MORPHINE - Policy for Standard Morphine Intravenous

MORPHINE – Policy for Standard Morphine Intravenous Patient Controlled Analgesia in Paediatrics

Page 1 of 13 Date Issued: 13th December 2017

Review Date: May 2021 (ext1)

MORPHINE - Policy for Standard Morphine Intravenous Patient

Controlled Analgesia in Paediatrics

Issue Date: 13th

December 2017

Disclaimer

Overarching policy statements must be adhered to in practice.

Clinical guidelines are for guidance only. The interpretation and application of them remains the responsibility of the individual clinician. If in doubt contact a senior colleague or expert.

The Author of this clinical document has ultimate responsibility for the information within it.

This clinical document is not controlled once printed. Please refer to the most up-to-date version on the intranet.

Caution is advised when using clinical documents once the review date has passed. Clinical Document Template: v4.1 / 04-01-2016




CONTENTS

SECTION DESCRIPTION PAGE

1 INTRODUCTION 2

2 SCOPE OF DOCUMENT 3

3 DEFINITIONS AND/ OR ABBREVIATIONS 3,4

4 ROLES AND RESPONSIBILITIES 4

5 NARRATIVE 5-8

6 EVIDENCE BASE / REFERENCES 8

7 EDUCATION AND TRAINING 8

8 MONITORING COMPLIANCE 9

9 CONSULTATION 9

10 EQUALITY IMPACT ASSESSMENT (EIA) 9,10

11 KEYWORDS 10

12 APPENDICES (list)

Appendix A – Equality Impact Assessment Form

10 11-12

DOCUMENT CONTROL (Last page) 13

ASSOCIATED DOCUMENTS

CADD® Solis Quick Guide

CADD® Solis Operator's Manual

Hyperlinked

to Pain Management Intranet Site

1. INTRODUCTION This policy is issued and maintained by the Chief Nurse on behalf of The Trust, at the issue defined on the front sheet. “The complexities associated with prescribing, preparing and administrating injectable medicines mean that there are greater potential risks for patients than for other routes of administration. Weak operating systems increase the potential risk of harm and a safe system of work is needed to minimise these risks.” (NPSA, 2008) This policy is to establish standards of safe practice for children using morphine IV PCA post operatively or for the management of pain following trauma or during acute flare of disease. This policy is written in accordance with and reflects standards set out in the Trust’s policy for ‘The Care of the Patient Undergoing Intravenous Therapy (Bolus, Continuous and Intermittent)’, (version 2, 2017). All registered healthcare professionals as defined in this policy, can check IV morphine in accordance with their professional registration, but they are prevented from administering this medication unless they have received the Trust’s IV medicines administration training relevant to their area of practice (RD04/RD04.4/RD05). This policy identifies which members of staff can prescribe morphine PCA and use this equipment. It also specifies the level of training the practitioner must complete: its place is to ensure the highest standard of care delivery to patients. Failure to comply with this policy may be regarded as misconduct and dealt with in accordance with the Trust’s disciplinary procedures and potentially the practitioner’s regulatory body.

http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?contentid=40419

http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?contentid=40425




2. SCOPE OF DOCUMENT This clinical document applies to: Staff group(s)

Appropriately trained registered nurses

Appropriately trained paediatric nurses

HCPC registered operating department practitioners

Anaesthetists

Clinical area(s)

Theatres/Theatre Recovery (Kings Mill only)

Ward 25

Patient group(s)

Patients under the age of 18years following major surgery, or surgery that has

resulted in severe symptoms of pain.

Patients under the age of 18years with severe acute pain following traumatic injury or

disease.

Exclusions

Patients 18years and over

Patients who lack mental or physical capacity needed to use the equipment (self-

administration button)

Related Trust policies and guidelines and/or other Trust documents

Operational Policy for Infection Prevention and Control

Policy for the Care of the Patient Undergoing Intravenous Therapy (Bolus, Continuous

and Intermittent)

The Observations (and PEWS) Policy for Paediatric Patients

Medicines Policy

Medical Equipment User Training Policy

Medical Device Management Policy

Policy for Consent to Examination, Treatment and Care

3. DEFINITIONS AND/OR ABBREVIATIONS

Trust Sherwood Forest Hospitals NHS Foundation Trust

Staff All employers of the Trust including those managed by a third party on behalf of the Trust

RN Registered nurse

mL Millilitres

mg milligrams

G grams

mcg micrograms




TDS Three times a day

QDS Four times a day

PRN As required

IV Intravenous

PO Per oral

NSAID Non-steroidal anti-inflammatory drug

IV PCA Intravenous patient controlled analgesia

PEWS Paediatric Early Warning Score

PAPPC Paediatric Acute Pain Prescription Chart

VIP Visual inflammatory phlebitis

EIA Equality Impact Assessment

SOC Specialist Observation Chart (Anaesthetics / Theatre Recovery )

EOS Electronic Observation System

4. ROLES AND RESPONSIBILITIES

RESPONSIBILITIES OF THE ANAESTHETIST:

Be conversant with this policy and access informal pump training if required via the

Pain Team, Theatre Recovery Team or medical equipment training facilitator;

ensuring competent use of the equipment

Discuss the IV PCA with the patient to establish patient compliance, physical mental

capacity to use the system and any sensitivity to morphine

Ensure the IV PCA is prescribed using the Trust Acute Pain Prescription Chart

When used post operatively document the IV PCA details on the anaesthetic chart

Ensure awareness of their patient’s post-operative progress

RESPONSIBILITIES FOR THE REGISTERED NURSE/ODP:

Be conversant with this policy

Access formal training and be assessed as competent in the use of the grey

CADD®Solis IV PCA and associated equipment

Ensure required patient observations are carried out as per this policy

Appropriately respond to untoward events

4.4 RESPONSIBILITIES FOR WARD SISTER/CHARGE NURSES:

To act as role models and are accountable for the implantation of the policy

Ensure all staff have the required training to develop competencies.

Responsible for ensuring that all staff accountable to them are aware of this policy

and adhere to its statement.




5. NARRATIVE

IV PCA is suitable for pre and post-operative pain management and the management

of pain caused by trauma or acute flare of disease. PCA allows the patient to have

more control over their analgesia and avoids peaks and troughs in plasma

concentration which can occur with the SC route.

IV PCA is an electronically controlled pump that delivers a specified amount of IV

morphine when the patient presses a button. It is programmed to deliver a dose at set

intervals. In paediatrics the dose is set according to the child’s weight.

Caring for patients with IV PCA requires specialist knowledge and training for using

the infusion pump and awareness of potential side effects or complications.

All personnel involved in the care of patients with IV PCA must be trained and

competent to do so.

5.1 SETTING UP AN I.V. MORPHINE PCA (See Appendix A)

Dedicated grey CADD®-Solis pump with a lock box and configured for morphine IV

PCA must be used.

Dedicated CADD®-Solis giving sets must have anti-syphon and anti-reflux valves and

Y- extension.

The pump programme MUST be checked by two qualified practitioners who are

appropriately trained.

The process for priming the line and preparing the pump is described in the quick

guide for CADD®-Solis and the CADD®-Solis Operators Manuel (appendix A & B).

The pump will be programmed to deliver a weight specific bolus dose, as per

Paediatric Acute Pain Prescription Chart (prescribing guidance below) with a 5-minute

lockout. Refer to the Trust IV policy for opioid checking procedures.

No background infusion to be set with this system.

5.2 THE PRESCRIPTION Morphine bolus (= 20 micrograms/kg/dose)

Child’s weight Bolus dose in mg Bolus dose in ml Bolus dose in mcg

15-20kg 0.3mg 0.3ml 300 micrograms

20-25kg 0.4mg 0.4ml 400 micrograms

25-30kg 0.5mg 0.5ml 500micrograms





>50kg 1mg 1ml 1000micrograms




Prefilled Bag - Morphine 100mg in 0.9% Sodium Chloride 100ml concentration = 1mg/1ml.

Changes from the standard prescription MUST be agreed with the Pain Team or first

on call anaesthetist and a reason documented in the medical notes. Any changes to

the original prescription MUST be documented and prescribed on the Acute Pain

Prescription Chart by a doctor or non-medical prescriber.

5.3 SUPPORTIVE ANALGESIA: These are an essential part of PCA management. The requirement for opioids and severity of side effects can be effectively minimised with additional analgesia.

Paracetamol - PO - 18.75mg/kg 4-6 hourly, max QDS (reduce to 15mg/kg QDS on discharge)

Ibuprofen – PO - 5mg/kg 4- 6hourly, max QDS (review after 72 hours)

5.4 ANTIEMETICS Follow post-operative nausea and vomiting protocol:

First line: Ondansetron 100micrograms/kg (max per dose 4mg)

Second line: Cyclizine ˂ 5yrs 0.5-1mg/kg (max per dose 25mg) 6-11yrs 25mg TDS 12-17yrs 50mg TDS

5.5 PATIENT MONITORING

Ensure the child is monitored as stipulated below as morphine has a significant side effect profile. The child must be nursed in an area where they can be easily observed.

Document via: Observation Half hourly for first:

Then hourly for next:

Then 2-4 hourly for: (child’s condition determines)

EOS / SOC Blood pressure 2 hours 4 hours Duration of IV PCA

EOS / SOC Pulse 2 hours 4 hours Duration of IV PCA

EOS/ SOC Respirations 2 hours 4 hours Duration of IV PCA

EOS / SOC AVPU 2 hours 4 hours Duration of IV PCA

EOS / SOC Oxygen saturations 2 hours 4 hours Duration of IV PCA

EOS / SOC Temperature 2 hours 4 hours Duration of IV PCA

EOS / SOC PEWS 2 hours 4 hours Duration of IV PCA

EOS / SOC & PAPPC

Pain Assessment 2 hours 4 hours Duration of IV PCA

PAPPC Itching 2 hours 4 hours Duration of IV PCA

PAPPC Nausea & Vomiting 2 hours 4 hours Duration of IV PCA




The table above demonstrates standard requirements for child monitoring with IV PCA. Observations may be increased if a child’s condition deteriorates as per Trust Observation Escalation Policy.

5.6 THE PUMP AND SYSTEM

Pump settings MUST be checked against the prescription by performing a

programme review:

o On hand over from the theatre recovery staff to the ward staff nurse and

documented on the PAPPC

o At every shift change with two qualified nurses, one from either shift to ensure

programming is correct.

Ensure that the pump screen is displaying the morphine programme on a blue background

Document the PCA bolus dose, lockout period, PCA demands and quantity administered on the PAPCC at the observation times stated above.

5.7 CANNULA

The cannula must be checked as per VIP Trust Protocol

This is to be recorded on the Cannulation Documentation Chart. 5.8 TROUBLESHOOTING PROBLEMS

Unrelieved pain:

Should be reviewed by a surgical F2 doctor/registrar to eliminate underlying causes.

Follow the quick guide for the CADD®-Solis (see Appendix A )

Inform the pain nurse specialist or the on call anaesthetist.

5.9 SEDATION AND RESPIRATORY DEPRESSION If the child is drowsy or difficult to rouse (AVPU – P or U) and/or respiratory rate is less than 10 breaths/min:

The handset MUST be taken away from the child and pump stopped

Administer oxygen at 4L/min via face mask

Prepare Naloxone IV (see PAPCC for guidance)

Inform the on call anaesthetist and the pain nurse specialist and record event on the PAPPC

IV PCA SHOULD NOT BE RECOMMENCED WITHOUT ADVICE FROM THE FIRST ON CALL ANAESTHETIST OR PAIN NURSE SPECIALIST




5.10 CAUTIONS Only the child must press the PCA button. 5.11 DISCONTINUATION

Ensure adequate step-down analgesia is prescribed prior to discontinuation of the IV PCA.

Please return the pump / power cable to Theatre Recovery promptly following discontinuation

6 EVIDENCE BASE / REFERENCES

Australia and New Zealand College of Anaesthetists (ANZCA) (2015) Acute Pain Management: Scientific Evidence: 4th Edition. ANZCA. Melbourne.

The Royal Marsden Hospital (2011) Manual of Clinical Nursing Procedures. Royal Marsden Hospital. London.

Macintyre PE (2001) Safety and efficacy of patient controlled analgesia. BJA 87 (1): 36-46

Rowbotham D J & Macintyre PE (2003). Clinical Pain Management: Acute Pain. 219-234. (2003)

Smiths Medical (2011) CADD®-Solis 2100, 2110 Ambulatory Infusion Pumps- Operator’s Manual. Smiths Medical. Watford

Smiths Medical (2009) Quick Guide for the CADD®-Solis. Smiths Medical. Watford

7 EDUCATION AND TRAINING

7.1 For Anaesthetists

Be conversant with this policy and access informal training available Pain/Theatre Recovery Teams. Ensure competent to use the equipment.

7.2 For Nurses/ODP

To be conversant with this policy. This policy will be promoted by a pain nurse specialist during Induction Programme and the Pain Management Study Day.

To have completed the IV PCA training package and have been assessed as competent by a senior member of staff or a member from the Pain Team.




8 MONITORING COMPLIANCE Monitoring of compliance and competencies will be achieved via the database on the register of training retained in the Training and Development Department. WHO is going to monitor this element (job title of person/ group responsible)

WHAT element of compliance or effectiveness within the procedural document will be monitored

HOW will this element be monitored (method used)

WHEN will this element be monitored (frequency/ how often)

REPORTING Which committee/ group will the resultant report and action plan be reported to and monitored by (report should include any areas of good practice/ organisational learning)

Ward Leaders Competency packs are complete

Appraisals, Induction

On going Department leaders/ ward leaders

Training and Development

Training completion packs

Register of training On going Practice development forum

Pain nurse consultant

Reported incidents

Datix Following each incident

Anaesthetic Governance Group

9 CONSULTATION

The following individuals, groups of staff and Trust group(s)/ committee(s) have been consulted in the development/ update of this document:

Contributors: Communication Channel: e.g. Email

1:1 meeting/ phone

Group/ committee meeting

Date:

Anaesthetic Lead in Paediatrics-Puran Khandelwal email 30/05/17

Pharmacy representative - Andrea Rumsby email 30/05/17

Matron - Paediatrics- Rachel Barker email 30/05/17

Theatre Recovery Lead Nurse- Claire Wythes-Liddle email 30/05/17

Clinical Governance Advisor- paediatrics- Colin Dunkley email 30/05/17

Speciality Anaesthetic Clinical Governance Group meeting 19/09/17 & 21/11/17

Drugs and Therapeutics Committee meeting 10/11/17

Lead Pharmacist- Thomas Bell email 30/05/17

Paediatric Practice Development Matron- Kate Rodgers email 30/05/17

10 EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies, procedures and guidelines discriminates against individuals directly or indirectly on the basis of gender, colour, race, nationality, ethnic or national origins, age, sexual orientation, marital status, disability, religion, beliefs, political affiliation, trade union membership, and social and employment




status. An EIA of this policy/guideline has been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee. See Appendix A for Complete EIA form.

11 KEYWORDS Programming; Grey; CADD®-Solis; pump; morphine

12 APPENDICES Appendix A – Equality Impact Assessment Form




Appendix A Equality Impact Assessment (EqIA) Form (please complete all sections) Guidance on how to complete an EIA Sample completed form

Name of service/policy/procedure being reviewed: Policy for Morphine Intravenous Patient Controlled Analgesia – Paediatric Patients

New or existing service/policy/procedure: New

Date of Assessment: 5th December 2017 For the service/policy/procedure and its implementation answer the questions a – c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)

Protected

Characteristic

a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups’ experience? For example, are there any known health inequality or access issues to consider?

b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening?

c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality

The area of policy or its implementation being assessed:

Race and Ethnicity: Non-English speaking patients may face potential issues on understanding the explanation given on how to use the bolus button and rationale behind patient controlled analgesia (PCA).

Verbal translation will be required via a Trust appointed language translator or via use of ‘big word’ telephone translation.

None

Gender:

None None None

Age:

None None None

Religion: None None None

Disability:

Patients with physical disabilities affecting use of hands will not be able to operate this equipment. Patients who lack the mental capacity to effectively uses this device will not be offered this analgesic technique

Alternative analgesic techniques / plans will be available / prescribed for patients who cannot physically operate the self-administration (bolus) button or for patients who lack the mental capacity understand or use the device

None

http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?ContentId=49233

http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?ContentId=49236




Sexuality:

None None None

Pregnancy and Maternity:

None None None

Gender Reassignment:

None None None

Marriage and Civil Partnership:

None None None

Socio-Economic Factors (i.e. living

in a poorer neighbourhood /

social deprivation):

None None None

What consultation with protected characteristic groups including patient groups have you carried out? Consultation for this policy via speciality (anaesthetics) governance and key clinicians / pharmacists associated with the use of IV PCA in approved clinical areas

What data or information did you use in support of this EqIA? None

As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? No

Level of impact From the information provided above and following EqIA guidance document, please indicate the perceived level of impact: Low Level of Impact For high or medium levels of impact, please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting.

Name of Responsible Person undertaking this assessment:

Signature: Lorraine Winter

Date: 05/12/2017




Document control/ supporting information for this clinical document

Title:


Document category: Clinical Policies and Guidelines

Reference:

CPG-PAIN-IVPCAPaed

Version number:

1.0

Approval:

v. Approved by:

Approval Date:

1.0 Anaesthetic Clinical Governance Group 21-11-2017

Issue date:

13th December 2017

Review date: May 2021 (ext1)

Job title of author responsible for the document/ author name:

Lorraine Winter – Senior Pain Nurse Specialist

Division & Specialty/ Department/ Service responsible for reporting the status of the document

Surgery/ Anaesthetics, Critical Care & CSSD – Aneasthetics (Pain Management)

Document Sponsor:

Chief Nurse

Date Equality Impact Assessment completed/ updated:

05/12/2017

Superseded document(s): (Ref No., Version number, previous title if changed, date issued – review date)

Not Applicable – New Policy

Version History and Practice Changes/ Amendments

Issue Date Version Comments

13-12-2017 1.0 New policy

Distribution (Circulation):

This document will be accessible via the Trust’s intranet.

Communication:

Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin/ nursing bulletin and/ or other agreed communication method.

Documents

MORPHINE - Policy for Standard Morphine Intravenous