Patient Controlled Analgesia (PCA)
Patient Controlled Analgesia (PCA)
The American Society for Pain Management Nursing (ASPMN), in order to address the Sentinel alerts issued by JCAHO (December, 2004) and ISMP (Nurse Advise-ERR January and February, 2005) concerning "PCA by Proxy", has developed a position statement and clinical practice recommendations on Authorized versus Unauthorized (PCA by Proxy) Dosing of Analgesic Infusion Pumps.
This statement clarifies and distinguishes between the unsafe practice of "PCA by Proxy", in which unauthorized individuals activate the dosing button of an analgesic infusion pump for a patient receiving Patient Controlled Analgesia, and the safe practice of Authorized Agent Controlled Analgesia (AACA). In the latter, certain individuals are educated and authorized to activate the analgesic infusion pump's dosing button when a patient is not able to self dose. ASPMN does not support the use of "PCA by Proxy". ASPMN does, however, support the practice of Authorized Agent Controlled Analgesia in a variety of patient care settings when the agency has in place clear guidelines outlining the conditions under which this practice shall be implemented and outlining monitoring procedures that will insure safe use of the therapy. Furthermore, the paper examines the ethical and safety issues and outlines the necessary screening and patient/family education needed to implement AACA. The position statement describes criteria for the use of AACA, guidelines for selection and education of the authorized agent, key prescription and monitoring recommendations during therapy, and quality improvement activities to insure safety and effectiveness.
Patient Controlled Analgesia (PCA) was first introduced three decades ago. As the understanding of pain and pain management improved the use of PCA technology continued to advance moving PCA into the mainstream of patient care. By the 1990's, PCA became a common technique for managing pain, especially in the post operative period. Not all patients, however, are good candidates for PCA therapy. For example, young children are not developmentally able to self dose with an analgesic infusion device. Studies done in the early 1990's, to determine the safety of PCA in children, utilized the technique of having nurses and/or family members activate the dosing button of a PCA pump in order to deliver analgesics to very young children in a timely and safe fashion (Gureno & Reisinger, 1991; Welcon, Connor, & White, 1993). In addition to these studies which had positive findings, some clinical experts employed and wrote about the not uncommon practice of educated and authorized individuals providing Nurse Activated Dosing or Family Activated Dosing for patients who could not self administer doses via a pump (Pastero & Mc-Caffery, 1993; Pasero, Portenoy, & McCaffery, 1999).
Unfortunately when many agencies were safely utilizing PCA pump technology to expand on the availability of safe, timely analgestic delivery by having such educated nurses and family members activate the analgesic pump, there was also a trend toward extending the use of PCA therapy to patients who were less than ideal candidates (Nurse Advise, 1-05). Due to poor patient selection and/or due to poor PCA prescription the practice of well meaning nurses, doctors, and significant others haphazardly pressing the buttons (or advising family and visitors to press the button) evolved in an attempt to improve pain control. While well intentioned, this practice can lead to serious deleterious effects, including death.
In order to alert the health care community to this potentially lethal practice the Institute for Safe Medical Practices (ISMP) and the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) issued alerts advising against the practice of PCA by Proxy . In December of 2004 JCAHO published in its Sentinel Event Alert, Patient controlled analgesia (PCA) is an effective and efficient method of controlling pain, and when it is used as prescribed and intended, the risk of oversedation is significantly reduced. However, serious adverse events can result when family members, caregivers or clinicians who are not authorized become involved in administering the analgesia for the patient 'by proxy'. [This Alert does not address situations in which others are authorized to administer analgesia] (JCAHO, 2004).
In an effort to comply with JCAHO's recommendations, many health care agencies responded by limiting the technology and advantages that the PCA modality offers to Patient Controlled Analgesia only. The practice of identifying authorized agents to activate the dosing button, Authorized Agent Controlled Analgesia (AACA), was effectively eliminated, which, as JCAHO indicated, had not been an intent of the alert. The loss of a viable method of providing analgesia, especially one which can, at times, offer advantages over other methods of relieving pain was seen as a great loss by the American Society for Pain Management Nursing. Therefore, in 2005 a task force was convened to consider this issue and to provide recommendations concerning the practice of Authorized Agent Controlled Analgesia.
Abstract and Introduction
Abstract
The American Society for Pain Management Nursing (ASPMN), in order to address the Sentinel alerts issued by JCAHO (December, 2004) and ISMP (Nurse Advise-ERR January and February, 2005) concerning "PCA by Proxy", has developed a position statement and clinical practice recommendations on Authorized versus Unauthorized (PCA by Proxy) Dosing of Analgesic Infusion Pumps.
This statement clarifies and distinguishes between the unsafe practice of "PCA by Proxy", in which unauthorized individuals activate the dosing button of an analgesic infusion pump for a patient receiving Patient Controlled Analgesia, and the safe practice of Authorized Agent Controlled Analgesia (AACA). In the latter, certain individuals are educated and authorized to activate the analgesic infusion pump's dosing button when a patient is not able to self dose. ASPMN does not support the use of "PCA by Proxy". ASPMN does, however, support the practice of Authorized Agent Controlled Analgesia in a variety of patient care settings when the agency has in place clear guidelines outlining the conditions under which this practice shall be implemented and outlining monitoring procedures that will insure safe use of the therapy. Furthermore, the paper examines the ethical and safety issues and outlines the necessary screening and patient/family education needed to implement AACA. The position statement describes criteria for the use of AACA, guidelines for selection and education of the authorized agent, key prescription and monitoring recommendations during therapy, and quality improvement activities to insure safety and effectiveness.
Patient Controlled Analgesia (PCA) was first introduced three decades ago. As the understanding of pain and pain management improved the use of PCA technology continued to advance moving PCA into the mainstream of patient care. By the 1990's, PCA became a common technique for managing pain, especially in the post operative period. Not all patients, however, are good candidates for PCA therapy. For example, young children are not developmentally able to self dose with an analgesic infusion device. Studies done in the early 1990's, to determine the safety of PCA in children, utilized the technique of having nurses and/or family members activate the dosing button of a PCA pump in order to deliver analgesics to very young children in a timely and safe fashion (Gureno & Reisinger, 1991; Welcon, Connor, & White, 1993). In addition to these studies which had positive findings, some clinical experts employed and wrote about the not uncommon practice of educated and authorized individuals providing Nurse Activated Dosing or Family Activated Dosing for patients who could not self administer doses via a pump (Pastero & Mc-Caffery, 1993; Pasero, Portenoy, & McCaffery, 1999).
Unfortunately when many agencies were safely utilizing PCA pump technology to expand on the availability of safe, timely analgestic delivery by having such educated nurses and family members activate the analgesic pump, there was also a trend toward extending the use of PCA therapy to patients who were less than ideal candidates (Nurse Advise, 1-05). Due to poor patient selection and/or due to poor PCA prescription the practice of well meaning nurses, doctors, and significant others haphazardly pressing the buttons (or advising family and visitors to press the button) evolved in an attempt to improve pain control. While well intentioned, this practice can lead to serious deleterious effects, including death.
In order to alert the health care community to this potentially lethal practice the Institute for Safe Medical Practices (ISMP) and the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) issued alerts advising against the practice of PCA by Proxy . In December of 2004 JCAHO published in its Sentinel Event Alert, Patient controlled analgesia (PCA) is an effective and efficient method of controlling pain, and when it is used as prescribed and intended, the risk of oversedation is significantly reduced. However, serious adverse events can result when family members, caregivers or clinicians who are not authorized become involved in administering the analgesia for the patient 'by proxy'. [This Alert does not address situations in which others are authorized to administer analgesia] (JCAHO, 2004).
In an effort to comply with JCAHO's recommendations, many health care agencies responded by limiting the technology and advantages that the PCA modality offers to Patient Controlled Analgesia only. The practice of identifying authorized agents to activate the dosing button, Authorized Agent Controlled Analgesia (AACA), was effectively eliminated, which, as JCAHO indicated, had not been an intent of the alert. The loss of a viable method of providing analgesia, especially one which can, at times, offer advantages over other methods of relieving pain was seen as a great loss by the American Society for Pain Management Nursing. Therefore, in 2005 a task force was convened to consider this issue and to provide recommendations concerning the practice of Authorized Agent Controlled Analgesia.
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