by Pete Weber, BA, RRT, RPSGT

Editor’s Note: Bellin Health in Green Bay, Wisconsin, had experienced serious patient safety events related to respiratory depression and oversedation in patients during the postoperative period.

These events led the 167-bed hospital to initiate a program for continuous electronic monitoring. Since implementing the program, Bellin has experienced zero respiratory events since May 19^th, 2009. Pete Weber, who managed and led the project, offers Bellin’s experience in the guest article below.

At Bellin Health, a 167-bed hospital in Green Bay, Wisconsin, we knew we needed to prevent deaths related to oversedation and respiratory compromise after experiencing adverse safety events in patients during the postoperative period.

These patients, we observed, often demonstrated indicators that put them at higher risk of oversedation. By focusing education, monitoring, and intervention efforts on patients at high risk for respiratory depression, Bellin has been free of serious respiratory events since May 19, 2009.

At the project’s inception, our overall aims were straightforward: create a protocol to identify and handle high risk patients. This protocol would need to:

• Define high risk patients
• Trigger the Bellin System to their arrival
• Plan a communication process to maintain focus on the risks involved with treating high risk patients for every caregiver
• Implement care and monitoring for high risk patients, and
• Identify sleep apnea patients at risk for oversedation.

The Department of Health and Human Services reported in January 2012 that 86 percent of patient reportable harm went unreported. For Bellin, being able to prevent and report patient harm begins with identifying high-risk patients.

Framing the Risk

For Bellin Health it was important to ensure that all reportable harm was considered within the context of the population we serve. Over 24 percent of the Wisconsin population has obstructive sleep apnea (OSA), which often goes undiagnosed.

It was therefore necessary for Bellin to develop a model for diagnosing sleep apnea and defining the risk factors associated with OSA upon their arrival at the Bellin Health System.

Other risk factors for respiratory compromise and oversedation include morbid obesity and chronic uncontrolled medical conditions. Specific pain management and sedation techniques contribute to the degree of risk associated with respiratory compromise and oversedation, as well.

At Bellin, we estimated that 40 to 45 percent of patients coming into the Bellin System were at high risk for respiratory compromise and oversedation based on these risk factors.

The STOP scoring model proved crucial in identifying high risk patients. This tool makes assessing patients for risk simple enough to assess the degree of risk for OSA before prescribing a pain management program.

• S – Snore
• T – Tired
• O – Obstruction (apnea)
• P – Blood pressure is high

If two out of these four conditions are met, the patient has a 50 percent possibility of experiencing OSA. If three conditions are met, that possibility rises to 60-70 percent. If the patient experiences all four conditions, it is 90 percent likely that the patient has OSA.

The STOP scoring system provided a framework for enabling frontline staff to identify risk for OSA.

Phase 1: A Successful Education and Pilot Program with Capnography

Once the protocol for handling high-risk patients we implemented Phase 1. Phase 1 of the project focused on educating nursing and respiratory care staff on how to identify patients at high risk of respiratory depression when being sedated during the postoperative period. The education program also explained physiological indicators of oversedation so that nurses could intervene in a timely manner.

Nursing and respiratory staff were taught about end tidal CO2 (EtCO2) monitors and interventions that prevented adverse events.

Phase 1 also introduced a pilot of the continuous electronic monitoring program. The pilot proved successful:

• Bellin experienced a reduction in Naloxone (Narcan) administrations/events.
• No deaths.
• No serious patient safety events related to respiratory depression.

Critical to the success of the pilot project was the use of capnography in monitoring exhaled carbon dioxide (EtCO2). Capnography provides the earliest indication of respiratory depression and gave Bellin staff the ability to intervene before respiratory depression progressed into an adverse event.

Phase 2: Redefining the Project and Engaging Surgeons

With “high risk patient” defined, a communication plan in place and working as intended, and a successful pilot project, it was time for the High Risk Team to redefine the definition and scope of the project.

Upon reviewing the project’s definition and scope, the team decided it would explore monitoring that integrates with Bellin’s common technology platform.

It was also time to engage surgeons. We presented the results of the orthopedic pilot to the Surgical Committee, reported back with the changes to the project’s definition and scope, and shared a plan to spread the continuous electronic monitoring program to the surgical floor.

The second phase of education on high-risk indicators and tools was rolled out to target areas and aimed to reach all patient care areas.

Since implementing Phase 2 of the project, Bellin Health has experienced no serious respiratory events since May 19, 2009.

The project also showed a reduction in Narcan administration and events since expanding the pilot project from orthopedics to the surgical, medical, and cardiac departments.

Some considerations underlie these accomplishments in reducing the number of adverse respiratory events.

One such consideration was the assignment of caregivers to high-risk patients. The acuity of a patient’s presenting symptoms and conditions is assessed. This assessment determines the patient’s proximity to the nursing station, the nurse’s level of experience with high-risk patients, and the frequency and scope of documentation.

Importantly, EtCO2 and respiratory rate quality was documented hourly in addition to pain medication dose on set, peak, and half-life.

Phase 3: Next Steps

By the time the continuous electronic monitoring program was in place, 409 patients per month were being monitored on EtCO2 with capnography.

Next steps include:

• spreading the continuous electronic monitoring program to the rest of the system
• integrating monitoring and risk assessment into procedural areas
• assuring compliance and sustainability
• including ASA guidelines for conscious (moderate) sedation monitoring, and
• publishing our results.

We believe that our success with continuous electronic monitoring will add to the growing body of research and case studies that support end tidal CO2 monitoring in the postoperative period. Bellin Health’s success in eliminating respiratory events since May 19, 2009 is an accomplishment of which we are proud.

I encourage other hospitals to consider implementing continuous electronic monitoring and high-risk patient protocols at your facilities.

• Respiratory Compromise