1. PCA (patient controlled analgesia) 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: SEPTEMBER 2, 2014 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. PCA (patient controlled analgesia) chart - adult The PCA 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 PCA chart is not suitable for use in paediatric patients. Standardisation of this chart promotes best practice in prescribing, pain assessment and management of adverse effects in those patients receiving an opioid via PCA. 2

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

4. PCA chart - adult 4 Page 1 Management guidelines Yellow and Red Zone response instructions Page 2 PCA prescription, program, Neuraxial opioid + PCA, Naloxone prescription, Oxygen therapy, PCA ceased Page 3 PCA drug administration, Drug discard, Naloxone administration Booklet format Prescription valid for 4 days Observation pages for 4 days

5. PCA chart - adult 5 Observation pages: for up to 4 days

6. 6 For detailed information regarding PCA prescribing and management refer to local hospital PCA policy or procedure Space provided for the contact details of your Acute Pain Service or equivalent medical officer who manages PCA Instructions for managing patients whose observations are in the Yellow or Red Zone

7. Prescription page: 7 Page 2 Patient label and allergy adverse reactions PCA prescription PCA program - Allows for 2 further changes to the program Record of administration of a neuraxial opioid Prescription for naloxone Oxygen therapy Private patients: pain specialist referral, name and signature of the doctor making the referral

8. PCA prescription: 8 Below is an EXAMPLE prescription Refer to hospital PCA policy for local guidelines on PCA prescribing PLEASE REFER TO YOUR LOCAL HOSPITAL POLICY FOR STANDARDISED PCA DRUG SOLUTIONS SMITH 5/10/14 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. PCA prescription: 9 Below is an EXAMPLE prescription Refer to hospital PCA policy for local guidelines on PCA prescribing A PCA prescription is for one opioid only. When changing from one opioid to another, a new PCA chart must be commenced Morphine 60 mg NIL IV 60 mL 5/10/14 SMITHTSmith PCA prescription to include: route, primary drug (e.g. morphine or fentanyl) total amount in mg or microgram, total volume and primary drug concentration Space is provided for an additional drug to be added if needed Space provided for pharmacist reconciliation Prescriber’s signature, printed name and contact 1 mg/mL 7511

10. PCA program: 10 Below is an EXAMPLE program Refer to hospital PCA policy for local guidelines on PCA prescribing When changing from one opioid to another, a new PCA chart must be commenced 1 mg 1 5 mins NIL 10:00 5/10/14 1 mg 1 5 mins 09:00 6/10/14 SMITH TSmith JACK S.Jack 1.5 mg 1.5 PCA bolus dose (state unit of drug and volume) Lockout interval in minutes Background infusion (State mg or microgram and mL per hour) Two additional rows are provided for changes to the PCA program Prescriber’s signature, print name and contact 7511 3852

11. Neuraxial opioid + PCA: IF a dose of opioid has been administered via the spinal or epidural route during a procedure, AND the patient is to receive a PCA, the following is to be completed 11 The frequency of observations (hourly for 6 hours or hourly for 12 hours) must be determined by the medical officer who administered the opioid dose Morphine Spinal 200 microgram 10:00 5/10/14 SMITH TSmith  7511

12. Naloxone prescription: Naloxone is indicated for SEDATION SCORE 3 (difficult to rouse or unresponsive) OR SEDATION SCORE 2 (constantly drowsy unable to stay awake) and a RESPIRATORY RATE LESS THAN OR EQUAL TO 5 breaths per minute. 12 Naloxone X 4 100 microgram IV 5/10/14 SMITH TSmith 2 -3 minutely 7511

13. Oxygen guidance: 13 PCA can be ceased according to instructions in the medical record: Date and time prompt provided (Check local policy for use of this prompt) Give oxygen to maintain Sa02 above 95% Smith(SMITH) 6/10/14 Administration of oxygen therapy default as stated OR space is provided for individual patient instructions for oxygen delivery

14. Administration and discard of PCA opioid and administration of naloxone: 14 PCA commenced Discard of any remaining PCA opioid or drug Naloxone that may have been administered Page 3

15. Administration and discard of PCA drug: IF a PCA syringe or bag is empty when the next one is commenced, document ‘NIL’ discarded There are 14 rows provided to record PCA administration and discard Any opioid or drug remaining from a syringe or bag to be recorded on the corresponding row from its administration 15 10:00 5/10/14 THall SRose 20:00 5/10/14 BLoh JLucas NIL 20:00 BLoh JLucas 09:00 6/10/14 Plambert TBuckley 15 mL 5/10/14

16. Record of naloxone administered: 16 08:30 IV 100 microgram 06/10/14 Plambert TBuckley 08:33 IV 100 microgram 06/10/14 Plambert TBuckley 08:36 IV 100 microgram 06/10/14 Plambert TBuckley 08:39 IV 100 microgram 06/10/14 Plambert TBuckley Naloxone may only be administered when the prescription section of the PCA chart has been completed in full OR if a naloxone standing order is in available

17. Observations: The PCA chart provides observations for a maximum of 4 days. If the PCA continues beyond 4 days, a new PCA chart must be started and a new prescription written. 17 Observation pages

18. Documenting observations: Pain Assessment: ‘R’ for rest ‘M’ for movement 18 RR RR R MMR M M 1100 1200 1300 1500 1400 05/10/14

19. Documenting observations: Sedation, respiratory rate, oxygen therapy, nausea and vomiting 19 2L 6L NP FM Assessments to be recorded graphically as indicated  A sedation score or a respiratory rate in the ‘Red Zone’ requires a Rapid Response to be initiated AND contact the Acute Pain Service (or equivalent medical officer) A sedation score or a respiratory rate in the ‘Yellow Zone’ requires a Clinical Review by the Acute Pain Service (or equivalent medical officer)

20. Documenting observations: PCA delivery 20 JS 2 mg 10 mg 13 mg 20 mg 25 mg TJ 1 mg 2 2 10 13 30 25 13 16 25 20 Ondanestron given JS TJ NIL – – – – – – Total primary PCA dose (cumulative) Circle the unit that is being used Background infusion rate (if in use) Total demands / successful demands (different pumps use different words to describe how many times the button is pressed) PCA program checked: once per shift and on patient transfer - to ensure the pump program matches the prescription Comments section blank for free text Assessor’s initial Two initials are required for change of PCA program JS

21. The next slide details the front page PCA Management Guidelines 21

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23. The standardisation of this chart promotes best practice in prescribing, pain assessment and management of adverse effects in those patients receiving an opioid via PCA. 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 23