Can Failure-to-Rescue be Improved?

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

There is a need to improve rapid response teams and code blue activations. 50% of Code Blue events involve patients receiving opioids. Moreover, unrecognized postoperative respiratory failure that results in cardiopulmonary arrest is a daily occurrence at healthcare facilities across the United States.

In a recent interview with the Physician-Patient Alliance for Health & Safety (PPAHS), Eyal Zimlichman, M.D., MSc., spoke at length about improving rapid response teams and code blue activations.

Rapid Response Systems
Rapid Response Systems

Dr Zimlichman holds dual appointments as Deputy Director General and Chief Quality Officer at Sheba Medical Center in Israel and at the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital and Harvard Medical School

The success of rapid response team deployment and Code Blue activations is hugely dependent on timing – the earlier patient deterioration is identified and acted upon, the sooner intervention may take place. Dr. Zimlichman spoke about the need for early detection and intervention:

… mostly in general floors, we have intermittent vital signs checks. These checks would go and somewhere between every six hours or even eight hours or sometimes four hours, but certainly not continuous…

So by the time of intervention between one vital sign check to the other, we actually would get to the patient bedside only when he goes into cardiac arrest. If that deterioration occurs. So being able to continuously monitor patients on general floors, much like we do on ICUs, could be something that would make a significant contribution to preventing these preventable deaths inside hospitals.

Dr Zimlichman says that continuous electronic monitoring of patients holds the key to improving early detection and intervention:

… I think that’s a common notion today among the experts that continuous monitoring is what we call the missing link to making rapid responses to the work …

[Research has] shown that hospitals have implementation of rapid response system have not shown an improvements in outcomes, have not shown a decrease in mortality that we were aiming to see. And there is always that question, why is that the case? And if we look closely into rapid response systems, we know that there’s an efferent and an efferent we’re mainly saying that there is first of all, understanding that there’s a need to activate the team and then once we understand that there’s the actions that the team take …

[Using the continuous monitoring system in our research] there’s a 50% chance that [when the alarm sounds] this patient would need an ICU. When the nurse gets that alert on top of her clinical judgement, it reinforces her decision making and I think that factor alone contributes to a better and efficient activation of the system.

To listen to the complete interview with Dr. Zimlichman, please click here.

For another interview with a clinician who has been able to reduce the need for rapid response activations by more than 50%, please click here.

 

 

 

Clinicians Must Recognize the Signs of Respiratory Compromise: An Interview With Pamela Parker, BSN, RN, CAPA

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

On July 23, 2007, 17-year old Logan died after successfully undergoing routine surgery to correct his sleep apnea.

Click on the image of 17-year old Logan to hear his mother, Pamela Parker, BSN, RN, CAPA discuss his death and lessons she has learned from it.
Click on the image of 17-year old Logan to hear his mother, Pamela Parker, BSN, RN, CAPA discuss his death and lessons she has learned from it.

In a podcast recently released by the Physician-Patient Alliance for Health & Safety, Pamela Parker, BSN, RN, CAPA describes her son, Logan, as “a red haired, fair skinned, seventeen year old fun big kid … [who] was very silly and … even embraced the term ‘goofy’.”

Logan had obstructive sleep apnea (OSA) with elements of central sleep apnea. He underwent surgery to have “his tonsils and his uvula removed, septum and his turbinate repaired. Basically, opening up the airway by removing the tissue in the back of his airway.”

Below are some key excerpts from the interview with Ms. Parker:

On Logan’s Respiratory Assessment:

Logan received IV morphine. Two milligrams administered at 12:50, again at 12:53, and again at 13:10. His IV was removed eight minutes later and he was discharged at 13:25, just fifteen minutes after his last dose of morphine…

 There was not any scoring tool used to track his level of sedation during his recovery period. The surgery center only used the Alrdete Score during his anesthesia recovery period. And in reality Logan died in 2007 prior to the common use of the Pasero Opioid Induced Sedation Scale …

Based upon the [Pasero Opioid Induced Sedation] Scale Logan was probably a three. Changing the probe from one finger to another, it might have stopped the pulse oximeter alarm from going off, but it did not address the true problem. It can now be assumed that Logan was already having ventilation issues. According to that to the Pasero Opioid Induced Sedation Scale, Logan’s condition was unacceptable and this required a decreased opiate opioid dose – 25 to 50 percent – or notify the prescriber.

On the Need for Process Improvement:

We can do better.

Each health care provider needs to consider the risk of respiratory compromise in planning a patient’s care, and this includes all clinicians involved in creating and implementing a plan, including the surgeon, the anesthesiologist, and the nurses. And, it should entail frequency of respiratory assessment and the types of monitors being used. Capnography should be used on all patients who are at risk for increased carbon dioxide.

Other considerations include minimal usage of medications that increase respiratory depression, such as phenergan and benadryl. Additionally, the patient should receive full reversal medications by anesthesia at the end of surgery. Clinicians must create a better plan for the at-risk patient.

I am a recovery room nurse, and yet I did not have the tools and I could not save him.  

After discharge, his deterioration was already rolling down too an accelerated path.

We must do better. Screen our patients for risk. Know the signs of deterioration in a timely manner with a thorough, a thorough nursing assessment and intervene earlier. I firmly believe that the appropriate monitors have been used – specifically capnography – and if he had received additional and longer monitoring in an un-stimulated environment, July 23rd of 2007 would have had a different ending…

The recent guidelines for respiratory depression have come after his death. Unfortunately, it often takes a bad outcome to create a better process. Logan’s bad outcome was absolutely heart wrenching and devastating for our family. Now, now is a time for process improvement.

Do not just use capnography, use it and use it well. Understand it. Use it to become a better nurse in your assessment of your patients. Do not be a task oriented health care provider. Thoroughly assess your patient’s respiratory status. Look at the big picture.

Remember this story. Remember that if the seventeen year old boy could die from complications of sleep apnea, anyone can. 

Pamela Parker, BSN, RN, CAPA
Pamela Parker, BSN, RN, CAPA

Ms. Parker has been a registered nurse for almost 25 years. She is a recovery room nurse and works in the ambulatory procedure unit at a hospital in Indiana. In addition to providing patient care, Pamela is a clinical educator and provides bereavement support. To help others with the loss of loved ones, she writes a blog “Hope for Grieving Mothers” (http://www.holeheartedmamas.com/).

To listen to the interview with Ms. Parker on YouTube, please click here.

For a pdf transcript of the interview, please click here.

Reducing Rapid Response Calls by 50% and Avoiding Respiratory Depression During Conscious Sedation: An Interview with Richard Kenney, RRT

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

White Memorial Medical Center in Los Angeles has experienced a “better than fifty percent reduction in calls of rapid responses”, according to Richard Kenney, MSM, RRT, NPS, ACCS, RCP (Director, Respiratory Care Services, White Memorial Medical Center).

To better understand what Adventist Health hospitals have done to reduce rapid response calls and improve patient safety and health outcomes, the Physician-Patient Alliance for Health & Safety (PPAHS) interviewed Mr. Kenney.

In this interview titled, “Avoiding Respiratory Depression During Conscious Sedation”, Mr. Kenney says using capnography monitoring has reduced rapid response calls by more than 50%.

The combination of using both capnography and pulse oximetry monitoring has delivered a huge win-win for Mr. Kenney’s hospital and for patient safety. As he describes:

The combination of the two allows us to cover, if you will, our bases, meaning that we can monitor the respiratory rate, the heart rate and cases of the pulse oximetry it gives us a better reading knowing that their profusion status is good. What I think is even better today than just a few years ago, is that the end tidal CO2 device and the pulse oximetry were two separate machines that took up a lot of space on the patient’s bedside table with long cables running all over the place but, with today’s devices that we’re currently using have the pulse oximetry and the end tidal CO2 in one device. They have a built in algorithm rhythms that will let the respiratory therapist or the nurse taking care of that patient, give them the advantage of knowing that something is starting to happen with this patient because these two parameters are not matching in a way that they should, and you need to come in and evaluate your patient. And so because of that, we can intervene much quicker for patient safety than we did in the past; so the combination of being able to monitor both oxygen and ventilatory status is a win-win for the patient.

The result has been a significant reduction in rapid response calls:

since the implementation of this combination of monitoring the patient, the number of rapid responses to those areas where the patient comes out with that PCA pump have – I want to say – a better than fifty percent reduction in calls of rapid responses.

In the interview, Mr. Kenney offered 5 keys to avoiding respiratory depression during conscious sedation:

  1. Recognize that Each Patient Reacts Differently to Opioid Dosages
  2. Don’t Rely Upon Pulse Oximeter Monitoring
  3. Monitoring with Capnography Provides a More Accurate Assessment of Patient’s Ventilatory Status
  4. Ensure that Nursing and Respiratory Therapists are Working as a Team
  5. Using Capnography Monitoring has Reduced Rapid Response Calls by More Than 50%

To view the complete interview with Mr. Kenney, this can be done either:

  • On YouTube – please click here.
  • At iTunes – please click here.

To read a transcript of the interview, please click here.

Proposal Extension to February 1, 2016

The Respiratory Compromise Institute (RCI) has called for proposals to conduct a structured literature review or meta-analysis of various clinical conditions that pose a moderate to high risk for the development of respiratory failure leading to critical illness or death.

To provide researchers more time to complete their applications, RCI has extended the time for application submission to 5pmET on February 1, 2016.

Further details on the request for applications can be found by going to http://www.respiratorycompromise.org/wp-content/uploads/2015/12/RFA-final.pdf

Respiratory Compromise Institute Calls for Proposals on Respiratory Failure Leading to Critical Illness or Death

The Respiratory Compromise Institute (RCI) today called for proposals to conduct a structured literature review or meta-analysis of various clinical conditions that pose a moderate to high risk for the development of respiratory failure leading to critical illness or death. The request for applications can be found by going to http://www.respiratorycompromise.org/research-and-grants/

Respiratory compromise is the primary antecedent to ‘code blue’, the leading trigger of rapid response calls, and the number one cause of ICU admissions. Respiratory compromise is one of three indicators accounting for 66 percent of all preventable patient safety issues and causes higher mortality rates, longer hospital and ICU stays, and millions of healthcare dollars every year.

Respiratory Compromise consists of respiratory insufficiency, distress, arrest, and failure. Respiratory Compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency, respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation.

The Physician-Patient Alliance for Health & Safety (PPAHS) is on the advisory committee of the Respiratory Compromise Institute. For a roster of the organizations on the Clinical Advisory Committee, please go to http://www.respiratorycompromise.org/who-we-are/

For more about RCI, please go to www.respiratorycompromise.org

About Respiratory Compromise Institute

The Respiratory Compromise Institute (RCI) is a nonprofit group dedicated to improving patient health and safety by reducing the risk of respiratory compromise in varied settings, including the hospital, nursing home and the home.  RCI brings together a broad-based coalition of organizations, companies, and individuals dedicated to reducing—and eventually eliminating—preventable adverse events and deaths due to respiratory compromise.

A How-To Guide for Reducing Adverse Drug Events Related to Opioids (RADEO)

By Sean Power, Community Manager, Physician-Patient Alliance for Health & Safety

Respiratory compromise is the primary antecedent to ‘code blue’, the leading trigger of rapid response calls, and the number one cause of ICU admissions. Respiratory compromise is one of three indicators accounting for 66 percent of all preventable patient safety issues and causes higher mortality rates, longer hospital and ICU stays, and millions of healthcare dollars every year.

Respiratory compromise consists of respiratory insufficiency, distress, arrest, and failure. Respiratory Compromise is a state in which there is a high likelihood of decompensation into respiratory insufficiency, respiratory failure or death, but in which specific interventions (enhanced monitoring and/or therapies) might prevent or mitigate decompensation.

The incidence of opioid-related respiratory depression is anywhere from 0.16% to 5.2% according to studies. Approximately one in 200 hospitalized postoperative patients experience postoperative respiratory depression. One study found that 16% of inpatient adverse drug reactions were attributable to opioids.

1 in 200 hospitalized postoperative patients experience respiratory depression #ptsafety Click To Tweet

In 2012, The Joint Commission (TJC) issued Sentinel Event Alert 49 on the safe use of opioids in hospitals. The TJC Alert suggested that hospitals develop effective processes, use safe technology, deliver appropriate education and training, and provide effective tools to combat opioid-related adverse drug events.

Against this backdrop, The Society of Hospital Medicine put together the Reducing Adverse Drug Events related to Opioids (RADEO) Implementation Guide. RADEO was developed by an expert panel led by Thomas W. Frederickson, MD, MBA, FACP, SFHM, Medical Director, Hospital Medicine, CHI Health.

“RADEO is a step-by-step guide to assist hospital teams in implementing a successful quality improvement program,” says Dr. Frederickson. “RADEO will help clinicians facilitate safer prescribing practices and reduce adverse events associated with opioid therapy.”

As the RADEO Implementation Guide suggests:

“Perhaps your facility has not had a serious safety event related to opioid administration, but you are a chief medical officer (CMO), chief quality officer (CQO), chief of staff (CoS) or a member of your hospital’s safety committee and have noticed there are frequent activations of your hospital’s rapid response team due to opioid-related sedation or respiratory depression. Many of these events may have resulted in respiratory failure and unplanned transfers to your intensive care unit (ICU).

“Alternatively, you may be a member of your hospital’s pharmacy and therapeutics committee and you have noted that there continues to be a persistent, and what seems to you to be too frequent, use of unplanned opioid reversal agents in your facility. Perhaps you are part of the frontline staff, a nurse or hospitalist who has noticed many ‘near misses’ due to prescribing too high a dose of hydromorphone, or an incorrect patient-controlled analgesia (PCA) setting.

“These errors were caught, but if perhaps the nurse or pharmacist had been less experienced, there would have been patient harm.”

The Physician-Patient Alliance for Health and Safety (PPAHS) will feature Dr. Frederickson in an upcoming podcast. Please fill out the form on the PPAHS website to be notified when the podcast is available.

Respiratory Compromise Institute Unites Key Medical Societies to Address Growing Incidence and Burden of Inpatient Respiratory Issues

– Coalition Will Advance Patient Safety Initiatives to Reduce Adverse Events and Deaths Due to Respiratory Compromise –

– Respiratory Compromise recognized as a top Preventable Patient Safety Challenge –

Today, the National Association for Medical Direction of Respiratory Care (NAMDRC) announced, with the support of key medical and healthcare stakeholders, the launch of the Respiratory Compromise Institute (www.respiratorycompromise.org) to drive actionable solutions that increase education about and reduce the incidence of respiratory compromise in inpatient hospital settings. Continue reading “Respiratory Compromise Institute Unites Key Medical Societies to Address Growing Incidence and Burden of Inpatient Respiratory Issues”