18-year-old Amanda came down with strep throat after her high school graduation party. Her parents never thought the treatment she received in the hospital would abruptly end her life.
I recently heard Cindy Abbiehl share the heartbreaking story of her daughter Amanda who died from treatment for strep throat. Amanda had developed an extremely painful episode of strep throat and couldn’t eat. She was hospitalized for treatment of dehydration, prescribed antibiotics and was initially given IV morphine (an opioid) for the pain.
After continued pain, she was hooked up to a patient-controlled analgesia (PCA) pump to give her another opioid analgesic, hydromorphone. The medicine finally kicked in and Amanda was feeling better and ready to go home the next day. Her parents left in the evening after visiting hours and the next morning, Amanda was found dead in her hospital bed.
Cindy and her husband Brian quickly learned about the well-documented risk of respiratory depression from opioids than can lead to a respiratory arrest (especially for patients on a PCA pump).
The danger here is the use and overuse of opioids.
Although opioids are essential to treat moderate to severe pain, they must be used appropriately and safely. PCA pumps also remain an effective tool to deliver opioids – by quickly easing pain and giving patients more control to achieve better pain management. But we must be aware of the unintended consequences with its use.
Opioid use is common
Opioids are widely used in hospitals and acute care settings. A recent Premier study documented that opioids were used in more than half of hospital admissions of non-surgical patients at 286 U.S. hospitals. Among pediatric inpatients, 2 specific opioids (fentanyl and morphine) were found to be among the top 10 most administered medications.
Some people are at higher risk
Some patients are more prone to respiratory depression and the risk factors include:
- Very low body weight
- Sleep apnea
- Chronic obstructive pulmonary disease
- The use of other medications that have sedative effects
Screening patients to identify those at higher risk is a key component of safer use of opioids, although any patient may develop opioid-induced respirator depression. Amanda had no obvious risk factors but her swollen throat and initial dose of morphine still in her system when started on PCA may have put her at high risk.
Spot checks are not the answer
What is known as “dead in bed syndrome” in layman’s terms, is caused by respiratory depression when the rate of breathing is below 12 breaths per minute and the lungs aren’t fully ventilated. More than two-thirds of patients suffering opioid-induced respiratory depression cannot be resuscitated, leading to a tragic outcome for family members and the entire healthcare team.
The common practice of spot checking these patients (even as frequently as every 2 hours) may not detect early onset of respiratory depression.
Spot checks often arouse the patient and make them more alert briefly. If they have respiratory depression, they will fall right back into a dangerous state when the clinician leaves the room. Spot checks will not detect early onset of respiratory depression. Patients need a safety net. It takes electronic monitoring to support the work of clinicians and other safety protocols to help detect subtle changes or gradual declines in respirations leading to respiratory arrest and support.
Electronic monitoring can be cost-effective
In addition to the tragedy of lives cut short by preventable mortality, opioid-associated adverse events are costly. A recent study found that post-surgical patients who experienced an opioid-related adverse event were significantly more likely to incur greater cost, have a longer LOS and experience readmission.
Studies from early adopters of electronic monitoring are proving these technologies to be cost-effective. And these technologies create a return on investment by reducing patient harm, length of stay and follow-up care.
2 monitoring technologies being used are:
- Pulse oximetry: Measures the oxygen saturation in blood with a non-invasive sensor (usually a finger probe)
- Capnography: Measures respiratory rate and concentration of exhaled carbon dioxide with a sensor connected to a nasal cannula
CMS, Joint Commission: “Continuously monitor patients on opioids”
In addition to many safety and profession organizations, The Joint Commission and CMS call for continuous monitoring of patients receiving IV opioids.
- The Joint Commission: Sentinel event alert on opioids
- CMS: Memo to states
- CMS: Conditions for participation – interpretive guidelines for hospitals
Are you ready to take the challenge?
Is your organization ready to take the challenge of reducing opioid-related harm and death? Continuous electronic monitoring is being used successfully at innovative, patient safety-focused hospitals to support the work of clinicians.
Visit the Premier Safety Institute® for tools and resources on safer use of opioids.