By Sean Power
May 21, 2015
At the inaugural meeting in November 2014 of the National Coalition to Promote Continuous Monitoring of Patients on Opioids, James D. Harrell, RCP, from the San Diego Patient Safety Council (SDPSC) offered compelling reasons why hospitals need to change the way they monitor patients outside of the intensive care unit (ICU) for respiratory compromise.
Respiratory compromise continues to be a major problem at hospitals across the United States. It is the second-most frequently occurring preventable patient safety issue according to a recent report by HealthGrades.
According to Mr. Harrell:
“There is growing evidence supporting what clinicians, providers, anesthesiologists, and pharmacists know is a serious patient safety risk: patients are subject to significant harm or death while receiving sedating medications without appropriate monitoring and intervention.”
Below we highlight three reasons outlined in Mr. Harrell’s presentation why hospitals need to monitor patients for respiratory compromise outside of the ICU.
1. Preventable deaths and anoxic brain injury from unrecognized opioid-related sedation and respiratory depression remain a serious and growing safety concern, according to the Anesthesia Patient Safety Foundation (APSF).
In 2011 the APSF issued a statement that “clinically significant, drug-induced respiratory depression in the postoperative period remains a serious patient safety risk.”
At that time the Physician-Patient Alliance for Health and Safety (PPAHS) conducted a survey on the APSF conclusions and recommendations. The survey also sought perspectives on the American Society of Anesthesiologists (ASA) Standards of Basic Anesthetic Monitoring (ASA Standards).
PPAHS asked doctors, nurses, physician assistants, healthcare administrators, and patient advocates what they thought of the APSF recommendations and ASA Standards.
We found that 90 percent believe continuous electronic monitoring of oxygenation and ventilation should be available and considered for all patients. Such monitoring would reduce the likelihood of unrecognized clinically significant opioid-induced respiratory depression in the postoperative period.Yes! I agree: patients need to be monitored for #respiratorycompromise outside the ICU #ptsafety Click To Tweet
Hospitals need to monitor patients for respiratory depression outside of the ICU to reduce the likelihood of opioid-induced respiratory depression.
2. The Joint Commission (TJC)’s Sentinel Event Alert Issue 49 identified opioid administration as an underlying cause of sentinel events.
In 2012, TJC issued a Sentinel Event Alert on the safe use of opioids in hospitals. Among other suggestions, TJC said that hospitals should implement a number of practices to reduce the risk of serious adverse events related to the administration of opioids. These suggestions can be implemented outside of the ICU. Recommendations include:
- Screen patients for respiratory depression risk factors
- Assess any history of analgesic use or abuse, duration, and possible side effects to identify potential opioid tolerance or intolerance
- Individualize the treatment and adopt a multimodal approach. Such an approach combines strategies including psychosocial support, the coordination of care, and the promotion of healthy behavior, among other options
- Not all pain will go away. Focus on managing pain rather than eliminating it.
PPAHS released a PCA Safety Checklist to help address some of these areas for improvement for patients receiving opioids via patient-controlled analgesia (PCA). Download it here.My hospital has made strides in respiratory monitoring outside the ICU #ptsafety Click To Tweet My hospital is actively working to improve respiratory monitoring outside the ICU #ptsafety Click To Tweet
3. The SDPSC has put forth a number of recommendations for respiratory monitoring outside of the ICU. These recommendations make it straightforward for bedside caregivers to improve patient safety.
Mr. Harrell outlined eight steps contained within the SDPSC’s Respiratory Monitoring of Patients Outside the ICU: Guidelines for Care Tool Kit:
1. Assess for risk. The bedside caregiver assesses the patient for the presence of identified risk factors. This assessment involves using standardized and validated tools for obstructive sleep apnea (OSA) and sedation. It also entails identifying respiratory depression risk factors, such as medication related factors and medical condition/physical state factors.
2. Identify risk level. A number of medication-related and known or suspected OSA/sleep disorder risk factors exist. The graphic below illustrates escalating factors for respiratory compromise outside of the ICU.
3. Decide whether to monitor. SDPSC acknowledges that many hospitals are not fully equipped to offer end tidal CO2 (EtCO2) monitoring for all patients. They suggest triaging the monitors based on risk factors until the appropriate number of monitors is acquired.
4. Determine monitoring method. EtCO2 monitoring measures ventilation; pulse oximetry monitoring (SpO2) measures oxygenation. Hospitals need to monitor patients for both ventilation (to detect hypoventilation) and oxygenation (to detect hypoxia) in tandem to fully safeguard against respiratory compromise.
5. Educate, engage, and coach. SDPSC recommends providing printed education materials to the patient and family/care partner at the appropriate times. Patients should also be engaged in discussion before monitoring about the purpose and importance of monitoring. While being monitored, patients should receive education about the importance of wearing the monitoring cannula or non-invasive ventilation appropriately. When discontinuing monitoring, caregivers should explain to the patient and family/care partner that the monitoring would be provided until the clinicians deem it to be no longer necessary.
6. Monitor the patient. Ensure adequate surveillance of the patient. SDPSC suggests considering spot checks versus continuous monitoring versus central monitoring. PPAHS and others recommend continuous monitoring for all patients receiving opioids.
7. Intervene. When respiratory compromise occurs, intervene rapidly to prevent injury or death.
8. Document, evaluate, and communicate. Document screening results, risk level, sedation score, the moment when the monitoring protocol is initiated, and any patient condition changes. Evaluate the decision to discontinue respiratory monitoring after a re-assessment of the patient and respiratory risk factors. Notify patient and the family/care partner of the patient’s respiratory risk level and apprise all care team members at shift change.
What would you add to the SDPSC’s recommendations?