The use of T34 syringe pumps during Covid-19 pandemic

Maria Drummond & Professor Bridget Johnston on behalf of ScotPalCovid

We searched CINAHL and Medline databases with key words: Pandemic, public health emergency, covid, palliative, end of life, hospice, dying, syringe driver, syringe pump. We followed these searches with a google and twitter search.

Due to the limited results related to covid-19 management and the use of syringe drivers we have also included general syringe driver literature and emerging covid-19 clinical guidelines in our review.

Please access the Scottish palliative care guidelines for general T34 Syringe Pump palliative and end of life care here , and the new covid-19 Scottish palliative care guidelines for when a syringe driver is not available here.

Figure 1: SIGN 50 Levels of evidence (https://www.sign.ac.uk/assets/sign50_2011.pdf)

Updated 22/04/20

  • Home visits for people with suspected or confirmed covid-19 should only be carried out following telephone triage.  (Level 4: European Association of Palliative Care, 2020 – Operational Example Guideline)
  • It is essential that services have an adequate stock of syringe drivers available due to their necessity in covid-19 symptom management. They should be used proactively and promptly due to the risk of sudden deterioration. (Level 4: Arya et al, 2020; Level 3: Lovell et al, 2020)
  • Community nursing teams should liaise with local pharmacies to ensure areas have adequate stock of common “as required” medication for people with covid-19 requiring palliative, community-based symptom management. (Level 4: British Geriatrics Society, 2020 – Clinical Guideline)
  •  Anticipatory syringe driver prescriptions should not be used. Medication to be administered via syringe drivers should only be prescribed at the time they are required by an experienced and competent clinician. (Level 4: Gosport War Memorial Hospital, 2018 – Inquiry Report)
  • Analysis of 1072 patient safety incident reports in palliative care during out of hours found that syringe drivers and other medication-related errors accounted for more than half of the reports. Many of these incidents had serious consequences for patients, their caregivers and clinicians, including (but not limited to) uncontrolled pain, emotional distress and death. Poor staffing and lack of training/knowledge were attributed to errors. (Level 2+: Williams, et al., 2019 – Secondary analysis report)
  • Clinicians should discuss myths in palliative care related to DNACPR, advance decisions and common signs of death that do not necessarily indicate pain or discomfort to help caregivers understand palliative care and reduce the likelihood of over-medicating. (Level 4: Royal College of Physicians, 2018 – Clinical Guideline; Level 2++ Watts, et al., 2019 – Literature Review)
  • When syringe drivers are indicated but unavailable, clinicians should consider alternative medication administration routes that caregivers might be able to administer to reduce house visits by clinicians. These can include transdermal patches (e.g. fentanyl or buprenorphine), transmucosal preparations, suppositories (e.g. paracetamol) and regular subcutaneous injections. (Level 4: Scottish Palliative Care Guidelines, 2020; Level 4: West Midlands Palliative Care Physicians, 2020 – Clinical Guideline)
  • When a syringe driver is commenced, it is strongly recommended that a subcutaneous or intravenous bolus is also administered due to the time that it takes for medication delivered via subcutaneous infusion to become effective. (Scottish Palliative Care Guidelines, 2020)
  • Deterioration in patients with covid-19 can be sudden. Medication administration for symptom management might not be possible when there is a wait between telephone triage and home visit. Where possible, non-pharmacological symptom management should also be encouraged. (Level 4: Lawrie & Murphy, 2020 APM Guidelines)

Please see Scottish palliative care guidelines for T34 syringe pumps and PRN symptom management for breathlessness, cough, delirium, fever and pain in patients with covid-19. (Lawrie & Murphy, 2020; Scottish Palliative Care Guidelines, 2020; West Midlands Palliative Care Physicians, 2020) 

References

ARYA, A., BUCHMAN, S., GAGNON, B. & DOWNAR, J. 2020. Pandemic palliative care: beyond ventilators and saving lives. Canadian Medical Association Journal, cmaj.200465.

British Geriatrics Society, 2020. Covid-19: Managing the COVID-1 pandemic in care homes. [Online]
Available at: https://www.bgs.org.uk/resources/covid-19-managing-the-covid-19-pandemic-in-care-homes
[Accessed 26 March 2020].

European Association of Palliative Care, 2020. Palliative care network framework in response to Covid-19 emergency. [Online]
Available at: https://www.eapcnet.eu/Portals/0/adam/Content/9mJL4s6J4k2llSSDO-dEEQ/Text/Example%20operational%20guidelines-LPCN-Bologna_17-Mar-20%20ENG%20PLUS%20questionnaire.pdf
[Accessed 26 March 2020].

Gosport War Memorial Hospital, 2018. The Report of the Gosport Independent Panel. [Online]
Available at: https://www.gosportpanel.independent.gov.uk/media/documents/070618_CCS207_CCS03183220761_Gosport_Inquiry_Whole_Document.pdf
[Accessed 26 March 2020].

Lawrie, I. & Murphy, F., 2020. COVID-19 and Palliative, End of Life and Bereavement Care in Secondary Care: Role of the specialty and guidance to aid care. [Online]
Available at: https://elearning.rcgp.org.uk/pluginfile.php/149056/mod_resource/content/1/COVID-19%20and%20Palliative%20End%20of%20Life%20and%20Bereavement%20Care%2022%20March%202020.pdf
[Accessed 26 March 2020].

Lovell, N., Maddocks, M., Etkind, S. N., Taylor, K., Carey, I., Vora, V., . . . Sleeman, K. E. Characteristics, symptom management and outcomes of 101 patients with COVID-19 referred for hospital palliative care. Journal of Pain and Symptom Management. doi:10.1016/j.jpainsymman.2020.04.015

Royal College of Physicians, 2018. Talking about dying: How to begin honest conversations about what lies ahead. [Online]
Available at: https://www.rcplondon.ac.uk/projects/outputs/talking-about-dying-how-begin-honest-conversations-about-what-lies-ahead
[Accessed 26 March 2020].

Scottish Palliative Care Guidelines, 2020. [Online]
Available at: https://www.palliativecareguidelines.scot.nhs.uk/
[Accessed 26 March 2020].

Watts, T., Willis, D., Noble, S. & Johnston, B., 2019. Death rattle: reassuring harbinger of imminent death or a perfect example of inadequacies in evidence-based practice. Current Opinion in Supportive and Palliative Care, 13(4), pp. 380-383.

West Midlands Palliative Care Physicians, 2020. Covid-19 & Specialist Palliative Care. [Online]
Available at: http://www.wmcares.org.uk/covid-19/
[Accessed 26 March 2020].

Williams, H. et al., 2019. Quality improvement priorities for safer out-of-hours palliative care: Lessons from a mixed-methods analysis of a nation incident reporting database. Palliative Medicine, 33(3), pp. 346-356.

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