By Harold Oglesby, RRT, Manager, Pulmonary Medicine, St. Joseph’s Hospital/Candler Health System, and Michael Wong, JD, Executive Director, Physician-Patient Alliance for Health & Safety
(This article first appeared in Becker’s Clinical Quality & Infection Control.)
Though continuous electronic monitoring of all patients receiving patient-controlled analgesia is not a universal practice among the nation’s hospitals today, a new survey indicates it may become one soon.
At our presentation on Nov. 13th at the Partnership for Patients annual conference, we discussed the results of the “First National Patient-Controlled Analgesia Survey of Hospital Practices” conducted by A Promise to Amanda Foundation and the Physician-Patient Alliance for Health & Safety, and the track record of “event-free” monitoring by St. Joseph/Candler Hospitals in Savannah, Ga., which is now almost approaching its tenth anniversary.
The National PCA Survey found a strong positive correlation between continuous electronic monitoring and a reduction in adverse events and/or costs and expenses (including litigation costs). Of the 168 hospitals responding to the survey from across 40 states, 137 said that they continuously monitor some or all of their patients.
Of those hospital that monitor, 65 percent believe that continuously electronically monitor experienced positive results — either in terms of a reduction of overall adverse events or have had a return on investment when measured against costs and expenses (including litigation costs). The other 35 percent of those that monitor say it is “too early to determine or have not determined” whether they have seen a reduction in adverse events, costs or expenses.
Those hospitals that do monitor and have experienced a positive result are split as to whether they use both monitoring devices or just one is used. Slightly less than half of these hospitals (44 percent) monitored with both pulse oximetry and capnography, while the others (56 percent) monitored with either one of pulse oximetry or capnography.
While the merits or demerits of using pulse oximetry or capnography have been much debated, the survey found a significant correlation with those using smart pumps with integrated end tidal monitoring. Those using smart pumps with integrated end tidal monitoring were almost three times more likely to have had a reduction in adverse events or a return on investment when measured against costs and expenses (including litigation costs) that might have been incurred. (OR=2.789; 95% CI 1.112-6.996).
This positive experience reported by survey respondents in averting adverse events or reducing costs and the role of end tidal monitoring is evidenced by the track record of St. Joseph’s/Candler Hospitals.
Based in Savannah, Georgia, SJ/C are two of the oldest continuously operating hospitals in the nation. SJ/C average about 25,000 patient discharges each year. Its staff includes 407 physicians, 716 nurses, 95 respiratory therapists and 50 pharmacists, all of whom have a highly interactive and collaborative relationship with administration.
In the fall of 2002, SJ/C implemented an advanced, modular IV medication-safety system for large volume and syringe pumps. Prompted by three opioid-related events with serious outcomes that had occurred in the preceding two years, SJ/C was absolutely determined to improve its patient safety record.
As SJ/C implemented the system, it recognized that the safe use of PCA required both correct pump programming and monitoring of patients’ individual respiratory response to opioids. Early in the decision-making process, SJ/C’s respiratory care team was called in to address monitoring options. SJ/C believed that having respiratory care involved was critical because respiratory threapists have strong clinical assessment skills, they understand capnography monitoring and its limitations, and they are able to apply solid clinical judgment as they guide the care of patients suffering from respiratory issues. SJ/C also made sure that its nursing staff had an active role in the process, which greatly increased the staff’s knowledge of and willingness to use the new monitoring modules.
After a six-month beta testing revealed that capnography, not pulse oximetry, provided the first indication of opioid-related respiratory depression, SJ/C decided to require a capnography module for each PCA infusion and to use a pulse oximetry module for selected PCA patients with preexisting comorbidities.
Early on in the evaluation process, a problem was identified: Staff noticed that the capnography monitor would alarm, indicating a high respiratory rate of 40 breaths per minute even though the patient’s actual rate was just 20 bpm. SJ/C resolved that issue by collaborating with the device’s manufacturer to decrease the monitor’s threshold so that true breaths and not fluctuations in the respiratory pattern would be counted as breaths. Also early on, SJ/C developed a new cannula, designed specifically to provide an increased surface area for CO2 sampling — and as a result, improve the accuracy of the monitoring.
As SJ/C’s clinicians grew more comfortable with capnography, a wealth of benefits from the technology was realized. The clinicians were far better equipped to identify unforeseen risk and undiagnosed clinical conditions that predispose patients to respiratory complications from IV opioids. In particular, capnography enabled them to identify such “high risk” situations as:
- Narcotic overdose leading to respiratory depression
- Apnea alarms
- Undiagnosed sleep apnea
- Post-op pneumonia and atelectasis
- Congestive heart failure
SJ/C found that because opioid-induced respiratory depression poses a real risk to patient safety, clinicians tend to be overly cautious in administering narcotics, often resulting in inadequate pain control for the patient. This issue is solved with capnography because continuous monitoring provides clinicians with assessment tools that assist in the detection of respiratory depression and allow safer administration of analgesics.
Ultimately, SJ/C found that compared to traditional methodology, capnography greatly improves patient safety and also enables PCA patients to effectively manage their pain. Moreover, in June of 2013, SJ/C celebrated nine years of “event-free” PCA use.
Beyond the intangible value of protecting the lives and safety of patients, SJ/C has also achieved significant tangible savings in keeping them from harm’s way. In fact, SJ/C’s estimates show that by implementing capnography for PCA patients, it saved more than $3.9 million over a five-year period (2002 to 2007) — and that’s not even factoring in potentially multi-million-dollar litigation costs.
The story of SJ/C is but one example of how capnography improves patient safety and lowers costs. The national survey indicates that are many others, which suggested that perhaps one day continuous electronic monitoring of all patients receiving PCA will become standard hospital practice.