Amie Lloyd-Jones QUM Project – Mater Children’s Emergency Department (Under supervision of Dr David Herd and Aaron Basing) University of Queensland

 Children in pain receive less analgesia than adults 1-3 ◦ Communication barrier ◦ Lack of evidence-based medicine  IV morphine – gold standard for strong pain in children 4  IN fentanyl – alternative to IV morphine (no needles!)  Fast, safe and effective pain relief without the need for IV access

 RCT – Borland et al  Demonstrated IN fentanyl = IV morphine ◦ No significant difference in analgesic effect or time to analgesia  IN fentanyl use is off-label and off-licence ◦ Not commercially formulated for IN use

 Characterise the governance of intranasal fentanyl in Queensland Emergency Departments having at least 1000 paediatric attendances per annum ◦ Determine the usage of intranasal fentanyl in paediatric patients of Queensland emergency departments and the utilisation of governance structures ◦ Characterize the clinical indication and dose for intranasal fentanyl use in paediatric patients ◦ Characterize the inclusion and exclusion criteria of intranasal fentanyl in paediatric patients of Queensland emergency departments ◦ Make recommendations about the governance of intranasal fentanyl in paediatric emergency department patients

 Participants – QLD Emergency Departments with ≥1000 paediatric attendances in 2009  5 minute phone interview ◦ Is INF used & main indications ◦ Can nurses initiate ◦ Does policy exist ◦ Inclusion/exclusion criteria and doses

 Most Qld Emergency Departments use IN fentanyl  Majority have policy/procedure documents for use ◦ Ideally want all to have standard policy ◦ Include more thorough dosing and inclusion/exclusion criteria guides ◦ Role for experience sharing between hospitals ◦ Further research/publication into this area

 Very few have nurse initiation ◦ Some are moving towards this ◦ Nurse educators suggested that IN fentanyl is currently under-used and under-dosed ◦ Way to increase QUM ◦ Shown to be safe and effective if correct policy in place 6 ◦ Potential to reduce time to analgesia

 Limitations ◦ Theoretical policy may not reflect clinical practice ◦ Short time frame of study limited the follow up of participants

 IN fentanyl is an effective alternative to IV morphine in the paediatric emergency setting  Further research and refinement is required to reduce ambiguities in administration policies  Nurse initiation can effectively reduce the time to analgesia and improve QUM

1. Furyk JS, Grabowski WJ, Black LH. Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: A randomized controlled trial. Emerg Med Australas. 2009; 21: Alexander J, Manno M. Underuse of analgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med. 2003; 41: Bauman BH, McManus JJG. Pediatric Pain Management in the Emergency Department. Emerg Med Clin North Am. 2005; 23: Analgesic Expert Group. Minor trauma pain: dislocations and fractures. Therapeutic Guidelines [serial on the internet]. 2007; Analgesic. 5. Borland M, Jacobs I, King B, O’Brien D. A Randomized Controlled Trial Comparing Intranasal Fentanyl to Intravenous Morphine for Managing Acute Pain in Children in the Emergency Department. Ann Emerg Med. 2007; 49: Fry M, Holdgate A. Nurse-initiated intravenous morphine in the emergency department: Efficacy, rate of adverse events and impact on time to analgesia. Emerg Med. 2002; 14: