1. Neuraxial Opioid Single Dose Observation Chart - adult Education Slide Presentation A presentation prepared by the Pain Interest Group Nursing Issues in association with the Agency of Clinical Innovation Pain Management Network Please direct comments to : Emily Edmonds Coordinator State Pain Forms Pain Interest Group Nursing Issues CNC Acute Pain Service Blacktown Hospital Phone: 9881 7649 Email: emily.edmonds@swahs.health.nsw.gov.au emily.edmonds@swahs.health.nsw.gov.au Jenni Johnson Manager Pain Management Network Agency for Clinical Innovation (ACI) Phone: 9464 4636 Email: jenni.johnsons@aci.health.nsw.gov.au jenni.johnsons@aci.health.nsw.gov.au OR March 21, 2013

2. Neuraxial opioid single dose Observation chart - adult The neuraxial opioid single dose observation chart for adult patients has been developed by a team of experts in the field of acute pain including clinical nurse consultants, anaesthetists and pharmacy representatives. Standardisation of this chart promotes best practice in pain assessment and management of adverse effects in those patients who have received an opioid via the neuraxial route. The term ‘neuraxial’ encompasses injections given in close proximity to the nerve roots of the central nervous system including spinal and epidural. 2

3. Aim of this presentation: This presentation aims to explain  how to use the chart to record the administration of an opioid via the neuraxial route  how to complete the clinical observations  guidelines on the management of patients who have received an opioid via the neuraxial route including the management of adverse effects 3

4. Neuraxial Opioid Single Dose Observation Chart - adult Page 1: - Neuraxial opioid administration information - Naloxone prescription - Management guidelines Page 1 4

5. Neuraxial Opioid Single Dose Observation Chart - adult Inside pages Inside pages: - Observation pages for up to 2 days 5

6. Neuraxial Opioid Single Dose Observation Chart - adult Back page: - Clinical review and Rapid Response Criteria - Management of adverse effects Back page 6

7. Patient allergy status and patient label Private patients: require a signature from the referring Doctor to the Pain Service Neuraxial opioid administration information Naloxone prescription OR standing order sticker affixed Record of naloxone administration Management guidelines Contact details Page 1 7

8. Documentation of the administration of an opioid via the neuraxial route: Below is an EXAMPLE of documenting the administration of an neuraxial opioid The frequency of observations (hourly for 6 hours or hourly for 12 hours) must be determined by the medical officer who administered the opioid dose Morphine Spinal 200 micrograms 09:00 15/04/13 SMITH TSmith Handwrite patient details or affix patient label (First prescriber to check patient label is correct if sticker is used) Private patients: require a signature from the referring Doctor to the Pain Service Prescriber to complete patient allergy and ADR section in full  SMITH TSmith 15/04/13 8

9. Naloxone prescription: Naloxone is indicated for SEDATION SCORE 3 (difficult to rouse or unresponsive) OR SEDATION SCORE 2 (constantly drowsy unable to stay awake) and a RESPIRATORY RATE LESS THAN OR EQUAL TO 5 breaths per minute. This section MUST be completed in full OR a sticker affixed which states the standing order PRIOR to any administration of naloxone. Naloxone X 4 100 micrograms IV 15/04/13 SMITH T Smith 2 -3 minutely 9

10. Record of naloxone administration and neuraxial opioid management guidelines: 16/4/13 08:30 08:33 08:36 08:39 100 micrograms PLambert TBuckley PLambert TBuckley PLambert TBuckley PLambert TBuckley 16/4/13 10

11. Clinical Review & Rapid Response Criteria: The back page of the chart displays instructions explaining how to make a Clinical Review or a Rapid Response These instructions incorporate track and trigger colour zones (from the Between the Flags Program) to promote the recognition of the deteriorating patient in relation to the administration of opioids Back page 11

12. Clinical Review Criteria: 12

13. Rapid Response Criteria: 13

14. Managing neuraxial opioid adverse effects: 14

15. R M R M R M R M 11 00 12 00 13 00 14 00 15 00 15/04/13 R M Observations: A patient label must be affixed or details written on each page that records observations Pain assessment: record ‘R’ for rest and ‘M’ for movement 15

16. A sedation score or a respiratory rate in the ‘Red Zone’ requires a Rapid Response to be initiated AND contact the Acute Pain Service (or equivalent medical officer) A sedation score or a respiratory rate in the ‘Yellow Zone’ requires a Clinical Review by the Acute Pain Service (or equivalent medical officer) 2L Ondanestron given Naloxone given 2L 8L NP FM NH AT Nausea or vomiting assessment Pruritus assessment Comments for free text Oxygen therapy and Oxygen device (see front page for device key) Assessors initial 16

17. Standardisation of this chart promotes best practice in pain assessment and management of adverse effects in adult patients who have received an opioid via the neuraxial route. Comments or questions can be directed to your implementation officer or the project leaders Emily Edmonds or Jenni Johnson (for contact details see introduction slide) The feedback register can be located on the ACI website: http://www.aci.health.nsw.gov.au/networks/pain-management/acute-pain-forms 17