Patient Monitoring, Patient Safety

Physician-Patient Alliance Recommends Continuous Respiratory Monitoring of All Patients Receiving Opioids

The Physician-Patient Alliance for Health & Safety today issued the following statement encouraging the continuous electronic monitoring of all patients receiving opioids:

To improve patient safety and save patients’ lives, we recommend adopting continuous respiratory monitoring of all patients receiving opioids with pulse oximetry for oxygenation and with capnography for adequacy of ventilation to improve timely recognition of respiratory depression, decompensation or clinical deterioration.

In Amanda's Memory, Always Monitor

The Centers for Medicare & Medicaid Services (CMS) issued on March 14, 2014 revised guidance, “Requirements for Hospital Medication Administration, Particularly Intravenous (IV) Medications and Post-Operative Care of Patients Receiving IV Opioids”.

The CMS 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.”

In addition and more importantly, the CMS guidance necessitates monitoring for all patients receiving opioids when in hospital:

Narcotic medications, such as opioids, are often used to control pain but also have a sedating effect. Patients can become overly sedated and suffer respiratory depression or arrest, which can be fatal. Timely assessment and appropriate monitoring is essential in all hospital settings in which opioids are administered, to permit intervention to counteract respiratory depression should it occur.

“In issuing this statement,” explains Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), “we are especially reminded of Amanda Abbiehl, Leah Coufal, John LaChance, and countless others who may still be alive today had they been continuous electronically monitored.”

Physician-Patient Alliance released these and other stories of patients who suffered opioid-induced respiratory depression at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids. For a full copy of all of the stories shared with the meeting’s attendees, please click here.

The CMS guidance provides increased vigilance to patients receiving opioids, particularly those patients receiving opioids postoperatively. CMS explains the reason behind the issue for this guidance:

 Each year, serious adverse events, including fatalities, associated with the use of IV opioid medications occur in hospitals. Opioid-induced respiratory depression has resulted in patient deaths that might have been prevented with appropriate risk assessment for adverse events as well as frequent monitoring of the patient’s respiration rate, oxygen and sedation levels. Hospital patients on IV opioids may be placed in units where vital signs and other monitoring typically is not performed as frequently as in post-anesthesia recovery or intensive care units, increasing the risk that patients may develop respiratory compromise that is not immediately recognized and treated.

Capnography, Patient Monitoring, Patient Stories

Patient Stories Shared at First Meeting of National Coalition to Promote Continuous Monitoring of Patients on Opioids

The Physician-Patient Alliance for Health and Safety today released the patient stories it shared at the inaugural meeting of the National Coalition to Promote Continuous Monitoring of Patients on Opioids.

“We hope that the adverse events and deaths of patients who have suffered opioid-induced respiratory compromise may serve as inspiration to encourage the adoption of continuous electronic monitoring of all patients receiving opioids,” said Physician-Patient Alliance Executive Director and Founder Michael Wong, JD.

In particular, two moving stories were shared at the inaugural meeting.

Brian Abbiehl, who is on the board of directors for Physician-Patient Alliance, recounted the tragic events leading to the death of his daughter Amanda. Along with his wife Cindy, Brian established A Promise to Amanda Foundation as a tribute to Amanda, and to educate patients and their loved ones about the need for continuous monitoring of patients receiving opioids.

Retired Michigan State Trooper Matt Whitman shared his own experience with opioid-induced respiratory compromise that nearly claimed his life.

For a full copy of all of the stories shared with the meeting’s attendees, please click here.

Patient Monitoring, Patient Safety, Patient Stories

What Puts More Than Half a Million Lives at Risk Each Year and Costs the US Healthcare System $7.8 Billion Annually?

Join the newest Physician-Patient Alliance Initiative to Reduce the Risk of Respiratory Compromise and Save Lives. By simply signifying your support for reducing the risk of Respiratory Compromise and for saving the lives of patients, you can help ensure changes are made.

If steps had been taken sooner, the lives of countless numbers of patients might have been saved, including:

Amanda Abbiehl Amanda Abbiehl

John LaChance

To help save lives and learn more, please click here.

Capnography, Patient Monitoring

Open Letter for Patient Safety and Use of Continuous Electronic Monitoring

In the story, “Hypoxia After Surgery Much More Common Than Previously Believed — Study finds high rate of prolonged bouts of desaturation on wards” (Anesthesiology News, March), Daniel Sessler, MD (Michael Cudahy Professor & Chair, Department of Outcomes Research, The Cleveland Clinic; Director, Outcomes Research Consortium) who helped conduct the study, described its results as “sobering.”

This research found that a large fraction of patients experiences prolonged periods of hypoxemia while recovering from surgery – approximately 21 percent of patients averaged at least 10 minutes per hour with SpO2 values below 90 percent, approximately 8 percent of patients averaged at least 20 minutes per hour, and approximately 8 percent of patients averaged at least 5 minutes per hour with SpO2 less than 85 percent. As Dr. Sessler noted, most health experts agree that long periods of oxygen desaturation are not good for patients. Dr. Sessler also pointed out that physicians need an early warning sign for respiratory distress, which is currently only possible through continuous electronic monitoring.

We couldn’t agree more with his description. A recent research report from HealthGrades confirms the seriousness of these findings. HealthGrades examined nearly 288,000 life-threatening events that occurred among Medicare patients in U.S. hospitals from 2009 through 2011. According to HealthGrades, three patient safety-indicators accounted for two-thirds (66.7 percent) of these adverse events: respiratory failure after surgery; deep blood clots in the lungs or legs following surgery; and accidental punctures or lacerations during a procedure. A more relevant fact was that respiratory failure represented 60,632 (22 percent) of the 287,630 adverse events listed in the HealthGrades report.

Dr. Sessler states that because hypoxia is so common, he believes continuous pulse oximetry will become a standard of care in the next five to 10 years. However, five to 10 years is too long to wait, according to the Anesthesia Patient Safety Foundation (APSF).

Referring to a recent released video by the APSF, Robert Steolting, MD (President, APSF) believes that there must be a paradigm shift in the way that we monitor receiving opioids. As he says:

“It’s time for a change in how we monitor postoperative patients receiving opioids. We need a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.”

Continuous electronic monitoring of all patients receiving opioids with pulse oximetry for oxygenation and capnography for adequacy of ventilation, as recommended by the APSF, would be the “alert” that we need to intervene in a timely manner for better patient safety and outcomes.

Although we fervently concur that continuous electronic monitoring needs to be a national patient-safety standard, we sincerely hope this occurs far sooner than Dr. Sessler predicts. Why? Because patients’ lives are literally at stake. We can’t afford to wait any longer. Having lost our otherwise healthy loved ones — Amanda, John, and Leah — to undetected respiratory depression, we know this all too well.

Sincerely,

Cindy and Brian Abbieh (Founders, A Promise to Amanda Foundation)

Patricia LaChance (Wife of John Michael LaChance)

Lenore Alexander (Founder & Executive Director, LeahsLegacy)

Michael Wong, JD (Founder & Executive Director, Physician-Patient Alliance for Health & Safety) – for all patients – and their families – who have suffered an adverse event or death due to undetected respiratory depression

Capnography, Monitoring Liability and Costs, Patient Monitoring, Patient Safety, Patient Stories, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

PPAHS Mourns the Fourth Anniversary of the Passing of Amanda Abbiehl

by Sean Power
July 24, 2014

This past weekend (July 17) marks the anniversary of the tragic death of 18-year old Amanda Abbiehl, whose story serves as a powerful reminder of the need for continuous electronic monitoring.

Lynn Razzano, Clinical Nurse Consultant with the Physician-Patient Alliance for Health & Safety, offers an appeal to her clinical colleagues:

“On the four year anniversary of the untimely passing away of 18-year old Amanda, hospitals need to think of how this could have been actively prevented. My hope is that this promotes more vigilance in appropriately assessing a patient when opioids are in use and ensuring that all patients receiving opioids are continuously electronically monitored.

“The time is now to prevent death from opioid-induced respiratory depression. It is as easy as ensuring the order is placed for continuous monitoring whenever opioids are ordered. This should be the new current standard of practice and one that proactively prevents opioid deaths from occurring.”

Join us in making a #Promise to Amanda today.

Patient safety champions: Promise to do everything you can to make it mandatory at your hospital for all patients on PCA pumps to be continuously electronically monitored with capnography and pulse oximetry.

Nurses, physicians, and respiratory therapists: Encourage patients and families to share their experiences with respiratory monitoring. Promise to talk to decision makers about capnography and respiratory monitoring every chance you get. Use the PCA Safety Checklist before, during, and after initiating PCA treatment.

Hospital administrators: Build redundancies into the system. Mistakes are going to be made but adverse events are preventable. Monitor every patient and save lives. Tell us if your hospital monitors patients with capnography while they are connected to PCA pumps.

Patients and families: Come forward to share your story about capnography. Write, phone, or email your local congressperson about making zero preventable deaths a policy priority.

Read more about Amanda’s story at promisetoamanda.org or at WNDU’s latest coverage of the Promise to Amanda Foundation.

APSF, Capnography, Patient Monitoring, Patient Safety, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

New CMS Guidance Recommends Monitoring of All Patients Receiving Opioids

By Michael Wong, JD (executive director, Physician-Patient Alliance for Health & Safety)

(This article first appeared in Becker’s Hospital Review.)

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” [page 19] 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.” [page 1]

In addition and more importantly, the CMS guidance necessitates monitoring for all patients receiving opioids when in hospital:

“Narcotic medications, such as opioids, are often used to control pain but also have a sedating effect. Patients can become overly sedated and suffer respiratory depression or arrest, which can be fatal. Timely assessment and appropriate monitoring is essential in all hospital settings in which opioids are administered, to permit intervention to counteract respiratory depression should it occur.” [page 15]

 What does the CMS guidance mean by “appropriate monitoring“?

Does “appropriate monitoring” mean intermittent assessment, as was recommended in last year’s CMS proposed quality measure (#3040)?

Proposed measure #3040 provided that monitoring needs to be “documented” and the time between documentation must “not exceed 2.5 hours.” This means that a nurse or other caregiver must document the patient’s condition and do this in intervals of not greater than 2.5 hours.

In the report submitted by the National Quality Forum to HHS, the measure was not endorsed and it was decided that the measure “requires modification or further development.”

Robert Stoelting, MD, president of the Anesthesia Patient Safety Foundation, in commenting on proposed measure #3040 said:

“The conclusions and recommendations of APSF are that intermittent ‘spot checks’ of oxygenation (pulse oximetry) and ventilation (nursing assessment) are not adequate for reliably recognizing clinically significant evolving drug-induced respiratory depression in the postoperative period. For the CMS measure to better ensure patient safety, APSF recommends that monitoring be continuous and not intermittent, and that continuous electronic monitoring with both pulse oximetry for oxygenation and capnography for the adequacy of ventilation be considered for all patients.”

 Or does “appropriate monitoring” mean continuous electronic monitoring?

The CMS guidance provides two examples — one from the Institute for Safe Medication Practices and one from APSF — which could suggest that the guidance may be referring to continuous electronic monitoring. For example, the guidance provides the following from ISMP which refers to monitoring for saturation of peripheral oxygen via pulse oximetry and end-tidal dioxide via capnography:

ISMP

The CMS guidance also refers to APSF recommendations and its recent video on opioid induced ventilatory impairment.

APSF

In its video, APSF states that continuous electronic monitoring of oxygenation and ventilation, when combined with traditional nursing assessment and vigilance, will greatly decrease the likelihood of unrecognized, life threatening, opioid induced respiratory impairment. The clinical significance continuous electronic monitoring offers is the opportunity for prompt and predictable improvement in patient safety.

APSF is calling for a paradigm shift in opioid safety. According to APSF’s Dr. Stoelting:

 “It‘s time for a change in how we monitor postoperative patients receiving opioids. We need a complete paradigm shift in how we approach safer care for postoperative patients receiving opioids.”

Could CMS guidance have saved a life?

Following this CMS guidance for monitoring of patients receiving opioids wherever they are in the hospital could have saved the life of 18-year old, Amanda Abbiehl.

amanda-abbiehl

Amanda was admitted to hospital for severe step throat. She did not receive surgery. She was placed patient-controlled analgesia to manage her pain, but was not monitored.

As Amanda’s father asks:

“It isn’t standard practice to monitor patients with Capnography. However, if Amanda’s CO2 level had been monitored, wouldn’t this have alerted her caregivers so her life could have been saved?”

By this measure – continuous electronic monitoring with traditional nursing assessment and vigilance – Amanda may still be alive today. For this, CMS should be applauded for its new guidance.

Alarm Fatigue, Capnography, Patient Monitoring, Patient Safety, Patient Stories, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

Perspectives on Opioid Safety and Continuous Electronic Monitoring

by Sean Power
March 11, 2014

In honor of Patient Safety Awareness Week last week, the Premier Safety Institute gathered experts on opioid safety to participate in a webinar discussion. The panel, moderated by Gina Pugliese, RN, MS, vice president, Premier Safety Institute, Premier Inc., featured several authorities on opioid safety, including:

  • Michael Wong, JD, executive director, Physician-Patient Alliance for Health and Safety
  • Harold Oglesby, RRT, manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph’s/Candler Health System
  • Joan Speigel, MD, assistant professor, anesthesiology, Harvard Medical School and Beth Israel Deaconess Medical Center
  • Bhavani S. Kodali, MD, associate professor, Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School.

You can listen to the full recording here, download the slides here, and learn more about opioid safety here.

This article is the first of a two-part series. It summarizes the presentations on opioid safety. The second part will recap the question and answer period with the entire panel.

Will continuous monitoring become a standard of care for patients receiving patient controlled analgesia (PCA)?

The Physician-Patient Alliance for Health and Safety teamed up with A Promise to Amanda Foundation to conduct the first-ever national survey on PCA practice.

“Part of the impetus for the survey was the sheer number of respiratory events that occur each year,” says Mr. Wong.

impetus-for-the-survey

Between 20,000 and 676,000 PCA patients will experience opioid-induced respiratory depression every year.

“However for our purposes, and for A Promise to Amanda, the main impetus is the patients,” Mr. Wong continues.

patients-on-pca

The survey was developed with input from a number of patient safety experts including Richard Dutton, MD, MBA, Executive Director of Anesthesia Quality Institute, and Frank Federico, RPh, Executive Director of the Institute for Healthcare Improvement, Patient Safety Advisory Group, The Joint Commission, among others.

Six patient risk factors have been identified by major health care organizations like The Joint Commission and Institute for Safe Medication Practices (ISMP). These risk factors include:

  • Obesity
  • Low body weight
  • Concomitant medications that potentiate sedative effects of opiate PCA
  • Pre-existing conditions (such as asthma, chronic obstructive pulmonary disease, and sleep apnea)
  • Advanced age
  • Opioid naive

“The survey results show great variability in the risk factors being considered by hospitals across the country,” adds Mr. Wong.

According to the survey results, less than 40 percent of hospitals are considering all six patient risk factors.

Almost one out of five hospitals are not assessing patients for being opioid naïve. Three out of ten hospitals do not consider obesity as a patient risk factor. Three out of 20 hospitals do not consider advanced age.

Approximately 70 percent of PCA adverse events are due to errors associated with pump use, according to the Pennsylvania Patient Safety Authority. Double-checks advocated by ISMP and others can prevent errors from happening.

Patient identification, allergies, drug selection and concentration, dose adjustments, PCA pump settings, and line attachments all need to be double-checked.

“There is a great variation between hospitals performing these very simple six double checks. Sadly, only slightly more than half of all hospitals are performing all six double checks,” says Mr. Wong.

The PCA survey, conducted prior to The Joint Commission’s National Patient Safety Goal on alarm safety, found that 95 percent of hospitals are concerned about alarm fatigue. Almost nine in ten hospitals (87.8 percent) believe that a reduction of false alarms would increase the use of patient monitoring devices like an oximeter or capnograph.

“Hospitals also indicated the value of continuously electronically monitoring their patients receiving opioids,” says Mr. Wong. “All those who reported monitoring said that monitoring reduced adverse events and hospital expenditures, or that it was too early to determine the effect of monitoring.”

Moreover, hospitals using smart pumps with integrated end tidal CO2 (EtCO2) monitoring were almost three times more likely to have had a reduction in adverse events or a return on investment in terms of a reduction in costs and expenses.

The challenge of balancing effective analgesia with safety

Mr. Oglesby was involved in implementing continuous electronic monitoring at St. Joseph’s/Candler Hospitals in Savannah, Georgia, and has spoken about being opioid-related event free for eight years, as well as the return on investment that came with the program.

SJ/C is the largest health care system in southeast Georgia with 675 beds and approximately 25,000 annual discharges. In the two years preceding the implementation of continuous electronic monitoring, SJ/C experienced three opioid-related events with serious outcomes.

“We made sure that we used smart pumps to address the appropriate programming of our pumps. We also wanted to assess what would be the best way of monitoring our patients,” says Mr. Oglesby.

The team that drove the continuous monitoring program was initially comprised of pharmacy and nursing staff. Respiratory therapy was called in to address monitoring options early on in the decision making process.

According to Mr. Oglesby:

“We were specifically asked that question: as respiratory therapists, what did we think would be the earliest indicator of problems with ventilation versus saturation? We quickly said that capnography would be the earliest indicator of ventilatory problems.”

Since the nursing team was new to capnography, and since respiratory therapists were new to pain scales, education was central to the success at SJ/C.

Patient education was equally central.

“We put respiratory therapy in the role of being bedside educators,” says Mr. Oglesby, since respiratory therapists have a good foundational understanding of EtCO2 and its limitations.

“There were times when we would get calls to the bedside from the nursing staff who would say that this patient’s alarm was going off, and going off for no reason,” says Mr. Oglesby. “When you get to the bedside you would go back and review the patient’s trends and look at the waveforms. You would actually see that the patient had good reason for the alarms going off.”

The respiratory therapists found that patients often experienced undiagnosed sleep apnea and that the patients were having moments of apnea.

According to Mr. Oglesby:

“The education at the bedside resulted in the nursing staff becoming really good at using end tidal CO2 to the point that they would take monitors and put them on other patients that weren’t receiving PCA just to do an assessment of those patients.”

Capnography also provided the earliest indication of respiratory depression for patients receiving PCA treatment.

pca-monitoring-trend-data

These screens from an actual patient highlight a few key points about the effectiveness of capnography at providing the earliest indication of respiratory compromise.

“You can see on that monitor that it gives you the time,” explains Mr. Oglesby. “Highlighted on both is 10:00 AM. At 10:00 AM you see the patient’s morphine dose was 2.5 milligrams. The patient’s [oxygen] saturation was 97 percent. Pulse ox was 88. The end tidal CO2 was 43 and the respiratory rate was 20.”

Mr. Oglesby explains that at 10:30 AM, the screens show, EtCO2 rose to 50, which was outside of the established range, and an alarm sounded. The pulse oximeter alarm did not sound until 11:30.

“This was typical,” says Mr. Oglesby. “We were finding that the end tidal CO2 gave us at least that hour window—gave us an hour earlier indication that something was changing with the patient’s status. So if we just had pulse oximetry, we wouldn’t have known until an hour later that something was really going on with that patient.”

According to Mr. Oglesby:

“We truly believe that end tidal CO2 provides us with the earliest indicator of a decline in our patient’s respiratory function.”.

Monitoring patients receiving PCA with capnography at SJ/C resulted in an increased likelihood of better-sustained pain control, faster recovery and discharge, a better patient experience, and eight years of event free usage of PCA therapy.

Alarm Fatigue, Capnography, Patient Monitoring, Patient Safety, Patient Stories, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring, Postoperative Pain

The Intertwined Stories of Amanda Abbiehl and Continuous Electronic Monitoring

In the recent article, “Silent Danger: PCA Pumps and the Case for Continuous Monitoring” published by Association for the Advancement of Medical Instrumentation in Biomedical Instrumentation & Technology, the story of 18-year old Amanda Abbiehl is told as a powerful reminder of the need for continuous electronic monitoring.

Amanda was admitted to hospital for “severe strep throat”, placed on a patient-controlled analgesia pump to manage her pain, and passed away – most likely because of opioid-induced respiratory depression.

In this slide share, this article has been adapted and retold.

The Physician-Patient Alliance for Health and Safety wishes you the best for this holiday season. Our New Year’s Resolution is to do everything we can to eliminate tragedies like Amanda’s. Join us in making a #promise to Amanda to achieve zero preventable deaths associated with opioid-respiratory depression at your hospital.

Alarm Fatigue, Capnography, Patient Monitoring, Patient Safety, Patient Stories, Patient-Controlled Analgesics, PCA, Post-Operative Monitoring

3 Questions About Patient Safety and PCA with Brian and Cindy Abbiehl from A Promise to Amanda Foundation

by Sean Power
December 12, 2013

The Physician-Patient Alliance for Health and Safety released their findings from the First National Survey on Patient-Controlled Analgesia (PCA) Safety Practices.

The report on the National Survey on Patient Safety with PCA is available to download for free here. It asked pharmacists, doctors, nurses, respiratory therapists, and administrators at hospitals from 40 states about their safety measures for PCA.

Brian and Cindy Abbiehl, founders of A Promise to Amanda Foundation (which co-sponsored the research), recently shared their thoughts on some of the findings on the patient risk factors being considered at hospitals during the administration of PCA.

The Abbiehls founded A Promise to Amanda Foundation to raise awareness about respiratory depression after the death of their 18 year-old daughter Amanda. Amanda was admitted to a hospital for an infection and was hooked up to a PCA pump to manage her pain. Less than twelve hours after Amanda was put on a PCA using Delaudid she was found unresponsive. Amanda’s parents believe that, had Amanda been monitored with capnography and pulse oximetry, nurses would have been alerted that she was in trouble and been able to intervene.

You can find a copy of the survey results here.

SP: The survey asked respondents about which risk factors they consider before patients initiate PCA. Was there anything in the results that surprised you?

Cindy Abbiehl: I don’t think we had any expectations going into the survey so I wouldn’t say we were surprised by any of the findings.

I think it’s more accurate to say that the results disappointed us in the sense that, for PCA to be administered safely, every risk factor included in the survey should be considered for every patient before initiating PCA. Not all hospitals consider every factor. That needs to change.

The risk factors include obesity, low body weight, concomitant medications that potentiate sedative effects of opiate PCA, pre-existing conditions such as asthma and sleep apnea, advanced age, and opioid naïve.

These risk factors were identified in the Physician-Patient Alliance’s PCA Safety Checklist last year, which was assembled by a number of well-respected health care professionals. The impact of not considering these risk factors can be tragic.

Brian Abbiehl: Cindy and I are talking from experience when we use the word “tragic.” Our daughter, Amanda, was administered PCA to manage pain despite Amanda being opioid naïve. The PCA survey reveals that around 1 in 5 hospitals do not consider whether the patient is opioid naïve before initiating PCA.

Checking if patients are opioid naïve will raise a red flag to health care providers and can prevent tragic outcomes. The Food and Drug Administration associated PCA with 56,000 adverse events and 700 patient deaths between 2005 and 2009. Considering all risk factors can help to prevent these tragic outcomes.

CA: The survey showed that non-pharmacists were about four times less likely than pharmacists to say that they consider opioid naïve as a patient risk factor. As the front line professionals interacting with patients, this reality needs to change. Pharmacists, physicians, nurses, respiratory therapists, and other health care professionals all need to be on the same page when administering PCA.

SP: You two have spoken about Amanda’s death many times in the past. What would you like to see come out of the findings of the survey?

BA: We’re hopeful that the survey will bring attention to the fact that PCA can be dangerous without the proper safety measures in place.

One of the survey’s key findings is that there exists a great lack of consistency in safety procedures being followed by hospitals across the country. Indicated by the survey are a number of safety recommendations for health care providers.

For instance, the survey provides a list of patient risk factors to consider when initiating PCA. It outlines when to perform double-checks, and what to double-check. It highlights the use of capnography, pulse oximetry, and “smart pumps” to keep patients safe. There are a number of other safety practices that can be followed.

CA: When you ask what we’d like to see from the survey, the ultimate answer is better patient outcomes. Safer care. Fewer adverse events. Zero preventable deaths associated with PCA.

Implementing some of the safety practices asked about in the survey, partnered with a culture of safety at hospitals in the United States, will save lives.

SP: Are there any safety practices you believe are particularly important for the administration of PCA?

CA: They’re all critical—especially those contained in the PCA Safety Checklist I mentioned earlier.

A Promise to Amanda Foundation focuses on the continuous electronic monitoring of all patients every time a patient is placed on a PCA pump, is sedated, requires a stay in the PACU following general anesthetic, or requires a stay in the PACU following sedation.

Continuously monitoring with capnography and pulse oximetry is key because it provides a technological safety net. For instance, “smart pumps” with forcing functions monitor trends in the quality of breath. Should these trends indicate that the patient is experiencing respiratory depression, it stops infusing medicine and alerts nurses to intervene.

Without smart pumps, the nurse might not be aware that the patient is experiencing respiratory depression until the nurse’s next “spot check”, which could occur as far as four hours from the time of respiratory depression at some hospitals.

For these reasons, A Promise to Amanda Foundation focuses on making continuous electronic monitoring mandatory in the administration of PCA. It enables health care professionals to prevent adverse events and clinically intervene.

Even if health care professionals miss a double-check, or fail to consider every risk factor, or overlook any other critical safety practice, capnography and pulse oximetry will help to prevent respiratory depression by notifying caregivers before the patient’s condition deteriorates to Code Blue levels.

BA: We understand that alarm fatigue continues to be a main obstacle to implementing the patient monitoring with capnography and pulse oximetry. The survey found that 9 out of 10 hospitals believe reducing false alarms would increase the use of such devices.

In addition to using capnography and pulse oximetry, then, we would insist that reducing the incidence of false alarms is a safety practice that is particularly important for safer PCA use.

The Joint Commission is expected to announce a National Patient Safety Goal on alarm management in 2014. We hope that health care professionals will rally behind them and make PCA safety a priority by improving alarm safety at their hospital.

Capnography, PCA, Post-Operative Monitoring

PPAHS Speaks at A Promise to Amanda Foundation Fundraiser

by Sean Power
August 21, 2013

On behalf of the Physician-Patient Alliance for Health and Safety I would like to congratulate A Promise to Amanda Foundation on a successful fundraiser and awareness campaign.

I would also like to thank Brian and Cindy Abbiehl for inviting PPAHS to speak about the four essentials for safety. The Physician-Patient Alliance hopes that the nearly 400 audience members will share with their doctors and nurses the four essentials for safety while using patient-controlled analgesia pain pumps (PCA):

  1. Ensure patients/families are provided information on proper use of the PCA pump, so they understand
    1. Pump delivers a powerful narcotic
    2. No PCA by proxy
  2. Make sure patients/families understand why they must be monitored for safety reasons:
    1. Oximetry clip on finger
    2. Capnography cannula on nose
  3. Save yourself some trouble and educate patients and families about monitor readouts.
  4. Educate patients why alarms sound and what to do when they do sound.

As promised, I’ve made these slides available on the PPAHS website for download in PDF format here.

The Physician-Patient Alliance is excited by the progress on PCA safety and we hope Amanda’s friends, family, and the South Bend community will join us in making a #promise to Amanda. As Dr. Cheryl Wibbens, Chief Medical Officer at Memorial Hospital in South Bend has stated:

“Monitoring patients for how much carbon dioxide they are breathing out with capnography provides us with the earliest possible indicator to detect the onset of opioid-induced respiratory depression.”

Memorial Hospital joins many hospitals across the country now monitoring with capnography – for some of these hospitals, please view this interactive map.

As Dr. Wibbens further explains:

“Every patient at Memorial that has opioids is a little safer now. Continuously electronically monitoring with capnography will save lives.”

The motto of A Promise to Amanda Foundation is “Capnography saves lives”. Let’s make it a priority at hospitals across the country to save lives.

The lines of communication between healthcare professionals and their patients need to be open for safety to become a priority. These slides can help break the ice for the conversation about patient safety.

Please give these slides to your doctors, nurses, and respiratory therapists and make sure they know that your safety is important. You can play a central role in your own safety. Insist that your healthcare team follows these four essentials the next time you or a loved one are treated with PCA.

To view the local NBC affiliate’s coverage of the event, please click here.