Capnography, Monitoring Liability and Costs, Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

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).

Harold Oglesby - Celebrating 10 Years's Event Free

(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.”

Patient Safety, Postoperative Pain

Pain is not the “5th vital sign”

By Skeptical Scalpel

No, contrary to what you may have heard, pain is not the 5th vital sign. It’s not a sign at all.

Vital signs are the following: heart rate; blood pressure; respiratory rate; temperature.

What do those four signs have in common?

They can be measured.

A sign is defined as something that can be measured. On the other hand, pain is subjective. It can be felt by a patient. Despite efforts to quantify it with numbers and scales using smiley and frown faces, it is highly subjective. Pain is a symptom. Pain is not a vital sign, nor is it a disease.

How did pain come to be known as the 5th vital sign?

The concept originated in the VA hospital system in the late 1990s and became a Joint Commission standard in 2001 because pain was allegedly being undertreated. Hospitals were forced to emphasize the assessment of pain for all patients on every shift with the (mistaken) idea that all pain must be closely monitored and treated .

This is based on the (mistaken) idea that pain medication is capable of rendering patients completely pain free. This has now become an expectation of many patients who are incredulous and disappointed when that expectation is not met.

Talk about unintended consequences. The emphasis on pain, pain, pain has resulted in the following.

Diseases have been discovered that have no signs with pain as the only symptom.

Pain management clinics have sprung up all over the place.

People are dying. In 2010, 16,665 people died from opioid-related overdoses, a four-fold increase from 1999 when only 4,030 such deaths occurred. And the number of opioid prescriptions written has doubled from 109 million in 1998 to 219 million in 2011.

Meanwhile in the 10 years from 2000 to 2010, the population of the US increased by less than 10% from 281 million to 308 million.

Doctors are caught in the middle. If we don’t alleviate pain, we are criticized. If we believe what patients tell us—that they are having uncontrolled severe pain—and we prescribe opioids, we can be sanctioned by a state medical board or even arrested and tried.

Some states now have websites where a doctor can search to see if a patient has been “doctor shopping.” I once saw a patient with abdominal pain in an emergency room. After looking up her history on the prescription drug website, I noted that she had received 240 Vicodin tablets from various doctors in the four weeks preceding her visit.

That’s a lot of Vicodin, not to mention a toxic amount of acetaminophen if she had taken them all herself during that month.

What is the solution to this problem?

I don’t know, but as long as pain is touted as the fifth vital sign, I do not see it getting any better.

 

Capnography, Monitoring Liability and Costs, Patient Monitoring, Patient Safety, Patient Stories, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

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.

Capnography, Patient Monitoring, Patient Safety, Post-Operative Monitoring, Postoperative Pain

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.

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

  1. 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
  2. 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
  3. 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%).

findings

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!

APSF, Capnography, Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

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:

ISMP

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

APSF

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-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.

Patient Monitoring, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

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.

Patient Monitoring, Post-Operative Monitoring, Postoperative Pain

Identifying Patients at Risk for Postsurgical Opioid-Related Adverse Events

By Laura Menditto, MPH, MBA (Independent Health Outcomes Research Consultant, Laura A Menditto LLC )

What if there existed a way for perioperative nurses to identify patients at high risk of experiencing opioid-related adverse events (ORADEs)? Could hospitals evaluate the potential benefits of targeting high-risk patients for strategies aimed at reducing ORADEs? Could nurses and doctors use the scoring model to predict—and avoid—ORADEs in future patients?

At the annual conference of Association of periOperative Registered Nurses (AORN), which took place March 30 – April 2, 2014, researchers from Memorial Hermann Memorial City Medical Center in Houston, TX, led by Kathy Nipper-Johnson, BSN, RN, CCM (Director of Case Management and Social Services, Memorial Hermann Memorial City Medical Center) presented research seeking to answer these questions. They researched whether it is possible to develop and validate a risk score model to identify patients for pain management strategies.

The risk score model aims at reducing postsurgical ORADEs using hospital administrative data in adults who received opioids following gastro-intestinal (GI) or orthopedic surgeries.

You can download the poster presentation here.

High risk patients lead to more adverse events, longer stays, and greater costs

The researchers analyzed administrative claims data to identify adults who receive opioids following gastro-intestinal or orthopedic surgeries. Using logistic regression, the researchers stratified patients according to risk before applying generalized linear and binomial regression models to compare cost and length of stay (LOS).

The researchers found:

  • Of all 4,888 patients analyzed, 551 (11.3 percent) experienced ORADEs;
  • Risk factors included age, gender, pre-surgical opioid use, and several comorbidities such as diabetes and obstructive sleep apnea;
  • Higher risk patients stayed longer (7.2 days versus 4.1 days); and,
  • It costs more to care for higher risk patients ($21,292 versus $14,849).

Perioperative nurses, suggests the findings, should explore alternative postoperative pain management strategies in higher risk patients. If doing so could decrease ORADE incidence by 25 percent to 100 percent, length of stay could be decreased by 74 to 294 days, and accompanying costs decrease by $255,811 to $1,023,243 per 1,000 patients.

Table 3

One in four men and three in ten women were classified as high-risk, totaling 29.1 percent of patients. Overall, 22 percent of high-risk patients experienced one or more ORADEs, compared to only 6.9 percent of low-risk patients.

The final composite risk score model effectively predicted specific ORADEs and 30-day readmissions. Of all high-risk patients, 12.3 percent were readmitted within 30 days, compared to 9.1 percent for the low-risk population.

Figure 2

Compared to low-risk patients, high-risk patients tended to have longer LOS (7.2 days versus 4.1 days) and higher hospitalization costs ($21,292 versus $14,849).

Figure 3

Based on these results, alternative pain management strategies intended to decrease ORADE incidence from 25 percent to 100 percent, have the potential to reduce LOS by 74 to 294 days per 1,000 surgical patients, with accompanying savings of $255,811 to $1,023,243.

Figure 4

One size does not fit all when it comes to pain management

Opioids and their related adverse events threaten patient safety, lead to prolonged hospital stays, and increase the economic burden on hospital systems.

By using a risk score model, perioperative teams can identify high-risk patients who are not only pre-disposed to ORADEs based on their risk profile, but who are also more likely to have additional downstream consequences such as longer hospital length of stay, higher readmission rates, and greater hospitalization costs.

Initiatives that target high-risk patients for non-opioid pain management strategies may reduce opioid requirements and prevent these downstream consequences.

Editor’s note: Laura Menditto is a researcher with more than two decades of experience in health economics and outcomes research in the pharmaceutical industry. She received an MPH in 1999 from Drexel University, an MBA in 1995 from Philadelphia University and a BS, cum laude in 1981 from the University of the Sciences in Philadelphia. Ms. Menditto’s work has resulted in more than 40 peer-reviewed presentations at scientific meetings and journal publications. For this project, Ms. Menditto contributed expertise included knowledge of hospital database analyses methods, construction of predictive risk models and writing for scientific meeting presentation and publication.

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

Perspectives on Opioid Safety and Continuous Electronic Monitoring

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.

You can listen to the full recording here, download the slides here, and learn more about opioid safety here.

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.

impetus-for-the-survey

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.

patients-on-pca

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:

  • Obesity
  • 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.

pca-monitoring-trend-data

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.

Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

Identifying Risk of Respiratory Compromise for Patients Using Patient-Controlled Analgesia: Lessons Learned from a National Hospital Survey

In an article recently published in the Society of Anesthesia & Sleep Medicine newsletter (page 4), Michael Wong, JD and Lynn Razzano, RN, MSN, ONCC discuss identifying risk of respiratory compromise for patients receiving patient-controlled analgesia (PCA).

As noted by SASM’s editor (page 2), Satya Krishna Ramachandran, MD, FRCA (Assistant Professor in Anesthesiology and Director of Perioperative Quality Improvement, University of Michigan):

This newsletter contains articles that span preoperative screening, implementation of a screening tool in the electronic health record and the development of a PCA safety checklist. Michael Wong and Lynn Razzano present the findings of their 2013 survey of 40 hospitals regarding PCA safety and propose the development of a PCA safety checklist. They identify significant safety gaps in knowledge, screening, ongoing assessment and monitoring of patients on PCA. Such work is crucial to our refinement of monitoring standards and lays the platform for future observational research. 

To read a full copy of the article, please click on this link: http://sasmhq.org/wp-content/uploads/2014/02/SASM_Newsletter_01_2014.pdf

Capnography, Monitoring Liability and Costs, Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

PPAHS Joins Anesthesia Patient Safety Foundation in Call for a “Paradigm Shift” in Opioid Safety

by Sean Power
February 19, 2014

“It’s time for a change in how we monitor postoperative patients receiving opioids,” declares Dr. Robert Stoelting, president of the Anesthesia Patient Safety Foundation (APSF). “We need a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.”

The APSF recently released a video highlighting the conclusions and recommendations that came out of a 2011 conference on opioid-induced ventilatory impairment. You can find the video here.

In the 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.

According to Lenore Alexander, founder and executive director of Leah’s Legacy, a patient safety organization focused on safe opioid use:

“A monitor would have saved my child’s life. I have made the goal of continuous postoperative monitoring my commitment.

“All that stands between us and universal post op monitoring is the will to require it.”

In the APSF video, health experts warned of the risks of selectively monitoring some patients.

According to Nikolaus Gravenstein, MD, Professor of Anesthesia, University of Florida School of Medicine, APSF Committee on Technology:

“Who should be monitored electronically? I would say any inpatient but certainly any inpatient prescribed narcotics, because if they are prescribed they can be received.”

According to Michael DeVita, MD, Critical Care Medicine, St. Vincent’s Hospital:

“You need to absolutely require a continuous monitoring system if it’s your goal to prevent every possible death. Who should be monitored? Everyone.”

Mark Montoney, MD, MBA, Executive Vice President and Chief Medical Officer, Vanguard Health Systems, also argued that the costs of continuous electronic monitoring should not be an impediment to saving patients’ lives:

“No matter where you set the thresholds, I think you get too many false negatives and false positives. We either get this sense of security that everything is all right, when in fact it may not be. Or, we have these alarms that are going off that eventually our caregivers get desensitized to.

“I would agree with the notion of continuous monitoring. I don’t see the value of intermittent monitoring. I really stop short at talking about high-risk patients because, while we can define them in a category, we’re going to get burned when we try to differentiate because you don’t always know who’s a high-risk patient.

“One of the questions that’s been asked is, ‘Boy, this is going to cost a lot, isn’t it?’ And I say, ‘Can we not afford to do this?’”

The Physician-Patient Alliance for Health and Safety (PPAHS) applauds the APSF for its goal to prevent every possible death and adverse event associated with opioid induced ventilatory impairment and PCA therapy.