additionally the device must be returned to NRS. An incident report form must becompleted, as per procedure, and a copy of this should also be sent to NRS

- 1form to the Incident Reporting Team,- 1 form to NRS

Collated by Clinical Effectiveness SOP No 1 Use of the McKinley T34 Syring PumpVersion 4 (May 2020)

Appendix 11

Scope of this SOP – This document applies only for the use of the McKinley T34syringe pump device and is applicable to Registered Nursing staff.

Competencies required –Registered Nurse employed by Torbay and South DevonNHS Foundation Trust (T&SDFT) within the community hospital/unit or community/homesetting, evidence of attendance at annual mandatory training and anaphylaxis trainingand successful completion of a drug calculation test annually. Evidence of attendance atsyringe pumps training session (yearly community staff, 2yrly acute hospital staff)Attendance at Medicines Policy Training for Registered Staff. Successful completionand evidence of competency assessment.

Managers/matrons & team leaders should ensure that relevant training takes place atinduction and ongoing maintenance of competency records are maintained of staff thatare trained and competent to use the pump.

Patients covered – Adult clients (aged 16yrs and over) within the acute hospitalcommunity hospital unit or community setting.

Procedure – Prior to commencing a syringe pump a full assessment of the patient andclinical needs must be made and the indication for the use of the syringe pump should beclearly and accurately documented in the patient’s records. The decision to commence asyringe pump must be agreed with the prescriber, nurse on duty and the patient and/orcarer.

Document Type: Standard Operating ProcedureReferenceNumber : 1719

VersionNumber: 2

NextReview Date: February 2022

Title: McKinley T34 syringe Pump Device, Administration ofmedicine using

Document Author: Consultant in Palliative Care

Applicability: All patients and staff as indicated


1. Preparation – Equipment Required:

For Torbay areasFor Community staff the device and 14 days supply of consumables should be obtainedby telephone with NRS stores and request of a ‘start up box’ made. This will then bedelivered directly to the patient’s home address within 2 hours of request. A NRSrequisition form must be forwarded to NRS within 24hrs.A further 14 days supply of consumables should be made by requesting a ‘resupplybox’ and forwarding the appropriate requisition form to NRS This requisition needs tobe made at least 48hours before new stock is required. (NB. A ‘resupply box’ will not bedelivered within 2 hours). Regular checks of stock levels must be made to ensurerequisition and delivery of ‘resupply’ box can be made in a timely manner.Nurse required to supply: Sharps container, Drug additive labels,prescription/authorisation sheet, all documentation, and all prescribed medications

Provision of device between 9pm and 8am:For a request to commence a syringe pump between these hours the night communitynursing service will supply and set up the device. The day service will be informed andwill need to contact NRS and follow procedure for request of a ‘start up box’Refer to Syringe Pump Policy Appendix 9 - Torbay Area Procedure for obtaining &returning box

· McKinley T34 syringe pump device and lock box – check that the device is inworking order and has been serviced within the last 12 months to promote patientsafety (Medical Devices Agency (MDA) 2003; National Patient Safety Agency(NPSA) 2004)

· Ensure the edition of the T34 is correct for the care delivery area. Communitysetting, including community hospitals 2nd Edition, Torbay Hospital 3rd Edition

· 9V battery

· Saflo Infusion cannula set and a 100cm infusion line which allows patient greaterfreedom of movement.

· Luer- Lok syringe of suitable size – to prevent leakages or accidental disconnectionluer slip syringes should not be used

· Drugs and diluent as prescribed

· Blunt fill – filter needle to draw up drug from glass ampoules preventingcontamination of drug

· Drug additive label

· A legible patient’s prescription chart and medication administration record· Sharps bin


2. Obtaining Consent - Explain and discuss the procedure with the patient in order toensure he/she understands and is able to give informed consent (NMC 2008). Whereinformed consent has not been obtained from the client in either setting, the nurse mustbe able to demonstrate that a multi-disciplinary assessment has been made including anassessment of capacity. Appropriate documentation must be completed to demonstratethat any decision to proceed has been made in the best interests of the client. (MentalCapacity Act 2005 section1(5)

3. Calculating the rate of infusion – The T34 McKinley device is programmed inmillilitres per hour thereby reducing the opportunity for user error. The device has theoption for fixed (LOCK ON) or variable (LOCK OFF) infusion. At this time all TCTMcKinley devices will be programmed for use with LOCK ON infusions only, deliveringinfusions over a 24 hour period.

3.1 VARIANCE

4. Infection Control - procedure will be carried out in accordance with local infectioncontrol protocols and should include hand washing at intervals throughout the settingup process i.e. at the beginning, before drawing up, before insertion of the infusiondevice and at the end of the process, to minimize the risk of infection. The deviceshould be cleaned after each patient using a disposable cloth, dampened with milddetergent. The syringe pump device MUST NOT be immersed in water at any time.For Torbay areas - In the Community setting no items should be replaced orinserted into the start up or resupply box to avoid contamination.

TSDFT has 2nd and 3rd Edition T34 Syringe pumps. They have different methods toset up an infusion and different battery life, therefore they will be supplied and usedin defined areas to prevent confusion and incorrect use. T34 2nd edition will be usedin the community, home and hospital setting and 3rd edition in Torbay Hospital.

Follow this link to view video’s of the differences between the editions and how toset up the 3rd editionhttps://www.bd.com/en-uk/products/infusion/infusion-devices/cme-ambulatory-infusion-systems/t-series-syringe-pumps/t34-ambulatory-syringe-pump-3rd-edition

Video instructions for the use of the 2nd and 3rd Edition are available on the HIVE‘T34 Syringe Pump (2nd and 3rd Editions)’The Safe Transfer of Care Guidelines (syringe pump policy appendix 7) should be usedto support the transfer of patients across organisations ensuring safe and effectivetreatment continuity.

https://www.bd.com/en-uk/products/infusion/infusion-devices/cme-ambulatory-infusion-systems/t-series-syringe-pumps/t34-ambulatory-syringe-pump-3rd-edition


5. Drawing up the drugs – To protect the patient from harm before administering anyprescribed drug, check against the medication administration record that it is due andhas not already been given (NPSA 2007). Consult the patient’s prescription chart toensure the patient is given the correct drug in the prescribed dose by the correct routeand ascertain the following:

o Drug

o Dose

o Date & time of administration

o Route and method of administration

o Diluent as appropriate

o Validity of prescription, legibility and Doctors signature

Where controlled drugs are in use the receiving, checking and recording must be inaccordance with national and local policies and operating procedures. The AccountableOfficer is responsible for ensuring the safe and effective use and management ofcontrolled drugs within the organization (DH 2006) and should be informed of anyincidents relating to the use of controlled drugs and a copy of the incident reportprovided.

Within the community hospital/unit the setting up of a syringe pump should be checkedand a second signatory obtained which should be another registered health professionalor student nurse in accordance with T&SDFT policy. In the interests of patient carewhere this is not possible a second suitable person who has been assessed ascompetent may sign. It is good practice that the second signatory witnesses the wholeadministration process.Within the community/home setting checking and obtaining a second signatory shouldbe based on local risk assessment and following local policies.

A prescription/ prescribers authorisation can be used for up to 72hours from hospitaldischarge where the patient’s symptoms remain stable.

Calculate and check dosages of drugs, check the name, strength and volume ofsubcutaneous drug(s) against the prescription chart. Check the expiry date of thedrug(s) to prevent an ineffective or toxic compound being given and that the packagingof all drugs and equipment is intact to ensure that no contamination has occurred (NPSA2007).Where more than one drug is to be drawn up, each should be measured individuallyagainst syringe markings. Refer to Injectable Medicines Policy for RegisteredProfessionals.Check the identity and amount of drug to be prepared and in order to ensure safe andeffective administration of the drug consider the following:


a) Compatibility of the drugs and compatibility with the diluentb) Stability of the mixture over the prescribed timec) Any special directions for dilutiond) Sensitivity to external factorse) Any anticipated allergic reactionIf any doubts exist about the listed points the practitioner should consult thePrescriber or pharmacist before proceeding.Using the appropriate sized luer-lok syringe (10ml, 20ml, 30ml) and blunt tip needledraw up the medications and diluent. NB. A 50ml luer lok syringe can be used withthe device however the lockable case cannot be used with a 50ml syringe. Themaximum volume of fluid that can be drawn up is 34ml.It is considered best practice to make the solution as dilute as possible to reducethe likelihood of drug incompatibility and minimise site irritation. Therefore usediluent to draw fluid up to:

· 10ml in a 10ml syringe· 17ml in a 20ml syringe· 22ml in a 30ml syringe

For general principles of procedure for drawing up drugs refer to The RoyalMarsden Hospital Manual of Clinical Nursing Procedures (2008) Seventh Edition,chapter 11. p 203 – 251.Inspect the fluid for discoloration, haziness or crystalline matter in order to detectany incompatibility or degradation and to prevent any toxic or foreign matter beinginfused into the patient (NPSA 2007). If this occurs discard and re-evaluate drugcompatibility.Complete the drug additive label fully and adhere it to the syringe takingcare to avoid covering the syringe markings.

6. Setting up the McKinley T34 syringe pump –6.1 Setting up an infusion for the first time when new infusion device and infusion

lines are required:· Check that a syringe is not loaded and that the barrel clamp arm is down on

the device· Install a 9V battery· Press and hold the ON/OFF button to turn the device on and observe the

completion of the pre-programmed start up sequence (actuator movement).During pre-programming check the LCD display to confirm the default settingsof the device.

· Press the info button to observe the battery power available. This must be atleast 35% for community use of 2nd Edition T34. Normal battery use is 3-4days but will depend on the number of times the display feature buttons areaccessed.


· Where the 3rd Edition T34 is in use a new battery must be inserted withevery syringe change as normal battery use is 24 hours

· Allow pre-loading to complete, the actuator will always return to the presetposition of the previous infusion.

For 2nd Edition T34· Visually align the 3 syringe sensors to the syringe and use the FF/back keys to

adjust as necessary. Lift the barrel clamp and load the syringe with the flangefacing downwards, replace the barrel clamp. Observe the LCD screen andconfirm correct placement.

· Check that the device has correctly identified the syringe brand and size,confirm by pressing YES or use the up/down arrows to select as appropriate.

· Check that the LCD screen displays correct duration and volume of infusion,confirm by pressing YES.

· DO NOT PRIME THE LINE AT THIS STAGE.

Risk Management: Select “Load and Prime” at all times with 2nd Edition T34.Under no circumstances should staff setting up or changing a 2nd Edition T34syringe pump adopt the “prime and load”system as this could result in underdosing.

· Lift and turn the barrel clamp arm to remove the prepared syringe from thepump, replace the barrel clamp.

· Connect the cannula to the luer lok end of the infusion line, connect theinfusion line to the prepared luer lok syringe

· Gently prime the infusion line and cannula· Visually align the 3 syringe sensors to the syringe and use the FF/back keys to

adjust as necessary. Lift the barrel clamp and load the syringe with the flangefacing downwards, replace the barrel clamp. Observe the LCD screen andconfirm correct placement.


· The screen will then display ‘press YES to resume, NO for new syringe’ PressYES to resume the same programme.

· Check LCD screen for correct duration and volume of infusion. Note thevolume and duration will be different due to priming the line however therate will be the same.

For 3RD Edition T34· Gently prime the infusion line· Visually align the 3 syringe sensors to the syringe and use the FF/back keys

to adjust as necessary. Lift the barrel clamp and load the syringe with theflange facing downwards, replace the barrel clamp. Observe the LCD screenand confirm correct placement.


· The screen will then display ‘Start Infusion’ press yes to commence


For Both Editions of T34· Insert sub-cutaneous cannula using manufactures guidance· Skin sites for insertion of cannula should be rotated regularly to maintain skin

integrity and minimise discomfort. For general principles of procedure formonitoring site and frequency of cannula change refer to The Royal MarsdenHospital Manual of Clinical Nursing Procedures (2008) Seventh Edition.

· Press YES to confirm and YES to start the infusion, ensure ‘pump delivering’ isdisplayed on the screen. The green light will flash intermittently.

· Activate the keypad lock by pressing and holding the ‘INFO’ key until the screendisplays a progress bar moving from left to right. Hold the key until the bar hasmoved completely across the screen and a beep is heard to confirm keypad islocked.

· To De-activate the keypad lock press and holding the ‘INFO’ key until thescreen displays a progress bar moving from right to left. Hold the key until the barhas moved completely across the screen and a beep is heard to confirm keypadlock is de-activated.

· Place the syringe pump in the lock box and lock in place. Place the key in asecure place – in the community setting the key must remain with the device boxunless a documented risk assessment indicates otherwise.

6.2. Setting up a subsequent infusion when the infusion line and cannula areintact:

· Press stop to discontinue the existing infusion, lift the barrel clamp and remove theexisting syringe from the device, replace the barrel clamp.

· Visually align the 3 syringe sensors to the new prepared syringe and use the FF/Backkeys to adjust as necessary.

· Lift the barrel clamp and load the syringe, replace the barrel clamp and observe theLCD screen and confirm correct placement.

· Check that the device has correctly identified the syringe brand and size, confirm bypressing YES or use the up/down arrows to select as appropriate.

· 2nd edition only - The LCD screen will display ‘resume infusion or new syringe’, pressNO for new syringe.

· Check that the LCD screen displays correct duration and volume of infusion,confirm by pressing YES.

· Press the info button to observe the battery power available. This must be at least35% for community use. Normal battery use is 3-4 days but will depend on thenumber of times the display feature buttons are accessed. For 3rd Edition a newbattery must be used with each syringe change as the battery life is 24hours.

· Remove the existing empty syringe from the infusion line and dispose inaccordance with policy.

· Attach the new filled syringe; press YES to start the infusion.· Ensure ‘pump delivering’ is displayed on the screen. The green light will flash

intermittently.· Activate the keypad lock by pressing and holding the ‘INFO’ key until the screen

displays a progress bar moving from left to right. Hold the key until the bar has movedcompletely across the screen and a beep is heard to confirm keypad is locked.


· To De-activate the keypad lock press and holding the ‘INFO’ key until the screendisplays a progress bar moving from right to left. Hold the key until the bar has movedcompletely across the screen and a beep is heard to confirm keypad lock is de-activated.

7. Complete all documentation – to comply with national and local policy ‘Medicinespolicy for Registered Professionals C107’ and to avoid confusion or errors amongstaff. This must include recording the following

· Infusion device serial number and date of calibration/test

· Date, time, start volume and infusion rate setting

· Drug dose, diluent, batch number(s), expiry date(s)

· Route and method of administration

· Name and signature of nurse(s)

· Frequency of infusion site/patient checks· Infusion device checks should include checking and recording the date, time, rate

and volume remaining and that the device is working. Subcutaneous site should bechecked for pain, discomfort, swelling, and induration, erythema, leaking orbleeding.

8 Discard waste appropriately – using designated receptacle for sharps to preventinjury. Disposal of drugs including controlled drugs, must be in accordance withnational and local policies (Waste Management Policy) and recorded in careplan/syringe driver administration chart.

9. Patient/carer information – The patient and/or carer must have information aboutcaring for the individual with a syringe pump and know how and when it is appropriateto contact a Registered Nurse or Medical Practitioner. Provision of the PatientInformation Leaflet (syringe driver policy appendix 8). Ask the patient to report anycomplaints of pain or tenderness at the infusion site and if they experience any changein their symptoms.

9.1 VARIANCE Within the care home setting a copy of the medicinesadministration record must be left as part of the care home clients records at the endof the District and Community Nursing episode of care in accordance withCommission for Social Care Inspection (CSCI) regulations.


10. Cleansing, decontamination and maintenance of the device

· Cleansing of the syringe pump and plastic case should be carried out inaccordance with the makers instructions, 70% alcohol wipe forthe pump and general detergent wipe for the plastic case

· If any additional cleansing is needed, e.g. the treads of the screws the actuatormoves along, contact Medical Electronics for advice.

· In the event that the pump is accidentally dropped in water, or damaged in any wayit must be withdrawn from use immediately and sent to Medical ElectronicsDepartment for maintenance and checks. Torbay Areas: the device must bereturned to NRS with a copy of the incident report.

· All syringe pumps are serviced regularly according to a defined schedule and atleast annually, whether used or not. Medical Electronics department will notify theidentified user/team of the service date. Torbay Areas: responsibility for annualservicing lies with NRS

11. Incident Reporting Incidents may involve patients/members of staff/visitors/contractors and/or equipment/consumable items/defective medicines.

All staff are expected to:

· Record and report incidents or near misses.· Notify incidents to the accountable manager or senior clinician.· Co-operate in any investigation process.· Learn from incidents to prevent other similar incidents.· Share this learning across the organization.

Managing and Reporting Incidents· Take immediate action to prevent further harm – syringe pump device must be

removed from use immediately and an alternative device used to ensurecontinuation of treatment.

· When the incident involves a patient, ensure appropriate medical assessment andtreatment - details of the incident should also be recorded in the medical/nursingrecords this should include the date, brief summary of the incident, who treatedthe patient, monitoring of the patient and the outcome.

· Report the incident to the person in charge, if the incident occurs out of hours thiswill be the on call manager.

12. Monitoring – Individual patient assessment should determine the need to changethe cannula, indications may include: signs of redness, leakage, hardness, swelling,discomfort or blood in the tubing. When recited it is advised to place new cannula aminimum of 3cm from the previous site.Assess the patient’s current status, effectiveness of symptom management and anyside effects of medication


Observe, check and document;· insertion site for signs of redness, leakage, hardness, swelling, discomfort or

blood in the tubing.· syringe and infusion set for kinks in the tubing, leakage, precipitation or

discoloration of medication.· LED light flashing intermittently· battery level (%)· syringe fluid remaining in mls· infusion rate· time remaining· running to time· symptoms controlled

Within the acute or community hospital: 4 hourly checks should be made or morefrequently if clinical need indicated. Checks should be clearly documented using the T34syringe pump observation chart (Appendix 5) or community hospital PMAR (Appendix 4).

Within the community/home setting: the syringe pump and cannula site should beobserved and checked at each visit and this should be a minimum of 24 hrly.Checks should be clearly documented in the patient care record.

13. Closing down and removing the syringe pump – A syringe pump and infusion setshould only be removed by an appropriately trained practitioner. A syringe that is notempty must NEVER be taken off the syringe pump while connected to the patient.

13.1 Discontinuing a syringe pump when no longer required.

· When the infusion is complete and the syringe is empty the pump willstop automatically and the alarm will sound.

· If the infusion is to be stopped before the syringe is empty, it should bedisconnected at the syringe end from the patient for safety reasons before thesyringe is taken off the pump.

· If the syringe pump is no longer required for the patient, press the INFO buttonand record the date, time, volume infused and the volume remaining on thesyringe driver Prescription Medication Administration record (PMAR)subcutaneous route

· Press STOP to stop the infusion· Press OFF to turn off the syringe pump· Remove the battery from the syringe pump· Remove the cannula and cover the site with an appropriate dressing if required.· Dispose of and record any medication remaining in the syringe in accordance with

localMedicines Policy and Waste Management Policy.

· Dispose of all remaining waste in accordance with the local Waste ManagementPolicy.


13.2 Discontinuing a syringe pump when the patient dies while the pump is running.

· If there are doubts about the circumstances of the patient’s death the pump shouldbe left in place until the patient is seen by the Medical Practitioner.

· In an expected death situation the syringe pump and infusion set should beremoved by a Medical Practitioner or Registered Nurse who is appropriatelytrained and when verification of death has been undertaken in accordance withTSDFT Policy ‘Verification of an Expected Death by a Registered Professional’

· Press the INFO button and record the date, time, volume infused and the volumeremaining on the Prescription Medication Administration record (PMAR)subcutaneous route

· Press STOP to stop the infusion· Press OFF to turn off the syringe pump· Remove the battery from the syringe pump· Remove the cannula and cover the site with an appropriate dressing if required.· Dispose of and record any medication remaining in the syringe in accordance with

local· Medicines Policy and Waste Management Policy.· Dispose of all remaining waste in accordance with local Waste Management Policy.

14. Cleansing, Decontamination and Maintenance

Cleansing of the syringe pump and plastic case should be carried out inaccordance with the makers instructions, 70% alcohol wipe for the pumpand general detergent wipe for the plastic case If any additional cleansing isrequired the device should be bagged and a label applied detailing that additionalcleansing is required. Inpatient settings should contact the Medical Electronicsdepartment and complete a decontamination form


15. Problem solving

Problem Possible Cause ActionThe pump will not start or haspowered off

No batterypresentBattery installedincorrectlyBattery level isvery lowPump is faulty

Insert a batteryRealign terminalsInsert a new batteryService required

The infusion appears to berunning too quickly

Incorrect syringebrand confirmedduring set upPump faulty orincorrectlycalibrated

Check syringe brandused and if correct brandfound remove devicefrom use immediately andundertake followingactions:· Use alternative device

to ensurecontinuation ofpatient treatment

· Assess patientsymptoms andmonitor

· Inform manager,senior nurse, teamleader and Doctor ifrequired

· Complete incidentreport

Retrain user to preventrepeat – use competenceassessment (TCTSyringe Pump Policyappendix 3)Service calibrationrequired


Problem Possible Cause Action

The pump has stopped beforeemptying the syringe

Alarm state hasoccurred

Check the alarmcondition and resolve

AlarmsWhen an alarm is activated:· the infusion stops· an audible alarm sounds

Before trouble shootingor solving any alarmpress YES toacknowledge and silencethe alarmFollow the LCD screenmessage

· keypad LED turns to red· LCD screen displays a

text message andinstructions to helpidentify the cause

Near End Infusion nearlycomplete

This is an alert only – theinfusion does not stop

Low Battery Low Battery Prepare to change thebattery – this is an alertonly, the infusion does

not stop

Occlusion The infusion lineis trapped,kinked or

clamped at anypoint

When checked andsatisfied press YES to

restart the infusionIf the alarm repeats and

there is no sign ofocclusion/obstruction,

press ON/OFF power thepump off, resite the line

Syringe displaced Syringe notfitted correctly ordisplaced

On screen messageidentifies which sensor

to check


Problem Possible Cause Action

Pump paused too long Left in stop orprogramme mode

for 2 minuteswithout a key press

If pump has beenaccidentally stopped

press YES to restart orfinish the programming

Syringe empty End of programme Press ON/OFF to poweroff the pump

End battery Battery power is out Change battery now andrestart the infusion

Turn pump on, confirmsyringe and resume

infusion

For further recommended preventative measures and nursing actions refer to The RoyalMarsden Hospital Manual of Clinical Nursing Procedures (2008) Seventh Edition,chapter 11. p. 307-308.

13. Standards: The Registered Practitioner will ensure the use of the syringe driver isin line with Care Quality Commission Guidance Essential standards of quality andsafety March 2010.

Outcome 9: Safe Management of MedicinesThe registered person must protect service users against the risks associated with theunsafe use and management of medicines, by means of the making of appropriatearrangements for obtaining, recording, handling, using, safe keeping, dispensing, safeadministration and disposal of medicines used for the purposes of the regulated activity

Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations2010

Outcome 11: Safety, availability and suitability of equipment1: The registered person must make suitable arrangements to protect service users and

others who may be at risk from the use of unsafe equipment by ensuring that equipmentprovided for the purposes of the carrying on of a regulated activity is—(a) properly maintained and suitable for its purpose; and(b) used correctly.(c) The correct edition of the T34 for their practice area. 2nd Edition for community

based patients, to include community hospitals. 3rd Edition only to be used inthe acute bedded areas of Torbay Hospital.

2: The registered person must ensure that equipment is available in sufficient quantities inorder to ensure the safety of service users and meet their assessed needs.


3: Where equipment is provided to support service users in their day to day living, theregistered person must ensure that, as far as reasonably practicable, such equipmentpromotes the independence and comfort of service users.

4: For the purposes of this regulation—(a) “equipment” includes a medical device; and(b) “medical device” has the same meaning as in the Medical DevicesRegulations 2002.Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations2010

14. Monitoring: Torbay & South Devon NHS Foundation Trust, through the clinical governanceframework will ensure a process for monitoring compliance and effectiveness of thisdocument. The process will include reviewing incidents reported through the incidentreporting process and be part of the process relating to the maintenance of medicaldevices.

Individual practitioner monitoring through competency assessments, training records andreviewed as part of annual appraisal process.

Item % ExceptionsAll registered community staff required to useMcKinley syringe pump devices to haveknowledge of this SOP

100 Nil

How will monitoring be carried out? Competency assessments as outlined insyringedriver policyWhen will monitoring be carried out? Annually

Who will monitor compliance with theguideline?

Service leads managerially responsible fordelivering care

References:1. Medical Devices Agency (2003) Infusion Systems Device Bulletin. DB 9503.

Medical Devices2. Agency. London.3. Medicines and Healthcare Products Regulatory Agency (2006) Reporting

Adverse Incidents and disseminating medical device alerts. DB2006 (01).4. Medicines and Healthcare Products Regulatory Agency (2008) Proposal for

amendments to medicine legislation to allow mixing of medicines in palliativecare. MLX356.

5. Mental Capacity Act 2005: Deprivation of liberty safeguards - Code of Practice tosupplement the main Mental Capacity Act 2005 Code of Practice.

6. National Patient Safety Agency (2004) Safer Practice Notice 01: Infusion Devices.National Patient Safety Agency.

7. National Patient Safety Agency (2007) Promoting Safer use of Injectable Medicines.Alert no. 2007/20.

8. Nursing and Midwifery Council (2008) Standards for Medicines Management. NMC.London.

9. Pratt, RJ. Et al (2007) Epic 2: National evidence-based guidelines for preventinghealthcare associated infections in NHS hospitals in England. Journal of HospitalInfection, 65 (supply), s2-12

10. The Royal Marsden Hospital Manual of Clinical Nursing Procedures (2008) SeventhEdition.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085476

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085476


11. TSDFT Protocol for Anaphylaxis/Anaphylactic Shock (November 2006).12. TSDFT Infection Control Policy13. TSDFT Protocol for Verification of an Expected Death by a Registered Nurse14. TSDFT Injectable Medicines Policy for Registered Professionals and associated

standard operating procedures.

Collated by Clinical Effectiveness McKinley T34 Syringe Pump Device, administration of medicationVersion 4 (May 2020) Document Control Information

Document Control Information

This is a controlled document and should not be altered in any way without the expresspermission of the author or their representative.

Please note this document is only valid from the date approved below, and checks shouldbe made that it is the most up to date version available.

If printed, this document is only valid for the day of printing.

This guidance has been registered with the Trust. The interpretation and application ofguidance will remain the responsibility of the individual clinician. If in doubt contact a seniorcolleague or expert. Caution is advised when using clinical guidance after the review date,or outside of the Trust.

Have you identified any issues on the Rapid (E)quality ImpactAssessment. If so please detail on Rapid (E) QIA form. Yes ☐

Please selectYes No

Does this document have implications regarding the Care Act?If yes please state: ☐ ☐

Does this document have training implications?If yes please state: ☐ ☐

Ref No: 1719

Document title: McKinley T34 syringe Pump Device, Administration ofmedication using

Purpose of document:

To provide a consistent and evidence based framework forthe management of battery operated syringe pumps used byTorbay & South Devon NHS Foundation Trust (TSDFT) staff,minimizing hazards to clients and ensuring that all staffrequired to use them are able to do so effectively and safely.This policy covers the principles of management of theMcKinley syringe pump

Date of issue: 22 May 2020 Next review date: 22 May 2023Version: 4 Last review date:Author: Consultant in Palliative CareDirectorate: Organisation WideEquality Impact: The guidance contained in this document is intended to be

inclusive for all patients within the clinical group specified,regardless of age, disability, gender, gender identity, sexualorientation, race and ethnicity & religion or belief

Committee(s)approving thedocument:

Work Stream 1 Recovery Cell MeetingClinical Director of Pharmacy

Date approved: 22 May 2020Links or overlaps withother policies:

Collated by Clinical Effectiveness McKinley T34 Syringe Pump Device, administration of medicationVersion 4 (May 2020) Document Control Information

Does this document have financial implications?If yes please state: ☐ ☐

Is this document a direct replacement for another?If yes please state which documents are being replaced: ☐ ☐

Document Amendment History

DateVersion

no.Amendment

summary Ratified by:15 January 2016 1 New Consultant in Palliative Care

Clinical Director of PharmacyCare and Clinical Policies GroupMeeting

26 January 2017 2 Revised Clinical Director of PharmacyCare and Clinical Policies GroupChief NurseMedical Director

20 February 2018 2 Review dateextended from 2years to 3 years

10 May 2019 3 Revised Chief NurseMedical DirectorClinical Director of PharmacyCare and Clinical Policies GroupMeeting

22 May 2020 4 Revised Clinical Director of PharmacyWork Stream 1 Recovery Cell Meeting

Collated by Clinical Effectiveness McKinley T34 Syringe Pump Device, administration of medicationVersion 4 (May 2020) The Mental Capacity Act

The Mental Capacity Act 2005

The Mental Capacity Act provides a statutory framework for people who lack capacity tomake decisions for themselves, or who have capacity and want to make preparations for atime when they lack capacity in the future. It sets out who can take decisions, in whichsituations, and how they should go about this. It covers a wide range of decision makingfrom health and welfare decisions to finance and property decisions

Enshrined in the Mental Capacity Act is the principle that people must be assumed to havecapacity unless it is established that they do not. This is an important aspect of law that allhealth and social care practitioners must implement when proposing to undertake any actin connection with care and treatment that requires consent. In circumstances where thereis an element of doubt about a person’s ability to make a decision due to ‘an impairment ofor disturbance in the functioning of the mind or brain’ the practitioner must implement theMental Capacity Act.

The legal framework provided by the Mental Capacity Act 2005 is supported by a Code ofPractice, which provides guidance and information about how the Act works in practice.The Code of Practice has statutory force which means that health and social carepractitioners have a legal duty to have regard to it when working with or caring for adultswho may lack capacity to make decisions for themselves.

All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy,Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment,checklists and Independent Mental Capacity Advocate referral forms on iCare

http://icare/Operations/mental_capacity_act/Pages/default.aspx

Infection Control

All staff will have access to Infection Control Policies and comply with the standards withinthem in the work place. All staff will attend Infection Control Training annually as part of theirmandatory training programme.

“The Act is intended to assist and support people who maylack capacity and to discourage anyone who is involved incaring for someone who lacks capacity from being overlyrestrictive or controlling. It aims to balance an individual’sright to make decisions for themselves with their right to beprotected from harm if they lack the capacity to makedecisions to protect themselves”. (3)

http://icare/Operations/mental_capacity_act/Pages/default.aspx

Collated by Clinical Effectiveness McKinley T34 Syringe Pump Device, administration of medicationVersion 4 (May 2020) Quality Impact Assessment

Quality Impact Assessment (QIA)

Please selectWho may be affected by thisdocument? Patient / Service Users ☒ Visitors / Relatives ☒

General Public ☐Voluntary / Community

Groups ☐

Trade Unions ☐ GPs ☐

NHS Organisations ☐ Police ☐

Councils ☐ Carers ☐

Staff ☐Other Statutory

Agencies ☐

Others (please state):

Does this document require a service redesign, or substantial amendments to an existingprocess? ☐

If you answer yes to this question, please complete a full Quality Impact Assessment. No

Are there concerns that thedocument could adverselyimpact on people andaspects of the Trust underone of the nine strands ofdiversity?

Age ☐ Disability ☐

Gender re-assignment☐

Marriage and CivilPartnership ☐

Pregnancy and maternity ☐Race, including

nationality and ethnicity ☐

Religion or Belief ☐ Sex ☐

Sexual orientation ☐ No

If you answer yes to any of these strands, please complete a full Quality Impact Assessment.If applicable, what actionhas been taken to mitigateany concerns?

n/a

Who have you consultedwith in the creation of thisdocument?

Note - It may not be sufficientto just speak to other health &social care professionals.

Patients / Service Users ☐ Visitors / Relatives ☐

General Public ☐Voluntary / Community

Groups ☐

Trade Unions ☐ GPs ☐

NHS Organisations ☐ Police ☐

Councils ☐ Carers ☐

Staff ☐Other Statutory

Agencies ☐

Details (please state): Community staff

Collated by Clinical Effectiveness McKinley T34 Syringe Pump Device, administration of medicationVersion 4 (May 2020) Rapid (E)quality Impact ASsessment

Rapid Equality Impact Assessment (for use when writing policies and procedures)Policy Title (and number) 1719 - Policy for the

Administration ofMedication usingMcKinley T34 SyringePump Device

Version

Date

2

2/8/16

Policy Author Strategic Lead for Palliative & End of Life CareAn equality impact assessment (EIA) is a process designed to ensure that a policy, project or scheme doesnot discriminate or disadvantage people. EIAs also improve and promote equality. Consider the nature andextent of the impact, not the number of people affected.EQUALITY ANALYSIS: How well do people from protected groups fare in relation to the general population?PLEASE NOTE: Any ‘Yes’ answers may trigger a full EIA and must be referred to the equality leadsbelowIs it likely that the policy/procedure could treat people from protected groups less favorably than thegeneral population? (see below)Age Yes ☐ No☒ Disability Yes ☐ No☒ Sexual Orientation Yes ☐ No☒Race Yes ☐ No☒ Gender Yes ☐ No☒ Religion/Belief

(non)Yes ☐ No☒

GenderReassignment

Yes ☐ No☒ Pregnancy/ Maternity Yes ☐ No☒ Marriage/ CivilPartnership

Yes ☐ No☒

Is it likely that the policy/procedure could affect particular ‘Inclusion Health’ groups lessfavorably than the general population? (substance misuse; teenage mums; carers1;travellers2; homeless3; convictions; social isolation4; refugees)

Yes ☐ No☒

Please provide details for each protected group where you have indicated ‘Yes’.

VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusionIs inclusive language5 used throughout? Yes ☒ No☐Are the services outlined in the policy/procedure fully accessible6? Yes ☒ No☐Does the policy/procedure encourage individualised and person-centered care? Yes ☒ No☐Could there be an adverse impact on an individual’s independence or autonomy7? Yes ☐ No☒If ‘Yes’, how will you mitigate this risk to ensure fair and equal access?

EXTERNAL FACTORSIs the policy/procedure a result of national legislation which cannot be modified inany way?

Yes ☐ No☒

What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?)Review

Who was consulted when drafting this policy/procedure? What were therecommendations/suggestions?Community Staff / Medicines management

ACTION PLAN: Please list all actions identified to address any impactsAction Person

responsibleCompletion date

AUTHORISATION:

Collated by Clinical Effectiveness McKinley T34 Syringe Pump Device, administration of medicationVersion 4 (May 2020) Rapid (E)quality Impact Assessment

By signing below, I confirm that the named person responsible above is aware of the actions assigned tothemName of person completingthe form

Strategic Lead for Palliative & Endof Life Care

Signature

Validated by (line manager) Chief Nurse Signature

Collated by Clinical Effectiveness McKinley T34 Syringe Pump Device, administration of medicationVersion 4 (May 2020) Clinical and Non-Clinical Documents – Data Protection

Clinical and Non-Clinical Policies – Data Protection

Torbay and South Devon NHS Foundation Trust (TSDFT) has a commitment to ensurethat all policies and procedures developed act in accordance with all relevant dataprotection regulations and guidance. This policy has been designed with the EU GeneralData Protection Regulation (GDPR) and Data Protection Act 2018 (DPA 18) in mind, andtherefore provides the reader with assurance of effective information governance practice.

The UK data protection regime intends to strengthen and unify data protection for allpersons; consequently, the rights of individuals have changed. It is assured that theserights have been considered throughout the development of this policy. Furthermore, dataprotection legislation requires that the Trust is open and transparent with its personalidentifiable processing activities and this has a considerable effect on the way TSDFTholds, uses, and shares personal identifiable data.

Does this policy impact on how personal data is used, stored, shared or processed in yourdepartment? Yes ☐ No ☐

If yes has been ticked above it is assured that you must complete a data mapping exerciseand possibly a Data Protection Impact Assessment (DPIA). You can find more informationon our GDPR page on ICON (intranet)

For more information:· Contact the Data Access and Disclosure Office on [email protected],· See TSDFT’s Data Protection & Access Policy,· Visit our Data Protection site on the public internet.

https://icon.torbayandsouthdevon.nhs.uk/areas/gdpr/Pages/default.aspx

mailto:[email protected]

https://icon.torbayandsouthdevon.nhs.uk/areas/information-governance/Policies/TSDFT%20Policy%20Data%20Protection%20and%20Access.pdf

https://www.torbayandsouthdevon.nhs.uk/about-us/data-protection/