7/14/2014 RE: Patient Controlled Analgesia (PCA): Adult and Pediatric...

- Davis, Aurora
https://pod51038.outlook.com/owa/projection.aspx 1/6
RE: Patient Controlled Analgesia (PCA): Adult and Pediatric Policy
and Procedure Updates, With Changes
Hi.
Great discussion!
More thoughts:
Please directly cite the pain management policy for usage of appropriate pain scales; this emphasizes
a difference of pain vs. sedation scales.
Yes, there is a movement to sedate intubated patients appropriately [to encourage a more awake
patient] and utilize PCAs in this population more for analgesic control. (which would then also cover our
ventilated trach patientswho also may be put on a PCA). It is MD specific and some have really
embraced using PCAs in the ICU. The protected airway/ventilator dependent question came up a lot
this past summer with regard to this policy & monitoring expectationsas we were training all ICU RN
staff to the RASS scale.
We see a combination of narcotic therapy options-- more acutely ill patients will have Alaris pump
infusions and then PCAs for the more awake folks and/or those impending transfers out of ICU.
RobI dont believe there was a definitive decision on what sedation scale level would direct an RN
to stop PCA therapy specific to RASS assessment..I believe notifications/stoppage/reversal is set for
respiratory rate decreases in the order sets? Not sure what North/South campuses have set for this
either. I have not found evidence linking RASS rating with nursing action for PCAs. Level -3 is
moderate sedation & level -4 is deep sedation--you make a good point that notification should come
sooner at a level -3 and level -4 potentially stopping the agent. [with regard to the MR scale.levels 3
and 4 point to considering decreasing/stopping sedatives--opioids & increasing monitoring, but level 5
prescribes the stop]
Maxyou may want to discuss the concept of an updated system wide Pain Management policy at
CPGG; to accompany our UCH specific need to update the policy. You and Barb have a better sense of
where we are on the pain mgmt. policy update process though..

Thanks!

Shannon Johnson Bortolotto RN MS APN CCNS
Critical Care Clinical Nurse Specialist
University of Colorado Hospital
Johnson-Bortolotto, Shannon
Wed 4/30/2014 4:57 PM
Inbox
To:Montgomery, Robert <Robert.Montgomery@ucdenver.edu>; Davis, Aurora <Aurora.Davis@uchealth.org>; Swedhin, Amanda
M <Amanda.Swedhin@uchealth.org>;
Cc:Krumbach, Barbara <Barbara.Krumbach@uchealth.org>; Youngwerth, Jean M <Jean.Youngwerth@ucdenver.edu>; Levin,
Dimitriy <Dimitriy.Levin@ucdenver.edu>; Fiegel, Matthew <Matthew.Fiegel@ucdenver.edu>;
7/14/2014 RE: Patient Controlled Analgesia (PCA): Adult and Pediatric... - Davis, Aurora
https://pod51038.outlook.com/owa/projection.aspx 2/6
Department of Professional Resources
720-848-0945
Please note email change: shannon.bortolotto@uchealth.org

The department of Professional Resources improves lives by empowering healthcare professionals to influence quality care
through education, discovery and navigation of change.




From: Montgomery, Robert [mailto:Robert.Montgomery@ucdenver.edu]
Sent: Wednesday, April 30, 2014 12:53 PM
To: Davis, Aurora
Cc: Johnson-Bortolotto, Shannon; Krumbach, Barbara; Youngwerth, Jean M; Levin, Dimitriy; Fiegel, Matthew; Swedhin,
Amanda M
Subject: RE: Patient Controlled Analgesia (PCA): Adult and Pediatric Policy and Procedure Updates, With Changes

Hi,
Here are my thoughts/comments:
Agree: modify policy title to delete pediatric
RE: adding pain assessment scales: Agree with Shannons perspective of staff confusing pain/sedation
assessment; however, I would not add pain scales to this policy (or epidural infusion policy when that
one is updated). The scales are described and included in the Pain Management policy (see below). I
like Shannons suggestion of pointed reference to the Pain Management policy for use of appropriate
scale.
RE: protected airway monitoring for ICU: Shannon, do we have patients on PCA with a protected
airway?

Here are some new questions for Shannon in ICU on the RASS and others on the Moline Roberts scale about the
levels of sedation that trigger a required response.
I was part of the team that helped decide which sedation scales were to be used in ICU and M-S settings,
but I dont recall what was decided about the level of assessment requiring a response for opioid
induced sedation? Did the roll out of the scales give direction to RNs for stopping PCA therapy based on
sedation level?
RE: the Moline-Roberts: A level 5 for notification/stopping therapy seems too far down on the scale for
safety. Since North campus was already using this scale, did we use the same level(s) they were using
for IVPCA? A level 4 seems more appropriate for notification and 5 for stopping therapy.
RE: RASS: how was a level -4 level chosen for notification? Do we have evidence for that level? That
seems too far down on the scale for safety. I would advocate for a -3 level for notification and a -4 level
for stopping therapy. Granted, I have limited evidence for these levels due to lack of study on RASS in
this application (one local health system research project), but these levels seem more in line with
providing the proper level of safety for monitoring patients.
7/14/2014 RE: Patient Controlled Analgesia (PCA): Adult and Pediatric... - Davis, Aurora
https://pod51038.outlook.com/owa/projection.aspx 3/6

The last new item is that the Pain Management policy needs to be updated to reflect the new system wide pain
assessment scales we previously adopted. I was reminded of this needed change during review of this PCA
policy. I think Barb and Max had started on this?

Thanks. -Rob

From: Johnson-Bortolotto, Shannon [mailto:Shannon.Bortolotto@uchealth.org]
Sent: Wednesday, April 30, 2014 10:15 AM
To: Davis, Aurora; Montgomery, Robert; Krumbach, Barbara; Youngwerth, Jean M; Levin, Dimitriy; Fiegel,
Matthew; Swedhin, Amanda M
Subject: RE: Patient Controlled Analgesia (PCA): Adult and Pediatric Policy and Procedure Updates, With
Changes

HI.
Rationale for including the pain assessment scales are based on staff combining/confusing sedation assessment
w/ pain management in their clinical heads. Since we note the sedation scales (which is good to outline) in
this policy, am thinking at least a mention that pain management requires different tools is helpful. We can be
broad in describing (self-report and behavioral tools descriptions), since there are many scaleswith pointed
reference to the pain management policy; which provides more granular descriptions of appropriate pain
management assessment tools. Would like to hear what others have to say on this as well

With regard to references, all will need an APA format (6
th
Ed) review and change to UCH numeric LOE ratings.
(Am happy to review them for you, Aurora, prior to submission to PPPPC)
Thanks!

Shannon Johnson Bortolotto RN MS APN CCNS
Critical Care Clinical Nurse Specialist
University of Colorado Hospital
Department of Professional Resources
720-848-0945
Please note email change: shannon.bortolotto@uchealth.org

The department of Professional Resources improves lives by empowering healthcare professionals to influence quality care
through education, discovery and navigation of change.




From: Davis, Aurora
Sent: Tuesday, April 29, 2014 4:47 PM
To: Johnson-Bortolotto, Shannon; Montgomery, Robert; Krumbach, Barbara; Youngwerth, Jean M; Levin, Dimitriy;
7/14/2014 RE: Patient Controlled Analgesia (PCA): Adult and Pediatric... - Davis, Aurora
https://pod51038.outlook.com/owa/projection.aspx 4/6
Fiegel, Matthew; Swedhin, Amanda M
Subject: RE: Patient Controlled Analgesia (PCA): Adult and Pediatric Policy and Procedure Updates, With Changes

Shannon,

Thank you for all the great feedback, particularly the ICU sedation scale information--I'd been looking for
that!

I'd like to get a group consensus on whether or not we need to include pain scales in this policy. I'm
not sure if this is the appropriate venue for these scales. At the moment, the policy simply states that the
patient's pain intensity needs to be assessed at least every four hours and a one hour reassessment must
be performed after increasing the PCA settings or bolusing the patient. It does not specify which scale
must be used, regardless of the area. Can I get some thoughts on this, please?

Shannon, regarding the APA Format, did you want me to just update the old references to make sure their
formatting is correct? I believe the ones I added are okay--please let me know if I'm doing it wrong.

Thanks,
Aurora

Aurora Davis, RN, BA, BSN, OCN
Relief Charge Nurse
Oncology and Bone Marrow Transplant Unit
University of Colorado Hospital
Aurora.Davis@uchealth.org
From: Johnson-Bortolotto, Shannon
Sent: Tuesday, April 29, 2014 4:26 PM
To: Davis, Aurora; Montgomery, Robert; Krumbach, Barbara; Youngwerth, Jean M; Levin, Dimitriy; Fiegel,
Matthew; Swedhin, Amanda M
Subject: RE: Patient Controlled Analgesia (PCA): Adult and Pediatric Policy and Procedure Updates, With
Changes

HI Aurora & team;
Nice job on updates!
I added a few suggestions via track changes (attached).
Here are my thoughts:
I added the RASS scale below the MR scale with explanations of who uses which scale.for sedation
assessment. I also attached the RASS scale for you with references.
We need to add the pain assessment tools as well categorized as self-report (010 numeric rating,
faces) and behavioral tools (CPOT in ICU; CNPI in non-ICU) and nursing assessment hierarchy for
neurologic impairment.
I added further clarification for ICU assessment with a protected airway in monitoring section.
Take out any phone #s.as they do change & PPPPC will ask for removal
Do we have anything in this policy for peds? If not, the policy name may have to change for adults
7/14/2014 RE: Patient Controlled Analgesia (PCA): Adult and Pediatric... - Davis, Aurora
https://pod51038.outlook.com/owa/projection.aspx 5/6
only??
References need to be in APA format, 6
th
edition
o here is a helpful link:
http://office.microsoft.com/en-us/templates/apa-style-report-6th-edition-TC103982351.aspx
Update UCH levels of evidence (new evidence table attached for you)

Let me know if you have any further questions. This is a big policy!


Shannon Johnson Bortolotto RN MS APN CCNS
Critical Care Clinical Nurse Specialist
University of Colorado Hospital
Department of Professional Resources
720-848-0945
Please note email change: shannon.bortolotto@uchealth.org

The department of Professional Resources improves lives by empowering healthcare professionals to influence quality care
through education, discovery and navigation of change.




From: Davis, Aurora
Sent: Tuesday, April 29, 2014 3:40 PM
To: Montgomery, Robert; Krumbach, Barbara; Youngwerth, Jean M; Levin, Dimitriy; Fiegel, Matthew; Johnson-Bortolotto,
Shannon; Swedhin, Amanda M
Subject: Patient Controlled Analgesia (PCA): Adult and Pediatric Policy and Procedure Updates, With Changes

Dear Clinical Stakeholders,

In response to feedback from stakeholders, I have made some additional changes to the Patient Controlled
Analgesia (PCA): Adult and Pediatric Policy and Procedure. In addition to the changes noted in my last
email, I have now: changed the PCA dosing table to reflect the recommendations of the Acute Pain
Service; adopted several phrasing tweaks per Dr. Youngwerth; added an additional reference for opioid
sedation management per Barb Krumbach; removed references to pediatric dosing per APS, Dr.
Youngwerth, and UCH Admission Policies for pediatric patients; and verified the appropriateness of using
the terms "Alaris" and "CADD".

Please look over and review the attached policy. I am looking for either your approval as is or
suggestions/rationales for change. Please have all feedback to me by Monday, May 5th, 2014, as I will be
taking the policy to the Kaizen Committee and would like your suggestions before then. If, by May 5th,
2014, your comments have not been received, your approval is assumed.
7/14/2014 RE: Patient Controlled Analgesia (PCA): Adult and Pediatric... - Davis, Aurora
https://pod51038.outlook.com/owa/projection.aspx 6/6

Thank you.

Attached document:
1. Patient Controlled Analgesia (PCA): Adult and Pediatric Policy and Procedure, Updated
Aurora Davis, RN, BA, BSN, OCN
Relief Charge Nurse
Oncology and Bone Marrow Transplant Unit
University of Colorado Hospital
Aurora.Davis@uchealth.org