Embed Size (px)
Citation preview
9/17/2013
1
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
9/17/2013
2
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
9/17/2013
3
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
9/17/2013
4
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
9/17/2013
5
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
9/17/2013
6
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
9/17/2013
7
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.
9/17/2013
8
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
9/17/2013
9
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
9/17/2013
10
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
9/17/2013
11
Change to
EPIC
Auditing Documentation in EPIC
9/17/2013
12
Improving Documentation
Adjusting in Epic
Improving in Epic
9/17/2013
13
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.
9/17/2013
14
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
