Implementation of Standard Order Sets for Patient-controlled Analgesia

Purpose: The implementation of standard order sets for patient-controlled analgesia (PCA) is described.

Summary: A review of naloxone usage at the University of Minnesota Medical Center (UMMC) from January to June 2004 found that 8% of patients receiving PCA had severe respiratory depression. A subanalysis of each event found that 85% of these patients had never before received opioid therapy. To reduce the risk of respiratory depression with PCA, separate standard order sets were developed for patients new to or tolerant of opioid therapy. A major component of both order sets was the standardization of a 10-minute lockout interval between each PCA dose. Implementation of the new PCA order sets raised concerns among health care professionals at UMMC that medication safety may be improved at the cost of increased pain. After implementation of the order sets, prescriber compliance, pharmacist interventions, the frequency of adverse effects, and patients' pain management were evaluated. After implementation of standard order sets for patients receiving PCA, 57% of patients' pain was documented as being controlled, and the orders for 93% of patients were in compliance with the recommended dosage interval of > or =10 minutes. There were no reports of oversedation or respiratory depression requiring reversal with naloxone.

Conclusion: The implementation of standard order sets for PCA resulted in a dramatic decrease in the number of cases of severe respiratory depression and increased use of the order set for patients new to opioid therapy. Changing the order sets to improve medication safety did not appear to negatively affect patients' satisfaction with pain management.