Continuous electronic monitoring of patients receiving opioids to manage their pain after surgery should be a universal standard of care, leading opioid safety experts said during a recent webinar.
"There is no doubt that patients who have either sedation or postoperative pain management do require some sort of monitoring," said Bhavani S. Kodali, MD, Associate Professor, Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School.
Dr. Kodali was joined in the PSI webinar by:
- Harold Oglesby, RRT, Manager, The Center for Pulmonary Health, Candler Hospital, St. Joseph's/Candler Health System (SJC);
- Joan Speigel, MD, Assistant Professor, Anesthesiology, Harvard Medical School and Beth Israel Deaconess Medical Center;
- Gina Pugliese RN MS FSHEA, Vice President, Premier Safety Institute (moderator); and
- Michael Wong, JD, Executive Director, Physician-Patient Alliance for Health and Safety.
These experts agreed that continuous monitoring of post-surgical patients receiving patient-controlled analgesia (PCA) – with the use of capnography or pulse oximetry – should be a requirement in all hospitals. Specifically, capnography assesses how effectively patients are breathing by measuring exhaled carbon dioxide (CO2) and alerts caregivers when life-threatening respiratory depression could occur. Oximetry monitors patients' blood oxygen levels and alarms staff when a patient may potentially may not be receiving sufficient oxygen.
"What I'd like to point out is that these alarms do is two things," said Dr. Speigel. "One, it's the essence of the alarm itself, but also just having the device there, so an end tidal CO2 alarm, actually is a surrogate for patient attention. I find that to be fascinating whether or not it's really the device that's helping the patient or whether or not it's the nursing staff and the family who is paying attention to the device and hence the patient. Regardless, if the outcomes are better, I think that's a very interesting thing to think about."
These health experts also emphasized the importance of training and patient education. When instituting continuous monitoring, hospitals must ensure that their nursing staffs are thoroughly trained and should be deemed competent at least annually in its use and safety, the experts stressed.
"One point that is very, very clear is: to establish monitoring in the postoperative period, it requires a lot of training," said Dr. Kodali. "Sometimes it is very, very difficult to achieve good monitoring in big hospitals because of the simple nature of personnel involved. As [Mr. Oglesby] pointed out, it requires first of all an initiative by the respiratory therapists who can understand capnography. Anesthesiologists know very well capnography but they are not actually the persons to implement it."
Educating PCA patients and their loved ones about monitoring when opioids are used are safety components that should also be a key initiatives in hospitals, the experts agreed. Patients may be knowledge-naïve in this monitoring respect and need to be enabled to advocate for themselves.
"Communication with patients and their families is just so critical in achieving safe and effective PCA use and better alarm management," said Mr. Wong.
Mr. Oglesby concurred and added that patient and family education – combined with essential staff training and competencies– have helped SJC to avoid any opioid-related event since it started using capnography to monitor PCA patients more than nine years ago.
"The key for us in order to have the success that we had was, one, education; particularly patient and family education where we educated the patients, specifically on why they were wearing the device and educated the family on why they were wearing the device," said Mr. Oglesby. "We had much higher compliance with the device. Sometimes the patients and family members had to educate some of the staff and remind them why the patient was on the end tidal CO2 monitor and not to get too hyped about alarms. We developed a basic and understandable education for the families and the patients. When they understood what it was there for, our compliance shot out the roof and we had no issues with compliance in wearing the device."
For a transcript about the discussion on continuous monitoring, please click here.