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.

Capnography, Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring

Opioid Safety Experts Say Continuous Monitoring of Post-Surgical Patients Receiving Opioids Should Be Universal Standard

Continuous electronic monitoring of patients receiving opioids to manage their pain after surgery should be a universal standard of care, leading opioid safety experts said during a recent webinar.

The March 4, 2014 webinar was hosted Premier Safety Institute as part of their Advisor Live series.

“There is no doubt that patients who have either sedation or postoperative pain management do require some sort of monitoring,” said Bhavani S. Kodali, MD, Associate Professor, Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School.

Dr. Kodali was joined in the PSI webinar by:

  • Harold Oglesby, RRT, Manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System (SJC);
  • Joan Speigel, MD, Assistant Professor, Anesthesiology, Harvard Medical School and Beth Israel Deaconess Medical Center;
  • Gina Pugliese RN MS FSHEA, Vice President, Premier Safety Institute (moderator); and
  • Michael Wong, JD, Executive Director, Physician-Patient Alliance for Health and Safety.

These experts agreed that continuous monitoring of post-surgical patients receiving patient-controlled analgesia (PCA) – with the use of capnography or pulse oximetry – should be a requirement in all hospitals. Specifically, capnography assesses how effectively patients are breathing by measuring exhaled carbon dioxide (CO2) and alerts caregivers when life-threatening respiratory depression could occur. Oximetry monitors patients’ blood oxygen levels and alarms staff when a patient may potentially may not be receiving sufficient oxygen.

“What I’d like to point out is that these alarms do is two things,” said Dr. Speigel. “One, it’s the essence of the alarm itself, but also just having the device there, so an end tidal CO2 alarm, actually is a surrogate for patient attention. I find that to be fascinating whether or not it’s really the device that’s helping the patient or whether or not it’s the nursing staff and the family who is paying attention to the device and hence the patient. Regardless, if the outcomes are better, I think that’s a very interesting thing to think about.”

These health experts also emphasized the importance of training and patient education. When instituting continuous monitoring, hospitals must ensure that their nursing staffs are thoroughly trained and should be deemed competent at least annually in its use and safety, the experts stressed.

“One point that is very, very clear is: to establish monitoring in the postoperative period, it requires a lot of training,” said Dr. Kodali. “Sometimes it is very, very difficult to achieve good monitoring in big hospitals because of the simple nature of personnel involved. As [Mr. Oglesby] pointed out, it requires first of all an initiative by the respiratory therapists who can understand capnography. Anesthesiologists know very well capnography but they are not actually the persons to implement it.”

Educating PCA patients and their loved ones about monitoring when opioids are used are safety components that should also be a key initiatives in hospitals, the experts agreed. Patients may be knowledge-naïve in this monitoring respect and need to be enabled to advocate for themselves.

“Communication with patients and their families is just so critical in achieving safe and effective PCA use and better alarm management,” said Mr. Wong.

Mr. Oglesby concurred and added that patient and family education – combined with essential staff training and competencies– have helped SJC to avoid any opioid-related event since it started using capnography to monitor PCA patients more than nine years ago.

“The key for us in order to have the success that we had was, one, education; particularly patient and family education where we educated the patients, specifically on why they were wearing the device and educated the family on why they were wearing the device,” said Mr. Oglesby. “We had much higher compliance with the device. Sometimes the patients and family members had to educate some of the staff and remind them why the patient was on the end tidal CO2 monitor and not to get too hyped about alarms. We developed a basic and understandable education for the families and the patients. When they understood what it was there for, our compliance shot out the roof and we had no issues with compliance in wearing the device.”

Capnography, Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring

8 Key Points to Improving Patient Safety: Physician-Patient Alliance for Health & Safety Presents at AORN Annual Conference 2014

At the annual conference of Association of periOperative Registered Nurses (AORN), which took place March 30 – April 2, 2014, the Physician-Patient Alliance for Health & Safety (PPAHS) presented eight key points to improve patient safety and health outcomes.

Three of the most commonly overlooked clinical points are:

  • Verify hand–off or transition of care from nurse-to–nurse that continuous electronic monitoring is in place, has been maintained and double-checked.
  • Double check PCA dosing, pump parameters, and continuous monitor settings.
  • Include in the post-operative orders daily lead changes and hands off communication on lead changes to decrease nuisance alarms.

Lynn Razzano RN, MSN, ONCC (Clinical Nurse Consultant for PPAHS), who represented PPAHS at the AORN conference, says that the tremendous interest shown by AORN nurses in the PPAHS presentation shows how important is the proper management and monitoring of patients receiving opioids. Ms. Razzano recounts what conference attendees told her about the vital need to order continuous electronic monitoring:

“Perioperative nurses emphasized to me that they should be the identified patient advocate for safety and ensure all patients receiving opioids are ordered continuous electronic monitoring. Although perioperative pace is hectic and there is tremendous pressure to conduct quick operating room turnover, perioperative nurses can never forget that their commit to the patient does not end following surgery. Following surgery, the post-operative order for continuous electronic monitoring should be made for all patients receiving opioids.”

The eight key clinical relevant points were contained in poster presentation #29 entitled, “First National Survey of Patient –Controlled Analgesia Practices: Results and Implications for Standards, Nursing Assessment and Patient Safety”. Please click here to view a PDF of the handout of the PPAHS poster.

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

Why You Should Let Patients Participate in PCA Safety Checklists, Too

by Sean Power

(This article first appeared in Healthcare News.)

Last month, in an Outpatient Surgery e-weekly newsletter, Jim Burger shared research by Tulane University Hospital and Clinic in New Orleans, suggesting that surgical teams are more likely to use the World Health Organization’s (WHO) Surgical Safety Checklist when patients know about the existence of such checklists. All of the informed patients said that knowing about the checklist made them feel more comfortable going into surgery.

In the study, which was presented at the American Society of Anesthesiologists’ conference, students secretly monitored 104 procedures. In 43 cases, patients were told about the checklist; in the other 61 procedures, patients were left in the dark.

According to the article, compliance on all of the items on the checklist was higher when patients were aware of its existence.

Below, I outline three reasons why, like the WHO Surgical Safety Checklist, you should share the Patient-Controlled Analgesia PCA Safety Checklist with your patients.

1. Evidence-based checklists improve patient safety. Sharing checklists with patients will increase patient confidence, comfort, and satisfaction.

Peter Pronovost, MD, PhD, FCCM (Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient Care), describes the process of translating evidence into practice:

  • Summarize the evidence in a checklist.
  • Identify local barriers to implementation.
  • Measure performance.
  • Ensure all patients get the evidence.

Evidence should guide decisions. Since checklists summarize evidence it is crucial that physicians comply with the steps outlined by checklists.

Based on the Tulane research, patients will feel more confident, more comfortable, and more satisfied when they see the PCA Safety Checklist before they receive anesthesia.

2. Checklists help communicate with patients and families and clarify the patient’s role in safe care.

Since checklists are evidence-based, when you share them with patients you effectively give them a crash course on all of the evidence behind the care that they are about to receive.

Physician compliance to checklists, demonstrated by the Tulane study, is important to safe care. Patient compliance is equally important. When patients understand what is expected of them in light of the evidence at hand, they are more likely to comply.

For example, some patients receiving PCA complain of discomfort from the capnograph’s nasal cannula that measures carbon dioxide in exhalations. When nurses explain the importance of capnography, and that measuring end tidal CO2 can alert medical staff if the patient has stopped breathing, patients become more willing to comply.

Tammy Haslar, Oncology Clinical Nurse Specialist at the Franciscan Alliance at St. Francis Health, suggests nurses discuss the monitoring program “during pre-op appointments” and “while going over surgery instructions.” Doing so sets expectations for the patient and offers reasons for complying with safety measures.

Sharing the PCA Safety Checklist with patients before their operation helps to make sure that nothing is overlooked and that expectations are communicated clearly. This communication will increase the likelihood that patients fulfill their own expectations.

3. Sharing checklists with patients fosters a culture of transparency.

Dr. Pronovost explains that transparency prevents harm:

“To be accountable for patient harms, health care needs valid and transparent measures, knowledge of how often harms are preventable, and interventions and incentives to improve performance.”

Transparency with patients promotes accountability, which leads to safe care. Accountability both rewards good behavior and deters poor performance. Sharing checklists with patients enables them to participate in the accountability discussion.

The PCA Safety Checklist is a free resource offered by the Physician-Patient Alliance for Health & Safety that was developed by a multidisciplinary team of experts. It is designed to minimize adverse events associated with PCA. You can download Word version here or a “checkable” PDF here.

Have you shared the PCA Safety Checklist with your patients? What kind of reaction did you receive?

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.

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

The Intertwined Stories of Amanda Abbiehl and Continuous Electronic Monitoring

In the recent article, “Silent Danger: PCA Pumps and the Case for Continuous Monitoring” published by Association for the Advancement of Medical Instrumentation in Biomedical Instrumentation & Technology, the story of 18-year old Amanda Abbiehl is told as a powerful reminder of the need for continuous electronic monitoring.

Amanda was admitted to hospital for “severe strep throat”, placed on a patient-controlled analgesia pump to manage her pain, and passed away – most likely because of opioid-induced respiratory depression.

In this slide share, this article has been adapted and retold.

The Physician-Patient Alliance for Health and Safety wishes you the best for this holiday season. Our New Year’s Resolution is to do everything we can to eliminate tragedies like Amanda’s. Join us in making a #promise to Amanda to achieve zero preventable deaths associated with opioid-respiratory depression at your hospital.

Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA

Continuous Electronic Monitoring Reduces Adverse Events and Hospital Expenditures: Physician-Patient Alliance for Health & Safety Awarded Permanente Journal Service Quality Award

The Physician-Patient for Health & Safety (PPAHS) is pleased to announce that its presentation on the national survey of hospitals on patient-controlled analgesia (PCA) hospital practices was awarded the Permanente Journal Service Quality Award. The award was presented December 10, 2013 at The 25th Annual IHI National Forum on Quality Improvement in Health Care.

For a pdf of the poster presentation, please PPAHS IHI Poster.

Respondents to the survey consisted of almost 200 hospitals from 40 states and provide a benchmark for measuring what hospitals are doing and not doing to ensure patient safety practices with PCA.

The survey is the first time that hospital practices regarding PCA have been surveyed nationally. Michael Wong, JD (Executive Director at the Physician-Patient Alliance for Health & Safety) says that the survey provides a benchmark of practices.

“The survey shows what hospitals are doing and not doing when initiating and continuing patients on PCA, which likely accounts for the adverse events and deaths related to PCA use” says Mr. Wong. “The survey found that hospitals across the country are not consistently assessing patients for risk factors. For example, almost one out of five hospitals are not assessing patients for being opioid naive, and about three out of 10 hospitals do not consider obesity as a patient risk factor, despite the indications of many studies that have shown the increased risk of using anesthesia with obese patients.”

Moreover, the survey also found that hospitals have been able to reduce adverse events, costs, and expenditures through continuous electronic monitoring of their patients.

“Hospitals that have implemented continuous electronic monitoring of patients are realizing tremendous patient safety benefits as a result,” says Mr. Wong. “In fact, 65 percent of the surveyed hospitals that electronically monitor said they have not only reduced incidences of respiratory depression and other adverse events significantly, but also lowered their post-surgical costs and expenses.  The remaining 35 percent stated that it was either too early to determine or that they have not yet determined what benefits they have derived from the technology.”

“Considering this positive finding of the survey,” says Frank Federico, RPh (Executive Director at the Institute for Healthcare Improvement and a member of the Patient Safety Advisory Group at The Joint Commission), “it seems obvious that hospitals that have not yet implemented continuous electronically monitoring of their patients on PCA would be wise to do so.  That’s not to suggest that continuous monitoring is a ‘silver bullet’ solution for reducing adverse events.  Clearly, the safe use of opioids is a multi-step process, and its success requires systemic collaboration within the hospitals that implement it.  However, the opportunity to reduce adverse events and death, and to decrease costs and expenditures is not only good for patients but for our healthcare system looking to achieve cost savings.