Strategies to Prevent Opioid-Induced Respiratory Depression

(OIRD) in Acute Care

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Purpose & ObjectivesBy the end of this presentation the learner should be able to:

• Identify two evidence-based strategies to promote safe, quality pain management in acute care

• Discuss two strategies to decrease sentinel events related to opioid-induced sedation and respiratory depression

Pain is associated with negative patient outcomes

•• 2 Demand Ischemia, MI, UA• Risk for DVT• Hypoxia• pneumonia, atelectasis• weakness, fatigue,

Comfort is associated with positive patient outcomes

• Immune Function•Desirable effects on BP, HR & RR•Patient Satisfaction• -Seeking Behaviors•Peaceful Death

Pain is defined asAn unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP, 1994, 2014)Pain is whatever the experiencing person says it is existing whenever he/she says it does (McCaffrey, 1968, 1999)

Historical Perspective

• IASP founded – 1974• APS founded – 1977• NPA – 1987• ASPMN – 1990• 1990-2000 – Various Standards of

Practice & Guidelines Published– WHO Cancer/Palliative Care, Acute Pain

Management, Chronic Pain in Elderly

Sheldon Teaches Penny Physics

The Decade of Pain Control & Research

• TJC: Pain Standards – 2000– Requiring hospitals to provide safe and

effective pain management • US Congress - 2000-2010

– Declared the “Decade of Pain Control & Research”

• IASP 2010– “access to pain management is a fundamental

human right”

Scope of the Problem

• IOM - 2011• Pain is the primary reason patients seek

healthcare

Current State Opioid AddictionAddiction is characterized by:• Inability to consistently Abstain;• Impairment in Behavioral control;• Craving; or increased “hunger” for drugs or

rewarding experiences;• Diminished recognition of significant problems

with one’s behaviors and interpersonal relationships; and

• A dysfunctional Emotional response.

ASAM, 2011

• New knowledge• Prevent pain chronification• Need to improve pain assessments• Promote self management• Taper/DC Ineffective Tx when

risk>>>benefits

How do we fix this?

B – Balanced Approach R – Realistic Goal SettingA - AssessC – Conscientious Care PlanningE – End-Tidal C02

Overmedicate Undermedicate

Balanced AnalgesiaAge, Cr Cl, LFTs, tolerance, fear of addiction, concom. sedatives

Follow orders, trust the system, empathetic, well-intentioned

B R A C E

Comfort/Function Goals

1.SMART goals 1.Does NOT need to be a #2.Relate to function or activity that

supports overall outcome goals (recovery, healing, restoration of previous functioning, etc.)

1.Incentive Spirometry2.PT/OT3.Mobility4.Sleep

B R A C E

Patient’s Perspective

• “When I am not in pain and I can function”• “Just make me comfortable”• “Help control my pain”• “Removing cause of pain or providing relief of pain until cause can be

determined or removed”• “My hope is that they can find out what is causing my pain”• “When I’m not in pain anymore”• “Tolerable and can function”• “The doctor does not believe me, need to listen to the patient”• “Lidocaine works great for me for bone marrow biopsy; no need for strong

medication or opioids”

B R A C E

Sentinel AlertB R A C E

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Problem Recommendations• Significant morbidity and mortality from

inappropriate management of pain• Overuse of opiates• Lack of multimodal therapies• Lack of risk stratification• Insufficient monitoring in at-risk

patients

• Policies & Procedures • Address ongoing monitoring of

patients receiving opioids• Serial sedation and

respiratory assessments• Second level review by a Pain

Management Specialist for high-risk opioids

• Safe Technology

• Sedation• Tolerant/Naïve (avoid dosing to #’s)• Risk Stratification

– STOPBANG– MOSS

• Capnography vs. CPOTJC, 2012

B R A C E Evidence-Based Practice Recommendations

• Documentation tools can be useful in communicating patients’ underlying conditions, comorbidities and risk factors, previous use and response to opioid therapystatus, anesthesia history, and current opioid therapy and response. Class IIa

• Institutions should establish procedures to ensure safe monitoring practices to help prevent opioid-induced adverse events. Class I

ASPMN, 2011

Assessment B R A C E Pasero Opioid-Induced Sedation Scale (POSS)

Note the “Row Information”

B R A C E

Evidence-Based PracticeOpioid Safety

31%

0% 0%

65%

51% 51%

0%

10%

20%

30%

40%

50%

60%

70%

Pain Sedation Both

Assessment 11-13 hrs post-fentanyl patch application

Before 1/6

After 1/16

STOPBANG• Snoring• Tiredness• Observed apnea• Pressure (HTN)• Body Mass• Age• Neck Size• Gender

B R A C E

MOSS B R A C E

“It is more important to know where we are going than to get there quickly.”

-Anonymous

(ISMP, 2006)

Failure Modes and Effects Analysis (FMEA)

• A team-based systematic and proactive approach for identifying the ways that a process can fail, why it might fail, the effects of that failure, and how it can be made safer.

• The goal is to eliminate or minimize the potential for failures, to stop failures before harm reaches the patient, or to minimize the consequences of the failure.

• FMEA focuses on how and when a process will fail, not IF it will fail

Harpel & Giannini, 2014

Functional Block Diagram with Task Identification

Planning EMR Build Evaluation

Tasks2.1 Documentation Committee2.2 Across applications2.3 View for other disciplines

Tasks 3.1Method3.2Audience3.3 Other Disciplines3.4 Content

Tasks 4.1 Go-Live Support4.2 Timeline4.3 Just in time education4.4

Education Implementation

1 2 3 4 5

Tasks1.1 Key Stakeholders1.2Alignment with other initiatives1.3 Timeline

Tasks5.1 ongoing PI5.2 Risk Mgmt reporting5.3 PDCA Follow-up Plan

Harpel & Giannini, 2014

SWOT

» Strengths

» Weaknesses

» Opportunities

» Threats

Strengths• Supporting Literature• Pain Champions• Clear Assessment

Times (Q4H x24)• Multimodal Pain

Management Order Sets

Weaknesses• Double Documentation

(Paper & Electronic)• Turnover of RN/Nurse

Leadership

Opportunities• Improve Patient Safety• Increase RN autonomy

with Nurse Driven Tool• Decrease RRT• Decrease Narcan Use

Threats• Other competing pilots• Challenge to Assess

Pain Post-Op r/t Sedation Half-Life

(Sisco, L., Cooper, M., & Rayburn, V.; personal communication, 2014)

MOSS Cont.

Fall Risk

B R A C E Best Practice Advisory - BPA

© 2015 Epic Systems Corporation. Used with permission.

Risk for OIRD

OIRD: Opioid Induced Respiratory Depression

B R A C E Care Plan for Highest Risk– Obstructive Sleep Apnea– Obesity Hypoventilation Syndrome (OHS)– Central Sleep Apnea

• Respirations most vulnerable during sleep/sedation:• Loose muscle tone in

pharyngeal airway• Loss of protective wake

mechanism

B R A C E

Respiratory (Patho)physiology

• Chemoreceptors regulate breathing–

• C02 crosses BBB– Is RR the best indicator of (impending) respiratory

depression?

• What happens when you add opioids?–––

heeeeemoooooooooooooooooooooooooooooooooooooorrrrrrrrrrrrrrrrrrrrrrrrrrreeeeeeeeeeeeeeceptors regulate bbbbbbbbbbbbbbbrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrreeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaatttttttttttttttttttttttttttttttttttttttttthhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhinggggggggggggggggggggggggg

• CCC0CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC 2 cccccccrcc osses BBB– IIIs IsIIIsIIIIIIIIIs RR the best indicator of (impendididiiiiiiiiiiiiiiiiiiiiiddiiiiiiiidiidiiiddiidiiing)nnnnn rereeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeespissssssspspsssssssssssssssssssssssssssssssssss ratoryy

deeeeedeped ression?

hhaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaattttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttttt hhhhaaaappens when you adddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd oooooooopioids???

Capnography• What is it?

– The non-invasive continuous measurement of the partial pressure of carbon dioxide (C02) at the end of an exhaled breath (aka End Tidal C02= EtC02)

– Can detect hypoventilation, airway obstruction and increasing respiratory depression sooner than decreasing Sa02 values

• Normal Value = 35-45 mmHg

B R A C E

Capnography vs. OximetryCapnography OximetryReflects ventilation=movement of air in and out of lungs & how we get rid of C02

Reflects oxygenation= transport of O2 via bloodstream to cells

Detects apnea and hypoventilation immediately

May take many minutes to detect apnea or hypoventilation

Not affected by perfusion to extremity

Affected by perfusion to extremity

Reflects changes in:-Ventilation= air movement -Diffusion=gas exchange at alveoli-Perfusion=circulation of blood

Reflects changes of oxygen concentration in blood stream

Capnography Equipment

Handheld “N85” EtCO2Monitor for use in Codes

Alaris EtCO2 module that hooks to IV pumps

EtCo2 nasal cannula for use in non-intubated, adult patients

EtCo2 capnoline for use in intubated, adult patients

Can use up to 5L 02 per NC

Indications for EtC02 Monitoring1. Cardiac arrest per American Heart Association (AHA),

monitored after advanced airway in place2. Sedation procedures — Part of Narrator3. Patients at risk of respiratory compromise who have an opioid

PCA/PCEA. Risk factors include:a. Age > 65 yearsb. Obesity (BMI >35 kg/m2)

c. Untreated obstructive sleep apnea (OSA)* d. History of witnessed apneae. Concomitant use of benzodiazepines or antihistaminesf. Opioid naïve and basal rate on PCA/PCEAg. Use of naloxone during current episode of careh. ASA class 3-5

*OSA= is a disorder in which a person frequently stops breathing during sleep. Untreated = no CPAP use by patient but has been diagnosed with OSA.

Normal Capnography Waveform

EtC02

The key to understand the capnogram is to watch the trending of the waveforms

Abnormal Waveform-Hypoventilation

SEEN IN:• Sedation• Shallow breathing• Fever

INTERVENTION:• Encourage patient

to take deep breaths• Adjust sedative

meds• Adjust ventilator

settings

Abnormal Waveform-Partial Airway Obstruction

SEEN IN:• Asthma• COPD• Secretions/Mucous Plug• Relaxation of upper

airway (Sleep Apnea)• Kinked ETT/vent circuit

INTERVENTION:• Open Airway/CPAP• Bronchodilators• Suction• Bronchoscopy• Un-kink ETT/circuit

“SHARK FIN”

Abnormal Waveform-Apnea

Apnea

SEEN IN:• Sedation• Complete upper

airway obstruction• Apnea

INTERVENTION:• Stimulate patient• Head tilt/chin lift• Discontinue sedation• Get help/SRRT/Code

Blue

Abnormal Waveform-Rebreathing

SEEN IN:• Insufficient oxygen flow• Material over patient face• Increased ventilator dead

space

INTERVENTION:• Remove anything over

patient face• Increase oxygen flow• Assess equipment• Decrease ventilator dead

space

EtC02 in Cardiac Arrest

• EtC02 of 10-20 mmHg during CPR = good quality compressions

• Return of Spontaneous Circulation (ROSC) = sudden and

• The only way to measure EtC02 during an arrest is AFTER an advanced airway (i.e. endotracheal tube) has been placed

EtC02

• Arousal Effect– Sp02 vs. EtC02

• Intermittent vs. Continuous

How do we fix this?

B – Balanced Approach R – Realistic Goal SettingA - AssessC – Conscientious Care PlanningE – End-Tidal C02

Safe Medication Disposal

http://disposemymeds.org/

Over 60% of diverted

prescription medications are obtained from a family member

or friend Patient

Education!

Safe Pain Management

• Caymich data submission (April – present 2016)– # pts who received an IV opioid + Naloxone/# pts who

received an IV opioid– Target rate is currently 1.75%

• Sparrow currently is at .64%

• 75-90% of adult patients have a MOSS completed within 25 hours of admission

• of sedation assessment• 2016 TJC visit

Quality Pain Management What is a Pain Resource Nurse?

“A Pain Resource Nurse is a registered nurse who functions both as a resource and a change agent

in disseminating information, interfacing with nurses, physicians and other healthcare providers, and patients and families to facilitate quality pain

management”Pain Resource Nurse Role: Description and Responsibilities

City of Hope Professional Resource Center www.cityofhope.org/prc

(Ferrell, Grant, Ritchey, Ropchan & Rivera, 1993)

HCAHPS Pain Domain Team Created

Literature review andexamine best practices

SPRN Education –Group 1

SPRN Education –Group 2

SPRN Education –Group 3

PRN Program Development

PAIN Education –Group 4

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2Q2014

3Q2014

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1Q2015

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4Q2015

1Q2016

2Q2016

HCAPHS Inpatient OverallPain Domain

IP Overall National Average Linear (IP Overall)

PAIN Education –Group 5

Purpose & ObjectivesBy the end of this presentation the learner should be able to:

• Identify two evidence-based strategies to promote safe, quality pain management in acute care

• Discuss two strategies to decrease sentinel events related to opioid-induced sedation and respiratory depression

References• D’Arcy, Y. (2013). Turning the tide on respiratory depression. Nursing2013, 43(9), p. 38-45.

• Good, V. & Luehrs, P. (2011). Continuous End-tidal carbon dioxide monitoring. In Wiegand, D (Ed.), AACN procedure manual for critical care (p.105-112). St. Louis: Elsevier Saunders.

• Hutchinson, R. (2006). Capnography monitoring during opioid PCA administration. Journal of Opioid Management, 2(4), 207-208.

• Hutchinson, R. & Rodriquez, L. (2008). Capnography and respiratory depression. American Journal of Nursing, 108(2). p.35-39.

• Jarzyna, D., Jungquist, C., Pasero, C., Willens, J., Nisbet, A., Oakes, L., Dempsey, S., Santangelo, D., & Polomano, R. (2011). American society for pain management nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Management Nursing, 12(3), 118-145.

• Kodali, B. (2013). Capnography outside the operating rooms. Anesthesiology, 118(1), p. 192-201.• Langhan, M. (2009). Continuous end-tidal carbon dioxide monitoring in pediatric intensive care units. Journal of Critical

Care, 24, 227-230. • Overdyk, F., Carter, R., Maddox, R., Callura, J., Herrin, A., & Henriquez, C. (2007). Continuous oximetry-capnometry

monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Anesthesia & Analgesia, 105(2), p.412-418.

• Sinz, E., Navarro, K., Soderberg, E. (2011). Advanced cardiovascular life support provider manual. American Heart Association.

• Weinger, M. (2007). Dangers of postoperative opioids. The Official Journal of the Anesthesia Patient Safety Foundation, 21(4), 61-88.

• Whitaker, D. (2011). Time for capnography everywhere. Anaesthesia, 66, 539-549.• White, P. F., & Song, D. (1999). New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified

Aldrete's scoring system. Anesthesia & Analgesia, 88(5), 1069-1072.

References• American Nurses Association and American Society for Pain Management Nursing (2016). Pain

Management Nursing: Scope and Standards of Practice (2nd Ed.). Silver Spring, MD: ANA & ASPMN.• American Society of Addiction Medicine. (2011) Public Policy Statement: Definition of Addiction. Chevy

Chase, MD: American Society of Addiction Medicine. • Institute of Medicine (US). Committee on Advancing Pain Research, Care, and Education. (2011). Relieving

pain in America: A blueprint for transforming prevention, care, education, and research. National Academies Press.

• Chung, F., Liao, P., Yang, Y., Andrawes, M., Kang, W., Mokhlesi, B., & Shapiro, C. M. (2015). Postoperative sleep-disordered breathing in patients without preoperative sleep apnea. Anesthesia & Analgesia, 120(6), 1214-1224.

• Egea-Santaolalla, C., & Javaheri, S. (2016). Obesity Hypoventilation Syndrome. Current Sleep Medicine Reports, 2(1), 12-19.

• Loeser, J. D. (2000). Pain and suffering. The Clinical journal of pain, 16(2), S2-S6.• Reznick, D. B., Rehm, M., & Minard, R. B. (2001). The undertreatment of pain: Scientific, clinical, cultural

and philosophical factors. Medical Health Care Philosophy, 4, 277–288. • Mezei, L., Murinson, B. B., & Johns Hopkins Pain Curriculum Development Team. (2011). Pain education in

North American medical schools. The Journal of Pain, 12(12), 1199-1208.• Oliver, J., Coggins, C., Compton, P., Hagan, S., Matteliano, D., Stanton, M., ... & Turner, H. N. (2012).

American Society for Pain Management nursing position statement: Pain management in patients with substance use disorders. Pain Management Nursing, 13(3), 169-183.

ReferencesImages:• https://www.ismp.org/newsletters/longtermcare/LTC_Newsletter_Sample.pdf• http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-

facts-figures.pdf• https://images.google.com/imgres?imgurl=http%3A%2F%2Fwww.relatably.co

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