Opioid Safety, Respiratory Compromise

12 Years of Event-Free Opioid Use

The Physician-Patient Alliance for Health & Safety (PPAHS) recently interviewed Harold Oglesby RRT, Manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System (SJ/C).  

The PPAHS has had the pleasure of featuring Mr. Oglesby in the past; in 2014, SJ/C celebrated 10 years free from opioid-related adverse outcomes under his leadership.  A key driver in this was the successful implementation capnography monitoring modules to the hospital’s existing IV safety platform.  As a result, the Georgia-based hospital has been held as a model nationwide for patient safety using opioids.

Since 2014, Mr. Oglesby and his team have continued to refine best practices to ensure the safety of the hospital’s patients; 25,000 patients discharged from 675 beds annually.  During the interview, Mr Oglesby highlighted 5 key learnings from the SJ/C’s now-12 years of success.

#1. Be proactive and implement continuous monitoring

For SJ/C, the first pilot program in 2004 to reduce adverse events stemmed from several patient incidences.  Mr. Oglesby began the interview by calling for a more proactive approach:

“[D]on’t wait for a patient death or an adverse event to occur to be proactive, and implement some type of continuous monitoring for your patients before you get behind the eight ball and you have a bad outcome.”

SJ/C first piloted their project with a small pool of patients receiving patient-controlled analgesia (PCA).  The results, and corresponding learnings, from the pilot formed the basis for a broader rollout across the hospital.

#2. Respiratory therapists are an integral part of the implementation process

Mr. Oglesby highlights that one of the key challenges at the beginning of SJ/C’s success was the implementation process.  Building the right cross-functional team to manage the implementation of capnography monitoring is key.

“[R]espiratory therapists tend to have the expertise in dealing with capnography outside of the OR.  They understand it, they can relate that understanding not only to the patients, but also to the staff on the floors that may not be used to monitoring the patient with capnography.”

At SJ/C, respiratory therapists (RTs) walk the patient floor once a shift to see patients.  They serve as escalation touchpoints for nurses with questions about the capnography devices.  RTs also conduct assessments of crucial patient vitals: respiratory rate, respiratory effort, SpO2, and end tidal CO2.  Mr. Oglesby emphasized end tidal CO2 trends as a key metric, adding that RTs have the experience to understand this metric in the context of a patient’s medication.

#3. Treat the patient, not the monitor

SJ/C tackles the issue of alarm fatigue by individualizing monitor settings to individual patient needs.  Explains Mr. Oglesby:

“[O]ur default settings are very, very wide. Our high end tidal CO2, it defaults at 60. Our low end tidal CO2 defaults at 6, no breaths detected is 30 seconds. Our high respiratory rate is set at 35, and our low respiratory rate is set at 6.  

[…] The key is that we have a respiratory therapist that will go and monitor the patient, look at their trends, and set their alarms based on what’s happened with the patient at the bedside.”

Attending to alarms begins with a visual inspection of the patient to address any overt causes to the alarm.  Clinicians at SJ/C then systematically review monitors and trends to determine if additional action is needed.  

#4. Educate both patients and staff

A common complaint regarding patient compliance with capnography monitors is that the nasal cannula can be uncomfortable.  Mr. Oglesby and his team addressed this by improving patient education at bedside:

“[W]e developed some patient handouts that were customized through our organization, and we pulled back the nursing staff and reeducated the nursing staff on how to educate the patients.

So, then the education went more like ‘You know, Mr Davis, we’re putting this cannula on you for your safety.  It’s here to protect you. We’ve talked about some of the poor outcomes.’”

Mr. Oglesby found that effective communication increased patient adoption of the monitors; SJ/C found that in the case of high-risk patients, such as sickle cell patients using a PCA, this enabled for better pain management because staff felt more comfortable administering correct dosages.

Mr. Oglesby also found that staff education was a key factor in deciding to implement capnography monitoring across the hospital, rather than for targeted patient groups:

“[I]f you go to the www.PromiseToAmanda.org website, you’ll see that a lot of the patients that had bad, bad outcomes – that didn’t walk out of the hospital – aren’t those patients that would fit into any algorithm that says you need to monitor this patient.

[…] that was part of the reason we decided that if we were going to do it, we just had a go full house and do the whole thing.”

#5. The ‘Eyeball Test’ is not enough

Mr. Oglesby recommends that all patients receiving opioids receive continuous monitoring, as the ‘eyeball test’ is not always a good indicator of who may or may not require more attention:

“My guidance would be to never assume who is going to be a ‘good’ patient versus who’s going to be a ‘troublesome’ patient; that you monitor all the patients the same way; that you are vigilant with all your patients; and that you denote the changes when you see them happening.”

However, he adds that continuous monitoring with capnography enhances, rather than overshadows, the human factor:

“You [still] have to put your eyeballs on the patients, observe the patients, know what’s going on with your patients, know their histories, know where they are, know what what they look like the day before, know what they looked at it like at the beginning of the shift, denote any changes, monitoring closely, and then pray to have good outcomes. “

To watch the full interview, with corresponding visuals, on YouTube, please click here.

To download a PDF version of the transcript, please click here.

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