Developing guidelines for syringe driver management

"Palliative Syringe Driver"? A Mixed-Methods Study in Different Hospital Departments on Continuous Infusions of Sedatives and/or Opioids in End-of-Life Care

OBJECTIVES

Continuous infusions of sedatives and/or opioids (continuous infusions) are frequently used in end-of-life care. Available data indicate challenges in nonspecialist palliative care settings. We aimed to assess the use of continuous infusions during the last week of life in different hospital departments.

METHODS

In a sequential mixed-methods design, a retrospective cohort study was followed by consecutive qualitative interviews in 5 German hospital departments. Medical records of 517 patients who died from January 2015 to December 2017 were used, and 25 interviews with physicians and nurses were conducted. Recorded sedatives were those recommended in guidelines for "palliative sedation": benzodiazepines, levomepromazine, haloperidol (≥5 mg/d), and propofol. Exploratory statistical analysis (R 3.6.1.) and framework analysis of interviews (MAXQDA 2018.2) were performed.

RESULTS

During the last week of life, 359 of 517 deceased patients (69%) received continuous infusions. Some interviewees reported that continuous infusions are a kind of standard procedure for "palliative" patients. According to our interviewees' views, equating palliative care with continuous infusion therapy, insufficient experience regarding symptom control, and fewer care needs may contribute to this approach. In addition, interviewees reported that continuous infusions may be seen as an "overall-concept" for multiple symptoms. Medical record review demonstrated lack of a documented indication for 80 of 359 patients (22%). Some nurses experienced concerns or hesitations among physicians regarding the prescription of continuous infusions.

CONCLUSIONS

Continuous infusions seem to be common practice. Lack of documented indications and concerns regarding the handling and perception of a "standard procedure" in these highly individual care situations emphasize the need for further exploration and support to ensure high quality of care.

Use of hypodermoclysis in the treatment of elderly people in institutional care

Introduction: Hypodermoclysis is a way of administering fluids to the body by using a subcutaneous infusion. Research shows that this procedure is as effective as the more established intravenous infusion, posing no serious complications.Method: For this study, a descriptive quantitative method was used. The data were gathered through a structured survey questionnaire specifically designed for the purpose of the study. It consisted of 14 questions. The questionnaire was completed and returned by 40 nursing care managers in the old people’s homes. The questionnaire was designed and distributed by means of the 1ka web tool on February 10, 2013 and the answers were collected by February 26,  2013. The data analysis was performed using the software package 1ka, MS Office (Word, Excel) and SPSS 18.0.Results: With regard to geographical location of the old people’s homes inSlovenia, the familiarity with and the use of hypodermoclysis does not vary substantially (χ2 = 0.440, p = 0.507). Complications related to this procedure of administering fluids are rare when it is administered in conformity with accepted indications and guidelines. The risks of hypodermoclysis are not directly related to the rate of administration (χ2 = 0.000, p = 1.000). The research did not establish any correlation between the frequency of complications and the education level of the nursing staff (χ2 = 3.900, p = 0.420).Discussion and conclusion: The research shows that hypodermoclysis is an established and widely used procedure among the professionals who took part in the research. As hypodermoclysis is a safe, easy and financially accessible way of administering fluids, suitable for use both in institutions as well as in home care, the time has come for resurrection and evaluation of this alternative infusion technique for widespread future use.   

Optimizing the use of intravenous therapy in internal medicine

BACKGROUND

We aimed to evaluate the impact of physicians' educational programs in the reduction of inappropriate intravenous lines in internal medicine.

METHODS

Fifty-six French internal medicine units were enrolled in a nationwide, prospective, blinded, randomized controlled trial. Forms describing the patients with an intravenous line and internal medicine department characteristics were filled out on 2 separate days in January and April 2007. Following the first visit, all units were randomly assigned to either a specific education program on the appropriate indications of an intravenous line, during February and March 2007, or no training (control group). The Investigators' Committee then blindly evaluated the clinical relevance of the intravenous line according to pre-established criteria. The primary outcome was the percentage of inappropriate intravenous lines.

RESULTS

During January 2007, intravenous lines were used in 475 (24.9%) of the 1910 hospitalized patients. Of these, 80 (16.8%) were considered inappropriate. In April 2007, 416 (22.8%) of the 1823 hospitalized patients received an intravenous line, which was considered in 10.2% (21/205) of patients managed by trained physicians, versus 16.6% (35/211) of patients in the control group (relative difference 39%; 95% confidence interval, -0.6-13.3; P = .05). Reduced intravenous administration of fluids, antibiotics, and analgesics accounted for the observed decrease.

CONCLUSION

The use of a simple education program reduced the rate of inappropriate intravenous lines by almost 40% in an internal medicine setting (NCT01633307).

Letters

Syringe driver guidelines