5 Key Steps to Assessing and Identifying At-Risk Patients for Respiratory Compromise

The cost of opioid-related adverse events, in terms of both human life and hospital expenses, remains at the forefront of the public eye. It has been estimated that yearly costs in the United States associated with opioid-related post-operative respiratory failure were estimated at $2 billion.

The Society of Hospital Medicine, which is the largest organization representing hospitalists and a resource for hospital medicine, recently released a comprehensive guide, “Reducing Adverse Drug Events Related to Opioids” (otherwise known as the RADEO guide).

To better understand the RADEO guide, the Physician-Patient Alliance for Health & Safety interviewed its lead author, Thomas W. Frederickson MD, FACP, SFHM, MBA.

In this 2-part interview, Dr. Frederickson’s uncovers some key takeaways from the comprehensive publication. In part one, he focuses on 5 key steps to identifying and addressing for patient conditions that pose a greater risk of respiratory depression:

1. Screen for sleep apnea

Dr. Frederickson identifies a key complication that can raise the risk of respiratory compromise, in particular with obese patients: obstructive sleep apnea (OSA). The condition, both common in the adult population and often undiagnosed, can render traditional monitoring and observation for respiratory compromise ineffective:

Patients with obstructive sleep apnea are dependent upon their arousal mechanism in order to avoid respiratory depression and eventual respiratory failure. When these patients receive opioid medication, it decreases this ability for arousal. That puts them at risk for a sudden spiral that includes respiratory insufficiency and respiratory arrest. This can happen very quickly and part of the risk is that the traditional monitoring for sedation that we use in the hospital – that is on a periodic basis and depends upon nursing interventions and questioning – really becomes much less effective in this patient population that can have a respiratory arrest, because of failure to arouse, very quickly. So, a monitoring regimen that takes place every 60 minutes is likely to be ineffective.

2. Use a screening tool to identify patients with OSA

Dr. Frederickson recommends the use of an evaluation tool to identify at-risk patients; this is most effective as part of a pre-operative evaluation, saying that the STOPBang tool is one of the most sensitive:

Probably the most common one, and the most effective one in terms of being sensitive, is the STOPBang tool. Many hospitals implement screening for sleep apnea using the STOPBang. It’s an eight point questionnaire. The questions are easily answered by talking to the patient or with a questionnaire given to the patient.

The Berlin Questionnaire and Epworth Scale screens are more specific for sleep apnea, said Dr. Frederickson, but lack some of the sensitivity of the STOPBang questionnaire.

3. Build multi-modal and opioid sparing strategies for at-risk patient groups

“Pain is among the most common reasons to need to be in the hospital,” stated Dr. Frederickson. For patients with chronic pain, or habituated to opioids, it’s also a contributing factor to respiratory depression. For these and other at-risk patients, Dr. Frederickson recommends a strategy that incorporates a multi-modal and opioid sparing approach:

[F]olks with chronic pain – whether they are habituated to opioids or not – we’re likely to have as clinicians a more difficult time controlling those patients’ pain. They’re likely to need higher doses of opioids to control pain. And with the higher doses, come higher risks of sedation and eventual respiratory depression. So, it’s good to have, you know, strategies. It’s good to be including multi-modal strategies to and to use opioid sparing techniques in all patients – but particularly in this subset of patients.

4. Educate on the risks of interactions with other medication

The side effects of opioids can have an additive effect if combined with other medication with sedating effects. Dr. Frederickson highlights the benzodiazepine class as the biggest risk:

[T]hey’re very common. Many patients come into the hospital taking benzodiazepines. They’re commonly used for anxiety and other conditions as well. So, patients, who are already on benzodiazepines, habituated benzodiazepines, need to continue that medication in the hospital.

5. Empower clinicians with the right tools and policies

Dr. Frederickson concludes the first part of the interview acknowledging that any quality improvement (QI) policies implemented at a clinical level needs to be seamless and easy for clinicians to follow:

[A] QI approach that involves policies, that involves making it easy for clinicians to do the right thing through appropriate tools and interventions, is so important in this realm; because the medicine and the patients can be complicated and clinicians need to have it easy for them to make good decisions and to treat their patients in a way that is going to be effective but safe.

Follow PPAHS for the conclusion to our interview with Dr. Frederickson. In the last half of this in-depth interview with the lead author of the RADEO Guide, Dr. Frederickson focuses on key strategies to implement in effective patient monitoring.

For a full transcript of the interview, please click here.

Watch the interview with accompanying slides on YouTube here.

One thought on “5 Key Steps to Assessing and Identifying At-Risk Patients for Respiratory Compromise

  1. This is very powerful. When you look at the math, it becomes even more compelling to pursue equipping each non monitored bed with continuous monitoring. It is estimated that there are approximately 650,000 beds which do not have continuous monitoring, which has an average cost of around $4000 per bed. That would have an ROI of 17 months! From that point forward, the $2 billion mentioned goes directly back to the Health Care organizations.

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