Pain Management - Leadership Responsibility: Patient Monitoring Following Sedation or Anesthesia- LD.04.03.13 EP 7

Does The Joint Commission have any recommendations or standards concerning the monitoring of post-operative patients on opiates (and/or on opiates combined with other pain medications)?

Any examples are for illustrative purposes only.

Decisions on monitoring requirements to detect post-procedure drug-induced respiratory depression are determined by the clinical team responsible for providing care and based on evidence-based guidelines, accepted standards of practice, etc.  Leadership commitment is required to ensure that appropriate equipment is available to monitor patients deemed highest risk (that is, patients with sleep apnea, patients receiving continuous intravenous opioids, patients on supplemental oxygen, etc.).
The requirements found in the Provision of Care (PC) chapter at PC.03.01.01 through PC.03.01.07 speak specifically to sedation and anesthesia care. Because of the vast variations from one entity to the next, these standards require organizations to develop policies, procedures, assessment/reassessment requirements, staff qualifications and competency, education and training, etc., requirements based on the services provided and patient populations served by the organization. 
Organizations are encouraged to convene a group of clinicians that are involved in the pain assessment, pain management, and safe opioid prescribing to discuss and re-evaluate the organization’s approach to pain assessment and management. Participants may include members of the medical staff, nursing, pharmacists, social workers, etc.
Review of evidence-based guidelines will assist leadership and the medical staff in developing policies, protocols, metrics and other quality indicators, etc. During survey, clinicians may be asked to describe how they identify a patient that is high risk and how they would manage and monitor that patient.
References to consider:
American Society of Anesthesiology
Anesthesia Patient Safety Foundation
American Pain Society
The American Society for Pain Management Nursing
The American Pain Society Guideline on Management of Postoperative Pain (2016)
Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines (2017).

R3 Report: Pain assessment and management standards for hospitals
R3 Report: Pain assessment and management standards for Critical Access Hospitals
Sentinel Event Alert Issue 49: Safe use of opioids in hospitals

Last updated on August 03, 2020
Manual: Hospital and Hospital Clinics
Chapter: Leadership LD

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