Opioid use is often one of the first lines of therapy for inpatient moderate to severe pain. While effective for managing pain, these medications also impact the center of the brain, which controls breathing, and can, in turn, result in respiratory depression or respiratory arrest. These events, also known as “failure-to-rescue” events, result from a lack of close monitoring and a failure to detect early signs of patient deterioration when action could be taken before an arrest takes place. Organizations should develop policies and processes to ensure the safety of patients when opioid pain management is in use. Some best practices recommended are risk assessments to identify high-risk patients and implement continuous patient monitoring.
Although any patient has the potential to become over-sedated with the use of opioid medications, factors such as a history of snoring, sleep apnea or no previous opioid use can contribute to a patient being at a higher risk. Organizations should develop policies requiring risk assessments to help identify high-risk patients and create protocols guiding the level of monitoring for patients based on pain management. CMS Conditions of Participation and Interpretive Guidelines (482.23 (c) (4)) describe minimum monitoring requirements for all patients receiving opioid therapy. This regulation also states that the frequency of monitoring is to be determined through evaluation of risk factors, dosing frequency, route and duration. Current policies and procedures should be reviewed to ensure they meet these standards of care.
Other best practices for continuous monitoring of patients, such as pulse oximetry and capnography, should also be considered when reviewing policies related to the monitoring of patients receiving IV opioids. Dartmouth-Hitchcock Medical Center and Johns Hopkins Hospital recently shared patient safety projects, demonstrating how continuous patient monitoring helped save lives in their organizations. The articles below discuss numerous best practices they put into place as well as their outcomes and recommendations.
- Safeguarding Patients with Surveillance Monitoring, Dartmouth-Hitchcock Medical Center
- Continuous Monitoring of Patient Vital Signs to Reduce Failure-to-Rescue Events, Johns Hopkins Hospital
Where should your organization start?
- Review current policies and procedures to ensure they meet the minimum standards of care.
- Ensure that a risk assessment is in place to evaluate patients prior to the development of a pain management plan involving opioid administration.
- Work with medical staff to develop protocols for continuous patient monitoring based upon patient risk factors, dosing, route of administration and duration of therapy.
- Consider implementation of pulse oximetry and capnography when it is applicable per best practice guidelines.
- Categorize opioids as “high-risk medications” and assign specific safety measures such as continuous patient monitoring to be in place when they are used.
- Educate nursing and medical staff regarding your organization’s policies and protocols. Then hold staff accountable for following them correctly.
- Include critical continuous patient monitoring alarm systems in your evaluation of critical alarms.
- Ensure that alarms are audible from the nursing station.
- Set up PI measures to monitor performance such as:
- Failure-to-rescue events related to over-sedation
- Over-sedation events that required moving the patient to a higher level of care
- Over-sedation events that required activation of the rapid response team
- Administrations of Narcan
Questions regarding continuous patient monitoring or other medical issues? LHA Trust Funds toolkits have answers. Visit our toolkits here or contact your Patient Safety consultant here for more information.