Leah walked into a Los Angeles hospital a healthy, 11-year old girl. She needed an elective surgery to repair a condition called pectus carinatum. Despite delays, the surgery went well, but Leah was in considerable pain; to manage it, she was given escalating doses of fentanyl, along with Ativan.
Her mother, Lenore Alexander, was concerned by Leah’s increasing unresponsiveness – but was assured by staff that Leah would be ready to walk out of the hospital in the morning. Exhausted, Lenore took a nap by her daughter’s bedside; it would be the last time Leah was seen alive. Lenore woke to find Leah dead in bed.
In 2012, Lenore wrote an article for PPAHS asking if continuous monitoring would have saved her daughter, Leah. The answer, then, was a resounding “yes”. During her hospital stay, Leah received only infrequent spot checks from staff to confirm her condition despite the administration of powerful opioids. If only she were monitored with capnography and pulse oximetry – we would not have another tragic story to tell.
Now, on the 14th anniversary of Leah’s death, we ask the same question: would continous monitoring have saved Leah’s life?
The answer remains the same. Yes. Continuous monitoring would have saved Leah’s, and many more.
Time has strengthened, rather than eroded, this position. The PPAHS has featured countless articles and studies showing the successful use of continuous capnography monitoring in reducing opioid-related adverse events. A landmark example is St. Joseph/Candler Hospitals in Savannah, GA; after implementing continuous electronic monitoring with capnography, St. Joseph/Candler has reduced adverse events to zero for now more than 12 years.
Sadly, we continue to tell the story of patients that have succumbed to opioid harm. For the families of patients – people – lost, and the clinicians who cared for them, it’s easy to feel alone. But these are not isolated occurrences; they are the casualties of a systemic oversight in patient safety.
Opioid-related adverse events are preventable. We must learn from stories like Amanda. We must learn from from stories like Logan. We must learn from stories like John. We must learn from stories like Leah, who would have turned 25 this year. As a medical community – clinicians, administrators, patient safety advocates, and more – we need to act faster, because each delay in implementing continuous electronic monitoring means another patient life at risk.
For clinicians, though the answer is multifaceted, it begins with the right processes and technology in place. Here are six lessons from Pamela Parker, BSN, RN, CAPA, and mother to Logan:
- All patients receiving opioids should be assessed for risk for over sedation and respiratory depression.
- Clinicians must recognize the signs of respiratory compromise.
- All patients receiving opioids should be continuously electronically monitored.
- Do not rely upon pulse oximeters, monitor with capnography.
- All patients should be monitored for an extended period in an un-stimulated environment prior to discharge.
- Medical interventions should not be based upon human heroics, but should be based upon a process and process improvement.
Moreover, caregivers need the right tools to effectively engage with patients’ families. From Promise to Amanda, there are four essentials for safety:
- Ensure patients/families are provided information on proper use of the PCA pump
- Make sure patients/families understand why they must be monitored for safety reasons
- Save yourself some trouble and educate patients and families about monitor readouts
- Know why alarms sound and what to do when they sound
To learn more about Leah’s story, please visit Leah’s Legacy.