Revised: 9/26/13

University of Colorado Hospital

Professional Practice, Policy and Procedure Committee
(PPPPC)

Screening Tool

This is the preparation tool for presenting or creating practice, policy, and procedure changes or revisions.
This form MUST be completed and submitted to UCH-ProfessionalPracticePolicyProcCommittee@uch.edu
prior to or along with additional documentation. Notice will be sent via email within 30 days with next
steps. See TIPS at end of tool.

Name: Aurora Davis Phone: 720-848-4275 Date: June 14, 2014
Title/Credentials: Clinical RN Unit: BMT/Oncology Mailstop: F 787
Division Mgr: Jennifer Zwink Educator: Kyle Hammond & Annsley Buffington

Policy, Practice or Procedure title (only one per form): Patient Controlled Analgesia
(PCA): Adult and Pediatric

Select the type of document being submitted (check all that apply):
[ ] Practice: The use by a health care professional of knowledge and skill to provide a service in the
prevention, diagnosis, and treatment of illness and in the maintenance of health.

[X] Policy : Statements which specify conditions and /or resources which must be met to facilitate
patient care. These statements do not address psychomotor skills that are not negotiable and they do
not allow for judgment or interpretation. Policy statements are not included in procedures however
they are referred to as appropriate.

[X] Procedure : Outlines which specify how a psychomotor skill is to be performed.

[ ] Nursing Guideline: Recommendation for a specific clinical practice at the unit or service level.
Guidelines are based on valid and current evidence and do not conflict with hospital policy or
procedure. This must go thru Nursing Guideline Committee first Not PPPPC.

Select One: [X] Existing [ ] NEW [ ] DELETE

Select One: [X] Major Change [ ] Minor Change [ ] References Only Updated

Reason for modification or creation of policy, practice or procedure:
[ ] Mission/strategic initiatives [ ] Needs of the customer
[X] Current clinical business practice [ ] Risk/sentinel events
[ ] Other: ________________________________________________

Keyword Search (Please list up to 5 words for acronyms/lingo, no need to list any in the title):
Pain Sedation

Does your policy affect practice change in the following areas?
[X] Yes [ ] No
If yes, check all that apply: [X] Inpatient [ ]Outpatient (ambulatory)

Revised: 9/26/13
Who does your policy affect?
[ ] AHT [ ] Case Management [ ] Clinical Lab
[ ] CNA [X] Pharmacy [ ] PSC
[ ] PT/OT [ ] Rad Tech [X] RN
[ ] RT [ ] Social Work [ ] Other______________________________

What Committees will you need to consult?
[ ] Any Electronic Health Record or computer changes: In Patient Informatics Committee
[X] Medication, dosing changes, or administration: Kaizen Committee or Pharmacy and
Therapeutics Committee
[ ] Acquisitions of products or a product change: Clinical Products Committee
[ ] Affects critical care: Critical Care Quality Improvement Committee
[ ] Affects ambulatory: AS-PPC council (e-mail: Marianne.Sherman@uch.edu)
[ ] Affects patient or family perception: Patient and Family Center Care Advisory Council
[ ] Potential affects legal or risk: Clinical Quality, Risk Management, and Patient Safety Committee
[ ] Any laboratory impact: Clinical Lab Practice Committee
[ ] Any OR impact: OR Committee
[X] Other describe: Pain Champions of Change Committee

List ALL Stakeholders below:
Stakeholders AND Educator must sign off prior to submission of document to the PPPPC, or
alternatively, specific Email approvals or meeting minutes are also acceptable and can be forwarded
to: UCH-ProfessionalPracticePolicyProcCommittee@uch.edu or Mailstop F796
Date Name/Title/Department (required) Signature or attach email
6/13/14
Amanda Swedhin, MSPCU Educator, Pain
Champions Co-Chair
Assumed approval based on
attached stakeholders email
6/8/14 Rob Montgomery, ND, Acute Pain Service Email approval attached
6/13/14
Barbara Krumbach, Perianesthesia Clinical Educator,
Pain Champions Co-Chair
Assumed approval based on
attached stakeholders email
6/13/14
Matt Fiegel, MD, Medical Director, Acute Pain
Service
Assumed approval based on
attached stakeholders email
6/13/14 Dimitriy Levin, MD, Hospitalist Oncology Team
Assumed approval based on
attached stakeholders email
6/13/14 Jeanie Youngwerth, MD, Palliative Care Team
Assumed approval based on
attached stakeholders email
6/6/14 Shannon Johnson-Bortolotto, CNS, CCQI Chair Email approval attached




Describe the present practice and potential practice change:

Situation:
Revised: 9/26/13
University of Colorado Health has made several changes to PCA practice since the last time the policy was
updated.

Background:
The last PCA Policy update was January, 2011.

Assessment:
Current practice changes include the use of the EPIC electronic medical record system and electronic
physician order entry, the use of new Alaris PCA pumps with accompanying standard drug dose changes,
the increased use of subcutaneous PCA infusions, and the use of a new sedation scale.

Recommendation:
The PCA policy has been updated to reflect all current practice changes.

REFERENCES and Levels of Evidence (must be reviewed within 5 years unless they are Gold Standard)
Were these reviewed & updated? [X] Yes [ ] No

Related Policies & Procedures (exact title must be listed)
Were these reviewed & updated? [X] Yes [ ] No

Table of Contents (required for documents of 5 pages or more)
Was this reviewed & updated? [X] Yes [ ] No

Will the Practice, Policy, or Procedure change require an educational roll out?
[ ] Yes consult the Nursing Educational Council [X] No


Explain below how you will measure outcomes of this change and when do you plan to report back to
the committee. Recommended timeline is 6 months.

The change has already been implemented; the policy update is retroactive to existing practice changes.



_____________________________________________________________________________________
TIPS:
1. It is the responsibility of the reviewer/author/owner to check entire policy or procedure for any updates
and include those in the final draft.
2. Review the algorithm and determine if the practice, policy or procedure can be combined with any other
or consider if it could be a guideline instead (check with your unit educator).
3. Screening Tool must be submitted prior to or along with edited practice, policy or procedure.
4. Items to check before submitting the draft:
- Verify Related Policies & Procedures
- Table of Contents is required for documents of 5 pages or more
- Include any related attachments and links
- Verify References and Levels of Evidence
(The LOE list can be located under the Frequently Asked Questions on the following link -
http://hub.uch.edu/champions-committees/ppppc/resources/)
5. Do not modify headers & footers or document number on existing policies.