High Risk Patient Protocol: Preventing Respiratory Complications - PDF document

5/3/2012 High Risk Patient Protocol: Preventing Respiratory Complications Tuesday, May 1, 2012 Pete Weber, BA, RRT, RPSGT Team Leader – Pulmonary and Sleep Medicine High Risk Team Members • Pete Weber, Respiratory Care – Project Manager • Jennie Cumicek, Nurse Educator - Surgery • Laura Hieb, Chief Nursing Officer • Dr. Mark Reinke, ENT and Sleep Medicine - Physician Champion • Dr. Franz Igler, Anesthesia - Physician Champion • Colleen Groenier - Pharmacy • Judy Johnson, Team Facilitator - Perioperative Services • Teresa Dzekute, Team Leader - Bush Orthopedic Department • Kathy Beaumier, Team Leader – PrePARE • Kevin Drewieske, Team Facilitator Respiratory Care 2 1

5/3/2012 3 Background • We have experienced serious patient safety events at Bellin related to respiratory depression and oversedation in patients during the postoperative period. • These patients often demonstrate risk factors that may place them at higher risk for postoperative oversedation and respiratory complications. 4 2

5/3/2012 Aim of Project • Project Description Prevent deaths related to oversedation and respiratory compromise at Bellin. • Overall Aims • Define High Risk Patient • Trigger Bellin System to their arrival • Plan communication process to maintain focus on risk • Implement care and monitoring for high risk patients 5 National Attention 6 3

5/3/2012 National Attention 100,000 lives Any percentage is too large! 86% of patient reportable harm went unreported. 44% of serious patient harms were easily preventable. 1 of 7 patients suffered serious or long term injuries, or death. 7 Statewide Attention 8 4

5/3/2012 Statewide Attention 9 Statewide Attention 10 5

5/3/2012 Framing the Risk • Over 24% of Wisconsin population has Obstructive Sleep Apnea – Often undiagnosed • Morbid Obesity is an independent risk factor for events • Chronic uncontrolled medical conditions add to risk • Pain management and sedation techniques contribute • Estimated high risk patients coming in to the Bellin System (OSA and chronic co-morbidities) 40-45% 11 STOP • S – snore • T – Tired • O – Obstruction (apnea) • P – Blood pressure is high • 2 Yes – 50% possibility of OSA • 3 Yes – 60-70% possibility of OSA • 4 Yes – 90% possibility of OSA 12 6

5/3/2012 Timeline of Project – Phase 1 and 2 (Completed) • Leadership - system priority • Team defined including MD identified champions • System-wide case study review for • Literature reviewed, best practice all nursing staff identified • Pulled together departments that • Purchased initial ETCO2 monitors are key to the handoff process of the surgical patient. • Definition, plan, and new equipment piloted • Created a SWAT Status board • Spread to all patient care areas 13 14 7

5/3/2012 (Patient Sticker) 8/4/09 Revised 1/11/12 HIGH RISK PATIENT IDENTIFICATION TOOL Instructions: Initiate identification of high-risk early, review/initial at each interdepartmental hand off. Place High Risk sticker on front of chart when High Risk status validated on admission. This is a tool; please use clinical judgement. One condition checked indicates high-risk status. Nonsurgical patients may require two indicators. High Risk Medical Condition (Uncontrollable) Completed if patient is going to receive anesthesia, sedation for procedure, or opioid pain medications. Validate after each patient transition. PrePARE Admit RN Preop Floor /JFL/ED     Diagnosed OSA     Suspected OSA ( Inpatient: 75% on sleep apnea risk assessment or > 50% + BMI > 35; ED: Patient history snoring, frequently tired, observed apnea/obstruction)     BMI over 40     CHF with recent hospitalization (12 months) or CHF with Dyspnea on Exertion     COPD with recent hospitalization (12 months) or home O 2     Renal Failure with GFR less than 35 or chronic dialysis     Liver Failure     Psychiatric disorder and currently taking 2 or more psych medications     Currently taking greater than 8 prescribed home medications (Do not count eye drops/supplements)     No high risk medical conditions Initials Initials Initials Initials Sedation Related Conditions (Controllable) Complete during opioid administration in ED, PACU, and on nursing unit. ICU ED PACU Floor Richmond Agitation Sedation     Poor pain control followed by rapid good control Scale (RASS): +4 = Combative – overtly     Continuous PCA (basal rate) or epidural (excluding labor epidurals) combative, violent, immediate danger to staff     More than 1 type of opioid or route (ED: more than 1 route) +3 = Very Agitated – pulls or     Opioids in combination with benzodiazepines/other CNS depressant. removes tube(s) or catheter(s); aggressive     Anxiety: Displaying clinical symptoms (agitated/several PCA attempts) +2 = Agitated – frequent     Prolonged Anesthesia time (Major abdominal, multilevel fusion, redo unpurposeful movements, fights ventilator orthopedic, or greater than 3 hours) +1 = Restless – anxious but     ASA Score of 4 or 5 movements not aggressive, vigorous     RASS Score of – 3 or less (PACU) 0 = Alert and calm RASS Score of – 2 or less (Floor/ED)     -1 = Drowsy – not fully alert, but has sustained (more than 10     RASS Score of -2 after post procedural frequent monitoring (Floor) seconds) awakening with eye contact to voice     No high risk sedation related conditions -2 = Light Sedation – briefly (less Initials Initials Initials Initials than 10 seconds) awakening with eye contact to voice -3 = Moderate Sedation – any Baseline ETCO2: movement, but no eye Clinical Judgment contact to voice -4 = Deep Sedation – no response ICU ED PACU Floor to voice, but any movement to     Patient with potential for rapid deterioration due to complex diagnosis. physical stimulation Swat notified upon transfer -5 = Unarousable – no response to voice or physical  Notify RT when patient being monitored with ETCO 2 arrives on floor. stimulation Nurse’s Initial/Signature:  Medical: Patient Placed on Protocol Date Initiated: 15 Location Communication Tool Initiated: Procedure/Surgery Date: Procedure/Surgery: 16 8

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5/3/2012 Timeline of Project – Phase 1 (Completed) • Nursing and Respiratory Care staff educated • Identification of Risk • Physiology • Monitoring and Interventions • Operational in pilot area • Reduction in Naloxone (Narcan) administrations/events • No deaths • No serious patient safety events – respiratory 19 Exhaled Carbon Dioxide (EtCO2) Monitoring 20 10

5/3/2012 Timeline of Project – Phase 2 • Refine definition and scope • Explore monitoring that will integrate with common technology platform • Engage surgeons • Present results of orthopedic pilot to Surgical Committee • Report back with definition/scope changes • Present plan to spread to surgical floor • Second phase of education on High Risk indicators and tools rolled out to target areas. All Patient Care areas. 21 Results: No serious respiratory events since May 19 th , 2009 22 11

5/3/2012 Results – Reduction in Narcan Narcan Event Reduction Ortho events Surgical events 10 Medical events Spread to cardiac 8 6 4 2 0 Q1 2009 Q2 2009 Q3 2009 Q4 2009 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 23 Considerations of High Risk Patient Care • Care giver assignments:  Acuity assessed  Proximity to nursing station and nursing care  Experienced RN assigned to High Risk Patients • Interventions by Care givers:  Hourly Documentation -  RASS done in all areas (standardized)  Pain Medications tracked for Dose, on-set, peak and half-life  EtCO2, RR quality assessed  Patient position 24 12

5/3/2012 PreOp in-patient surgical assessments 25 Hospital Wide (Peri-Op, PACU to Floors) Monitored on ETCO2 January-10 46 February-10 44 March-10 60 April-10 99 May-10 103 …..Q1 2012 409/month 26 13

5/3/2012 Next Steps – Phase 3 increase scope 27 Next Steps – Phase 3 • Spread to System • Integrate into procedural areas • Assure Compliance and Sustainability • Include ASA guidelines for Conscious Sedation Monitoring • Publish our results – in 2012 28 14

5/3/2012 References • Sleep 2008. Aug1:31(8) 1079-85 • Anesthesiology. 2008 May;108(5):812-21 • Obesity Surgery. 2000. 10:2 154-159 • Journal of Clinical Anesthesia. 2007. 19:130-134 • American Journal of Respiratory Critical Care Medicine. 2002. 166: 1338-1334 29 Thank you Pete Weber PTWebe@Bellin.org 920-433-36699 15