1. Continuous Opioid Infusion Chart – adult Education Slide Presentation A presentation prepared by the Pain Interest Group Nursing Issues in association with the Agency of Clinical Innovation Pain Management Network Please direct comments to: APRIL 15, 2015 Emily Edmonds Coordinator State Pain Forms Pain Interest Group Nursing Issues CNC Acute Pain Service Blacktown Hospital Phone: 9881 7649 Email: emily.edmonds@health.nsw.gov.au emily.edmonds@health.nsw.gov.au Jenni Johnson Manager Pain Management Network Agency for Clinical Innovation (ACI) Phone: 9464 4636 Email: jenni.johnsons@aci.health.nsw.gov.au jenni.johnsons@aci.health.nsw.gov.au OR

2. Continuous Opioid Infusion Chart - adult The Continuous Opioid Infusion prescription and observation chart for adult patients has been developed by a team of experts in the field of acute pain including clinical nurse consultants, anaesthetists and pharmacy representatives. This chart has been designed for a patient receiving a continuous opioid infusion in a ward environment. This chart is not suitable for paediatric patients. Standardisation of this chart promotes best practice in prescribing, pain assessment and management of adverse effects in those patients receiving a continuous opioid infusion via an infusion modality. 2

3. Aim of this presentation: This presentation aims to explain  how to use the chart for prescribing a continuous opioid infusion  how to record the administration and discard of drugs used for a continuous opioid infusion  how to complete the clinical observations  guidelines on the management of patients receiving an a continuous opioid infusion including the management of adverse effects 3

4. Continuous Opioid Infusion Chart - adult 4 Booklet format Prescription valid for 4 days Observation pages for 4 days Page 1 Management guidelines Yellow and Red Zone Instructions Page 1 Page 2 Page 3 Page 2 Continuous opioid prescription, naloxone prescription, oxygen therapy, ceasing Page 3 Administration and discard Opioid administration, drug discard, record of naloxone administration

5. Continuous Opioid Infusion Chart - adult 5 Observation pages: for up to 4 days

6. 6 Managing adverse effects For detailed information regarding continuous opioid infusion prescribing and management refer to local hospital continuous opioid infusion policy or procedure Instructions for managing patients whose observations fall into the Yellow or Red Zone

7. Prescription (Page 2) 7 Patient label and allergy and adverse reactions Private patients: pain specialist referral, name and signature of the doctor making the referral Opioid prescription: Primary opioid drug Option for additional drugs Continuous infusion range Start rate Additional bolus dose Oxygen therapy Ceasing instruction Naloxone prescription

8. Continuous opioid infusion prescription: 8 SMITH 3/3/15 PSmith Prescriber to complete patient allergy and ADR section in full Handwrite patient details OR affix patient label (First prescriber to check patient label is correct) PRIVATE PATIENTS: A pain specialist referral from the referring doctor (name), signature and date

9. Continuous opioid prescription: 9 Below is an EXAMPLE prescription Refer to hospital policy for local guidelines on prescribing a continuous opioid infusion 5 1 mg NIL Morphine 1 mg/mL 3/5/15 SMITH TSmith Space provided for pharmacist reconciliation 100 7511 NIL 1 3 mg 1 mg1 3 mg 3 IV 15 2 100 mg 3

10. Naloxone prescription: 10 10/5/15 naloxone IV 100 microgram x4 2 – 3 Tsmith SMITH minutes

11. Oxygen therapy and cessation of epidural: 11 Administration of oxygen therapy default as stated OR space is provided for individual patient instructions for oxygen delivery Give oxygen to maintain Sa02 above 95% Smith(SMITH) 3/515 CEASE continuous opioid infusion as per Acute Pain Service or equivalent medical officer

12. Administration and discard of epidural solution: 12 Opioid infusion commenced Discard of any remaining opioid solution Page 3 6/4/15 10:00 SLee SRose 6/4/15 21:00 10mL THall GLamb 5/4/15 10:00 Thall SRose 5/4/15 20:00 5mL ALoh JLucas

13. 13 The Continuous Opioid Infusion Chart provides observations for a maximum of 4 days. If the infusion continues beyond 4 days, a new chart must be started and a new prescription written. Observation pages

14. 14 Observations: Pain score Sedation score and Respiratory rate Opioid infusion delivery -Infusion rate -Total dose -Bolus dose -Program check Oxygen therapy and oxygen device mode

15. Documenting observations: Pain Assessment: ‘R’ for rest ‘M’ for movement 15 RR RR R MMR M M 1100 1200 1300 1500 1400 05/4/15

16. 16 Documenting observations: Sedation, respiratory rate, oxygen therapy, Infusion delivery Observations in the ‘Red Zone’ requires a Rapid Response to be initiated AND contact the Acute Pain Service (or equivalent medical officer) Observations in the ‘Yellow Zone’ requires a Clinical Review by the Acute Pain Service (or equivalent medical officer)     2L 2L NP NP      2 2 2 2 mg mg TS TS TS 3 mg TS BJ

17. The next 2 slides detail: Continuous opioid management guidelines Yellow and Red Zone Instructions 17

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20. The standardisation of this chart promotes best practice in prescribing, pain assessment and management of adverse effects in those patients receiving a continuous opioid infusion Comments or questions can be directed to your implementation officer or the project leaders Emily Edmonds or Jenni Johnson (for contact details see introduction slide) The feedback register can be located on the ACI website: http://www.aci.health.nsw.gov.au/networks/pain-management/acute-pain-forms 20