Confusion over pain med administration

Specialties Pain

Published

I am orientating to a new hospital and while orientating on the floor, pain management was brought up between my orientator and me. My patient had an order for Norco 1-2 tabs every 6 hours. At the bottom of the order it also said "give one and if pain not controlled after an hour, give another." My patient received one tab and approximately 5 hours later was having more pain. I brought up to the RN working with me that she can have another Norco because the order was 1-2 within 6 hrs. She had only received one. She told me I can't do that. If they only take one and don't take the second within an hour they can't have another tab for 6 hours. What? I argued with her and she said I'd have to call the doctor to get an order to give a second tab early. This just seemed bizarre to me. Seems like she would not be properly controlling the patients pain by this method.

"give one and if pain not controlled after an hour, give another."

It literally says when to reassess and to give another.

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Specializes in Critical Care.
"give one and if pain not controlled after an hour, give another."

It literally says when to reassess any to give another.

I think you're confusing an instruction to reassess in one hour and give the second tab if needed as an instruction that this is the only time the pain can be reassessed and the remainder of the range given. The instruction is simply clarifying something that is true of all range orders; you should reassess about an hour after the initial part of the range dose is given, there is no mention that the remaining portion of the range dose cannot be given at 1 hour and 15 minutes, 2 hours, etc.

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[...]

The legal standards for range orders as well as regulatory standards are well established, there is no standard prohibition for giving the remainder of a range order within the ordered timeframe.

Source?

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I think you're confusing an instruction to reassess in one hour and give the second tab if needed as an instruction that this is the only time the pain can be reassessed and the remainder of the range given. The instruction is simply clarifying something that is true of all range orders; you should reassess about an hour after the initial part of the range dose is given, there is no mention that the remaining portion of the range dose cannot be given at 1 hour and 15 minutes, 2 hours, etc.

I'm not "confusing" anything. I'm taking a clear instruction as it's stated. Two parts in a single sentence : 1. Reassess in one hour 2. Give second dose of painful. I literally had this discussion last year with JC last year when we got dinged on our ordersets.

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Specializes in Critical Care.
I'm not "confusing" anything. I'm taking a clear instruction as it's stated. Two parts in a single sentence : 1. Reassess in one hour 2. Give second dose of painful. I literally had this discussion last year with JC last year when we got dinged on our ordersets.

If it said "if second tab not required at 1 hour, may not give remainder of range dose until 6 hours after the first tab" then you'd have a point, but it doesn't say that.

I'm my facility's liaison with our regulatory auditor and I've had many conversations regarding range orders and it's never reflected what you're referring to and neither does their published guidance.

The Joint Commission's standard on Range orders is that there must be a common understanding of how the order will be interpreted, so the only way to know for sure is to clarify the order. To assume the physician meant the order to be interpreted as meaning a second tab couldn't be given at hour 3 if it wasn't needed at hour 1 is a big stretch since it makes no mention of this and this would make it an irrational order.

You'll certainly come across individual JC surveyor that don't have the understanding of the regulatory criteria that you would expect, which is why it's important for the facility to also have a good understanding of regulatory requirements.

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If it said "if second tab not required at 1 hour, may not give remainder of range dose until 6 hours after the first tab" then you'd have a point, but it doesn't say that.

I'm my facility's liaison with our regulatory auditor and I've had many conversations regarding range orders and it's never reflected what you're referring to and neither does their published guidance.

The Joint Commission's standard on Range orders is that there must be a common understanding of how the order will be interpreted, so the only way to know for sure is to clarify the order. To assume the physician meant the order to be interpreted as meaning a second tab couldn't be given at hour 3 if it wasn't needed at hour 1 is a big stretch since it makes no mention of this and this would make it an irrational order.

You'll certainly come across individual JC surveyor that don't have the understanding of the regulatory criteria that you would expect, which is why it's important for the facility to also have a good understanding of regulatory requirements.

Negative. It gives a clear instruction on when to reassess and when the second dose *should* be given. 1 hour after administration of the first. 1-2 q6...second dose 1 hour after. The ONLY written instruction is when to reassess and the parameters to give the second dose (1 hour after). If the order said something along the lines of "may give second dose whenever the hell you want for x pain score"...then certainly whenever. And it wasn't one surveyor. It was something their whole team sat down with us and had us develop a plan to fix it.

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Specializes in Critical Care.
Source?

The applicable JC version of CMS regulatory requirements relating to range orders is MM.04.01.01 "Medication orders are clear and accurate" which states that a facility must ensure that there is "consistent interpretation" of range orders but does not establish any one particular interpretation that must be used. Their extended guidance refers to the American Society for Pain Management Nursing and APS joint position statements on Range Orders, which can be found here:

http://www.aspmn.org/documents/RangeOrderPublished2014.pdf

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Specializes in Critical Care.
Negative. It gives a clear instruction on when to reassess and when the second dose *should* be given. 1 hour after administration of the first. 1-2 q6...second dose 1 hour after. The ONLY written instruction is when to reassess and the parameters to give the second dose (1 hour after). If the order said something along the lines of "may give second dose whenever the hell you want for x pain score"...then certainly whenever. And it wasn't one surveyor. It was something their whole team sat down with us and had us develop a plan to fix it.

Based on that logic, if the order hadn't said to reassess the patient's pain and give the remainder of the dose if needed, you would interpret the order to mean that you would given one tab, then not assess or re-medicate until 6 hours had passed?

What specifically did the JC surveyors have an issue with in your case?

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Based on that logic, if the order hadn't said to reassess the patient's pain and give the remainder of the dose if needed, you would interpret the order to mean that you would given one tab, then not assess or re-medicate until 6 hours had passed?

What specifically did the JC surveyors have an issue with in your case?

JC had no problem with range orders. They had a problem with interval of re-administration. They wanted specific parameters for second doses in any range orders. So MDs needed to provide PRN with an indication followed by when to give second or third doses within the overarching range. We got dinged on this because the JC took the same order and went to multiple nurses to gauge when/if the next nurse would give the next dose. They described the lack of parameters as "nurse prescribing".

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Based on that logic, if the order hadn't said to reassess the patient's pain and give the remainder of the dose if needed, you would interpret the order to mean that you would given one tab, then not assess or re-medicate until 6 hours had passed?

What specifically did the JC surveyors have an issue with in your case?

forgot to address the first part. Our hospital pain policy states to reassess pain no more than 1hr after any pain medication administration. I suspect most hospitals have some form of policy dictating frequency of assessment for various situations.

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Specializes in Critical Care.
JC had no problem with range orders. They had a problem with interval of re-administration. They wanted specific parameters for second doses in any range orders. So MDs needed to provide PRN with an indication followed by when to give second or third doses within the overarching range. We got dinged on this because the JC took the same order and went to multiple nurses to gauge when/if the next nurse would give the next dose. They described the lack of parameters as "nurse prescribing".

They found differing interpretations of range orders, which then requires that the facility establish a common understanding, the JC does not dictate what that understanding must be. You will certainly find surveyors or even entire teams of surveyors that might recommend what standardization to use even, even suggestions that are bad practice, this is one of the many reasons why DNV has surpassed the JC as a CMS surveyor.

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Specializes in Critical Care.
forgot to address the first part. Our hospital pain policy states to reassess pain no more than 1hr after any pain medication administration. I suspect most hospitals have some form of policy dictating frequency of assessment for various situations.

You have a policy says pain reassessments can only be done at 1 hour? A common time to reassess pain aside from when you would expect it to take effect is when you would expect it to no longer be effective, why would you limit nurses to reassessing only the initial effect?

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