Wednesday, December 03, 2008

Research Abstract with Commentary

Authors’ Abstract

The use of "as needed" or "pro re nata" (PRN) range opioid analgesic orders is a common clinical practice in the management of acute pain, designed to provide flexibility in dosing to meet an individual's unique needs. Range orders enable necessary adjustments in doses based on individual response to treatment. However, PRN range opioid orders have recently come under scrutiny as a source of confusion and as a medication management safety issue. How nurses administer range orders may vary based on their interpretation of the intent of an order, inadequate knowledge of analgesic titration, or exaggerated concerns about opioid safety.

The purpose of this study was to investigate nurses' opinions of the appropriate implementation of range orders. Six hundred two nurses from one large academic medical center and one multihospital system completed an online survey using theoretic clinical vignettes to examine their opinions of appropriate analgesic administration practices.

The majority of participants chose appropriate responses to the vignettes; however, there was a great deal of variability in responses. Those who had attended pain management courses were more likely to have a higher percentage of appropriate responses than those who had not attended courses. Years in practice and educational level were not significantly related to percentage of appropriate responses; however, there was a trend for nurses with a master's degree to have a higher percentage than nurses with other educational preparation. Consideration of opioid pharmacokinetics can provide logic to develop a new paradigm where range orders are replaced with orders that provide more explicit instructions to titrate an opioid to the most effective dose.

Gordon, D. B., Pellino, T. A., Higgins, G. A., Pasero, C., & Murphy-Ende, K. (2008). Nurses' opinions on appropriate administration of PRN range opioid analgesic orders for acute pain. Pain Management Nursing, 9, 131-140.

Commentary by Dana N. Rutledge, RN, PhD, Nursing Research Facilitator, & Mary Welly, RN, BSN, Clinical Educator

This fascinating article documents the difficulty that nurses face in administering PRN opioid pain medications ordered using dose ranges. In the literature review, authors delineate a brief history of safety initiatives that have led to the need to understand dose range administration issues. Changes in The Joint Commission expectations in the past decade have changed ordering habits of physicians, but have not necessarily clarified best practice for nurses.

The clinical problem addressed stems from nurse confusion with PRN range orders in terms of (a) which dose to administer within the range and (b) the total time interval during which the maximum dose can be administered. The study aim was to document nurse opinions of correct practice given 4 specific patient scenarios developed by the authors. The authors note that the “correct” answers (that they determined) are not absolute. In fact, due to disagreement among the researchers, they did not score responses to one of the scenarios. Correctness was based upon drug pharmacokinetics, patient assessment parameters, side and adverse effects and their interpretation, and administration issues.

Nurses surveyed came from several hospitals in the mid-Atlantic and Midwestern US. Response rates were 36% of nurses emailed a participation invitation, 11% of nurses who saw a posted invitation. These rates are typical of nurse response rates to similar surveys. When interpreting results, however, one must think about the nurses who chose NOT to respond, and how the non-respondents may be different from respondents. Survey respondents were similar to St. Joseph nurses by education (67% BS or higher; 57% of SJH nurses have a BS or higher based upon 2007 NDNQI data). Respondents were experienced (47% had been in nursing 16 years or greater, and primarily worked medical/surgical or intensive care (69%).

The discussion of results delineates options selected by nurses according to the authors’ determination of “correctness.” A key concept was titration, which is determination of “effective dose by giving graduated increases or decreases in the amount of the drug” (p. 138). Titration of oral drugs is similar to that of intravenous drug titration that may be more familiar to nurses. The authors note that accurate and safe titration may require a more lengthy order set or use of pre-established protocols than is normally used in hospitals.

Implications from the results indicate that a substantial portion of nurses (1/3 to ½) would under medicate or delay medicating patients in pain using PRN range dosing even where a patient exhibited no side effects. Another issue pointed out was that 43% of nurses did not cite sedation as one of three factors to consider when selecting opioid dose, perhaps indicating lack of appreciation of the importance of sedation assessment.

Of interest was the finding that 21% of nurses would give a dose less than what was ordered without calling a physician first. This finding was documented in numerous earlier studies as well, particularly with opioids. It certainly merits discussion among nurses in terms of what this means for nurse/physician communication and for pain management. Authors conclude that “flexibility in dosing made possible by a range order does not include adjusting the dose limits of the order” (p.139).

Do nurses at St. Joseph have a policy or protocol in place to direct practice for PRN opioid range dosing? If so, how many are aware of it? How many practice using it? Are there practice situations that are unclear as to “best” practice? We would urge further discussion by nurses at St. Joseph on your units as to these issues.

NOTE: Policy RX-475 Medication Ordering Procedures (approved 01/08) notes that “medication orders should NOT be written with dosage ranges” unless the order titrates to specific outcomes or doses matched to specific clinical parameters are allowed (such as the scenarios in the Gordon et al. study). Interpretation of dose and frequency ranges in this policy are in section II.C. 2. a. and 3.

A consensus statement about PRN medications is available from the American Society for Pain Management Nursing and the American Pain Society at Gordon et al. (2004). The use of “as-needed” range orders for opioid analgesics in the management of acute pain. Pain Management Nursing, 5, 53-58.