McKinley T34 Syringe Pump Management · Page 14 Completion of infusion; Stopping pump once infusion completed. What to do if the patient dies when syringe pump is running; Monitoring

Source: Palliative Care Team Status: Approved Page 1 of 35 Issue Date: August 2019 Review Date: July 2022 Doc Ref: PP(19)287

Trust Policy and Procedure Document ref. no: PP(19)287

McKinley T34 Syringe Pump Management

For use in: All clinical areas

For use by: Medical and Qualified Nursing Staff & Pharmacy

For use for: For use for delivery of medication via a continuous

subcutaneous infusion to palliative care patients

Document owner: Palliative Care Team

Status:

Purpose of the Policy The objectives of this policy are: To ensure the safe and effective management of a syringe pump To ensure the safe and effective administration of medications To prevent the occurrence of errors due to malfunction of syringe pump use Contents Page 2 Algorithm. Page 3 Introduction; Rationale for the use of a syringe pump. Page 4 Where to access WSFT written patient information on syringe Pump/discussion prior to commencing a syringe pump; Setting up the McKinley T34 syringe pump- Equipment required. Page 5 Converting oral morphine to subcutaneous morphine, oxycodone or diamorphine; Other common medications used in syringe pumps. Page 6 As required (PRN) medications; Preparing medications and diluents. Page 7 Setting up the McKinley T34 for use. Page 8-10 Insertion procedure for the primed cannula (Saf-T- Intima). Page 10-11 Commencing the infusion- Initial set up; Starting the infusion- Syringe renewal Only; Activation/deactivation of keypad lock. Page 12 Lock boxes; Medical Devices Alert (2016); Management of the infusion- Temporarily stopping and resuming the infusion. Page 13 How to stop the infusion and prime a new extension line/cannula; How to change the battery whilst syringe pump is running. Page 14 Completion of infusion; Stopping pump once infusion completed. What to do if the patient dies when syringe pump is running; Monitoring the infusion. Page 15-16 Monitor symptoms; Cleaning and decontamination of pump; Syringe Pump Problem solving. Page 17 Syringe pump alarm conditions. Page 17-19 Discharge from hospital with a syringe pump. Page 19-20 References Page 20-21 Development of the policy. Page 22-35 Appendices (Syringe pump prescription chart; Quick pump set up guide; Algorithm of the process for the use of the McKinley T34 subcutaneous infusion; Theoretical assessment questionnaire; Practical assessment McKinley T34 Competency Sheet); Discharge Pack Information Sheet.


Syringe Pump to be safely and effectively managed

Rationale for the use of a Syringe Pump (see no: 1)

Convert from oral administration to subcutaneous administration (see no: 3)

Ensure medication is prescribed Check calculations (see no: 3)

No

Administer loading dose (PRN) as prescribed (see no: 4)

Assemble equipment (see no: 2)

Prepare medication and diluents in syringe (see no: 5)

Ensure as required (PRN) medication is prescribed

(see no: 4)

Are the patient’s symptoms controlled?

Yes

McKinley T34 set up (see no: 6)

u u

Insert the cannula (see no: 7)

Commence infusion (see no: 8)

Monitor infusion and symptoms… use syringe pump prescription chart (see nos: 8, 9 &

Appendix 1)

Syringe Pump delivers medication safely and effectively


RECOMMENDATIONS AND PROCEDURES

Training is mandatory for all staff before using the McKinley T34 syringe pump (although, primarily, Registered Nurses are responsible for setting up infusion devices administering medications) . Please see your ward manager for details of training provided by your ward assessor or alternatively, by the hospital palliative care team.

INTRODUCTION

Following the ‘Rapid Response Report NPSA/2010/RRR019: Safer ambulatory syringe drivers’ (2010), the West Suffolk Hospital Foundation Trust (WSFT) changed to the McKinley T34 syringe pump in 2012. These syringe pumps are used by patients for symptom management and are set up to deliver the syringe contents by continuous subcutaneous infusion in millilitres (ml) per hour over a 24 hour (lock on) period. At the WSFT, the initial McKinley T34 training is mandatory, comprising a theoretical component which involves reading the McKinley T34 Syringe Pump Policy, which includes the set up and management of the device; and completing a questionnaire (see appendix 4a and 4b) prior to the practical component, which is the practical assessment provided by a ward syringe pump assessor or by the hospital Palliative Care Team. The Palliative Care Team offer four formal practical sessions per year (contact Team Secretary on ext 3776 to book).Alternatively, separate training can be provided on request. On successful completion of the competencies, both assessor and assesse will sign the McKinley T34 Mandatory Training Competency Statement. This must then be recorded on your individual Diagnostic & Therapeutic Equipment Competency Assessment held by your ward manager. Reassessment is based on individual needs and re-evaluated at your annual appraisal and Competency Assessment updated accordingly. As the Nursing and Midwifery Council (NMC 2015) state, “keep your knowledge and skills up to date, taking part in appropriate and regular learning and professional development activities that aim to maintain and develop you competence and improve your performance”.

1. RATIONALE FOR THE USE OF A SYRINGE PUMP:

The use of a syringe pump should be carefully considered and may be appropriate if a patient has required two or more as required PRN medications for symptom management . Syringe pumps are used for the administration of medication for patients with the following:-

Persistent nausea and vomiting

Swallowing difficulties

Severe weakness

Unconsciousness, dying

Advantages of a syringe pump:

Continuous relief of multiple symptoms via one route

Variations in plasma concentration levels are avoided

Avoids repeated injections

Maintains independence and mobility when appropriate

Loaded once a day only


Points to remember: Prior to starting the syringe pump, it’s use should be fully discussed with the patient (if possible) and family. Offer to give patient/family a syringe pump information leaflet (can be downloaded from: http://www.wsh.nhs.uk/CMS-Documents/Patient-leaflets/PalliativeCare/5584-5SyringePumps.pdf

Discussion to include:

Syringe pumps are not better at controlling symptoms than oral medication given regulary. They are used as an alternative route when the oral route is not suitable and/or there are problems with medication absorption via the oral route

They should only be used after a full assessment of the patient’s condition and suitability

They may be for short term use and patients’ may then revert to the oral route

They do not hasten a patient’s decline

Do not use mobile phones near the syinge pump

2. SETTING UP THE MCKINLEY T34 SYRINGE PUMP- EQUIPMENT REQUIRED: NB: The cost to replace one of these syringe pumps if lost/mislaid on the ward or not returned from discharge destination is £1300. It will be the responsibility of the ward from which the syringe pump was loaned to, to cover the cost of any lost pumps. The cost of replacing pumps lost to the community may be recovered from the ward from which patient

was discharged from. Please refer to WSFT policy PP(17) 024 (section 6).

McKinley T34 syringe pump and plastic lockbox. This is obtained through the Medical Equipment Library (MEL) between 08:00- 19:00 hours (Monday- Friday)and via Porters outside these hours.

Duracell 9 volt battery. A new battery is supplied when pump is obtained and will last for approximately 4-5 days depending on number of accesses to LCD screen. Replacement batteries are stocked on the wards

Lockbox and key (key to be kept on ward CD key ring)

20ml Braun Omnifix luer lock syringe

Blue Saf-T-Intima cannula (priming volume 0.2 ml)

Additional Saf-T-Intima for giving PRN doses

Use BMS Critical Care Ltd code no: 25-7150 extension set. This is 150cm long and uses a priming volume of 1.30mls. Alternatives with smaller priming volume are to be sourced following the discontinuation of the 100cm line BMS line previously used by WSFT.

Transparent adhesive dressing e.g. Tegaderm

Syringe Pump Prescription paper chart with authorized prescription

Prescribed medicines and diluent

1ml/2ml syringes and selection of needles to draw up prescribed individual small volumes of medications

Clean field for preparation, hands and gloves (refer to Aseptic Non-Touch Technique (ANTT) Policy PP (19) 266

http://www.wsh.nhs.uk/CMS-Documents/Patient-leaflets/PalliativeCare/5584-5SyringePumps.pdf

http://www.wsh.nhs.uk/CMS-Documents/Patient-leaflets/PalliativeCare/5584-5SyringePumps.pdf


2% chlorhexidine/70% alcohol wipe for skin preparation

Single use razor for excess hair removal

Sharps disposal container

Holster (if patient is mobile) can be requested through MEL or Palliative Care Team ( or patients can use their own shoulder bag)

3. ENSURE MEDICATION IS PRESCRIBED:

Most drugs are not licensed for use as a continuous subcutaneous infusion (see WSFT guideline for use of unlicensed medications- CG10048-6).

NB: It is WSFT policy that no more than three medications are added to one syringe. If additional medication is required, or there are incompatabilities with certain medication mixtures, then commencement of a second pump may be necessary. Or consider alternative route of administration, if feasible. Contact the Palliative Care Team and/or Pharmacy for advice. Outside office hours, advice can be sought from on call Palliative Medicine Consultant via switchboard, or on call hospital Pharmacist. To convert from oral morphine to a subcutaneous morphine, oxycodone or diamorphine infusion

Assess & add up the analgesic requirements of the patient for the previous 24 hour period: include as required (PRN) doses

- Divide the total oral morphine dose by 2 to give the 24 hour subcutaneous morphine dose

- Divide the total oral morphine dose by 4 to give the 24 hour subcutaneous oxycodone dose

- Divide the total oral morphine dose by 3 to give the 24 hour subcutaneous diamorphine dose

NB: For patients with poor renal function (eGFRgfr less than 15ml/min) subcutaneous Alfentanil is used. Please contact Palliative care Team and/or Pharmacy for advice.

Other medications used via subcutaneous route: Sedatives - Midazolam, levomepromazine, haloperidol Anti-emetics - Haloperidol, cyclizine, metoclopramide, levomepromazine, ondansetron

Antispasmodic/antisecretory - Hyoscine butylbromide (Buscopan) NB: Diazepam, chlorpromazine and prochlorperazine should not be given via the subcutaneous route. Contact WSFT Pharmacy Medicines Information to check for compatibility of medications, Palliative Care Team or visit www.pallcare.info (found via the ‘Education and Resource’ link on the End of Life Care section of the Pink Book). Click on ‘syringe drivers’ on left hand side then ‘search’ for compatibilities.

http://www.pallcare.info/


Points to remember:

Currently the syringe pump prescription remains a paper chart. A ‘Placeholder’ will need to be added by the prescriber to the ‘Requests/Care Plans’ section on the patient’s electronic record (eCare)

On commencing the syringe pump, medicine will take 4-6 hours to reach its maximum effect. If patient is symptomatic always give a stat dose as the pump is commenced

Accurate records must be kept and the infusion checklist is integral in the paper syringe pump prescription chart. Symptom control checks are to be recorded on Care Compass on eCare

4. AS REQUIRED (PRN) SUBCUTANEOUS MEDICATION:

A separate Saf-T-Intima cannula primed with 0.9% Normal Saline should be sited purely for administration of PRN subcutaneous medication (see section 7 for insertion procedure).

Morphine, Oxycodone, or Diamorphine -

A “breakthrough” as required (PRN) dose, for subcutaneous analgesia such as morphine, oxycodone,and diamorphine, is calculated as 1/6th of the 24 hour total dose and should be prescribed subcutaneously on the patient’s ecare drug chart. Seek advice from palliative care team team/Pharmacist for breakthrough analgesia for patients receiving Alfentanil via syringe pump.

Other Medications –

For breakthrough symptoms if medications in the pump are at the optimum level, prescribe an alternative medication, depending on the clinical need ie: in a patient treated for nausea with cyclizine 150mg in the syringe pump, prescribe haloperidol 0.5mg subcutaneously three times a day as required (if no contraindications). NB: The maximum volume for drug administration for PRN subcutaneous medication is 2ml (this includes 0.3ml flush). NB: If giving more than one PRN at the same time, flush between and after administering medications . If the total volume with flush is over 2mls, a second Saf-T- Intima PRN should be considered, or administer one of the medications via subcutaneous injection.

5. PREPARE MEDICATION & DILUENTS:

Diluents -

Use water for injection (WSFT uses as standard) as a diluent except when using:

- ketamine - octreotide

- ondansetron

when 0.9% Normal saline should be used (or if there are actual or potential problems with water for injection, discuss with pharmacy). NB: Always use water for injection as diluent with cyclizine in a syringe pump


Draw up prescribed medication into 20ml Braun Omnifix luer lock syringe and then add diluent to make a total volume of 17mls

Draw up a little air into syringe, invert it gently several times to mix and then dispel the air. Take care not to expel any of the medication

Contact the Palliative Care Team or Pharmacy if the volume of drug(s) is greater than 17mls or does not allow room for the diluent.

Complete medication additives label as per drug administration policy and attach label to the syringe

Ensure the label does not interfere with the mechanism of the infusion device, ie, where there is contact with the barrel clamp arm. The syringe scale must be visible for monitoring of the infusion

6. SETTING UP THE McKINLEY T34 SYRINGE PUMP FOR USE:

The McKinley T34 syringe pump is calibrated in ml per hour. Staff must check that the display shows T34 followed by ID: WSH- asset number when switched on.

a) Initial set up:

Connect the Saf-T-Intima to the extension line and then the line securely to the filled luer lock syringe

Then gently depress the syringe plunger to manually prime the line and Saf-T-Intima

b) Pre-loading procedure:

Install the battery. Switch on device ensuring that the barrel arm clamp is in the down position. The LCD display will read ‘PRE-LOADING’ and the actuator will start to


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

Check battery life by pressing ‘INFO’ key once and then press ‘YES’ to confirm. Discard the battery if there is less than 30% life remaining at the start of the infusion. The maximum battery life starting at 100% is 5 days, depending on frequency of access to LCD screen

NB: During Pre-Loading the actuator always returns to the start position of the last infusion programmed. Do not interrupt this process. c) Fitting the syringe to the syringe pump:

Align the filled syringe to the pump so that the collar sits above the central rest. The syringe collar should be vertical. Ensure that the scale on the syringe barrel is facing upwards so that it can be easily read

If the actuator is not in the correct position to accommodate the syringe plunger use the ‘FF’ or ‘BACK’ buttons on the keypad to move the actuator

NB: Forward movement of the actuator is set up to move in pulses and requires repeated presses of the ‘FF’ key. Backwards movement is not restricted.

Once the syringe is correctly aligned, fit it into position and lower the barrel clamp arm to secure syringe barrel to pump

The syringe graphic on the screen ceases to flash when the syringe is correctly seated at all 3 points

The syringe size and brand option, 20ml Braun Omnifix, will then be displayed on the screen. Confirm that the syringe size and brand match the screen message. Press ‘YES’ to confirm.

NB: There are three position sensors to ensure correct syringe placement in the device. Plunger sensor, collar sensor and barrel clamp. The device will not infuse if the syringe is not correctly loaded.

7. INSERTING THE PRIMED CANNULA:

Use the general non-touch technique procedure to prepare hands, tray and equipment needed, following the ANTT principles of 'peripheral venepuncture/phlebotomy’ and ‘cannulation’ process for Saf-T-Intima insertion (Please refer to WSFT Aseptic Non-Touch Technique (ANTT) Policy PP(19)266). Administration is via the blue SAF-T-INTIMA cannula. Do not use a metal butterfly needle. Suitable sites for insertion include:

Anterior aspect of upper arm (unless turning patient frequently or cannot be avoided)


Anterior aspect of thigh

Anterior chest wall (with caution for cachectic patients)

Anterior abdominal wall

Scapula region (recommended for agitated patients only if assessed to be of benefit)

But :

Avoid areas of ascites, oedema, lymphoedema or damaged skin

Avoid upper arms if patient is to be turned frequently

And:

Use area with the most flesh for patients who are emaciated

Ensure skin is clean. Use a 2% chlorhexidine/70% alcohol wipe for skin preparation (Wash area with soap and water if visibly soiled prior to using alcohol wipe if needed

Remove excess hair if necessary, using single use razor

Insertion procedure –

Prime PRN SC cannula with 0.9% Normal Saline. (Remember for SC cannula for syringe pump infusion, prime cannula (and the extension line, if new set up) from the syringe with the syringe pump prescription’s prepared medication

Remove the sheath from the cannula

Ensure the bevel is uppermost (if not twist the white cannister until the bevel is in the correct position)

The pebble side of the cannula wings should lie on the patients skin, therefore grasp the pebbled side of wings between finger and thumb, pinching firmly

Approaching slowly at a very LOW angle insert cannula almost parallel to the skin. Advance the entire unit and release wings. After insertion it should be possible to feel the cannula under the skin, if not replace at a lower angle. If it is too deep it may prevent delivery of medication and pump will stop

Stabilise cannula wings, place a finger and thumb firmly on each wing to prevent movement of the s/c cannula

Grasp the white cannister, on the pebbled area only, and pull quickly and sharply in a straight continuous movement

The cannister will come off containing the needle which is safely secured in the cannister. Place in sharps box

The cannula and looped line should be secured with a semi-permeable transparent dressing to allow for observation of the site and to prevent cannula movement

Do NOT use the white clamp on the cannula, as these are only for use when cannula is used for intravenous delivery or for subcutaneous PRN medication for ‘breakthrough’ symptom control. The clamp can be removed at set up

Record site of cannula insertion on the paper syringe pump prescription chart check list


NB: It is generally agreed and supported in literature that a Saf-T-Intima and extension line used for a continuous syringe pump infusion can be changed weekly unless the patient reports discomfort or there are visible signs of inflammation or leakage at the site; or there is visible precipitation of medications in the syringe/line; or new medications in prescription.

8. COMMENCING THE INFUSION:

Explain procedure to patient. Check prescription and confirm identity of the patient.Check for any known allergies (see WSFT Policy for the use of medicines- PP (19) 200). a) Starting the infusion - INITIAL SET UP (following manual priming and siting of cannula): NB: The pump calculates and displays the deliverable volume, duration of infusion (24hrs) and rate of infusion (mls per hour) by way of the sensor in the barrel clamp arm and the syringe type and size pre-programmed in syringe pump by WSFT EBME. The rate will vary according to the volume in syringe. The display shows (for eg).

Volume 16.0ml Duration 24.00 Rate 0.66ml/h Confirm, Press YES

Press ‘YES’ to confirm the infusion parameters are correct

Pump screen prompts ‘Start Infusion?’ (the pump will alarm after every 2 minutes if no confirmation is given. Press ‘YES’ to stop alarm)

Check the line is connected to the pump and place pump in plastic lockbox and lock with universal key

Press ‘YES’ to confirm and commence infusion

Lock keypad lock (see c below)

b) Starting the infusion- SYRINGE RENEWAL ONLY: NB: Always fully turn off syringe pump by disabling the keypad lock and turning off between inserting new syringes to ensure pump recalibrates to a new 24 hour infusion.

Make up new syringe as described in step 5

Press ‘Yes’ to confirm the end of completed infusion

Unlock keypad lock (see c below) and switch off pump using the ‘ON/OFF’ button.

Unlock lockbox and remove pump from lockbox.

Remove spent syringe from pump (still connected to the extension line)

Switch pump on and ensure ‘PRE-LOADING’ sequence occurs

Check battery life by pressing ‘INFO’ key once and then press ‘YES’ to confirm

Load new syringe using ‘FF/BACK’ keys if required

Confirm syringe type and follow screen prompts


Disconnect spent syringe from extension line and connect newly filled syringe to extension line

Press ‘YES’ to confirm the infusion parameters are correct

Pump screen prompts ‘Start Infusion?’

Re-check the extension line is connected to the new syringe securely

Check the connection to the patient remains patent

Place syringe pump in the lockbox and lock

Press ‘YES’ to confirm and commence infusion

Lock keypad lock (see c below)

The syringe pump then commences a new 24 hour infusion period. NB: If the infusion is to be stopped (ie; prescription change) before the current syringe is empty it should be disconnected at the syringe end of the extension line for safety reasons before the syringe is taken off the pump. A syringe that is not empty must never be taken off the pump while connected to the patient due to the risk of siphonage.

When the pump is running the screen display shows :

Green LED indicator flashes every 32 seconds

It takes 4-6 hours for medicines to reach therapeutic blood plasma levels via a syringe pump. Therefore, a stat dose of PRN s.c medication as prescribed on the patient’s eCare drug chart, may be required when the syringe pump is set up if the patient has unrelieved symptoms

The syringe pump must be placed level with the infusion site as it is possible for the contents to siphon out

Do NOT place the syringe pump in an area where it may become too warm (eg, under the bedclothes). This may result in a change in the solution temperature, thereby altering a medication’s pH and therefore its efficacy

NB: If the infusion has not been started and a button has not been pressed for more than two minutes, an alarm will sound and the message ‘Pump Paused Too Long Confirm’. Press ‘YES’ will show the LCD display. To stop the alarm press ‘YES’ and continue programming the infusion c) Keypad lock: The McKinley T34 pump allows the user to lock the operation of the keypad during infusion. This function should be routinely used to prevent tampering of the device. To activate the Keypad lock:

With the pump infusing press and hold ‘INFO’ key until a display shows a “progress” bar moving from left to right. Hold the key until the bar has moved completely across the screen and a beep is heard to confirm the lock has been activated

NB: Although the keypad lock is on, the following buttons are still active: NO/STOP; YES/START; INFO. To de-activate the Keypad lock: (pump must be infusing):

Time Remaining 23:59 Rate 0.66ml/h

Pump Delivering


Repeat as for activating Keypad lock. The bar will now move from right (lock) to left (unlock) and a beep will be heard

d) Lock boxes: Every T34 will be supplied with a lockbox.

After starting the infusion, place the pump in the supplied lockbox

Universal key (each clinical area to keep a key on Controlled Drugs keyring). If the key is lost then contact the palliative care team on ext 3776 for replacement. Out of hours, as a temporary measure, please borrow the key from your nearest ward

NB: MEDICAL DEVICE ALERT issued by the Medicines and Healthcare Products Regulatory Agency (MHRA 2016) CME Medical recommend the need for protection of the Mckinley ambulatory syringe pumps when exposed to direct sunlight outside.This does not pertain to indoor use. Pumps can be placed in a shoulder bag or in the CME Medical disposible pouches provided via MEL or Palliative Care Team.

9. STOPPING THE INFUSION:

a) Temporarily stopping the infusion:

Press and hold INFO key to disable the keypad lock, then press ‘STOP’ . Next, press the ‘ON/OFF’ button

Do NOT remove syringe from pump

Document reason for stopping the infusion on syringe pump prescription chart

- Resuming the infusion:

Check the prescription, syringe label and patient details match

Reconnect line to the cannula and syringe on the pump if it has been disconnected

Press and hold ‘ON’ button until a beep is heard. The screen will request confirmation of the syringe size and brand

The Screen will display-

Press ‘YES’ to resume the previous program

The screen will display ‘Remaining volume, duration and rate of infusion’.Press ‘YES’ to confirm. Screen then displays ‘Start Infusion’. Press ‘YES’ to confirm

Activate keypad lock

NB: If ‘NO’ is pressed, the pump interprets this as a completely new 24 hour period and the remaining contents in the syringe will be delivered over the next 24 hours from confirming ‘Start Infusion’. If ‘NO’ is pressed in error, the syringe contents must be discarded and a new syringe prepared and set-up as otherwise the patient will not receive the prescribed dose.

Press YES to Resume,

NO for New Program


b) How to stop the infusion and prime a new extension line and/ or cannula after the infusion has started:

Press ‘STOP’ to pause the infusion

Deactivate the keypad lock but do NOT switch the pump off

Disconnect the existing extension line from the syringe. Remove line from the patient or, if cannula needs replacing, remove cannula along with attached extension line

Remove the syringe from the pump. Attach and manually prime a new line (and new cannula, if applicable)

Reposition the actuator and place the syringe in the pump

Confirm the size and make of the syringe

Attach the new extension line to the existing cannula/site new cannula

Press ‘YES’ to resume the previous programme

The screen will display- the remaining volume, duration and rate of infusion. Press ‘YES’ to confirm. Screen then displays ‘Start Infusion’. Press ‘YES’ to confirm

Activate the keypad lock

The time remaining for the infusion will decrease to compensate for the solution that was used to prime the replacement line. The mls per hour rate will remain the same.

NB: Record remaining volume (mls) on syringe pump prescription chart.

c) How to change the battery when an infusion pump is running:

With the infusion still running remove the old battery from the pump and replace with a new one

Switch the pump back on using the ‘ON/OFF’ button

Confirm the size and make of the syringe

Press ‘YES’ to resume the infusion

The screen will display: Remaining volume, duration and rate of infusion’.Press ‘YES’ to confirm. Screen then displays ‘Start Infusion’. Press ‘YES’ to confirm

NB: MEDICAL DEVICE ALERT issued by the Medicines and Healthcare Products Regulatory Agency (MHRA 2018) for all T34 Ambulatory Syringe Pumps. Variance in 9V battery size can cause problems with connections in the battery housing causing risk of unintended pump shutdown and delay in treatment. Before using the pump, check that the battery has adequate connection within the battery housing. Also check the connections after each battery change. Following this alert, the WSFT supplies Duracell 9V batteries for the syringe pump.d) Completion of current infusion ( and renewal of syringe/ or change in prescription):

When the infusion is near completion, a warning will be shown on the LCD display 15 minutes before the end of the infusion. When the infusion is complete and the syringe empty, the pump will automatically stop and an alarm will sound.

Press ‘YES’ to confirm end of infusion. Unlock keypad lock and switch off pump using the ‘ON/OFF’ button. Then follow instructions in 5,6,7, 8a or b (as applicable)

NB: It is not necessary to change the cannula and line if only the dose of medication is being changed.


e) Stopping completed infusion and removing the syringe pump:

If the syringe pump is no longer required for the patient, press ‘YES’ to confirm the end of the infusion. Disable the keypad lock and press and hold the ‘ON/OFF’ button to switch off the pump.

NB: If the infusion is stopped before the syringe is empty, the line must be disconnected from the syringe on the pump to prevent siphonage of medication to the patient.

f) What to do if the patient dies when syringe pump is running:

Stop the pump only after death has been formally verified

Stop the infusion by pressing the ‘STOP’ button. Disconnect line from the Saf-T-Intima which must be left in situ as per WSFT guidelines. Switch off the pump by disabling the keypad lock and then press and hold the ‘ON/OFF’ button

Record on the syringe pump prescription chart, the date, time and amount of solution remaining in the syringe (mls). Discard contents as per policy and sign

10. MONITOR INFUSION:

It is important that pump checks are carried out as per policy and documented on the checklist on the syringe pump prescription chart.

Check pump and cannula site within ONE HOUR of set- up/renewal of syringe

With FOUR HOURLY checks thereafter

NB: If there are any adverse incidents with the pump, the pump’s internal memory of all button presses can be accessed via the Event Log. In such cases, refer to an experienced user of the device and/or EBME. If in any doubt as to pump’s safe use, STOP the infusion and return device to EBME. Datix any adverse incidents.

Observation checks should include:

Date and time of check

Check that the rate has not been altered

Check the volume remaining in the syringe (VTBI) and volume infused (VI) by pressing ‘INFO’ once. LOOK at the syringe contents- does it match? The Keypad lock does NOT need to be disabled to access this information. Document the volume. This will assess if the pump is delivering medication at the desired rate

Battery life is checked by pressing the ‘INFO’ key twice

Check that the green LED light is flashing every 32 seconds. The bottom line of the LCD

display must be alternating between ‘ Pump Delivering’ and make/size of syringe

Observe syringe for precipitation, cloudiness, change in colour and crystalisation of the contents, which must be discarded if these occur.

Check that the line is securely attached to syringe and not leaking and line is not kinked or trapped

Observe the cannula insertion site for redness, inflammation and leakage of fluid. Change site if these signs are present and record location and reason for change, on the syringe pump prescription check list


At commencement and reloading of the syringe pump the prescription must be checked by 2 nurses as per IV drug administration (see section 4.4 PP (17) 200 WSFT Policy for the use of medicines).

11. MONITOR SYMPTOMS:

Every FOUR HOURS complete symptom control check list on back of pump prescription chart

A change of medication in prescription means a new syringe, new extension set and cannula

12. CLEANING AND DECONTAMINATION OF SYRINGE PUMP ON WARD:

Do not immerse pump in water

Cleaning should be carried out with a soft disposable cloth using warm water and general-purpose detergent, or PDI detergent wipes for hard surfaces, ensuring the syringe pump is appropriately labelled stating that it has been decontaminated

Do not use acetone/similar solvents or Cliniwipes (or similar) as this will cause damage to the components and labels

Return pump to MEL when pump is no longer required by patient for tracking, servicing or for other patients needs around the hospital. Not returning a pump can seriously delay symptom management for another patient. Do NOT keep on the ward for use by another patient, contact MEL to issue a newly logged pump to that patient.

For patients with an infection control risk, additional cleaning with a chlorine based solution, i.e; SoChlor maybe required. Please seek advice from Infection Prevention Team if necessary

13. SYRINGE PUMP PROBLEM SOLVING:

Common Problems/Problem solving:

Fault Possible Cause Action

The Pump will not start.

1. No battery inserted.

2. Battery inserted incorrectly.

3. Battery is depleted/very low.

4. Pump is faulty.

1. Fit a battery.

2. Re-align battery terminals.

3. Fit a new battery.

4. Service required. Return to EBME.

Infusion ended early/going too quickly (ie. running more than 1 hour ahead of expected time).

1. Wrong syringe brand/size used during set up/ incorrect volume measured by pump.

2. Disconnection of line or cannula.

1. Stop infusion and set up a fresh infusion. If any doubts return to EBME

2. Check connections are secure.

3. Stop infusion and discuss with


3. Air is present in syringe (solution will siphon if barrel cracked).

4. Pump has been placed above the height of the patient (siphonage could have occurred).

5. Pump faulty or incorrectly calibrated

Doctor/Palliative Care Team. Set up of fresh infusion may be required. Document action on syringe pump prescription chart and patient’s eCare notes.

4. Stop infusion and seek medical/palliative care team advice. Monitor patient for adverse effects. Document action on syringe pump prescription chart and patient’s eCare notes.

5. Return to EBME for servicing/recalibration.

Pump is running too slowly (ie.running more than 1 hour behind expected time).

1. Battery is depleted/very low.

2 .Wrong syringe brand/size selected.

3. Syringe pump may have been stopped and restarted.

4. Is cannula insertion site red/sore/ lumpy/hard?

5. Do contents of syringe and line have signs of crystallisation?

1. Check syringe pump light is GREEN and flashing. Check battery level. Fit a new battery.

2. Stop infusion and discuss with Doctor/Palliative Care Team. Set up a fresh infusion.

3. Check syringe pump prescription chart/ documentation for possible reason this occurred.

4. Change cannula site, if necessary. Check compatabilities of medication combination (see Pink Book /check with Pharmacy/Palliative Care Team). Consider separating medications into 2 syringe pumps for greater dilution of medication.

5. Check compatabilities of medication combination (see Pink Book/check with Pharmacy/palliative care team). Consider separating medications into 2 syringe pumps for greater dilution of medication.

The pump has stopped before emptying syringe

1.Exhausted battery.

2. Check cannula insertion site and contents of syringe for crystallisation

3. Faulty pump?

1. Fit new battery, turn pump on, confirm syringe size and brand. Select to resume infusion.

2. See 4 & 5 in section above.

3.Return to EBME for servicing.

14. McKINLEY T34 PUMP ALARM CONDITIONS

When the pump detects a problem four things occur:

The infusion stops

An audible alarm is activated

A message appears on the display screen indicating the cause of the alarm

The LED indicator turns RED


Alarm conditions:

LCD Display Alarm Type Possible Cause Action

Occlusion or syringe empty

Occlusion/ syringe Empty

Check line & Syringe

Press YES to confirm

Audible and visual alarm.

Patient cannula/line kinked.

Occlusion.

Infusion has finished. Pump will stop

Remove occulsion and restart as per 9a or b. Change cannula and/or extension if needed Switch pump off

Syringe Displaced

Syringe displaced,

Check Syringe

Press YES to Confirm

Audible and visual alarm-

intermittent beep.

Syringe has been removed or displaced. Pump will stop.

Check and confirm syringe seated correctly and resume infusion. Syringe collar needs to be in vertical position at all times.

Near End

Near End


intermittent beep.

15 minutes from end of infusion. Pump still infusing.

Prepare to change syringe or switch off.

End Program

End Program

Press YES to confirm


intermittent beep.

Infusion complete. Pump will stop.

Pump will alarm. Press ‘YES’ to confirm end of program and press‘OFF’ to switch pump off.

Low Battery

Low Battery

Visual and intermittent audible alarm.

Battery is almost depleted (30 minutes left). Pump still infusing.

Prepare to change battery and resume infusion.

End Battery

End Battery

Visual and continuous audible alarm.

Battery is depleted. Once exhausted,alarm and pump will stop.

Change battery and resume infusion.

15. PATIENTS BEING DISCHARGED FROM HOSPITAL INTO THE COMMUNITY:

This section applies to any patient being discharged from hospital with a continuous subcutaneous infusion via a McKinley T34 syringe pump to their own home, nursing home, another hospital or hospice. Forward planning is essential and if possible should be organised the day before discharge to avoid any delay.

The individual ward is responsible for contacting MEL (or porters out of hours, if essential) to inform them that a patient is being discharged from hospital with a McKinley T34 syringe pump and give information regarding the discharge destination. A self- addressed padded envelope is provided by MEL for return of the pump to MEL as soon as possible from the discharge destination ie; nursing home or via the patient’s district nursing team when the destination has exchanged the hospital pump for one of their own devices.

Three indemnity forms will be issued by MEL and must be completed by ward staff. One copy to be kept by MEL, one copy added to the patient’s hospital notes and a third copy,


for the patient, which can be be added to the padded envelope. This is to aid a paper trail in the event that the pump is mislaid or lost.

When a patient is discharged to their home address, a referral for daily reloading of the syringe pump must be sent to the District Nursing team (via EVOLVE for Suffolk patients’). Details must include: when current syringe was commenced and when it is due for renewal; what medications are being administered and when cannula/extension line was sited. For other discharges, such as to another hospital, hospice or nursing home complete a “Nursing Transfer Document for Discharge” form with the syringe pump details and send the white copy with the patient on discharge. For District Nursing Teams outside of Suffolk, please telephone the team directly

Nurse to load new syringe and new battery within 2 hours of expected discharge time. Remember to take the plastic lockbox off the pump prior to discharge and ensure the keypad lock on the syringe pump has been activated.

NB: A pump bag for safer transfer of pump on discharge can be obtained from Palliative Care Team.

Important points to remember

It is imperative that the patient’s hospital medical team telephone the patient’s receiving medical team regarding the syringe pump prescription to update them as well as complete and send a Discharge Summary (which if the patient meets the Fast Track CHC criteria, it is hospital policy to update GP by telephone)

TTO medications for syringe pumps will need to be prescribed separately from other medications such as end of life Just In Case PRN SC medications for symptom management. It will be necessary for medications to be dispensed for the syringe pump to continue for some days following discharge until further medication can be obtained by the community teams

Currently, the Palliative Care Team medical team and Independent Nurse Prescribers’ write community prescription administration charts (for syringe pump and PRN Just In Case medication) for patients’ known to the team when the patient’s responsible medical/surgical team have added TTO’s to discharge summary. If a patient is not already known and requires these written prescriptions, please contact the Palliative Care Team

It is the ward staff’s responsibility to ensure that a referral is sent for District Nurse input for daily re-loading of the syringe and is followed up by telephone to the relevant District Nursing Team to ensure this information has been received. For all other discharge destinations, ward staff must contact the receiving nursing teams with this information

Communication with receiving medical/nursing teams must include discussion on their responsibility for the return of the syringe pump to the West Suffolk Hospital as soon as possible.

Communicate with transferring ambulance teams that patient has a syringe pump

Remember: Prior to patient leaving the hospital, the plastic lockbox MUST be removed from the syringe pump. Ensure the keypad lock remains activated. Send the A4 padded envelope for pump return, a copy of the indemnity form and a paper copy of the patient’s electronic medical discharge summary.


References

Dawkins L, Britton D, Johnson I, Higgins B, Dean T, (2000) ‘A randomized trial of winged Vialon cannulae and metal butterfly needles’. International Journal of Palliative Nursing 6 (3) PP.110-116

Dickman A, Schnider J, Varga J (2016) The syringe driver: continuous subcutaneous infusions in palliative care. 4th edition. Oxford University Press.

Evans N, Palmer A (1998) ‘Controlling breakthrough pain in palliative care’. Nursing Standard. 13 (7) pp. 53-54

INS (Infusion Nurses Society) (2016) Infusion therapy standards of practice, Journal of Infusion Nursing, 39(1S), available: INS Digital Press. (V)

Medical Devices Agency (2000) Equipped to care: the safe use of medical devices in the 21st century. London: MDA.

Medicines and Healthcare Products (March 2016) Ambulatory syringe pumps (T34 and T60) and syringe extension sets used with the T34 pump, manufactured by Caesarea Medical Electronics (CME). Department of Health, Social Services and Public Safety.

Medicines and Healthcare Products (March 2018) Medical Device Alert All T34 ambulatory syringe pumps- risk of unintended pump shutdown and delay to treatment. Department of Health. Crown Copyright. Available at: https://www.gov.uk/drug-device-alerts/all-t34-ambulatory-syringe-pumps-risk-of-unintended-pump-shutdown-and-delay-to-treatment (Accessed 29 December 2018)

Mitton T (2001) ‘Subcutaneous drug infusions: a review of the problems and solutions’. International Journal of Palliative Nursing. 7 (2) pp. 75-85

NHS Greater Glasgow and Clyde (2015) Guidelines for the use of the McKinley T34TM ambulatory syringe pump by CME Medical for adults in palliative care. Available at: http://www.palliativecareggc.org.uk/wp-content/uploads/2013/10/T34Guideline_Oct2016.pdf (Accessed 8th January 2018).

Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behavior for nurses and midwives. London: Nursing and Midwifery Council.

RCN (2016) Standards for infusion therapy (4th edition).

The Royal Children’s Hospital Melbourne (2014) Subcutaneous catheter devices management of insuflon and BD safTIntima devices. Available at: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Subcutaneous_catheter_devices_management_of_insuflon_and_BD_safTIntima_devices/ (Accessed 8th January 2018).

Torre M (2001) ‘Subcutaneous infusion: non-metal vs metal butterfly needles’. British Journal of Community Nursing. l7 (7) pp. 365-369

Twycross R (2002) Symptom Management in Advanced Cancer. 3rd Edition. Oxon: Radcliffe Medical Press.

Twycross R, Wilcock A, Charlesworth S, Dickman A, (2017) Palliative Care Formulary. 7th edition. Oxon: Radcliffe Medical Press.

West Suffolk Hospital (2017) Clinical guideline: Last days of life/care of the dying-adult. CG 10057-8

West Suffolk Hospital (2019) Clinical guideline: Trust guidelines on the use of unlicensed medicines. CG10048-6

West Suffolk Hospital Pink Book (2018) End of Life Care Education/resource including symptom management- syringe driver compatibilities

West Suffolk Hospital (2019) Trust Policy and Procedure: Aseptic Non-Touch Technique (ANTT) Policy. PP (19)266

https://www.gov.uk/drug-device-alerts/all-t34-ambulatory-syringe-pumps-risk-of-unintended-pump-shutdown-and-delay-to-treatment

https://www.gov.uk/drug-device-alerts/all-t34-ambulatory-syringe-pumps-risk-of-unintended-pump-shutdown-and-delay-to-treatment

http://www.palliativecareggc.org.uk/wp-content/uploads/2013/10/T34Guideline_Oct2016.pdf

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Subcutaneous_catheter_devices_management_of_insuflon_and_BD_safTIntima_devices/

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Subcutaneous_catheter_devices_management_of_insuflon_and_BD_safTIntima_devices/


West Suffolk Hospital (2019) Trust Policy and Procedure: Diagnostic and therapeutic equipment training. PP (19) 206

West Suffolk Hospital (2019) Trust Policy and Procedure: Policy for the use of medicines. PP (19) 200

West Suffolk Hospital (2017) Trust Policy and Procedure: Management of medical equipment policy. PP(17)024

www.pallcare.info and www.palliativedrugs.com

Development of the policy

Statement of clinical evidence

Administration of drugs by Continuous Subcutaneous Infusion (CSCI) using a portable battery powered syringe driver is common practice in palliative care in the UK (Twycross 2003). The move to the McKinley T34 syringe pump for administration of medications follows the Rapid Response Report NPSA/2010/RRR019: safer ambulatory syringe drivers. A literature review was carried out (see reference list) confirming that medication given via CSCI ensures constant symptom control when the oral route is contraindicated. The review confirms that the use of non-metal cannulae are superior to metal cannulae by maintaining the duration of the subcutaneous infusion and reducing risk of needlestick injury to staff and patients. Contributors and peer review

Sarah Ryan Palliative Care Specialist Nurse.

Dr Mary McGregor Consultant in Palliative Medicine.

Palliative Care Team

Distribution list/dissemination method

To be distributed to all clinical areas, pharmacy, directorates and consultants within the West Suffolk Hospitals NHS Trust.

Document configuration information

Author(s): Sarah Ryan. Palliative Care Nurse Specialist

Other contributors Dr Mary McGregor; Palliative Care Team; Morag Truscott Medicines Information Pharmacist; Michelle Smith, Infection Prevention.

Approvals and endorsements: Drugs and Therapeutics Committee. Infection Prevention

Consultation:

Issue no: 17

File name: O:Palliative Care/Policies/

Supercedes: PP(16) 287

Equality Assessed Yes



Implementation This document will be widely circulated within the Trust, including all heads of department and ward managers and will be made availability on the Trust’s Intranet and Internet sites. Relevant changes will be brought to the attention of employees during circulation. Comprehensive training programmes exist including mandatory training and relevant modules as detailed in the Trust’s training prospectus. Specialist training will also be targeted at those with responsibility for managing hazards with a high-risk rating.

Monitoring: (give brief details how this will be done)

A biannual audit on an aspect of syringe pump management will be carried out to monitor practice

Other relevant policies/documents & references:

Nil

Additional Information: Patient Information Leaflet: Syringe Pumps. Reference: 5584-5


APPENDIX 1

SUBCUTANEOUS SYRINGE PUMP PRESCRIPTION SHEET

WARD: . . . . . . . . . . . . . . . . . . . . CONSULTANT: . . . . . . . . . . . . . . . . . . . . . .

INSTRUCTIONS FOR PRESCRIBING DRUGS VIA A SYRINGE PUMP

1. All drugs must be prescribed by generic name in BLOCK CAPITALS. 2. Prescribe a dose per 24 hours for each drug. 3. The prescription must be reviewed and rewritten every 72 hours or more frequently if

clinically indicated. 4. Information on doses and compatibility of drugs may be obtained from the BNF,

www.pallcare.info , the Palliative Care Team or the pharmacy department’s ‘Medicines Information’ service.

5. PRN doses for all drugs in the syringe pump should be prescribed on the standard drug chart.

6. If the syringe pump is to be stopped indicate this clearly on the chart, sign and date. 7. A reference to the use of a syringe pump should be clearly made on the standard drug

chart.

INSTRUCTIONS FOR SETTING UP A SYRINGE PUMP

1. Draw up medication and add diluent to make total syringe volume to 17mls using a 20ml Leur Lock syringe (if volume greater than 17mls, consider a second pump or refer to Palliative Care team and/or pharmacy for advice).

2. Use the appropriate diluent:

Water for Injection for the majority of drugs. Sodium chloride 0.9% for ketamine, octreotide and ondansetron.

3. The pump calculates and displays the deliverable volume, duration of infusion (24hrs) and rate of infusion (mls per hour). See McKinley T34 guidelines for set up instructions.

Carry out pump checks and patient checks, initially after 1 hour then every 4 hours thereafter. Record overleaf.

Attach Addressograph Here:


Source: Palliative Care Team Status: Approved Page 23 of 35 Issue Date: February 2016 Review Date: February 2018 Doc Ref: PP(16)287

PATIENT NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _HOSPITAL NUMBER: _ _ _ _ _ _ _ _ _ _ _ _

MEDICATION (INCLUDING DOSE)

DATE:

DATE:

DATE

Drug 1:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose:_ _ _ _ _ _ _ _ _ Drug 2:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose:_ _ _ _ _ _ _ _ _ Drug 3:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose:_ _ _ _ _ _ _ _ _ Route: SC Total Quantity: 17mls Duration: 24 hours Diluent: Water for Injection / Sodium Chloride 0.9% (delete as appropriate) Signature: Date: (valid for a maximum of 72 hours)

Set up by:

Set Up By: Set Up By:

Checked By: Checked By: Checked By:

Pump no: Pump no: Pump no:

Time Set Up

Rate at set up:

Time Set Up: Rate at Set Up: Time Set Up: Rate at Set Up:

Pharmacy:


DATE:

DATE:

DATE:

Drug 1: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose:_ _ _ _ _ _ _ _ Drug 2: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose:_ _ _ _ _ _ _ _ Drug 3: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose:_ _ _ _ _ _ _ _ Route: SC Total Quantity: 17mls Duration: 24 hours Diluent: Water for Injection / Sodium Chloride 0.9% (delete as appropriate) Signature: Date: (valid for a maximum of 72 hours)

Set Up By:


Checked By:

Checked By: Checked By:


Time Set Up: Rate at Set Up: Time Set Up: Rate at Set Up: Time Set Up: Rate at Set Up:

Pharmacy:


DATE:

DATE:

DATE:

Drug 1:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose:_ _ _ _ _ _ _ _ _ Drug 2:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose:_ _ _ _ _ _ _ _ _ Drug 3:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Dose:_ _ _ _ _ _ _ _ _ Route: SC Total Quantity: 17mls Duration: 24 hours Diluent: Water for Injection / Sodium Chloride 0.9% (delete as appropriate) Signature: Date: (valid for a maximum of 72 hours)

Set Up By:


Checked By:

Checked By: Checked By:


Time Set Up: Rate at Set Up: Time Set Up: Rate at Set Up: Time Set Up: Rate at Set Up:

Pharmacy:

Source: Palliative Care Team Status: Approved Page 24 of 35 Issue Date: February 2016 Review Date: February 2018 Doc Ref: PP(16)287

SYRINGE PUMP CHECKLIST (INITIALLY AFTER 1 HOUR then EVERY FOUR HOURS) Date Time Rate

(mls per hour)

Starting Volume (mls)

Volume Remaining At Check

(mls)

Drug Solution 1. Clear

2. Cloudy 3. Crystallised

Write battery percentage

Cannula Position Initials

Source: Palliative Care Team Status Page 25 of 35 Issue Date: August 2019 Review Date: August 2022 Doc Ref: PP(17)287

SYMPTOM CONTROL CHECKLIST: PATIENTS ON SYRINGE PUMP (EVERY FOUR HOURS)

Pain Score Nausea Score Needle Site

(0 – 10) (0 – 2) (0 – 2)

0 = no pain 0 = no nausea 0 = satisfactory 5 = moderate pain 1 = nausea controlled 1 = slightly pink 10 = severe pain 2 = uncontrolled nausea 2 = inflamed – change site

Date Time Pain Score (0 – 10)

Nausea Score (0 – 2)

Agitation Present? Yes/No

Respiratory Secretions? Yes/No

Cannula Site Condition

Actioned as Appropriate (tick)

Initials


Appendix 2: McKinley T34 Syringe Pump Quick Set up Guide.

Draw up prescribed medication in 20ml Omnifix luer lock syringe with appropriate diluent

↓

Manually prime extension line and Saf-T-Intima -do not load syringe

↓

Switch pump on- Displays 'T34 and ID:WSH-asset number’

↓

Pump goes through pre-loading process (actuator moves backwards and returns to previous start position). Once pump displays 'Load Syringe', press 'INFO' key.

↓

Select battery level

↓

Press 'YES' to verify sufficient battery power- change if 30% or less. Screen will revert to 'Load Syringe' if no other buttons are pressed.

↓

Ensure barrel clamp arm down. Fit pump to syringe using 'FF' or 'BACK' keys to adjust position.

↓

Lift barrel clamp arm, seat syringe collar and plunger in correct position and secure with barrel clamp arm (ensure medication label is clear of barrel clamp).

↓

Screen syringe graphic will cease to flash when syringe correctly positioned.

↓

Confirm syringe size and brand match screen display by pressing 'YES'

↓

Now displays 'Volume, Duration, Rate'. Check and confirm 'YES'

↓

Displays 'Start Infusion?'

↓

Connect syringe to extension line and Saf-T-Intima (if replacing syringe only); or site and secure newly primed extension set and Saf-T-Intima.

↓

Press 'YES' to start. Running screen displays: 'Time Remaining/Rate/Syringe size and brand' alternating with 'Pump delivering'; green LED indicator flashes.

↓

Press and hold 'INFO' button to lock keypad and place syringe pump in plastic lock box.

↓

Checks during infusion: Press 'INFO' key once- displays volume to be infused and volume infused. Press ‘ INFO’ key twice for battery %


Appendix 3


Appendix 4a

Mandatory Training for McKinley T34 Syringe Pump This training comprises both a theoretical component and a practical assessment, to be successfully completed and competency signed off by a syringe pump assessor following the practical assessment, before the McKinley T34 syringe pump can be set up by the staff member. A staff member who has not had mandatory training can be the second checker for the set up or reloading of the syringe pump. Please see your ward manager for details of training and assessment provided by your ward assessor or alternatively, please contact the hospital palliative care team who provide four practical assessment training sessions per year (contact the Palliative Care office on ext: 3776 to book), or bespoke training on request.

Theoretical training The McKinley T34 Syringe Pump Management Policy MUST be read and the questionnaire on the next page below completed (appendix 4b), prior to taking the practical assessment arranged with your ward assessor or palliative care team.


Appendix 4b. Questions to be completed by assesse before practical assessment 1.List 5 reasons why a patient may need a syringe pump 2.The McKinley T34 syringe pump is battery powered a)True b)False 3. Medication is delivered over 24 hours (lock on) via a syringe pump a)By continuous intravenous infusion b)By continuous subcutaneous infusion c)By subcutaneous bolus medication 4. List 5 medications that can be added to a syringe pump prescription 5. At the WSFT, what is the maximum number of medications that can be added to one syringe pump prescription? a)3 b)2 c)4 6.How long does it take for the medications to reach its optimum level when commencing a pump? a)Straight away b)4-6 hours c)2 hours 7.Explain how would symptom control be achieved during this time? 8.List the sites where the Saf-T-Intima subcutaneous cannula can be sited for syringe pump infusion and/or prn use? 9.When should the syringe pump checks be performed and where documented? a)1 hour after each loading of the syringe pump and every 4 hours thereafter, recording checks on the syringe pump prescription chart b)Whenever it is possible and just verbally hand it over to the oncoming staff nurse c)1 hour after initial set up of pump and every four hours until the pump is no longer needed, recording checks on the syringe pump prescription chart 10.Once a syringe pump is no longer needed a)Keep it on the ward for the next patient who may need one b)Clean it and return to MEL. Request a newly issued pump for another patient Please bring this completed questionnaire to your practical assessment


Appendix 5

Practical Assessment CME McKinley T34 Syringe Pump Competency Sheet (March 2018) For Subcutaneous infusion Competency level key: 0=No training and not competent to use syringe pump 1= Some training but not competent to use syringe pump unsupervised 2= Training successfully completed and competent to use syringe pump unsupervised 3= Competent to use syringe pump unsupervised and to train and assess others

Performance Criteria Intended Answer/Outcome Level

Achieved

1.SETTING UP THE DEVICE

Demonstrate pre-operational inspection and set up of McKinley T34 syringe pump

a) Identify correct prescription and observation check chart to be used for the McKinley T34.

Syringe pump prescription chart with observation

checks chart and placeholder on eCare prescription

chart

b) Describe process for obtaining

T34 syringe pump from MEL

(Medical Equipment Library).

Contact Medical Equipment (MEL) during office hours

and via Porters out of hours

c) Identify correct type of syringe

and extension line and cannula to

be used with the device

20ml Braun Omnifix Luer Lock syringe and 150cm

extension line- BMS Critical Care (25-7150) (or agreed

alternative). Blue Saf-T-Intima cannula

d) Check device Clean and visually intact.

Trust equipment label and service not yet due.

e) Prepare syringe and extension

line

Wash hands and wear clean gloves as per

hospital policy

Draw up medication according to prescription

Affix label to syringe ensuring it doesn’t

interfere with barrel clamp arm on pump

Prime extension line and Saf-T-Intima


f) Power up device and check it

passes self-test

Insert battery

Ensure no syringe in place before switching

device on

After self- test completed, check battery power

is sufficient to commence infusion (˃30%). A

new battery lasts approx 5 days depending on

use. Green LED indicator flashes every 32

seconds

g) Position actuator and load

syringe onto the syringe pump.

Use FF and BACK buttons as necessary

before loading syringe onto pump

Check syringe is located correctly at the 3

syringe detection points

Check pump recognises syringe make and

size correctly, making corrections as

necessary

h) Check infusion settings as

displayed on LCD screen

Check Volume displayed on syringe pump

matches the amount observed in syringe

Discusses/demonstrates where to document

Volume, duration and infusion rate on the

prescription/observation chart

Practical skill in using Saf-T-Intima cannula

a) Demonstrate/discuss insertion of cannula and securing of extension line following above set up of syringe pump; and how long these can remain in situ

Identify appropriate infusion sites

Has knowledge of insertion procedure in

found in Syringe Pump policy and practical

demonstration; cannula and line can remain in

situ up to 7 days provided no precipitation in

line or problems with cannula insertion site/or

change of prescription

Identifies appropriate sites and those to be

avoided

b) Discuss rationale for choice of dressing to secure cannula

Clear dressing in order to monitor site.

c) Describe clinical situation that

would lead to change in cannula

Inflammation, hardness or leakage at site,

pump not working when all other explanations

excluded

Change of prescription

2.USING THE DEVICE

Demonstrate the ability to operate the McKinley T34 syringe pump

a) Start infusion and lock keypad

using ‘INFO’ key

Demonstrate use of lock box and

identify appropriate key and where

Demonstrate/discuss. Refer to section 8a & c

of McKinley T34 syringe pump policy


key is located Key kept with CD medication cupboard keys

b) Discuss/demonstrate

observations required during

infusion and how to obtain the

information from the device.

Discuss when checks must be

carried out

Rate, Volume infused, Volume remaining and

Battery state. Press ‘INFO’ key once for VI

and VTBI. Press ‘INFO’ key twice for battery

level

1 hour from commencement of set

up/replenished syringe and every 4 hours

thereafter

c)Describe alerts and alarms for:

1) Near end of infusion

Pump paused too long Occlusion Syringe displaced End of infusion

2) Low battery

3) End battery

d)Describe /demonstrate how to change battery and ensure infusion setting is not lost

1) Alarm is audible intermittent beep and visually

displayed on LCD screen

2) Alarm is audible intermittent beep and visually

displayed on LCD screen. 30 minutes power

remaining

3) Visual and continuous audible alarm until

battery is depleted

With infusion still running remove the old

battery from the pump and replace with a new

one

Switch the pump back on using the ‘ON/OFF’

button. Confirm the size and make of the

syringe . Press ‘YES’ to resume the infusion.

The screen will display: ‘Remaining volume,

duration and rate of infusion

Press ‘YES’ to confirm. Screen then displays

‘Start Infusion’. Press ‘YES’ to confirm and

current infusion continues

e) Discuss correct action for renewal of syringe on completion of infusion (or change in prescription)

Please refer to the McKinley T34 policy;

section 8b- Syringe renewal only and 9d

f) Discuss/demonstrate how to stop infusion and prime a new extension line and/or cannula

Press ‘STOP’ to pause infusion

Deactivate keypad lock but do NOT switch

pump off

Then refer to section 9b


g) Discuss what to do if the patient dies when syringe pump is running

Stop the pump, by pressing ‘STOP’ button

only when death has been formally verified

Disconnect line from Saf-T-Intima, which must

be left in situ as per WSFT guidelines

Switch pump off by disabling keypad lock and

then holding down the ‘ON/OFF’ button

Record action on syringe pump prescription

chart and discard remaining contents as per

WSFT policy

h) Discuss/demonstrate correct

cleaning methods to be used after

syringe pump is no longer required

by patient

Ensure pump is not immersed in water

Clean with a soft disposable cloth using warm

water and general-purpose detergent, or PDI

detergent wipes for hard surfaces

Do not use acetone/similar solvents or

Cliniwipes (or similar)

Return pump to MEL when pump is no longer

required by patient

For patients with an infection control risk,

additional cleaning with Chlorclean is

required. Please seek advice from Infection

Prevention Team if necessary

3. DISCONTINUATION OF PUMP OR DISCHARGE FROM HOSPITAL

a)Discuss/demonstrate correct

action for returning pump to MEL

Refer to the algorithm, ‘Process for continuous

subcutaneous infusion’ in appendix 3 in

McKinley T34 Syringe Pump Management

Policy. Do not use pump for another patient

b)Discuss discharge process when

a patient is to be discharged from

hospital with a McKinley T34

Contact MEL, requesting Discharge Pack and

inform MEL of discharge destination. Discuss

preparation of syringe pump for discharge

Discusses process for discharge for patients’

to their own (Suffolk) home and to those

discharged to all other destinations

c) Explain the documentation

required in order to keep track of

syringe pump on patient’s

discharge.

MEL will issue 3 Indemnity forms to be

completed. One for MEL records, a copy for

the patient and a copy for patient’s hospital

notes


WSFT McKinley T34 Mandatory Training Competency Statement- is assessed as *competent to use the McKinley T34 syringe pump/ *competent as a McKinley T34 assessor. (*delete as appropriate). Device User: Signed: Print name: Date: Assessor: Signed: Print name: Date: One copy of the competency statement to be held in Palliative Care Team/ward assessors records and one copy given to the Device User/Assessor for their KSF portfolio. This must then be recorded on your individual Diagnostic & Therapeutic Equipment Competency Assessment held by your ward manager. Reassessment is based on individual needs and re-evaluated at your annual appraisal and Competency Assessment updated accordingly. As the Nursing and Midwifery Council (NMC 2015) state, “keep your knowledge and skills up to date, taking part in appropriate and regular learning and professional development activities that aim to maintain and develop you competence and improve your performance”.


Discharge Pack Information Sheet

This information sheet must accompany patients’ discharged from hospital with a Mckinley T34 syringe pump and must include:

A padded envelope for pump return to WSFT Medical Equipment Library

A copy of the Indemnity Form

A printed copy of the patient’s medical discharge summary

A nursing discharge summary (green copy of DHA) with details to include: when current syringe was commenced and when it is due for renewal; what medications are being administered and when cannula/extension line was sited. Neither the eCare nor nursing discharge summary is a prescription

For patients’ known to the hospital palliative care team, being discharged for end of life care and/or have a Mckinley T34 syringe pump, the palliative care team medical and non-medical prescribers will complete paper community administration charts for the sc prn anticipatory and/or syringe pump once medications are added to TTOs. These charts will then be added to the Yellow My Care Wishes Folder. If patient is NOT known to the Palliative Care Team, please contact the team via Medic Bleep or telephone ext 3776

NB: Remember to remove pump from plastic lock box prior to discharge and ensure keypad lock is activated

Instructions for Discharge destination:

Do NOT stop the syringe pump unless advised by a member of the community team (such as GP, District Nurses, Community Palliative Care Team)

Please exchange the McKinley T34 syringe pump for a community syringe pump as soon as possible. Return the WSFT McKinley T34 syringe pump to WSFT Medical Equipment Library, in the self- addressed padded envelope provided

How to stop the McKinley T34 at discharge destination, if unfamiliar with this syringe pump, is as follows.

1. Stop the infusion by pressing the ‘STOP’ button Disconnect the extension line from the syringe which is attached to the pump (NB: If the infusion is stopped before the syringe is empty, it should be disconnected as described, for safety reasons before the syringe is taken off the pump, otherwise there is risk of siphonage of contents to patient)

2. With the keypad lock on, the pump will not switch off. To deactivate lock, press and hold the ‘INFO’ key until a display shows a “progress” bar. Hold the key until the bar has moved completely across the screen from right to left. A beep will be heard to confirm the lock has been deactivated

3. Press and hold the ‘ON/OFF’ button to switch off the pump

4. Remove 9 volt battery from housing at the back of the McKinley T34

5. Remove the syringe from the pump by lifting and turning the clamp arm 180° to release

the syringe barrel. Discard contents as per local policy

If there are any queries, please contact the discharging ward via the hospital switchboard on

01284 713000 or direct dial 01284____________________

Appendix 6