Pain Committee Friday, September 7, 2012 Penrose Board Room
Attendance: Drs. Oram-Smith, Ross, Finn; Psychologist – Mann;Nurses - Dan Chatelain, Mike Force, Audrey Simpson, Carlos Johnson, Katie Lammi, Rose Ann Moore, Carolyn Cusic, Deb Nussdorfer, Kathy Guy; Rehabilitation - Charlie Stine; Medical Staff Services - Jeanne Rice
Subject / Discussion / Action / ResponsibilityCall to Order / The meeting was called to order at 7:04am
Review of Minutes / The April 2012 minutes were reviewed and approved as submitted (last committee meeting held).
Follow up Items:
Introduction – Katie Lammi, NP / Katie is the new Pain/Palliative Care nurse; will be housed at SFMC. She is working toward prescriptive authority. This represents changes in nurse staffing to meet identified need for expanded clinical expert services at SFMC and is consistent with this committees request. / Katie is currently orienting and will establish office at SFMC by middle of October.
Katie will provide ongoing education and mentoring to nurses at SFMC. This is especially critical with our new graduate nurses. / Katie Lammi RN, Kathy Guy RN
Narcan data / Had one Narcan rescue last week – PACU to 11th floor. Float nurse was caring for patient, no sedation level had been done at all. Dan worries that float nurses/agency nurses not trained as well. PSFHS nurses receive orientation and competency monitoring including pain management, sedation monitoring, PCA use. Dan discussed elderly patient with elevated creatinine receiving morphine, risk, and complications.
Rose Ann said nursing audits reflect either practice or documentation deficits with reassessment process following administration of pain management. The Nursing Practice Council (NPC) reviewed practices, obtained recommendations from expert pain nurses in three other organizations, reviewed the literature and made decision to require we wake patients to reassess pain and sedation per policies. For example if we are reassessing morphine effectiveness at one hour we will wake the patient – to improve patient safety. The NPC discussed partnering with patients and informing them of this practice for their safety to reduce potential irritation at being wakened. Article in nursing TLC newsletter. / Do education with float pool nurses.
Support Nursing Practice Council revision to standard of practice. / Dan Chatelain RN
Katie Lammi RN
Nursing Leadership, Pain nurses
Narcan Rescue QI / Deb distributed a graph of Narcan Rescues at Penrose Jan 2008 through July 2012. Actions taken by this council and by the Nursing Practice Council are continuing to reduce iatrogenic over sedation in patients at PH. We have decreased phenergan dosing, revised order sets, educated nursing and physician, provided tip sheets, expanded assessment and monitoring of patients with sleep apnea, created an active pain resource nurse team, quarterly pain newsletter for nurses, identified and implemented new evidence based practices. / Recommend we review pain satisfaction scores for same time frame with critical eye to any decrease in satisfaction scores that may be related to changes in practice to reduce risk of over sedation.Great results as we note the significant improvement during these last two years! Plan for expansion to SFMC as Katie takes on leadership role. / Dan Chatelain RN
Katie Lammi RN
PCA Protocols / Dilaudid PCA protocol and morphine PCA protocol are not equal. Dilaudid protocol stops at .4 – morphine protocol is a full mg higher.
Physicians are the ones ordering; Dr. Oram-Smith says need to confront them.
Alison said standard Centura PCA protocol for go-live CPOE. Alison brought copies for Committee to review. Mike says very similar. Dr. Ross feels this looks like very appropriate option. Dr. Oram-Smith said surgeons are used to ordering standard protocol and this gives them several choices. Mike said proposal now is to split into three separate orders by drug.
Substitute this order set for our protocol.
How do we roll out? Education? / Alison said every hospital using CPOE is using this order set. Dr. Oram-Smith said this order set will be embedded in every post-op order set.
How best to convey this change? PACU sometimes has old order sets – start there. Train unit managers and unit secretaries. Send out information to all who use PCAs. Follow-up next month. Need to be in totally different places (personal order sets) – these are embedded in Meditech and will be the driver for us.
Dan do education? / Kathy Guy
Nucynta 50 mg – our order sets could potentially be putting patients at risk because it is written that could exceed 500 mg/day. XL has quicker half-life per Mike. / Mike and Alison both said our order set okay and within pharmacological standard of care.
New Business: / Opana – Dan said he feels less euphoria with Opana. If less euphoria, patients might be less likely to come back seeking. Alison will do more in-depth research. Dr. Ross is unsure if this will be helpful and worth spending a lot of time on this subject.
Plans to expand pain service to SFMC / Kathy and Dr. Ross have met and discussed how to move forward to FMC expansion.
SFMC pain service is currently the anesthesiologist on call. Dr. Ross feels that if we offer these services via Katie (nursing expertise), we’ll find the need has been there all along. / Meeting with Guy, Chatelain, Lammi, Kjosa, Hartman, SFMC anesthesiology and SFMC hospitalists next month.
Keep track of service and how it’s utilized at SFMC.
Dan had incident of patient’s wife calling Dan’s wife in the middle of night saying “wake Dan up.” Dr. Ross intervened and Dan was grateful. / Pager information will not be published or given to public. For professionals only.
Inadequate pumps causing patients to be in pain. Dan feels causing pain and putting patients in danger. He gave several incidents. Katie will attest to this. / Dr. Oram-Smith said this effort is being pushed.
Oral methylnatroxone for OIC/Amitiza for IBS-C. Dan said for everone’s information, they are starting to make in pill form. Feels this is a medication that could be used on the 11th floor more. Finally have 11th floor bowel protocol available per Alison. Should we add to pain protocol?
Amitiza is used for irritable bowel syndrome. Mike said Dr. House has ordered. Dan said only FDA approved for females.
Research: Narcan Rescue in Community Hospital / Nussdorfer, Ross, Schlang research data has been gathered / The multidisciplinary team will meet to analyze, identify implications and complete article for submission. Will provide report to this committee within the next quarter. / Deb Nussdorfer RN
Research: Chronic Pain Patient Management / Protocol submitted to IRB. Multidisciplinary research proposal across continuum of care to improve effective management of pain in hospitalized post op inpatients with chronic pain. / Anticipate review by IRB in October meeting and initiate research following approval. / Kathy Guy RN
Adjournment There being no further business to discuss, the meeting was adjourned at 7:48 am.
Scott Ross, DO Medical Director, PSF Pain Program