Six years ago on July 27, 2011, I posted the first article on a free Wordpress blog for the Physician-Patient Alliance for Health & Safety. It was titled “Is it possible to survive 96-minutes without a heart beat?”. Howard Snitzer, a man who suffered a heart attack survived after two volunteer paramedics responded and began a 96-minute CPR marathon. The ordeal involved 20 others, who took turns pumping his chest. This life-saving feat was only possible with the use of capnography readings, which told the volunteer paramedics that Howard was still alive and that they needed to continue their efforts.
Little would I know that that article would lead to an invitation by the University of Notre Dame and the beginnings of a 6-year friendship with the parents of Amanda Abbiehl. Amanda was admitted to hospital for “severe strep throat.”
Her parents, Brian and Cindy Abbiehl, write about what happened to Amanda:
“As parents of a teenage daughter, our worst fears were that our daughter would become pregnant, take drugs, or drink and drive. Never did we imagine that our daughter would go into a hospital with an infection, be hooked to a patient-controlled analgesia (PCA) pump to manage her pain, and never come out alive; but this is exactly what happened.”
To listen to an interview with the Abbiehls on YouTube, please click here.
Six years ago, I made a promise to Amanda’s mother, Cindy, to do what I could do, and thus began my battle to advocate for the continuous electronic monitoring of all patients receiving opioids. To help achieve that goal, PPAHS had made great strides.
PCA Safety Checklist
In 2012, PPAHS brought together a of renowned medical experts to develop the PCA Safety Checklist. This panel included intensive care specialist and a leader in medical checklist development Peter J. Pronovost, MD, PhD, FCCM, Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient; and Atul Gawande, MD, Professor in the Department of Health Policy and Management at the Harvard School of Public Health, who is a surgeon at Brigham and Women’s Hospital Professor of Surgery at Harvard Medical School and author of “The Checklist Manifesto.” A free resource on the PPAHS site, the PCA Safety Checklist provides concise recommendations for initiating PCA administration and continuing PCA administration.
National Coalition to Promote Continuous Monitoring of Patients on Opioids
To enlist broader support for continuous electronic monitoring of patients receiving opioids, I made a personal appeal to the board of AAMI to develop a National Coalition to Promote Continuous Monitoring of Patients on Opioids. Subsequently, AAMI formed the National Coalition to Promote Continuous Monitoring of Patients on Opioids, which coalition was co-convened by many organizations, including:
- The Anesthesia Patient Safety Foundation (APSF)
- Institute for Safe Medication Practices (ISMP)
- National Patient Safety Foundation (NPSF)
- The Joint Commission
- VA National Center for Patient Safety
This vision of continuous monitoring for patients receiving opioids has been endorsed by organizations, including:
- American College of Clinical Engineering (ACCE)
- American Association of Nurse Anesthetists (AANA)
- American Association for Respiratory Care (AARC)
- American Society for Pain Management Nursing (ASPMN)
The Respiratory Compromise Institute
To further enlist broader support for continuous electronic monitoring of patients receiving opioids, PPAHS is a founding member of the coalition, the Respiratory Compromise Institute, an organization with the goal of assisting “the broad medical community to address respiratory compromise in varied settings, including the hospital, nursing homes, and the home.” The RCI coalition includes representatives appointed by a broad range of key medical societies:
- American Association for Respiratory Care
- American College of Chest Physicians
- American College of Emergency Physicians
- American Society of Anesthesiologists
- American Thoracic Society
- Canadian Society of Respiratory Therapists
- National Association of Clinical Nurse Specialists
- National Association of EMS Physicians
- National Association for Medical Direction of Respiratory Care
- Physician Patient Alliance for Health & Safety
- Society of Anesthesia & Sleep Medicine
- Society of Critical Care Medicine
- Society of Hospital Medicine
Clinical Education Podcasts
Beginning in January 2016, PPAHS released its first clinical education podcast. These podcasts offer in-depth interviews with thought leaders, researchers, patients, and healthcare professionals on how to reduce opioid-related adverse events. These podcasts which can be listened to on the PPAHS YouTube channel, have been viewed as of this writing more than 155 thousand times.
Has the needle moved on improving the safety of patients receiving opioids in-hospital?
Unfortunately, I still hear about deaths from anesthesia, and tragically these deaths involve children. Recently, Annie Kaplan, MD, Patricia Salber, MD, MBA, and I wrote an article, “No Child Should Ever Die from Elective Dental Anesthesia”. This article featured the story of Caleb Sears, a healthy 6-year-old boy who tragically died after his elective dental surgery. To ensure the safety of children before, during, and after sedation for diagnostic and therapeutic procedures, the American Academy of Pediatrics (AAP) and the American Academy of Pediatric Dentistry (AAPD) guidelines state that there must be a clinician present other than the practitioner whose sole responsibility is to monitor the patient’s vital signs:
“The use of moderate sedation shall include the provision of a person, in addition to the practitioner, whose responsibility is to monitor appropriate physiologic parameters and to assist in any supportive or resuscitation measures, if required…
During deep sedation, there must be 1 person whose only responsibility is to constantly observe the patient’s vital signs, airway patency, and adequacy of ventilation and to either administer drugs or direct their administration.”
Fortunately, with news of further patient adverse events and death, I have also received good news about continuous electronic monitoring. I recently received an email from Pamela Parker, BSN, RN, CAPA. We did a podcast with Ms. Parker about the death of her 17-year old son, Logan. Logan had obstructive sleep apnea (OSA) with elements of central sleep apnea. He underwent surgery to open his airway. He tragically died of opioid-induced respiratory depression. In the interview, Ms. Parker discusses Logan’s death and lessons she has learned from it. As a result of that podcast, PPAHS received two requests for articles:
- Advance for Nurses, “Six Nursing Lessons Nurse and mother reflects on the untimely death of her teenage son”
- Outpatient Surgery, “My Son Did Not Have to Die: Learn from the avoidable opioid-induced hypoxia that took his life”
But, have these podcast and articles changed clinical practice?
In an email, Ms. Parker told me about an encounter she had when attending this year’s American Society of PeriAnesthesia Nurses (ASPAN) conference:
I have been attending the ASPAN conference this week. During one of the lectures, the speaker began to discuss negative outcomes with post tonsil patients. I was surprised when she mentioned several case studies- which were very similar to Logan’s story. Some of her data came from the closed claim analysis. Logan was not even included in this data.
Afterwards, I felt the need to talk to the speaker. Several people gathered to wait. When I mentioned this to the speaker and the small crowd, one of the other nurses asked me- “Did you write an article?” I replied- “yes, I did. Two actually.” She told me that she brought the outpatient surgery article to her staff meeting. She made every nurse read a paragraph in the article out loud as they passed it around the room. Afterwards, there “was not a dry eye in the room.” She then explained to her staff- “THIS…. this is why we are using capnography in our PACU.” I smiled.
While Ms. Parker’s email and other stories that I hear are indicative of a growing adoption of continuous electronic monitoring, there is still much work to be done, as evidenced by the pediatric dentistry deaths.
PPAHS will continue to develop clinical education podcasts on opioid safety. These podcasts will continue to discuss the experience and recommendations of clinicians to prevent opioid-related adverse events.
I call upon safety advocates, the pharmaceutical industry who manufacturers opioids, and the medical device industry who manufactures pulse oximetry, capnography, and other devices to monitor patients to join us in improving opioid safety. Only together will we be able to eventually say that opioid-related adverse events and deaths are a nightmare from the past.