7/14/2014 RE: PCA question - Davis, Aurora

https://pod51038.outlook.com/owa/projection.aspx 1/5
RE: PCA question
Hi, Everyone.
Let me get in on this.
1) My understanding is that PCAs are not currently required to have a dual sign off for boluses in the high
risk medications policy. Only with new bag, handoff, and rate/dose/setting changes. (Sorry, I'm at home
today and can't verify this for certain.)
2) The PCA policy itself does not explicitly state that PCA boluses must be verified. Section 2M says
"Nurses may adjust pump settings within ranges and give bolus doses as ordered", which makes it sound
like nurses can do this independently per MD order.
Section 2N says:
"Two RNs must independently verify drug, volume, concentration, and rate including all pump settings
against the orders when:
1. Initiating the PCA infusion
2. Accepting patient from another floor
3. Changing shift (with off-going RN to oncoming RN)
4. Changing any settings or changing drug"
Boluses are not specifically mentioned. Individual interpretation could say that settings includes boluses,
or that it does not, although the fact that boluses are discussed in section 2M makes me think that they
are NOT included here.
3) On our unit, we train nurses that they do NOT have to have two RNs to verify bolus doses. This is based
on the idea that giving a bolus is the same thing you'd be doing by delivering a PRN medication
through going to the pyxis, pulling up a drug, and administering it to the patient--a chain of events that
also does NOT require an RN double-check. We have also always taught our nurses to chart boluses in the
Doc Flowsheets rather than in the MAR, so the MAR stop for dual sign off could be avoided for boluses
ONLY. (I seem to remember being told it was an all or nothing for the dual sign off and that we had to
have it for everything, including boluses.)
4) On a side note, I've been updating the PCA policy and have included a clarification that two RNs are
NOT required to verify a bolus, specifically because of the confusion surrounding the current language in
the policy. Max, I'd really like to know what the other M/S educators report they do on their units. If I need
Davis, Aurora
Wed 3/26/2014 3:23 PM
Sent Items
To:Swedhin, Amanda M <Amanda.Swedhin@uchealth.org>; Park, Sylvia <Sylvia.Park@uchealth.org>; May, Sondra - UCH Med
Safety Coord <Sondra.May@uchealth.org>; Bonnes, Deborah G <Deborah.Bonnes@uchealth.org>; Pratt, Timothy
<Timothy.Pratt@uchealth.org>;
Cc:Fulton, Krystle L <Krystle.Fulton@uchealth.org>;
7/14/2014 RE: PCA question - Davis, Aurora
https://pod51038.outlook.com/owa/projection.aspx 2/5
to take that language back out of the policy to leave it vague, I could, but it seems like a better idea might
be to get everyone on the same page regarding practice and then make it clear in the policy, whichever
way we all do it.
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: Swedhin, Amanda M
Sent: Wednesday, March 26, 2014 2:59 PM
To: Park, Sylvia; May, Sondra - UCH Med Safety Coord; Bonnes, Deborah G; Pratt, Timothy
Cc: Fulton, Krystle L; Davis, Aurora
Subject: RE: PCA question


What a lively discussion weve started! The Pain Champions team (which I am co-chair for) is currently looking
into revamping ALL Policies related to pain management. Let me speak to the policy as it sits currently:
1. Two RNs must independently verify drug, volume, concentration, and rate including all pump
settings against the orders when:
a. Initiating the PCA infusion
b. Accepting patient from another floor
c. Changing shift (with off-going RN to oncoming RN)
d. Changing any settings or changing drug
When I have discussed this with Rob Montgomery previously, the wording was left ambiguous in order to allow
RNs in specific areas to give bolus per their unit needs (ie: ICU vs. PCU vs. Floor). Changing any settings is in
reference to changing a continuous basal rate, but could be interpreted as a bolus rate change per unit policy.
ICUs do not require co-signs for bolus doses on continuous drips, and training on the PCUs does not indicate
that we need a co-sign for a bolus dose from a PCA because it is considered a PRN pain treatment and we
wouldnt require it for that purpose. I will not speak to M/S Floor practice, but having worked on the 7
th
floor
previously, we were trained to get two RNs to verify for bolus. Im not sure what current practice shows is
being done, but I assume that this is still the norm (Ive sent out an inquiry to the M/S Educators group to
confirm this).
I did not realize that EPIC was requiring a double sign-off for bolusI assume it is not required of continuous
opioid infusions in the ICUs? Do we need to address the different levels of care in the re-vamp of the policy and
in the Intravenous IV Drug Drip chart and can we adjust this in the EPIC order sets to reflect level of care?

Amanda Max Swedhin, RN, BSN, CMSRN
Medical/Surgical PCU Educator, Pain Champions Co-Chair
Amanda.Swedhin@uchealth.org
Office: 720-848-7720
Pager: 303-266-0461
7/14/2014 RE: PCA question - Davis, Aurora
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Cell: 720-339-6819

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From: Park, Sylvia
Sent: Wednesday, March 26, 2014 12:30 PM
To: May, Sondra - UCH Med Safety Coord; Bonnes, Deborah G; Pratt, Timothy
Cc: Swedhin, Amanda M; Fulton, Krystle L
Subject: RE: PCA question

Krystle,

When you talked to Aurora Davis (whos working on updating the PCA policy), can you mention that Rob
Montgomery defines PCA settings as: PCA/Demand Dose, Basel/Continuous, and Lock out. Max (copied on this
email) can probably confirm this as well. I think the TIPS sheet we presented is fine as is, we just need to clarify
what Sondra describes below.

Thanks!

Sylvia Park RN BSN
Medication Safety Clinical Nurse Specialist
Department of Pharmacy
University of Colorado Hospital
12401 East 17
th
Avenue, LB 928
Aurora, Colorado 80045
Email: sylvia.park@UCHealth.org
Office: 720-848-7189
Cell: 720-775-9179
Fax: 720-848-5502

From: May, Sondra - UCH Med Safety Coord
Sent: Wednesday, March 26, 2014 12:16 PM
To: Bonnes, Deborah G; Pratt, Timothy
Cc: Park, Sylvia; Swedhin, Amanda M; Fulton, Krystle L
Subject: RE: PCA question

In looking at the PCA Policy it states:

1. Two RNs must independently verify drug, volume, concentration, and rate including all pump
settings against the orders when:
a. Initiating the PCA infusion
b. Accepting patient from another floor
c. Changing shift (with off-going RN to oncoming RN)
7/14/2014 RE: PCA question - Davis, Aurora
https://pod51038.outlook.com/owa/projection.aspx 4/5
d. Changing any settings or changing drug

My recommendation is to ask the Pain Service (Owners of the PCA Policy) what their intent is. After discussing
with Krystle further, Im leaning towards interpreting that this policy does NOT require the bolus double check.
Either way though, the wording should be clarified in both the PCA policy and the Double Check policy and EPIC
made to match if possible. Im sure if the decision is that at a hospital level the bolus does not require a
double check, some other units that have unit guidelines that do require the double check would want the
prompt still there.so not sure what the next steps would be. I have asked Krystle to first check with the nurse
who is currently updating the PCA policy to see what Pain Services intent is.


Sondra May, Pharm.D.
Medication Safety Coordinator
The Uni versi ty of Col orado Hospi tal | Department of Pharmacy
Mai l Stop F757 | 12401 E. 17th Avenue; Offi ce 921 | Aurora, CO 80045
Phone: 720-848-6965 | NOTE New Email Address: sondra.may@uchealth.org
Fax: 720-848-5507 | Pager: 303-266-1335

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From: Bonnes, Deborah G
Sent: Wednesday, March 26, 2014 10:42 AM
To: May, Sondra - UCH Med Safety Coord; Pratt, Timothy
Cc: Park, Sylvia; Swedhin, Amanda M; Fulton, Krystle L
Subject: RE: PCA question

Can you send me the MRN of one of these patients that has an active order, so that I can see the order?

From: May, Sondra - UCH Med Safety Coord
Sent: Wednesday, March 26, 2014 10:39 AM
To: Pratt, Timothy
Cc: Park, Sylvia; Swedhin, Amanda M; Fulton, Krystle L; Bonnes, Deborah G
Subject: Re: PCA question

I have to admit, I'm still very confused. Policy states:

PCA, PCEAs, & Intrathecal Infusions IV infusion New Bag, Handoff, and Rate, Dose or Setting Changes
7/14/2014 RE: PCA question - Davis, Aurora
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Therefore, I thought dual sign-off was required with the bolus as this is a "dose" or "setting" change. I asked
about this when the Alaris team started working on the education. Perhaps this needs further clarification since
it looks like the system is prompting for the double check? Is a bolus dose NOT a dose / rate change? I have cc'd
Deb Bonnes for an Epic perspective.

Sondra
On Mar 26, 2014, at 10:07 AM, "Pratt, Timothy" <Timothy.Pratt@uchealth.org> wrote:
Hello,

For our patients on the MS PCU with PCA, we have a hard stop (RN double check) when we are
doing boluses off the bag. I was curious if there was a way to eliminate that hard stop from the
Bolus from Bag option only. Any feedback would be extremely helpful.

Thanks

Timothy Pratt RN, BSN PCCN
Associate Nurse Manager
Medical Surgical Progressive Care Unit
University of Colorado Hospital
Office 720 848-4739
Pager 303-266-4843