OXYCODONE Policy for Oxycodone Intravenous Patient ... › media › 8954 ›...

OXYCODONE – Policy for Oxycodone Intravenous Patient Controlled Analgesia – Adult Patients

Page 1 of 14 Date Issued: 31st October 2017

Review Date: April 2021 (ext1)

OXYCODONE – Policy for Oxycodone Intravenous Patient Controlled

Analgesia – Adult Patients

Issue Date: 31st

October 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 4

4 ROLES AND RESPONSIBILITIES 4

5 NARRATIVE 5-9

6 EVIDENCE BASE / REFERENCES 9

7 EDUCATION AND TRAINING 10

8 MONITORING COMPLIANCE 10

9 CONSULTATION 11

10 EQUALITY IMPACT ASSESSMENT (EIA) 11

11 KEYWORDS 11

12

APPENDICES

Appendix A – Equality Impact Assessment Form

11 12-13

DOCUMENT CONTROL (Last page) 14

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 aims to establish standards of safe practice for adult patients using oxycodone 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 oxycodone 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).

http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?contentid=40419http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?contentid=40425




This policy identifies which members of staff can prescribe oxycodone IV 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.

2. SCOPE OF DOCUMENT

This clinical document applies to:

Staff group(s)

Appropriately trained registered nurses

Appropriately trained registered midwives

HCPC registered operating department practitioners

Anaesthetists

Clinical area(s)

ICCU

Main & Day Case Theatres/ Theatre Recovery (Kings Mill only)

Wards 11,12,14,31 & 32

Sherwood Birthing Unit & Maternity Ward

Patient group(s)

Adult patients following major surgery, or surgery that has resulted in severe

symptoms of pain.

Adult patients with severe acute pain following traumatic injury or disease.

Maternity patients post Caesarean section with severe symptoms of pain.

Exclusions

Patients under the age of 16 years old.

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

Standard Operating Procedure Infection Prevention and Control ICP 1

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

and Intermittent)

The Observations and Escalation Policy for Adult 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

L Litres

TDS Three times a day

QDS Four times a day

PRN As required

IV Intravenous

PR Per rectum

PO Per oral

NG Nasogastric tube

IV PCA Intravenous patient controlled analgesia

NEWS National Early Warning Score

APPC Acute Pain Prescription Chart

SOC Specialist Observation Chart

ICCU Integrated Critical Care Unit

NSAID Non-steroidal anti-inflammatory drug

VIP Visual inflammatory phlebitis

EIA Equality Impact Assessment

EOS Electronic Observation System

4. ROLES AND RESPONSIBILITIES

4.1 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 and

mental capacity to use the system and any sensitivity to oxycodone.

Ensure prescription of the correct opioid drug for the IV PCA on the Trust APPC.

Ensure awareness of their patient’s post-operative progress.

4.2 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 pump and associated equipment.

Ensure required patient observations are carried out as dictated in this policy.

Appropriately respond to untoward events.

Ensure correct preparation of opioid drug as per prescription.




4.3 RESPONSIBILITIES FOR WARD SISTER/CHARGE NURSES:

To act as excellent role models and be responsible and accountable for the policy

implementation among staff in practice, and the monitoring of standards and best

practice associated with it.

Ensure that all staff in the sphere of their responsibility have access to training

required to develop the skills and competence. This includes the completion of the

associated work books, medical equipment competency documents and study

sessions in a timely manner.

Ensure that all staff accountable to them are aware of this policy and adhere to its

statement.

4.4 RESPONSIBILITY OF PHARMACISTS:

To monitor prescribing and oversee the administration of medicinal therapies.

To alert prescribers and other health care professionals to potential or actual

problems.

4.5 RESPONSIBILITY OF ALL ABOVE:

Report incidents or near misses relating to IV medicines using the Trust incident

reporting system (Datix).

To gain valid consent. Patients have the legal and ethical right to determine what

happens to them. Valid consent to treatment is essential to all forms of healthcare and

paramount when considering invasive techniques. Obtaining consent is also a matter

of common courtesy between the healthcare provider and recipient.

5. NARRATIVE

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

of pain caused by traumatic injury or acute flare of disease. PCA allows the patient to

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

concentration which can occur with the IM or SC route. IV PCA has also been found to

save on nursing time and empowers patients to self- manage pain. Caring for patients

with IV PCA requires specialist knowledge and training of the bolus only infusion pumps

and awareness of potential side effects or complications. All clinicians involved in the care of patients with IV PCA must be trained and assessed as competent to do so.

In the interest of patient safety- IV PCA should not be used concomitantly with

PCEA unless in a critical care environment.




5.1 THE PRESCRIPTION/ OXYCODONE INFUSION BAG

IV PCA (oxycodone) standard prescription:

Oxycodone 0.5mg bolus with a 5 minute lockout interval (standard dose) - no

background infusion.

The initial prescribed dose will be determined by the prescribing anaesthetist and

may differ from the standard dose.

Changes from the initial prescription MUST be agreed by the Pain Team or on-call

anaesthetist and the reason for the change documented in the patient’s medical

notes. Any changes to the original prescription must be documented and

prescribed on the APPC chart by a doctor.

Infusion bags are to be mixed by a registered practitioner under the direct

observation of a second registered practitioner. The infusion bag will contain

oxycodone 50mg (5 x 10mg ampules) in 100ml of 0.9% sodium chloride;

concentration = 0.5mg per ml. The bag will clearly display a yellow drug additive

label, which is dated and signed as per Medicines Policy. When mixed, the

oxycodone infusion bag will have a life of 24 hours.

If commenced in Theatre Recovery, prior to discharge from this area the RN will

inform the patients residing ward/ICCU that an oxycodone PCA is insitu: this is to

allow time for injectable oxycodone ampule stock to be ordered from Pharmacy

(injectable oxycodone will not be routine ward stock).

5.2 SETTING UP AN IV Oxycodone PCA (See CADD® Solis Quick Guide for full

guidance).

Dedicated grey CADD®-Solis pump with a lock box, marked for ‘intravenous use

only’ and specifically configured for IV PCA must be used.

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

and “Y”- extension.

The pump programme and opioid infusion bag MUST be checked by two qualified

practitioners who are appropriately trained as per Medicines Policy.

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

o CADD® Solis Quick Guide

o CADD® Solis Operator's Manual

Ensure the ‘oxycodone’ programme is selected (morphine and fentanyl

programme options are also available on these pumps).

The pump is automatically programmed to deliver a 0.5mg bolus dose of

oxycodone with a 5-minute lockout as standard, but this programme may need to

be changed on occasion due to higher / lower prescribed dose based on individual

patient need.

The pump will only allow for bolus delivery and will not allow a background

infusion.

All patients with an oxycodone IV PCA must be referred to the Pain Team for daily

monitoring.

http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?contentid=40419http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?contentid=40419http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?contentid=40425




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-

supportive analgesia includes:

Paracetamol 1g QDS - PO/PR/NG/IV (if appropriate consider nature of surgery

when selecting route for administration.

NSAID (unless contra-indicated) - oral ibuprofen 200mg-400mg TDS or IV

Parecoxib 40mg (Theatre Recovery only).

Weak opioids e.g. tramadol 50-100mg QDS or codeine phosphate /

dihydrocodeine 30-60mg QDS. This provides background analgesia and may

reduce the amount of oxycodone required.

5.4 ANTIEMETICS

Follow Trust post-operative nausea and vomiting guidance:

First line: IV/PO ondansetron 4mg 6 hourly either PRN or QDS

Second line: IV/PO cyclizine 50mg 8 hourly either PRN or TDS

5.5 ITCHING

Opioids can cause itching:

Explain to the patient that this can be an effect of intravenous opioids.

Consider administering ondansetron 4mg IV or an antihistamine such as

chlorphenamine (chlorphenamine is a sedating anti-histamine which could

potentially lead to increased levels of sedation when used alongside oxycodone).

5.6 PATIENT MONITORING

Ensure the patient is monitored as stipulated below as oxycodone has a significant

side effect profile…

Document via:

Observation

First 2

hours

Next 4

hours

Then 2 – 4 hourly for:

(patient’s condition

determines)

EOS /SOC Blood pressure 30 mins Hourly Duration of IV PCA

EOS /SOC Pulse 30 mins Hourly Duration of IV PCA

EOS /SOC & APPC Respirations 30 mins Hourly Duration of IV PCA

EOS /SOC & APPC AVPU 30 mins Hourly Duration of IV PCA

EOS /SOC Oxygen saturation 30 mins Hourly Duration of IV PCA

EOS/SOC Temperature 30mins Hourly Duration of IV PCA

EOS /SOC & APPC Pain 30 mins Hourly Duration of IV PCA

APPC Itching 30 mins Hourly Duration of IV PCA

EOS / SOC Nausea & Vomiting 30 mins Hourly Duration of IV PCA

EOS NEWS 30 mins Hourly Duration of IV PCA




The table above demonstrates standard requirements for patient monitoring with IV

PCA. Observations may need to be increased if a patient’s condition deteriorates as

per guidelines set out in the Trust’s Observations and Escalation Policy for Adult

Patients.

5.7 PUMP AND SYSTEM

Pump settings MUST be checked against the prescription by performing a

programme review:

On hand over from the Theatre Recovery RN/ODP to the ward RN and

documented on the APPC

At every shift change with two qualified nurses/midwives, one from either shift to

ensure programming is correct.

Also ensure that:

The pump screen is displaying the oxycodone programme on a purple

background (not the morphine programme on a blue background / fentanyl

programme on a green background)

You document the PCA bolus dose, lockout period and PCA demands on the

APPC at the observation times stated above.

5.8 CANNULA

The cannula must be checked as per VIP Trust Protocol

This is to be recorded on the Cannulation Documentation Chart.

5.9 TROUBLESHOOTING PROBLEMS

5.9.1 Unrelieved pain:

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

causes.

Inform the pain nurse specialist or on call anaesthetist.

Check the pump is functioning correctly.

5.9.2 De-functioning pump:

Follow CADD® Solis Quick Guide

Contact the pain nurse specialists via Vocera

If pain nurse unavailable contact the Theatre Recovery Team for advice on

ext.3704

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




5.9.3 Sedation and respiratory depression:

If the patient is drowsy or difficult to rouse (AVPU – P or U) and/or respiratory rate is

less than 8 breaths per minute:

The handset MUST be taken away from the patient and pump stopped.

Administer oxygen at 4L/min via face mask.

Prepare Naloxone 200mcg IV and contact the ward doctor immediately

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

the APPC

The IV PCA must not be recommenced without prior advice from the on call

anaesthetist or pain nurse specialist.

5.10 CAUTIONS

Only the patient must press the PCA button.

Ensure the bolus demand button is visible at all times.

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 and cleaning (Clinell wipe).

6. EVIDENCE BASE / REFERENCES

Australia and New Zealand College of Anaesthetists (ANZCA) (2015) Acute Pain

Management: Scientific Evidence: 4th Edition. ANZCA. Melbourne.

Lee A, O’Loughlin E, Roberts LJ (2013) A double-blinded randomized

evaluation of alfentanil and morphine PCA versus fentanyl PCA: analgesia

and sleep trial. BJA 110 (2): 293 – 298

Macintyre PE (2001) Safety and efficacy of patient controlled analgesia. BJA

87 (1): 36-46

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.

The Royal Marsden Hospital (2015) Manual of Clinical Nursing Procedures:

9th Edition. Royal Marsden Hospital. London.




7. EDUCATION AND TRAINING

7.1 For Anaesthetists:

Be conversant with this policy and access informal training available via Pain or

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 Trust 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 of 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

Pain nurse

specialists

Daily audit trail Recorded onto

pain management

database via Orion

For each patient

with oxycodone

IV PCA

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 Acute Pain- Dr Hasan Pathan email 9/8/17

Divisional Head of Midwifery / Nursing – Alison Whitham email 9/8/17

Matron for Surgery – Marie Sissons email 9/8/17

Matron for Theatres & ICCU – Sharon Baxter email 9/8/17

Lead Pharmacist- Thomas Bell email 9/8/17

Theatre Recovery Lead Nurse- Claire Wythes-Liddle email 9/8/17

Practice Development Lead Nurse – Claire Madon email 9/8/17

Drugs and Therapeutics Committee meeting

Speciality Anaesthetic Clinical Governance Group meeting 18/10/2017

10. EQUALITY IMPACT ASSESSMENT (EIA)

The Trust is committed to ensuring that none of its policies, procedures and guidelines

discriminate 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

completed form.

11. KEYWORDS

IV; PCA; IVPCA; Programming; Grey; CADD®-Solis; pump; oxycodone

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 Oxycodone Intravenous Patient Controlled Analgesia – Adult Patients

New or existing service/policy/procedure: Existing

Date of Assessment: 1st November 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

Sexuality:

None None None

Pregnancy and Maternity:

None None None

Gender Reassignment:

None None None

http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?ContentId=49233http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?ContentId=49236




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: Clare Burton

Date: 01/11/2017




Document control/ supporting information for this clinical document

Title:


Document category: Clinical Policies and Guidelines

Reference:

CPG-TW-IVPCA(Fentanyl)

Version number:

1.0

Approval:

v. Approved by:

Approval Date:

1.0 Anaesthetic Clinical Governance Group 18-10-2017

Issue date:

31st October 2017

Review date: April 2021 (ext1)

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

Pain Management Nurse Consultant/ Clare Burton

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

Surgery

Anaesthetics, Critical Care & CSSD – Anaesthetics/ Pain Management

Document Sponsor:

Chief Nurse

Date Equality Impact Assessment completed/ updated:

Date Month Year

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

Not Applicable – NEW

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.

OXYCODONE Policy for Oxycodone Intravenous Patient ... › media › 8954 ›...

Documents

Transcript of OXYCODONE Policy for Oxycodone Intravenous Patient ... › media › 8954 ›...