Range Orders

[HamsterRN, ADN, RN]

Now that we're a few years out from the Joint Commission's suggestions on Narcotic range orders, I'm curious what the response has been; How many facilities have done away with range orders all together? How many still use range orders but have significantly altered the policies regarding their use?

Where changes were made, was there any noticeable change in rates of oversedation or other adverse events? Was there any noticeable beneficial or negative effect on pain control?

[BluegrassRN]

Our facility actively fought to keep range orders. We now no longer have range orders such as "give 1 to 10 mg morphine IV q4 hrs prn" but we still have range orders such as "1-2 lortab 5, q4 hrs prn". The huge ranges, which were inappropriate in my opinion anyway, are no longer allowed, but the smaller ranges are.

Our facility's stance was that it is entirely appropriate to have nurses use their judgment to determine whether a patient needs one or two lortab. We did not get dinged on it, we defended ourselves well to them apparently.

[DeeAngel]

My facility no longer allows range orders of any kind and has not allowed it for several years now. What you end up with is several more orders for pain medications of varying doses instead of just one range order.

To me it seems like the end result is exactly the same.

[classicdame, MSN, EdD]

we have a policy stating how range orders are to be interpreted but are seriously looking at eliminating the whole idea.

[HamsterRN, ADN, RN]

Our facility actively fought to keep range orders. We now no longer have range orders such as "give 1 to 10 mg morphine IV q4 hrs prn" but we still have range orders such as "1-2 lortab 5, q4 hrs prn". The huge ranges, which were inappropriate in my opinion anyway, are no longer allowed, but the smaller ranges are.

Our facility's stance was that it is entirely appropriate to have nurses use their judgment to determine whether a patient needs one or two lortab. We did not get dinged on it, we defended ourselves well to them apparently.

While 1-10mg is an unusually huge range, sometimes a patient's minimum and maximum pain control needs do not equal a 1:2 ratio; sometimes their pain might be controlled with 1 mg and sometimes it might take 3mg, which is why my facility didn't go along with that particular (or any other) JC range order suggestion. If they do actually require 10mg at times why does it make sense then to require that at least 5mg be given whenever Morphine pain control is needed?

I am curious about how the range order ratio limit works in practice. If a patient's pain can be controlled by 1mg at times then is the upper limit set at 2mg? Or do you go by the maximum pain control dose requirement which may be 4mg, and require that at least 2mg be given even though only 1 might be sufficient. Either way it doesn't make much sense to me since it guarantees either under-treating or over-treating, but maybe I'm missing something?