In an article recently published in The Journal of Nursing Administration, Carla Jungquist, PhD, ANP-BC, of the University of Buffalo School of Nursing and her colleagues, looked at data from eight US hospitals that volunteered to share information on how post-operative patients are assessed by their nurses.
The data came from nurse-abstracted electronic healthcare records (EHRs) and focused on nursing assessments conducted every 2 and 4 hours (in practice, assessments were conducted at the 2.5 and 4.5 hour periods because 30 additional minutes were needed for entry into EHRs). The assessments examined three key indicators:
- oxygen saturation via pulse oximetry
- respiratory rate
- sedation score
Michael Wong, JD, founder and executive director, Physician-Patient Alliance for Health & Safety spoke with Jungquist about her research.
The Lippincott Manual of Nursing Practice recommends that respiratory rate, sedation score, and oxygenation be checked periodically on an hourly, 2-hour, or 4-hour basis. A chart developed by the San Diego Patient Safety Council recommends more frequent assessments of the patient, together with a respiratory assessment that includes end-tidal CO2.
Why is it important for these nursing assessments to be done on a regular basis?
Nurses have the responsibility to ensure that patients receive safe and effective pain management while they're hospitalized. In the US, hospitals are graded on their patient's satisfaction with pain management, an initiative endorsed by The Joint Commission. Since the advent of this initiative, hospital staff members have been more aggressive with using opioid medications to address uncontrolled acute pain. Unfortunately, opioids are a "quick fix" solution to a potentially chronic problem. With the increased use of opioid medications, there's been an increase in adverse events, such as severe respiratory depression resulting in anoxic brain injury and death.
When a nurse administers any medication they're responsible for assessing both medication effectiveness and adverse effects. Opioids are well-known to cause respiratory depression, so it's logical for nurses to assess respiration at the time of peak drug effect and every 2 hours for at least the first 24 hours after opioid initiation. All patients respond differently to opioids--most will do fine, but certain patients, such as those with sleep-disordered breathing, can quickly develop advanced respiratory depression especially when sedated or sleeping. Therefore, it's important for nurses to assess the patient's breathing frequently, and in some cases, to use continuous electronic monitoring.
Nurses assess respiration by counting breaths per minute and assessing breath quality (depth and presence of snoring) with certain devices, such as pulse oximetry or capnography. Nurses also know that before respiratory arrest, a patient will experience decreased levels of consciousness. If this occurs, they can use sedation scales to assess level of consciousness.
Your findings showed that recommended patient assessments occurred in only 8.3% of the patients. Why do you believe such assessments didn't occur in the other 91.7% of the patients? And, what do you think could be done to ensure that nursing assessments are conducted more frequently?
I believe that hospitals are slow to develop policies that direct safe monitoring practices for our patients, most likely because of lack of knowledge or awareness of the problem and lack of scientific research on which to base best practices.
One of my missions with my research is to get the word out about mortality and near-miss events that continue to occur, as well as to establish best practices. Many questions exist about how to identify at-risk patients, and then how to best monitor those patients.
ECRI Institute recently released its 2016 Top 10 Patient Safety Concerns for Healthcare Organizations. Of the top 10 patient safety concerns, inadequate monitoring for respiratory depression was listed as the greatest likelihood of preventable harm. This occurs when the patient receives opioids and isn't monitored effectively. ECRI says that inadequate monitoring for respiratory depression in patients receiving opioids poses the greatest risk to patients and assigned it a risk map of 80 out of 100. Would you recommend continuous electronic monitoring together with regular nursing assessments be conducted? Or do you think that it's the combination of nurses using appropriate continuous electronic monitoring that would improve patient safety?
I recommend assessing all patients for sleep-disordered breathing and, if found, using continuous monitoring devices to ensure patient safety. I also recommend multi-modal pain management strategies that are opioid sparing. I absolutely believe we can improve patient safety by instituting better monitoring strategies coupled with multi-modal pain management.
In your research, nursing assessments looked at three key indicators: oxygen saturation via pulse oximetry, respiratory rate, and sedation score. In your study, you noted that monitoring trended data rather than just looking at threshold rates may be important. Why is important to look at trends rather than thresholds? And, what can be done to ensure that trends are assessed?
Current practice calls for nurses to assess their patient and then use the data and their critical thinking skills to decide future interventions or changes in the plan of care. Nurses currently use thresholds set by providers to determine if data are outside of a normal range or at a point where the provider needs to be notified. I'm advocating for nurses to use trend monitoring, which is when a nurse compares the patient's normal or baseline data with their current data. If the nurse sees a significant change from baseline, they should contact the provider and alter the plan of care.
Electronic device and EHR companies should change the way data are displayed for nurses. If graphics showing a patient's data overtime were included, nurses could easily see any changes. For now, nurses should look at baseline data points for comparison.
More and more professional societies are issuing guidelines supporting the increased use of capnography for patient monitoring. The Association of periOperative Registered Nurses (AORN) recently released a moderate sedation guideline update saying that perioperative nurses should monitor exhaled CO2 by capnography in addition to Sp02 by pulse proximity during moderate sedation analgesia procedures. Capnography was also recently identified by the Association for Radiologic and Imaging Nursing stating that it endorses the routine use of capnography for all patients who receive moderate sedation analgesia during procedures in the imaging environment. Would you also recommend monitoring with capnography for adequacy of ventilation? What other physiological parameters do you think should be monitored?
Capnography is a great tool that's needed in certain situations same with pulse oximetry. There's also a newer device that measures minute ventilation that has shown promise. The problem with using pulse oximetry is that patients are often wearing supplemental oxygen during surgery or other procedures. Measuring oxygen levels while using supplemental oxygen results in a false negative assessment of respiratory status. In this case, capnography is a better choice because it measures end tidal carbon dioxide levels and isn't affected directly by supplemental oxygen.
Your research showed that no patients who were assessed at least every 2.5 hours received naloxone. What message does this tell nurses and hospital executives?
I think this confirms that if nurses assessed their patients at least every 2 hours, then hospitals will see fewer near-miss or completed adverse effects from opioid medications.