Continuous Monitoring of Patients on Opioids: Initiatives at Community Health Network and Methodist Specialty and Transplant Hospital Friday, August 26, 2016
AAMI Foundation Vision: To drive the safe adoption and safe use of healthcare technology • National Coalition for Infusion Therapy Safety • National Coalition to Promote Continuous Monitoring of Patients on Opioids • Compendium: Opioid Safety & Patient Monitoring • National Coalition for Alarm Management Safety • Compendium: AAMI Foundation Management of Clinical Alarm www.aami.org/thefoundation Please Consider Making a Donation! http://my.aami.org/store/donation.aspx
A Special Thanks
Thank You to Our Premier Industry Partners Without their financial support, we would not be able to undertake the various initiatives under the National Coalition to Promote Continuous Monitoring of Patients on Opioids. The AAMI Foundation and its co-convening organizations appreciate their generosity. The AAMI Foundation is managing all costs for the series. The seminar does not contain commercial content. Diamond Platinum Gold
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Nursing Continuing Education Disclosure Statement • This seminar is jointly provided today with our co-provider, the National Association of Clinical Nurse Specialists (NACNS). • 1.0 contact hour will be awarded for this seminar. This seminar may be accessed online at the AAMI Foundation website for nursing CE up to two years from today’s date. http://my.aami.org/store/detail.aspx?id=CONMONSEM • This continuing nursing education activity was approved by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation (ANCC). • Criteria for successful completion includes attendance at the session and submission of a completed evaluation form. You can submit the fee for the CE credit by going to the AAMI store at (link will be sent in follow-up email). A link to the evaluation form will be sent to you for completion and a certificate sent to you upon completion of the evaluation. • The planning committee members have declared no conflict of interest along with our faculty for today’s session. • Contributions to the AAMI Foundation have been received from the identified sponsors to support program initiatives and projects. However, the program content for today’s seminar has been planned independently by AAMI staff with the seminar presenters. • Approval of the continuing education activity does not imply endorsement by the provider, ANCC or the Alabama State Nurses Association.
Polling Questions
Speaker Introductions Julie Painter MSN RN OCN, Clinical Nurse Specialist , Community Health Network Indianapolis, Indiana Theresa Kloewer, MSN, RN Vice President of Nursing Methodist Specialty and Transplant Hospital San Antonio, Texas
Community Health Indianapolis Indiana We are: • 7 Hospital System • >2million patient encounters/year • 1049 staffed beds • 53,576 Inpatient admissions/year • 12, 662 Inpatient surgeries/year • Outpatient visits >1million/year • 82, 274 Outpatient surgeries/year • ER visits 273,941 • Births 7,899
Smart Pump Technology • We were early adopters of CareFusion Smart Pump technology in 2007 • We utilize smart pumps, Patient controlled analgesia modules, etCO2 modules & syringe modules • Our patient care delivery with products, processes, policies & interventions are standardized to reduce variation in care & reduce harm across all facilities and the continuum
What is capnography & what is its’ value? • Capnography has evolved into a standard of monitoring during anesthesia because it has proven itself to be a valuable tool in recognizing ventilatory and circulatory events that could potentially lead to deleterious effects
Sedation & Ventilation Status • Historically we have relied on oxygen levels to tell us about a patients respiratory/ventilation status • Oximetry is not an indicator of ventilation status • Measurement of CO2 is a better predictor of ventilation status and helps us intervene earlier to address respiratory compromise before needing reversal agents or a higher level of care
Our Journey • Early adopters of smart pump technology-2007 • All 7 hospitals utilize same products, same policies and have a process to promote evidence based practice, standardization & reduction of variation • #1 customer is the patient-Do what is best for our patients! • Goal is to reduce harm & provide the highest quality, safest care with the best outcomes possible • Etco2 often only used with patient controlled analgesia
Impetus for Improvement • Data from largest facility within our network, revealed a high number of patients with over- sedation requiring consultation from rapid response team for respiratory compromise; use of naloxone for reversal; and many required a higher level of care & monitoring • Note this project was before the Partnership in Patient Safety national projects to reduce adverse drug events with naloxone
Improvement Team Project Lead: Julie Painter Clinical Nurse Specialist Physician Champion: Scott Vore MD-Anesthesia & Michael Caldwell MD-Anesthesia Members: Director, manager of PACU, pharmacy, nursing leaders from acute care units
Goal of Improvement Goal: Reduce unwanted respiratory depression due to opioids post-operatively & reduce naloxone utilization. Data Revealed: Higher amounts of naloxone administered on the largest campus that did surgeries & at the time we were only using etCO2 monitoring on PCA patients. Many patients with high BMI, COPD &/or Sleep apnea higher risk but not aware Finding: PACU staff & leaders were not aware of patient compromise once they left PACU
The Improvement Interventions • Developed & implemented education for all PACU staff about data & how the team would work to reduce harm • Implemented end tidal CO2 monitoring on all PACU patients before they left PACU • Improved bedside handoff communication between PACU RN & Unit receiving RN about any issues or concerns, specifically what meds had they received that have potential to cause sedation • Began process improvement October 2013 & analyzed process & data through all of 2014 and in 2015 began the spread of improvement through all facilities • Patient education sheet developed with talking points
Changes in the PACU • All patients have an end tidal CO2 module attached to Infusion pump with nasal cannula in place in the PACU • The etCO2 module will be activated & turned on & measuring as PACU transports patient from PACU to acute care • Discharge criteria for PACU remains the same otherwise • Note elevation in etCO2 alerts us to help patient take deep cleansing breathes & to exhale to rid of excess CO2
End tidal CO2 monitoring 19
End tidal CO2 Module & Controls
Nasal Cannula
Key Considerations to Success • Have the right team members • Educate patient regarding cannula • Have experts and leaders who can serve as champions aka “barrier busters” • Engage staff & help them digest & understand the data • Make it real---take the data, deep dive a couple of cases & develop a case story---Reality sinks in more than probability
The Challenges • Fear of alarms bothering patients & decreasing patient satisfaction • Orders being entered to discontinue etCO2 monitoring • Staff ability to articulate & explain to patients why this is important & why we do it • Providers desiring to select only those patients at risk for sedation? • Inability to know who is at risk-Providers asked why put on everyone?
Hardwiring Change • Be methodical-don’t try to do all places at one time • Support both areas PACU and Acute care on go live day and ongoing after • Train champions & unit experts • Have building resources • Immediately address concerns or issues & resolve face to face • Realize change takes time & when busy we easily digress to old habits • Monitor events real-time-we discuss naloxone events daily in our safe day huddles & consider them ADE’s until reviewed
Current State • Complete implementation across acute care • Expansion to OB • Staff nurse can place etCO2 module on any patient with concerns of compromise & increased risk of sedation-this allows a nurse the ability to better assess their patients in a more accurate way
Current State • Project team working as a network to verify that all end tidal CO2 monitoring during procedures are using most current technology • Note that naloxone use remains significantly low based on percentage of patients who receive opioids & would have potential for reversal • Looking beyond opioids now & other sedation medications
Methodist Specialty and Transplant (MSTH) Theresa Kloewer, MSN, RN Vice President of Nursing Methodist Specialty and Transplant Hospital
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