Failure to Effectively Monitor Postoperative Patients May Lead to Brain Injury or Death

ECRI Institute recently released its report, “Top Ten Technology Hazards for 2016”, which noted that failure to effectively monitor postoperative patients for opioid-induced respiratory depression can lead to brain injury or death.

This concern of ECRI is yet another call for improved safety measures for patient’s receiving opioids.

In August 2012, The Joint Commission issued Sentinel Event Alert #49 “Safe use of opioids in hospitals” which said:

While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation.

According to The Joint Commission:

A sentinel event is a Patient Safety Event that reaches a patient and results in any of the following:

  • Death
  • Permanent harm
  • Severe temporary harm and intervention required to sustain life

The Joint Commission issues Sentinel Event Alerts “because they signal the need for immediate investigation and response”.

In March 2014, CMS issued guidance “Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids.” This guidance recommends “at a minimum” that hospitals “have adequate provisions for immediate post-operative care, to emphasize the need for post-operative monitoring of patients receiving IV opioid medications, regardless of where they are in the hospital.”

In addition and more importantly, the CMS guidance necessitates monitoring for all patients receiving opioids when in hospital:

“Narcotic medications, such as opioids, are often used to control pain but also have a sedating effect. Patients can become overly sedated and suffer respiratory depression or arrest, which can be fatal. Timely assessment and appropriate monitoring is essential in all hospital settings in which opioids are administered, to permit intervention to counteract respiratory depression should it occur.

So, what constitutes “timely assessment and appropriate monitoring”?

According to the recent ECRI report, “Intermittent spot checks of oxygenation and ventilation every few hours are inadequate for reliably detecting opioid induced respiratory depression.”

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

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

APSF Video
Please click on the image to view the APSF video.

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.

The clinical significance continuous electronic monitoring offers is the opportunity for prompt and predictable improvement in patient safety.

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