A recent Wall Street Journal article, “Hospitals Find New Ways to Monitor Patients 24/7,” discusses a critical patient safety issue—patients receiving opioids can suffer from respiratory compromise and decompensate rapidly, resulting in a serious adverse events or death.
The article refers to a study led by David Westfall Bates, MD (Chief Quality Officer and Chief of General Internal Medicine, Brigham and Women’s Hospital and Professor, Harvard Medical School). During their investigation, researchers found that “continuous monitoring on a medical-surgical unit was associated with a significant decrease in total length of stay in the hospital, and in intensive care unit, days for transferred patients, as well as lower code blue rates.”
Dr. Bates and his colleagues also showed that “implementation of this monitoring system was associated with a highly positive return on investment.”
This and similar research raises four questions all patients and their loved ones want answered:
1. Why are hospital executives and doctors not aware of this issue?
Hospital executives and doctors should be aware of this issue, as there has been much discussion about it already.
In 2012, The Joint Commission issued Sentinel Event Alert 49 on the safe use of opioids in hospitals, which underscores the association of adverse events with the use of opioid analgesics. In particular, the Sentinel Event Alert highlights some of the causes for opioid-related adverse events: lack of knowledge about opioid potency, improper prescribing and administration, and inadequate patient monitoring.
Moreover, on March 14, 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.”
Lastly, the National Coalition to Promote Continuous Monitoring of Patients on Opioids has been established to educate and encourage hospitals to adopt continuous monitoring for all patients on opioids. Some of the organizations involved include The Joint Commission, The Anesthesia Patient Safety Foundation, the Institute for Safe Medication Practices, and the undersigned, the Physician-Patient Alliance for Health & Safety.
2. Is patient decompensation just related to opioid use?
Although respiratory compromise may be most associated with opioid use, particularly in patients following surgery, according to the DHHS Agency for Healthcare Research and Quality, $7.8 billion was spent on respiratory compromise in U.S. hospitals in 2007, and costs are going up.
In addition, respiratory compromise increases patient mortality rates by over 30% and increases hospital and ICU stays by almost 50%.
3. What are the consequences of hospital executives and doctors ignoring this issue?
First, patients and their loved ones may “vote with their feet” and go to hospitals that continuously electronically monitor their patients. For example, patients in Savannah, Georgia may choose to go St. Joseph/Candler Hospitals as they just celebrated 10 years of being “event free”. Starting with capnography monitoring for patients using patient-controlled analgesia, “monitoring technology is now 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,” says Harold Oglesby, RRT (Manager, The Center for Pulmonary Health, Candler Hospital, and St. Joseph’s/Candler Health System).
Second, if an adverse event or death occurs resulting from respiratory compromise, patients and their families would like to know who is responsible. This raises the question of what is the applicable standard of care.
While medical journals and academia may wrestle with what constitutes the standard of care, at the end of any malpractice trial, the average juror, who will have little—if any—medical training, will decide whether the defendant practitioner has met the standard of care. Thus, any evidence that shows that a breach of the standard of care resulted in some detriment to the patient is powerful, no matter how “weak” it actually is.
Have proclamations by The Joint Commission and the CMS set a standard of care? If they haven’t, these may certainly put lawyers, who represent patients harmed by respiratory compromise, on notice of what they should look for in the standard of care they will be asking courts to measure health care providers against.
4. What is the medical community doing to address this issue?
Several key societies have joined together to support the new Respiratory Compromise Institute which has a mission to educate physicians and the public about risks and solutions related to respiratory compromise.
Patient Safety Monitor Journal reported in its May 2015 issue about the recent respiratory compromise roundtable discussion. At this meeting hosted by the National Association for Medical Direction of Respiratory Care (NAMDRC), healthcare leaders discussed guidelines for identifying and preventing respiratory compromise.
Organizations that participated in the roundtable discussion were:
- American Association for Respiratory Care (AARC)
- American Association of Critical-Care Nurses (AACN)
- American College of Emergency Physicians (ACEP)
- American Thoracic Society (ATS)
- National Association for Medical Direction of Respiratory Care (NAMDRC)
- Physician-Patient Alliance for Health & Safety (PPAHS)
- Society of Critical Care Medicine (SCCM)
As one of the members of the Clinical Advisory Committee of the Respiratory Compromise Institute, we hope that clinicians and their patients will support us in reducing the risk of respiratory compromise and, in doing so, saving patients’ lives.