PCA By Proxy
Maria Tanzi, PharmD
A recent event of patient-controlled analgesia (PCA) by proxy—a term used to describe conditions under which someone other than the patient administers one or more doses of an opioid to the patient using the PCA device—has prompted a review of the safeguards needed to prevent these types of events.1
Matthew Grissinger, RPh, FASCP, director of error reporting at the Institute for Safe Medication Practices (ISMP), suggests that clinicians reassess practices on PCA use to ensure safety steps are in place to prevent PCA-by-proxy events.
“Patient, family, and staff education; proper selection of patients for PCA use; visual reminders to avoid activation of doses by anyone other than the patient; and appropriate patient monitoring” are all critical safety steps that should be implemented to minimize the occurrence of PCA by proxy events, Grissinger said.
The recent case reported to ISMP involved a postsurgical patient on a PCA for pain control and haloperidol for management of agitation and confusion. The patient was assigned a hospital-employed, unlicensed safety companion to stay in her room around the clock. Upon shift change, the staff realized that the safety companion, during his 4-hour shift, had activated seven PCA doses for the patient.
The safety companion understood that the patient could receive a dose every 6 minutes, but he thought the patient was unable to press the button to activate a dose for herself, so instead he delivered a dose for the patient about every 30 minutes.
He stated that he was unaware that only the patient should deliver a dose. The patient experienced little respiratory depression and was not permanently harmed, but the event highlighted the need to reinforce education on proper PCA use.
Education is critical
Clinicians, patients, and their families must be educated on proper use of the PCA and that only the patient should administer doses when needed.
Overall pain management is the first topic to cover with clinicians, said Grissinger. “Pharmacists need to know what types of medications (e.g., acetaminophen, NSAIDs, opioids) are appropriate for certain types of pain, such as nociceptive, neuropathic, and others.”
He noted that some pharmacists may review orders for opioids but may not be aware of the condition being treated, so they are unable to identify if the therapy is appropriate.
Multimodal pain therapy should be a component of staff education to ensure they understand the various treatments used in overall pain management.
Grissinger also highlighted the concept of determining a patient’s opioid status (i.e., opioid naive vs. opioid tolerant), as this will determine the appropriateness of PCA therapy.
For example, Grissinger said, “Clinicians should know that basal infusions of opioids via PCA should only be used in opioid-tolerant patients and not in opioid-naive patients.” He noted that bolus-dose-only PCA therapy may be appropriate for opioid-naive patients.
Clinicians should also consider patient-specific information when prescribing and screening orders for PCA therapy, such as comorbid conditions that may impact the dose (e.g., obesity, respiratory conditions like sleep apnea, patient age, and renal status). They should assess concurrent medications to look for drugs that may enhance the sedative properties of an opioid (e.g., anxiolytics).
Patient selection, monitoring key
Proper patient selection and monitoring are key to preventing PCA-by-proxy events. Ideal candidates for PCA include those who are mentally alert and have the cognitive, physical, and psychological ability to manage their own pain. Less-than-ideal candidates are those who may require practitioner-initiated doses, such as infants, young children, or confused patients.
Monitoring should focus on identifying and rapidly responding to respiratory insufficiency.
“While this may be out of the pharmacist’s scope of practice, it would be beneficial if they know how patients are going to be monitored and what is being monitored while on PCA therapy,” said Grissinger. “Based on past experience, we’ve learned that organizations were relying solely on monitoring pulse oximetry, which is not the best method to detect impending respiratory depression compared with end tidal CO2 monitoring using capnography.”
Reference
Grissinger M, et al. P&T. 2019;44(10):580–1