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

Respiratory Therapy Magazine Highlights Flawed Monitoring Practices, Features PPAHS Article on Opioid Safety

by Sean Power

Volume 8 Number 1 February-March 2013 of Respiratory Therapy Magazine features an article by the Physician-Patient Alliance for Health & Safety that summarizes the points of view of four experts.

The magazine calls attention to four flawed monitoring practices discussed at a webinar involving Dr. Frank Overdyk, Professor of Anesthesiology at Hofstra North Shore-LIJ School of Medicine; Ray Maddox, Director of Clinical Pharmacy, Research and Pulmonary Medicine at St. Joseph Candler; Tammy Haslar, Oncology Clinical Nurse Specialist at the Franciscan Alliance at St. Francis Health, and Debbie Fox, Director of Respiratory Care at Wesley Medical Center.

Let’s recap those flawed practices:

  1. Trusting that intermittent spot checks of vital signs are sufficient for assessing respiratory rate and CO2 levels.
  2. Continuously monitoring only “high risk” patients.
  3. Relying on pulse oximetry alone to detect respiratory depression.
  4. Implementing a monitoring program without creating an education plan.

The article present solutions for each problem highlighting that safer patient care is within reach of hospitals. The Respiratory Therapy Magazine feature comes on the heels of Patient Safety Awareness Week during which the PPAHS re-announced our PCA Safety checklist.

To hear a replay of the webinar, please click here.

What other flawed monitoring practices have you encountered? What solutions work?

Patient Safety, Patient-Controlled Analgesics, PCA

Health Experts Discuss Four Flawed Monitoring Practices

by Sean Power

Recently four health experts participated in a webinar on The Joint Commission’s Sentinel Event Alert on the safe use of opioids. On the panel were patient safety experts including Dr. Frank Overdyk, Professor of Anesthesiology at Hofstra North Shore-LIJ School of Medicine; Ray Maddox, Director of Clinical Pharmacy, Research and Pulmonary Medicine at St. Joseph Candler; Tammy Haslar, Oncology Clinical Nurse Specialist at the Franciscan Alliance at St. Francis Health, and Debbie Fox, Director of Respiratory Care at Wesley Medical Center.

The panel discussed the role of continuous monitoring in opioid safety. To watch the entire webinar, please click here.

Below we’ve outlined four flawed monitoring practices discussed in the webinar that can be fixed to improve outcomes for patients using patient-controlled analgesia (PCA) pumps.

1. Trusting that intermittent spot checks of vital signs are sufficient for assessing respiratory rate and CO2 levels.

Vital sign monitoring occurs at two- to four-hour time intervals. When a patient receives a particular dose of opioids in between spot checks, it is impossible to predict how the patient will respond to the dose in terms of respiratory depression. As Dr. Overdyk observes, some of the “tell-tale signs” of opioid induced respiratory depression are best appreciated by trends in vital signs of nursing assessments such as respiratory rate, level of CO2, and level of consciousness. “Spot checks completely miss these trends,” says Dr. Overdyk.

Instead of intermittent spot checks, Dr. Overdyk recommends continuous monitoring of ventilation and oxygenation with capnography and pulse oximetry.

2. Continuously monitoring only “high risk” patients.

“The Joint Commission recommends risk stratifications as to who we monitor continuously,” says Dr. Overdyk. The list of risk factors include a number of criteria including patients who are on higher opioid doses, morbid obese, at extremes of age, experience sleep apnea/snoring, are opioid naïve, smoke, use synergistic RD drugs such as sleeping pills, and a have history of tolerance or abuse. Meeting one of these conditions makes a patient “high risk” according to The Joint Commission. “To be honest,” continues Dr. Overdyk, “I look at this list, I can’t remember a patient in recent history who did not have one or more of these conditions.”

Part of the challenge to categorizing patients as “high risk” is that some of these criteria go undiagnosed. For instance, 12.5 million Americans take pain relievers for non-medical uses and there exist 8 million chronic opioid users in the United States. Obstructive sleep apnea is undiagnosed in 85-95% of patients. These conditions may not appear in a patient’s history.

Sharing his own experience implementing a continuous monitoring program at St. Joseph Candler, Mr. Maddox says the hospital learned that “undiagnosed sleep apnea is more prevalent than expected.” The difficulty in assessing risk level makes risk stratification ineffective in some cases.

The solution is to continuously monitor all patients using PCA pumps after surgery. “That would serve a zero tolerance policy,” explains Dr. Overdyk, helping hospitals to meet the 2006 recommendation by the Anesthesia Patient Safety Foundation that no patient shall be harmed by opioid induced respiratory depression in the postoperative period.

3. Relying on pulse oximetry alone to detect respiratory depression.

As Ms. Fox presents, “The respiratory cycle has two separate processes: ventilation and oxygenation.”

Dr. Overdyk explains, “Pulse oximetry and capnography basically measure two different processes that are vital to our existence; namely, the intake of oxygen on one side and the elimination of carbon dioxide on the other.”

Until recently, pulse oximetry, which measures oxygenation, was the only way to assess respiratory function. When respiratory depression occurs, oxygenation levels will gradually fall to a point where the pulse oximeter detects the respiratory depression event.

According to Ms. Fox, this delay between the moment when pulse oximetry detects an RD event and the moment when the event actually occurs is increased by supplemental oxygen. “The patient may be breathing,” says Ms. Fox, “but the oximeter will not reveal quantitatively how well the patient is actually ventilating and moving air.”

Monitoring end tidal CO2 measures breath-to-breath ventilation and detects hypoventilation. Oximetry measures oxygenation and detects hypoxia. “If you want to effectively monitor the respiratory status then both capnography and pulse oximetry should be used,” says Ms. Fox.

4. Implementing a monitoring program without creating an education plan.

Introducing and implementing a monitoring program requires buy in and participation from key stakeholders including nurses, respiratory therapists, physicians, hospital leadership, and risk management teams. Sustaining change, notes Ms. Haslar, requires patient buy in and participation, as well. By communicating the purpose and benefits of the monitoring program, hospitals can set “patient expectations for compliance with monitoring,” notes Ms. Haslar.

Ms. Haslar offers some ideas on communicating with community stakeholders and patients. “Consider an awareness campaign for going live,” says Ms. Haslar. Promoting the hospital’s key stakeholders who were included in the decision-making process can establish peace of mind and build unity behind the program. Discuss the monitoring program “during pre-op appointments” and “while going over surgery instructions,” suggests Ms. Haslar. Provide a patient brochure on essential monitoring strategies. Utilize nurses, respiratory therapists, and physicians to help improve patient compliance.

As Ms. Fox notes, “Patient education is the key to patient compliance. It would be ideal to educate patients prior to surgery.” These tactics should be part of a broader individualized patient plan that reflects monitoring strategies that minimize adverse outcomes from opioid therapies.

In addition to educating patients, hospitals need to remember to implement a training program for new hires. “It’s definitely important to add education for your new hires as well,” says Ms. Haslar. “Sometimes that can be overlooked.”

Sean Power is the Community Manager for the Physician-Patient Alliance for Health and Safety (PPAHS). He also blogs for a non-profit medical and research foundation, AMREF, that focuses on improving healthcare in Africa. Power cares deeply about achieving better clinical outcomes for all patients in every healthcare facility.

Capnography, Monitoring Liability and Costs, Patient Safety, Patient-Controlled Analgesics, PCA

How often do errors with patient-controlled analgesia (PCA) occur?

by Michael Wong

Many readers of this website have asked, how often do errors with patient-controlled analgesia (PCA) occur?

In a retrospective analysis lead by Rodney Hicks (who at the time of the study was Manager, Patient Safety Research and Practice, United States Pharmacopeia), the magnitude, frequency, and nature of non-harmful and harmful medication errors associated with PCA were studied. (Professor Hicks is now Professor, Western University College of Graduate Nursing, Pomona, California).

Over the five-year review period, of the 919,241 medication errors records from the 801 reporting healthcare facilities, just 1% (or 9,571) were associated with PCA. Although 1% may seem insignificant, this analysis was based on the voluntary medication error reporting program, MedMarx.

“Although generalization of voluntary reported findings to the general population should be done cautiously,” as Professor Hicks points out, “The general rule of thumb is that for every reported event, there can be between 300-1,000 unreported events.”

Using this rule of thumb, based on 9,571 reported events, this would mean that between 2.8 million and 9.6 million total events (unreported & reported) occurred over the five-year period from July 1, 2000 to June 30, 2005. On an annualized basis, this would mean that about 600,000 to 2 million events per year could involve PCA.

“A further study would need to be done to ascertain the total number of PCA events,” explains Professor Hicks, “but the problem is extensive in my opinion.”

Moreover, when the study looked at the number of events that caused harm, there were 624 records of PCA associated with harm, corresponding to 6.5% of the patients. Again, while 6.5% may seem small, as the study found, “By comparison, during the same period, only 1.5% of all other errors reported to MedMarx led to harm. This represents a fourfold higher relative risk of harm for PCA events.”

“All health care disciplines were implicated in the errors, including physicians, pharmacists, and nurses” Hicks reported.  “Therefore, it will take an inter-disciplinary team to resolve the problems”.

As Professor Hicks concludes:

Our analysis was in no means trying to discourage the use of PCA pumps. Many studies have shown the benefits of using PCA, including improved pain management, better utilization of nursing resources, increased patient satisfaction, and improved pulmonary function.

However, this is clearly an area that standardization needs to occur and organizations need to invest in training and policies and procedures as well as equipment – all areas to promote safety.

Moreover, although elimination of error is critical, studies have shown even a correctly programmed PCA pump poses patient safety risks. In their study, “Continuous Oximetry/Capnometry Monitoring Reveals Frequent Desaturation and Bradypnea During Patient-Controlled Analgesia”, Dr. Frank Overdyke and his colleagues point out, “The most serious complication of patient-controlled analgesia (PCA) is respiratory depression (RD).” They found that:

continuous respiratory monitoring is optimal for the safe administration of PCA, because any RD event can progress to respiratory arrest if undetected.

As Ray Maddox and his colleagues point out in their study “Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and ‘Smart’ Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes”:

Even correctly programmed, appropriate doses of opiates can suppress respiration and decrease heart rate and blood pressure. Episodes of bradypnea and desaturation can escalate to respiratory depression (RD) requiring rescue. The success rate for in-hospital cardiopulmonary resuscitation remains less than one in five patients. If detected early, most cases of opioid-induced respiratory depression can be treated with naloxone. However, severe cases can be fatal.The risk of patient harm due to medication errors with PCA pumps is 3.5-times the risk from any other type of medication administration error.

These researchers therefore recommend:

Capnographic monitoring—measurements of ventilation using respiration and exhaled carbon dioxide (EtCO2)—is particularly important because it can provide an earlier warning of respiratory depression than pulse oximetry (SpO2) in some patient populations.

What do you think? Are you aware of any other studies that have looked at PCA error incidence rates?