Pain Management PRN vs. Around the Clockpain medication administration in hospital inpatientsBy: Isabella Kocienski
JCAHO Joint Commission on Accreditation of Healthcare Organizations (JCAHO): Released the pain management standards in 2001 JCAHO stated that it pain standards are its first evidence-based standards. Standards were derived from evidence-based clinical practice guidelines developed by groups, i.e. American Pain Society (APS) also the Agency for Healthcare Research and Quality (AHRQ). Home Healthcare Nurse, (2005).
JCAHO Standards are a formal part of the survey. JCAHO requires that accredited healthcare facilities:1) Recognize the right of the patients to appropriate assessment and management of pain.2) Assess pain in all patients.3) Record the assessment in a way that facilitates regular reassessment and follow-up.4) Educated patients, families and providers about effective pain management.5) Establish policies that support appropriate prescription or ordering of pain medicines.6) Include patients’ needs for symptom control in discharge planning. Collect data to monitor the appropriateness and effectiveness of pain management. Home Healthcare Nurse, (2005).
Pain Treatment Quality pain management begins with an affirmation by clinicians that patients should have access to the best pain relief that can safely be provided. The most effective treatment for all pain is a multimodal and balanced approach that combines both pharmacologic and non-pharmacologic strategies. However, pharmacologic therapy is the mainstay of treatment for many painful conditions. The Journal of Pain, (2005).
PRN Medication Pro Re Nata (PRN): From the Latin meaning for an occasion that has arisen. PRN orders for opioid analgesics in acute pain management is common in clinical practice. This approach provides flexibility in dosing to meet individual patients unique needs and analgesic requirements. Acute pain is often undertreated because physicians under prescribe opioid analgesics, order inappropriately low doses or prolonged dosing intervals and nurses give inadequate doses. The Journal of Pain, (2005).
PRN Medication Factors to account for while administering PRN Medications:1) Reasonable Range2) Patients prior drug exposure3) Prior Response4) Age5) Liver and Renal Function6) Pain Severity7) Anticipated Pain Duration8) Kinetics: Onset-Peak-Duration9)Co-morbidities that may affect a patients response10) Concomitant administration of other sedating drugs11) Combination Drugs The Journal of Pain, (2005).
ATC Medication Around the clock: (ATC) or time contingent dosingScheduled dosing of opioids is believed to provide more effective analgesia when compared to PRN administration of the drug. Few studies have evaluated the efficacy of this approach. This quality improvement study found scheduled dosing was associated with decreased pain intensity rating and there was no difference in the frequency of adverse events. There were no differences in the amount of opioid ordered or given, however, the percentage of opioid given when ordered on a schedule was approximately twice the amount when compared to PRN delivery. These findings support the use of scheduled dosing of opioids in an inpatient medical population. The Journal of Pain, (2005).
ATC Medication Scheduled opioid administration may provide improved pain relief by overcoming several patient and healthcare professional barriers to adequate pain control. Numerous studies document patient barriers including reluctance to report pain and to ask for medication in part due to fears of addiction or tolerance. By offering the medications on a regular schedule, patients do not have to initiate requests for analgesics. Patients feel greater sense of control by permitting them to refuse the medication if pain control is adequate. Patients commented that support their relief at not having to ask for the drug not having to watch the clock and not feeling like and addict. The Journal of Pain, (2005).
Pain Management in Summary Previous studies demonstrate that although physicians tend to under prescribe, nurses complicate this by administering less than the total amount ordered. Patients are reluctant to report dissatisfaction with pain management despite having significant pain. In summary this quality improvement study shows the benefits of scheduled dosing of opioids in an inpatient medicine population. The Journal of Pain, (2005).
Bibliography Paice, J. A., Noskin, G. A., Vanagunas, A., & Shott, S. (2005). Efficacy and Safety of Scheduled Dosing of Opioid Analgesics: A Quality Improvement Study. The Journal of Pain, Vol 6, No 10, 639-643. Cowley, C., Dahl, J., Fine, P. G., Finley, R. S., Fishman, S., Foster, R. L., Frandsen, J., Gordon, D. B., Miaskowski, C., & Phillips, P. (2005). The Use of ‘As-Needed’ Range Orders for Opioid Analgesics in the Management of Acute Pain: Home Healthcare Nurse, Vol 23, No 6, 388-398