Interprofessional Opioid Safety in the Medical-Surgical Unit
Elizabeth Thomas: Could you provide some background for your project?
Brooke Schmitt: A few years ago, we had an adverse event involving an elderly patient who was admitted for a hip fracture. We were treating their pain, giving IV push opioids. We didn't have ETCO2 (end-tidal carbon dioxide) monitoring in place, and the patient ended up with respiratory suppression that required elevated care. While we didn't have a serious safety event, it was a precursor event that we wanted to learn from. We completed an Apparent Cause Analysis (ACA), which is like a "mini" RCA (Root Cause Analysis) that initiated our work on developing an improved process for preventing Opioid-Induced Respiratory Suppression (OIRS).
Thomas: So, this is research, not evidence-based practice?
Schmitt: Correct. Because of our intention to disseminate the information, we classified it as research versus evidence-based practice.
Thomas: When you went into the literature, you didn't find it, so you had to create it?
Schmitt: There was literature to support it, but our specific process and protocol was not necessarily out there prior.
Thomas: Looking at your background, you have orthopedic, neurology, urology, ENT, and general medical patients. Are most of your pain medications administered to your ortho patients?
Jessica Scheideler: No, we administer pain medications to all types of patients. In our study, we found that more of our medical patients were treated with IV opioids.
Thomas: Prior to this, were you using capnography, or was that part of what you implemented?
Scheideler: We were already using capnography, primarily when we were managing patient's pain with a patient-controlled analgesia (PCA) pump. We had a well-established protocol for managing patients with a PCA, but we didn't have a protocol where we were using it for IV pushes. We were often pushing more opioids than what a patient would push on a PCA. We realized we need that monitoring, and it was something our nurse educators had been talking about for a while. So, as a result of the ACA we completed, we addressed the gap by developing and implementing our OIRS monitoring protocol.
Schmitt: There wasn't a defined process for implementing the monitoring. The option to put an end-tidal monitor on a patient was there if you called for the order, but there were no clear guidelines on when to initiate. The tool that we utilize was created by a pharmacist at one of our sister hospitals, but it really helped nurses understand the difference in potency between the medications as well. Understanding the strength of the medication you’re giving is a huge part of it. It was a nice visual for nurses to understand that in general, kind of like your morphine milligram equivalents (MMEs), but then also understand that the patient has risk factors in place, and we're regularly assessing for that. We’re identifying that we’re giving X dose and should probably have some monitoring in place, and we do. We had administered opioids more via IV push than we do on a PCA. We rarely use PCAs.
Thomas: For the capnography, you don't require an order? Is it part of your protocol now?
Scheideler: Correct. We made it nurse-driven. Part of the protocol is that if the patient has at least two doses of IV opioids within a 12-hour shift, and if they have any risk factors for oversedation, then we can put in orders for capnography and continuous pulse ox. It’s not only nurse-driven to initiate; it’s nurse-driven to discontinue as well. So, for instance, if the patient had good pain control with oral medications, was not showing signs of respiratory suppression, and was not requiring IV opioids, then four hours after the last dose of IV opioids, we would discontinue monitoring.
Thomas: Were the physicians on board with giving you the freedom to make those clinical decisions because you're the ones doing the assessments?
Scheideler: Absolutely. We already had this process in place. We just wanted to make sure they were on board with it right away.
Schmitt: It made it easier for them by decreasing phone calls to the provider. Before, if we'd want to put monitoring in place, we'd have to call, but now we collaborate with respiratory therapy, too. It was a very simple sell to our medical providers.
Thomas: That’s wonderful. As part of this, did you put policies and procedures in place adjunct to this?
Scheideler: Our hospital already had policies/procedures in place as far as standards of care, supporting important assessments, and the use of capnography. This protocol just brought together a lot of resources into a defined process for a specific high-risk population. Respiratory therapy has a protocol when they have it on patients, so they help with that as well.
Thomas: Nice. It’s very interdisciplinary. I like the table with the stoplight — green, yellow, red. Is that the protocol, or paired with the q4h (every four hours)?
Schmitt: Yes. There were two tools we used. One had the green, yellow, and red sections and included the protocol at the bottom. The other piece was an algorithm that we created to make the process easier. The algorithm visually helped guide staff through each step of the protocol. Essentially, it was their instructions on how/what to assess for OIRS and implement the appropriate monitoring. Now, we really don't need to utilize the algorithm per se because the nurses understand that process. They're just looking at the dose and the risk factors.
Thomas: I saw in your presentation that if someone has the risk factors, you used an alternate delivery method. Would you switch the route of administration, or would you move to a PCA?
Scheideler: If the patient was receiving doses of IV push opioids that were within the "red" range on the equivalency chart, then it is highly encouraged to consider an alternative delivery method, such as a PCA or an epidural. It would depend on their diagnosis and cause of pain.
Schmitt: There might be situations where they consider an epidural, depending on what surgical intervention the patient had done and where their pain is. There are lots of other things to consider, other modes or a patch, etc.
Thomas: But predominantly you would move to a PCA?
Schmitt: Yes, if the doses are high enough, as long as they’re not in that red zone. But a lot of work has been done at our facility to manage appropriate dosing, so we don’t really see orders for those high doses. And that’s kind of a limitation to the study. In a facility where providers may still be ordering some of those larger doses, there might be a bigger opportunity for change.
Thomas: Did you already have multimodal strategies in place?
Schmitt: Yes. For the sake of the study, we only looked at IV push medications. But there are multiple patients receiving both IV and oral medications or several oral medications who could benefit from the monitoring as well. Since the study, we've added a component addressing sedatives as well. That was due to a scenario on a different unit where a patient was receiving a sedative and some opioids and ended up having a respiratory event, and that patient wasn’t being monitored. Sometimes it's not opioids, but you're giving Ativan or Valium, for instance, and the patient has a depressed respiratory system.
Thomas: Did you update protocol based on that potential event?
Schmitt: Yes.
Thomas: Are the tools displayed throughout the unit, or are they attached to the EHR?
Schmitt: The goal would be to have it attached to the EHR, but right now we have them available on the units. We've expanded it by educating nurses on our progressive care unit and in our intensive care unit (ICU), who sometimes have patients who are no longer ICU status for whom this would be appropriate. All our nurses have been educated on it now.
Thomas: So, it’s not location-based but specifically for the medical-surgical population?
Schmitt: Our study was focused on patients within our medical-surgical unit, but now it is not unit specific and can be utilized for any non-ICU patient receiving IV push opioids. It could be a patient anywhere on the acute floors.
Thomas: How long was your trial period?
Scheideler: The actual study period was slightly over three months.
Thomas: You found that your medical patients receive IV opioids more often than your surgical patients. Was this a surprise to you?
Scheideler: It was in one respect because I didn't think we were pushing that much IV opioids with our medical patients. But there are a lot of medical conditions that are treated with IV opioids, and with surgical patients, we usually have different levels of pain management that we can utilize. We can use oral medications, which are a better form of pain control. We also use non-pharmacological pain management, such as ice and positioning.
Thomas: After looking at that data, did it spur any change with your orders for medical patients?
Schmitt: It didn't result in any specific changes, but it made us more aware of at-risk patients in general. We have specific/routine order sets that we utilize for post-surgical patients that include routine pain management regimens and monitoring. Medical patients don't necessarily have that, and we see more variation in pain management interventions for those patients. Greater awareness of the opioids we are giving and patient risk factors, regardless of diagnosis/procedure, increases patient safety.
Thomas: Is it accurate to say it’s a little more individualized with medical patients and more standardized with post-op patients?
Scheideler: With our surgical patients, it’s clear what to do and what to use because we have the same orders, the same routine, and the same doctors, whereas with medical patients, it all depends. Each case of pancreatitis, for instance, is different, so what works with one patient may not work with another. There’s a lot more guesswork and trying to figure out what makes the patient more comfortable.
Thomas: Congratulations on no rapid response team (RRT) activation for those three months. That's wonderful. Have you been able to sustain that?
Schmitt: We haven't had any RRTs related to opioids use or anything else.
Thomas: What do you want to impress upon the medical-surgical nurses reading about your study? What do you think is the biggest take-home message for them?
Schmitt: Identify patients who are at risk early and often, and when things have changed, reevaluate. It’s not so much about what medications you are giving but what they’re at risk for when they’re receiving those medications and putting monitoring in place so that you catch it early if they are receiving too much. Every patient is going to be different. It’s also important to understand the difference between opioids and narcotics. It’s important especially with newer nurses to have the tool available to say, for instance, “Don’t forget, when you’re giving Dilaudid that it’s more potent than morphine.” The tool even includes oral medications, so that helps them differentiate as well.
Thomas: Is there anything else you’d like to highlight?
Schmitt: I would love to see facilities or units that have a lot of Narcan use implement something like this and see how it impacts patient outcomes. We have minimal Narcan use because of all the procedures we’ve implemented, so I hope the tool could help other facilities, units, and their patients.
Thomas: Just for a frame of reference, I work at a 500-bed Level 1 trauma center in Philadelphia with six medical-surgical units, and I don’t have the data on how much Narcan is used in this type of scenario. So, this is very interesting to me. I think this type of intervention could benefit everyone.
Schmitt: Pharmacists have a strong understanding of MMEs, but nurses might not understand what that means. Our tool is very simple and something nurses can relate to easily. At the convention, when I asked for a raise of hands of those who have heard of or utilize MMEs, maybe two people raised their hands. This proved my point about how this tool is a simplified way for nurses to understand the strength/potency of the medications they are giving to patients and when they should implement monitoring.
Scheideler: I like that it's a cut and dry process. If I have a patient who’s a certain age or has a certain diagnosis, that automatically clues me in that I need to be careful about the types of medications I give them or that I have to monitor this patient. And that monitoring gives me the confidence to say, “Yes, this is safe. This patient is doing OK. There's X, Y, and Z, so we can go ahead and do this.” The nurse-driven initiation and discontinuation gave me a greater sense of ownership over the care I provide to patients.
Thomas: Patients always benefit when we nurses put ourselves in the driver’s seat.
Schmitt: Alarm fatigue is a thing, and whether we would be implementing monitoring on every patient was a question that came up during the study. What's nice about this is that, no, you're not monitoring everybody. If you have a patient who doesn't have risk factors, and you're giving doses that are in that green zone, where it's considered a safe dose, you don't have to put monitoring in place. It's not just that they have risk factors, but it considers the dose that you're giving and how often you're giving it. It's very individualized, so it's not like we saw this mass increase in monitoring.
Content published on the Medical-Surgical Monitor represents the views, thoughts, and opinions of the authors and may not necessarily reflect the views, thoughts, and opinions of the Academy of Medical-Surgical Nurses.