Pain at the Pump

Patient-controlled analgesia (PCA), well accepted and widely used to quickly ease post-operative and acute pain, is safe and effective—in skilled hands. But there are complications, caveats, and safety concerns hospitalists should consider to incorporate this tool into their pain management routines and hospital protocols.

Studies show patients prefer the PCA compared with other analgesic routes.1-2 Less clear is whether it is more effective or leads to lower opioid use.

Some hospitalists use the PCA for their patients with pain—others defer to anesthesiologists, pain services, or palliative care consultants to manage the PCA and its multifaceted dosing requirements.

“There are a lot of misconceptions about the PCA,” says Deb Gordon, RN, MS, FAAN, senior clinical nurse specialist and pain consultant at the University of Wisconsin (UW) Medical Center in Madison. “There is a misunderstanding that the PCA is a magic black box for pain relief,” which can lead to its overuse. As a general rule of pain management, patients prefer the oral route of analgesic administration, Gordon says, unless that is a problem or rapid titration is needed.

“I don’t think [the PCA is] rocket science—it’s just a tool to deliver analgesics conveniently,” Gordon says. “I think every hospitalist should learn how to use the PCA, but there are always nuances of how to titrate opioids by any route.” UW has implemented PCA protocols, which staff can use for ballpark dosing recommendations.

Target PCA for Safety Programming

Many hospitals have policies, protocols, or guidelines for how to use the PCA. These may address recommended drugs and specific doses, as well as titration, monitoring, and other concerns—even who is credentialed to operate the PCA. If your hospital does not have such resources, this is a good project for a multidisciplinary, ad-hoc quality group—convened and led by hospitalists—to review the literature and develop policies and orders specific to your institution.

Chandler Regional Hospital in Ariz., implemented a revised PCA policy in May 2006, after reviewing the latest pump technology and selecting a new PCA system for the hospital. The eight-page hospital policy spells out how the PCA will be used, while a detailed physician order sheet summarizes the policy and guides choice of drug, dose, lockout interval, and how to increase dosage.

“Since employing the new policy and technology, we definitely feel we provide a safer environment for PCA administration within the hospital,” says clinical pharmacist Anthony Lucchi, PharmD.

The University of Utah Medical Center in Salt Lake City has taken PCA safety a step further by certifying its physicians in PCA use with a brief seminar and a test on the content. The self-learning “Module on PCA and Acute Pain Management” is offered online and takes about an hour to complete, says Dirim Acord, APRN, pain clinical nurse specialist and education coordinator for the medical center’s acute pain service. The pain service handles complex pain procedures but encourages residents and their attendings to become certified in PCA use. Roughly 30% of attendings in the facility, including some hospitalists, have done so.

“The knowledge difference between physicians who have gone through the course and those who have not is quite dramatic,” she adds. “Residents are just not getting this information in their basic training.”

For more information on Chandler Hospital’s PCA policy and order sheet, contact Donna Nolde, [email protected]. For information on the University of Utah’s PCA policy and self-learning module, contact Dirim Acord, [email protected].—LB

How Hospitalists Use the PCA

The PCA delivers pain medication intravenously via a computerized pump with a button the patient can press when needed—without waiting for busy nurses to answer a call button and then confirm, prepare, and administer an analgesic treatment.