Patient selection for Intravenous PCA (PCIA) is a collaborative decision between nursing, medical staff and the patient.

This document contains an outline of the key management concepts.

Nursing staff are required to utilise suite of appendices that details specific clinical management processes regarding intravenous analgesic device / patient control analgesic management.

1. To ensure that intravenous analgesic medications are administered safely and within hospital guidelines to achieve optimal patient comfort and benefit.

2. To govern the practice of staff members caring for patients in acute clinical areas, who are receiving an intravenous analgesia including Patient Controlled Intravenous Analgesia (PCIA) via intravenous analgesic device as indicated.

3. To provide sufficient effective analgesia safely via PCIA using device program parameters: PCIA, bolus delivery and /or continuous infusion delivering metered parenteral analgesia.

4. To measure effectiveness using patient satisfaction and functional outcomes:

• Assessment of pain and side effects,

• Appropriate, timely use of supplementary regular and prn adjunctive analgesia as ordered,

• Reassessment of patient oral intake, with consideration to the appropriateness of pain control method being used, the demands to delivery dose registered and total dosing required,

• The promotion of earlier mobilisation, thus contributing to earlier discharge and a reduction in complications and associated costs.

Intravenous opioid / analgesic infusion: Device that administers a prescribed amount hourly.

Patient Controlled Intravenous Analgesia (PCIA): A method of intravenous opioid administration which allows the patient to self-administer bolus doses of medication when required by pushing a handset linked to an analgesic pump. The PCIA pump can be set to deliver a specific dose with a specific lock-out period for dose delivery, and if required an upper limit on the number of doses over each hour.   In addition, a constant rate infusion may be provided as background analgesia, in conjunction with PCIA opioid pump parameters.

Nurse initiated (controlled) analgesia: Analgesic pump is programmed for delivery by the handset; however, the patient is deemed unable to self-administer i.e., cognition limitations and therefore the nurse has control of delivering the analgesia by using the handset. Nurse inserted instead of Patient Controlled MR 675. Handset is kept on the analgesic pump and labelled appropriately. In all cases, parameters are prescribed by the anaesthetist or medical officer and programmed into the analgesic pump.

Organisational Authorised/Competent Clinician: Grampian Health Ballarat Nursing Directorate has deemed intravenous analgesia device competency an organisational requirement for acute nursing staff directly involved in the management of patients with intravenous analgesia.  Staff obtain/maintain competency via successful completion of the intravenous analgesic device practical assessment process and yearly Professional Development Program (PDP) education participation.

Nurse: Registered nurse (RN), midwife or enrolled nurse (EN).

Enrolled nurse (EN): Registered with the Nursing and Midwifery Board of Australia as an Enrolled Nurse and whose registration does not preclude the handling and administration of medications.

There are no longer endorsements for administration of medicines by Enrolled Nurses.

An Enrolled Nurse who has a notation on their registration indicating that they are not qualified to administer medication. 

The notation states: 'Does not hold Board-approved qualification in administration of medicines'. This notation will remain in place until the enrolled nurse provides evidence of having completed a Board-approved administration of medicines unit.

Independent double checking: Double-checking of medicine by two or more authorised health practitioners independently checking each element in the medicine administration process and, independently confirm the details are correct.

Double-checking is a risk management strategy where Schedule 8 medications are double checked prior to administration.

Such checking should be by two qualified clinicians which may include a combination of a registered nurse, midwife, enrolled nurse without a notation, medical officer.

Additionally, this checking process facilitates verification before an intervention is implemented, it can be performed in the presence or absence of the first nurse. Most critical is to maximize the independence of the double check by ensuring that the first nurse does not communicate the expected outcome, which would create bias and reduce the visibility of the mistake.

CEASED criteria: Criterion that facilitates ceasing of a PCIA, on adult patient only, by ward staff or parent medical team. 

Patients' must attain the CEASED criteria in order for parent team or nurses to initiate cessation of the PCIA and change to oral analgesia. CEASED criteria guide Appendix A - B, not applicable to pediatric patients.

COOLED strategy:  Process that allows ward nurses and ward medical staff to identify patients ready to have sublingual buprenorphine weaned or converted to oral analgesia. These patients must reach certain criteria before the change from sublingual buprenorphine to oral analgesia is initiated. (Refer to Appendix C- D)

Dangerous drugs (DD) safe: Safe in which Schedule 8 medication located, the safe is located within a secure/ limited access clinical area with the safe securely attached to a part of the premises. Entry to the secure area is via swipe access of or key, while access to the safe is via key or individual swipe access of two registered staff.

Drugs of Dependence: All Schedule 8 medicines such as oxycodone, morphine, alprazolam, methylphenidate and dexamphetamine and some Schedule 4 medicines including all benzodiazepines, zolpidem, zopiclone, quetiapine and codeine.

Schedule 8 medications: Medication with strict legislative controls, including opioid analgesics.

OIVI: Opioid Induced Ventilatory Impairment

1. Safe and effective analgesia via the intravenous route as assessed by Acute Pain Service (APS) anaesthetic staff.

2. Patient selection for PCIA includes:

   • A willingness to participate in own analgesia administration,

   • Be able to activate the handset button, and cognitively understand the activation process.

   • Being cooperative and compliant with therapy with an ability to understand the concept of PCIA  

3.  In ward areas, analgesic intravenous infusion where adjunctive analgesia to opioid PCIA is required by a 2nd analgesic device, is restricted to delivery by specific analgesic device only.                                     

1. Patients who do not meet the criteria listed in the indications section for PCIA.

2. Patients with known allergy to opioid.

3. CEASED criteria and COOLED strategy is not applicable to paediatric patients.

Staff considerations

1. A compete registered nurse/midwife is required to supervise and be involved in the management of patients with intravenous analgesia.

2. Administration of S8 drugs: Refer to POL0244: Opioid prescribing policy

 Patient considerations

1. Patients outside indications parameters will be assessed on a case-by-case basis by APS medical staff.

2. Patients who use a CPAP machine must have their machine on during sleep periods.

3. Analgesic infusions (Opioid or Ketamine) may be administered via the infusion pump (Alaris critical care library) in the Intensive Care Unit, Ketamine only in the Emergency Department.

4. Oxygen requirement via nasal canula at < 4litres per minute as a response to clinical indication SpO2 <93%.

   • Prior to commencement where possible a potential cause should be identified and resolved.

   • Routine supplemental oxygen use can carry risk in and of itself.

 Practice Point

• Oxygen SpO2 level at 100% with supplemental oxygen in use may mask clinical signs of decreasing respiratory effort leading to OIVI

• OIVI (Opioid Induced ventilatory impairment) is only one cause of hypoxemia, particularly in the post-operative period other factors include:

  • reduced lung volumes particularly vital and functional residual capacities, commonly seen after major surgery.

  • patient age,

  • upper abdominal and lesser extent abdominal, thoracic or major joint surgery,

  • obesity,

  • pre-existing lung disease,

  • smoking and

  • severe pain.

• Regardless of cause unless continuous SpO2 monitoring utilized the frequency and severity of episodic hypoxemia, which may be exacerbated during sleep can be significantly understated.

Equipment

Refer to Appendix E: 'Equipment' for details and illustrations:

Analgesic Device: CADD Solis (TM) grey pump is an analgesic pump used for intravenous analgesic drug delivery. (Appendix F)

Required:

• Intravenous (IV) fluids

• Inline anti-reflux /anti-syphon (one way) valve

• Clear analgesic device administration line

• Analgesic Device components: Specific to analgesic IV delivery incorporating: 2 - way flow valve; lockable shell: solution, device and program parameters to ensure patient safety; and schedule 8 legal requirement. Patient remote dose cord access/handset.

• Medication/ Line labels

• Completed 'Medication Pain Control Intravenous order form' ((Refer Appendix G: MR/675) - incidents typically related to incomplete forms

• ONLY one prescription per form

• Analgesic solution

Standard general adult solutions using 100 ml Sodium Chloride bag, the following may be added:

 Note: In rare circumstances, only the nominated consultant anaesthetist for the APS or anaesthetic Registrar has the authority to prescribe outside the above standard orders, as would be the case in paediatric PCA prescribing.

 Prescribed drug in solution. Opioids or ketamine either premix or in component parts, drug requiring being added in sodium chloride 100ml bag.

Refer to PCA Management Summaries:

• Appendix H - I: PCA commencement

• Appendix J: PCA ongoing management

• Appendix K: PCA cessation / discontinuation