Smith-Farrington - 1E Monitoring Over-Sedation.ppt · Monitoring Over-Sedation in Adult ... •...

Monitoring Over-Sedation in Adult and Pediatric Patients Receiving Opioids for Pain

ASPMN 21st National ConferenceTucson, AZ

September 9, 20110845-0945

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Monitoring Over‐Sedation in Adult and Pediatric Patients Receiving

Opioids for Pain

Michele Farrington, BSN, RN, CPHONmichele‐[email protected]

Staff Nurse

Anne Smith, MSN, RN‐BCanne‐m‐[email protected]

Advanced Practice Nurse

Department of Nursing Services and Patient CareUniversity of Iowa Hospitals and Clinics, Iowa City, Iowa

Acknowledgement

Special acknowledgement and thanks to the Pain Resource Nurses and Pain Staff Nurse

Champions on the Nursing Pain 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.



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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 over‐sedation in patients receiving opioid analgesia and future improvement plans.

Evidence-Based Practice Framework

The Iowa Model ofEvidence-Based Practice to Promote Quality Care

Problem Focused Triggers1. Risk Management Data2. Process Improvement Data3. Internal/External Benchmarking Data4. Financial Data5. Identification of Clinical Problem

Knowledge Focused Triggers1. New Research or Other Literature2. National Agencies or Organizational

Standards & Guidelines3. Philosophies of Care4. Questions from Institutional

Standards Committee

ConsiderOther

Triggers

Is this Topica PriorityFor the

Organization?

Form a Team

Yes

No = a decision Point

DO NOT REPRODUCE WITHOUT PERMISSION

REQUESTS TO:Office of Nursing Research & EBP

The University of Iowa Hospitals and ClinicsIowa City, IA 52242-1009

Revised: April 1998 © UIHC(Titler, Kleiber, Steelman, et al., 2001)



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Project TriggersFall 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





Standards Committee

ConsiderOther

Triggers

Is this Topica Priority

For theOrganization?

Form a Team

Yes








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Organizational Priority

• Existed before the project started due to adverse patient event

• Pressure to quickly make changes was challenging





Standards Committee

ConsiderOther

Triggers

Is this Topica PriorityFor the

Organization?

Form a Team

Yes






Team FormationJanuary – May 2009

• Primary team members– Pain Resource Nurses

• Represent all nursing divisions

• Informatics

• Secondary team members– Staff Nurse Champions

– Nursing Pain Management Subcommittee

– Interdisciplinary Pain Committee

– External Pain Experts



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Is Therea SufficientResearch

Base?

Assemble Relevant Research & Related Literature

Critique & Synthesize Research for Use in Practice

Pilot the Change in Practice1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design Evidence-Based

Practice (EBP) Guideline(s)4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify the Practice Guideline

Base Practice on OtherTypes of Evidence1. Case Reports2. Expert Opinion3. Scientific Principles4. Theory

Conduct Research

Yes No

= a decision Point


REQUESTS TO:Office of Nursing Research & EBPThe University of Iowa Hospitals and ClinicsIowa City, IA 52242-1009

Revised: April 1998 © UIHC

(Titler, Kleiber, Steelman, et al., 2001)

Literature SearchJanuary – May 2009

• Articles and evidence obtained from benchmarking and gleaned from available pain journals and books

• Contacted pain expert

(C. Pasero)


Base?






Conduct Research

Yes No

= a decision Point







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Synthesis of EvidenceJanuary – 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)


• 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)



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• 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


Base?






Conduct Research

Yes No

= a decision Point





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



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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 inactivities 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 andmanagement. In R. G. Hughes (Eds.), Patient Safety and Quality: An evidence‐basedhandbook for nurses, (Ch. 17). (AHRQ Publication No. 08‐0043). Rockville, MD: Author. Obtained @ http://www.ahrq.gov/qual/nurseshdbk/]

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



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Sedation LevelModified 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 alertAcceptable; no action necessary; may increase opioid dose if needed/ordered

2 = Slightly drowsy, easily arousedAcceptable; no action necessary; may increase opioid dose if needed/ordered

3 = Frequently drowsy, arousal, drifts off to sleep during conversationUnacceptable; 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 stimulationUnacceptable; 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



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• 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


• 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



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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

Sedation Assessment: POSS Scale

0 = Sleep and easy to arouse Acceptable; no action necessary; may increase opioid dose if needed/ordered

1 = Awake and alertAcceptable; no action necessary; may increase opioid dose if needed/ordered

2 = Slightly drowsy, easily arousedAcceptable; no action necessary; may increase opioid dose if needed/ordered

3 = Frequently drowsy, arousal, drifts off to sleep during conversationUnacceptable; 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 stimulationUnacceptable; 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 minutesIV opioids: 30 minutes

Pain Reassessment:Complete at the time of sedation re-assessment

Pocket Cards

Monitoring Standards for Sedation after Opioid Administration

Continuous Infusions/PCA/Frequent NCA*/longacting 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

Is ChangeAppropriate for

Adoption inPractice?

Continue to EvaluateQuality of Care and

New Knowledge

No YesInstitute the Change in Practice

Monitor and Analyze Structure,Process, and Outcome Data

- Environment- Staff- Cost- Patient and Family

Disseminate Results

= a decision Point





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):497-509.



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Project IntegrationAugust – 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)




New Knowledge




Disseminate Results

= a decision Point








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Implementation September 2010

• PowerPoint™ presentation on hospital computer education system

• Live in‐services

• One‐page flier

• Pocket cards

Revised Documentation

Documentation – Pain Report



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New Knowledge




Disseminate Results

= a decision Point






Post‐Implementation Knowledge SurveyApril – May 2011

• Completed by nurses on the pilot units (n=67)

• Used same web‐based knowledge survey (pre/post comparison)

Knowledge Survey Results

Strongly Disagree

Strongly Agree



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Knowledge Survey Results (cont.)

Strongly Disagree

Strongly Agree


Strongly Disagree

Strongly Agree


Strongly Disagree

Strongly Agree



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Evaluation

• Audit and Feedback

– Pain Resource Nurses

– Nurse Managers

– Assistant Nurse

Managers

– Pain Staff Nurse Champions

• Ongoing chart audits





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Audit‐Feedback Tool – Intermittent Opioids



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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 Pain 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:‐ IVmedications peak: 30 minutes ‐ POmedications 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



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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




New Knowledge




Disseminate Results

= a decision Point








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Dissemination

• Posters

– Nursing Recognition Day (2010 & 2012)

– National Evidence‐Based Practice Conference (2012)

• Presentations

– 17th 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

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