Health Experts Say Continuous Monitoring of Post-Surgical Patients Receiving Opioids Should Be Standard

Continuous electronic monitoring of patients receiving opioids to manage their pain after surgery should be a standard of care, leading health 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;

Below is a transcript of the discussion to which we have added topic headers for ease of referral.

On Whether Continuous Electronic Monitoring Should be a Standard of Care

BK: There is no doubt that patients who have either sedation or postoperative pain management, they do require some sort of monitoring-continuous or intermittent. There is no doubt as far as this statement is concerned.

Mr. [Harold] Oglesby says earlier papers show that there are times when these patients go through periods of hypoxia and respiratory depression. The question is, what monitor is best for this patient? There are a few things on the horizon, which it is still not known which monitor will ultimately be the best. Given the current circumstances, capnography and pulse oximetry seem to be the options now.

One point that is very, very clear is, to establish monitoring in the postoperative period, it requires a lot of training. Sometimes it is very, very difficult to achieve good monitoring in big hospitals because of the simple nature of personnel involved. As Harold [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.

The second thing is, there is a lot of training that is necessary for nurses about capnography. And then, there has to be some teaching to the patients themselves, as was pointed out, because to keep that nasal cannula in position requires some support on the part of the patient. The patient’s families should ensure that it doesn’t fall off by fixing it. The fixation of the catheter again is a training thing because the catheters can be fixed and stay for a pretty long time.

The last one is about alarms. There has to be a lot of education and also filtering certain false alarms and making alarms that are more predictable of some ongoing process rather than false alarm. Sometimes the combination is better—pulse oximetry with capnography to see if the false alarms can be minimized—but so far there is no standard criteria that has come up that can be used on a much wider scale in every postop position to say that this thing should be the most reliable methodology. In absence of that, it probably has to be worked out at each location. Train people, train the patients, and use the systems. Make sure that they get more predictable results.

MW: I just wanted to comment, you mentioned standard of care. For a lot of health care folks, it means standard of care for medicine. For an attorney, standard of care really means anything that my litigation colleagues can convince a judge and jury about. As an attorney I can say that I’d rather represent the hospital client that monitors outside the OR than one that doesn’t.

On The Need for Monitoring Training

JS: With end tidal CO2, of course, the training is the most important thing, is what to ignore and what not to ignore. Certainly it requires a lot of training. I don’t know how much I take it for granted that I understand the device very well—in capnography, that is. For the untrained person, what is going to trigger an alarm is very different than for myself.

It would be interesting for me to actually see these things in place before I make a decision about it. I don’t see them in the PACU [postoperative anesthesia care unit] very much—I’d like to see that—and do almost a QA [quality assurance] pilot trial to see in my experience what that looks like and what the alarm does. I can look at the data and everybody tells me that the alarms are very loud so I’d like to see a little bit more data on this and patients postop and get more empiric data on this before I can say what can be done to revise it.

HO: I can tell you from personal experience that our devices, and the way our facilities our designed, is we are based in our campuses with pods. We don’t only monitor capnography on the PCAs but it has expanded because of the success of monitoring patients on PCA. We also monitor patients that are on high dose opioids; say, for instance, dilaudid. If they’re on a dose that’s higher than two milligrams within every three hours or so, they have to have end tidal CO2 monitoring on them.

We also monitor end tidal CO2 on patients that are receiving propofol for moderate sedation. There are a lot of patients that are being monitored and if you’re in a pod and the alarm goes off, the alarm is loud and it is annoying. The alarm itself is part of the reason we have stimulations of our patients. If it stimulates the patient, it also stimulates the staff.

It is one of those alarms that is hard to ignore and it is definitely loud.

BK: No, actually, we don’t do any sleep studies pre-op because the system is probably not in place although it is a good practice if there is a recommendation to do it. Logistically it is difficult because if patients are seen in the pre-anesthetic test center, then they come into the operating room, then to get an appointment for sleep apnea, so we go mostly by the history and the physical presentation of the patient and go from there.

Also, I wanted to make one point about capnography monitoring. If any individual who gets well trained in capnography and gets very good in interpreting the use of capnography, gets so dedicated to his monitor that he will not be able to manage another patient without it.

What is very interesting about capnography is, if you understand how it works, how it can be monitored, how you can get the alarms set correctly to give you the right information, it is automatic that everyone will start depending on it. It is a very good sign because, as soon as you enter the room, you will be able to see how the patient is breathing, and what are the values compared to the baseline.

HO: I have one quick story that will shed some light on what you just said. When we first started using the end tidal CO2 monitor outside of the ICU [intensive care unit] and outside of the OR on our patients on the floors, we had one of our pulmonologists who wasn’t very receptive of capnography outside of the ICU or outside of the OR. But he had a patient that needed to be moved outside of the room and he wanted him monitored.

He said, “Just put him on capnography and monitor him and we’ll see if it really does anything.” It indicated that the patient was having some difficulty. We were able to resolve the issue out on the floor. Once the physician saw the value of the capnography on that particular patient he became a fond user of capnography outside of the ICU and outside of patients on PCA.

On Work Load

HO: That question was asked early on if we were going to have to increase our respiratory staff. We did not increase our respiratory staff. Part of the reason was because, prior to using the end tidal CO2 monitoring, we probably spent a good bit of our respiratory staff time resolving issues that were related to patients that got into trouble.

The other part of that was the fact that, just the design of our facility—like I said before, our facilities our designed in pods—so what happens is we get a print out each morning from our pharmacy and it’s actually in our EMR [electronic medical record]. We can go in and see exactly which patients are on PCA.

That becomes part of the therapist’s assignment so the therapist that is assigned to that area will do his visit to the patient that is on PCA and then does the documentation. We call it our end tidal CO2 assessment. They assess the respiratory rate, the respiratory effort, the pulse ox, the end tidal CO2, breaths sounds, the trend on the pulse ox, the sedation scale, and the level of consciousness.

They document that, 97 percent of the time, they’re already in that pod delivering therapy to another patient. It doesn’t take them very long to do the assessment that needs to be done. We did not require any additional therapists to do that.

On Need for Patient Education and Communication

HO: 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.

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.

MW: Communication with patients and their families is just so critical in achieving safe and effective PCA use and better alarm management. At PPAHS, we’ve recommended four essentials for patient safety. First, to ensure patients and their families are provided with information on proper use of the PCA pump.

HO: The other thing I just want to put out there is the fact that a lot of the staff wanted to put an end tidal CO2 monitor just on the patients that look the sickest—just on the patients with the biggest necks, the patient that looked like they would be probable. When you go back and look at Michael [Wong]’s pictures from those patients who just had poor outcomes and deaths, only a couple of them looked like they were sick. The other ones looked like they should walk out of the hospital.

MW: You’ll see, except for Robert Goode and Louise Batz, the other four are teenagers. You expected them to leave the operating room, in which case, they did. All of them had successful procedures. It was just postoperatively when the adverse events occurred. Ensuring that the patients know what the pump is doing—and I think that ISMP [Institute for Safe Medication Practices] and others have said no PCA by proxy—make sure the families understand that they’re being monitored for safety reasons.

Make sure the oximetry is clipped on their finger and the capnography is on the nose. Those kinds of things. Save yourself some trouble and educate the patient on what read-outs there are on these machines.

Lastly, educate the patients on why the alarms are sounding and what to do when they sound. Gesturing with the hand upon which the oximetry is clipped could sound an alarm. Taking off the capnography cannula will sound the alarm. Those kinds of things. So save yourself some trouble and that’s going to decrease the number of nuisance alarms that you hear.


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