As registered nurses we are responsible and accountable for the care that we provide. The NMC state that we should always practice using the best evidence available (NMC 2015).

NHS Borders are committed to providing safe and effective evidence based care to all patients therefore the aim of this document is to reduce the variations in the present practice of subcutaneous fluid (SCF) administration within both the Borders General and Community Hospitals. In doing so it is intended to provide a consistent approach to patient care and to promote the delivery of a high standard of patient care.

This procedure is intended for use for all registered nursing staff and assistant practitioners involved in the administration of subcutaneous fluids within the Borders General and Community Hospitals.
The aim of this procedure is to:

• Deliver care based on the best available evidence or best practice
• Ensure the safe and effective administration of subcutaneous fluids
• Ensure that infusions run at the prescribed rate
• Improve patient safety and reduce potential risks

Research shows that subcutaneous fluid administration is a relatively safe, cost effective technique used to achieve fluid balance or fluid replacement in mild to moderately dehydrated patients. (Brown and Warbeck, 2000; Yap et al, 2001).

Subcutaneous fluid administration is used in the non emergency treatment of patients not only in hospitals but also in the community. Subcutaneous fluid administration is effective in the care of elderly and stroke patients; its use has also been found useful to prevent the side effects of dehydration such as constipation with palliative care patients.

The use of SCF in palliative care has ethical issues which need addressed and discussed as most palliative care patients die peacefully without artificial hydration (NHS Scottish Palliative Care guidelines 2019).

The introduction of evidence based practices will reduce the variations we have at the present and promote the delivery of a high standard of patient care across the wards.

Prescribing staff should consider any ethical implications of the administration of subcutaneous fluid which should be discussed with the patient and / or next of kin and consent to treat obtained. Prescribers will be responsible for ensuring that their instructions are clear and prescribed on a fluid administration chart.

All staff involved must be aware that Intravenous fluids are licensed but prescribed ‘off label’ for subcutaneous route and the implications of this. Refer to the NHS Borders code of Practice for the Control of Medicines (2019).

According to NMC guidelines on record keeping (2009) it is the nurse’s role to ensure that:

• The use of subcutaneous fluids is indicated
• Patients do not have any contraindications for its use
• That fluids prescribed are suitable for subcutaneous administration
• The administration site is individually assessed
• Infusion is documented and monitored
• Infusion will be administered at prescribed rate and completed on time

All registered nurses and assistant practitioners will be required to undertake subcutaneous fluid administration training. Cascade trainers will be identified when staff attend the Subcutaneous training Programme. Cascade trainers will then give training to staff in ward areas. Competency will be recorded on the Competency
Assessment Recording System (CARS).

This procedure should be read in conjunction with:

• The National Infection Prevention and Control Manual, page 10, Personal Protective Equipment
• Zero Tolerance Hand Hygiene Policy
• The McKinley T34 Syringe Pump Protocol
• The Consent to Treatment Policy
• NHS Borders code of Practice for the Control of Medicines
• NMC guidelines on record keeping

All are available on the NHS Borders Intranet micro-sites

Patients with any of the following:

• Patients who are unable to maintain their optimum level of fluid intake
• Vomiting and/or diarrhoea
• Mild to moderate dehydration
• With poor venous access

• Patients requiring large amounts of fluids infused i.e. more than 2 litres in 24hours
• Severe dehydration
• Oedema
• Coagulation disorders
• Where precise rate of infusion is required
• Low platelets
• Fluid overload
• Poor tissue perfusion

Advantages

• No need to find a vein
• BD Saf-T- Intima can be inserted by any trained nurse
• BD Saf-T- Intima can remain in situ for 7 days
• Very little discomfort or pain
• Incidence of infection is low and localised
• Eliminates the risk of thrombosis
• More cost effective
• No clot formation
• Can be used intermittently

Disadvantages

• Cannot be used in an emergency
• Cannot be used in a hypotensive patient or a patient in shock
• Cannot be used in patients who require large amounts of fluids
• Only electrolyte solutions can be used
• Has limitations on administration of electrolytes and additives
• Leakage at insertion site
• Poor absorption of fluids in some patients
• Localised infection

Medically assisted hydration via subcutaneous infusion in palliative care is provided with the intent of improving quality of life. Some indications when considering subcutaneous fluids are irreversible dysphasia, irreversible bowel obstruction, and symptomatic
dehydration secondary to high GI output, or myoclonic jerks and sedation secondary to opioid toxicity. The literature does point to the burdens of subcutaneous infusion treatment such as oedema, site inflammation, ascites and effusions and this should be
taken into account when taking the decision around subcutaneous infusion. Good mouth hygiene is paramount and should be the primary management before considering any assessment for subcutaneous fluids.

The Scottish Palliative Care Guidelines (2019) provides a flowchart when assessing for  the potential benefits and burdens on an individual basis.

The decision to initiate or discontinue subcutaneous infusion at end of life should be taken by the clinician in charge of the patients care and must be based on consideration of the needs and circumstances of the particular individual. Decisions should be promptly communicated and carefully explained to family and loved ones, and decisions should be reviewed regularly.

Hydration is often an emotional topic for families and patients when approaching end of life. There is a necessity for ongoing sensitive discussions about goals of care and realistic expectations of treatment. The views of the patient and any advanced care
planning should be considered throughout, and support for the carers when these decisions are being made is essential (Scottish Palliative Care guidelines 2019).

This guideline can support the use of SC fluids in the community only where the patient is thought to be in the last days to weeks of life and hospital admission is not clinically indicated or not wished by the patient. If the clinical assessment is that hospital admission is indicated for parenteral hydration then this should be discussed
with the patient. This should not be used to delay an indicated hospital admission. If the patient has made an informed decision not to be admitted to hospital then the
option of SC fluids should be considered by the clinician. SC fluids are not appropriate for all patients and will not reverse established dehydration/ acute kidney injury (Guideline for the Administration of Subcutaneous Fluids in a Community Setting During the Last Weeks or Days of Life, 2017).

All prescriptions should be recorded on NHS Borders Intravenous /
Subcutaneous Fluid Prescription chart.

• Infusion will be by gravity only, no infusion pumps to be used
• All fluids must be prescribed on a fluid prescription chart
• All fluids must be recorded on fluid prescription chart
• No other medication should be added to fluids to be administered subcutaneously

Isotonic or hypotonic solutions only should be used (for example 0.9% NaCl)
(Scottish Palliative Care Guidelines, 2019)

Choose a healthy, intact, clean oedema free area that is suitable for the individual patients comfort and convenience. The most appropriate sites are:

• Lower abdominal wall
• Anterior lateral aspect of the upper arms and thighs
• Anterior chest wall below the clavicle
• Occasionally, the back

For cannula placement and insertion refer to the McKinley T34 Syringe pump Protocol. Please note that upper arms are only appropriate for the administration of small volumes of subcutaneous fluids (less than 30 mls).

Do not use on skin that is

• Discoloured
• Over breast tissue
• Near joint
• Oedematous

Refer to the McKinley T34 Syringe pump guidance for sites to be avoided.

The insertion site should be wiped with a 2% chlorhexidine in 70% alcohol skin cleansings wipe for a minimum of 30 seconds then allowed to air dry prior to inserting BD Saf-T- Intima cannula. This is to prevent skin contaminants entering the subcutaneous space.

The dressing should have a semi permeable membrane and should be transparent to allow staff to observe the insertion site and surrounding skin. The date and time should be documented on the dressing and/or in the patient’s notes.

Once subcutaneous fluid administration is started the following should be documented in the patients notes.

• Position and date of BD Saf-T- Intima cannula insertion
• Which fluids are being administered, batch number, time commenced and the rate the fluids are running at i.e. drops per minute
• Sign chart for accountability

The insertion site and flow rate should be monitored 15 minutes after
commencement then at 4 hourly intervals or at medicine rounds and documented.
Drop rate can be adjusted as required.

• Observe for signs of leakage from insertion site
• Observe for oedema
• Observe for local irritation, infection, bruising and pain
• Change infusion site every 7days or when contraindications occur
• Administration set should be changed every 48 hours and documented in notes
• If complication occurs stop infusion and remove BD Saf-T- Intima cannula

Explain procedure to patient. Obtain consent from the patient and document this in notes. If the patient is unable to consent ensure Adult with incapacity form has been completed before commencing procedure. Refer to the Consent to Treatment Policy (2018).

The Policy is available on the NHS Borders intranet micro-site.

• Signed prescription chart
• 24g cannula BD Saf-T- Intima with removable needle
• Intrafix SafeSet Gravity Giving set
• 0.9% Sodium chloride 50 mls to prime the Intrafix SafeSet Gravity Giving set
• 2% chlorhexidine in 70% alcohol skin cleansings wipes
• Occlusive dressing
• Gloves and apron
• Appropriate face covering
• Fluids prescribed, check expiry date
• Sharps container
• Drip stand