Second Signatory: Hindrance to Effective Breakthrough Pain Management?

Background: Breakthrough cancer pain is defined as a transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. Fentanyl citrate sublingual Tablet (FST) is administered to control breakthrough pain (BTP) and a ‘top-up’ dose is administered in 15 minutes if the pain does not respond. However, Nursing & Midwifery council (UK) recommends that for administration of controlled drugs (CD), a secondary signatory is required within secondary care. Aims: To establish that breakthrough analgesia is administered on an in-patient unit according to the guidance. Methods: Retrospective data was collected on patients at an adult Palliative care unit, requiring second dose of FST. Results and Analysis: Over a period of 3 months, 46 episodes of BTP requiring second dose of FST were recorded. Top-up dose was signed for at 15 minutes for only 13 (28.2%) episodes. Further 14 (30.4%) doses were signed for with 5 minutes delay (20 minutes in total from first dose). 19 (41.3%) doses were signed for after 20 minutes with a range of 25-50 minutes (10 – 35 minutes delay). Note that there will be a further delay in administering the dose. Conclusion: Majority of patients have BTP for less than 45 minutes. After reporting, it takes time to get the medication to patient. Second dose may get further delayed causing pain prolongation. This delay is due to finding second nurse to check medication. There are various solutions which could be employed to prevent this delay and to achieve effective BTP management.