PCA managing inadequate pain relief of patient controlled analgesia (adult)
If the patient's pain score is over 4 follow below:
Welcome to the Right Decision Service (RDS) newsletter for August 2024.
Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.
We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages. Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.
I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.
2.National IV fluid prescribing calculator
This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery. It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.
Please do spread the word about this new calculator and get in touch with any questions.
The following toolkits are now live;
We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.
We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit. We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process. The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.
To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)
7 Evaluation projects
Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.
We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.
If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.
With kind regards
Right Decision Service team
Healthcare Improvement Scotland
Please note this guidance is for use in in-patients and is not designed for managing patients with chronic pain.
Patients with PCA must be nursed on a ward recognised by the Acute Pain Team and Department of Anaesthetics.
Within Raigmore Patient Controlled Analgesia may be used in:
A registered nurse caring for a patient with PCA should have attended the acute pain study and declare her/himself competent in the management of the PCA.
All PCA Infusion must be delivered via the Agilia PCA pump
Hospital SOPs on Preparation and Administration of Controlled Drugs (see resources) must always be adhered to.
The surgical medical staff or nurse practitioner should be called in the first instance for all routine surgical problems including:
If further advice is required, please contact the Acute Pain Nurse (bleep 1003) and if not available, the ITU anaesthetist.
All patients receiving PCA must have oxygen 4L/min by facemask or 2L/min via nasal cannula, for 24 hours postoperatively and then overnight until PCA is discontinued, unless directed to do so otherwise by an Anaesthetist.
NO OTHER OPIOIDS are to be administered to the patient whilst PCA is in use (oral, subcutaneous, intramuscular, intravenous or topical) unless directed to do so by an Anaesthetist or Acute Pain Nurse.
Ensure Naloxone 400 microgram injection is available on the ward.
PCA keys to be kept in the Controlled Drugs cupboard.
The standard prescription is Protocol A
The prescriber must complete a PCA chart, including the following details :
If a ward doctor or non-medical prescriber wishes to prescribe an alternative dose, discussion should first take place with the Acute Pain Nurse or an Anaesthetist.
Background infusions should only be used in patients who have been on long term opioids and must only be initiated by an Anaesthetist or Acute Pain Nurse.
The Prescription should be prescribed in the regular or 'As required' section of the Drug Kardex and affix a “PCA/Epidural Opioid in Progress” onto the Kardex.
Alternatives to Morphine may be used if required, please contact Acute Pain Nurse or ITU anaesthetist.
Anti-emetics must be prescribed on the Drug Kardex if patient is to have PCA, see TAM postoperative nausea and vomiting guidelines.
Preparation of each syringe must be witnessed by a trained nurse or doctor, in accordance with Hospital SOPs on Preparation and Administration of Controlled Drugs (see resources).
Change of syringe
Each change of syringe must be witnessed by a trained nurse or doctor who has received PCA training. Follow the Hospital SOPs on Preparation and Administration of Controlled Drugs (see resources).
Changing PCA extension sets
Patients with PCA need regular observations of pain, nausea, sedation and respiratory rate, in addition to the conventional postoperative recording.
Monitoring PCA Infusions
1. Pain score must be recorded on the observation chart
2. Sedation scores and respiration rate must be recorded on the observation chart
3. Nausea score must be recorded on the observation chart
NSAIDs and paracetamol help to minimise opioid side-effects by reducing the total dose of opioid required and should be prescribed regularly not PRN.
Moderate respiratory depression (respiratory rate less then 9 breaths per minute AND sedation score of 1 or 2)
Severe respiratory depression (respiratory rate less then 7 breaths per minute OR sedation score of 3.)
CALL FOR HELP, INITIATE CPR PROCEDURES, IF THE PATIENT IS APNOEIC, CALL 2222
Patient Controlled Analgesia should be discontinued when the patient no longer requires it, for example.
Note: Changing from PCA to subcutaneous injections is not acceptable when an oral route has been established. This may only be acceptable when intravenous access is difficult.
If a pump is broken or damaged in any way, please send to Medical Physics with a description of the fault.