8 Surprising Facts From a 7 Day Cohort Study: Mortality After Surgery

By Sean Power
October 16, 2014

A recent article in The Lancet published findings that suggest mortality after non-cardiac surgery in Europe may be higher than expected.

Dr. Rupert Pearse and a team of researchers conducted the European Surgical Outcomes Study (EuSOS)—a study that spanned 28 European countries and included 498 hospitals—in an attempt to describe mortality after non cardiac surgery at a national and international level.

Heterogeneity between hospitals suggests potential to improve care for patients—in particular, high risk surgical patients who are appropriate for post op ICU admission. It also makes it difficult to describe clinical outcome improvement at the national and international level. This difficulty in the actual potential to improve care remained unconfirmed and provided impetus for the EuSOS Study.

Assessing outcomes after non-cardiac surgery, EuSOS conducted a seven-day cohort study between April 4 and April 11, 2011. Researchers collected data describing consecutive patients aged 16 and older undergoing inpatient non-cardiac surgery.

The researchers looked at in-hospital mortality, duration of hospital stay, and admission to critical care in its assessment of clinical outcomes. They found that mortality rate for inpatient non-cardiac surgery was higher than expected, at 4 percent.

“Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients,” say the authors.

Contained within the article are eight facts about non-cardiac surgery that may surprise you:

1. More than 230 million major surgical procedures are undertaken worldwide each year.
2. Ten percent of patients undergoing surgery in the UK are high risk and account for 80 percent of the country’s postoperative deaths.
3. Up to 25 million patients undergo high risk surgical procedures each year, of whom, 3 million do not survive until discharge.
4. The EuSOS Study, which provided a data population of more than 46,000 unselected patients undergoing inpatient surgery from 28 European countries, revealed mortality rate of 4 percent for non-cardiac inpatient surgery patients.
5. Cultural, demographic, socioeconomic, and political differences might affect population health and health care outcomes. Countries such as Ireland, Latvia, Poland, and Romania all had higher mortality rates than countries such as Finland, France, Germany, and the UK.
6. In the EuSOS Study, unplanned admissions to critical care were associated with higher mortality rates than were planned admissions.
7. Most patients who died (73 percent) were not admitted to critical care at any stage after surgery; of patients who died after admission to critical care, 43 percent did so after the initial episode was complete and the patient had been discharged to a standard ward. This may indicate insufficient acute care post operative monitoring or staff whose skill set cannot early on detect onset of possible adverse event or deterioration from baseline status.
8. Patients who develop complications but survive to leave the hospital often have reduced functional independence capacity and long-term survival, which cause a poorer quality of life than those that do not develop complications.

According to the authors, the findings may indicate a “systematic failure in the process of allocation of critical care resources”, saying that the study suggests both the need and potential to implement measures to improve postoperative outcomes.

The authors conclude that the quality of perioperative care is likely to be among the most important reasons why outcomes for cardiac and non-cardiac surgical patients differ. They point towards preoperative assessment, optimization of coexisting medical disease, WHO surgical checklists, advanced haemodynamic monitoring during surgery, early admission to critical care, acute pain management, and hospital discharge planning as possible areas for improvement.

Are you involved in non-cardiac surgeries at a hospital? Tell us what you think of the EuSOS Study.

A Decade of Excellence: Hospital Celebrates 10 “Event Free” Years of Patient Safety

By Briggs Adams (Editorial Manager, Physician-Patient Alliance for Health & Safety)

When the leader of St. Joseph’s/Candler Hospital respiratory therapy team was initially considering using capnography to monitor patients receiving opioids after surgery, he predicted the outcome would go in one of two ways.

“Quite honestly, we thought capnography was either going to be tremendously successful or a complete disaster,” said Harold Oglesby, Registered Respiratory Therapist (RRT), Manager, The Center for Pulmonary Health, Candler Hospital, and St. Joseph’s/Candler Health System (SJ/C).

(for the Georgia Hospital Association video awarding Harold Oglesby the “Hospital Hero” award, please click the picture)

Disaster never struck. And it’s been averted for more than a decade, which demonstrates a high level of clinical achievement.

In fact, since Mr. Oglesby and his respiratory therapy (RT) staff decided to use capnography to continuously monitor patients receiving patient-controlled analgesia (PCA) in June 2004, SJ/C has been “event free” in terms of opioid-related adverse outcomes. As a result, the Savannah, Georgia hospital has become a role model for hospitals across the nation to institute this type of “best practice”. This has prompted many to consult with Mr. Oglesby to gain his insights on how to achieve similar success with capnography monitoring at their respective institutions.

“I’ve had several nursing directors, RT directors and other hospital staff reach out to me, and we’ve helped them bypass some of the pitfalls,” he said.

SJ/C’s journey to perfection began on a relatively small scale, with a six-month beta test in which new PCA and monitoring modules were integrated with the hospitals existing IV safety platform. A small group of patients were selected for the pilot test.

During the test, the team gained invaluable insights not only into capnography, but also into alarm management. Among the important lessons learned, Mr. Oglesby said, was that “the team recognized that the safe use of PCA requires correct pump programming, along with monitoring of the patient’s individual respiratory response to opioids.”

Another key learning, he said, was that early in the decision-making process, SJ/C found that having the respiratory care team intrically involved was critical.

“Respiratory therapists have strong clinical assessment skills, they understand capnography monitoring and its limitations, and they are able to apply solid clinical judgment as they guide the care of patients suffering from respiratory issues,” Mr. Oglesby said. He added that it was equally critical for the nursing staff to have an active role in the pilot test, because it ultimately increased the staff’s knowledge and enthusiasm for using the new technology.

After the beta test was completed, SJ/C concluded that capnography, not pulse oximetry, provided the first indication of opioid-related respiratory depression. As a result, SJ/C now requires that capnography module be used for all PCAs infusions and pulse oximetry modules for selected PCA patients with pre-existing comorbidities.

Though it was used on a small scale 10 years ago, capnography has become widespread at SJ/C. The monitoring technology is now utilized for both non-intubated and intubated patients, in the ICU, on the general floor wherever patients are receiving opioids, in the emergency room and for patients who are having procedural sedation, Mr. Oglesby said.

As capnography grows more pervasive at SJ/C, so, too, does the possibility for an adverse event. But thanks to the constant vigilance of the RT team, the hospital remains “event free.”

“Whenever we find ourselves becoming complacent, we remind ourselves how important it is what we’re doing,” he said.

In addition to the enthusiasm that SJ/C’s caregivers have for capnography, patient education has played a critical role in helping the hospital prevent adverse events, Mr. Oglesby said.

When patients and their families understand the benefits of capnography and that it’s being used for their safety, they’re much more compliant and willing to wear the cannula,” he said.

Ten “event free” years at SJ/C has not only delivered immeasurable value in protecting the lives and safety of numerous patients, but also hard-dollar patient-care savings. The hospital’s estimates show that by implementing capnography for PCA patients, it saved nearly $4 million dollars between 2002 and 2007.

Understandably, the RT team takes considerable pride in its decade of perfection, but as Mr. Oglesby pointed out “It’s first and foremost a victory for the patient.”

4 Lessons Learned from the Death of Joan Rivers

By Kenneth P. Rothfield, M.D., M.B.A., Chairman, Department of Anesthesiology, Saint Agnes Hospital (Baltimore, MD), Lynn Razzano, RN, MSN, ONCC (Clinical Nurse Consultant, Physician-Patient Alliance for Health & Safety), and Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

It is often said that a death is meaningful if it serves as lessons for others to learn from and increase awareness so they “speak up” when found in a similar situation. So, what can be learned from the death of Joan Rivers?

Joan Rivers – she made us laugh

As reported by CNN, the facts surrounding the death of Ms. Rivers were as follows:

Comedian Joan Rivers lost her life after having an apparently minor elective procedure at a Manhattan medical clinic last week.

The routine surgery was on her throat, according to the New York Fire Department. She apparently suffered cardiac and respiratory arrest during the procedure at Yorkville Endoscopy. She was transferred by ambulance to Mount Sinai Hospital and died on Thursday …

Rivers’ autopsy was inconclusive, the medical examiner’s office said.

Although there are still many questions the answers to which are not known or have not yet been made public – such as, what was the exact procedure that was being performed or whether a sedative, opioids, or anesthetic was given – here are 4 lessons learned from the death of Joan Rivers.

1. Even “minor” procedures can have major risks and “hidden harm”

The American Society of Anesthesiologists reminds us that although “anesthesia is safer than ever before, every person scheduled for a procedure or surgery must have a serious conversation with their physician anesthesiologist about their anesthesia care delivery plan ahead of time … Even ‘minor procedures’ are not risk-free.”

2. Ask questions to fully understand the medical procedure you are to undergo

Physicians must communicate and patients need to fully understand the full nature of the medical procedure. It is often helpful to have a family member, friend or significant other with you to check if you asked all your questions and another set of “ears” to listen to what is being told or explained to you.

U.S. Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) believe “clinicians and patients [need] to engage in effective two-way communication to ensure safer care and better health outcomes.”

This type of patient engagement and education should be told to the patient, and then have the clinican ask for verbal or written feedback from the patient on the level of understanding. This is termed ”readback feedback”.

AHRQ encourages patients to ask their medical providers questions, as illustrated in this humorous video which shows how patients ask many questions everywhere (such as in a restaurant) but not in the doctor’s office (please click on the image to view the video):

AHRQ Restaurant Ad

3. Make sure you are monitored electronically, with both pulse oximetry and capnography, if you are to receive sedation, opioids or anesthesia

Even “routine” procedures may entail the use of a sedative, opioids, or anesthesia. The endoscopic procedure performed on Ms. Rivers, which would have likely involved insertion of a large scope into her mouth, is a simple and common procedure, but, as noted by Dr. Karen Siebert, “uncomfortable enough that most patients are given sedation or, less commonly, general anesthesia.”

The Anesthesia Patient Safety Foundation believes that clinically significant drug-induced respiratory depression in the postoperative period remains a serious patient safety risk that continues to be associated with significant morbidity and mortality.

Continually evaluating and monitoring respiratory and circulatory status prior to, during, and following the procedure is essential. As a recent video released by the APSF provides, continuous electronic monitoring of oxygenation (the adequacy of oxygen in the blood) with pulse oximetry and ventilation (adequacy of breathing) with capnography, when combined with traditional in-depth nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment and distress.

Virtually all proceduralists use pulse oximetry to measure blood oxygen levels, Assessing ventilation is another story. Being able to tell by simple observation if a patient is breathing adequately or not during a procedure can be tricky. Surprisingly, standards for capnography monitoring are not the same for all medical specialists. Anesthesiologists, the recognized experts in administering sedation and anesthesia, are required by the American Society of Anesthesiologists to measure the adequacy of ventilation using capnography (a device which measures exhaled carbon dioxide) to provide breath-by-breath monitoring. Other specialists, such as gastroenterlogists and dentists, are not required to use this technology. Without capnography, several critical minutes can elapse after a patient stops breathing before medical professionals are alerted to the situation, Unfortunately, by this time, a serious problem, or even a cardiac arrest may occur.

4. Equipment and resources at an outpatient clinic may be different than at a hospital

If your procedure is scheduled at a “Outpatient Clinic”, be sure to ask about available emergency equipment at the clinic. Just because your procedure is scheduled in an outpatient type of clinic, do not take this lightly and ask about code cart availability, emergency drugs to manage your condition and any adverse events, and lastly trained clinicians available and knowledgeable about handling potential life threatening emergencies.

Exactly what procedure was performed and how that procedure was performed are facts that the public still does not know about the death of Joan Rivers. However, keeping these 4 simple points in mind could save the life of you or your loved one.

(This article was first posted on The Doctor Weighs In.)

Risk Stratification of Sleep Apnea Patients – A Recipe for Death?

By Kenneth P. Rothfield, M.D., M.B.A., Chairman, Department of Anesthesiology, Saint Agnes Hospital (Baltimore, MD)

The American Society of Anesthesiologists recently updated its practice guidelines for the perioperative management of obstructive sleep apnea (published February 2014).

The purpose of these practice guidelines are to:

improve the preoperative care and reduce the risk of adverse outcomes in patients with confirmed or suspected OSA who receive sedation, analgesia, or anesthesia for diagnostic or therapeutic procedures under the care of an anesthesiologist.

These guidelines provide a scoring system for perioperative risk for obstructive sleep apnea, which assigns a numerical score for severity of sleep apnea, invasiveness of surgery and anesthesia, and requirement for postoperative opioids. Surprisingly, this scientific-looking table has had no clinical validation whatsoever—but it is included in the guidelines.

Attempting to stratify the level of risk, and providing only some sleep apnea patients with postoperative monitoring could lead to adverse events and death. Perhaps no one has experienced the tragic consequences of this more than the family and friends of John LaChance.

 

As recounted in this video by his wife, Patricia LaChance, John suffered from sleep apnea. Despite this diagnosis, John died because his medical history was ignored and because he wasn’t properly monitored after he was placed on a powerful intravenous opioid to ease the pain from his surgery to repair a torn rotator cuff in his shoulder.

As I noted in my letter to the editor published in Anesthesiology:

Risk stratification for opioid-induced respiratory depression is by no means an exact science, and failure to rescue remains a significant source of human suffering and healthcare expense. The Anesthesia Patient Safety Foundation recognizes this fact, and has stated “…risk stratification for increased postoperative electronic monitoring would potentially miss a large population of patients that is at increased risk for opioid-induced respiratory depression.” Not surprisingly, the Anesthesia Patient Safety Foundation has advocated for continuous respiratory monitoring for all postoperative patients receiving parenteral opioids.

Practice guidelines, like those for the perioperative management of obstructive sleep apnea, are needed and may be helpful to providers to help make sound clinical decisions. However, the inclusion of an untested numerical risk assessment scale, which goes against the recommendations of the Anesthesia Patient Safety Foundation for risk stratification should be read with caution, even if there is a disclaimer in fine print at the bottom of the table shown above.

What Does New CMS Guidance on Monitoring Post-Operative Patients Receiving Opioids Mean for Hospital Practice?

by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

[This article first appeared in Patient Safety & Quality Healthcare. To read the full article, please click here.]

In its guidance, “Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids,” CMS explains the reason behind the issue for this guidance:

Each year, serious adverse events, including fatalities, associated with the use of IV opioid medications occur in hospitals. Opioid-induced respiratory depression has resulted in patient deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoring of the patient’s respiration rate, oxygen and sedation levels. Hospital patients on IV opioids may be placed in units where vital signs and other monitoring typically is not performed as frequently as in post-anesthesia recovery or intensive care units, increasing the risk that patients may develop respiratory compromise that is not immediately recognized and treated. [page 2]

This guidance recommends “at a minimum” [page 19] that hospitals “have adequate provisions for immediate post-operative care, to emphasize the need for post-operative monitoring of patients receiving IV opioid medications, regardless of where they are in the hospital.” [page 1]

Clinicians and hospital executives trying to understand this new guidance may wonder what CMS means by “monitoring.” Does it mean intermittent monitoring?

To read the full article, please click here.

PPAHS Mourns the Fourth Anniversary of the Passing of Amanda Abbiehl

by Sean Power
July 24, 2014

This past weekend (July 17) marks the anniversary of the tragic death of 18-year old Amanda Abbiehl, whose story serves as a powerful reminder of the need for continuous electronic monitoring.

Lynn Razzano, Clinical Nurse Consultant with the Physician-Patient Alliance for Health & Safety, offers an appeal to her clinical colleagues:

“On the four year anniversary of the untimely passing away of 18-year old Amanda, hospitals need to think of how this could have been actively prevented. My hope is that this promotes more vigilance in appropriately assessing a patient when opioids are in use and ensuring that all patients receiving opioids are continuously electronically monitored.

“The time is now to prevent death from opioid-induced respiratory depression. It is as easy as ensuring the order is placed for continuous monitoring whenever opioids are ordered. This should be the new current standard of practice and one that proactively prevents opioid deaths from occurring.”

Join us in making a #Promise to Amanda today.

Patient safety champions: Promise to do everything you can to make it mandatory at your hospital for all patients on PCA pumps to be continuously electronically monitored with capnography and pulse oximetry.

Nurses, physicians, and respiratory therapists: Encourage patients and families to share their experiences with respiratory monitoring. Promise to talk to decision makers about capnography and respiratory monitoring every chance you get. Use the PCA Safety Checklist before, during, and after initiating PCA treatment.

Hospital administrators: Build redundancies into the system. Mistakes are going to be made but adverse events are preventable. Monitor every patient and save lives. Tell us if your hospital monitors patients with capnography while they are connected to PCA pumps.

Patients and families: Come forward to share your story about capnography. Write, phone, or email your local congressperson about making zero preventable deaths a policy priority.

Read more about Amanda’s story at promisetoamanda.org or at WNDU’s latest coverage of the Promise to Amanda Foundation.

5 Findings From an Opioid Awareness Survey Conducted at AORN Annual Conference

by Amy Smalarz, PhD, President and Co-Founder, Strategic Market Insight
July 8, 2014

Although opioids may be used as the “standard of care” or “common practice” for postsurgical pain management, it is important to understand the impact of their use as it’s directly related to the Triple Aims.

It has been documented that opioids can cause adverse events while in the hospital and potentially lead to opioid addiction after discharge but to what degree are nurses aware of the potential safety, clinical and economic implications of using opioids for postsurgical pain management?

At this year’s Association of PeriOperative Registered Nurses (AORN) Annual Conference, a recently conducted survey assessed nurses’ levels of awareness of these areas.

The survey was well received as 146 nurses took the time to respond. Of the nurses who responded, approximately 34% work in Magnet Hospitals (recognized by the American Nurses Credentialing Center after demonstrating excellence in patient care). Approximately 69% work in not-for-profit institutions, over 80% work in community and urban areas, and approximately 70% have 20+ years’ experience (69%).

Notable findings from this survey include:

Awareness

1. Almost all of the nurses (97%) knew that people who have an opioid-related adverse event are at 3-times higher risk of inpatient mortality
2. A majority (75%) knew that the number of drug overdose deaths for opioids was greater than heroin, cocaine and benzodiazepines combined (25% responded “False”).

Learning Opportunities

3. While it has been reported that 90-99% of patients who undergo common surgical procedures receive opioids only 37% of nurses were aware of this level of opioid use, i.e., almost two-thirds of the nurses under-estimated the percentage of people receiving opioids
4. Less than a third (26%) of nurses knew that approximately 20% of inpatient adverse drug reactions are attributable to opioids; 74% of nurses under-estimated the percentage of adverse events caused by opioids
5. A majority (52%) of survey respondents under-estimated the percentage of older adults that are more likely to become long-term opioid users after receiving prescribed opioids for the first time within 7 days of ambulatory surgery (which is approximately 44%).

The results of this survey demonstrate that while nurses are aware of some safety concerns and issues regarding opioid use, an opportunity exists to educate nurses about opioid adverse events, potential unnecessary use as well as opioid long-term use and potential addiction.

Therefore, the next steps include:

• expanding the audience of the survey and including more nurses who work in the post-anesthesia care units (PACU)
• surveying nurses to ask about the impact of postsurgical pain management medication choices on their workflow, burden of documentation, communication with other clinicians and patients as well as satisfaction.

Stay tuned for updated information regarding the dissemination of this and future nursing studies!

New CMS Guidance Recommends Monitoring of All Patients Receiving Opioids

By Michael Wong, JD (executive director, Physician-Patient Alliance for Health & Safety)

(This article first appeared in Becker’s Hospital Review.)

On March 14, 2014, CMS issued guidance “Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids.”

This guidance recommends “at a minimum” [page 19] that hospitals “have adequate provisions for immediate post-operative care, to emphasize the need for post-operative monitoring of patients receiving IV opioid medications, regardless of where they are in the hospital.” [page 1]

In addition and more importantly, the CMS guidance necessitates monitoring for all patients receiving opioids when in hospital:

“Narcotic medications, such as opioids, are often used to control pain but also have a sedating effect. Patients can become overly sedated and suffer respiratory depression or arrest, which can be fatal. Timely assessment and appropriate monitoring is essential in all hospital settings in which opioids are administered, to permit intervention to counteract respiratory depression should it occur.” [page 15]

 What does the CMS guidance mean by “appropriate monitoring“?

Does “appropriate monitoring” mean intermittent assessment, as was recommended in last year’s CMS proposed quality measure (#3040)?

Proposed measure #3040 provided that monitoring needs to be “documented” and the time between documentation must “not exceed 2.5 hours.” This means that a nurse or other caregiver must document the patient’s condition and do this in intervals of not greater than 2.5 hours.

In the report submitted by the National Quality Forum to HHS, the measure was not endorsed and it was decided that the measure “requires modification or further development.”

Robert Stoelting, MD, president of the Anesthesia Patient Safety Foundation, in commenting on proposed measure #3040 said:

“The conclusions and recommendations of APSF are that intermittent ‘spot checks’ of oxygenation (pulse oximetry) and ventilation (nursing assessment) are not adequate for reliably recognizing clinically significant evolving drug-induced respiratory depression in the postoperative period. For the CMS measure to better ensure patient safety, APSF recommends that monitoring be continuous and not intermittent, and that continuous electronic monitoring with both pulse oximetry for oxygenation and capnography for the adequacy of ventilation be considered for all patients.”

 Or does “appropriate monitoring” mean continuous electronic monitoring?

The CMS guidance provides two examples — one from the Institute for Safe Medication Practices and one from APSF — which could suggest that the guidance may be referring to continuous electronic monitoring. For example, the guidance provides the following from ISMP which refers to monitoring for saturation of peripheral oxygen via pulse oximetry and end-tidal dioxide via capnography:

The CMS guidance also refers to APSF recommendations and its recent video on opioid induced ventilatory impairment.

In its video, APSF states that continuous electronic monitoring of oxygenation and ventilation, when combined with traditional nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment. The clinical significance continuous electronic monitoring offers is the opportunity for prompt and predictable improvement in patient safety.

APSF is calling for a paradigm shift in opioid safety. According to APSF’s Dr. Stoelting:

 “It‘s time for a change in how we monitor postoperative patients receiving opioids. We need a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.”

Could CMS guidance have saved a life?

Following this CMS guidance for monitoring of patients receiving opioids wherever they are in the hospital could have saved the life of 18-year old, Amanda Abbiehl.

Amanda was admitted to hospital for severe step throat. She did not receive surgery. She was placed patient-controlled analgesia to manage her pain, but was not monitored.

As Amanda’s father asks:

“It isn’t standard practice to monitor patients with Capnography. However, if Amanda’s CO2 level had been monitored, wouldn’t this have alerted her caregivers so her life could have been saved?”

By this measure – continuous electronic monitoring with traditional nursing assessment and vigilance – Amanda may still be alive today. For this, CMS should be applauded for its new guidance.

The Good and Bad News for Patients Receiving Opioids: Physician-Patient Alliance Presents Survey Results at International Anesthesia Research Society Annual Conference

At the International Anesthesia Research Society annual conference, which took place May 17-20, 2014, the Physician-Patient Alliance for Health & Safety presented results from the first national survey of patient-controlled analgesia (PCA) practice. The survey results showed good news and bad news for patients receiving opioids.

Attendees present at the results lecture expressed disappointment that hospitals were not assessing patients for risk factor (such as opioid naïve, age, weight, etc) and performing double checks to ensure opioids were administered safely.

Michael Wong, JD, founder and executive director of the Physician-Patient Alliance, said that double checks ensure that the five rights of medication administration practice have been followed. Says Mr. Wong, “This means ensuring that these five rights occur – the right patient receives the right medication and the right dose via the right route at the right time.”

Optimism was expressed by attendees regarding the role of continuous electronic monitoring of patients receiving opioids. The survey found that adverse events have been averted and/or costs and expenses reduced by hospitals that are continuously monitoring their patients with pulse oximetry and/or capnography. This finding demonstrates the critical importance of using continuous monitoring as a technological safety net for patients. Additionally, it identifies a way in which hospitals may reduce their costs and expenditures.

“However, when we looked at the type of smart pump being used at the facilities reporting a decline in adverse events or a return on investment, there was a significant correlation with those using smart pumps with integrated end tidal monitoring,”says Mr. Wong. “Those using smart pumps with integrated end tidal monitoring were almost three times more likely to have had a reduction in adverse events or a return on investment when measured against costs and expenses (including litigation costs) that might have been incurred. These are critically important and significant findings a hospital can use to improve quality and safety while reducing total costs.”

The Physician-Patient Alliance is preparing a follow-on survey with those hospitals that said that they were continuously monitoring its patients receiving opioids. Explains Mr. Wong, “This second survey will provide better understanding of the role continuous monitoring has in reducing adverse events and hospital expenditures, and illuminate those best practices from these hospitals.”

For a pdf of the poster presentation, please click here.

CMS Guidance Recommends Monitoring of All Patients Receiving Opioids

The Centers for Medicare & Medicaid Services (CMS) issued on March 14, 2014 revised guidance, “Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids”.

In an open letter to CMS discussing the guidance, the Physician-Patient Alliance for Health & Safety applauds CMS for this guidance as a step in the right direction to improving the safety of patients receiving opioids.

The CMS guidance recommends “at a minimum” that hospitals “have adequate provisions for immediate post-operative care, to emphasize the need for post-operative monitoring of patients receiving IV opioid medications, regardless of where they are in the hospital.”

In addition and more importantly, the CMS guidance necessitates monitoring for all patients receiving opioids when in hospital:

Narcotic medications, such as opioids, are often used to control pain but also have a sedating effect. Patients can become overly sedated and suffer respiratory depression or arrest, which can be fatal. Timely assessment and appropriate monitoring is essential in all hospital settings in which opioids are administered, to permit intervention to counteract respiratory depression should it occur.

 This CMS guidance provides increased vigilance to patients receiving opioids, particularly those patients receiving opioids postoperatively. CMS explains the reason behind the issue for this guidance:

Each year, serious adverse events, including fatalities, associated with the use of IV opioid medications occur in hospitals. Opioid-induced respiratory depression has resulted in patient deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoring of the patient’s respiration rate, oxygen and sedation levels2. Hospital patients on IV opioids may be placed in units where vital signs and other monitoring typically is not performed as frequently as in post-anesthesia recovery or intensive care units, increasing the risk that patients may develop respiratory compromise that is not immediately recognized and treated.