John R. Zaleski, Ph.D., Chief Analytics Officer of Bernoulli

John Zaleski, PhD, CAP, CPHIMS, is Chief Analytics Officer of Bernoulli, a leader in real-time connected healthcare. With expertise in designing, developing, and implementing clinical and non-clinical point-of-care applications for hospital enterprises, Dr. Zaleski is the author of numerous peer-reviewed articles and conference papers on clinical use of medical device data, information technology and medical devices.

Opioid-induced respiratory depression and monitoring patients diagnosed with obstructive sleep apnea

March 17, 2017 AT 3:16 PM

Managing patients on the general care floor (GCF) who are either at risk or diagnosed with obstructive sleep apnea (OSA), and those in particular who meet the requirements of the STOP-BANG criteria for OSA, can be quite challenging. The ECRI Institute, a federally-certified patient safety and research organization, has identified in its 2017 list of Top 10 Health Technology Hazards “Undetected Opioid-Induced Respiratory Depression” as Number 4 [1]. Opioids used for treatment of acute postoperative pain is rather commonplace, and patients at-risk for OSA, if left unattended, can experience anoxic brain injury or death. The Association for the Advancement of Medical Instrumentation (AAMI), reports that “approximately one-third of code blue arrests in hospitals are from respiratory depression…accounting for up to 20,000 patients annually.” [2, p. 8]

Recommendations to achieving improved safety include continuous electronic monitoring (CEM) of patients on opioids. Continuous monitoring of peripheral pulse oximetry (SpO2), end-tidal carbon dioxide (etCO2), as well as pulse and respiratory rate can provide needed information that indicate respiratory drive and patient state over time. While “the majority of stakeholders agree that CEM must be made available to all patients on parenteral opioids, and not just those meeting risk criteria” [2, p. 7], challenges to nursing on the GCF include possible lack of continuous bedside monitoring, false alarms, and lack of coverage for patients at risk. Furthermore, staff on general care floors may not have the requisite training to handle patients undergoing continuous monitoring, or tele-rooms may not be outfitted to manage patients on these units.

The issue of alarm fatigue, of particular concern in the intensive care units (ICU), has the potential to impact general care floor nursing staff for those patients under continuous monitoring for respiratory depression. High nursing ratios combined with a predominance of non-actionable alarm signals being issued by bedside monitors could make responding to alarms impossible or intolerable, and patient care could decline because truly actionable clinical messages could be overshadowed by noise and non-clinically-actionable alarm signals [3, p. 9].

Technology can assist in improving the situation, but the solution is not entirely technologically-based: educating staff, improving techniques for identifying and separating actionable from non-actionable alarm signals, educating patients and their families as to risks, and identifying early-warning indicators of patients at risk for OSA while under the influence of opioid pain medication are all steps that can be taken. Another key understanding is that data from multiple sources may be required to achieve improvements in patient safety, including the electronic health record and real-time data from medical devices. Moment-to-moment changes in patient vitals are not usually available in the long-term clinical record, so a hybrid approach involving both real-time and aperiodic and discrete data would be required to improve the overall surveillance of these patients. The target objective of improving patient safety will require multiple sources of data and the talents of multiple individuals working in concert to achieve a measurable and positive improvement of the care of patients.

References

[1]

ECRI, "Executive Brief: Top 10 Health Technology Hazards for 2017 - A Report from Health Devices, November 2016," ECRI, Plymouth Meeting, PA, 2017.

[2]

AAMI, "National Coalition to Promote Continuous Monitoring of Patients On Opioids," in Opioid Safety & Patient Monitoring Conference Compendium, Chicago, IL, 2014.

[3]

AAMI, FDA, TJC, ACCE, and ECRI, "2011 Clinical Alarms Summit," in A Siren Call to Action: Priority Issues from the Medical Device Alarms Summit, Herndon, VA, 2011.