by Sean Power
502 Bad Gateway
Patient safety experts recently participated in a webinar on reducing adverse drug events and harm associated with postoperative opioid pain management programs. Premier Safety Institute, an organization dedicated to coordinating safety-related activities among national organizations to help improve safety, hosted the webinar.
The panel featured four patient safety experts:
- Chris Pasero, MS, RN-BC, FAAN, Pain Management Educator and Clinical Consultant;
- Brian and Cindy Abbiehl from A Promise to Amanda Foundation
- Harold Julius A. Oglesby, RRT/RCP, Manager, Respiratory Care, Pulmonary Diagnostics, & Sleep Disorders from St. Joseph/Candler Hospitals
- Michael Wong, JD, Founder and Executive Director of the Physician-Patient Alliance for Health & Safety.
We’ve highlighted four key insights shared by the panel that improve clinical outcomes during pain management and reduce the chance for adverse drug events to occur.
You can download a recording of the webinar here.
1. Multi-modal pain plans provide better pain relief and result in fewer adverse events than opioid-only pain treatment plans.
“There are some underlying problems that I think we need to address that are affecting the way we are managing pain,” says Ms. Pasero. Short length of stay is a primary objective of care. Hospitals are focused on patient satisfaction scores rather than improved patient outcomes. Health care providers start pain management postoperative intervention rather than preoperative planning and there exists a “more is better” mentality with opioid-only treatment plans.
“When someone has some mild pain, we give them opioids. They have a little more pain, we give them more opioids. They have severe pain, we give more opioids. And, of course, at the top of this pyramid is where we see adverse events including patient deaths,” explains Ms. Pasero. “What’s happening nation-wide is a focus on opioid-only treatment plans. This is problematic.”
The Joint Commission’s Sentinel Event Alert highlighted the problem. Ms. Pasero outlined the elements that make up a sentinel event, and referred to what she called a “recipe for disaster”:
The Alert states that opioid adverse events are among the most common of all adverse drug events. The action plan proposed by TJC: screen for risk (for example, by using tools like the STOP Bang model), build red flags into electronic medical records to prompt respiratory and sedation assessments, use a scale to assess sedation, and adopt multimodal analgesia plans.
“What I think is the most important thing is that we have got to start using multimodal analgesia plans,” says Ms. Pasero. What this means, she explains, is “combining both pharmacologic and non-pharmacologic interventions that can attack more than one underlying pain mechanism. The goal really should be that we are able to provide better pain relief with fewer adverse effects of each of the drugs in the treatment plan than would be possible with a single intervention.”
“This is critical to an action plan: we have to reframe the discussion with patients,” Ms. Pasero says. There exists a misunderstanding that patients have the right to be pain-free. “That is unrealistic,” explains Ms. Pasero. “We’ve got to revisit that, be honest with patients, and reframe the whole discussion.” This conversation should happen ideally before surgery takes place. Ms. Pasero advises that frontline staff discuss with the patients the idea that the purpose of managing pain is to enable them to achieve functional goals. Doing so shifts expectations such that patients become members of the pain management team.
2. Educating patients and families about opioid PCA pumps leads to better clinical outcomes.
Mr. and Mrs. Abbhiel shared their experience as the parents of an 18-year old girl who died in 2010 because she was not adequately monitored with EtCO2, and shared with the audience their four essentials for caregivers to engage patients and their families in improving patient safety when using patient-controlled analgesia (PCA) pumps:
“Basically what we’re looking at is the essentials for safety,” says Ms. Abbiehl. “Ensure patients and families are provided information on proper use of PCA pumps,” she explains. “A lot of people don’t realize that these pumps do deliver a powerful narcotic. It tends to be an issue if the patient is administering it or if somebody else pushes the button for the patient.”
Proper patient education about the devices with which they manage their pain is therefore essential to safe care. “That’s why we need to make sure that patients and families understand why they must be monitored for safety reasons,” Ms. Abbiehl continues. She explains that oximetry on the finger and a capnography cannula on the nose will prevent adverse drug events for patients using PCA pumps to manage pain.
Educating patients and families about how to interpret monitor readouts helps frontline staff monitor patients. “Brian and I both have discussed how we wished that we could have seen some warning sign. With capnography, it pretty much puts the warning sign on the machine and alerts the nurses without them having to come in.”
“Our main goal is really monitoring,” says Mr. Abbiehl. “We just want patients to be safe when they’re on an opioid infusion. We think that the technology is there at the present and we just want people to use it so that everyone can be safe.”
3. Respiratory monitoring technology such as capnography and pulse oximetry can aid in patient assessments and prevent serious adverse events.
St. Joseph’s/Candler Hospitals have not had any opioid-related serious adverse drug events over the last eight years in either of the two hospitals it operates. This achievement is impressive, for SJCHS is the largest healthcare system in southeast Georgia with 675 beds and approximately 25,000 annual discharges.
In the two years preceding the implementation of its advanced safety system, SJCHS experienced three opioid-related events with serious outcomes. These events prompted the hospitals to develop a multidisciplinary team to make delivery of the medication safe.
“We looked at issues and we knew that what we needed to correct was we needed to make sure that the programming of the pump itself was being done in a safe manner and also that the monitoring of these patients was being done at the best possible rate and with the best possible method,” explains Mr. Oglesby.
The hospitals used continuous electronic monitoring with capnography and pulse oximetry as part of a wider process for monitoring respiration and preventing respiratory depression. Mr. Oglesby describes the process: “The first thing we [respiratory therapists] look at is always the patient, not the machine, so we assess the patient’s history, we assess what the patient looks like, we look at their trends [for EtCO2, SpO2, respiratory rate, and PCA medication rates.” The respiratory therapist also provides bedside education with patients and families.
In addition to respiratory assessments at the beginning of every shift, SJCHS determined it was important to make sure everybody is on the same page. They developed action steps for nursing staff that included assessing the patient’s ABCs, stimulating the patient if necessary, ensuring the airway is open and that the cannula is in the right place.
“There is also a change in culture with our PCA patients because not only were we able to monitor these patients but we were also able to give them effective pain management,” continues Mr. Oglesby.
Mr. Oglesby outlines the benefits of the monitoring: “Better pain control, more appropriate pain control, and a safe environment for our patients. Patients tend to have a better outcome.”
4. As many as 50 percent of PCA-related adverse drug events could be prevented with effective monitoring.
“In studies cited by The Joint Commission,” says Mr. Wong, “opioid analgesics rank among the drugs most frequently associated with adverse drug events.” Three causes of opioid-induced respiratory depression include lack of knowledge about opioid potency, improper prescribing and administration of opioids, and inadequate monitoring of patients on opioids.
“The incidence of opioid-related respiratory depression is anywhere from 0.16% to 5.2% according to studies. If we take the 13 million patients each year who receive patient controlled analgesia, this means that each year up to 676,000 patients will have a PCA adverse event. This number excludes other forms of opioid administration,” explains Mr. Wong.
Dr. Robert Stoelting, President of the Anesthesia Patient Safety Foundation, estimates that as many as 50% of PCA adverse events could be prevented with effective monitoring. Dr. Richard Dutton, Executive Director of the Anesthesia Quality Institute, states, “any published estimate is likely to be only the tip of the iceberg.”
With the goal of reducing adverse events, the Physician-Patient Alliance for Health & Safety developed a PCA Safety Checklist with a working group of patient safety experts. The concise checklist reminds caregivers of essential steps to initiate and continue to assess patient use of PCA.
The PCA Safety Checklist can be downloaded for free here.
What are your recommendations for improving the safety of patients on opioid pain management programs?