Continuous Patient Monitoring
Over the past decade, a surprisingly high number of hospital patients have suffered complications and even died after surgery due to undetected respiratory depression after receiving opioids. This hass given rise to a movement to increase the usage of continuous patient monitoring to help reduce these kinds of post-operative incidents
The stories of patients who have died due to respiratory depression after their surgeries are heartbreaking. They include a healthy 15-year-old boy and a healthy 11-year-old girl, both of whom underwent elective surgeries to correct chest deformities; an 18-year-old woman admitted to the hospital with a severe sore throat; and a man who had routine shoulder surgery.
Meanwhile, a state trooper who went into respirator depression in the middle of the night after neck surgery was only saved because a nurse happened to walk past his room and noticed he wasn’t breathing. None of these patients on opioid pain medication after surgery was being electronically monitored.
The state trooper, who was without oxygen for six minutes, was one of the lucky patients who suffer respiratory depression post-surgery and survive. Approximately 70 percent of these patients cannot be resuscitated.
“It’s clear that patients receiving opioids for pain management after surgery need continuous monitoring because they sometimes don’t react well to the medication and have a respiration event,” says Janet Dillione, the CEO of Cardiopulmonary Corp., which provides extensible platforms for medical device connectivity, alarm management and clinical surveillance.
Dillione points out that “inadequate monitoring for respiratory depression in patients taking opioids” was listed as number 9 in the ECRI Institute’s Top 10 Patient Safety Concerns for 2014.
“Increased use of opioids (for pain management) raises the possibility of adverse events,” states the ECRI Institute. Opioids are considered a high-alert medication. The most serious adverse effect of opioids is respiratory depression, which is often preceded by sedation.”
“Several event reports submitted to the ECRI Institute PSO suggest that patients receiving opioids are not being adequately assessed and monitored for respiratory depression,” The ECRI Institute continues.
Monitoring is especially critical during the first 24 hours after a patient is given opioids post-operatively, the ECRI Institute adds. During this time, it recommends that nursing staff carefully assess the patient’s tolerance for the drug as it reaches its peak effect, especially if the patient has never received opioids before.
“The first 24 hours puts the patient at greatest risk for over-sedation,” states Stephanie Uses, Pharm.D., M.J., J.D., patient safety analyst at ECRI Institute PSO.
A study published in the Journal of Nursing Administration demonstrated significant benefits for patients and nurses when continuous patient monitoring is performed in the hospital. Such monitoring provides an early alert to nurses about potential medical problems so they can intervene in a more timely way, the study concluded.
The timeliness of a continuous patient monitoring early warning system improves early recognition of patient distress, according to the study. In addition, other studies have demonstrated that continuous patient monitoring can reduce patient fall rates by between 40 and 90 percent.
The AAMI Foundation’s Healthcare Technology Safety Institute believes that there are technology solutions available that can provide continuous patient monitoring and thus help save lives. This is one of the reasons it launched the National Coalition to Promote Continuous Monitoring of Patients on Opioids last November.
The Coalition points out that there is evidence to support not only positive patient outcomes, but that there’s also a strong financial justification for continuous patient monitoring.
It has demonstrated that when hospitals invest in continuous patient monitoring technology for patients on opioids, this results in fewer adverse patient outcomes, fewer ICU transfers, shorter lengths of stay in the hospital, and lower overall costs. The technology can pay for itself within six to 18 months, according to the Coalition.
Cardiopulmonary Corp’s. Bernoulli Enterprise platform is one technology solution that extends continuous patient monitoring not just to post-operative patients on opioids, but throughout the hospital to improve clinician response and patient safety. Dillione says the platform is especially beneficial in high-acuity areas like the OR, post-anesthesia and the ICU.
The platform does more than just pass along alarm information, Dillione adds.
“It intelligently evaluates data from medical devices the way a physician or nurse would and provides real-time information that can be used at the point of care,” she says.
However, the Coalition believes that technology alone is not enough to solve this problem. Hospitals also need to consider such factors as clinician, nurse and patient education and the huge culture shift that must occur within hospitals. For example, nurses, clinicians and even patients might object to using continuous monitoring equipment due to the high volume of false alarms they might set off or possible discomfort of the equipment.
The patient benefits of using technology solutions for continuous patient monitoring are fairly obvious. But hospitals can reap tremendous benefits by using the data captured by these solutions, says Chris Bloodworth, Director of Product Strategy, Clinical Solutions, at MEDHOST.
“The question is, what are hospitals doing with the information that’s generated from continuous patient monitoring technology,” she says. “The key is to integrate the output that’s generated from the technology into their electronic health records (EHR). This can help hospitals demonstrate Meaningful Use as required by the EHR Incentive program, which was part of the American Recovery and Reinvestment Act (ARRA).”
Dillione agrees with Bloodworth.
“There’s a tremendous amount of data that’s being generated by the monitoring technology that needs to be part of the patient record,” she says. “This data needs to be viewed across the entire continuum of patient care.”
Monitoring in the OR
Lisa Spruce, RN, CNS-CP, CNOR, ACNS, ACNP, Director, Evidence-Based Perioperative Practice for the Association of periOperative Registered Nurses (AORN), stresses the importance of continuous patient monitoring within the operating room itself.
“This is what AORN’s evidence-based practice guidelines have been designed to ensure,” she says. “The guidelines contribute to continuous patient monitoring in the OR. However, they are only as good as the people who use them.”
To help OR personnel keep AORN’s evidence-based practice guidelines top-of-mind, AORN will soon be releasing myAORNguidelines. This is an iPad-based tool that lets OR managers see how OR personnel are doing with regard to following the evidence-based practice guidelines.
Spruce says myAORNguidelines will start by monitoring four important guidelines where there is the greatest potential for errors and breakdowns: hand hygiene, preoperative skin antisepsis, cleaning and care of surgical instruments, and sterilization.
“Continuous monitoring in the OR goes beyond just monitoring the patient’s vital signs,” says Spruce. “OR personnel need to be monitoring the entire room. This requires an ‘OR consciousness’ to always be vigilant and on-guard, especially for a breach in sterile technique.”
In addition, hospitals need to have policies in place to make sure that the evidence-based practice guidelines are being followed by all OR personnel at all times, Spruce adds.
“OR personnel can never let their guard down, not even for a second,” she says.