Acknowledgement. Speaker Disclosure Statement. ASPMN 21 st National Conference Tucson, AZ September 9,

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1 Monitoring Over Sedation in Adult and Pediatric Patients Receiving Opioids for Michele Farrington, BSN, RN, CPHON michele Staff Nurse Anne Smith, MSN, RN BC anne m smith@uiowa.edu Advanced Practice Nurse Department of Nursing Services and Patient Care University of Iowa Hospitals and Clinics, Iowa City, Iowa Acknowledgement Special acknowledgement and thanks to the Resource Nurses and Staff Nurse Champions on the Nursing Management Subcommittee for their support and assistance with this project! Speaker Disclosure Statement The speakers have no industry relationships to disclose. No off label use will be discussed. 1

2 Objectives Outline steps for an evidence based practice project. Identify factors that place adult and pediatric patients receiving opioid analgesia at higher risk for over sedation and respiratory depression. Outline monitoring responsibilities of nursing staff to reduce the patient s risk of over sedation and respiratory depression after opioid administration. Discuss development and implementation of a policy to address monitoring over sedation in patients receiving opioid analgesia. Describe evaluation strategies related to monitoring oversedation in patients receiving opioid analgesia and future improvement plans. Evidence-Based Practice Framework The Iowa Model of Evidence-Based Practice to Promote Quality Care Problem Focused Triggers 1. Risk Management Data 2. Process Improvement Data 3. Internal/External Benchmarking Data 4. Financial Data 5. Identification of Clinical Problem Knowledge Focused Triggers 1. New Research or Other Literature 2. National Agencies or Organizational Standards & Guidelines 3. Philosophies of Care 4. Questions from Institutional Standards Committee Consider Other Triggers No Is this Topic a Priority For the Organization? = a decision Point Yes Form a Team DO NOT REPRODUCE WITHOUT PERMISSION REQUESTS TO: Office of Nursing Research & EBP The University of Iowa Hospitals and Clinics Iowa City, IA (Titler, Kleiber, Steelman, et al., 2001) Revised: April 1998 UIHC 2

3 Project Triggers Fall 2008 Problem Focused Over sedation events in patients of all ages within our institution and across the country Knowledge Focused New published recommendations and literature Purpose Standardize monitoring for over sedation in adult and pediatric patients receiving opioid analgesia in order to provide safe care for patients with pain The Iowa Model of Evidence-Based Practice to Promote Quality Care Problem Focused Triggers 1. Risk Management Data 2. Process Improvement Data 3. Internal/External Benchmarking Data 4. Financial Data 5. Identification of Clinical Problem Knowledge Focused Triggers 1. New Research or Other Literature 2. National Agencies or Organizational Standards & Guidelines 3. Philosophies of Care 4. Questions from Institutional Standards Committee Consider Other Triggers No Is this Topic a Priority For the Organization? = a decision Point Yes Form a Team DO NOT REPRODUCE WITHOUT PERMISSION REQUESTS TO: Office of Nursing Research & EBP The University of Iowa Hospitals and Clinics Iowa City, IA (Titler, Kleiber, Steelman, et al., 2001) Revised: April 1998 UIHC 3

4 Organizational Priority Existed before the project started due to adverse patient event Pressure to quickly make changes was challenging The Iowa Model of Evidence-Based Practice to Promote Quality Care Problem Focused Triggers 1. Risk Management Data 2. Process Improvement Data 3. Internal/External Benchmarking Data 4. Financial Data 5. Identification of Clinical Problem Knowledge Focused Triggers 1. New Research or Other Literature 2. National Agencies or Organizational Standards & Guidelines 3. Philosophies of Care 4. Questions from Institutional Standards Committee Consider Other Triggers No Is this Topic a Priority For the Organization? = a decision Point Yes Form a Team DO NOT REPRODUCE WITHOUT PERMISSION REQUESTS TO: Office of Nursing Research & EBP The University of Iowa Hospitals and Clinics Iowa City, IA (Titler, Kleiber, Steelman, et al., 2001) Revised: April 1998 UIHC Team Formation January May 2009 Primary team members Resource Nurses Represent all nursing divisions Informatics Secondary team members Staff Nurse Champions Nursing Management Subcommittee Interdisciplinary Committee External Experts 4

5 DO NOT REPRODUCE WITHOUT PERMISSION REQUESTS TO: Office of Nursing Research & EBP The University of Iowa Hospitals and Clinics Iowa City, IA = a decision Point Revised: April 1998 UIHC Assemble Relevant Research & Related Literature Critique & Synthesize Research for Use in Practice Yes Pilot the Change in Practice 1. Select Outcomes to be Achieved 2. Collect Baseline Data 3. Design Evidence-Based Practice (EBP) Guideline(s) 4. Implement EBP on Pilot Units 5. Evaluate Process & Outcomes 6. Modify the Practice Guideline Is There a Sufficient Research Base? No Base Practice on Other Types of Evidence 1. Case Reports 2. Expert Opinion 3. Scientific Principles 4. Theory Conduct Research (Titler, Kleiber, Steelman, et al., 2001) Literature Search January May 2009 Articles and evidence obtained from benchmarking and gleaned from available pain journals and books Contacted pain expert (C. Pasero) DO NOT REPRODUCE WITHOUT PERMISSION REQUESTS TO: Office of Nursing Research & EBP The University of Iowa Hospitals and Clinics Iowa City, IA = a decision Point Revised: April 1998 UIHC Assemble Relevant Research & Related Literature Critique & Synthesize Research for Use in Practice Yes Pilot the Change in Practice 1. Select Outcomes to be Achieved 2. Collect Baseline Data 3. Design Evidence-Based Practice (EBP) Guideline(s) 4. Implement EBP on Pilot Units 5. Evaluate Process & Outcomes 6. Modify the Practice Guideline Is There a Sufficient Research Base? No Base Practice on Other Types of Evidence 1. Case Reports 2. Expert Opinion 3. Scientific Principles 4. Theory Conduct Research (Titler, Kleiber, Steelman, et al., 2001) 5

6 Synthesis of Evidence January December 2009 Why should you monitor your patient receiving opioids? To ensure adequate oxygenation, ventilation, and patient safety To evaluate response to treatment The first 24 hours is the most crucial time for monitoring: After surgery When existing doses of analgesics are altered When new analgesic modalities are introduced (Pasero, 2009; Pasero & McCaffery, 2008) Synthesis of Evidence (cont.) Patients at risk for over sedation Obstructive sleep apnea, snoring, obesity, and/or BMI >35 Age End stage organ failure Altered CNS function Concurrent use of sedating medications (American Society of Anesthesiologists Task Force on Neuraxial Opioids, 2009; DuBose & Berde, 1997; Hagle, Tutag Lehr, Brubakken, & Shippee, 2004; ISMP, 2009; Nisbet & Mooney Cotter, 2009; Overdyk, 2008; Pasero, 2009; Stoelting & Weinger, 2009; Valdez Lowe, Ghareeb, & Artinian, 2009; Weber, Ghafoor, & Phelps, 2008; Weinger, 2007) Synthesis of Evidence (cont.) Patients at risk for over sedation (cont.) Supplemental oxygen use (oximetry may mask hypoventilation) Patient Controlled Analgesia (especially with a basal rate) Caregiver Controlled Analgesia Altered airways (American Society of Anesthesiologists Task Force on Neuraxial Opioids, 2009; DuBose & Berde, 1997; Hagle, Tutag Lehr, Brubakken, & Shippee, 2004; ISMP, 2009; Nisbet & Mooney Cotter, 2009; Overdyk, 2008; Pasero, 2009; Stoelting & Weinger, 2009; Valdez Lowe, Ghareeb, & Artinian, 2009; Weber, Ghafoor, & Phelps, 2008; Weinger, 2007) 6

7 Synthesis of Evidence (cont.) Various sedation tools reviewed, such as: Richman Agitation Sedation Scale Riker Motor Activity Assessment Scale Ramsey Sedation Scale Post Anesthesia Care Unit considerations Pasero Opioid Induced Sedation Scale Chosen because it was developed for monitoring and early detection of unintended sedation with opioid administration Sedation usually precedes respiratory depression DO NOT REPRODUCE WITHOUT PERMISSION REQUESTS TO: Office of Nursing Research & EBP The University of Iowa Hospitals and Clinics Iowa City, IA = a decision Point Revised: April 1998 UIHC Assemble Relevant Research & Related Literature Critique & Synthesize Research for Use in Practice Yes Pilot the Change in Practice 1. Select Outcomes to be Achieved 2. Collect Baseline Data 3. Design Evidence-Based Practice (EBP) Guideline(s) 4. Implement EBP on Pilot Units 5. Evaluate Process & Outcomes 6. Modify the Practice Guideline Is There a Sufficient Research Base? No Base Practice on Other Types of Evidence 1. Case Reports 2. Expert Opinion 3. Scientific Principles 4. Theory Conduct Research (Titler, Kleiber, Steelman, et al., 2001) Pilot April June 2010 Units Chosen 3RCP (adult med/surg, ortho, urology) 3JCP (pediatric med/surg, including trauma, hem/onc, and bone marrow transplant) 4RCP (adult cardiology) 7RCS (adult leukemia and bone marrow transplant) Units Excluded ICU 7

8 Pilot (cont.) Pre pilot web based knowledge survey completed on the pilot units (n=76) Policy developed Respiratory monitoring Sedation scale Electronic medical record documentation updated Monitoring Guidelines 2 required components: Respiratory Assessment * Respiratory rate Respiratory rhythm/pattern Respiratory effort Respiratory depth Airway characteristics (e.g., presence of snoring) Sedation Assessment POSS scale *Based on nursing judgment, patients alert, awake and/or participating in activities may not require a full respiratory assessment [American Society of Anesthesiologists Task Force on Neuraxial Opioids, 2009; McCaffery & Pasero, 1999; Pasero, 2009; Pasero & McCaffery, 2008; Wells, Pasero & McCaffery (2008). Improving the quality of care through pain assessment and management. In R. G. Hughes (Eds.), Patient Safety and Quality: An evidence based handbook for nurses, (Ch. 17). (AHRQ Publication No ). Rockville, MD: Author. Monitoring Guidelines (cont.) Frequency of Assessment based on: Route and Delivery Opioid IV infusions/drips/pca/cca with and without a basal rate Scheduled or PRN doses, any route Special consideration for sleeping patients Assess respiratory status first Assess sedation (e.g. responsiveness to stimuli, such as, patient stirs when the bed is bumped) Awaken patient if concerned or patient is snoring End of life and Palliative Care patients Monitoring can be requested by LIP 8

9 Sedation Level Modified Pasero Opioid Induced Sedation Scale (POSS) 0 = Sleep and easy to arouse Acceptable; no action necessary; may increase opioid dose if needed/ordered 1 = Awake and alert Acceptable; no action necessary; may increase opioid dose if needed/ordered 2 = Slightly drowsy, easily aroused Acceptable; no action necessary; may increase opioid dose if needed/ordered 3 = Frequently drowsy, arousal, drifts off to sleep during conversation Unacceptable; continue to monitor more frequently until return to baseline; notify LIP and consider calling the Rapid Response Team and giving dilute naloxone 4 = Somnolent, minimal or no response to physical stimulation Unacceptable; stop opioid; continue to monitor more frequently until return to baseline; notify LIP and consider calling the Rapid Response Team and giving dilute naloxone (McCaffery & Pasero, 1999; Pasero, 2009; Pasero & McCaffery, 2008) Frequency of Assessment Opioid IV infusions/drips/pca/cca with and without a basal rate, and/or long acting or sustained released opioids At initiation Initial re assessment after opioid administration should consider factors such as: Peak effect of opioid administered Patient activity Risk factors for over sedation Previous exposure to sedation (Note: if the patient has been on ongoing opioid therapy for more than 24 hours and then is switched over to a long acting or sustained release opioid, monitoring may proceed at the current frequency; monitoring does not need to start over when a new opioid is started) Frequency of Assessment (cont.) Opioid IV infusions/drips/pca/cca with and without a basal rate, and/or long acting or sustained released opioids (cont.) Every hour for 12 hours Then every 2 hours for 12 hours Then every 4 hours for duration if: POSS Score < 3 Respiratory rate at baseline Absence of respiratory distress, apnea, and snoring 9

10 Frequency of Assessment (cont.) Opioid IV infusions/drips/pca/cca with and without a basal rate, and/or long acting or sustained released opioids (cont.) More frequent per nursing discretion if: POSS Score of 3 or 4 Change in respiratory rate Presence of respiratory distress/apnea/snoring Patient unstable Patient condition warrants Notify LIP Consider calling Rapid Response Team Consider giving dilute Naloxone Frequency of Assessment (cont.) Nurse Administered (e.g. PRN or scheduled) doses, any route each dose given At initiation Initial re assessment after opioid administration should consider factors such as: Peak effect of opioid administered Patient activity Risk factors for over sedation Previous exposure to sedation After the initial 24 hours, stable patients receiving around the clock opioid dosing, should have re assessments for sedation and pain level completed every 4 hours Pilot Documentation Flowsheet 10

11 Pilot (cont.) Education In Services Rapid Cycle Improvement Method Unit Reference Binders Policy Research articles Educational material PPT, case scenarios Opioid reference guides/cards, IV administration guidelines Pocket Cards Pocket Cards Monitoring Standards for Sedation after Opioid Administration Continuous Infusions/PCA/Frequent NCA*/long acting opioids: Respiratory Assessment AND Sedation Assessment (POSS): Prior to initiation 1st reassessment considering peak, risk factors, previous opioids, and patient activity Then ever y 1 hr x 12 hrs; every 2 hrs x 12 hrs; then every 4 hrs if stable Scheduled, PRN Opioids, Infrequent/Routine NCA*: Respiratory Assessment AND Sedation Assessment (POSS): Prior to administration (for first 24 hr if ATC) Re assessment after each opioid dose considering peak, risk factors, previous opioids, and patient activity (for first 24 hr if ATC then q4 hrs if stable) Respiratory Assessment Is: Respiratory rate, effort, depth, and airway characteristics NCA= Nurse Controlled Analgesia via locked infusion pump Sedation Assessment: POSS Scale 0 = Sleep and easy to arouse Acceptable; no action necessary; may increase opioid dose if needed/ordered 1 = Awake and alert Acceptable; no action necessary; may increase opioid dose if needed/ordered 2 = Slightly drowsy, easily aroused Acceptable; no action necessary; may increase opioid dose if needed/ordered 3 = Frequently drowsy, arousal, drifts off to sleep during conversation Unacceptable; Continue to monitor more frequently until return to baseline. Notify LIP and consider calling the Rapid Response Team and giving dilute naloxone 4 = Somnolent, minimal or no response to physical stimulation Unacceptable; stop opioid; Continue to monitor more frequently until return to baseline. Notify LIP and consider calling the Rapid Response Team and giving dilute naloxone Peak Effects: PO opioids: 60 minutes IV opioids: 30 minutes Reassessment: Complete at the time of sedation re-assessment Continue to Evaluate Quality of Care and New Knowledge No Is Change Appropriate for Adoption in Practice? Yes Institute the Change in Practice Disseminate Results Monitor and Analyze Structure, Process, and Outcome Data - Environment - Staff - Cost - Patient and Family = a decision Point DO NOT REPRODUCE WITHOUT PERMISSION Titler MG, Kleiber C, Steelman V, Rakel B, Budreau G, Everett LQ, Buckwalter KC, Tripp Reimer T, & Goode C (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4): REQUESTS TO: Office of Nursing Research & EBP The University of Iowa Hospitals and Clinics Iowa City, IA Revised: April 1998 UIHC 11

12 Project Integration August September 2010 Infrastructure links Inpatient Care (excluded ICUs) Adult & Pediatrics Quality Management Staff Education Committee Professional Nursing Practice Committee (policy) Informatics Unit activities Staff Nurse Involvement Unit Resource Manual APN Role NM Commitment Policy & Staff Education Development Policy Revised after pilot complete based on feedback Approved by the Professional Nursing Practice Committee (Aug. 2010) Staff Education Approved by the Staff Education Committee (Aug. 2010) Informatics Documentation changes in EMR completed (Aug. 2010) Continue to Evaluate Quality of Care and New Knowledge No Is Change Appropriate for Adoption in Practice? Yes Institute the Change in Practice Disseminate Results Monitor and Analyze Structure, Process, and Outcome Data - Environment - Staff - Cost - Patient and Family = a decision Point DO NOT REPRODUCE WITHOUT PERMISSION Titler MG, Kleiber C, Steelman V, Rakel B, Budreau G, Everett LQ, Buckwalter KC, Tripp Reimer T, & Goode C (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4): REQUESTS TO: Office of Nursing Research & EBP The University of Iowa Hospitals and Clinics Iowa City, IA Revised: April 1998 UIHC 12

13 Implementation September 2010 PowerPoint presentation on hospital computer education system Live in services One page flier Pocket cards Revised Documentation Documentation Report 13

14 Continue to Evaluate Quality of Care and New Knowledge No Is Change Appropriate for Adoption in Practice? Yes Institute the Change in Practice Disseminate Results Monitor and Analyze Structure, Process, and Outcome Data - Environment - Staff - Cost - Patient and Family = a decision Point DO NOT REPRODUCE WITHOUT PERMISSION Titler MG, Kleiber C, Steelman V, Rakel B, Budreau G, Everett LQ, Buckwalter KC, Tripp Reimer T, & Goode C (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4): REQUESTS TO: Office of Nursing Research & EBP The University of Iowa Hospitals and Clinics Iowa City, IA Revised: April 1998 UIHC Post Implementation Knowledge Survey April May 2011 Completed by nurses on the pilot units (n=67) Used same web based knowledge survey (pre/post comparison) Knowledge Survey Results Strongly Agree Strongly Disagree 14

15 Knowledge Survey Results (cont.) Strongly Agree Strongly Disagree Knowledge Survey Results (cont.) Strongly Agree Strongly Disagree Knowledge Survey Results (cont.) Strongly Agree Strongly Disagree 15

16 Audit and Feedback Resource Nurses Nurse Managers Assistant Nurse Managers Staff Nurse Champions Ongoing chart audits Evaluation Documentation Report Documentation Report 16

17 Documentation Report Documentation Report Audit Feedback Tool Intermittent Opioids 17

18 Audit Feedback Tool Continuous Opioids Chart Audit Data POSS Reminders. (February 2011) Make it THOROUGH Sedation assessment requires all these: POSS Scale and Respiratory Assessment and Respiratory Rate for all opioids of all routes Morphine, Dilaudid, Oxycodone, Lortab, Tylenol #3, etc. Make it EASY: Complete and Sedation Assessment together! (Sedation Assessment includes POSS, Respiratory Assessment and RR) Reassessments (for both pain and sedation) should occur at baseline and peak of intervention: IV medications peak: 30 minutes PO medications peak: 60 minutes If receiving ATC interventions: After the first 24 hours, q 4 hr assessments may be done (including extended release opioids like OxyContin) Applies to patients who have been on the same opioid, same route and who have been stable over the previous 24 hours Make it ACCURATE: Check your charting times It s easy to chart that everything happened on the hour or the half hour (e.g. 1200, 1230, 1600, 1630) but is that accurate? Give IV analgesics over 5 minutes on the pump Adjust your pain and sedation reassessment times if you: Administer the analgesic over a longer time Do not have a fast enough carrier solution for the med to reach the patient in a timely fashion Use a lot of extra tubing between the medication and the patient» Priming volume of standard ext set + 1 stopcock = 4.2 ml» Priming volume of microbore ext set + 1 stopcock = 0.57ml Pass on to the next shift when the next sedation and pain assessments are due Keep your patients SAFE: Continuous oximeters are required for pediatric patients with basals Giving Benadryl to help patients sleep can be dangerous with opioids Always be thinking about risk factors for over sedation when giving an opioid via any route Meds that increase sedation (e.g. ATIVAN, anticonvulsants, Benadryl, Phenergan) Patient Conditions SNORING/airway/pulmonary compromise Infant < 12 months Obesity Renal/Liver Insufficiency Cognitive Impairment Neuromuscular Disease Opioid naïve (< 5 days of opioid exposure) Head Trauma/Craniotomy Sudden cessation of pain First 24 hours post op 18

19 Opioid Over Sedation Monitoring Change and Reminders (June 2011) Continuous Pulse Oximetry: *****ONLY needed for the first 48 hours for pediatric patients with basal rates/opioid infusions (if stable) ******* Sedation assessment and documentation MUST include: POSS Scale Score Respiratory Rate Respiratory Assessment Respiratory rhythm or pattern Respiratory effort Respiratory depth Airway characteristics All opioids and All routes (IV, PO) Assessment Frequency: PRN or Scheduled Opioids Baseline Peak (30 min for IV meds; 60 min for PO meds) After 24 hrs of ATC dosing, may change to Q4 hrs for stable patients PCAs/NCAs/CCAs/Opioid Infusions Baseline Peak (30 min) Q1 hr *12 hours Q2 hrs *12 hours Then Q4 hrs if stable PLEASE do not complete rows in POSS section of Peds Cares flowsheet Someone may forget to re activate later when opioid given Next Steps Targeted education/re infusion Continue audit/feedback Revisions to documentation in EMR Continue to Evaluate Quality of Care and New Knowledge No Is Change Appropriate for Adoption in Practice? Yes Institute the Change in Practice Disseminate Results Monitor and Analyze Structure, Process, and Outcome Data - Environment - Staff - Cost - Patient and Family = a decision Point DO NOT REPRODUCE WITHOUT PERMISSION Titler MG, Kleiber C, Steelman V, Rakel B, Budreau G, Everett LQ, Buckwalter KC, Tripp Reimer T, & Goode C (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4): REQUESTS TO: Office of Nursing Research & EBP The University of Iowa Hospitals and Clinics Iowa City, IA Revised: April 1998 UIHC 19

20 Dissemination Posters Nursing Recognition Day (2010 & 2012) National Evidence Based Practice Conference (2012) Presentations 17 th National Evidence Based Practice Pre Conference (April 2010) Evidence Based Practice Staff Nurse Internship (March 2011) ASPMN Conference (September 2011) Manuscript Conclusion Don t take on the world Be flexible Use data to support your efforts Include nurses caring for patients Questions/Comments 20