Microsoft word - 16. subcutaneous infusion v1.3l.doc

___________________________________________________________________________ CLINICAL GUIDELINES for
Clinical Policy Folder Ref No: 16
Policy and Guideline Ratification Group (PGRG) Date of Issue: July 2010
Version No: 1.3
Date of review: May 2012
Author: Alison Griffiths. Matron District Nursing

NHS South Gloucestershire
Document status: Current
Amendments from Lead Nurse for Clinical Governance incorporated. Further amendments from Lead Nurse for Clinical Governance incorporated. Document put into correct format and sent to Policy and Guidelines Ratification Group for If you need further copies of this document please contact: Matron District Nursing.

NHS South Gloucestershire has made every effort to ensure this policy does not have
the effect of discriminating, directly or indirectly, against employees, service users ,
contractors or visitors on grounds of race, colour, age, nationality, ethnic (or national)
origin, sex, sexual orientation, marital status, religious belief or disability. This policy
will apply equally to full and part time employees. All NHS South Gloucestershire
policies can be provided in large print or Braille formats if requested, and language
line interpreter services are available to individuals of different nationalities who
require them.

Scope (including stakeholders)
Principles & Purpose
Roles and responsibilities
Equalities Impact Assessment
Procedure for Subcutaneous infusion
8.1 Purposes for Subcutaneous Infusions
8.2 Starting subcutaneous fluids
8.3 Selection of Fluids and Rate of Infusion
8.4 Considerations in Terminal care
8.5 Selection of Sites and Change of sites/giving set.
8.6 Potential Problems
8.7 Documentation
8.8 Equipment & Procedure
Implementation plan
Links to other PCT documents
Appendix 1 – Audit Tool
The failure to comply/adhere to these guidelines may be investigated in line with the
‘Investigating (Employment) complaints and allegations policy and procedure’ and
may result in disciplinary action, up to and including dismissal.

Community services offer therapy to enable service users to remain in their own homes preventing hospital admissions where possible. Research shows recovery and rehabilitation is most effective in service users own environment. Where this document refers to ‘the PCT’, it shall be understood to mean NHS South Gloucestershire. When referring to users of health services in the PCT, e.g. service users, clients, service users etc, the word ‘service user’ must be used. This policy applies to all Registered Nurses employed by the PCT in Provider Services and working in community nursing teams, Henderson Ward and Intermediate care Services. Principles and Purpose
This policy sets out the process underlying the clinical procedure for subcutaneous infusions. Definitions
Hypodermoclysis is the administration of fluids via subcutaneous infusion. Subcutaneous infusions can be carried out in the home setting if service users, relatives or carers feel confident and can be assessed by the district nurse to demonstrate safe techniques in caring for infusion and cannula sites. Roles and responsibilities:

Registered Nurses -
All Registered Nurses in the PCT will practice to the standards laid down by their Professional body, the Nursing and Midwifery Council (NMC). You must have the knowledge and skills for safe and effective practice when working without direct supervision. You must recognise and work within the limits of your competence. You must keep your knowledge and skills up to date throughout your working life. You must take part in appropriate learning and practice activities that maintain and develop your competence and performance. Adhere to and comply with PCT procedural documents. Report all untoward incidents to line managers using the PCT incident reporting process. Ensure risk assessments are carried out prior to procedure and follow safe systems. Service users and carers are given appropriate information to obtain consent for the procedure. Line managers and service leads must ensure: RNs are supported in terms of resources and training to enable them to provide the service. Training and updates are available and staff are supported to attend. Audits are carried out to evaluate the service and service user satisfaction. Incidents are investigated and lessons learnt are disseminated within teams. Consultation
Provider Services Senior Nursing Management team. Equalities Impact Assessment
The PCT’s equality impact assessment template has been completed, and no potential discriminatory impacts have been found. Procedure for Subcutaneous infusion

Purposes for Subcutaneous Infusions:
Subcutaneous infusion is indicated for maintaining: • Adequate short term hydration in service users who are unable to take adequate fluids orally. who are mildly to moderately dehydrated. and in whom it is difficult or impractical to insert an intravenous (IV) line. Subcutaneous infusion should only be considered in situations where: • there is acute inadequate oral intake, eg service users with dysphagia or cognitive impairment or in terminal care. the service user is distressed by symptoms of dehydration such as weakness, postural hypotension or thirst. Subcutaneous infusions should not be considered in the following circumstances: Emergency situations, eg shock, circulatory failure, severe dehydration. Obvious coagulopathy (clotting disorders). Fluid overload, eg congestive cardiac failure, marked oedema. Where service user requires intravenous treatment, eg for hypercalcaemia. In any service users where precise control of fluid balance is clinically important. Commencing subcutaneous fluids:
Starting subcutaneous fluids should be considered carefully and then reviewed every 48 hours, taking account of the service user’s condition, prognosis and wishes. Consideration and discussion also needs to be given around the issue of when to discontinue subcutaneous fluids. Discussion of these difficult issues may be easier if the conversation starts with the premise that the procedure will be used whilst it appears beneficial to the service user but will be discontinued at a later date, i.e. when the service user improves or becomes unconscious. Consultation regarding the best interests of the service user must be made with family/next of kin where service users are unable to make decisions or communicate their own needs. Staff must be aware of the legislation regarding mental capacity, ensuring that people who lack capacity remain at the centre of decision making and are fully safeguarded (NMC 2008). Selection of Fluids and Rate of Infusion:
Fluids must be prescribed by the GP or palliative care team in accordance with South Gloucestershire PCT Administration of Medications policy. Fluids can then be obtained by a local pharmacist or through District Nursing teams (although there may be some delay in ordering these). Advice must be given to service users and carers regarding storage of fluids in the home setting. Infusion fluids should be kept at room temperature and out of direct sunlight at all times. Prior to administration the items must be checked for signs of contamination or leakage to ensure sterility. 8.3.1 Recommended fluids for infusion:
Sodium Chloride: 0.9% or 0.45% (most common). Dextrose Saline: 2.5% glucose, 0.45% sodium chloride. 8.3.2 Additives
RN must not add any medications to bags of fluid for subcutaneous infusion, unless specifically prescribed. 8.3.3 Recommended Infusion Rates
Usual rate only 1 ml per minute per site. Maximum of 1.5 litres in 24 hours using a single site or 3 litres in 24 hours if using 2 sites. Two infusion sites may be used if more than 1 litre in 24 hours is required (Bruera et al 1996; Ferrand & Campbell 1996). Subcutaneous fluids should only be infused via gravity using a standard IV giving set connected to a long tube butterfly needle via luer lock connections. Drop Calculation Formula

Volume of fluid (mls) x No. of drops per ml (giving set)
Number of drops per minute = Prescribed duration of Infusion (minutes) The above formula may be used to calculate the required drops per minute rate, but the number of drops per ml for the particular giving set being used must be known, this can usually be found on the administration set packaging. Considerations in Terminal care
When considering the volume of fluid to be infused, it is important to be aware that clinical studies have suggested that terminally ill service users with cancer may achieve adequate hydration with much lower fluid volumes than recommended for medical and surgical service users (Bruer et al, 1996). The provision of artificial hydration to terminally ill service users has provoked debate amongst specialists in palliative care. Terminal cancer service users usually stop eating and drinking near the end of life and as a result of this there is a corresponding reduction in bodily secretions. Clinically there is a reduction in saliva and respiratory secretions that may result in less dyspnoea and coughing; a reduction in gastro-intestinal secretions similarly reducing nausea and vomiting and in addition reduced urine production. Opponents of the treatment point out studies showing that nutrition and hydration have not been proved to prolong life or improve service users’ well-being (Dunlop et al, 1995; Waller et al, 1994). However proponents of parenteral fluids in terminal care claim that dehydration increases the risk of service users becoming agitated or delirious, a situation that can in turn give rise to admission to hospital or hospice. Where service user choice and comfort can be maximised by the use of subcutaneous infusion of fluids, it should be considered. RN must discuss these complex issues with the service users palliative care team prior to commencing such treatment. Selection of Sites and Change of sites/giving set:
8.5.1 The subcutaneous infusion should be sited in a position with
good lymphatic drainage to maximise absorption.
Anterior chest wall, below the clavicle (caution should be exercised when using this site in cachectic service users). Back, usually below the shoulder blade (useful in confused service users). Lower limb sites should be avoided in ambulatory service users because blood may backflow into the line and block cannula. 8.5.2 Infusions should not be sited in the following areas:
Pre-existing oedema sites or in lymphoedematous limbs (tissue viability is compromised and absorption is affected). Sites of previous radiotherapy (skin perfusion is reduced in these areas). Sites with skin damage, swelling or scarring. On the side of a mastectomy or close to a stoma. 8.5.3 Changing site and giving set
The length of time a site can be used can vary from 1 to 14 days (Kain et al. 2006). No clinical evidence exists to recommend how often the site and giving set should be changed. However anecdotal and case study evidence exists to suggest that changing the infusion site and giving set every 48 – 72 hours is safe practice (Abdullah & Keast, 1997; Macmillan et al, 1994; Yap, 2001). However caution should be taken not to exceed the maximum life-span recommended by the manufacturer of the particular device so that their product liability can be maintained. The site must be checked at least daily to look for signs of redness, induration, tenderness, bleeding, oedema or leaking. The site must be changed when required regardless of its duration if any of these complications are observed. When the site is changed the giving set must be changed at the same time. Sites should be rotated to minimise tissue damage. 8.5.4 Checking the site
The site must be checked within 30 minutes to assess skin integrity and to avoid tissue overload. Once hypodermoclysis is established the service user or carer should be educated about checking the infusion at agreed intervals and this should be clearly documented in service users’ notes. The service user or carer should be shown how to stop the infusion if any adverse reactions occur and to contact the district nursing team if any concerns arise. Potential Problems
The risks of hypodermoclysis are minimal when these indications and guidelines are adhered to. However any of the following adverse effects may be observed: Local Oedema: Most common side-effect which may be resolved by gently massaging the area to promote absorption. Infusion should be re-sited elsewhere if a service user is experiencing discomfort. Redness/Swelling/Inflammation at Infusion Site: May be due to local reaction to cannula. A Teflon cannula (eg Softset) may be used as an alternative if nickel allergy is suspected. Cellulitis at the insertion site should also be considered if the above clinical signs are evident. However the incidence of infection is reported to be rare when aseptic technique is employed on insertion of the cannula (Das Gupta et al, 2000; Yap, 2001). Pain/Discomfort at Infusion Site: Usually related to insertion of needle. Adjust needle position slightly if uncomfortable. If pain persists, needle may have been inserted intradermally (at too shallow an angle). In this case remove and re-site cannula elsewhere. Discomfort at the insertion site may also be a sign that the infusion rate is too rapid. Puncture of Blood Vessels: If blood appears when needle is inserted or begins to track down the line, remove needle and re-site elsewhere using new equipment. Pulmonary Oedema: Infusion must be stopped immediately and medical advice sought if symptoms of cardiac overload, such as increased shortness of breath are observed following commencement of hypodermoclysis or at any stage in the process. Documentation
Administration of subcutaneous fluids should be documented in the service users’ care plan in accordance with PCT policy for management of records. In addition to the date and time of commencement of hypodermoclysis the following must be recorded: Insertion site, including whether cannula has been re-sited or not and condition of surrounding skin. Type of giving set/cannula used. Expected timed of end of infusion and actual time of finish, if any discrepancy. Service users response to therapy and any adverse effects observed. Equipment and procedure
See (8.3) Selection of Fluids and Rate of Infusion in guidance notes. Check prescription and solution as per NHS South Gloucestershire Medicines policy. gauge) or a Softset plastic infusion set 70% Isopropyl alcohol swabs Suitable stand or hook to allow solution bag to be hung higher than the level of the service user Document all batch numbers and serial numbers prior to starting infusion. Check solution bag for contaminants and ensure sterile packaging is intact. Prepare all equipment using aseptic technique. Connect up giving set to subcutaneous infusion needle set. Pierce infusion bag port, with giving set and prime entire length of tubing with solution. Select infusion site, taking into account service user choice and the guidance notes (8.5.1) Selection of Sites. Prepare site with alcohol swabs. Begin at site centre and spiral outwards, allowing 30-60 seconds contact time and allow to dry. Insert the infusion needle into the skin at an angle of 45o (for winged infusion sets) and support the butterfly at the correct angle with a small piece of gauze if required. Softset infusion devices should be inserted at a 90o angle by grasping a fold of skin and inserting the needle to its full length so that the device is flush with the skin. Create a loop in the tubing around the needle site to avoid the needle from being pulled out if giving set is inadvertently pulled. Secure needle and loop against the skin with a sterile occlusive dressing. Implementation Plan
RN’s are undertaking subcutaneous infusion therapy and no action is required for implementation. An audit of whether the procedure was adhered to will be carried out annually in all District Nursing teams, Henderson ward and Intermediate care. See Appendix 1 An annual audit of user satisfaction of the service will also be carried out. Links to other PCT procedural documents
Prevention and Control of Infection policies and guidelines Clinical and Non Clinical Incident reporting and Serious Incident reporting policy incorporating the Being Open policy and Procedure Safeguarding Adults and Cause for Concern guidance Safeguarding Children policy and procedures Mental Capacity Act 2005 Practice Guidance Policy for the Administration, handling and recording of medications (all routes) References
Abdullah A, Keast J (1997) Hypodermoclysis as a means of rehydration. Nursing Times: 93, 29, 54-57 Bruera E, Belzile M, Watanabe S, Fainsinger RL (1996) Volume of hydration in terminal cancer service users. Support Cancer Care: (4):147-50 Dasgupta M, Binns MA, Rochon PA (2000) Subcutaneous fluid infusion in a long term care setting. Journal of American Geriatric Association: 48:795-9 Dunlop RJ, Ellershaw JE, Baines MJ, et al (1995) On withholding nutrition and hydration in the terminally ill. A reply. Journal of Medical Ethics: 21:141-3 Farrand S, Campbell AJ (1996) Safe, simple, subcutaneous fluid administration. British Journal of Hospital Medicine: 55(11):690-2 Kain, al. (2006) Developing guidelines for syringe driver management. Int J Palliat Nurs, 12(2), 60–8. NMC (2008) The code: Standards of conduct, performance and ethics for nurses and midwives Macmillan K, Bruera E, Kuehn N, Selmser P, Macmilan A (1994) A Prospective comparison study between a butterfly needle and a Teflon cannula for subcurtaneous narcotic administration. Journal of Pain and Symptom Management: 9(2):82-4 Waller A, Hershkowitz M, Adunsky A (1994) The effect of intravenous fluid infusion on blood and urine parameters of hydration and on state of consciousness in terminal cancer service users. American Journal of Hopice Palliative Care: 11:622-7 Yap LKP, Tan SH, Koo WH (2001) Hypodermoclysis or Subcurtaneous infusion revisted. Singapore Medical Journal: 42(11):526-529 Bibliography
Donnelly M (1999) The benefits of hypodermoclysis. Nursing Standard: 13,52, 44-45 Jain S et al (1999) Subcutaneous fluid administration – better than the intravenous approach? Journal of Hospital Infection: 41:4; 269-72 Joint Working Party: National council for hospice and Specialists Palliative Care Services and the Ethics Committee for the Association of Palliative medicine of Great Britain and Ireland (1997). Statement of ethics of artificial hydration @ 1.htm Lothian Palliative Care Guidelines Group (2002) Subcutaneous fluid administration in Palliative Care Mansfield S et al (1998) Subcutaneous fluid administration and site maintenance. Nursing Standard: (Tissue Viability Supplement) 13:12; 56-62 Policies and Procedures (2002) IV Therapy: Continuous Subcutaneous Infusion @ www.ResourceNurse.Com Scottish Borders Palliative and Cancer Care Information Site (1999) Newsletter No 2. Clinical Debate: Parenteral Fluids in Terminal Care @ Sasson M, Shvartzman P (2001) Hypodermoclysis: An alternative infusion technique. American Family Physician @ Appendix 1
Implementation Date: ………………………. Hypodermoclysis (Subcutaneous Infusion) Review Date:…………………………… All service users on Community Nursing Caseload Authorised by: …………………………Lead Nurse Clinical Governance Date: ………………… Objective: All community nursing staff will demonstrate competence in relation to Hypodermoclysis in accordance with Primary Care Trust guidelines All nurses undertaking this procedure Ask Nurse: will be trained to administer subcutaneous fluids. The nurse will discuss treatment details for the community nursing service. Spare giving set/infusion fluids will be Evidence in


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