(450) Identification of inappropriate patient-controlled analgesia (PCA) prescribing patterns to improve patient safety

Abstract

Recent reports suggest the occurrence of PCA-related adverse events may be increasing, possibly due to inappropriately high bolus doses and use of basal rates in opioid-naïve patients. In 2011, the FDA decreased the recommended initial intravenous hydromorphone dose, but prescribers may be unaware of this change. In 2013, equianalgesic opioid conversion information was added to the institution’s PCA order form. This study aims to (1) determine if the frequency of inappropriate morphine and hydromorphone PCA orders has changed since 2012 and (2) identify factors associated with prescribing of inappropriate PCA orders. An institutional review board-approved retrospective, single-center review of morphine and hydromorphone PCA orders in post-operative, opioid-naïve adult inpatients identified through pharmacy records from 1/2012-2/2012 and 7/2013-1/2014 was conducted. Patient demographics, surgery types, prescribers, and initial PCA order components were recorded. 332 PCA orders met the inclusion criteria, 111 (56 morphine, 55 hydromorphone) in 2012 and 221 (64 morphine, 157 hydromorphone) in 2013. There was no significant difference in the overall frequency of inappropriate PCA orders (23.4% vs. 24.9%, p=0.90, Fisher’s exact) between 2012 and 2013. However, prescribing of PCA basal rates increased from 14.4% to 24.4% (p=0.05, Fisher’s exact), and inappropriate PCA bolus doses decreased from 9% to 0.5% (p=0.0001, Fisher’s exact). There was also a statistically significant decrease in the mean bolus dose of hydromorphone PCA from 2012 to 2013 (mean difference=0.13mg, p=0.0002, T-test). Logistic regression did not identify factors associated with an increased likelihood of PCA basal rate prescribing. Although prescribing of inappropriately high hydromorphone PCA bolus doses decreased from 2012 to 2013 after changes in the PCA order form, the prescribing of PCA basal rates increased. Prescriber education and modification of the PCA order form may help reduce the frequency of inappropriate PCA orders in the future. Recent reports suggest the occurrence of PCA-related adverse events may be increasing, possibly due to inappropriately high bolus doses and use of basal rates in opioid-naïve patients. In 2011, the FDA decreased the recommended initial intravenous hydromorphone dose, but prescribers may be unaware of this change. In 2013, equianalgesic opioid conversion information was added to the institution’s PCA order form. This study aims to (1) determine if the frequency of inappropriate morphine and hydromorphone PCA orders has changed since 2012 and (2) identify factors associated with prescribing of inappropriate PCA orders. An institutional review board-approved retrospective, single-center review of morphine and hydromorphone PCA orders in post-operative, opioid-naïve adult inpatients identified through pharmacy records from 1/2012-2/2012 and 7/2013-1/2014 was conducted. Patient demographics, surgery types, prescribers, and initial PCA order components were recorded. 332 PCA orders met the inclusion criteria, 111 (56 morphine, 55 hydromorphone) in 2012 and 221 (64 morphine, 157 hydromorphone) in 2013. There was no significant difference in the overall frequency of inappropriate PCA orders (23.4% vs. 24.9%, p=0.90, Fisher’s exact) between 2012 and 2013. However, prescribing of PCA basal rates increased from 14.4% to 24.4% (p=0.05, Fisher’s exact), and inappropriate PCA bolus doses decreased from 9% to 0.5% (p=0.0001, Fisher’s exact). There was also a statistically significant decrease in the mean bolus dose of hydromorphone PCA from 2012 to 2013 (mean difference=0.13mg, p=0.0002, T-test). Logistic regression did not identify factors associated with an increased likelihood of PCA basal rate prescribing. Although prescribing of inappropriately high hydromorphone PCA bolus doses decreased from 2012 to 2013 after changes in the PCA order form, the prescribing of PCA basal rates increased. Prescriber education and modification of the PCA order form may help reduce the frequency of inappropriate PCA orders in the future.