Assessment and Intervention of Opioid Induced Respiratory ... · • Specific to opioid-induced...

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Assessment and Interventionof

Opioid Induced Respiratory Depression

Using the “POSS”

Ann Quinlan-Colwell,

PhD, RNC, DAAPM

Conflict of Interest Disclosure

• Conflicts of Interest for author is:NONE

A conflict of interest is a particular financial or non-financial circumstance that might compromise, or appear to compromise, professional judgment. Anything that fits this should be included. Examples are owning stock in a company whose product is being evaluated, being a consultant or employee of a company whose product is being evaluated, etc.

– Taken in part from “On Being a Scientist: Responsible Conduct in Research”. National Academies Press. 1995.

Objectives

The participant will be able to:

• describe and explain the POSS

• describe and explain two ways the POSS can improve patient safety

• explain how to incorporate the POSS in routine practice

• list three benefits of the POSS

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The New Hanover Regional Medical Center Journey

Purposes of the Journey

• Insure Safety of all patients

• NHRMC has zero tolerance for Opioid Induced Respiratory Depression (OIRD)

• Satisfy JC requirements

• Adopt a user friendly tool to improve assessment of and intervention for patients at risk of OIRD

• Educate nurses how to use and document this assessment tool

The Beginning

• Commit to patient safety as priority

• Literature review

• Identified Pasero Opioid Sedation Scale as tool for:– Assessment

– documentation

• Presented to Clinical Claims Committee

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Illness – Trauma - Surgery

NSAIDS

Pain

Adjuvants

LocalAnesthetics

Acetaminophen

Opioids

Side Effects

Like all medications Opioids have side effects.

Opioids Work through the Central Nervous System

Common Opioid Side Effects

• Nausea and vomiting

• Pruritus

• Constipation

• Sedation

• Respiratory Distress/Depression

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Respiratory Depression• Characterized by:

– Less than 8 to 12 breaths per minute– Reduced oxygen saturation– Altered arterial CO2 tension– Cyanosis– Periodic apnea– Drowsiness, sedation

• Danger is progression to Respiratory Arrest

Respiratory Depression

• A “vicious cycle”

• Opioid Induced Respiratory Distress occurs due to:

– a lowered carbon dioxide (CO2) drive

– Blunting of chemoreceptor response to oxygen & CO2

– Prolonged exhalation

– Suppression of depth of respirations

– Impaired gas exchange

Clinical Challenges

• Early identification of patients at risk for developing respiratory compromise

• Appropriate assessment for sedation

• Identify sedation that is advancing

• Early intervention to prevent respiratory arrest

• Reasonable documentation

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Increased Risk for OIRD

• First 24 post operative hours

• Untreated Obstructive Sleep Apnea (OSA)

• Respiratory compromise

• Morbid Obesity

• Certain genotypes

• Elderly

• Opioid Naïve

• Opioid Tolerant with changes in dose or opioid

• Concomitant sedating medications

Early Identification of Respiratory Compromise

• Advancing sedation is the earliest sign of respiratory compromise!

• Identify factors that increase risk of OIRD

• Assess Respiratory Function

– Rate for one full minute

– Character and quality

Limitations of Technology

• Reliability and sensitivity issues of the equipment

• Patient compliance with equipment

• Expense

• Hypoxemia measured by pulse oximetry is a late finding

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Nurse Assessment is the Best Intervention to

Prevent OIRD

Challenges

• How to describe the level of sedation that is assessed so that others understand what was assessed?

• How to document the level of sedation that was assessed so that others understand what was assessed?

• What should be done with the information assessed?

Literature Review Search

• RASS

• Ramsay Sedation Scale

• POSS

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Pasero Opioid-Induced Sedation

Scale

(POSS)

The POSSLevel State Dosing Guidance

S Sleepy, easy to arouse

Acceptable; no action necessary; may increase opioid dose if needed.

1 Awake and alert Acceptable; no action necessary; may increase opioid dose if needed.

2 Slightly drowsy, easily aroused

Acceptable; no action necessary; may increase opioid dose if needed.

3 Frequently drowsy

Unacceptable; decrease opioid dose 25%-50% or notify primary MD or anesthesiologist for orders; administer a non-sedating, opioid sparing nonopioid such as acetaminophen or a NSAID; monitoring respiratory status & sedation until level is less than 3 & respiratory status is satisfactory.

4 Somnolent; minimal or no response to physical stimuli

Unacceptable; stop opioid; consider administering naloxone; notify primary MD or anesthesiologist; monitor respiratory status and sedation level closely until sedation level is less than 3 and respiratory status is satisfactory.

Adapted from Sedation scale developed by C. Pasero in 1990; copyright 1994, C. Pasero; Published originally in Pasero, C. (1994) Acute Pain Service: Policy & Procedure Guideline Manual.

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Benefits of POSS

• Specific to opioid-induced sedation

• High reliability (Chronbach’s alpha >.90)

• Clear and simple to use

• No extra time required to assess

• Provides an agreed upon number for ease of documentation

• Provides established guidance for nursing intervention

• Satisfies JC mock survey recommendation

When to Use the POSS

• With every assessment and re-assessment for pain, assess sedation in the person who received opioid analgesia

• Utilize the “Dosing Guidelines” prior to administering additional opioids

• Document in HED, the sedation level using the appropriate letter (S) or number (1, 2, 3, or 4)

Benefits for Patient Safety

• Guidance for safe administration of opioids

• Criteria for using range orders

• Tool to increase patient safety after opioid administration

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More Benefits of Using POSS

• Component of Patient Education

• Tool to improve consistency of documentation

• Tool to document patient status

Introducing The POSS

Incorporating the POSS in Routine Practice

• Education

• Incorporate into EMR

• Audit use

• Incorporate into EPIC

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Educating About The POSS

• Staff meetings and huddles

• Computer Based Learning Module

• Handouts

• New Nurse Orientation

• Staff meetings and huddles

Monitoring Use of the POSS

• Weekly Audits

• Soliciting feedback

TJC Sentinel Alert on Opioids

• “… most serious (adverse) effect being respiratory depression, which is generally preceded by sedation.”

• “the potential for opioid-induced respiratory depression should always be considered”

• 29% of opioid AE were related to improper monitoring

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Change to

EPIC

Auditing Documentation in EPIC

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Improving Documentation

Adjusting in Epic

Improving in Epic

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The Best of Epic

Benefits of Using The POSS

• Encourage routine assessment of sedation

• Easy documentation of sedation

• One criteria for Range Orders

• Improve patient safety

• Satisfy TJC requirements

• Facilitates communication

Remember:

Sedation always

occurs before

respiratory depression!

If a person is sedated as a result of an

opioid, assess respiratory status and

intervene according to the POSS guide.

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References• American Society of Anesthesiologists Task Force. (2009). Practice Guidelines for the prevention,

detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology, 110, 218-230.

• Cronrath, P., et al. (2011). PCA oversedation: Application of healthcare failure mode effect analysis (HFMEA™). Nurse Economics, 2011, 79-87.

• McCaffery, M. & Pasero, C. (1999). Pain: clinical manual (2nd Ed). St. Louis: Mosby.

• Nisbet, A. T. & Mooney-Cotter, F. (2009). Comparison of selected sedation scales for reporting opioid-induced sedation assessment. Pain Management Nursing, 10, 154-164.

• Pasero, C. & McCaffery, M. (2011). Pain assessment and pharmacologic management. St. Louis: Mosby Elsevier.

• Pasero, C. & McCaffery, M. (2002). Monitoring sedation: It’s the key to preventing opioid-induced respiratory depression. American Journal of Nursing, 102 (2), 67-69.

• Pasero, C. (1994). Acute pain management service: Policy & procedure guideline manual. Los Angeles: Academy Medical Systems.

• Smith, L. H. (2007). Opioid safety: is your patient at risk for respiratory depression? Clinical Journal of Oncology Nursing, 11, 293-296.

• Young-McCaughan, S. & Miaskowski, C. (2001). Definition of and mechanism of opioid-induced sedation. Pain Management Nursing, 2, 84-97.

Ann Quinlan-Colwell, PhD, RNCPain Management CNS

Ann.quinlan-colwell@nhrmc.org910-343-7065