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 ToolsDecember 2015

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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

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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.

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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.

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Local Health District governance for Paediatric Patient Controlled Analgesia must include the following:

• 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.

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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

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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

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Paediatric PCA/NCA – Management Guide

• 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.

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Paediatric PCA/NCA – Management Guide

For detailed information regarding Paediatric PCA/ NCA prescribing, administering and management

refer to local hospital procedures

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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 and >50 kg

Prescription page

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PCA prescription: Below is an EXAMPLE prescriptionRefer to hospital PCA policy for local guidelines on PCA prescribing

Additional information about overweight children

P. SMITH 5/10/14PSmit

h

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

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PCA prescription Below is an EXAMPLE prescriptionRefer 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

Morphine25 mg

IV

5/10/15 T 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 provided for pharmacist reconciliation

Prescriber’s signature, printed name and contact

20 microgram/mL

7511

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PCA program Below is an EXAMPLE programRefer 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 NIL10:005/10/15

0.5 mL = 250 microgram5 mins09:006/10/15

SMITHTSmi

thJACKS.Jack1 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

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Naloxone prescription

NALAXONE INDICATIONS

5 microgram x 25 kg = 125 microgram = 100 microgram

max dose

100 microgram

IV

5/10/15

SMITHTSmith

2 -3 minutely

7511

10:15

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Oxygen therapy and Paediatric PCA/ NCA

Provide oxygen therapy as required to maintain oxygen saturations

above 95%

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Record of administration and discard of PCA opioid & administration of naloxone:

PCA commenced

Discard of any remaining PCA opioid or drug

Naloxone that may have been administered

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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

10:055/10/15 THall

SRose 20:205/10/15 BLoh JLucasNIL

20:40 BLoh JLucas 09:156/10/15Plambert

TBuckley15 mL5/10/15

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Record of naloxone administered

08:30 IV 100 microgram06/10/15

Plambert

TBuckley

08:33 IV 100 microgram06/10/15

Plambert

TBuckley

08:36 IV 100 microgram06/10/15

Plambert

TBuckley

08:39 IV 100 microgram06/10/15

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

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Paediatric PCA chart Observations

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.

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Documenting Paediatric Pain Scores

R

R

R

R

M

M

R

M

M

11001200

13001500

1400

05/10/14

Pain Assessment: ‘R’ for rest ‘M’ for movement

Tick to record paediatric pain scale used

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Sedation observations (Paediatric UMSS score)

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 PAEDIATRICOBSERVATION CHARTS (SPOC)

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Paediatric Vital Signs Observations

ALL other paediatric vital signs observations to be completed

HOURLY and recorded on the correct Standard Paediatric Observation

Chart (SPOC).

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PCA delivery observations

JS

2mg

10mg

13mg

20mg

25mg

TJ

1mg

2

2 10 13

30

25

13 16 25

20

Ond

anes

tron

giv

en

JS JS JS 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

N N

N

N

Y

N N

Y

JS

Y or N for adverse reactions

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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

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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.au

• Catherine Jones, Senior Analyst, Paediatric Healthcare Team, NSW Kids and Families, Phone: 9424 5978, Email: cjone@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-forms

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Paediatric PCA Working PartyWorking 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

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