Balancing pain management with technology, safely and effectively
Opioid abuse and addiction has become a nationwide problem. Over the past 15 years, the number of opioid-related deaths has quadrupled to nearly 170,000, corresponding with a four-fold increase in prescriptions. Over the last 10 years, opioid-related inpatient stays increased by 64 percent and opioid-related emergency department visits increased 99 percent, according to the Agency for Healthcare Research and Quality.
Research conducted by Premier Inc. found that at nearly 300 U.S. hospitals, opioids were being used in more than half of hospital admissions of non-surgical patients.1 Among pediatric inpatients, two specific opioids (fentanyl and morphine) were found to be among the top 10 most administered medications. In addition, research also found that patients who experienced an opioid-related adverse event had greater costs, long length of stay, and more readmissions.2 The government, clinicians, healthcare organizations and professional societies are working to curb opioid misuse, but there is still much work to be done.
Understanding the risks
Opioids are an essential treatment for patients with severe pain when used appropriately and safely. PCA (patient controlled analgesia) machines are also a proven and effective tool to deliver opioids and for their ability to quickly ease pain, and allow patients to achieve better pain management.
But we must be aware of the unintended consequences with their use, such as programming errors, and the chance that a family member might think they are helping by pressing the medication administration button, a phenomenon called “PCA by proxy.” While effectively controlling pain, opioids can also sedate the part of the brain that controls breathing, causing it to be dangerously slow or stop. Respiratory depression or arrest is the most serious adverse event related to opioids. Other adverse effects are nausea, vomiting, dizziness, delirium, hallucinations, hypotension, falls and aspiration pneumonia.
Moreover, caregivers need to be cognizant of the risk factors in the patients themselves. Certain people are at higher risk for opioid-related respiratory depression. They include those who have never had opioids, those who are elderly, overweight, or have sleep apnea, asthma, or those who are on other drugs with sedative effects. But risk assessment tools to identify these risks are not universally used and do not catch all patients with such risks.
Electronic monitoring: Safety net
A promising and effective measure is continuous electronic monitoring, which can detect early and subtle signs of respiratory depression that eludes a spot check of vital signs. Many safety and professional organizations recommend continuous monitoring of oxygenation and/or ventilation of patients receiving opioids postoperatively, including the Anesthesia Patient Safety Foundation (APSF) and the Institute for Safe Medication Practices (ISMP).
The Joint Commission’s Sentinel Event Alert #49 suggests use of pulse oximetry be used to monitor oxygenation and capnography to monitor ventilation and when used, to be continuous monitoring rather than intermittently.3
In its Conditions of Participation for Hospital Medication Administration CMS updated its guidance on best practices related to IV opioid use, including frequency of monitoring and use of technology-supported monitoring.4
Despite efforts to increase awareness of electronic monitoring efficacy, the adoption on general patient care units has been relatively slow. The good news for this technology is that it has advanced significantly in the past few years to the point in which it can be used reliably on both intubated and non-intubated patients, adult and pediatric, as well as those patients receiving oxygen.
Electronic monitoring: Cost-effective?
There can be no price tag placed on saving a life from an opioid-overdose. But there does need to be assessment of the potential for technology to reduce risk of serious outcomes and related costs. A recent survey by the Physician-Patient Alliance for Health & Safety found that hospitals with continuous monitoring report a reduction in adverse events, costs and expenses.5
After three serious opioid-related adverse outcomes, St. Joseph’s/Candler Health System focused safety efforts on administration of IV medication. After success in beta testing on one unit, the health system expanded its IV PCA system that monitored both capnography and pulse oximetry to all patients receiving IV PCA opioid therapy. After five years and more than 5,000 patients, the respiratory monitoring alone averted at least 35 PCA related undesirable outcomes resulting in no PCA-related respiratory events with a serious outcome (i.e., no intubation, transfers to ICU, or deaths/brain damage). After deducting the cost of averted outcomes/errors from the total purchase costs plus disposables, the technology investment yielded a five-year ROI of more than $2.5 million.
Act now
There is no single solution that fits all hospitals. A multi-discliplinary approach has shown to be quite effective. If you are considering implementing or expanding a continuous monitoring system, you will need to involve nursing, anesthesia, respiratory therapy, patient safety, pharmacy and others to evaluate your current system and capabilities and before you buy it, determine what you want your new system to accomplish and what patient population it will serve. You may need to consider potential upgrades to your networking infrastructure, as well as staffing, to assure proper implementation that will include changes to workflow and policies, addressing alarm fatigue from other devices, and staff education. Also, consider choosing a system that can easily be upgraded and integrated with the electronic medical record (EMR).
If EMR integration is a goal, consider workflow requirements. Even if you don’t want to integrate these systems now, you may want to do so in the future.
Cost is another key factor. Consider both the implementation costs and the operational costs of the system, including disposables, software licenses and maintenance agreements. Offsetting savings from improved patient outcomes should also be considered. Few hospitals have the financial resources to implement continuous electronic monitoring on all patients on general floors who are on IV opioids. But the time is now. You can start small focusing on the highest risk patients and expand later.
References
- https://www.ncbi.nlm.nih.gov/pubmed/24227700
- https://www.ncbi.nlm.nih.gov/pubmed/23302094
- http://www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf
- https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-15.pdf
- http://www.ppahs.org/wp-content/uploads/2013/10/ppahs-sasm-handout.pdf
