Capnography, Patient Monitoring, Patient Stories

Patient Stories Shared at First Meeting of National Coalition to Promote Continuous Monitoring of Patients on Opioids

The Physician-Patient Alliance for Health and Safety today released the patient stories it shared at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids.

“We hope that the adverse events and deaths of patients who have suffered opioid-induced respiratory compromise may serve as inspiration to encourage the adoption of continuous electronic monitoring of all patients receiving opioids,” said Physician-Patient Alliance Executive Director and Founder Michael Wong, JD.

In particular, two moving stories were shared at the inaugural meeting.

Brian Abbiehl, who is on the board of directors for Physician-Patient Alliance, recounted the tragic events leading to the death of his daughter Amanda. Along with his wife Cindy, Brian established A Promise to Amanda Foundation as a tribute to Amanda, and to educate patients and their loved ones about the need for continuous monitoring of patients receiving opioids.

Retired Michigan State Trooper Matt Whitman shared his own experience with opioid-induced respiratory compromise that nearly claimed his life.

For a full copy of all of the stories shared with the meeting’s attendees, please click here.

Patient Monitoring, Patient Safety, Patient Stories, VTE, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Nov 7, 2014)

This week’s must-reads bring the worst possible news: patient deaths.

Death After Routine Teeth Extraction

Seven-year-old Tyneisha Bell died five hours after visiting the dentist for a routine procedure – three teeth extracted.

Tyneisha Bell

(To view the FOX news report, please click here)

For the procedure, Tyneisha was given general anesthesia.

Death During Childbirth

ABC news reports that “Kymberlie Shepherd, 26, died shortly after giving birth … The cause of her death was a rare amniotic fluid embolism (AFE), a leading cause of maternal mortality in the developed world.”

Kymberlie Shepherd

(Kymberlie Shepherd with her fiancé, Wayde)

Death Because of a Failure to Monitor and Rescue

In this emotional video about the death of her father, Annette Smith makes a plea for continuous electronic monitoring.

Curtis James Bentley

(Curtis James Bentley)

If you’d support Annette’s plea for continuous electronic monitoring, please support the work of the National Coalition to Promote Continuous Monitoring of Patients on Opioids and join the Respiratory Compromise Institute.

Patient Monitoring, Patient Safety, Patient Stories

What Puts More Than Half a Million Lives at Risk Each Year and Costs the US Healthcare System $7.8 Billion Annually?

Join the newest Physician-Patient Alliance Initiative to Reduce the Risk of Respiratory Compromise and Save Lives. By simply signifying your support for reducing the risk of Respiratory Compromise and for saving the lives of patients, you can help ensure changes are made.

If steps had been taken sooner, the lives of countless numbers of patients might have been saved, including:

Amanda Abbiehl Amanda Abbiehl

John LaChance

To help save lives and learn more, please click here.

Alarm Fatigue, Patient Monitoring, Patient Safety, Patient Stories, Weekly Must Reads in Patient Safety

Weekly Must Reads in Patient Safety (Oct 24, 2014)

It’s National Healthcare Quality Week and National Respiratory Care Week!

However, according to Pascal metrics, there is no reason to celebrate. Studies show that a third of patients are harmed in U.S. hospitals and the consequent financial burden of this harm may run to over $100 billion annually.

John LaChance died of opioid-induced respiratory depression. His story is retold by his wife, Patricia LaChance, in this poignant plea for better patient assessment and use of continuous electronic monitoring.

So, in keeping with the theme of quality and more particularly the need for better quality in respiratory care, here are this week’s reads on how to improve the quality of healthcare.

Quality Improves When Doctors and Nurses Work Together

Thank you @Nursiverse for pointing out this article by @paulinechen on research that nurses and doctors working together in the obstetrics and gynecology unit of a hospital “resulted in a significant decrease in the number of adverse patient outcomes, like traumatic birth injuries, admissions to the intensive care unit and death”.

Interesting! But, isn’t that the same thing that parents teach their elementary children – play nice in the sand box?

Actions Produce Results

Want to be a leader? Act like one. The leaders that act are generally most admired than those that just lip service to principles.

Hats off to @TGandhi_NPSF for tweeting about this study about the affects of rounds, culture, and caregiver burnout. If leaders want to change culture and behavior, they need to be involved.

Don’t Get Caught Up in Crying Wolf

Great tweet @ECRI_Institute on this article that compares alarm fatigue with “crying wolf” – except for patients, the “wolf” could be an adverse event or death.

Strict Malpractice Laws Do Not Reduce Health Care Costs

Thanks @Paduda for pointing out this study.

According a RAND Corporation study published in the New England Journal of Medicine, laws that make it harder to sue physicians for malpractice do not reduce hospital emergency department care costs.

To Improve Quality, Data is Needed

To make changes that improve quality, data is needed. According to a recent survey, patient safety leaders lack detailed, real-time harm data.

Unfortunately, efforts to prevent the flow of data have been undertaken at CMS.

Revision notice: An earlier draft mistakenly included a link to It has been replaced by the appropriate link. Our apologies.

Capnography, Patient Monitoring, Patient Safety, Patient Stories

Sleep Apnea + Opiods = Post-Surgical Preventable Death

[Editor’s note: This article first appeared in The Doctor Weighs In. The team at Physician-Patient Alliance for Health & Safety thank Pat for her tremendous courage and working with us on this tragic story of what happened to her husband. We hope that in this retelling, hospitals will be encouraged to ensure that similar events become “never events”.]

By Patricia LaChance

After undergoing what most people would consider a routine surgery, my husband John, died. Just as heartbreaking as John’s passing was to me is the fact that his death was entirely preventable.

Please click on the picture to view the video about John.

Please click on the picture to view the video about John.

John died because his medical history was ignored and because he was not properly monitored after he was placed on a strong narcotic to ease the pain from his surgery to repair a torn rotator cuff in his shoulder.

That is the simple version of John’s story, but of course, there’s much more to it than that. Since he left us in March of 2007, I have come to learn a lot about what caused his death, and I want to share my experience so that other families, nurses, doctors and hospitals can prevent what happened to him.

John suffered from sleep apnea, which John and I thought at the time was merely a sleep issue. We had no idea it could also be a fatal issue.

John underwent two surgeries. His first was a same day surgery. After this first procedure, he experienced a great deal of trouble recovering from the anesthesia. He struggled for hours to wake up enough to be able to leave the hospital.  He was very groggy, nauseated and dizzy.

During the months that followed, he struggled with similar side effects from several narcotics that were prescribed for his pain management. He had two severe episodes at work – one he was able to sleep off at home; the other required an ambulance ride to the emergency room.

Six months later, John’s shoulder injury required a second repair. Immediately following this second surgery, John — like millions of Americans who undergo surgery — was placed on patient-controlled analgesia (PCA), commonly known as a “pain pump” that intravenously delivered opioid medication to help him manage his pain. We were familiar with PCA, but unaware of the dangers associated with it.

Prior to and following John’s second shoulder surgery, I discussed his opioid-intolerance and sleep apnea with all of his caregivers, but he was nevertheless placed on PCA. Once again, his body rejected the medication and became extremely ill.

Observing John’s discomfort, a nurse disconnected him from the PCA pump and directly administered Dylaudid, a stronger opioid. With the removal of the PCA pump, the Pulse Oximetry and supplemental oxygen were also removed. Within minutes, he seemed to be comfortable – comfortable to the point that he did not move or speak to me again – he just stared at the ceiling. I was concerned about his condition, but the nurse was not.

Thinking John was finally going to get some much needed rest at the end of a trying day, I kissed him on the forehead, told him that I loved him, and promised to return first thing in the morning to take him home.

But that isn’t what happened. In the early hours of the morning, John passed away.

With all my heart, I wish I had known that night what I have come to understand today: Patients receiving opioids after surgery – especially those with sleep apnea – are at very real risk of fatal respiratory depression.

That’s exactly what happened with John. He fell into a deep sleep, and was not able to awake. Because he was not monitored, his caregivers had no idea that he was in trouble.

This did not need to happen. If the hospital had used technology such as capnography and pulse oximetry to continually monitor John’s respiratory status, he would still be with me today.

John meant the world to me, our children and his family, and many friends. Together, we sincerely hope that other families never have to go through what we did. For that to happen, I strongly believe that there are two critical patient safety issues that our nation’s hospitals must immediately address:

  1. In far too many instances, post-surgical patients are placed on opioid therapy with little or no consideration given to their medical histories, especially as they relate to medication tolerance. When I recently spoke to the Maryland Association of Nurse Anesthetists, one of the points I made was that each individual patient needs to be assessed for medication intolerance. Not all patients can tolerate the same medications. Yet, my observation is that far too often, opioids are automatically the medication of choice, and the patient’s medical history is not taken into consideration. My husband is a prime example.
  1. Continuous monitoring of all post-surgical patients receiving opioids should be a national standard of care. Recently, the Centers for Medicaid Centers for Medicare & Medicaid Services (CMS) issued guidance recommending that patients receiving opioids after surgery should be continuously monitored for signs of respiratory depression.

The CMS guidance perhaps summarizes this best when it states:

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.



Patient Monitoring, Patient Safety, Patient Stories, Post-Operative Monitoring

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.

Procedural Guidelines Table

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.

 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.

Patient Monitoring, Patient Stories

Medical Error Takes a Father’s Life: A Daughter’s Plea for Answers

By Annette Smith

My 65 year old father, Curtis James Bentley, died in a hospital, and yet almost two years after his death, I still do not know what happened to him. The hospital and my father’s physicians have not provided this information. Why?

Curtis Bentley

My father had recently undergone successful surgery to place a stent in his heart at Emory Healthcare. The procedure had gone well. I was told that he was “100% clear,” and he was discharged from the hospital and went home. However, a review of his discharge summary recently revealed he was sent home with eight abnormal blood levels. This was a beginning of his demise in my opinion.

While recuperating at home, he started bleeding. He was coughing up blood, having nose bleeds and blood was present in his stool and in the toilet.

I took him to the ER at Piedmont Henry Hospital, where he was diagnosed with a lesion in his colon and admitted to ICU. That was Friday, September 7, 2012. I left once on Saturday to get food and clothes in preparation for staying with him the entire weekend if need be. We were supposed to go fishing.

However, on Sunday morning, I woke up from dozing on and off. No one had been in my father’s room for the past two hours since 2 am. A nurse finally came into my father’s room around 4 am. It was very brief. After not checking him for two hours, you would think it would be more thorough. I took the opportunity to take a much needed break from my vigilance at my father’s bedside.

I went to the restroom, stopped at the snack machine, called my husband and sat for awhile in the waiting room. While I was away from my father’s room, I heard a Code Blue sound. At first I thought it was for him, but it was for the neighboring patient. I sat a little while longer, but then I had an uneasy feeling. Something told me to go check on him.

I went back and saw that the Code Blue was indeed for the neighboring patient and that many physicians and nurses had responded. However, no one was with my father.

When I walked in, I couldn’t see my father’s face right away. One leg was hanging out the bed. Embarrassed, I asked him what was he doing, but he did not respond. I asked him a second time as I was covering him up. The TV went to a commercial at that moment and the light hit his face which was down against the railing. He was positioned like he was trying to get out, perhaps trying to get help. When I looked closer, I saw that my father was taking his last breath. I knew immediately that it was his last breath, as my step father had died in my arms. Their last breaths were identical.

I ran out calling for help.

A nurse came. During this time I’m yelling, “Where were you, where were you?” One nurse had the nerve to tell me, “You need to calm down!” I told her, “Don’t tell me to calm down! Where were you? Why wasn’t a code called for him?” She had no answer.

I had been in the room with my dad. No nurse had been present. No machine had alerted them to his deteriorating condition. Someone should have seen him, visually, as recommended by the Institute for Safe Medication Practices.

My father was intubated and placed on life support. I found out by reading his medical records that he had gone into a coma, was brain dead, suffered paralysis and necrosis. No one at the hospital told me that. He was in a coma for seven days and he never came out of it. Research shows, those types of adverse events are sustained from going too long without oxygen. What happened to Curtis James Bentley from 4-4:45? Was he calling for me? This was a critical moment that was not documented and haunts me.

A day or so after the code, I talked to the charge/manager nurse about what her staff had done (or rather not done) on that awful morning. She brought one of her fellow nurses in as a witness, I guess. My sister was there, too. I explained to her that there was no one around when my dad coded. No one was at the station monitoring him, nor any of the other patients for that matter – all except for the neighboring patient for whom the Code Blue had been called.

The charge/manager nurse told me “Well, when our adrenaline gets going, our focus is on one patient.”

I took a deep breath. The tears started rolling. I asked her, “You mean to tell me, if you have 15 patients on ICU, they are going to go uncared for because your focus is on one patient!?” She couldn’t say a word. She knew that was the wrong thing to say. She had just admitted that they had neglected to treat my father, while attending to that one neighboring patient.

I told her she shouldn’t say that to people. Then she said, “I’m sorry; someone is supposed to be monitoring these patients at all times.” I expressed my guilt for leaving his side and she fed me this story about leaving her mother home alone. She died too. It brought no comfort to me. Not after what she had previously said.

During those next seven days, I talked to my father, because I was told the hearing is the last to go. I called to him. I begged him not to go. I finally said enough is enough. It took everything in me to sign the form to take him off life support. My oldest sister and I lay on his chest until … My baby sister and my best friend were there giving us much needed support. I had to endure those last breaths…one-last-time…

This nurse and her colleagues had dropped the ball. But, tragically, this was not a game – my father lost his life, because they dropped the ball.

Isn’t that why patients are admitted to the ICU, because they need and must receive constant intensive care second by second? And, in order to receive that intensive care, should his nurses have been watching him, rather than leaving him alone for more than two hours? Should they not have used available monitoring technology to alert them of his condition when they were not in his room assessing his condition? How did they know the neighboring patient had coded, but not my father?

My father did not receive timely care and rapid response – I was the one who found him unresponsive and alerted the nurses to his last breath. There were no monitors that could have and should have alerted his nurses that he was in trouble? Why?

I have asked the hospital and his physicians these and many other questions. I deserve an explanation. All families deserve an explanation when something happens to their loved one.

I feel betrayed by the hospital, his physicians and nurses. I entrusted my father into their care, and they don’t care enough to speak openly and honestly with me about what happened.

Must I sue the hospital just to find out?

I wonder how many out there have gotten a call in the night saying, we’ve done all we could do, but you really don’t know if they did. You weren’t there. Or you stepped away and suddenly they are gone. Just how much trust should we put in the hands of these doctors and nurses?

I want to bring awareness in the name of my father, Curtis James Bentley, to people who have loved ones in ICU, to take notes, get involved, and know every nurse, doctor, procedure, times, machine hookups, medications and everything about your loved ones. Don’t assume when you walk through the doors of a hospital, that your loved ones are in great hands. Know the hospital you are choosing for them. Know what their success rates, health grades and complaints are. Get involved!

Would my father be here today had the proper monitoring taken place? Sadly, I will never know…

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 or at WNDU’s latest coverage of the Promise to Amanda Foundation.

Patient Stories, VTE

Recurrent Stroke Victims’ Stories Illustrate Need for New Treatment Guidelines

By Michael Wong, JD, Executive Director, Physician-Patient Alliance for Health & Safety

(This article was first printed in Becker’s Hospital Review. What follows is just an excerpt. To read the full article, please click here.)

Heart-rending cases like that of Steven Spence — a 68-year-old man who suffered a second stroke in his home only hours after being treated for his first one in a hospital — underscore the urgent need to create new standards for in-hospital and transition-of-care treatment of stroke patients, advocated by neurological health and patient safety experts.

In this article, expert opinion on stroke is provided by two members of the stroke patient safety group assembled by PPAHS. The stroke patient safety group will ultimately compile a stroke VTE safety recommendations to help guide and remind healthcare providers in the in-hospital and transition-of-care treatment of stroke patients.

The two members of this expert panel are:

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.


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:

  • 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.


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.