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.