Supporting Patients, Educating Caregivers, Saving Lives

Respiratory Compromise Blog

The RCI aims to reduce the incidence and consequences of Respiratory Compromise through increased awareness and education. Through the RCI alliance, healthcare professionals across specialties are working together to diagnose and treat Respiratory Compromise.

Read more about the RCI’s position on current topics pertaining to Respiratory Compromise, as well as our initiatives to encourage updated strategies for the early identification of Respiratory Compromise.

SONORIA and PPAHS Announce Alliance to Improve Clinical Collaboration

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

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:

Opioid-Monitoring-Risk-Map
Opioid-Monitoring-Risk-Map

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.

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.