5/3/2012

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High Risk

Patient Protocol: Preventing

Respiratory Complications Tuesday, May 1, 2012

Pete Weber, BA, RRT, RPSGT

Team Leader – Pulmonary and Sleep Medicine

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High Risk Team Members

• Pete Weber, Respiratory Care –Project Manager

• Jennie Cumicek, Nurse Educator - Surgery

• Laura Hieb, Chief Nursing Officer

• Dr. Mark Reinke, ENT and Sleep Medicine - Physician

Champion

• Dr. Franz Igler, Anesthesia - Physician Champion

• Colleen Groenier - Pharmacy

• Judy Johnson, Team Facilitator - Perioperative Services

• Teresa Dzekute, Team Leader - Bush Orthopedic

Department

• Kathy Beaumier, Team Leader – PrePARE

• Kevin Drewieske, Team Facilitator Respiratory Care

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Background

• We have experienced serious patient safety events at

Bellin related to respiratory depression and oversedation

in patients during the postoperative period.

• These patients often demonstrate risk factors that may

place them at higher risk for postoperative oversedation

and respiratory complications.

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Aim of Project

• Project Description Prevent deaths related to oversedation and respiratory compromise at

Bellin. • Overall Aims

• Define High Risk Patient • Trigger Bellin System to their arrival • Plan communication process to maintain focus on risk • Implement care and monitoring for high risk patients

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National Attention

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National

Attention

100,000 lives

Any percentage is too large!

86% of patient reportable

harm went unreported.

44% of serious patient harms

were easily preventable.

1 of 7 patients suffered

serious or long term injuries,

or death.

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Statewide

Attention

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Statewide

Attention

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Statewide

Attention

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Framing the Risk

• Over 24% of Wisconsin population has Obstructive Sleep Apnea

– Often undiagnosed

• Morbid Obesity is an independent risk factor for events

• Chronic uncontrolled medical conditions add to risk

• Pain management and sedation techniques contribute

• Estimated high risk patients coming in to the Bellin System (OSA

and chronic co-morbidities) 40-45%

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STOP

• S – snore

• T – Tired

• O – Obstruction (apnea)

• P – Blood pressure is high

• 2 Yes – 50% possibility of OSA

• 3 Yes – 60-70% possibility of OSA

• 4 Yes – 90% possibility of OSA

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Timeline of Project – Phase 1 and 2

(Completed)

•Leadership - system priority identified

•System-wide case study review for all nursing staff

•Pulled together departments that are key to the handoff process of the surgical patient.

•Created a SWAT Status board

•Team defined including MD champions

•Literature reviewed, best practice identified

•Purchased initial ETCO2 monitors

•Definition, plan, and new equipment piloted

•Spread to all patient care areas

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8/4/09 Revised 1/11/12

HIGH RISK PATIENT IDENTIFICATION TOOL

Instructions: Initiate identification of high-risk early, review/initial at each interdepartmental hand off. Place High Risk sticker on front of chart when High Risk status validated on admission. This is a tool; please use clinical judgement. One condition checked indicates high-risk status. Nonsurgical patients may require two indicators.

High Risk Medical Condition (Uncontrollable) Completed if patient is going to receive anesthesia, sedation for procedure, or opioid pain medications. Validate after each patient transition.

PrePARE/JFL/ED

Admit RN Preop Floor

Diagnosed OSA

Suspected OSA (Inpatient: 75% on sleep apnea risk assessment or > 50% + BMI > 35; ED:

Patient history snoring, frequently tired, observed apnea/obstruction)

BMI over 40

CHF with recent hospitalization (12 months) or CHF with Dyspnea on Exertion

COPD with recent hospitalization (12 months) or home O2

Renal Failure with GFR less than 35 or chronic dialysis

Liver Failure

Psychiatric disorder and currently taking 2 or more psych medications

Currently taking greater than 8 prescribed home medications (Do not count eye drops/supplements)

No high risk medical conditions

Initials Initials Initials Initials

Sedation Related Conditions (Controllable) Complete during opioid administration in ED, PACU, and on nursing unit.

ICU ED PACU Floor

Poor pain control followed by rapid good control

Continuous PCA (basal rate) or epidural (excluding labor epidurals)

More than 1 type of opioid or route (ED: more than 1 route)

Opioids in combination with benzodiazepines/other CNS depressant.

Anxiety: Displaying clinical symptoms (agitated/several PCA attempts)

Prolonged Anesthesia time (Major abdominal, multilevel fusion, redo orthopedic, or greater than 3 hours)

ASA Score of 4 or 5

RASS Score of –3 or less (PACU)

RASS Score of –2 or less (Floor/ED)

RASS Score of -2 after post procedural frequent monitoring (Floor)

No high risk sedation related conditions

Initials Initials Initials Initials

Baseline ETCO2:

Clinical Judgment

ICU ED PACU Floor

Patient with potential for rapid deterioration due to complex diagnosis. Swat notified upon transfer

Notify RT when patient being monitored with ETCO2 arrives on floor.

Nurse’s Initial/Signature:

(Patient Sticker)

Medical: Patient Placed on Protocol

Date Initiated:

Location Communication Tool Initiated:

Procedure/Surgery Date:

Procedure/Surgery:

Richmond Agitation Sedation Scale (RASS):

+4 = Combative – overtly combative, violent, immediate danger to staff

+3 = Very Agitated – pulls or removes tube(s) or catheter(s); aggressive

+2 = Agitated – frequent unpurposeful movements, fights ventilator

+1 = Restless – anxious but movements not aggressive, vigorous

0 = Alert and calm

-1 = Drowsy – not fully alert, but has sustained (more than 10 seconds) awakening with eye contact to voice

-2 = Light Sedation – briefly (less than 10 seconds) awakening with eye contact to voice

-3 = Moderate Sedation – any movement, but no eye contact to voice

-4 = Deep Sedation – no response to voice, but any movement to physical stimulation

-5 = Unarousable – no response to voice or physical stimulation

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Timeline of Project – Phase 1

(Completed)

• Nursing and Respiratory Care staff educated

• Identification of Risk

• Physiology

• Monitoring and Interventions

• Operational in pilot area

• Reduction in Naloxone (Narcan) administrations/events

• No deaths

• No serious patient safety events – respiratory

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Exhaled Carbon Dioxide (EtCO2) Monitoring

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Timeline of Project – Phase 2

• Refine definition and scope

• Explore monitoring that will integrate with common technology platform

• Engage surgeons • Present results of orthopedic pilot to Surgical Committee

• Report back with definition/scope changes

• Present plan to spread to surgical floor

• Second phase of education on High Risk indicators and tools rolled out to target areas. All Patient Care areas.

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Results: No serious respiratory events since

May 19th, 2009

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Results – Reduction in Narcan

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Q1 2009 Q2 2009 Q3 2009 Q4 2009 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011

Narcan Event Reduction Ortho events

Surgical events

Medical events

Spread to cardiac

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Considerations of High Risk Patient Care

• Care giver assignments:

Acuity assessed

Proximity to nursing station and nursing care

Experienced RN assigned to High Risk Patients

• Interventions by Care givers:

Hourly Documentation -

RASS done in all areas (standardized)

Pain Medications tracked for Dose, on-set, peak and half-life

EtCO2, RR quality assessed

Patient position

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PreOp in-patient surgical assessments

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Hospital Wide (Peri-Op, PACU to Floors)

Monitored on ETCO2

January-10 46

February-10 44

March-10 60

April-10 99

May-10 103

…..Q1 2012 409/month

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Next Steps – Phase 3 increase scope

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Next Steps – Phase 3

• Spread to System

• Integrate into procedural areas

• Assure Compliance and Sustainability

• Include ASA guidelines for Conscious Sedation Monitoring

• Publish our results – in 2012

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References

• Sleep 2008. Aug1:31(8) 1079-85

• Anesthesiology. 2008 May;108(5):812-21

• Obesity Surgery. 2000. 10:2 154-159

• Journal of Clinical Anesthesia. 2007. 19:130-134

• American Journal of Respiratory Critical Care

Medicine. 2002. 166: 1338-1334

Thank you Pete Weber

PTWebe@Bellin.org

920-433-36699