5 Keys to Successful Monitoring of Patients Receiving Opioids
We wanted to know what are the keys to successful patient monitoring.
We could think of no better person to speak with than Harold Oglesby, RRT, Manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System (SJ/C). Since June 2004, SJC has been more than 10 “event free” years of patient safety.
Moreover, although a human life should never be measures in dollars and cents, SJ/C calculated that their decision made great financial sense. Over the 5-year period from 2002 to 2007, SJ/C:
- Saved $4 million — estimated potential expenses averted (not including potential litigation costs)
- Had a 5-year return on investment of $2.5 million.
SJ/C is a two hospital system, with tertiary care, community, and referral centers. Comprised of two of the oldest continuously operating hospitals in the nation, SJ/C is the largest healthcare system in southeast Georgia with 675 beds and approximately 25,000 annual discharges.
What prompted SJ/C to continuously monitor its patients receiving opioids?
Although I’d like to think that SJ/C has always been monitoring our patients receiving opioids, unfortunately this is not the case.
We experienced three opioid-related events with serious outcomes in the two years preceding our embarking on a multiyear process of implementing an advanced IV medication safety system. This system is a modular IV medication safety system with PCA pumps and pulse oximetry and capnography monitors on a common technology platform.
This advanced IV medication system was used initially on a small scale more than 10 years ago. Now, capnography monitoring has become widespread at SJ/C. The monitoring technology is currently utilized for both non-intubated and intubated patients, in the ICU, on the general floor wherever patients are receiving opioids, in the emergency room, and for patients who are having procedural sedation.
However, please don’t wait for the death of a patient or, as we did, for a serious adverse event to occur. If you truly believe in providing the best care you can for your patients, you’ll be implement improvements now and not wait or a poor outcome to occur.
Why did SJ/C choose capnography over other monitoring technology, such as pulse oximetry?
Don’t rely on pulse oximetry – that’s a lesson we quickly learned during our 6-month beta testing period.
This 6-month beta test of new patient-controlled analgesia (PCA) pumps and monitoring modules integrated with the existing IV safety platform was begun in June 2004. Beta testing revealed the difficulty of predicting which patients actually were high-risk. We did note that capnography, not pulse oximetry, provided the first indication of opioid-related respiratory depression. As a result, the decision was made to require a capnography module for each PCA infusion and to use a pulse oximeter module for selected patients receiving PCA analgesics who have preexisting co-morbidities.
In order to implement continuous monitoring, were there adjustments that had to be made to how SJ/C’s clinical staff took care of patients?
Optimal care of patients is a team effort. For patient monitoring to be successful on nursing units, at SJ/C, physicians, nurses, pharmacists, and respiratory therapists worked together to develop policies and procedures, standardized PCA dosing forms, physician notification parameters, opioid drug libraries, routine order sets for SpO2 and EtCO2 monitoring, criteria for discontinuing monitoring, and a reversal agent protocol. The use of supplemental oxygen was aligned with policies.
However, two clinical teams are particularly important to the day-to-day, frontline implementation of continuous electronic monitoring.
First, having nurses involved at every step of preparation and implementation greatly increased the nursing staff’s knowledge of and willingness to use the new monitoring modules.
Second, respiratory care must be an integral part of the process. Why? Respiratory therapists have an EtCO2/SpO2 knowledge base, keen clinical assessment skills, ability to intervene and resolve potential respiratory emergencies, and are available around the clock.
We often hear from clinical staff that too many alarms sounding is what prevents them from using patient monitoring more extensively. In a national survey we conducted across 40 states in the United States, 90 percent of hospitals believe reducing false alarms would increase the use of patient monitoring devices (like pulse oximeters and capnographs). This survey was conducted before The Joint Commission made better alarm management a patient safety goal. What has SJ/C done to avoid nuisance alarms?
During our beta testing period, the team programmed the system to generate an alert if a patient’s respiratory rate was less than or equal to 10 bpm or there was “no breath” for 30 seconds. In practice, this resulted in an unexpectedly high number of “nuisance” alarms.
When they do their assessments, the respiratory therapist may make adjustments depending on the patient. For example, if they have a COPD [chronic obstructive pulmonary disease] patient that normally runs a higher EtCO2, then they will make an adjustment based on that patient.
However, although “false” alarms can be annoying, remember this – an alarm that sounds may stimulate the patient who is experiencing respiratory compromise.
“False” alarms should not be ignored, but should spur clinical teams to find out what needs adjustments – the patient’s treatment or the monitor’s default settings.
We have heard from some clinicians, who have become patients, that wearing the nasal cannula for the capnography machine can be uncomfortable. How have you gotten your patients to “buy into” wearing the cannula?
Compliance can indeed be an issue. The key for us in order to have the success that we have had is education. In particular, we educate patients and their families on why they are wearing the device.
Once patients and their families understood what the nasal cannula was there for, our compliance shot through the roof and we had no issues with compliance in wearing the device.
Sometimes the patients and family members have even educated some of our staff and remind them why the patient was on the end tidal CO2 monitor and not to get too concerned about alarms.
Most of the patients featured on the Physician-Patient Alliance for Health & Safety website, who have died because of respiratory compromise, were those who looked like they should have no medical issues before being sent home. Sadly, many of them were soon to be discharged – like John LaChance – or had been discharged – like Logan Parker. What do you say to these clinicians?
Some clinicians refer to the “eye ball” test as a predictor of who needs more attention and who may not. They may want to use end tidal CO2 monitoring just on the patients that look the sickest.
However, our beta testing revealed the difficulty of predicting which patients actually were at high-risk. So, now SJ/C requires capnography module be used for all PCA infusions and, as I mentioned earlier, end tidal monitoring is used across our hospital units – in the ICU, on the general floor wherever patients are receiving opioids, in the emergency room, and for patients who are having procedural sedation.