by Sean Power
March 11, 2014
In honor of Patient Safety Awareness Week last week, the Premier Safety Institute gathered experts on opioid safety to participate in a webinar discussion. The panel, moderated by Gina Pugliese, RN, MS, vice president, Premier Safety Institute, Premier Inc., featured several authorities on opioid safety, including:
- Michael Wong, JD, executive director, Physician-Patient Alliance for Health and Safety
- Harold Oglesby, RRT, manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System
- Joan Speigel, MD, assistant professor, anesthesiology, Harvard Medical School and Beth Israel Deaconess Medical Center
- Bhavani S. Kodali, MD, associate professor, Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School.
This article is the first of a two-part series. It summarizes the presentations on opioid safety. The second part will recap the question and answer period with the entire panel.
Will continuous monitoring become a standard of care for patients receiving patient controlled analgesia (PCA)?
The Physician-Patient Alliance for Health and Safety teamed up with A Promise to Amanda Foundation to conduct the first-ever national survey on PCA practice.
“Part of the impetus for the survey was the sheer number of respiratory events that occur each year,” says Mr. Wong.
Between 20,000 and 676,000 PCA patients will experience opioid-induced respiratory depression every year.
“However for our purposes, and for A Promise to Amanda, the main impetus is the patients,” Mr. Wong continues.
The survey was developed with input from a number of patient safety experts including Richard Dutton, MD, MBA, Executive Director of Anesthesia Quality Institute, and Frank Federico, RPh, Executive Director of the Institute for Healthcare Improvement, Patient Safety Advisory Group, The Joint Commission, among others.
Six patient risk factors have been identified by major health care organizations like The Joint Commission and Institute for Safe Medication Practices (ISMP). These risk factors include:
- Low body weight
- Concomitant medications that potentiate sedative effects of opiate PCA
- Pre-existing conditions (such as asthma, chronic obstructive pulmonary disease, and sleep apnea)
- Advanced age
- Opioid naive
“The survey results show great variability in the risk factors being considered by hospitals across the country,” adds Mr. Wong.
According to the survey results, less than 40 percent of hospitals are considering all six patient risk factors.
Almost one out of five hospitals are not assessing patients for being opioid naïve. Three out of ten hospitals do not consider obesity as a patient risk factor. Three out of 20 hospitals do not consider advanced age.
Approximately 70 percent of PCA adverse events are due to errors associated with pump use, according to the Pennsylvania Patient Safety Authority. Double-checks advocated by ISMP and others can prevent errors from happening.
Patient identification, allergies, drug selection and concentration, dose adjustments, PCA pump settings, and line attachments all need to be double-checked.
“There is a great variation between hospitals performing these very simple six double checks. Sadly, only slightly more than half of all hospitals are performing all six double checks,” says Mr. Wong.
The PCA survey, conducted prior to The Joint Commission’s National Patient Safety Goal on alarm safety, found that 95 percent of hospitals are concerned about alarm fatigue. Almost nine in ten hospitals (87.8 percent) believe that a reduction of false alarms would increase the use of patient monitoring devices like an oximeter or capnograph.
“Hospitals also indicated the value of continuously electronically monitoring their patients receiving opioids,” says Mr. Wong. “All those who reported monitoring said that monitoring reduced adverse events and hospital expenditures, or that it was too early to determine the effect of monitoring.”
Moreover, hospitals using smart pumps with integrated end tidal CO2 (EtCO2) monitoring were almost three times more likely to have had a reduction in adverse events or a return on investment in terms of a reduction in costs and expenses.
The challenge of balancing effective analgesia with safety
Mr. Oglesby was involved in implementing continuous electronic monitoring at St. Joseph’s/Candler Hospitals in Savannah, Georgia, and has spoken about being opioid-related event free for eight years, as well as the return on investment that came with the program.
SJ/C is the largest health care system in southeast Georgia with 675 beds and approximately 25,000 annual discharges. In the two years preceding the implementation of continuous electronic monitoring, SJ/C experienced three opioid-related events with serious outcomes.
“We made sure that we used smart pumps to address the appropriate programming of our pumps. We also wanted to assess what would be the best way of monitoring our patients,” says Mr. Oglesby.
The team that drove the continuous monitoring program was initially comprised of pharmacy and nursing staff. Respiratory therapy was called in to address monitoring options early on in the decision making process.
According to Mr. Oglesby:
“We were specifically asked that question: as respiratory therapists, what did we think would be the earliest indicator of problems with ventilation versus saturation? We quickly said that capnography would be the earliest indicator of ventilatory problems.”
Since the nursing team was new to capnography, and since respiratory therapists were new to pain scales, education was central to the success at SJ/C.
Patient education was equally central.
“We put respiratory therapy in the role of being bedside educators,” says Mr. Oglesby, since respiratory therapists have a good foundational understanding of EtCO2 and its limitations.
“There were times when we would get calls to the bedside from the nursing staff who would say that this patient’s alarm was going off, and going off for no reason,” says Mr. Oglesby. “When you get to the bedside you would go back and review the patient’s trends and look at the waveforms. You would actually see that the patient had good reason for the alarms going off.”
The respiratory therapists found that patients often experienced undiagnosed sleep apnea and that the patients were having moments of apnea.
According to Mr. Oglesby:
“The education at the bedside resulted in the nursing staff becoming really good at using end tidal CO2 to the point that they would take monitors and put them on other patients that weren’t receiving PCA just to do an assessment of those patients.”
Capnography also provided the earliest indication of respiratory depression for patients receiving PCA treatment.
These screens from an actual patient highlight a few key points about the effectiveness of capnography at providing the earliest indication of respiratory compromise.
“You can see on that monitor that it gives you the time,” explains Mr. Oglesby. “Highlighted on both is 10:00 AM. At 10:00 AM you see the patient’s morphine dose was 2.5 milligrams. The patient’s [oxygen] saturation was 97 percent. Pulse ox was 88. The end tidal CO2 was 43 and the respiratory rate was 20.”
Mr. Oglesby explains that at 10:30 AM, the screens show, EtCO2 rose to 50, which was outside of the established range, and an alarm sounded. The pulse oximeter alarm did not sound until 11:30.
“This was typical,” says Mr. Oglesby. “We were finding that the end tidal CO2 gave us at least that hour window—gave us an hour earlier indication that something was changing with the patient’s status. So if we just had pulse oximetry, we wouldn’t have known until an hour later that something was really going on with that patient.”
According to Mr. Oglesby:
“We truly believe that end tidal CO2 provides us with the earliest indicator of a decline in our patient’s respiratory function.”.
Monitoring patients receiving PCA with capnography at SJ/C resulted in an increased likelihood of better-sustained pain control, faster recovery and discharge, a better patient experience, and eight years of event free usage of PCA therapy.