Capnography, Patient Safety, Patient-Controlled Analgesics, PCA

How to Prevent ‘Dead-in-Bed’ Syndrome With Patients After Surgery: Q&A With Physician Experts and PPAHS

by Rob Kurtz (Editor in Chief, Becker’s ASC Review)

[With permission of ASC Review this article has been reprinted here. Copyright ASC Communications. For the original article, please click here.]

The Physician-Patient Alliance for Health & Safety (PPAHS), an advocacy group devoted to improving patient health and safety, has recently announced it is putting together a working group to create a checklist targeted towards patient-controlled analgesia (PCA).

This checklist would reinforce the need for continuous electronic monitoring for oxygenation with pulse oximetry and ventilation with capnography to help prevent so-called “dead in bed” syndrome.

Becker’s Operating Room Clinical Quality & Infection Control E-Weekly asked several health experts and a PPAHS leader about the importance of the development and use of such a checklist in helping to prevent this rare but devastating condition.

Q: What are the existing guidelines for PCA?

Karen Rago, RN, MPA, FAAMA, FACCA, Executive Director Service Line Administration, University of California San Francisco Medical Center: The Anesthesia Patient Safety Foundation (APSF) recommends continuous electronic monitoring of oxygenation and ventilation. I believe that these elements of care could be part of a checklist. They also could be part of a standard order set used for all patients on PCA.

Q: What can go wrong with PCA that would necessitate a checklist and how would a checklist help prevent these complications?

Dr. Elliot Krane, Director, Pediatric Pain Management, at Lucile Packard Children’s Hospital at Stanford in Palo Alto, Calif.: A checklist would help avoid many things that could go wrong with PCA. The receiving party needs full knowledge of underlying medical conditions, verbal report of what went right and what went wrong in the patient’s previous location (OR, PACU, etc.), allergies and drug sensitivities, etc. Then the receiving RN and the delivering RN need to go over the orders that follow the patient line by line.

A checklist would help ensure that necessary procedures are followed when a patient is provided with a PCA pump.

When there is a handoff of a patient from team to team, or location to location (such as OR to PACU, OR to ICU, ICU to OR, etc.), I have been impressed that there are times in which things fall through the cracks, from relatively minor things like missed doses of antibiotics, to critical things like ventilators not being properly connected, potentially resulting in hypoxia.

Dr. Julius Cuong Pham, Department of Emergency Medicine, Department of Anesthesia and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine in Baltimore: The value of a checklist has not been evaluated (as far as we know) with regards to PCA and safety. Safe design principles tell us that for critical steps in a process, a double-check should occur. That double-check can take on many forms, one of which is a checklist. In practice, checklists serve as a mental reminder of critical steps that we may or may not remember. Therefore, the value of a checklist with regards to PCAs would be to remind us/double check a critical step in the process. That critical step might be different for different situations in different institutions.

We do know several things about adverse events related to PCAs. Most are due to a combination of wrong dose (#1) and wrong medication (#3). Most occur during the administration phase of the medication process. The major risk of PCAs is respiratory depression, usually associated with an excessive dosage.

Dr. Richard Dutton, Executive Director, Anesthesia Quality Institute: A checklist would help to avoid simple but recurrent errors in packaging and programming the PCA. Is the drug right? Is the concentration right? Is it the right bag or syringe in the pump? Is it connected to the right thing (IV vs. epidural)? Is the pump programmed correctly (rate, lockout, limits)? Has the patient received appropriate instructions? The use of a checklist can make sure that the appropriate monitors have been placed, and that alarm limits are correctly programmed.

Karen Rago: The biggest value to having a checklist for PCA would be that the programming steps for use of the pump could be part of the checklist to eliminate over or under dosing a patient.

In particular, handoffs are an area where checklists would improve safety. The patients are transferred from OR to recovery and possibly a nursing unit and then from shift to shift. Frequency of monitoring by the nurses and central monitoring of EKG and pulse oximetry would improve safety.

Q: How would this checklist add to the APSF recommendations?

Dr. Brendan Carvalho, Associate Professor, Department of Anesthesia, Stanford University in Palo Alto, Calif.: While the APSF recommendations are important, they are part of a bigger picture of improving care of these patients. The checklist would be to remind clinician’s of some of the recommendations that should be considered. The checklist should not be telling clinician’s to blindly follow recommendations that may or may not be necessary or work. The checklist would many other aspects (as outlined in the next question) that are not specifically covered by the APSF.

Q: What issues would a good checklist address?

Dr. Brendan Carvalho: Here are 11 of the issues a good checklist would address:

  1. Reminder to screen/categorize patients at risk preoperatively (e.g., OSA, obesity, receiving other sedatives, preoperatively opioid use/chronic pain).
  2. Reminder regarding appropriate monitoring (e.g., regular nursing checks for respiratory and sedation in low risk patients to continuous electronic monitoring of oxygenation and ventilation and increased nursing care in high risk patients).
  3. Reminder to prescribe rescue treatments (oxygen, naloxone).
  4. Reminder to have resuscitation equipment nearby patient.
  5. Reminder to document clinical triggers (e.g., resp<10, low saturation) to call physicians.
  6. Reminder to communicate to nursing/physicians any potential risk factors/complications.
  7. Nursing reminders regarding nursing ratios, nursing areas to provide appropriate care.
  8. Reminders to double check dosing of IV or neuraxial narcotics with another nurse.
  9. Reminder to increase monitoring each time treatment/doses are changes.
  10. Reminder to double-check equipment for potential failure.
  11. Monitor patients for appropriate length of time as outlined by ASA (e.g., 24 hours after neuraxial morphine).

Q: What elements are necessary to ensure patient safety other than a checklist?

Dr. Andrew Kofke, Co-Director at Hospital of the University of Pennsylvania Neurocritical Care Program in Philadelphia: You would needtrained caregivers, the use of continuous monitoring and adequate patient instruction and confirmation that only the patient is pushing the button.

Dr. Richard Dutton: Trained caregivers providing education and then ongoing patient observation are key. The best monitor for an oversedated patient remains an interactive doctor or nurse. In their absence, other monitors are also useful, and continuous observation of O2 saturation and ventilation (respiratory rate) are an emerging standard. Capnography is the most commonly available respiratory rate monitor.

Dr. Julius Cuong Pham: Good medication practice suggests that we should confirm the five “rights” before administration of any medication (right medication, right dose, right patient, right time, right route). PCAs should be no different in this regards. PCAs deal with narcotics, one of the highest risk medications that we administer. Therefore, extra attention should be paid during their administration. The research suggests that two of the top three types of PCA errors violate the five rights (#1 wrong dose, #3 wrong medication).

Q: What will be the process for developing this checklist?

Michael Wong, PPAHS: A checklist will only be as a good as the people using it and the technology being used with it. The resuscitation of Howard Snitzer is a great example of this. Howard survived 96 minutes without a pulse. Not only is Howard’s story a testament to people’s perseverance (his very determined rescuers) but of the use of technology to aid this effort (their use of capnography to monitor his exhaled breath). For more on his story, please click here.

With the help of health professionals, advocates and patients, PPAHS is hoping to develop a safety checklist that reminds caregivers of essential steps not to be forgotten. For example, ensure that patients know how to use PCA and make sure that the patient is monitored with capnography as Dr. Dutton has suggested.

PPAHS will be developing a draft checklist with these and other health experts. Then, this checklist will be tested “in the real world” at healthcare facilities. Once tested and validated, the checklist will be distributed.

Q: What assistance are you looking for from other physicians and healthcare professionals? How can they become involved in this project?

Michael Wong: PPAHS believes that only a concerted effort, engaging many interested parties — such as, physicians, nurses, hospital administrators, patient advocates and patients — will produce a safety checklist that will not only be good, but be used. PPAHS therefore welcomes the involvement of all healthcare professionals and interested parties.

Additionally, PPAHS is looking for support for this safety checklist initiative and welcomes discussion with foundations and corporations interested in improving patient safety. Please visit the PPAHS website at https://ppahs.wordpress.com or you can email me, Mike Wong, at mike.ppahs@gmail.com.

One thought on “How to Prevent ‘Dead-in-Bed’ Syndrome With Patients After Surgery: Q&A With Physician Experts and PPAHS

  1. I like to add to the answers in Q5: What elements are necessary to ensure patient safety other than a checklist?

    Remember that even the best checklists are only as good as the humans using them. A pharmacy technician in a Cleveland hospital mixed wrong drugs for a patient. She was distrated by discussions about her wedding in a week. The checklist required that a registered pharmacist must verify the ingredients and that she should hold all the ingredients for verification. The pharmacist unfortunately was too busy getting his computer fixed to catch up on orders. He trusted the technician and signed the verification document without verifying. The patient died. The phamacist served jail time for six months.

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