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Policies,Clinical,UW Health Clinical,Medications and Pharmacy

Use of a Patient’s Own Medication Delivery Device (6.1.12)

Use of a Patient’s Own Medication Delivery Device (6.1.12) - Policies, Clinical, UW Health Clinical, Medications and Pharmacy

6.1.12


UW HEALTH CLINICAL POLICY 1
Policy Title: Use of a Patient’s Own Medication Delivery Device (Adult & Pediatric)
Policy Number: 6.1.12
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: October 20, 2017

I. PURPOSE

This policy is intended to ensure the safe care of patients who continue the use of their own medication
delivery devices while receiving care at a UW Health facility. The expectations of the policy are not
applicable to implantable pumps (e.g., baclofen), insulin pumps, or continuous glucose monitoring systems.

For patients using their own subcutaneous insulin pumps and/or continuous glucose monitoring systems,
please also refer to UW Health Clinical Policy #2.3.19, Subcutaneous Insulin Pump (Patient’s Own) and
Continuous Glucose Monitor Use in the Hospital Setting (Adult & Pediatric).

II. POLICY ELEMENTS

A. This policy applies to all patients that meet any of the following criteria:
i. Inpatient status
ii. Undergoing procedure with sedation or anesthesia
iii. Receiving a radiology study by any of these modalities: X-ray, computerized tomography (CT),
positron emission tomography (PET) scan, or any other test, procedure, or surgery that uses
radiation or magnetic fields
iv. Any other encounter that requires manipulation of the device by the patient or primary support
B. Requirements for Patient-Owned Medication Device Management:
i. The patient or designated primary support managing the device for the patient (e.g.,
parent/guardian) must be capable (including oriented to person, place, time) and competent of
managing the device safely as determined by the care team (see section III, C, Competency
Assessment).
ii. The patient or designated primary support must demonstrate physical dexterity and visual ability to
use the device. If a patient or designated primary support has physical or visual impairments, the
patient or designated primary support must be able to verbalize or demonstrate strategies used to
overcome these barriers (such as magnifiers, etc.).
iii. The patient or designated primary support must have access to necessary specialty supplies (e.g.,
batteries, tubing) required for device use.
iv. Competence and capability are assessed and documented upon admission (or when therapy
begins during hospitalization) and re-assessed if patient’s cognitive status changes or if staff caring
for the patient suspect the patient’s level of competence has changed since initial assessment.
v. Reasons to consider discontinuing use of a patient’s own medication device include but are not
limited to:
a. Patient or designated primary support is unable to safely manage the device. In these
cases, the primary team, nurse, pharmacist, and (respiratory therapist for inhalation route)
should be notified to develop a new plan of care for the patient. Continuation of a patient’s
own medication delivery device may be approved by a provider when it is determined that
the benefits of device use outweigh the risks (e.g., transitioning from a patient’s own
device to a UW Health device).
b. Patient is suicidal or at risk for suicide.
c. Patient cannot provide his/her own device supplies.
C. Provider orders are required to continue use of a patient’s own medication delivery device (see section III, B,
Orders).
D. The Agreement to Use a Patient’s Own Medication Delivery Device must be completed within the first 24
hours of admission or prior to a patient resuming use of their own device (see Appendix A in Related section
on U-Connect).
E. Exceptions to the requirements/criteria for use of a patient’s own medication delivery device may be
approved by an authorized physician/provider when it is determined the benefits of device use outweigh the
risks (e.g., while transitioning from a patient’s own device to a UW Health device, or when UW Health device
is not available).

III. PROCEDURE



UW HEALTH CLINICAL POLICY 2
Policy Title: Use of a Patient’s Own Medication Delivery Device (Adult & Pediatric)
Policy Number: 6.1.12


A. The provider and patient’s care team will collaborate to complete an initial competency and capability
assessment. If it is determined the device will be continued during the inpatient stay, the agreement form to
use a patient’s own medication delivery device must be signed by both the patient and provider (see
Appendix A in Related section on U-Connect).
B. Orders
i. The provider will enter an order for the medication being administered by the device into the
electronic medical record to facilitate reconciliation of device programming and orders.
ii. The pharmacist will enter a “Note: Patient’s Own Medication Delivery Device” order in the electronic
medical record with administration instructions that will read as follows:
a. Patient/caregiver assessed to be competent and capable of expectations according to UW
Health Clinical Policy #6.1.12, Use of a Patient’s Own Medication Delivery Device (Adult &
Pediatric). The pharmacist will specify which medication is being administered by the
medication delivery device in the note order.
C. Competency Assessment
i. A competency assessment should include the following as applicable, as evidenced by
verbalization and/or demonstration by the patient or designated primary support managing the
device:
a. Knowledge of infusion site care.
b. Knowledge of device set-up and programming.
c. Knowledge of trouble-shooting measures including how to contact the device
manufacturer customer service phone number.
ii. Staff nurses, pharmacists, respiratory therapists and providers may all participate in the
competency assessment and documentation process.
iii. Competence should be assessed and documented upon admission and reassessed as necessary
as a patient’s condition changes.
D. Device Assessment
i. If there are concerns about the safety of the device, clinical engineering should be consulted to
conduct an equipment safety check prior to use. Considerations include the following: if the device
plugs into an outlet, has a transceiver/transmitter or connects to the internet to send/receive
information.
E. Documentation
i. The Agreement to Use a Patient’s Own Medication Delivery Device must be completed within the
first 24 hours of admission or prior to a patient resuming use of their own device (see Appendix A in
Related section on U-Connect).
ii. The device should be added to the appropriate Lines/Drains/Airways (LDA) Doc Flowsheet in the
electronic health record. The medication being delivered by the device should be specified within
the LDA.
iii. Document initial and ongoing assessments in the appropriate LDA Doc Flowsheet in the electronic
health record and in the Patient Education activity as appropriate.
iv. Medications administered by the device must be documented using a specific order placed in the
medication administration record.
F. Considerations for Radiology Procedures and Perioperative Settings
i. To protect the medication delivery device from being deprogrammed or damaged by exposure to
ionizing or magnetic fields, the primary team and radiology must jointly determine if the device must
be disconnected and taken outside of the room for ANY of the following procedures:
a. X-rays
b. Computerized tomography (CT)
c. Positron emission tomography (PET) scan
d. Any test, procedure, or surgery that would use radiation or magnetic fields
ii. For patients with a medication delivery device who require magnetic resonance imaging (MRI), an
appropriate compatible medication delivery device may be used.
iii. For a procedure or a surgery the primary team and proceduralist/surgeon must jointly determine if
changes or modifications related to the medication delivery device are needed before, during, or
after the procedure/surgery.

IV. FORMS




UW HEALTH CLINICAL POLICY 3
Policy Title: Use of a Patient’s Own Medication Delivery Device (Adult & Pediatric)
Policy Number: 6.1.12

Agreement to Use a Patient’s Own Medication Delivery Device (301503-DT)

V. COORDINATION

Author: Program Director, Medication Use Strategy & Innovation
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Nurse Manager, Acute Medical and Progressive Care; Pharmacy Intern, Pharmacy Resident
Program; Nursing Education Specialist, Overnight Care at TAC; CNS, Diabetes (Adult); CNS, Diabetes
(Pediatrics);
Approval committees: UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: July 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

A. Appendix A: Agreement to Use a Patient’s Own Medication Delivery Device (see Related section on U-
Connect)
B. Hospital administrative policy #8.17, Administration of Medications
C. UW Health Clinical Policy #2.3.19, Subcutaneous Insulin Pump (Patient’s Own) and Continuous Glucose
Monitor Use in the Hospital Setting (Adult & Pediatric)
D. Nursing Patient Care policy #10.27, Treprostinil (Remodulin) Administration

VIII. REVIEW DETAILS

Version: Original
Last Full Review: October 2017
Next Revision Due: October 2020
Formerly Known as: #10.26AP, Use of a Patient’s Own Medication Delivery Device (Adult & Pediatric)