Intranasal diamorphine (IND) is a safe and effective analgesic in children attending A&E with clinically suspected limb fractures.1 To introduce IND for paediatric analgesia in our unit, we developed an integrated care pathway (ICP)2 and subjected its use to an audit cycle.3
To formulate the INDICP, various information sources were interrogated for evidence about IND use in paediatric analgesia (Medline database, article bibliographies, published guidelines). Only one multi‐centre randomised controlled trial was identified, in which IND was found to have a faster onset of pain relief and better tolerability and acceptability than intramuscular morphine.1 IND use was mentioned in guidelines from the British Association for Emergency Medicine (http://www.emergencymed.org.uk/BAEM/) and the Scottish Intercollegiate Guideline Network (www.sign.ac.uk/guidelines/fulltext/58/evidence.html). The final INDICP incorporated inclusion and exclusion criteria, tasks to be performed, and their sequence and timescales.2 These included recording of weight, baseline clinical observations, pain score, verbal consent to treatment, how to deliver IND, monitoring of oxygen saturation, and further pain scores at 10 and 20 min. Appropriate staff training was undertaken before the INDICP was introduced.
An audit of the first 6 months of INDICP use was undertaken.3 This identified good safety (no patient required naloxone) and acceptability of IND use, but poor recording of verbal consent (essential for the unlicensed use of a licensed medicine), clinical observations, and pain scores. Accordingly a simple, one page, clinical proforma, which could be included in the patient notes, was developed to capture these data. Re‐audit by means of a rapid‐cycle sampling method3 found verbal consent, clinical observations, and pain scores were recorded in 50%, 66%, and 50% of cases, respectively.
To sustain this improvement in patient care, further cycles of staff instruction and re‐audit will be required. We believe that the ICP and the clinical proforma are generally applicable for paediatric analgesia in other A&E departments.
Footnotes
Competing interests: none declared
INDICP and clinical proforma are available from the first author on request
References
- 1.Kendall J M, Reeves B C, Latter V S, on behalf of the Nasal Diamorphine Trial Group Multicentre randomised controlled trial of nasal diamorphine for analgesia in children and teenagers with clinical fractures. BMJ 2001332261–265. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Campbell H, Hotchkiss R, Bradshaw N.et al Integrated care pathways. BMJ 1998316133–137. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.National Institute for Clinical Excellence Principles for best practice in clinical audit. Oxford: Radcliffe Medical Press, 2002