Inadequate monitoring for respiratory depression in patients receiving opioids poses the greatest risk and potentially resulting harm to patients. ECRI Institute recently released the 2016 Top 10 Patient Safety Concerns for Healthcare Organizations and assigned inadequate monitoring its highest risk map of 80:

2016 Top 10 Patient Safety ConcernsWhat can clinicians proactively do to reduce the risk of adverse events related to patients receiving opioids?

 

5 steps to reduce the risks

Below are five steps clinicians can implement:

Step 1: Detect patient deterioration as early as possible

In their review of the approaches to address inadequate failure-to-rescue (FTR), “A Review of Current and Emerging Approaches to Address Failure-to-Rescue,” Andreas H. Taenzer, MD, MS, and his colleagues at Dartmouth found that failure-to-rescue has had limited success to-date because such attempts have focused on improving responses to a recognized patient crisis, rather than on recognizing the ensuing signs of patient deterioration.

As illustrated by Taenzer et al in the chart below, early detection of a patient’s deteriorating condition allows for timely and effective clinical intervention:

Patient Surveillance SystemContinuous electronic monitoring of patients provides the opportunity to identify at the critical time point possible signs of patient deterioration to prevent predictable patient harm. If we can identify these signs early, in order to effectively intervene, then we may be able to reverse and avoid adverse events including patient deaths.

 

Step 2: Monitor with capnography

Three prominent medical societies recently recommended the routine use of capnography to monitor for the adequacy of ventilation:

Association of periOperative Registered Nurses (AORN): “the perioperative RN should monitor exhaled CO2 (i.e., end-tidal CO2 [EtCO2]) by capnography in addition to SpO2 by pulse oximetry during moderate sedation/analgesia procedures.”

Association for Radiologic and Imaging Nursing (ARIN): “ARIN endorses the routine use of capnography for all patients who receive moderate sedation/analgesia during procedures in the imaging environment. This technology provides the critical information necessary to detect respiratory depression, hypoventilation, and apnea, thus allowing the timely initiation of appropriate interventions to rescue the individual patient. Capnography use is associated with improved patient outcomes.”

American Academy of Pediatrics (AAP) and American Academy of Pediatric Dentistry (AAPD): The lead guideline author Charles J. Coté, MD explained that the updated guidelines contain two major changes. “The first has been to add capnography monitoring of children who are deeply sedated and to encourage capnography for children who are moderately sedated. Capnography measures expired carbon dioxide to ensure airway patency and gas exchange.””

The Anesthesia Patient Safety Foundation has published a consensus statement 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.

 

Step 3: Ensure high-risk patients are monitored

Ideally, all patients receiving opioids should be monitored. As Frank Overdyk, MSEE, MD argues in “Monitoring the High-Acuity Patient: Does Risk Stratification Increase or Decrease Patient Safety?,” there are risks associated with condition monitoring. In condition monitoring, only patients determined to have higher risk—such as those with sleep apnea, obesity, low body weight, or age—are continuously monitored. In reality, the true clinical fact is patients deemed to be at a “low risk” may equally develop respiratory compromise from opioids.

Additionally, resource constraints may mean hospitals select which patients are continuously monitored and which are not. In such a case, The Joint Commission has provided guidance in Sentinel Event Alert #49, “Safe use of opioids in hospitals“. In the chart below, characteristics and clinical conditions of patients most at risk of oversedation and respiratory depression are identified:

Characteristics and clinical conditions of patients with oversedation and/or respiratory depression

Step 4: Utilize reminder alerts to monitor patients

Alerts to clinicians built into the electronic health record for continuous monitoring when opioids are prescribed could significantly decrease opioid related harm. As The Joint Commission points out,

“If available, use information technology to monitor prescribing of opioids. Build red flags or alerts into e-prescribing systems for all opioids. The red flags can be either for dosing limits or alerts or for verifications.”

 

Step 5: Empower nurses to drive the protocol

Empowering nurses to pro-actively intervene, through an established protocol ordered by the prescriber, at the signs of opioid-induced respiratory depression could save patient’s lives by using clinical knowledge and not losing critical time contacting physicians for a necessary reversal agent order.

Nurses are usually the first clinician to notice ensuing and early signs of patient deterioration. Patient death or irreversible damage could occur due to delays in reaching a physician to administer the reversal agent, naloxone, for respiratory depression caused by sedation. After nurses administer naloxone, they should contact the attending physician, so that the patient can be assessed and any necessary changes in medication and/or dosing made.

 

Continuously monitor all patients receiving opioids

As the 2016 Top 10 Patient Safety Concerns for Healthcare Organizations points out,

“Patients receiving opioids are at risk for respiratory depression, which, if it goes unnoticed, can lead to brain injury or death. In some reported events, staff avoided formally assessing patients’ sedation levels because they appeared to be sleeping. But in reality, they were experiencing the progression to respiratory depression.”

Continuous electronic monitoring provides real-time evaluation, patient assessment, and whether these patients are suffering respiratory compromise due to oversedation from opioids.

Ideally, the clinical decision to monitor or not monitor patients receiving opioids with the available technology of pulse oximetry (for oxygenation) and capnography (for ventilation adequacy) should not be an option. However, hospital resource constraints may pose impediments to monitoring all patients receiving opioids.

Michael Wong, JD
Michael Wong, JD is the founder and Executive Director of the Physician-Patient Alliance for Health and Safety (PPAHS). He has been at the forefront in driving practical solutions that reduce healthcare costs, decrease medical errors, and improve patient health outcomes. He has been particularly active in these areas that most affect patient safety: • Improving patient adherence (i.e. helping patients to take their medications as prescribed by their physicians) • Enhancing patient access to healthcare • Reducing medical errors (PPAHS), is an advocacy group of physicians, patient advocates, and healthcare organizations. Supporters of and commenters for PPAHS include highly respected physicians and healthcare organizations, including the The Joint Commission, Anesthesia Patient Safety Foundation, Anesthesia Quality Institute, Johns Hopkins School of Medicine, Harvard Medical School, Stanford University School of Medicine, and the Cleveland Clinic.

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