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Intravenous Patient Controlled Analgesia (PCA) for Adult and Pediatric Patients (6.1.2)

Intravenous Patient Controlled Analgesia (PCA) for Adult and Pediatric Patients (6.1.2) - Policies, Clinical, UW Health Clinical, Medications and Pharmacy


Policy Title: Intravenous Patient Controlled Analgesia (PCA) for Adult and Pediatric
Policy Number: 6.1.2
Category: UW Health
Type: Inpatient
Effective Date: November 21, 2017


To provide for the safe self-administration of intravenous (IV) controlled substances by patients within the
limits prescribed by a provider.


A. Patient Controlled Analgesia (PCA): Patient is provided a method to request and receive a pre-determined
dose of controlled substance through delivery by a pump by pushing a button. Typically this is intravenous
medication delivered through an intravenous line.
B. PCA-by-proxy: is defined as family members, or caregivers, who are normally not authorized to administer
controlled substance, to do so by using the PCA button for the patient who is unable to perform this
task. This is separate and distinct from nurse-assisted PCA where the RN assigned to care for a patient
assists the patient with delivery of PCA doses during nursing care.


A. IV access is available and patient's condition requires parenteral analgesia.
B. Patient must be mentally alert and able to understand and comply with instructions and procedures.
C. If patient’s condition warrants PCA and an appropriate caregiver is available, the team may decide to
institute PCA by proxy, as defined above.


A. Equipment
i. Alaris
Point of Care Unit
ii. Alaris
PCA module
iii. PCA microbore tubing (CS Item: 2200556) and anti-reflux Y-set extension (CS Item: 2200557)
iv. Syringe filled with prescribed medication

B. Documentation and Patient Monitoring
i. IV PCA is a High Alert Medication. Refer to UWHC Policy #8.33, High Alert Medication
Administration. A double-check of the medication and IV pump programming and line connections
by a second licensed person is required as described in this policy.
a. Due to the high risk of nature of these medications to the pediatric population, RNs
caring for pediatric patients will get an independent double check for all PCA pump
changes including RN boluses.
ii. Patient education is critical to the success of IV PCA therapy. Health Facts For You (HFFY) #4273
is available for this purpose. If the patient is not getting sufficient pain relief or if the patient does
not understand the use of the pump, re-education may be needed or adjustment of prescription
may be necessary.
iii. Document all patient teaching and level of comprehension in the clinical record. Refer to UWHC
Guidelines for Continuous Opioid Intravenous Infusions for Adult and Pediatric Inpatients for
information about dosing and side effects.
iv. If the patient reports persistent unrelieved pain when using PCA, the RN will check to ensure that
the vascular access device is patent and the PCA pump is functioning before any actions are
taken. Refer to Nursing Patient Care Policy #1.23AP, Continuous Peripheral Intravenous Therapy,
for information on site care and tubing changes.
v. RN will assess and document the following parameters:
a. Patient's respiratory rate, depth and regularity for one full minute, every 2 hours for the
duration of therapy.
1. The exception to this rule is patients intubated with a set respiratory rate on the

Policy Title: Intravenous Patient Controlled Analgesia (PCA) for Adult and Pediatric Patients
Policy Number: 6.1.2

b. Sedation level every 2 hours for the duration of therapy.
c. Pain score and vital signs should be documented every 4 hours for the duration of
therapy, or more frequently if ordered by the team. Awaken patient only if unable to
distinguish between normal sleep and sedation.
vi. Pumps should be cleared every 8 hours, typically at the end of shift or when a patient is transferring
to another unit (see point a below) and the total amount of drug infused (in mg or mcg) since last
cleared should be documented in the clinical record. This is the minimal, required documentation.
Individual units may require additional documentation. Refer to related reference, Alaris Directions
for use manual (Pages 3-25 and 3-26) or the Alaris PCA Module Pocket Guide.
a. When the patient is transferring to another unit, the pump should be cleared, amount of
drug infused documented (e.g., transfer from ICU to acute care unit or from PACU to
inpatient unit).
b. When patients are transferring to another location for limited period of time, the pump
does not need to be cleared. Examples include patients transferring to radiology for a
procedure and returning to the same unit.
vii. Drug Wastage
a. All controlled substance wastage must be completed and documented as indicated in UW
Health Clinical Policy #6.1.13, Controlled Substance Control Systems in Patient Care
b. At the completion of therapy, all remaining controlled substance should be discarded and
documented as indicated above. Controlled substances remaining should not be left in
pump for return to Central Services.
viii. Discontinuation of therapy
a. PCA pump modules will be turned completely off only when therapy is discontinued and
will be removed from the Alaris programming unit.
b. Return PCA pump modules to the soiled utility room as soon as possible after PCA
therapy is discontinued.
ix. Suspected Pump Malfunction
a. In the event of a suspected PCA pump malfunction or an adverse patient event possibly
related to PCA therapy, the pump should be removed from the patient (it may be replaced
with a new pump if therapy is to be continued), with history retained, labeled and sent
immediately to Biomedical Engineering for performance evaluation. A Patient Safety Net
(PSN) report should be completed. Refer to Nursing Patient Care Policy #8.39, Repair or
Replacement of Essential Equipment in Case of Breakdown and UWHC Administrative
Policy #12.40, Reporting of Device-Related Adverse Events and other Product Problems.
C. PCA by proxy: Family members, friends, or visitors (or anyone other than the patient) should never press the
button for the patient unless the team has given them special instructions and the reason for PCA-by-proxy
is documented. The primary team ordering the PCA (physicians ordering the medication and RNs caring for
the patient) must determine if PCA by proxy is an appropriate method of medication delivery for each patient
situation. PCA by proxy requires a discussion with the team, identification of an appropriate proxy, an order
from the physician and education by the RN documented in the EMR. PCA by proxy is defined in Section II.
i. In certain circumstances it may be deemed appropriate to allow PCA-by-proxy. The criterion for
this decision is:
a. A patient who can report pain (or pain behaviors are unmistakable) but is physically or
mentally unable to administer IV PCA by themselves.
b. An appropriate proxy can be identified and agreed upon by the team members. The
reason for use of PCA by proxy should be documented in the patient’s clinical record.
c. The selected proxy must be able to:
1. Articulate an understanding of the relationship between dosing and risk of
oversedation and respiratory depression.
2. Understand the purpose and goals of the patient's pain management plan.
3. Recognize signs of pain and side effects and adverse reactions to the controlled
substance and to immediately contact a staff member if they notice any change
in patient condition such as change in respiratory rate or sedation level.
4. Spend a significant amount of time with the patient.
d. If the proxy needs to leave, or is determined to be unreliable, the team should stop the
practice and provide pain control through other appropriate measures.

Policy Title: Intravenous Patient Controlled Analgesia (PCA) for Adult and Pediatric Patients
Policy Number: 6.1.2

ii. If PCA-by-proxy is determined to be appropriate for an individual patient, an order is needed.
Additionally, specific instruction must be provided to the proxy by the RN caring for the patient and
documented in the EMR. Minimally, the education should include elements included in A, B and C
above. Health Facts For You #7697 PCA by Proxy, is available for teaching these key principles.
D. To avoid medication errors, pumps designated for IV PCA will not be used to administer epidural analgesia.
E. Leaving the floor: Per UW Health Clinical Policy # 2.3.27, Inpatient Absence Policy, “If the patient is
receiving an infusion of a controlled substance, such as through patient controlled analgesia (PCA) or
patient controlled epidural analgesia (PCEA), the patient must notify staff that they are leaving the unit so
the infusion can be stopped and disconnected. The (attending) physician will be notified.”
F. Use of the one-hour limit programming feature on the Alaris
PCA module is optional. If the provider orders
it, that number should be programmed into the PCA pump settings. If the field for one hour limit is left blank,
that step in the pump programming may be skipped. Refer to “Alaris Directions for Use Manual” posted on


IP – Intravenous Patient Controlled Analgesia (PCA) – Adult – Supplemental
IP – Intravenous Patient Controlled Analgesia (PCA) – Pediatric – Supplemental
Pain infusion flow sheet
PCA by proxy education documentation (Optional)


Author: Pain Clinical Nurse Specialist
Senior Management Sponsor: SVP, Patient Care Services and CNO
Reviewers: Pain Clinical Nurse Specialists; Infusion Clinical Nurse Specialist; Center for Drug Policy
Pharmacist; Medical Director, Pediatric Pain Service
Approval Committees: Pediatric Practice Council; Nursing Practice Council; Pharmacy and Therapeutics
Committee; UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: October 16, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


Center for Clinical Standards and Quality/Survey and Certification Group. March 14, 2014 Requirements for
hospital medication administration, particularly intravenous (IV) medications and post-operative care of
patients receiving IV opioids.
Cooney, MF; Czarnecki M; Funwoody, C; Eksterowicz, N; Merkel, S; Oakes, L; Wuhrman, E; 2013 American
Society for Pain Management Nursing position statement with clinical practice guidelines: Authorized agent
controlled analgesia. Pain Management Nursing 14(3); 176-181.
Cohen, MR; Weber, RJ; Joss, J
The Joint Commission Sentinel Event Alert, Issue 33; December 20, 2004: Patient controlled analgesia by
Institute for Safe Medication Practices (ISMP). Independent double checks: undervalued and misused:
selective use of this strategy can play an important role in medication safety. ISMP Medication Safety Alert!

Policy Title: Intravenous Patient Controlled Analgesia (PCA) for Adult and Pediatric Patients
Policy Number: 6.1.2

2013. Retrieved from: https://www.ismp.org/newsletters/acutecare/default.aspx
Alaris PCA Module Pocket Guide
HFFY 7697 Patient Controlled Analgesia (PCA) by Proxy
HFFY 4273 Intravenous Patient Controlled Analgesia (IV PCA)
UWHC policy #8.33, High Alert Medication Administration
UW Health Clinical Policy #6.1.13, Controlled Substance Control Systems in Patient Care Areas
UWHC Policy #12.40, Reporting of Device-Related Adverse Events and other Product Problems
Nursing Patient Care policy #1.23AP, Continuous Peripheral Intravenous Therapy (Adult and Pediatric)
Nursing Patient Care policy #8.39AP, Repair or Replacement of Essential Equipment in Case of Breakdown
(Adult and Pediatric)
UW Health clinical policy #2.3.27, Inpatient Absence Policy

Version: Revision
Last Full Review: March 21, 2016
Next Revision Due: March 2019
Formerly Known as: Nursing Patient Care policy #1.17