PCA managing inadequate pain relief of patient controlled analgesia (adult)
If the patient's pain score is over 4 follow below:
The transfer of ownership of the Right Decision Service from the Digital Health & Care Innovation Centre to Healthcare Improvement Scotland was formally announced in a media release issued on 20th November 2023. This NHS ownership is key to embedding the Right Decision Service as a national asset for Scotland's health and care.
Quotations from this media release below:
Health Secretary, Michael Matheson, said:
“This is a groundbreaking example of a digital service that has been developed and piloted with our partners Digital Health and Care Innovation Centre (DHI) through to delivery. The programme is now transitioning into a national service in support of our workforce to be led by a national NHS Board (HIS) and highlights the success of our collaborative approach.
“I’d like to thank all of those involved in the development of the Right Decision Service and look forward to our health and care workforce being able to make greater use of decision support tools.” “I’d like to thank all those involves in the development of the Right Decision Service and look forward to the programmes future success.”
Safia Qureshi, Director of Evidence & Digital, Healthcare Improvement Scotland, comments:
"We are delighted that the Right Decision Service will be joining us, as it presents a unique opportunity to deliver our advice and guidance at the point of care. This will significantly benefit patient safety, making it easier for health and care professionals to access the information they need to make the right decisions, at the right time. We hope that the future development of the Right Decision Service will have a significant, positive impact for health and care staff, freeing up more of their time and using resources available to them as efficiently as possible.
"I would also like to thank the Digital Health & Care Innovation Centre for their outstanding work in establishing this invaluable service. We are really excited to embark on this exciting project together.”
Dr Ann Wales, Programme Lead for Knowledge and Decision Support, Healthcare Improvement Scotland, said:
“The Once for Scotland Right Decisions app is a step-change in support for evidence-based health and social care decisions. It harnesses the power of evidence and technology to bring decision-making tools to the fingertips of health and social care practitioners. It frees up practitioner time to care, enables safer, more consistent care and support across Scotland, and strengthens the focus on individuals’ needs.
“I am hugely grateful to the Digital Health & Care Innovation Centre for steering and championing the Right Decision Service through its early stages of development. I’m delighted that the service is now moving fully into the NHS with leadership from Healthcare Improvement Scotland. This will consolidate the role of the Right Decision Service as a driving force for evidence-based practice and improvement across Scotland.”
Professor George Crooks OBE, Chief Executive Officer, Digital Health & Care Innovation Centre (DHI), said:
“The transfer of the Right Decision service from DHI into Healthcare Improvement Scotland, where it will continue to flourish and add increasing value to the delivery of high quality, safe health and care services for the people of Scotland, demonstrates how a national innovation centre can support, nurture and grow a new digital service to the point where it can successfully move to national adoption and scale. DHI is a national asset that will continue to support the people of Scotland and importantly those charged with delivering health and care services to access world class digital health and care solutions.”
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.
If the patient's pain score is over 4 follow below:
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.