PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL POLICIES
Section 3.40
Policy for the management of infusions with pumps
Title
Manager
/committee
responsible
CLINICAL LEAD IV THERAPY TEAM
SENIOR MEDICAL DEVICE TRAINER
GOVERNANCE COMMITTEE
Date issued
19.07.2005V2
Issue number
3.40
Review date
Author
Ratified by
JULY 2006
ROBERT KIGHTLEY - SENIOR MEDICAL DEVICE TRAINER
BARRY BUCHANAN - CLINICAL LEAD IV THERAPY TEAM
PROFESSIONAL ADVISORY COMMITTEE – 01.07.2005
Amendments:
April 2010. Section 11. References and Associated Documentation. By Trust Policy Officer.
CONTENTS:
1. Item
2. Status
3. Policy Statement
4. Scope
5. Definitions
6. Responsibilities
7. Procedures
7.1 Procedures for the Purchase and Management of the Pumps
7.2 General Procedures for the Administration of Infusions with a pump
7.2.1 Training
7.2.2 Preparation
7.2.3 Set up
7.2.4 Record keeping
7.2.5 Safety
7.3 Procedures for Specialist Infusions
8. Forums for Discussion
9. Training
10. Audit
11. References and Associated Documentation
APPENDICES:
Appendix 1
Forms to record infusion pump settings
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CLINICAL POLICIES
Section 3.40
1. Item
Policy for the management of infusions with pumps.
(“Pumps” includes volumetric pumps, syringe pumps and syringe drivers.)
2. Status
This is a Clinical Policy
3. Policy Statement
The aim of this policy is two fold: firstly to ensure that any infusion is given correctly and safely by the most
appropriate method and secondly to ensure that the pumps and their associated consumable items are
managed to ensure their optimum performance.
It will ensure the following points:
3.1 The correct pumps are purchased
3.2 The pumps are ready for use at the correct place and at the correct time, are maintained correctly, are
stored correctly and are in the best working order
3.3 All staff (including clinical and technical) that have contact with the pumps have the appropriate training,
competence and confidence to perform their duties correctly and demonstrable competencies are recorded
with the Trust
3.4 The pumps are checked and prepared correctly immediately prior to their use
3.5 The fluids and medication are correctly attached to the pump
3.6 The infusion is given at the correct rate and dose
3.7 The administration is recorded correctly
3.8 Any adverse incidents are correctly managed and recorded
3.9 That any problems with the infusion, pumps or disposables are reported in the correct manner to the
correct authority
3.10 The infusion is terminated correctly and safely
3.11 The equipment is correctly and appropriately decontaminated or disposed of after use
3.12 The equipment is correctly stored ready for the next use
4. Scope
The scope of this policy relates to all people who use or manage infusion devices; including but not
exclusively doctors, nurses, midwives, operating department practitioners, clinical engineering technicians and
specialist medical technicians.
This policy covers the correct delivery, use and management of infusions when given with a pump and the
correct use and management of the pumps and associated hardware, consumables and systems.
The policy does not cover any medication; where mentioned it is assumed that the writing and checking of the
prescription, dispensing, preparation and checking of the medicine has been performed correctly and to the
appropriate policies.
The policy does not cover the insertion, siting or management of cannulae for which a separate policy exists.
This policy does not cover infusions not given by a pump, including gravity IV infusions, IV, IM, subcutaneous
and similar injections or enteral feeds given via a pump.
This policy should be read in conjunction with the Portsmouth Hospitals NHS Trust policies and guidelines
detailed in section 11.
5. Definitions
5.1 An infusion system – As defined in DB2003(02). See Ref. 4
“An infusion system is the process by which an infusion device and any associated disposables are used to
deliver fluids or drugs in solution to the patient by the intravenous, subcutaneous, epidural, parenteral or
enteral route.
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CLINICAL POLICIES
Section 3.40
The process comprises:
prescription of the fluid or drug;
preparation of the infusion solution;
selection of the appropriate infusion device;
calculation and setting of the rate of infusion;
administration of the fluid to the patient;
monitoring and recording of the actual delivery,
disposal.
The simplest devices, gravity controllers, employ a clamping action to vary the flow of liquid under the force of
gravity. More complex systems use a positive pumping action for infusion. Infusion pumps are powered items
of equipment, which, together with an appropriate administration set, provide an accurate flow of fluids over a
prescribed period. Volumetric pumps may employ a linear peristaltic pumping mechanism or use a special
cassette. Syringe pumps work by pushing the plunger of a disposable syringe along at a predetermined rate.
The type of pump used will depend on the required volume and speed of infusion.”
MDA publication DB2003(02) gives more detailed descriptions of the different types of pumps.
5.2 Parenteral route - Entering the body not by the alimentary tract but rather by another means (such as the
subcutaneous or the intravenous route).
5.3 User – The person performing the procedure or action including: the setting up of an infusion, the altering
of an infusion and the monitoring of an infusion
Note: Different people will have different roles in the whole process; any mention of a “user” does not
necessarily apply to all members of the above group.
5.4 Technical support - The management, provision and maintenance of the equipment needed to give an
infusion.
5.5 Clinical practitioners – a generic term for all registered clinical staff including but not exclusively registered
nurses, midwives, operating department practitioners and medical practitioners. It is assumed that under their
respective professional registrations theses staff groups are qualified to give or operate infusions. Some staff
groups, e.g. radiographers, may be able to give infusions in limited clinical situations
5.6 Clinical line managers – Staff who manage more junior staff and who take responsibility for the actions of
non-registered staff.
5.7 Senior clinical practitioners – Staff who have had in-depth training and are experienced in their particular
field.
5.8 Administration set – the part of the infusion system, usually disposable, that contains the fluid and the
lines that connect it to the patient. This can be either a bag or syringe of fluid depending on the type of pump
and lines that are generic or dedicated to one model of pump.
5.9 Therapy group classification for pumps – Infusion pumps have been divided in to three therapy groups by
the MHRA. In general the group A pumps are of a higher specification and should be used for critical
infusions, for drugs with a short half-life and for neonates. The specification decreases through group B which
can be used for general use infusions and group C which are for non-critical, low risk infusions. The
manufacturers or suppliers declare which group their pump falls in to. Details of these groups can be found in
Appendix 1 of DB2003(02). See Ref. 4.
5.10 Extravasation - Extravasation occurs when fluid that should be delivered intravenously is inadvertently
delivered into a tissue space. It can be caused by misplaced cannulae. The cannulae can migrate and
puncture the vessel wall or thrombosed veins.
5.11 Infiltration – The unintended infusion of fluid in to tissue instead of a vein by an intravenous infusion.
5.12 Specialist Infusion – An infusion that is delivered via a route other than subcutaneous or intravenous or
one that delivers a drug that is not encountered in general practice e.g. anaesthetic drugs or X-ray contrast
media
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Section 3.40
6. Duties and Responsibilities
6.1 It is the responsibility of all clinical practitioners to ensure the correct and safe administration of an infusion
by being competent and confident in the use of the equipment and in the procedure.
6.2 It is the responsibility of clinical line managers and senior clinical practitioners to monitor the work of junior
or non-registered staff and to ensure that measurable competency has been observed prior to autonomous
practice.
6.3 It is the responsibility of the user to make sure that they have had adequate training in the procedure that
they are performing.
6.4 It is the responsibility of the Trust and its managers to provide the appropriate training and to allow access
to this training.
6.5 It is the duty of the Trust to provide all the necessary equipment required to set up an infusion safely and
correctly.
7. Procedures
7.1 Procedures for the Purchase and Management of the Pumps
Action
The purchasing of infusion pumps must
be managed so as to minimise the
number of different models in the Trust.
(The medical device management
policy will give guidance on the correct
methods for assessing equipment for
purchase.)
Infusion pumps with features that meet
only the current and any probable
future requirements of clinical users
should be purchased.
Infusion pumps should generally be
managed as part of a centralised
equipment library system. Specialist
pumps will be managed in their own
areas.
Rationale
Fewer models of pumps leads to less
user errors.
Evidence
1, 2, 3, 4
Additional unused features add to the
expense of the pump and the likelihood
of user error.
1, 4, 5, 11
Correct storage and management
leads to fewer damaged pumps,
increased reliability, increased
availability and reduces the overall
number of pumps required by the
Trust. Hence reducing the purchase
and maintenance costs.
The pumps must perform safely,
correctly, accurately and reliably.
1, 2, 3, 4
Infusion pumps must receive regular
planned safety and performance tests
in line with manufacturer’s
recommendations.
Staff maintaining pumps must be
The maintenance is performed
competent and confident to perform the correctly.
tasks required of them.
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3, 5, 6, 11
6, 11
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CLINICAL POLICIES
Section 3.40
7.2 General Procedures for the Administration of Infusions with a pump
7.2.1 Training
Action
Rationale
Any person operating a pump or
Staff must not put patients at risk by
managing an infusion must be familiar
performing actions that could be
with the process, be proved competent unsafe.
and be confident to perform the task
safely and correctly.
The Trust must make device training
Staff require training to perform actions
and competency checks available for
safely and correctly.
all device users.
The equipment instructions and any
Staff may need to refresh their
user guides must be readily available.
knowledge prior to performing an
action.
When staff teach patients or their
The pump is operated in a correct and
carers about the use of patient
safe manner when it is not under the
operated infusion devices they must
direct supervision of a member of staff.
ensure that the person has fully
understood the function and operation
of the device, the consequences of
incorrect use or misuse and any checks
that need to be done to ensure that the
device is operating correctly.
The staff member giving this teaching
To confirm that the correct information
must record all the teaching and advice has been imparted.
given to patients or carers.
7.2.2 Preparation
Action
The infusion pump must be of the
correct type for the infusion route and
application.
The infusion pump must be of the
correct type for the fluid volume and
rate being infused.
A pump of an appropriate therapy
category must be used for the infusion.
Rationale
Different pumps are designed and
optimised for different uses.
Different pumps are designed and
optimised for different types of
infusions.
Pumps of lower therapy categories do
not have sufficient features or alarms to
ensure a safe infusion.
The pump must be physically inspected The equipment is safe to use and will
for lack of damage and a valid service
operate correctly and accurately, and is
date prior to use.
unlikely to fail in use.
Only giving sets and syringes that are
The pump will only operate correctly
appropriate and approved use with for and safely with the correct
the specific pump must be used.
administration set and/or syringe.
The giving sets and syringe must be
The drugs and solutions reach the
checked for compatibility with the drugs patient unaltered and at the correct
and solutions being infused.
dose.
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Evidence
1, 5, 7, 8, 9, 10,
11, 27
5, 7, 8, 9, 11, 27
5, 7, 8, 9, 11, 27
4, 5
4, 13
Evidence
1, 4
1, 4
1, 4
1, 4
4
Manufacturers
instructions
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CLINICAL POLICIES
Section 3.40
7.2.3 Set up
Action
The giving set or syringe must be
correctly attached to the pump.
Rationale
If not the pump might operate
incorrectly causing an incorrect
infusion.
The settings for rate, volumes,
The pump must be set correctly for the
pressures and alarms must be correctly infusion to be delivered correctly and
set taking in to account the
safely without nuisance alarms.
prescription, drug, patient and cannula
type, site and size as well as other
physical factors.
Only syringes with a Luer lock
The risk of disconnection is reduced.
connectors must be used with syringe
pumps and drivers.
Blood must only be given through
The blood is not damaged by the
pumps that have been approved for the pumping action of approved pumps.
delivery of blood.
Blood must only be given through
The giving set material does not alter
giving sets specially designated for
the blood.
blood delivery
Drugs that are photosensitive must be
These giving sets prevent light from
given through opaque or appropriately reaching the fluid, preventing its
coloured giving sets.
chemical breakdown.
The pump function and settings must
To ensure the pump is functional and
be checked immediately prior to
the settings are correct and that the
commencing the infusion and
infusion is given as prescribed.
immediately after any alteration to
settings that might affect the delivery of
the infusion.
7.2.4 Record keeping
Action
The asset number of the infusion pump
as well as any settings and the drug or
fluid being infused must be recorded in
the patient record. Any alteration to
these settings, including the completion
of an infusion, must be recorded when
made. See appendix 1.
If an adverse incident involving an
infusion occurs it must be reported
following Trust procedures. All
equipment associated with the pump,
including disposables, must remain
with the pump when they are detached
from the patient.
Rationale
Should an adverse incident occur the
pump can be identified for subsequent
electronic interrogation to compare the
actual settings and actions against the
intended ones.
The disposables form part of the whole
infusion system and might be the part
that is at fault.
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Evidence
10, 12
12
1, 4, 22, 23
4, 19
4, 19
Manufacturers
instructions
1, 4, 6
Local specialist
policies may
also apply
Evidence
13
14, 15
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Section 3.40
7.2.5 Safety
Action
If possible the pump operation must be
locked if the environment in which the
pump is being used might mean it
could be altered by unauthorised
people, e.g. by children or confused
people. (If the pump does not have the
facility to be electronically locked, a
physical method of preventing access
to the controls such as a locked box
must be used)
Only registered clinical practitioners
can stop or temporarily halt an infusion,
alter its settings or adjust the
administration set or syringe once a
pump has been started.
The settings of the pump must be
regularly and frequently checked. See
appendix 1.
The settings of any alarms must be
regularly and frequently checked and
altered if necessary.
Rationale
To prevent tampering which might
cause the infusion to be given
incorrectly.
Evidence
1, 7,
Manufacturers
instructions
This prevents the accidental alteration
of the settings by a non-registered
practitioner and ensures a continuous
delivery of the infusion.
8
To ensure the settings remain correct
and the infusion continues to be
delivered as prescribed.
An alteration in the patient’s condition
or position might mean that a previous
alarm setting needs to be altered to
ensure continued safety without
causing nuisance alarms.
On completion of the infusion the single Drugs and clinical waste must be
use items must be disposed of in the
disposed of correctly to ensure the
correct manner.
safety of patients, staff, the public and
the environment.
The pump must be decontaminated as Prevention of cross infection.
per the decontamination policy before
storage.
7, Manufacturers
instructions
16, 17, 18
16, 18,
Manufacturers
instructions
16, 18, Draft
medical device
decontamination
policy
All pumps that record and retain
The next user only records the volumes Manufacturers
volume totals and similar readings must of the current infusion. (In an
instructions
have these reset to zero or default
emergency situation there may not be
values prior to storage.
time to clear totals prior to use.)
The pump must be stored on
The pump is in its optimum condition
1, 2, 3, 4
designated shelving in an approved
for the next user.
area so that it is unlikely to be
There is no unnecessary damage,
physically damaged and the battery, if
adding to the cost of ownership.
fitted, can be charged.
The line to the patient must be
It is possible to accidentally infuse
1, 4,
manually clamped when the pump is
excessive fluid in to the patient or to
Manufacturers
not infusing or when alterations are
cause siphoning to or from the patient if instructions
being made to the location of the giving they are connected directly to the fluid
set.
source without a clamped line.
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7.2.5 Safety continued
Infusion sites must be regularly
inspected for signs of cannula
extravasation and fluid infiltration.
If a boost or bolus may be required,
only pumps that record the number of
boluses given and limit the total volume
that is given must be used.
The rate setting of pumps needs to be
carried out with extreme care.
Some pumps do not have a syringe
size detection mechanism, these must
be used with extreme care and the
dose rate carefully calculated taking in
to account the size of the syringe in
use.
Section 3.40
The pressure of an infusion can
decrease with extravasation so
pressure alarms may not detect this
situation.
Harm may occur to the patient if
repeated boosts or boluses of the drug
are given. This may be through
excessive drug delivery or local fluid
overload.
The units of rate with some pumps can
be different from those normally
encountered. (mm/hr or mm/day
instead of ml/hr)
The volume rate of infusion varies with
syringe size and will not be
automatically calculated by the pump.
4, 20, 21
4
4, Manufacturers
instructions
4, Manufacturers
instructions
7.3 Procedures for Specialist Infusions and Situations
Action
Specialist infusions such as intrathecal
or epidural infusions must only be set
up by staff who have received
additional specific, specialist training
and have shown themselves
competent to do so.
Intravenous anaesthesia infusions
must be managed only by suitably
qualified and competent anaesthetists
Staff caring for patients with patient
controlled analgesia and epidural
anaesthesia infusions must ensure that
the patient has been taught how to
operate them correctly, and that the
infusions are operating correctly and
effectively.
Highly specialist infusions, such as Xray contrast injectors, must follow local
policies and guidelines and only be
used by people who have received
specialist training in that area.
Rationale
Patient safety can be compromised by
inexperienced staff performing actions
that they are not trained or competent
to do.
Evidence
8, 22, 24, 25, 28
Patient safety is not compromised.
26
The pain relief is effectively delivered to 27, 28
the patient. The patient may not know
what to expect from the infusion so
would not know if it were not operating
correctly.
Detailed, specialist, specific, knowledge 22
is needed to operate this equipment
safely, along with knowledge of any
associated equipment.
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Section 3.40
8. Forums for Discussion
The following have been involved in the formation of this policy:
Clinical lead IV therapy team
Head of clinical engineering
Medical device training team
Representatives of senior nurses (Nursing and Midwifery CASE group)
The revision of this policy should be co-ordinated by the clinical lead of the IV therapy team and senior
medical device trainer. They should involve those who assisted in its initial drafting along with any specialist or
general users of infusion pumps especially representatives of nurses and midwives who are the largest user
group.
9. Training
All registered clinical practitioners will have received some education on infusions as part of their training.
They are required to undertake specific study programmes as part of their post registration training prior to
administering or managing IV therapy. Only practitioners who have undergone this additional training should
manage infusions with pumps. Registered clinical practitioners who have not undergone this training should
be supervised whilst managing infusions, as should all non-registered staff.
All staff should receive training on the operation of the specific models of pumps that are used in this Trust
even if they have received detailed training on infusions in a previous employment.
All staff should receive specific training on the operation of any new models of pumps when they are
introduced.
10. Audit
Supervisors of clinical practice will be responsible for monitoring compliance with the guidelines on an ongoing
basis.
The medical device training team and IV therapy team will audit compliance as part of the medical device
training and clinical practice audit process.
A snapshot audit to monitor clinical practice during cannulation, infusion set up, and pump set up and
operation will be undertaken by the IV therapy team as part of its total IV therapy audit.
This data will be presented as part of the over all monitoring process of infusions to the governance leads of
each division.
The relevant data will be passed to the medical device training team to help identify any required amendment
of the training programme.
11. References and Associated Documentation
External
1. Safer practice notice 01 Improving infusion device safety, NPSA, May 2004
2. Standardising and centralising infusion devices – A project to develop safety solutions for NHS trusts,
NPSA, May 2004
3. The Management of medical equipment in NHS acute trusts in England. National Audit Office, June 1999
4. Device Bulletin DB2003(02): Infusion systems, Medical Devices Agency, March 2003
5. Device Bulletin DB9801: Medical device and equipment management for hospital and community-based
organisations, Medical Devices Agency, January 1998 (and subsequent supplements).
6. Equipped to care – The safe use of medical devices in 21st century, Medical Devices Agency, 2000
7. Guidelines for the Administration of Medicines. United Kingdom Central Council for Nursing, Midwifery &
Health Visiting. Reprinted by Nursing and Midwifery Council, 2002
8. Reducing the risk of user error with infusion pumps, Professional Nurse Vol.15 No.6, March 2000
9. DB2005(02) Adverse incident reports 2004, Medicines and Healthcare products Regulatory Agency, March
2005
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Section 3.40
10. Devices in practice – a guide for health and social care professionals, Medical Devices Agency, 2001
11. Pickstone, Dr Martin, A pocketbook for safer IV therapy (Drugs, giving sets and infusion pumps), Scitech
Educational, Margate, 1999
12. DB2005(01) Reporting adverse incidents and disseminating medical device alerts, Medicines and
Healthcare products Regulatory Agency, January 2005
13. Smith J, Building a safer NHS for patients – Improving medication safety. Department of Health. London,
2004
14. Mallett J and Dougherty L (eds.). Royal Marsden Hospital 2003 Manual of Clinical Nursing Procedures.
5th edition. Blackwell. Oxford
15. Miller, D R, Intravenous infusion anaesthesia and delivery devices. Canadian Journal of Anaesthesia
2004; 41:639-51
PHT documentation
Policy and protocol for the management of medical devices
Policy and associated protocols for the completion and management of health care records at ward /
departmental level
Management of Adverse Events and Near Misses Policy
Trust policy and protocol for the safe handling and disposal of sharps
Policy for the prevention, control and management of infection
Blood Transfusion Policy
Intravenous Cannulation & Infusion Therapy
Medicines Policy
Trust policy for intrathecal chemotherapy oncology / haematology departments
Management of continuous epidural infusions
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Section 3.40
Appendix 1: Forms to record infusion pump settings
In order that any change of setting of an infusion device can be readily identified the pump must be regularly
inspected and the settings recorded and compared with previous settings. This task must be performed by or
under the direct supervision of a registered practitioner. To facilitate this, a record form has been devised.
Below are two forms that should be used to monitor infusions when delivered by a pump and record settings
and readings. These forms should be used if no other similar record of infusions is made.
The first is a form specific to the Graseby MS26 syringe driver. This is set up and used in a way that is
different to other infusion pumps.
The second form can be used for most other infusions whether given by other syringe pumps or
volumetric pumps. Dependent on the model of pump or the way in which it is being used some of the
readings might not be available. (Infusion pumps do not normally display the measured infusion pressure only
the pressure alarm limit.) In this case a note should initially be made in the appropriate column to record this
fact. For volumetric pumps drawing from a bag of fluid an estimation of the volume remaining in the bag
should be made.
If a setting has been changed the person altering the pump must record the fact by entering the new settings
in the appropriate column and initialling the record.
If a setting is different from a previous one or if excessive fluid is missing from the syringe or infusion bag, the
staff discovering this should try to ascertain if a person has altered the settings and not recorded it or if
excessive fluid has been lost through over bolusing. If these investigations do not provide a suitable answer
an adverse clinical incident must be raised and medical assistance sort to investigate any possible side effects
of any drug misadministration.
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Section 3.40
GRASEBY MS26 SYRINGE DRIVER MONITORING
This chart MUST be completed hourly for all patients receiving medication via a syringe
driver and when complete filed in their records. Any change in settings must be initialled
next to the recorded value.
Pump Asset Number:
(Medical Equipment Number)
Patient
Identification label:
Date &Time commenced:
Medication & Dosage:
Commenced by:
Total Volume (ml):
Time
Volume
Remaining
(mls)
Pain
Score
Site
Checked
Site
Changed
Indicator
flashing
Y/N
Rate (mm/hr):
Vital Signs if
indicated
Signature
00:
01:
02:
03:
04:
05:
06:
07:
08:
09:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
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Section 3.40
INFUSION PUMP MONITORING
This chart MUST be completed hourly for all patients receiving medication via a syringe driver and when
complete filed in their records. Any change in settings must be initialled next to the recorded value.
Pump Asset Number:
(Medical Equipment Number)
Patient
Identification label:
Date &Time commenced:
Medication & Dosage:
Commenced by:
Total Volume(ml):
Time
Volume
Remaining
(ml)
Set Rate
Measured
Infusion
Pressure
Pressure
Alarm
Setting
Total
Volume
Infused
Rate (ml/hr):
Infusion Site
Inspected
Signature
00:
01:
02:
03:
04:
05:
06:
07:
08:
09:
10:
11:
12:
13:
14:
15:
16:
17:
18:
19:
20:
21:
22:
23:
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