Why Hospitalists should care about Respiratory Compromise

This week is the Society for Hospital Medicine (SHM)’s Annual Conference, and the Respiratory Compromise Institute (RCI) believes that hospitalists play a key part in the prevention – and eventual elimination – of respiratory compromise. Dr. Jeff Vender, who serves on RCI’s clinical advisory committee, has written an article published in “The Hospitalist” on why this is.

Respiratory Compromise is a state in which there is a high likelihood of decompensation into respiratory failure and/or death, but, in which specific interventions – be it therapeutic and/or monitoring – might prevent or mitigate this decompensation. “Respiratory failure is the second leading avoidable patient safety issue.1 It is one of the top five conditions leading to increasing hospital costs2 and the third most rapidly increasing hospital inpatient cost in the United States.3,” states Phil Porte, Executive Director of the Respiratory Compromise Institute.

Dr. Vender begins his article with a reference to research conducted by Dr. Adriana Ducci, on “Improving Survival from Sepsis in Noncritical Units: Role of Hospitalists and Sepsis Team in Early Detection and Initial Treatment of Septic Patients,” and makes a comparison between sepsis and respiratory compromise. Sepsis has been successfully prevented countless times because of hospitalist-managed protocols, and he believes that the same principles apply to respiratory compromise.

“I believe that greater awareness about respiratory compromise will lead to earlier diagnosis and interventions, which will theoretically improve patient outcomes. Moreover, as with the sepsis awareness campaign, hospitalists can play a key role in recognizing respiratory compromise and in the implementation of appropriate interventions,” says Dr. Vender in the article.

Dr. Vender discusses several examples of how respiratory compromise can occur, and offers a few suggestions on steps we can take together as nurses, hospitalists, or physicians, but most importantly he emphasizes that “simple recognition and greater awareness of respiratory compromise, just as with sepsis awareness campaigns, will mean more patients are diagnosed earlier, more appropriate interventions are made, and hopefully more adverse events and patient deaths are averted.”

Read the full article from The Hospitalist here, and join the conversation about respiratory compromise and ways to prevent it by leaving a comment, or following RCI on Twitter, LinkedIn, or Facebook.

2018 NAEMSP Annual Meeting Features More Than 50 Education, Research and General Sessions, Highlighting the Importance of EMS

Meeting Underscores the Value of Technology and Innovation in EMS Care, Including the Use of Capnography 


By Michael Levy, MD, FACEP, FACP, FAEMS (Secretary/Treasurer, National Association of EMS Physicians)

Since its founding in 1984, the National Association of EMS Physicians’ (NAEMSP) mission has been to create and support a peer organization to serve as a resource and an advocate for EMS physicians and non-physician providers, and, in doing so, foster excellence in out-of-hospital emergency medical services. As an association of more than 1,100 physicians, paramedics, nurses, administrators, educators, researchers, and EMS personnel, NAEMSP convenes every January, bringing together members from across the country and the globe — including attendees from Europe, Asia, Latin America, the Middle East and Canada — to network and learn. At each meeting, members and NAEMSP leadership share new research, host skills and development workshops, and provide updates on best practices.

The 2018 NAEMSP annual meeting continued to demonstrate the organization’s leadership in advancing the care of patients, featuring more than 50 education, research, and general sessions representing the depth and breadth of EMS practice. In addition, days of research posters and oral presentations of abstracts on new science were hosted throughout the meeting.

Key highlights from 2018 NAEMSP, included:

  • a three-day National EMS Medical Directors Course & Practicum, which provided participants with the skills they need to become EMS medical directors;
  • sessions on a new approach to EMS, called Mobile Integrated Healthcare (MIH), which aims to improve patient care and reduce costs;
  • an Out-of-Hospital Critical Procedure Cadaver Lab, which provided a review of anatomy associated with critical care; and
  • a session, entitled “Cutting the Edge: Innovations in Prehospital Critical Care,” which examined concepts and technologies for prehospital care transports.

Capnography — a patient monitoring tool which measures exhaled carbon dioxide — is one such technology and can prevent respiratory compromise, a state in which there is a high likelihood of patient deterioration into respiratory insufficiency, respiratory failure or death.

National EMS Medical Directors Course & Practicum

The three-day National EMS Medical Directors Course & Practicum provided participants with a foundation upon which to function effectively as EMS medical directors. Among other skills, participants learned how to: outline organizational and design options for EMS systems, including system staffing and response configurations; identify the major communications and dispatch issues for EMS systems; describe the process for incident review and strategies for problem-solving in EMS systems; define the fundamentals and priorities for implementing quality improvement programs in EMS systems; and compare and contrast rural, urban, international, and suburban EMS delivery systems. The practicum was sold out, as it was last year, reflecting the growing interest in understanding how to lead an EMS team, and how EMS functions within the broader emergency care system at all levels.

Mobile Integrated Healthcare

Several sessions focused on a new platform for EMS known as Mobile Integrated Healthcare (MIH), featuring healthcare providers with established MIH programs offering guidance to practitioners looking to create their own MIH programs and those with established programs connecting with colleagues to discuss solutions to challenges. MIH envisions EMS playing a key role in healthcare by provisioning — in the out-of-hospital environment — patient-centered, mobile care, which can include: the use of community paramedicine (CP), helping patients with chronic disease management, employing preventive care strategies, conducting post-discharge follow-up visits with patients, or referring them to care settings outside the emergency department. Conceptually, MIH is grounded within the Institute for Healthcare Improvement’s IHI Triple Aim philosophy of improving the patient care experience, improving population health, and reducing the per capita cost of healthcare. Hallmarks of an effective MIH program include, among others:

  • integrating the program into existing healthcare systems;
  • collaborating with local community stakeholders to better understand and define community health needs;
  • using data to develop evidence-based performance measures;
  • having a multidisciplinary approach to medicine, engaging physicians and other clinicians to oversee the MIH program, alongside the patient’s primary care network, and using telemedicine as needed;
  • and providing specialized training to CP personnel.

As part of a MIH program, CP personnel would help bridge the many gaps we find in healthcare systems and avoid unneeded hospital readmissions by providing at-home, focused interventions. CP practitioners would reduce the burden of these readmissions by working with a MIH program team to assess patient needs and respond accordingly, saving patients trips to the emergency room.

Out-of-Hospital Critical Procedure Cadaver Lab

The Out-of-Hospital Critical Procedure Cadaver Lab provided participants with an opportunity to review anatomy associated with critical care, such as the airway and chest cavity, and lifesaving emergency procedures, such as vascular access. Vascular access is especially important when performing extracorporeal cardiopulmonary resuscitation (ECPR). ECPR provides external circulatory support to patients, helping keep them alive while they are being transported to a hospital.

Capnography & “Cutting the Edge: Innovations in Prehospital Critical Care

A session, entitled “Cutting the Edge: Innovations in Prehospital Critical Care,” provided an overview of concepts and technologies being implemented for prehospital critical care transports. One such technology is capnography, which is used to monitor respiratory status in patients undergoing transport. It is an especially important monitoring tool for patients who require airway intervention or support; for patients who have been intubated; or for those overdosing on opioids who need naloxone, an opioid reversal drug.

Opioids — the abuse of which is a national epidemic — was even a focus of one of the general sessions, where its impact on public safety and first responders was discussed. Opioids can contribute to respiratory compromise, leading to death. Management of patients overdosing on opioids involves typical prehospital interventions, such as endotracheal intubation, supplemental oxygen administration, upper airway management and patient assessment, among others. Continuous evaluation of ventilation via capnography should also be used to monitor overdosing patients experiencing respiratory compromise. Finally, as naloxone is administered, capnography can also be used to avoid or lessen the chance naloxone triggers violent withdrawal symptoms, by helping with the timing and dosage of naloxone administration. And, even when naloxone is administered, airway management should remain an important consideration for the care of patients overdosing on opioids, as the drugs are often mixed and include other toxins.

NAEMSP & the Respiratory Compromise Institute

NAEMSP’s support of capnography as a life-saving monitoring tool for patients experiencing respiratory compromise in the prehospital or intra-transport hospital setting cannot be overstated. Moreover, as a member society of the Respiratory Compromise Institute (RCI), NAEMSP recognizes the importance of: continued research about the potentially deadly condition; more adoption of best care practices to reduce respiratory compromise’s incidence; and increased awareness and education about the condition as a serious patient safety issue.

RCI and its member societies have and will continue to do great work in bringing attention to respiratory compromise. Together, we can prevent the morbidity and mortality associated with respiratory compromise, regardless of whether patients receive care in the field, during transport or in the hospital.

To learn more about the 2018 NAEMSP annual meeting, see the schedule here: http://www.naemsp.org/Pages/2018-Annual-Meeting-Schedule.aspx

Visit the NAEMSP website for more information on the organization by clicking here: http://www.naemsp.org/Pages/default.aspx

For more information about the 2019 NAEMSP meeting, being held in January in Austin, Texas, click here: http://www.naemsp.org/Pages/Annual-Meeting.aspx                                                                                                                    


View the RCI’s brochure on Respiratory Compromise

Download the RCI’s presentation at CHEST 2017

Read the latest press release about RCI’s newest member society, the American Association of Nurse Anesthetists, represented by Vanderbilt University Medical Center’s Chief Nurse Anesthetist

See an animation about Respiratory Compromise

About Michael Levy

Michael Levy, MD, FACEP, FACP, FAEMS, serves as the Secretary/Treasurer of NAEMSP. He is currently an Emergency Department Physician at Alaska Regional Hospital in Anchorage, Alaska; the Medical Director for the Anchorage Fire Department; and an Affiliate Associate Professor, UAA College of Health, WWAMI School of Medical Education, University of Alaska Anchorage. Dr. Levy is also an EMS Medical Director for the State of Alaska, as well as the Medical Director for Areawide EMS Anchorage Alaska and the Kenai Peninsula Borough EMS. His EMS experience spans rural, remote, urban, military and medevac-to-urban settings and care scenarios. Dr. Levy is a reviewer for Prehospital Emergency CareAnnals of Emergency Medicine, and Asian EMS Journal. He completed his undergraduate studies in Molecular, Cellular, and Developmental Biology at the University of Colorado Boulder and received his MD from Northwestern University Feinberg School of Medicine. Dr. Levy is board certified in Internal, Emergency Medicine, and EMS Medicine. Among other many other awards, he received the Michael Keys Copass Award in 2017, a national award given annually to an EMS Director who has demonstrated longstanding service and leadership, and has served as a role model for other EMS Directors.

For National COPD Awareness Month, Learn How COPD is a Risk Factor for Respiratory Compromise

November marks National COPD Awareness Month, an annual observance aimed at increasing public awareness about chronic obstructive pulmonary disease (COPD). By engaging patients, clinicians and respiratory health organizations to communicate about COPD and support awareness events, the observance helps to enhance recognition of and drive education about the disease. One of the member societies of the Respiratory Compromise Institute, the American Association for Respiratory Care, is among the many organizations working to increase awareness about COPD this month.

COPD, a progressive life-threatening lung disease that causes breathlessness, is the third leading cause of death in the United States. Globally, it is estimated that more than three million people died of the disease in 2015, accounting for five percent of all deaths in that year. Not only is COPD itself a life-threatening disease, but it is also a risk factor for respiratory compromise, a potentially lethal condition impacting patients across the care continuum.

Respiratory compromise is a gradual, sometimes subtle imbalance in a person’s breathing response that encompasses respiratory failure and arrest. The condition can occur in nearly any clinical setting, including the home. Patients who undergo anesthesia for medical procedures or recover from surgery may be at particular risk for respiratory compromise, dramatically increasing the likelihood of adverse outcomes and cost of patient care. The condition is a leading patient safety issue and people on the general care floor with respiratory compromise are 29 times more likely to die.

Despite the dangers posed by respiratory compromise, respiratory failure resulting from the condition is potentially avoidable in many cases. For example, detection, mitigation and prevention of respiratory compromise can be aided with the use of patient monitoring technologies, including capnography. Capnography measures exhaled levels of carbon dioxide and is a commonly known, but underutilized, monitoring technology.

Individuals with COPD are just one kind of patient at increased risk of respiratory compromise who may benefit from monitoring with capnography. Older patients are also at risk, as are individuals with obesity, sleep apnea and asthma. -9

For National COPD Awareness Month, speak to those you know with COPD. Talk to them about how they may be at risk for respiratory compromise, that the condition can be prevented, and that addressing it with their healthcare providers is important.

To learn more about respiratory compromise, view the following resources:

SONORIA and PPAHS Announce Alliance to Improve Clinical Collaboration

by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

The Society for Non OR Intervention and Anesthesia (SONORIA) and the Physician-Patient Alliance for Health & Safety (PPAHS) are pleased to announce their new alliance focused on promoting safety and optimized outcomes for patients undergoing procedures outside of the Operating Room. Wendy Gross MD, President of SONORIA and Michael Wong JD, CEO and Executive Director of PPAHS have each agreed to serve as advisors to their respective organization’s Boards.

Continue reading at http://www.ppahs.org/2017/01/sonoria-ppahs-announce-alliance/

Reducing Respiratory Compromise Incidence With Better Monitoring

by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

A new study from Jikei University found that better patient monitoring may help reduce respiratory compromise, according to a recent article in Anesthesiology News. The study findings, presented at the 2016 annual meeting of the American Society of Anesthesiologists, suggested that sending patients with obstructive sleep apnea who are undergoing endoscopic sinus surgery to the ICU for intensive monitoring during the first postoperative night improves respiratory complication–related outcomes.

The incidence and awareness of respiratory compromise outside the operating room anesthesia setting has increased significantly in recent years, according to Jeffery S. Vender, MD, clinical professor of anesthesiology at the University of Chicago Pritzker School of Medicine. Multiple studies have shown a higher incidence of respiratory complications outside the operating room, and have suggested that better monitoring can help to prevent a higher death rate, according to Dr. Vender.

Read more at Anesthesiology News http://www.anesthesiologynews.com/Multimedia/Article/01-17/Better-Monitoring-Reduces-Post-op-Respiratory-Complications/40144

12 Years of Event-Free Opioid Use

by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

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).  

Continue reading “12 Years of Event-Free Opioid Use”

5 Strategies to Keep Patients Safe When Receiving Opioids

by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

The Physician-Patient Alliance for Health & Safety (PPAHS) had the pleasure of interviewing Thomas W. Frederickson, MD, FACP, SFHM, MBA – lead author of the Society of Hospital Medicine RADEO guide (“Reducing Adverse Drug Events Related to Opioids”).  The guide is a comprehensive clinician manual created with the aim to decrease opioid-related adverse events in an inpatient setting.

In the first of this two-part interview, Dr. Frederickson discusses five key steps to identify and address patient conditions that pose a greater risk of respiratory depression.  For readers that have yet to listen to the podcast, please click here; it’s an insightful interview relevant for any clinician working in quality improvement or directly with patients prescribed opioids.

In part two, interviewer Pat Iyer and Dr. Frederickson switches gears and focuses on monitoring issues associated with caring for at-risk patients.  You can watch/listen to the interview below: Continue reading “5 Strategies to Keep Patients Safe When Receiving Opioids”

5 Key Steps to Assessing and Identifying At-Risk Patients for Respiratory Compromise

by Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety)

The cost of opioid-related adverse events, in terms of both human life and hospital expenses, remains at the forefront of the public eye. It has been estimated that yearly costs in the United States associated with opioid-related post-operative respiratory failure were estimated at $2 billion.

The Society of Hospital Medicine, which is the largest organization representing hospitalists and a resource for hospital medicine, recently released a comprehensive guide, “Reducing Adverse Drug Events Related to Opioids” (otherwise known as the RADEO guide).

To better understand the RADEO guide, the Physician-Patient Alliance for Health & Safety interviewed its lead author – and member of RCI’s advisory commitee – Thomas W. Frederickson MD, FACP, SFHM, MBA.  Continue reading “5 Key Steps to Assessing and Identifying At-Risk Patients for Respiratory Compromise”

5 Key Learnings to Create a Culture of Patient Safety with Capnography: Physician-Patient Alliance for Health & Safety Releases Interview With Peggy Lange, RT

The Physician-Patient Alliance for Health & Safety today released an interview with Peggy Lange, RT (Director of the Respiratory Care Department, St. Cloud Hospital) about a project that examined acute response team (ART) calls regarding patients who had received procedural or conscious sedation 24 hours prior to the event. 

As Ms. Lange wrote in her article published in ADVANCE for Respiratory Care and Sleep Medicine, “Culture of Safety Includes Capnography”:

“We looked at patient monitoring practices in the outpatient procedural areas and we addressed the very real issue of too many alarms on the hospital patient floor. We also undertook a literature review for the project as we prepared to consider implementing capnography outside the operating room at our institution.”

For the project, St. Cloud Hospital brought together a team of clinicians that included physicians, nurses, respiratory therapists, and pharmacists who represented different clinical areas like pain, sedation, endoscopy, and surgery.

In this interview, Ms. Lange discussed 5 key learnings from this project:

Key Learning #1 – Capnography Assists with Assessment of the Quality of Ventilation

Ms. Lange said that their review of the relevant literature and their experience showed that monitoring with capnography is a valuable tool to assess the patient’s quality of ventilation:

“We reviewed the literature and then budgeted through normal channels for approval for the equipment, and then worked closely with the surgical floor for the trial period. We found that the literature talked about CO2 monitoring was providing an earlier indicator of respiratory compromise before the patient became hypoxic.

“So, even before oximetry would be a reading, CO2 monitoring provided that earlier indication. We found that it was recommended as a tool for procedural sedation. And during the recovery for sedation, we found that end tidal CO2 monitoring was recommended to assist with the quality of ventilation. It was a standard of care for anesthesia for a number of years for intubated and mechanically vented patients, and it’s also in the ACLS guidelines for cardiopulmonary arrest management.”

Key Learning #2 – Monitor Patients Continuously, Not Intermittently

To be effective, capnography monitoring should be done continuously and not intermittently, said Ms. Lange:

“We know that intermittent monitoring can stimulate the patient to a higher level of consciousness. But again, when they’re left alone, they can experience that respiratory depression. We want people to document the trended numbers, not just the numbers when you stimulate somebody, because it’s not giving the full picture to the next caregiver.”

For all five key learnings, please listen to the interview with Ms. Lange on YouTube by clicking here.

5 Keys to Reducing Harms from Opioids: A Discussion with Stephanie Uses, PharmD, MJ, JD, Patient Safety Analyst, ECRI Institute

ECRI Institute recently released the 2016 Top 10 Patient Safety Concerns for Healthcare Organizations.

Of ECRI’s top 10 patient safety concerns, inadequate monitoring for respiratory depression has the greatest likelihood of preventable harm. This occurs when the patient receives opioids and is not monitored effectively and sufficiently. ECRI says that inadequate monitoring for respiratory depression in patients receiving opioids poses the greatest risk to patients and assigned it a risk map of 80:


In order to improve clinical understanding of how patient harm from opioids may be reduced, Lynn Razzano, (RN, MSN, ONCC) and Michael Wong, JD of the Physician-Patient Alliance for Health & Safety (PPAHS) had a discussion with ECRI’s Patient Safety Analyst, Stephanie Uses, PharmD, MJ, JD.

To read a copy of the article on the interview and the 5 keys to reducing harms from opioids, please click here.

To listen to the entire discussion on YouTube, please click here.