The Respiratory Compromise Institute (RCI) has recently published a new report titled “Respiratory Compromise as a New Paradigm for the Care of Vulnerable Hospitalized Patients”. PPAHS is a member of RCI, along with other health organizations such as the Society of Hospital Medicine, American Association for Respiratory Care, and CHEST/American College of Chest Physicians. Read More
The following is an excerpt of an article written by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety). It first appeared on Healthcare Business Today on April 9, 2017. To read the full article, please click here.
As the Executive Director of the Physician-Patient Alliance for Health & Safety, a non-profit whose mission is the improvement of patient safety, I am often asked how to tell a “good” hospital (i.e. patient safe) from a “bad” hospital (i.e. unsafe).
In thinking about “good” and “bad” hospital leadership, I am reminded of two discussions I had with hospital leaders – which leaders’ hospital would you rather be a patient at or, if you are a clinician, work at?
I spoke with the CEO of a hospital, who was dealing with the family of a child that had died within the hospital from opioid-induced respiratory depression. His clinicians had not employed continuous electronic monitoring with pulse oximetry for oxygenation or with capnography for adequacy of ventilation. Read More
The Physician-Patient Alliance for Health & Safety (PPAHS) has released a YouTube video which discusses in nine minutes how to improve opioid safety. The video features highlights from over 10 hours of in-depth interviews released by PPAHS in 2016; altogether, the podcast series has generated over 130,000 cumulative views on YouTube. The podcast series brings together physicians, nurses, and respiratory therapists discussing how they have improved opioid safety in their hospitals.
According to Michael Wong, JD, Founder and Executive Director of PPAHS:
“In just nine minutes, the video summarizes experiences of clinicians in improving opioid safety in their hospital or healthcare facility, and reminds us of the tragic consequences of adverse events and deaths that may ensue if clinicians and healthcare executives are not proactive in promoting safety. We hope that the video will energize quality improvement and patient safety teams to strive to reduce adverse events and deaths related to opioid use.”
The opioid epidemic was one of the most heavily-covered, and hotly-debated, topic in patient safety covered in 2016. This dialogue has been mostly centered around the effects of ‘street’ use and abuse of prescription painkillers. In contrast, the PPAHS podcast series aims to highlight the preventable harm of opioid-induced respiratory depression during hospital procedures. Read More
A recent article published by the American Association for Respiratory Care (AARC) has highlighted how respiratory therapists (RT) can play an integral role in using capnography to detect the signs of respiratory depression. The post focuses on the experiences of Peggy Lange, BA, RRT (RT Department Director, St. Cloud Hospital in St. Cloud, MN).
Over a three month period, St. Cloud Hospital ran a pilot program to test the effectiveness of continuous capnography monitoring Center for Surgical Care, PACU, surgical care units, interventional radiology, electrophysiology lab, and emergency trauma center. The trial was successful, proving the monitors gave an early alert to the signs of respiratory distress, as well as resolving issues caused by nuisance alarms – particularly with patients experiencing sleep apnea or periods of hyperventilation. As a result, continuous capnography monitoring was implemented hospital-wide. Read More
Leah walked into a Los Angeles hospital a healthy, 11-year old girl. She needed an elective surgery to repair a condition called pectus carinatum. Despite delays, the surgery went well, but Leah was in considerable pain; to manage it, she was given escalating doses of fentanyl, along with Ativan.
Her mother, Lenore Alexander, was concerned by Leah’s increasing unresponsiveness – but was assured by staff that Leah would be ready to walk out of the hospital in the morning. Exhausted, Lenore took a nap by her daughter’s bedside; it would be the last time Leah was seen alive. Lenore woke to find Leah dead in bed.
In 2012, Lenore wrote an article for PPAHS asking if continuous monitoring would have saved her daughter, Leah. The answer, then, was a resounding “yes”. During her hospital stay, Leah received only infrequent spot checks from staff to confirm her condition despite the administration of powerful opioids. If only she were monitored with capnography and pulse oximetry – we would not have another tragic story to tell.
Now, on the 14th anniversary of Leah’s death, we ask the same question: would continous monitoring have saved Leah’s life? Read More
This year, St. Joseph’s/Candler Health System (SJ/C) celebrated 12 years free from opioid-related adverse events. The PPAHS had the pleasure of interviewing Harold Oglesby, RRT, Manager to uncover the SJ/C team’s learnings in implementing the quality improvement project.
From the inception of the project, continuous electronic monitoring with capnography has been a cornerstone technology to keeping patients at SJ/C safe. Mr. Oglesby and his team implemented a continuous monitoring program with capnography after identifying a need for reliable, early indication of patient decline in ventilation. Since the initial pilot, the monitors have shown tangible results:
“There was a couple of ‘aha’ moments when we saw that capnography giving us, sometimes an hour earlier, [indication] of a patient that was getting into distress.”
Effective implementation is crucial whenever new technology is introduced in a clinical setting. During our interview, Mr. Oglesby speaks to three key learnings to make continuous monitoring with capnography a success. Read More
In a recent interview with Harold Oglesby, RRT, Manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System (SJ/C), our discussion focused on the success factors that contributed to SJ/C’s 12 years free from opioid-related adverse events.
During the interview, Mr. Oglesby highlighted five key learnings from his experiences in implementing and continuously improving SJ/C’s QI initiative. One of these learnings was the importance of involving Respiratory Therapists (RT) throughout the process. Read More
Pamela Parker BSN, RN, CAPA, has recently published a new article in Outpatient Surgery Magazine detailing her experiences losing her own son, Logan, to opioid-related hypoxia. Read More
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).