Opioid-induced
respiratory depression has long been one of our most frequently discussed
patient safety issues (see the full list of our prior columns at the end of
today’s column). Shortly after The Joint Commission issued its Sentinel Event
Alert “Safe Use of Opioids in Hospitals” in 2012 (see our September 2012 What's
New in the Patient Safety World column “Joint
Commission Sentinel Event Alert on Opioids”), CMS (Centers for Medicare and
Medicaid Services) announced its intent to develop a quality measure related to
monitoring hospitalized patients receiving opioids. CMS’s intention was to
develop a measure that could collected via data submitted electronically from
EMR’s. And, while patients receiving opioids via any route are at risk for
respiratory depression, it was felt that the most accurate measures could be
determined on those patients receiving opioids via PCA (patient-controlled
analgesia).
Eight US hospitals
volunteered to participate in pilot data collection for CMS. A report of the
results of that pilot data were recently published and should be a wake-up
call for all hospitals (Jungquist
2016).
The data came from nurse-abstracted electronic medical
records and focused on the monitoring of 3 key indicators and 2 key timeframes:
The two timeframes
looked at were every 4.5 hours and every 2.5 hours. Actually, the two intended
timeframes were 2 and 4 hours but it was felt that it might take up to 30
additional minutes for entry of the indicators into the EMR so the extra 0.5
hours was added to each timeframe.
Strikingly, only
8.4% of the patients had full monitoring of all 3 parameters as per the
specifications of the measure. Even at the 4.5 hour timeframe only 26.8% had
all 3 assessments.
A very important
finding was that naloxone administration, used to rescue patients with
respiratory depression, was not needed in any patient who was assessed at least
every 2.5 hours (1.3% of all patients on PCA received naloxone).
Note that the
hospitals in this pilot project had different local policies regarding
monitoring patients on PCA so it should not be surprising that the overall
compliance rates varied by hospital. Those hospitals that allowed PCA only in
higher levels of care had higher compliance rates.
We’ve, of course,
discussed appropriate monitoring of patients receiving opioids on many
occasions and strongly recommend use of capnography and/or apnea monitoring.
Pulse oximetry by itself, whether episodic (“spot check”) or continuous, can be
misleading, especially in patients receiving supplemental oxygen. Similarly,
monitoring respiratory rate visually is misleading unless you are sure to watch
the respiratory rate while the patient is asleep. There was extreme variability
of the respiratory rate measurements in the study, perhaps reflecting different
rates when the patient was awake or asleep (note that most EMR’s don’t
currently capture the state of awakeness when the
respiratory rate is measured). The authors of the current study allude to the
fact that certified nursing assistants often do the respiratory rate
measurement so must be educated on how to appropriately assess the respiratory
rate.
Use of a numeric
sedation scale, like the Pasero Opioid-induced
Sedation Scale (POSS) or the RASS (Richmond Agitation Sedation Scale), is most
helpful in patients receiving episodic rather than continuous opioids (see our
May 6, 2014 Patient Safety Tip of the Week “Monitoring
for Opioid-induced Sedation and Respiratory Depression”). Before the next
dose of an opioid is given a nurse would assess the patient’s level of sedation
and determine whether the next dose should be given as ordered, or withheld, or
adjusted. It is somewhat less useful when patients are using PCA but still
should be done since a nurse might recommend cessation of PCA if a patient is
too sedated while using PCA. If the sedation scale parameter were removed from
the proposed CMS quality measure, the overall compliance rates would increase
to 33.4 % at 2.5 hours and 53.9% at 4.5 hours.
The authors of the
current study also note that monitoring trended data rather than just looking
at threshold rates may be important. We concur but with the caveat that, particularly
in patients with obstructive sleep apnea, changes may occur precipitously
without an antecedent worrisome trend.
The Jungquist paper has good references to the evidence-based
guidelines for monitoring patients receiving opioids as do our many columns
listed below.
Perhaps the best
advice made by Jungquist and colleagues is that “electronic
monitoring should complement and not replace vigilance in nursing assessments
and monitoring practices”. We concur wholeheartedly.
CMS may need to
rethink some of the technical and practical issues involved in data collection
for this much-needed quality measure. But every hospital needs to take a good
look at its own current practices for monitoring patients receiving opioids
regardless of whether CMS or other regulatory body is collecting data on such.
You will likely find you have some work to do to get your organization up to
snuff on best practices for monitoring your patients who are on opioids.
Our other Patient
Safety Tips of the Week pertaining to opioid-induced respiratory depression and
PCA safety:
References:
Jungquist CR, Correll
DJ, Fleisher LA, et al. Avoiding Adverse Events Secondary to Opioid-Induced
Respiratory Depression: Implications for Nurse Executives and Patient Safety. J
Nurs Admin 2016; 46(2): 87-94
http://journals.lww.com/jonajournal/Abstract/2016/02000/Avoiding_Adverse_Events_Secondary_to.8.aspx
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