To honor the life of Amanda Abbiehl, who died after being connected to a patient-controlled analgesia (PCA) pump on July 17, the Physician-Patient Alliance for Health & Safety (PPAHS) calls for continuous electronic monitoring with pulse oximetry for oxygenation and with capnography for adequacy of ventilation.

PCA pumps deliver powerful opioids to patients to manage pain. Use of opioids can lead to respiratory compromise. According to the U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality, respiratory compromise is the third most rapidly increasing hospital inpatient cost in the United States, with $7.8 billion spent on respiratory compromise in US hospitals in 2007. Respiratory compromise increases patient mortality rates by over 30 percent and increases hospital and ICU stays by almost 50 percent.

18-year old Amanda Abbiehl tragically died in 2010 at Saint Joseph Regional Medical Center (SJRMC).

The cause — a PCA (patient-controlled analgesia) pump error. As the petition filed with Indiana’s Patient Compensation Fund states:

 “Against her treating physician’s orders, Amanda was given a constant dose of Hydromorphone once she was connected to the PCA pump … Amanda’s family, as well as SJRMC staff, have indicated it took several staff members a long time to program the pump.”

As Amanda’s father, Brian Abbiehl, said:

 “My wife and I believe in our hearts and minds that had there been a protocol in place requiring the use of a monitor … she would still be with us today.”

 The Anesthesia Patient Safety Foundation (APSF) has called for a substantial change in the way patients receiving opioids are monitored.

“It’s time for a change in how we monitor postoperative patients receiving opioids,” declares Dr. Robert Stoelting, president of the APSF. “We need a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.”

The APSF released a video highlighting the conclusions and recommendations that came out of a 2011 conference on opioid-induced ventilatory impairment.

In the video, APSF states that continuous electronic monitoring of oxygenation and ventilation, when combined with traditional nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment.

To help address adverse events and death associated with the use of PCA, PPAHS brought together a group of renowned health experts to develop the PCA Safety Checklist, including intensive care specialist and a leader in medical checklist development Peter J. Pronovost, MD, PhD, FCCM, Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient; and Atul Gawande, MD, Professor in the Department of Health Policy and Management at the Harvard School of Public Health, who is a surgeon at Brigham and Women’s Hospital Professor of Surgery at Harvard Medical School and author of “The Checklist Manifesto.”

The PCA Safety Checklist is a concise checklist that reminds caregivers of the essential steps needed to be taken to initiate PCA with a patient and to continue to assess that patient’s use of PCA.

The checklist:

• Summarizes information about the characteristics of patients at higher risk for over sedation and respiratory depression;
• Helps to ensure that patients have been appropriately educated about their pain management before using a PCA pump
• Reminds healthcare providers of potential red flags
• Makes sure the patient is electronically monitored with both pulse oximetry and capnography, and
• Provides guidance on assessment and pump settings verification at shift change.

 The PCA Safety Checklist is a free resource on the PPAHS site at: https://ppahs.org/pca-safety-checklist-download/

• Opioid Safety
• Respiratory Compromise