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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 Anesthesiologists practice parameters define specific criteria for management of postoperative patient care to reduce the potential for a medical mistake. With increasing obesity, the incidence of sleep apnea is rising, which contributes to greater risk for an adverse health outcome with the use of IV sedation during postoperative care. The Joint Commission expects care providers to implement patient safety improvement measures to ensure freedom from medical errors for patients. Financially, health care providers face reduced reimbursement when an unexpected adverse event occurs during a routine admission. Increasingly, third-party payors expect safe care without medical errors and have stopped paying for preventable adverse events. Evidence supports the need to implement monitoring to reduce the incidence of respiratory depression in 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) on 41 million Medicare admissions to nonfederal hospitals from 2004 through 2006. To trend the data, the AHRQ developed potentially preventable patient safety indicators based on the Institute of Medicine’s definition of patient safety.1 One specific patient safety incident, postoperative respiratory failure, demonstrated increasing incidence of .49% when compared to 2004 data.2 The report reveals that postoperative respiratory failure represents an incidence of 17 per 1,000 at-risk hospitalizations in this patient sample (Table 1). Review of 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.

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SCOPE OF THE PROGRAM

The scope of 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 medications to manage pain. In addition, comorbidities, 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. Critical to implementation of a successful initiative is the support and leadership of a strong clinical and administrative team. Take time to identify a clinical leader who exhibits the passion for improvement of clinical care while promoting the outcomes for patient safety.

This requires starting a dialogue with pivotal leaders. Define the clinical champions who have a clinical understanding of specialized assessment and monitoring needs in potentially high-risk patients receiving anesthesia or sedating medications. Start with an anesthesiologist, a surgeon, or a pulmonologist and a hospitalist. The PACU manager, a critical care manager, and the rapid response team manager all possess an advanced clinical understanding of the importance of proactively assessing and continuously monitoring patients on a defined protocol to promote perioperative safety.

Ask the clinical team to assist with identifying an administrative leader or leaders, who are vested in patient safety and are committed to reducing the liability associated with preventable morbidity and mortality. The director of pharmacy, clinical quality team leader, risk manager, and chief medical officer are practiced at incorporating tools to implement evidence-based guidelines to facilitate change in clinical practice.

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CLINICAL DOCUMENTATION RESOURCES

Develop a packet of peer-reviewed articles to give to each of the care providers and administrative leaders to support your discussion, and outline three or four key outcomes from the articles to introduce each discussion. These key outcomes need to be tailored to the respective audience: Focus on clinical outcomes when talking with clinical champions; focus on reduction of risk factors with cost savings inherent in facilitated patient safety protocols with administrative leaders. Take time to relate the content of the articles with the respective organization’s practice specialties and marketing messages: for the anesthesiologist, the American Society of Anesthesiologists practice parameters address the importance and process of developing this initiative. A document defining clinical risk for hypoventilation or respiratory failure associated with sedating drugs and the effects of anesthesia is evidence all clinical providers will respect. An article on the downstream financial impact of adverse effects due to postoperative respiratory failure is a great educational resource for the chief medical officer, a clinical quality committee leader, the risk manager, critical care practitioners, and the rapid response team leader.

To present these materials, have printed originals organized in a portfolio that is branded with the company logo and contact information.

DEVELOPING A CLINICAL PROTOCOL

The discussions with the clinical and administrative leaders will evolve into questions about development of clinical protocols for management of the at-risk patient. The following questions need to be addressed to identify the clinical direction a protocol requires:

  1. What is the role of preadmission service in screening patients to identify those at risk for perioperative respiratory depression?
  2. What screening tool will be used to identify at-risk patients?
  3. What screening will be done for patients admitted to the general care floor?
  4. Are patients with diagnosed sleep apnea required to bring treatment devices for use during perioperative care?
  5. Will all diagnostic and interventional procedural services such as endoscopy, interventional radiology, and cardiology and the emergency room incorporate preprocedural screening of patients?
  6. Who will be responsible for defining specific order sets for at-risk patients, which address contraindications and dosage adjustments of medications when indicated?
  7. Who initiates specific order sets to care for the at-risk patient?
  8. What monitoring is required to identify impending hypoventilation, as well as the unique characteristics of the patient’s history and physical status that increase the patient’s risk?
  9. What coordination is required among clinical services such as pharmacy, the rapid response team, the hospitalist, anesthesia, and the surgeon to implement the clinical protocols?
  10. What criteria are required to transfer the patient to another level of care?
  11. What criteria are required for defining an appropriate discharge to home?
  12. What indicators will be trended to measure a reduction in preventable adverse events?
  13. Who will participate in a committee with the responsibility to periodically review patient outcomes and recommend changes in practice?
Table 2

1) HealthGrades – The Fifth Annual HealthGrades Patient Safety in American Hospitals Study; 2) Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290(14):1868-1874; 3) Assumes five year straight line depreciation schedule.

The development of a protocol, which integrates the answers to these questions, 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 postprocedural 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. When pharmaceutical contraindications are recognized, alternative drugs and dosages are dictated.

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 postoperative patient-controlled analgesia, to support the routinely performed nursing assessments. When patients have decreased level of consciousness or alertness, respiratory impairment, or sleep apnea—or are elderly—that places them at a higher risk for respiratory compromise, 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 (capnometry) would improve the detection of progressive or unrecognized hypoventilation.”3,4 Standardized protocols with continuous monitoring of ventilation are required with patients receiving medications for pain control and patients admitted for bariatric surgery.

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Equally important as implementation of standardized clinical protocols to maintain an open airway and integration of continuous ventilator monitoring is the need for professional and patient education. All care providers need education on recognizing risk factors related to sleep-disordered breathing, plus the effects of anesthesia and medications on patients with sleep apnea. Training on the use of continuous capnography with oximetry is valuable to augment early detection and management of a declining respiratory status. Ancillary staff such as pharmacists, therapists, technologists, patient transporters, and nursing assistants must be included in educational offerings as they are routinely involved in the care of all patients. Patients and their families must understand the risk anesthesia and other sedating medications may present, especially if patients are diagnosed with sleep apnea or possess risk factors for sleep apnea. They must have an understanding of the need for increased monitoring of their vital signs postoperatively to maintain a safe recovery.

With the assistance of these leaders, identify any established quality improvement processes or clinical protocols that may serve as a collaborative anchor for integrating this initiative. Since many organizations are publicly reporting their patient safety data, take time to search the Internet and the organization’s Web site for information about the organization and clinical initiatives. It can identify a link to a proactive discussion, as most organizations are certainly more interested in enhancing an already established clinical improvement process than adding a new one.

CHALLENGES OF IMPLEMENTATION

One of the challenges associated with implementation of a program of this magnitude is measuring the financial impact: revenue verses cost avoidance. Primarily, calculating the financial assumptions focuses primarily on cost avoidance.

Decreasing the incidence of respiratory failure will improve patient care, reduce length of stay (LOS), and improve a hospital’s bottom line. The Fifth Annual HealthGrades Patient Safety in American Hospitals Study reports an incidence of respiratory failure at a rate of 17 per 1,000 admissions for Medicare patients in nonfederal hospitals, resulting in a $53,502 excess charge per occurrence.2 Another nationwide sample for ages 18 and over by the AHRQ reports an incidence of respiratory depression, 2004 through 2006, of 11 per 1,000 admissions.5 Zhan and Miller report the increased length of stay associated with postoperative respiratory failure is normally around 9.08 days.6 Encinosa and Hellinger report that the actual costs per occurrence of postoperative respiratory failure were $28,218 with at least 80% of those costs associated with inpatient treatment.7

To reduce costs, hospitals must identify opportunities to address preventable adverse events while improving patient care. One opportunity may be realized through improved continuous monitoring of ventilation with integration of capnography to identify risk for postoperative respiratory failure.

Studies have demonstrated that end-tidal CO2 monitoring provides information about a patient’s ventilation before other monitoring modalities such as pulse oximetry and visual monitoring.4 The end-tidal CO2 trending data can be an effective clinical tool to improve patient outcomes and decrease hospital costs through earlier identification of respiratory depression. Using hospital-specific data, a return-on-investment (ROI) for implementation of capnographic monitoring is calculated. Additionally, associated cost savings can be calculated with the reduced LOS. A model for this ROI was developed by Peter Boyd, a graduate student in law and business at the University of Virginia who worked as a consultant for Oridion.8 An example of this ROI is in Table 2.

The financial example demonstrates the opportunity for financial savings a hospital may realize with implementation of capnography. The model may be adapted to any hospital-specific data.

The financial opportunity can be supportive of the clinical patient safety opportunity and lends significant impact in consideration for implementing a program of this magnitude.

SUMMARY

Integration of specific clinical protocols standardizes the care delivery to improve patient outcomes. A comprehensive and integrative clinical program reduces risk for postoperative respiratory depression. Critical to implementation of a successful initiative is the support and leadership of a strong clinical and administrative team. This requires starting a dialogue with key clinical and administrative leaders, who will work with you to lead the process. Researching these opportunities and using your supporting references will lead to a more successful encounter.


Kathryn Hansen, BS, REEGT, CPC, is a senior consultant on the advisory team, Sleep Center Management Institute, Atlanta. For further information, contact [email protected]

REFERENCES

  1. HealthGrades. The Fifth Annual HealthGrades Patient Safety in American Hospitals Study. April 2008. Available at: www.healthgrades.com/business/library/research-studies.aspx. Accessed June 2, 2011.
  2. Agency for Healthcare Research and Quality. Patient Safety Indicators Resources. Updated June 2007. Available at: www.qualityindicators.ahrq.gov/Modules/psi_resources.aspx. Accessed June 2, 2011.
  3. Stoelting RK, Weinger MB. Dangers of postoperative opioids—is there a cure? APSF Newsletter (Summer 2009). Available at: [removed]www.apsf.org/newsletters/html/2009/summer/index.htm[/removed]. Accessed June 2, 2011.
  4. McCarter T, Ahai Z, Scarfo K, Thompson LJ. Capnography monitoring enhances safety of postoperative patient-controlled analgesia. American Health & Drug Benefits. June 2008;1(5). Available at: www.ahdboline.com/past issues. Accessed June 2, 2011.
  5. AHRQ. National Healthcare Quality Report. Patient Safety. Available at: www.ahrq.gov/qual/nhqr09/Chap3.htm. Accessed June 2, 2011.
  6. Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290:1868-74.
  7. Encinosa WE, Hellinger FJ. The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients. Health Serv Res. 2008;43:2067-85. E pub 2008 Jul 25.
  8. Boyd P. Return-on-investment analysis of capnography monitoring in post-operative care. Oridion Technologies.