Alarm Fatigue, Capnography, Patient Monitoring, Patient Safety, Patient Stories, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring

3 Questions About Patient Safety and PCA with Brian and Cindy Abbiehl from A Promise to Amanda Foundation

by Sean Power
December 12, 2013

The Physician-Patient Alliance for Health and Safety released their findings from the First National Survey on Patient-Controlled Analgesia (PCA) Safety Practices.

The report on the National Survey on Patient Safety with PCA is available to download for free here. It asked pharmacists, doctors, nurses, respiratory therapists, and administrators at hospitals from 40 states about their safety measures for PCA.

Brian and Cindy Abbiehl, founders of A Promise to Amanda Foundation (which co-sponsored the research), recently shared their thoughts on some of the findings on the patient risk factors being considered at hospitals during the administration of PCA.

The Abbiehls founded A Promise to Amanda Foundation to raise awareness about respiratory depression after the death of their 18 year-old daughter Amanda. Amanda was admitted to a hospital for an infection and was hooked up to a PCA pump to manage her pain. Less than twelve hours after Amanda was put on a PCA using Delaudid she was found unresponsive. Amanda’s parents believe that, had Amanda been monitored with capnography and pulse oximetry, nurses would have been alerted that she was in trouble and been able to intervene.

You can find a copy of the survey results here.

SP: The survey asked respondents about which risk factors they consider before patients initiate PCA. Was there anything in the results that surprised you?

Cindy Abbiehl: I don’t think we had any expectations going into the survey so I wouldn’t say we were surprised by any of the findings.

I think it’s more accurate to say that the results disappointed us in the sense that, for PCA to be administered safely, every risk factor included in the survey should be considered for every patient before initiating PCA. Not all hospitals consider every factor. That needs to change.

The risk factors include obesity, low body weight, concomitant medications that potentiate sedative effects of opiate PCA, pre-existing conditions such as asthma and sleep apnea, advanced age, and opioid naïve.

These risk factors were identified in the Physician-Patient Alliance’s PCA Safety Checklist last year, which was assembled by a number of well-respected health care professionals. The impact of not considering these risk factors can be tragic.

Brian Abbiehl: Cindy and I are talking from experience when we use the word “tragic.” Our daughter, Amanda, was administered PCA to manage pain despite Amanda being opioid naïve. The PCA survey reveals that around 1 in 5 hospitals do not consider whether the patient is opioid naïve before initiating PCA.

Checking if patients are opioid naïve will raise a red flag to health care providers and can prevent tragic outcomes. The Food and Drug Administration associated PCA with 56,000 adverse events and 700 patient deaths between 2005 and 2009. Considering all risk factors can help to prevent these tragic outcomes.

CA: The survey showed that non-pharmacists were about four times less likely than pharmacists to say that they consider opioid naïve as a patient risk factor. As the front line professionals interacting with patients, this reality needs to change. Pharmacists, physicians, nurses, respiratory therapists, and other health care professionals all need to be on the same page when administering PCA.

SP: You two have spoken about Amanda’s death many times in the past. What would you like to see come out of the findings of the survey?

BA: We’re hopeful that the survey will bring attention to the fact that PCA can be dangerous without the proper safety measures in place.

One of the survey’s key findings is that there exists a great lack of consistency in safety procedures being followed by hospitals across the country. Indicated by the survey are a number of safety recommendations for health care providers.

For instance, the survey provides a list of patient risk factors to consider when initiating PCA. It outlines when to perform double-checks, and what to double-check. It highlights the use of capnography, pulse oximetry, and “smart pumps” to keep patients safe. There are a number of other safety practices that can be followed.

CA: When you ask what we’d like to see from the survey, the ultimate answer is better patient outcomes. Safer care. Fewer adverse events. Zero preventable deaths associated with PCA.

Implementing some of the safety practices asked about in the survey, partnered with a culture of safety at hospitals in the United States, will save lives.

SP: Are there any safety practices you believe are particularly important for the administration of PCA?

CA: They’re all critical—especially those contained in the PCA Safety Checklist I mentioned earlier.

A Promise to Amanda Foundation focuses on the continuous electronic monitoring of all patients every time a patient is placed on a PCA pump, is sedated, requires a stay in the PACU following general anesthetic, or requires a stay in the PACU following sedation.

Continuously monitoring with capnography and pulse oximetry is key because it provides a technological safety net. For instance, “smart pumps” with forcing functions monitor trends in the quality of breath. Should these trends indicate that the patient is experiencing respiratory depression, it stops infusing medicine and alerts nurses to intervene.

Without smart pumps, the nurse might not be aware that the patient is experiencing respiratory depression until the nurse’s next “spot check”, which could occur as far as four hours from the time of respiratory depression at some hospitals.

For these reasons, A Promise to Amanda Foundation focuses on making continuous electronic monitoring mandatory in the administration of PCA. It enables health care professionals to prevent adverse events and clinically intervene.

Even if health care professionals miss a double-check, or fail to consider every risk factor, or overlook any other critical safety practice, capnography and pulse oximetry will help to prevent respiratory depression by notifying caregivers before the patient’s condition deteriorates to Code Blue levels.

BA: We understand that alarm fatigue continues to be a main obstacle to implementing the patient monitoring with capnography and pulse oximetry. The survey found that 9 out of 10 hospitals believe reducing false alarms would increase the use of such devices.

In addition to using capnography and pulse oximetry, then, we would insist that reducing the incidence of false alarms is a safety practice that is particularly important for safer PCA use.

The Joint Commission is expected to announce a National Patient Safety Goal on alarm management in 2014. We hope that health care professionals will rally behind them and make PCA safety a priority by improving alarm safety at their hospital.

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