Standardizing Opioid Administration for an Acute Rehabilitation Unit

From the 2023 HVPA National Conference

Hyun Kim, Bachelors of Science (University of Colorado Anschutz Medical Campus) Jamie Baker MD

Background:
Pain control is not one size fits all. It is thus common practice for providers to utilize an order set with multiple pain medications of various dosages allowing nurses to find the best option for each patient. Medication management however is a high-risk and error prone process where nurses play an important role. In 2021, the Colorado Hospital Association suggested that over 70,000 patients who visited hospitals were at risk of opioid overdose.<sup>1 </sup> With the increase in overdose risk for patients, it is essential that healthcare professionals intervene by limiting potentially harmful medical practices. Although suggestions are available for nurses, they further highlight the overwhelming responsibility nurses bear to safely manage as needed (PRN) medication administration.<sup>2</sup> At our academic affiliated, community-based acute rehabilitation unit we noted that our pain management order set had multiple various narcotic options for PRN administration causing nursing practice variability in administration and increased risk for iatrogenic overdose.

Objective:
We implemented a new standardized protocol and educational series for nursing as needed (PRN) administration of pain medications on our acute rehabilitation floor.

Methods:
We developed and implemented a standardized pain treatment administration card which included a standardized pain scale with a suggested administration strategy based on pain level reported by the patients. Education was provided to nurses during daily huddles, emphasizing the pain control strategies such as starting with the lowest dose possible with every pain medication. We also included reminders of using alternative pain control modalities such as muscle relaxants, cold packs and heating pads. Nurses were asked to keep the pocket-sized cards with them during every shift. For the next month, pain scores and medication administered were recorded by the nurses on 29 random patients. A random selection of patient chart reviews was performed prior to the initiation of the cards with similar data collection.

Results:
The averages of reported pain scores among patients were equivocal before and after the intervention at 6.13 and 6.03. There was a decrease in the dose of opioids administered from 337 mg morphine equivalents to 164.8 mg after implementation. We also found an increase in nursing implementation of the non-narcotic options. In follow-up verbal focus group sessions, the unit nurses reported satisfaction with the tool, increased awareness of non-narcotic pain control options and increased confidence in the safety of administrating PRN narcotic medications.

Conclusion:
By developing and distributing our standardized pain medication administration card, we decreased the number of opioids administered on our acute rehabilitation unit. Nurses also increased their implementation of non-narcotic methods. Nurses felt empowered by participating as stakeholders in this project and remain invested in future studies investing other outcomes of this protocol including assess for decreased sedation, increased patient participation in therapy, decreased constipation and decreased length of stay.

Clinical Implications:
Providing nurses with a standardized protocol for administrating as needed (PRN) medications was well received. Nurses reported increased confidence with using our tool for medication administration and administered less narcotics while maintaining comparable pain control. This is an example of how clinical care pathways and protocols improve quality and reduce practice variability. Medication error in acute care settings is a top threat to patient safety and more work such as this is needed in effort to reduce variability in as needed (PRN) medication administration particularly those with high-risk side effects.

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