Kathryn Hansen, BS, REEGT, CPC
Integration Consultants, Lexington, KY
Kentucky Sleep Society, Lexington, KY
Consultant, Oridion Technologies
Implementing a monitoring program to reduce respiratory risk in patients receiving sedating medication is supported by published clinical and scientific evidence. The American Society of Anesthesia practice parameters define specific criteria for management of postoperative patient care to reduce the potential for a medical mistake. The Joint Commission expects care providers implement patient safety improvement measures to ensure freedom from medical errors for consumers. Financially, healthcare providers face reduced reimbursement, when an unexpected adverse event occurs during a routine admission. Increasingly, third party payers expect safe care without medical errors and preventable adverse events. Evidence supports the need to implement monitoring to reduce the incidence of respiratory depression into the care continuum.
In 2008, HealthGrades published information on hospital patient safety. They reviewed patient safety data reported by the Agency for Healthcare Research and Quality (AHRQ) of 41 million Medicare admissions to non-federal hospitals in 2004 – 2006. To trend the data, the AHRQ developed potentially preventable patient safety indicators based on the Institute of Medicine’s (IOM) definition of patient safety.1 One patient safety incident, post-operative respiratory failure, demonstrated increasing incidence of .49% in incidence when compared to 2004 data.2 The report reveals that post-operative respiratory failure represents an incidence of 17 per 1,000 at risk hospitalizations in this patient sample. This data supports the need for implementation of a specific program with clinical protocols to facilitate a safer clinical practice to improve patient care and reduce the costs associated with the additional care resulting from a patient safety incident.
Scope of the Program
A clinical program to care for patients at risk for perioperative respiratory failure begins with the intent to reduce adverse events in patients who receive anesthesia and medications causing sedation, such as medications for nausea, anxiety, and depression, and pain. Co-morbidities such as chronic obstructive pulmonary disease, sleep apnea, increased sensitivity to sedating drugs, difficulty with intubations, and increased sleep deprivation contribute to elevated risk in the perioperative patient.
The development of a protocol requires a core committee with representatives from each clinical service caring for at risk patients. Physicians working with the committee will be invaluable for writing the protocols, which develop the framework for writing specific order sets for clinical management of the postoperative and post-procedural patient.
Order sets are developed to define specific criteria for assessment and screening of patients at risk, the integration of continuous monitoring for oxygenation and ventilation, vital signs to be monitored and nursing assessments to be completed.
Central to developing the standardized protocols with specific order sets is the concern for vital sign monitoring to protect the patient at risk for respiratory depression.
Traditionally, standardized protocols include continuous monitoring of oxygenation (oximetry) and ventilation (capnography) in patients receiving sedating medications, such as opioids and post-operative PCA, to support the routinely performed nursing assessments. When patients have decreased level of consciousness or alertness, respiratory impairment, sleep apnea, or are elderly, they are at a higher risk for respiratory compromise, and continuous trending of ventilation is a requirement to predict future respiratory depression. Patients receiving supplemental oxygen will have improved detection of compromised respirations with the use of capnography. An editorial in the Anesthesia Patient Safety Foundation Newsletter, Summer 2009, supports this practice. “The use of respiratory monitoring technology (capnography) would improve the detection of progressive or unrecognized hypoventilation.” 4, 5 Standardized protocols with continuous monitoring of ventilation are required with patients receiving medications for pain control and patients admitted for bariatric surgery.
About Kathryn Hansen:
Kathryn Hansen is the Executive Director and past President of the Kentucky Sleep Society and has worked with sleep medicine academically and clinically. Recently she has been collaborating with Legislative initiatives to draft legislation on drowsy driving. The Kentucky Sleep Society, under her direction, has received granting from the Rural Health Outreach Federal program to evaluate and treat modifiable health risks of obesity, diabetes, and heart disease for patients with untreated sleep apnea with special emphasis on childhood overweight.
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