1. Paediatric PCA (patient controlled analgesia) / NCA (nurse controlled analgesia) chart Implementation Education A presentation prepared by NSW Kids and Families in association with the Agency of Clinical Innovation Pain Management Network with acknowledgements to Adult PCA chart Educational Tools December 2015 Office of Kids and Families

2. Aim of this presentation: This presentation aims to explain: Who can use this chart Guidelines on the management of patients receiving PCA including the management of adverse effects 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 2 Office of Kids and Families

3. Paediatric PCA/NCA chart The PCA prescription and observation chart for paediatric patients has been developed by a team of experts in the fields of paediatrics and acute pain including clinical nurse consultants, anaesthetists and pharmacy. The experts represented specialist children’s hospitals as well as metro, regional and rural non-tertiary paediatrics. This Paediatric PCA chart is a mandated NSW chart primarily for use in non- tertiary paediatric facilities. Standardisation of this chart promotes best practice in prescribing, pain assessment and management of adverse effects in paediatric patients receiving an opioid via a PCA or NCA. 3 Office of Kids and Families

4. Paediatric PCA/NCA – Local Governance Paediatric PCA/NCA is ONLY to be used in facilities with local governance structures in place to ensure its safe and effective use in children. These must include a PCA/NCA guideline (including specific paediatric information), appropriate environment, staff training, supervision and support. 4 Office of Kids and Families

5. Local Health District governance for Paediatric Patient Controlled Analgesia must include the following: 5 An endorsed policy/guideline for Patient Controlled Analgesia (including specific paediatric information) A dedicated paediatric in-patient area (level 4 paediatric facilities) Adequate provision of onsite 24/7 medical cover Escalation of Care procedures Adequate provision of nursing staff to provide paediatric high/ close observation care Appropriately trained staff in care of paediatric patients and PCA/NCA Specification of the range of procedures and criteria to be supported through PCA/NCA Selection criteria of patient suitable/ unsuitable for paediatric PCA/NCA e.g. cognitive ability of the child Appropriate paediatric oxygen therapy Provide continuous oxygen saturation monitoring Accurate monitoring of fluid infusion rate/balance Accurate monitoring of IV lines for occlusion Must have background IV fluids (TKVO) running with paediatric PCA/NCA Administration of Paediatric PCA using syringes and/or bags Ensure that no other opioids or sedatives to be administered unless ordered by the Acute Pain Service or equivalent medical officer Provision of naloxone Regular auditing of Paediatric PCA/NCA charts Clinical incidence reviews Minimum of daily review of patients by the Acute Pain Service or equivalent medical officer. Office of Kids and Families

6. Paediatric PCA/NCA chart Booklet format (8 pages): Page 1 – Management Guidelines & Escalation of Care Page 2 – Prescription Guide & Prescription for PCA/ NCA & Naloxone Page 3 – Administration & discard of PCA/NCA medication Pages 4-7 – Hourly Observations (up to 48 hours) Page 8 – Paediatric Pain assessment Tools 6 Office of Kids and Families

7. 7 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 officers who manage PCA Instructions for escalating care for patients whose observations are in the Blue, Yellow or Red Zones Front page

8. Office of Kids and Families Paediatric PCA/NCA – Management Guide 8 Paediatric Ward: Children or adolescents with a PCA or NCA MUST be cared for in a dedicated paediatric ward or paediatric inpatient area with appropriately trained staff. Pain and Sedation Observations recorded HOURLY on this form for the duration of the PCA/ NCA or more frequently as the patient's clinical condition warrants. All other observations to be recorded HOURLY on a Standard Paediatric Observation Chart. Continuous pulse oximetry MUST be used. Oxygen therapy as required to maintain oxygen saturations above 95%. No other opioids or sedatives to be administered unless ordered by the Acute Pain Service or equivalent medical officer. The PCA pump settings to be checked by 2 nurses at the commencement of each shift, on transfer of care or patient transfer and when the syringe or bag is changed. Pruritus or nausea or vomiting: Administer PRN medication as prescribed on the Paediatric National Inpatient Medication Chart. If adverse effect continues contact the Acute Pain Service or equivalent medical officer. PCA: Only the child is to press the PCA button. NCA: Only the allocated registered nurse is to press the button. A dedicated PCA giving set with anti-reflux and anti-siphon device must be used.

9. Paediatric PCA/NCA – Management Guide For detailed information regarding Paediatric PCA/ NCA prescribing, administering and management refer to local hospital procedures 9 Office of Kids and Families

10. 10 Patient label and allergy adverse reactions PCA prescription PCA program - allows for 2 further changes to the program Prescription for naloxone Paediatric PCA or NCA prescription guide with dosage information for children 50 kg Prescription page

11. PCA prescription: 11 Below is an EXAMPLE prescription Refer to hospital PCA policy for local guidelines on PCA prescribing Additional information about overweight children P. 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) MUST have an accurate weight recorded X Office of Kids and Families

12. PCA prescription 12 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 25 mg IV 5/10/15 T SMITH TSmith 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 provided for pharmacist reconciliation Prescriber’s signature, printed name and contact 20 microgram/mL 7511 Office of Kids and Families

13. PCA program 13 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 mL = 500 microgram 5 mins NIL 10:00 5/10/15 0.5 mL = 250 microgram 5 mins 09:00 6/10/15 SMITH TSmith JACK S.Jack 1 mL = 500 microgram 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 Office of Kids and Families

14. Naloxone prescription NALAXONE INDICATIONS 14 5 microgram x 25 kg = 125 microgram = 100 microgram max dose 100 microgram IV 5/10/15 SMITH TSmith 2 -3 minutely 7511 10:15 Office of Kids and Families

15. Oxygen therapy and Paediatric PCA/ NCA 15 Provide oxygen therapy as required to maintain oxygen saturations above 95% Office of Kids and Families

16. Record of administration and discard of PCA opioid & administration of naloxone: 16 PCA commenced Discard of any remaining PCA opioid or drug Naloxone that may have been administered Office of Kids and Families

17. 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 17 10:05 5/10/15 THall SRose 20:20 5/10/15 BLoh JLucas NIL 20:40 BLoh JLucas 09:15 6/10/15 Plambert TBuckley 15 mL 5/10/15 Office of Kids and Families

18. Record of naloxone administered 18 08:30 IV 100 microgram 06/10/15 Plambert TBuckley 08:33 IV 100 microgram 06/10/15 Plambert TBuckley 08:36 IV 100 microgram 06/10/15 Plambert TBuckley 08:39 IV 100 microgram 06/10/15 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 available Office of Kids and Families

19. Paediatric PCA chart Observations 19 The PCA chart provides observations for a maximum of 48 hours (4 pages x 12 hours observations) If the PCA continues beyond 48 hours, a new PCA chart must be started and a new prescription written. Office of Kids and Families

20. Documenting Paediatric Pain Scores 20 R R R R M M R M M 1100 1200 1300 1500 1400 05/10/14 Pain Assessment: ‘R’ for rest ‘M’ for movement Tick to record paediatric pain scale used Office of Kids and Families

21. Sedation observations ( Paediatric UMSS score) 21 Assessments to be recorded graphically as indicated  YOU MUST CALL FOR A RAPID RESPONSE (as per local CERS), FOLLOW THE RED ZONE RESPONSE INSTRUCTIONS ON THE NSW STANDARD PAEDIATRIC OBSERVATION CHARTS (SPOC) AND INITIATE APPROPRIATE CARE AS STATED ABOVE YOU MUST FOLLOW THE RESPONSE INSTRUCTIONS ON THE NSW STANDARD PAEDIATRIC OBSERVATION CHARTS (SPOC) AND INITIATE APPROPRIATE CARE AS STATED ABOVE YOU MUST FOLLOW THE RESPONSE INSTRUCT IONS ON THE NSW STANDARD PAEDIATRIC OBSERVATION CHARTS (SPOC) Office of Kids and Families

22. Paediatric Vital Signs Observations 22 ALL other paediatric vital signs observations to be completed HOURLY and recorded on the correct Standard Paediatric Observation Chart (SPOC). Office of Kids and Families

23. PCA delivery observations JS 2 mg 10 mg 13 mg 20 mg 25 mg TJ 1 mg 2 2 10 13 30 25 1316 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 N N NN N N Y N N Y Y or N for adverse reactions

24. 24 FLACC Observational pain assessment tool – for infants and non-verbal children FLACC-r for children with cognitive impairment Pain faces tool For verbal children over 4 years old Paediatric Pain Tools Visual analogue tool For verbal children over 7 years old

25. The standardisation of this chart promotes best practice in prescribing, pain assessment and management of adverse effects in paediatric patients receiving an opioid via PCA. Comments or questions can be directed to your Paediatric or Pain CNC or the project leaders: Jenni Johnson, Manager, Pain Management Network, Agency for Clinical Innovation (ACI), Phone: 9464 4636, Email: jenni.johnsons@health.nsw.gov.aujenni.johnsons@health.nsw.gov.au Catherine Jones, Senior Analyst, Paediatric Healthcare Team, NSW Kids and Families, Phone: 9424 5978, Email: cjone@doh.health.nsw.gov.aucjone@doh.health.nsw.gov.au The feedback register can be located on the ACI website: http://www.aci.health.nsw.gov.au/networks/pain- management/acute-pain-formshttp://www.aci.health.nsw.gov.au/networks/pain- management/acute-pain-forms 25 Office of Kids and Families

26. Paediatric PCA Working Party Working Party Members Catherine Jones (chair) – NSW Kids and Families Jenni Johnson (secretary) – Agency for Clinical Innovation David Anderson - Paediatric Clinical Nurse Consultant, Acute Pain, Sydney Children’s Hospitals Network, Randwick Katharine Barry - Paediatric Clinical Nurse Consultant, Children’s Healthcare Network Mia Chong - Paediatric Clinical Nurse Consultant, Children’s Healthcare Network Emily Edmonds - Clinical Nurse Consultant, Acute Pain Service, Blacktown Hospital Katrina Harman – Pharmacist, Sydney Children’s Hospital Network, Westmead Paul Hudson – Clinical Excellence Commission Paul Hunstead – Clinical Excellence Commission Megan James – Paediatric Clinical Nurse Consultant, Acute Pain, Sydney Children’s Hospitals Network, Randwick Sonia Markocic - Nurse Practitioner, Wollongong Hospital Nicola McKay - Paediatric Clinical Nurse Consultant, Children’s Healthcare Network, WSLHD Ian McPhee – VMO Anaesthetist, Tweeds Hospital Tony Sara – State Forms Management Committee Allison Taylor – Nurse Practitioner, Acute Pain Service, Tweed Hospital Tiana Trappel - Paediatric Clinical Nurse Consultant, Children’s Healthcare Network Jordan Wood – Anaesthetist, Sydney Children’s Hospitals Network, Randwick Ali Zwain - VMO Anaesthetist, Dubbo Hospital Consultation Prof Les White – Chief Paediatrician Matthew Crawford – Director of Pain & Anaesthetics, Sydney Children’s Hospitals Network, Randwick Chief Executives of Sydney Children’s Hospitals Network and Kaleidoscope 26 Office of Kids and Families