Respiratory depression (RD) often strikes patients within 24 hours of surgery and causes death or brain damage in the most serious of these cases, yet these injuries are often preventable, a new study from the Anesthesia Closed Claims Project and Anesthesia Quality Institute found.
More than 88% of the RD events that led to malpractice cases occurred within 24 hours of surgery, with 77% resulting in severe brain damage or death, according to a report in Anesthesiology (2015;122:659-665). Top causes were multiple physicians prescribing pain medications for the same patient, the layering on of sedatives atop opioid-based medications and inadequate responses or assessments by clinical staff.
However, the overwhelming majority of cases—97%—were judged to have been preventable if there had been better monitoring of the patients or a more adequate response once RD was identified, according to a team of researchers affiliated with the Anesthesia Closed Claims Project. The researchers recommended tighter controls over the prescription of sedatives and opioid-based pain medication, better training of clinical staff in assessing the signs of RD and more effective postoperative monitoring of patients who are prescribed opioids.
“It becomes confusing if the surgeon or other physician writes for an opioid medication postoperatively, but the doctor in charge of the pain service is not aware of it,” said Lorri A. Lee, MD, the lead author and professor of anesthesiology and neuroanesthesiology at Vanderbilt University Medical Center, Nashville, Tenn.
Multiple Opioid Scripts
The study examined 357 acute pain cases from the Anesthesia Closed Claims Project, which includes records on 9,799 malpractice claims from hospitals across the country. The study found that RD was possible, probable or definite in 92 of the claims.
The issue of RD has drawn increasing attention over the past few years, with recommendations for improving patient safety emanating from the Joint Commission, the Institute for Safe Medication Practices and the Anesthesia Patient Safety Foundation.
This study’s proposed interventions are based on an in-depth analysis of cases identified as RD, as well as the factors that too often resulted in serious brain injury or death, the researchers noted. “Careful review of rare sentinel events is one method to identify causal factors that, if modified or eliminated, could prevent undesirable outcomes,” the researchers said.
In one of its key recommendations, the study urged hospitals to coordinate clinicians prescribing pain medications during the postoperative period. In at least one-third of the malpractice claims analyzed, more than one physician prescribed opioid-based pain medication for the same patient. Issues related to the administration of opioid-based pain medications have previously been flagged in recent studies as a major driver behind RD.
Ideally, all prescriptions for opioid-based pain medications should go through one physician, Dr. Lee said. “If they feel the patient needs additional pain medication, they should contact the pain service or other physician in charge of prescribing opioids for the patient,” she said. Hospitals also need to coordinate the use of “nonopioid sedative medications in patients who are receiving opioids in a similar fashion,” the study noted. In one-third of the cases, patients receiving opioid-based pain medications were also prescribed sedatives. One of the “definitive” signs of RD includes the combination of oversedation, respiratory arrest and the need for resuscitation. Hospitals and medical centers across the country need to consider “institutional policies that discourage, limit or prevent more than one opioid-prescribing physician,” the researchers noted.
Meanwhile, more also needs to be done to monitor at-risk patients more closely and to train clinical staff to identify the signs of RD early on. In 31% of the closed claims examined, nursing checks were found lacking. The nurses in these cases did not recognize that clinical signs, such as “somnolence and/or oxygen desaturation,” are signs of RD. Also, nurses sometimes did not check their patients frequently enough, thereby missing the opportunity to intervene.
An example is given of an obese man in his 40s who was described after surgery as snoring loudly, slow to rouse and sleepy. After his oximeter read 49%, oxygen was replaced and his reading improved to 93%. Without speaking to a doctor, the nurse then left to do her rounds, noting the patient was “without complaints.” The patient was apneic within 28 minutes and died a few days later of anoxic brain injury. “These findings suggest a need for repeated careful assessments postoperatively and increased education regarding signs of opioid toxicity, including the correlation between ventilatory depression and excessive sedation,” the study noted.
Yet although closer monitoring of patients at risk for RD is needed, how to accomplish this is another question, given the sometimes extremely rapid onset of the potentially fatal condition. In a dozen of the malpractice cases analyzed in the study, RD occurred within 15 minutes of a nursing check. “It is not possible for nurses to be able to be in the room that much given the way we currently staff nurse-to-patient ratios,” Dr. Lee said.
Given the realities of staffing in modern health care, a growing number of hospitals are turning to electronic monitoring of all patients, not just those at risk, to prevent RD. Yet the effectiveness of some of the monitoring systems is highly questionable, the study noted. Basic pulse oximetry monitoring was being used in at least one-third of the malpractice claims involving RD, Dr. Lee and her fellow researchers wrote. The missing link, the researchers noted, was the lack of centralized or telemetric alarms, which could have altered outcomes by providing effective alerts to nurses and physicians. “If you have an electronic monitoring system, it needs to have an alarm that is sent to a care provider,” Dr. Lee said.
Even so, there are a number of barriers to the wider rollout of this combination of continuous electronic monitoring with a centralized alarm system. It can be difficult to get nurses and doctors to adopt the new technology; alarm fatigue may make the alarms less effective; and concerns about interrupting the sleep of patients are potential obstacles. Simply finding the m oney to acquire and install an expensive monitoring alarm system can be difficult as well. Even so, the potential gains outweigh the costs, the study concluded.
“These and other data support a more comprehensive monitoring and response approach to prevent what are considered to be avoidable devastating events,” the researchers concluded.