Clinical Guidelines for the Safe Use of McKinley T34 Syringe Pump

Table of ContentsIntroduction and Purpose.............................................................................................................5Definitions ....................................................................................................................................6Duties, Roles and Responsibilites................................................................................................6Scope...........................................................................................................................................8Indications for The Use of the Guideline ......................................................................................8Qualification and Training ............................................................................................................9Equipment..................................................................................................................................10Audit...........................................................................................................................................10Procedure ..................................................................................................................................10Register of medical devices .......................................................................................................10Decontamination of the McKinley T34 Syringe Pump ................................................................10Incident reporting .......................................................................................................................11Obtaining informed consent .......................................................................................................11Preparing the syringe.................................................................................................................11Labelling.....................................................................................................................................12Connecting infusion set to the syringe .......................................................................................12Preparing the McKinley T34 Syringe Pump ...............................................................................13Fitting the syringe to the syringe pump ......................................................................................13Setting the infusion parameters .................................................................................................14Connecting the infusion to the patient........................................................................................14Starting the syringe pump ..........................................................................................................15Keypad lock ...............................................................................................................................15Stopping the infusion and removing the syringe pump ..............................................................16Resuming the infusion................................................................................................................16What to do if the patient dies whilst the syringe pump is running...............................................17Sites for placement of cannula for syringe pump infusion..........................................................17Page 3 of 33

INTRODUCTION AND PURPOSEIn accordance with the national policy and guidance outlined in the Medical Devices Directive93/42/EEC, NHS Halton & St Helens has a responsibility to ensure that all medical devices areused in a safe and appropriate manner in accordance with both the manufacturers’ instructionsand recognised best practice.In line with the first domain of the Standards for Better Health, the Primary Care Trust also hasa responsibility to take all necessary steps to ensure that patient safety is enhanced by the useof its health care processes, working Practice’s and systemic activities that prevent or reducethe risk of harm to its Patients. The development of this guideline will establish systems andprocedures that aim to protect patients and help to reduce the risks associated with theacquisition and use of medical devices. To this end, these Guidelines will provide evidence tomeet the Standards for Better Health core Standards C4 (b), C5 (a) and the developmentstandards D1 and D2 (a).The syringe driver was originally developed in 1979 by Dr Martin Wright for Use in treatingthalassaemia with infusions of Desferrioxamine (Wright & Galland, 1979). The use of a portablebattery operated syringe driver for Subcutaneous medications is now a well establishedtechnique in palliative Care and its use is fully supported by Dickman et al (2005) who suggests"that It is particularly suited to palliative care".The benefits of employing the syringe driver is that it "allows for a minimally Invasive route ofdrug administration, which produces relatively constant Levels of medication which avoidspeaks that can result in reduced symptom Control" (Hunt 2002). Palliative care patients oftenpresent with multiple symptoms that can necessitate the need to use several drug treatments. Ifthe patient’s condition deteriorates and the oral route cannot be used, Dickman et al (2005)further suggests "that a continuous subcutaneous infusion via the syringe pump provides asimple and effective way to control symptoms".As a consequence of safety issues highlighted with the Graseby MS26 Syringe Driver, thesyringe pump of choice within Halton & St Helens Primary Care Trust is now the McKinley T34Syringe Pump.Parenteral administration of medicines carries a number of risks which have been welldocumented (Doyle et al, 1993). These can be attributed to a number of reasons, including usererror, maintenance, damage and contamination problems as well as device-related issues suchas performance, degradation, quality assurance and design and labelling (Medical DevicesAgency Device Bulletin 2003 (02)).Additionally, it is also recognised that syringe pumps may only be used intermittently andprofessional competency can be difficult to maintain where its use is infrequent. Furthermore,the introduction of any new medical device brings with it the associated risks of unfamiliarity andthe need to develop the required competences. The provision of local guidance on the use ofthe McKinley T34 Syringe Pump will introduce and establish robust procedures to promote aconsistent approach to its use across the Primary Care Trust.Page 5 of 33

As such, the main aim of these guidelines is to assist health care professionals administeringdrugs via the McKinley T34 Syringe Pump and to promote a procedural uniformity across Halton& St Helens Primary Care Trust.To this end, these guidelines also aim to:I. Introduce and establish rigorous procedures to ensure a consistent approach to the use ofthe McKinley T34 Syringe Pump.II. Reduce the potential risk of adverse incidents (Medical Devices Agency Device Bulletin2003(02)).III. Improve patient safety and clinical outcomes.IV. Provide evidence for the organisation to meet the Standards for Better HealthV. Establish key performance indicators to monitor and evaluate the effectiveness of theguidanceThis document should be read in conjunction with the Policy for administration of ControlledDrugs, Decontamination Policy Infection Prevention and Control Policy and the End of Life CarePathway.DEFINITIONSThe McKinley T34 syringe pump is a portable battery-operated infusion pump weighingapproximately 210g (excluding the battery) and measuring 169mm by 53mm by 23mm. It isused for the administration of medication subcutaneously over a 24 hour period.DUTIES, ROLES AND RESPONSIBILITESAuthor(s) are responsible for ensuring that:a) Once ratified, the clinical guideline is maintained in an editable electronic version (mastercopy).b) An Impact Assessment has been completed for the document and submitted to the Headof Corporate Services and Business.c) The responsible committee or officers are alerted of any necessary review to beundertaken.d) All amendments are completed subsequent to the findings of any review.Responsible Committee or Officers are responsible for:a) Undertaking any review of the document: In response to any recommendation(s) madefollowing an audit of the document. In line with the agreed review date (a maximum ofPage 6 of 33

) Ensuring that if the author of the clinical guideline leaves, or their responsibilities changein relation to the guideline, that the Chair of the Multi-Disciplinary Clinical GuidelineRatification group is informed to whom responsibility of being the author(s) is transferredfor the relevant document.Multi-Disciplinary Guideline Ratification Group is responsible for:a) Ensuring that clinical guidelines are written in line with the Policy Standard.b) Ensuring that a master set of documents is maintained on behalf of the Primary CareTrust.c) Ensuring that the clinical guideline complies with all relevant legislation including Equality& Diversity.d) Monitoring and reviewing compliance against relevant Core and DevelopmentalStandards for Better Health and Risk Management Standards.e) Monitoring all clinical guidelines to ensure that they are in date.f) Alerting the Primary Care Trust of all new clinical guidelines.The Head of Corporate Services and Business is responsible for:a) Maintaining copies of impact assessments and the action(s) necessary to ensuredocuments meet statutory requirements and other guidance.b) Publishing impact assessments on the Primary Care Trust’s public website and staffExtranet.The Governance Manager is responsible for:a) Notifying ‘receivers’ as identified on the Distribution Lists set up via the Policy CascadeSystem that a new document has been issued.b) Maintaining and updating distribution lists on the Policy Cascade System.The ‘receiver’, as identified by their Director, is responsible for:a) Updating the paper copy of the document in the paper files for which they areresponsible.Page 7 of 33

) Responding to the Policy Cascade System Alert to ensure appropriate action is taken.c) Informing relevant staff of an amended existing document or the introduction of a newone.Heads of Service and line managers are responsible for:a) Bringing the attention of their staff to the publication of a new document.b) Providing evidence that the document has been cascaded within their team ordepartment.c) Where appropriate, ensuring the new document is effectively implemented.d) Ensuring that their staff attend all training identified in respect of a new documents.The Employee is responsible for:All staff employed by NHS Halton & St Helens are responsible for adhering to this guideline,regardless of role, band, discipline or service area. All employees of Halton & St Helens PrimaryCare Trust have a contractual obligation to follow this document.SCOPEThis guidance is aimed at all qualified nursing staff working within NHS Halton & St Helens whoare currently registered with the Nursing and Midwifery Council and who have completed therelevant in-service training and are deemed competent in the use of the McKinley T34 SyringePump.INDICATIONS FOR THE USE OF THE GUIDELINEThe guidance contained in this document should be followed on all occasions when a McKinleyT34 Syringe Pump is required to administer medication.The McKinley T34 Syringe Pump is used to deliver drugs at a predetermined rate via thesubcutaneous route over a 24 hour period. Typical applications include its use in pain andsymptom control. Other indications for the use of the McKinley T34 Syringe Pump are:Intractable nausea and vomitingIntestinal obstructionDysphagiaHead and neck lesions/surgerySemi or unconscious statePage 8 of 33

MalabsorptionUnsatisfactory response to oral drugs (uncommon)StomatitisPatient compliancePatient not be well enough to take the oral medications they requireThe advantages of using the McKinley T34 Syringe Pump are:The ability to infuse a combination of drugs via one route negates the need for repeatedinjectionsPortable, lightweight and compact, allowing mobility and independenceSimple calculation of dosages over a 24 hour periodAvoids or reduces the need for oral medicationPlasma concentrations remain level, therefore improved symptom controlInfusion timing accuracyThe standard delivery period for a continuous subcutaneous infusion is a 24 hour period inpalliative care. The McKinley T34 pump may be used with most makes of syringes. The mostcommonly used syringes have been 10 ml and 20 ml. However, it has been more recentlyadvocated that a 20ml syringe is the recommended minimum (Dickman et al 2002) as thisallows a larger dilution to be used, which will reduce both the risks of an adverse site reactionand also any potential incompatibility. In addition, it will also accommodate larger doses ofcertain drugs (Merseyside and Cheshire Palliative Care Network 2006). It is thereforerecommended that 20ml and 30ml syringes should be used and that they have a luer lockfacility in order to avoid leakage or accidental disconnection.NB: The 50 ml Luer lock syringe is the largest syringe that will fit the McKinley T34 syringepump. The benefits are that it allows drugs to be diluted up to approximately 34 mls volume forBecton Dickinson (BD) syringes and 44 mls for Terumo syringes. This reduces the risk ofreactions at the infusion site and also reduces the need for a further syringe pump when givinglarger volume drugs.QUALIFICATION AND TRAININGMedical and non medical prescriber’s with V300 qualification are responsible for prescribing thedrugs to be administered via a syringe pump.Medications can only be administered via a McKinley T34 Syringe Pump by a competentRegistered General Nurse who has undertaken and completed the required training in thisprocedure.Competency based training is provided within Halton & St Helens Primary Care Trust throughDistrict Nurse Team Leader and Assistant Team Leaders.Page 9 of 33

EQUIPMENT McKinley T34 syringe pump Battery: 6LR61 Duracell MN1604 alkaline or lithium. Plus spare new battery 20 ml, 30 ml or 50 ml luer lock syringe, e.g. Becton Dickinson (BD) McKinley infusion set Alcohol wipe Transparent adhesive dressing, e.g. TEGADERM Prescribed medicines I diluents Syringe pump prescription I recording sheet I drug labelAUDITAudit requirements and competencies in relation to nursing staff using the pumps is theresponsibility of each individual Team Leader. The Team Leaders will evidence that they areauditing these requirements on an annual basis.PROCEDUREMaintenance schedule All syringe pumps must be serviced annually, whether they have beenused or not. The responsibility for the annual service / maintenance contract lies with theClinical Services Manager; however it is the responsibility of individual Team Leaders(community) to ensure compliance with the contract.Additionally, syringe pumps should be sent for maintenance checks if they have been droppedor submerged in fluid or if there is any doubt as to their handling operation whilst out on loan.REGISTER OF MEDICAL DEVICESA register of all such devices within Halton & St Helens Primary Care Trust area is maintained.When new syringe pumps are introduced into the system or syringe pumps are removed fromservice, the Medical Devices Coordinator must be notified according to procedures outlined inHalton & St Helens Primary Care Trust Medical Devices Policy.DECONTAMINATION OF THE MCKINLEY T34 SYRINGE PUMPDecontamination should be carried out with a damp disposable cloth (use warm water andgeneral-purpose detergent). Dry thoroughly. If any additional cleaning is needed, e.g. thethreads of the screws the actuator moves along, contact the Infection Prevention and ControlTeam for advice. The pump must not be submerged in water: if it is accidentally dropped inwater, it must be withdrawn from use immediately and sent for repair (Decontamination Policy;Infection Prevention and Control Policy).Page 10 of 33

INCIDENT REPORTINGSystems are in place within Halton & St Helens Primary Care Trust to report and monitorincidents involving medical devices. Staff using the McKinley T34 Syringe Pump should befamiliar with the Primary Care Trust’s Incident Reporting System.The following incidents should be reported and investigated:Administration of incorrect medication, dose and/or diluent selectionIncorrect rate setting on syringe pumps resulting in infusions completing ahead ofintended time or carrying on beyond intended time of completionDevice not alarmingAny other incident or near miss which may compromise patient safety or comfort NB Anydevice involved in an adverse incident should be taken out of service and sent to theClinical Services manager.OBTAINING INFORMED CONSENTNo Action Rationale1 Ensure that informed patient consent has already beenobtained by the prescribing professional.To enable procedure tocommence2 Explain procedure to the patient To ensure that the patientunderstands the process andhas the opportunity to raiseany concerns.3 Provide the patient with relevant information leaflet(Appendix C ) with completed contact telephonenumbersTo reiterate the informationgiven and to provide thepatient / carer with furtherinformation and advice.(The Mental Capacity Act has been introduced to help people who are unable to makedecisions for them selves).PREPARING THE SYRINGENo Action Rationale1 Draw up the medication and diluents into a luer locksyringe of at least 20ml (BD).It may not be possible to fill all sizes of syringe to fullcapacity, between 34-44 ml can be delivered from a50ml syringe and approximately 24ml from a 30mlsyringe.2 Complete the details on the drug additive label as perlabelling sectionTo Ensure the correctmedication is given within theappropriate volume of diluent.To ensure accurate recordkeeping.Page 11 of 33

LABELLINGNo Action Rationale1 All syringes containing drug additives must be labelled To ensure accurate recordkeeping2 If there is any doubt as to the contents of a syringe, thecontents should be discarded into denaturing kit.3 Complete the label details in black ink or other indelibleprint. The label requires to state: The name of the patient for whom it is intended; The date and time of preparation; The full name of the person preparing thecontents; The name and quantity of all drugs; The name of the diluent; The total volume of the contents; The time period over which the contents are tobe infused; The intended route of infusion; The date and time the infusion started4 Ensure the label does not interfere with the mechanismof the infusion device, i.e. where there is contact withthe barrel clamp arm.5 Attach the label to the syringe. Ensure that the labeldoes not obscure any visuals scales.To ensure that any risks to thepatient are minimised and tocomply with Halton & StHelens Primary Care TrustPolicy for the Disposal ofControlled Drugs.To ensure accurate recordkeeping.Ensuring safe practice and toprevent malfunctioning ofpumpTo ensure the visual scalescan be viewed during theinfusionCONNECTING INFUSION SET TO THE SYRINGENo Action Rationale1 McKinley infusion sets must be used To ensure the correct infusionfor the administration ofmedication via a syringepump.2 Connect it securely to the syringe To prevent leakage andwastage of medications anddisconnection3 If it is a new infusion set, prime the line Prevents time delay in patientreceiving medicationPage 12 of 33

PREPARING THE MCKINLEY T34 SYRINGE PUMPNo Action Rationale1 Install the battery. 6LR61 Duracell MN1604 alkaline orlithium to be used. Ensure that any battery with a lifeless than 40% is replaced.2 Before placing the syringe into the Pump ensure lift andturn the barrel clamp arm. Turn and lower the barrelarm. Press and hold the "ON/OFF" key until the "SELFTEST" screen appears3 The LCD display will show "PRELOADING" and theactuator will start to move. Wait until it stops movingand the syringe sensor detection screen (syringegraphic) appears. NOTE: During Pre-Loading, theactuator always returns to the start position of the lastinfusion programmed.4 If the actuator is not in the correct position toaccommodate the syringe, leave the barrel clamp armdown and use the "FF" or "BACK" buttons on thekeypad to move the actuator. Forward movement of theactuator is limited, for safety; therefore repeatedpresses of the "FF" key may be required when movingthe actuator forward. Backwards movement is notrestricted5 Check the battery Press "INFO" key repeatedly until thebattery level appears on the screen and then press"YES" to confirmIn order to power the pumpTo ensure the pump isworking correctly.To ensure LCD display isworking properly.The barrel clamp arm needsto be in the down position toenable the “FF” and “BACK”buttons to work.In order to verify there issufficient battery power for theprogramme. (The averagebattery life, starting at 100%,is approx 3 -4 days dependingon use.) Discard the battery ifless than 40% life remaining.FITTING THE SYRINGE TO THE SYRINGE PUMPNo Action RationaleENSURE THE LINE IS NOT CONNECTED TO THE PATIENT (unless repriming only)1 Lift and turn the barrel clamp arm This will enable syringe to beplaced on the pump2 Seat the filled syringe collar/ear and plunger so theback of the collar/ear sits against the back of the centralslot (ensure correct placement with the syringe scalefacing the front). The syringe collar/ears should bevertical3 Turn and lower the barrel clamp arm to secure thesyringeTo ensure the safe delivery ofmedication.To ensure the safe delivery ofmedication.Page 13 of 33

NOTE: The syringe graphic on the screen ceases to flash at each point as the syringe iscorrectly seated.Confirm that the syringe size and brand match the screen message. Press "YES" to confirm orscroll up + down - arrows to view other syringe manufacture choices, select press “YES” toconfirm.SETTING THE INFUSION PARAMETERSNew PatientAfter the syringe confirmation, the firstscreen that appears is displayedSame PatientAfter the syringe confirmation, the first screenthat appears will showVol. 15.73 (of) 15.7mlDuration: 24.00Rate: 0.66/hConfirm. Press YesThe pump calculates and displaysthe deliverable volume, duration of infusion(24hrs) and rate of infusion (millilitres per hour)Press Yes to confirm.PressYES to RESUMENO for New ProgramN.B. If the original syringe is still inplace, pressing "No for New programwill reset the 24 hour clock, this means thatthe remaining contents of the syringe will bedelivered over the next 24 hoursfrom confirming "start infusion".Pump screen prompts “ START INFUSION”Check the line is connected to the pumpCONNECTING THE INFUSION TO THE PATIENTNo Action Rationale1 Shave or clip excess hair from theselected site2 Insert the needle inverted (bevel up) at an angleof 30-45 degrees into the subcutaneous tissue atthe selected site.To enable site to be viewedand to ensure that anydressing used will adhereproperly.To ensure needle is placedcorrectly.3 Secure the needle with a transparent dressing To ensure that the site can beviewed at all times.4 Include a loop of the infusionset under the dressing.To avoid any direct pull on theneedle.Page 14 of 33

5 Ensure the patient and carers know that thesyringe pump must NOT be placed at a levelhigher than the infusion site.6 Record in the appropriate documents, thedrugs/diluent administered and the time theinfusion commenced.7 Never take a syringe that is not empty off thepump if it is still connected to the patient.To ensure that the contents do notsiphon out.To ensure accurate recordkeeping.To prevent the patient fromreceiving an accidentaladministration of medication.N.B. It takes 4-6 hours for drugs to reach therapeutic blood plasma levels via the syringe pump,therefore, an additional stat dose of themedication may require to be administered when the syringe pump is set up if the patient hasunrelieved symptoms.STARTING THE SYRINGE PUMPIn order to start the infusion, press “YES” on the syringe pump. When the pump is running, thescreen displays the following:• Top line -infusion duration time remaining;• Main line -infusion rate in ml/hour;• Bottom line -alternates between syringe size/brand and the message"«« Pump delivering". The green LED indicator will also flash.KEYPAD LOCKThe T34 allows all users to lock the operation of the Keypad during infusion. This functionshould be routinely used to prevent tampering with the device.I. Activating the keypad lockWith the pump infusing press and hold the "INFO" key until a chart is displayed showing a'progress' bar moving from left to right. Hold the key until the bar has moved completelyacross the screen and a beep is heard to confirm the lock has been activated. NB Thefollowing buttons are still active Stop / No, Start / Yes, Information.II. Deactivating the keypad lockTo turn the lock off, repeat the above procedure. The bar will now move from right (lock) toleft (unlock) and a beep will be heard.Page 15 of 33

STOPPING THE INFUSION AND REMOVING THE SYRINGE PUMPEach practitioner will be issued with a key and will be responsible for its safe keeping. NB. IR1must be completed if a key is lost. Any member of staff leaving the PCT must return the key tothe Clinical Services Manager.No Action Rationale1 Removal of the Cannula and/ordiscontinuation of infusion must only becarried out by an appropriately trained healthprofessional.2 When the infusion is complete and thesyringe is empty, it will stop automatically andthe alarm will sound. If the syringe pump isno longer required for the patient, press"OFF" and then remove the battery from thesyringe pump.3 If the infusion is to be stopped before thesyringe is empty, it should also bedisconnected at the syringe end from thepatient for safety reasons before the syringeis taken off the pump. A syringe that is notempty must NEVER be taken off the pumpwhile connected to the patient.4 Clean the pump and the cover (do notimmerse pump in water). Dry and replace inpackaging if no longer required for use.5 Temporary Interruption of Infusion,e.g. bathing: Press STOP6 Press and hold "OFF" button untila beep is heard; the screen willgo blank.To ensure patient safety and maintainprofessionalresponsibilityTo ensure the pump is off and theremaining battery life is saved.To ensure there is no accidentaladministration of drugs to the patient.To comply with infection controlguidelines.To ensure pump is off while bathing.To ensure pump is switched off7 Do not remove syringe from pump. To ensure pump can reset to originalregime.8 Disconnect the line from the syringe and capthe end of the line and syringe tip.To avoid contamination of line andsyringe.RESUMING THE INFUSIONNo Action Rationale1 Check that the prescription, syringe label andpatient details match.2 Reconnect the line to the syringe on thepump.To ensure that this is the correctsyringe for this patient.To ensure pump can reset to originalregime.Page 16 of 33

3 Press and hold the "ON" button until a beepis heard.To ensure pump is switched on.4 The screen will request confirmation ofsyringe size and syringe brand.5 The screen will display the remaining volume,duration and rate of infusion.To ensure the correct rate of infusionis calculated.To confirm the correct amount andduration of infusion remaining.6 Press "YES" to confirm If you press "NO" the pumpinterprets this as a completely new24hr period. In this case, you wouldrequire setting up a completely newprescription from the start.7 The screen will display "StartInfusion".To confirm that the infusion is to berecommenced.8 "YES" to confirm Press. To start infusion.WHAT TO DO IF THE PATIENT DIES WHILST THE SYRINGE PUMPIS RUNNINGNo Action Rationale1 Stop the pump To discontinue the infusion.2 Press the "INFO" button and record the date,time and amount of solution remaining to beinfused in the syringe (ml).3 If there are doubts about the circumstancesof the death, leave the pump in place andcontact the Line Manager for advice.4 In a straightforward situation, followingidentification of death, remove the needleand line from the patient and discardcontents into denaturing kitTo ensure accurate record keeping.To ascertain any legal requirements.To ensure compliance with NHSHalton & St Helens policy for Disposalof Controlled Drugs5 Remove the battery. To protect battery life and pump.6 Record the signature(s) of person(s)destroying the remaining solution.To ensure compliance with the HealthRecords Policy.SITES FOR PLACEMENT OF CANNULA FOR SYRINGE PUMPINFUSIONI. Appropriate sites for continuous infusion of subcutaneous drugs are as follows: Anterior chest wall AbdomenPage 17 of 33

Lateral aspects of upper arms and thighsBack (scapula) -particularly suitable for confused patientsII. Areas which should not be used for syringe pump infusion Lymph oedematous limbs or trunk Sites over bony prominences Sites near a joint Previously irradiated skin Infected skin/skin lesionsCARE OF INFUSION SITENo Action Rationale1 A transparent dressing must be used. To permit visible monitoring ofsite.2 If there is evidence of inflammation or poorabsorption (hard subcutaneous swelling), theinfusion site should be renewed.3 The needle site should be changed at leastevery 3 days.4 Inspect for leakage at the cannula site and atthe connection sites.This may effect absorption ofmedication and patient comfortTo reduce the risk of irritation /inflammation / cannula displacement.In order to minimise the risk of anymalfunction or administrationproblems.SITE BREAKDOWNNo Action Rationale1 Further dilute drug if possible To reduce any site irritation2 Change infusion device, e.g. Thalus set ifpatient has allergy to metal (Unomedical -available through NHS Logistics).To reduce any site reaction andprevent absorption problems.3 Change type of site dressing To reduce any site irritation4 Change site more often To reduce any site reaction.5 Check diluent To ensure the appropriate diluentis used.6 Check compatibility of drugs. (Seek advicefrom a pharmacist on whether an alternativediluent would be appropriate).To reduce the possibility of druginteractions.7 Consider the use of an additional pump. To reduce any possible druginteractions.Page 18 of 33

CARE DURING INFUSIONNo Action Rationale1 Explain care of the pump to carers e.g. avoidspillage of liquids on it or avoid dropping.Report if light stops flashing or if alarmshould sound.Good communication enables betterpatient/family experience and ensuresearly intervention of health careprofessionals if pump malfunctions.2 Check battery daily To ensure sufficient battery life.3 Avoid using mobile telephone nearer than 1metre to the syringe pump (McKinley MedicalUK Ltd).To ensure there is no interference withthe operation of the syringe pump.4 When the patient is mobile, ensure syringepump is well supported.To ensure the comfort of the patientand also to prevent pump malfunction.CHECKS TO BE MADE WHILST SYRINGE PUMP IS IN USENo Action Rationale1 Assess symptom control regularly Individualised care/ good practice.2 Check site for redness, inflammation,infection or needle displacement.3 Check syringe and infusion line forcrystallisation, precipitation, cloudiness orcolour change of contents or leakage.Re-prime pump if this is the case.4 Check the display -pump is delivering andinfusion rate is as programmed.To ensure early detection of siteproblems.To ensure early detection of drug /diluent incompatibility.To ensure the pump is delivering thecorrect infusion rate as required.5 Record rate setting To ensure accurate record Keeping6 Press the "INFO" key to check: Single press -VTBI (Volume to beInfused) and volume infused andrecord. Double press -battery life remaining.7 Visually check fluid remaining in syringe ateach check and compare with pump readingkeeping a record of measurement at eachvisit.To verify infusion rate and batterylife.To verify that contents of thesyringe reflect pump reading.Page 19 of 33

TROUBLESHOOTINGNo Action RationaleIf fast (running more than 1 hour ahead of expected time)1 Check the rate setting is correct. To ensure pump rate is not set too fast.2 Check the correct syringe brand or sizehas been selected.3 Change the entire syringe pump for a newone and send for servicing.To ensure exact calculation by syringepump of rate.In order to maintain patient safety and incompliance with NHS Halton & StHelens Medical Devices Policy.4 Inform the patient’s medical practitioner ifthe patient's clinical condition gives causefor concern.5 Report the incident through the PrimaryCare Trust’s incident reporting system.To obtain expert medical adviceTo ensure compliance with Halton & StHelens Primary Care Trust IncidentReporting Policy.No Action RationaleIf slow (running more than 1 hour behind expected time).1 Check the syringe pump light is on. To ensure that the pump has power.2 Check the battery level. (If battery leveldisplays 40% or below, change battery.)To ensure the power level is sufficient tocomplete the safe delivery of drugs overa 24 hour period.3 Check the rate setting is correct. To ensure the appropriate dose isdelivered.4 Check the correct syringe brand or sizehas been selected.5 Check that syringe is inserted correctly intosyringe pump.6 Ascertain if syringe pump has beenstopped and restarted for any reason.7 Check contents of syringe and line -is thereany evidence of crystallisation/kinking oftubing8 Check needle site -is this red / hard /lumpy/sore?To ensure exact calculation by pump ofrate of administration.The pump will not work if the syringeinserted incorrectly.This will affect the functioning of thepump.This may slow delivery of contents.This may affect absorption9 Change needle site if necessary To improve absorption.10 Consider further dilution of drugs tominimise irritation by setting up a freshTo prevent irritation.Page 20 of 33

syringe.11 Consider metal allergy from needle. Patient may have an allergy to the metalin the needle.If a patient is assessed as having anallergy to the McKinley giving sets, thesecan be substituted with Teflon coatedgiving set to ensure that the patient’shypoallergenic issue is addressed.12 If the syringe pump continues to runthrough too slowly, change the entire pumpand send for servicing.13 Check the rate of infusion at regularintervals.To ensure that any problems withthe syringe pump are investigated andrepaired if necessary. To ensure thepatient receives correct medication overcorrect timeCheck the rate of infusion at regularintervals.IF THE PUMP ALARM ACTIVATESWhen 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.The following table indicates the appropriate actions should the pump alarm.Actions to be taken by the patient / carer in the event that the pump alarms are also outlined inthe Patient Information Leaflet (Refer to Appendix 2)Alarm Possible Cause ActionOcclusion or SyringeEmpty.Patient access deviceblocked, kinked, clamped.Release clamp. Flush orreplace access device.Syringe DisplacedPump UnattendedOcclusion.Actuator has reachedminimum travel position.Syringe has been removed ordisplaced.Pump left or no key pressesdetected for 2 minutes.Remove occlusion and restart.End of program, switch pumpoff.Check and confirm syringeseated correctly and resume.Start infusion, continueprogramming or switchoff.Page 21 of 33

Near End15 minutes from end ofinfusion.Prepare to change syringe orswitch off.End Program Infusion complete The pump will either default toKVO, (keep vein open) awaitnurse, or it will alarm in whichcase switch pump off.DRUG ADMINISTRATION USING SYRINGE PUMPI. Prescribing for Syringe PumpsAnticipation of symptoms and corresponding patient requirements is advocated forat least 24 hours. Appropriate quantities of supplies require to be obtained forpatients' foreseeable needs. (For further information, please refer to NHS Halton &St Helens End of Life Care Pathway).The prescription should contain: Patient demographic details Drug name Drug dose Diluent Route of administration Duration of infusionAdditional 'as required' stat doses of analgesia should always be prescribed on theappropriate prescription sheet and be available for administration by nursing staff asrequired.II. Prescribed medications:Four groups of drugs are commonly prescribed:Analgesics (usually Diamorphine or Morphine Sulphate or Oxycodone)Anti-emetics (Cyclizine, Haloperidol, Levomepromazine, Metoclopramide)Sedatives (Midazolam)Anti-secretory drugs (Glycopyrronium, Hyoscine hydro bromide) for further guidanceabout drug prescriptions and conversions please contact the Macmillan SpecialistPalliative Care Team or GP.Page 22 of 33

CARE OF MEDICATIONSNo Action Rationale1 Protect the syringe from directlight whenever possible.2 Visual inspection of drug solutionsshould be made at eachmonitoring check (at least daily)and discarded if evidence ofcrystallisation, precipitation,cloudiness or discolouration.3 Avoid high concentrations of drugsused singly or in combination.4 Do not infuse contents of syringepump over a period longer than 24hoursSome drugs may be lightsensitive.To enable early detection of drug interactions.This will minimise the risk of site irritation.Prescriptions are only issued withinHalton & St Helens Primary CareTrust for 24 hour delivery.It remains the responsibility of each individual practitioner to ensure that the drug(s) prescribedare suitable for continuous subcutaneous infusion, and are stable under these conditions. If inany doubt, seek advice from an appropriate Pharmacist or other appropriate professional.DILUENTSA greater dilution of syringe pump contents reduces:The risk of incompatibilityThe impact of priming a lineInjection site skin reactionsKEY PERFORMANCE INDICATORSI.The number of untoward incidents reported relating to drug errors whilst using theMcKinley T34 Syringe Pump.II.The number of untoward incidents reported relating to the performance of theMcKinley T34 Syringe Pump.III.The number of staff attending Syringe Pump training annually.AUDIT PLANMcKinley T34 Syringe Pump Audit will be carried out on an annual basis which will be based onthe above key performance indicators.Page 23 of 33

ACKNOWLEDGEMENTSWe extend our thanks and appreciation to Western Cheshire for allowing us to utilise their ownguidelines as a basis for this document.Page 24 of 33

REFERENCESReferenceRelevance (wholedocument orsection, pleasestate)British Medical Journal, 2(6190): 582 Section ReportDickman, A. Littlewood, C. Varga, J (2005) TheSyringe Driver. University Press, Oxford.Doyle, D. Hanks, G. Cherry, N. Calman, K. (1993)Oxford Textbook of Palliative Medicine, 3rd Edition,Oxford University Press, Oxford.Hunt, T. (2002) in: Pension, J. Fisher, R. (eds)Palliative care for people with Cancer. London: Arnold.McKinley Medical UK Limited. Ambulatory SyringePump Instruction Manual. McKinley T34, June 2005.Medical Devices Agency (2003). Devices Bulletin:Infusion Systems. Medical. Devices Agency, March2003.Merseyside and Cheshire Palliative Care NetworkAudit Group, 3rd edition (2006).Western Cheshire Primary Care Trust (2008). End ofLife Care Pathway. (Guidelines for Strong OpioidSubstitution in Palliative Care.)Wright, B.M. & Callan K. (1979) Slow drug infusionsusing a portable syringe driver.NHS Halton and St Helens, Records ManagementPolicy 2007WholeEvidenceGradePolicyNHS Halton and St Helens, Consent Policy 2009 Whole PolicyPage 25 of 33

APPENDIX 1Glossary of TermsThe following terms are used in this document;Stat: The injection of a drug (or drugs) in a high quantity at once, the opposite of gradualadministration (as in intravenous infusion).Cannula: A tube which can be inserted into the body, often for the delivery or removal of fluid.Diluent: An agent used for effecting dilution.Infusion set: An implantable device consisting of a fine needle and tubing which is attached toa syringe to enable the delivery of drugs via a syringe pump.Page 26 of 33

APPENDIX 2McKinley Syringe PumpsPatient Information LeafletWhat is a Syringe Pump?This is a small, portable battery controlled pump. It can be carried about in a pouch attached toa belt, on a shoulder holster, or in your pocket. The pump is fitted with a syringe, which givesyour medicines through a needle just under the skin. The medicines are absorbed directly intoyour bloodstream. The pump runs 24 hours a day, avoiding the need for repeated injections.Why do I need one?Sometimes it is easier for you to have some of your medicines this way.This may be because: You have been vomiting, and find it difficult to keep your medicines down. Medicines tohelp stop vomiting are given in the syringe pump, along with medicines to help othersymptoms such as pain. Once the vomiting has settled you may go back to having yourmedicines by mouth. You have so many medicines to take that you are finding it difficult to manage them all.Putting some of the medicines in the syringe pump can reduce the number of medicinesyou need to take by mouth. You are unable to swallow medicines. Medicines to help your symptoms can be put intothe syringe pump. Starting a syringe pump doesn’t mean that your medicines havestopped working or aren’t strong enough, only that this is a more effective way of gettingthem into your body, if you cannot take them by mouth.Page 27 of 33

Who will look after my syringe pump?If you are at home, your community nurse will come in each day to replace the syringe, checkthat the needle is comfortable and that there are no problems with the medicines.If you are staying in the hospital, hospice or care home the staff there will check your syringepump regularly to make sure it is working well. The syringe will be changed each day by thestaff. They will check that the needle is comfortable and that you are not having any problemswith the medicines.The medicines in your syringe pump have been prescribed by your doctor to help yoursymptoms; you do not need to do anything to the syringe pump. The medicines will continue tobe absorbed over 24 hours, helping your symptoms round the clock.What does a syringe pump look like?The syringe pump currently in use in Halton & St Helens Primary Care Trust is the McKinleyT34 syringe pump. The pump (actuator) pushes the medicine into the giving set, through theneedle and into the tissues under the skin where it is absorbed into your bloodstream. While thepump is running the indicator light will flash to let you know that it is working.The pump is lightweight and about 15cm long by 5cm tall. It may have a clear plastic cover toprotect it and may be in a fabric bag, to protect the syringe from light. Your nurse or doctor willbe able to show you the syringe pump.Some dos and don’tsThe medicines in the syringe pump will flow into your blood stream throughout the 24-hourperiod, controlling your symptoms. Any adjustments required will be made by your GP orCommunity Nurse or by the hospital or hospice staff. Do not interfere with the syringe or thepump.You must keep the syringe pump and the infusion site dry. Take care when washing or bathingto keep the syringe pump dry. If you drop it into water contact your nurse, a new syringe pumpwill be needed to be sure that your medicines are being given at the right rate.The syringe in the pump should not be exposed to direct sunlight– you should keep it in thefabric pouch to protect it from light.The syringe pump should not be exposed to extremes of heat. Avoid placing the syringe pumpnext to a heat pad, electric blanket or hot water bottle.Avoid the use of mobile phones within a metre of the pump if at all possible as they mayinterfere with the way the pump works. If a call is unavoidable, keep the length of the calls asshort as possible.If you notice any of the following contact your nurse/GP:Page 28 of 33

The colour of the medicines in the giving set has changed.There is a cloudiness or sediment in the giving set.The skin around the needle is red, swollen or painful.The alarm on the pump sounds.How will I know the syringe pump is working?The green light on the case will flash so long as there is power in the battery. If the light goesout while the syringe pump is running, the battery will need to be replaced when the nextsyringe is put in. There is no need to change the battery before then the rest of the medicine inyour syringe will be given. A new battery will last for three to four days.If the alarm sounds it may mean your infusion is complete, or that there is a blockage in thesyringe or giving set. Contact your nurse who will check the pump.If I have any worries who should I contact?District Nurse: TelOut of Hours contact: TelVersion No: 1.0Date of Issue: October 2009Page 29 of 33

APPENDIX 3ChecklistThe McKinley T34 Syringe Pump Monitoring Checklist needs to be completed for every patientwho has a pump in operation. The trained member of staff undertaking the visit needs to ensurethat this form is complete at every visit.Following completion, if the staff member has any concerns the syringe pump needs to bediscontinued and the Team Leader informed immediately.Click here to download the checklistName:NHS Number:D.O.B.Date commenced:Syringe pump number:All syringe pumps should be checked. At Every Visit. Checkcorrect delivery rate, site condition and for signs ofcrystallisation or precipitation. Nurses must sign and date whenthe driver is commenced and checked. Document the siteposition in the patients’ care plan and any subsequent sitechange. Any problems should be recorded in the commentsbox, patients’ health records and acted upon. Contact TeamLeader or on-call clinician.DrugsTimecheckedRemainingvolume tobe infusedVTBIVolumeinfusedVIBatteryLiferemainingas %PumpdeliveringY/NTimeRemainingSitepositionandconditionDesignationPrintSignatureStartTimeDateAStartVolumeBatteryLife %RateTimeRemainingBCDDiluentStartTimeDateAStartVolumeBBatteryLife %RateTimeRemainingCDDiluentPage 30 of 33

StartTimeDateAStartVolumeBBatteryLife %RateTimeRemainingCDDiluentPage 31 of 33

APPENDIX 4EQUALITY IMPACT ASSESSMENT TOOLTo be completed with the policy document when submitted to the appropriate committee forconsideration, approval and ratification.1. Does the policy/guidance affect one group less ormore favourably than another on the basis of:Yes/No Race No Ethnic origins (including gypsies and travellers) No Nationality No Gender No Culture No Religion or belief NoSexual orientation including lesbian, gay andbisexual people Age NoDisability - learning disabilities, physical disability,sensory impairment and mental health problems2. Is there any evidence that some groups areaffected differently?3. If you have identified potential discrimination, arethere any exceptions valid, legal and/orjustifiable?4. Is the impact of the policy/guidance likely to benegative?5. If so can the impact be avoided? No6. What alternative are there to achieving thepolicy/guidance without the impact?7. Can we reduce the impact by taking differentaction?NoNoNoNoNoNoNoCommentsIf you have identified a potential discriminatory impact of this policy document, please refer it to[insert name of appropriate person], together with any suggestions as to the action required toavoid/reduce this impact. For advice in respect of answering the above questions, pleasecontact [insert name of appropriate person and contact details].Page 32 of 33

APPENDIX 5DISSEMINATION AND TRAINING PLANTo be completed with the policy document when submitted to the appropriate committee forconsideration, approval and ratification.The status column must be given a Red, Amber or Green rating with evidence to demonstratean action has been completed.DISSEMINATION PLANTitle of document: Clinical Guidelines forthe Safe Use of McKinley T34 SyringePumpDissemination Lead: (Print name andcontact details) Sharon Woods, LorraineHodsonProposed action to retrieve out-of-datecopies of the document: N/ATo be disseminated to:All District NursesTRAINING PLANDate finalised: September 2009Previous document already being used? No (Please delete asappropriate)Disseminatedby whom?Event (Please provide details of available training venues/dates toeducate staff about this policy document)Timescale(Date)StatusR A GPaperorElectronicCommentsTimescale Owner StatusR A GE-Learning cascaded to all District Nurses4 weeksandOngoingTeamLeadersG2 x 2 day Training courses delivers to all District Nurses. Including Trainthe Trainer4 weeksandOngoingTeamLeadersGTraining Plan Lead (Please provide details of staff who will beresponsible for overseeing this training)AnnualupdateSr LorraineDowney/SrJean MorrisDistrict Nurse Team LeadersAdditional information (Please provide details of any processes in placeto support implementation)Ongoing training will be supplied and coordinated by the Team leaders fornew staffDenotes: Action not yet taken or deadline for action not met. Action plan to address this must be provided.Denotes: Action partially implemented.Denotes: Action complete.Page 33 of 33