Patient Safety Science & Technology Summit 2014

1. Patient Safety Science & Technology Summit2014

2. Michael Ramsay, MD, FRCA • Chairman, Department of Anesthesiology, Baylor University Medical Center,President Baylor Research Institute

3. Failure to Rescue

4. Failure To Rescue • When a complication is not recognized in a timely manner or treated appropriately • Many deaths and permanent disabilities could be avoided if: • Adopted safe practices • Implemented systems that facilitate patient safety • Failure to Rescue is a measure of hospital quality • More dependent on the hospital characteristics than the acuity of the patient • Jeffrey Silber 1992

5. Failure to Rescue Post-Operative Surgical Patients • Opioid analgesics are associated with adverse effects and cause respiratory depression • - 0.5% of post-surgical patients • Opioid-related adverse drug events – including deaths –reported to The Joint Commission’s Sentinel Event database (2004-2011) • - 47% wrong dosing medication errors • - 29% improper monitoring of the patient • - 11% other factors including dosing, med interactions, adverse drug reactions

8. APSF Recommendations (2011) • All patients should have oxygenation monitored by continuous pulse oximetry (Patient Surveillance System) • Measure adequacy of ventilation when supplemental oxygen is needed • Intermittent checks of oxygenation (oximetry) and ventilation (nursing assessment) are inadequate • Assessment of consciousness/sedation is critical • Alarm fatigue and inadequacy of threshold-based alarms

9. Joint Commission Sentinel Event Alert (August 8, 2012) • Causes of adverse events • Lack of knowledge about potency • Improper prescribing/multiple opioids • Inadequate monitoring

10. CMS Proposed Quality Measure #3040(2013) • Calls for “appropriate monitoring of patients receiving PCA” • Defined as maximum period between documented respiratory rate, sedation score and pulse oximetry does not exceed 2.5 hours • Intermittent monitoring would meet the minimum requirement • CMS received significant feedback that monitoring should be continuous • Final determination not announced yet by CMS

11. The Baylor Breathe TeamMission: To eliminate patient harm from postoperative respiratory depression • Physicians • Nurses • Pharmacists • Administrators • Safety officers • Respiratory Therapists

13. Actions • Standardized post-operative opioid (PCA) order sets. Over 50 different sets existed. • Stopped continuous PCA in opioid naïve patients • Instituted the :Oxygen Withdrawal Trial” in PACU • Screened pre-operatively for patients at increased risk for respiratory depression and applied blueberry wrist band

14. Considerations • Sedation precedes respiratory pauses. (Rising PaCO2) • Sedation drugs can potentiate respiratory depression. (esp. phenergan, benadryl) • Avoid rapid dose escalation in opioid tolerant patients • Avoid using opioids to meet an arbitrary pain rating • Dosing should be based on individual’s need and condition • Take extra precautions when transferring between departments and facilities • Deployment of continuous monitoring of respiration, oxygenation with a closed loop notification

15. OUTCOMES • Orthopedic Surgical Floor 0.83 Rapid Response Team (RRT) Calls per Month • All Hospital: 8 RRT Calls per month reduced to 3.58 • No Postoperative Respiratory Depression deaths

16. Steven C. Moreau Julianne Morath, MS, RN J.P. Abenstein, MD Dean Chittock, MD Andreas H. Taenzer, MD, MS Susan Lorenz, DrNP, RN, NEC-BC, EDAC Helen Haskell President & CEO, St. Joseph Hospital President & CEO, Hospital Quality Institute, California ASA President Elect, Division of Cardiovascular and Thoracic Anesthesiology, Associate Professor of Anesthesiology, Mayo College of Medicine, Rochester, MN Founder of Mothers Against Medical Error Associate Professor of Medicine at the University of British Columbia Associate Professor of Anesthesiology and Pediatrics, Director, Pediatric Acute Pain Service, Dartmouth-Hitchcock Medical Center, Director of the Dartmouth Patient Deterioration Prediction Laboratory (DP2L) Vice President of Patient Care Services/Chief Nursing Officer, Princeton HealthCare System Failure to Rescue

17. Failure to Rescue

18. Patient Safety Science & Technology Summit2014