Clinical Guideline for Intravenous Opioids for Adults in Recovery Areas The Recovery Protocol 1. Aim/Purpose of this Guideline 1.1. To Provide safe and efficient administration of Opioids in Recovery. 1.2. Registered Nurses working in High Dependency Areas. 2. The Guidance 2.1. General Principles 2.1.1. Nursing staff holding a current IV Certificate may administer intravenous opioids in Recovery Areas. 2.1.2. Opioids will be administered in accordance with this document. 2.1.3. The prescribing clinician should choose an appropriate opioid protocol from the available recovery opioid schedules on the EPMA system. If EPMA is not available the prescribing clinician should indicate ont eh emergency drug chart the opioid, the maximum dose and that the recovery IV opioid protocol that is to be used, eg Morphine up to 20mg as per recovery protocol and / or Fentanyl up to 200mcgs as per recovery protocol 2.1.4. Any deviation from the recovery IV opioid protocols available on EPMA must be prescribed on EPMA with clear instructions, and discussed with the High Dependency nurse by the clinician concerned. 2.1.5. Naxolone should be available at all times 2.1.6. This protocol should not be used in paediatric patients 2.2. Activation of Policy 2.2.7. The policy is activated if an ipioid recovery protocol is prescribed on EPMA. 2.2.8. Alternatively, the prescribing clinician must indicate on the Emergency Drug Chart that the Recovery IV Opioid Policy is to be used if EPMA is not available. 2.2.9. The clinician must specify which opioid is to be used. Page 1 of 11
2.2.10. If the anaesthetist clinician wishes to use a different bolus range to that specified in the policy, the required bolus size must be specified on EPMA or the Emergency Drug Chart and discussed with the nurse caring for the patient. 2.3. Use of Policy 2.3.11. Once the policy has been activated, the attached flow chart is followed. A senior clinician must review patients whose pain remains uncontrolled after 10 boluses or maximum prescribed dose. 2.4. Observations 2.4.12. Observations are to be performed as described in the attached flow chart 2.4.13. Observations specified in this policy will be performed in addition to other routine observations. 2.4.14. No patient is to be left behind closed curtains after IV opioids have been administered unless the nurse remain with the patient at all times 2.4.15. All patients who have received IV opioids must remain in clear view of nursing staff for a minimum of 15 minutes after the last bolus has been given. 2.4.16. A minimum of one nurse must remain in the area at all times whenever IV opioids have been administered. 2.4.17. A pulse oximeter must be available at all times whenever IV opioids are used. If there is any doubt about adequacy of ventilation or the patients has a depressed level of consciousness, supplemental mask oxygen must be administered and oxygen saturation monitored continuously by pulse oximetry. 2.5. Preparation of Drugs 2.5.18. Morphine: 10mg of morphine diluted to 10ml (1mg/ml) with normal saline 2.5.19. Fentanyl: 100mcg of fentanyl diluted to 10ml (10ug/ml) with normal saline. 2.6. Use of Naloxone Naloxone is a pure opioid antagonist that should be needed only rarely if the protocol is followed. Naloxone is usually titrated to effect. 2.6.20. Indications for the use of Naloxone Page 2 of 11
Respiratory rate less than 6 breaths per minute Apnoea following the use of opioid analgesics Any other situation where ventilation is judged to be inadequate, whether by pulse oximetry or clinical assessment. 2.6.21. Preparation of Naloxone Naloxone 0.4mg should be diluted to a total of 4ml with normal saline. Strength of solution is 100mcgs/ml. 2.6.22. Administration of Naloxone 1ml increments (100mcg) should be given IV at 2 minute intervals until: o The respiratory rate is above 6 breaths per minute, and o Adequate ventilation has returned (clinical judgement, pulse oximetry). 2.6.23. Use of Naloxone General Points Whenever naloxone is used medical assistance must be requested immediately. Supplementary oxygen must always be given whenever ventilation is judged to be inadequate. Severe respiratory depression may require ventilation by bag and mask. 2.7. Management of respiratory depression during administration of IV opioids. 2.7.24. Ensure an opened airway, assess breathing and circulation 2.7.25. No Pulse: Administer Basic Life Support and follow resuscitation protocols. Activate emergency alarm or dial 2222 2.7.26. No breathing: Ventilate by bag and mask Activate emergency alarm or dial 2222 Administer naloxone 0.4mg IV 2.7.27. Respiratory depression, patient breathing and pulse present: Give supplemental oxygen by mask Ensure an open airway Page 3 of 11
Pulse oximetry Administer IV naloxone as described in section 6 of this protocol Call for medical assistance 2.8. For the Recovery Protocol Flowchart refer to Appendix 1. Page 4 of 11
3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Adherence to RCHT guidelines Acute Pain Lead Regular audits and regular surveillance will occur throughout the year and reported to the regular acute pain meetings and appropriate governance meetings. Yearly audit as required by NPSA guidelines will be undertaken The committee reviewing the cases will be the Anesthesia Directorate. Cases will be discussed at audit meetings and the details will be recorded in the minutes. See Above. Required changes to practice will be identified and actioned within a month. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders. 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 5 of 11
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Appendix 2. Governance Information Document Title Date Issued/Approved: 21/01/2015 Intravenous Opioids for Adults in Recovery Areas The Recovery Protocol Date Valid From: 21/01/2015 Date Valid To: 21/01/2018 Directorate / Department responsible (author/owner): Dr Keith Mitchell Consultant Anaesthetist Contact details: 01872 258195 Brief summary of contents A guideline for the provision of safe and efficient opioid administration in Recovery. Suggested Keywords: Target Audience Executive Director responsible for Policy: Recovery, Theatres, Acute Pain, Opioids RCHT PCH CFT KCCG Medical Director Date revised: 14 January 2015 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Intravenous Opioids for Adults in Recovery Areas The Recovery Protocol Anaesthetic Department Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Divisional Manager: Mr Duncan Bliss Speciality leads of General Anaesthesia Critical Care and Pain {Original Copy Signed} Name: {Original Copy Signed} Internet & Intranet Clinical / Anaesthesia Intranet Only Page 7 of 11
Links to key external standards Related Documents: Training Need Identified? AAGBI Royal College of Anaesthetists British Pain Society Administration of Intravenous Drugs (Peripheral and Central) Guidelines for the assessment and documentation of Pain (Adults). G15 viii Guidelines for the administration of Hourly opiates. G15 (vi) Guidelines for Intravenous Morphine Administration in Clinical Areas. G17 National Documents: Association of Anaesthetists: 2002: Immediate Postanaesthetic Recovery 2006: Controlled Drugs in Perioperative Care. 2007 NPSA Patient Safety Alert 20 Promoting Safer Use of injectable Medicines No Version Control Table Date Version No 31 Oct 11 V1.0 Initial Issue Summary of Changes 14 Jan 15 V2.0 Review & Updated Formatting Changes Made by (Name and Job Title) Keith Mitchell Consultant Anaesthetist Keith Mitchell Consultant Anaesthetist All or part of this document can be released under the Freedom of Information Page 8 of 11
Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 9 of 11
Appendix 3. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Intravenous Opioids for Adults in Recovery Areas The Recovery Protocol Directorate and service area: Is this a new or existing Policy? Theatres & Anaesthesia Existing Name of individual completing Telephone: 01872 258195 assessment: Dr David Elliott 1. Policy Aim* To provide information for safe and efficient administration of Opioids in Recovery. 2. Policy Objectives* To provide information for safe and efficient administration of Opioids in Recovery. 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? Safe and Efficient administration of Opioids in Recovery. Monitoring through audit and case discussion at governance meetings Patients No b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Sex (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Page 10 of 11
Disability - Learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. No negative impact. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment 1. 2. Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Date Page 11 of 11