Continuous Monitoring of Patients on Opioids: Initiatives at Community Health Network and Methodist Specialty and Transplant Hospital

Continuous Monitoring of Patients on Opioids: Initiatives at Community Health Network and Methodist Specialty and Transplant Hospital Friday, August 26, 2016

AAMI Foundation Vision: 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

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. Diamond Platinum Gold

LinkedIn Questions Please post questions on the AAMI Foundation s LinkedIn page. OR Type a question into the question box on the webinar dashboard.

Nursing Continuing Education Disclosure Statement This seminar is jointly provided today with our co-provider, the National Association of Clinical Nurse Specialists (NACNS). 1.0 contact hour will be awarded for this seminar. This seminar may be accessed online at the AAMI Foundation website for nursing CE up to two years from today s date. http://my.aami.org/store/detail.aspx?id=conmonsem This continuing nursing education activity was approved by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation (ANCC). Criteria for successful completion includes attendance at the session and submission of a completed evaluation form. You can submit the fee for the CE credit by going to the AAMI store at (link will be sent in follow-up email). A link to the evaluation form will be sent to you for completion and a certificate sent to you upon completion of the evaluation. The planning committee members have declared no conflict of interest along with our faculty for today s session. Contributions to the AAMI Foundation have been received from the identified sponsors to support program initiatives and projects. However, the program content for today s seminar has been planned independently by AAMI staff with the seminar presenters. Approval of the continuing education activity does not imply endorsement by the provider, ANCC or the Alabama State Nurses Association.

Polling Questions

Speaker Introductions Julie Painter MSN RN OCN, Clinical Nurse Specialist, Community Health Network Indianapolis, Indiana Theresa Kloewer, MSN, RN Vice President of Nursing Methodist Specialty and Transplant Hospital San Antonio, Texas

Community Health Indianapolis Indiana We are: 7 Hospital System >2million patient encounters/year 1049 staffed beds 53,576 Inpatient admissions/year 12, 662 Inpatient surgeries/year Outpatient visits >1million/year 82, 274 Outpatient surgeries/year ER visits 273,941 Births 7,899

Smart Pump Technology We were early adopters of CareFusion Smart Pump technology in 2007 We utilize smart pumps, Patient controlled analgesia modules, etco2 modules & syringe modules Our patient care delivery with products, processes, policies & interventions are standardized to reduce variation in care & reduce harm across all facilities and the continuum

What is capnography & what is its value? Capnography has evolved into a standard of monitoring during anesthesia because it has proven itself to be a valuable tool in recognizing ventilatory and circulatory events that could potentially lead to deleterious effects

Sedation & Ventilation Status Historically we have relied on oxygen levels to tell us about a patients respiratory/ventilation status Oximetry is not an indicator of ventilation status Measurement of CO2 is a better predictor of ventilation status and helps us intervene earlier to address respiratory compromise before needing reversal agents or a higher level of care

Our Journey Early adopters of smart pump technology-2007 All 7 hospitals utilize same products, same policies and have a process to promote evidence based practice, standardization & reduction of variation #1 customer is the patient-do what is best for our patients! Goal is to reduce harm & provide the highest quality, safest care with the best outcomes possible Etco2 often only used with patient controlled analgesia

Impetus for Improvement Data from largest facility within our network, revealed a high number of patients with oversedation requiring consultation from rapid response team for respiratory compromise; use of naloxone for reversal; and many required a higher level of care & monitoring Note this project was before the Partnership in Patient Safety national projects to reduce adverse drug events with naloxone

Improvement Team Project Lead: Julie Painter Clinical Nurse Specialist Physician Champion: Scott Vore MD-Anesthesia & Michael Caldwell MD-Anesthesia Members: Director, manager of PACU, pharmacy, nursing leaders from acute care units

Goal of Improvement Goal: Reduce unwanted respiratory depression due to opioids post-operatively & reduce naloxone utilization. Data Revealed: Higher amounts of naloxone administered on the largest campus that did surgeries & at the time we were only using etco2 monitoring on PCA patients. Many patients with high BMI, COPD &/or Sleep apnea higher risk but not aware Finding: PACU staff & leaders were not aware of patient compromise once they left PACU

The Improvement Interventions Developed & implemented education for all PACU staff about data & how the team would work to reduce harm Implemented end tidal CO2 monitoring on all PACU patients before they left PACU Improved bedside handoff communication between PACU RN & Unit receiving RN about any issues or concerns, specifically what meds had they received that have potential to cause sedation Began process improvement October 2013 & analyzed process & data through all of 2014 and in 2015 began the spread of improvement through all facilities Patient education sheet developed with talking points

Changes in the PACU All patients have an end tidal CO2 module attached to Infusion pump with nasal cannula in place in the PACU The etco2 module will be activated & turned on & measuring as PACU transports patient from PACU to acute care Discharge criteria for PACU remains the same otherwise Note elevation in etco2 alerts us to help patient take deep cleansing breathes & to exhale to rid of excess CO2

End tidal CO2 monitoring 19

End tidal CO2 Module & Controls

Nasal Cannula

Key Considerations to Success Have the right team members Educate patient regarding cannula Have experts and leaders who can serve as champions aka barrier busters Engage staff & help them digest & understand the data Make it real---take the data, deep dive a couple of cases & develop a case story---reality sinks in more than probability

The Challenges Fear of alarms bothering patients & decreasing patient satisfaction Orders being entered to discontinue etco2 monitoring Staff ability to articulate & explain to patients why this is important & why we do it Providers desiring to select only those patients at risk for sedation? Inability to know who is at risk-providers asked why put on everyone?

Hardwiring Change Be methodical-don t try to do all places at one time Support both areas PACU and Acute care on go live day and ongoing after Train champions & unit experts Have building resources Immediately address concerns or issues & resolve face to face Realize change takes time & when busy we easily digress to old habits Monitor events real-time-we discuss naloxone events daily in our safe day huddles & consider them ADE s until reviewed

Current State Complete implementation across acute care Expansion to OB Staff nurse can place etco2 module on any patient with concerns of compromise & increased risk of sedation-this allows a nurse the ability to better assess their patients in a more accurate way

Current State Project team working as a network to verify that all end tidal CO2 monitoring during procedures are using most current technology Note that naloxone use remains significantly low based on percentage of patients who receive opioids & would have potential for reversal Looking beyond opioids now & other sedation medications

Methodist Specialty and Transplant (MSTH) Theresa Kloewer, MSN, RN Vice President of Nursing Methodist Specialty and Transplant Hospital

About Methodist Specialty and Transplant (MSTH) MSTH is a 275-bed acute care facility Part of Methodist Healthcare System in San Antonio, Texas MSTH is known for unique specialized care in: Kidney, pancreas and liver transplant Multi-specialty surgical services Medical rehabilitation Psychiatry Emergency medicine

Learning Objectives 1. Describe why failure-to-rescue is important for all hospitals, and the role for technology that is driven by clinical need. 2. Discuss the major outcome benefits associated with early detection of a deteriorating patient. 3. Define components of a vital sign surveillance monitoring solution covering technical and clinical practice and outcome metrics.

Failure-to-Rescue Definition: Failure to prevent a clinically important deterioration from a complication of an underlying illness or a complication of medical care http://www.ahrq.gov/

Nursing Surveillance The purposeful and ongoing collection and analysis of information about the patient and the environment for use in promoting and maintaining patient safety. Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby.

Why Is Failure-to-Rescue Important? Up to 75 percent of adverse events and preventable deaths 1 84 percent of patients exhibit signs of deterioration 2 bed 1 http://www.ihi.org/education/conferences/apacforum201 2/Documents/I2_Presentation_Diagnostics_Haraden.pdf 2 AHA database, 2013 3 Schein RM et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990;98:1388-92. Up to 60 percent of all hospital patients are monitored continuously 2 In order to rescue, one needs to know they re deteriorating and respond immediately 3

Why Is Failure-to-Rescue Important? Wendlandt, B et al. Association between ICU Transfer Delay and Hospital Mortality: A Multicenter Investigation (abstract). Journal or Hospital Medicine 2015:10 (suppl 2). For every one-hour increase in transfer delay, the odds of an in-hospital death increased 3 percent For patients who survived until discharge, delayed transfer was associated with a longer length of stay

Why Is Failure-to-Rescue Important? The Impact of Nursing Surveillance on Failure to Rescue Leah L. Shever, PhD, RN When nursing surveillance is performed an average of 12 times a day or greater, there is a significant decrease in the odds of experiencing failure to rescue Research and Theory for Nursing Practice: An International Journal, Vol. 25, No. 2, 2011

Metrics for Quality Improvement Early identification of deterioration (sepsis, opioid induced hypoventilation, reoperation, hypertension, etc.) Efficiency number of steps and time for vital signs Operational Code blue and rapid response calls Satisfaction

Three Fundamental Problems According to the Institute for Healthcare Improvement and the 5 Million Lives campaign (2007): 1. Failures in planning includes assessments, treatments, goals 2. Failure to communicate patient-to-staff, staffto-staff, staff-to-physician, etc. 3. Failure to recognize a problem These three problems often lead to failure to rescue.

Recognizing a Problem Vital signs obtained for five minutes every four hours represents 2 percent of a patient s day Yet it represents hours of RN/PCT time for each shift RNs are in patient rooms for 1.5 hours out of a 12-hour shift 1 Spend less than 7 percent of time assessing the patient 3 Average of nine cognitive shifts per hour 2 Refocus from one patient to another every six to seven minutes 4 1. http://www.healthleadersmedia.com/content/nrs-248752/cms-will-soon-track-your-failure-to- Rescue-DatamdashAre-You-Ready.html## 2. JONA, Volume 42, Number 7/8, pp 361-368 3. Hendrich Study 4. AHA database, 2013

Condition vs. Surveillance Monitoring Condition Monitoring: use of a patient monitoring system which is limited to clinical targets based upon a patient s unique, identifiable risk profile Surveillance Monitoring: use of a patient monitoring system which has continuous broad clinical targeting independent of a patient s unique, identifiable risk profile, recognizing that all risks cannot be identified a priority

About Methodist Specialty and Transplant Two medical-surgical type units were identified to introduce surveillance and continuous vital sign monitoring: Transplant Unit: 57 beds that provide pre- and post-transplant care Surgical Unit: 47 beds that provide post-surgical care to bariatric, endocrine, gyn, urological, maxofacial, vascular, colon-rectal, plastics and general surgery patients

Our Method Methods Patients admitted to the medical-surgical and transplant care unit at MSTH from July to October 2015 were included Materials Continuous vital sign monitoring for heart rate, blood pressure, respiratory rate and oxygen saturation, including alarms and alerts, to notify the nurse of necessary intervention

Workflow Analysis - Efficiency Analyzing traditional workflow compared to the new workflow state with selected continuous vital sign system Identifying operational efficiencies Using workflow analysis tool(s) to gather data 1. Nurse finds traditional vital sign device 2. Nurse brings device to patient room 3. Nurse takes vital signs in three stages: temperature, blood pressure, pulse oximetry 4. Nurse returns vital sign device to storage location 5. Nurse documents vital signs in electronic health record (or validates if automatically transmitted)

Workflow Time Spent Per Day Overall assumptions: 40-bed unit, vitals every four hours for a 24-hour period Continuous vital sign assumptions: Calibrate and bump twice/day, initial setup for 1/3 of patients assuming an avg. 3-day length of stay. Traditional Vital Signs Counts: 40 pts x 6 vitals/day = 240 vitals in 24 hours Calculation: 5 min each x 240 vitals = 1200 min, or 20 hrs Total: 20 hours in a 24 hr time period Continuous Vital Signs Counts: 40 pts x.33 set up = 13 set ups in 24 hours 40 pts x 2 calibrate = 80 calibrations 40 pts x 2 bump = 80 bump / swap Calculations: 5.9 min x 13 setups = 77 min, or ~ 1.28 hrs 2.65 min x 80 calibrates = 212 min, or ~ 3.5 hrs 3.81 min x 80 bump/swaps = 305 min, or ~5 hrs Total: 9.78 hours in a 24 hour time period Potential 10 hours/day time saving

Components Body-worn continuous physiological monitor Four-ounce ICU-grade monitor All vital signs are continuous Wi-fi connectivity EHR-compatible Distributed monitoring and alarming possible

Measurement Basic continuous Monitoring SpO 2 /Pulse Rate Continuous vital signs+ SpO 2 /pulse rate Respiration rate and skin temperature ECG 3 and 5 lead NIBP (cuff-based) Continuous NIBP (cnibp) Continuous non-invasive blood pressure (cnibp) Based on pulsearrival-time (PAT) Initial cuff-based calibration Cuff removed after calibration to measure PAT based beat-tobeat blood pressure ECG P Q R S T P A T PPG Time

Results Over 99,500 hours of patient vital sign data were logged There were over 75 clinically meaningful nursing interventions to alarms recorded that either detected or prevented deterioration Interventions were coded to determine early deterioration diagnosis (such as sepsis, hypertension and pulmonary vascular congestion) There were 33 diagnoses related to deterioration. All patients were treated and discharged alive

Parameters That Detected Deterioration Parameters That Detected Deterioration Analysis of RN Intervention Logs (10 week sample) RR 15% cnibp 23% Sp02 53% Sp02 HR RR BP HR 9% Events Where Nursing Intervention Prevented Deterioration (10 week sample) Hemodynamic Cardiac 14 Events 4 1 1 27 Events Respiratory

Average Alarm Events Per Session Per Day Transplant Unit

Average Alarm Events Per Session Per Day Medical-Surgical Unit

Event Examples Hemodynamic 66-year-old female admitted with pyelonephritis Alarm: Blood pressure 200/110 on admission day two Intervention: Diltiazem ordered; patient s blood pressure returned to stable

Event Examples Pulmonary vascular congestion 55-year-old male with cadaver kidney transplant, post-op day four Alarm: High RR (34) with high cardiac rate (150) and temp (102) Intervention: Chest x-ray ordered, showed pulmonary vascular congestion; sepsis prevented; orders for bumetanide and oxygen; remained on floor and discharged home without further complications

Event Examples Cardiac 62-year-old female live donor kidney transplant, history of atrial fibrillation Alarm: High HR alarm (150) Intervention: Wave form on monitor irregular, heart sounds irregular, EKG ordered confirming AFib and rapid ventricular response (RVR); started on metoprolol, repeat EKG showed sinus rhythm with premature atrial contractions; started on amiodarone; remained on floor and discharged home after normal post-transplant hospital course

Re-Operation Event Examples Post-op day one for laparoscopic excision of gastric mass Alarm: Low O2 saturation (80) and hypotension Intervention: CT abdomen and upper GI ordered, showed gastric anastomotic site leak; returned to OR for repair of gastric leak; develops respiratory failure due to left base atelectasis, systematic inflammatory response syndrome due to gastric leak and acute respiratory infection due to hypovolemia and hypotension; worked up for deep vein thrombosis and pulmonary embolism (all negative); transferred to telemetry and discharged home

Results Staff Comments The [system] has saved lives. I was skeptical until it happened to my patient. Without the [system], we probably would have coded the patient. The [system] alerts help us to be proactive and anticipate changes. It s a timesaver. The [system] helps with healing. We don t have to wake up patients to take vitals.

Results Patient Comments I can have a good night sleep. I don t even know it s there. Thanks to your [system] I was comfortable and able to get six-plus uninterrupted hours of sleep additionally and have my data transmitted and recorded accurately.

Technology Considerations Need for conducting site survey with vendor to ensure complete Wi-Fi coverage throughout facility Plan resources appropriately to work on interfacing development/testing, for both point of use and connection to EHR Conduct weekly project status calls (to include interfacing) Keep up-to-date project plan and issue log Ensure sufficient physical space for equipment

Implementation Challenges Staff (RN and patient care assistant) buy-in Role and responsibility definition Staff training How to use the system How your day changes How to educate patients Physician education Physical storage limitations

Conclusions With timely access to more data, nurses on noncritical care units are forming meaningful conclusions to: Improve outcomes Lower costs Tailor responses to meet individual patient needs A continuous vital sign surveillance system can be implemented on any inpatient unit to help identify conditions for immediate intervention and early detection of more serious complications

Future/Ongoing Initiatives 9/25/2013 58

Thank you for attending! If you are interested in obtaining a 1.0 CE credit after you watch this Patient Safety Seminar, you may purchase the credit at the AAMI Store for $25.00 at this link: http://my.aami.org/store/detail.aspx?id=conmon SEM

Mark Your Calendars! September 12, 2016; 12pm to 1pm Continuous Monitoring of Patients on Opioids: Initiative at Evergreen Health in Kirkland, WA Nancee Hoffmeister, MSN, RN, NE-BC VP Nursing Chief Nursing Officer Nancy will discuss how her hospital implemented continuous monitoring of their patients on parenteral opioids in the general care setting. To register: https://attendee.gotowebinar.com/register/6071667409049354499

Complimentary Resources Safety Innovations Series Alarms Management Patient Safety Seminars Seminar Recordings Webinar Slides Key Points Checklists Opioid Safety & Patient Monitoring Compendium AAMI Foundation Alarm Compendium

Questions? Post a question on AAMI Foundation s LinkedIn Type your question in the Question box on your webinar dashboard Or you can email your question to: mflack@aami.org.

Consider Making a Donation to the AAMI Foundation Today! Making Healthcare Technology Safer, Together http://my.aami.org/store/donation.aspx Thank you for your support!

Thank you for attending! This presentation will be posted to this webpage within one week: http://www.aami.org/patientsafety/content.aspx?it emnumber=2933&navitemnumber=3086