NAVIGATING THE HEALTHCARE LANDSCAPE TOGETHER JENNIFER FRUITTICHER, RN CLINICAL PRODUCT SPECIALIST

PRESENTATION OBJECTIVES: Provide a better understanding of

Capnography vs. Pulse Oximetry

Define Respiratory Compromise and the complications associated with disease process

Recognize organizations recommending capnography as a standard of care

Examine capnography case studies and results of capnography utilization

Show technology available and benefits to hospitals/clinicians

RESPIRITORY COMPROMISE KNOWS NO BOUNDARIES

4 Medtronic Outcomes Pledge Program

July 2010

• Thursday, July 15th Admitted to the hospital for severe sore throat. Treatment with oral analgesics was not relieving pain.

• Friday, July 16th Put on a PCA pump with opioids; monitored intermittently by spot check oximetry and vitals.

• Saturday, July 17th Amanda was was found unresponsive and resuscitation efforts were unsuccessful.

www.promisetoamanda.org/amandas-story

WHY CAPNOGRAPHY?

Name: Amanda Abbiehl

Age: 18

Diagnosis: Severe pain from throat infection

Monitoring: Intermittent SpO2 and vitals

5 Presentation Title (Edit on Slide Master) | June 1, 2015 | Confidential, for Internal Use Only

WHAT’S THE DIFFERENCE?

CAPNOGRAPHY

Measures ventilation (CO2)

Detects hypoventilation immediately

Early indicator of hypoventilation

Should be used WITH pulse oximetry

PULSE OXIMETRY

Measures oxygenation

Detects hypoxemia

Late indicator of hypoventilation

Should be used WITH capnography

RESPIRATORY COMPROMISE A COMMON, COSTLY & DEADLY PROBLEM

Affects 30% of post-op patients

7% of Medicare patients suffer respiratory compromise

$18K additional cost per patient

29x more likely to die than the general patient population

1. Shander A, Fleisher LA, Barie PS, Bigatello LM, Sladen

RN, Watson CB. Clinical and economic burden of

postoperative pulmonary complications: patient safety

summit on definition, risk-reducing interventions, and

preventive strategies. Crit Care Med. 2011;39(9):2163-

2172.2. Agarwal SJ, Erslon MG, Bloom JD. Projected

incidence and cost of respiratory failure, insufficiency and

arrest in Medicare population, 2019. Abstract presented at

Academy Health Congress, June 2011.3. Canet J, Gallart L.

Postoperative respiratory failure: pathogenesis, prediction,

and prevention. Curr Opin Anaesthesiol. 2014;20(1):56-62.4.

Burt CC, Arrowsmith JE. Respiratory failure. Surgery

(Oxford). 2009;27(11): 475-479.

6

POST-OP INDUCED RESPIRATORY DEPRESSION

A CLOSED CLAIM ANALYSIS

• Anesthesia Closed Claims Project- Dr Lee and Dr Caplan

• Database of 9,799 claims– 357 Acute Pain Claims 1990-2009

• 92 of 357- Resp Depression judged possible, probable, or definite

• 88% of RD occurred in the first 24 hours after surgery

• 77% resulted in severe brain damage or death

• 55% of RD claims associated with death

• 22% of RD claims associated with brain damage

POST-OP INDUCED RESPIRATORY DEPRESSION

A CLOSED CLAIM ANALYSIS

• Anesthesia Closed Claims Project- Dr Lee and Dr Caplan

• 97% were judged as preventable with better monitoring

• Time between last nursing check and discovery of RD

• 2 hours in 42% of claims

• 15 mins in 16% of claims

Anesthesiology 2015 Vol 122, 659-665

Opioid Induced Respiratory Depression

Patients are at the greatest risk for respiratory failure in the first 24

hours postoperatively

•75% of deaths related to critical respiratory events occur in the first 24 hours

postoperatively[7]

•81% of critical respiratory events occur in the first 24 hours postoperatively[7]

•77% of naloxone reversal of postoperative narcotics for pain management occur in

the first 24 hours postoperatively[8]

7. Ramachandran SK, Haider N, Saran KA, et al. Life-threatening critical respiratory events: a retrospective study of postoperative patients found unresponsive

during analgesic therapy. Jf Clin Anesth. 2011;23(3):207-213. [ View Abstract ]

8. Taylor S, Kirton OC, Staff I, Kozol RA. Postoperative day one: a high risk period for respiratory events. Am J Surg. 2005;190(5):752-756. [ View Abstract ]

OPIOD INDUCED RESPIRATORY DEPRESSION

Respiratory Compromise Prevention Capnography Solutions

CAPNOGRAPHY GROWING AT AN ACCELERATED RATE

11 |

6 statements in 8 years

1999 - 2007 2007 - 2009 2010 - 2014

7 statements in 3 years 33 statements from

Oct 2010 – Apr 2014

(> 9 per year) 13 statements in 11 years

(~1 per year)

November 2010 - American Heart Association (AHA) Guidelines for CPR and ECC

“Continuous qualitative waveform capnography is now recommended for intubated adult patients throughout the peri-arrest period”

July 2011 - Standards for Moderate or Deep Sedation Procedural Sedation Practices-ASA

“Adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide…”

August 2011- APSF Postoperative Monitoring with Opioids Use

“Continuous electronic monitoring of oxygenation and ventilation should be available and considered for all patients”

September 2012 - Joint Commission Sentinel Event Alert

“In addition to monitoring respiration and sedation, pulse oximetry can be used to monitor oxygenation, and capnography can be used to monitor ventilation”

RECENT RECOMMENDATIONS AND GUIDELINES FOR CAPNOGRAPHY USE

Covidien Respiratory and Monitoring Solutions

| October 20, 2016 | 12 |

RESPIRATORY DEPRESSION - SAO2 AND SUPPLEMENTAL O2

Becker DE, Casabianca AB. Anesth Prog 2009;56:14-22.

CAPNOGRAPHY & REMOTE MONITORING RESULTS (CONT.) PROVIDENCE ST. PETER HOSPITAL, OLYMPIA, WASHINGTON

Source: Jensen, D et al. Capnographic Monitoring Can Decrease Respiratory Compromise and Arrest in

the Post-Operative Surgical Patient. Respiratory Therapy. Spring 2016;11(2):30-32.

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CAPNOGRAPHY & REMOTE MONITORING RESULTS (CONT.) PROVIDENCE ST. PETER HOSPITAL, OLYMPIA, WASHINGTON

Source: Jensen, D et al. Capnographic Monitoring Can Decrease Respiratory Compromise and Arrest in

the Post-Operative Surgical Patient. Respiratory Therapy. Spring 2016;11(2):30-32.

• 65% reduction in code blues

over 24 months

• Zero high-risk patients on

capnography experienced a

code blue event since

program initiation.

• “Cost effectiveness ratio”:

• 2.15 0.72 codes/month =

approx. 17 codes per year

saved

• Estimated cost of $50,412

per code

• Total savings > $850K/yr

Expansion to other at-risk

populations in progress

15

16 Medtronic Outcomes Pledge Program

GENERAL CARE FLOOR

Capnography Monitoring Clinical Evidence

100% Reduction1,2

Candler/St. Joe’s Savannah, GA

• Three opioid-related events two years pre-Microstream™ capnography monitoring implementation

• Post-implementation - no events in 11+ years (2012 data)

• Based on avoided adverse events over 5 years, $1.87M savings

78% Reduction3,4

Wesley Medical Center Wichita, KS

• 31% rate of severe adverse events prior to Microstream™ monitoring

• 7% post-implementation in year one with immediate 78% reduction in severe adverse events

• By year three, 1.5% incidence

85% Reduction5

Bellin Hospital Green Bay, WI

• After implementation of high risk protocol inclusive of etCO2 monitoring, 85% decrease in emergent Narcan administration

1. Danello SH, Maddox RR, Schaack GJ. Intravenous Infusion Safety Technology: Return on Investment. Hospital Pharmacy 2009; 44:(8)680–687, 696.

2. Maddox R. Clinical Experience with Capnography Monitoring for PCA Patients. APSF Newsletter Winter 2012.

3. Fox D, Wencel M. Integral Role of Respiratory Therapists in a Comprehensive Pain Management Program using End Tidal CO2 Monitoring. 2011 AARC Congress

– Respiratory Care 2011;56:1636.

4. Fox D, AARC Webcast – etCO2 Monitoring: Riding the Wave, April 2013.

5. Weber P. High Risk Patient Protocol: Preventing Respiratory Complications. 2011 AARC Congress – Respiratory Care 2011;56:1636.

17 Medtronic Outcomes Pledge Program

GENERAL CARE FLOOR

Capnography Monitoring Clinical Evidence

100% Reduction1

St. Francis Grand, NE

• 100% reduction in transfers to higher level of care for respiratory suppression with PCA narcotics post Microstream™ capnography implementation

100% Reduction2,3

Wesley Medical Center Wichita, KS

• 12.5% incidence of severe adverse drug events, progressing to Code Blue, prior to Microstream™ capnography monitoring implementation

• One year post-implementation: 0%

65% Reduction4

Providence St. Peter Olympia, WA

• 65% reduction in Code Blue events over the 24 month period following implementation of Microstream™ capnography monitoring

1. Pohlenz P, Woodward K, Rosacker L, Nickels B, . Capnography Monitoring For Patient Controlled Analgesia. 2011 AARC Congress – Respiratory Care

2011;56:1636.

2. Fox D, Wencel M. Integral Role of Respiratory Therapists in a Comprehensive Pain Management Program using End Tidal CO2 Monitoring. 2011 AARC Congress

– Respiratory Care 2011;56:1636.

3. Fox D, AARC Webcast – etCO2 Monitoring: Riding the Wave, April 2013.

4. Jensen D, Williamson, J , Allen M, et al. Capnographic Monitoring Can Decrease Respiratory Compromise and Arrest in the Post-Operative Surgical Patient.

Respiratory Therapy Spring 2016. Volume 11 No. 2, P30-32.

THE CAPNOSTREAM® 20P PATIENT MONITOR

Microstream etCO2 and Nellcor SpO2 monitoring

Crisp, clear full-color display

Customizable display settings

Neonatal to adult patient modes

Easy-to-use, ‘turn and click’ user interface

Smart Capnography™ algorithms

Trend reporting options

Multiple connectivity options

Handheld options also available

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Reinventing What’s Humanly Possible.

Vital Sync™ Virtual Patient Monitoring Platform

Vital Sync™

HOW DOES VITAL SYNC™ WORK?

Vital Sync™

Virtual Patient

Monitoring

Platform (VPMP)

Vital Sync™

Informatics

Manager

HOSPITAL NETWORK

REPORTS

Device-Level

Patient-Level

System &

Administrative

CONNECTIVITY

EMR

CIS

ADT

Alarm Forwarding Systems

Remote & Mobile Monitoring

(desktops, tablets, smart

phones, laptops,

Workstations on Wheels,

central station)

CONNECTED DEVICES

Nellcor Pulse Oximeters

Microstream Capnography Monitors

Puritan Bennett Ventilators

Newport Ventilators

Version 2.5 : Added BIS & INVOS

Version 2.6: Add Wearable

Wireless

APPLICATIONS

Workflow Apps

Clinical Apps

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VITAL SYNC - PATIENT TILE VIEW

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VITAL SYNC - DETAILED CAPNOGRAPH VIEW

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VITAL SYNCTM REPORTS

Patient-specific ventilation report

Patient-specific oxygenation report

Ventilator Associated Condition report

Ventilator Associated Event report

Alarm frequency (by device or by unit/floor)

Alarm duration (by time of day)

Alarm recognition (by time of day)

Setting change frequency (by device)

Average days on ventilator (by unit/floor)

Number of monitored patients (by day)

Custom Reports

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THANK YOU