Multi-Disciplinary Process for Staged Implementation of Centralized Pulse

Oximetry

Monday, September 12, 2016

AAMI FoundationVision: To drive the safe adoption and safe use of

healthcare technology• National Coalition for Infusion Therapy Safety• National Coalition to Promote Continuous Monitoring of

Patients on Opioids• Compendium: Opioid Safety & Patient Monitoring

• National Coalition for Alarm Management Safety• Compendium: AAMI Foundation Management of Clinical

Alarm www.aami.org/thefoundation

Please Consider Making a Donation!http://my.aami.org/store/donation.aspx

NEW!! Chicago Meeting!!Co-Sponsored by NACNS, AARC, and INS

September 27 and 28, 2016; 7.4 CEs18 Presentations

First Day: Monitoring patients on opioids Alarm management safety

Second Day: Infusion therapy safetyTo Register:www.aami.org

Click on Events in left navigation column…..scroll down to Sept 27, 28

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A Special Thanks

Thank You to Our Premier Industry Partners

Without their financial support, we would not be able to undertake the various initiatives under the National Coalition to Promote Continuous Monitoring of Patients on Opioids. The AAMI Foundation

and its co-convening organizations appreciate their generosity. The AAMI Foundation is managing all costs for the series. The seminar does not contain commercial content.

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Polling Questions

Speaker Introductions

• Nancee Hofmeister, MSN, RN, NE-BC, Vice President of Nursing, Chief Nursing Officer, EvergreenHealth

• Debra Ghazan, BSN, RN, CNML, Clinical Nurse Manager, Ortho, Spine, Neuro Unit, EvergreenHealth

Introduction

The Need Identified

Respiratory depression & hypoxia are known adverse effects caused by IV opioids used to treat pain• Risk Factors Include:

• Post Operative patients• Obesity• Obstructive sleep apnea (OSA)• Pulmonary, kidney, cardiac impairments

(Hagle, Lehr, Brubakken, & Shippee, 2004)

Risk Factors

Statistics surrounding risk factors:• Post Operative patients 0.19%-5.2% significant

respiratory depression with opioid use (Addison et al.,2014)

• Obesity occurrence nearing 36% of adults (Flegal, 2010)

• Obstructive Sleep Apnea (OSA) prevalence estimated 19.7% for males and 7.4% for females (Sharma et al 2006)

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Research shows an increase in near misses, failure to rescue and other adverse events related to over sedation of post operative patients receiving IV opioids.

(Smith, Farrington, Matthews, 2014)EvergreenHealth’s experiences prior to the new CMS requirement in 2014 surrounding Opioids included:

• Post op day 2, on oral opioids, OSA, obesity, planned D/C that day

• Admit from free standing ED, SBO, 1 dose IV opioid, undiagnosed OSA

The Risk Identified

National Patient Safety Goal

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Meeting the CMS regulations

To meet the new CMS requirements, as well as the NPSG for safe clinical alarms, EvergreenHealth focused on the high risk patients with Obstructive Sleep Apnea (OSA)

Continuous centralized monitoring of Pulse Oximetry (CPOX) has been shown to reduce the incidents of failure to rescue events from adverse respiratory decline by standardization of the use of CPOX in this patient population.

(Hagle,Tutag, Brubakken, & Shippee, 2001)

Centralized Pulse Oximetry

• 3 vendors were evaluated• Demo’s with IT staff, Biomed, RN’s, Physicians,

Purchasing and Administration present• Reference Calls• Site visit • Masimo was the final decision

Infrastructure

• Wireless upgrade• Phases

• Adult med/surg• Obstetrical

• Monitor Room • Telemetry monitor, Video patient observation (War

Room)• Heat distribution • Room relocation

Implementation

• Selecting the vendor that is right for you• Workflows

• Who to monitor• OSA• Post Op• IV opioids

• Education• E-learning• Live education sessions• Vendor support at go live • Unit Champions

Implementation

• Workflows• Checked out from “War Room”• Patient notification on the system while in War Room

• Monitor Techs• Escalation process • Communication is critical to the process

Evaluation

• Delay of patient on the system• Staff time away from bedside• Equipment movement• Breakdown in communication

• New Process• Decentralized equipment (unit based)• Changed notification to monitor techs• Ortho, Spine, Neuro unit-assigned and mounted units

in each room

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Evaluation

• Alarm Management• Originally

• SPO2 set at 88%• Delay 15 sec

• Changed to Manufacturers recommendations suggest a reduction in actionable alarms up to 91% (Masimo Corporation, 2012)

• SPO2 set at 85• Delay of 15 secs

• Physician buy-in

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Change in Parameter

Results: Example from typical random patientSpo2 setting at 88%• 67 alarm events (none actionable)Spo2 settings at 85%• 35 alarm events (none actionable)Potential reduction of current none actionable alarms by 50%

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Obstructive Sleep Apnea

• STOPBANG to STOPBAG• Snoring-do you snore loudly?

• Tired- do you often feel fatigued during the daytime?

• Observed-has anyone observed you gasp or stop breathing during your sleep?

• Pressure-do you have high blood pressure?

• Body Mass Index-is your BMI higher than 35?

• Age- are you 50 or older?

• Gender-are you male?

Pre-Op Assessment

Post Op Assessment

Other Hospital Initiatives

• Quality Plan • Failure to Rescue

• Rapid Response• Family Initiative Rapid Response• Overhaul of pain meds on the spine surgery

power plans (order sets)• Implementation of the Modified Early Warning

System (MEWS)

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Modified Early Warning System (MEWS)

Outcomes

• Desaturation events • Cardiac events• Pulmonary events• 6 known lives with early intervention

EvergreenHealth 2016:Cardiac Arrest Outside CCU

Next Steps• Expansion of Centralized Pulse Oximetry

• Now moving to all post op patients receiving IV opioids

• Pre-op screening• In office screening orthopedics

• Algorithms for OSA diagnosis in any setting

• Sedation assessment outside of the CCU

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References

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• Hagle, M. E., Lehr, V. T., Brubakken, K., & Shippee, A. (2004, January/February). Respiratory depression in adult patients with intravenous patient-controlled analgesia. Orthopaedic Nursing, 23(1), 18-27.

• Addison, P. S., Watson, J. N., Mestek, M. L., Ochs, J. P., Uribe, A. A., & Bergese, S. D. (2014, May 6). Pulse oximetry-derived respiratory rate in general floor patients. [Journal]. Journal of Clinical Monitoring and Computing. http://dx.doi.org/10.1007.s10877-014-9575-5

• Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. Journal of the American Medical Association. 2012; 307(5):491–97. Available online: http://jama.jamanetwork.com/article.aspx?articleid=1104933

• Sharma SK, Kumpawat S, Banga A, Goel A. Prevalence and risk factors of obstructive sleep apnoea syndrome in a population of Delhi, India. Chest. 2006;130:149–56. [PubMed]

• Smith, A., Farrington, M., & Matthews, G. (2014, March 28). Monitoring sedation in patients receiving opioids for pain management. Journal of Nursing Care Quarterly

Future/Ongoing Initiatives

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Mark Your Calendars!October 14, 2016; 12pm to 1pm EST

Continuous Monitoring of Patients on Opioids: Initiative at BJC Healthcare in St. Louis, MO

Paul Milligan, PharmDSystem Medication Safety Pharmacist

Paul will discuss how his hospital is rolling out capnography to continuously monitor their patients on opioids

To register: https://attendee.gotowebinar.com/register/2139626912914220802

Thank You to Our Premier Industry Partners

Without their financial support, we would not be able to undertake the various initiatives under the National Coalition to Promote Continuous Monitoring of Patients on Opioids. The AAMI Foundation

and its co-convening organizations appreciate their generosity. The AAMI Foundation is managing all costs for the series. The seminar does not contain commercial content.

PlatinumDiamond Gold

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Foundation’s LinkedIn

• Type your question in the “Question” box on your webinar dashboard

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