SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY

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1 +PS1006 SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY TITLE: INTRAVENOUS PATIENT CONTROLLED ANALGESIA AND NARCOTIC INFUSIONS Job Title of Reviewer: Acute Pain Coordinator EFFECTIVE DATE: REVISED DATE: POLICY TYPE: (Patient Care) (Pharmacy) 12/87 11/17 DEPARTMENTAL INTERDEPARTMENTAL DEPARTMENTS PROVIDING NURSING CARE 1 of 17 PURPOSE: POLICY STATEMENT: To provide optimal and safe pain relief for patients on patient controlled analgesia or narcotic infusions, with minimal side effects. 1. Patient Controlled Analgesia (PCA) and IV narcotic infusions will be instituted when ordered by physician. 2. Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) will manage the PCA system in conjunction with the patient. 3. All IV PCA and IV narcotic infusions will be placed on a hospital approved locked Pain pump. EXCEPTION: Nurse Activated Dosing: In the event the patient is unable (or unwilling) to push the PCA button due to cognition problems (temporary due to anesthesia/sedating adjunct medications or permanent due to baseline cognitive impairment), the patient should NOT be given the PCA button. Instead, the PCA button shall be placed away from the patient and the primary RN or LPN will push the PCA button for the patient when the patient either self-reports pain or shows signs and symptoms of pain (i.e. grimacing, restlessness, etc.). In this case, the modality is called Nurse Activated Dosing and should be documented as such. ICU Nurse activated dosing may be implemented by nursing if a PCA had been prescribed if the pain criteria have been met on the non-verbal pain scale. Nurse activated dosing may be implemented on any nursing unit that accept patients with PCA pump including DNR patients. 4. Nursing personnel will instruct the patient on the use of the PCA system. When possible in Preadmission Testing (PAT) (or floor), The patient will receive a set of written instructions

2 2 of 17 regarding IV PCA that outlines the operational aspects of IV PCA and safety features associated with its working. This information is available in Exit Care. Patients, family members, and visitors will be warned that only the patient should press the PCA to deliver a dose. In addition, any patient observed to be tampering with the Pain Pump itself, will have the Pain Pump removed. The physician will be notified and an alternate form of pain control will be prescribed. 5. The physician will prescribe the initial parameters for PCA administration (Demand Dose, Demand Dose Lockout, and One Hour Limit) using the order sets in SCM. Physicians must use this order set to prescribe IV PCA. Continuous rates will not be part of the standard IV PCA order set. The Physician or the Acute Pain Service may add a continuous rate to the patient s prescription if the patient has a demonstrated need (i.e. chronic opioid therapy at home, heavy ETOH etc.) 6. If the patient is mechanically ventilated and IV PCA is ordered, the patient will have a continuous opioid infusion added to their prescription (if the patient is hemodynamically stable). The Acute Pain Service RN may adjust this rate based upon the patient s prior opioid tolerance if needed. The Critical Care RN, in conjunction with the Respiratory Therapist, may decrease and remove the continuous rate prior to extubation. 7. If the PCA IV site is peripheral, the patient does not need a concurrent primary IV unless ordered by the physician. If the patient has PCA and/or a continuous rate a central line, extended dwell, and midlines the patient must have a primary IV infusing. If the physician has not ordered IV fluids, and the patient has a central line, run normal saline at 15 ml/hr with the IV PCA. 8. IV PCA Therapy and patient assessment will be documented in SCM. The IV PCA Parameter will be accessed by adding it to the Pain Management flowsheet or the Assessment/ Reassessment Flowsheet upon initiation of therapy. 9. A Pain pump may be initiated in a patient who has or is expected to experience pain due to a surgical procedure, treatment or disease progression.

3 3 of Patient selection criteria: a. Patient demonstrates ability to understand, operate and comply with PCA instruction and to self-manage pain. b. Anticipated duration of IV analgesia > 12 hours. c. No known allergies or hypersensitivity to prescribed analgesic. 11. PCA pump keys are to be securely stored in the Pyxis when not in use. Exception: Acute Pain RNs and a select group of designated providers may possess his/her own PCA pump key. 12. The PCA key must be secured at all times, within the Pyxis or in the nurse s eyesight when in use. The key is never to be left on a counter or unattended. 13. Keys to PCA pumps are considered controlled substances. PCA keys require accurate accounting of their removal and return from the Pyxis. 14. Keys must be removed and returned under the patient for whom the key is being used. The key must be returned promptly after each use to the Pyxis it was removed from. NOTE: PCA keys cannot be handed off between nurses. 15. A lost or missing PCA key is to be treated as a missing controlled substance. Every effort should be made to locate the missing PCA key in a timely manner. 16. If unable to locate a missing PCA key: Report to immediate supervisor Notify Pyxis Administrator via Complete an occurrence report Occurrence Report Tip Sheet NOTE: If a replacement PCA key is needed urgently after hours, contact Pharmacy. 17. For Patients who have an IV PCA prescription that exceeds the designated Biomed programmed SMH ranges, a Polka Dot/No Range Pump will be utilized. 8WT medication room houses a Polka Dot/No Range Pump for distribution to Polka Dot/No Range Pump Eligible floors Patients who require a Polka Dot/No Range pump will be on the following Polka Dot/No Range Pump Eligible floors only- 6ET, 8WT, orthopedics, 7CYT, PACU, or Critical Care (hence the term Polka Dot/No Range pump eligible).

4 4 of 17 Polka Dot/No Range Pumps may be programmed by Pain Resource RNs or Acute Pain Service Nurses. Rationale: Polka Dot/No Range pumps have no built in range limits and therefore having designated pump programmers and limited nursing units where these patients will be cared for is a Patient Safety initiative. Critical Care units have their own Polka Dot/No Range pumps for their own use. These pumps are for Critical Care use only and may not be distributed outside the Critical Care units. 12. Fentanyl and Morphine IV PCA will only be utilized in situations where patients have experienced unacceptable side effects with Dilaudid. Exception: In certain trauma patients, Fentanyl IV PCA will be a first line choice. a. When a physician orders IV PCA Fentanyl or Morphine, the Pharmacy at the point of order entry will notify the Acute Pain Service (if present). The Pharmacy will ensure that the patient is a candidate for the appropriate medication. b. The Pharmacy and The Acute Pain Service (if present) will utilize the order sets in SCM to activate the appropriate IV PCA order. c. Fentanyl IV PCA may only be programmed by an Acute Pain Service Nurse, a Pain Resource Nurse, PACU nurse, Critical Care Nurse, or a specially trained 6ET nurse. d. The patient with a Fentanyl IV PCA may reside on any nursing unit that would normally care for patients with IV PCA. EXCEPTIONS: DNR Patients: Specific patients identified by physician who require IV PCA and yet require different titration and side effect parameters. These patients may not need the degree of monitoring that other patients require as the primary goal is comfort. Patient Controlled Analgesia will not be utilized in CRU, NICU, ER, and Sarasota Memorial Infusion. IV Narcotic Infusions will not be utilized in CRU, NICU, Sarasota Memorial Infusion, or the Emergency Room.

5 5 of 17 Only RNs in the High Volume areas will be allowed to program an IV PCA pump with an MD order (refer to chart below): High Volume Area Personnel Oncology, Medical- Wound, General Surgical, Cardio-step-down, Ortho, Critical Care, PACU, Interventional Radiology and Pain Resource Nurses, Intervention Nurses Assess patient s pain and response to therapy (Medicate for side effects utilizing the PCA MD orders). Titrate the Demand dose up or down per protocol and document on the IV PCA Parameter on the Pain Management or Assessment/ Reassessment Flowsheet. Initiate IV PCA. Hang a new bag of medication. Low Volume Area Personnel Cardiac/8ET, Cardiac Acute, Medical Resp, Neuro Unit, Gen-Med Surg, MAC, MBU, L&D, Peds, All Observation Units, Overflow Units, Float Nurses Assess patient s pain and response to therapy (Medicate for side effects following the PCA MD orders). Read pump history and document on the IV PCA Parameter on either the Pain Management or Assessment/ Reassessment Flowsheet. Turn pump off. **Perform Independent Double Checks according to ISMP Standards. Procedural Areas Radiology, Endo, Cath Lab, Hyperbaric, Pre-op, OR, Dialysis Assess patient s Pain and response To therapy Read pump history **Perform Independent Double Checks According to ISMP standards As needed. Read pump history and document. ** Perform Independent Double Checks according to ISMP Standards. Note: 1. A high volume RN with a valid high volume competency checklist may program a pump for a patient on a

6 6 of 17 low volume nursing floor. 2. RNs on Low Volume nursing units as indicated on the above list, are not permitted to program a pump. These nurses as well as LPNs are still required to perform assessments and check pump programming and pump history as dictated by this policy. 3. Fentanyl IV PCA will be programmed by Pain Resource RNs, PACU RNs, Acute Pain Service RNs, Critical Care RNs and specially trained 6ET nurses. 4. Polka Dot/No Range Pumps will be programmed by Pain Resource and Acute Pain Service RNs only. 5. RN Travelers will follow Low volume Pump responsibilities. Any exceptions may be considered after approval of the Acute Pain Coordinator. 6. Select pain pump trained RNs in L&D and Interventional Radiology, may initiate and program IV PCA pumps for IV PCA. DEFINITIONS: Acute Pain Service: A collaborative interdisciplinary team comprised of Acute Pain Service RNs and Patient Care Pharmacists under the direction of the Acute Pain Coordinator CNS and the Director of Pharmacy. Clinical decision making needs to be done between and Acute Pain RN and Patient Care Pharmacist or between 2 Patient Care Pharmacists. Medical oversight, direction and consultation is provided by the Medical Director of the Acute Pain Service. Advanced Pain Resource RNs: A Pain Resource RN whose primary role is to intervene and serve as a resource to the primary RN in patient care. Advanced Pain Resource RNs in conjunction with pharmacy have extensive protocols that they are allowed to perform if the patient meets criteria. Pain Resource RN: An RN who is chosen by both her director and her clinical manager to participate in an advanced pain management program. Education and Advanced Pain Management training will allow the nurse to serve as a resource to her staff. Pain resource nurses are allowed to perform the unrelieved pain protocol on patients who meet the criteria. Critical Care RN: An RN who regularly works in the Critical Care unit and has received training for Fentanyl IV PCA. IV Patient Controlled Analgesia: An intravenous pain control method that may incorporate a continuous rate and allows a

7 7 of 17 patient to administer preset doses of a prescribed analgesic from a hospital approved locked programmed pump. Polka Dot/No Range Pain Pump: This is a pain pump with no built ranges for each pain pump setting in the IV PCA Prescription (Concentration, Continuous rate, Demand Dose). Patients who require a Polka Dot/No Range pump will be on the following Polka Dot/No Range pump eligible nursing units only: 6ET, 8WT, 7CYT, Critical Care, Orthopedics, and PACU. 8WT medication room houses a Polka Dot/No Range Pump for distribution to Polka Dot/No Range pump eligible floors listed above. Critical Care units have their own Polka Dot/No Range pumps for their own use. These pumps may not be distributed outside Critical Care units. Polka Dot/No Range pumps may only be programmed by Pain Resource RNs or Acute Pain Service Nurses. Level of Sedation: The degree of arousability that a patient is experiencing as per the following descriptors: Level 1 = Alert; easy to arouse (awake) Level 2 = Occasionally drowsy; easy to arouse (slightly drowsy) Level 3 = Frequently drowsy (arousable, but drifts off to sleep during conversations when not directly stimulated, cannot participate in activities required for recovery Level 4 = Somnolent; difficult to arouse (or unarousable) Z = Sleeping; easy to arouse Independent Verification: A process whereby a second licensed nurse verifies the pump programming (pain pump settings) performed by the first person without cues from the person doing the initial programming. The second check should then be compared to the current physician order. Pain Pump Settings: Refers to the Concentration of the drug, the Continuous rate, the Demand dose, Demand Dose Lockout, One Hour Limit, and Reservoir Volume. Pain Pump Programming Changes: Refers to hanging a new bag of the same prescription, titrating the Demand dose up or down, adding, removing or changing a Continuous rate, and the administration of Clinician bolus doses. Visual Analogue Scale (VAS): A scale that quantifies the patient s

8 8 of 17 pain by requesting that the patient rate his pain on a scale from 0-10 (with 0 being no pain and 10 being the worst pain imaginable). The use of the Wong-Baker FACES Pain Rating Scale (see below) assists with the quantification of the patient s pain. This tool enables the patient to point to the appropriate face/descriptor to describe their pain intensity. Wong-Baker FACES Pain Rating Scale. From Wong D.L., Hockenberry-Eaton M, Wilson D., Winkelstein M.L., Schwartz P: Wong s Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p Copyrighted by Mosby, Inc. Reprinted by permission. Non-Verbal Pain Scale: An observational, validated pain scale for non-verbal or intubated patients who cannot self-report. The scale incorporates categories of facial expression, activity, guarding, vital signs, and respiratory assessment into a numerical entity that diagnoses pain in the above patient. Only for use in the ICU. (See Pain Management Policy #00.PAT.44.) PROCEDURE: A. PATIENT EDUCATION: 1. The success of IV PCA is dependent upon the patient s understanding of and ability to demonstrate correct use of the pump and his ability to self-manage his pain. Ideally, pre-op teaching, with return demonstration, will take place in Preadmission Testing (PAT). Patients who are expected to receive IV PCA for pain management will receive written instructions outlining the basics of IV PCA and the warning that only the patient may push the PCA button and that the patient may not tamper with the Pain Pump itself. 2. For patients not going through PAT, education will occur as soon as orders are received to teach PCA or it becomes known that the patient will be on IV PCA. 3. IV PCA teaching will be reinforced PRN to patients, families and visitors. 4. If anyone other than the patient is suspected of pushing the button for the patient, education will be reinforced once. Should the behaviors continue, the Pain Pump will be removed from the patient and the MD contacted for an alternative form of pain control. B. INITIATION: 1. Upon initiation, a Registered Nurse (RN) and a second nurse will

9 9 of 17 verify the label with the physician s order and the patient s identification band prior to hanging any analgesia solution bag. A patient label with the patient s name will be affixed to the PCA solution bag. All IV PCA bags administered will be documented and cosigned on the EMAR. 2. The IV PCA analgesia solution bag should be placed in the pump so that the label is visible through the pump. The Pain pump procedure booklet should be followed in order to prime the tubing, set up the dosing prescription, and secure the narcotic. 3. IV PCA solutions will be handled as all other controlled substances. Any wasted drugs must be countersigned by two licensed nurses, one of whom is an RN. The PCA waste must be documented in the Pyxis. See Discontinuation of IV PCA below. C. PUMP PROGRAMMING: 1. Only RNs working in High Volume areas (as indicated in chart), Pain Resource Nurses, or Acute Pain Service Nurses may program a Pain pump. 2. The steps on how to program the Pain pump are outlined in the instruction booklet. This booklet is available on every nursing unit where Pain pumps are utilized. In addition, each Pain Resource Nurse has their own pocket card-refer to the card for specific pump technology directions. 3. All pain pump programming settings need to be independently verified by another nurse prior to initiation of the therapy. This includes initiation of IV PCA therapy and all subsequent pain pumpprogramming changes. Both nurses will document on the Pain Management or Assessment/ Reassessment Flowsheet in SCM. Pain Pump settings will be checked for accuracy against the physician orders and or flowsheet at the beginning of each shift as part of the ongoing assessment of the patient. 4. When a patient goes to surgery or for a procedure off the nursing unit, the pump settings will be checked when the patient arrives back on the floor. 6. All pain pump concentration changes need to be done by a Pain Resource Nurse or Acute Pain Nurse (see resource list above Pyxis). 7. If pain pump programming is needed on a Low Volume or Procedural area (see chart), the Low Volume RN must call a member of the Pain Resource Team (list of members is above the Pyxis). The Pain Resource RN will come to the nursing unit or procedural area for pain pump programming. 8. When IV PCA settings are changed (by protocol or by direct physician order); the RN must place a Med order communication to pharmacy into SCM with the new IV PCA prescription changes. This will automatically link with the E-MAR to reflect the new pain prescription. D. ANALGESIA SOLUTION AND TUBING: 1. Upon assuming care of the patient with a Pain pump, the receiving nurse will check the IV PCA Pump programming against the flowsheet

10 10 of 17 and the emar. (This includes shift change and when a patient is received from another nursing unit or procedural area) 2. Controlled substance continuous infusions will be run using a Pain pump and appropriate tubing. The tubing will be proximal to the site. 3. The PCA infusion device tubing and medication bag will be changed every 96 hours. E. ASSESSMENT: Includes level of sedation, respiratory rate and pain rating scale. Upon initiation of IV PCA, perform patient assessment: Every 1 hour x 4 Then every 2 hours for total of 24 hours After 24 hours post-op, may do patient assessment with vitals every 4 hours if patient is stable After 24 hours post initiation of therapy, may do patient assessment with vitals every 4 hours if patient is stable. NOTE: If patient is sleeping soundly, do not wake him to assess his pain rating scale. Assess level of sedation and respirations without stimulating the patient. PROCEDURE (continued): NOTE: For any increase in titration, perform patient assessment Q2H X 2. NOTE: Document all assessments using the IV PCA parameter on either the Pain management or Assessment/ Reassessment flowsheet. NOTE: If the patient has one of the following risk factors, determined by H&P, lab-work, or direct observation, a continuous pulse oximeter will be placed on the patient by the primary nurse caring for the patient. These risk factors may increase the possibility of opioid induced respiratory depression. Elderly over age 80 BMI > 30 Sleep apnea Very compromised pulmonary function, eg. COPD, Asthma Renal failure/renal insufficiency (serum creatinine > 1.5) Stated sensitivity to medication NOTE: Only the patient may push the PCA button. EXCEPTION: Nurse Activated Dosing. In the case where the patient is unable to push the PCA button, the primary nurse will push the button for the patient. In this case, the PCA button will not be in the patient s hand; it will be hung up on the IV pole away from the patient. F. Pain Resource RN UNRELIEVED OR ANTICIPATED PAIN PROTOCOL: a. For patients with intense pain or for patients who anticipate

11 11 of 17 increased pain from a procedure or therapy, a specially trained Pain Resource RN may administer a specified amount of opioid according to set parameters (see attachment # 1 ). G. ACUTE PAIN SERVICE NURSE Or Advanced Pain Resource RN PROTOCOLS: 1. Acute Pain Service or Advanced Pain Resource RN s may administer IV opioids as needed via pain pump until pain is manageable and LOS 1-3 (see attachment #1). 2. Acute Pain Service or Advanced Pain Resource RNs may initiate the adverse drug reaction protocol in the presence of adverse drug reactions (see attachment #2). 3. Acute Pain Service or Advanced Pain Resource RNs may use the Equianalgesic Dosing Protocol for patients with significant history of chronic medication use resulting in an unusual opiate requirement. (see Attachment #2). 4. In collaboration with the Primary RN and the Patient Care Pharmacist, Acute Pain Service or Advanced Pain Resource RNs may increase the concentration of an IV PCA analgesic if the patient is using more than 1 bag of medicine every shift. Together, the Acute Pain Service RN and Patient Care Pharmacist will decide it the patient should go to a Polka Dot/No Range Pump Floor (6ET, 8WT, 7CYT, Orthopedics, or Critical Care) H. PCA INFUSION DEVICE (PUMP READINGS): 1. Complete pump readings will be done initially and every 4 hours for the duration of the therapy. I. SIDE EFFECT MANAGEMENT: 1. Side effects are managed by following the protocols outlined in the IV PCA Physician order set. Note: Anytime Narcan is given to a patient on IV PCA: a. If possible, call the Acute Pain Service prior to administration. b. Take the PCA button away and remove continuous rate if present. c. Alert the ADR Hotline, ext. 2880, for any Narcan administration. J. PATIENT OFF THE UNIT: The patient on an IV PCA may not leave the nursing unit unless a physician has prescribed a test or procedure. The nurse may not disconnect the patient from the pain pump. NOTE: The patient may leave the hospital with the pain pump to go to physician prescribed radiation therapy. In this case, the patient will be transported and accompanied by appropriate personnel as mandated by Integrated Case Management.

12 12 of 17 K. DISCONTINUATION OF IV PCA: 1. When discontinuing IV PCA, the PCA infusion pump, solution bag, and the tubing must be removed from the patient s bedside. Any amount of opioid that has not been used by the patient should be appropriately wasted as soon as possible. NOTE: The nurse who removes the PCA pump from the patient is responsible for initiating the appropriate waste of the PCA medication. 2. To waste the unused medication, two nurses must be present when PCA pump is opened to remove the solution bag. 3. Two nurses must visualize the physical waste of the medication. 4. One nurse removes the tubing from the bag and empties the medication into a measuring cup. The nurse then empties the medication into a sink drain. These two steps must be witnessed by the second RN. 5. After performing the waste, the PCA waste must be documented in Pyxis with the nurse who witnessed the waste. Again, the RN who removes the PCA pump from the patient is responsible for the medication and should serve as the initiator for the waste (as opposed to the witness for the waste). To initiate a PCA waste in Pyxis: 1. Log in to Pyxis. 2. Select the patient. 3. Select Waste. 4. Select the PCA medication: NOTE: There are two possible ways to locate the medication in Pyxis. a. If it was removed from that Pyxis station, the medication will appear under Meds to Waste. Type the medication name in the search field. After selecting the medication, select Waste. b. If it was removed from another Pyxis station or delivered by pharmacy to the unit, the medication will appear under Search All Meds. Select Search All Meds and type the drug name in the search field to find the PCA medication. After selecting the medication, select Waste. 5. Enter the Waste amount in the ml field. 6. After the correct Waste amount is shown, select Accept. 7. Witness then enters ID/biometrics NOTE: The amount recorded should be the amount physically wasted, not the volume displayed on the PCA pump.

13 13 of 17 It will be the responsibility of the Department Managers/Directors to see that nursing personnel are aware of, and adhere to, this policy. REFERENCES: Duezel, Vecibe MD. September 2011 A Study on the Correlation between the Nurses and Patients Post-Op Pain Assessments. Pain Management Nursing Volume 12 Number Three. Institute of Safe Medication Safety Alert, December 2009, Volume 14 Issue 2 Pain Management and Patient Controlled Analgesia, Improving Safety and Quality of Care, Proceedings from the Sixth Conference Center for Medication Safety and Clinical Improvement, November 17-18, 2005 San Diego, Ca. Unrecognized sleep apnea in the surgical patient Implications for the Perioperative setting, Kaw, Michota, Jaffer, etc. (Chest : ) McCaffery and Pasero. (2011) Pain Assessment and Pharmacologic Management American Society for Pain Management Nursing Position Statement with Clinical Practice Guidelines: Authorized Agent Controlled Analgesia. Cooney, Czarnecki, Dunwoody, Eksterowicz, Merkel, Oaks, Wuhrman. Pain Management Nursing Volume 14 November 3- September Sarasota Memorial Hospital Nursing Department Policies. Acute and Post- Operative Epidural/Intrathecal Pain Control. ( ). Sarasota, FL Sarasota Memorial Hospital Corporate Policy. Pain Management. (00.PAT.44). Sarasota, FL: Author SMH Policy. Transportation and Monitoring of Patients (01.PAT.23). SMH: Author. Registered Nurse Management and Monitoring of Analgesia by Catheter Techniques: Position Statement. Pasero, Eksterowicz, Primeau, Cowley. Pain Management Nursing Volume 8, Number 2 (June) 2007 pp New, Kimberly. (July 2015) Detecting and Responding to Drug Diversion. Pharmacy Purchasing & Projects. REVIEWING AUTHOR(S): Diane Scheb, RN, MSN, Acute Pain Coordinator/CNS Dave Jungst, Director, Pharmacy

14 14 of 17 ATTACHMENT(S): 1. IV PCA Unrelieved Pain Protocol (Pain Resource RN) 2. IV PCA ADR Management and Equianalgesic Dosing Protocol (by Acute Pain Service RN or Advanced Pain Resource RN) 3. Information about Fentanyl APPROVALS: Signatures indicate approval of the new or reviewed/revised policy Signature: Date 11/3/17 Title: Dave Jungst, Director, Pharmaceutical Care Services Signature: Title: Diane Scheb, RN, MSN, Acute Pain Coordinator Signature: Title: Signature: Title: Committee/Sections (if applicable): Clinical Practice Council 11/2/17 Vice President/Administrative Director (if applicable): 11/7/17 Signature: Name and Title: Signature: Lorrie Liang, Chief Operating Officer 11/14/17 Name and Title: Connie Andersen, Vice President & Chief Nursing Officer

15 15 of 17 Sarasota Memorial Hospital IV PCA Unrelieved Pain Protocol 1. Criteria for Initiation (by Pain Resource Team): (ALL of the following must be present to Initiate) Pain greater than or = to7 or expected to reach 7/10 due to procedure/ therapy. Respiratory rate > 12/min. Sedation level 1 or 2. Absence of excessive nausea, vomiting, pruritus, or confusion Notify Acute Pain Service (beeper 1832 or Ext. 8599). Pain Resource RN Titration Parameters Dilaudid 0.4 mg. every 10 minutes via pain pump (up to 2 mg of Dilaudid). Fentanyl 25 mcg once via pain pump 2. Acute Pain Service RN or Advanced Pain Resource Nurses- Titration Parameters: In collaboration with Acute Pain Pharmacist or Acute Pain Medical Director as needed. (includes above criteria) plus: Respiratory rate > 10/ min. Titration Parameters for bolus doses May administer Dilaudid 0.5 mg IV every 5 minutes via pain pump until pain is manageable and level of sedation 1-3. May increase each dose by 0.5 mg IV if insufficient response and no change in level of sedation- up to a maximum incremental dose of 1.5 mg. If patient is opioid tolerant, may start with a dose of Dilaudid 1.5 mg IV. (Advanced Pain Resource Nurses may not exceed a total of Dilaudid 3 mg IV.) May administer Morphine 3 mg IV every 5 minutes via pain pump until pain is manageable and level of sedation 1-3. May increase dose to 4 mg if insufficient response and no change in level of sedation. (Advanced Pain Resource Nurses may not exceed a total of Morphine 15 mg IV.) May administer Fentanyl 25 mcgs every 5 minutes via pain pump as needed until pain is manageable and level of sedation is 1-3. (Advanced Pain Resource Nurses may not exceed a total of 75 mcg.) May add continuous rate as necessary. In collaboration with Acute Pain Pharmacist or Acute Pain Medical Director, may modify any IV PCA parameter to ensure both patient safety and patient comfort. Attachment #1

16 16 of 17 IV PCA Adverse Drug Reaction Management and Equianalgesic Dosing Protocol (by Acute Pain Service RN or Advanced Pain Resource Nurses) 1. Adverse Drug Reaction Management (Intolerable/Unacceptable ADR s) Presence of excessive nausea, vomiting, pruritus and the determination is made that these symptoms are due to the opioid in the IV PCA Titration Parameters May switch current PCA analgesic to alternative opiate, ensuring an equianalgesic Interchange. May modify or discontinue a continuous rate. 2. Equianalgesic Dosing Protocol Patients with significant history of chronic use of any of the following (resulting in atypical opiate requirements): Opiates benzodiazepines alcohol illicit drugs methadone maintenance Modification of IV PCA Guidelines In collaboration with Acute Pain Pharmacist or Acute Pain Medical Director, may modify IV PCA to ensure an equianalgesic switch from ambulatory therapy to IV PCA. In collaboration with Acute Pain Pharmacist or Acute Pain Medical Director, may modify any IV PCA parameter to ensure both patient safety and patient comfort. Attachment #2

17 17 of 17 Fentanyl IV PCA Information *Used at SMH only when patient has demonstrated unacceptable side effects while on Dilaudid or Morphine. **Assessment and Monitoring parameters are the same as Dilaudid and Morphine ***Pain Resource RNs, Acute Pain RNs, PACU RN s, or Critical Care RNs must do all pump programming and bag changes. Very strong and fast acting-kicks in fast, wears off fast Concentrated in micrograms/ml (mcg/ml) Standard concentration of Fentanyl PCA is 10 mcg/milliliter- (Use a purple IV PCA Pump) Demand dose and continuous rate are delivered in micrograms/hr (mcg/hr) In addition to all the normal opioid adverse effects, it may cause chest wall rigidity when given in accidental overdose. This chest wall rigidity may only be reversed by a neuromuscular blocker. Metabolized in the liver-no active metabolites The patient with a Fentanyl IV PCA may reside on any nursing unit that would normally care for patients with IV PCA. Pain Resource Nurses, Acute Pain Nurses, PACU Nurses, or Critical Care Nurses must do all pump programming and bag changes for Fentanyl IV PCA. Attachment #3