Pain Pump

This package was designed to provide best practice information about the 4 most commonly utilized infusion pumps in the Waterloo Wellington LHIN.  These pumps include:

Basic Considerations

Preamble:
The purpose of this information package is to support healthcare providers in their understanding of the correct use and maintenance of various infusion devices. Our aim is to enhance provider’s capacity in the delivery of best practice hospice palliative care with the ultimate goal of improved patient safety.
This package is not intended to replace comprehensive education in pain and symptom assessment and management. Please refer to your individual organizational policies and procedures.
Please refer to our Useful Links section for additional resources including Best Practice Guidelines and Standards of Practice.

Client Teaching

Patient and Family Education

  • Understanding patient’s expectations and fears can positively influence the outcome of pain management, since patient and family attitudes have been shown to modify pain perception and analgesic requirements.
  • Patients should be informed that effective methods of pain relief are available. They should be aware of their analgesic options, and know that they have a right to effective and safe pain relief.
  • Methods should include verbal explanations and should be reinforced with written information, diagrams and demonstrations whenever possible.
  • The following are some common reasons why patients may under-report their pain:
    • Reluctance to report pain to nursing staff
    • Want to be perceived as a “good patient”
    • Underlying concerns about the meaning of the pain
    • Concerns about side effects I still hear this from seniors/everybody when I round
    • Fear of addiction & developing tolerance
    • Myths about the inevitability of pain
    • Culture and religious issues
    • Patients should be given verbal and written information that effective pain management and relief is an important part of their treatment and that their report of unrelieved pain is important to report to ensure prompt intervention by staff.
    • The patient’s self-report is the single most reliable indicator of pain and should be the primary source of assessment for cognitively intact patients. Staff should help patients select a pain intensity scale that is age, condition and language appropriate.
    • Staff will also ask patients to set a comfort (pain relief) goal, by discussing with the patient what an acceptable or satisfactory pain rating would be to him or her, considering the activities required for recovery or for maintaining a satisfactory quality of life.
    • Patients who do not speak English should be given information about pain management in their chosen language through an interpreter.
    • Important to ensure the patient and family understand the PCA pump’s function and let them be aware the nursing staff will closely monitor them.
    • Inform patient and family that only the patient or nurse should push the button to activate the pump.
    • Explain how the pain medication works and possible side effects, as well as other treatments available.
    • Tell the patient to report unrelieved pain or side effects to their nurse.

    Documentation

    Download a sample documentation form below.

    Sample documentation PDF Form
    Sample documentation Word Document

    Glossary of Terms

    AACA – Authorized Agent Controlled Analgesia – a method of pain control in which a consistently available and competent individual is authorized by a prescriber and properly educated to activate the dosing button of an analgesic infusion pump when a patient is unable, in response to that patient’s pain.

    APS: Acute Pain Service

    Base/ Basal rate: Amount of continuous infusion in mcg or mg per hour

    Bolus/demand dose: a dose of a substance given by injection for the purpose of rapidly achieving the needed therapeutic concentration in the bloodstream

    BTD: Breakthrough Dose

    CADD: Computerized Ambulatory Drug Delivery system. A type of infusion pump.

    Cannula: A hollow tube made of silastic, rubber, plastic, metal or other substance used for accessing the body

    CVAD: Central Vascular Access Device: Catheter inserted into a centrally located vein with the tip residing in the vena cava; permits intermittent or continuous infusion and/or access into the venous system.

    Caregiver Controlled Analgesia (CCA) – the authorized agent is a nonprofessional individual (i.e. parent, significant other)

    Epidural Analgesia: Analgesia by intermittent or continuous injection of drugs into the epidural space.

    Hypodermoclysis: The subcutaneous infusion of fluids

    Implanted Port: A catheter surgically placed into a vessel or body cavity and attached to a reservoir located under the skin.

    Intrathecal Analgesia: Analgesia delivered into the subarachnoid space.

    Lockout Interval: amount of time that must elapse between PCA bolus/demand dose administration

    mcg: Microgram (µg or mcg) is a unit of mass equal to one millionth (1/1,000,000) of a gram (1 × 10−6), or 1/1000 of a milligram.

    mg: Milligram is a unit of mass equal to one thousandth (10-3) of a gram

    MRP: Most Responsible Physician

    Nurse Controlled Analgesia (NCA) – the authorized agent is the nurse responsible for the patient

    PCA: Patient Controlled Analgesia. Patient self administered opioid intravenous or subcutaneous infusion via a specialized pump.

    PCA by Proxy – Activation of the analgesic infusion pump by anyone other than the patient.

    PCEA: Patient Controlled Epidural Analgesia: Patient self administered opioid epidural infusion via a specialized pump.

    PICC: Peripherally Inserted Central Catheter. A soft, flexible central venous catheter inserted into a peripheral vein and advanced until the tip is positioned in the vena cava

    Purge: to cause evacuation from

    Titration: Adjusting the amount (i.e. adjusting the dose of opioid)

    Medical Dictionary online resource. Retrieved July 2012 from: http://www.nlm.nih.gov/medlineplus/mplusdictionary.html

    ISMP Information

    Institute for Safe Medical Practices (ISMP)

    Consider the following to reduce medication errors with infusion pump devices:

    1. Is the patient appropriate for medication delivery via an infusion pump?
      1. Infants, young children and cognitively impaired elderly are at an increased risk for improper use of an infusion pump since they are unable to self-administer medication when indicated and rely on a proxy (caregiver) to administer medication.
      2. Obese patients, those who suffer from asthma and/or sleep apnea are at an increased risk of oversedation.
    2. Has the correct medication and correct dose been prescribed?
      1. Ensure the conversion from oral to parenteral is accurate.
      2. Ensure the medication selected is the most appropriate for the patient. i.e. Morphine for a patient with a high creatinine may result in a build up of metabolites and an increased risk of undesirable side effects.
      3. Ensure medication checks have been performed accurately to prevent transcription errors.
      4. Allergies should be checked to ensure there is no contraindication to the medication selected.
      5. Independent checks have been performed to ensure the pump has been programmed correctly. If working in isolation, contact your manager for instruction on how to double check a pump programming.
      6. Pay special attention to decimal places and ensure the decimal is in the correct place and the programming is correct
      7. If you are having difficulty reading an order, or something about the order doesn’t make sense, CALL FOR CLARIFICATION!!

    ISMP suggestions to reduce infusion pump medication errors

    1. Limit medication choices
    2. Improve access to information i.e. quick guides and medication warnings
    3. Improve label readability
    4. Highlight the drug concentration on labels
    5. Program default settings into pump configuration
    6. Introduce new pumps slowly
    7. Consider the possibility error if the patient is not responding to the bolus dose
    8. Employ double checks
    9. Assess proximity of the PCA infusion pump to a general infusion pump (i.e. IV line) to reduce mix up
    10. Educate patients and caregivers about proper infusion pump use

    To view the full ISMP document click the link below:

    ISMP PCA downloaded from:
    http://www.ismp.org/profdevelopment/PCADrugLibrariesforwebce.pdf

    Patient Controlled Analgesia: Making It Safer For Patients. A Continuing Education Program for Pharmacists and Nurses downloaded from:http://www.ismp.org/profdevelopment/PCAMonograph.pdf

    Pearls

      • A patient should not receive a subcutaneous dose of more than 3ml at a time. Ensure the concentration of the medication will not require a bolus dose of more than 3ml at a time.
      • A patient receiving an infusion via IV must have enough medication infusing to provide a rate of at least 10ml per hour to ensure the vein is kept open. Ensure the concentration for an IV route is appropriate for IV infusion.
      • The subcutaneous site must be checked at least daily (or per visit for community nurses) to ensure the site is still good and the cannula has not bent. If a patient has an unexplained increase in pain, check the site to make sure the medication is absorbing properly and there is not a problem with the site.

    • If the resources provided have not helped resolve a problem, contact the pump agency representative for assistance.
    • Whenever possible, program the pump away from the bedside where you can concentrate easier with less pressure and less distraction. The pump can be disconnected from the patient and reconnected to allow more privacy for working through an issue or a change in programming

    ISMP Dangerous Abbreviations List: downloaded from http://www.ismp-canada.org/download/ISMPCanadaListOfDangerousAbbreviations.pdf

    Useful Links

    Source: RNAO Best Practice Guideline: Assessment and Device Selection for Vascular Access. Retrieved from: http://pda.rnao.ca/content/educational-resources-0

    College of Nurses of Ontario Practice Standard: Medication, Revised 2008. Retrieved from: http://www.cno.org/Global/docs/prac/41007_Medication.pdf

    CADD Legacy 6300
    http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2004-04.pdf– pump safety precautions
    http://www.smiths-medical.com/Upload/products/PDF/CADD_Legacy_Pumps/IN19882.pdf– quick guide
    http://www.smiths-medical.com/Upload/products/product_relateddocs/infusion/CADD-Legacy-PCA-6300/40-5483-51B%20online.pdf– Operator’s Manual
    http://www.smiths-medical.com/Upload/products/PDF/CADD_Legacy_Pumps/IN19883.pdf-quick reference guide for clinicians
    http://www.smiths-medical.com/Upload/products/product_relateddocs/infusion/CADD-Legacy-PCA-6300/40-5493-51A.pdf– patient information guide
    http://www.smiths-medical.com/Upload/products/PDF/CADD_Legacy_Pumps/IN19884.pdf– training guide
    Link to CADD Legacy pump options: http://www.smiths-medical.com/catalog/ambulatory-pumps-sets/cadd-ambulatory-infusion-pumps/cadd-legacy/

    Link to Hospira GemSTAR pump information: http://www.hospira.com/products/gemstarinfusionsystem.aspx

    Link to CADD Solis support site: http://www.smiths-medical.com/landing-pages/promotions/md/caddsolis.html

    Link to CADD Prizm information guides: http://www.smiths-medical.com/education-resources/downloads/pain-management/cadd-prizm-vip-system.html