(These are excerpts of the poster presentation made at the recent annual meeting of the American Society of Anesthesiologists. It is reprinted with permission.)
Introduction
Preventable deaths in hospitals remain a major public health hazard worldwide. Analysis of registries for cardiopulmonary arrests (CPA) identified missed vital signs and symptoms of decompensation and spurred the development of RRT and MET teams. Although widely adopted, their impact on overall hospital morbidity and mortality remains unclear.
‘Alarm fatigue’, where poor ergonomics, integration and response to alarms on medical devices desensitizes providers to alarms was identified by the ECRI as the top health technology hazard for 2012, causing 500+ preventable deaths . The FDA, JC, AAMI, and ACCE have joined forces to remedy this patient safety hazard.
Alarm fatigue deaths are likely dwarfed by deaths from unrecognized opioid induced respiratory depression (OIRD) in patients who do not receive continuous electronic monitoring. The alarm fatigue cohort was made ‘visible’ by a 1990 US law, which requires manufacturers to report medical device related deaths. Similarly, “PCA by proxy” was identified by this mechanism. But preventable deaths from unrecognized RD constitute an ‘invisible’ group. The afferent loop of the RRT, which includes monitoring, is increasingly scrutinized as a potential cause for the lack of impact of RRT’s.
Patients receiving opioids and sedatives are exposed to OIRD by a SOC that allows VS to be taken as infrequently as every 4 hours, and provider education that has not kept up with the increasing acuity of in-patients and the side effects/proper dosing of new analgesics, anxiolytics, and sleep aids with RD side effects. The increasing prevalence of obesity and chronic opiate use, and associated co morbidities (OSA, obesity hypoventilation syndrome), have shifted the risk equation dramatically against the patient.
Objectives
To date, there is no registry that captures preventable deaths due to OIRD. These tragic cases are traumatic and emotional for both victims and providers, without consensus on cause, and details often sequestered behind legal firewalls. However, this set of closed legal cases typify non fatal conditions that may lead to death from unrecognized OIRD.
None of these patients received continuous monitoring. There was no evidence of PE, arrhythmias, ischemia, stroke or other etiology that explained CPA. Opioid induced respiratory depression is the likely common pathway in the demise of these patients with and w/o risk factors (suspected OSA, chronic opioid use, difficult airway). However, the medical/surgical conditions with which these patients presented to the health system were relatively benign.
[To preserve patient confidentiality, patient photos that appeared in this poster presentation are not reproduced. Instead below are photos of patients who died and were not continuously electronically monitored for oxygenation with pulse oximetry and adequacy of ventilation with capnography.
Leah Coufal (healthy 11-year old girl, found dead by her mother after elective surgery)
Louise Batz (grandmother, died after elective surgery)
Justin Micalizzi (died after surgery to incise and drain swollen ankle)
Amanda Abbiehl (18-year old college bound student, admitted to hospital for infection)
Please click on their photos to read their stories.]
Conclusions
Preventable deaths in hospitalized patients remain a serious patient safety hazard. Although alarm fatigue has been recognized as a risk in continuously e-monitored patients, deaths in patients with benign admission diagnoses experiencing unrecognized OIRD without continuous e-monitoring occur with regularity. Mechanisms to quantify the scope of this problem need to be urgently devised.
References:
Resuscitation 81 (2010) 1305–1352; www.ecri.org/2012_Top_10_Hazards; Resuscitation 81 (2010) 375–382; Anaesth & Intensive Care 39(4); https://ppahs.org
Some emailed comments:
Pediatric Anesthesiologist — “I can tell you with some degree of certainty that there are/were one or two narcotic related respiratory depression events each year at most pediatric hospitals that lead to either a respiratory arrest or in the worst case scenario go on to precipitate a cardiac arrest.”
Professor at Children’s Hospital — “all patients on PCA should be receiving supplemental oxygen with a delivery device that is capable of measuring CO2, and a pulse oximeter”
Pediatrics — “Certainly for non-fatal events this [respiratory depression] is ALMOST always the case (excluding sudden rhythm issues)”
Critical Care Physician — “The question is how to intervene, and how to treat pain and monitor safely.”
Anesthesiologist — “opiates are dangerous drugs and that monitoring would be a good idea IF we knew what to monitor (a drop in pulse oximetry is usually too late a sign)”
today, we have a new generation of monitors available . They are approved, on the market, and reduce false alarms by up to 95%. There is NO EXCUSE not to be using these monitors in every hospital in this country.If 4 children are left to die in a hospital bed, in each hospital , because we are not using technology that is available to us, that alone is 400 children dying needlessly. Just using the low numbers and assuming 100 hospitals. As a nation, we are mourning the deaths of those poor children in connecticut. Why can’t we talk about the hundreds, thousands of our babies dying needlessly within our medical system every day with a fraction of the outrage, and compassion ? Especially when the solution already exists!
Agreed. The solutions exist today. Let’s use them!
PPAHS encourages people to contact CMS to express their support for their proposed measure #3040 to adequately monitor patients using PCA (for more info, please see http://wp.me/p1JikT-q5):
* Email: measureapplications@qualityforum.org
* Subject line: CMS Proposed Quality Measure #3040
* Message suggestion: “Please adopt measure #3040 to ensure the safety of patients using patient-controlled analgesia by ensuring that all patients are continuously electronically monitored for ventilation with capnography and oxygenation with oximetry, as recommended by the Anesthesia Patient Safety Foundation.”