Strategies to Prevent Opioid-Induced Respiratory Depression
(OIRD) in Acute Care
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Purpose & ObjectivesBy the end of this presentation the learner should be able to:
• Identify two evidence-based strategies to promote safe, quality pain management in acute care
• Discuss two strategies to decrease sentinel events related to opioid-induced sedation and respiratory depression
Pain is associated with negative patient outcomes
•• 2 Demand Ischemia, MI, UA• Risk for DVT• Hypoxia• pneumonia, atelectasis• weakness, fatigue,
Comfort is associated with positive patient outcomes
• Immune Function•Desirable effects on BP, HR & RR•Patient Satisfaction• -Seeking Behaviors•Peaceful Death
Pain is defined asAn unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP, 1994, 2014)Pain is whatever the experiencing person says it is existing whenever he/she says it does (McCaffrey, 1968, 1999)
Historical Perspective
• IASP founded – 1974• APS founded – 1977• NPA – 1987• ASPMN – 1990• 1990-2000 – Various Standards of
Practice & Guidelines Published– WHO Cancer/Palliative Care, Acute Pain
Management, Chronic Pain in Elderly
Sheldon Teaches Penny Physics
The Decade of Pain Control & Research
• TJC: Pain Standards – 2000– Requiring hospitals to provide safe and
effective pain management • US Congress - 2000-2010
– Declared the “Decade of Pain Control & Research”
• IASP 2010– “access to pain management is a fundamental
human right”
Scope of the Problem
• IOM - 2011• Pain is the primary reason patients seek
healthcare
Current State Opioid AddictionAddiction is characterized by:• Inability to consistently Abstain;• Impairment in Behavioral control;• Craving; or increased “hunger” for drugs or
rewarding experiences;• Diminished recognition of significant problems
with one’s behaviors and interpersonal relationships; and
• A dysfunctional Emotional response.
ASAM, 2011
• New knowledge• Prevent pain chronification• Need to improve pain assessments• Promote self management• Taper/DC Ineffective Tx when
risk>>>benefits
How do we fix this?
B – Balanced Approach R – Realistic Goal SettingA - AssessC – Conscientious Care PlanningE – End-Tidal C02
Overmedicate Undermedicate
Balanced AnalgesiaAge, Cr Cl, LFTs, tolerance, fear of addiction, concom. sedatives
Follow orders, trust the system, empathetic, well-intentioned
B R A C E
Comfort/Function Goals
1.SMART goals 1.Does NOT need to be a #2.Relate to function or activity that
supports overall outcome goals (recovery, healing, restoration of previous functioning, etc.)
1.Incentive Spirometry2.PT/OT3.Mobility4.Sleep
B R A C E
Patient’s Perspective
• “When I am not in pain and I can function”• “Just make me comfortable”• “Help control my pain”• “Removing cause of pain or providing relief of pain until cause can be
determined or removed”• “My hope is that they can find out what is causing my pain”• “When I’m not in pain anymore”• “Tolerable and can function”• “The doctor does not believe me, need to listen to the patient”• “Lidocaine works great for me for bone marrow biopsy; no need for strong
medication or opioids”
B R A C E
Sentinel AlertB R A C E
SSSeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeennnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiinnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnneeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeelllllllllllllllllllllllllllllllllllllllllll AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAlllllllllllllllllllllllllllllllllllllllleeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeertt
Problem Recommendations• Significant morbidity and mortality from
inappropriate management of pain• Overuse of opiates• Lack of multimodal therapies• Lack of risk stratification• Insufficient monitoring in at-risk
patients
• Policies & Procedures • Address ongoing monitoring of
patients receiving opioids• Serial sedation and
respiratory assessments• Second level review by a Pain
Management Specialist for high-risk opioids
• Safe Technology
• Sedation• Tolerant/Naïve (avoid dosing to #’s)• Risk Stratification
– STOPBANG– MOSS
• Capnography vs. CPOTJC, 2012
B R A C E Evidence-Based Practice Recommendations
• Documentation tools can be useful in communicating patients’ underlying conditions, comorbidities and risk factors, previous use and response to opioid therapystatus, anesthesia history, and current opioid therapy and response. Class IIa
• Institutions should establish procedures to ensure safe monitoring practices to help prevent opioid-induced adverse events. Class I
ASPMN, 2011
Assessment B R A C E Pasero Opioid-Induced Sedation Scale (POSS)
Note the “Row Information”
B R A C E
Evidence-Based PracticeOpioid Safety
31%
0% 0%
65%
51% 51%
0%
10%
20%
30%
40%
50%
60%
70%
Pain Sedation Both
Assessment 11-13 hrs post-fentanyl patch application
Before 1/6
After 1/16
STOPBANG• Snoring• Tiredness• Observed apnea• Pressure (HTN)• Body Mass• Age• Neck Size• Gender
B R A C E
MOSS B R A C E
“It is more important to know where we are going than to get there quickly.”
-Anonymous
(ISMP, 2006)
Failure Modes and Effects Analysis (FMEA)
• A team-based systematic and proactive approach for identifying the ways that a process can fail, why it might fail, the effects of that failure, and how it can be made safer.
• The goal is to eliminate or minimize the potential for failures, to stop failures before harm reaches the patient, or to minimize the consequences of the failure.
• FMEA focuses on how and when a process will fail, not IF it will fail
Harpel & Giannini, 2014
Functional Block Diagram with Task Identification
Planning EMR Build Evaluation
Tasks2.1 Documentation Committee2.2 Across applications2.3 View for other disciplines
Tasks 3.1Method3.2Audience3.3 Other Disciplines3.4 Content
Tasks 4.1 Go-Live Support4.2 Timeline4.3 Just in time education4.4
Education Implementation
1 2 3 4 5
Tasks1.1 Key Stakeholders1.2Alignment with other initiatives1.3 Timeline
Tasks5.1 ongoing PI5.2 Risk Mgmt reporting5.3 PDCA Follow-up Plan
Harpel & Giannini, 2014
SWOT
» Strengths
» Weaknesses
» Opportunities
» Threats
Strengths• Supporting Literature• Pain Champions• Clear Assessment
Times (Q4H x24)• Multimodal Pain
Management Order Sets
Weaknesses• Double Documentation
(Paper & Electronic)• Turnover of RN/Nurse
Leadership
Opportunities• Improve Patient Safety• Increase RN autonomy
with Nurse Driven Tool• Decrease RRT• Decrease Narcan Use
Threats• Other competing pilots• Challenge to Assess
Pain Post-Op r/t Sedation Half-Life
(Sisco, L., Cooper, M., & Rayburn, V.; personal communication, 2014)
MOSS Cont.
Fall Risk
B R A C E Best Practice Advisory - BPA
© 2015 Epic Systems Corporation. Used with permission.
Risk for OIRD
OIRD: Opioid Induced Respiratory Depression
B R A C E Care Plan for Highest Risk– Obstructive Sleep Apnea– Obesity Hypoventilation Syndrome (OHS)– Central Sleep Apnea
• Respirations most vulnerable during sleep/sedation:• Loose muscle tone in
pharyngeal airway• Loss of protective wake
mechanism
B R A C E
Respiratory (Patho)physiology
• Chemoreceptors regulate breathing–
• C02 crosses BBB– Is RR the best indicator of (impending) respiratory
depression?
• What happens when you add opioids?–––
heeeeemoooooooooooooooooooooooooooooooooooooorrrrrrrrrrrrrrrrrrrrrrrrrrreeeeeeeeeeeeeeceptors regulate bbbbbbbbbbbbbbbrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrreeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaatttttttttttttttttttttttttttttttttttttttttthhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhinggggggggggggggggggggggggg
• CCC0CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC 2 cccccccrcc osses BBB– IIIs IsIIIsIIIIIIIIIs RR the best indicator of (impendididiiiiiiiiiiiiiiiiiiiiiddiiiiiiiidiidiiiddiidiiing)nnnnn rereeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeespissssssspspsssssssssssssssssssssssssssssssssss ratoryy
deeeeedeped ression?
hhaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaattttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttt hhhhaaaappens when you adddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd oooooooopioids???
Capnography• What is it?
– The non-invasive continuous measurement of the partial pressure of carbon dioxide (C02) at the end of an exhaled breath (aka End Tidal C02= EtC02)
– Can detect hypoventilation, airway obstruction and increasing respiratory depression sooner than decreasing Sa02 values
• Normal Value = 35-45 mmHg
B R A C E
Capnography vs. OximetryCapnography OximetryReflects ventilation=movement of air in and out of lungs & how we get rid of C02
Reflects oxygenation= transport of O2 via bloodstream to cells
Detects apnea and hypoventilation immediately
May take many minutes to detect apnea or hypoventilation
Not affected by perfusion to extremity
Affected by perfusion to extremity
Reflects changes in:-Ventilation= air movement -Diffusion=gas exchange at alveoli-Perfusion=circulation of blood
Reflects changes of oxygen concentration in blood stream
Capnography Equipment
Handheld “N85” EtCO2Monitor for use in Codes
Alaris EtCO2 module that hooks to IV pumps
EtCo2 nasal cannula for use in non-intubated, adult patients
EtCo2 capnoline for use in intubated, adult patients
Can use up to 5L 02 per NC
Indications for EtC02 Monitoring1. Cardiac arrest per American Heart Association (AHA),
monitored after advanced airway in place2. Sedation procedures — Part of Narrator3. Patients at risk of respiratory compromise who have an opioid
PCA/PCEA. Risk factors include:a. Age > 65 yearsb. Obesity (BMI >35 kg/m2)
c. Untreated obstructive sleep apnea (OSA)* d. History of witnessed apneae. Concomitant use of benzodiazepines or antihistaminesf. Opioid naïve and basal rate on PCA/PCEAg. Use of naloxone during current episode of careh. ASA class 3-5
*OSA= is a disorder in which a person frequently stops breathing during sleep. Untreated = no CPAP use by patient but has been diagnosed with OSA.
Normal Capnography Waveform
EtC02
The key to understand the capnogram is to watch the trending of the waveforms
Abnormal Waveform-Hypoventilation
SEEN IN:• Sedation• Shallow breathing• Fever
INTERVENTION:• Encourage patient
to take deep breaths• Adjust sedative
meds• Adjust ventilator
settings
Abnormal Waveform-Partial Airway Obstruction
SEEN IN:• Asthma• COPD• Secretions/Mucous Plug• Relaxation of upper
airway (Sleep Apnea)• Kinked ETT/vent circuit
INTERVENTION:• Open Airway/CPAP• Bronchodilators• Suction• Bronchoscopy• Un-kink ETT/circuit
“SHARK FIN”
Abnormal Waveform-Apnea
Apnea
SEEN IN:• Sedation• Complete upper
airway obstruction• Apnea
INTERVENTION:• Stimulate patient• Head tilt/chin lift• Discontinue sedation• Get help/SRRT/Code
Blue
Abnormal Waveform-Rebreathing
SEEN IN:• Insufficient oxygen flow• Material over patient face• Increased ventilator dead
space
INTERVENTION:• Remove anything over
patient face• Increase oxygen flow• Assess equipment• Decrease ventilator dead
space
EtC02 in Cardiac Arrest
• EtC02 of 10-20 mmHg during CPR = good quality compressions
• Return of Spontaneous Circulation (ROSC) = sudden and
• The only way to measure EtC02 during an arrest is AFTER an advanced airway (i.e. endotracheal tube) has been placed
EtC02
• Arousal Effect– Sp02 vs. EtC02
• Intermittent vs. Continuous
How do we fix this?
B – Balanced Approach R – Realistic Goal SettingA - AssessC – Conscientious Care PlanningE – End-Tidal C02
Safe Medication Disposal
http://disposemymeds.org/
Over 60% of diverted
prescription medications are obtained from a family member
or friend Patient
Education!
Safe Pain Management
• Caymich data submission (April – present 2016)– # pts who received an IV opioid + Naloxone/# pts who
received an IV opioid– Target rate is currently 1.75%
• Sparrow currently is at .64%
• 75-90% of adult patients have a MOSS completed within 25 hours of admission
• of sedation assessment• 2016 TJC visit
Quality Pain Management What is a Pain Resource Nurse?
“A Pain Resource Nurse is a registered nurse who functions both as a resource and a change agent
in disseminating information, interfacing with nurses, physicians and other healthcare providers, and patients and families to facilitate quality pain
management”Pain Resource Nurse Role: Description and Responsibilities
City of Hope Professional Resource Center www.cityofhope.org/prc
(Ferrell, Grant, Ritchey, Ropchan & Rivera, 1993)
HCAHPS Pain Domain Team Created
Literature review andexamine best practices
SPRN Education –Group 1
SPRN Education –Group 2
SPRN Education –Group 3
PRN Program Development
PAIN Education –Group 4
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HCAPHS Inpatient OverallPain Domain
IP Overall National Average Linear (IP Overall)
PAIN Education –Group 5
Purpose & ObjectivesBy the end of this presentation the learner should be able to:
• Identify two evidence-based strategies to promote safe, quality pain management in acute care
• Discuss two strategies to decrease sentinel events related to opioid-induced sedation and respiratory depression
References• D’Arcy, Y. (2013). Turning the tide on respiratory depression. Nursing2013, 43(9), p. 38-45.
• Good, V. & Luehrs, P. (2011). Continuous End-tidal carbon dioxide monitoring. In Wiegand, D (Ed.), AACN procedure manual for critical care (p.105-112). St. Louis: Elsevier Saunders.
• Hutchinson, R. (2006). Capnography monitoring during opioid PCA administration. Journal of Opioid Management, 2(4), 207-208.
• Hutchinson, R. & Rodriquez, L. (2008). Capnography and respiratory depression. American Journal of Nursing, 108(2). p.35-39.
• Jarzyna, D., Jungquist, C., Pasero, C., Willens, J., Nisbet, A., Oakes, L., Dempsey, S., Santangelo, D., & Polomano, R. (2011). American society for pain management nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Management Nursing, 12(3), 118-145.
• Kodali, B. (2013). Capnography outside the operating rooms. Anesthesiology, 118(1), p. 192-201.• Langhan, M. (2009). Continuous end-tidal carbon dioxide monitoring in pediatric intensive care units. Journal of Critical
Care, 24, 227-230. • Overdyk, F., Carter, R., Maddox, R., Callura, J., Herrin, A., & Henriquez, C. (2007). Continuous oximetry-capnometry
monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Anesthesia & Analgesia, 105(2), p.412-418.
• Sinz, E., Navarro, K., Soderberg, E. (2011). Advanced cardiovascular life support provider manual. American Heart Association.
• Weinger, M. (2007). Dangers of postoperative opioids. The Official Journal of the Anesthesia Patient Safety Foundation, 21(4), 61-88.
• Whitaker, D. (2011). Time for capnography everywhere. Anaesthesia, 66, 539-549.• White, P. F., & Song, D. (1999). New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified
Aldrete's scoring system. Anesthesia & Analgesia, 88(5), 1069-1072.
References• American Nurses Association and American Society for Pain Management Nursing (2016). Pain
Management Nursing: Scope and Standards of Practice (2nd Ed.). Silver Spring, MD: ANA & ASPMN.• American Society of Addiction Medicine. (2011) Public Policy Statement: Definition of Addiction. Chevy
Chase, MD: American Society of Addiction Medicine. • Institute of Medicine (US). Committee on Advancing Pain Research, Care, and Education. (2011). Relieving
pain in America: A blueprint for transforming prevention, care, education, and research. National Academies Press.
• Chung, F., Liao, P., Yang, Y., Andrawes, M., Kang, W., Mokhlesi, B., & Shapiro, C. M. (2015). Postoperative sleep-disordered breathing in patients without preoperative sleep apnea. Anesthesia & Analgesia, 120(6), 1214-1224.
• Egea-Santaolalla, C., & Javaheri, S. (2016). Obesity Hypoventilation Syndrome. Current Sleep Medicine Reports, 2(1), 12-19.
• Loeser, J. D. (2000). Pain and suffering. The Clinical journal of pain, 16(2), S2-S6.• Reznick, D. B., Rehm, M., & Minard, R. B. (2001). The undertreatment of pain: Scientific, clinical, cultural
and philosophical factors. Medical Health Care Philosophy, 4, 277–288. • Mezei, L., Murinson, B. B., & Johns Hopkins Pain Curriculum Development Team. (2011). Pain education in
North American medical schools. The Journal of Pain, 12(12), 1199-1208.• Oliver, J., Coggins, C., Compton, P., Hagan, S., Matteliano, D., Stanton, M., ... & Turner, H. N. (2012).
American Society for Pain Management nursing position statement: Pain management in patients with substance use disorders. Pain Management Nursing, 13(3), 169-183.
ReferencesImages:• https://www.ismp.org/newsletters/longtermcare/LTC_Newsletter_Sample.pdf• http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-
facts-figures.pdf• https://images.google.com/imgres?imgurl=http%3A%2F%2Fwww.relatably.co
m%2Fm%2Fimg%2Ffunny-memes-big-bang-theory%2Fvalentines-meme-big-bang-theory-funny-meme-theory-72.jpg&imgrefurl=http%3A%2F%2Fwww.relatably.com%2Fm%2Ffunny-memes-big-bang-theory&docid=KuNipQy8Qe0EFM&tbnid=J79GlR48tuzI-M%3A&w=430&h=409&hl=en-US&source=sh%2Fx%2Fim