Developing guidelines for syringe driver management

Clinical

Developing guidelines for syringe driver management Victoria J Kain, Patsy M Yates, Linda Barrett, Toni Bradley, Mary Circosta, Anthony Hall, Janet Hardy, Fiona Israel, Lesley McLeod, Rohan Vora, Helene Wheatley

T

Abstract

he aim of this project was to develop clinical practice guidelines for the use and administration of pharmacological agents for symptom control via syringe drivers within Australia. By developing evidence-based clinical practice guidelines for the use of this common device, this project aimed to improve patient outcomes, reduce practice variation, minimize errors and encourage more efficient use of resources. A literature review identified current literature regarding syringe driver management and an expert panel was assembled to assist in the development of the guidelines. The development of these practice guidelines provides an example of how palliative care practitioners can use a framework of contemporary evidence to enhance clinical practice.

Victoria J Kain is Project Officer, Centre for Palliative Care Research and Education, Royal Brisbane and Women’s Hospital, Patsy M Yates is Acting Director, Centre for Palliative Care Research and Education, Royal Brisbane and Women’s Hospital and Professor, School of Nursing, Queensland University of Technology, Post Office Herston QLD 4029, Linda Barrett is Project Manager, Centre for Palliative Care Research and Education, Royal Bisbane and Women’s Hospital, Toni Bradley is Palliative Care Nurse Unit Manager, Palliative Care Service, The Prince Charles Hospital, Rode Road, Chermside, QLD, Mary Circosta is Palliative Care Clinician, Palliative Care Services, Mt Olivet Hospital, Main Street, Kangaroo Point, QLD, Anthony Hall is Team Leader, High Risk Medications and Systems, Queensland Health, and Honorary Senior Lecturer, School of Pharmacy, University of Queensland Correspondence to: Victoria J Kain Email: [email protected]

60

S

yringe drivers are defined as powerdriven devices that drive the plunger of a syringe at an accurately controlled rate to deliver medications (McNeilly et al, 2004). Their use as a method of drug delivery to control symptoms in palliative care is a common and accepted practice. They provide symptom control via subcutaneous infusion of drugs to treat pain and other distressing symptoms when other routes are inappropriate or ineffective. Many of the medications used in syringe drivers have narrow margins of error; therefore, any errors that occur during prescription, preparation, administration and documentation of these infusions can result in adverse drug events and presents an ongoing risk for patient safety (Reymond and Charles, 2004). There is evidence that such adverse incidents arise as a result of the following: ● Errors in drug calculations (Dunne et al, 2000) ● Drug incompatibilities and instabilities (Dunne et al, 2000) ● Equipment failure (including disconnection) (Dunne et al, 2000) ● Incorrect rates of infusion (Dunne et al, 2000) ● Inadequate user training (Mitten, 2001; Hayes et al, 2005)

● Inadequate documentation and record keeping (Dunne et al, 2000) ● Poor servicing of equipment (McQuillan and Finlay, 1996; Mitten, 2001). The aim of this project was to develop clinical practice guidelines for the use and administration of pharmacological agents for symptom control via syringe drivers within Australia. The development of these guidelines did not aim to provide a prescriptive tool for clinicians. Rather, the guidelines were developed for use by nurses and other healthcare professionals, to inform care decisions within the context of individual patient preferences and clinical circumstances.

Methods

As there is limited high-level evidence regarding syringe driver management in the published literature, the guidelines in this project were developed from a review of the literature, as well as through a consensus process involving a multidisciplinary panel of experts in the field. A literature review was undertaken to identify the most current evidence regarding syringe driver management. The following databases were searched: CINAHL, Medline, PsycArticles and PsycInfo. The review of the literature was limited to adult patients and the English language, and covered a 10-year period from 1995–2005. Search terms included: ‘syringe drivers’; ‘subcutaneous infusions’; ‘end-of-life care’; ‘Graseby’; and ‘palliative care’. An internet search using the Google search engine was also undertaken using the same search terms. This identified relevant websites relating to syringe driver management. Personal libraries were also used to identify other literature relevant to this review. All abstracts identified in the database searches were assessed by the first author, and articles were retrieved for all papers that were identified as being of relevance International Journal of Palliative Nursing, 2006, Vol 12, No 2

Developing guidelines for syringe driver management to the review topic. In addition, clinical notes, websites and books about syringe driver devices identified as relevant to the project were retrieved. A total of 43 published and unpublished papers were considered for inclusion in the guidelines; 19 were included. The literature was rated for its level of evidence using the Joanna Briggs Levels of Evidence (Joanna Briggs Institute, 2005). Each manuscript or report was reviewed and rated independently by two members of an expert panel. Discussions were held to achieve consensus where discrepancies in ratings occurred. The expert multidisciplinary review panel consisted of individuals working in relevant clinical areas. This panel was generated from a targeted sample of known experts, representing several disciplines, in this field of health care. This sample was generated from within southeast Queensland. Panel members included palliative care nurses, physicians, and a pharmacist with expertise in palliative care medications. The multidisciplinary review panel was involved in reviewing the literature using set criteria, and providing feedback on the quality and relevance of the draft guidelines. Consensus was sought by holding regular meetings to discuss development of the guidelines, as well as providing opportunities for written comment on the draft documents during all phases of guideline development. The review panel also provided comments on the format for presenting, disseminating and promoting uptake of the guidelines. Authors’ details continued Janet Hardy is Director Palliative Care, Mater Health Services, Raymond Terrace, South Brisbane, QLD, Raymond Terrace, South Brisbane, QLD, Fiona Israel is Clinical Nurse Consultant (Research), Brisbane South Palliative Care Collaborative, Main Street, Kangaroo Point, QLD, Lesley McLeod is Nurse Unit Manager, Brisbane South Palliative Care Service, Main Street, Kangaroo Point, QLD, Rohan Vora is Trainee Registrar Chapter of Palliative Medicine, Mt. Olivet Hospital, Kessels Road, Coopers Plain, QLD, and Helene Wheatley is Clinical Nurse, Blue Care Nursing Services (Palliative Care), Blue Care Head Office, 56 Sylvan Road, Toowong, QLD, Australia

Findings

A review of the literature was undertaken to describe patient experiences and care issues associated with syringe driver use, and to develop guidelines on the following areas: ● Equipment ● Selection and preparation of the site ● Drugs and diluents ● Patient/family needs ● Patient assessment and monitoring. The recommendations in the guidelines, informed by the literature findings and consensus by the expert panel, were developed to inform clinical decision making in this field. They are intended to be applied in practice in ways that are suitable to individual clinical circumstances and patient preferences. The guidelines generated from this process also require further validation, as the recommendations for practice identified

International Journal of Palliative Nursing, 2006, Vol 12, No 2

through this process are based upon comparatively limited high-level evidence. The patient experience Although some studies report that subcutaneous infusions are well accepted and can achieve almost 100% compliance among people with life-limiting illnesses (Morgan and Evans, 2004), some people may view the device as an invasion of their body privacy, and remind them of a poor prognosis (Coleridge-Smith, 1997). They may also restrict a person’s daily activity. Syringe drivers should be used when it is determined that improved symptom control will result from the continuous delivery of medication, and that other less invasive routes for administering medication are not possible (Gomez, 2000). Equipment and selection of syringe drivers The most common syringe drivers identified within the literature were the SIMS Graseby® MS16A and the MS26 (McQuillan and Finlay, 1996; ColeridgeSmith, 1997; O’Doherty et al, 2001), that are electronic, battery-driven syringe drivers. Regardless of which model Graseby® battery-driven device used, the literature suggests that the size and brand of the syringe is an important consideration (Mitten, 2001; Dickman et al, 2005). It is important to note that different brands of syringes have different diameters and lengths (Mitten, 2001). Another important consideration when selecting a syringe type is that a LuerLok® syringe is used to minimize the risk of disconnection from the infusion line (Dickman et al, 2002; McNeilly et al, 2004). Table 1 provides a summary of the equipment-related guidelines. The selection and preparation of the site Site problems will cause the patient discomfort and may interfere with drug absorption, thus compromising effective symptom control. The selection of an appropriate site for subcutaneous infusion via a syringe driver can help avoid site problems, and minimize restrictions on the patient’s normal functioning. The general principles for appropriate site selection include the following (Dickman et al, 2005): ● An area with a good depth of subcutaneous fat should be used ● The site should not be near a joint ● A site that is easily accessible, such as the chest or abdomen, should be selected (Figure 1).

61

Developing guidelines for syringe driver management

Use a site that is not near a joint

Select a site that is easily accessible, such as the chest or abdomen

Use an area with a good depth of subcutaneous fat

Figure 1. Appropriate site selection.

Site selection will depend upon whether the patient is ambulatory, agitated and/ or distressed. From a local, Australian perspective, the chest or abdomen is generally the preferred site. These sites are recommended because they are accessible easily, oedematous rarely, and permit easy inspection by the caregiver (Dickman et al, 2005). However, alternative sites may include the upper, anterior chest wall above the breast, but away from the axilla (Dickman et al, 2005). The upper arm can

be used, but this makes it difficult for the patient to lie on their side and may lead to problems such as bruising (Dickman et al, 2002). If the patient is distressed or agitated, using the area on the back over the scapula may be useful to prevent dislodgement (Mitten, 2001; Dickman et al, 2002). Inappropriate site selection includes the following (Dickman et al, 2005): ● Lymphoedematous areas ● Areas where there is broken skin ● Sites that have been irradiated recently ● Sites of infection ● Bony prominences ● Close proximity to a joint ● Sites of tumour ● Skin folds ● Inflamed skin areas ● Wherever ascites or pitting oedema are present ● Where scarring is present ● Areas where lymphatic drainage may be compromised (Gomez, 2000), e.g. in women who have had a mastectomy. Reducing site irritation Many factors contribute to site reactions such as the tonicity of the medication,

Table 1. Summary of equipment-related guidelines The most common syringe drivers in clinical use are the SIMS Graseby® MS16A and the MS26 (McQuillan and Finlay, 1996; Coleridge-Smith, 1997; O’Doherty et al, 2001) The organization’s protocol regarding the preparation and set up for changing the device should always be used to guide practice The syringe driver is normally used to deliver medications over a 24-hour period (Coleridge-Smith, 1997; Ratcliffe, 1997; O’Doherty et al, 2001; Dickman et al, 2002) A 10 mm (Mitten, 2001) Luer-Lok® syringe (Dickman et al, 2002; McNeilly et al, 2004) should be used if volume/concentration permits. Twenty and 30 mm syringes can be used, but may not fit as well (Mitten, 2001) The same brand of syringe should be used each time to minimize errors in setting up the syringe driver and calculating the rate (Mitten, 2001; Dickman et al, 2002) The syringe should be measured every time the device is set up, as different brands of syringes have different diameters and lengths (Mitten, 2001) An aseptic technique should be used when preparing and setting up the infusion (Ratcliffe, 1997) A minimum volume extension set should be used to minimize dead space in the line (Dickman et al, 2005) When changing the extension set and/or cannula, prime the line after drawing up the prescribed medications to the appropriate length in the syringe (Ratcliffe, 1997; Gomez, 2000; Mitten, 2001; Dickman et al, 2005). After priming the line, measure the syringe and document the line change and the time the syringe is calculated to finish Teflon® or Vialon® cannulas are associated with less risk of site inflammation than stainless steel cannulas (Mitten, 2001; Morgan and Evans, 2004; Dickman et al, 2005)

62


Developing guidelines for syringe driver management the pH of the solution, infection and prolonged presence of a foreign body (Morgan and Evans, 2004). Specific drugs used in palliative care that may cause site irritation include cyclizine (Dickman et al, 2002; McNeilly et al, 2004), levomepromazine, methadone, promethazine, morphine tartrate and ketamine (Dickman et al, 2005). Techniques that may be considered to minimize site irritation include: ● Diluting the medications by using a larger syringe size (Dickman et al, 2002) ● Using normal saline 0.9% (if applicable), instead of water for injection (Dickman et al, 2002) ● Adding 1mg of dexamethasone to the syringe (Mitten, 2001). One Australian trial found that the addition of 1mg of dexamethasone to syringe drivers can significantly extend the longevity of the subcutaneous infusion site (Reymond et al, 2003) ● The use of Teflon® or Vialon® cannulas (Dickman et al, 2002). A UK study suggests that 1500 units of hyaluronidase can be injected into the site before the commencement of the infusion if the skin is not already irritated. Hyaluronidase acts to macerate the subcutaneous tissue, thereby increasing drug absorption (Mitten, 2001). The use of hyaluronidase for subcutaneous drug administration is uncommon in Australia, and is more commonly used for the administration of subcutaneous fluid for rehydration. Hyaluronidase is also

contraindicated in patients with asthma (Mitten, 2001). The longevity of the site can vary considerably from 1–14 days. Many variables influence the longevity of the site, such as the type of medication and needle used. Rather than relying on a time frame for resiting the infusion, the onset of a site reaction should dictate this practice (Mitten, 2001). Site inspection Meticulous site inspection is integral to early identification and prevention of site-related complications, and should be performed as part of routine care (Coleridge-Smith, 1997; Ratcliffe, 1997; Mitten, 2001) (Table 2). Site problems can cause patient discomfort. They also interfere with drug absorption and compromise effective symptom control. When inspecting the site, the following features should be checked: ● Tenderness or hardness at the site ● Presence of a haematoma ● Leakage at the insertion site ● Swelling — a sterile abscess can occur at the insertion site, causing local tissue irritation (Ratcliffe, 1997) ● Erythema (redness) ● The presence of blood in the tubing ● Displacement of the needle (Dickman et al, 2005). In addition to checking the site regularly (4 hourly is recommended; Dickman et al, 2005), other important patient checks include (Dickman et al, 2005):

Table 2. Summary of site selection guidelines General principles for appropriate site selection include (Dickman et al, 2002): using an area with a good depth of subcutaneous fat; using a site that is not near a joint; selecting a site that is easily accessible, such as the chest or the abdomen The longevity of the site can vary considerably from 1–14 days. Many variables influence the longevity of the site, such as the type of medication and type of needle used Select and use sites on a rotating basis (Gomez, 2000) When the tubing is placed against the skin, form a loop to prevent dislodgement if the tubing is pulled accidentally (Mitten, 2001) Use a transparent, semi-occlusive dressing to cover the site, as this permits inspection of the site by the caregiver (Mitten, 2001) Factors that cause site reactions include: the tonicity of the medication; the pH of the solution, infection and prolonged presence of a foreign body (Morgan and Evans, 2004) Site selection will depend upon whether the patient is ambulatory, agitated and/or distressed The chest or abdomen are the preferred sites (Dickman et al, 2002), specifically the upper, anterior chest wall above the breast, away from the axilla. If the patient is cachectic, the abdomen is a preferred site (Dickman et al, 2002)

64


Developing guidelines for syringe driver management ‘Subcutaneous infusion is a commonly used method for delivering a wide range of medication, particularly when other drug routes are no longer available, or are unacceptable to the patient...’

66

● Asking the patient how they feel (or family member/carer, if the patient is unable to do so themselves) — is their pain controlled and are other symptoms controlled? ● Ensuring that the light on the syringe driver is flashing. A ‘whirring’ sound should be heard as the device delivers the infusion ● Checking the volume remaining in the syringe and that the device is running to time ● Ensuring there are no leakages, and that the connections to the syringe and the cannula are firm. Drugs and diluents Subcutaneous infusion is a commonly used method for delivering a wide range of medication, particularly when other drug routes are no longer available, or are unacceptable to the patient (Mitten, 2001). Pain is the most common symptom for which syringe drivers are used, but the use of syringe driver devices is not limited to pain control. Drugs to control other symptoms, such as nausea, vomiting, dyspnoea, agitation, delirium and terminal phase ‘noisy breathing’ can also be prescribed for continuous subcutaneous infusions and administered in the same syringe (Gomez, 2000). Commonly, two to three drugs and occasionally up to four drugs (McNeilly et al, 2004) may be mixed in a syringe for a subcutaneous infusion. The maximum drugs that most clinicians are prepared to mix in a single syringe is four (O’Doherty et al, 2001). However, when mixing large amounts of drugs in the same syringe, specialist palliative care advice should be sought. The more drugs that are mixed together, the greater the risk of precipitation and reduced efficacy (Mitten, 2001). It has been reported that a wide variety of drugs can be used in different combinations with no clinical evidence of loss of efficacy (Lichter and Hunt, 1995). If compatibility is an issue, the use of two syringe driver devices (ColeridgeSmith, 1997) may be considered. In the Australian context, symptoms that are encountered at the end of life are generally well controlled by the use of nine commonly used medications. These include the following: ● Morphine sulphate/tartrate (an opioid) ● Hydromorphone (e.g. Palladone, an opioid) ● Haloperidol (e.g. Serenace, an antipsychotic/antiemetic)

● Midazolam (e.g. Hypnovel, a short-acting benzodiazepine) ● Metoclopramide (e.g. Maxolon, an antiemetic) ● Hyoscine hydrobromide (an antimuscarinic/antiemetic) ● Clonazepam (e.g. Rivotril, a benzodiazepine derivative) ● Hyoscine butylbromide (e.g. Buscopan, an antimuscarinic) ● Fentanyl (e.g. Durogesic, a narcotic). An important safety consideration, before mixing any drugs together in a subcutaneous infusion, is to check for stability information (Coleridge-Smith, 1997; Mitten, 2001; Dickman et al, 2002). Information can be confirmed and clarified with hospital pharmacists or at www.pallcare.info regarding stability. Temperature, as well as exposure to light, may affect the stability of drugs. This can be overcome by ensuring that the syringe driver device is placed on top of bed clothes and outside of clothing, rather than beneath them (Dickman et al, 2002). Medications contraindicated for use in syringe drivers Drugs such as prochlorperazine (an antiemetic), diazepam (an anxiolytic) (Mitten, 2001) and chlorpromazine (an antipsychotic) (British Medical Association and Royal Pharmaceutical Society of Great Britain, 2005) are specifically contraindicated for use in subcutaneous infusions owing to severe localized reactions. There are several drugs that have also been linked to abscess formation when used in subcutaneous infusions. These include pethidine (hydrochloride pethidine, an analgesic), prochlorperazine (e.g. Stemetil, an antiemetic) and chlorpromazine (e.g. Largactil, an antipsychotic) (Dickman et al, 2005). Diluents The choice between water for injection and 0.9% saline (normal saline) as a diluent is a matter of debate. The literature is divided with some recommending water for injection as the diluent (Mitten, 2001; Dickman et al, 2002; Flowers and McLeod, 2005), and recent literature recommending normal saline (Dickman et al, 2005) as the diluent. Normal saline can be used for most drugs, the main exception being cyclizine (Dickman et al, 2002). Normal saline is used most commonly within Australia for two reasons (Dickman et al, 2005) — firstly, the majority of drugs can be diluted with normal saline International Journal of Palliative Nursing, 2006, Vol 12, No 2

Developing guidelines for syringe driver management with only two exceptions: cyclizine and diamorphine (neither of which are commonly used in Australia). Secondly, normal saline is isotonic, as are most injectable formulations. By diluting with normal saline, the tonicity of the solution is unaltered. Water for injection is hypotonic. Using this as a diluent will potentially produce a hypotonic solution. The literature suggests that hypotonicity can contribute to the development of site reactions (Dickman et al, 2005). For example, the use of water for injection has been linked to pain owing to its hypotonicity, although normal saline is more likely to cause precipitation (British Medical Association and Royal Pharmaceutical Society of Great Britain, 2005). There is a need for ambiguities to be addressed by further research, given the lack of clinical evidence or recommendations regarding diluents (Flowers and McLeod, 2005). Table 3 shows a summary of drugs and diluents guidelines. Patient/family education needs Careful explanation and education about what the device will do, and its advantages

and possible disadvantages is required (www.palliativedrugs.org). Patient and family information guidelines are shown in Table 4. Patient assessment and monitoring This section of the guidelines addresses patient assessment and monitoring principles. These principles are highlighted in Table 5.

Conclusion

Although syringe drivers alone do not achieve symptom control, they can be a useful way to deliver drugs in order to achieve this important goal. There are many benefits that syringe drivers present to the patient, in terms of convenience and effective management of symptoms. However, use of this device has not been without its risks and limitations, including the inflexibility of prescription, technical problems, safety issues and skin reactions at the site of the infusion. Syringe drivers may also cause concerns and fears for some patients and their families because they are associated with disease progression (Mitten, 2001).

Table 3. Summary of drugs and diluents guidelines Syringe drivers can be used to deliver drugs to treat a variety of symptoms. Common symptoms include pain, nausea, vomiting, breathlessness, agitation, delirium and ‘noisy breathing’ The more drugs that are mixed together, the greater the risk of precipitation and reduced efficacy (Mitten, 2001) Two to three drugs may be mixed in a syringe for a subcutaneous infusion (occasionally up to four drugs (Dickman et al, 2002; McNeilly et al, 2004)). When mixing large amounts of drugs in the same syringe, specialist palliative care advice should be sought If compatibility is an issue, the use of two syringe driver devices (Coleridge-Smith, 1997) or regular or pro re nata (prn; as required) subcutaneous injection should be considered Before mixing any drugs together in a subcutaneous infusion, check for stability information (Coleridge-Smith, 1997; Mitten, 2001; Dickman et al, 2002) and check with hospital pharmacists Use of the boost facility is not recommended because it rarely provides enough analgesia to cover uncontrolled pain, and if other drugs are being infused, overdosing could occur of the other drug(s) (Dickman et al, 2002) It is better to use breakthrough medication to treat uncontrolled symptoms than the boost facility (Lloyd-Williams and Rashid, 2003) Normal saline is the most commonly used diluent in Australia (Flowers and McLeod, 2005) The use of water for injection has been linked to pain owing to its hypotonicity, although normal saline may be more likely to cause precipitation (British National Formulary, 2005) Five per cent dextrose is used only occasionally as a diluent (Dickman et al, 2002), and is less commonly used in Australia (www.palliativedrugs.org)


67

Developing guidelines for syringe driver management The guidelines developed in this project are intended as a guide to promote a best-practice approach to clinical care in Australia. In so doing, they aim to minimize practice errors that may result in serious adverse events that present a risk for patient safety. The guidelines are, however, not intended to be prescriptive. They are intended to be used within the context of decisions about individual, clinical circumstances and patient preferences. Moreover, the majority of evidence in this field is at the expert opinion level. It is important,

therefore, to recognize the limitations of the evidence that is available to develop guidelines such as those that have been developed from this project. Evaluation of these guidelines will be conducted within 12 months and evaluation will be ongoing to reflect changes in clinical practice.

We would like to acknowledge the expertise and support of our expert panel: Professor Janet Hardy (Director of Palliative Care, Mater Health Services), Linda Barrett (Project Manager, Centre for Palliative Care

Table 4. Summary of patient/family guidelines Patient and family education promotes safety and acceptance of the syringe driver as a means to providing improved symptom control (Morgan and Evans, 2004) Patient and family education includes: explanation and education about what the device will do, and its advantages and possible disadvantages; safety aspects; ways to incorporate a subcutaneous infusion into their everyday life; and troubleshooting guidelines (Mitten, 2001)

Table 5. Summary of patient assessment and monitoring guidelines When troubleshooting the equipment used in subcutaneous infusions, it is important to understand the normal functioning of the device (Mitten, 2001) Ensure that drug calculations are checked by two qualified healthcare professionals when the syringe driver is set up (Reymond and Charles, 2004) Use only one type of syringe driver in each setting to prevent confusion that may lead to errors (Wilson, 2000; Dickman et al, 2002; McNeilly et al, 2004) Ensure that the organizational protocol is followed regarding priming of the line (Ratcliffe, 1997; Gomez, 2000; Mitten, 2001; Dickman et al, 2002; www.palliativedrugs.org) Ensure that drugs being delivered are compatible (Coleridge-Smith, 1997; www.pallcare.info) Ensure that a spare 9 volt battery is always available (O’Doherty et al, 2001; Dickman et al, 2002; www.palliativedrugs.org) Thorough patient assessment is important when caring for patients with a subcutaneous infusion (Ratcliffe, 1997; Morgan and Evans, 2004) Principles to include in patient assessment recording and documentation are as follows: • Routine careful inspection of site, at least 4 hourly, for signs of inflammation and site reaction and document findings (Reymond and Charles, 2004); • Careful inspection of syringe volume remaining (Dickman et al, 2002), at least 4 hourly, and document findings • Ask the patient how they feel (or family member/carer, if the patient is unable to comprehend), e.g. is their pain controlled and are other symptoms controlled? Document symptom control and efficacy of interventions • Careful inspection of tubing for patency (Mitten, 2001; www.palliativedrugs.org) at least 4 hourly and document findings • Site inspection should be performed as part of routine care — 4-hourly is suggested and includes principles such as checking for tenderness at the site, presence of a haematoma and leaking at the insertion site (Coleridge-Smith, 1997; Ratcliffe, 1997; Mitten, 2001)

68


Developing guidelines for syringe driver management

Key words ● Syringe drivers

● Palliative care

● Subcutaneous infusions

● Graseby

● End-of-life care

● Guideline

development

TPF-00703-2_new.ai

Research and Education), Fiona Israel (Clinical Nurse Consultant – Research, Brisbane South Palliative Care Collaborative), Dr Rohan Vora (Trainee Registrar Chapter of Palliative Medicine, Mt Olivet Hospital), Anthony Hall (Senior Lecturer, School of Pharmacy, University of Queensland), Helene Wheatley (Clinical Nurse, Blue Care Nursing Services, Palliative Care), Mary Circosta (Palliative Care Services, Mt Olivet Hospital), Lesley McLeod (Nurse Unit Manager, Brisbane South Palliative Care Service) and Toni Bradley (Nurse Unit Manager, Palliative Care Services, Prince Charles Hospital). Funding for this project was generously provided by the Queensland Health Central Zone Management Unit, Brisbane Australia. British Medical Association and Royal Pharmaceutical Society of Great Britain (2005) British National Formulary. BMA and RPSGB, London Coleridge-Smith E (1997) The use of syringe drivers and Hickman lines in the community. British Journal of Community Health Nursing 2: 292, 294, 296 Dickman A, Littlewood C, Varga J (2002) The Syringe Driver. Oxford University Press, Oxford Dickman A, Schneider J, Varga J (2005) The syringe driver — continuous subcutaneous infusions in palliative care. 2nd edn. Oxford University Press, Oxford Dunne K, Garvey A, Kernohan G, Diamond A, Duffy C, Hutchinson J (2000) An audit of subcutaneous syringe drivers in a non-specialist hospital. Int J Palliat Nurs 6: 214, 216–19 Flowers C, McLeod F (2005) Diluent choice for subcutaneous infusion: a survey of the literature and Australian practice. Int J Palliat Nurs 11: 54–60 16/02/2006

12:46:57

Gomez Y (2000) The use of syringe drivers in palliative care. Aust Nurs J 8(2 Supple): 1–3 Hayes A, Brumley D, Habeggar L, Wade M, Fisher J, Ashby M (2005) Evaluation of training on the use of Graseby syringe drivers for rural non-specialist nurses. Int J Palliat Nurs 11: 84–92 Joanna Briggs Institute (2005) Levels of Evidence. Joanna Briggs Institute, Adelaide Lichter I, Hunt E (1995) Drug combinations in syringe drivers. N Z Med J 108: 224–6 Lloyd-Williams M, Rashid A (2003) An analysis of calls to an out-of-hours palliative care advice line. Public Health 117: 125 McNeilly P, Price J, McCloskey S (2004) The use of syringe drivers: a paediatric perspective. Int J Palliat Nurs 10: 399–404 McQuillan R, Finlay I (1996) The utilization of syringe drivers at a teaching hospital. Palliat Med 10: 52 Mitten T (2001) Subcutaneous drug infusions: a review of problems and solutions. Int J Palliat Nurs 7: 75–85 Morgan S, Evans N (2004) A small observational study of the longevity of syringe driver sites in palliative care. Int J Palliat Nurs 10: 405–12 O’Doherty C, Hall E, Schofield L, Zeppetella G (2001) Drugs and syringe drivers: a survey of adult specialist palliative care practice in the United Kingdom and Eire. Palliat Med 15: 149–54 Ratcliffe N (1997) Syringe drivers. Community Nurse 3: 25–6 Reymond E, Charles M (2004) An Intervention to Decrease Medication Errors in Palliative Patients Requiring Subcutaneous Infusions. Brisbane South Palliative Care Service and Adverse Drug Event Prevention Program, Brisbane Reymond L, Charles MA, Bowman J, Treston P (2003) The effect of dexamethasone on the longevity of syringe driver subcutaneous sites in palliative care patients. Med J Aust 178: 486–89 Wilson V (2000) Clinical guidelines for use of the MS26 daily rate syringe driver in the community. British Journal of Community Health Nursing 5:162–8

C

M

Y

CM

MY

CY

CMY

K


69