PCA managing inadequate pain relief of patient controlled analgesia (adult)
If the patient's pain score is over 4 follow below:
Welcome to the Right Decision Service (RDS) newsletter for April 2024.
Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May. If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.
Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.
Thank you for your patience and understanding while we achieve a full resolution.
A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.
The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.
The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.
Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.
These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.
Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.
Figure 1: Impact of RDS on direct delivery of care
Key figures
Figure 2 shows RDS impact to date on delivery of health and care services
Key figures
These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.
Saving time and money
Quality assurance and governance
Service innovation and workforce development
A few examples of toolkits published to live in the last month:
Some of the toolkits the RDS team is currently working on:
Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.
Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions. We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.
Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine. The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.
With kind regards
Right Decision Service team
Healthcare Improvement Scotland
TAM feedback form
Please state 'TAM' in the feedback so that your feedback is triaged to the NHSH TAM team. Thank you.
Please note this guidance is for use in in-patients and is not designed for managing patients with chronic pain.
Patients with PCA must be nursed on a ward recognised by the Acute Pain Team and Department of Anaesthetics.
Within Raigmore Patient Controlled Analgesia may be used in:
A registered nurse caring for a patient with PCA should have attended the acute pain study and declare her/himself competent in the management of the PCA.
All PCA Infusion must be delivered via the Agilia PCA pump
Hospital SOPs on Preparation and Administration of Controlled Drugs (see resources) must always be adhered to.
The surgical medical staff or nurse practitioner should be called in the first instance for all routine surgical problems including:
If further advice is required, please contact the Acute Pain Nurse (bleep 1003) and if not available, the ITU anaesthetist.
All patients receiving PCA must have oxygen 4L/min by facemask or 2L/min via nasal cannula, for 24 hours postoperatively and then overnight until PCA is discontinued, unless directed to do so otherwise by an Anaesthetist.
NO OTHER OPIOIDS are to be administered to the patient whilst PCA is in use (oral, subcutaneous, intramuscular, intravenous or topical) unless directed to do so by an Anaesthetist or Acute Pain Nurse.
Ensure Naloxone 400 microgram injection is available on the ward.
PCA keys to be kept in the Controlled Drugs cupboard.
The standard prescription is Protocol A
The prescriber must complete a PCA chart, including the following details :
If a ward doctor or non-medical prescriber wishes to prescribe an alternative dose, discussion should first take place with the Acute Pain Nurse or an Anaesthetist.
Background infusions should only be used in patients who have been on long term opioids and must only be initiated by an Anaesthetist or Acute Pain Nurse.
The Prescription should be prescribed in the regular or 'As required' section of the Drug Kardex and affix a “PCA/Epidural Opioid in Progress” onto the Kardex.
Alternatives to Morphine may be used if required, please contact Acute Pain Nurse or ITU anaesthetist.
Anti-emetics must be prescribed on the Drug Kardex if patient is to have PCA, see TAM postoperative nausea and vomiting guidelines.
Preparation of each syringe must be witnessed by a trained nurse or doctor, in accordance with Hospital SOPs on Preparation and Administration of Controlled Drugs (see resources).
Change of syringe
Each change of syringe must be witnessed by a trained nurse or doctor who has received PCA training. Follow the Hospital SOPs on Preparation and Administration of Controlled Drugs (see resources).
Changing PCA extension sets
Patients with PCA need regular observations of pain, nausea, sedation and respiratory rate, in addition to the conventional postoperative recording.
Monitoring PCA Infusions
1. Pain score must be recorded on the observation chart
2. Sedation scores and respiration rate must be recorded on the observation chart
3. Nausea score must be recorded on the observation chart
NSAIDs and paracetamol help to minimise opioid side-effects by reducing the total dose of opioid required and should be prescribed regularly not PRN.
Moderate respiratory depression (respiratory rate less then 9 breaths per minute AND sedation score of 1 or 2)
Severe respiratory depression (respiratory rate less then 7 breaths per minute OR sedation score of 3.)
CALL FOR HELP, INITIATE CPR PROCEDURES, IF THE PATIENT IS APNOEIC, CALL 2222
Patient Controlled Analgesia should be discontinued when the patient no longer requires it, for example.
Note: Changing from PCA to subcutaneous injections is not acceptable when an oral route has been established. This may only be acceptable when intravenous access is difficult.
If a pump is broken or damaged in any way, please send to Medical Physics with a description of the fault.