Patients receiving parenteral and neuraxial opioids are at risk of depressed respiration. Traditional practice in medical-surgical units and other general care areas has been to intermittently monitor these patients, typically at four-hour intervals, using vital signs monitors. These monitors can be used to spot-check pulse rate, blood pressure, temperature, and oxygen saturation; and while the monitor is operating, the clinician counts respirations for a fraction of a minute to determine respiration rate.
Respiratory depression, however, can quickly lead to anoxic brain injury or death if not detected. Thus, assessing the condition of these patients at such long intervals will not reliably detect hypoventilation associated with this condition. As a result, several organizations now recommend that these patients be continuously monitored for respiratory depression.
This recommendation presents some significant challenges for health care providers. ECRI Institute has identified and answered some of the key questions that will need to be addressed as health care facilities work to meet these challenges.
Which Monitoring Technology Should Be Used?
Monitors for detecting respiratory depression need to continuously assess the adequacy of ventilation and alarm for incipient respiratory compromise. Two technologies offer promise for this application (ECRI Institute has tested and rated several models specifically for their ability to help detect respiratory depression):
Capnometers, which measure the amount of carbon dioxide in the exhaled breath that is sampled via a nasal/oral cannula. This technology is commonly referred to as end-tidal carbon dioxide (EtCO2) monitoring.
Monitors that use bioimpedance to estimate minute ventilation. One model that ECRI Institute has evaluated uses a chest electrode padset to sense movement of the thorax and air associated with breathing. The monitor interprets frequency and amount of movement as respiration rate and volume of the exhaled breath (tidal volume), respectively.
Both types of monitors can be used in medical-surgical units for low-acuity, postoperative patients who are receiving parenteral opioids for pain management. They also can be used to monitor patients who receive opioids for pain management in general care areas and during procedural sedation for which sedatives or dissociative agents are administered with or without analgesics/anesthetics.
It’s worth noting that ECRI Institute does not recommend purchasing pulse oximetry to monitor patients receiving opioids. Respiratory depression is insidious in onset and may not be accompanied by oxygen desaturation, especially for patients receiving supplemental oxygen.
Intensive care monitors are likewise not an appropriate option for this application. For patients in an intensive care setting, continuous physiologic monitoring is already standard practice. However, simply expanding the use of intensive care monitoring technologies to medical-surgical and other general care areas is not a viable option. Reasons include:
How Does a Facility Budget for Acquiring and Operating Monitors?
Analyzing the costs for continuous monitoring technologies requires looking at more than just the acquisition cost. Hospitals should also:
Consider the cost of consumables. The cost of consumables can differ significantly among alternatives. Over the lifetime of the device, such expenditures can far exceed the monitor’s acquisition cost.
Calculate the number of monitors needed. Determining the number of monitors needed is not as simple as counting beds. It requires an understanding of how monitoring will be implemented in each care area. For instance, if a policy is adopted to monitor patients for at least 24 hours but then to discontinue monitoring if certain conditions are met, most clinical care areas will not require a monitor for every bed, since not all patients in the care area will be monitored for the full length of their stay. For example, a 20-bed medical-surgical unit might need only 12 monitors on rolling stands, allowing for one or two patients in a full-census unit to continue on monitoring after 24 hours.
Weigh the cost of ownership for continuous monitoring against the cost saving from early detection of respiratory compromise.
Which Patients Will Be Monitored, and for How Long?
ECRI Institute suggests:
What Impact Will Continuous Monitoring Have on Workflow?
Monitoring for opioid-induced respiratory depression will present clinicians with a significant change in workflow. Continuous monitoring is being introduced into clinical care areas where monitoring has typically been limited to taking vital signs at periodic intervals.
A central station with real-time monitoring information from each room is not necessary. However, facilities must implement measures to ensure that:
How Will the Monitors Be Deployed?
ECRI Institute recommends that that monitors be mounted on the same IV pole with a patient-controlled analgesic (PCA) pump whenever a pump is requested for parenteral or neuraxial pain management on general care units. When an opioid is not delivered using a PCA pump, we suggest deploying monitors on rolling stands or IV poles.
How Will Clinicians Be Reliably Alerted to Alarms throughout the Care Area?
Interfacing with a nurse call system can be a cost-effective option for remote alarm annunciation. Alternatively, a facility may wish to connect through a third-party integration solution to alarm management middleware.
Who Should Be Involved?
Teams involved with implementing monitoring for opioid-induced respiratory depression should include the chief medical officer, the safety and quality officer, a risk manager, the director of nursing, the nurse manager, a pharmacist and a clinical engineering representative.
This article was adapted from ECRI Institute’s PSO Deep Dive™: Opioid Use in Acute Care. The executive brief is publicly available for download. The comprehensive report is available to ECRI Institute PSO and partner PSO members online; nonmembers can purchase a PDF of the report. To learn more, visit www.ecri.org/opioids; call 610-825-6000; or email firstname.lastname@example.org.
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