The goal in the development of rapid response teams has been to prevent failure-to-rescue. This failure to recognize when a patient’s condition has deteriorated is a key contributor to in-hospital mortality.
The early detection of the onset of respiratory compromise is clearly a key in knowing when a patient’s condition has deteriorated. Consequently, it was the goal of early intervention that Texas Health Southlake Hospital sought to achieve.
Since we began monitoring our postoperative patients receiving opioids with capnography, our facility has experienced a 90% reduction in the number of rapid response activations.
Predicting the Unpredictable
Texas Health Southlake Hospital is a multispecialty surgical hospital in Dallas that provides acute care by more than 300 attending physicians in more than 15 distinct specialties ranging from general surgery, orthopedics and neurosurgery to plastic surgery and emergency medicine.
Because we are a 100% surgical hospital, the majority of our patients (approximately 5,500 annually) require medication to adequately manage post-surgical pain. But although administering opioids is often optimal care for the patient emerging from surgery, it can result in respiratory depression in the postoperative period.
The Joint Commission cautions the use of opioids in its Sentinel Event Alert #49 : “While opioid use is generally safe for most patients, opioid analgesics may be associated with adverse effects, the most serious effect being respiratory depression, which is generally preceded by sedation.”
The reaction of each patient to opioid therapy can be different and predicting the onset of respiratory compromise can be challenging to even the most attentive and experienced clinician. A systematic review of the literature regarding failure-to-rescue demonstrates this difficulty.
As Andreas Taenzer, MD, and his colleagues at Dartmouth Medical School and Dartmouth-Hitchcock Medical Center observed : “Despite the preponderance of risk scoring techniques, there is no system that has been shown to perform reliably the difficult task of separating patients who will deteriorate from those of a similar acuity level who will not.”
Timely & Appropriate Intervention
As part of Texas Health Southlake Hospital’s efforts to improve patient safety and achieve optimal outcomes, a team of Patient Safety Champions was convened to examine the patient’s postoperative experience.
This team knew that the early detection of the onset of respiratory compromise is clearly a key in knowing when a patient’s condition has deteriorated. This prompt recognition allows for timely and appropriate intervention, and would decrease the number of rapid response activations.
Based on years of clinical experience and the collaborative exchange of information between colleagues, we knew that by the time a patient’s pulse oximetry is alerted, intervention is unnecessarily delayed, as pulse oximetry is a lagging indicator of respiratory compromise.
This team found the measurement of end tidal CO2 consistently and continuously assessed for all patients receiving opioids for the management of pain following surgery provided an early detection of the onset of respiratory compromise. We started with all patients on opioids as Inpatients.
Once familiarity with procedures and equipment had been established, we implemented these same protocols for use in our moderate sedation cases, as well.
Monitoring Technology Does Not Replace Nurses
End-tidal carbon dioxide monitoring is the noninvasive measurement of exhaled carbon dioxide and is most useful when applied directly to patient care. Through the use of end-tidal CO2 vital sign for our postoperative patients, nurses have been able to intervene earlier and achieve better results for the patient and as a result, adverse events have been significantly reduced.
Despite this success, two concerns are generally raised with the use of end-tidal CO2 monitoring: the extent to which monitoring replaces professional nursing oversight and whether additional alarms are helpful.
Monitoring is an important part of patient care depending on the setting involved, but it will never replace the importance of hands-on nursing care. The reality is that the combination of monitoring and nurse vigilance improves patient safety and enhances patient care and the profession at the same time.
Fundamental nurse teaching that nothing will replace the nurse’s focus and professional attention to the care of the patient. However, nurses are also taught that technology and medical devices are provided as tools to keep our patients safe.
Capnography is just that, it is a tool, like a blood pressure reading: A capnograph measures the levels of excreted carbon dioxide, into the bloodstream. A capnograph is used for patients undergoing anesthesia to ensure that the patient receives enough oxygen throughout the procedure; however, they are also used when a patient receives an endotracheal tube, to ensure proper placement of the tube.
Normal patient values range between 30 and 40 but a patient’s oxygen levels are detected to be to low or carbon dioxide is too high and the value drops below 30, patients risk respiratory distress. Respiratory compromise is an umbrella term for respiratory failure, respiratory arrest and respiratory insufficiency or depression.
It is entirely likely within the next 10 years, end-tidal CO2 will be a required vital sign in all hospitals where patients receive respiratory altering medications; however it is already a required vital sign in our hospital because we have seen its benefit to patient care.
The wonderful thing about evolving and improving technology is that tools are made available to nurses that contribute to the delivery of high quality patient care. Technology will never replace the humanness of a nurse, the importance of rounding and assessing patients frequently, but it clearly plays an important role in the everyday nursing process.
Managing Alarms Better
Some clinicians may avoid additional monitoring because of a concern for an increase in annoying alarms. While one can never dismiss the question of excessive alarms in the patient care environment the solution calls for careful policy review and careful attention to alarm management strategies. That fact that there may be an additional alarm is not in and of itself a justification for rejecting a technology that has proved to enhance patient care.
Those decision makers who might decline the use of additional patient monitoring risk compromising the goal for excellent healthcare delivery and will deny the organization the opportunity to raise patient safety and advocacy to the next level.
In the final analysis, what we do as nurses is about our patients and what we can do to aid in their recovery and to keep them as safe as possible. If technology can support this work, then an additional layer of protocols and procedures should be of minimal concern to the avoidance of a safety event.
Continually Improving the Continuum of Care
Patient care only rises to the level of excellent healthcare delivery when medical professionals are highly attentive, collaborative, and utilize the best available technology to assist in achieving optimal care and outcomes.
Implementing this life-saving equipment – capnography – in our facility was an easy “yes” for everyone on our team of Patient Safety Champions. Reducing rescue activations by 90% has validated our decision.
References for this article can be accessed here.
Jessica Hill is VP of patient care services and chief nursing officer at Texas Health Southlake Hospital in Dallas.