Capnography---Supporting the New Intermountain Standard

National Trendsand

System Project Overview

Kim Bennion MHS, RRT, CHC, ACPIntermountain Healthcare

System Respiratory Care Service QA Project Manager

National Trends

Center for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, Mortality File. (2015). Number and Age-Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 2000–2014. Atlanta, GA: Center for Disease Control and Prevention. Available at http://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000- 2014.pdf.

Centers for Disease Control and Prevention. (2014). Opioid Painkiller Prescribing, Where You Live Makes a Difference. Atlanta, GA: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vitalsigns/opioid-prescribing//5/2015

• Drug overdose is the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014.

• Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers.

• In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills.

JC Sentinel Alert #49

NOTE THE 2012 DATE OF PUBLICATION!

https://www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf

JC Sentinel Alert #49 High Risk Patients

CMS Conditions of ParticipationTransmittal #116June 6, 2014

• Proposals for “high risk” medicationso Includes patient monitoring

Capnography—AHA 2010-2015 Recommendations

VQ Matching: It’s all about the ventilation AND perfusion!

• “Continuous waveform capnography with clinical assessment is the most reliable method of confirming and monitoring endotracheal tube placement.”

• “Waveform capnography allows providers to monitor CPR quality, optimize chest compressions and detect ROSC during chest compressions (10-20 mmHg).”

AHA: https://acls-algorithms.com/waveform-capnography/

Wait! Why Capnography???

Barriers Discussed

• Too costly for equipment and supplies

• Too large of a culture change

• Too complex to do correctly

• Clinical workflows when high risk patients are found

• Technology too complex/too much to learn

• MD

• RT

• RN

• Family/Caregivers

Acoustic Monitoring

…and this too????

Acoustic Monitoring is a measurement that allows clinicians to noninvasively and continuously monitor patients’ respiration rate.

Indications:

• Cannot wear ETCO2 cannula

or mask (e.g., facial trauma)

• Flow > 15 LPM

(high flow nasal cannula, CPAP/BiPAP)

System Opioid Patient Safety & Monitoring Project

Who Is the Boss…and How Did We Get Here?

• System Quality and Patient Safety request

• COLT and Key Process Teams (oversight)oRegulatory Search

o Literature Search

o Expert Guidelines• American Society of Anesthesiology

• American Association for Respiratory Care

• American Academy of Family Practice

• CDC

• ….and the list goes on and on….

ARCIE

SE# 49 Opioid Safety Capnography In Procedural Settings---ARCIE

Authors: Steve Abplanalp and Kim Bennion

Date Drafted: February 15, 2015

Revised: August 26, 2105

Revised: February 10, 2016

Revised: October 20, 2016

Revised: November 22, 2016

_

ETCO2 Summary of Inventory 9-17-14.xlsx

RCS & Quality Proposal for Sedated, Pain Medicated, Higher Risk Patients-Kim's DRAFT.pptx 9-16-14.pptx

Opioid Monitoring Crosswalk 2-6-2013.docx

Oversight Committee: Intermountain Healthcare Key Process Team, Clinical Operations

Leadership Team (COLT), Dr. Doug Smith, Respiratory Care Services (RCS) Corporate

Administration (Steve Abplanalp & Kim Bennion), Quality & Patient Safety (Robin

Betts), Patient Safety Task Force, Key Process Team

Committee Chair(s)/Corporate Sponsors: Gay Cunningham, SWR CNO and Dr. Bill

Hamilton

Team Scribe: Kim Bennion

Objective(s):

Coordinate the process and forms creation, implementation, education and auditing and

monitoring for Sentinel Event #49 Opioid Safety utilizing Capnography in Procedural

Settings in association with physician/LIP, nursing, respiratory and other clinical support

services.

Corporate Facilitators and Content Experts:

Key Process Team (Bonnie Jacklin, Robin Betts, Doug Smith, Associate CMO)

COLT Team Members

Steve Abplanalp, System Director Pulmonary and Sleep Services

Kim Bennion, RCS System Quality Assurance Program Manager

Robin Betts, System Quality & Patient Safety

Alicia Dean, CR Surgical Services

Katie Liljestrand, CR Surgical Services

Bill Hamilton, Anesthesia Development Group

Sentinel Event #49 Opioid Safety with use of Capnography

ARCIE

Project “Buckets”

PreviouslyDiagnosed

& SuspectedOSA

MonitoringDuring Sedated

Procedures

Pain

Opioid Project “Buckets”

• Pain (System Pain Services)oAcute

oChronic

• Monitoring During Conscious Sedation (Anesthesiology Development Team)oContinuous Pulse Oximetry

oETCO2/Acoustic Monitoring

• Previously Diagnosed and Suspected OSA (System Respiratory Care Services)oAdult RET Phase 1 (Previously Diagnosed OSA)

oAdult RET Phase 3 (Suspected OSA)

Pain

• Use of STOPBANG Score at all hospital point of entry

• Inpatient Opioid Induced Respiratory Depression Assessment

• Opioid Prescribing Guideline

Monitoring During Sedated Procedures

• Decision: Anesthesia Development Team decision for continuous pulse ox and ETCO2/acoustic monitoring during ALL sedated procedures

• RCS led capnography (ETCO2) vendor selection (June 6, 2016)oPhillips “brick”

oMasimo ROOT (has acoustic monitoring capabilities)

Suspected & Previously Diagnosed OSA

• Adult RET Phase 1: included care for previously diagnosed OSA

• Adult RET Phase 3: included care for suspected OSAo STOPBANG at all hospital points of entry• Requires nursing, RT, physicians and other caregivers

• > 5 would be the “trigger” (Debate: > 3 or 5???)

• ED: only patients undergoing sedated procedure and /or being prescribed opioids for discharge

• L&D: scoring would occur once on Mom/Baby Unit

Does this picture make anyone else LOL?

Adult RT Eval and Treat PAP for OSA Protocol

Definition of “Recurrent Respiratory Events”

How Are High Risk Patients Currently Defined?

• STOPBANG > 5

• Recurrent Respiratory Events in the unstimulated patient

• IV Narcotics

PAP for OSA Appendix A (addition for 2017)

Adult RT Eval & Treat Capnography Protocol

Nursing Capnography Protocol

Related But Out of Scope of System Opioid Project

• Operational implementation of STOPBANG at all point of hospital entry

• iCentra documentation alerts and response expectations

• Formal PACU PAP Education to Nursingo Shawna Murray has coordinated this in the CR (great resource!)

oAppendix A of PAP for OSA Protocol

• Code Blue/Rapid Response Team ETCO2 (mainstream vs sidestreamoUpdate on EMMA status and demo

So, What Should Facilities/Regions Be Doing?

• Equipment and SuppliesoOversight of CNO and Nursing Department Directors (RCS Directors & Managers as

Consultants)• Standards: Phillips capnography :brick” and/or Masimo ROOT (Capnography & acoustic monitoring)

o Supplies: Contact the Supply Chain or your RCS Director/Manager

• MD, RT and Nursing Education (CBTs and on-site, vendor trainings)

• RTs to be the hospital consultants/experts for ETCO2 & Acoustic Monitoring

• Tele-Critical Care Consults and Support Workflows in progress

Tele-Critical Care Consults

Education and Communications

Capnography CBT Assignments

• RCS Super User Trainings & CBTs (April 30, 2017 & September 30, 2017) and Quizzes

• Nursing CBT created and assigned July 1, 2017

• Physician/LIP CBT created for assignment Q3 2017:http://media.co.ihc.com/ihcumedia/ihcu/rsp/capnographyForPhysicians/index.html

Challenges Regarding Physician Education

• Assigning Physician CBT (LMS for Tracking)

• Solutions:

• Physicians can request CBT assignment via Regional Nurse Educators

• Capnography Grand Round---Dr. Bill Beninati

• RCS Clinical Program Development Teams’ Agenda Timeo Hospitalists

o Intensive Medicine

o ED

o Surgical Services/Anesthesia

o ???

Education and Communications…continued

•Regional/Facility Webinarso Initial system communication of the project overview• 2017 project introductory webinars scheduled/completed by region/facility

o Both CNOs and RDTs to assure all key stakeholders were invited

o Webinars preceded the onsite, vendor trainings

• Onsite Vendor Hospital Trainingso RTs supported but not be in charge of onsite hospital trainings• Scheduled with both vendors by the regional nurse educators

• System Education led hospital in-services and nursing training

Full Implementation Date

December 30, 2017!

How We Feel Now…

“Getting there” takes time and intentional effort!

Questions?