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Patient-Controlled Analgesia |
| In their Sentinel Event Alert, Issue 33, December
20, 2004, The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), raised safety issues regarding the use of
Patient-Controlled Analgesia (PCA) by proxy. This concept refers to the
use of the PCA by an individual other than the patient, such as a parent
or nurse. This alert raised significant concerns, which you can
find here on the JCAHO web site. Subsequently, a number of physicians
and nurses,
respected leaders in the field of pediatric palliative care and pain
control, responded on a list-serve. Their comments are listed below. It is
our hope that this information not only helps provide safety for patients
using PCA devices, but also helps medical providers in using PCA to
control patients' pain maximally. |
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We share the strong view that the folks at Hopkins have.
We routinely employ proxy PCA in our organization. Both nurses and parents
are allowed to participate. We do it for anyone who is not capable of
self-dosing. We recently reviewed our data and presented them at the Intl
Forum on Peds Pain in Nova Scotia. We are expanding the data set and will
try to publish in near future.
Steven J. Weisman, MD
Jane B. Pettit Chair in Pain Management
Children's Hospital of Wisconsin
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I suspect Myron is referring to the program
which is reported here...
Monitto CL, Greenberg RS, Kost-Byerly S, Wetzel R, Billett C, Lebet RM,
Yaster M. The safety and efficacy of parent-/nurse-controlled analgesia in
patients less than six years of age. Anesth Analg. 2000 Sep;91(3):573-9
Seems to work very well.
I suspect that there is nothing to change in programs that work well and
demonstrate a process by which the parent/nurse is effectively taught how
to participate in the patient's care.
Robert S. Greenberg, M.D.
Associate Professor
Blalock 912A;
Department of ACCM
The Johns Hopkins Hospital
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I think Dr. Buckley nailed it (is that a Yank expression?): the point of
the alert and the
current patient safety movement is that systematic safeguards should be in
place when dangerous drugs/procedures intersect with real people.
"Systematic safeguards" in this case include patient selection, parent
screening/selection, parent education, frequent clinician assessment and
monitoring, careful dose selection and parameters for pump settings, nurse
education, and so forth.
Linda Oakes raises an important issue: Do any of us put our patients and
selves at risk by having inadequate safeguards in our procedures? It
doesn't take much effort to review them when an opportunity like this
presents itself. I suspect that Drs. Yaster and Weissman don't have much
to worry about--the fact that they have systematically reviewed their
practices over a number of years demonstrates precisely the point of the
discussion.
Too bad both parent and proxy start with 'p.' Better alternative acronyms
would be nice.
Tom Quinn
Massachusetts General Hospital
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I suspect that, as Dr Greenberg points out in his posting, the key thing
is having a process in place for instruction and supervision/monitoring
when proxy interventions are in use.
Norm Buckley, MD, FRCPC
Associate Professor,
Chair, Department of Anaesthesia
McMaster University
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I apologize about the confusion...specifically we use Parent and Nurse
Controlled Analgesia (we call it PNCA) in our practice and have done so
since 1991...in our practice, IV pca or PNCA involves the use of opioids
administered by continuous infusion (virtually always) with supplemental
demand dosing...the demand dosing in young children, developmentally or
physically handicapped children is by the patient's nurse or
parent...there is no age limit...we have done this in neonates and up...as
many of you know the Johns Hopkins Hospital is a large multi-disciplinary
hospital with patients of all ages...children are cohorted into their own
hospital within the hospital... we have reviewed our safety data
(children) with IV PCA and PNCA and our complication rate when compared to
the adults is actually better even with continuous infusions and nurse or
parent demand ("bolus") dosing....indeed, the patients who appear to be at
the highest risk of complications with IV PCA even with demand only dosing
are the elderly...
Myron Yaster
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Practice-wise the only thing we'll be changing is making sure the verbal
instruction given is reinforced with written instruction. And our Biomed
crew is looking at putting some sort of warning label on the pump. We use
PCA by proxy and don't intend to change anything related to that.
We do not obtain written consent for use of PCA.
Pat BeVier, RN, MSN=20
CNS Pain Management Service=20
Children's Hospital of Michigan=20
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We do not obtain consent for PCA, either.
Kenneth R. Goldschneider, MD
Director, Division of Pain Management
Children's Hospital Medical Center
3333 Burnet Avenue
Cincinnati, Ohio 45229-3039
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We do not obtain consent but neither do we have parent controlled
analgesia. Our PCA's/NCA's are either patient or RN controlled analgesia.
When it is RN controlled we increase the dose and interval knowing that
the RN will not be available every 10 minutes. We also encourage the
parent to be in the loop calling the RN if they feel their child is
needing another button dose.
John B. Ray, RN, BSN, Pain Nurse Clinician
The Children's Hospital, Denver CO. Pain Consultation Service
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We do not obtain consent for PCA use.
Christine O'Leary MSN RN CPNP
Pediatric Nurse Practitioner
Acute Pain Service
Alberta Children's Hospital
Calgary, Alberta, Canada
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We do not obtain written consent for use of PCA.
Pat BeVier, RN, MSN
CNS Pain Management Service
Children's Hospital of Michigan
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Geri, thanks for your thoughtful response. In USA now the issue of the
parent boosting for their child when he is too young/ill to understand is
a hot issue due to some deaths as per JCAHO....when you look at the JCAHO
(and other repetitive documents) about this, the literature they use to
support this is not evidence-based or complete. I have polled pain experts
on this list serve and determined there are 2 groups at least for those
who
responded: "never, no way" and "with careful parent selection and
education, and we are not going to change that practice based on the JCAHO
alert". My organization is the 2nd group at least from the Pain Management
Service stance at this point.
So I am asking those that think that parents can boost for their children
(proxy or
whatever word is used)....is anyone interested in developing a position
statement on how this can be done safely and effectively and have it
possibly endorsed by pain organizations such as ASPMN or APS....much like
others did for the "range order" issue a year or so ago?
If you are interested, let me know including the name of your
organization. I am not
looking for work to do but feel it may take this to convince
administrators it is okay to continue this practice if all safety measures
are in place. If the restriction of proxy boosting goes away, not
necessary but I "hear" a lot of chatting about restricting this from any
practice based on the JCAHO alert.
Linda Oakes RN MSN
Clinical Nurse Specialist
Pain Management Service
St Jude Children's Research Hospital
Memphis TN
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I have had 2 experiences over the past year where the increased emphasis
on opioid therapy (other than the usual discussions about possible adverse
effects, etc) was very distressing to families and only served to greatly
increase their baseline opioid angst.
One family was asked for their agreement prior to initiating opioid
therapy and the other family was required to sign that the pharmacy had
dispensed the opioid. In both instances, the parents were terrified to
initiate the therapy, stating "This must be a very dangerous drug because
they are treating it so differently than other treatments my
child has had" and "My child has gone thorough chemotherapy and has
received many dozens of different drugs and this is the very first time I
have had to sign for her medication!" The father was tearful when talking
about this & required much additional reassurance.
In the context of patients with advanced illness in our palliative care
service, we use PCA in our opioid tolerant population (where "P" may mean
patient & parent & health professional).
I suggest that the proposed policy of acquiring consent for PCA use be
carefully considered before instituting a process that may be
counter-productive to the child's & parental comfort.
Dr. Gerri Frager
Medical Director Pediatric Palliative Care
IWK Health Centre
5850/5980 University Ave. PO Box 9700
Halifax, Nova Scotia, Canada B3K 6R8
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I feel very strongly about this issue. PCA's were just beginning to be
used on children in 1989 when my 8 yr old son was diagnosed with a Wilm's
Tumor. I was then (and still am) a practicing, experienced pediatric
nurse. Our son was the youngest child ever allowed to have a PCA at this
major medical center at that time. I utilized both parent and child/pt.
When I knew it was time for him to get up, walk, do TCDB, I gave a dose,
waited the appropriate lockout, gave another dose, waited the lockout and
woke him up. He was quite apprehensive (many issues,---monitor, recently
having seen his great aunt on a monitor and suddenly die, pain, etc etc)so
he would immediately reach for the "magic button" and push. Then he would
get up, TCDB, and walk down the hall. Of course, if he had had a basal at
that time, the pre-treats may not have been necessary but in his case, he
actually used very little PCA even given his huge incision, etc. After the
walk, he would
usually sit in chair, give himself a dose after about 1/2 hr and then get
back into bed. I wish JCAHO could look at the entire issue. I agree that
with carefully selected parental involvement and nursing involvement and
teaching, that it would be much better to involve the parents. Anyone have
any more questions, ideas, feel free to write me personally. Thanks!
Mary Kay Beasley Richmond, VA
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