New Joint Commission Regulations for PACU Medications

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Specializes in OR, PACU, Dialysis.

My hospital recently hired a JCAHO consultant to "walk" through the hospital and advise the department managers of "potential" problems with the units and how to "beef up" the areas for the next Joint Commission inspection. One of the "requirements" for PACU is for Anesthesia to list the order in which pain medications are to be given (if there is more than 1 option). The consultant stated Joint Commission is watching for this now. So our anesthesia providers have to mark next to the medications what order the meds are to be given and the nurses MAY NOT deviate from the list. The nurse MUST give ALL of med #1 prior to advancing to med#2 and so on. It makes no since to me. Where is the critical care aspect of nursing? Especially in the PACU. Has anyone else come across this issue? Until now, I've never heard of such a thing. Is it a true Joint Commission reg?

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Hi nmred,

Yes. We had the same recommendation. Here's what our "anes md's" did: We have a pre-printed order form that lists meds with doses based on patients pain levels. We start with the number one analgesic/narcotic, say, Fentanyl up to 200mcg, based on patient's response, then add MS or Dilaudid (if checked off on the pre-printed sheet) if the situation warrants. I see this are a better communication of managing patient pain, based on clearly written guidelines. This saves a lot of unneccessary phone calls for add'l pain med orders. Also, both the RN and MD collobarate to customize the dosing based on indivdual patient factors. Hope this helps. We've used this system now for the past 6 months, and found the we can give narcs, quicker, and pt's pain scores drop quicker, and d/c from the PACU is faster. One caveat. Be careful with OSA patients...they have to stay in our PACU for 3 hours after the last dose of narcotic to monitor for apneic episodes. (we had a sentinel event on the med-surg unit after a OSA patient was d/c'd from PACU after 30 minutes post narcotic. So now, even though we have this pre-printed narcotic pain orders, nursing/medical judgement always rules. JACHO is satisfied, because it is now documented, very clearly, what our approach to pain management is. Isn't that what JACHO is always looking for? A documented approach to trace patient care. Sorry for the long answer, but this was a hot issue in our PACU (large city hospital).

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Specializes in PACU, ED.

Our orders are very similar to yours except we don't have to give the max dose of one med before moving on to another. I can't tell you how many times I've started with one med which showed no response, then switched to another and got pain relief for the patient. It's not in the patient's best interest to force me to give them the maximum of a narcotic which is not relieving pain before I switch to another. Most of my anesthesiologists will write for 2 or 3 narcotics and leave the decision about which to use to my assessment of how the patient is responding.

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Specializes in PACU, OR.
Hi nmred,

Yes. We had the same recommendation. Here's what our "anes md's" did: We have a pre-printed order form that lists meds with doses based on patients pain levels. We start with the number one analgesic/narcotic, say, Fentanyl up to 200mcg, based on patient's response, then add MS or Dilaudid (if checked off on the pre-printed sheet) if the situation warrants. I see this are a better communication of managing patient pain, based on clearly written guidelines. This saves a lot of unneccessary phone calls for add'l pain med orders. Also, both the RN and MD collobarate to customize the dosing based on indivdual patient factors. Hope this helps. We've used this system now for the past 6 months, and found the we can give narcs, quicker, and pt's pain scores drop quicker, and d/c from the PACU is faster. One caveat. Be careful with OSA patients...they have to stay in our PACU for 3 hours after the last dose of narcotic to monitor for apneic episodes. (we had a sentinel event on the med-surg unit after a OSA patient was d/c'd from PACU after 30 minutes post narcotic. So now, even though we have this pre-printed narcotic pain orders, nursing/medical judgement always rules. JACHO is satisfied, because it is now documented, very clearly, what our approach to pain management is. Isn't that what JACHO is always looking for? A documented approach to trace patient care. Sorry for the long answer, but this was a hot issue in our PACU (large city hospital).

Hi Nannymcphee, I see this is a fairly old post but I'm hoping you can clarify. OSA-are you referring to obstructive sleep apnea?

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Hello, I was wanting to clarify...is the 3 hour minimum PACU stay for OSA patients receiving Narcotics in the PACU in the Joint Commission standards somewhere? I was doing a search and cannot find it. If you have a link I would love to have it. Thanks for your help...:nurse:

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Oh yes. Joint commision has come and has stated that we are not allowed to "mix" medications such as antibiotics that my need a vented hood (Ancef). The new stuff coming is that I'm not allowed to calculate medications, therefore, for my pediatric pts the anesthesiologist has to have signed, calculated, awakend the pt before he gets to me. Now the anesthesiologist can not sign the medication orders until the surgery is complete. Which most are aware will take the doc a few minutes to get to the bedside, in between seeing the pt's pre-op, at the beginning of the case, during the case, and awakening, coming by the bed, and signing pt's out to ICU/floor/home, among seeing them in PACU. I'm a real professional, I can't give any med until it's been caculated by the doc.

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Our unit has been getting prepared for Joint Commission the entire month of May the new rules are: 1)Give pain meds in order as marked #1, #2, etc. 2)Anesthesia Dr. can't sign the orders until pt is in the PACU-which means we are calling him to the bedside, our unit can't afford a secretary. 3)Pediatric pts now have 10 order sets to choose from based on their weight. So, leave the bedside, pull the orders, and call the Dr. ,but you must find a free nurse to watch your pt then have her verify your pt's name and weight and she must sign the paper to make it legal. 4) 5/27/11-All medication orders must be verified by a pharmacist; RN has to leave bedside once again to retrieve order sheet, call Dr. for pain med that he has calculated. The RN must leave bedside a third time to fax the orders to the pharmacist to verify the medicine will not harm the patient- RN has allergy info as bedside. All this is in order to keep with Joint Commissions goal of quality of care and safe care.

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Specializes in PACU, ED.

Our doctors enter the orders electronically into the chart which saves a lot of time for us.

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Specializes in neuro med, telemetry, icu, pacu.

perhaps your institution can check into associating certain drugs with level of pain the patient is reporting.. as in pain at levels 5- 10 can receive BOTH fentanyl and dilaudid at prescribed time intervals.....

how we solved the same dilemma...

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Specializes in critical care, pain management, pacu.

I know I'm not the only one out there reading these posts and getting so mad my head's spinning!!!:mad::mad::mad: Doesn't JCAHO or anyone like that read stuff like this and think about all this time we are LEAVING our patient's bedsides to go get doctors, get orders, fax orders, write orders, punch numbers in computers to get meds out, make phone calls to get meds that got lost or messed up, etc!!! Who's taking care of our patients??? This is not what I became a nurse for. I want to be a nurse, quality is very, very important to me, but these answers are hurting our patients. Do these agencies really think we are not going to do what is best for our patients???:confused::confused::confused:

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Specializes in PACU, ED.

I had a pt. in respiratory distress this week. I had the racemic epi and dex at the bedside waiting for a return call from my doc. When I got the verbal order those meds went into the patient before I entered the order in the computer. We still ended up giving some support with a BVM. To me, the patient comes first and waiting for docs to enter the order and pharmacy to check it before giving the meds is not always in the best interest of the patient.

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